Ortho Bullets Volume One Trauma 2017
Ortho Bullets Volume One Trauma 2017
Ortho Bullets Volume One Trauma 2017
ORTHO BULLETS
Volume
One
Trauma
2017
Collected By : Dr AbdulRahman AbdulNasser
[email protected]
Preface
Orthobullets.com is an educational resource for
orthopaedic surgeons designed to improve
training through the communal efforts of those
who use it as a learning resource. It is a simple but
powerful concept. All of our topics, technique
guides, cases, and user-generated videos are
free, and will stay that way.
3. Humeral Shaft Fractures ....... 152 4. Hamate Body Fracture .......... 241
IV. Hand Trauma .......................... 210 2. Dog and Cat Bites ................. 271
3. Nail Bed Injury ...................... 274 1. Ankle Fractures .................... 377
4. High-Pressure Injection Injuries 2. Talar Neck Fractures ............ 387
................................................ 276 3. Talus Fracture (other than neck)
5. Frostbite............................... 278 ................................................ 390
V. Pelvis Trauma .......................... 284 4. Subtalar Dislocations ............ 394
A. Pelvis ................................... 285 5. Calcaneus Fractures............. 396
1. Pelvic Ring Fractures............ 285 VII. Foot & Ankle Trauma ............ 405
2. SI Dislocation & Crescent A. Ankle Sprains ....................... 406
Fractures ................................. 294 1. High Ankle Sprain &
3. Sacral Fractures ................... 297 Syndesmosis Injury .................. 406
4. Ilium Fractures ..................... 301 2. Low Ankle Sprain .................. 410
B. Acetabulum .......................... 303 B. Mid & Forefoot Trauma ......... 414
1. Acetabular Fractures............ 303 1. Lisfranc Injury (Tarsometatarsal
2. Hip Dislocation ..................... 311 fracture-dislocation) ................. 414
VI. Lower Extremity ...................... 314 2. 5th Metatarsal Base Fracture 420
ORTHO BULLETS
I.Genaral Trauma
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Evaluation
A. Evaluation
Primary Survey
Airway
o includes cervical spine control
Breathing
Circulation
o includes hemorrhage control and resuscitation (below)
o pregnant women should be placed in the left lateral decubitus position to limit positional
hypotension
Hemorrhagic Shock Classification & Fluid Resuscitation
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OrthoBullets2017 Genaral Trauma | Evaluation
Introduction
o average adult (70 kg male) has an estimated 4.7 - 5 L of circulating blood
o average child (2-10 years old) has an estimated 75 - 80 ml/kg of circulating blood
Methods of Resuscitation
o fluids
crystalloid isotonic solution
o blood options
O negative blood (universal donor)
Type specific blood
Cross-matched blood
transfuse in 1:1:1 ratio (red blood cells: platelets: plasma)
Indicators of adequate resuscitation
o MAP > 60
o HR < 100
o urine output 0.5-1.0 ml/kg/hr (30 cc/hr)
o serum lactate levels
most sensitive indicator as to whether some circulatory beds remain inadequately
perfused (normal < 2.5 mmol/L)
o gastric mucosal ph
o base deficit
normal -2 to +2
Risk of transfusion
o risk of viral transmission following allogenic blood transfusion
hepatitis B (HBV) has highest risk: 1 in 205,000 donations
hepatitis C (HCV): 1 in 1.8 million donations
human immunodeficiency virus (HIV): 1 in 1.9 million
transfused blood is screened for
HIV-1 (cause of AIDS)
HIV-2
hepatitis B
hepatitis C
West Nile virus
syphilis
o clerical error leading to transfusion reaction (1:12,000 to 1:50,000)
o bacterial contamination leading to sepsis (1:1million)
o anaphylactic reaction (1:150,000)
Septic Shock
Septic shock vs. hypovolemic shock
o the key variable to differentiate septic shock and hypovolemic shock is that systemic
vascular resistance is decreased with septic shock and increased with hypovolemic shock
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Evaluation
Imaging
Delay of fracture diagnosis is most commonly caused by failure to image extremity
AP Chest
o mediastinal widening
o pneumothorax
Lateral C-spine
o must visualize C7 on T1
o not commonly utilized in lieu of increased sensitivity with cervical spine CT
AP Pelvis
o pelvic ring
further CT imaging should be delayed until preliminary pelvic stabilization has
been accomplished
o acetabulum
o proximal femur
CT Scan
o C spine, chest, abdomen, pelvis
o often used in initial evaluation of trauma patient to rule out life threatening injuries
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OrthoBullets2017 Genaral Trauma | Evaluation
therefore only potentially life-threatening injuries should be treated in this period
including
compartment syndrome
fractures with vascular injuries
unreduced dislocations
long bone fractures
unstable spine fractures
open fractures
Stabilization followed by staged definitive management
o to minimize trauma, initial stabilization should be performed and followed by staged
definitive management
includes initial pelvic volume reduction via sheet, pelvic packing, skeletal traction,
binder, or external fixation
if hemodynamically stable
proceed with further imaging including CT chest, abdomen, pelvis
if not hemodynamically stable
consider pelvic angiography and embolization
o definitive treatment delayed for
7-10 days for pelvic fractures
within 3 weeks for femur fractures (conversion from exfix to IMN)
7-10 days for tibia fractures (conversion from external fixation to IMN)
2. Gustilo Classification
Abridged version
Type I
o wound < 1 cm
Type II
o 1-10cm
Type III A
o > 10 cm, high energy
o adequate tissue for coverage
o includes segmental / comminuted fractures even if wound <10cm
o farm injuries are automatically Gustillo III
Type IIIB
o extensive periosteal stripping and requires free soft tissue transfer
Type IIIC
o vascular injury requiring vascular repair
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Evaluation
Complete version
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OrthoBullets2017 Genaral Trauma | Evaluation
Figure I:1 Gustillo type one Figure I:2 Gustillo type two
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Evaluation
Antibiotic Indications for Open Fractures
Gustillo Grade I and II
o 1st generation cephalosporin
Gustillo Grade III
o 1st generation cephalosporin + aminoglycoside
traditionally recommended, but there is no evidence in the literature to support its
use
With farm injury / bowel contamination
o 1st generation cephalosporin + aminoglycoside + PCN
o add PCN for clostridia
Duration
o initiate as soon as possible
increased infection rate when antibiotics are delayed > 3 hours from time of injury
o continue for 72 hours after I&D
o 48 hours after each procedure
Tetanus booster if not up to date
3. Tscherne Classification
Closed Fractures
Oestern and Tscherne classification of soft tissue injury in closed fractures
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OrthoBullets2017 Genaral Trauma | Evaluation
Open Fractures
The Oestern and Tscherne classification for open fractures uses wound size, level of
contamination, and fracture pattern to grade open fractures
Grade II Open injuries with small skin and soft tissue contusions
moderate contamination
variable fracture patterns
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Evaluation
3: >30
2: 6-9
1: 1-5
0: 0
Calculation
o Glasgow coma scale score + systolic blood pressure score + respiratory rate score
Interpretation
o lower score indicates higher severity
o RTS <4 proposed for transfer to trauma center
Pros
o useful during triage to determine which patients need to be transported to a trauma center
Cons
o can underestimate injury severity in patients injured in one system
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OrthoBullets2017 Genaral Trauma | Evaluation
5 - severe (critical, survival uncertain)
6 - maximal, possibly fatal
ISS
ISS = sum of squares for the highest AIS grades in the three most severely injured
ISS body regions
2 2 2
ISS = A + B + C
where A, B, C are the AIS scores of the three most severely injured
ISS body regions
scores range from 1 to 75
single score of 6 on any AIS region results in automatic score of 75
Interpretation
ISS > 15 associated with mortality of 10%
Pros
integrates anatomic areas of injury in formulating a prediction of outcomes
Cons
difficult to calculate during initial evaluation and resuscitation in emergency room
difficult to predict outcomes for patients with severe single body area injury
New Injury Severity Score (NISS) overcomes this deficit
Modifications
Modified Injury Severity Score (MISS)
similar to ISS but for pediatric trauma
categorizes body into 5 areas, instead of 9
sum of the squares for the highest injury score grades in the three most severely
injured body regions
New Injury Severity Score (NISS)
takes three highest scores regardless of anatomic area
more predictive of complications and mortality than ISS
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Evaluation
Sickness Impact Profile
Introduction
o evaluates the impact of disease on physical and emotional functioning
Variables
o 12 categories
sleep
eating
work
home management
recreation
physical dimension
ambulation
body care
movement
psychosocial dimension
social interaction
alertness behavior
emotional behavior
communication
Relevance to trauma
o lower extremity injuries
psychosocial subscale does not improve with time
o polytrauma
at 10 year follow-up after a major polytrauma, females have
decreased quality-of-life scores
increased PTSD rates
increased absentee sick days when compared to males
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OrthoBullets2017 Genaral Trauma | Evaluation
o respiratory rate > 20 or PaCO2 < 32mm (4.3kPa)
o temperature less than 36 degrees or greater than 38 degrees
Calculation
o each component (heart rate, WBC count, respiratory rate, temperature) is given 1 point if
it meets the above criteria
Interpretation
o score of 2 or more meets criteria for SIRS
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Evaluation
Stabilize
o splint fracture for temporary stabilization
decreases pain, further injury from bone ends, and disruption of clots
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OrthoBullets2017 Genaral Trauma | Evaluation
Tetanus Prophylaxis
Initiate in emergency room or trauma bay
Two forms of prophylaxis
o toxoid dose 0.5 mL, regardless of age
o immune globulin dosing
<5-years-old receives 75U
5-10-years-old receives 125U
>10-years-old receives 250U
o toxoid and immunoglobulin should be given intramuscularly with two different syringes in
two different locations
Guidelines for tetanus prophylaxis depend on 3 factors
o complete or incomplete vaccination history (3 doses)
o date of most recent vaccination
o severity of wound
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Specific Presentations
B. Specific Presentations
Presentation
Symptoms
o pain, deformity
Physical exam
o perform careful neurovascular exam
o clinical suspicion for compartment syndrome
secondary to increased muscle edema from higher velocity
wounds
o examine and document all associated wounds
massive bone and soft tissue injuries occur even with low
velocity weapons
I:7 This clinical photo demonstrates a
Evaluation large soft tissue wound with exposed
Radiographs tibialis anterior and bone at the level of
the ankle joint
o obtain to identify bone involvement and/or fracture pattern
CT scan
o identify potential intra-articular missile
o detect hollow viscus injury that may communicate with
fracture
high index of suspicion for pelvis or spine fractures given
increased risk of associated bowel injury
Treatment General
Nonoperative
o local wound care
indications
low velocity GSW with no bone involvement and clean
wound edges I:8 This sagittal CT image
o local wound care, tetanus +/- short course of oral antibiotics demonstrates an intra-articular
bullet in the ankle joint
indications
low-velocity injury with no bone involvement or non-
operative fractures
technique
primary closure contraindicated
antibiotic use controversial but currently recommended if wound appears contaminated
Operative
o treatment of other non-orthopedic injuries
for trans-abdominal trajectories, laparotomy takes precedence over arthrotomy
o ORIF/external fixation
indications
unstable/operative fracture pattern in low-velocity gunshot injury
technique
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Specific Presentations
treatment dictated by fracture characteristics similar to closed fracture without gunshot
wound
stabilize extremity with associated vascular or nerve injuries
stabilize soft tissues in high velocity/high energy gunshot injuries
grossly contaminated/devitalized wounds managed with aggressive debridement per
open fracture protocol
o arthrotomy
indications
intra-articular missile
may lead to local inflammation, arthritis and lead intoxication (plumbism)
transabdominal GSW
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OrthoBullets2017 Genaral Trauma | Specific Presentations
GSW to Hand/Foot
Nonoperative
o antibiotics
indications
gross contamination
joint penetration I:9 This image
demonstrates a
extent of contamination unclear comminuted femoral
Operative shaft fracture
secondary to a
o surgical debridement +/- ORIF/external fixation ballistic injury
indications
articular involvement
unstable fractures
presentation 8 or more hours after injury
tendon involvement
superficial fragments in the palm or sole
I:10 This image
GSW to Femur demonstrates immediate
Operative intramedullary nailing
of a femur fracture from
o intramedullary nailing a gun shot wound
indications
diaphyseal femur fracture secondary to low-velocity gunshot wound
superficial wound debridement and immediate reamed nailing
similar union and infection rates to closed injuries
o external fixation
indications
high-velocity gunshot wounds or close range shotgun blasts
stabilize soft tissues and debride aggressively
associated vascular injury
temporize extremity until amenable to intramedullary nailing
GSW to Spine
Nonoperative
o broad spectrum IV antibiotics for 7-14 days
indications
gunshot wounds to the spine with associated perforated viscus
bullets which pass through the alimentary canal and cause spinal cord injuries do not
require surgical removal of the bullet
Operative
o surgical decompression and bullet fragment removal
indications
when a neurologic deficit is present that correlates with
radiographic findings of neurologic compression
a retained bullet fragment within the spinal canal in patients
with incomplete motor deficits is a relative indication for
surgical excision of the fragment I:11 This axial CT image
demonstrates a retained
bullet in the spinal canal
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Specific Presentations
2. Amputations
Introduction
May be used to treat trauma
o infection
o tumor
o vascular disease
o congenital anomalies
Prognosis
o outcomes are improved with involvement of psychological counseling for coping mechanisms
o amputation vs. reconstruction
LEAP study
impact on decision to amputate limb
severe soft tissue injury
highest impact on decision-making process
absence of plantar sensation
2nd highest impact on surgeon's decision making process
not an absolute contraindication to reconstruction
plantar sensation can recover by long-term follow-up
outcome measure
SIP (sickness impact profile) and return to work not significantly different between
amputation and reconstruction at 2 years in limb-threatening injuries
most important factor to determine patient-reported outcome is the ability to return to
work
Complications
o wound healing
o neuroma
o phantom limb pain : mirror therapy is a noninvasive treatment modality
Metabolic Demand
Metabolic cost of walking
o increases with more proximal amputations
perform amputations at lowest possible level to preserve function
exception
Syme amputation is more efficient than midfoot amputation
o inversely proportional to length of remaining limb
Ranking of metabolic demand (% represents amount of increase compared to baseline)
o Syme - 15%
o transtibial
traumatic - 25% average
short BKA - 40%
long BKA - 10%
vascular - 40%
o transfemoral
traumatic - 68%
vascular - 100%
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OrthoBullets2017 Genaral Trauma | Specific Presentations
o thru-knee amputation
varies based on patient habitus but is somewhere between transtibial and transfemoral
most proximal amputation level available in children to maintain walking speeds without
increased energy expenditure compared to normal children
o bilateral amputations
Wound Healing
Dependent on
o vascular supply
o nutritional status
o immune status
Improved with
o albumin > 3.0 g/dL
o ischemic index > .5
measurement of doppler pressure at level being tested compared to brachial systolic pressure
o transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg)
o toe pressure > 40 mm Hg (will not heal if < 20 mm Hg)
o ankle-brachial index (ABI) > 0.45
o total lymphocyte count (TLC) > 1500/mm3
Hyperbaric oxygen therapy
o contraindications include
chemo or radiation therapy
pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator,
pacemaker, dorsal column stimulator, insulin pump)
undrained pneumothorax
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Specific Presentations
o transhumeral versus elbow disarticulation
elbow disarticulation advantages
indicated in children to prevent bony overgrowth seen in transhumeral amputations
Techniques
o transcarpal
transect finger flexor/extensor tendons
anchor wrist flexor/extensor tendons to carpus
o wrist disarticulation : preserve radial styloid flare to improve prosthetic suspension
o transradial amputation : middle third of forearm amputation maintains length and is ideal
o transhumeral amputation : maintain as much length as possible
o shoulder disarticulation : retain humeral head to maintain shoulder contour
Transfemoral Amputation
Maintain as much length as possible
o however, ideal cut is 12 cm above knee joint to allow for prosthetic
fitting
Technique
o 5-10 degrees of adduction is ideal for improved prosthesis function
o adductor myodesis
improves clinical outcomes
creates dynamic muscle balance
provides soft tissue envelope that enhances prosthetic fitting
I:15 Illustration showing
Through-Knee-Amputation adductor myodesis technique.
Indications
o ambulatory patients who cannot have a transtibial amputation
o non-ambulatory patients
Technique
o suture patellar tendon to cruciate ligaments in notch
o use gastrocnemius muscles for padding at end of amputation
Outcomes (based on LEAP data)
o slower self-selected walking speeds than BKA
o similar amounts of pain compared to AKA and BKA
o worse performance on the Sickness Impact Profile (SIP) than BKA and
AKA
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OrthoBullets2017 Genaral Trauma | Specific Presentations
o physicians were less satisfied with the clinical, cosmetic, and functional recovery
o require more dependence with patient transfers than BKA
Below-Knee-Amputation (BKA)
Long posterior flap
o 12-15 cm below knee joint is ideal
ensures adequate lever arm
o need approximately 8-12 cm from ground to fit most modern high-impact prostheses
o osteomyoplastic transtibial amputation (Ertl) technique
create a strut from the tibia to fibula from a piece of fibula or osteoperiosteal flap
o "dog ears"
left in place to preserve blood supply to the flap
Modified Ertl
o designed to enhance prosthetic end-bearing
o technique
the original Ertl amputation required a corticoperiosteal flap bridge
the modified Ertl uses a fibular strut graft
requires longer operative and touniquet times than standard BKA transtibial amputation
fibula is fixed in place with cortical screws, fiberwire suture with end buttons, or heavy
nonabsorbable sutures.
Ankle/Foot Amputation
Syme amputation (ankle disarticulation)
o patent tibialis posterior artery is required
o more energy efficient than midfoot even though it is more proximal
o stable heel pad is most important factor
o used successfully to treat forefoot gangrene in diabetics
Pirogoff amputation (hindfoot amputation)
o removal of the forefoot and talus followed by calcaneotibial arthrodesis
o calcaneus is osteotomized and rotated 50-90 degrees to keep posterior aspect of calcaneus distal
o allows patient to mobilize independently without use of prosthetic
Chopart amputation (hindfoot amputation)
o a partial foot amputation through the talonavicular and calcaneocuboid joints
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Specific Presentations
o primary complication is equinus deformity
avoid by lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar
neck
Lisfranc amputation
o equinovarus deformity is common
caused by unopposed pull of tibialis posterior and gastroc/soleus
prevent by maintaining insertion of peroneus brevis
Pediatric Amputation
Most common complication is bone overgrowth
o prevent by performing disarticulation or using epihphyseal cap to cover medullary canal
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OrthoBullets2017 Genaral Trauma | Specific Presentations
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Specific Presentations
o risks for domestic abuse
female
19-29 years
pregnant
low-income families/low socioeconomic status
o characteristic injuries or patterns
injuries inconsistent with history
long delay between injury and treatment
repeat injuries
o characteristics of abused patient
change in affect
constantly seeking partner approval
finding excuses to stay in treatment facility for prolonged period of time
repeated visits to the emergency department
significant time missed at work or decreased productivity at work
o characteristics of the abuser
refuses to leave patient alone
overly attentive
aggressive or hostile
refuses to let the patient answer their own questions
o barrier to reporting
fear of retaliation
shame
difficulty reporting to male physicians
fear of custody conflicts
Treatment
o duty to act
health care workers should inquire into the safety environment at home in cases of suspected
abuse
emotional abuse is more difficult to discern than physical violence
reporting requirements for adult abuse is not standardized among states
a physician does not have authority to provide protection to abused spouses in most states
should encourage victim to seek protection and report case to law enforcement
physician should document encounter completely and be familiar with their state laws
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OrthoBullets2017 Genaral Trauma | Specific Presentations
infection
pancreatitis
multiple blood transfusions
lung injury
sepsis or shock
major trauma
large surface area burns
fat emboli
thromboembolism
multi-system organ failure
Prognosis : high mortality rate (50% overall) is associated with ARDS even in setting of ICU
Classification
ARDS is represented by three phases
Presentation
Symptoms
o acute onset (12-48 hours) of
dyspnea
fever
mottled or cyanotic skin
Physical exam
o resistant hypoxia
o intercostal retractions
o rales/crackles and ronchi
o tachypnea
Evaluation
Hypoxemia is refractory to O2
o 3 different categories of ARDS based on degree of hypoxemia
o PaO2 / FIO2 ratio < 300 mm Hg= mild
o PaO2 / FIO2 ratio < 200 mm Hg= moderate
o PaO2 / FIO2 ratio < 100 mm Hg= severe
Chest xray
o shows patchy pulmonary edema (air space disease)
o diffuse bilateral pulmonary infiltrates
normal sized heart
makes CHF less likely
Respiratory compliance (<40 mL/cm H20)
Positive end-expiratory pressure (>10cm H20)
Corrected expired volume per minute (>10L/min)
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Specific Presentations
Differential
Cardiogenic pulmonary edema (i.e. CHF or MI), bilateral pneumonia, SARS
Treatment
Nonoperative
o PEEP ventilation and steroids
o treat the underlying pathology/disease
Operative
o early stabilization of long bone fractures (femur)
Prevention
o closely monitor PEEP in patients at-risk of ARDS
o serial X-rays in concerning patients can assist in early identification and intervention
Complications
Pneumothorax
o secondary to ventilator with high PEEP
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OrthoBullets2017 Genaral Trauma | Compartment Syndrome
C. Compartment Syndrome
Introduction
Devastating condition where an osseofascial compartment pressure rises to a level that decreases
perfusion , may lead to irreversible muscle and nerve damage
Epidemiology
o location : compartment syndrome may occur anywhere that skeletal muscle is surrounded by
fascia, but most commonly
leg
forearm
hand
foot
thigh
buttock
shoulder
paraspinous muscles
Pathophysiology
o etiology
trauma
fractures (69% of cases)
crush injuries
contusions
gunshot wounds
tight casts, dressings, or external wrappings
extravasation of IV infusion
burns
postischemic swelling
bleeding disorders
arterial injury
o pathoanatomy
cascade of events includes
local trauma and soft tissue destruction>
bleeding and edema >
increased interstitial pressure >
vascular occlusion >
myoneural ischemia
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Compartment Syndrome
extensor hallucis longus
extensor digitorum longus
peroneus tertius
o lateral compartment
function
plantarflexion and eversion of
foot
muscles
peroneus longus
peroneus brevis
isolated lateral compartment
syndrome would only affect
superficial peroneal nerve
o deep posterior compartment
function
Presentation
Symptoms
o pain out of proportion to clinical situation is usually first symptom
may be absent in cases of nerve damage
pain is difficult to assess in a polytrauma patient and impossible to assess in a sedated patient
difficult to assess in children (unable to verbalize)
Physical exam
o pain w/ passive stretch : is most sensitive finding prior to onset of ischemia
o paresthesia and hypoesthesia
indicative of nerve ischemia in affected compartment
o paralysis
late finding
full recovery is rare in this case
o palpable swelling
o peripheral pulses absent
late finding
amputation usually inevitable in this case
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OrthoBullets2017 Genaral Trauma | Compartment Syndrome
Imaging
Radiographs
o obtain to rule-out fracture
Studies
Compartment pressure measurements
o indications
polytrauma patients
patient not alert/unreliable
inconclusive physical exam findings
o relative contraindication
unequivocally positive clinical findings should prompt emergent operative
intervention without need for compartment measurements
o technique
should be performed within 5cm of fracture site
anterior compartment
entry point
1cm lateral to anterior border of tibia within 5cm of fracture site if possible
needle should be perpendicular to skin
deep posterior compartment
entry point
just posterior to the medial border of tibia
advance needle perpendicular to skin towards fibula
lateral compartment
entry point
just anterior to the posterior border of fibula
superficial posterior
entry point
middle of calf within 5 cm of fracture site if possible
Diagnosis
o based primarily on physical exam in patient with intact mental status
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Compartment Syndrome
Treatment
Nonoperative
o observation
indications
diastolic differential pressure (delta p) is > 30
presentation not consistent with compartment syndrome
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OrthoBullets2017 Genaral Trauma | Compartment Syndrome
Special considerations
o pediatrics
children are unable to verbalize feelings
if suspicion, then perform compartment pressure measurement under sedation
o hemophiliacs : give Factor VIII replacement before measuring compartment pressures
Techniques
Emergent fasciotomy of all four compartments
o dual medial-lateral incision
approach
two 15-18cm vertical incisions separated by 8cm skin bridge
anterolateral incision
posteromedial incision
technique
anterolateral incision
identify and protect the superficial peroneal nerve
fasciotomy of anterior compartment performed 1cm in front of intermuscular
septum
fasciotomy of lateral compartment performed 1cm behind intermuscular septum
posteromedial incision
protect saphenous vein and nerve
incise superficial posterior compartment
detach soleal bridge from back of tibia to adequately decompress deep posterior
compartment
post-operative
dressing changes followed by delayed primary closure or skin grafting at 3-7 days post
decompression
pros
easy to perform
excellent exposure
cons : requires two incisions
o single lateral incision
approach: single lateral incision from head of fibula to ankle along line of fibula
technique
identify superficial peroneal nerve
perform anterior compartment fasciotomy 1cm anterior to the intermuscular septum
perform lateral compartment fasciotomy 1cm posterior to the intermuscular septum
identify and perform fasciotomy on superficial posterior compartment
enter interval between superficial posterior and lateral compartment
reach deep posterior compartment by following interosseous membrane from the
posterior aspect of fibula and releasing compartment from this membrane
common peroneal nerve at risk with proximal dissection
pros : single incision
cons : decreased exposure
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Compartment Syndrome
Anatomy
3 thigh compartments
o anterior compartment
muscles
quadriceps
sartorious
nerves
femoral nerve
o posterior compartment
muscles
hamstrings
nerves
sciatic nerve
o adductor compartment
muscles
adductors
nerves Figure I:27 Thigh Compartments
obturator nerve
Presentation
Symptoms
o pain out of proportion to clinical situation is usually first symptom
may be absent in cases of nerve damage
pain is difficult to assess in a polytrauma patient and impossible to assess in a sedated
patient
difficult to assess in children (unable to verbalize)
Physical exam
o pain with passive stretch : is most sensitive finding prior to onset of ischemia
must test each compartment separately
anterior compartment
pain with passive flexion of knee
posterior compartment
pain with passive extension of knee
medial compartment
pain with passive abduction of hip
o paraesthesia and hypoesthesia : indicative of nerve ischemia in affected compartment
o paralysis
late finding
full recovery is rare in this case
o palpable swelling
o peripheral pulses absent
late finding
amputation usually inevitable in this case
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OrthoBullets2017 Genaral Trauma | Compartment Syndrome
Evaluation
Diagnosis
o based primarily on physical exam in patient with intact mental status
Radiographs
o obtain to rule-out fracture
Compartment pressure measurements
o indications
polytrauma patients
patient not alert/unreliable
inconclusive physical exam findings
o relative contraindication
unequivocally positive clinical findings should prompt emergent operative
intervention without need for compartment measurements
o technique
should be performed within 5cm of fracture site or area of maximal swelling
must test each compartment separately
Treatment
Nonoperative
o observation
indications
delta p > 30, and
presentation not consistent with compartment syndrome
Operative
o emergent fasciotomy of all affected compartments
indications
clinical presentation consistent with compartment syndrome
compartment pressures with absolute value of 30-45 mm Hg
compartment pressures within 30 mm Hg of diastolic blood pressure (delta p)
intraoperatively, diastolic blood pressure may be decreased from anesthesia
must compare intra-operative measurement to pre-operative diastolic pressure
contraindications
missed compartment syndrome
Surgical Techniques
Thigh fasciotomies
o approach
anterolateral incision over length of thigh
o technique
single incision technique for anterior and posterior compartments
incise fascia lata
expose and decompress anterior compartment
retract vastus lateralis medially to expose lateral intermuscular septum
incise lateral intermuscular septum to decompress posterior compartment
may add medial incision for decompression of adductor compartment
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Compartment Syndrome
Complications
Associated with significant long-term morbidity
o over 50% will experience functional deficits
including
pain
decreased knee flexion
myositis ossificans
sensory deficits
decreased strength
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OrthoBullets2017 Genaral Trauma | Compartment Syndrome
Presentation
Symptoms
o pain out of proportion to clinical situation is usually first symptom
may be absent in cases of nerve damage
difficult to assess in
polytrauma
sedated patients
children
Physical exam
o pain w/ passive stretch of fingers
most sensitive finding
o paraesthesia and hypoesthesia
indicative of nerve ischemia in affected compartment
o paralysis
late finding
full recovery is rare in this case
o palpable swelling
tense hand in intrinsic minus position
most consistent clinical finding
o peripheral pulses absent
late finding
amputation usually inevitable in this case
Evaluation
Radiographs : obtain to rule-out fracture
Compartment pressure measurements
o indications
polytrauma patients
patient not alert/unreliable
inconclusive physical exam findings
o relative contraindication
unequivocally positive clinical findings should prompt emergent operative intervention
without need for compartment measurements
o threshold for decompression
controversial, but generally considered to be
absolute value of 30-45 mm Hg
within 30 mm Hg of diastolic blood pressure (delta p)
intraoperatively, diastolic blood pressure may be decreased from anesthesia
if delta p is less than 30 mmHg intraoperatively, check preoperative diastolic
pressure and follow postoperatively as intraoperative pressures may be low and
misleading
Treatment
Nonoperative
o indications
exam not consistent with compartment syndrome
delta p > 30
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Compartment Syndrome
Operative
o emergent forearm fasciotomies
indications
clinical presentation consistent with compartment syndrome
compartment measurements with absolute value of 30-45 mm Hg
compartment measurements within 30 mm Hg of diastolic blood pressure (delta p)
intraoperatively, diastolic blood pressure may be decreased from anesthesia
must compare intra-operative measurement to pre-operative diastolic pressure
o emergent hand fasciotomies
indications
clinical presentation consistent with compartment syndrome
compartment measurements with absolute value of 30-45 mm Hg
compartment measurements within 30 mm Hg of diastolic blood pressure (delta p)
intraoperatively, diastolic blood pressure may be decreased from anesthesia
must compare intra-operative measurement to pre-operative diastolic pressure
Surgical Techniques
Forearm
o emergent fasciotomies of all involved compartments
approach
volar incision
decompresses volar compartment, dorsal compartment,
carpal tunnel
incision starts just radial to FCU at wrist and extends
proximally to medial epicondyle
may extend distally to release carpal tunnel
dorsal incision
decompresses mobile wad
dorsal longitudinal incision 2cm distal to lateral
epicondyle toward midline of wrist
technique
volar incision
open lacertus fibrosus and fascia over FCU
retract FCU ulnarly, retract FDS radially
open fascia over deep muscles of forearm Figure I:31 Volar incision
dorsal incision
dissect interval between EDC and ECRB
decompress mobile wad and dorsal
compartment
post-operative
leave wounds open
wound VAC Figure I:32 Dorsal incision
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OrthoBullets2017 Genaral Trauma | Compartment Syndrome
possible delayed primary wound closure
VAC dressing when closure cannot be obtained
follow with split-thickness skin grafting at a
later time
Hand
Figure I:33 Leave the wound open
o emergent fasciotomies of all involved
compartments
approach
two longitudinal incisions over 2nd and 4th
metacarpals
decompresses volar/dorsal interossei and
adductor compartment
longitudinal incision radial side of 1st metacarpal
decompresses thenar compartment
longitudinal incision over ulnar side of 5th
metacarpal
decompresses hypothenar compartment
technique Figure I:34 Hand incisions
first volar interosseous and adductor pollicis muscles are
decompressed through blunt dissection along ulnar side of 2nd metacarpal
post-operative
wounds left open until primary closure is possible
if primary closure not possible, split-thickness skin grafting is used
Complications
Volkman's ischemic contracture
o irreversible muscle contractures in the forearm, wrist and hand that result from muscle
necrosis
o contracture positioning
elbow flexion
forearm pronation
wrist flexion
thumb adduction
MCP joints in extension
IP joints in flexion
o classification : Tsuge Classification (see table below)
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Compartment Syndrome
Presentation
Symptoms
o pain out of proportion to injury
Physical exam
o pain with dorsiflexion of toes (MTPJ)
places intrinsic muscles on stretch
o tense swollen foot
o loss of two-point discrimination
o pulses
presence of pulses does not exclude diagnosis
Evaluation
Radiographs
o obtain to rule-out fracture
Compartment pressure measurements
o indications
polytrauma patients
patient not alert/unreliable
inconclusive physical exam findings
o relative contraindication
unequivocally positive clinical findings should prompt emergent operative intervention
without need for compartment measurements
o technique
central compartment
base of first metatarsal
direct needle lateral and plantar through abductor hallucis
medial compartment
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OrthoBullets2017 Genaral Trauma | Compartment Syndrome
base of first metatarsal advancing 2cm into abductor hallucis
interosseous
second, third, and fourth webspaces
advance plantar 2cm to puncture extensor fascia
lateral
midshaft of fifth metatarsal
advance 1cm medial and plantar
o threshold for decompression
controversial, but generally considered to be
absolute value of 30-45 mm Hg
within 30 mm Hg of diastolic blood pressure (delta p)
intraoperatively, diastolic blood pressure may be decreased from anesthesia
must compare intra-operative measurement to pre-operative diastolic pressure
Treatment
Nonoperative
o observation
indications
delta p > 30
exam not consistent with compartment syndrome
Operative
o emergent foot fasciotomies
indications
clinical presentation consistent with compartment syndrome
compartment measurements with absolute value of 30-45 mm Hg
compartment measurements within 30 mm Hg of diastolic blood pressure (delta p)
intraoperatively, diastolic blood pressure may be decreased from anesthesia
must compare intra-operative measurement to pre-operative diastolic pressure
Surgical Technique
Emergent fasciotomies of all compartments
o dual dorsal incisions (gold standard)
approach
dorsal medial incision
medial to 2nd metatarsal
releases 1st and 2nd interosseous, medial, and deep central compartment
dorsal lateral incision
lateral to 4th metatarsal
releases 3rd and 4th interosseous, lateral, superficial and middle
central compartments
technique
dorsal fascia of each interosseous compartment opened longitudinally
strip muscle from medial fascia in first interosseous compartment
split adductor compartment
may add medial incision for decompression of calcaneal compartment
post-operative
delayed wound closure with possible skin grafting
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By Dr, AbdulRahman AbdulNasser Genaral Trauma | Compartment Syndrome
pros
direct access to all compartments
provides exposure for Chopart, Lisfranc, or tarsometatarsal fractures
cons
does not provide access for fixation of calcaneus fractures
o single medial incision
technique
single medial incision used to release all nine compartments
cons
technically challenging
Complications
Chronic pain and hypersensitivity
o difficult to manage
Fixed flexion deformity of digits (claw toes)
o release flexor digitorum brevis and longus at level of digits
Figure I:38 surgical approach for dual dorsal incisions Figure I:39 claw toes
Chapter of infections (adult osteomyelitis, septic arthritis, wound & hardware infections, necrotizing
fasciitis and Gas gangrene) all these topics moved from trauma to pathology volume eight.
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OrthoBullets2017 Spine Trauma | Compartment Syndrome
ORTHO BULLETS
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Spinal Cord Injury
History
Details of accident
o energy of accident
higher level of concern when there is a history of high energy trauma as indicated by
MVA at > 35 MPH
fall from > 10 feet
closed head injuries
neurologic deficits referable to cervical spine
pelvis and extremity fractures
o mechanism of accident
e.g., elderly person falls and hits forehead (hyperextension injury)
e.g., patient rear-ended at high speed (hyperextension injury)
o condition of patient at scene of accident
general condition
degree of consciousness
presence or absence of neurologic deficits
Identify associated conditions and comorbidities
o ankylosing spondylitis (AS)
o diffuse idiopathic skeletal hyperostosis (DISH)
o previous cervical spine fusion (congenital or acquired)
o connective tissue disorders leading to ligamentous laxity
Physical Exam
Useful for detecting major injuries
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OrthoBullets2017 Spine Trauma | Spinal Cord Injury
Primary survey
o airway
o breathing
o circulation
o visual and manual inspection of entire spine should be performed
manual inline traction should be applied whenever cervical immobilization is removed for
securing airway
seat belt sign (abdominal ecchymosis) should raise suspicion for flexion distraction injuries
of thoracolumbar spine
Secondary survey
o cervical spine exam
remove immobilization collar
examine face and scalp for evidence of direct trauma
inspect for angular or rotational deformities in the holding position of the patient's head
rotational deformity may indicate a unilateral facet dislocation
palpate posterior cervical spine looking for tenderness along the midline or paraspinal tissues
absence of posterior midline tenderness in the awake, alert patient predicts low
probability of significant cervical injury7,
log roll patient to inspect and palpate entire spinal axis
perform careful neurologic exam
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Spinal Cord Injury
II:2 standard Lat crvical spine II:3 standard open-mouth odontoid view
II:1 standard AP crvical spine radiograph radiograph radiograph
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OrthoBullets2017 Spine Trauma | Spinal Cord Injury
cons
high rate of false positives
only effective if done within 48 hours of injury
can be difficult to obtain in obtunded or intoxicated patients
o MR and CT angiography
pros : effective for evaluating vertebral artery
Treatment
Nonoperative
o cervical collar
indications : initiated at scene of injury until directed examination performed
o early active range of motion
indications
"whiplash-like" symptoms and
cleared from a serious cervical injury by exam or imaging
Complications
Delayed clearance associated with increased complication rate including
o increased risk of aspiration
o inhibition of respiratory function
o decubitus ulcers in occipital and submandibular areas
o possible increase in intracranial pressure
Relevant Anatomy
See Spinal Cord Anatomy
Classification
Descriptive
o atetrplegia
injury to the cervical spinal cord leading to impairment of function in the arms, trunk, legs,
and pelvic organs
o paraplegia
injury to the thoracic, lumbar or sacral segments leading to impairment of function in the
trunk, legs, and pelvic organs depending on the level of injury. Arm function is preserved
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OrthoBullets2017 Spine Trauma | Spinal Cord Injury
o complete injury
an injury with no spared motor or sensory function below the affected level.
patients must have recovered from spinal shock (bulbocavernosus reflex is intact) before an
injury can be determined as complete
classified as an ASIA A
o incomplete injury
an injury with some preserved motor or sensory function below the injury level
incomplete spinal cord injuries include
anterior cord syndrome
Brown-Sequard syndrome
central cord syndrome
posterior cord syndrome
conus medullaris syndromes
cauda equina syndrome
ASIA Classification
Determine if patient is in spinal shock
o check bulbocavernosus reflex
Determine neurologic level of injury
o lowest segment with intact sensation and antigravity (3 or more) muscle function strength
o in regions where there is no myotome to test, the motor level is presumed to be the same as the
sensory level.
Determine whether the injury is COMPLETE or INCOMPLETE
o COMPLETE defined as (ASIA A)
no voluntary anal contraction (sacral sparing) AND
0/5 distal motor AND
0/2 distal sensory scores (no perianal sensation) AND
bulbocavernosus reflex present (patient not in spinal shock)
o INCOMPLETE defined as
voluntary anal contraction (sacral sparing)
sacral sparing critical to determine complete vs. incomplete
OR palpable or visible muscle contraction below injury level OR
perianal sensation present
Determine ASIA Impairment Scale (AIS) Grade:
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Spinal Cord Injury
Acute Phase Conditions
Neurogenic shock
o characterized by hypotension & relative bradycardia in patient with an acute spinal cord injury
potentially fatal
o mechanism
circulatory collapse from loss of sympathetic tone
disruption of autonomic pathway within the spinal cord leads to
lack of sympathetic tone
decreased systemic vascular resistance
pooling of blood in extremities
hypotension
o treatment
Swan-Ganz monitoring for careful fluid management
pressors to treat hypotension
Spinal shock
o defined as temporary loss of spinal cord function and reflex activity below the level of a spinal
cord injury.
o characterized by
flaccid areflexic paralysis
bradycardia & hypotension (due to loss of sympathetic tone)
absent bulbocavernosus reflex
reflex characterized by anal sphincter contraction in response to squeezing the glans
penis or tugging on an indwelling Foley catheter
o timing
variable but usually resolves within 48 hours
at its conclusion spasticity, hyperreflexia, and clonus slowly progress over days to weeks
o mechanism
neurophysiologic in nature
neurons become hyperpolarized and unresponsive to stimuli from brain
o evaluation
important because one cannot evaluate neurologic deficit until spinal shock phase has
resolved
end of spinal shock indicated by return of the bulbocavernous reflex
conus or cauda equina injuries may lead to permanent loss of the bulbocavernous reflex
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OrthoBullets2017 Spine Trauma | Spinal Cord Injury
Evaluation
Field treatment
o treatment of potential spinal cord injuries begins at the accident scene with proper spinal
immobilization
o immobilization
immobilization should include rigid cervical collar and transport on firm spine board with
lateral support devices
patient should be rolled with standard log roll techniques with control of cervical spine
o athletes
in the setting of sports-related injuries helmets and shoulder pads should be left on until
arrival at hospital or until experienced personnel can perform simultaneous removal of
helmet and shoulder pads in a controlled situation
Initial evaluation
o primary survey
airway
breathing
SCI above C5 likely to require intubation
circulation
initial survey to inspect for obvious injuries of head and spine
visual and manual inspection of entire spine should be performed
seat belt sign (abdominal ecchymoses) should raise suspicion for flexion distraction
injuries of thoracolumbar spine
o secondary survey
cervical spine exam
remove immobilization collar
examine face and scalp for evidence of direct trauma
inspect for angular or rotational deformities in
the holding position of the patient's head
rotational deformity may indicate a unilateral
facet dislocation
palpate posterior cervical spine looking for
tenderness along the midline or paraspinal
tissues
absence of posterior midline tenderness in
the awake, alert patient predicts low
probability of significant cervical injury7,
log roll patient to inspect and palpate entire
spinal axis
perform careful neurologic exam
o cervical spine clearance
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Spinal Cord Injury
Acute Treatment
Nonoperative
o high dose methylprednisone
indications
nonpenetrating SCI within 8 hours of injury
recommended by NASCIS III
contraindications include
GSW
pregnancy
under 13 years
> 8 hours after injury
brachial plexus injuries
technique
load 30 mg/kg over 1st hour (2 grams for 70kg man)
drip 5.4 mg/kg/hr drip
for 23 hours if started < 3 hrs after injury
for 47 hours if started 3-8 hours after injury
outcomes
leads to improved root function at level of injury
may or may not lead to spinal cord function improvement
o monosialotetrahexosylganglioside (GM-1)
indications
remains controversial
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OrthoBullets2017 Spine Trauma | Spinal Cord Injury
large multicenter RCT did not show long term benefit
some evidence of faster recovery
o acute closed reduction with axial traction
indications
alert and oriented patient with neurologic deficits and compression due to
fracture/dislocation
bilateral facet dislocation with spinal cord injury in alert and oriented patient is most
common reason to perform acute reduction with axial traction
technique
reasons to abort
overdistraction
worsening neurologic exam
failure to obtain reduction
o DVT prophlaxis
indications
most patients
contraindications include
coagulopathy
hemorrhage
modalities
low-molecular weight heparin
rotating bed
pneumatic compression stocking
o cardiopulmonary management
careful hemodynamic monitoring and stabilization is critical in early treatment
hypotension should be avoided
implement immediate aggressive pulmonary protocols
Operative : rarely indicated in acute setting
Definitive Treatment
Nonoperative
o bracing and observation
indications
most GSWs
exceptions listed below
metastatic CA patients with < 6 mos life expectancy
presence of six variables below correspond to short life expectancy
multiple spinal mets
multiple extraspinal mets
unresectable lesions in major organs
SCI (complete or incomplete)
aggressive CA: lung, osteosarcoma, pancreas
critically ill
Operative
o surgical decompression and stabilization
indications
most incomplete SCI (except GSW)
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Spinal Cord Injury
decompress when patient hits neurologic plateau or if worsening neurologically
decompression may facilitate nerve root function return at level of injury (may
recover 1-2 levels)
most complete SCI (except GSW)
stabilize spine to facilitate rehab and minimize need for halo or orthosis
decompression may facilitate nerve root function return at level of injury (may
recover 1-2 levels)
consider for tendon transfers
e.g. Deltoid to triceps transfer for C5 or C6 SCI
metastatic CA patients with > 6 mos life expectancy
~ no for six question above
GSW with
progressive neurological deterioration with retained bullet within the spinal canal
cauda equina syndrome (considered a peripheral nerve)
retained bullet fragment within the thecal sac
CSF leads to the breakdown of lead products that may lead to lead poisoning
Complications
Skin problems
o treatment is prevention
o start in ER
do not leave on back board
start log rolling early
proper bedding
Venous Thromboembolism
o prevent with immediate DVT prophylaxis
Urosepsis
o common cause of death
o strict aseptic technique when placing catheter
o don't let bladder become overly distended
Sinus bradycardia
o most common cardiac arrhythmia in acute stage following SCI
Orthostatic hypotension
o occurs as a result of lack of sympathetic tone
Autonomic dysreflexia
o potentially fatal
o presents with headache, agitation, hypertension
o caused by unchecked visceral stimulation
check foley
disimpact patient
Major depressive disorder
o ~11% of patients with spinal cord injuries suffer from MDD
o MDD in spinal cord injury patients is highly associated with suicidal ideation in both the acute
and chronic phase.
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OrthoBullets2017 Spine Trauma | Spinal Cord Injury
Rehabilitation
Goals
o goal is to assess and identify mechanisms for reintegration into community based on functional
level and daily needs
o patients learn transfer techniques, self care retraining, mobility skills
Restoring hand function
o hand function is often limiting factor for many patients
o tendon transfers can be used to restore function to paralyzed arms and hands by giving working
muscles different jobs
Modalities
o functional electrical stimulation is a technique that uses electrical currents to stimulate and
activate muscles affected by paralysis
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Spinal Cord Injury
Classification
Clinical classification
o anterior cord syndrome (see below)
o Brown-Sequard syndrome
o central cord syndrome
o posterior cord syndrome
ASIA classification
o method to scale
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OrthoBullets2017 Spine Trauma | Spinal Cord Injury
ASIA Impairment Scale
A Complete No motor or sensory function is preserved in the sacral segments S4-S5.
B Incomplete Sensory function preserved but not motor function is preserved below the
neurological level and includes the sacral segments S4-S5.
C Incomplete Motor function is preserved below the neurological level, and more than half of
key muscles below the neurological level have a muscle grade less than 3.
D Incomplete Motor function is preserved below the neurological level, and at least half of key
muscles below the neurological level have a muscle grade of 3 or more.
E Normal Motor and sensory function are normal.
Brown-Sequard Syndrome
Caused by complete cord hemitransection
o usually seen with penetrating trauma
Exam
o ipsilateral deficit
LCS tract
motor function
dorsal columns
proprioception
vibratory sense
o contralateral deficit
LST
pain
temperature
spinothalamic tracts cross at spinal cord level (classically 2-levels below)
Prognosis
o excellent prognosis
o 99% ambulatory at final follow up
o best prognosis for function motor activity
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OrthoBullets2017 Spine Trauma | AtlantoAxial Trauma
Posterior Cord Syndrome
Introduction : very rare
Exam
o loss : proprioception
o preserved : motor, pain, light touch
B. AtlantoAxial Trauma
Anatomy
Osteology
o occipital condyles are paired prominences of the occipital bone
o oval or bean shaped structures forming lateral aspects of the foramen magnum
Joint articulations
o intrinsic relationship between occiput, atlas and axis to form the occipitoatlantoaxial complex or
CCJ
o 6 main synovial articulations
anterior and posterior median atlanto-odontoid joints
paired occipitoatloid joints
paired atlantoaxial joints
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
Ligamentous structures
o intrinsic ligaments are located within the spinal canal, provide most of the ligamentous stability.
They include
transverse ligament
primary stabilizer of atlantoaxial junction
connects the posterior odontoid to the anterior atlas arch, inserting laterally on bony
tubercles.
paired alar ligaments
connect the odontoid to the occipital condyles
relatively strong and contributes to occipitalcervical stability
apical ligament
relatively weak midline structure
runs vertically between the odontoid and foramen magnum.
tectorial membrane
connects the posterior body of the axis to the anterior foramen magnum and is the
cephalad continuation of the PLL
Neurovascular considerations
o proximity of the occipital condyles to:
medulla oblongata
vertebral arteries
lower cranial nerves (CN IX - CN XII)
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OrthoBullets2017 Spine Trauma | AtlantoAxial Trauma
Classification
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
Presentation
History
o clinical presentation is highly variable
o presentation is largely dependent on associated injury (eg, head injury, brainstem injury, vascular
injury)
o neurological deficits may be acute (63% of cases) or delayed (37% of cases)
Symptoms
o high cervical pain
o reduced head/neck ROM
o torticollis
o lower cranial nerve deficits
o motor paresis
Physical Examination
o lower cranial nerve deficits most commonly affect CN IX, X, and XI
Imaging
Radiographs
o recommended views
AP, lateral, open-mouth AP view
o alternative views
traction is generally not recommended
o findings
diagnosis rarely made on plain radiographs due to superimposition of structures (maxilla,
occiput) blocking view of occipital condyles
open-mouth AP view may depict occiptal condyle injuries
CT
o indications
method of choice
routine CT imaging in high-energy trauma patients
clinical criteria:
altered consciousness
occipital pain and tenderness
impaired CCJ motion
lower cranial nerve paresis
motor paresis
o views : must include cranial-cervical junction with thin-section technique
o findings : occiput fracture or CCJ instability
MRI
o indications
evaluation of soft-tissue craniocervical trauma
fractured fragment located in the vertebral canal
spinal cord or brain stem ischemia
o views
MR angiogram may be considered with suspected vascular injury
o findings
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OrthoBullets2017 Spine Trauma | AtlantoAxial Trauma
MRI better than CT for the assessment of associated brain and brain-stem injuries, although
CT still considered standard for evaluating acute subarachnoid hemorrhage
Treatment
Nonoperative
o analgesics, cervical orthosis
indications
Type 1 and 2
Type 3 without overt instability
modalities
semi-rigid or rigid cervical collar
Operative
o occipitocervical fusion
indications
Type 3 with overt instability
neural compression from displaced fracture fragment
associated occipital-atlantal or atlanto-axial injuries
technique
C0-C2/C3 occipitocervical arthrodesis using rigid segmental fixation or posterior
decompression and instrumented fusion
may require bone grafting or removal of boney fragments compressing neurovascular
structures.
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
o acquired
pathoanatomy
dueto bony dysplasia or ligament and soft-tissue laxity
Associated conditions
o atlantoaxial instability
also seen in Down syndrome patients
o neurologic deficits
o vertebral or carotid artery injuries
o Down Syndrome
Classification
Stage III Gross craniocervical misaligment (BAI or BDI > 2mm beyond normal
Unstable
limits)
Imaging
Radiographs
o recommended views
AP, lateral and odontoid views
o findings
low sensitivity in detecting injury (57%)
o measurements
used to diagnosis occipitocervical dislocation
Powers ratio = C-D/A-B
C-D: distance from basion to posterior arch
A-B: distance from anterior arch to opisthion
significance
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OrthoBullets2017 Spine Trauma | AtlantoAxial Trauma
ratio ~ 1 is normal
if > 1.0 concern for
anterior dislocation
ratio < 1.0 raises concern for
posterior atlanto-occipital dislocation
odontoid fractures
ring of atlas fractures
Harris rule of 12
basion-dens interval or basion-posterior axial interval
>12mm suggest occipitocervical dissociation
CT
o indications
II:9 Harris rule of 12: >12mm suggests
occipitocervical dissociation
considered gold standard for osseous injuries of the spine
o views
midsaggital CT reconstruction
MRI
o indications
suspected ligamentous injury with preserved alignment or occult injury
neurological deficits
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
Treatment
Nonoperative
o provisional stabilization while avoiding traction
indications
traumatic instability with distraction of the occipitoatlantal joint
techniques
halo vest
tongs
prolonged cervical orthosis is not recommended due to poor stabilization of the AOJ
outcomes
use of traction should be avoided in most cases
traction may be considered in stage 2 injuries when MRI demonstates soft-tissue injury
with perserved aligment
Operative
o posterior occipitocervical fusion (C0 - C2 or lower)
indications
most traumatic cases require stabilization
acquired cases when evidence of myelpathy or significant symptomatic neck pain
invagination and atlanto-axial impaction secondary to inflammatory arthropathy (e.g.,
rheumatoid arthritis)
tumor
Technique
Posterior occipitocervical fusion
o approach
midline posterior approach to base of skull
o instrumentation
rigid occipitocervical screw-rod or plate construct
aim for 3 bicortical occipital screws on each side of the midline (total 6 screws in occiput)
extend to C2 or lower with polyaxial
pedical screws to achieve fixation
the safe zone for occipital screws is located
within an area measuring 20mm lateral to
the external occipital protuberance along the
superior nuchal line
the major dural venous sinuses are located
just below the external occipital protuberance
and are at risk of penetrative injury during
occipitocervical fusion
autogenous bone graft
Complications
Nonunion
Bleeding
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OrthoBullets2017 Spine Trauma | AtlantoAxial Trauma
3. Atlantoaxial Instability
Introduction
The atlantoaxial joint is an important "transitional zone" in the cervical spine
o prone to instability by both degenerative and traumatic processes.
Pathophysiology
o adult causes
degenerative
Down's syndrome
Rheumatoid Arthritis
Os odontoideum
traumatic
Type I odontoid fracture (very rare)
Atlas fractures
Transverse ligament injuries
o pediatric causes
degenerative
JRA
Morquio's Syndrome
lysosomal storage disorder
trauma/infection
rotatory atlantoaxial subluxation
Anatomy
Osteology
o bony articulations
C1-C2 facet joints
Ligaments
o transverse apical alar ligament complex
transverse ligament
most important stabilizer
apical ligament
single midline structure
alar ligaments
paired parasagittal ligament
Biomechanics
o the atlantoaxial joint provides ~50% of rotation in the cervical spine
this is enabled by the peg (C2)-ring(C1)
anatomy
Physical Exam
Symptoms
o symptomatic
o neck pain
o neurologic symptoms
Physical exam
o neurologic deficits
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
often appear late in disease process due to capacious nature of spinal canal at the C1 level
myelopathic symptoms
hyperreflexia (patellar tendon reflex)
muscles weakness
broad based gait
decreased hand dexterity
loss of motor milestones
bladder problems
Imaging
Radiographs
o flexion-extension xrays
atlanto-dens interval (ADI)
measurement
distance between odontoid process and the posterior border of the anterior arch of the
atlas
adult parameters
> 3.5mm considered unstable
> 10mm indicates surgery in RA
other
must get preoperative flexion-extension radiographs to clear all high-risk patients for
any type of surgery
space-available-cord (SAC) = posterior atlanto-dens-interval (PADI)
measurement
distance from posterior surface of dens to anterior surface of posterior arch of atlas
adult parameters
in adults with RA < 14 mm associated with increased risk of neurologic injury and is
an indication for surgery
o open mouth odontoid
sum of lateral mass displacement
measurement
lateral mass are connect by ring of C1, and therefore can only be displaced relative to
each other if
there is a bony fracture (disruption of the ring)
the transverse ligament is ruptured
transverse ligaments binds them together
adult parameters
if > 8.1 mm, then a transverse ligament rupture is assured and the injury pattern is
considered unstable
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Treatment
Determined by specific condition
o adult atlantoaxial instability
Down's syndrome
Rheumatoid Arthritis
Os odontoideum
Odontoid fracture
Atlas fractures
Transverse ligament injuries
o pediatric atlantoaxial instability
JRA
Morquio's Syndrome
Rotatory atlantoaxial subluxation
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
plough fracture
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
Imaging
Radiographs
o lateral radiographs
atlantodens interval (ADI)
< 3 mm = normal in adult (< 5mm normal in child)
3-5 mm = injury to transverse ligament with intact alar and apical ligaments
> 5 mm = injury to transverse, alar ligament, and tectorial membrane
o open-mouth odontoid
open-mouth odontoid view important to identify atlas fractures
sum of lateral mass displacement
if sum of lateral mass displacement is > 7 mm (8.1mm with radiographic magnification)
then a transverse ligament rupture is assured and the injury pattern is considered unstable
CT
o study of choice to delineate fracture pattern and identify associated injuries in the cervical spine
MRI
o more sensitive at detecting injury to transverse ligament
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Treatment
Nonoperative
o hard collar vs. halo immobilization for 6-12 weeks
indications
stable Type I fx (intact transverse ligament)
stable Jefferson fx (Type II) (intact transverse ligament)
stable Type III (intact transverse ligament)
technique : controversy exists around optimal form of immobilization
Operative
o posterior C1-C2 fusion vs. occipitocervical fusion
indications
unstable Type II (controversial)
unstable Type III (controversial)
technique : may consider preoperative traction to reduce displaced lateral masses
Techniques
Posterior C1-C2 fusion
o preserves motion compared to occipitocervical fusion
o fixation
C1 lateral mass / C2 pedicle screw construct
may be sufficient if adequate purchase with C1 lateral mass screws
C1-2 transarticular screw placement
Occipitocervical fusion (C0-C2)
o uses when unable to obtain adequate purchase of C1 (comminuted C1 fracture)
o leads to significant loss of motion
Complications
Delayed C-spine clearance
o higher rate of complications in patients with delayed C-spine clearance so it is important to clear
expeditiously
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
Pathophysiology
o mechanism
displacement may be anterior (hyperflexion) or posterior (hyperextension)
anterior displacement
is associated with transverse ligament failure and atlanto-axial instability
posterior displacement
caused by direct impact from the anterior arch of atlas during hyperextension
o biomechanics
a fracture through the base of the odontoid process severely compromises the stability of the
upper cervical spine.
Associated conditions
o Os odontoideum
appears like a type II odontoid fx on
xray
previously thought to be due to
failure of fusion at the base of the
odontoid
evidence now suggests it may
represent the residuals of an old traumatic process
treatment is observation
Anatomy
Axis Osteology
o axis has odontoid process (dens) and body
o embryology
develops from five ossification centers
subdental (basilar) synchondrosis is an initial
cartilagenous junction between the dens and vertebral
body that does not fuse until ~6 years of age
the secondary ossification center appears at ~ age 3 and fuses to the dens at ~ age 12
Axis Kinematics
o CI-C2 (atlantoaxial) articulation
is a diarthrodal joint that provides
50 (of 100) degrees of cervical rotation
10 (of 110) degrees of flexion/extension
0 (of 68) degrees of lateral bend
o C2-3 joint
participates in subaxial (C2-C7) cervical motion which
provides
50 (of 100) degrees of rotation
50 (of 110) degrees of flexion/extension
60 (of 68) degrees of lateral bend
Occipital-C1-C2 ligamentous stability
o provided by the odontoid process and its supporting ligaments
transverse ligament: limits anterior translation of the atlas
apical ligaments : limit rotation of the upper cervical spine
alar ligaments : limit rotation of the upper cervical spine
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OrthoBullets2017 Spine Trauma | AtlantoAxial Trauma
Blood Supply
oa vascular watershed exists between the apex and the base of the odontoid
apex is supplied by branches of internal carotid artery
base is supplied from branches of vertebral artery
the limited blood supply in this watershed area is thought to affect healing of type II odontoid
fractures.
Classification
Anderson and D'Alonzo Classification
Anderson and D'Alonzo Classification
Type I Oblique avulsion fx of tip of odontoid. Due to avulsion of alar ligament. Although
rare, atlantooccipital instability should be ruled out with flexion and extension
films.
Type II Fx through waist (high nonunion rate due to interruption of blood supply).
Type III Fx extends into cancellous body of C2 and involves a variable portion of the C1-C2
joint.
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
Presentation
Symptoms
o neck pain worse with motion
o dysphagia may be present when associated with a large retropharyngeal hematoma
Physical exam
o myelopathy
very rare due to large cross section area of spinal canal at this level
Imaging
Radiographs
o required views
AP, lateral, open-mouth odontoid view of cervical spine
o optional views
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flexion-extension radiographs are important to diagnose occipitocervical instability in Type I
fractures and Os odontoideum
instability defined as
atlanto-dens-interval (ADI) > 10mm
< 13mm space available for cord (SAC)
o findings
fx pattern best seen on open-mouth odontoid
CT
o study of choice for fracture delineation and to assess stability of fracture pattern
CT angiogram
o required to determine location of vertebral artery prior to posterior instrumentation procedures
MRI
o indicated if neurologic symptoms present
Treatment
Treatment Overview
Os Odontoideum Observation
Type I Cervical Orthosis
Type II Young Halo if no risk factors for nonunion
Surgery if risk factors for nonunion
Type II Elderly Cervical Orthosis if not surgical candidates
Surgery if surgical candidates
Type III Cervical Orthosis
Nonoperative
o observation alone
indications
Os odontoideum
assuming no neurologic symptoms or instability
o hard cervical orthosis for 6-12 weeks
indications
Type I
Type II in elderly who are not surgical candidates
union is unlikely, however a fibrous union should provide sufficient stability except in
the case of major trauma
Type III fractures
no evidence to support Halo over hard collar
o halo vest immobilization for 6-12 weeks
indications
Type II young patient with no risk factors for nonunion
contraindications
elderly patients
do not tolerate halo (may lead to aspiration, pneumonia, and death)
Operative
o posterior C1-C2 fusion
indications
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
Type II fractures with risk factors for nonunion
Type II/III fracture nonunions
Os odontoideum with neurologic deficits or instability
o anterior odontoid osteosynthesis
indications
Type II fractures with risk factors for nonunion AND
acceptable alignment and minimal displacement
oblique fracture pattern perpendicular to screw trajectory
patient body habitus must allow proper screw trajectory
outcomes
associated with higher failure rates than posterior C1-2 fusion
o transoral odontoidectomy
indications
severe posterior displacement of dens with spinal cord compression and neurologic
deficits
Surgical Techniques
Halo immobilization
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Complications
Nonunion
o increased risk in Type II fractures due to poor
blood supply
average nonunion rate 33% (up to as high as
88%)
o risk factors for nonunion include
≥ 6 mm displacement (>50% nonunion rate)
strongest reason to opt for surgery
age > 50 years
fx comminution
angulations > 10° II:16 Anterior odontoid screw osteosynthesis
delay in treatment
smoker
II:17 posterior C1 lateral mass screw and C2 pedicle screw construct II:18 posterior C1-C2 transarticular screws construct
Presentation
Symptoms
o neck pain
Physical exam
o patients are usually neurologically intact
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By Dr, AbdulRahman AbdulNasser Spine Trauma | AtlantoAxial Trauma
Imaging
Radiographs
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OrthoBullets2017 Spine Trauma | SubAxial Cervical Trauma
Treatment
Nonoperative
o rigid cervical collar x 4-6 weeks
indications
Type I fractures (< 3mm horizontal displacement)
o closed reduction followed by halo immobilization for 8-12 weeks
indications
Type II with 3-5 mm displacement
Type IIA
reduction technique
Type II use axial traction combined + extension
Type IIA use hyperextension (avoid axial traction in Type IIA)
Operative
o reduction with surgical stabilization
indications
Type II with > 5 mm displacement and severe angulation
Type III (facet dislocations)
technique
anterior C2-3 interbody fusion
posterior C1-3 fusion
bilateral C2 pars screw osteosynthesis
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By Dr, AbdulRahman AbdulNasser Spine Trauma | SubAxial Cervical Trauma
Classification
Descriptive classification (subaxial cervical spine injuries)
o includes
compression fracture
burst fraction
flexion-distraction injury
facet dislocation (unilateral or bilateral)
facet fracture
o more commonly used in clinical setting
Allen and Ferguson classification (of subaxial cervical spine injuries)
o typically used for research and not in clinical setting
o based solely on static radiographs and mechanisms of injury
Presentation
Physical exam
o monoradiculopathy
seen in patients with unilateral dislocations
C5/6 unilateral dislocation
usually presents with a C6 radiculopathy
weakness to wrist extension
numbness and tingling in the thumb
C6/7 unilateral dislocation
usually presents with a C7 radiculopathy
weakness to triceps and wrist flexion
numbness in index and middle finger
o spinal cord injury symptoms
seen with bilateral dislocations
symptoms worsen with increasing subluxation
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OrthoBullets2017 Spine Trauma | SubAxial Cervical Trauma
Imaging
Radiographs
o lateral shows subluxation of vertebral bodies
o unilateral dislocations lead to ~ 25% subluxation
o bilateral facet dislocation leads to ~ 50% subluxation on xray
o loss of disc height might indicated retropulsed disc in canal
CT scan
o essential to demonstrate
bony anatomy of the injury
malalignment or subtle subluxation of facet
facet fracture
associated fractures of the pedicle or lamina
MRI
o indications are controversial but include
acute facet dislocation in patient with altered mental status
failed closed reduction and before open reduction to look for disc herniation
any neurologic deterioration is seen during closed reduction
o timing
timing of MRI depends on severity and progression of neurologic injury
an MRI should always be performed prior to open reduction or surgical stabilization
if a disc herniation is present with compression on the spinal cord, then you must go
anterior to perform a anterior cervical diskectomy
o valuable in demonstrating
disc herniations
extent of posterior ligamentous injury
spinal cord compression or myelomalacia
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By Dr, AbdulRahman AbdulNasser Spine Trauma | SubAxial Cervical Trauma
Treatment
Nonoperative
o cervical orthosis or external immobilization (6-12 weeks)
indications
facet fractures without significant subluxation, dislocation, or kyphosis
Operative
o immediate closed reduction, then MRI, then surgical stabilization
indications
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always obtain MRI prior to open reduction and stabilization
ifdisc herniation with presence of spinal cord compression then you must use an
anterior approach and do a discectomy
Techniques
Closed reduction
o requirements
adequate anesthesia
sedation
supervision of respiratory function
serial cross table laterals
o technique
gradually increase axial traction with the addition of weights
a component of cervical flexion can facilitate reduction
perform serial neurologic exams and plain radiographs after addition of each weight
abort if neurologic exam worsens and obtain immediate MRI
Anterior open reduction & ACDF
o indications
facet dislocations reduced through closed methods with a MRI showing cervical disc
herniation with significant compression on the spinal cord
unilateral facet dislocations that fail closed reduction with a disc herniation with significant
compression on the spinal cord
o anterior open reduction techniques
can be used to reduce a unilateral facet dislocation
reduction technique involves distracting vertebral bodies with caspar pins and then rotating
the proximal pin towards the side of the dislocation
not effective for reducing bilateral facet dislocations
Posterior reduction & instrumented stabilization
o indications
when unable to reduce by closed or anterior approach
no anterior compression of spinal cord(no disc herniation)
o technique
performed with lateral mass screws
usually have to fuse two levels due to inadequate lateral mass purchase at level of dislocation
Combined anterior decompression and posterior reduction / stabilization
o indications
when disc herniation present that requires decompression in patient that can not be reduced
through closed or open anterior technique
o technique
go anterior first, perform discectomy, position plate but only fix plate to superior vertebral
body
this way the plate will prevent graft kick-out but still allows rotation during the posterior
reduction
this technique eliminates the need for a second anterior procedure
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By Dr, AbdulRahman AbdulNasser Spine Trauma | SubAxial Cervical Trauma
Classification
Kotani Classification
Kotani Classification
Fracture Type Fracture Description Rates of Anterior Rates of Anterior
Translation (same Translation
level) (adjacent level)
Type A -
2 fracture lines of unilateral lamina and
Separation 91% 20%
pedicle
fracture
Type B - Multiple fracture lines with lateral wedging
- 50%
Comminution type in coronal plane
Type C - Split type Vertical fracture line in the coronal plane,
with invagination of the superior articular 80% 0%
process of the caudal vertebra
Type D - Bilateral horizontal fracture lines of the
Traumatic pars interarticularis, leading to separation 100% 50%
spondylolysis of the anterior-posterior spinal elements
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OrthoBullets2017 Spine Trauma | SubAxial Cervical Trauma
Presentation
History
o commonest mechanisms (Allen and Ferguson classification)
extension-compression
lateral flexion : results in Type B Comminuted subtype
flexion-distraction
Symptoms
o neurologic symptoms common (up to 66%)
radicular pain, radiculopathy or spinal cord injury/myelopathy
can be classified by Frankel grade or ASIA impairment scale
Physical exam
o inspection
torticollis, paravertebral muscle spasm
o neurovascular
radicular pain and numbness
myelopathy
Imaging
Radiographs
o recommended views
AP, lateral, oblique views
o findings
disc space narrowing
often difficult to detect on plain radiographs
instability
>3.5mm displacement
>10deg kyphosis
>10deg rotation difference compared with adjacent vertebra
o sensitivity and specificity
low sensitivity
38% pickup rate on plain radiographs
CT
o indications
to further evaluate fracture morphology
fracture line extends
rostrally/caudally into adjacent superior/inferior facets
ventrally into foramen transversarium, transverse process and pedicle
dorsally into lamina
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By Dr, AbdulRahman AbdulNasser Spine Trauma | SubAxial Cervical Trauma
o findings
translationof fractured/adjacent vertebrae in sagittal and coronal planes
uncovertebral joint subluxation
degree of vertebral body destruction
MRI
o findings
disruption of ligaments
50-75% rupture of anterior longitudinal ligament (ALL)
30-35% disruption of posterior longitudinal ligament (PLL)
10-75% disruption interspinous and supraspinous ligaments (ISL and SSL)
disruption of intervertebral disc
bone bruising
Treatment
Nonoperative
o NSAIDS, rest, immobilization
indications
stable injuries without neurological deficit
hyperextension/rotation is poorly immobilized in a halo
techniques
Miami J collar
halo vest
outcomes
long term results of non-operative treatment are less desirable
may be successful in the absence of instability
surveillance is necessary to detect late instability and persistent pain
spontaneous fusion rate is only 20%
Operative
o posterior decompression and two-level instrumented fusion
indications
most cases require surgery
main injured structures are posterior, thus preferred approach is posterior
also indicated for nonoperatively managed cases with late instability and persistent pain
techniques
two-level lateral mass or pedicle screw and rod fixation
lateral mass plating
outcomes
risk of anterior disc space collapse and late kyphotic deformity
midline fusion does not control rotation
o anterior plating and interbody fusion
indications
controls anterior collapse and rotation
techniques
using iliac crest bone graft
o single posterior pedicle screw
indications
Type A Separation fracture without instability
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o anterior and posterior decompression and fusion
indications
if additional anterior column support is needed
if anterior approach is attempted initially, with unsuccessful reduction because of
complicated fracture morphology or late presentation
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By Dr, AbdulRahman AbdulNasser Spine Trauma | SubAxial Cervical Trauma
prognosis
associated with SCI
treatment
unstable and usually requires surgery
o extension teardrop avulsion fracture
characterized by
small fleck of bone is avulsed of anterior endplate
usually occur at C2
must differentiate from a true teardrop fracture
mechanism
extension
prognosis
stable injury pattern and not associated with SCI
treatment
cervical collar
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OrthoBullets2017 Spine Trauma | SubAxial Cervical Trauma
Presentation
Symtoms : incomplete vs. complete cord injury
Imaging
Must determine if there is a posterior ligamentous injury so MRI often important
Treatment
Nonoperative
o collar immobilization for 6 to 12 weeks
indications
stable mild compression fractures (intact posterior ligaments & no significant kyphosis)
anterior teardrop avulsion fracture
o external halo immobilization
indications
only if stable fracture pattern (intact posterior ligaments & no significant kyphosis)
Operative
o anterior decompression, corpectomy, strut graft, & fusion with instrumentation
indications
compression fracture with 11 degrees of angulation or 25% loss of vertebral body height
unstable burst fracture with cord compression
unstable tear-drop fracture with cord compression
minimal injury to posterior elements
o posterior decompression, & fusion with instrumentation
indications
significant injury to posterior elements
anterior decompression not required
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By Dr, AbdulRahman AbdulNasser Spine Trauma | SubAxial Cervical Trauma
Prognosis
o stable injury in isolation
o very rarely assoicated with neurological injury
o high union rate
Presentation
Symptoms
o sudden onset of pain between the shoulder blades or base of neck
o reduced head/neck ROM
Physical exam
o inspection
localized swelling and tenderness
crepitus
o motion
document flexion-extension of cervical spine
o neurovascular examination
Imaging
Radiographs
o recommended views
cervical +/- throacic xrays that should always be obtained on evaluation
o alternative views : flexion and extension views
o findings
lateral view
fracture line is usually obliquely oriented with the fragment displaced posteroinferior
AP view
double spinous process shadow is suggestive of displaced fracture
CT
o indications
method of choice
routine CT imaging in high-energy trauma patients
clinical criteria
altered consciousness
midline spinal pain or tenderness
impaired CCJ motion
lower cranial nerve paresis
motor paresis
o views : fracture is best seen on lateral view
MRI
o indications : not required in isolation
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OrthoBullets2017 Spine Trauma | Cervical Trauma Procedures
Complications
Chronic pain
Neck stiffness
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Cervical Trauma Procedures
Patient position
Preferred setting
o emergency room, operating room, ICU for close observation and frequent
fluoroscopy/radiographs
Patient position
o supine with reverse trendelenburg or use of arm and leg weights can help prevent patient
migration to the top of the bed with addition of weights.
Sedation
o small doses of diazepam can be administered to aid in muscle relaxation
o however patient must remain awake and able to converse
Pin Placement
Pin placement (Gardner-Wells pins)
o pin placement is 1 cm above pinna, in line with external auditory meatus and below the equator
of the skull.
if the pin is placed too anterior, the temporalis muscles and superficial temporal artery and
vein are at risk
an anterior pin will apply an extension moment to the cervical spine
if the pin is placed too posterior, it can apply a flexion moment to the cervical spine.
a posterior pin with a flexion moment may facilitate reduction of a facet dislocation.
Pin tightness
o On Gardner-Wells tongs, pins are tightened until spring loaded indicator protrudes 1 mm above
surface
this is the equivalent of 139 newtons (31 lbs) of force
overtightening by 0.3 mm leads to 448 newtons (100 lbs)
failure of temporal bone occurs at 965 +/- 200 newtons (216 lbs)
note Mayfield pins are tightened to 60 lbs
o overtightening of the pins can result in penetration of the
inner table of the calvarium
this may cause cerebral hemorrhage or abscess
Pin strength
o stainless steel pins have higher failure loads than titanium
and MRI-compatible graphite and should be used with
traction of > 50lbs.
Reduction with Serial Traction
Serial traction
o an initial 10lbs is added.
o weights are increased by 10lb increments every 20 minutes
o serial exams and radiographs are taken after each weight is
placed
o maximal weight is controversial
some authors recommend weight limits of 70 lbs
recent studies report that up to 140 lbs is safe
Reduction maneuvers
o reduction of a unilateral facet dislocation
reduction maneuver performed after facet is distracted to a perched position
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maintain axial load and rotate head 30-40 degrees past midline, in the direction of the
dislocation
stop once resistance is felt, and confirm with radiographs
o reduction of bilateral facet dislocation
reduction maneuver performed after facet is distracted to a perched position
palpate the stepoff in the spinal process posteriorly and apply an anterior directed force
caudal to the level of the dislocation
rotate the head 40 degrees beyond midline in one direction, and then rotate 40 degrees in the
other direction while axial traction is maintained.
Complications
Failure to reduce
o a bilateral, irreducible facet dislocation is unstable and should be treatment with urgent open
reduction after an MRI is performed..
Change in neurologic exam
o with any change in the neurologic exam the weights should be removed and an MRI should be
obtained.
Indications
Adult
o definitive treatment of cervical spine trauma including
occipital condyle fx
occipitocervical dislocation
stable Type II atlas fx (stable Jefferson fx)
type II odontoid fractures in young patients
type II and IIA hangman’s fractures
o adjunctive postoperative stabilization following cervical spine surgery
Pediatric
o definitive treatment for
atlanto-occipital dissociation
Jefferson fractures (burst fracture of C1)
atlas fractures
unstable odontoid fractures
persistent atlanto-axial rotatory subluxation
C1-C2 dissociations
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Cervical Trauma Procedures
subaxial cervical spine trauma
o preoperative reduction in the patients with spinal deformity
Contraindications
Absolute
o cranial fractures
o infection
o severe soft-tissue injury
especially near proposed pin sites
Relative
o polytrauma
o severe chest trauma
o barrel-shaped chest
o obesity
o advanced age
recent evidence demonstrates an unacceptably high mortality rate in patients aged 79
years and older (21%)
Imaging
CT scan prior to halo application
o indications
clinical suspicion for cranial fracture
children younger than 10 to determine thickness of bone
Adult Technique
Adults
o torque
tighten to 8 inch-pounds of torque
o location
total of 4 pins
2 anterior pins
safe zone is a 1 cm region just above the lateral one third of the orbit (eyebrow) at or
below the equator of the skull
this is anterior and medial to temporalis fossa/temporalis muscle
this is lateral to supraorbital nerve
2 posterior pins
placed on opposite side of ring from anterior pins
o followup care
can have patient return on day 2 to tighten again
proper pin and halo care can be done to minimize chance of infection
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Pediatric Technique
Pediatrics
o torque
best construct involves more pins with less torque
total of 6-8 pins
Complications
Higher complications in children (70%) than adults (35%)
Loosening (36%)
o can be treated with retightening
o if continues to loosen, should be treated with pin exchange
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Cervical Trauma Procedures
Infection (20%)
o can especially occur with posterior pin in temporalis fossa because
pins hidden in hairline
bone is thin
temporalis muscle moves with chewing
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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OrthoBullets2017 Spine Trauma | Thoracolumbar Trauma
E. Thoracolumbar Trauma
Anatomy
Biomechanics
o thoracic spine from T2 to T10 has increased stiffness due to
increased rigidity by articulation with ribs
ribs articulate with sternum, adding secondary stability
facet joints oriented in coronal plane
disks are thin increasing stiffness and rotational stability
kyphosis concentrates axial load on anterior column
o definitions of spinal stability
Blood supply
o "watershed area" in middle thoracic spine
is a vascular watershed area
vascular injury can lead to cord ischemia
Spinal cord
o spinal cord ends and cauda equina begins at level of L1/L2
variable so valuable to identify beginning of cauda equina on MRI in relation to pathology
injuries below L1 have a better prognosis because the nerve roots (cauda equina and nerve
roots within thecal sac) are affected as opposed to the spinal cord
Classification
Magerl classification (of thoracic spine injuries)
o Type A : compression caused by axial loading
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Thoracolumbar Trauma
o Type B
B1: ligamentous distraction injury posterior
B2: osseoligamentous distraction injury posterior
o Type C
multidirectional injuries, often fracture dislocations
very unstable with high likelihood of neurologic injury
AO classification (of thoracolumbar spinal fracture)
o Type A: Compression injuries
o Type B: Distraction injuries
o Type C: Torsional injury
each type then broken down further into
fracture morphology
bony versus ligamentous failure
direction of displacement
Imaging
Radiographs
o obtain radiographs of entire spine (concomitant spine fractures in 20%)
CT scan indications
o fracture on plain film
o neurologic deficit in lower extremity
o inadequate plain films
MRI useful to evaluate for
o injury to anterior and posterior ligament complex
o spinal cord compression by disk or osseous material
o cord edema or hemorrhage
Treatment
Treatment varies by condition, but the following should be considered
o degree of neurologic deficits seen on physical exam
o degree of spinal cord compression and imaging evidence of myelomalacia
o spinal stability
Nonoperative
o indications
most thoracic and thoracolumbar fractures (burst and compression) can be treated
nonoperatively when the patient is neurologically intact
treat in orthosis for 6 to 12 weeks depending on degree of instability
Operative
o indications for surgery
progressive neurologic deficits
myelomalacia seen on MRI
gross spinal instability
posterior osseoligamentous stability compromised
Surgical Techniques
Approaches
o surgical approach is dictated by
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OrthoBullets2017 Spine Trauma | Thoracolumbar Trauma
site of compression (anterior or posterior)
unlike thecal sack, the spinal cord can not be manipulated or medialized
surgical window needed to restore spinal stability
often times anterior column needs to be reconstructed
o thoracic approaches used include
midline posterior approach
indicated only when spinal cord compression is posterior
costotransverse
can be open or thoracosopic
transthoracic
Anatomy
Denis three column system
o clinical relevance
only moderately reliable in determining clinical degree of stability
o definitions
anterior column
anterior longitudinal ligament (ALL)
anterior 2/3 of vertebral body and annulus
middle column
posterior longitudinal ligament (PLL)
posterior 1/3 of vertebral body and annulus
posterior column
pedicles
lamina
facets
ligamentum flavum
spinous process
posterior ligament complex (PLC)
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Thoracolumbar Trauma
instability defined by
injury to middle column
as evidenced by widening of interpedicular distance on AP radiograph
loss of height of posterior cortex of vertebral body
disruption of posterior ligament complex combined with anterior and middle column
involvement
Posterior Ligamentous Complex
o considered to be a critical predictor of spinal fracture stability
o consists of
supraspinous ligament
interspinous ligament
ligamentum flavum
facet capsule
o evaluation
determining the integrity of the PLC can be challenging
conditions where PLC is clearly ruptured
bony chance fracture
widening of interspinous distance
progressive kyphosis with nonoperative treatment
facet diastasis
conditions where integrity of PLC is indeterminant
MRI shows signal intensity between spinous process
Imaging
Radiographs
o recommended views
obtain radiographs of entire spine (concomitant spine fractures in 20%)
o AP shows
widening of pedicles
coronal deformity
o lateral shows
retropulsion of bone into canal
kyphotic deformity
CT scan
o indications
fracture on plain film
neurologic deficit in lower extremity
inadequate plain films
MRI
o useful to evaluate for
spinal cord or thecal sac compression by disk or osseous material
cord edema or hemorrhage
injury posterior ligament complex
signal intensity in PLC is concerning for instability and may warrant surgical intervention
Treatment
Nonoperative
o ambulation as tolerated with or without a thoracolumbosacral orthosis
indications
patients that are neurologically intact and mechanically stable
posterior ligament complex preserved
kyphosis < 30° (controversial)
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vertebral body has lost < 50% of body height (controversial)
TLICS score = 3 or lower
thoracolumbar orthosis
recent evidence shows no clear advantage of TLSO on outcomes
if it provides symptomatic relief, may be beneficial for patient
outcomes
retropulsed fragments resorb over time and usually do not cause neurologic deterioration
Operative
o surgical decompression & spinal stabilization
indications
neurologic deficits with radiographic evidence of cord/thecal sac compression
both complete and incomplete spinal cord injuries require decompression and
stabilization to facilitate rehabilitation
TLICS score = 5 or higher
unstable fracture pattern as defined by
injury to the Posterior Ligament Complex (PLC)
progressive kyphosis
> 30°kyphosis (controversial)
> 50% loss of vertebral body height (controversial)
> 50% canal compromise (controversial)
Techniques
Anterior decompression and stabilization (with or without posterior stabilization)
o indications
indicated when neurologic deficits caused by anterior compression (bony retropulsion)
scientific data has not shown a benefit to early decompression and stabilization
o technique
usually includes corpectomy and strut grafting followed by anterior +/- posterior
instrumentation
advantage is that you do not need to do a laminectomy which will further destabilize the
spine by compromising the posterior supporting structures
Posterior Decompression and Fusion
o indications
unstable fracture pattern with no need for neurologic decompression
complete neurologic injury (allows earlier rehab)
o neural decompression
direct decompression
retropulsed bone can be removed via transpedicular approach
indirect decompression
via ligamentotaxis may occur by restoring height and sagittal alignment with posterior
instrumentation
o arthrodesis
fusion should be performed with instrumentation
instrumentation should be under distraction to restore vertebral body height and achieve
indirect decompression
historically it was recommended to instrument three levels above and two levels below
modern pedicle screws have changes this to one level above and one level below
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avoid laminectomy if possible as it will further destabilize the spine by compromising the
posterior supporting structures
Posterior Fusion Alone (no decompression)
o indications
progression kyphosis or clear injury to posterior ligament complex, but with no significant
neurologic compression
Complications
Entrapped nerve roots and dural tear
o from associated lamina fractures
Pain
o most common
Progressive kyphosis
o common with unrecognized injury to PLL
Flat back
o leads to pain, a forward flexed posture, and easy fatigue
o post-traumatic syringomyelia
Associated injuries
o high rate of gastrointestinal injuries (50%)
Imaging
Radiographs
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MRI
o important to evaluate for injury to the posterior elements
CT
o important to evaluate degree of bone injury and retropulsion of posterior wall into canal
Treatment
Nonoperative
o immobilization in cast or TLSO
indications
neurologically intact patients with
stable injury patterns with intact posterior elements
bony Chance fracture
technique
may cast or brace (TLSO) in extension
must be followed for non-union and kyphotic deformity
Operative
o surgical decompression and stabilization
indications
patients with neurologic deficits
unstable spine with injury to the posterior ligaments (soft-tissue Chance fx)
techniques
anterior decompression and stabilization
usually with vertebrectomy and strut grafting followed by instrumentation
posterior indirect decompression and stabilization and compression fusion construct
historically three levels above and two levels below
modern pedicle screws have changed this to one level above and one level below
distraction construct in burst fractures
compression construct in Chance fractures
Complications
Pain
o most common
Deformity
o scoliosis
o progressive kyphosis
common with unrecognized injury to PLL
o flat back
leads to pain, a forward flexed posture, and easy fatigue
o post-traumatic syringomyelia
Nonunion
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4. Thoracolumbar Fracture-Dislocation
Introduction
Fractures associated with posterior facet dislocation occuring at the thoracolumbar junction (AO type
C)
Epidemiology
o incidence
approx. 4% of spinal cord injuries admitted to Level 1 trauma centres
50-60% of fracture-dislocations are associated with spinal cord injuries
o demographics
4:1 male-to-female ratio
o location
most commonly occur at the thoracolumbar junction
o risk factors
high energy injuries
motor vehicle accident (most common)
falls
sports
violence
Pathophysiology
o mechanism of injury
acceleration/deceleration injuries
resultng in hyperflexion, rotation and shearing of the spinal column
o associated injury
neurologic deficits
head injury
concomitant injuries in thorax and abdomen
Classification Systems
o Thoracolumbar Injury Classification System (TLICS)
categorizes injuries based on
morphology of injury
neurologic injury
posterior ligamentous complex integrity
treatment recommendation based on total score
nonsurgical = 3 or lower
indeterminate = 4
surgical = 5 or higher
Anatomy
Lumbothoracic junction
o Definition
T10 - L2
transition zone between thoracic spine (kyphosis) and lumbar spine (lordosis)
o Pathoanatomy
greater mobility in the lumbar spine compared to thoracic spine
results in an area of the spine that is vulnerable to shearing forces
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high risk of injury to the spinal cord, conus or cauda equina depending on the patients
anatomy and degree of dislocation
Presentation
Pre-hospital
o patients almost exclusively present as a major trauma with or without neurological deficit
o transportation to a trauma center using spine immobilization precautions with a spinal board and
cervical collar.
Clinical Approach
o ATLS
Airway, Breathing, Circulation
Neurological assessment
Inspection
open injury
deformity (e.g. kyphosis)
Palpation
point tenderness
step-off deformity
crepitus
Neurological Impairment
GCS
ASIA Impairment score
sensory, motor, or reflexes impairment
rectal examination
History
Physical examination
Imaging
Radiographs
o recommended views
AP and lateral view of thoraco-lumbar spine
o indications
suspected spinal column injury with bone tenderness
recognize stable versus unstable spine injuries
o findings
fracture type, pattern and dislocation
CT scan
o indications
better visualization of fracture pattern and type compared to plain radiographs (e.g. unilateral
facet dislocations, etc)
blunt trauma patients requiring a CT scan to screen for other injuries
o findings
cannot adequately visualize and describe the spinal canal and other associated ligaments
MRI
o indications
better visualisation of the spinal cord and supporting ligamentous structures
level of neurological deficit does not align with apparent level of spinal injury
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o findings
important to evaluate for injury to the posterior longitudinal ligament
Treatment
Operative
o posterior open reduction with instrumented fusion
indications
most patients with thoracolumbar fracture dislocation
unstable fracture patterns
disrupted supporting ligamentous structures
technique
midline incision
identify fracture-dislocation site
use pedicle screws for distraction to obtain anatomical reduction
insert posterior instrumentation two levels above and two levels below the site of injury
outcomes
early decompression and instrumentation has been shown to have better outcomes than
delayed surgery or non-operative treatment
obtain postoperative CT/MRI to see if their is any residual anterior compression
Complications
Neurological injury
Cauda equina syndrome
DVT
Non-union after spinal fusion
Post-traumatic pain
o most commoncomplication
o greater with increased kyphotic deformity
Deformity
o scoliosis
o progressive kyphosis
common with unrecognized injury to PLL
o flat back
leads to pain, a forward flexed posture, and easy fatigue
o post-traumatic syringomyelia
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Thoracolumbar Trauma
affects up to
25% people over 70 years
50% people over 80 years
o risk factors
history of 2 VCFs
is the strongest predictor of future vertebral fractures in postmenopausal women
Pathoanatomy
o osteoporosis
characteristics
bone is normal quality but decreased in quantity
cortices are thinned
cancellous bone has decreased trabecular continuity
bone mineral density in the lumbar spine (BMD)
peaks at
between 33 to 40 yrs in women
between 19 to 33 years in men
peak BMD is widely variable based on demographic factors and location in
body
decreases with age following peak mass
correlate well with bone strength and is a good predictor of fragility fracture
definition
WHO defines osteoporosis as T score below -2.5
Associated conditions
o compromised pulmonary function
increased kyphosis can affect pulmonary function
each VCF leads up to 9% reduction in FV
Prognosis
o mortality
1-year mortality ~ 15% (less than hip fx)
2-year mortality ~20% (equivalent to hip fx)
Presentation
Symptoms
o pain
25% of VCF are painful enough that patients seek medical attention
pain usually localized to area of fracture
but may wrap around rib cage if dermatomal distribution
Physical exam
o focal tenderness
pain with deep palpation of spinous process
o local kyphosis
multiple compression fractures can lead to local kyphosis
o spinal cord injury
signs of spinal cord compression are very rare
o nerve root deficits
may see nerve root deficits with compression fractures of lumbar spine that lead to severe
foraminal stenosis
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Imaging
Radiographs
o obtain radiographs of the entire spine (concomitant spine fractures in 20%)
o will see loss of anterior, middle, or posterior vertebral height by 20% or at least 4mm
CT scan
o usually not necessary for diagnosis
o indications
fracture on plain film
neurologic deficit in lower extremity
inadequate plain films
MRI
o usually not necessary for diagnosis
o useful to evaluate for
acute vs chronic nature of compression fracture
injury to anterior and posterior ligament complex
spinal cord compression by disk or osseous material
cord edema or hemorrhage
Studies
Laboratory
o a full medical workup should be performed with CBC, BMP
o ESR may help to rule out infection
o Urine and serum protein electrophoresis may help rule out multiple myeloma
Differential Diagnosis
Metastatic cancer to the spine
o must be considered and ruled out
o the following variables should raise suspicion
fractures above T5
atypical radiographic findings
failure to thrive and constitutional symptoms
younger patient with no history of fall
Treatment
Nonoperative
o observation, bracing, and medical management
indications
majority of patients can be treated with observation and gradual return to activity
PLL intact (even if > 30 degrees kyphosis or > 50% loss of vertebral body height)
technique
if the fracture is less than five days old
calcitonin can be used for four weeks to decrease pain
medical management can consist of bisphosphonates
to prevent future risk of fragility fractures
some patients may benefit from an extension orthosis
although compliance can be an issue
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Thoracolumbar Trauma
Operative
o vertebroplasty
indications
not indicated
AAOS recommends strongly against the use of vertebroplasty
outcomes
randomized, double-blind, placebo-controlled trials have shown no beneficial effect of
vertebroplasty
vertebroplasty has higher rates of cement extravasation and associated complications than
kyphoplasty
o kyphoplasty
indications
patient continues to have severe pain symptoms after 6 weeks of nonoperative treatment
AAOS recommend may be used, but recommendation strength is limited
technique
kyphoplasty is different than vertebroplasty in that a cavity is created by balloon
expansion and therefore the cement can be injected with less pressure
pain relief thought to be from elimination of micromotion
o surgical decompression and stabilization
indications
very rare in standard VCF
progressive neurologic deficit
PLL injury and unstable spines
technique
to prevent possible failure due to osteoporotic bone II:21 kyphoplasty
consider long constructs with multiple fixation points
consider combined anterior fixation
Techniques
Kyphoplasty vs. vertebroplasty
o performed under fluoroscopic guidance
o percutaneous transpedicular approach used for cannula
o vertebroplasty
PMMA injected directly into cancellous bone without cavity creation
performed when cement is more liquid
requires greater pressure because no cavity is created
increased risk of extravasation into spinal canal is greater
o kyphoplasty
cavity created with expansion device (e.g., balloon) prior to PMMA injection
performed when cement is more viscous
may be possible to obtain partial reduction of fracture with balloon expansion
Complications
Neurological injury
o can be caused by extravasation of PMMA into spinal canal
higher risk with vertebroplasty than kyphoplasty
important to consider defects in the posterior cortex of the vertebral body
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Relevant Anatomy
Spinal cord
o conus medullaris
tapered, terminal end of the spinal cord
terminates at T12 or L1 vertebral body
o filum terminale
non-neural, fibrous extension of the conus medullaris that attaches to the coccyx
o cauda equina (horse's tail)
collection of L1-S5 peripheral nerves within the lumbar canal
compression considered to cause lower motor neuron lesions
Bladder
o receives innervation from
parasympathetic nervous system (pelvic splanchnic nerves and the inferior hypogastric
plexus) and
sympathetic plexus (hypogastric plexus)
o external sphincter of the bladder is controlled by the pudendal nerve
o lower motor neuron lesions of cauda equina will interrupt the nerves forming the bladder reflex
arcs
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By Dr, AbdulRahman AbdulNasser Spine Trauma | Thoracolumbar Trauma
Presentation
History
o two distinct clinical presentations: acute (e.g. disc herniation, trauma) and insidious (e.g. spinal
stenosis, tumor)
Symptoms
o bilateral leg pain
o saddle anesthesia
o impotence
o sensorimotor loss in lower extremity
o neurogenic bladder dysfunction
disruption of bladder contraction and sensation leads to urinary retention and eventually to
overflow incontinence
o bowel dysfunction is rare
Physical exam
o inspection
lower extremity muscle atrophy with insidious presentations (e.g. spinal stenosis)
fasciculations are rare
o palpation
lower back pain/tenderness is not a distinguishing feature
palpation of the bladder for urinary retention
o neurovascular examination
bilateral lower extremity weakness and sensory disturbances
decreased or absent lower extremity reflexes
o rectal/genital examination
reduced or absent sensation to pinprick in the perianal region (S2-S4 dermatomes), perineum,
and posterior thigh
decreased rectal tone or voluntary contracture
diminished or absent anal wink test and a
bulbocavernosus reflex
Imaging
MRI
o study of choice to evaluate neurologic compression
CT myelography
o study of choice if patient unable to undergo MRI
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Treatment
Operative
o urgent surgical decompression within 48 hours
indications
significant suspicion for CES
severity of symptoms will increase the urgency of surgical decompression
techniques
diskectomy
laminectomy
outcomes
studies have shown improved outcomes in bowel and bladder function and resolution of
motor and sensory deficits when decompression performed within 48 hours of the onset
of symptoms
Surgical Techniques
Surgical decompression of neural elements
o approach
posterior midline approach to lumbar spine
o diskectomy vs. wide laminectomy and diskectomy
no comparison studies between microdiskectomy alone and wide decompression combined
with microdiskectomy.
Complications
Delayed presentation or decompression
o sexual dysfunction
o urinary dysfunction requiring catheterization
o chronic pain
o persistent leg weakness
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Thoracolumbar Trauma
ORTHO BULLETS
III.Upper Extremity
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A. Shoulder
Anatomy
Anatomy
o brachial plexus motor and sensory innervation
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Classification
Preganglionic vs. postganglionic
o preganglionic
avulsion proximal to dorsal root ganglion
involves CNS which does not regenerate – little potential recovery of motor function
(poor prognosis)
lesions suggesting preganglionic injury:
Horner’s syndrome
disruption of sympathetic chain
winged scapula medially
loss of serratus anterior (long thoracic nerve) rhomboids (dorsal scapular nerve) leads
to medial winging (inferior border goes medial)
presents with motor deficits (flail arm)
sensory deficits
absence of a Tinel sign or tenderness to percussion in the neck
normal histamine test (C8-T1 sympathetic ganglion)
intact triple response (redness, wheal, flare)
elevated hemidiaphragm (phrenic nerve
rhomboid paralysis (dorsal scapular nerve)
supraspinatus/infraspinatus (suprascapular nerve)
latissimus dorsi (thoracodorsal)
evaluation
EMG may show loss of innervation to cervical paraspinals
o postganglionic
involve PNS, capable of regeneration (better prognosis)
presentation
presents with motor deficit (flail arm)
sensory deficits
evaluation
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EMG shows maintained innervation to cervical paraspinals
abnormal histamine test
only redness and wheal, but NO flare
Classification based on location
Presentation
History
o high energy injury
Physical exam
o Horner's syndrome
features include
drooping of the left eyelid
pupillary constriction
anhidrosis
usually show up three days after injury
represents disruption of sympathetic chain via C8 and/or T1 root avulsions
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Shoulder
o severe pain in anesthetized limb
correlates with root avulsion
o important muscles to test
serratus anterior (long thoracic nerve) and rhomboids (dorsal scapular nerve)
if they are functioning then it is more likely the C5 injury is postganglionic
o pulses
check radial, ulnar and brachial pulses
arterial injuries common with complete BPIs
Imaging
Radiographs
o chest radiograph
recommended views
PA and lateral
fractures to the first or second ribs suggest damage to the overlying brachial plexus
evidence of old rib fractures can be important in case intercostal nerve is needed for nerve
transfer
inspiration and expiration can demonstrate a paralyzed diaphragm (indicates upper nerve root
injury)
o cervical spine series
recommended views
AP and lateral
transverse process fracture likely indicates a root avulsion
o scapular and shoulder series
recommended views
at least AP and axillary (or equivalent)
scapulothoracic dissociation is associated with root avulsion and major vascular injury
o clavicle
recommended views
orthogonal views
fracture may indicate brachial plexus injury
CT myelography
o indications
gold standard for defining level of nerve root injury
o avulsion of cervical root causes dural sheath to heal with meningocele
o scan should be done 3-4 weeks after injury
allows blood clot in the injured area to dissipate and meningocele to form
MRI
o indications
suspect injury is distal to nerve roots
can visualize much of the brachial plexus
CT/myelogram demonstrates only nerve root injury
o findings
traumatic neuromas and edema
mass lesions in nontraumatic neuropathy of brachial plexus and its branches
consistent with injury include
pseudomeningocele (T2 highlights water content present in a pseudomeningocele )
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empty nerve root sleeves (T1 images highlight fat content nerve roots and empty sleeves)
cord shift away from midline (T1 highlights fat of cord)
Studies
Electromyography (EMG)
o tests muscles at rest and during activity
o fibrillation potentials (denervation changes)
as early as 10-14 days following injury in proximal muscles
as late as 3-6 weeks in distal muscles
o can help distinguish preganglionic from postganglionic
examine proximally innervated muscles that are innervated by root level motor branches
rhomboids
serratus anterior
cervical paraspinals
Nerve conduction velocity (NCV)
o performed along with EMG
o measures sensory nerve action potentials (SNAPs)
distinguishes preganglionic from postganglionic
SNAPs preserved in lesions proximal to dorsal root ganglia
cell body found in dorsal root ganglia
if SNAP normal and patient insensate in ulnar nerve distribution
preganglionic injury to C8 and T1
if SNAP normal and patient insensate in median nerve distribution
preganglionic injury to C5 and C6
Nerve action potential (NAPs)
o often intraoperative
o tests a nerve across a lesion
o if NAP positive across a lesion
preserved axons
or significant regeneration
o can detect reinnervation months before EMG
NAP negative-neuropraxic lesion
NAP positive- axonotmetic lesion
Sensory and Motor Evoked Potential
o more sensitive than EMG and NCV at identifying continuity of roots with spinal cord (positive
finding)
a negative finding can not differentiate location of discontinuity (root avulsion vs.
axonotmesis)
o perform 4-6 weeks after injury to allow for Wallerian degeneration to occur
o stimulation done at Erb's point and recording done over cortex with scalp electrodes
(transcranial)
Treatment
Nonoperative
o observation alone waiting for recovery
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indications
most managed with closed observation
guns shot wounds (in absence of major vascular damage can observe for three months)
signs of neurologic recovery
advancing Tinel sign is best clinical sign of effective nerve regeneration
Operative
o immediate surgical exploration (< 1 week)
indications
sharp penetrating trauma (excluding GSWs)
iatrogenic injuries
open injuries
progressive neurologic deficits
expanding hematoma or vascular injury
techniques
nerve repair
nerve grafting
neurotization
o early surgical intervention (3-6 weeks)
indicated for near total plexus involvement and with high mechanism of energy
o delayed surgical intervention (3-6 months)
indications
partial upper plexus involvement and low energy mechanism
plateau in neurologic recovery
best not to delay surgery beyond 6 months
techniques
usually involves tendon/muscle transfers to restore function
Surgical Techniques
Direct nerve repair
o rarely possible due to traction and usually only possible for acute and sharp penetration injuries
Nerve graft
o commonly used due to traction injuries (postganglionic)
o preferable to graft lesions of upper and middle trunk
allows better chance of reinnervation of proximal muscles before irreversible changes at
motor end plate
o donor sites include sural nerve, medial brachial nerve, medial antebrachial cutaneous nerve
o vascularized nerve graft includes ulnar nerve when there is a proven C8 and T1 avulsion
(mobilized on superior ulnar collateral artery)
Neurotization (nerve transfer)
o transfer working but less important motor nerve to a nonfunctioning more important denervated
muscle
o use extraplexal source of axons
spinal accessory nerve (CN XI)
intercostal nerves
contralateral C7
hypoglossal nerve (CN XII)
o intraplexal nerves
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phrenic nerve
portion of median or ulnar nerves
pectoral nerve
Oberlin transfer
ulnar nerve used for upper trunk injury for biceps function
Muscle or tendon transfer
o indications
isolated C8-T1 injury in adult (reinervation unlikely due to distance between injury site and
hand intrinsic muscles)
o priorities of repair/reconstruction
elbow flexion (musculocutaneous nerve)
shoulder stability (suprascapular nerve)
brachial-thoracic pinch (pectoral nerve)
C6-C7 sensory (lateral cord)
wrist extension / finger flexion (lateral and posterior cords)
wrist flexion / finger extension
intrinsic function
o technique
gracilis most common free muscle transfer
2. Sternoclavicular Dislocation
Introduction
Traumatic or Atraumatic
o traumatic dislocation
direction
anterior (more common)
posterior (mediastinal structures at risk)
important to distinguish from medial clavicle physeal fracture (physis doesn't fuse until
age 20-25)
mechanism : usually high energy injury (MVA, contact sports)
o atraumatic subluxation
occurs with overhead elevation of the arm
affected patients are younger
many demonstrate signs of generalized ligamentous laxity
subluxation usually reduces with lowering the arm
treatment is reassurance and local symptomatic treatment
Anatomy
Medial clavicle
o first bone to ossify and last physis to close (age 20-25)
Sternoclavicular joint
o osteology
diarthrodial saddle joint
incongruous (~50% contact)
fibrocartilage
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o stability
stability depends on ligamentous structures
posterior capsular ligament
most important structure for anterior-posterior stability
anterior sternoclavicular ligament
primary restraint to superior displacement of medial clavicle
costoclavicular (rhomboid) ligament
anterior fasciculus resists superior rotation and lateral displacement
posterior fasciculus resists inferior rotation and medial displacement
intra-articular disk ligament
prevents medial displacement of clavicle
secondary restraint to superior clavicle displacement
Presentation
Symptoms
o anterior dislocation
deformity with palpable bump
o posterior dislocations
dyspnea or dysphagia
tachypnea and stridor worse when supine
Physical exam
o palpation
prominence that increases with
arm abduction and elevation
o ROM and instability : decreased arm ROM
o neurovascular
parasthesias in affected upper extremity
venous congestion or diminished pulse when
compared with contralateral side
o provocative maneuvers
turning head to affected side may relieve pain
Imaging
Radiographs
o recommended views
AP and serendipity views
o findings
difficult to visualize on AP
serendipity views ( beam at 40 cephalic tilt)
anterior dislocation : affected clavicle above contralateral clavicle
posterior dislocation : affected clavicle below contralateral clavicle
CT scan
o study of choice
axial views can visualize mediastinal structures and injuries
can differentiate from physeal fractures
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Shoulder
Techniques
Closed reduction under general anesthesia
o reduction technique
place patient supine with arm at edge of table and prep entire chest
abduct and extend arm while applying axial traction and direct pressure
simultaneously apply direct posterior pressure over medial clavicle
manipulate medial clavicle with towel clip or fingers
Medial clavicle excision
o approach
3. Clavicle Fractures
Introduction
Epidemiology
o incidence : clavicle fractures make up ~4% of all fractures
o demographics : often seen in young active patients
Pathophysiology
o mechanism
direct blow to lateral aspect of shoulder
fall on an outstretched arm or direct trauma
o pathoanatomy
in displaced fractures, the
sternocleidomastoid muscle pulls the
medial fragment posterosuperiorly,
while pectoralis and weight of arm pull
the lateral fragment inferomedially
open fractures buttonhole through platysma
Associated injuries
o are rare but include
ipsilateral scapular fracture
scapulothoracic dissociation
should be considered with significantly
displaced fractures
rib fracture
pneumothorax
neurovascular injury
Pediatric Clavicle fractures
o fracture patterns include
medial clavicle physeal injury
distal clavicle physeal injury
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Relevant Anatomy
Acromioclavicular Joint Anatomy
AC joint stability
o acromioclavicular ligament
provides anterior/posterior stability
has superior, inferior, anterior, and posterior components
superior ligament is strongest, followed by posterior
o coracoclavicular ligaments (trapezoid and conoid)
provides superior/inferior stability
trapezoid ligament inserts 3 cm from end of clavicle
conoid ligament inserts 4.5 cm from end of clavicle in the posterior border
conoid ligament is strongest
o capsule, deltoid and trapezius act as additional stabilizers
Classification
Allman Classification with Neer's Modification
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Group I - Middle third (80-85%)
Nondisplaced Less than 100% displacement Nonoperative
Displaced Greater than 100% displacement
Operative
Nonunion rate of 4.5%
Group II - Neer Classification of Lateral third (10-15%)
Type I Fracture occurs lateral to coracoclavicular ligaments (trapezoid,
conoid) or interligamentous Nonoperative
Usually minimally displaced
Stable because conoid and trapezoid ligaments remain intact
Type IIA Fracture occurs medial to intact conoid and trapezoid ligament
Medial clavicle unstable Operative
Up to 56% nonunion rate with nonoperative management
Type IIB Fracture occurs either between ruptured conoid and intact
trapezoid ligament or lateral to both ligaments torn Operative
Medial clavicle unstable
Up to 30-45% nonunion rate with nonoperative management
Type III Intraarticular fracture extending into AC joint
Conoid and trapezoid intact therefore stable injury Nonoperative
Patients may develop posttraumatic AC arthritis
Type IV A physeal fracture that occurs in the skeletally immature
Displacement of lateral clavicle occurs superiorly through a tear in
the thick periosteum Nonoperative
Clavicle pulls out of periosteal sleeve
Conoid and trapezoid ligaments remain attached to periosteum
and overall the fracture pattern is stable
Type V Comminuted fracture
Conoid and trapezoid ligaments remain attached to comminuted Operative
fragment
Medial clavicle unstable
Group III - Medial third (5-8%)
Anterior Most often non-operative
Nonoperative
displacement Rarely symptomatic
Posterior Rare injury (2-3%)
displacement Often physeal fracture-dislocation (age < 25)
Stability dependent on costoclavicular ligaments Operative
Must assess airway and great vessel compromise
Serendipity radiographs and CT scan to evaluate
Surgical management with thoracic surgeon on standby
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Imaging
Radiographs
o standard AP view of bilateral shoulders
to measure clavicular shortening
o 45° cephalic tilt determine superior/inferior displacement
o 45° caudal tilt determines AP displacement
CT
o may help evaluate displacement, shortening, comminution, articular extension, and nonunion
o useful for medial physeal fractures and sternoclavicular injuries
Treatment
Nonoperative
o sling immobilization with gentle ROM exercises at 2-4 weeks and strengthening at 6-10
weeks
indications
nondisplaced Group I (middle third)
stable Group II fractures (Type I, III, IV)
nondisplaced Group III (medial third)
pediatric distal clavicle fractures (skeletally immature)
outcomes
nonunion (1-5%)
risk factors for nonunion
Group II (up to 56%)
comminution
100% displacement & shortening (>2 cm)
advanced age and female gender
poorer cosmesis
decreased shoulder strength and endurance
seen with displaced midshaft clavicle fracture healed with > 2 cm of shortening
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Shoulder
Operative
o open reduction internal fixation
indications
absolute
unstable Group II fractures (Type IIA, Type IIB, Type V)
open fxs
displaced fracture with skin tenting
subclavian artery or vein injury
floating shoulder (clavicle and scapula neck fx)
symptomatic nonunion
posteriorly displaced Group III fxs
Techniques
Sling Immobilization
o technique
sling or figure-of-eight (prospective studies have not shown difference between sling and
figure-of-eight braces)
after 2-4 weeks begin gentle range of motion exercises
strengthening exercises begin at 6-10 weeks
no attempt at reduction should be made
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precontoured anatomic
plates
Superior plate Anterior plate
intramedullary screw or
3.5mm reconstruction plate hook plate nail fixation
Open Reduction Internal Fixation
o technique
plate and screw fixation
superior vs anterior (anteroinferior) plating
superior plating biomechanically higher load to failure and bending
superior plating better for inferior bony comminution
superior plating has higher risk of neurovascular injury during drilling
anteroinferior plating has longer screws
anteroinferior plating has to remove portion of deltoid attachment
limited contact dynamic compression plate
3.5mm reconstruction plate
locking plates
precontoured anatomic plates
lower profile needing less chance for removal surgery
intramedullary screw or nail fixation
higher complication rate including hardware migration
hook plate
AC joint spanning fixation
postoperative rehabilitation
sling for 7-10 days followed by active motion
strengthening at ~ 6 weeks when pain free motion and radiographic evidence of union
full activity including sports at ~ 3 month
Coracoclavicular ligament repair
o technique
coracoclavicular ligament primary repair (most common)
most add supplementary suture (mersilene tape, fiberwire, ethibond) tied around coracoid
and either into or around clavicle
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Shoulder
Coracoclavicular ligament reconstruction
o see AC separation Techniques section
techniques include
modified Weaver-Dunn
free tendon graft
Complications
Nonoperative treatment
o nonunion (1-5%)
risks
comminution
Z deformity
female
older
smoker
distal clavicle higher risk than middle third
treatment of nonunion
if asymptomatic, no treatment necessary
if symptomatic, ORIF with plate and bone graft (particularly atrophic nonunion)
Operative treatment
o hardware prominence
~30% of patient request plate removal
superior plates associated with increased irritation
o neurovascular injury (3%)
superior plates associated with increased risk of subclavian artery or vein penetration
subclavian thrombosis
o nonunion (1-5%)
o infection (~4.8%)
o mechanical failure (~1.4%)
o pneumothorax
o adhesive capsulitis
4% in surgical group develop adhesive capsulitis requiring surgical intervention
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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4. Scapula Fractures
Introduction
Uncommon fracture pattern associated with high energy trauma
o 2-5% associated mortality rate
usually pulmonary or head injury
associated with Increased Injury Severity Scores
Epidemiology
incidence : less than 1% of all fractures
o location : 50% involve body and spine
Associated injuries (in 80-90%)
o orthopaedic
rib fractures (52%)
ipsilateral clavicle fracture (25%)
spine fracture (29%)
brachial plexus injury (5%) : 75% of brachial plexus
injuries resolve
o medical
pulmonary injury
pneumothorax (32%)
pulmonary contusion (41%)
head injury (34%)
vascular injury (11%) III:1 Floating Shoulder
Classification
Classification is based on the location of the fracture and includes
o coracoid fractures
o acromial fractures
o glenoid fractures
o scapular neck fractures
look for associated AC joint separation or clavicle fracture
known as "floating shoulder"
o scapular body fractures
described based on anatomic location
o scapulothoracic dissociation
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Shoulder
Ideberg Classification of Glenoid Fracture
Type Ia Anterior rim fracture
Type Ib Posterior rim fracture
Type II Fracture line through glenoid fossa exiting scapula laterally
Type III Fracture line through glenoid fossa exiting scapula superiorly
Type IV Fracture line through glenoid fossa exiting scapula medially
Type Va Combination of types II and IV
Type Vb Combination of types III and IV
Type Vc Combination of types II, III, and IV
Type VI Severe comminution
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Imaging
Radiographs
o recommended views
true AP, scapular Y and axillary lateral view
CT
o intra-articular fracture
o significant displacement
o three-dimensional reconstruction useful
Treatment
Nonoperative
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Shoulder
5. Scapulothoracic Dissociation
Introduction
A traumatic disruption of the scapulothoracic articulation often associated with
o severe neurologic injuries
o vascular injuries
o orthopaedic injuries
Mechanism
o usually caused by a lateral traction injury to the shoulder girdle
o involves significant trauma to heart, chest wall and lungs
Associated conditions
o orthopaedic
scapula fractures
clavicle fractures
AC dislocation/separation
sternoclavicular dislocation
flail extremity (52%)
complete loss of motor and sensory function rendering the extremity non-functional
o vascular injury
subclavian artery most commonly injured
axillary artery
o neurologic injury (up to 90%)
ipsilateral brachial plexus injury (often complete)
neurologic injuries more common than vascular injuries
Prognosis
o mortality rate of 10%
o functional outcome is dependent on neurologic injury
if return of neurological function is unlikely, early amputation is recommended
Anatomy
Scapulothoracic joint
o a sliding joint
o articulates with ribs 2-7
o moves into abduction at 2:1 ratio
GH joint 120°
ST joint 60°
Neurovascular anatomy
o brachial plexus
o subclavian artery
o axillary artery
Presentation
History
o history of high energy trauma
Symptoms
o pain in involved upper extremity (UE)
o numbness/tingling in involved UE
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Physical exam
o inspection
significantswelling in shoulder region
bruising around shoulder
o vascular exam
decreased or absent pulses in involved UE
o neurological exam
neurologic deficits in UE
neurological status critical part of exam
Imaging
Radiographs
o required views
AP chest III:3 Laterally displaced scapula
o recommended view
AP and lateral of shoulder as tolerated
appropriate images of suspected fracture sites
o findings
laterally displaced scapula
edge of scapula displaced > 1 cm from spinous process as compared to contralateral side
widely displaced clavicle fx
AC separation
sternoclavicular dislocation
Angiogram
o indicated to detect injury to subclavian and axillary artery
Treatment
Nonoperative
o immobilization/supportive care
indications
patients without significant vascular injury who are hemodynamically stable
patients may have adequate collateral flow to UE even with injury
Operative
o high lateral thoracotomy with vascular repair
indications : axillary artery injury in hemodynamically unstable patient
o median sternotomy with vascular repair
indications : more proximal arterial injury (i.e., subclavian artery) in a hemodynamically
unstable patient
o ORIF of the clavicle or AC joint
indications : associated clavicle and AC injuries
o forequarter amputation
indications : complete brachial plexus injury
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Shoulder
6. Flail Chest
Introduction
Defined as 3 or more ribs with segmental fractures
Epidemiology
o bimodal distribution
younger patients involved in trauma
older patients with osteopenia
Mechanism
o blunt forces
o deceleration injuries
Associated Injuries
o scapula fractures
o clavicle fractures
o hemo/pneumothorax III:4 paradoxical respiration
Prognosis
o varies depending on underlying pulmonary injury or other concomitant injuries
Anatomy
Osteology
o 12 ribs per side
the first seven pairs are connected with the sternum
the next three are each articulated with the lower border of the cartilage of the preceding rib
the last two have pointed extremities
o can have an accessory clavicular rib
o anterior ribs articulate with the sternum via the costal cartilage
Blood Supply
o derived from intercostal vessels
Presentation
Symptoms
o pain
o respiratory difficulty
o hemopneumothorax
Exam
o paradoxical respiration
area of injury "sinks in" with inspiration, and
expands with expiration (opposite of normal
chest wall mechanics) III:5 may see associated hemothorax
o chest wall deformity can be seen
o bony or soft-tissue crepitus is often noted
Imaging
Radiographs
o may be hard to distinguish non- or minimally-displaced rib fractures
o may see associated hemothorax
CT : improved accuracy of diagnosis with CT (vs. radiographs)
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Treatment
Nonoperative
o observation
indications
no respiratory compromise
no flail chest segment (>3 consecutive segmentally fractured ribs)
techniques
pain control
systemic narcotics or local anesthetics
positive pressure ventilation
Operative
o open reduction internal fixation
indications
displaced rib fractures associated with intractable pain
flail chest segment (3 or more consecutive ribs with segmental injuries)
rib fractures associated with failure to wean from a ventilator
open rib fractures
technique
approach
full thoracotomy approach
limited exposure approach
open reduction and internal fixation
plate and screw constructs
intramedullary splinting
postop
early shoulder and periscapular range of motion
Complications
Intercostal neuralgia
Periscapular muscle weakness
Pneumonia
Restrictive type pulmonary function
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B. Humerus
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Classification
Valgus impacted
o not true 4-part fractures
o have preserved posterior medial capsular vascularity to the articular segment
AO/OTA
o organizes fractures into 3 main groups and additional subgroups based on
fracture location
status of the surgical neck
presence/absence of dislocation
Neer classification
o based on anatomic relationship of 4 segments
greater tuberosity
lesser tuberosity
articular surface
shaft
o considered a separate part if
displacement of > 1 cm
45° angulation
Evaluation
Symptoms
o pain and swelling
o decreased motion
Physical exam III:6 AO/OTA of proximal humeral frx
o inspection
extensive ecchymosis of chest, arm, and forearm
o neurovascular exam
45% incidence of nerve injury (axillary most common)
distinguish from early deltoid atony and inferior subluxation of humeral head
arterial injury may be masked by extensive collateral
circulation preserving distal pulses
Imaging
Radiographs : recommended views
o complete trauma series
true AP
scapular Y
axillary
o additional views
apical oblique
Velpeau
West Point axillary
o findings
combined cortical thickness (>4 mm)
studies suggest correlation with increased lateral plate pullout strength
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Humerus
CT scan : indications
o preoperative planning
o humeral head or greater tuberosity position uncertain
o intra-articular comminution
MRI : indications
o rarely indicated
o useful to identify associated rotator cuff injury
Treatment
Nonoperative
o sling immobilization followed by progressive rehab
indications
85% of proximal humerus fractures are minimally displaced and can be treated
nonoperatively including
minimally displaced surgical neck fracture (1-, 2-, and 3-part)
greater tuberosity fracture displaced < 5mm
fractures in patients who are not surgical candidates
additional variables to consider
age
fracture type
fracture displacement
bone quality
dominance
general medical condition
concurrent injuries
technique
start early range of motion within 14 days
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Operative
o CRPP (closed reduction percutaneous pinning)
indications
2-part surgical neck fractures
3-part and valgus-impacted 4-part fractures in patients with good bone quality, minimal
metaphyseal comminution, and intact medial calcar
o ORIF
indications
greater tuberosity displaced > 5mm
2-,3-, and 4-part fractures in younger patients
head-splitting fractures in younger patients
o intramedullary rodding
indications
surgical neck fractures or 3-part greater tuberosity fractures in
younger patients
combined proximal humerus and humeral shaft fractures
outcomes
85% success rate in younger patients
o hemiarthroplasty
indications
anatomic neck fractures in elderly (initial varus malalignment >20 degrees) or those that
are severely comminuted
4-part fractures and fracture-dislocations (3-part if stable internal fixation unachievable)
rotator cuff compromise
glenoid surface is intact and healthy
chronic nonunions or malunions in the elderly
head-splitting fractures with incongruity of humeral head
humeral head impression defect of > 40% of articular surface
detachment of articular blood supply (most 3- and 4-part fractures)
outcomes
improved results if
performed within 14 days
accurate tuberosity reduction
cerclage wire passed through hole in prosthesis and tuberosities
poor results with
tuberosity malunion
proud prosthesis
retroversion of humeral component > 40°
o total shoulder arthroplasty
indications
rotator cuff intact
glenoid surface is compromised (arthritis, trauma)
o reverse shoulder arthroplasty
indications
elderly individuals with nonreconstructible tuberosities
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Humerus
Treatment by Fracture Type
One-Part Fracture (most common)
Surgical Neck fx • Most common type • if stable then early ROM
• if unstable then period of immobilization followed by ROM
once moves as a unit
Anatomic Neck fx • ORIF in young patient
• ORIF vs. hemiarthroplasty in elderly patient
• hemiarthroplasty if severely comminuted
Two-Part Fracture
Surgical Neck • Most common fx pattern (85%) Nonoperative
• Deforming forces: • Closed reduction often possible
1) pectoralis pulls shaft anterior and • Sling
medial 2) head and attached tuberosities Operative
stay neutral • indicated for >45° angulation
• Posterior angulation tolerated better • technique
than anterior and varus angulation - CRPP
- Plate fixation
- Enders rods with tension band
- IM device
Greater tuberosity • Often missed Nonoperative
• Deforming forces: GT pulled superior • indicated for GT displaced < 5 mm
and posterior by SS, IS, and TM Operative
• Can only accept minimal displacement • indicated for GT displacement > 5 mm
or else it will block ER and ABD •AP radiograph of a left shoulder demonstrates a 2-part
proximal humerus fracture at the surgical neck.
- isolated screw fixation only in young with good bone stock
- nonabsorbable suture technique for osteoporotic bone (avoid
hardware due to impingement)
- tension band wiring
Lesser tuberosity • Assume posterior dislocation until Operative
proven otherwise • ORIF if large fragment
• excision with RCR if small
Anatomic neck • Rare Operative
• ORIF in young
• ORIF vs. hemiarthroplasty in elderly patient
Three-Part Fracture
Surgical neck and GT • Subscap will internally rotate articular
segment
• Often associated with longitudinal RCT
Surgical neck and LT • Unopposed pull of external rotators lead • Trend towards nonoperative management with high
to articular surface to point anterior complications with ORIF
• Often associated with longitudinal RCT • Young patient
- percutaneous pinning (good results, protect axillary nerve)
- blade plate / fixed angle device
- IM fixation (violates cuff)
- T plate (poor results with high rate of AVN, impingement,
infection, and malunion)
• Elderly patient
- hemiarthroplasty with RCR or tuberosity repair
Four-Part Fracture
Valgus impacted 3- • Radiographically will see alignment • 74% good results with ORIF
and 4-part fracture between medial shaft and head • Low rate of AVN if posteromedial component intact thus
segments preserving intraosseous blood supply
• Surgical technique
1. raise articular surface and fill defects
2. repair tuberosities
4-part with articular • Characterized by removal of soft tissue • Young patient
surface and head- from fracture fragment leading to high - ORIF vs. hemiarthroplasty (nonreconstructible articular
splitting fracture risk of AVN (21-75%) surface, severe head split, extruded anatomic neck fracture)
• Deforming forces: 1) shaft pulled
medially by pectoralis • Elderly patient
- hemiarthroplasty
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Techniques
CRPP (closed reduction percutaneous pinning)
o approach
percutaneous
o technique
use threaded pins but do not cross cartilage
externally rotate shoulder during pin placement
engage cortex 2 cm inferior to inferior border of humeral head
o complications
with lateral pins
risk of injury to axillary nerve
with anterior pins
risk of injury to biceps tendon, musculocutaneous n., cephalic vein
ORIF
o approach
shoulder anterior approach (deltopectoral)
shoulder lateral (deltoid-splitting) approach
indicated for GT and valgus-impacted 4-part fractures
increased risk of axillary nerve injury
o technique
heavy nonabsorbable sutures
(figure-of-8 technique) should be used for greater tuberosity fx reduction and fixation
(avoid hardware due to impingement)
isolated screw
may be used for greater tuberosity fx reduction and fixation in young patients with good
bone stock
locking plate
has improved our ability to fix these fractures
screw cut-out (up to 14%) is the most common complication following fixation of 3- and
4- part proximal humeral fractures and fractures treated with locking plates
more elastic than blade plate making it a better option in osteoporotic bone
place plate lateral to the bicipital groove and pectoralis major tendon to avoid injury to the
ascending branch of anterior humeral circumflex artery
placement of an inferomedial calcar screw can prevent post-operative varus collapse,
especially in osteoporotic bone
Intramedullary rodding
o approach
superior deltoid-splitting approach
o technique
lock nail with trauma or pathologic fractures
o complications
rod migration in older patients with osteoporotic bone is a concern
shoulder pain from violating rotator cuff
nerve injury with interlocking screw placement
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Humerus
Hemiarthroplasty
o approach
shoulder anterior approach (deltopectoral)
o technique for fractures
cerclage wire or suture passed through hole in prosthesis and tuberosities improves fracture
stability
place greater tuberosity 10 mm below articular surface of humeral head (HTD = head to
tuberosity distance)
impairment in ER kinematics and 8-fold increase in torque with nonanatomic placement
of tuberosities
height of the prosthesis best determined off the superior edge of the pectoralis major tendon
post-operative passive external rotation places the most stress on the lesser tuberosity
fragment
Total shoulder arthroplasty
Reverse shoulder arthroplasty
Rehabilitation
Important part of management
Best results with guided protocols (3-phase programs)
o early passive ROM for first 6 weeks
o active ROM and progressive resistance
o advanced stretching and strengthening program
Prolonged immobilization leads to stiffness
Complications
Screw penetration
o most common complication after locked plating fixation (up to 14%)
Avascular necrosis
o risk factors
4 part fractures
head split
short calcar segments
disrupted medial hinge
o no relationship to type of fixation (plate or cerclage wires)
Nerve injury
o axillary nerve injury (up to 58%)
increased risk with anterolateral acromial approach
axillary nerve is found 7cm distal to the tip of the acromion
o suprascapular nerve (up to 48%)
Malunion
o usually varus apex-anterior or malunion of GT
o results inferior if converting from varus malunited fracture (with GT in varus necessitating
osteotomy) to TSA
use reverse TSA instead
Nonunion
o usually with surgical neck and tuberosity fx
o treatment of chronic nonunion/malunion in the elderly should include arthroplasty
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o lessertuberosity nonunion leads to weakness with lift-off testing
o greater tuberosity nonunion leads to lack of active shoulder elevation
o greatest risk factors for non-union are age and smoking
Rotator cuff injuries and dysfunction
Missed posterior dislocation
Adhesive capsulitis
Posttraumatic arthritis
Infection
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Humerus
Anatomy
Humeral head
o shape : spheroidal in 90% of individuals
o size : average diameter is 43 mm
o orientation
retroverted 30° from transepicondylar axis of the distal humerus
neck-shaft agle usually 130° to 140°
Greater tuberosity
o position important for rotator cuff muscle fuction
horizontal position : medial edge of tuberosity is 10mm lateral to humeral canal axis
vertical position : superior edge of tuberosity is 6mm inferior to upper edge of humeral head
Classification
Beredjiklian et al.
Beredjiklian
TypeI • Malposition of the greater or lesser tuberosity ( e.g. >1 cm from native anatomical
position)
Type II • Articular incongruity ( e.g. intra-articular fracture extension, osteoarthritis)
Type III • Articular surface malalignment ( e.g. >45° of deformity with respect to the humeral shaft
in the coronal, sagittal, or axial planes
Boileau et al.
Boileau
Type I • Humeral head necrosis or impaction
Type II • Chronic dislocations or fracture-dislocations
Type III • Nonunion of the surgical neck
Type IV • Severe malunion of the tuberosity
Presentation
History
o initial evaluation
date and mechanism of injury
current and prior function
handedness
treatment to date
specific goals of treatment
Symptoms
o pain and weakness
o limitations
Physical exam
III:9 Humeral head orientation
o inspection
features of systemic disease
muscle atrophy
diffuse tenderness
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o motion
active and passive shoulder range-of-motion
blocks or crepitus should be noted
rotator cuff
greater tuberosity malunion = weakness with abduction, external rotation
lesser tuberosity malunion = weakness with internal rotation
instability
humeral head malunion = apprehension test
o neurovascular
Imaging
Radiographs
o recommended views
true AP, scapular Y, axillary
o optional views
apical oblique
Velpeau
West Point axillary
o findings III:10 fracture fragment displacement
neck-shaft angle = varus or valgus
greater tuberosity = superiorly and posteriorly displaced, externally rotated
lesser tuberosity = medialized
o measurements
humeral head
> 45° of deformity in any plane
symptomatic articular incongruity
neck-shaft angle <120° or >150°
greater or lesser tuberosity
>1 cm from native anatomical position
CT scan
o indications
preoperative planning
assess bone stock, orientation and articular surface
o findings
humeral head and greater tuberosity displacement
glenoid version and glenoid bone stock
articular injury
MRI
o indications
preoperative planning
soft-tissue structures
o findings
rotator cuff or labral injury
deltoid atrophy secondary to axillary nerve injury
long-head biceps injury
osteonecrosis
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Humerus
Studies
Labs : CBC, ESR, CRP, blood cultures to rule out infection
Electrodiagnositcs : concern for nerve dysfunction
Treatment
Nonoperative
o NSAIDS, physical therapy, occasional corticosteriod injection
indications
low-demand patient
painless shoulder limitations
unable to comply with rehabilitation protocol
modalities
physical therapy
maximize ROM and strengthening program
outcomes
impacted varus and valgus fractures show good-to-excellent results
return to 90% of normal fuction
Operative
o humeral head preserving techniques
indications
symptomatic malunion following
nonoperative treatment
failed internal fixation
anatomical requirements
adequate bone stock for fixation
preserved articular surface
intact blood supply to humeral head
techniques
humeral head deformities
minor deformity techniques
open/arthroscopic tuberoplasty +/- acromioplasty +/- capsular release +/-
bursectomy
severe deformity techniques
varus/valgus osteotomy +/- rotational osteotomy and lateral plate fixation
treated with corrective osteotomy/fixation if patient is young or active
augmentation with strut allograft for poor bone stock
greater tuberosity deformities
<1.5 cm displacement
arthroscopic subacromial decompression +/- rotator cuff repair
>1.5 cm displacement
open/arthroscopic tuberosity osteotomy +/- subacromial decompression
outcomes
complication rates associated with surgical management of malunions are higher than
those associated with acute fractures
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o humeral head replacing techniques
indications
symptomatic malunion following
nonoperative treatment
failed internal fixation
anatomical requirements
inadequate bone stock for fixation techniques
articular incongruity, destruction or collapse (e.g. osteonecrosis or head-split)
compromised blood supply
chronic dislocation
techniques
hemiarthroplasty
total shoulder arthroplasty
reverse total shoulder arthroplasty
Complications
Persistent pain and weakness
Stiffness
Loss of fixation
Infection
Bleeding
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Humerus
Classification
OTA
o bone number: 1
o fracture location: 2
o fracture pattern: simple:A, wedge:B, complex:C
Descriptive
o fracture location: proximal, middle or distal third
o fracture pattern: spiral, transverse, comminuted
Holstein-Lewis fracture
o a spiral fracture of the distal one-third of the humeral shaft commonly
associated with neuropraxia of the radial nerve (22% incidence)
Presentation
Symptoms
o pain III:11 Holstein-Lewis fracture
o extremity weakness
Physical exam
o examine overall limb alignment
o preoperative or pre-reduction neurovascular exam is critical
examine and document status of radial nerve pre and post-reduction
Imaging
Radiographs : views
o AP and lateral
be sure to include joint above and below the site of injury
o transthoracic lateral
may give better appreciation of sagittal plane deformity
o traction views
may be necessary for fractures with significant shortening, proximal
or distal extension but not routinely indicated
III:12 AP radiograph fracture
Treatment humerus
Nonoperative
o coaptation splint followed by functional brace
indications
indicated in vast majority of humeral shaft fractures
criteria for acceptable alignment include:
< 20° anterior angulation
< 30° varus/valgus angulation
< 3 cm shortening
absolute contraindications
severe soft tissue injury or bone loss
vascular injury requiring repair
brachial plexus injury
relative contraindications III:13 transthoracic lateral
see relative operative indications section
radial nerve palsy is NOT a contraindication to functional bracing
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outcomes
90% union rate
increased risk with proximal third oblique or spiral fracture
varus angulation is common but rarely has functional or cosmetic sequelae
o damage control orthopaedics (DCO)
closed humerus fractures, including low velocity GSW, should be initially managed with a
splint or sling
type of fixation after trauma should be directed by acceptable fracture alignment parameters,
fracture pattern and associated injuries
Operative
o open reduction and internal fixation
absolute indications
open fracture
vascular injury requiring repair
brachial plexus injury
ipsilateral forearm fracture (floating elbow)
compartment syndrome
relative indications
bilateral humerus fracture
polytrauma or associated lower extremity fracture III:14 standard
allows early weight bearing through humerus functional brace
pathologic fractures
burns or soft tissue injury that precludes bracing
fracture characteristics
distraction at fracture site
short oblique or transverse fracture pattern
intraarticular extension
o intramedullary nailing (IMN)
relative indications
pathologic fractures
segmental fractures
severe osteoporotic bone
overlying skin compromise limits open approach
polytrauma III:15 open reduction and
internal fixation
Techniques
Coaptation Splint & Functional Bracing
o coaptation splint
applied until swelling resolves
adequately applied splint will extend up to axilla and over shoulder
common deformities include varus and extension
valgus mold to counter varus displacement
o functional bracing
extends from 2.5 cm distal to axilla to 2.5 cm proximal to humeral condyles
sling should not be used to allow for gravity-assisted fracture reduction
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shoulder extension used for more proximal fractures
Open Reduction Internal Fixation with Plating
o approaches
anterolateral approach to humerus
used for proximal third to middle third shaft fractures
distal extension of the deltopectoral approach
radial nerve identified between the brachialis and
brachioradialis distally
posterior approach to humerus
used for distal to middle third shaft fractures although
can be extensile
triceps may either be split or elevated with a lateral
paratricipital exposure III:16apply plate in bridging mode n severe
radial nerve is found medial to the long and lateral comminution
heads and 2cm proximal to the deep head of the
triceps
radial nerve exits the posterior compartment through lateral intramuscular septum 10 cm
proximal to radiocapitellar joint
lateral brachial cutaneous/posterior antebrachial cutaneous nerve serves as an anatomic
landmark leading to the radial nerve during a paratricipital approach
o techniques
plate osteosynthesis commonly with 4.5mm plate (narrow or broad)
3.5mm plates may function adequately
absolute stability with lag screw or compression plating in simple patterns
apply plate in bridging mode in the presence of significant comminution
o postoperative
full crutch weight bearing shown to have no effect on union
Closed Intramedullary Nailing (IMN)
o techniques : can be done antegrade or retrograde
o complication
nonunion
nonunion rates not shown to be different between IMN and
plating in recent meta-analyses
IM nailing associated with higher total complication rates
shoulder pain
increased rate when compared to plating (16-37%)
nerve injury
radial nerve is at risk with a lateral to medial distal locking
screw
musculocutaneous nerve is at risk with an anterior-posterior
locking screw
III:17 Closed Intramedullary
o postoperative Nailing
full weight bearing allowed and had no effect on union
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Complications
Malunion
o varus angulation is common but rarely has functional or cosmetic sequelae
o risk factors : transverse fracture patterns
Nonunion
o incidence
2 to 10% in nonoperative management
5 to 10% with surgical management
o risk factors
distraction at the fracture site on injury films
open fracture
metabolic/endocrine abnormalities (Vitamin D deficiency most common)
segmental fracture
infection
shoulder or elbow stiffness (motion directed to fracture site)
patient factors (smoking, obesity, malnutrition, noncompliance)
o treatment
compression plating with bone grafting
shown to be superior to both IM nailing with bone grafting and compression plating
alone
lateral, posterior or paratricipital (Gerwin) approach to allow exploration of the radial
nerve
Radial nerve palsy
o incidence
seen in 8-15% of closed fractures
increased incidence distal one-third fractures
neuropraxia most common injury in closed fractures and neurotomesis in open fractures
85-90% of improve with observation over 3 months
spontaneous recovery found at an average of 7 weeks, with full recovery at an average of 6
months
o treatment
observation
indicated as initial treatment in closed humerus fractures
obtain EMG at 3-4 months
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Humerus
Anatomy
Osteology
o elbow is a hinged joint
o trochlea
articulates with sigmoid notch
allows for flexion and extension
o capitellum
articulates with proximal radius : allows for forearm rotation
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Muscles
o common flexors (originate from medial epicondyle)
pronator teres
flexor carpi radialis
palmaris longus
FDS
FCU
o common extensors (originate from lateral epicondyle)
anconeus
ECRL
ECRB
extensor digitorum comminus
EDM
ECU
Ligaments
o medial collateral ligament
anterior bundle originates from distal medial epicondyle
inserts on sublime tubercle
primary restraint to valgus stress at the elbow from 30 to 120 deg
tight in pronation
o lateral collateral ligament
originates from distal lateral epicondyle
inserts on crista supinatorus
stabilizer against posterolateral rotational instability
taut in supination
Nerves
o ulnar nerve : resides in cubital tunnel in a subcutaneous position below the medial condyle
o radial nerve
resides in spiral groove 15cm proximal to distal humeral articular surface
between brachioradialis and brachialis proximal to elbow
divides into PIN and superficial radial nerve at level of radial head
Classification
Can be classified as
o supracondylar fractures
o distal single column fractures
subclassified using Milch classification system (see table)
lateral condyle more common than medial
o distal bicolumnar fractures
classified using Jupiter classification system (see table)
5 major articular fragments have been identified
capitellum/lateral trochlea
lateral epicondyle
posterolateral epicondyle
posterior trochlea
medial trochlea/epicondyle
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Presentation
Symptoms : elbow pain and swelling
Physical exam
o gross instability often present
avoid ROM due to risk of neurovascular damage
o neurovascular exam
check function of radial, ulnar, and median nerve
check distal pulses
brachial artery may be injured
if pulse decreased, obtain noninvasive vascular studies; consult vascular surgery if
abnormal
o monitor carefully for forearm compartment syndrome
Imaging
Radiographs
o recommended views
obtain AP and lateral of humerus and elbow
include entire length of humerus and forearm
o additional views
obtain wrist radiographs if elbow injury present or distal tenderness on exam
oblique radiographs may assist in surgical planning
traction radiographs may assist in surgical planning
specifically evaluate if there is continuity of the trochlear fragment to medial epicondylar
fragment, this can influence hardware choice
CT
o often obtained for surgical planning
o especially helpful when shear fractures of the capitellum and trochlea are suspected
o 3D CT scan improves the intraobserver and interobserver reliability of several classification
systems
MRI
o usually not indicated in acute injury
Treatment
Nonoperative
o cast immobilization
indications
nondisplaced Milch Type I fractures
technique
immobilize in supination for lateral condyle fractures
immobilize in pronation for medial condyle fractures
Operative
o closed reduction and percutaneous pinning
indications
displaced Mich Type I fractures
o open reduction internal fixation
indications
supracondylar fractures
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Humerus
intercondylar / bicolumnar fractures
Milch Type II fractures
o total elbow arthroplasty
indications
distal bicolumnar fractures in elderly patients
Techniques
Open Reduction Internal Fixation
o positioning
lateral decubitus position
on foam mattress with radiolucent arm board
prone position
useful in patients with spine injuries or contralateral extremity fractures
supine positioning
can be used in a polytrauma situation or with contraindications to other positioning
obtain test imaging before prepping and draping
prep entire arm from shoulder to hand
o approach
articular surface exposure
olecranon osteotomy 57%
triceps-reflecting 46%
triceps-splitting 35%
posterior superficial approach
raise full thickness medial and lateral soft tissue flaps
elevate deep fascia to identify ulnar and radial nerves
triceps splitting (Campbell)
split triceps tendon in midline down to olecranon
tricep sparing (known as paratricipital, Alonso-Llames, medial and lateral windows)
indications
extra articular fractures or fractures with simple articular split)
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can be converted to olecranon osteotomy if needed
medial side
identify ulnar nerve and dissect it 15cm proximal to elbow joint proximally, and
distally to first motor branch to FCU
elevate triceps from posterior aspect of humerus on medial side and free it from
medial intermuscular septum
posterior band of MCL is elevated and posterior joint capsule entered to visualize
trochlea
lateral side
identify radial nerve proper proximally if fracture is distal
if fracture is distal and does not require long plates, proper radial nerve does not
need to be exposed
elevate remainder of tricep from posterior aspect of humerus
anconeus may be divided or dissected on lateral side to improve exposure
olecranon osteotomy
indications : complex intra articular fragments and/or presence of coronal splint)
contraindications : total elbow arthroplasty is planned/may be required
technique
identify bare area of sigmoid notch medially and laterally
pre-drill (for 6.5mm screw) or plate prior to making bone cut
pass sponge through ulnohumeral joint to protect articular surface while making cut
fluoroscopy is used to confirm location of osteotomy
shallow chevron (apex distal) is cut down to subchondral bone (95% cut)
finish cut (remaining 5%) with osteotome
peel olecranon and triceps proximally and wrap with saline soaked sponge
fixation
screw, K wires and tension band or plate
clamp osteotomy from medial and lateral side with large pointed reduction clamps
insert 6.5, 7.0 or 7.3mm screw (or plate) in previously drilled hole
apply tension band
still preferable for posterior trochlea fx and medial epicondyle fx
complications
AIN nerve injury
check ability to flex thumb interphalangeal joint in recovery
triceps reflecting (Bryan-Morrey)
reflect triceps tendon, forearm fascia and periosteum from medial to lateral off olecranon
repair through transosseous drill holes
immobilize to protect triceps repair for 4-6wk postop
triceps-reflecting anconeous pedicle (O'Driscoll)
elevate anconeous subperiosteally from proximal ulna
medial exposure is Bryan-Morrey triceps reflecting approach
lateral muscles interval
is an alternative to visualize the articular
elevate ECRB and part of ECRL of supracondylar ridge
usually able to work anterior to and sacrifice LCL
if fx of lateral column, utilize and mobilize
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sublux joint to assist in articular visualization
o fixation principles (O'Driscoll)
fixation in the distal fragment must be maximized
all fixation in distal fragments should contribute to stability between the distal fragments and
the shaft.
o fixation objectives (O'Driscoll)
every screw in the distal fragments should pass through a plate
engage a fragment on the opposite side that is also fixed to a plate
as many screws as possible should be placed in the distal fragments
each screw should be as long as possible
each screw should engage as many articular fragments as possible
the screws in the distal fragments should lock together by interdigitation, creating a fixed-
angle structure
this creates the architecural equivalent of an arch, which gives the most biomechanical
stability
plates should be applied such that compression is achieved at the supracondylar level for both
columns
the plates must be strong enough and stiff enough to resist breaking or bending before union
occurs at the supracondylar level.
o fixation
countersunk / headless screw to fix articular fragments 1st after provisional reduction with k-
wires
if metaphyseal injury is not comminuted, reducing one column to the metaphysis first
may be beneficial
consider using positional screws when reducing trochlea to avoid narrowing it with
compression
then address condyles and epitrochlear ridge
lateral epicondyle may be fix with tension band wire or plate
two plates in orthogonal planes used to fix articular segment to shaft
place 3.5-mm LCDC plate or one of equivalent strength on lateral side
place 2.7-mm or 3.5-mm LCDC plate on medial side
interdigitate screws if possible to increase strength
new literature supports parallel plates
if ulnar nerve contacts medial hardware during flexion/extension, can transpose however
literature does not support decreased ulnar n. symptoms with transposition
postoperative
place in splint with elbow in approx 70 degrees of flexion
remove splint at 48 hours post-operatively, initiate ROM exercises
if osteotomy performed patient may do active and active assisted flexion and
extension for 6 weeks; no active extension against gravity or resistance
if not osteotomy, permitted to do active motion against gravity without restrictions
no restrictions to rotation
start gentle strengthening program at 6 weeks, and full strengthening program at 3 months
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Complications
Elbow stiffness : most common
Heterotopic ossification
o reported rate of 8%
o routine prophylaxis is not warranted
increased rate of nonunion in patients treated with indomethacin
Nonunion
o low incidence
o avoid excessive soft-tissue stripping
Malunion
o avoided by proper surgical technique
cubitus valgus (lateral column fxs)
cubitus varus (medial column fxs)
DJD
Ulnar nerve injury
AIN Injury : can be seen with olecranon osteotomy
C. Elbow
1. Elbow Dislocation
Introduction
Epidemiology
o incidence
elbow dislocations are the most common major joint dislocation second to the shoulder
account for 10-25% of injuries to the elbow
posterolateral is the most common type of dislocation (80%)
o demographics : predominantly affects patients between age 10-20 years old
Pathophysiology
o mechanism
usually a combination of
axial loading
supination/external rotation of the forearm
posterolateral based valgus force
a varus posteromedial mechanism has also been reported
posterior dislocations may involve more than one injury mechanism
o pathoanatomy
associated with complete or near complete circular disruption of capsuloligamentous
stabilizers
pathoanatomic cascade
progression of injury is from lateral to medial
LCL fails first (primary lesion)
by avulsion of the lateral epicondylar origin
midsubstance LCL tears are less common but do occur
MCL fails last depending on degree of energy
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Anatomy
Static and dynamic stabilizers confer stability to the elbow
o static stabilizers (primary)
ulnohumeral joint
anterior bundle of the MCL
LCL complex (includes the LUCL)
o static stabilizers (secondary)
radiocapitellar joint
capsule
origins of the flexor and extensor tendons
o dynamic stabilizers : includes muscles crossing elbow joint
anconeus
brachialis
triceps
See complete Anatomy and Biomechanics of Elbow
Classification
Anatomic description
o based on anatomic location of olecranon relative to humerus
posterolateral : most common
Simple vs. complex
o simple
no associated fracture
III:19 lateral radiograph of terrible triad
account for 50-60% of elbow dislocations injury
o complex
associated fracture present
may take form of
terrible triad injury
involves a disruption of the LUCL, a radial head fracture, a coronoid tip fracture and a
dislocation of the elbow
varus posteromedial rotatory instability
the coronoid fracture may be comminuted
medial facet of the coronoid is usually involved
Presentation
Symptoms : pain may be the primary symptom
Physical exam
o important to assess
the status of the skin
presence of compartment syndrome
neurovascular status
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Imaging
Radiographs
o recommended views
AP and lateral films
need to check the status of the congruency of the joint
o optional views
oblique views
may give clearer sense of periarticular bony involvement
CT scan
o indications
suspicion of complex injury pattern
useful to identify osseous involvement
Treatment
Nonoperative
o reduction and splinting at 90° for 7-10 days, early therapy
indications
acute simple stable dislocations
o reduction splinting in hinged brace at 90° for 2-3 weeks
indications
acute simple unstable elbow dislocations (unstable with extension following reduction)
Operative
o ORIF (coronoid, radial head, olecranon) , LCL repair, +/- MCL repair
indications
acute complex elbow dislocations
persistent instability after reduction
reduction blocked by entrapped soft tissue or osteochondral fragments
outcomes
improved with use of this systematic algorithm
o open reduction, capsular release, and dynamic hinged elbow fixator
indications
chronic dislocations
postoperative
hinged external fixator indicated in chronic dislocation to protect the reconstruction and
allow early range of motion
Nonoperative Technique
Closed reduction with splinting
o reduction maneuver
inline traction to correct coronal displacement
supination to clear the coronoid beneath trochlea
flexion of elbow while placing pressure on tip of olecranon
o assess post reduction stability
elbow is often unstable in extension
if LCL is disrupted then usually more stable in pronation
if MCL is disrupted then usually more stable in supination
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o immobilize and obtain post-reduction radiographs
check for concentric reduction of joint
if concentric then immobilize (5-7 days) and start early therapy
Rehabilitation
o initial
immobilize for 5-7 days
o early
supervised (therapist) active and active assist range-of-motion exercises within stable arc
extension block brace is used for 3-4 weeks
proceed with light duty use 2 weeks from injury
o late rehabilitation
extension block is decreased such that by 6-8 weeks after the injury full stable extension is
achieved
Operative Technique
ORIF of coronoid, radial head, repair of LCL +/- MCL
o approach
posterior utility approach used
Kocher interval laterally (ECU/anconeus)
o reconstruction
coronoid
fixation can usually be completed laterally via radial head fracture
severe comminution may necessitate medial approach
radial head
ORIF
when placing fixation on the proximal radius, one must be aware of the "safe zone" (a
90° arc in the radial head that does not articulate with the proximal ulna)
the "safe zone" can be identified by its relationship to Lister's tubercle and the
radial styloid
radial head arthroplasty
indicated if radial head can not be reconstructed
if radial head is replaced the replacement should be anatomic and restore normal
length/size
this improves the varus and external rotatory stability of the elbow, but stability
isn't restored until LCL is addressed
excision of the radial head leads to varus/external rotatory instability when the
LCL function is absent
LCL
reconstructed or repaired relative to the anatomic axis of rotation
extensor origin avulsion is common and may be repaired
MCL
if instability persists following LCL repair, the MCL is repaired or reconstructed
o postoperative care
depending on stability of the elbow, active ROM exercises may commence while using a
brace
an extension block may or may not be used
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Complications
Varus Posteromedial instability
o injury to the LCL and fracture of the anteromedial facet of the coronoid
o solid fixation of the anteromedial facet is critical for functional outcome and prevention of
arthrosis
Loss of motion
o loss of terminal extension is the most common sequelae after closed treatment of a simple elbow
dislocation
o early active ROM can help prevent this from occurring
o static, progressive splinting can be utilized after inflammation has diminished
Neurovascular injuries (ulnar/median nerves)
Compartment syndrome
Damage to articular surface
Chronic instability
Heterotopic ossification
o may require excision to improve elbow range of motion
Contracture/stiffness
o correlated with immobilization beyond 3 weeks
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elbow dislocation
terrible triad (elbow dislocation, radial head fracture, coronoid fracture)
carpal fractures
scaphoid fracture
Anatomy
Osteology
o elbow joint contains two articulations
ulnohumeral (hinge)
radiocapitellar (pivot)
60% load transfer across elbow joint
o proximal radius
nonarticular portion of the radial head is a ~90 degree arc from radial styloid to Lister's
tubercle (safe zone for hardware placement)
Ligaments
o lateral collateral ligament complex
lateral ulnar collateral ligament (LUCL)
primary stabilizer to varus and external rotation stress
deficiency results in posterolateral rotatory instability
radial collateral ligament (RCL)
accessory lateral collateral ligament
annular ligament
stabilizes proximal radioulnar joint
o medial (ulnar) collateral ligament (MCL)
three bundles
anterior bundle
primary stabilizer to valgus stress
(radial head is second)
posterior bundle
transverse bundle
Biomechanics
o radial head confers two types of stability to the elbow
valgus stability
secondary restraint to valgus load at the elbow, important if MCL deficient
longitudinal stability
restraint to proximal migration of the radius
contributions from interosseous membrane and DRUJ
load-sharing from wrist to radiocapitellar joint, dependant on radiocapitellar surface area
loss of longitudinal stability occurs when
radial head fracture + DRUJ injury + interosseous membrane disruption (Essex-
Lopresti)
radial head must be fixed or replaced to restore stability, preventing proximal
migration of the radius and ulnocarpal impaction
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Classification
Mason Classification (Modified by Hotchkiss and Broberg-Morrey)
Nondisplaced or minimally displaced (<2mm), no mechanical block to
Type I
rotation
Displaced >2mm or angulated, possible mechanical block to forearm
Type II
rotation
Type III Comminuted and displaced, mechanical block to motion
Type IV Radial head fracture with associated elbow dislocation
Presentation
Symptoms
o pain and tenderness along lateral aspect of elbow
o limited elbow or forearm motion, particularly supination/pronation
Physical exam
o range of motion
evaluate for mechanical blocks to elbow motion
flexion/extension and pronation/supination
aspiration of joint hematoma and injection of local anesthesia aids in evaluation of
mechanical block
o stability
elbow
lateral pivot shift test (tests LUCL)
valgus stress test (tests MCL)
DRUJ
palpate wrist for tenderness
translation in sagittal plane > 50% compare to contralateral side is abnormal
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may be difficult to determine on exam, can get dynamic CT scan in neutral, pronation
and supination for subtle injury
interosseous membrane
palpate along interosseous membrane for tenderness
radius pull test
>3mm translation concerning for longitudinal forearm instability (Essex-Lopresti)
Imaging
Radiographs
o recommended views
AP and lateral elbow
check for fat pad sign indicating occult minimally displaced fracture
o additional views
radiocapitellar view (Greenspan view)
oblique lateral view of elbow
beam angled 45 degrees cephalad
allows visualization of the radial head without coronoid overlap
helps detect subtle fractures of the radial head
CT
o further delineate fragments in comminuted fractures
o identify associated injuries in complex fracture dislocations
III:21 The radiocapitellar (Greenspan) view is obtained by aiming the beam 45 degree cephalad,
lessening the overlap between the proximal radius and olecranon, making subtle radial head fractures easier to identify
Treatment
Nonoperative
o short period of immobilization followed by early ROM
indications
isolated minimally displaced fractures with no mechanical blocks (Mason Type I)
outcomes
elbow stiffness with prolonged immobilization
good results in 85% to 95% of patients
Operative
o ORIF
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indications
Mason Type II with mechanical block
Mason Type III where ORIF feasible
presence of other complex ipsilateral elbow injuries
outcomes
# fragments
ORIF shown to have worse outcome with 3 or more fragments compared to ORIF
with < 3 fragments
isolated vs. complex
ORIF isolated radial head fractures versus complex radial head fractures (other
associated fracture/dislocation) show no significant difference in outcomes at 4 years
isolated fractures trended towards better Patient-Rated Elbow Evaluation score, lower
complication rate and lower rate of secondary capsular release
o fragment excision (partial excision)
indications
fragments less than 25% of the surface area of the radial head or 25%-33% of capitellar
surface area
outcomes : even small fragment excision may lead to instability
o radial head arthroplasty
indications
comminuted fractures (Mason Type III) with 3 or more fragments where ORIF not
feasible and involves greater than 25% of the radial head
elbow fracture-dislocations or Essex Lopresti lesions
radial head excision will exacerbate elbow/wrist instability and may result in proximal
radial migration and ulnocarpal impingement
outcomes
radial head fractures requiring replacement have shown good clinical outcomes with
metallic implants
compared to ORIF for fracture-dislocations and Mason Type III fractures, arthroplasty
results in greater stability, lower complication rate and higher patient satisfaction
o radial head resection
indications
low demand, sedentary patients
in a delayed setting for continued pain of an isolated radial head fracture
contraindications
presence of destabilizing injuries
forearm interosseous ligament injury (>3mm translation with radius pull test)
coronoid fracture
MCL deficiency
Techniques
Approaches to Radial Head
o overview
PIN crosses the proximal radius from anterior to posterior within the supinator muscle 4cm
distal to radial head
in both Kocher and Kaplan approaches, the forearm should be pronated to protect PIN
pronation pulls the nerve anterior and away from the surgical field
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o Kocher approach
interval
between ECU (PIN) and anconeus (radial n.)
key steps
incise posterior fibers of the supinator
incise capsule in mid-radiocapitellar plane
anterior to crista supinatoris to avoid damaging LUCL
pros
less risk of PIN injury than Kaplan approach (more posterior)
cons
risk of destabilizing elbow if capsule incision is too posterior and LUCL is
violated, which lies below the equator of the capitellum
o Kaplan approach
interval
between EDC (PIN) and ECRB (radial n.)
key steps
incise mid-fibers of supinator
incise capsule anterior to mid-radiopatellar plane (have access)
pros
less risk of disrupting LUCL and destabilizing elbow than Kocher approach (more
anterior)
better visualization of the coronoid
cons
greater risk of PIN and radial nerve injury
The Kaplan approach uses the Pronation of the forearm pulls the PIN
more anterior interval between anteromedially and away from the lateral surgical
ECRB and EDC. The Kocher field.
approach uses the more
posterior interval between ECU
and anconeus.
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ORIF
o approach
Kocher or Kaplan approach
o plates
fracture involved head and neck
posterolateral plate placement
safe zone (nonarticular area) consists of 90-110 degree arc from radial styloid to Lister's
tubercle, with arm in neutral rotation to avoid impingement of ulna with forearm rotation
bicipital tuberosity is the distal limit of plate placement
anything distal to that will endanger PIN
countersink implants on articular surface
o screws
headless compression screws (Hebert) if placed in articular surface
better elbow range of motion and functional outcome scores at 1 year compared to plate
fixation
Radial head arthroplasty
o approach
Kocher or Kaplan approach
o technique
metal prostheses
loose stemmed prosthesis
that acts as a stiff spacer
bipolar prosthesis
that is cemented into the neck of the radius
silicon replacements are no longer used
III:22 Safe zone
indepedent risk factor for revision surgery
o complications
overstuffing of joint that leads to capitellar wear problems and malalignment instability
overstuffing of joint is best assessed under direct visualization
Radial head resection
o approach
Kocher or Kaplan approach
o complications after excision of the radial head include
muscle weakness
wrist pain
valgus elbow instability
heterotopic ossification
arthritis
proximal radial migration
decreased strength
cubitus valgus
Complications
Displacement of fracture
o occurs in less than 5% of fractures; serial radiographs do not change management
Posterior interosseous nerve injury (with operative management)
Loss of fixation
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Loss of forearm rotation
Elbow stiffness
o first-line management incluides supervised exercise therapy with static or dynamic progressive
elbow splinting over a 6 month period
Radiocapitellar joint arthritis
Infection
Heterotopic ossification
Hardware loosening
Complex regional pain syndrome
3. Coronoid Fractures
Introduction
Coronoid fractures are pathognomonic of an episode of elbow instability
o may be
isolated coronoid fracture : less common than previously thought
coronoid fracture + associated injuries
commonly occur with elbow dislocation
associated with recurrent instability after dislocation
Mechanism
o traumatic shear injury
typically occurs as distal humerus is driven against coronoid with an episode of severe varus
stress or posterior subluxation
not an avulsion injury as nothing inserts on tip
Pathoanatomy
o fractures at the coronoid base can amplify elbow instability given that
anterior bundle of the medial ulnar collateral ligament attaches to the sublime tubercle 18 mm
distal to tip
anterior capsule attaches 6 mm distal to the tip of the coronoid
Epidemiology
o incidence : 10-15% of elbow injuries
Associated conditions
o posteromedial rotatory instability
coronoid anteromedial facet fracture and LCL disruption III:23 anteromedial facet fracture
Anatomy
Coronoid osteology
o coronoid tip
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is an intraarticular structure
can be visualized during elbow arthroscopy
o medial facet
important for varus stability
provides insertion for the medial ulnar collateral ligament
Coronoid biomechanics
o coronoid functions as an anterior buttress of the olecranon greater sigmoid notch
important in preventing recurrent posterior subluxation
o primary resistor of elbow subluxation or dislocation
Classification
Regan and Morrey Classification
Type I coronoid process tip fracture
Type II fracture of 50% or less of height
Type III fracture of more than 50% of height
O'Driscoll Classification
Subdivides coronoid injuries based on location and number of coronoid
fragments
Recognizes anteromedial facet fractures caused by varus posteromedial rotatory
force
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Presentation
Symptoms
o elbow deformity & swelling
o elbow pain
o forearm or wrist pain may be a sign of associated injuries
Physical exam
o inspection & palpation
varus or valgus deformity
ecchymosis & swelling
diffuse tenderness
o range of motion & instability
document flexion-extension and pronation-supination
crepitus should be noted
varus/valgus instability stress test
challenging but important for an accurate diagnosis
o neurovascular exam
Imaging
Radiographs
o recommended views : AP and lateral elbow views I II:25 anteromedial facet
coronoid fracture ap and
o findings : interpretation may be difficult due to overlapping structures lateral radiographs
CT scan : useful for high grade injuries and comminuted fractures
Treatment
Nonoperative
o brief period of immobilization, followed by early range of motion
indications : Type I, II, and III that are minimally displaced with stable elbow
Operative
o ORIF with medial approach
indications
Type I, II, and III with persistent elbow instability
posteromedial rotatory instability
o ORIF with posterior approach
indications
olecranon fracture dislocation
terrible triad of elbow
o hinged external fixation
indications
large fragments
poor bone quality
difficult revision cases to help maintain stability
Techniques
ORIF with medial approach
o approach
III:26 ORIF with buttress
plate fixation and screws
medial exposure through an interval between two heads of FCU
exposure more anteriorly through a split in flexor pronator mass
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o technique
cerclage wire or No. 5 suture through ulna drill holes for Type I injuries
ORIF with retrograde cannulated screws or plate for Type II or III injuries
ORIF with buttress plate fixation or pins and lateral ligament repair for posteromedial
rotatory instability
o postoperative rehabilitation
depends on intraoperative exam following the procedure
thermoplastic resting splint
applied with elbow at 90° and forearm in neutral
restrict terminal 30° extension for 2-4 weeks
avoid shoulder abduction for 4-6 weeks
to prevent varus moment on arm
early active motion
dynamic muscle contraction may improve gapping of the ulnohumeral joint after surgical
repair
ORIF with posterior approach
o approach : posterior
o technique
mobilize olecranon fracture to access coronoid fracture for associated olecranon fracture-
dislocations
repair coronoid fragment first prior to reducing main ulnar fracture
olecranon ORIF with dorsal plate and screws
Complications
Recurrent elbow instability : especially medial-sided
Elbow stiffness
Posttraumatic arthritis
Heterotopic ossification
Early failure : associated with failure to recognize and repair underlying elbow instability
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Anatomy
Radial head
o forearm in neutral rotation, lateral portion of articular
margin devoid of cartilage
roughly between radial styloid and listers tubercle
o provides anterior and valgus buttress
Coronoid process
o provides an anterior and varus buttress
Medial collateral ligament
o anterior bundle, posterior bundle, and transverse
ligament components III:28Lateral collateral ligament
o anterior bundle most important to stability, restraint to
valgus and posteromedial rotatory instability
inserts on sublime tubercle (anteromedial facet of coronoid)
specifically inserts 18.4mm dorsal to tip of coronoid process
Lateral collateral ligament
o inserts on supinator crest distal to lesser sigmoid notch
o restraint to varus and posterolateral rotatory instability
o two components
lateral ulnar collateral ligament (most important for stability)
lateral radial collateral ligament : attaches to annular ligament
Presentation
Symptoms : patients complain of pain, clicking and locking with elbow
in extension
Physical exam
o varus instability
o may show valgus instability if injury to MCL
Imaging
Radiographs
o evaluate for concentricity of ulnohumeral and radiocapitellar joints
o line drawn through center of radial neck should intersect the center of the capitellum regardless
of radiographic projection
o evaluate lateral radiograph for coronoid fracture
CT
o better evaluation of coronoid fracture
o 3D imaging for determining fracture line propagation
Treatment
Nonoperative
o immobilize in 90 deg of flexion for 7-10 days
indications (rare)
ulnohumeral and radiocapitellar joints must be concentrically reduced
elbow should extend to at least 30 degrees before becoming unstable
CT must show insignificant radial head/neck fx, no block to motion
coronoid fx limited to tip
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technique
active motion initiated with resting splint at 90 degrees, avoiding terminal extension
static progressive extension splinting at night after 4-6 weeks
strengthening protocol after 6 weeks
Operative
o acute radial head stabilization, coronoid ORIF, and LCL reconstruction, MCL
reconstruction if needed
indications
terrible triad elbow injury that includes a unstable radial head fracture, a type III coronoid
fracture, and an associated elbow dislocation
Techniques
Acute radial head stabilization, coronoid ORIF, and LCL reconstruction, MCL reconstruction
if needed
o approach
posterior skin incision advantageous
allows access to both medial and lateral aspect of elbow
lower risk of injury to cutaneous nerves
more cosmetic
o technique
radial head ORIF vs. arthroplasty
radial head arthroplasty indicated for comminuted radial head fracture
use of modular prosthesis preferable
sizing based on fragments removed from elbow
implant should articulate 2mm distal to the tip of the coronoid process
radial head resection without replacement is NOT indicated in presence of Essex-
Lopresti lesion or in young active patient
it <25% head damaged or fragments not reconstructable and nonarticulating, can excise
fractured portion if elbow stable (rarely indicated)
radial head ORIF indicated if non comminuted with good bone stock and fracture
involves < 40% articular surface
1.5, 2.0, or 2.4mm countersunk screws
plating if necessary; 2.0 plates cause minimal loss of motion even when placed on
radial neck
coronoid ORIF
can be fixed through radial head defect laterally
fix with suture passed through 2 drill holes, or posterior to anterior lag screws if fragment
large
basal coronoid fxs (rare) fixed with anteromedial or medial plate on proximal ulna
LCL repair
usually avulsed from origin on lateral epicondyle
reattach with suture anchors or transosseous sutures
must be reattached at center of capitellar curvature on lateral epicondyle
if MCL is intact, LCL is repaired with forearm in pronation
if MCL injured, LCL is repaired with forearm in supination to avoid medial gapping due
to overtightening
repairs are performed with elbow at 90 degrees of flexion
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MCL repair
indicated if instability on exam after LCL and fracture fixation, especially with extension
beyond 30 degrees
instability after complete bone and soft tissue repair indicates need for hinged or static elbow
fixator application
postoperative
immobilize elbow in flexion with forearm pronation to provide stability against posterior
subluxation
if both MCL and LCL were repaired, splint in flexion and neutral rotation.
Complications
Instability : more common following type I or II coronoid fractures
Failure of internal fixation
o most common following repair of radial neck fractures
poor vascularity leading to osteonecrosis and nonunion
Posttraumatic stiffness
o very common
o initiate early ROM to prevent
Heterotopic ossification
o consider prophylaxis in pts with head injury or in setting of revision surgery
Posttraumatic arthritis : due to chondral damage at time of injury and/or residual instability
5. Olecranon Fractures
Introduction
Epidemiology
o bimodal distribution
high energy injuries in the young
low energy falls in the elderly
Pathophysiology
o mechanism
direct blow
usually results in comminuted fracture
indirect blow
fall onto outstretched upper extremity
usually results in transverse or oblique fracture
Anatomy
Osteology
o together with coronoid process, forms the greater sigmoid (semilunar) notch
o greater sigmoid notch articulates with trochlea
provides flexion-extension movement
adds to stability of elbow joint
Muscles
o triceps
inserts onto posterior, proximal ulna
blends with periosteum
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innervated by radial nerve (C7)
o anconeus
insertson lateral aspect of olecranon
innervate by radial nerve (C7)
Classification
Mayo Classification
Based on comminution, displacement, fracture-
dislocation
Colton Classification
Nondisplaced - Displacement does not increase with elbow flexion
Avulsion (displaced)
Oblique and Transverse (displaced)
Comminuted (displaced)
Fracture dislocation
Schatzker Classification
Type A Simple transverse fracture
Type B Transverse impacted fracture
Type C Oblique fracture
Type D Comminuted fracture
Type E More distal fracture, extra-articular
Type F Fracture-dislocation
AO Classification
Type A Extra-articular
Type B Intra-articular
Type C Intra-articular fractures of both the radial head and olecranon
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Elbow
Colton Classification
Schatzker Classification
Type A Type B
Imaging
Radiographs
o recommended views
AP/lateral radiographs
true lateral essential for determination of fracture pattern
o additional views
radiocapitellar may be helpful for
radial head fracture
capitellar shear fracture
CT : may be useful for preoperative planning in comminuted fractures
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Treatment
Nonoperative
o immobilization
indications
nondisplaced fractures
displaced fracture is low demand, elderly individuals
technique
immobilization in 45-90 degrees of flexion initially
begin motion at 1 week
Operative
o tension band technique
indications
transverse fracture with no comminution
outcomes
excellent results with appropriate indications
o intramedullary fixation
indications
transverse fracture with no comminution (same as tension band technique)
o plate and screw fixation
indications
comminuted fractures
Monteggia fractures
fracture-dislocations
oblique fractures that extend distal to coronoid
o excision and triceps advancement
indications
elderly patients with osteoporotic bone
fracture must involve <50% of joint surface
nonunions
outcomes
salvage procedure that leads to decreased extension strength
may result in instability if ligamentous injury is not diagnosed before operation
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Surgical Techniques
Tension band technique: technique
converts distraction force of triceps into a compressive force
engaging anterior cortex of ulna with Kirschner wires may prevent wire migration
avoid overpenetration of wires through anterior cortex
may injury anterior interosseous nerve (AIN)
may lead to decreased forearm rotation
use 18-gauge wire in figure-of-eight fashion through drill holes in ulna
o cons
high % of second surgeries for hardware removal (40-80%)
does not provide axial stability in comminuted fractures
Intramedullary fixation: technique
can be combined with tension banding
intramedullary screw must engage distal intramedullary canal
Plate and screw fixation
o technique
place plate on dorsal (tension) side
oblique fractures benefit from lag screws in addition to plate fixation
one-third tubular plates may not provide sufficient strength in comminuted fractures
may advance distal triceps tendon over plate to avoid hardware prominence
o pros : more stable than tension band technique
o cons : 20% need second surgery for plate removal
Excision and triceps advancement
o technique : triceps tendon reattached with nonabsorbable sutures passed through drill holes in
proximal ulna
Complications
Symptomatic hardware : most frequent reported complication
Stiffness : occurs in ~50% of patients , usually doesn't alter functional capabilities
Heterotopic ossification : more common with associated head injury
Posttraumatic arthritis
Nonunion : rare
Ulnar nerve symptoms
Anterior interosseous nerve injury
Loss of extension strength
6. Capitellum Fractures
Introduction
Coronal fracture of the distal humerus at capitellum
Epidemiology : 1% of elbow fractures
Mechanism of injury : fall on outstretched hand
Prognosis
o most patients will gain functional range of motion but have residual stiffness
o surgical treatment results are generally favorable
reoperation rates as high as 48%
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Classification
Bryan and Morrey Classification (with McKee modification)
Type I Large osseous piece of the capitellum involved
Can involve trochlea
Type II Kocher-Lorenz fracture
Shear fracture of articular cartilage
Articular cartilage separation with very little subchondral bone attached
Type III Broberg-Morrey fracture
Severely comminuted
Multifragmentary
Type IV McKee modification
Coronal shear fracture that includes the capitellum and trochlea
Type I Type II
Type III
Presentation
History : fall on outstretched arm
Symptoms : elbow pain, swelling
Physical exam : may have mechanical block to flexion and extension
Imaging
Radiographs : recommended
o AP and lateral of the elbow
best demonstrated on lateral radiograph
CT : delineates fracture anatomy and classification
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Treatment
Nonoperative
o posterior splint immobilization for < 3 weeks
indications : nondisplaced Type I and Type II fractures (<2 mm displacement)
Operative
o open reduction and internal fixation
indications
displaced Type I fractures (>2mm)
Type IV fractures
o fragment excision
indications
displaced (>2mm) Type II fractures
displaced (>2mm) Type III fractures
o total elbow arthroplasty
indications : unreconstructable capitellar fractures in elderly patients with associated medial
column instability
Technique
ORIF
o approach
lateral approach recommended for Type IV fx
posterior approach can be used if associated with other elbow injuries
o screw fixation
headless screw fixation
minifragment screw using posterior to anterior fixation
counter sink screw using anterior to posterior fixation
o avoid disruption of the blood supply that comes from the posterolateral aspect of the elbow
Complications
Elbow contracture (most common)
Nonunion (1-11% with ORIF)
Ulnar nerve injury
Heterotopic ossification (4% with ORIF)
AVN of capitellum
Nonunion of olecranon osteotomy
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D. Forearm
1. Monteggia Fractures
Introduction
Injury defined as proximal 1/3 ulnar fracture with associated radial head dislocation/instability
Epidemiology
o rare in adults
o more common in children with peak incidence between 4 and 10 years of age
different treatment protocol for children
Associated injuries
o may be part of complex injury pattern including
olecranon fracture-dislocation
radial head fx
coronoid fx
LCL injury
terrible triad of elbow
Prognosis : if diagnosis is delayed greater than 2-3 weeks complication rates increase significantly
Anatomy
Ligament : annular ligament
Classification
Bado Classification
Type I Fracture of the proximal or middle third of the ulna with anterior
60% dislocation of the radial head (most common in children and young
adults)
Type II 15% Fracture of the proximal or middle third of the ulna with posterior
dislocation of the radial head (70 to 80% of adult Monteggia fractures)
Type III Fracture of the ulnar metaphysis (distal to coronoid process) with lateral
20%
dislocation of the radial head
Type IV Fracture of the proximal or middle third of the ulna and radius with
5%
dislocation of the radial head in any direction
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Presentation
Symptoms
o pain and swelling at elbow joint
III:29 Jupiter Classification of Type II Monteggia
Physical exam Fracture-Dislocations
o inspection
may or may not be obvious dislocation at radiocapitellar joint
should evaluate skin integrity
o ROM & instability : may be loss of ROM at elbow due to dislocation
o neurovascular exam
PIN neuropathy
radial deviation of hand with wrist extension
weakness of thumb extension
weakness of MCP extension
most likely nerve injury
Imaging
Radiographs
o recommended view
AP and Lateral of elbow, wrist, and forearm
CT scan : helpful in fractures involving coronoid, olecranon, and radial head
Treatment
Nonoperative
o closed reduction
indications
more common and successful in children
must ensure stabilty and anatomic alignment of ulna fracture
technique : cast in supination for Bado I and III
Operative
o ORIF of ulna shaft fracture
indications
acute fractures which are open or unstable (long oblique)
comminuted fractures
most Monteggia fractures in adults are treated surgically
o ORIF of ulna shaft fracture, open reduction of radial head
indications
failure to reduce radial head with ORIF of ulnar shaft only
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ensure ulnar reduction is correct
complex injury pattern
o IM Nailing of ulna
indications : transverse or short oblique fracture
Techniques
ORIF of ulnar shaft fracture
o approach
lateral decubitus position with arm over padded support
midline posterior incision placed lateral to tip of olecranon
develop interval between flexor carpi ulnaris and anconeus along ulnar border proximally,
and interval between FCU and ECU distally
o techniques
with proper alignment of ulna radial head usually reduces and open reduction of radial head is
rarely needed
failure to align ulna will lead to chronic dislocation of radial head
ORIF of radial head
o approach : posterolateral (Kocher) approach
o technique
annular ligament often found interposed in radiohumeral joint preventing anatomic reduction
after ulnar ORIF
treatment based on involved components (radial head, coronoid, LCL)
Complications
PIN neuropathy
o up to 10% in acute injuries
o treatment
observation for 2-3 months
spontaneously resolves in most cases
if no improvement obtain nerve conduction studies
Malunion with radial head dislocation
o usually caused by failure to obtain anatomic alignment of ulna
o treatment
ulnar osteotomy and open reduction of the radial head
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Forearm
Anatomy
Osteology
o axis of rotation of forearm runs through radial head (proximal) and ulna fovea (distal)
distal radius effectively rotates around the distal ulna in pronosupination
Interosseous membrane (IOM)
o occupies the space between the radius and ulna
o comprised of 5 ligaments
central band is key portion of IOM to be reconstructed
accessory band
distal oblique bundle
proximal oblique cord
dorsal oblique accessory cord
Classification
Descriptive
o closed versus open
o location
o comminuted, segmental, multifragmented
o displacement
o angulation
o rotational alignment III:30 Interosseous membrane
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OTA classification
o radial and ulna diaphyseal fractures
Type A : simple fracture of ulna (A1), radius (A2), or both bones (A3)
Type B : wedge fracture of ulna (B1), radius (B2), or both bones (B3)
Type C : complex fractures
Presentation
Symptoms
o gross deformity, pain, swelling
o loss of forearm and hand function
Physical exam
o inspection
open injuries
check for tense forearm compartments
o neurovascular exam
assess radial and ulnar pulses
document median, radial, and ulnar nerve function
o pain with passive stretch of digits
alert to impending or present compartment syndrome
Imaging
Radiographs
o recommended views
Treatment
Nonoperative
o functional fx brace with good interosseous mold
indications
isolated nondisplaced or distal 2/3 ulna shaft fx (nightstick fx) with
< 50% displacement and
< 10° of angulation
outcomes
union rates > 96%
acceptable to fix surgically due to long time to union
Operative
o ORIF without bone grafting
indications
displaced distal 2/3 isolated ulna fxs
proximal 1/3 isolated ulna fxs
all radial shaft fxs (even if nondisplaced)
both bone fxs
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Gustillo I, II, and IIIa open fractures may be treated with primary ORIF
outcomes
most important variable in functional outcome is to restore the radial bow
o ORIF with bone grafting
indications
cancellous autograft is indicated in radial and ulnar fractures with bone loss
bone loss that is segmental or associated with open injury
nonunions of the forearm
o external fixation
indications
Gustillo IIIb and IIIc open fractures
o IM nailing
indications
poor soft-tissue integrity
not preferred due to lack of rotational and axial stability and difficulty maintaining radial
bow (higher nonunion rate)
Techniques
ORIF
o approach
usually performed through separate approaches due to risk
of synostosis
radius
volar (Henry) approach to radius
best for distal 1/3 and middle 1/3 radial fx
dorsal (Thompson) approach to radius
best for middle and proximal 1/3 radial fx
ulna
subcutaneous approach to ulna shaft
o technique
3.5 mm DCP plate (AO technique) is standard
longer plates are preferred due to high torsional stress in forearm
locked plates are increasingly indicated over conventional plates in osteoporotic bone and
in bridging comminuted fractures
bone grafting
vascularized fibula grafts can be used for large defects and have a lower rate of infection
o postoperative care
early ROM unless there is an injury to proximal or distal joint
should be managed with a period of non-weight bearing due to risk of secondary
displacement of the fracture
Complications
Synostosis
o uncommon with an incidence of 3 to 9%
o associated with ORIF using a single incision approach
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o heterotopic bone excision can be performed with low recurrence risk as early as 4-6 months post-
injury when prophylactic radiation therapy and/or indomethacin are used postoperatively
Infection
o 3% incidence with ORIF
Compartment syndrome
o increased risk with
high energy crush injury
open fxs
low velocity GSWs
vascular injuries
coagulopathies (DIC)
Nonunion
o commonly result from technical error or use of IM fixation
o atrophic nonunions can be treated with 3.5 mm plates and autogenous cancellous bone grafting
Malunion
o direct correlation between restoration of radial bow and functional outcome
Neurovascular injury
o uncommon except
PIN injury with Monteggia fxs and Henry (volar) approach to middle and upper third radial
diaphysis
Type III open fxs
o observe for three months to see if nerve function returns
explore if no return of function after 3 months
Refracture
o increased risk with
removing plate too early
large plates (4.5 mm)
comminuted fx
persistent radiographic lucency
o do not remove plates before 15 mos.
o wear functional forearm brace for 6 weeks and protect activity for 3 mos. after plate removal
3. Radioulnar Synostosis
Introduction
Bony bridge which develops between radius and ulna secondary to a specific event
o must differentiate from congenital radioulnar synostosis
Epidemiology
o incidence : 3% to 9%
o risk factors
trauma related
Monteggia fracture
both bone forearm fractures at the same level
open fracture,
significant soft-tissue lesion
comminuted fracture
high energy fracture
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associated head trauma
bone fragments on the interosseous membrane
treatment related
use of one incision for both radius and ulna
delayed surgery > 2 weeks
screws that penetrate interosseous membrane
bone grafting into interosseous membrane
prolonged immobilization
Anatomy
Forearm anatomy
Presentation
History : previous trauma or surgery in forearm
Symptoms
o pain with incomplete synostosis
o no pain with complete synostosis
Physical exam : pronation and supination blocked both actively and passively
Imaging
Radiographs
o recommended views : AP and lateral of forearm, elbow, and wrist
o findings : bony bridge between radius and ulna
Treatment
Operative
o surgical resection of synostosis, irradiation, and indomethacin
indications
mature post-traumatic synostosis that impairs function
excision indicated at 4-6 months
timing is controversial
excision too early can lead to recurrence
excision too late can lead to surrounding joint contractures
results : results of resection are poor except for midshaft synostosis
o proximal radial excision
indications
reserved for patients who have a proximal radioulnar synostosis that is too extensive to
allow a safe resection, involves the articular surface, and is associated with an
anatomic deformity.
results
can provide forearm rotation
associated with radioulnar and/or elbow instability
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Classification
Fernandez: based on mechanism of injury
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Fernandez classification:
This is a mechanism-based classification system.
Type I: Metaphyseal bending fracture with the inherent problems of loss of palmar tilt and
radial shortening relative to the ulna (DRUJ injury)
Type II: Shearing fracture requiring reduction and often buttressing of the articular segment
Type III: Compression of the articular surface without the characteristic fragmentation; also the
potential for significant interosseous ligament injury
Type IV: Avulsion fracture or radiocarpal fracture dislocation
Type V: Combined injury with significant soft tissue involvement owing to high-energy injury
From Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition
Frykman: based on joint involvement (radiocarpal and/or radioulnar) +/- ulnar styloid fx
Frykman Classification
Distal Ulna Fracture
Distal Radius Fracture
Absent present
Extraarticular I II
Intraarticular involving radiocarpal joint III IV
Intraarticular involving distal radioulnar joint
V VI
(DRUJ)
Intraarticular involving radiocarpal and DRUJ VII VIII
From Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition
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Eponyms: see table for list of commonly used eponyms
Eponyms
Die-punch fxs A depressed fracture of the lunate fossa of the articular surface of the distal radius
Barton's fx Fx dislocation of radiocarpal joint with intra-articular fx involving the volar or dorsal lip
(volar Barton or dorsal Barton fx)
Chauffer's fx Radial styloid fx
Colles' fx Low energy, dorsally displaced, extra-articular fx
Smith's fx Low energy, volar displaced, extra-articular fx
AP Radial height 13 mm
<5 mm shortening
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Treatment
Successful outcomes correlate with
o accuracy of articular reduction
o restoration of anatomic relationships
o early efforts to regain motion of wrist and fingers
Nonoperative
o closed reduction and cast immobilization
indications
extra-articular
<5mm radial shortening
dorsal angulation <5° or within 20° of contralateral distal radius
technique (see below)
Operative
o surgical fixation (CRPP, External Fixation, ORIF)
indications: radiographic findings indicating instability (pre-reduction radiographs best
predictor of stability)
displaced intra-articular fx
volar or dorsal comminution
articular margins fxs
severe osteoporosis
dorsal angulation >5° or >20° of contralateral distal radius
>5mm radial shortening
comminuted and displaced extra-articular fxs (Smith's fx)
progressive loss of volar tilt and loss of radial length following closed reduction and
casting
associated ulnar styloid fractures do not require fixation
Closed reduction and cast immobilization
Indications : most extra-articular fxs
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Technique
o rehabilitation
no significant benefit of physical therapy over home exercises for simple distal radius
fractures treated with cast immobilization
Outcomes : repeat closed reductions have 50% less than satisfactory results
Complications
o acute carpal tunnel syndrome : (see complications below)
o EPL rupture : (see complications below)
Percutaneous Pinning
Indications
o can maintain sagittal length/alignment in extra-articular fxs with stable volar cortex
o cannot maintain length/alignment when unstable or comminuted volar cortex
Techniques
o Kapandji intrafocal technique
o Rayhack technique with arthroscopically assisted reduction
Outcomes : 82-90% good results if used appropriately
External Fixation
Indications
o alone cannot reliably restore 10 degree palmar tilt
therefore usually combined with percutaneous pinning technique or plate fixation
Technical considerations
o relies on ligamentotaxis to maintain reduction
o place radial shaft pins under direct visualization to avoid injury to superficial radial nerve
o nonspanning ex-fix can be useful if large articular fragment
o avoid overdistraction (carpal distraction < 5mm in neutral position) and excessive volar flexion
and ulnar deviation
o limit duration to 8 weeks and perform aggressive OT to maintain digital ROM
Outcomes : important adjunct with 80-90% good/excellent results
Complications
o malunion/nonunion
o stiffness and decreased grip strength
o pin complications (infections, fx through pin site, skin difficulties)
pin site care comprising daily showers and dry dressings recommended
o neurologic (iatrogenic injury to radial sensory nerve, median neuropathy, RSD)
ORIF
Indications
o significant articular displacement (>2mm)
o dorsal and volar Barton fxs
o volar comminution
o metaphyseal-diaphyseal extension
o associated distal ulnar shaft fxs
o die-punch fxs
Technique
o volar plating
volar plating preferred over dorsal plating
volar plating associated with irritation of both flexor and extensor tendons
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rupture of FPL is most common with volar plates
associated with plate placement distal to watershed area, the most volar margin of the
radius closest to the flexor tendons
new volar locking plates offer improved support to subchondral bone
o dorsal plating
dorsal plating historically associated with extensor tendon irritation and rupture
dorsal approach indicated for displaced intra-articular distal radius fracture with dorsal
comminution
o other technical considerations
can combine with external fixation and PCP
bone grafting if complex and comminuted
study showed improved results with arthroscopically assisted reduction
volar lunate facet fragments may require fragment specific fixation to prevent early post-
operative failure
Complications
Median nerve neuropathy (CTS)
o most frequent neurologic complication
o 1-12% in low energy fxs and 30% in high energy fxs
o prevent by avoiding immobilization in excessive wrist flexion and ulnar deviation (Cotton-Loder
Position)
o treat with acute carpal tunnel release for:
progressive paresthesias, weakness in thumb opposition
paresthesias do not respond to reduction and last > 24-48 hours
Ulnar nerve neuropathy : seen with DRUJ injuries
EPL rupture
o nondisplaced distal radial fractures have a higher rate of spontaneous rupture of the extensor
pollicis longus tendon
extensor mechanism is felt to impinge on the tendon following a nondisplaced fracture and
causes either a mechanical attrition of the tendon or a local area of ischemia in the tendon.
o treat with transfer of extensor indicis proprius to EPL
Radiocarpal arthrosis (2-30%)
o 90% young adults will develop symptomatic arthrosis if articular stepoff > 1-2 mm
o may be nonsymptomatic
Malunion and Nonunion
o Intra-articular malunion : treat with revision at > 6 weeks
o Extra-articular angulation malunion
treat with opening wedge osteotomy with ORIF and bone grafting
o Radial shortening malunion
radial shortening associated with greatest loss of wrist function and degenerative changes in
extra-articular fxs
treat with ulnar shortening
ECU or EDM entrapment : entrapment in DRUJ injury
Compartment syndrome
RSD/CRPS
o AAOS 2010 clinical practice guidelines recommend vitamin C supplementation to prevent
incidence of RSD postoperatively
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Forearm
Anatomy
DRUJ
o arthrology
articulation occurs between the ulnar head and sigmoid notch (a shallow concavity found
along ulnar border of distal radius)
most stable in supination
o primary stabilizers
volar and dorsal radioulnar ligaments
TFCC
TFCC attaches to the fovea at the base of the ulnar styloid
components include
central articular disc
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meniscal homologue
volar
and dorsal radioulnar ligaments
ulnolunate and ulnotriquetral ligament origins
floor of the ECU tendon sheath
o biomechanics : joint motion includes both rotation and translation
Presentation
Symptoms
o pain and instability with acute DRUJ dislocation
o dorsal wrist pain and limited pronosupination with post-traumatic arthritis
Physical exam
o post-traumatic arthritis
snapping and crepitus
proximal rotation of the forearm with compression of the ulna against the radius elicits pain
decreased grip strength
Imaging
Radiographs
o AP shows widening of the DRUJ
o lateral shows dorsal displacement : instability of the DRUJ is present when the ulnar head is
subluxed from the sigmoid notch by its full width with the arm in neutral rotation
Dynamic CT
o useful in the diagnosis of subtle chronic DRUJ instability
o sequential CT scans are performed with the forearm in neutral and full supination and pronation
o >50% translation compared to the contralateral side is abnormal
MRI : useful in the identification of TFCC injuries
Treatment
Nonoperative
o closed reduction, immobilization
indications : DRUJ instability resulting from purely ligamentous
injury
techniques
closed reduction and immobilization in a position of stability III:31 MRI showig TFCC tear
for 4 weeks
dorsal instability is stable with the forearm in supination
volar instability is stable in pronation
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Forearm
outcomes : interposition of ECU may impede closed reduction
Operative
o DRUJ pinning, radioulnar ligament repair
indications : highly unstable DRUJ
techniques : pinning across joint with 0.062-inch K-wires
TFCC Tears
Mechanism of injury
o wrist extension, forearm pronation
in pronation, volar ligaments prevent dorsal subluxation
in supination, dorsal ligaments prevent volar subluxation
Classification
o type I - traumatic
o type II - degenerative (ulnocarpal impaction)
IIA - TFCC thinning III:32 Darrach procedure
IIB - IIA + lunate and/or ulnar chondromalacia
IIC - IIB + TFCC perforation
IID - IIC + LT ligament disruption
IIE - IID + ulnocarpal and DRUJ arthritis
Treatment
o nonoperative
immobilization, NSAIDS
indications : all acute traumatic TFCC tears
o operative
arthroscopic vs. open debridement and/or repair
indications
failure of nonoperative management
III:33Sauve-Kapandji procedure
persistent symptoms
techniques
type I injuries
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arthroscopic vs. open debridement and/or repair
type II injuries
TFCC pathology treated with arthroscopic or open debridement
ulnocarpal impaction treated with ulnar shortening osteotomy (in the absence of
DRUJ arthrosis) or wafer resection of the ulnar head
Ulnar Impaction Syndrome
Radial shortening leads to positive ulnar variance and altered mechanics
Sequelae includes
o lunate chondromalacia
o degenerative TFCC tears
Operative treatment
o TFCC debridement
o radial osteotomy
o ulnar shortening
o distal ulnar resection (Wafer procedure)
preserve ulnar attachment of TFCC
Essex-Lopresti Injuries
Radial head fracture with an interosseous membrane injury extending
to DRUJ
o unstable relationship between ulna and radius
o leads to proximal migration of the radius
o results in secondary DRUJ pathology and ulnocarpal abutment
Treatment
o treat bony pathology (radial head or shaft)
o pin DRUJ for 6 weeks in neutral to facilitate ligamentous healing
o if pinning fails (or the initial injury is missed) radial head
replacement may be required
Galeazzi Fractures
Distal one-third fracture of the radius and a DRUJ injury
ECU entrapment may cause DRUJ to be irreducible
Treatment
o nonoperative
splint in supination
indications : rarely indicated for stable injuries
o operative
radial ORIF and DRUJ pinning
indications : often required to achieve a stable reduction
6. Galeazzi Fractures
Introduction
Definition
o distal 1/3 radius shaft fx AND
o associated distal radioulnar joint (DRUJ) injury
Incidence of DRUJ instability
o if radial fracture is <7.5 cm from articular surface : unstable in 55%
o if radial fracture is >7.5 cm from articular surface : unstable in 6%
Mechanism
o direct wrist trauma : typically dorsolateral aspect
o fall onto outstretched hand with forearm in pronation
Anatomy
DRUJ
o sigmoid notch
found along ulnar border of distal radius
is a shallow concavity for the articulating ulnar head
o volar and dorsal radioulnar ligaments
function as the primary stabilizers of the DRUJ
o most stable in supination
Classification
OTA classification of radius/ulna
o included under subgroups and qualifications
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Presentation
Symptoms : pain, swelling, deformity
Physical exam
o point tenderness over fracture site
o ROM : test forearm supination and pronation for instability
o DRUJ stress : causes wrist or midline forearm pain
Imaging
Radiographs
o recommended views
AP and lateral views of forearm, elbow, and wrist
o findings : signs of DRUJ injury
ulnar styloid fx
widening of joint on AP view
dorsal or volar displacement on lateral view
radial shortening (≥5mm)
Treatment
Operative
o ORIF of radius with reduction and stabilization of DRUJ
indications
all cases, as anatomic reduction of DRUJ is required
acute operative treatment far superior to late reconstruction
Surgical Techniques
ORIF of radius
o approach : volar (Henry) approach to radius
o plate fixation
perform anatomic plate fixation of radial shaft
radial bow must be restored/maintained
Reduction & stabilization of DRUJ
o approach : dorsal capsulotomy
o reduction technique
immobilization in supination (6 weeks)
indicated if DRUJ stable following ORIF of radius
percutaneous pin fixation
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By Dr, AbdulRahman AbdulNasser Upper Extremity | Forearm
indicated if DRUJ reducible but unstable following ORIF of radius
cross-pin ulna to radius : leave pins in place for 4-6 weeks
open surgical reduction
indicated if reduction is blocked
suspect interposition of ECU tendon
open reduction internal fixation
indicated if a large ulnar styloid fragment exists
fix styloid and immobilize in supination
Complications
Compartment syndrome
o increased risk with
high energy crush injury
open fractures
vascular injuries or coagulopathies
o diagnosis
pain with passive stretch is most sensitive
Neurovascular injury : uncommon except type III open fractures
Refracture
o usually occurs following plate removal
o increased risk with
removing plate too early
large plates (4.5mm)
comminuted fractures
persistent radiographic lucency
o prevention
do not remove plates before 18 months after insertion
amount of time needed for complete primary bone healing
Nonunion
Malunion
DRUJ subluxation : displaced by gravity, pronator quadratus, or brachioradialis
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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OrthoBullets2017 Hand Trauma | Forearm
ORTHO BULLETS
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
A. Tendon Injuries
Anatomy
Muscles
o flexor digitorum profundus (FDP)
functions as a flexor of the DIP joint
assists with PIP and MCP flexion
shares a common muscle belly in the forearm
o flexor digitorum superficialis (FDS)
functions as a flexor of the PIP joint
assists with MCP flexion
individual muscle bellies exist in the forearm
FDS to the small finger is absent in 25% of people
o flexor pollicis longus (FPL)
located within the carpal tunnel as the most radial structure
o flexor carpi radialis (FCR) IV:1 Campers chiasm
primary wrist flexor
inserts on the base of the second metacarpal
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
Classification
Presentation
Symptoms
o loss of active flexion strength or motion of the involved digit(s)
Physical exam
o inspection
observe resting posture of the hand and assess the digital cascade
evidence of malalignment or malrotation may indicate an underlying fracture
assess skin integrity to help localize potential sites of tendon injury
look for evidence of traumatic arthrotomy
o range of motion
passive wrist flexion and extension allows for assessment of the tenodesis effect
normally wrist extension causes passive flexion of the digits at the MCP, PIP, and DIP
joints
maintenance of extension at the PIP or DIP joints with wrist extension indicates flexor
tendon discontinuity
active PIP and DIP flexion is tested in isolation for each digit
o neurovascular exam
important given the close proximity of flexor tendons to the digital neurovascular bundles
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Treatment
Nonoperative
o wound care and early range of motion
indications
partial lacerations < 60% of tendon width
outcomes
may be associated with gap formation or triggering
Operative
o flexor tendon repair and controlled mobilization
indications
lacerations > 60% of tendon width
outcomes
depends on zone of injury
o flexor tendon reconstruction and intensive postoperative rehabilitation
indications
failed primary repair
chronic untreated injuries
outcomes
subsequent tenolysis is required more than 50% of the time
o FDS4 transfer to thumb
single stage procedure
indication
chronic FPL rupture
Surgical Technique
Flexor Tendon Repair of Complete Lacerations
o approach
incisions should always cross flexion creases transversely or obliquely to avoid contractures
(never longitudinal)
o timing of repair
perform repair within three weeks of injury (2 weeks ideal)
waiting longer leads to difficulty due to tendon retraction
o technique
# of suture strands that cross the repair site is more important than the number of grasping
loops
linear relationship between strength of repair and # of sutures crossing repair
4-6 strands provide adequate strength for early active motion
high-caliber suture material increases strength and stiffness and decreases gap formation
locking-loops decrease gap formation
ideal suture purchase is 10mm from cut edge
core sutures placed dorsally are stronger
meticulous atraumatic tendon handling minimizes adhesions
circumferential epitendinous suture
improves tendon gliding
improves strength of repair (adds 20% to tensile strength)
allows for less gap formation (first step in repair failure)
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
simple running suture is recommended
sheath repair is controversial
theoretically improves tendon nutrition through synovial pathway
clinical studies show no difference with or without sheath repair
most surgeons will repair if it is easy to do
pulley management
critical to preserve A2 and A4 pulleys in digits and oblique pulley in thumb
FDS repair
in zone 2 injuries, repair of one slip alone improves gliding when compared to repair of
both slips
o outcomes
repair failure
tendon repairs are weakest between postoperative day 6 and 12
repair usually fails at suture knots
Flexor Tendon Repair of Partial Lacerations
o indications
>75% laceration
≥50-60% laceration with triggering
epitendinous suture at the laceration site is sufficient
no benefit of adding core suture
Wide-Awake Flexor Tendon Repair
o performed under tumescent local anesthesia using lidocaine with epinephrine
dosing
usually epinephrine 1:100,000 and 7mg/kg lidocaine
from 1:400,000 to 1:1000 is safe
if <50cc is needed
1% lidocaine with 1:100,000 epi for a 70kg person
if 50-100cc is needed
dilute with saline (50:50) to get 0.5% lidocaine, 1:200,000 epi
if 100-200cc is needed for large fields (tendon transfer, spaghetti wrist)
dilute with 150cc saline to get 0.25% lidocaine and 1:400,000 epi
for longer surgery >2h
add 10cc of 0.5% bupivacaine with 1:200,000 epi
location
proximal and middle phalanges, use 2ml
distal phalanx, use 1ml
palm, use 10-15ml
o no tourniquet, no sedation
o 4 advantages
allows intraoperative assessment for repair gaps by getting awake patient to actively flex digit
reduces need for postop tenolysis by allowing intraoperative assessment of whether repair
will fit through pulleys
allows on-the-spot debulking of bunched repairs
allows division of A4 pulley and venting (partial division) of A2 pulleys
allows repair of tendons inside tendon sheaths as patients can demonstrate that the inside of
the sheath has not been inadvertently caught
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facilitates postop early active motion
immobilize for 3 days
begin active midrange motion after day 3 (form a partial fist with 45 degree flexion at
MP, PIP and DIP joints, or "half a fist 45/45/45 regime")
Reconstruction Technique
o requirements
supple skin
sensate digit
adequate vascularity
full passive range of motion of adjacent joints
o techniques of reconstruction involving silicone rods
Hunter-Salisbury two-stage procedure
Stage I - silicone rod is placed to create a favorable tendon bed
Stage II (3-4 months) - retrieve SR and pass a tendon graft through the mesothelium lined
pseudosheath
only perform a single-stage reconstruction if the flexor sheath is pristine and the digit has
full ROM
pulvertaft weave proximally and end-to-end tenorrhaphy distally
Paneva-Holevich two-stage technique
Stage I - SR is placed in the flexor sheath, pulleys are reconstructed (as needed), and a
loop between the proximal stumps of FDS and FDP is created in the palm
Stage II - SR is retrieved, FDS is cut proximally and reflected distally through
pseudosheath and attached directly to FDP stump/or secured with button
advantages
graft (FDS) size is known at the time of silicone rod selection
less graft diameter-rod diameter mismatch
FDS graft is intrasynovial (fewer adhesions than extrasynovial grafts)
only relying on 1 tenorrhaphy site (distal or proximal) to heal at any one time (vs
Hunter technique where 2 tennoprhaphy sites are healing simultaneously)
disadvantage
graft tensioning is at the distal end during stage II
the proximal end has already healed after stage I
o graft choices
palmaris longus (absent in 15% of population)
most common
plantaris (absent in 19%)
indicated if longer graft is needed
long toe extensor
o pulley reconstruction
one pulley should be reconstructed proximal and distal to each joint
methods include belt loop method and FDS tail method
Tenolysis
o indications
localized tendon adhesions with minimal to no joint contracture and full passive digital
motion
may be required if a discrepancy between active and passive motion exists after therapy
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
o timing of procedure
wait for soft tissue stabilization (> 3 months) and full passive motion of all joints
o technique
careful technique to preserve A2 and A4 pulleys
o postoperative care
follow with extensive therapy
Postoperative Rehabilitation
Postoperative controlled mobilization has been the major reason for improved results with tendon
repair
o especially in zone II
o leads to improved tendon healing biology
o limits restrictive adhesions and leads to increased tendon excursion
Early active motion protocols
o moderate force and potentially high excursion
o dorsal blocking splint limiting wrist extension
o perform “place and hold” exercises with digits
Early passive motion protocols
o Duran protocol
low force and low excursion
active finger extension with patient-assisted passive finger flexion
o Kleinert protocol
low force and low excursion
active finger extension, dynamic splint-assisted passive finger flexion
o Mayo synergistic splint
low force and high tendon excursion
adds active wrist motion which increases flexor tendon excursion the most
Immobilize children and noncompliant patients
o Children should be immobilized following repair
o Casts or splints are applied with the wrist and MCP joints positioned in flexion and the IP joints
in extension
Complications
Tendon adhesions : most common complication following flexor tendon repair
Rerupture
o 15-25% rerupture rate
o treatment
if <1cm of scar is present, resect the scar and perform primary repair
if >1cm of scar is present, perform tendon graft
if the sheath is intact and allows passage of a pediatric urethral catheter or vascular
dilator, perform primary tendon grafting
if the sheath is collapsed, place Hunter rod and perform staged grafting
Joint contracture : rates as high as 17%
Swan-neck deformity
Trigger finger
Lumbrical plus finger
Quadrigia
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2. Jersey Finger
Introduction
Refers to an avulsion injury of FDP from insertion at base
of distal phalanx
o a Zone I flexor tendon injury
Epidemiology
o ring finger involved in 75% of cases
during grip ring fingertip is 5 mm more prominent
than other digits in ~90% of patients
therefore ring finger exposed to greater average force than other fingers during pull-away
Pathophysiology
o FDP muscle belly in maximal contraction during forceful DIP extension
Anatomy
Muscles
o Flexor Digitorum Profundus (ulnar n. and AIN n.)
Flexor zones : zone I extends from insertion of FDS distally
Classification
Leddy and Packer classification
(based on level of tendon retraction and presence of fracture)
Type Description Treatment
Type I FDP tendon retracted to palm. Leads to disruption of Prompt surgical treatment within 7 to 10
the vascular supply days
Type II FDP retracts to level of PIP joint Attempt to repair within several weeks for
opitmal outcome
Type III Large avulsion fracture limits retraction to the level of Attempt to repair within several weeks for
the DIP joint opitmal outcome
Type IV Osseous fragment and simultaneous avulsion of the If tendon separated from fracture
tendon from the fracture fragment ("Double avulsion” fragment, first fix fracture via ORIF then
with subsequent retraction of the tendon usually into reattach tendon as for Type I/II injuries
palm)
Ruptured tendon with bone avulsion with bony
Type V comminution of the remaining distal phalanx (Va,
extraarticular; Vb, intra-articular)
Presentation
Physical exam
o pain and tenderness over volar distal finger
o finger lies in slight extension relative to other fingers in resting position
o no active flexion of DIP
o may be able to palpate flexor tendon retracted proximally along flexor sheath
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
Imaging
Radiograhs
o may see avulsion fragement
Treatment
Operative
o direct tendon repair or tendon reinsertion with dorsal button
indications
acute injury (< 3 weeks)
technique
advancement of > 1 cm carries risk of a DIP flexion contracture or quadrigia
postoperative rehab should include either
early patient assisted passive ROM (Duran) or
dynamic splint-assisted passive ROM (Kleinert)
o ORIF fracture fragment
indications
types III and IV (for type IV then repair as for Type
I/II injuries)
techniques
with K-wire, mini frag screw or pull out wire
examine for symmetric cascade once fixation
completed
o two stage flexor tendon grafting
indications
chronic injury (> 3 months) in patient with full
PROM of the DIP joint
o DIP arthrodesis
indicated as salvage procedure in chronic injury (> 3
months) with chronic stiffness
Complications
Quadrigia
o advancement of > 1 cm carries risk of a DIP flexion contracture or quadrigia
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Classification
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
Presentation
Zone I
o Inability to extend at the DIP joint
Zone III
o Elson test
flex the patient's PIP joint over a table 90 degrees and ask them to extend against resistance
if central slip is intact, DIP will remain supple
if central slip disrupted, DIP will be rigid
Zone V
o extensor lag and flexion loss common
o junctura tendinae may allow partial/temporary extension by connecting with intact adjacent
extensor tendons
o sagittal band rupture
rupture of stronger radial fibers of sagittal band may lead to extensor tendon subluxation
finger held in flexed position at MCP joint with no active extension
Imaging
Radiographs
o AP and lateral of digit to verify no bony avulsion (boney mallet)
Treatment
Nonoperative
o immobilization with early protected motion
indications
lacerations < 50% of tendon in all zones if patient can extend digit against resistance
o DIP extension splinting
indications
acute (<12 weeks) Zone 1 injury (mallet finger)
nondisplaced bony mallet
chronic mallet finger (>12 weeks) if joint supple, congruent
techniques
full-time splinting for six weeks
part-time splinting for four to six weeks
avoid hyperextension, which may cause skin necrosis
maintain PIP motion
outcomes
noncompliance is a common problem
IV:2 Mallet Finger
o PIP extension splinting
indications
closed central slip injury (zone III)
techniques
full-time splinting for six weeks
part-time splinting for four to six weeks
maintain DIP flexion
IV:3 Boutonniere deformity
o MCP extension splinting
indications
closed zone V sagittal band rupture
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techniques
full-time splinting for four to six weeks
Operative
o immediate I&D
indications
fight bite to MCP joint
techniques
close loosely or in delayed fashion
IV:4 Sagittal band rupture
treat with culture-specific antibiotics, although Eikenella corrodens is a common mouth
organism
o tendon repair
indications
laceration > 50% of tendon width in all zones
o fixation of bony avulsion
indications
boney mallet finger with P3 volar subluxation
techniques
closed reduction and percutaneous pinning through DIP joint
extension block pinning
ORIF if it involves >50% of the articular surface
o tendon reconstruction
indications
chronic tendon injury or when repair not possible
o central slip reconstruction
techniques
tendon graft
extensor turndown
lateral band mobilization
transverse retinacular ligament
FDS slip
o EIP to EPL tendon transfer
indications
chronic EPL rupture
Surgical Techniques
Tendon Repair
o incision technique
utilize laceration, when present, and extend incision as needed to gain appropriate exposure
longitudinal incision may be utilized across joints on the dorsum of digits, unlike the palmar
side
o suture technique
# of suture strands that cross the repair site is more important than the number of grasping
loops
in general strength increases with increasing number of sutures crossing the repair site,
thickness of the suture, and locking of the stitch
4-6 strands provide adequate strength for early active motion
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
o circumferential epitendinous suture
Optional for reinforcement
o repair failure
tendon repairs are weakest between postoperative day 6 and 12
repair usually fails at knots
Tendon Reconstruction
o usually done as two stage procedure
first a silicon tendon implant is placed to create a favorable tendon bed
wait 3-4 months and then place biologic tendon graft
only perform single stage reconstruction if flexor sheath is pristine and digit has full ROM
o available grafts include
palmaris longus (absent in 15% of population)
most common
plantaris (absent in 19%)
indicated if longer graft is needed
long toe extensor
o pulley reconstruction
one pulley should be reconstructed proximal and distal to each joint
methods include belt loop method and FDS tail method
Tenolysis
o indications
adhesion formation with loss of finger flexion
wait for soft tissue stabilization (> 3 months) and full passive motion of all joints
o postoperative
o follow with extensive therapy
Rehabilitation
Early active short-arc motion (SAM)
o indications
after zone III central slip repair
o advantages over static immobilization
increases total arc of motion
decrease duration of therapy
increase DIP motion
creates 4mm of tendon excursion and prevents adhesions.
Complications
Adhesion formation
o leads to loss of finger flexion
o common in zone IV and VII and older patients
o prevented with early protected ROM and dynamic splinting (zone IV)
o treatment
extensor tenolysis with early motion indicated after failure of nonoperative management,
usually 3-6 months
tenolysis contraindicated if done in conjunction with other procedures that require joint
immobilization
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Tendon rupture
o causes include poor suture material or surgical technique, aggressive therapy, and
noncompliance
o incidence
5%
most frequently during first 7 to 10 days post-op
o treatment
early recognition may allow revision repair
tendon reconstruction for late rupture or rupture with excessive scarring
Swan neck deformity
o caused by prolonged DIP flexion with dorsal subluxation of lateral bands and PIP joint
hyperextension
o treatment
Fowler central slip tenotomy
spiral oblique ligament reconstruction
Boutonniere deformity (DIP hyperextension)
o caused by central slip disruption and lateral band volar subluxation
o treatment
dynamic splinting or serial casting for maximal passive motion
terminal extensor tenotomy, PIP volar plate release
4. Mallet Finger
Introduction
A finger deformity caused by disruption of the terminal extensor
tendon distal to DIP joint
o the disruption may be bony or tendinous
Epidemiology
o risk factors
usually occur in the work environment or during participation
in sports
o demographics
common in young to middle-aged males and older females
o body location
most frequently involves long, ring and small fingers of dominant hand
Pathophysiology
o mechanism of injury
traumatic impaction blow
usually caused by a traumatic impaction blow (i.e. sudden forced flexion) to the tip of the
finger in the extended position.
forces the DIP joint into forced flexion
dorsal laceration
a less common mechanism of injury is a sharp or crushing-type laceration to the dorsal
DIP joint
Classification
Doyle's Classification
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
Doyle's Classification of Mallet Finger Injuries
Type I • Closed injury with or without small dorsal avulusion fracture
Type II • Open injury (laceration)
Type III • Open injury (deep soft tissue abrasion involving loss skin and tendon substance)
Type IV • Mallet fracture
A = distal phalanx physeal injury (pediatrics)
B = fracture fragment involving 20% to 50% of articular surface (adult)
C = fracture fragment >50% of articular surface (adult)
Presentation
Symptoms
o primary symptoms
painful and swollen DIP joint following impaction injury to finger
often in ball sports
Physical exam
o inspection
fingertip rest at ~45° of flexion
o motion
lack of active DIP extension
Imaging
Radiographs
o findings
usually see bony avulsion of distal phalanx
may be a ligamentous injury with normal bony anatomy
Treatment
Nonoperative
o extension splinting of DIP joint for 6-8 weeks
indications
acute soft tissue injury (< than 12 weeks)
nondisplaced bony mallet injury
technique Bony avulsion Ligamintous injury
maintain free movement of the PIP joint
worn for 6-8 weeks
volar splinting has less complications than dorsal splinting
avoid hyperextension
begin progressive flexion exercises at 6 weeks
Operative
o CRPP vs ORIF
indications
absolute indications
volar subluxation of distal phalanx
relative indications
>50% of articular surface involved
>2mm articular gap
o surgical reconstruction of terminal tendon
indications
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chronic injury (> 12 weeks) with healthy joint
outcomes
tendon reconstruction has a high complication rate (~ 50%)
o DIP arthrodesis
indications
painful, stiff, arthritic DIP joint
o Swan neck deformity correction
indications : Swan neck deformity present
Techniques
CRPP vs ORIF
o approach
dorsal midline incision
o fixation
simple pin fixation
dorsal blocking pin
Surgical reconstruction of terminal tendon
o repair
this may be done with direct repair/tendon advancement, tenodermodesis, or spiral oblique
retinacular ligament reconstruction
Swan neck deformity correction
o techniques to correct Swan neck deformity include
lateral band tenodesis
FDS tenodesis
Fowler central slip tenotomy
for deformities of <35° extensor lag
minimal Swan Neck deformities may correct with treatment of the DIP pathology alone
Complications
Extensor lag
o a slight residual extensor lag of < 10° may be present at completion of closed treatment
Swan neck deformities
o occurs due to
attenuation of volar plate and transverse retinacular ligament at PIP joint
dorsal subluxation of lateral bands
resulting PIP hyperextension
contracture of triangular ligament maintains deformity
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
Anatomy
Extensor mechanism comprises
o tendons
EDC/EIP/EDM
lumbricals
interossei
o retinacular system
sagittal bands
the sagittal bands are part of a closed cylindrical tube (or girdle) that surrounds the
metacarpal head and MCP along with the palmar plate
origin
volar plate and intermetacarpal ligament at the metacarpal neck
insertion
extensor mechanism (curving around radial and ulnar side of MCP joint)
retinacular ligaments
triangular ligament
Sagittal band
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o function
the SB is the primary stabilizer of the extensor tendon at the MCP joint
juncturae tendinum are the secondary stabilizers
resists ulnar deviation of the tendon, especially during MCP flexion
prevents tendon bowstringing during MCP joint hyperextension
o biomechanics
ulnar sagittal band
partial or complete sectioning does not lead to extensor tendon dislocation
radial sagittal band
distal sectioning does not produce extensor tendon instability
complete sectioning leads to extensor dislocation
sectioning of 50% of the proximal SB leads to extensor tendon subluxation
extensor tendon
instability after sectioning is greater with wrist flexion
instability after sectioning is greater in the central digits (than border digits)
the least stable tendon is the middle finger
the most stable tendon is the little finger
junctura tendinum stabilize the small finger
Classification
Rayan and Murray Classification of Closed SB Injury
Type Description
Type I SB injury without extensor tendon instability
Type II SB injury with tendon subluxation
Type III SB injury with tendon dislocation
Presentation
Symptoms
o MCP soreness
Physical exam
o tendon snapping
o ulnar deviation of the digits at the MCP joint (rheumatoid arthritis)
o inability to initiate extension
o pseudo-triggering
o extensor tendon dislocation into intermetacarpal gully
most unstable during MCP flexion with wrist flexed
least unstable during MCP flexion with wrist extended
o provocative test
pain when extending MCP joint against resistance (with both IP joints extended)
Imaging
Radiographs
o required views
hand PA, lateral, oblique
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Tendon Injuries
o optional view
Brewerton view
AP with dorsal surface of fingers touching the cassette and MCP joints flexed 45deg
stress view
to rule out collateral ligament avulsion/injury
o findings
exclude mechanical/bony pathology limiting extension, or predisposing to sagittal band
rupture
may show dropped fingers and ulnar deviation in rheumatoid arthritis
Ultrasound (dynamic)
o indications : when swelling obscures the physical exam
o findings : subluxation of EDC tendon relative to metacarpal head on MCP flexion
MRI
o indications
to establish diagnosis of SB disruption (radial or ulnar SB)
may show underlying etiology e.g. synovitis in rheumatoid arthritis
o views
axial images at the level of the long MCP
with MCP joint flexed for maximum EDC tendon displacement
o findings
poor definition, focal discontinuity and focal thickening in acute injury
subluxation of extensor tendon in radial direction due ulnar SB defect
dislocation of extensor tendon into ulnar intermetacarpal gully radial SB defect
Differentials
MCP joint collateral ligament injury
EDC tendon rupture
Trigger finger
Junctura tendinum disruption
Congenital sagittal band deficiency
MCP joint arthritis
Treatment
Nonoperative
o extension splint for 4-6 weeks
indications IV:5 extension splint IV:6 direct repair
(Kettlekamp)
acute injuries (within one week)
Operative
o direct repair (Kettlekamp)
indications
chronic injuries (more than one week) where primary repair is possible
professional athlete
o extensor centralization procedure
indications
chronic injuries (more than one week) where primary repair is NOT possible
professional athlete
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Techniques
Extensor Centralization Procedures
o various techniques described including
trapdoor flap
ulnar based partial thickness capsular flap created
tendon placed deep to flap
flap resutured to capsule
Kilgore tendon slip
IV:7 trapdoor flap
distally based slip of EDC tendon on radial side
looped around radial collateral ligament
sutured to itself after tensioning to centralize tendon
Carroll tendon slip
distally based slip of EDC tendon on ulnar side
routed deep to affected tendon and around radial collateral ligamnt
sutured to itself after tensioning to centralize tendone
McCoy tendon slip
proximally based slip of EDC tendon
looped around lumbrical insertion
sutured to itself after tensioning to centralize tendon IV:8 McCoy tendon slip
Watson EDC tendon transfer
distally based slip of EDC tendon slip
looped under deep transverse metacarpal ligament
weaved to remaining EDC tendon after tensioning to centralize tendon
Wheeldon junctural reinforcement
for a middle finger radial SB rupture, the juncturae tendinum (JT) of the ring finger
is divided close to the ring finger,
bring JT over the extensor tendon
attach JT to the torn SB
fascial strips or free tendon graft
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Wrist Trauma
B. Wrist Trauma
1. Scaphoid Fracture
Introduction
Scaphoid is most frequently fractured carpal bone
Epidemiology
o incidence : accounts for up to 15% of acute wrist injuries
o location
incidence of fracture by location
waist -65%
proximal third - 25%
distal third - 10%
distal pole is most common location in kids due to ossification sequence
Pathoanatomy
o most common mechanism of injury is axial load across hyper-extended and radially deviated
wrist
common in contact sports
o transverse fracture patterns are considered more stable than vertical or oblique oriented fractures
Associated conditions
o SNAC (Scaphoid Nonunion Advanced Collapse)
Prognosis
o incidence of AVN with fracture location
proximal 5th AVN rate of 100%
proximal 3rd AVN rate of 33%
Anatomy
Articular surface
IV:10 Blood supply of scaphoid
o > 75% of scaphoid bone is covered by articular cartilage
Blood supply
o major blood supply is dorsal carpal branch (branch of the radial artery)
enters scaphoid in a nonarticular ridge on the dorsal surface and supplies proximal 80% of
scaphoid via retrograde blood flow
o minor blood supply from superficial palmar arch (branch of volar radial artery)
enters distal tubercle and supplies distal 20% of scaphoid
Motion
o both intrinsic and extrinsic ligaments attach and surround the scaphoid
o the scaphoid flexes with wrist flexion and radial deviation and it extends during wrist extension
and ulnar deviation (same as proximal row)
Also see Wrist Ligaments and Biomechanics for more detail
Presentation
Physical exam
o anatomic snuffbox tenderness dorsally
o scaphoid tubercle tenderness volarly
o pain with resisted pronation
IV:11 scaphoid tubercle tenderness
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Imaging
Radiographs
o recommended views
AP and lateral
scaphoid view
30 degree wrist extension, 20 degree ulnar deviation
45° pronation view
o findings
if radiographs are negative and there is a high clinical suspicion
should repeat radiographs in 14-21 days
Bone scan
o effective to diagnose occult fractures at 72 hours
specificity of 98%, and sensitivity of 100%, PPV 85% to 93% when done at 72 hours
MRI
o indications
most sensitive for diagnosis occult fractures < 24 hours
immediate identification of fractures / ligamentous injuries
assessment of vascular status of bone (vascularity of proximal pole)
proximal pole AVN best determined on T1 sequences
CT scan with 1mm cuts
o less effective than bone scan and MRI to diagnose occult fracture
o can be used to evaluate location of fracture, size of fragments, extent of collapse, and progression
of nonunion or union after surgery
Treatment
Nonoperative
o thumb spica cast immobilization
indications
stable nondisplaced fracture (majority of fractures)
if patient has normal xrays but there is a high level of suspicion can immobilize in thumb
spica and reevaluate in 12 to 21 days
technique
start immobilization early (nonunion rates increase with delayed immobilization of > 4
weeks after injury)
long arm spica vs short arm casting is controversial
with no consensus
duration of casting depends on location of fracture
distal-waist for 3 months
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Wrist Trauma
mid-waist for 4 months
proximal third for 5 months
athletes should not return to play until imaging shows a healed fracture
may opt to augment with pulsed electromagnetic field (studies show beneficial in delayed
union)
outcomes
scaphoid fractures with <1mm displacement have union rate of 90%
Operative
o ORIF vs percutaneous screw fixation
indications
in unstable fractures as shown by
proximal pole fractures
displacement > 1 mm
15° scaphoid humpback deformity
radiolunate angle > 15° (DISI)
intrascaphoid angle of > 35°
scaphoid fractures associated with perilunate dislocation IV:12 screw fixation of scaphoid
comminuted fractures
unstable vertical or oblique fractures
in non-displaced waist fractures
to allow decreased time to union, faster return to work/sport, similar total costs
compared to casting
outcomes
union rates of 90-95% with operative treatment of scaphoid fractures
CT scan is helpful for evaluation of union
Technique
ORIF vs percutaneous screw fixation
o approach
dorsal approach
indicated in proximal pole fractures
care must be taken to preserve the blood supply when entering the dorsal ridge by limiting
exposure to the proximal half of the scaphoid
percutaneous has higher risk of unrecognized screw penetration of subchondral bone
volar approach
indicated in waist and distal pole fractures and fractures with humpback flexion
deformities
allows exposure of the entire scaphoid
uses the interval between the FCR and the radial artery
arthroscopic assisted approach
has also been described
o fixation
rigidity is optimized by long screw placed down the central axis of the scaphoid
o radial styloidectomy
should be performed if there is evidence of impaction osteoarthritis between radial styloid
and scaphoid
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Complications
Scaphoid Nonunion
o treatment
inlay (Russe) bone graft
indications
if minimal deformity and there is no adjacent carpal collapse or excessive flexion
deformity (humpback scaphoid)
outcomes
92% union rate
interposition (Fisk) bone graft
indications
if there is adjacent carpal collapse and excessive flexion deformity (humpback
scaphoid)
technique
an opening wedge graft that is designed to restore scaphoid length and angulation
outcomes
results show 72-95% union rates
vascular bone graft from radius
indications
gaining popularity and a good option for
proximal pole fractures with osteonecrosis
confirmed by MRI
technique
1-2 intercompartmental supraretinacular artery (branch of radial artery) is
harvested to provide vascularized graft from dorsal aspect of distal radius
vascular bone graft from medial femoral condyle
corticoperiosteal flap that provides highly osteogenic periosteum
indications
proximal pole fractures with osteonecrosis
lack of pancarpal arthritis and collapse
technique
utilize the descending genicular artery pedicle (from the superficial femoral artery)
if DGA is too small, use superomedial genicular artery (from popliteal artery)
identify and protect MCL (distal to flap)
o SNAC wrist (scaphoid nonunion advanced collapse)
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Wrist Trauma
Anatomy
Normal wrist anatomy
Osseous
o proximal row
scaphoid
lunate
triquetrum
pisiform
o distal row
trapezium
trapezoid
capitate IV:17 Normal wrist anatomy
hamate
Ligaments
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o interosseous ligaments
run between the carpal bones
scapholunate interosseous ligament
lunotriquetral interosseous ligament
major stabilizers of the proximal carpal row
o intrinsic ligaments
ligaments the both originate and insert among the carpal bones
dorsal intrinsic ligaments
volar intrinsic ligaments
o extrinsic ligaments
connect the forearm bones to the carpus
volar extrinsic carpal ligaments
dorsal extrinsic carpal ligaments
Classification
Mayfield Classification
Stage I • scapholunate dissociation
Stage II • + lunocapitate disruption
Stage III • + lunotriquetral disruption, "perilunate"
Stage IV • lunate dislocated from lunate fossa (usually volar)
• associated with median nerve compression
Presentation
Symptoms
o acute wrist swelling and pain
o median nerve symptoms may occur in ~25% of patients
most common in Mayfield stage IV where the lunate dislocates into the carpal tunnel
Imaging
Radiographs
o required views
PA/lateral wrist radiographs
o findings
AP
break in Gilula's arc
lunate and capitate overlap
lunate appears triangular "piece-of-pie sign"
IV:18 lateral xray
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Wrist Trauma
lateral
lossof colinearity of radius, lunate, and
capitate
SL angle >70 degrees
MRI
o usually not required for diagnosis
Treatment
IV:20 piece-of-pie sign IV:19 Abnormal alignment
Nonoperative
of scaphoid , lunate and
o closed reduction and casting triquetrum
indications
no indications when used as definitive management
outcomes
universally poor functional outcomes with non-operative management
recurrent dislocation is common
Operative
o emergent closed reduction/splinting followed by open reduction, ligament repair, fixation,
possible carpal tunnel release
indications
all acute injuries <8 weeks old
outcomes
emergent closed reduction leads to
decreased risk of median nerve damage
decreased risk of cartilage damage
return to full function unlikely
decreased grip strength and stiffness are common
o proximal row carpectomy
indications
chronic injury (defined as >8 weeks after initial injury)
not
uncommon, as initial diagnosis frequently missed
o total wrist arthrodesis
indications
chronic injuries with degenerative changes
Techniques
Closed Reduction
o technique
finger traps, elbow at 90 degrees of flexion
hand 5-10 lbs traction for 15 minutes
dorsal dislocations are reduced through wrist extension, traction, and flexion of wrist
apply sugar tong splint
follow with surgery
Open reduction, ligament repair and fixation +/- carpal tunnel release
o approach (controversial)
dorsal approach
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longitudinal incision centered at Lister's tubercle
excellent exposure of proximal carpal row and midcarpal joints
does not allow for carpal tunnel release
volar approach
extended carpal tunnel incision just proximal to volar wrist crease
combined dorsal/volar
pros
added exposure
easier reduction
access to distal scaphoid fractures
ability to repair volar ligaments
carpal tunnel decompression
cons
some believe volar ligament repair not necessary
increased swelling
potential carpal devascularization
difficulty regaining digital flexion and grip
o technique
fix associated fractures
repair scapholunate ligament
suture anchor fixation
protect scapholunate ligament repair
controversy of k-wire versus intraosseous cerclage wiring
repair of lunotriquetral interosseous ligament
decision to repair based on surgeon preference as no studies have shown improved results
o post-op
short arm thumb spica splint converted to short arm cast at first post-op visit
duration of casting varies, but at least 6 weeks
Proximal row carpectomy
o technique
perform via dorsal and volar incisions if median nerve compression is present
volar approach allows median nerve decompression with excision of lunate
dorsal approach facilitates excision of the scaphoid and triquetrum
Anatomy
Hamate
o one of carpal bones, distal and radial to the pisiform
o articulates with
fourth and fifth metacarpals
capitate
triquetrum
o hook of hamate
forms part of Guyon's canal, which is formed by
roof - superficial palmar carpal ligament
floor - deep flexor retinaculum, hypothenar muscles
ulnar border - pisiform and pisohamate ligament
radial border - hook of hamate
one of the palpable attachments of the flexor retinaculum
deep branch of ulnar nerve lies under the hook
Presentation
Symptoms
o hypothenar pain
o pain with activities requiring tight grip
Physical examination
o provocative maneuvers
tender to palpation over the hook of hamate
hook of hamate pull test:
hand held in ulnar deviation as patient flexes DIP joints of the ulnar 2 digits, the flexor
tendons act as a deforming force on the fracture site, positive test elicits pain
o motion and strength : decreased grip strength
o neurovascular exam
chronic cases
parasthesia in ring and small finger
motor weakness in intrinsics
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Carpal Tunnel View
Imaging
Radiographs
o recommended views
AP and carpal tunnel view
o findings
fracture best seen on carpal tunnel view
CT
o indications
establish diagnosis if radiographs are negative
Treatment
Nonoperative
o immobilization 6 weeks
indications
acute hook of hamate fractures
body of hamate fx (rare)
Operative
o excision of hamate fracture fragment
indications : chronic hook of hamate fxs with non-union
o ORIF
indications : ORIF is possible but has little benefit
Complications
Non-union
Scar sensitivity
Iatrogenic injury to ulnar nerve
Closed rupture of the flexor tendons to the small finger
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Wrist Trauma
Anatomy
Hamate Bone
o osteology
triangular shaped carpal bone
composed of hook and body
o location
most ulnar bone in the distal carpal row
o articulation
4th and 5th metacarpals
capitate
triquetrum
Classification
Milch Classification of Hamate Fractures
Milch Classification
Type I Hook of Hamate Fx (most common)
Type II Body of Hamate Fx
Presentation
Symptoms
o ulnar-sided wrist pain and swelling
Physical exam
o inspection
focal tenderness over hamate
Imaging
Radiographs
o recommended views
oblique radiographs (30°) are usually required to visualize fracture
AP and lateral radiographs are less reliable
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o additional views
carpal tunnel view radiographs
CT
o usually required to delineate fracture pattern and determine operative
plan
Treatment
Nonoperative
o immobilization
indications
IV:21 30°oblique view
rarely may be used for extra-articular nondisplaced fracture
Operative
o ORIF
indications
most fracture are intra-articular and require open reduction
technique
interfragmentary screws +/- k-wires for temporary stabilization
Surgical Techniques
Open Reduction Internal Fixation
o approach : dorsal most common approach
o fixation technique
Complications
Stiffness
Malunion
Infection
5. Pisiform Fracture
Introduction
A rare carpal fracture
Epidemiology
o incidence
<1% of carpal fractures
rare injury and often missed
Pathophysiology
o mechanism of injury
usually occurs by direct impact against a hard surface
fall on outstretched hand
Associated conditions
o 50% occur as isolated injuries
o 50% occur in association with other carpal fractures or distal radius fractures
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Wrist Trauma
Anatomy
Pisiform Bone
o osteology
pea shaped, seasmoid bone
o location
most ulnar and palmar carpal bone in proximal row
located within the FCU tendon
o function
contributes to the stability of the ulnar column by preventing triquetral subluxation
Presentation
Symptoms
o ulnar sided wrist pain after a fall
o grip weakness
Physical exam
o inspection
hypothenar tenderness and swelling
rule out associated injury to other carpal bones and distal radius
Imaging
Radiographs
o recommended views
AP and lateral views of wrist
o additional views
pronated oblique and supinated oblque views
carpal tunnel view
o findings
best seen with 30 deg of wrist supination or utilizing the carpal tunnel view
CT
o indications
may be required to delineate fracture pattern and determine treatment plan
MRI
o indications
suspected carpal fracture with negative radiographs
o findings
may show bone marrow edema within the pisiform indicating fracture
Treatment
Nonoperative
o early immobilization
indications
first line of treatment
technique
short arm cast with 30 degrees of wrist flexion and ulnar deviation for 6-8 weeks
outcomes
most often go on to heal without posttraumatic osteoarthritis
Operative
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o pisiformectomy
indications
severely displaced and symptomatic fractures
painful nonunion
outcomes
studies show a pisiformectomy is a reliable way to relieve this pain and does not impair
wrist function
Complications
Malunion
Non-union
Chronic ulnar sided pain
Decreased grip strength
6. Seymour Fracture
Introduction
Displaced distal phalangeal physeal fracture with an associated nailbed injury
Epidemiology
o incidence : 20% to 30% of phalangeal fractures involve the physis in children
o body location
middle finger injury is most common
type of the distal phalangeal physeal fracture:
metaphyseal fractures 1 to 2 mm distal to the epiphyseal plate
Salter-Harris I fractures
Salter-Harris II fractures
type of nailbed injury:
nailbed laceration
nail plate subluxation
interposition of soft tissue at fracture site (usually germinal matrix)
Pathophysiology
o mechanism of injury : direct trauma or crush injury (e.g. caught in door, heavy object or sport)
o pathoanatomy
similar mechanism to mallet finger in adults
injury causes flexed posturing of the distal phalanx
deformity results from an imbalance between the flexor and the extensor tendons at the level
of the fracture
imbalance occurs due to different insertion sites of flexor and extensor tendons
extensor tendon inserts into the epiphysis of the distal phalanx
flexor tendon inserts into metaphysis of the distal phalanx
widened physis likely to have interposed tissue in the fracture site
Prognosis
o operative intervention is warranted to ensure that there is no interposed tissue in the fracture site
o failure to recognize injury may result in:
nailplate deformity
physeal arrest
chronic osteomyelitis
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Wrist Trauma
Presentation
Physical exam
o apparent mallet deformity
o echymosis and swelling
o nail plate lying superficial to the eponychial fold
Imaging
Radiographs
o AP : may appear normal on posteroanterior view
o lateral view
widened physis or displacement between epiphysis/metaphysis
flexion deformity at fracture site
Differential Diagnosis
Mallet finger
o pediatric mallet finger is usually osseous avulsion (SH III and SH IV)
o mallet finger fracture line enters DIPJ, while Seymour fracture line traverses physis (does not
enter DIPJ)
Treatment
Nonoperative
o closed reduction and splinting
indications
minimally displaced, closed fracture
no interposition of soft tissue at fracture site
Operative
o closed reduction and pinning across DIPJ
indications
displaced, closed fracture
no interposition of soft tissue at fracture site
o antibiotics, open reduction and pinning across DIPJ, nailbed repair
open management has fewer complications than closed management
indications : open fracture
technique
hyperflexion of the digit will permit removal of the interposed soft tissue from the
fracture site
thorough irrigation and debridement
anatomical reduction and retrograde k-wire fixation crossing the fracture site and DIP
joint
nailbed injury repair
Complications
Nail dystrophy
Growth disturbance of the distal phalanx and nail
Secondary fracture displacement
Chronic osteomyelitis (failure to treat as open fracture)
Flexion deformity
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7. TFCC Injury
Introduction
Mechanism of TFCC injury
o Type 1 traumatic injury
mechanism
most common is fall on extended wrist with forearm pronation
traction injury to ulnar side of wrist
traction injury to ulnar wrist
o Type 2 degenerative injury
associated with positive ulnar variance
associated with ulnocarpal impaction
Anatomy
TFCC made up of
o dorsal and volar radioulnar ligaments
deep ligaments known as ligamentum subcruentum
o central articular disc
o meniscus homolog
o ulnar collateral ligament
o ECU subsheath
o origin of ulnolunate and ulnotriquetral ligaments
Blood supply
o periphery is well vascularized (10-40% of the periphery)
o central portion is avascular
Origin
o dorsal and volar radioulnar ligaments originate at the sigmoid notch of the radius
Insertion
o dorsal and volar radioulnar ligaments converge at the base of the ulnar styloid
Classification
Class 1 - Traumatic TFCC Injuries
1A Central perforation or tear
1B Ulnar avulsion (without ulnar styloid fx)
1C Distal avulsion (origin of UL and UT ligaments)
1D Radial avulsion
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Wrist Trauma
Class 2 - Degenerative TFCC Injuries
2A TFCC wear and thinning
2B Lunate and/or ulnar chondromalacia + 2A
2C TFCC perforation + 2B
2D Ligament disruption + 2C
2E Ulnocarpal and DRUJ arthritis + 2D
Presentation
Symptoms
o wrist pain
o turning a door key often painful
Physical exam
o positive "fovea" sign
tenderness in the soft spot between the ulnar styloid and flexor carpi ulnaris tendon, between
the volar surface of the ulnar head and the pisiform
95% sensitivity and 87% specificity for foveal disruptions of TFCC or ulnotriquetral
ligament injuries
o pain elicited with ulnar deviation (TFCC compression) or radial deviation (TFCC tension)
Imaging
Radiographs
o usually negative
o zero rotation PA view evaluates ulnar variance
o dynamic pronated PA grip view may show pathology
Arthography
o joint injection shows extravasation
MRI
o has largely replaced arthrography
o tear at ulnar part of lunate indicates ulnocarpal impaction
o sensitivity = 74-100%
Arthroscopy
o most accurate method of diagnosis
o indicated in symptomatic patients after failing several months of splinting and activity
modification
Differential
Differential for ulnar sided wrist pain
See table next page
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Treatment
Nonoperative
o immobilization, NSAIDS, steroid injections
indications
all acute Type I injuries
first line of treatment for Type 2 injuries
Operative
o arthroscopic debridement
indications
type 1A
diagnostic gold standard
o arthroscopic repair
indications
type 1B, 1C, 1D
best for ulnar and dorsal/ulnar tears
generally acute, athletic injuries more amenable to repair than chronic injuries
outcomes
patient should expect to regain 80% of motion and grip strength when injuries are
classified as acute (<3 months)
o ulnar diaphyseal shortening
indications
Type II with ulnar positive variance is > 2mm
advantage of effectively tightening the ulnocarpal ligaments and is favored when LT
instability is present
o Wafer procedure
indications
Type II with ulnar positive variance is < 2mm
type 2A-C
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Wrist Trauma
o limited ulnar head resection
indications : type 2D
o Darrach procedure
indications
contraindicated due to problems with ulnar stump instability
Techniques
Arthroscopic debridement
o approach
arthroscopic approach to the wrist
performed through combination of 3-4 and 6R portal
o technique
maintain 2 mm rim peripherally otherwise joint can become unstable
o pros & cons
not effective if patient has ulnar positive variance
80% of patients obtain good relief of pain
Arthroscopic repair
o approach
arthroscopic approach to the wrist
o technique
many techniques exist such as outside-in and inside-out
generally suture based repair
o pros & cons
only works for peripheral tears where blood supply is present
patient immobilized for 6 weeks
o complications
ECU tendonitis from suture knot
dorsal sensory nerve injury
Ulnar diaphyseal shortening
o approach
dorsal approach to the forearm
o technique
osteotomy of the diaphysis or metaphysis followed by plate fixation
o pros & cons
can address > 2 mm ulnar variance
requires immobilization and time for fracture healing
can help tension the ulnocarpal ligaments
o complications
nonunion
hardware irritation necessitating removal
Wafer procedure
o approach : dorsal approach to the forearm
o technique
ulnar cortex is not disrupted
do not extend bone removal into the DRUJ
o pros & cons
intrinsic stability of ECU, TFCC, and ulnar periosteum obviate need for plate fixation
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Limited ulnar head resection
o approach
arthroscopic approach to the wrist
o technique
removal of approximately 2-4 mm of bone under the TFCC
distal ulnar burred through central TFCC defect
o pros & cons
can be technically difficult to obtain level shortening through TFCC window
only applicable when patient has < 2mm of ulnar variance
Darrach procedure
o approach
dorsal approach to the forearm
o technique
resection of the distal 1-2cm of the distal ulna
TFCC should be approximated to the wrist capsule
o pros & cons
salvage procedure for pain relief only
distal joint is unstable
o complications : ECU tendon can sublux over remaining ulna causing pain
C. Finger Trauma
1. Metacarpal Fractures
Introduction
Metacarpal fractures
o divided into fractures of metacarpal head, neck, shaft
o treatment based on which metacarpal is involved and location of fracture
o acceptable angulation varies by location
o no degree of malrotation is acceptable
Epidemiology
o incidence
metacarpal fractures account for 40% of all hand injuries
o demographics
men aged 10-29 have highest incidence of metacarpal injuries
o location
metacarpal neck is most common site of fracture
fifth metacarpal is most commonly injured
Mechanism of injury
o direct blow to hand or rotational injury with axial load
o high energy injuries (ie. automobile) may result in multiple fractures
Associated conditions
o wounds may indicate open fractures or concomitant soft tissue injury
tendon laceration
neurovascular injury
o compartment syndrome
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closed injuries with multiple fractures or dislocations
crush injuries
Anatomy
Metacarpal anatomy
o concave on palmar surface
o 1st, 4th, and 5th digits form mobile borders
o 2nd and 3rd digits form stiffer central pillar
index metacarpal is the most firmly fixed, while the thumb metacarpal articulates with the
trapezium and acts independently from the others
o three palmar and four dorsal interossei muscles arise from metacarpal shafts
Insertional anatomy
o extensor carpi radialis longus/brevis
insert on the base of metacarpal II, III (respectively); assist with wrist extension and radial
flexion of the wrist
o extensor carpi ulnaris
inserts on the base of metacarpal V; extends and fixes wrist when digits are being flexed;
assists with ulnar flexion of wrist
o abductor pollicis longus
inserts on the trapezium and base of metacarpal I; abducts thumb in frontal plane; extends
thumb at carpometacarpal joint
o opponens pollicis
inserts on metacarpal I; flexes metacarpal I to oppose the thumb to the fingertips
o opponens digiti minimi
inserts on the medial surface of metacarpal V; Flexes metacarpal V at carpometacarpal joint
when little finger is moved into opposition with tip of thumb; deepens palm of hand.
Presentation
Physical exam
o inspect for open wounds and associated injuries
fight wounds over MCP joint are open until proven otherwise
extensor tendon can be lacerated and retracted
dorsal wounds over metacarpal fractures are almost always open
fractures
o deformity indicates location
deformity at metacarpal base may indicate CMC dislocation
shortening can be assessed by comparing contralateral hand
malrotation assessed by lining up fingernail in partial flexion and full flexion if possible,
compare to contralateral side
o motor examination
typically no motor deficits unless open wounds present
check integrity of flexor/extensor tendons in presence of open wounds
o neurovascular examination
dorsal wounds may affect dorsal sensory branch of radial/ulnar nerve
volar wounds can involve digital nerves
test for radial and ulnar border two-point discrimination on the injured digit before any
regional/hematoma block or attempted reduction
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Imaging
Radiographs
o standard AP, oblique, and lateral films
o oblique radiographs
for evaluation of CMC joint and improved visualization
of affected digit
30°pronated lateral
to see 4th and 5th CMC fx/dislocation
30°supinated view
to see 2nd and 3rd CMC fx/dislocation
o Brewerton view for metacarpal head fractures
o Roberts view for thumb CMC joint
CT
o indications
inconclusive radiographs of CMC fractures/dislocations
multiple CMC dislocations
complex metacarpal head fractures
General Treatment
Nonoperative
o immobilization
indications
must be stable pattern
no rotational deformity
acceptable angulation & shortening (see table)
Operative
o operative treatment
general indications
intra-articular fxs
rotational malalignment of digit
significantly displaced fractures (see above criteria)
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Finger Trauma
Treatment - Metacarpal Head Fractures
Operative
o ORIF
indications
no degree of articular displacement acceptable
majority requires surgical fixation
o external fixation
indications
severely comminuted fractures
o MCP arthroplasty
indications
severely comminuted fractures
o MCP fusion
indications
arthritis late disease
Techniques
o ORIF
approach
dorsal incision
either centrally split extensor apparatus or release and repair sagittal band
fixation
hardware cannot protrude from joint surface
fix with multiple small screws in collateral recess, headless screws, or k-wires
ideal fixation should allow for early motion
Complications
o stiffness
most common
prevented with early motion
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Techniques
o closed reduction percutaneous pinning
place antegrade through metacarpal base or retrograde through collateral recess
remove pins at 4 weeks
o open reductions with lag screw
can use multiple lag screws for long spiral fractures
try to get at least two lag screws
o open reduction with dorsal plating
works best for transverse fractures
try to cover plate with periosteum to prevent tendon irritation
begin early motion to prevent tendon irritations
2. MCP Dislocations
Introduction
Epidemiology
o dorsal dislocations most common
o index finger most commonly involved
Mechanism
o a hyperextension injury
Classification
Simple vs. Complex
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o simple
volar plate not interposed in joint
treated with closed reduction
o complex
complex dislocations have interposition of volar plate and/or sesamoids
in index finger flexor tendon displaces ulnarly and lumbrical displaces radially which
tighten around metacarpal neck preventing reduction
in small finger flexor tendons and lumbrical displace radially and the abductor digiti
minimi and flexor digiti minimi ulnarly preventing closed reduction
may require open reduction
Kaplan's lesion (rare)
o most common in index finger
o complex dorsal dislocation of finger, irreducible
o metacarpal head buttonholes into palm (volarly)
o volar plate is interposed between base of proximal phalanx and metacarpal head
Presentation
Physical exam
o skin dimpling often seen in complex dislocations but absent in simple dislocations
Imaging
Radiographs
o lateral view best shows dislocation
o joint space widening may indicate interposition of volar plat
o useful to detect associated chip fractures
Treatment
Nonoperative
o closed reduction
indications
simple dislocations
technique
reduction technique involve applying direct pressure over proximal phalanx while the
wrist is held in flexion to take tension off the intrinsic and extrinsic flexors
avoid longitudinal traction and hyperextension during closed reduction, may pull volar
plate into joint
Operative
o open reduction
indications
complex dislocations
Surgical Techniques
Open reduction
o approach
dorsal approach
split extensor tendon to expose joint
may be able to push volar plate out with freer elevator
usually need to split volar plate to remove from joint
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use this approach for volar dislocations
volar approach
places neurovascular structures at risk
release A1 pulley to expose volar plate
3. Phalanx Fractures
Introduction
Common hand injuries that can be broken into the following injuries
o proximal phalanx
o middle phalanx
o distal phalanx
Epidemiology
o incidence
most common injuries to the skeletal system
account for 10% of all fractures
distal phalanx is most common fractured bone in the hand
Pathophysiology
o mechanism
depends on age
10-29 years of age: sports is most common
40-69 year of age: machinery is most common
>70 year of age: falls are most common
o pathoanatomy
proximal phalanx fx
deformity is usually apex volar angulation due to
IV:23 Proximal Phalynx fractures
proximal fragment in flexion (from interossei)
distal fragment in extension (from central slip)
middle phalanx
deformity is usually apex dorsal OR volar angulation
apex dorsal if fracture proximal to FDS insertion (from extension of proximal
fragment through pull of the central slip)
apex volar if fracture distal to FDS insertion (prolonged insertion from just distal to
the flare at the base to within a few mm of the neck)
a fracture through the middle third may angulate in either direction or not at all
secondary to the inherent stability provided by an intact and prolonged FDS insertion
Associated conditions
o nail bed injuries
associated with distal phalanx fractures
Presentation
Symptoms
o pain
Physical exam
o local tenderness
o deformity
o look carefully for open wounds
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Imaging
Radiographs
o finger xrays
must get true lateral of joint
o hand xrays to rule out associated fractures
30°pronated lateral to see 4th and 5th CMC x/dislocation
30°supinated view to see 2nd and 3rd CMC fx/dislocation
Complications
Loss of motion
o most common complication
o predisposing factors include prolonged immobilization, associated joint injury, and extensive
surgical dissection
o treat with rehab, and surgical release as a last resort
Malunion
o malrotation, angulation, shortening
o surgery indicated when associated with functional impairment
corrective osteotomy at malunion site (preferred)
metacarpal osteotomy (limited degree of correction)
Nonunion
o uncommon
o most are atrophic and associated with bone loss or neurovascular compromise
o surgical options
resection, bone grafting, plating
ray amputation or fusion
4. Phalanx Dislocations
Introduction
Common hand injuries can be broken into the following
o PIP joint
dorsal dislocations
dorsal fracture-dislocations
volar dislocation
volar fracture-dislocation
rotatory dislocations
o DIP joint
dorsal dislocations & fracture-dislocations
Associated conditions
o swan neck deformity
o nail bed injuries
associated with distal phalanx fractures
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Imaging
Radiographs
o finger xrays
must get true lateral of joint
o hand xrays to rule out associated fractures
30°pronated lateral to see 4th and 5th CMC x/dislocation
30°supinated view to see 2nd and 3rd CMC fx/dislocation
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Anatomy
Collateral ligaments of the digits
o located on the lateral aspect of the DIP, PIP and MCP joints
o crucial for opposing pinch stability
Presentation
Symptoms
o Pain at involved joint
o Instabilty with pinch once pain resolved
Physical exam
o inspection
swelling at involved joint
deformity of joint
o provocative tests
varus and valgus stress tests
Imaging
Radiographs
o recommended views
AP, lateral, and oblique views of digit
varus/valgus stress views may aid in diagnosis
MRI
o indicated if equivocal physical exam findings
Treatment
Nonoperative
o buddy taping for 3 weeks
indications
simple tears
o buddy taping for 6 weeks
indications
complete tears
Operative
o collateral ligament repair
indications
radial ligament injuries of index finger (ligament needed for pinch stability)
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Thumb Trauma
D. Thumb Trauma
Bennett Fracture
Intra-articular fracture/dislocation of base of 1st metacarpal characterized by
o volar lip of metacarpal based attached to volar oblique ligament
ligament holds this fragment in place
small fragment of 1st metacarpal continues to articulate with trapezium
Pathoanatomy
o lateral retraction of distal 1st metacarpal shaft by APL and
adductor pollicis
shaft pulled into adduction
metacarpal base supinated
Prognosis
o better than Rolando fx
Imaging
o radiographs
recommended views
fracture best seen with hyper-pronated thumb view
findings
minimal joint step-off considered best
Treatment
o nonoperative
closed reduction & cast immobilization
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indications
nondisplaced fractures
technique
reduction maneuver with traction, extension, pronation, and abduction
o operative
closed reduction and percutaneous pinning
indications
volar fragment is too small to hold a screw
anatomic reduction unstable
technique
can attempt reduction of shaft to trapezium to hold reduction
ORIF
indications
large fragment
2mm+ joint displacement
Complications
o post-traumatic arthritis
there is no agreement regarding the relationship of post-fixation joint incongruity and post-
traumatic arthritis
Rolando Fracture
Intra-articular fracture of base of 1st metacarpal characterized by
o intra-articular comminution
Epidemiology
o less common than Bennett's fracture
Pathoanatomy
o deforming forces are the same as Bennett's fracture
volar fragment should have volar oblique ligament
attached
shaft pulled dorsally
o typically the base is split into a volar and dorsal fragment
commonly called a 'Y' fracture
o often have more than two proximal fragments
Prognosis
o worse than Bennett fx
Treatment
o nonoperative
immobilization
indications
for severe comminution, stable
start early range of motion
o operative
external fixation, CRPP
indications
for severe comminution, unstable
technique
can approximate large fragments with k-wires
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Thumb Trauma
ORIF
indications
most common fixation method
technique
use t-plate or blade plate
can use k-wires of fragments are too small for screw purchase
Complications
o commonly results in post-traumatic osteoarthritis
Extra-articular fracture
Extra-articular fracture of base of 1st metacarpal
o can be transverse or oblique in nature
Treatment
o nonoperative
spica casting
indications
if joint is reduced and there is less than 30 degrees of angulation
o operative
CRPP
indications
if reduction cannot be held to result in less than 30 degrees of angulation
outcome
these fractures typically have the best outcome
Presentation
History
o collide onto fixed object/axial force on a flexed thumb
st
o dorsal force applied to 1 web space
e.g. handlebar driven into a motorcyclist’s thumb on impact)
Symptoms
o pain over thenar eminence
Physical exam
o swelling, bruising over thenar eminence
o unable to form a fist
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Imaging
Radiographs
o radiographs
hand AP, lateral, oblique
MRI
o indications
persistent/recurrent instability after reduction
guide to ligamentous reconstruction
Treatment
Nonoperative
o closed reduction and immobilization in extension and pronation
indications
stable on reduction (implying the AOL is intact)
Operative
o closed reduction and temporary pinning
o reconstruction of the dorsal capsuloligamentous complex with tendon autograft +
temporary pinning
recommended treatment
indications
grossly unstable joint (AOL possibly torn as well)
results
better abduction and pinch strength than closed reduction and pinning
Complications
Anterior osteophyte often visible
Low incidence of recurrent dislocation
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Anatomy
UCL is composed of
o proper collateral ligament
resists valgus load with thumb in flexion
o accessory collateral ligament and volar plate
resists valgus load with thumb in extension
valgus laxity in both flexion and extension is indicative of a complete UCL rupture
Presentation
History
o hyperabduction injury
Symptoms
o pain at ulnar aspect of thumb MCP joint
Physical exam
o inspection and palpation
mass from torn ligament and possible bony avulsion may be present
o stress joint with radial deviation both at neutral and 30° of flexion
instability in 30° of flexion indicates injury to proper UCL
instability in neutral indicates injury to accessory and proper UCL and/or volar plate
compare to uninjured thumb MCP joint
Imaging
Radiographs
o recommended views
AP, lateral and oblique of thumb
valgus stress view may aid in diagnosis if a bony avulsion has already
been ruled out
MRI
o can aid in diagnosis if exam equivocal
Treatment
Nonoperative
o immobilization for 4 to 6 weeks
indications
partial tears with < 20° side to side variation of varus/valgus instability
Operative
o ligament repair
indications
acute injuries with
> 20° side to side variation of varus/valgus instability
>35° of opening
Stener lesion
avulsed ligament with or without bony attachment is displaced above the adductor
aponeurosis
will not heal without surgical repair
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technique
can use suture, suture anchors, or small screw to repair ligament
o reconstruction of ligament with tendon graft, MCP fusion, or adductor advancement
indications
chronic injury
1. Human Bite
Introduction
Epidemiology
o incidence
third most common bite behind dog and cat
o demographics
more common in males
o location
typically dorsal aspect of 3rd or 4th MCP joint
"fight bite"
Pathophyiology
o mechanism
most often result of direct clenched-fist trauma (from tooth) after punching another individual
in the mouth
can also result from direct bite (i.e. child biting another child)
o pathoanatomy
tooth penetrates capsule of MCP joint
flora (bacteria) from mouth enter joint
bacteria become trapped within joint as fist is released from clenched position
bacteria now caught under extensor tendon and/or capsule
o microbiology
typically polymicrobial
most common organisms
alpha-hemolytic streptococcus (S. viridans) and staphylococcus aureus
eikonella corrodens in 7-29%
other gram negative organisms
Associated conditions
o extensor tendon lacerations
can be missed due to proximal tendon retraction
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Presentation
History
o direct clenched-fist trauma to another individual's mouth
often overlooked
must have high index of suspicion as patients often unwilling to reveal history
consider the injury a "fight-bite" until proven otherwise
o possible delay in presentation until symptoms become intolerable
Symptoms
o progressive development of pain, swelling, erythema, and drainage over wound
Physical exam
o fight bite
small wound over dorsal aspect of MCP joint
wound often transverse, irregular
typically 3rd and/or 4th MCPs, but can involve any digit
erythema, warmth, and/or edema overlying wound and joint
± purulent drainage
must assess for integrity of extensor tendon function
possible pain with passive ROM of MCP joint
typically no involvement of volar/flexor surface of digit
neurovascular status typically preserved
Imaging
Radiographs
o indicated to assess for foreign body (i.e. tooth fragment) and for fracture
Studies
Culture
o not routinely obtained in ED due to contamination
o deep culture obtained in OR
aerobic and anaerobic
Treatment
Operative
o I&D, IV antibiotics
indications
fight bite
joints or tendon shealths are involved
antibiotics
IV antibiotics directed at Staph, Strep, and gram-negative organisms
ampicillin/sulbactam (unasyn)
PO antibiotics upon discharge for 5 to 7 days
amoxicillin/clavulanic acid (augmentin)
debridement
debridement of wound and joint capsule
wound left open for drainage
obtain gram stain and culture
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inform lab about potential for Pasteurella
cultures require appropriate growth media and take 1wk to grow
dog bites
Pasteurella (50% of dog bite infections)
Pasteurella canis
Staphylococcus aureus
Streptococcus alpha-hemolytic
Corynebacterium
anerobes (e.g. Bacteroides)
Capnocytophaga canimorsus
rare, potentially fatal (in splenectomy patients)
causes cellulitis, sepsis, endocarditis, meningitis, DIC, ARDS and death
highest mortality in immunocompromised (30-60%)
cat bites
Pasteurella (most common, 70-80% of cat bite infections)
Pasteurella multocida and Pasteurella septica
causes intense pain, swelling in 48h
other organisms similar to dog bites
o rabies
caused by a rhabdovirus
common animal carriers include dogs, raccoons, bats, foxes
increased risk with open wounds, scratches/abrasions, mucous membranes
Prognosis
o serious and fatal bites include
large, aggressive dogs
small children
head and neck bites
Presentation
History
o important to determine
type of animal
time since injury
presence of comorbidities
Symptoms
o pain and swelling
o bleeding
o signs of local or systemic sepsis
Physical Exam
o evaluate depth of puncture wound and presence of crush injury
o check for neurovascular status
o look for joint penetration
o important to photograph wounds
Imaging
Radiographs
o indications to obtain
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crush injuries
suspected fracture
suspected foreign body
Studies
Culture
o indications
if signs of infection are present
routine culture not indicated
o technique
deep aerobic and anaerobic culture
Treatment
Noperative
o copious irrigation, prophylactic antibiotics, tetanus toxoid, +/- rabies prophylaxis
copious irrigation in emergency room
saline (>150ml) irrigation with 18-19G needle or plastic catheter
use povidone-iodine solution if high risk of rabies
indications for antibiotics
cat bites
presentation >8h
immune compromised or diabetic
hand bite
deep bites
choice of antibiotics
amoxicillin/clavulanic acid effective against Pasteurella multocida
cefuroxime
ceftriaxone
rabies prophylaxis
indicated when any suspicion for rapid animal
suspect if unprovoked attack by animal with bizarre behavior
human diploid cell vaccine and human rabies immunoglobulin
immobilization
immobilize and elevate extremity
Operative
o formal surgical debridement
indications
crush or devitalized tissue
foreign body
bites to digital pulp space, nail bed, flexor tendon sheath, deep spaces of the palm, joint
spaces
tenosynovitis
septic arthritis
abscess formation
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Anatomy
Nailbed and surrounding tissue
o perionychium
nail
nailbed
surrounding skin
o paronychium
lateral nail folds
o hyponychium
skin distal distal and palmar to the nail
o eponychium
dorsal nail fold
proximal to nail fold
o lunula : white part of the proximal nail
o matrix
sterile
soft tissue deep to nail
distal to lunula
adheres to nail
germinal
soft tissue deep to nail
proximal to sterile matrix
responsible for most of nail development
insertion of extensor tendon is approximately 1.2 to 1.4 mm proximal to germinal matrix
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Presentation
Symptoms
o pain
Physical exam
o examine for subungual hematoma
o inspect nail integrity
Imaging
Radiographs
o recommended
AP, lateral and oblique of finger
to rule out fracture of distal phalanx
Subungual Hematoma
Most commonly caused by a crushing-type injury
o causes bleeding beneath nail
Treatment
o drainage of hematoma by perforation
indications
less than 50% of nail involved
techniques
puncture nail using sterile needle
electrocautery to perforate nail
o nail removal, D&I, nail bed repair
indications
> 50 % nail involved
technique
nail bed repair (see techniques)
Avulsion Injuries
Avulsion of nail and portion of underlying nail bed
Mechanism
o usually caused by higher energy injuries
Associated conditions
o commonly associated with other injuries including
distal phalanx fracture
if present reduction is advocated
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Treatment
o nail removal, nail bed repair, +/- fx fixation
indications
avulsion injury with minimal or no loss of nail matrix, with or without fracture
technique
always give tetanus and antibiotics
fracture fixation depends on fracture type
o nail removal, nail bed repair, split thickness graft vs. nail matrix transfer, +/- fx fixation
indications
avulsion or crush injury with significant loss of nail matrix
technique
always give tetanus and antibiotics
nail matrix transfer from adjacent injured finger or nail matrix transfer from second toe
fracture fixation depends on fracture type
Techniques
Nail bed repair
o nail removal
soak nail in Betadine while repairing nail bed
o nail bed repair
IV:27 Hook nail
repair nail bed with 6-0 or smaller absorbable suture
RCT has demonstrated quicker repair time using 2-octylcyanoacrylate (Dermabond) instead
of suture with comparable cosmetic and functional results
o splint eponychial fold
splint eponychial fold with original nail, aluminum, or non-adherent gauze
Complications
Hook nail
o caused by advancement of the matrix to obtain coverage without adequate bony support
Treatment : remove nail and trim matrix to level of bone
Split nail
o caused by scarring of the matrix following injury to nail bed
Treatment
excise scar tissue and replace nail matrix
graft may be needed
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o leads to dissection along planes of least resistance (along neurovascular bundles)
o vascular occlusion may lead to local soft tissue necrosis
Prognosis
o Up to 50% amputation rate for organic solvents (paint, paint thinner, diesel fuel, jet fuel, oil)
o severity of the injury is dependent on
time from injury to treatment
force of injection
volume injected
composition of material
grease, latex, chloroflourocarbon & water based paints are less destructive
industrial solvents & oil based paints cause more soft tissue necrosis
Presentation
History
o important to document duration since event
Physical exam
o inspection
entry wound often benign looking
vascular occlusion may lead to local soft tissue necrosis
Imaging
Radiographs
o may be useful to detect spread of radio-opaque dye
Treatment
Nonoperative
o tetanus prophylaxis, parenteral antibiotics, limb elevation, early mobilization, monitoring
for compartment syndrome
indications
for injection of air and water
Operative
o irrigation & debridement, foreign body removal and broad-spectrum antibiotics
indications
most cases require immediate surgical debridement
technique
it is important to remove as much of the foreign material as possible
broad spectrum antibiotic coverage is important to reduce risk of post operative infection
outcomes
higher rates of amputation are seen when surgery is delayed greater than 10 hours after
injury
Complications
Amputation
o amputation rates approach 50% with oil-based paint injection injuries
Infection
o necrotic tissue is a good culture medium for bacterial growth
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5. Frostbite
Introduction
Definition
o extensive soft tissue damage associated with exposure to temperatures below freezing point
Epidemiology
o demographics
males (m:f = 10:1)
age 30-50 years
o risk factors
host factors
alcohol abuse
mental illness
peripheral vascular disease
peripheral neuropathy
malnutrition
chronic illness
tobacco use
race
African descent more likely to sustain frostbite than Caucasians who have better cold
induced vasodilatation
smoking
reduces nitric oxide (vasodilator)
potentiates thrombosis by increasing fibrinogen levels and platelet activity
environmental factors
degree of cold temperature
risk of frostbite is low at > -10°C
risk of frostbite is high at < -25°C
duration of exposure
windchill
tissues at -18°C freeze in 1h at windspeed of 10mph
tissues at -18°C freeze in 10min at windspeed of 40mph
altitude >17,000 feet
contact with conductive materials (water, ice, metal)
Pathophysiology
o with hypothermia (CBT <35°C) circulation shunted from periphery to maintain core body
temperature (CBT)
o cardiac effects
basal metabolic rate, HR and cardiac output drop
myocardial irritability (abnormal EKG)
o neurological effects
disorientation, coma
shivering (anaerobic) until CBT drops below 30-32°C
below 30-32°C, shivering stops and muscle rigidity ensures (like rigor mortis)
resembles death (absent respirations, dilated pupils, muscle rigidity)
must be rewarmed before pronounced dead (“no one is dead until warm and dead”)
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o limbs (4 phases)
phase I (cooling and freezing)
vasoconstriction/vasospasm followed by transient arteriovenous shunting (hunting
response) of cycles of vasodilatation/vasoconstriction every 10min
those who do not have this response are more prone to cold injury
with persistent cold, cycles cease and temperature in tissue drops to freezing point of
tissue (<-2°C)
ice crystals
extracellular ice crystals causes sludging/stasis and intracellular dehydration
(because of osmotic gradient)
intracellular ice crystals destroy cell membranes
interstitial crystallization is exothermic, maintains latent heat to keep limb above
freezing temperature
when crystallization is complete, limb temperature falls to ambient temperature
phase II (rewarming)
reverses freezing process
limb absorbs heat, intra/extracellular ice crystals melt
intracellular swelling occurs
endothelial cells of capillaries become permeable
fluid extravasation leads to blisters/edema
important to prevent re-freezing (freeze-thaw has severe effects on tissues)
phase III (progressive tissue injury)
inflammation, stasis/thrombosis, tissue necrosis
diminished prostaglandin E2 (vasodilator, antiplatelet)
elevated prostaglandin F2a and thromboxane B2 (vasoconstrictors, platelet-aggregating)
o phase IV (resolution)
complete healing with no symptoms
healing with sequelae
early tissue necrosis/gangrene
o cell biology
leads to movement of water from intracellular location to extracellular location
cellular dehydration leads to cell death
o biochemistry
o
ice crystal formation occurs within the extracellular fluid at -2 to -15°C
sensory nerve dysfunction occurs at -10°C
Associated conditions
o frostnip
mildest cold exposure injury
only affects superficial layers of skin (blanching, numbness) but no dermis damage
reversible
o chilblain (pernio)
occurs in cold, nonfreezing temperatures in dry conditions
burning sensation, with pruritus, swelling, erythema
may have blisters, ulceration
resolves in 2 weeks
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may leave chronic vasculitis esp in young/middle-aged women
o trench foot (immersion foot)
military personnel
prolonged wet nonfreezing condition <10°C
o frostbite
results in localized/extensive tissue necrosis
may require amputation
o hypothermia
when core body temperature is affected
can be fatal
Prognosis
o the severity is increased with
alcohol consumption/intoxication
contact of skin with metal or ice
elevated wind chill factor
Presentation
Physical exam
o hypothermia (mild, 32-35°C; moderate, 28-32°C; severe, <28°C)
tachycardia followed by bradycardia, decreased cardiac output, arrythymia (atrial and
ventricular fibrillation)
decreased respiratory rate
CO2 retention leads to hypoxia/respiratory acidosis
disorientation, comatose
o frostbite (similar to burns)
traditional classification
st
1 degree – central whitish area with surrounding erythema
nd
2 degree – clear/cloudy blisters within 24h
rd
3 degree – hemorrhagic blisters / hard black eschars
th
4 degree – tissue necrosis
newer classification
st nd
superficial (1 and 2 degree) has good prognosis
rd th
deep (3 and 4 degree) has poor prognosis
blisters form 6-24 hours after rewarming
superficial lesions present as clear blisters
deeper lesions form hemorrhagic blisters which may be painless
Imaging
MRI
o T2-weighted images shows enhanced signal in necrotic muscles because of disrupted cell
membranes and increased extracellular fluid
99m
Serial bone scans ( Tc)
o can be used to evaluate the severity of the soft-tissue damage
o 1st scan at 2 days after initial injury
absence of uptake has poor prognosis but may not indicate necrosis
o 2nd scan at 5 days after initial injury
normal blood/bone pool = treat expectantly
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Other Traumatic Injuries
diminished blood/bone pool = observation, with potential early debridement
absent blood/bone pool = early debridement or amputation
Treatment for Hypothermia
protect patient from further exposure to freezing temperature
rewarming
o only after confirmation that the patient can be maintained in a constant warm environment (avoid
freeze-thaw cycles)
o external-surface rewarming (for mild hyperthermia)
passive
dry clothes and warm room
active
disadvantage is too-rapid vasodilatation leads to metabolic waste rushing to core, leading
to paradoxical drop in core temperature (“afterdrop”) that can worsen arrythmia
heat lamps, radiant heaters, heating blanket, immersion in warm water with cardiac
monitoring
o internal-core rewarming (for moderate and severe hypothermia)
warmed oxygen, warm IV fluid
body cavity lavage (invasive)
cardiac bypass
requires systemic heparinization
continuous arteriovenous rewarming
blood from femoral arterial catheter into fluid heat exchanger
returns to body through subclavian venous catheter
achieves 1°C every 15min
o avoid alcohol/sedatives
dulls shivering response and further lowers CBT
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whirlpool hydrotherapy
PT and OT for preserve joint motion
Adjunctive (low molecular weight dextran, anticoagulants, tissue plasminogen activator)
o intravenous tPA within 24h reduces rate of digital amputations
indications
no blood flow on bone scan
2nd or 3rd degree (NOT superficial frostbite)
contraindications
general contraindications
alcoholic patients (risk of bleeding from concomitant head injuries)
active internal bleeding
intracranial hemorrhage/surgery within past 3 months
concurrent trauma
major surgery within previous 14 days
known aneurysm or vascular malformation
known bleeding diathesis
pregnancy
labile hypertension
cold-related contraindications
> 24 hours of cold exposure
warm ischemia times >6h
multiple freeze-thaw cycles
o hyperbaric oxygen (anecdotal evidence)
Operative
o immediate surgical escharotomy
circumferentially constrictive lesion of digit
o fasciotomy
for compartment syndrome
o debride clear blisters and apply aloe vera
reduces high levels of prostaglandin F2 and thromboxane B2
o drain/aspirate hemorrhagic blisters (represents deep injury) but leave intact
prevents dessication of underlying dermis
o late debridement/amputation for necrosis
“frostbite in January, amputate in July”
after demarcation occurs at 1-3months
o surgical sympathectomy
reduces duration of pain and time to demarcation of tissue
does not reduce extent of necrosis
Complications
Adults
o persistent pain (50%)
intolerable in 15%
o cold intolerance
o vasospastic disease (Raynauds phenomenon, cold sensitivity, persistent color changes,
hyperhidrosis)
treatment
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By Dr, AbdulRahman AbdulNasser Hand Trauma | Other Traumatic Injuries
calcium channel blockers, vasodilators, beta blockers, surgical sympathetectomy
indications
late, persistent vasospastic disease
o neuropathy (cold/heat hypersensitivity, hypesthesia, paresthesia)
decreased motor/sensory NCV
treatment
decompression e.g. carpal tunnel release
o musculoskeletal (osteopenia)
subchondral bone loss (frostbite arthropathy), joint contractures esp in DIPJ > PIPJ of hands
and feet
treatment
joint arthroplasty, resection arthroplasty
Children
o premature growth plate closure
1-2 years after exposure
secondary to chondrocytic injury
o joint laxity, angular deformities, short digits, excess skin, degenerative joint changes
seen after age 10 in patients with prior frost bite injuries
treatment
physeal arrest, osteotomy, arthrodesis
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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ORTHO BULLETS
V. Pelvis Trauma
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By Dr, AbdulRahman AbdulNasser Pelvis Trauma | Pelvis
A. Pelvis
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Ligaments
o anterior
symphyseal ligaments
resist external rotation
o pelvic floor
sacrospinous ligaments
resist external rotation
sacrotuberous ligaments
resist shear and flexion
o posterior sacroiliac complex (posterior tension band)
strongest ligaments in the body
more important than anterior structures for pelvic ring stability
anterior sacroiliac ligaments
resist external rotation after failure of pelvic floor and anterior structures
interosseous sacroiliac
resist anterior-posterior translation of pelvis
posterior sacroiliac
resist cephalad-caudad displacement of pelvis
iliolumbar
resist rotation and augment posterior SI ligaments
Physical Exam
Symptoms
o pain & inability to bear weight
Physical exam
o inspection
test stability by placing gentle rotational force on each iliac crest
low sensitivity for detecting instability
perform only once
look for abnormal lower extremity positioning
external rotation of one or both extremities
limb-length discrepancy
o skin
scrotal, labial or perineal hematoma, swelling or ecchymosis V:1 Morel-Lavallee lesion
flank hematoma
lacerations of perineum
degloving injuries (Morel-Lavallee lesion)
o neurologic exam
rule out lumbosacral plexus injuries (L5 and S1 are most common)
rectal exam to evaluate sphincter tone and perirectal sensation
o urogenital exam
most common finding is gross hematuria
more common in males (21% in males, 8% in females)
o vaginal and rectal examinations
mandatory to rule out occult open fracture
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By Dr, AbdulRahman AbdulNasser Pelvis Trauma | Pelvis
Imaging
Radiographs
o AP Pelvis
part of initial ATLS evaluation
look for asymmetry, rotation or
displacement of each hemipelvis
evidence of anterior ring injury needs
further imaging
o inlet view
X-ray beam angled ~45 degrees caudad
(may be as little as 25 degrees)
adequate image when S1 overlaps S2
body
ideal for visualizing: V:2 Normal AP pelvis
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By Dr, AbdulRahman AbdulNasser Pelvis Trauma | Pelvis
Young-Burgess Classification
Descriptions Treatment
Anterior Posterior Compression (APC)
APC I Symphysis widening < 2.5 cm Non-operative. Protected weight
bearing
APC II Symphysis widening > 2.5 cm. Anterior SI joint Anterior symphyseal plate or external
diastasis. Posterior SI ligaments intact. Disruption fixator +/- posterior fixation
of sacrospinous and sacrotuberous ligaments.
APC III Disruption of anterior and posterior SI ligaments Anterior symphyseal multi-hole plate or
(SI dislocation). Disruption of sacrospinous and external fixator and posterior
sacrotuberous ligaments. stabilization with SI screws or
APCIII associated with vascular injury plate/screws
Lateral Compression (LC)
LC Type I Oblique or transverse ramus fracture and Non-operative. Protected weight
ipsilateral anterior sacral ala compression bearing (complete, comminuted sacral
fracture. component. Weight bearing as
tolerated (simple, incomplete sacral
fracture).
LC Type II Rami fracture and ipsilateral posterior ilium Open reduction and internal fixation of
fracture dislocation (crescent fracture). ilium
LC Type III Ipsilateral lateral compression and contralateral Posterior stabilization with plate or SI
APC (windswept pelvis). screws as needed. Percutaneous or
Common mechanism is rollover vehicle accident open based on injury pattern and
or pedestrian vs auto. surgeon preference.
Vertical Shear
Vertical shear Posterior and superior directed force. Posterior stabilization with plate or SI
Associated with the highest risk of hypovolemic screws as needed. Percutaneous or
shock (63%); mortality rate up to 25% open based on injury pattern and
surgeon preference.
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Young-Burgess Classification
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helps to ensure pin placement within inner and outer table
AIIS pins can place the lateral femoral cutaneous nerve at risk
pedicle screws with internal subcutaneous bar may be used
superior iliac crest pin insertion
multiple half pins in the superior iliac crest
place in thickest portion of ilium (gluteal pillar)
may be placed with minimal fluoroscopy
should be placed before emergent laparotomy
o angiography / embolization
indications
controversial and based on multiple variables including:
protocol of institution, stability of patient, proximity of angiography suite , availability
and experience of IR staff
CT angiography useful for determining presence or absence of ongoing arterial
hemorrhage (98-100% negative predictive value)
contraindications
not clearly defined
technique
selective embolization of identifiable bleeding sources
in patients with uncontrolled bleeding after selective embolization, bilateral temporary
internal iliac embolization may be effective
complications include gluteal necrosis and impotence
Definitive Treatment
Nonoperative
o weight bearing as tolerated
indications
mechanically stable pelvic ring injuries including
LC1
anterior impaction fracture of sacrum and oblique ramus fractures with < 1cm of
posterior ring displacement
APC1
widening of symphysis < 2.5 cm with intact posterior pelvic ring
isolated pubic ramus fractures
parturition-induced pelvic diastasis
bedrest and pelvic binder in acute setting with diastasis less than 4cm
Operative
o ORIF
indications
symphysis diastasis > 2.5 cm
SI joint displacement > 1 cm
sacral fracture with displacement > 1 cm
displacement or rotation of hemipelvis
open fracture
chronic pain and diastasis in parturition-induced diastasis or acute setting >6cm
technique
for open fractures aggressive debridement according to open fracture principles
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By Dr, AbdulRahman AbdulNasser Pelvis Trauma | Pelvis
o anterior subcutaneous pelvic fixator (INFIX)
indications : same indications as anterior external fixation and symphyseal plating
o diverting colostomy
indications
consider in open pelvic fractures
especially with extensive perineal injury or rectal involvement
Techniques
Anterior ring stabilization
o single superior plate
apply through rectus-splitting Pfannenstiel approach
may perform in conjunction with laparotomy or GU procedure
Posterior ring stabilization
o anterior SI plating
risk of L4 and L5 injury with placement of anterior sacral retractors
o iliosacral screws (percutaneous)
good for sacral fractures and SI dislocations
safe zone is in S1 vertebral body
outlet radiograph view best guides superior-inferior screw placement
inlet radiograph view best guides anterior-posterior screw placement
L5 nerve root injury complication with errors in screw placement
entry point best viewed on lateral sacral view and pelvic outlet views
risk of loss of reduction highest in vertical sacral fracture patterns
o posterior SI "tension" plating
can have prominent HW complications
Anterior and posterior ring stabilization
o necessary in vertically unstable injuries
Ipsilateral acetabular and pelvic ring fractures
o reduction and fixation of the pelvic ring should be performed first
Complications
Neurologic injury
o L5 nerve root runs over sacral ala joint
o may be injured if SI screw is placed to anterior
o anterior subcutaneous pelvic fixator may give rise to LFCN injury (most common) or femoral
nerve injury
DVT and PE
o DVT in ~ 60%, PE in ~ 27%
o prophylaxis essential
mechanical compression
pharmacologic prevention (LMWH or Lovenox)
vena caval filters (closed head injury)
Chronic instability
o rare complication; can be seen in nonoperative cases
o presents with subjective instability and mechanical symptoms
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Urogenital Injuries
Present in 12-20% of patients with pelvic fractures
o higher incidence in males (21%)
Includes
o posterior urethral tear
most common urogenital injury with pelvic ring fracture
o bladder rupture
Anatomy
Ligaments
o the SI joint is stabilized by the posterior pelvic ligaments
sacrospinous
sacrotuberous
anterior sacroiliac
posterior sacroiliac
Nerves
o the L5 nerve root crosses the sacral ala approximately 2 cm
medial to SI joint
Blood supply
o the superior gluteal artery runs across SI joint
o exits pelvis via greater sciatic notch
Classification
No classification system specifically for SI injury
o included in Young- Burgess and Tile classification of pelvic fractures
o crescent fractures described as LC-2 injury according to Young-Burgess
Presentation
Symptoms : pelvic pain
Physical Exam
o assess hemodynamic status
o perform detailed neurological exam
o abdominal assessment to look for distention
o rectal exam
o examine urethral meatus for blood
Imaging
Radiographs : recommended views
AP pelvis
inlet and outlet views
CT scan
o evaluation of sacral fractures
o posterior pelvis better delineated
Treatment
Operative
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o immediate skeletal traction
indications : vertical translation of the hemipelvis
o anterior ring ORIF
indications
incomplete SI dislocations with pubic symphyseal diastasis
o anterior and posterior ring ORIF
indications
complete SI dislocations
vertically unstable require anterior and posterior pelvic ring fixation
o ORIF of ilium
indications
crescent fracture : required to restore posterior SI ligaments and pelvic stability
Techniques
Closed Reduction and Percutaneous Fixation
o positioning
intraoperative traction may aid in reduction
small midline bump under sacrum may assist with SI screw placement
o imaging
inlet view : shows anterior-posterior position of SI joint(s) for screw placement
outlet view : shows cephalad-caudad position of SI joint(s) for screw placement
lateral sacral view
ensures safe placement of SI or sacral screws relative to the anterior cortex of the sacral
ala and the nerve root tunnel
o complications
L5 nerve root at risk with anterior perforation of iliosacral screw as nerve goes inferiorly over
sacral ala
ORIF
o approach
anterior approach : lateral window with elevation iliacus back to SI joint
posterior approach : for fixation of crescent fragment to intact ilium
o fixation
plates
iliosacral lag screws (SI screws)
Complications
DVT : 35%-50%
Neurological injury
Loss of reduction and failure of fixation
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By Dr, AbdulRahman AbdulNasser Pelvis Trauma | Pelvis
3. Sacral Fractures
Introduction
Under-diagnosed and often mistreated fractures that may result in neurologic compromise
o common in pelvic ring injuries (30-45%)
o 25% are associated with neurologic injury
o frequently missed
75% in patients who are neurologically
intact
50% in patients who have a neurologic
deficit
Epidemiology
o young adults : as a result of high energy trauma
o elderly : as a result of low energy falls
Prognosis
o presence of a neurologic deficit is the most
important factor in predicting outcome
o mistreated fractures may result in
lower extremity deficits
urinary dysfunction
rectal dysfunction
sexual dysfunction
Anatomy
Osteology
o formed by fusion of 5 sacral vertebrae
o articulates with
5th lumbar vertebra proximally
coccyx distally
ilium laterally at sacroiliac joints
o contains 4 foramina which transmit sacral nerves
Nerves
o L5 nerve root runs on top of sacral ala
o S1-S4 nerve roots are transmitted through the sacral
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Classification
Denis classification
o zone 1
fracture lateral to foramina
characteristics
most common (50%)
nerve injury rare (5%)
usually occurs to L5 nerve root
o zone 2
fracture through foramina
characteristics
may be
stable
unstable
zone 2 fracture with shear component highly unstable
increased risk of nonunion and poor functional outcome
o zone 3
fracture medial to foramina into the spinal canal
characteristics
highest rate of neurologic deficit (60%)
bowel, bladder, and sexual dysfunction
Transverse sacral fractures
o higher incidence of nerve dysfunction
U-type sacral fractures
o results from axial loading
o represent spino-pelvic dissociation
o high incidence of neurologic complications
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By Dr, AbdulRahman AbdulNasser Pelvis Trauma | Pelvis
Presentation
History
o motor vehicle accident or fall from height most common
o repetitive stress
insufficiency fracture in osteoporotic adults
Symptoms
o peripelvic pain
Physical exam
o inspection
soft tissue trauma around pelvis should raise concerns for pelvic or sacral fracture
o palpation
test pelvic ring stability by internally and externally rotating iliac wings
palpate for subcutaneous fluid mass indicative of lumbosacral fascial degloving (Morel-
Lavallee lesion)
perform vaginal exam in women to rule-out open injury
o neurologic exam
rectal exam
light touch and pinprick sensation along S2-S5 dermatomes
perianal wink
bulbocavernosus and cremasteric reflexes
o vascular exam
distal pulses
if different consider ankle-brachial index or angiogram
Imaging
Radiographs
o only show 30% of sacral fractures
o recommended views
AP pelvis
inlet view
best assessment of sacral spinal canal and superior view of S1
outlet view
provides true AP of sacrum
o additional views
cross-table lateral
effective screening tool for sacral fractures
often of poor quality
o findings
L4 or L5 transverse process fractures
asymmetric foramina
CT
o diagnostic study of choice
o recommend coronal and sagittal reconstruction views
MRI
o recommended when neural compromise is suspected V:4 Cross table lateral view
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Treatment
Nonoperative
o progressive weight bearing +/- orthosis
indications
<1 cm displacement and no neurologic deficit
insufficiency fractures
Operative
o surgical fixation
indications
displaced fractures >1 cm
soft tissue compromise
persistent pain after non-operative management
displacement of fracture after non-operative management
o surgical fixation with decompression
indications
any evidence of neurologic injury
Surgical Techniques
Percutaneous screw fixation
o screws may be placed as sacroiliac, trans-sacral or trans-iliac trans-sacral
o useful for sagittal plane fractures
o technique
screws placed percutaneously under fluoroscopy
beware of L5 nerve root
avoid overcompression of fracture
may cause iatrogenic nerve dysfunction
o cons
may result in loss of fixation or malreduction
does not allow for removal of loose bone fragments
do not use in osteoporotic bone
Posterior tension band plating
o approach : posterior two-incision approach
o technique
may use in addition to iliosacral screws
o pros : allows for direct visualization of fracture
o cons : wound healing complications
Iliosacral and lumbopelvic fixation
o approach
posterior approach to lower lumbar spine and sacrum
o technique
pedicle screw fixation in lumbar spine
iliac screws parallel to the inclination angle of outer table of ilium
longitudinal and transverse rods
o pros
shown to have greatest stiffness when used for an unstable sacral fracture
o cons
invasive
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Decompression of neural elements
o technique
indirect
reduction through axial traction
direct
posterior approach followed by laminectomy or foraminotomy
Complications
Venous thromboembolism
o often as a result of immobility
Iatrogenic nerve injury
o may result from
overcompression of fracture
improper hardware placement
Malreduction
o more common with vertically displaced fractures
4. Ilium Fractures
Introduction
Most are unstable fractures
Typically progress from iliac crest to greater sciatic notch
Iliac wing fractures have high incidence of associated injuries
o open injuries
o bowel entrapment
o soft tissue degloving
Anatomy
Osteology
o pelvic girdle is comprised of
sacrum
2 innominate (coxal) bones
each formed from the union of 3 bones: ilium, ischium, and pubis
o ilium
2 important anterior prominences
anterior-superior iliac spine (ASIS)
origin of sartorius and transverse and internal abdominal muscles
anterior-inferior iliac spine (AIIS)
origin of direct head of rectus femoris and iliofemoral ligament (Y ligament of
Bigelow)
posterior prominences
posterior-superior iliac spine (PSIS)
located 4-5 cm lateral to the S2 spinous process
posterior-inferior iliac spine (PIIS)
Imaging
Plain radiographs
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o standard set of AP pelvis, inlet/outlet, and judet views
helpful for evaluating the iliac wing in addition to pelvic stability and possible acetabular
involvement
CT scan
o carefully assess CT scan for signs of bowel entrapment
o evaluate for presence of gas or air in the soft tissues which can be associated with open injury or
bowel disruption
Classification
No specific classification for iliac wing fractures
Generally described as specific subtypes of more common classification systems
o Tile Classification
stable (intact posterior arch)
A1-1: iliac spine avulsion injury
A1-2: iliac crest avulsion
A2-1: iliac wing fractures often from a direct blow
partially stable (incomplete disruption of posterior arch)
B2-3: incomplete posterior iliac fracture
unstable (complete disruption of posterior arch)
C1-1: unilateral iliac fracture
Treatment
Nonoperative
o mobilization with an assist device
indications
nondisplaced fractures
isolated iliac wing fractures
Operative
o open reduction and internal fixation
indications
displaced fractures of ilium
Operative Techniques
Wound Management
o evaluate all wounds for
soft tissue disruption or internal degloving injury
possible soft tissue or bowel entrapment in the fracture site
o prophylactic antibiotics as appropriate
o serial debridements as necessary
Open Reduction Internal Fixation
o approach
posterior approach
ilioinguinal approach
Stoppa approach (lateral window)
o recommend early reconstruction
single pelvic reconstruction plate or lag screw along the iliac crest
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By Dr, AbdulRahman AbdulNasser Pelvis Trauma | Acetabulum
supplemented with a second reconstruction plate or lag screw at the level of the pelvic brim
or sciatic buttress
o coordination with trauma team
injury to bowel may require diversion procedures
plan surgical intervention with trauma team to minimize recurrent trips to the operating room
Complications
Malunion with deformity of the iliac wing
Internal iliac artery injury
Bowel perforation
Lumbosacral plexus injury
B. Acetabulum
1. Acetabular Fractures
Introduction
Epidemiology
o demographics
bimodal distribution
high energy blunt trauma for young patients
low energy (fall from standing height) for elderly patients
o location
posterior wall fractures are most common
Pathoanatomy
o fracture pattern determined by
force vector
position of femoral head at time of injury
Associated conditions
o orthopaedic manifestations
extremity injury (36%)
nerve palsy (13%)
spine injury (4%)
o systemic injuries
head injury (19%)
chest injury (18%)
abdominal injury (8%)
genitourinary injury (6%)
Classification Systems
o Judet and Letournel
classifed as 5 elementary and 5 associated fracture patterns
o AO/OTA Classification
Anatomy
Osteology
o acetabular inclination & anteversion
mean lateral inclination of 40 to 48 degrees
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anteversion of 18 to 21 degrees
o column theory
acetabulum is supported by two columns of bone
form an "inverted Y"
connected to sacrum through sciatic buttress
posterior column
comprised of
quadrilateral surface
posterior wall and dome
ischial tuberosity
greater/lesser sciatic notches
anterior column
comprised of
anterior ilium (gluteus medius tubercle)
anterior wall and dome
iliopectineal eminence
lateral superior pubic ramus
Vascular V:5 column theory form inverted Y
o corona mortis
anastomosis of external iliac (epigastric) and internal iliac (obturator) vessels
at risk with lateral dissection over superior pubic ramus
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By Dr, AbdulRahman AbdulNasser Pelvis Trauma | Acetabulum
Letournel Classification
Elementary
• Most common
Posterior wall • "gull sign" on obturator oblique view
Posterior column • check for injury to superior gluteal NV bundle
Anterior wall • Very rare
Anterior column • More common in elderly patients with fall from standing (most common in
elderly is "anterior column + medial wall")
Transverse • Axial CT shows anterior to posterior fx line
• Only elementary fx to involve both columns
Associated
Associated Both Column • Characterized by dissociation of the articular surface from the inonimate bone
• will see "spur sign" on obturator oblique
Transverse + Post. Wall • Most common associated fx
T Shaped • May need combined approach
Anterior column or wall + • Common in elderly patients
Post. hemitransverse
Post. column + Post. wall • Only associated fracture that does not involve both columns
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Transverse + Post. Wall CT Transverse + Post. Wall x-ray Transverse + Post. Wall CT
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Imaging
Radiographs
o recommended views
AP pelvis, Judet views, inlet and outlet if
concerned for pelvic ring involvement
o 6 radiographic landmarks of the acetabulum
iliopectineal line (anterior column)
ilioischial line (posterior column)
anterior rim
posterior rim
teardrop
weight bearing roof
o superior acetabular rim may show os acetabuli
marginalis superior which can be confused for fracture in adolescents
o Judet views (45 degree oblique views)
obturator oblique
shows profile of obturator foramen
shows anterior column and posterior wall
iliac oblique
shows profile of involved iliac wing
shows posterior column and anterior wall
o roof arc measurements
show intact weight bearing dome if > 45 degrees on
AP, obturator, and iliac oblique
not applicable for associated both column or posterior
wall pattern because no intact portion of the
acetabulum to measure
CT scan
o important to
define fragment size and orientation
identify marginal impaction
identify loose bodies
look for articular gap or step-off
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Treatment
Nonoperative
o protected weight bearing for 6-8 weeks
indications
minimally displaced fracture (< 2mm)
< 20% posterior wall fractures
treatment based on size of posterior wall is controversial
exam under anesthesia using fluoroscopy best method to test stability
femoral head remains congruent with weight bearing roof (out of traction)
both column fracture with secondary congruence (out of traction)
displaced fracture with roof arcs > 45 degrees in AP and Judet views
relative contraindications to surgery
morbid obesity
open contaminated wound
presence of DVT
technique
lowest joint reactive forces seen with toe-touch weight
bearing and passive hip abduction
greatest joint contact force seen when rising from a
chair on the affecdted extremity
close radiographic follow-up
skeletal traction rarely indicated as definitive treatment
Operative treatment
o open reduction and internal fixation
indications
displacement of roof (>2mm)
posterior wall fracture involving > 40-50%
marginal impaction
intra-articular loose bodies
irreducible fracture-dislocation
pregnancy is not contraindication to surgical fixation
outcomes
associated hip dislocations should be reduced within 12 hours for improved outcomes
clinical outcome correlates with quality of articular reduction
earlier operative treatment associated with increased chance of anatomic reduction
postoperative CT scan is most accurate way to determine posterior wall accuracy of
reduction which has greatest correlation with clinical outcome
greatest stress on acetabular repair occurs when rising from a seated position using the
affected leg, and occurs in the posterior superior portion of the acetabulum
functional outcomes most strongly correlate with hip muscle strength and restoration of
gait postoperatively
o open reduction and internal fixation with acute total hip arthroplasty
indications
significant osteopenia and/or significant comminution
outcomes
up to 78% 10-year implant survival noted
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worse outcomes in males, patients <50 years old or >80kg, or if a significant acetabular
defect remains
o percutaneous fixation with column screws
indications
anterior column screws
Techniques
Percutaneous fixation with column screws
o approach
anterograde (from iliac wing to ramus)
retrograde (from ramus to iliac wing)
posterior column screws
o imaging
obturator oblique best view to rule out joint penetration
inlet iliac oblique view best to determine anteroposterior position of screw within the pubic
ramus
obturator oblique inlet view best to determine position of a supraacetabular screw within
tables of the ilium
ORIF
o approaches
approach depends on fracture pattern
two approaches can be combined
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Approaches Indications Risks
Anterior Approach • anterior wall and anterior column • femoral nerve injury
(Ilioinguinal) • both column fracture • LFCN injury
• posterior hemitransverse • thrombosis of femoral vessels
• laceration of corona mortis in 10-15%.
Posterior Approach • posterior wall and posterior column fx • increased HO risk compared with
(Kocher-Langenbach) • most transverse and T-shaped anterior approach
• combination of above •sciatic nerve injury (2-10%)
• damage to blood supply of femoral head
(medial femoral circumflex)
Extensile Approach • only single approach that allows direct • massive heterotopic ossification
(extended iliofemoral) visualization of both columns • posterior gluteal muscle necrosis
• associated fracture pattern 21 days after
injury
• some transverse fxs and T types
• some both column fxs (if posterior
comminution is present)
Modified Stoppa • access to quadrilateral plate to buttress • Corona mortis must be exposed and
Approach comminuted medial wall fractures ligated in this approach
Complications
Post-traumatic DJD
o most common complication
o 80% survival noted at 20 years for patients s/p ORIF
o risk factors for DJD include
age >40
associated fracture patterns
concomitant femoral head injury
o treat with hip fusion or THA
Heterotopic Ossification
o highest incidence with extensile approach
treat with
indomethacin x 5 weeks post-op
low dose external radiation (no difference shown in direct comparison)
o lowest incidence with anterior ilioinguinal approach
Osteonecrosis
o 6-7% of all acetabular fractures
o 18% of posterior fracture patterns
DVT and PE
Infection
Bleeding
Neurovascular injury
Intraarticular hardware placement
Abductor muscle weakness
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2. Hip Dislocation
Introduction
Epidemiology
o rare, but high incidence of associated injuries
o mechanism is usually young patients with high energy trauma
Hip joint inherently stable due to
o bony anatomy
o soft tissue constraints including
labrum
capsule
ligamentum teres V:8 Dashboard injury
Classification
Simple vs. Complex
o simple
pure dislocation without associated fracture
o complex
dislocation associated with fracture of acetabulum or
proximal femur
Anatomic classification
o posterior dislocation (90%)
occur with axial load on femur, typically with hip flexed V:9 Clinical picture of
and adducted posterior dislocation
axial load through flexed knee (dashboard injury)
position of hip determines associated acetabular injury
increasing flexion and adduction favors simple dislocation
associated with
osteonecrosis
posterior wall acetabular fracture
femoral head fractures
sciatic nerve injuries
ipsilateral knee injuries (up to 25%)
o anterior dislocation
associated with femoral head impaction or chondral injury
occurs with the hip in abduction and external rotation
inferior ("obturator") vs. superior ("pubic")
hip extension results in a superior (pubic) dislocation
Clinically hip appears in extension and external rotation
flexion results in inferior (obturator) dislocation
Clinically hip appears in flexion, abduction, and external rotation
Presentation
Symptoms
o acute pain, inability to bear weight, deformity
Physical exam
o ATLS
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95% of dislocations with associated injuries
o posterior dislocation (90%)
hip and leg in slight flexion, adduction, and internal rotation
detailed neurovascular exam (10-20% sciatic nerve injury)
examine knee for associated injury or instability
chest X-ray ATLS workup for aortic injury
o anterior dislocation
hip and leg in flexion, abduction, and external rotation
Imaging
Radiographs
o can typically see posterior dislocation on AP pelvis V:10 Anteior dislocation
femoral head smaller then contralateral side
Shenton's line broken
lesser trochanter shadow reveals internally rotated limb as compared to contralateral side
scrutinize femoral neck to rule out fracture prior to attempting closed reduction
CT
o helps to determine direction of dislocation, loose bodies, and associated fractures
anterior dislocation
posterior dislocation
o post reduction CT must be performed for all traumatic hip
dislocations to look for
femoral head fractures
loose bodies
acetabular fractures
MRI
o controversial and routine use is not currently supported
o useful to evaluate labrum, cartilage and femoral head vascularity
Loose fragment in
Anterior dislocation Posterior dislocation Associated neck fx the joint AP view posterior dislocation
Treatment
Nonoperative
o emergent closed reduction within 6 hours
indications
acute anterior and posterior dislocations
contraindications
ipsilateral displaced or non-displaced femoral neck fracture
Operative
indications
irreducible dislocation
radiographic evidence of incarcerated fragment
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By Dr, AbdulRahman AbdulNasser Pelvis Trauma | Acetabulum
delayed presentation
non-concentric reduction
should be performed on urgent basis
o ORIF
indications
associated fractures of
acetabulum
femoral head
femoral neck : should be stabilized prior to reduction
o arthroscopy
indications
no current established indications
potential for removal of intra-articular fragments
evaluate intra-articular injuries to cartilage, capsule, and labrum
Techniques
Closed reduction
o perform with patient supine and apply traction in line with deformity regardless of direction of
dislocation
o must have adequate sedation and muscular relaxation to perform reduction
o assess hip stability after reduction
o post reduction CT scan required to rule out
femoral head fractures
intra-articular loose bodies/incarcerated fragments
may be present even with concentric reduction on plain films
acetabular fractures
o post-reduction : for simple dislocation, follow with protected weight bearing for 4-6 weeks
Open reduction
o approach
posterior dislocation : posterior (Kocher-Langenbeck) approach
anterior dislocation : anterior (Smith-Petersen) approach
o technique
may place patient in traction to reduce forces on cartilage due to incarcerated fragment or in
setting of unstable dislocation
repair of labral or other injuries should be done at the same time
Complications
Post-traumatic arthritis
o up to 20% for simple dislocation, markedly increased for complex dislocation
Femoral head osteonecrosis : 5-40% incidence
o Increased risk with increased time to reduction
Sciatic nerve injury : 8-20% incidence
o associated with longer time to reduction
Recurrent dislocations : less than 2%
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ORTHO BULLETS
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Femur
A. Femur
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Classification
Pipkin Classification
Type I Fx below fovea/ligamentum (small)
Does not involve the weightbearing portion of the femoral
head
Presentation
History
o frontal impact MVA with knee striking dashboard
o fall from height
Symptoms
o localized hip pain
o unable to bear weight
o other symptoms associated with impact
Physical exam
o inspection
shortened lower limb
with large acetabular wall fractures, little to no rotational asymmetry is seen
posterior dislocation
limb is flexed, adducted, internally rotated
anterior dislocation
limb is flexed, abducted, externally rotated
o neurovascular
may have signs of sciatic nerve injury
Imaging
Radiographs
o recommended views
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Femur
AP pelvis, lateral hip and Judet views
both pre-reduction and post-reduction
inlet and outlet views
if acetabular or pelvic ring injury suspected
CT scan
o indications
after reduction
to evaluate:
concentric reduction
loose bodies in the joint
acetabular fracture
femoral head or neck fracture
o findings
femoral head fracture
intra-articular fragments
posterior pelvic ring injury
impaction
acetabular fracture
Treatment
Nonoperative
o hip reduction
indications VI:1 Fixation of head femur by scews
acute dislocations
reduce hip dislocation within 6 hours
technique
obtain post reduction CT
o TDWB x 4-6 weeks, restrict adduction and internal rotation
indications
Pipkin I
undisplaced Pipkin II with < 1mm step off
no interposed fragments
stable hip joint
technique
perform serial radiographs to document maintained reduction
Operative
o ORIF
indications
Pipkin II with > 1mm step off
if performing removal of loose bodies in the joint
associated neck or acetabular fx (Pipkin type III and IV)
polytrauma
irreducible fracture-dislocation
Pipkin IV
treatment dictated by characteristics of acetabular fracture
small posterior wall fragments can be treated nonsurgically and suprafoveal fractures
can then be treated through an anterior approach
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outcomes
outcomes mimic those of their associated injuries (hip dislocations and femoral neck
fractures)
poorer outcomes associated with
use of posterior (Kocher-Langenbeck) approach
use of 3.0mm cannulated screws with washers
o arthroplasty
indications
Pipkin I, II (displaced), III, and IV in older patients
fractures that are significantly displaced, osteoporotic or comminuted
Surgical Techniques
ORIF of femoral head (Pipkin I, II, III)
o approach
anterior (Smith-Peterson) approach
the anterior (Smith-Peterson) and anterolateral (Watson-Jones) approaches provide the
best visualization of the head compared with the posterior approach
utilizes internervous plane between the superior gluteal and femoral nerves
no increased risk of AVN
shorter surgical time
less blood loss
ease of reduction and fixation
because femoral head fragment is commonly anteromedial
can use surgical hip dislocation if needed
anterolateral (Watson-Jones)
utilizes intermuscular plane between the tensor
fascia lata and gluteus medius (both superior
gluteal nerve)
o exposure
periacetabular capsulotomy to preserve blood supply
to femoral head
o fixation
two or more 2.7mm or 3.5mm lag screws
countersink the heads of the screws to avoid screw head
prominence
headless compression screws
bioabsorbable screws
o postop
rehabilitation
mobilization
immediate early range of motion
weightbearing
delay weight bearing for 6-8 weeks
stress strengthening of the quadriceps and abductors
radiographs
radiographs after 6 months to evaluate for AVN and osteoarthritis
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Femur
ORIF of femoral head and acetabulum (Pipkin IV)
o approach
posterior (Kocher-Langenbeck) approach with digastric osteotomy
provides the best visualization of femoral head fracture and acetabular posterior wall
fracture
preserves the medial circumflex artery supply to the femoral head
utilizes plane created by splitting of gluteus maximus (no true internervous plane
gluteus maximus is not denervated because it receives nerve supply well medial to the
split
anterior (Smith-Peterson) approach
for fixation of suprafoveal fractures (if posterior wall fragments are small, they can be
treated nonsurgically)
Arthroplasty
o approach
can use any hip approach for arthroplasty
posterior (Kocher-Langenbeck) approach provides the best visualization of
acetabular posterior wall fracture
o pros & cons
allows immediate postoperative mobilization and weightbearing
hemiarthroplasty can be utilized if no acetabular fracture present
total hip arthroplasty favored if patient physiologically younger or if acetabular fracture
present
Complications
Heterotopic ossification
o overall incidence is 6-64%
anterior approach has increased heterotopic ossification
compared with posterior approach
o treatment
administer radiation therapy if there is concern for HO
especially if there is associated head injury
AVN
o incidence is 0-23%
risk is greater with delayed reduction of dislocated hip
the impact of anterior incision on AVN is unknown
VI:2 Heterotopic ossification
Sciatic nerve neuropraxia
o incidence is 10-23%
usually peroneal division of sciatic nerve
spontaneous recovery of function in 60-70%
DJD
o incidence 8-75%
o due to joint incongruity or initial cartilage damage
o Decreased internal rotation : may not be clinically problematic or cause disability
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Classification
Garden Classification
(based on AP radiographs and does not consider lateral or sagittal plane alignment)
Type I Incomplete, ie. valgus impacted
Type II Complete fx. nondisplaced
Type III Complete, partially displaced
Type IV Complete, fully displaced
Posterior roll-off and/or angulation of femoral head leads to increased reoperation rates
Pauwels Classification
(based on vertical orientation of fracture line)
Type I < 30 deg from horizontal
Type II 30 to 50 deg from horizontal
Type III > 50 deg from horizontal (most unstable with highest risk of nonunion and AVN)
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Presentation
Symptoms
o impacted and stress fractures
slight pain in the groin or pain referred along the medial side of the thigh and knee
o displaced fractures
pain in the entire hip region
Physical exam
o impacted and stress fractures
no obvious clinical deformity
minor discomfort with active or passive hip range of motion, muscle spasms at extremes of
motion
pain with percussion over greater trochanter
o displaced fractures
leg in external rotation and abduction, with shortening
Imaging
Radiographs
o recommended views
obtain AP pelvis and cross-table lateral, and full length femur film of ipsilateral side
consider obtaining dedicated imaging of uninjured hip to use as template intraop
traction-internal rotation AP hip is best for defining fracture type
Garden classification is based on AP pelvis
CT
o helpful in determining displacement and degree of comminution in some patients
MRI
o helpful to rule out occult fracture
o not helpful in reliably assessing viability of femoral head after fracture
Bone scan
o helpful to rule out occult fracture
o not helpful in reliably assessing viability of femoral head after fracture
Duplex Scanning
o indication
rule out DVT if delayed presentation to hospital after hip fracture
Treatment
Nonoperative
o observation alone
indications
may be considered in some patients who are non-ambulators, have minimal pain, and who
are at high risk for surgical intervention
Operative
o ORIF
indications
displaced fractures in young or physiologically young patients
ORIF indicated for most pts <65 years of age
Techniques
General Surgical Consideration
o time to surgery
controversial
reduction method and quality has more pronounced effect on healing than surgical timing
elderly patients with hip fractures should be brought to surgery as soon as medically optimal
the benefits of early mobilization cannot be overemphasized
improved outcomes in medically fit patients if surgically treated less than 4 days from
injury
o treatment approach based on
degree of displacement
physiologic age of the patient (young is < than 50
ipsilateral femoral neck and shaft fractures
priority goes to fixing femoral neck because anatomic reduction is necessary to avoid
complications of AVN and nonunion
o fixation with implants that allow sliding
permit dynamic compression at fx site during axial loading
can cause shortening of femoral neck
prominent implants
affects biomechanics of hip joint
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lower physical function on SF-36
decreased quality of life
anatomic reduction with intraop compression and placement of length stable devices decrease
shortening
o open versus closed reduction
worse outcomes with displacement > 5 mm (higher rate of osteonecrosis and nonunions)
no consensus on which reduction approach is superior
multiple closed reduction attempts are associated with higher risk of osteonecrosis of the
femoral head
ORIF
o approach
limited anterior Smith-Peterson
10cm skin incision made beginning just distal to AIIS
incise deep fascia
develop interval between sartorious and TFL
external rotation of thigh accentuates dissection plane
LFCN is identified and retracted medially with sartorius
identify tendinous portion of rectus femoris, elevate off hip capsule
open capsule to identify femoral neck
Watson-Jones
used to gain improved exposure of lower femoral neck fractures
skin incision approx 2cm posterior and distal to ASIS, down toward tip of greater
trochanter
incision curved distally and extended 10cm along anterior portion of femur
incise deep fascia
develop interval between TFL and gluteus medius
anterior aspect of gluteus medius and minimus is retracted posteriorly to visualize
anterior hip capsule
capsule sharply incised with Z-shape incision
capsulotomy must remain anterior to lesser trochanter at all times to avoid injury to
medial femoral circumflex artery
reduction (method may vary)
evacuate hematoma
place A to P k-wires into femoral neck/head proximal to fracture to use as joysticks for
reduction
insert starting k-wire (for either cannulated screw or sliding hip screw) into appropriate
position laterally, up to but not across the fracture
once reduction obtained, drive starting k-wire across fracture
insert second threaded tipped k-wire if adding additional fixation
Cannulated Screw Fixation
o technique
three screws if noncomminuted (3 screw inverted triangle shown to be superior to two
screws)
order of screw placement (this varies)
1-inferior screw along calcar
2-posterior/superior screw
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3-anterior/superior screw
obtain as much screw spread as possible in femoral neck
inverted triangle along the calcar (not central in the neck) has stronger fixation and higher
load to failure
four screws considered for posterior comminution
clear advantage of additional screws not proven in literature
starting point at or above level of lesser trochanter to avoid fracture
avoid multiple cortical perforations during guide pin or screw placement to avoid
development of lateral stress riser
Hemiarthroplasty
o approach
posterior approach has increased risk of dislocations
anterolateral approach has increased abductor weakness
o technique
cemented superior to uncemented
unipolar vs. bipolar
Total Hip Replacement
o technique
should consider using the anterolateral approach and selective use of larger heads in the
setting of a femoral neck fracture
o advantages
improved functional hip scores and lower re-operation rates compared to hemiarthroplasty
o complications
higher rate of dislocation with THA (~ 10%)
about five times higher than hemiarthroplasty
Complications
Osteonecrosis
o incidence of 10-45%
o recent studies fail to demonstrate association between time to fracture reduction and subsequent
AVN
o increased risk with
increase initial displacement
AVN can still develop in nondisplaced injuries
nonanatomical reduction
o treatment
major symptoms not always present when AVN develops
young patient
> 50% involvement then treat with FVFG vs THA
older patient
prosthetic replacement (hemiarthroplasty vs THA)
Nonunion
o incidence of 5 to 30%
increased incidence in displaced fractures
no correlation between age, gender, and rate of nonunion
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o varus malreduction most closely correlates with failure of fixation after reduction and cannulated
screw fixation.
o treatment
valgus intertrochanteric osteotomy
indicated in patients after femoral neck nonunion
can be done even in presence of AVN, as long as not severely collapsed
turns vertical fx line into horizontal fx line and decreases shear forces across fx line
free vascularized fibula graft (FVFG)
indicated in young patients with a nonviable femoral head
arthroplasty
indicated in older patients or when the femoral head is not viable
also an option in younger patient with a nonviable femoral head as opposed to FVFG
revision ORIF
Dislocation
o higher rate of dislocation with THA (~ 10%)
about seven times higher than hemiarthroplasty
3. Intertrochanteric Fractures
Introduction
Extracapsular fractures of the proximal femur between the greater and lesser trochanters
Epidemiology
o incidence
roughly the same as femoral neck fractures
o demographics
female:male ratio between 2:1 and 8:1
typically older age than patients with femoral neck fractures
o risk factors
proximal humerus fractures increase risk of hip fracture for 1 year
Pathophysiology
o mechanism
elderly
low energy falls in osteoporotic patients
young
high energy trauma
Prognosis
o nonunion and malunion rates are low
o 20-30% mortality risk in the first year following fracture
o factors that increase mortality
male gender (25-30% mortality) vs female (20% mortality)
higher in intertrochanteric fracture (vs femoral neck fracture)
operative delay of >2 days
age >85 years
2 or more pre-existing medical conditions
ASA classification (ASA III and IV increases mortality)
o surgery within 48 hours decreases 1 year mortality
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o earlymedical optimization and co-management with medical hospitalists or geriatricians can
improve outcomes
Anatomy
Osteology
o intertrochanteric area exists between greater and lesser trochanters
o made of dense trabecular bone
o calcar femorale
vertical wall of dense bone that extends from posteromedial aspect of femoral shaft to
posterior portion of femoral neck
helps determine stable versus unstable fracture patterns
Classification
Stability of fracture pattern is arguably the most reliable method of classification
o stable
definition
intact posteromedial cortex
clinical significance
will resist medial compressive loads once reduced
o unstable
definition
comminution of the posteromedial cortex
clinical significance
fracture will collapse into varus and retroversion when loaded
examples
fractures with a large posteromedial fragment
i.e., lesser trochanter is displaced
subtrochanteric extension
reverse obliquity
oblique fracture line extending from medial cortex both laterally and distally
Presentation
Physical Exam
o painful, shortened, externally rotated lower extremity
Imaging
Radiographs
o recommended views
AP pelvis
AP of hip, cross table lateral
full length femur radiographs
CT or MRI
o useful if radiographs are negative but physical exam consistent with fracture
Treatment
Nonoperative
o nonweightbearing with early out of bed to chair
indications
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nonambulatory patients
patients at high risk for perioperative mortality
outcomes
high rates of pneumonia, urinary tract infections, decubiti, and DVT
Operative
o sliding hip compression screw
indications
stable intertrochanteric fractures
outcomes
equal outcomes when compared to intramedullary hip screws for stable fracture patterns
o intramedullary hip screw (cephalomedullary nail)
indications
stable fracture patterns
unstable fracture patterns
reverse obliquity fractures
56% failure when treated with sliding hip screw
subtrochanteric extension
lack of integrity of femoral wall
associated with increased displacement and collapse when treated with sliding hip
screw
outcomes
equivalent outcomes to sliding hip screw for stable fracture patterns
use has significantly increased in last decade
o arthroplasty
indications
severely comminuted fractures
preexisting symptomatic degenerative arthritis
osteoporotic bone that is unlikely to hold internal fixation
salvage for failed internal fixation
Techniques
Sliding hip compression screw
o technique
must obtain correct neck-shaft relationship
lag screw with tip-apex distance >25 mm is associated with increased failure rates
4 hole plates show no benefit clinically or biomechanically over 2 hole plates
o pros
allows dynamic interfragmentary compression
low cost
o cons
open technique
increased blood loss
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Femur
medialization of shaft
can cause anterior spike malreduction in left-sided, unstable fractures due to screw torque
Intramedullary hip screw
o technique
short implants with optional distal locking
standard obliquity fractures
long implants
standard obliquity fractures
reverse obliquity fractures
subtrochanteric extension
o pros
percutaneous approach
minimal blood loss
may be used in unstable fracture patterns
o cons
increased incidence of screw cutout
periprosthetic fracture
higher cost than sliding hip screw
Arthroplasty
o technique
calcar-replacing prosthesis often needed
must attempt fixation of greater trochanter to shaft
o pros
possible earlier return for full weight bearing
o cons
increased blood loss
may require prosthesis that some surgeons are unfamiliar with
Complications
Implant failure and cutout
o incidence
most common complication
usually occurs within first 3 months
o cause
tip-apex distance >45 mm associated with 60% failure rate
o treatment
young
corrective osteotomy and/or revision open reduction and internal fixation
elderly
total hip arthroplasty
Anterior perforation of the distal femur
o incidence
can occur following intramedullary screw fixation
o cause
mismatch of the radius of curvature of the femur (shorter) and implant (longer)
Nonunion
o incidence : <2%
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o treatment
revision ORIF with bone grafting
proximal femoral replacement
Malunion
o incidence
varus and rotational deformities are common
o treatment : corrective osteotomies
4. Subtrochanteric Fractures
Introduction
Subtrochanteric typically defined as area from lesser trochanter to 5cm distal
o fractures with an associated intertrochanteric component may be called
intertrochanteric fracture with subtrochanteric extension
peritrochanteric fracture
Epidemiology
o usually in younger patients with a high-energy mechanism
o may occur in elderly patients from a low-energy mechanism
rule out pathologic or atypical femur fracture
denosumab or bisphosphonate use, particularly
alendronate, can be risk factor
Pathoanatomy
o deforming forces on the proximal fragment are
abduction I:3 atypical subtrochanteric fracture
V
with thickening of lateral cortix
gluteus medius and gluteus minimus
(bisphosphonate use )
flexion
iliopsoas
external rotation
short external rotators
o deforming forces on distal fragment
adduction & shortening
adductors
Anatomy
Biomechanics
o weight bearing leads to net compressive forces on medial cortex
and tensile forces on lateral cortex
Classification
Russel-Taylor Classification
Type I No extension into piriformis fossa
Type II Extension into greater trochanter with involvement of piriformis fossa
• look on lateral xray to identify piriformis fossa extension
• Historically used to differentiate between fractures that would amenable to an intramedullary nail (type I) and those
that required some form of a lateral fixed angle device (type II)
• Current interlocking options with both trochanteric and piriformis entry nails allow for treatment of type II fractures
with intramedullary implants
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All major features should be present to designate a fracture as atypical; minor features may or may not be
present in individual cases
Major • Located anywhere along the femur from just distal to the lesser trochanter to just proximal to
Criteria the supracondylar flare
• Associated with no trauma or minimal trauma, as in a fall from a standing height or less
• Transverse or short oblique configuration
• Noncomminuted
• Complete fractures extend through both cortices and may be associated with a medial spike;
incomplete fractures involve only the lateral cortex
Minor • Localized periosteal reaction of the lateral cortex
Criteria • Generalized increase in cortical thickness of the diaphysis
• Prodromal symptoms such as dull or aching pain in the groin or thigh
• Bilateral fractures and symptomscomplete fractures involve only the lateral cortex
• Delayed healing
• Comorbid conditions (eg, vitamin D deficiency, rheumatoid arthritis, hypophosphatasia)
• Use of pharmaceutical agents (eg, BPs, glucocorticoids, proton pump inhibitors)
• Specifically excluded are fractures of the femoral neck, intertrochanteric fractures with spiral
subtrochanteric extension, pathological fractures associated with primary or metastatic bone
tumors, and periprosthetic fractures
Russel-Taylor Classification
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Presentation
History
o long history of bisphosphonate or denosumab
o history of thigh pain before trauma occurred
Symptoms
o hip and thigh pain
o inability to bear weight
Physical exam
o pain with motion
o typically associated with obvious deformity (shortening and varus alignment)
o flexion of proximal fragment may threaten overlying skin
Imaging
Radiographs
o required views
AP and lateral of the hip
AP pelvis
full length femur films including the knee
o additional views
traction views may assist with defining fragments in comminuted patterns but is not required
o findings
bisphosphonate-related fractures have
lateral cortical thickening
transverse fracture orientation
medial spike
lack of comminution
Treatment
Nonoperative
o observation with pain management
indications
non-ambulatory patients with medical co-morbidities that would not allow them to
tolerate surgery
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limited role due to strong muscular forces displacing fracture and inability to mobilize
patients without surgical intervention
Operative
o intramedullary nailing (usually cephalomedullary)
indications
historically Russel-Taylor type I fractures
newer design of intramedullary nails has expanded indications
most subtrochanteric fractures treated with IM nail
o fixed angle plate
indications
surgeon preference
associated femoral neck fracture
narrow medullary canal
pre-existing femoral shaft deformity
Techniques
Intramedullary Nailing
o position
lateral positioning
advantages
allows for easier reduction of the distal fragment to the flexed proximal fragment
allows for easier access to entry portal, especially for piriformis nail
supine positioning
advantages
protective to the injured spine
address other injuries in polytrauma patients
easier to assess rotation
o techniques
1st generation nail (rarely used)
2nd generation reconstruction nail
cephalomedullary nail
trochanteric or piriformis entry portal
piriformis nail may mitigate risk of iatrogenic malreduction from proximal valgus bend of
trochanteric entry nail
o pros
preserves vascularity
load-sharing implant
stronger construct in unstable fracture patterns
o cons
reduction technically difficult
nail can not be used to aid reduction
fracture must be reduced prior to and during passage of nail
may require percutaneous reduction aids or open clamp placement to achieve and
maintain reduction
mismatch of the radius of curvature
nails with a larger radius of curvature (straighter) can lead to perforation of the anterior
cortex of the distal femur
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o complications
varus malreduction (see complications
below)
Fixed angle plate
o approach
lateral approach to proximal femur
may split or elevate vastus lateralis
off later intermuscular septum
dangers include perforating branches of profunda femoris
o technique
95 degree blade plate or condylar screw
sliding hip screw is contraindicated due to high rate of malunion and failure
blade plate may function as a tension band construct
femur eccentrically loaded with tensile force on the lateral cortex converted to
compressive force on medial cortex
o cons
compromise vascularity of fragments
inferior strength in unstable fracture patterns
Complications
Varus/ procurvatum malunion
o the most frequent intraoperative complication with antegrade nailing of a subtrochanteric femur
fracture is varus and procurvatum (or flexion) malreduction
Nonunion : can be treated with plating : allows correction of varus malalignment
Bisphosphonate fractures
o nail fixation
increased risk of iatrogenic fracture : because of brittle bone and cortical thickening
increased risk of nonunion with nail fixation resulting in increased need for revision surgery
o plate fixation : increased risk of plate hardware failure
because of varus collapse and dependence on intramembranous healing inhibited by
bisphosphonates
Anatomy
Osteology
o largest and strongest bone in the body
o femur has an anterior bow
o linea aspera
rough crest of bone running down middle third of posterior femur
attachment site for various muscles and fascia
acts as a compressive strut to accommodate anterior bow to femur
Muscles
o 3 compartments of the thigh
anterior
sartorius
quadriceps
posterior
biceps femoris
semitendinosus
semimembranosus
adductor
gracilis
adductor longus
adductor brevis
adductor magnus
Biomechanics
o musculature acts as a deforming force after fracture
proximal fragment
abducted
gluteus medius and minimus abduct as they insert on
greater trochanter
flexed
iliopsoas flexes fragment as it inserts on lesser trochanter
distal segment
varus
adductors inserting on medial aspect of distal femur
extension
gastrocnemius attaches on distal aspect of posterior femur
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Classification
Winquist and Hansen Classification
Type 0 • No comminution
Type I • Insignificant amount of comminution
Type II • Greater than 50% cortical contact
Type III • Less than 50% cortical contact
Type IV • Segmental fracture with no contact between proximal and distal fragment
OTA Classification
32A - Simple • A1 - Spiral
• A2 - Oblique, angle > 30 degrees
• A3 - Transverse, angle < 30 degrees
32B - Wedge • B1 - Spiral wedge
• B2 - Bending wedge
• B3 - Fragmented wedge
32C - Complex • C1 - Spiral
• C2 - Segmental
• C3 - Irregular
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Presentation
Initial evaluation
o Advanced Trauma Life Support (ATLS) should be initiated VI:5 OTA classification
Symptoms
o pain in thigh
Physical exam
o inspection
tense, swollen thigh
blood loss in closed femoral shaft fractures is 1000-1500ml
for closed tibial shaft fractures, 500-1000ml
blood loss in open fractures may be double that of closed fractures
affected leg often shortened
tenderness about thigh
o motion
examination for ipsilateral femoral neck fracture often difficult secondary to pain from
fracture
o neurovascular : must record and document distal neurovascular status
Imaging
Radiographs
o recommended views
AP and lateral views of entire femur
AP and lateral views of ipsilateral hip
important to rule-out coexisting femoral neck fracture
AP and lateral views of ipsilateral knee
CT
o indications
may be considered in midshaft femur fractures to rule-out associated femoral neck fracture
Treatment
Nonoperative
o long leg cast
indications
nondisplaced femoral shaft fractures in patients with multiple medical comorbidities
Operative
o antegrade intramedullary nail with reamed technique
indications
gold standard for treatment of diaphyseal femur fractures
outcomes
stabilization within 24 hours is associated with
decreased pulmonary complications (ARDS)
decreased thromboembolic events
improved rehabilitation
decreased length of stay and cost of hospitalization
exception is a patient with a closed head injury I:6 A piriformis entry B trochanteric entry
V
critical to avoid hypotension and hypoxemia
consider provisional fixation (damage control)
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o retrograde intramedullary nail with reamed technique
indications
ipsilateral femoral neck fracture
floating knee (ipsilateral tibial shaft fracture)
use same incision for tibial nail
ipsilateral acetabular fracture
does not compromise surgical approach to acetabulum
multiple system trauma
bilateral femur fractures
avoids repositioning
morbid obesity
outcomes
results are comparable to antegrade femoral nails
immediate retrograde or antegrade nailing is safe for early treatment of gunshot femur
fractures
o external fixation with conversion to intramedullary nail within 2-3 weeks
indications
unstable polytrauma victim
vascular injury
severe open fracture
o ORIF with plate
indications
ipsilateral neck fracture requiring screw fixation
fracture at distal metaphyseal-diaphyseal junction
inability to access medullary canal
outcomes
inferior when compared to IM nailing due to increased rates of:
infection
nonunion
I:7 piriformis entry
V
hardware failure
Surgical Techniques
Antegrade intramedullary nailing
o approach
3 cm incision proximal to the greater trochanter in line with the femoral canal
o technique
starting points
piriformis entry
pros
colinear trajectory with long axis of femoral shaft
cons
starting point more difficult to access, especially in obese patients
causes the most significant damage to
abductor muscles and tendons
may result in abductor limp
blood supply to the femoral head
may result in AVN in pediatric patients
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Femur
trochanteric entry
pros
minimizes soft tissue injury to abductors
easier starting point than piriformis entry nail
cons
not colinear with the long axis of femoral shaft
must use nail specifically designed for trochanteric entry
use of a straight nail may lead to varus malalignment
reaming
reamed nailing superior to unreamed nailing, with:
increased union rates
decreased time to union
no increase in pulmonary complications
indications for unreamed nail
consider for patient with bilateral pulmonary injuries VI:8 trochanteric entry
interlocking screws
technique
computer-assisted navigation for screw placement decreases
radiation exposure
widening/overlap of the interlocking hole in the proximal-
distal direction
correct with adjustment in the abduction/adduction plane
widening/overlap of the interlocking hole in the anterior-
posterior plane
correct with adjustment in the internal/external rotation
plane
o postoperative care
weight-bearing as tolerated
range of motion of knee and hip is encouraged
o pros
98-99% union rate
low complication rate
infection risk 2%
o cons
not indicated for use with ipsilateral femoral neck fracture
increased rate of HO in hip abductors with antegrade nailing
increased rate of hip pain compared with retrograde nailing
mismatch of the radius of curvature of the femoral shaft and intramedullary nails can lead to
anterior perforation of the distal femur
Retrograde intramedullary nailing
o approach
2 cm incision starting at distal pole of patella
medial parapatellar versus transtendinous approaches
nail inserted with knee flexed to 30-50 degrees
o technique
entry point
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center of intercondylar notch on AP view
extension of Blumensaat's line on lateral
posterior to Blumensaat's line risks damage to
cruciate ligaments
o postoperative care
weight-bearing as tolerated
range of motion of knee and hip is encouraged
o pros
technically easier
union rates comparable to those of antegrade nailing
VI:9 entry point of retrogade nail
no increased rate of septic knee with retrograde nailing
of open femur fractures
o cons
knee pain
increased rate of interlocking screw irritation
cartilage injury
cruciate ligament injury with improper starting point
External fixation with conversion to intramedullary nail within 2-3 weeks
o technique
safest pin location sites are anterolateral and direct lateral regions of the femur
2 pins should be used on each side of the fracture line
o pros
prevents further pulmonary insult without exposing patient to risk of major surgery
may be converted to IM fixation within 2-3 weeks as a single stage procedure
o cons
pin tract infection
knee stiffness
due to binding/scarring of quadriceps mechanism
Special considerations
o ipsilateral femoral neck fracture
priority goes to fixing femoral neck because anatomic reduction is necessary to avoid
complications of AVN and nonunion
technique
preferred methods
screws for neck with retrograde nail for shaft
screws for neck and plate for shaft
compression hip screw for neck with retrograde nail for shaft
less preferred methods
antegrade nail with screws anterior to nail
technically challenging
Complications
Heterotopic ossification
o incidence
25%
o treatment
rarely clinically significant VI:10 ipsilateral femoral neck fracture
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Pudendal nerve injury
o incidence
10% when using fracture table with traction
Femoral artery or nerve injury
o incidence
rare
o cause
can occur when inserting proximal interlocking screws during a retrograde nail
Malunion and rotational malalignment
o most accurately determined by the Jeanmart method
angle between a line drawn tangential to the femoral condyles and a line drawn through the
axis of the femoral neck
o incidence
proximal fractures 30%
distal fractures 10%
o risk factors
use of a fracture table increases risk of internal rotation deformities when compared to
manual traction
fracture comminution
night-time surgery
o treatment
if noticed intraoperatively, remove distal interlocking screws and manually correct rotation
if noticed after union, osteotomy is required
Delayed union
o treatment
dynamization of nail with or without bone grafting
Nonunion
o incidence
<10%
o risk factors
postoperative use of nonsteroidal anti-inflammatory drugs
smoking is known to decrease bone healing in reamed antegrade exchange nailing for
atrophic non-unions
o treatment
reamed exchange nailing
Infection
o incidence
< 1%
o treatment
removal of nail and reaming of canal
external fixation used if fracture not healed
Weakness
o quadriceps and hip abductors are expected to be weaker than contralateral side
Iatrogenic fracture etiologies
o risk factors
antegrade starting point 6mm or more anterior to the intramedullary axis
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however, anterior starting point improves position of screws into femoral head
failure to overream canal by at least .5mm
Mechanical axis deviation (MAD)
o lengthening along the anatomical axis of the femur leads to lateral MAD
o shortening along the anatomical axis of the femur leads to medial MAD
Anterior cortical penetration.
Classification
Descriptive
o supracondylar
o intercondylar
OTA: 33
o A: extraarticular
o B: partial articular
portion of articular surface remains in continuity with shaft
33B3 is in coronal plane (Hoffa fragment)
o C: complete articular
articular fragment separated from shaft
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Presentation
Physical exam
o pain, deformity, swelling localizing to distal thigh/knee
o evaluate skin integrity
o vascular evaluation
potential for injury to popliteal artery if significant displacement
if no pulse after gross alignment restored then angiography is indicated
Full trauma evaluation if high energy mechanism
Imaging
Radiographs
o obtain standard AP and Lateral
o traction views
AP, Lateral, and oblique traction views can help characterize
injury but are painful for patient
in elderly patients, evaluate for any pre-existing knee DJD
consider views of the remainder of the extremity to rule out
VI:11 vascular evaluation
associated injuries
consider views of contralateral femur for pre-operative planning and templating
CT
o obtain with frontal and sagittal reconstructions
o useful for
establishing intra-articular involvement
identifying separate osteochondral fragments in the area of the intercondylar notch
identifying coronal plane fx (Hoffa fx): 38% incidence of Hoffa fractures in Type C fractures
preoperative planning
o if temporizing external fixation required, CT obtained after external
fixation
Angiography
o indicated when diminished distal pulses after gross alignment restored
o consider if associated with knee dislocation
Treatment
Nonoperative
o hinged knee brace with immediate ROM, NWB for 6 weeks
indications (rare)
nondisplaced fractures
nonambulatory patient
patient with significant comorbidities presenting unacceptably high degree of
surgical/anesthetic risk
Operative
o external fixation
temporizing measure until soft tissues permit internal fixation, or until patient is stable
avoid pin placement in area of planned plate placement if possible
o open reduction internal fixation
indications
displaced fracture
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intra-articular fracture
nonunion
goals
need anatomic reduction of joint
stable fixation of articular component to shaft to permit early motion
preserve vascularity
technique (see below)
postoperative
early ROM of knee important
non-weight bearing or toe touch
weight-bearing for 6-8 weeks, up
to 10-12 weeks if comminuted
quadriceps and hamstring
strength exercises
o retrograde IM nail VI:12 retrograde nail
indications
good for supracondylar fx without significant comminution
preferred implant in osteoporotic bone
traditionally, 4 cm of intact distal femur needed but newer implants with very distal
interlocking options may decrease this number, can perform independent screw
stabilization of intercondylar component of fracture around nail
o distal femoral replacement
indications
unreconstructable fracture
fracture around prior total knee arthroplasty with loose component
Surgical Techniques
ORIF Approaches
o anterolateral
fractures without articular involvement or with simple articular extension
incision from tibial tubercle to anterior 1/3 of distal femoral condyle
extend up midlateral femoral shaft as needed
minimally invasive plate osteosynthesis: small lateral incision, slide plate proximally, use
stab incisions for proximal screw placement
o lateral parapatellar
fractures with complex articular extension
extend incision into quad tendon to evert patella
can be used for Hoffa fracture
o medial parapatellar
typical TKA approach
used for complex medial femoral condyle fractures
o medial/lateral posterior
used for very posterior Hoffa fragment fixation
patient placed in prone position
midline incision over popliteal fossa
develop plane between medial and lateral gastrocnemius m.
capsulotomy to visualize fracture
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Blade Plate Fixation
o indications
not commonly used, technically difficult
contraindicated in type C3 fractures
o technique
placed 1.5 cm from articular surface
Dynamic Condylar Screw Placement VI:13 Blade plate
o indications : identical to 95 degree angled blade plate
o technique
precise sagittal plane alignment is not necessary
placed 2.0 cm from articular surface
o cons VI:14 DCS
large amount of bone removed with DCS
difficult to place
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preferred implant in osteoporotic bone
short nail rarely indicated, implant should at least reach lesser trochanter
o approach
medial parapatellar
no articular extension present
2.5 cm incision parallel to medial aspect of patellar tendon
stay inferior to patella
no attempt to visualize articular surface
articular extension present
continue approach 2-8 cm cephalad
incise extensor mechanism 10 mm medial to
patella
eversion of patella not typically necessary
need to stabilize articular segments prior to
nail placement
o pros : requires minimal dissection of soft tissue
o cons
less axial and rotational stability
postoperative knee pain
Complications
Symptomatic hardware
VI:15 Distal femur malunion
o lateral plate
pain with knee flexion/extension due to IT band contact with plate
o medial screw irritation
excessively long screws can irritate medial soft tissues
determine appropriate intercondylar screw length by obtaining an
AP radiograph of the knee with the leg internally rotated 30 degrees
Malunions
o most commonly associated with plating, usually valgus
o functional results satisfactory if malalignment is within 5 degrees in
any plane
Nonunions
o up to 19%, most commonly in metaphyseal area, with articular portion
healed (comminution, bone loss and open fractures more likely in
metaphysis)
o decreasing with less invasive techniques
o treatment with revision ORIF and autograft indicated
o consider changing fixation technique to improve biomechanics
Infection
o treat with debridement, culture-specific antibiotics, hardware removal
if fracture stability permits I:16 Non union
V
Implant failure
o up to 9%
o titanium plates may be superior to stainless steel
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B. Knee
Meniscal tears and ligamintous injuries of knee discussed in Volume 3 (Sport)
1. Patella Fracture
Introduction
Patella fractures account for 1% of all skeletal injuries
o occur either by direct impact injury or indirect eccentric contraction
o male to female 2:1
o most fractures occur in 20-50 year olds
Patella sleeve fracture
o seen in pediatric population (8-10 year olds)
o high index of suspicion required
Bipartite patella
o may be mistaken for patella fracture
o affects 8% of population
o characteristic superolateral position
I:17 Bipartite patella
V
Anatomy
Patella is largest sesamoid bone in body
Articular cartilage thickest in body (up to 1cm)
Most important blood supply to the patella is located at the inferior pole
Classification
Can be described based on fracture pattern
o nondisplaced
o transverse
o pole or sleeve (upper or lower)
o vertical
o marginal
o osteochondral
o comminuted (stellate)
Presentation
Physical exam
o palpable patellar defect
o significant hemarthrosis
o unable to perform straight leg raise indicates failure of extensor mechanism
retinaculum disrupted
Imaging
Radiographs
o patella alta
o fracture displacement
best evaluated on lateral x-ray
VI:18 palpable patellar defect
degree of fracture displacement correlates with degree of retinacular disruption
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MRI
o obtain MRI if child has normal xrays but is unable to straight leg
raise
Treatment
Nonoperative
o knee immobilized in extension (brace or cylinder cast) and full
weight bearing
indications
intact extensor mechanism (patient able to perform straight
leg raise)
VI:19 Patela alta with
nondisplaced or minimally displaced fractures avulsion fracture of lower
vertical fracture patterns pole
early active ROM with hinged knee brace
early WBAT in full extension
progress in flexion after 2-3 weeks
Operative
o ORIF with tension band construct
indications
preserve patella whenever possible
extensor mechanism failure (unable to perform straight leg raise)
open fractures
fracture articular displacement >2mm
displaced patella fracture >3mm
patella sleeve fractures in children
techniques
minifrag lag screw fixation for independent fragments
tension bands
0.062 K wires with figure of 8 wire
longitudinal cannulated screws combined with tension band wires shown to be
biomechanically superior
circumferential cerclage wiring
good for comminuted fractures
interfragmentary screw compression supplemented by cerclage wiring
o partial patellectomy
indications
comminuted superior or inferior pole fracture measuring <50% patellar height ONLY if
ORIF is not possible
techniques
quadricep or patellar tendon re-attachment
reattachment close to articular surface prevents patellar tilt
medial and lateral retinacular repair essential
o total patellectomy
indications
reserved for severe and extensive comminution not amenable to salvage
quadriceps torque reduced by 50%
medial and lateral retinacular repair essential
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Knee
Complications
Weakness and anterior knee pain
Symptomatic hardware
o most common
Loss of reduction (22%)
o increased in osteoporotic bone
Nonunion (<5%)
o can consider partial patellectomy
Osteonecrosis (proximal fragment)
o thought to be due to excessive initial fracture displacement
o can observe these, as most spontaneously revascularize by 2 years
Infection
Stiffness
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2. Knee Dislocation
Introduction
Devastating injury resulting from high or low energy
o high-energy
usually from MVC or fall from height
commonly a dashboard injury resulting in axial load to flexed knee
o low-energy
often from athletic injury
generally has a rotational component
morbid obesity is a risk-factor
Pathoanatomy
o associated with significant soft tissue disruption
o 3/4 of ligaments generally disrupted
Associated injuries
o vascular injury
5-15% in all dislocations
40-50% in anterior/posterior dislocations I:20 Knee recurvatum when held in extension
V
(knee dislocation-clinical instability)
due to tethering at the popliteal fossa
proximal - fibrous tunnel at the adductor hiatus
distal - fibrous tunnel at soleus muscle
o nerve injury
usually common peroneal nerve injury (25%)
tibial nerve injury is less common
o fractures
present in 60%
tibia and femur most common
Prognosis
o complications frequent and rarely does knee return to pre-injury state
Classification
Descriptive
o Kennedy classification based on direction of displacement of the tibia
anterior (30-50%)
most common
due to hyperextension injury
usually involves tear of PCL
arterial injury is generally an intimal tear due to traction
posterior (25%)
2nd most common
due to axial load to flexed knee (dashboard injury)
highest rate of vascular injury (25%) based on Kennedy classification (direction of
dislocation)
highest rate of complete tear of popliteal artery
lateral (13%)
due to varus or valgus force
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usually involves tears of both ACL and PCL
highest rate of peroneal nerve injury
medial (3%)
varus or valgus force
usually disrupted PLC and PCL
rotational (4%)
posterolateral is most common rotational dislocation
usually irreducible
buttonholding of femoral condyle through capsule
Schenck Classification
o based on pattern of multiligamentous injury of knee dislocation (KD)
Presentation
Symptoms
o history of trauma and deformity of the knee
o knee pain & instability
Physical exam
o appearance
no obvious deformity
50% spontaneously reduce before arrival to ED (therefore underdiagnosed)
may present with subtle signs of trauma (swelling, effusion, abrasions)
obvious deformity
do not wait for radiographs, reduce immediately, especially if absent pulses
"dimple sign" - buttonholing of medial femoral condyle through medial capsule
indicative of an irreducible posterolateral dislocation
a contraindication to closed reduction due to risks of skin necrosis
o stability
diagnosis based on instability on exam (radiographs and gross appearance may be normal)
may see recurvatum when held in extension
assess ACL, PCL, MCL, LCL, and PLC
o vascular exam
priority is to rule out vascular injury on exam both before and after reduction
serial examinations are mandatory
palpate the dorsalis pedis and posterior tibial pulses
if pulses are present and normal
does not indicate absence of arterial injury
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collateral circulation can mask a complete popliteal artery occlusion
measure Ankle-Brachial Index (ABI)
if ABI >0.
then monitor with serial examination (100% Negative Predictive Value)
if ABI <0.9
perform arterial duplex ultrasound or CT angiography
if arterial injury confirmed then consult vascular surgery
If pulses are absent or diminished
confirm that the knee joint is reduced or perform immediate reduction and reassessment
immediate surgical exploration if pulses are still absent following reduction
ischemia time >8 hours has amputation rates as high as 86%
if pulses present after reduction then measure ABI then consider observation vs.
angiography
Imaging
Radiographs
Treatment
Initial Treatment
o reduce knee and re-examine vascular status
considered an orthopedic emergency
splint in 20-30° flexion
confirm reduction is held with repeat radiographs in brace/splint
vascular consult indicated if
if arterial injury confirmed by arterial duplex ultrasound or CT angiography
pulses are absent or diminished following reduction
Nonoperative
o indications : limited and most cases require surgical stabilization
Operative
o emergent surgical intervention with external fixation
indications
vascular repair (takes precedence)
open fx and open dislocation
irreducible dislocation
compartment syndrome
obese
multi trauma patient
technique
vascular intervention
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Knee
perform external fixation first
excision of damaged segment and repair with reverse saphenous vein graft
always perform fasciotomies after vascular repair
o delayed ligamentous reconstruction/repair
indications
generally instability will require some kind of ligamentous repair or fixation
patients can be placed in a knee immobilizer for 6 weeks for initial stabilization
improved outcomes with early treatment (within 3 weeks)
technique
PLC
early reconstruction before ACL reconstruction
postoperative
recommend early mobilization and functional bracing
Complications
Stiffness (arthrofibrosis)
o is most common complication (38%)
o more common with delayed mobilization
Laxity and instability (37%)
Peroneal nerve injury (25%)
o most common in posterolateral dislocations
o poor results with acute, subacute, and delayed (>3 months) nerve exploration
o neurolysis and tendon transfers are the mainstay of treatment
o Dynamic tendon transfer involves transferring the posterior tibial tendon (PTT) to the lateral
cuneiform.
Vascular compromise
o in addition to vessel damage, claudication, skin changes, and muscle atrophy can occur
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C. Leg
Anatomy
Osteology
o lateral tibial plateau
convex in shape
proximal to the medial plateau
o medial tibial plateau
concave in shape
distal to the lateral tibial plateau
Muscles
o anterior compartment musculature : attaches to anterolateral tibia
o pes anserine : attaches to anteromedial tibia
Biomechanics
o medial tibial plateau bears 60% of knee's load
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Leg
Classification
Schatzker Classification
Type I Lateral split fracture
Type II Lateral Split-depressed fracture
Type III Lateral Pure depression fracture
Type IV Medial plateau fracture
Type V Bicondylar fracture
Type VI Metaphyseal-diaphyseal disassociation
Schatzker Classification
Type I
Type II
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Presentation
History
o high-energy trauma in young patients
o low-energy falls in elderly
Physical exam
o inspection
look circumferentially to rule-out an open injury
o palpation
consider compartment syndrome when compartments are firm and not compressible
o varus/valgus stress testing
any laxity >10 degrees indicates instability
often difficult to perform given pain
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o neurovascular exam
any differences in pulse exam between extremities should be further investigated with anke-
brachial index measurement
Imaging
Radiographs
o recommended views
AP, lateral, oblique
oblique is helpful to determine amount of depression
o optional views
plateau view
10 degree caudal tilt
o findings
posteromedial fracture lines must be recognized
CT scan
o important to identify articular depression and comminution
o findings
lipohemarthrosis indicates an occult fracture
fracture fragment orientation and surgical planning
MRI
o indications
not well established
o findings
useful to determine meniscal and ligamentous pathology
Treatment
Nonoperative
o hinged knee brace, PWB for 8-12 weeks, and immediate passive ROM
indications
minimally displaced split or depressed fractures
low energy fracture stable to varus/valgus alignment
nonambulatory patients
Operative
o temporizing bridging external fixation w/ delayed ORIF
indications
significant soft tissue injury
polytrauma
o external fixation with limited open/percutaneous fixation of articular segment
indications
severe open fracture with marked contamination
highly comminuted fractures where internal fixation not possible
outcomes
similar to open reduction, internal fixation
o open reduction, internal fixation
indications
articular stepoff > 3mm
condylar widening > 5mm
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varus/valgus instability
all medial plateau fxs
all bicondylar fxs
outcomes
restoration of joint stability is strongest predictor of long term outcomes
worse results with
ligamentous instability
meniscectomy
alteration of limb mechanical axis > 5 degrees
Techniques
External fixation (temporary)
o technique
two 5-mm half-pins in distal femur, two in distal tibia
axial traction applied to fixator
fixator is locked in slight flexion
o advantages
allows soft tissue swelling to decrease before definitive fixation
decreases rate of infection and wound healing complications
External fixation with limited internal fixation (definitive)
o technique
reduce articular surface either percutaneously or with small incisions
stabilize reduction with lag screws or wires
must keep wires >14mm from joint
apply external fixator or hybrid ring fixation
o post-operative care
begin weight bearing when callus is visible on
radiographs
usually remain in place 2-4 months
o pros
minimizes soft tissue insult
permits knee ROM
o cons
pin site complications
Open reduction, internal fixation
VI:21 Butress plate
o approach
lateral incision (most common)
straight or hockey stick incision anterolaterally from just proximal to joint line to just
lateral to the tibial tubercle
midline incision (if planning TKA in future)
can lead to significant soft tissue stripping and should be avoided
posteromedial incision
interval between pes anserinus and medial head of gastrocnemius
dual surgical incisions with dual plate fixation
indications
bicondylar tibial plateau fractures
posterior : can be used for posterior shearing fractures
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o reduction
restore joint surface with direct or indirect reduction
fill metaphyseal void with autogenous, allogenic bone graft, or bone graft substitutes
calcium phosphate cement has high compressive strength for filling metaphyseal void
o internal fixation
absolute stability constructs should be used to maintain the joint reduction
screws
may be used alone for
simple split fractures
depression fractures that were elevated percutaneously
plate fixation
non-locked plates
non-locked buttress plates best indicated for simple partial articular fractures in
healthy bone
locked plates
advantages
fixed-angle construct
less compression of periosteum and soft tissue
o postoperative
hinged knee brace with early passive ROM
gentle mechanical compression on repaired osteoarticular segments improves
chondrocyte survival
NWB or PWB for 8 to 12 weeks
Complications
Post-traumatic arthritis
o rate increases with
meniscectomy during surgery
axial malalignment
intra-articular infection
joint instability
Anatomy
Osteology
o proximal tibia
triangular
wide metaphyseal region
narrow distally
Muscles
o deforming forces
patellar tendon
proximal fragment into extension
fracture into apex anterior, or procurvatum
hamstring tendons
distal fragment into flexion
pes anserinus
proximal fragment into varus
valgus deforming force of the fracture
anterior compartment musculature
valgus deforming force of the fracture
Classification
AO Classification - 42
Type A Simple fracture pattern
Type B Wedge fracture pattern
Type C Comminuted fracture pattern
Presentation
Symptoms
o pain, inability to bear weight
Physical exam
o inspection and palpation
contusions
blisters
open wounds
compartments
palpation
passive motion of toes
intracompartmental pressure measurement if indicated
o neurologic
deep peroneal n.
superficial peroneal n.
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sural n.
tibial n.
saphenous n.
o pulse
dorsalis pedis
posterior tibial : be sure to check contralateral side
Imaging
Radiographs
o recommended views
full length AP and lateral views of affected tibia
AP and lateral views of ipsilateral knee
AP and lateral views of ipsilateral ankle
CT
o indications : question of intra-articular fracture extension
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o percutaneous locking plate
indications
inadequate proximal fixation for IM nailing
best suited for transverse or oblique fractures
minimal soft-tissue compromise
technique
may be used medially or laterally
better soft tissue coverage laterally makes lateral plating safer
outcomes
lateral plating with medial comminution can lead to varus collapse
long plates may place superficial peroneal nerve at risk
Surgical Technique
Intramedullary nailing
o approach
lateral parapatellar
helps maintain reduction for proximal 1/3 fractures
requires mobile patella
medial parapatellar approach may lead to valgus deformity VI:25 suprapatellar approach
suprapatellar
facilitates nailing in semiextended position
o starting point
proximal to the anterior edge of the articular margin
just medial to the lateral tibial spine
use of a more lateral starting point may decrease valgus
deformity
use of a medial starting point may create valgus
deformity
o fracture reduction techniques VI:26 medial starting point may
blocking (Poller) screws create valgus deformity
coronal blocking screw
prevents apex anterior (procurvatum) deformity
place in posterior half of proximal fragment
sagittal blocking screw
prevents valgus deformity
place on lateral concave side of proximal fragment
enhance construct stability if not removed
unicortical plating
short one-third tubular plate placed anteriorly, anteromedially, or
posteromedially across fracture I:27 coronal blocking screw
V
Complications
Malunion VI:28 sagittal blocking screw
o incidence : 20-60% rate of malunion following intramedullary nailing (valgus/procurvatum)
o treatment
revision intramedullary nailing
osteotomy if fracture has healed
o prevention
blocking screws
temporary plating
VI:29 unicortical
universal distractors plating
nailing in semiextended position
Presentation
Symptoms
o pain, inability to bear weight, deformity
Physical exam
o inspection and palpation
deformity / angulation / malrotation
contusions
blisters
open wounds
compartments
palpation
pain
passive motion of toes
intracompartmental pressure measurement if indicated
o neurologic
deep peroneal n.
superficial peroneal n.
sural n.
tibial n.
saphenous n.
o pulse
dorsalis pedis
posterior tibial : be sure to check contralateral side
Imaging
Radiographs
o recommended views
full length AP and lateral views of affected tibia
AP, lateral and oblique views of ipsilateral knee and ankle
CT : indications
intra-articular fracture extension or suspicion of joint involvement
CT ankle for spiral distal third tibia fracture
to exclude posterior malleolar fracture
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Treatment of Closed Tibia Fractures
Nonoperative
o closed reduction / cast immobilization
indications
closed low energy fxs with acceptable alignment
< 5 degrees varus-valgus angulation
< 10 degrees anterior/posterior angulation
> 50% cortical apposition
< 1 cm shortening
< 10 degrees rotational malalignment
if displaced perform closed reduction under general anesthesia
certain patients who may be non-ambulatory (ie. paralyzed), or those unfit for surgery
technique
place in long leg cast and convert to functional brace at 4 weeks
outcomes
high success rate if acceptable alignment maintained
risk of shortening with oblique fracture patterns
risk of varus malunion with midshaft tibia fractures and an intact fibula
non-union occurs in 1.1% of patients treated with closed reduction
Operative
o external fixation
indications
can be useful for proximal or distal metaphyseal fxs
complications
pin tract infections common
outcomes : higher incidence of malalignment compared to IM nailing
o IM Nailing
indications
unacceptable alignment with closed reduction and casting
soft tissue injury that will not tolerate casting
segmental fx
comminuted fx
ipsilateral limb injury (i.e., floating knee)
polytrauma
bilateral tibia fx
morbid obesity
contraindications
pre-existing tibial shaft deformity that may preclude passage of IM nail
previous TKA or tibial plateau ORIF (not strict contraindication)
outcomes
IM nailing leads to (versus external fixation)
decreased malalignment
IM nailing leads to (versus closed treatment)
decrease time to union
decreased time to weight bearing
reamed vs. unreamed nails
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reamed possibly superior to unreamed nails for treatment of closed tibia fxs for
decrease in future bone grafting or implant exchange (SPRINT trial)
recent studies show no adverse effects of reaming (infection, nonunion)
reaming with use of a tourniquet is NOT associated with thermal necrosis of the tibial
shaft
o percutaneous locking plate
indications
proximal tibia fractures with inadequate proximal fixation from IM nailing
distal tibia fractures with inadequate
distal fixation from IM nail
complications
non-union
wound infection and dehiscence
long plates may place superficial peroneal
nerve at risk
Percutaneous plate shown to have (versus
infrapatellar IMN)
Equivalent time to union
Greater radiation exposrure
Longer surgical duration
Lower postoperative pain scores
More difficulty in hardware removal
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Technique
IM nailing of shaft fractures
o preparation
anesthesia : general anesthesia recommended
positioning
patient positioned supine on radiolucent table
bring fluoro in from opposite, non-injured, side
bump placed under ipsilateral hip
leave full access to foot and ankle to help judge intraoperative length, rotation, and
alignment of extremity
tourniquet
tourniquet placed on proximal thigh
not typically inflated
use in patients with vascular injury or significant bleeding associated with extensive soft
tissue injuries
deflate during reaming or nail insertion (weak data to support this)
o approach
options include
medial parapatellar
most common starting point
can lead to valgus malalignment when used to treat proximal fractures
lateral parapatellar
helps maintain reduction when nailing proximal 1/3 fractures
requires mobile patella
patellar tendon splitting
gives direct access to start point
can damage patellar tendon or lead to patella baja (minimal data to support this)
semiextended medial or lateral parapatellar
used for proximal and distal tibial fractures
suprapatellar (transquadriceps tendon)
requires special instruments
can damage patellofemoral joint
starting point
medial parapatellar tendon approach with knee flexed
incision from inferior pole of patella to just above tibial tubercle
identify medial edge of patellar tendon, incise
peel fat pad off back of patellar tendon
starting guidewire is placed in line with medial aspect of lateral tibial spine on AP
radiograph, just below articular margin on lateral view
insert starting guide wire, ream
semiextended lateral or medial parapatellar approach
skin incision made along medial or lateral border of patella from superior pole of
patella to upper 1/3 of patellar tendon
knee should be in 5-30 degrees of flexion
choice to go medial or lateral is based of mobility of patella in either direction
open retinaculum and joint capsule to level of synovium
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free retropatellar fat pad from posterior surface of patellar tendon
identify starting point as mentioned previously
o fracture reduction techniques
spanning external fixation (ie. traveling traction)
clamps
femoral distractor
small fragment plates/screws
intra-cortical screws
o reaming
reamed nails superior to unreamed nails in closed fractures
be sure tourniquet is released
advance reamers slowly at high speed
overream by 1.0-1.5mm to facilitate nail insertion
confirm guide wire is appropriately placed prior to reaming
o nail insertion
insert nail in slight external rotation to move distal interlocking screws anteriorly decreasing
risk of NVS injury
if nail does not pass, remove and ream 0.5-1.0mm more
o locking screws
statically lock proximal and distally for rotational stability
no indication for dynamic locking acutely
number of interlocking screws is controversial
two proximal and two distal screws in presence of <50% cortical contact
consider 3 interlock screws in short segment of distal or proximal shaft fracture
Complications
Knee pain
o >50% anterior knee pain with IM nailing
occurs with patellar tendon splitting and paratendon approach
pain relief unpredictable with nail removal
o lateral radiograph is best radiographic views to make sure nail is not too proud proximally
Malunion
o high incidence of valgus and procurvatum (apex anterior) malalignment in proximal third
fractures
o varus malunion leads to ipsilateral ankle pain and stiffness
o chronic angular deformity is defined by the proximal and distal anatomical/mechanical axis of
each segment
center of rotation of angulation is intersection of proximal and distal axes
Nonunion
o definition
delayed union if union at 6-9 mos.
nonunion if no healing after 9 mos.
o treatment
nail dynamization if axially stable
exchange nailing if not axially stable
reamed exchange nailing most appropriate for aseptic, diaphyseal tibial nonunions with
less than 30% cortical bone loss.
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consider revision with plating in metaphyseal nonunions
posterolateral bone grafting if significant bone loss
non-invasive techniques (electrical stimulation, US)
BMP-7 (OP-1) has been shown equivalent to autograft
often used in cases of recalcitrant non-unions
compression plating has been shown to have 92-96% union rate after open tibial fractures
initially treated with external fixation
Malrotation
o most commonly occurs after IM nailing of distal 1/3 fractures
o can assess tibial rotation by obtaining perfect lateral fluoroscopic image of knee, then rotating c-
arm 105-110 degrees to obtain mortise view of ipsilateral ankle
o reduced risk with adjunctive fibular plating
Compartment syndrome
o incidence 1-9% : can occur in both closed and open tibia shaft fxs
o diagnosis
high index of clinical suspicion
pain out of proportion
pain with passive stretch
compartment pressure within 30mm Hg of diastolic BP is most sensitive diagnostic test
o treatment
emergent four compartment fasciotomy
o outcome
failure to recognize and treat compartment syndrome is most common reason for successful
malpractice litigation against orthopaedic surgeons
o prevention
increased compartment pressure found with
traction (calcaneal)
leg positioning
Nerve injury
o LISS plate application without opening for distal screw fixation near plate holes 11-13 put
superficial peroneal nerve at risk of injury due to close proximity
o saphenous nerve can be injured during placement of locking screws
o transient peroneal nerve palsy can be seen after closed nailing
EHL weakness and 1st dorsal webspace decreased sensation
treated nonoperatively; variable recovery is expected
Anatomy
Osteology
o tibia
distal tibia forms an inferior quadrilateral surface and pyramid-shaped medial malleolus
articulates with the talus and fibula laterally via the fibula notch
Vascular anatomy
o anterior tibial artery
first branch of popliteal artery
passes between 2 heads of tibialis posterior and interosseous membrane (IOM)
lies anterior to IOM between tibialis anterior and EHL
terminates as dorsalis pedis artery
o posterior tibial artery
continues in deep posterior compartment of leg
courses obliquely to pass behind medial malleolus
terminates by dividing into medial and lateral plantar arteries
o peroneal artery
main branch takes off 2.5 cm distal to popliteal fossa
continues in deep posterior compartment between tibialis posterior and FHL
terminates as calcaneal branches
Nerves
o tibial nerve (L4-S3)
crosses over popliteus from the popliteal fossa and splits 2 heads of gastrocnemius
passes deep to soleus coursing to the posterior aspect of the medial malleolus
terminates as medial and lateral plantar nerves
muscular branches supply posterior leg (superficial and deep posterior compartments)
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o common peroneal nerve (L4-S2)
winds around neck of fibula and runs deep to peroneus longus
divides into superficial and deep peroneal nerves
o superficial peroneal nerve
courses along border between lateral and anterior compartments of leg
supplies muscular branches to peroneus longus and brevis (lateral compartment)
terminates as medial dorsal and intermediate dorsal cutaneous nerves
o deep peroneal nerve
courses along anterior surface of IOM
supplies musculature of anterior compartment and sensation to first web space
o saphenous nerve (L3-L4)
continuation of femoral nerve of the thigh
becomes subcutaneous on medial aspect of knee between sartorius and gracilis
supplies sensation to medial aspect of leg and foot
o sural nerve (S1-S2)
formed by cutaneous branches of tibial (medial sural cutaneous) and common peroneal
(lateral sural cutaneous) nerves
lies on lateral aspect of leg and foot
Classification
AO/OTA Classification
43-A Extra-articular
43-B Partial articular
43-C Complete articular
Each category is further subdivided based on amount and degree of comminution
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Presentation
Symptoms
o ankle pain, inability to bear weight, deformity
Physical exam
o inspection
examine soft tissue integrity
swelling, abrasions, ecchymosis, fracture blisters, open wounds
examine for associated musculoskeletal injuries
o ROM & stability
examine stability and alignment of the ankle joint
o neurovascular
check DP and PT pulses
look for neurologic compromise
check for signs of compartment syndrome
Imaging
Radiographs
o recommended views
AP, lateral, mortise views of ankle
full-length tibia/fibula and foot x-rays performed for fracture extension
CT scan
o delineate articular involvement
o surgical planning
o most useful after ligamentotaxis is provided by a spanning external fixator
Treatment
Nonoperative
o immobilization
indications
stable fracture patterns without articular surface displacement
critically ill or nonambulatory patients
significant risk of skin problems (diabetes, vascular disease, neuropathy)
technique
long leg cast for 6 weeks followed by fracture brace and ROM exercises
alternative treatment is with early ROM
outcomes
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intra-articular fragments are unlikely to reduce with manipulation of displaced fractures
loss of reduction is common
inability to monitor soft tissue injuries is a major disadvantage
Operative
o temporizing spanning external fixation across ankle joint
indications
acute management
provides stabilization to allow for soft tissue healing
fractures with significant joint depression or displacement
leave until swelling resolves (generally 10-14 days)
o ORIF
indications
definitive fixation for majority of pilon fractures
limited or definitive ORIF can be performed acutely with low complications in certain
situations
outcomes
ability to drive
brake travel time returns to normal 6 weeks after weight bearing
o external fixation alone
indications
may be indicated in select cases
o intramedullary nailing with percutaneous screw fixation
alternative to ORIF for fractures with simple intra-articular component (AO/OTA 43 C1/C2)
Techniques
External fixation
o fixation
joint-spanning articulated vs. nonspanning hybrid ring
none have been shown to be superior with respect to ankle stiffness
2 tibial shaft half pins connected to hindfoot half pins or calcaneal transfixation pin
with hybrid fixators, thin wires may be placed within joint capsule or within zone of injury
o soft tissues
maintain soft tissue attachments of fragments
Chaput fragment - anterior inferior tibiofibular ligament
o pros
decreased incidence of wound complications and deep infections compared to ORIF
can combine with limited percutaneous fixation using lag screws
o cons
pin and wire tract infections
loss of ankle motion
injury to neurovascular structures
anatomic articular reconstruction may not be possible, especially with central depression
ORIF (AO technique)
o approach
use of multiple small incisions that can include
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Leg
Complications
Wound slough (10%)
o free flap for postoperative wound breakdown
Dehiscence (9-30%)
o wait for soft tissue edema to subside before ORIF (1-2 weeks)
Infection (5-15%)
Varus malunion
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Nonunion
o usually at metaphyseal junction
o treat with bone grafting and plate fixation
o more common with hybrid fixation
Posttraumatic arthritis
o most commonly begins 1-2 years postinjury
o arthrodesis is not commonly required until many years later
Chondrolysis
Stiffness
Collected By : Dr AbdulRahman
AbdulNasser
June 2017
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Ankle and Hindfoot
1. Ankle Fractures
Introduction
Injury patterns
o isolated medial malleolus fracture
o isolated lateral malleolus fracture
o bimalleolar and bimalleolar-equivalent fractures
o posterior malleolus fractures
o Bosworth fracture-dislocations
o open ankle fractures
o associated syndesmotic injuries
isolated syndesmosis injury
Anatomy
Biomechanics
o deltoid ligament (deep portion)
primary restraint to anterolateral talar displacement
o fibula
acts as buttress to prevent lateral displacement of talus
Imaging
Radiographs
o external rotation stress radiograph
most appropriate stress radiograph to assess competency of deltoid ligament
a medial clear space of >5mm with external rotation stress applied to a dorsiflexed ankle
is predictive of deep deltoid disruption
more sensitive to injury than medial tenderness, ecchymosis, or edema
gravity stress radiograph is equivalent to manual stress radiograph
syndesmosis
decreased tibiofibular overlap
normal >6 mm on AP view
normal >1 mm on mortise view
increased medial clear space
normal less than or equal to 4 mm
increased tibiofibular clear space
normal <6 mm on both AP and mortise views
o radiographic measurements
talocrural angle
measured by bisection of line through tibial anatomical axis and another line through the
tips of the malleoli
shortening of lateral malleoli fractures can lead to increased talocrural angle
talocrural angle is not 100% reliable for estimating restoration of fibular length
can also utilize the realignment of the medial fibular prominence with the tibiotalar
joint
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Classification
Lauge-Hansen
o based on foot position and force of applied stress/force
o has been shown to predict the observed (via MRI) ligamentous injury in less than 50% of
operatively treated fractures
Lauge-Hansen Class Sequence
Supination - Adduction (SA) 1. Talofibular sprain or distal fibular avulsion
2. Vertical medial malleolus and impaction of anteromedial distal tibia
Supination - External Rotation (SER) 1. Anterior tibiofibular ligament sprain
2. Lateral short oblique fibula fracture (anteroinferior to
posterosuperior)
3. Posterior tibiofibular ligament rupture or avulsion of posterior
malleolus
4. Medial malleolus transverse fracture or disruption of deltoid
ligament
Pronation - Abduction (PA) 1. Medial malleolus transverse fracture or disruption of deltoid
ligament
2. Anterior tibiofibular ligament sprain
3. Transverse comminuted fracture of the fibula above the level of
the syndesmosis
Pronation - External Rotation (PER) 1. Medial malleolus transverse fracture or disruption of deltoid
ligament
2. Anterior tibiofibular ligament disruption
3. Lateral short oblique or spiral fracture of fibula (anterosuperior to
posteroinferior) above the level of the joint
4. Posterior tibiofibular ligament rupture or avulsion of posterior
malleolus
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Ankle and Hindfoot
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VI:34 Pronation -
Abduction
I:32 Pronation -
V
External Rotation
I:33 Pronation -
V
External Rotation
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Anatomic / Descriptive
o isolated medial malleolar
o isolated lateral malleolar
o bimalleolar
o trimalleolar
o Bosworth fracture-dislocation (posterior dislocation of the fibula behind incisura fibularis)
Danis-Weber (location of fibular fracture)
o A - infrasyndesmotic (generally not associated with ankle instability)
o B - transsyndesmotic
o C - suprasyndesmotic
AO / ATA
o 44A - infrasyndesmotic
o 44B - transsyndesmotic
o 44C - suprasyndesmotic
General Treatment
Nonoperative
o short-leg walking cast/boot
indications
isolated nondisplaced medial malleolus fracture or tip avulsions
isolated lateral malleolus fracture with < 3mm displacement and no talar shift
posterior malleolar fracture with < 25% joint involvement or < 2mm step-off
Operative
o open reduction internal fixation
indications
any talar displacement
displaced isolated medial malleolar fracture
displaced isolated lateral malleolar fracture
bimalleolar fracture and bimalleolar-equivalent fracture
posterior malleolar fracture with > 25% or > 2mm step-off
Bosworth fracture-dislocations
open fractures
technique
goal of treatment is stable anatomic reduction of talus in the ankle mortise
1 mm shift of talus leads to 42% decrease in tibiotalar contact area
see fracture patterns below for specific treatment
outcomes
overall success rate of 90%
prolonged recovery expected (2 years to obtain final functional result)
significant functional impairment often noted
worse outcomes with: smoking, decreased education, alcohol use, increased age, presence
of medial malleolar fracture
ORIF superior to closed treatment of bimalleolar fractures
in Lauge-Hansen supination-adduction fractures, restoration of marginal impaction of the
anteromedial tibial plafond leads to optimal functional results after surgery
postoperative rehabilitation
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time for proper braking response time (driving) returns to baseline at nine weeks for
operatively treated ankle fractures
braking travel time is significantly increased until 6 weeks after initiation of weight
bearing in both long bone and periarticular fractures of the lower extremity
Isolated Medial Malleolus Fracture
Nonoperative
o short leg walking cast or cast boot
indications
nondisplaced fracture and tip avulsions
deep deltoid inserts on posterior colliculus
symptomatic treatment often appropriate
Operative
o ORIF
indications
any displacement or talar shift
technique
lag screw fixation
lag screw fixation stronger if placed perpendicular to fracture line
antiglide plate with lag screw
best for vertical shear fractures
tension band fixation
utilizing stainless steel wire
Isolated Lateral Malleolus Fracture
Nonoperative
o short leg walking cast vs cast boot
indications
if intact mortise, no talar shift, and < 3mm displacement
classically fractures with more than 4-5 mm of medial clear space widening on stress
radiographs have been considered unstable and need to be treated surgically
recent studies have shown the deep deltoid may be intact with up to 8-10 mm of
widening on stress radiographs
if the mortise is well reduced, results from operative and non-operative treatment are
similar
Operative
o ORIF
indications
if talar shift or > 3 mm of displacement
can be treated operatively if also treating an ipsilateral syndesmosis injury
technique
open reduction and plating
plate placement
lateral
lag screw fixation with neutralization plating
bridge plate technique
posterior
antiglide technique
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lag screw fixation with neutralization plating
most common disadvantage of using posterior antiglide plating is peroneal
irritation if the plate is placed too distally
posterior antiglide plating is biomechanically superior to lateral plate placement
intramedullary retrograde screw placement
isolated lag screw fixation
possible if fibula is a spiral pattern and screws can be placed at least 1 cm apart
post-operative care
period of immobilization usually 4-6 weeks after ORIF
duration of immobilization should be doubled in Diabetic patients
Medial and Lateral (Bimalleolar) Fracture
Nonoperative
o total contact casting
indications
elderly or unable to undergo surgical intervention
Operative
o ORIF
indications
any lateral talar shift
technique
fibula
need to fix with one of the options listed in section above
medial malleolus
fixation options
cancellous lag screws
bicortical screws
tension band wiring
antiglide plate to treat a vertical medial malleolus fracture
orient screws parallel to joint for vertical medial malleolar fracture (Lauge-Hansen
supination-adduction fracture pattern)
Functional Bimalleolar Fracture (deltoid ligament tear with fibular fracture)
Operative
o ORIF of lateral malleolus
indications
examination has been shown to be largely unreliable in predicting medial injury
can see significant lateral translation of the talus in this pattern
technique
not necessary to repair medial deltoid ligament
only need to explore medially if you are unable to reduce the mortise
see isolated fibular fracture techniques above
Posterior Malleolar Fracture
Nonoperative
o short leg walking cast vs cast boot
indications
< 25% of articular surface involved
evaluation of percentage should be done with CT, as plain radiology is unreliable
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< 2 mm articular stepoff
syndesmotic stability
Operative
o ORIF
indications
> 25% of articular surface involved
> 2 mm articular stepoff
syndesmosis injury
technique
approach
posterolateral approach
posteromedial approach
decision of approach will depend on fracture lines and need for fibular fixation
fixation
anterior to posterior lag screws to capture fragment (if nondisplaced)
posterior to anterior lag screw and buttress plate
antiglide plate
syndesmosis injury
stiffness of syndesmosis restored to 70% normal with isolated fixation of posterior
malleolus (versus 40% with isolated syndesmosis fixation)
stress examination of syndesmosis still required after posterior malleolar fixation
posteroinferior tibiofibular ligament may remain attached to posterior malleolus and
syndesmotic stability may be restored with isolated posterior malleolar fixation
Bosworth Fracture-Dislocation
Overview
o rare fracture-dislocation of the ankle where the fibula becomes entrapped behind the tibia and
becomes irreducible
o posterolateral ridge of the distal tibia hinders reduction of the fibula
Operative
o open reduction and fixation of the fibula in the incisura fibularis
indicated in most cases
Open Ankle Fracture
Operative
o emergent operative debridement and ORIF
indicated if soft tissue conditions allow
primary closure at the index procedure can be performed in appropriately-selected Gustilo-
Anderson grade I, II, and IIIA open fractures in otherwise healthy patients sustaining low-
energy injuries without gross contamination
o external fixation
indications
soft tissue conditions and overall patient characteristics
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must remain non-weight bearing, as screws are not biomechanically strong enough to
withstand forces of ambulation
controversies
number of screws
1 or 2 most commonly reported
number of cortices
3 or 4 most commonly reported
size of screws
3.5 mm or 4.5 mm screws
implant material (stainless steel screws, titanium screws,
suture, bioabsorbable materials)
need for hardware removal
no difference in outcomes seen with hardware
maintenance (breakage or loosening) or removal at 1
year
outcome may be worse with maintenance of intact screws
Diabetic Ankle Fractures (with or without Neuropathy)
Risks
o prolonged healing
o high risk of hardware failure
o high risk of infection
Enhanced fixation
o multiple quadricortical syndesmotic screws (even in the absence of syndesmotic injury)
o tibiotalar Steinmann pins or hindfoot nailing
o ankle spanning external fixation
o augment with intramedullary fibula K-wires
o stiffer, more rigid fibular plates (instead of 1/3 tubular plates)
compression plates
small fragment locking plates
Delay weightbearing
o maintain non-weightbearing postop for 8-12 weeks (instead of 4-8 weeks in normal patients
Complications
Wound problems (4-5%)
Deep infections (1-2%)
o up to 20% in diabetic patients
largest risk factor for diabetic patients is presence of peripheral neuropathy
Post-traumatic arthritis
o rare with anatomic reduction and fixation
o corrective osteotomy requires anatomic fibular and mortise correction for optimal outcomes
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Ankle and Hindfoot
Anatomy
Articulation
o inferior surface articulates with posterior facet of calcaneus
o talar head articulates with
navicular bone
sustenaculum tali
o lateral process articulates with
posterior facet of calcaneus
lateral malleolus of fibula
o posterior process consist of medial and lateral
tubercles separated by groove for FHL
Blood supply
o talar neck supplied by three sources
posterior tibial artery
via artery of tarsal canal (dominant
supply)
supplies majority of talar body
deltoid branch of posterior tibial artery
supplies medial portion of talar body
Classification
Hawkins Classification
Type Description AVN
Hawkins I Nondisplaced 0-13% AVN
Hawkins II Subtalar dislocation 20-50%
Hawkins III Subtalar and tibiotalar dislocation 20-100%
Hawkins IV Subtalar, tibiotalar, 70-100%
and talonavicular dislocation
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Imaging
Radiographs
o recommended views
AP and lateral
Canale View
optimal view of talar neck
technique is maximum equinus, 15 degrees pronated,
Xray 75 degrees cephalad from horizontal
CT scan
o best study to determine degree of displacement, comminution and articular congruity
o CT scan also will assess for ipsilateral foot injuries (up to 89% incidence)
Treatment
Nonoperative
o emergent reduction in ER
indications
all cases require emergent closed reduction in ER
o short leg cast for 8-12 weeks (NWB for first 6 weeks)
indications
nondisplaced fractures (Hawkins I)
CT to confirm nondisplaced without articular stepoff
Operative
o open reduction and internal fixation
indications
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post-traumatic arthritis
mal-union
non-union
infection
wound dehiscence
Techniques
ORIF
o approach
two approaches recommended
visualize medial and lateral neck to assess reduction
typical areas of comminution are dorsal and medial
anteromedial
between tibialis anterior and posterior tibialis
preserve soft tissue attachments, especially deep deltoid ligament (blood supply)
medial malleolar osteotomy to preserve deltoid ligament
anterolateral
between tibia and fibula proximally, in line with 4th ray
elevate extensor digitorum brevis and remove debris from subtalar joint
o technique
anatomic reduction essential
variety of implants used including mini and small fragment screws, cannulated screws and
mini fragment plates
medial and lateral lag screws may be used in simple fracture patterns
consider mini fragment plates in comminuted fractures to buttress against varus collapse
o postoperative : non-weight-bearing for 10-12 weeks
Complications
Osteonecrosis
o 31% overall (including all subtypes)
o radiographs
hawkins sign
subchondral lucency best seen on mortise Xray at 6-8 weeks
indicates intact vascularity with resorption of subchondral bone
associated with talar neck comminution and open fractures
Posttraumatic arthritis
o subtalar arthritis (50%) is the most common complication
o tibiotalar arthritis (33%)
Varus malunion (25-30%)
o can be prevented by anatomic reduction
o treatment includes medial opening wedge osteotomy of talar neck
o leads to
decreased subtalar eversion
VI:37 hawkins sign
decreased motion with locked midfoot and hindfoot
weight bearing on the lateral border of the foot
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anterior tibial artery
supplies head and neck
perforating peroneal arteries via artery of tarsal sinus
supplies head and neck
deltoid artery (located in deep segment of deltoid ligament)
supplies body
may be only remaining blood supply with a talar neck fracture
Classification
Anatomic classification
o Lateral Process Fx
type 1 fractures do not involved the articular surface
type 2 fractures involve the subtalar and talofibular joints
type 3 fractures have comminution
o Posterior Process Fx
posteromedial tubercle fractures
result from an avulsion of the posterior talotibial ligament
or posterior deltoid ligament
posterolateral tubercle fractures
result from an avulsion of the posterior talofibular
ligament
o Talar Head Fx
o Talar Body Fx
Physical Exam
Symptoms
o pain VI:38 Lateral Process Fx
lateral process fractures often misdiagnosed as ankle sprains
Physical exam
o provocative tests
pain aggravated by FHL flexion or extension may be found with a posterolateral tubercle
fractures
Imaging
Radiographs
o recommended views
AP and lateral
lateral process fractures may be viewed on AP radiographs
Canale View
optimal view of talar neck
technique
maximum equinus
15% pronated
Xray 75 degrees cephalad from horizontal
VI:39 os trigonum
careful not to mistake os trigonum (present in up to 50%) for fracture
may be falsely negative in talar lateral process fx
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CT scan
o indicated when suspicion is high and radiographs are negative
best study for posterior process fx, lateral process fx, and posteromedial process fx
o helpful to determine degree of displacement, comminution, and articular congruity
MRI
o can be used to confirm diagnosis when radiographs are negative
Treatment
Nonoperative
o SLC for 6 weeks
indications
nondisplaced (< 2mm) lateral process fractures
nondisplaced (< 2mm) posterior process fractures
nondisplaced (< 2mm) talar head fractures
nondisplaced (< 2mm) talar body fractures
technique : cast molded to support longitudinal arch
Operative
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Ankle and Hindfoot
o ORIF/Kirshner wire Fixation
indications
displaced (> 2mm) lateral process fractures
displaced (> 2mm) talar head fractures
displaced (> 2mm) talar body fractures
medial, lateral or posterior malleolar osteotomies may be necessary
displaced (> 2mm) posteromedial process fractures
may require osteotomies of posterior or medial malleoli to adequately reduce the
fragments
o fragment excision
indications
comminuted lateral process fractures
comminuted posterior process fractures
nonunions of posterior process fractures
Technique
ORIF/Kirshner Wires
o approaches
lateral approach
for lateral process fractures
incision over tarsal sinus, reflect EDB distally
posteromedial approach
for medial tubercle of posterior process fracture or for entire posterior process fracture
that has displaced medially
between FDL and neurovascular bundle
posterolateral approach
for lateral tubercle of posterior process fractures
between peroneal tendons and Achilles tendon (protect sural nerve)
beware when dissecting medial to FHL tendon (neurovascular bundle lies there)
combined lateral and medial approach
required for talar body fractures with more than 2 mm of displacement
Fragment excisions
o incompetence of the lateral talocalcaneal ligament is expected with excision of a 1 cm fragment
this is biomechanically tolerated and does not lead to ankle or subtalar joint instability
Complications
AVN : Hawkins sign (lucency) indications revascularization
o Lack of Hawkins sign with sclerosis is indicative of AVN
Talonavicular arthritis
o posttraumatic arthritis is common in all of these fractures
o this can be treated with an arthrodesis of the talonavicular joint
Malunion
Chronic pain from symptomatic nonunion : may have pain up to 2 years after treatment
Subtalar arthritis : found in 45% of patients with lateral process fractures, treated either non-
operatively or operatively
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4. Subtalar Dislocations
Introduction
Typically from a high-energy mechanism
o 25% may be open
lateral dislocations more likely to be open
o 65% to 80% are medial dislocations
o remaining are lateral dislocations
o case reports of anterior or posterior dislocations
Associated injuries
o associated dislocations
talonavicular
o associated fractures (up to 44%)
with medial dislocation
dorsomedial talar head
posterior process of talus
navicular
with lateral dislocation
cuboid
anterior calcaneus
lateral process of talus
fibula
I:40 assiciated with posterior process fx of talus
V
Presentation
Physical exam
o foot will be locked in supination with medial dislocation
o foot will be locked in pronation with lateral dislocation
Imaging
Radiographs
o medial subtalar dislocation
talar head will be superior to navicular on lateral image
o lateral subtalar dislocation
talar head will be colinear or inferior to navicular on lateral image
CT scan
o perform following reduction
o look for associated injuries or subtalar debris
Treatment
Nonoperative
o closed reduction and short leg non-weight bearing cast for 4-6 weeks
indications
first line of treatment
60-70% can be reduced by closed methods
technique
requires adequate sedation
typical maneuvers include knee flexion and ankle plantar flexion
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Ankle and Hindfoot
followed by distraction and hindfoot inversion or eversion depending on direction of
dislocation
perform a post-reduction CT to look for associated injuries
Operative
o open reduction
indications
failure of closed reduction
up to 32% require open reduction
medial dislocation reduction blocked by lateral structures including
peroneal tendons
extensor digitorum brevis
talonavicular joint capsule
lateral dislocation reduction blocked by medial structures including
posterior tibialis tendon
flexor hallucis longus
flexor digitorum longus
place temporary transarticular pins as needed if joint remains unstable
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5. Calcaneus Fractures
Introduction
Epidemiology
o incidence
most frequent tarsal fracture
17% open fractures
Pathophysiology
o mechanism
traumatic axial loading is the primary mechanism of injury
fall from height
motor-vehicle accidents
o pathoanatomy
intra-articular fractures
primary fracture line results from oblique shear and leads to the following two primary
fragments
superomedial fragment (constant fragment)
includes the sustentaculum tali and is stabilized by strong ligamentous and
capsular attachments
superolateral fragment
includes an intra-articular aspect through the posterior facet
secondary fracture lines
dictate whether there is joint depression or tongue-type fracture
extra-articular fractures
strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site
on calcaneus
more common in osteopenic bone
anterior process fractures
inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament
Associated injuries
o orthopaedic
extension into the calcaneocuboid joint occurs in 63%
vertebral injuries in 10%
contralateral calcaneus in 10%
Prognosis
o poor with 40% complication rate
increased due to mechanism (fall from height), smoking, and early surgery
lateral soft tissue trauma increases the rate of complication
Anatomy
Osteology
o articular facets
superolateral fragment contains the articular facets
superior articular surface contains three facets that articulate with the talus
posterior facet is the largest and is the major weight bearing surface
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the flexor hallucis longus tendon runs just inferior to it and can be injured with errant
drills/screws that are too long
middle facet is anteromedial on sustentaculum tali
anterior facet is often confluent with middle facet
o sinus tarsi
between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that
together with the talar sulcus makes up the sinus tarsi
o sustentaculum tali
projects medially and supports the neck of talus
FHL passes beneath it
deltoid and talocalcaneal ligament connect it to the talus
contained in the anteromedial fragment, which remains "constant" due to medial
talocalcaneal and interosseous ligaments
o bifurcate ligament
connects the dorsal aspect of the anterior process to the cuboid and navicular
Classification
Extra-articular (25%)
o avulsion injury of
anterior process by bifurcate ligament
sustentaculum tali
calcaneal tuberosity (Achilles tendon avulsion)
Intra-articular (75%)
o Essex-Lopresti classification
VI:42 anterior process
the primary fracture line runs obliquely through the posterior facet
forming two fragments
the secondary fracture line runs in one of two planes
the axial plane beneath the facet exiting posteriorly in tongue-type fractures
when the superolateral fragment and posterior facet remain attached to the tuberosity
posteriorly
behind the posterior facet in joint depression fractures
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Ankle and Hindfoot
Essex-Lopresti Classification
PRIMARY FRACTURE LINE (A, D)
The posterolateral edge of the talus splits the calcaneus obliquely through the posterior facet. The fracture line exits
anterolaterally at the crucial angle or as far distally as the calcaneocuboid joint. Posteriorly, the fracture moves from
plantar medial to dorsal lateral, producing two main fragments: the sustentacular (anteromedial) and tuberosity
(posterolateral) fragments.
The anteromedial fragment is rarely comminuted and remains attached to the talus by the deltoid and interosseous
talocalcaneal ligaments.
The posterolateral fragment usually displaces superolaterally with variable comminution, resulting in incongruity of the
posterior facet as well as heel shortening and widening.
SECONDARY FRACTURE LINE
With continued compressive forces, there is additional comminution, creating a free lateral piece of posterior facet
separate from the tuberosity fragment.
Tongue fracture: (D, E, and F) a secondary fracture line appears beneath the facet and exits posteriorly through the
tuberosity.
Joint depression fracture (A, B and C) a secondary fracture line exits just behind the posterior facet.
Continued axial force causes the sustentacular fragment to slide medially, causing heel shortening and widening. As this
occurs, the tuberosity fragment will rotate into varus. The posterolateral aspect of the talus will force the free lateral piece
of the posterior facet down into the tuberosity fragment, rotating it as much as 90 degrees. This causes lateral wall
blowout, which may extend as far anteriorly as the calcaneocuboid joint. As the lateral edge of the talus collapses further,
there will be additional comminution of the articular surface.
Source : Koval, Kenneth J.; Zuckerman, Joseph D. Handbook of Fractures, 3rd Edition
o Sanders classification
based on the number of articular fragments seen on the coronal CT image at the widest point
of the posterior facet
Sanders Classification
Type I • Nondisplaced posterior facet (regardless of number of fracture lines)
Type II • One fracture line in the posterior facet (two fragments)
Type III • Two fracture lines in the posterior facet (three fragments)
Type • Comminuted with more than three fracture lines in the posterior facet (four or more
IV fragments)
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Presentation
Symptoms
o pain
Physical exam
o inspection
diffuse tenderness to palpation
ecchymosis and swelling
shortened, widened, heel with a varus deformity
Imaging
Radiographs
o recommended views
required
AP, lateral, and oblique foot
optional
Broden Harris view
allows visualization of posterior facet
useful for evaluation of intraoperative reduction of posterior facet
with ankle in neutral dorsiflexion take x-rays at 40, 30, 20, and 10
degrees of internal rotation
Harris view
visualizes tuberosity fragment widening, shortening, and varus positioning
place the foot in maximal dorsiflexion and angle the x-ray beam 45 degrees
AP ankle
demonstrates lateral wall extrusion causing fibular impingement
findings
reduced Bohler angle
increased angle of Gissane
calcaneal shortening
varus tuberosity deformity
o measurement
Bohler angle (normal is 20-40 degrees)
measured from lateral foot x-ray
flattening (decreased angle) represents collapse of the posterior facet
double-density highlights subtalar incongruity
angle of Gissane (normal is 130-145 degrees)
an increase represents collapse of posterior facet
CT
o indications
gold standard
o views
30-degree semicoronal
demonstrates posterior and middle facet displacement
axial
demonstrates calcaneocuboid joint involvement
sagittal : demonstrates tuberosity displacement
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Ankle and Hindfoot
MRI
o indications
used only to diagnose calcaneal stress fractures in the presence of normal radiographs and/or
uncertain diagnosis
Treatment
Nonoperative
o cast immobilization with nonweightbearing for 6 weeks
indications
calcaneal stress fractures
o cast immobilization with nonweightbearing for 10 to 12 weeks
indications
small extra-articular fracture (<1 cm) with intact Achilles tendon and <2 mm
displacement
Sanders Type I (nondisplaced)
anterior process fracture involving <25% of calcaneocuboid joint
comorbidities that preclude good surgical outcome (smoker, diabetes, PVD)
techniques
begin early range of motion exercises once swelling allows
Operative
o closed reduction with percutaneous pinning
indications
minimally displaced tongue-type fxs or those with mild shortening
large extra-articular fractures (>1 cm)
early reduction prevents skin sloughing and need for subsequent flap coverage
techniques
lag screws from posterior superior tuberosity directed inferior and distal
o ORIF
indications
displaced tongue-type fractures
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large extra-articular fractures (>1 cm) with detachment of Achilles tendon and/or > 2 mm
displacement
urgent if skin is compromised
Sanders Type II and III
posterior facet displacement >2 to 3 mm, flattening of Bohler angle, or varus
malalignment of the tuberosity
anterior process fracture with >25% involvement of calcaneocuboid joint
displaced sustentaculum fractures
timing
wait 10-14 days until swelling and blisters resolve and wrinkle sign present 10-14 days
no benefit to early surgery due to significant soft tissue swelling
outcomes
surgical outcome correlates with the number of intra-articular fragments and the quality
of articular reduction
factors associated with a poor outcome
age > 50
obesity
manual labor
workers comp
smokers
bilateral calcaneal fractures
multiple trauma
vasculopathies
men do worse with surgery than women
factors associated with most likely need for a secondary subtalar fusion
male worker's compensation patient who participates in heavy labor work with an
initial Böhler angle less than 0 degrees
o primary subtalar arthrodesis
indications
Sanders Type IV
techniques
combined with ORIF to restore height
Surgical Techniques
ORIF with extensile lateral or medial approach
o goals
restore congruity of subtalar joint
restore Bohler angle and calcaneal height
restore width
correct varus malalignment
o approach
extensile lateral L-shaped incision is most popular
provides access to calcaneocuboid and subtalar joints
high rate of wound complications
medial approach can also be used
full-thickness flap is created to maintain soft tissue integrity
o technique
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Ankle and Hindfoot
place a pin in the tuberosity to assist the reduction
provisional fixation with Kirschner wires
hold reduction with low profile implants
bone grafting provides no added benefit
o postoperative care
bulky posterior U splint
early supervised subtalar range of motion exercises
nonweightbearing for 10 weeks
ORIF with sinus tarsi approach and Essex-Lopresti maneuver
o technique
manipulate the heel to increase the calcaneal varus deformity
plantarflex the forefoot
manipulate the heel to correct the varus deformity with a valgus reduction
stabilize the reduction with percutaneous K-wires or open fixation as described above
Complications
Wound complications (10-25%)
o increased risk in smokers, diabetics, and open injuries
Subtalar arthritis
o increased with nonoperative management
Lateral impingement with peroneal irritation
Damaged FHL
o at risk with placement of lateral to medial screws, especially at level of sustentaculum tali
(constant fragment)
Compartment syndrome (10%)
o results in claw toes
Malunion
o introduction
loss of height, widening, and lateral impingement
o physical exam
limited ankle dorsiflexion
due to dorsiflexed talus with talar declination angle <20
o classification (see below)
o treatment
distraction bone block subtalar arthrodesis
indications
chronic pain from subtalar joint
incongruous subtalar joint/post-traumatic DJD
loss of calcaneal height
mechanical block to ankle dorsiflexion
results from posterior talar collapse into the posterior calcaneus
technique
goal is to correct
hindfoot height
ankle impingement
subfibular impingement
subtalar arthritis
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OrthoBullets2017 Lower Extremity | Ankle and Hindfoot
Collected By : Dr AbdulRahman
AbdulNasser
June 2017
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Ankle and Hindfoot
ORTHO BULLETS
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OrthoBullets2017 Foot & Ankle Trauma | Ankle Sprains
A. Ankle Sprains
Anatomy
See complete ligament of ankle
Ligaments
o distal tibiofibular syndesmosis includes
anterior-inferior tibiofibular ligaments (AITFL)
originates from anterolateral tubercle of tibia (Chaput's)
inserts on anterior tubercle of fibula (Wagstaffe's)
posterior-inferior tibiofibular ligament (PITFL)
originates from posterior tubercle of tibia (Volkmann's)
inserts on posterior part of lateral malleolus
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Ankle Sprains
strongest component of syndesmosis
interosseous membrane
interosseous ligament (IOL)
distal continuation of the interosseous membrane
main restraint to proximal migration of the talus
inferior transverse ligament (ITL)
Syndesmosis Biomechanics
o function
maintains integrity between tibia and fibula
resists axial, rotational, and translational forces
o normal gait
syndesmosis widens 1mm during gait
o deltoid ligament
indirectly stabilizes the medial ankle mortise
Presentation
Symptoms
o anterolateral ankle pain proximal to AITFL
o may have medial sided ankle tenderness/swelling
o difficulty bearing weight
VII:2 Syndesmotic ligaments
lateral ankle sprains are often able to bear weight
Physical exam
o palpation
syndesmosis tenderness
single best predictor for return to play
o provocative tests
squeeze test (Hopkin's)
compression of tibia and fibula at midcalf level causes
pain at syndesmosis
external rotation stress test VII:3 squeeze test
pain over syndesmosis is elicited with external rotation/dorsiflexion of
the foot with knee and hip flexed to 90 degrees
Cotton
widening of the syndesmosis with lateral pull on the fibula
fibular translation
anterior and posterior drawer force to the fibula with the tibia stabilized causes increased
translation of the fibula and pain
Imaging
Radiographs
o recommended views
AP, lateral, mortise view of ankle
AP, lateral of entire tibia
may show fracture of proximal fibula
o optional views
external rotation stress radiograph
gravity stress view
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will help determine competence of deltoid ligament
contralateral ankle radiographs
may help clarify syndesmosis widening versus normal anatomic variant
o findings
decreased tibiofibular overlap
normal >6 mm on AP view
normal >1 mm on mortise view
increased medial clear space
normal less than or equal to 4 mm
increased tibiofibular clear space
normal <6 mm on both AP and mortise views
CT
o indications
clinical suspicion of syndesmotic injury with normal radiographs
useful post-operatively to assess reduction of syndesmosis after fixation
o sensitivity and specificity
more sensitive than radiographs for detecting minor degrees of syndesmotic injury
MRI
o indications
clinical suspicion of syndesmotic injury with normal radiographs
o sensitivity and specificity
highly sensitive and specific for detecting syndesmotic injury
external rotation
stress gravity stress view
Mortis &AP radiograph of entire leg radiograph CT
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Ankle Sprains
o non-weight-bearing CAM boot or cast for 2 to 3 weeks
indications
syndesmotic sprain without diastasis or ankle instability
technique
delayed weight-bearing until pain free
physical therapy program using a brace that limits external rotation
outcomes
typically display a notoriously prolonged and highly variable recovery period
recovery may extend to twice that of standard ankle sprain
Operative
o syndesmosis screw fixation
indications
syndesmotic sprain (without fracture) with instability on stress radiographs
syndesmotic sprain refractory to conservative treatment
syndesmotic injury with associated fracture that remains unstable after fixation of fracture
outcomes
excellent functional outcomes if syndesmosis is accurately reduced
requires removal
o syndesmosis fixation with suture button
indications
same as for screw fixation
technique
fiberwire suture with two buttons tensioned around the syndesmosis
may be performed in addition to a screw II:4 suture button
V
outcomes
early results promising with some showing earlier return to activity when compared to
screw fixation
does not require removal
Surgical Techniques
Syndesmotic screw fixation
o technique
two 3.5 or 4.5 mm syndesmotic screws through 3 or 4 cortices
placed 2-5 cm above the plafond
screw material
no difference between stainless-steel and titanium screws
bioabsorbable screws with similar outcomes
number of cortices
no difference between 3 or 4 cortices
number of screws
fixation with two screws is preferable
position of foot during fixation
a recent study challenges the principle of holding the ankle in maximal dorsiflexion to
avoid overtightening
o postoperative
typically non-weight-bearing for 6-12 weeks
may prolong if screw breakage is a concern
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Complications
Posttraumatic tibiofibular synostosis
o incidence
~10% after Weber C ankle fractures
o treatment
surgical excision
reserved for persistent pain that fails to respond to
nonsurgical management
ossification must be "cold" on bone scintigraphy prior to
removal
Anatomy
Ligamentous anatomy of the ankle
ATFL
o most commonly involved ligament in low ankle sprains
o mechanism is plantar flexion and inversion
o physical exam shows drawer laxity in plantar flexion
CFL
o 2nd most common ligament injury in lateral ankle sprains
o mechanism is dorsiflexion and inversion
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Ankle Sprains
o physical exam shows drawer laxity in dorsiflexion
o subtalarinstability can be difficult to differentiate from posterior ankle instability because the
CFL contributes to both
PTFL : less commonly involved
Classification
Classification of Low Ankle Sprains
Ligament disruption Ecchymosis and swelling Pain with weight bearing
Grade I none minimal normal
Grade II stretch without tear moderate mild
Grade III complete tear severe severe
Presentation
Symptoms
o pain with weight bearing
o recurrent instability
o catching or popping sensation may occur following recurrent sprains
Physical exam
o focal tenderness and swelling over involved ligament(s)
o anterior drawer test
possible laxity with anterior drawer and eversion/inversion stress testing
Imaging
Radiographs
o indications for radiographs with an ankle injury include (Ottawa ankle rules)
inability to bear weight
medial or lateral malleolus point tenderness
5MT base tenderness
navicular tenderness
o radiographic views to obtain
standard ankle series (weight bearing)
AP
lateral
mortise
II:5 varus stress view
V
ER rotation stress view
useful to diagnosis syndesmosis injury in high ankle sprain
look for asymmetric mortise widening
medial clear space widening > 4mm
tibiofibular clear space widening of 6 mm
varus stress view
used to diagnose injury to ATFL or CFL
measures ankle instability by looking at talar tilt and anterior talar translation
MRI
o indications : consider MRI if pain persists for 8 weeks following sprain
o useful to evaluate
peroneal tendon pathology
osteochondral injury
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Treatment
Nonoperative
o RICE, elastic wrap to minimize swelling, followed by therapy
indications : Grade I, II, and III injuries
technique
may require short period (approx. 1 week) of weight-bearing immobilization in a walking
boot or walking cast, but early mobilization facilitates a better recovery
therapy
once swelling and pain have subsided and patient has full range of motion begin
neuromuscular training with a focus on peroneal muscles strength and proprioception
training
a functional brace that controls inversion and eversion is typically used during the
strengthening period and used as prophylactic treatment during high risk activities
thereafter
early functional rehabilitation allows for quickest return to physical activity
Operative
o anatomic reconstruction vs. tendon transfer with tenodesis
indications
Grade I-III that continue to have pain and instability despite extensive nonoperative
management
Grade I-III with a bony avulsion
technique (see below)
o arthroscopy
indications
recurrent ankle sprains and chronic pain caused by impingement lesions
anteriorinferior tibiofibular ligament impingement
posteromedial impingement lesion of ankle
procedure : debride impinging tissue
Surgical Techniques
Gould modification of Brostrom anatomic reconstruction
o procedure
an anatomic shortening and reinsertion of the ATFL and CFL
reinforced with inferior extensor retinaculum and distal fibular periosteum
o results
good to excellent results in 90%
consider arthroscopic evaluation prior to reconstruction for intra-articular evaluation
Tendon transfer and tenodesis (Watson-Jones, Chrisman-Snook, Colville, Evans)
o procedure
a nonanatomic reconstruction using a tendon transfer
o technique
any malalignment must be corrected to achieve success during a lateral ligament
reconstruction
Coleman block testing used to distinguish between fixed and flexible hindfoot varus
o results
subtalar stiffness is a common complication
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Ankle Sprains
Rehabilitation
Return to play
o depends on, grade of sprain, syndesmosis injury, associated injuries, and compliance with rehab
Complications
Pain and instability
o up to 50% continue to experience symptoms following and acute ankle sprain
o most common cause of chronic pain is a missed injury, including
injury to the anterior process of calcaneus
injury to the lateral or posterior process of the talus
injury to the base of the 5th metatarsal
osteochondral lesion
injuries to the peroneal tendons
injury to the syndesmosis
tarsal coalition
impingement syndromes
Collected By : Dr AbdulRahman
AbdulNasser
June 2017
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Anatomy
Osteology
o Lisfranc joint complex consists of three articulations including
tarsometatarsal articulation
intermetatarsal articulation
intertarsal articulations
Ligaments
o Lisfranc ligament
critical to stabilizing the second metatarsal and maintenance
of the midfoot arch
An interosseous ligament that goes from medial cuneiform
to base of 2nd metatarsal on plantar surface
Lisfranc ligament tightens with pronation and abduction of forefoot
o plantar tarsometatarsal ligaments
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Mid & Forefoot Trauma
injury of the plantar ligament between the medial cuneiform and the second and third
metatarsals along with the Lisfranc ligament is necessary to give transverse instability.
o dorsal tarsometatarsal ligaments
dorsal ligaments are weaker and therefore bony displacement with injury is often dorsal
o intermetatarsal ligaments
between second-fifth metatarsal bases
no direct ligamentous attachment between first and second metatarsal
Biomechanics
o Lisfranc joint complex is inherently stable with little motion due to
stable osseous architecture
second metatarsal fits in mortise created by medial cuneiform and recessed middle
cuneiform, "keystone configuration"
ligamentous restraints
see individual ligaments above
Columns of the midfoot
o medial column
includes first tarsometatarsal joint
o middle column
includes second and third tarsometatarsal joints
o lateral column
includes fourth and fifth tarsometatarsal joints (most mobile)
Classification
Multiple classification schemes described
o none proven useful for determining treatment and prognosis
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Physical Exam
Symptoms
o severe pain
o inability to bear weight
Physical exam
o inspection & palpation
medial plantar bruising
swelling throughout midfoot
tenderness over tarsometatarsal joint
o motion & stability
instability test
grasp metatarsal heads and apply dorsal force to forefoot while other hand palpates the
TMT joints
dorsal subluxation suggests instability
if first and second metatarsals can be displaced medially and laterally, global
instability is present and surgery is required
when plantar ligaments are intact, dorsal subluxation does not occur with stress exam and
injury may be treated nonoperatively
o provocative tests
may reproduce pain with pronation and abduction of forefoot
o compartment syndrome
always check for compartment syndrome and take compartment pressures if high suspicion
Imaging
Radiographs
o recommended views
AP, lateral, obliques
stress radiograph
may be helpful to show instability when non-weight bearing radiographs are normal and
there is high suspicion
weight-bearing radiographs with comparison view
may be necessary to confirm diagnosis
o findings
five critical radiographic signs that indicate presence of midfoot instability
disruption of the continuity of a line drawn from the medial base of the second metatarsal
to the medial side of the middle cuneiform
widening of the interval between the first and second ray
medial side of the base of the fourth metatarsal does not line up with medial side of
cuboid on oblique view
metatarsal base dorsal subluxation on lateral view
disruption of the medial column line (line tangential to the medial aspect of the navicular
and the medial cuneiform)
lateral
non weight-bearing radiographs may show dorsal displacement of the proximal base of
the first or second metatarsal
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Mid & Forefoot Trauma
AP
malalignment of medial margin of the second metatarsal base and the medial edge of the
middle cuneiform diagnostic of Lisfranc injury
may see bony fragment (fleck sign) in first intermetatarsal space
represents avulsion of Lisfranc ligament from base of 2nd metatarsal
diagnostic of Lisfranc injury
oblique
malalignment of fourth metatarsal and cuboid
CT scan
o useful for diagnosis and preoperative planning
MRI
o can be used to confirm presence of purely ligamentous injury
AP AP Lateral CT
Treatment
Nonoperative
o cast immobilization for 8 weeks
indications
no displacement on weight-bearing and stress radiographs and no evidence of bony injury
on CT (usually dorsal sprains)
certain nonoperative candidates
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nonambulatory patients
presence of serious vascular disease
severe peripheral neuropathy
instability in only the transverse plane
Operative
o open reduction and rigid internal fixation
indications
any evidence of instability (> 2mm shift)
favored in bony fracture dislocations as opposed to purely ligamentous injuries
outcomes
anatomic reduction required for a good result
o primary arthrodesis of the first, second and third tarsometatarsal joints
indications
purely ligamentous arch injuries
delayed treatment
chronic deformity
outcomes
level 1 evidence demonstrates equivalent functional outcomes and decreased rate of
hardware removal or revision surgery compared to primary ORIF
primary arthodesis is an alternative to ORIF in patients with any evidence of instability
Complications
Posttraumatic arthritis
o most common complication
o may cause altered gait and long term disability
o treat advanced midfoot arthrosis with midfoot arthrodesis
Nonunion
o uncommon
o revision surgery indicated unless patient is elderly and low demand
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OrthoBullets2017 Foot & Ankle Trauma | Mid & Forefoot Trauma
Anatomy
Osteology and Insertions
o divided into tubercle (tuberosity), base, shaft, head and neck
o peroneus brevis and lateral band of plantar fascia insert on base
o peroneus tertius inserts on dorsal metadiaphysis
Blood supply
o blood supply provided by metaphyseal vessels and diaphyseal nutrient artery
o Zone 2 (Jones fx) represents a vascular watershed area, making these fracture prone to nonunion
Classification
Classification
Class Description
Zone 1 Proximal tubercle (rarely enters 5th tarsometatarsal joint)
(pseudo Jones Due to long plantar ligament, lateral band of the plantar fascia, or contraction of the
fx) peroneus brevis
Nonunions uncommon
Zone 2 Metaphyseal-diaphyseal junction
(Jones fx) Involves the 4th-5th metatarsal articulation
Vascular watershed area
Acute injury
Increased risk of nonunion
Zone 3 Proximal diaphyseal fracture
Distal to the 4th-5th metatarsal articulation
Stress fracture in athletes
Associated with cavovarus foot deformities or sensory neuropathies
Increased risk of nonunion
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Mid & Forefoot Trauma
Presentation
Symptoms
o pain over lateral border of forefoot, especially with
weight bearing
o look for antecedent pain in setting of stress fracture
Physical Exam
o manual palpation of area of concern
o resisted foot eversion
Imaging
Radiographs : AP, lateral and oblique foot images
CT
o not routinely obtained
o consider in setting of delayed healing or nonunion
MRI : not routinely obtained
o consider in setting of delayed healing or nonunion
Treatment
Nonoperative
o protected weight bearing in stiff soled shoe, boot or cast
indications
Zone 1
technique
advance as tolerated by pain
early return to work but symptoms may persist for up to 6 months
o non weight bearing short leg cast for 6-8 weeks
indications
Zone 2 (Jones fx) in recreational athlete
Zone 3
technique : advance with signs of radiographic healing
Operative
intramedullary screw fixation : indications
zone 2 (Jones fx) in elite or competitive athletes
minimizes possibility of nonunion or prolonged restriction from activity
zone 3 fx with sclerosis/nonunion or in athletic individual
Complications
Nonunion
o increased risk in Zone 2 (Jones fx) and Zone 3 due to vascular supply
o smaller diameter screws (<4.5mm) associated with delayed union or nonunion
Failure of fixation : higher failure rate in
elite athletes
return to sports prior to radiographic union
fracture distraction or malreduction due to screw length
screws that are too long will straighten the curved metatarsal shaft or perforate the medial
cortex
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OrthoBullets2017 Foot & Ankle Trauma | Mid & Forefoot Trauma
3. Metatarsal Fractures
Introduction
Metatarsal fractures are among the most common injuries of the foot
o goals of treatment include:
maintenance of transverse and longitudinal arch of forefoot
restore alignment to allow for normal force transmission
across metatarsal heads
Epidemiology
o 5th metatarsal most commonly fractured in adults
o 1st metatarsal most commonly fractured in children less than 4
years old
o peak incidence between 2nd and 5th decade of life
o 3rd metatarsal fractures rarely occur in isolation
68% associated with fracture of 2nd or 4th metatarsal
Mechanism
o direct crush injury
may have significant associated soft tissue injury
o indirect mechanism (most common)
occurs with forefoot fixed and hindfoot or leg rotating
Associated conditions
o Lisfranc injury
Lisfranc equivalent injuries seen with multiple proximal metatarsal fractures
o stress fracture
consider metabolic evaluation for fragility fracture
look for associated foot deformity
seen at base of 2nd metatarsal in ballet dancers
may have history of amenorrhea
Prognosis
o majority of isolated metatarsal fractures heal with conservative management
o malunion may lead to transfer metatarsalgia
Anatomy
Osteology
o shape and function similar to metacarpals of the hand
o first metatarsal has plantar crista that articulates with sesamoids
widest and shortest
bears 30-50% of weight during gait
o second metatarsal is longest
most common location of stress fracture
Muscles
o muscular balance between extrinsic and intrinsic muscles
o extrinsics include
Extensor digitorum longus (EDL)
Flexor digitorum longus (FDL)
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Mid & Forefoot Trauma
o intrinsics include
Interossei
Lumbricals
o see Layers of the Plantar Foot
Ligaments
o Metatarsals have dense proximal and distal ligamentous attachments
o 2nd-5th metatarsal have distal intermetatarsal ligaments that maintain length and alignment with
isolated fractures
implicated in formation of interdigital (Morton's) neuromas
multiple metatarsal fractures lose the stability of intermetatarsal ligaments leading to
increased displacement
Blood supply
o dorsal and plantar metatarsal arteries
Biomechanics
o see Foot and Ankle Biomechanics
Classification
Classification of metatarsal fractures is descriptive and should include
o location
o fracture pattern
o displacement
o angulation
o articular involvement
Presentation
History
o look for antecedent pain when suspicious for stress fracture
Symptoms
o pain, inability to bear weight
Physical Exam
o inspection
foot alignment (neutral, cavovarus, planovalgus)
focal areas or diffuse areas of tenderness
careful soft tissue evaluation with crush or high-energy injuries
o motion
evaluate for overlapping or malrotation with motion
o neurovascular
semmes weinstein monofilament testing if suspicious for peripheral neuropathy
Imaging
Radiographs
o recommended views
required
AP, lateral and oblique views of the foot
optional
contralateral foot views
stress or weight bearing radiographs
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CT
o not
routinely obtained
o may be of use in periarticular injuries or to rule out Lisfranc injury
MRI or bone scan
o useful in detection of occult or stress fractures
Treatment
Nonoperative
o stiff soled shoe or walking boot with weight bearing as tolerated
indications
first metatarsal
non-displaced fractures
second through fourth (central) metatarsals
isolated fractures
non-displaced or minimally displaced fractures
stress fractures
second metatarsal most common
look for metabolic bone disease
evaluate for cavovarus foot with recurrent stress fractures
Operative
o percutaneous vs open reduction and fixation
indications
open fractures
first metatarsal
any displacement
no intermetatarsal ligament support
30-50% of weight bearing with gait
central metatarsals
sagittal plane deformity more than 10 degrees
>4mm translation
multiple fractures
techniques
antegrade or retrograde pinning
lag screws or mini fragment plates in length unstable fracture patterns
maintain proper length to minimize risk of transfer metatarsalgia
outcomes
limited information available in literature
Complications
Malunion
o may lead to transfer metatarsalgia or plantar keratosis
o treat with osteotomy to correct deformity
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Mid & Forefoot Trauma
Anatomy
Articulations
o navicular bone articulates with
cuneiforms
cuboid
calcaneus
talus
Biomechanics
o navicular bone and its articulations play an important role in inversion and eversion
biomechanics and motion
Classification
Sangeorzan Classification of Navicular Body Fractures
(based on plane of fracture and degree of comminution)
Transverse fracture of dorsal fragment that involves < 50% of bone.
Type I
No associated deformity
Oblique fracture, usually from dorsal-lateral to plantar-medial.
Type II
May have forefoot aDDuction deformity.
Central or lateral comminution.
Type IIII
ABDuction deformity.
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OrthoBullets2017 Foot & Ankle Trauma | Mid & Forefoot Trauma
Imaging
Radiographs VII:8 CT
o may be difficult to see and are often missed
o oblique 45 degree radiograph
best to visualize tuberosity fractures
CT
o more sensitive to identify fracture than radiographs
MRI
o will show signal intensity on T2 image due to inflammation
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Tendon Injuries
Treatment of Traumatic Fractures
Nonoperative
o cast immobilization with no weight bearing
indications
acute avulsion fractures
most tuberosity fractures
minimally displaced Type I and II navicular body fractures
Operative
o fragment excision
indications
avulsion fractures that failed to improve with nonoperative modalities
tuberosity fractures that went on to symptomatic nonunion
o open reduction and internal fixation
indications
avulsion fractures involving > 25% of articular surface
tuberosity fractures with > 5mm diastasis or large intra-articular fragment
displaced or intra-articular Type I and II navicular body fractures
technique
medial approach
used for Type I and II navicular body fractures
o ORIF followed by external fixation VS. primary fusion
indications
Type III navicular body fractures
technique
must maintain lateral column length
C. Tendon Injuries
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OrthoBullets2017 Foot & Ankle Trauma | Tendon Injuries
sudden forced plantar flexion
violent dorsiflexion in a plantar flexed foot
Pathoanatomy
o rupture usually occurs 4-6 cm above the calcaneal insertion in hypovascular region
Anatomy
Achilles tendon
o largest tendon in body
o formed by the confluence of
soleus muscle tendon
medial and lateral gastrocnemius tendons
o blood supply from posterior tibial artery
Presentation
History
o patient usually reports a "pop"
Symptoms
o weakness and difficulty walking
o pain in heel
Physical exam
o inspection
increased resting ankle dorsiflexion in prone position with knees bent
calf atrophy may be apparent in chronic cases
o palpation
palpable gap
o motion
weakness to ankle plantar flexion
increased passive dorsiflexion
o provocative test
Thompson test
lack of plantar flexion when calf is squeezed
Imaging
Radiographs
o indications
VII:10 Partial tear U/S
used to rule out other pathology
Ultrasound
o indications
may be useful to determine complete vs. partial ruptures
MRI
o indications
equivocal physical exam findings
chronic ruptures
o findings VII:11 Complete tear U/S
will show acute rupture with retracted tendon edges
Treatment
Nonoperative
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Tendon Injuries
o functional bracing/casting in resting equinus
indications
acute injuries with surgeon or patient preference for non-
operative management
sedentary patient
medically frail patients
outcomes
decreased plantar flexion strength compared to operative
management
new studies show that this may not be true
increased risk of re-rupture compared to operative management VII:12 MRI showing rupture
new studies show that this may not be significant achilles tendon
Surgical Techniques
Functional bracing/casting in resting equinus
o technique
cast/brace in 20 degrees of plantar flexion
early functional rehab for those treated without a cast
End-to-end achilles tendon repair
o approach
make incision just medial to achilles tendon to avoid sural nerve
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OrthoBullets2017 Foot & Ankle Trauma | Tendon Injuries
o technique
incise paratenon
expose tendon edges
repair with heavy non-absorbable suture
o postoperative care
immobilize in 20° of plantar flexion to decrease
tension on skin and protect tendon repair for 4-6
weeks
Percutaneous achilles tendon repair VII:13 VY advancement
o technique
Reconstruction with VY advancement
o technique
make V cut with apex at musculotendinous junction with limbs divergent to exit the tendon
V is incised through only the superficial tendinous portion leaving the muscle fibers intact
Flexor hallucis longus transfer ± VY advancement of gastrocnemius
o technique
excise degenerative tendon edges
release FHL tendon at the Knot of Henry and transfer through the calcaneus
Complications
Re-rupture
o incidence
higher with non-operative management (~10-40% vs 2%)
new Level 1 evidence has shown no difference in re-rupture rates
o treatment
surgical repair
Wound healing complications
o incidence
5-10%
o risk factors
smoking (most common)
female gender
steroid use
open technique (versus percutaneous)
o treatment
deep infection
debridement of necrotic/infected Achilles tendon
culture-specific antibiotics for 6 weeks
Sural nerve injury
o incidence
higher when percutaneous approach is used II:14 Wound healing
V
complications
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Tendon Injuries
Anatomy
Muscles & innervation
o peroneus brevis
innervated by the superficial peroneal nerve, S1
acts as primary evertor of the foot
tendinous about 2-4cm proximal to the tip of the fibula
lies anterior and medial to the peroneus longus at the level of the lateral malleolus
o peroneus longus
innervated by superficial peroneal nerve, S1
primarily a plantar flexor and foot and first metatarsal
can have an ossicle (os peroneum) located within the tendon body
Space & compartment
o peroneal tendons contained within a common synovial sheath that splits at the level of the
peroneal tubercle
o the sheath is runs in the retromalleolar sulcus on the fibula
peroneus longus is posterior in the sulcus (longus takes the long way around)
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peroneus brevis is anterior in the sulcus (brevis is behind the bone)
deepened by a fibrocartilaginous rim (still only about 5 millimeters deep)
covered by superior peroneal retinaculum (SPR)
originates from the posterolateral ridge of the fibula and inserts onto the lateral calcaneus
(peroneal tubercle)
the inferior aspect of the SPR blends with the inferior peroneal retinaculum
is the primary restraint the peroneal tendons within the retromalleolar sulcus
o at the level of the peroneal tubercle of the calcaneus
peroneus longus is inferior
peroneus brevis is superior
both tendons covered by inferior peroneal retinaculum
Classification
Ogden Classification of Superior Peroneal Retinaculum (SPR) Tears
Grade 1 The SPR is partially elevated off of the fibula allowing for subluxation of both
tendons
Grade 2 The SPR is separated from the cartilofibrous ridge of the lateral malleolus,
allowing the tendons to sublux between the SPR and the cartilofibrous ridge
Grade 3 There is a cortical avulsion of the SPR off of the fibula, allowing the subluxed
tendons to move underneath the cortical fragment
Grade 4 The SPR is torn from the calcaneous, not the fibula
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Tendon Injuries
Presentation
History
o patients often report they felt a pop with a dorsiflexion ankle injury
Symptoms
o clicking, popping and feelings of instability or pain on the lateral aspect of the ankle
Physical exam
o inspection
swelling posterior to the lateral malleolus
tenderness over the tendons
'pseudotumor' over the peroneal tendons
voluntary subluxation of the tendons +/- a popping sound
o provocative tests
apprehension tests
the sensation of apprehension or subluxation with active dorsiflexion and eversion against
resistance cause subluxation/dislocation and apprehension
compression test
pain with passive dorsiflexion and eversion of the ankle
Imaging
Radiographs
o recommended views
best recognized on an internal rotation view
o findings
may see a cortical avulsion off the distal tip of the lateral malleolus
(fleck sign, rim fracture)
needed to evaluate for varus hindfoot
MRI
o best evaluated with axial views of a slightly flexed ankle
o can demonstrate anatomic anomalies leading to pathology
peroneus quartus muscle
low-lying peroneus brevis muscle belly
VII:15 fleck sign
Treatment
Nonoperative
o short leg cast immobilization and protected weight bearing for 6 weeks
indications
all acute injuries in nonprofessional athletes
technique
tendons must be reduced at the time of casting
outcomes
success rates for nonsurgical management are only marginally better than 50%.
Operative
o acute repair of superior peroneal retinaculum and deepening of the fibular groove
indications
acute tendon dislocations in serious athletes who desire a quick return to a sport or active
lifestyle
presence of a longitudinal tear
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OrthoBullets2017 Foot & Ankle Trauma | Tendon Injuries
o groove-deepening with soft tissue transfer and/or osteotomy
indications
chronic/recurrent dislocation
technique
less able to reconstruct SPR so treatment focuses on other aspects of peroneal stability
typically involves groove-deepening in addition to soft tissue transfers or bone block
techniques (osteotomies to further contain the tendons within the sulcus)
plantaris grafts can act to reinforce the SPR
hindfoot varus must be corrected prior to any SPR reconstructive procedure
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Tendon Injuries
indications
simple tears
debridement of the tendon with tenodesis of distal and proximal ends of the brevis
tendon to the peroneus longus or reconstruction with allograft
indications
complex tears with multiple longitudinal tears and significant tendinosis (> 50% of
the tendon involved)
Anatomy
Ankle dorsiflexion
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OrthoBullets2017 Foot & Ankle Trauma | Tendon Injuries
o primary ankle dorsiflexor (80%)
tibialis anterior
o secondary ankle dorsiflexors
extensor hallucis longus
extensor digitorum longus
Presentation
History
o acute
patient reports a 'pop' followed by anterior ankle swelling
o chronic
patient reports difficulty clearing foot during gait
Symtpoms:
o acute
pain
o chronic
may be painless
Physical exam
o acute injury
pain swelling anterior to ankle
weakness in dorsiflexion of the ankle
delay in diagnosis is common because of intact ankle dorsiflexion that occurs as a result
of secondary function of the extensor hallucis longus and extensor digitorum longus
muscles
o chronic injury
inspection and palpation
swelling may be minimal
painless mass at the anteromedial aspect of the ankle
loss of the contour of the tibialis anterior tendon over the ankle (tendon not palpable
during resisted dorsiflexion)
weakness
use of the extensor hallucis longus and extensor digitorum communis to dorsiflex the
ankle
gait
steppage gait (hip flexed more than normal in swing phase to prevent toes from catching)
foot slaps down after heel strike
Imaging
Radiographs
o three views of foot and ankle helpful to exclude any associated osseous injury
CT : not indicated
MRI
o helpful to diagnose complete versus partial tear but not to determine if interposition graft is
necessary
Differential
Lumbar radiculopathy (L4)
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By Dr, AbdulRahman AbdulNasser Foot & Ankle Trauma | Tendon Injuries
o can be differentiated from TA rupture by
intact tendon palpable
no ankle mass
may have dermatomal sensory abnormality
positive lumbar spine MRI
Common peroneal nerve compression neuropathy
o EDL, EHL also affected
o sensory abormalities
o history of compression to common peroneal nerve
Treatment
Nonoperative
o ankle-foot orthosis
indications
low demand patient
o casting
indications
partial ruptures
Operative
o direct repair
indications
acute injury (<6 week) injuries
should be attempted up to 3 months out
outcomes
surgical repair leads to improved AOFAS scores and improved levels of activity
some residual weakness of dorsiflexion is expected
o reconstruction
indications
most often required in chronic (>6 week) old injuries
Technique
Direct repair
o approach
open laceration: incorporate laceration
closed rupture: longitudinal incision centered over palpable defect
o repair technique
distal end usually accessible through laceration, proximal end may retract ~3cm
place hemostat in wound under extensor retinaculum and pull tendon into wound
primary end-to-end non-absorbable suture with Krackow, Bunnell or Kessler technique
ends oversewn with small monofilament if frayed to create smoother gliding surface
in cases of avulsion, suture anchors or bone tunnels may be used for reattachment
Tendon reconstruction
o approach
curvilinear incision over course of tibialis tendon, may need to be extensile depending needs
of reconstruction
EHL can be divided through separate small incision and tunneled proximally
o sliding tendon graft
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OrthoBullets2017 Foot & Ankle Trauma | Tendon Injuries
harvest one half width of tibialis anterior tendon proximally and turn down to span gap
repair can be strengthened by securing tibialis anterior tendon to medial cuneiform or dorsal
navicular distal to extensor retinaculum
o free tendon graft
interposition of autograft (hamstring, plantaris) or allograft
o EHL tenodesis or EHL transfer
distal EHL stump tenodesed to EHB
proximal EHL stump used as tendon graft to repair tibialis anterior insertion
proximal tibialis anterior placed under tension prior to suturing to proximal EHL stump
Complications
Failure of reconstruction/repair
Weakness of dorsiflexion
Adhesion formation
Neuroma formation
Collected By : Dr AbdulRahman
AbdulNasser
June 2017
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Tendon Injuries
ORTHO BULLETS
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OrthoBullets2017 Pediatric trauma | Introduction
A. Introduction
1. Pediatric Abuse
Introduction
Epidemiology
o incidence
>1 million children are victims of substantiated abuse or neglect in United States each year
child abuse is the second most common cause of death in children behind accidental injury.
in child abuse, head injury is the most frequent cause of long term physical morbidity in the
child
o demographics
astounding 79% of all cases of nonaccidental trauma occur in children younger than 4 years
of age
50% of fractures in children younger than 1 year of age are attributable to abuse
the most common cause of femur fractures in the nonambulatory infant is nonaccidental
trauma
o social risk factors
recent job loss of parent
children with disabilities (cerebral palsy, premature)
step children
o 4 Types (can have more than one type present):
Neglect 78%
Physical Abuse 18%
Sexual 9%
Psychological 8%
III:1 corner fxs
V
Prognosis
o If unreported, 30-50% chance of repeat abuse and 5-10% chance of death from abuse
Differential Diagnosis
o true accidental injury
o osteogenesis imperfecta
o metabolic bone disease
Presentation
History
o injury often inconsistent with history
VIII:2 posterior rib fractures
o red flags
long bone fxs in infant that is not yet walking
multiple bruises
multiple fxs in various stages of healing
corner fxs
primary spongiosa (metaphyseal)
high specificity for child abuse
posterior rib fractures
bucket handle fractures VIII:3 bucket handle fractures
same as corner fractures
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Introduction
avulsed bone fragment is seen en face as a bucket handle
transphyseal separation of the distal humerus
Symptoms
o pain related to fractures
fractures are the second most common lesion in abused children
frequency of fractures
humerus > tibia > femur
diaphyseal fractures 4 times more common than metaphyseal
Physical exam
o skin lesions
most common presenting lesion
Imaging
Radiographs
o recommended views
AP and lateral of bone or joint of suspicion
initial evaluation should include skeletal survey
Bone scan
o alternative or adjunct to the radiographic skeletal survey in selected cases, particularly for
children older than 1 year. Scintigraphy provides increased sensitivity for detecting rib fractures,
subtle shaft fractures, and areas of early periosteal elevation. Not useful in metaphyseal or
cranial fractures. Not indicated after 5 years of age
Treatment
Nonoperative
o report abuse to appropriate agency
indications
Physicians are mandated reporters, and are legally obligated to report suspected child
abuse and neglect.
Physicians are granted immunity from civil and criminal liability if they report in good
faith, but may be charged with a crime for failure to report
early involvement of social workers and pediatricians is essential
o hospital admission
indications
early multidisciplinary evaluation
admit infants with fractures to the hospital and consult child protective services
obtain social service consult
Operative
o definitive treatment as indicated for particular injury
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OrthoBullets2017 Pediatric trauma | Introduction
Transport
Occipital cut-out needed in spine board when transporting children <6 y.o.
o larger head size can flex unstable cervical spine leading to injury during transport
Help tips
o Broselow tape = estimate medication doses, size of equipment, shock voltage for defibrillator
o ETT = (age/4) + 4 or (age+16)/4 = uncuffed
o BP = 80 + (age x 2)
o Chest tube = 4 x ETT
o Blood volume = 70 x wt (kg) or 75 - 80 mL/kg
Intraosseous lines commonly needed due to difficulty obtaining venous access
o Children may remain hemodynamically stable even after significant blood loss
hypovolemic shock may result from inadequate fluid resuscitation
o "triad of death" reflects inadequate resusitation and is characterized by:
acidosis
hypothermia
coagulopathy
Airway
Smaller airway
o greater risk of airway obstruction with foreign bodies
o small amounts of swelling will result in a relatively greater reduction in airway diameter
Larger tongue, floppy epiglottis,
Larger occiput
o flexes the head forward when placed supine on a flat surface.
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Introduction
o to achieve a neutral position, it may be necessary to lift the chin or place a pad under the torso of
the infant (or head cut out)
Larynx is higher and more anterior
o sits at the level of the C2-C3 vertebrae body in the young child, compared with C6-C7 in the
adult.
positioning of the larynx makes its visualisation in the paediatric airway more difficult than
in the adult.
Breathing
Most common cause of cardiorespiratory arrest is hypoventilation
Ribs positioned more horizontally
o with inspiration the ribs only move up, and not up-and-out, like the adult rib cage.
o limits the capacity to increase tidal volumes
Diaphragmatic breathing
Fewer Type 1 fibres in respiratory muscles
o smaller number of fatigue-resistant, Type I fibres in their respiratory muscles
o exhaust more quickly than adults
Respiratory rate varies with age
o higher oxygen demand = higher respiratory rates
Circulation
Initial bolus = 20ml/kg NS
After two boluses = 10ml/kg of PRBC’s
Blood volume is relatively larger, but absolute volume is smaller
o small volumes of blood will constitute significant blood loss in small children,
example = 100ml haemorrhage experienced by a 5 kg child represents the loss of
approximately 10% of their total blood volume.
Systemic vascular resistance is lower
o increases from birth to adulthood
Hypotension is a late sign
o remain normotensive until they are loosing large intravascular volumes
25-30% of blood volume before signs of shock
Smaller vessels / more subcutaneous tissue
o difficult to obtain vascular access due to small veins and increased subcutaneous tissue
IV access more difficult – consider intraosseus
Disability
Open sutures, presence of fontanelle
Thinner cranial bones
o thinner cranial bones of children do not afford as much protection to the brain tissue
Head relatively larger
o higher centre of gravity = higher incidence of head and neck trauma
Exposure
Relatively small size
o large head and organs
Higher BMR and surface area
o greater consumption of oxygen and other metabolites
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OrthoBullets2017 Pediatric trauma | Introduction
o higher respiratory and heart rates
o larger surface-area to body-mass ratio results in greater heat loss
Increased glucose requirements but decreased glycogen stores
o higher metabolic rate
o small glycogen stores
Injuries
Head and neck
o ICP can be elevated by pain
it is possible to decrease ICP by fracture fixation
o heterotopic ossification is more common following traumatic brain injury
increase serum alkaline phosphatase heralds onset of HO
NSAID prophylaxis is indicated in these situations
Peripheral nerve injuries
o most common in closed fractures
obtain EMG if no return of function 2-3 months after injury
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Introduction
3. Physeal Considerations
Introduction
Always look to see if physis is open
Unique principals in pediatric bone
o elasticity
more elastic which leads to unique fracture patterns
buckle fractures
greenstick fractures
o remodeling potential
open physes (growth plates) can allow extensive bone
deformity remodeling potential
occurs more rapidly in plane of joint motion
sagittal plane in wrist, due to primarily extension/flexion
occurs more at the most active physes, due to most growth and
potential for remodeling
most active physes in upper extremity
proximal humerus
distal radius
most active physes in lower extremity
distal femur
proximal tibia
Same principles as adult bone
o intra-articular fractures must be reduced
VIII:4 Illustration of blood supply of the physis VIII:5 Perichondrial fibrous ring of La Croix
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OrthoBullets2017 Pediatric trauma | Introduction
Physeal Anatomy
Physis Periphery
Groove of During the first year of life, the zone spreads over Osteochondroma
Ranvier the adjacent metaphysis to form a fibrous
circumferential ring bridging from the epiphysis to
the diaphysis.
This ring increases the mechanical strength of the
physis and is responsible for appositional bone
growths
o supplies chondrocytes to periphery
Perichondrial Dense fibrous tissue that is the primary limiting
fibrous ring of membrane that anchors and supports the physis
La Croix through peripheral stability
Perichondrial artery
o major source of nutrition to physis
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Introduction
Injury Classification
Salter-Harris classification
o Type 1- physeal separation
o Type 2- fracture traverses physis and exits metaphysis
most common type
Thurston Holland fragment
o Type 3- fracture traverses physis and exits epiphysis
o Type 4- fracture passes through epiphysis, physis, metaphysis
Thurston Holland fragment
o Type 5- crush injury to physis
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OrthoBullets2017 Pediatric trauma | Shoulder & Humerus Fractures
Treatment
Closed reduction vs. CRPP vs Open reduction
o depends on injury pattern
o intra-articular fractures must be reduced
Complications
Growth arrests
o overview
complete arrest leads to shortening
see Leg Length Discrepancy
partial arrest leads to angulation
o treatment
bar resection with interposition
indications
< 50% physeal involvement
> 2 years or 2cm growth remaining VIII:6 partial arrest leads to angulation
ipsilateral completion of arrest
indications
> 50% physeal involvement
can combine with contralateral epiphysiodesis and/or ipsilateral lengthening
Anatomy
Medial clavicle ossification center
o appears during later teenage years
o last physis to close in body (20-25yrs)
sternoclavicular dislocations in
teenagers/young adults are usually
physeal fracture-dislocations
Imaging
Radiographs
o difficult to visualize on AP, and radiographs usually unreliable to assess for fracture and degree
of displacement
o obtain serendipity views ( beam at 40 deg cephalic tilt)
anterior dislocation/fxs - affected clavicle is above contralateral clavicle
posterior dislocation/fxs - affected clavicle is below contralateral clavicle
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Shoulder & Humerus Fractures
Axial CT scan
o is study of choice
o can differentiate from sternoclavicular dislocations
o can visualize mediastinal structures and injuries
Treatment
Nonoperative
o observation
controversial
most asymptomatic injuries will remodel and do not require intervention
anterior displaced physeal fracture
has good functional results treated nonoperatively
o closed reduction in operating room under anesthesia
indications
early posterior displaced physeal fx
hoarsness
blunt or direct trauma to subclavian vessels
thoracic outlet syndrome
pneumothorax
technique
approach : thoracic surgeon available
reduction
traction and abduction of arm, while applying direct pressure
posterior displaced fractures usually require sterile towel clip for manipulation
convert to open
if irreducible by closed means, consider open approach
postreduction
if stable - obtain CT to document
if unstable - open reduction with wire/suture from medial clavicle to sternum/medial
epiphysis
immobilization : figure of 8 harness or sling and swathe x 4 weeks (anterior displaced)
Operative
o open reduction
rarely needed
indications
unreducible and symptomatic in a patient > 23 yrs old
instability after reduction
Complications
Delay in reduction >48h
o reduces success of closed reduction
o because of progressive callus formation in dislocated state
Late presenting posterior displaced injuries
o do NOT attempt closed reduction because medial clavicle may be adherent to vascular structures
in mediastinum
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OrthoBullets2017 Pediatric trauma | Shoulder & Humerus Fractures
Presentation
Symptoms
o pain, dysfunction, ecchymosis in older children
Physical exam
o pseudo-paralysis of the affected ipsilateral extremity may be present in newborns
reflexes remain intact following isolated clavicle fractures, which can help differentiate from
brachial plexus injuries
Imaging
Radiographs
o obtain AP and serendipity view to help define injury
Treatment
Nonoperative
o sling management
indicated in most cases, especially if periosteum is
intact
a new clavicle will form within the intact periosteal
sleeve, and the displaced clavicle will typically
reabsorb with time and growth
Operative
o surgical reduction
indications (rarely indicated)
open fractures
severly displaced fractures in older patients with near closed physis
Anatomy
Radiographic appearance of secondary ossification centers
o proximal humeral epiphysis at 6 mos
o greater tuberosity appears at 1-3 yrs
o lesser tuberosity appears at 4-5 yrs
Growth
o Proximal humerus physis closes at 14-17 in girls, 16-18 in boys
80% of humerus growth comes from the proximal physis
highest proximal:distal ratio difference (femur is second with 30:70 proximal:distal ratio)
high remodeling potential (most fractures can be treated nonoperatively)
Classification
Neer-Horowitz Classification
Neer-Horowitz Classification
Type I • Minimally displaced (<5m)
Type II • Displaced < 1/3 of shaft width
Type III • Displaced greater than 1/3 and less than 2/3 of shaft width
Type IV • Displaced greater than 2/3 of shaft width
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Type 2 Type 4
Presentation
History
o identify any precipitating injury
Symptoms
o shoulder pain
o dysfunction
o deformity
o ecchymosis
Physical exam
o inspection of skin
o motion and tenderness of neck, ipsilateral sternoclavicular joint and
elbow VIII:8 Y view
o neurovascular examination
brachial plexus distribution
vascular examination of arm
Imaging
Radiographs
o standard views
obtain AP, lateral, and scapula Y or axillary views of
shoulder
o as needed views
hand or elbow for bone age
contralateral shoulder for comparison views VIII:9 Axillary view
o findings
stress fractures in athletes
glenohumeral dislocation (very rare with associated fracture)
assess maximum angulation of fracture displacement
identify pathologic fracture if present
Classify fracture type: newborn, acute fracture, stress fracture, pathologic fracture
Ultrasound
o ultrasound may be neccessary in newborns before secondary ossification centers are formed
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Shoulder & Humerus Fractures
Treatment
Nonoperative
o immobilization
indications
acceptable alignment for non-operative management
<10y = any degree of angulation
10-13y = up to 60° of angulation
>13y = up to 45° of angulation and 2/3 displacement
technique
immobilization modalities
sling + swathe
shoulder immobilizer
coaptation splint
o closed reduction under anesthesia/analgesia and fluoroscopy, without fixation
indications
severely displaced (>Neer-Horowitz III or >66%) with >45° angulation and <2y of
growth left
risk of loss of reduction
Operative
o open reduction and fracture fixation
indications
severely displaced fractures > 13 years old failed closed reduction
>Neer-Horowitz III (>66% displaced)
severely angulated fractures in > 9 year old failed closed reduction
open fractures in any age
fractures associated with vascular injuries
intra-articular displacement
techniques
closed reduction ± k-wire fixation
reduction maneuver
longitudinal traction
shoulder abduction to 90 degrees
external rotation
percutaneous pinning
two or three lateral threaded pins
starting point must consider branches of axillary nerve (lateral) and
musculocutaneous nerve (anterior)
ideally divergent pattern across fracture
open reduction ± k-wire fixation
indications
unacceptable closed reduction maneuver
blocks to reduction
long head of biceps tendon (most common)
joint capsule
infolded periosteum
deltoid muscle
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approach
deltopectoral interval
fixation methods
wire fixation (smooth or threaded)
cannulated screw
retrograde flexible nails
Complications
Loss of reduction
o risk factors
unstable fractures treated with closed reduction WITHOUT pinning
Axillary nerve Injuries
o occur in <1% of case due to injury alone
typically are neuropraxias
associated with a medially displaced shaft
o higher risk with percutaneous pinning
avoid lateral pin entry 5-7cm distal to acromion
Malunion
o varus malalignment, more common in younger patients
may cause glenohumeral impingement
Limb-length inequality
o fracture shortening
<3cm usually well tolerated
o growth arrest
usually rare
Hypertrophic scar
o deltopectoral approach with open reduction and fixation
Pin site infection
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Shoulder & Humerus Fractures
Associated conditions
o radial nerve palsy
associated with up to 5% of humeral shaft fractures
Prognosis
o excellent
associated with enormous remodeling potential and rarely requires surgical intervention
up to 30° of angulation is associated with excellent outcomes due to the large range of motion
of the shoulder
Presentation
Symptoms
o history of traumatic event
o pain
o upper arm deformity
Physical exam
o inspection
mid-arm swelling and deformity
open fractures rare
o palpation
tenderness to palpation
o motion
weakness or absence of wrist and digit extension if radial nerve palsy is present
pseudoparalysis
irritability or refusal to move upper limb in neonates
Imaging
Radiographs
o recommended views
full length AP, lateral views of humerus
must include joint above and below
o optional views
orthogonal views of shoulder and elbow
required to rule out associated injuries
o findings
typical fracture patterns are transverse and oblique
examine closely for pathologic lesions
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OrthoBullets2017 Pediatric trauma | Shoulder & Humerus Fractures
Treatment
Nonoperative
o analgesia, immobilization
indications
uncomplicated diaphyseal fracture without intra-articular involvement in a child of any
age
utilized for almost all pediatric humeral shaft fractures
techniques
sling and swathe or cuff and collar in young children
Coaptation splint or hanging arm cast
Sarmiento functional brace in older children/adolescents
ROM exercises can be initiated in 2-3 weeks once pain is controlled
Operative
o open reduction internal fixation
indications
open fractures
multiply injured patient
ipsilateral forearm fractures
"floating elbow"
associated shoulder injury
techniques
flexible intramedullary nail fixation
anterior, anterolateral or posterior approach with plate fixation
Complications
Radial nerve palsy
o occurs in <5%
most commonly associated with middle and distal 1/3 fractures
o typically due to a neuropraxia
o spontaneous resolution is expected
o exploration is rarely needed
if function has not returned in 3-4 months, EMGs are performed and exploration considered
Malunion
o rarely produces functional deficits, due to the wide range of motion at the shoulder
up to 30° of angulation is associated with excellent outcomes
Delayed union
o rare given the capacity to remodel
o may consider ultrasound bone stimulation
Limb length discrepancy
o commonly occurs, but rarely causes functional deficits
Physeal growth arrest
o proximal and distal humerus growth plates contributes 80:20 percent to overall humeral length
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Shoulder & Humerus Fractures
Classification
Salter Harris classification
o older children (>3y) have Salter Harris II injuries
metaphyseal piece attached to distal fragment
o younger children (<3y) have Salter Harris I injuries
pure physeal
o rare cases have intra-articular extension (Salter Harris III or IV)
Presentation
History
o birthing process (see above)
o fall from height (bed, chair, down stairs)
o another child jumps/falls on younger child's elbow
o suspect nonaccidental trauma if
unwitnessed injuries
inconsistent explanations
history of multiple injuries, burns, bites, bruising
Physical exam
o inspection
pseudoparalysis / diminished spontaneous movement
o neurovascular
rarely neurovascular compromise
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Imaging
Radiographs
o recommended views
AP and lateral centered on the elbow
"baby gram" (radiograph of entire extremity) often miss diagnosis
stress radiographs may be helpful to clarify the diagnosis
skeletal survey if child-abuse suspected
o findings
in infant only sign may be posteromedial displacement of the radial
and ulnar shafts relative to the distal humerus
forearm not aligned with humeral shaft
soft tissue swelling, joint effusion (posterior fat pad)
anterior fat pad may be absent
if capitellar ossification center is present, will be aligned with radius shaft, making diagnosis
definitive
Ultrasound
o indications
uncertain diagnosis
o advantage
no need for sedation
o findings
static exam
detect separation of epiphysis from
metaphysis by noting lack of
III:10 Magnetic resonance imaging
V
cartilage at distal humeral metaphysis demonstrates fracture through the
dynamic exam humeral physes with posterior
displacement of the cartilaginous
detect instability of epiphysis relative to metaphysis epiphysis (curved arrow) but intact
MRI articulation with radius and ulna
(arrow)
o disadvantage : requires sedation
Elbow arthrography
o indications : uncertain diagnosis
o findings
visualization of entire distal articular surface and proximal radius
o technique
posterolateral approach or direct posterior approach
direct posterior into olecranon fossa recommended in young children to prevent scuffing
of articular cartilage when posterolateral portal is used
inject equal parts saline:contrast
bring through range of motion
if pinning is needed, arthrogram aids visualization of pin starting points on capitellum
aids assessment of quality of reduction by seeing anterior humeral line intersecting
capitellum
o advantage
if performed under anesthesia in OR, can perform reduction and stabilization simultaneously
if needed
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Shoulder & Humerus Fractures
Differentials
Elbow dislocation
o almost never happens in <3 yrs because physis is weaker than bone-ligament interface,
predisposing to physeal fracture rather than ligament disruption/dislocation
Other fractures
o often misdiagnosed (or delayed diagnosis up to 1 week) as supracondylar, condyle, epicondyle
fractures
Treatment
Nonoperative
o limited role because most fractures are displaced
o posterior long arm splint then long arm casting x 2-3wk
indications
nondisplaced fractures
late presenting fractures
treat nonop initially
deformity will persist/develop, requiring osteotomy in future
Operative
o closed reduction and pinning
pinning is necessary to ensure adequate reduction, which may be lost with casting alone once
swelling subsides
indications
displaced fractures
Technique
Closed reduction and pinning
o general anesthesia
o reduction maneuver
gentle traction (very little force required)
distal fragment may sometimes be grasped between index finger and thumb and reduced
to humeral shaft
correction of translation/malrotation
elbow flexion
o use elbow arthrogram to aid
o parameters
no cubitus varus
anterior humeral line should bisect capitellum
no malrotation
o pinning
2 or 3 x 0.062inch K wires
these larger pins help prevent loss of reduction
from lateral side, retrograde fashion
divergent
engage both cortices
good spread at fracture site
o then perform live fluoroscopy through range of motion
o bend / cut pins, splint the arm
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o postop care
admit overnight 24h for IV antibiotics, observe for compartment syndrome
see 1 week postop
see 3 weeks postop with radiographs and remove pins in office
allow active ROM at that time
Complications
Cubitus varus
o up to 70% have this complication
more common than with supracondylar fractures
o cause
AVN of medial condyle
malunion (common because of missed diagnosis, or loss of reduction)
o treatment
lateral closing wedge osteotomy
Medial condyle AVN
Loss of motion
o usually no functional limitation
Growth disturbance
o progressive cubitus varus
o joint irregularities
o angular deformity
o limb-length discrepancy
o treatment
observe initially, undertake surgery when >5yo
larger extremity
child more cooperative
C. Elbow Fractures
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
the most common nerve palsy seen with supracondylar humerus fractures
radial nerve palsy
second most common neurapraxia (close second)
ulnar nerve palsy
seen with flexion-type injury patterns
nearly all cases of neurapraxia following supracondylar humerus fractures resolve
spontaneously, and therefore, further diagnostic studies are not indicated in the acute setting
o vascular injury (1%)
rich collateral circulation can maintain circulation despite vascular injury
o ipsilateral distal radius fractures
Anatomy
Ossification centers of elbow
o age of ossification/appearance and age of fusion are two independent events that must be
differentiated
e.g., internal (medial epicondyle) apophysis
ossifies/appears at age 6 years (table below)
fuses at age ~ 17 years (is the last to fuse)
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Classification
Gartland Classification
(may be extension or flexion type)
Nondisplaced, beware of subtle medial comminution leading to cubitus varus
Anterior periosteum detached from anterior humerus by up to 3cm (but not
Type I torn)
Treated with cast immobilization x 3-4wks, with radiographs at 1 wk, pull pins
at 3 wks
Displaced, posterior cortex and posterior periosteal hinge intact
IIA - no rotational deformity/fragment translation
Type II IIB - has rotational deformity/fragment translation (high risk of coronal/rotational
malalignment)
Treated with CRPP
Completely displaced, no cortical contact but has intact posterior periosteal
Type III hinge
Treated with CRPP
Complete periosteal disruption with instability in flexion and extension
Type IV*
Treated with CRPP
Collapse of medial column, loss of Baumann angle (leads to varus
Medial comminution* malunion/classic gunstock deformity)
in Type II
Treated with CRPP
Shear mechanism, oblique orientation, inherently unstable
Flexion type
Treated with CRPP
*not a part of original Gartland classification
**diagnosed intraoperatively when capitellum is anterior to AHL with elbow flexion and posterior with extension on
lateral XR
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
Presentation
Symptoms
o pain
o refusal to move the elbow
Physical exam
o inspection
gross deformity
swelling
bruising
o motion
limited active elbow motion
o neurovascular
nerve exam
AIN neurapraxia
unable to flex the interphalangeal joint of his thumb and the distal interphalangeal
joint of his index finger (can't make A-OK sign)
radial nerve neurapraxia
inability to extend wrist or digits may be present due to radial nerve injury
neurapraxia
vascular exam
vascular insufficiency at presentation is present in 5 -17%
defined as cold, pale, and pulseless hand
a warm, pink, pulseless hand does not qualify as vascular insufficiency
treat with immediate reduction and pinning in OR. Attempted closed reduction in ER first
(see treatment below)
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Imaging
Radiographs
o recommended views
AP and lateral x-ray of the elbow
o findings
posterior fat pad sign
lucency along the posterior distal humerus and olecranon fossa is highly suggestive of
occult fracture around the elbow
o measurement
displacement of the anterior humeral line
anterior humeral line should intersect the middle third of the capitellum
capitellum moves posteriorly to this reference line in extension type fracture
alteration of Baumann angle
Baumann's angle is created by drawing a line parallel to the longitudinal axis of the
humeral shaft and a line along the lateral condylar physis as viewed on the AP image
normal is 70-75°, but best judge is a comparison of the contralateral side
deviation of >5° indicates coronal plane deformity and should not be accepted
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Techniques
Closed reduction and percutanous pinning (CRPP)
o fixation
closed reduction (extension-type)
posteromedial fragments: forearm pronated with hyperflexion
posterolateral fragments: forearm supinated with hyperflexion
2 lateral pins
usually sufficient in most cases
test stability under fluoroscopy
technical pearls
maximize separation of pins at fracture site
engage both medial & lateral columns proximal to fracture
engage sufficient bone in proximal & distal segments
low threshold for 3rd lateral pin if concern about stability with 1st 2 pins
for difficult cases (type IV free floating segment)
place 2 parallel lateral pins initially in distal fragment as joysticks
rotate fluoro (not the patients arm) to obtain lateral image
after adequate reduction, advance distal pins into proximal fragment
add a 3rd pin
3 lateral pins
biomechanically stronger in bending and torsion than 2-pin constructs
indications (where 2 lateral pins are insufficient)
comminution
type IV (free floating distal fragment)
no significant difference in stability between three lateral pins and crossed pins
risk of iatrogenic nerve injury from a medial pin makes three lateral pins the construct
of choice
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
crossed pins
biomechanically strongest to torsional stress
higher risk of ulnar nerve injury (3-8%)
highest risk if placed with elbow in hyperflexion as ulnar nerve subluxates anteriorly
over medial epicondyle in some children
reduce risk of ulnar nerve injury by
placing medial pin with elbow in extension
use small medial incision (rather than percutaneous pinning)
remove pins postop at 3 weeks
these techniques reduce complication risk to equal to lateral-only pins
Complications
Pin migration
o most common complication (~2%)
Infection
o occurs in 1-2.4%
o typically superficial and treated with oral antibiotics
Cubitus valgus
o caused by fracture malunion
o can lead to tardy ulnar nerve palsy
Cubitus varus (gunstock deformity)
o caused by fracture varus malunion, especially in De Boeck medial comminution pattern
o usually a cosmetic issue with little functional limitations
Recurvatum
o common with non-operative treatment of Type II and Type III fractures
Nerve palsy from injury
o usually resolve
o extension type fractures
neuropraxia in 11%
most commonly AIN (34% of extension-type fracture nerve injuries)
mechanism = tenting of nerve on fracture, or entrapment in fracture site
o flexion type fractures
neuropraxia in 17%
most commonly cause ulnar neuropraxia (91% of flexion-type fracture nerve injuries)
Vascular Injury
o radial pulse absent on initial presentation in 7-12%
o pulseless hand after closed reduction and pinning (3-4%)
o decision to explore is based on quality of extremity perfusion, rather than absence of pulse
o arteriography is NOT indicated in isolated injuries
Volkmann ischemic contracture
o rare, but dreaded complication
o result of brachial artery compression with treatment utilizing elbow hyperflexion casting than
true arterial injury
increase in deep volar forearm compartment pressures and loss of radial pulse with elbow
flexed >90°
o rarely seen with CRPP and postoperative immobilization in less than 90°
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Postoperative stiffness
o rare after casting or after pinning procedures
remove pins and allow gentle ROM at 3 weeks postop
o resolves by 6 months
o literature does not support the use of physical therapy
Anatomy
Common flexor wad muscles of medial epicondyle include
o pronator teres
o flexor carpi radialis
o palmaris longus
o flexor digitorum superficialis
o flexor carpi ulnaris
Presentation
Symptoms
o medial elbow pain
Physical exam
o tenderness over medial epicondyle
o valgus instability
Imaging
Radiographs
o recommended views
AP and lateral of elbow
axial view is most accurate as medial epicondyle is located on the posteromedial aspect of the
distal humerus
especially because fragment displaces anteriorly
internal oblique views helpful
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
3D CT
o most accurate but radiation dose is 200x that of plain film
Treatment
Nonoperative
o brief immobilization (1 to 2 weeks) in a long arm cast or splint
indications
< 5mm displacement usually treated non-operatively, 5-15 mm remains controversial
often heal with fibrous union
fibrous union of the fragment is not associated with significant symptoms or diminished
function
Operative
o open reduction internal fixation
indications
absolute
displaced fx with entrapment of medial epicondyle fragment in joint
if medial condyle is involved (articular surface)
relative
ulnar nerve dysfunction
> 5-15mm displacement
displacement in high level athletes
Techniques
Open Reduction Internal Fixation
o approach
medial approach to elbow
incision is made directly over medial epicondyle
brachialis / triceps interval, ulnar nerve at risk
patient supine on table with arm abducted to 90 degrees and externally rotated
o technique
identify ulnar nerve and protect
reduce fracture
use cannulated screw for fixation
K-wires indicated for smaller fragments or in younger children
Complications
Nerve injury
o ulnar nerve can become entrapped
o neuropathy with dislocatoin which usually resolves
Missed incarceration
o missed incarceration of fragment in elbow joint
Elbow stiffness
o loss of elbow extension, avoid prolonged immobilization
Non-union
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OrthoBullets2017 Pediatric trauma | Elbow Fractures
Classification
Milch Classification-controversial
Type I Fracture line is lateral to trochlear groove (less common, elbow is stable as fracture
does NOT enter trochlear groove)
Type II Fracture line into trochlear groove (more common, more unstable)
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
Fracture Displacement Classification-Jakob et al.
Type 1 <2mm, indicating intact cartilaginous hinge Casting
Type 2 >2 mm < 4 displacement, intact articular cartilage on Open/closed reduction
arthrogram and fixation
Type 3 >2-4 mm, articular surface disrupted on arthrogram Open reduction and
fixation
Presentation
History
o fall onto an outstetched hand
Symptoms
o lateral elbow pain
o mild swelling
Physical exam
o inspection
exam may lack the obvious deformity often seen with supracondylar fractures
swelling and tenderness are usually limited to the lateral side
o motion
may have increased pain with resisted wrist extension/flexion
may feel crepitus at the fracture site
Imaging
Radiographs
o recommended views
AP, lateral, and oblique views of elbow
internal oblique view most accurately shows fracture displacement because fracture is
posterolateral
o optional views
contralateral elbow for comparison when ossification is not yet complete
routine elbow stress views are not recommended due to risk of fracture displacement
o findings
fracture fragment most often lies posterolateral which is best seen on internal oblique views
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Arthrogram
o indications
to assess cartilage surface when there is incomplete/absent epiphyseal ossification
allows dynamic assessment
CT scan
o indication
improved ability to assess the fracture pattern in all planes
o findings
CT has limited ability to evaluate the integrity of articular cartilage
may require sedation to perform the test
MRI
o indication
provides the ability to assess the cartilaginous integrity of the trochlea
o expensive
o require GA/sedation to perform the test
o arthrograms preferred to MRI
Differential
Pediatric Elbow Injury Frequency
Fracture Type % elbow injuries Peak Age Requires OR
Supracondylar fractures 41% 7 majority
Radial Head subluxation 28% 3 rare
Lateral condylar physeal fractures 11% 6 majority
Medial epicondylar apophyseal fracture 8% 11 minority
Radial Head and Neck fractures 5% 10 minority
Elbow dislocations 5% 13 rare
Medial condylar physeal fractures 1% 10 rare
Treatment
Nonoperative
o long arm casting x 6wks
indications
only if < 2 mm displacement (cartilaginous hinge most likely intact) (30-70% are
nondisplaced)
sub-acute presentation (>4 weeks)
technique
cast with elbow at 90 degrees and forearm supination
weekly follow up and radiographs every 3-7 days x first 3 weeks
total length of casting 6 weeks
Operative
o CRPP + 3-6 wks in above elbow cast
indications
somewhat controversial, but Weiss et al suggest fractures with < 4 mm of displacement
have intact articular cartilage and can be treated with CRPP
technique
closed reduction performed by providing a varus elbow force and pushing the fragment
anteromedial
divergent pin configuration most stable
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
third pin may be used in transverse plane to prevent fragment derotation
arthrogram used to confirm joint congruity
o open reduction and fixation + 3-6 wks in above elbow cast
open reduction (rather than closed) necessary to align joint surface
indications
if > 2-4mm of displacement
any joint incongruity
fracture non-union
technique
interval between the triceps and brachioradialis
avoid dissection of posterior aspect of lateral condyle (source of vascularization
implants
most fractures can be fixed with 2 percutaneous pins (3 if comminuted) in parallel or
divergent fashion
single screw for large fragments or non-union ± bone grafting
o supracondylar osteotomy
indications
deformity correction in late presenting cubitus valgus
Complications
Stiffness
o most common complication
Nonunion
o higher rate of nonunion than other elbow fractures
o normal radiographic union of lateral condyle fracture is 6wks
o risk
nonsurgical management
o mechanism
constant pull by extensors
intra-articular (synovial fluid impede fracture healing)
poor metaphyseal circulation to distal fragment
o prevent nonunion by
preserving soft tissue attachments to lateral condyle
stable internal fixation
o treatment
ORIF + bone grafting
AVN
o occurs 1-3 years after fracture
o posterior dissection can result in lateral condyle osteonecrosis (may also occur in the trochlea)
Malunion
o caused from delay in diagnosis and improper treatment
o 20% cubitus varus in nondisplaced/minimally displaced fractures
traumatic inflammation leads to lateral overgrowth (see spurring below)
o 10% cubitus valgus ± tardy ulnar nerve palsy
because of lateral physeal arrest as fracture is Salter Harris IV
o fishtail deformity
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area between medial ossification center and lateral condyle ossification center resorbs or fails
to develop
does NOT predispose to arthritis
may predispose to further fracture
o treatment
supracondylar osteotomy
Tardy ulnar nerve palsy
o slow, progressive ulnar nerve palsy caused by stretch in cubitus valgus
o usually late finding, presenting many years after initial fracture
Lateral overgrowth/prominence (spurring)
o up to 50% regardless of treatment, families should be counseled in advance III:11 Fishtail deformity
V
o lateral periosteal alignment will prevent this from occurring
o spurring is correlated with greater initial fracture displacement
Growth arrest with or without angular deformity
Unsatisfactory appearance of surgical scar
Late elbow presentation or deformity
o cubitus varus most common in nondisplaced and minimally displaced fractures
o cubital valgus less common, but more likely with significant deformities that cause physeal
arrest
o controversy whether to treat subacute fractures (week 3-12) nonoperatively or surgically
o most deformities can be corrected after skeletal maturation with a supracondylar osteotomy
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
Associated conditions
o osteogenesis imperfecta
olecranon fractures are highly suspicious for osteogenesis imperfecta
Anatomy
Ossification centers of elbow
o age of ossification/appearance and age of fusion are two independent events that must be
differentiated
olecranon apophysis
ossifies/appears at age 9 years
fuses at age ~ 15 -17 years
Olecranon ossification
o fusion of the epiphysis to the metaphysis of the olecranon occurs from anterior to posterior
o average age of closure is between the ages of 15-17 years old
o partial closure may be mistaken for olecranon fracture
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Presentation
History
o acute fall onto outstretched hand or direct elbow trauma
Symptoms
o pain
o swelling of posterior elbow
o inability to extend elbow
Physical exam
o inspection
swelling and deformity
contusion or abrasion over elbow may be suggestive of direct trauma
o palpation
crepitus
defect detected between fracture fragments
gapping may suggest a disruption in the posterior periosteum, which makes the fracture more
unstable
o movement
lack of active elbow extension
Imaging
Radiographs
o recommended views
AP and lateral xrays that should always be obtained on evaluation
o findings
fracture configuration (transverse, oblique, longitudinal)
intra-articular displacement
associated fracture (radial neck, medial/lateral condyle, distal radius, etc.)
Treatment
Nonoperative
o NSAIDS, rest, immobilization with avoidance of elbow resistance exercises
indications
partial stress fractures
outcomes
monitor until there is clinical improvement
convert to casting if needed
o long arm splint or casting
indications
minimally displaced fractures
integrity of posterior olecranon periosteum maintained
duration
3-4 weeks total
repeat imaging at 7-10 days to ensure no significant displacement
Operative
o ORIF
I ndications
displaced fractures
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
techniques
tension band wiring
AO technique with axial K-wires
congruent articular surface
consider early range of motion post-operatively
tension band suturing
use absorbable sutures (e.g. Number 1 polydioxanone (PDS) suture)
may combine with oblique cortical lag screw with PDS with metaphyseal fractures
plate and screws
considered with comminuted fractures with partially fused ossification centers
Complications
Nonunion
Delayed Union
Compartment syndrome
Ulnar nerve neurapraxia due to pseudarthrosis with inadequate fixation
Loss of Reduction
Elbow stiffness
Anatomy
There are 6 ossification centers around the elbow joint
o age of ossification is variable but occurs in the following order (C-R-I-T-O-E) at an average age
of (years)
Capitellum (1 yr.)
Radius (3 yr.)
Internal or medial epicondyle (5 yr.)
Trochlea (7 yr.)
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Olecranon (9 yr.)
External or lateral epicondyle (11 yr.)
Ossification center of radial head appears between and 3 and 5 years of age
o may be bipartite
o radial head fuses with radial shaft between ages of 16 and 18 years
Classification
Chambers Classification
Group 1: Primary displacement of radial Valgus Injury
head (most common) A: Salter-Harris I or II
B: Salter-Harris IV
C: metaphyseal
Elbow Dislocation
D: reduction injury
E: dislocation injury
Group 2: Primary displacement of radial neck Monteggia variant
Group 3: Stress injury Osteochondritis dissecans
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
Presentation
Symptoms
o elbow pain
o refusal to move
Physical exam
o inspection
lateral swelling
o motion
pain exacerbated by motion, especially supination and
pronation. VIII:13 AP and lateral of the elbow, radial
o must have high suspicion for forearm compartment syndrome head intersect capitellum in both views.
o pain may be referred to the wrist
Imaging
Radiographs
o recommended views
AP and lateral of the elbow
radiocapitellar (Greenspan) view
oblique lateral performed by placing the arm on the radiographic table with the elbow
flexed 90 degrees and the thumb pointing upward
The beam is directed 45 degrees proximally
o findings
nondisplaced fractures may be difficult to visualize
look for fat pads signs
a portion of the radial neck is extra-articular and
therefore an effusion and fat pads signs may be
absent.
Treatment
Nonoperative
o immobilization ± closed reduction
indications
most fractures can be treated closed
if < 30° angulation immobilize without closed reduction
if >30° angulation perform closed reduction and immobilize if angulation reduced to <
30°
followup
begin early ROM at 3-7 days to prevent stiffness
Operative
o operative percutaneous reduction
indications
> 30° of residual angulation
3-4 mm of translation
< 45° of pronation and supination
outcomes
improved outcomes with younger patients, lesser degrees of angulation, and isolated
radial neck fractures
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OrthoBullets2017 Pediatric trauma | Elbow Fractures
o open reduction
indications
fracture that cannot be adequately reduced with closed or percutaneous methods
outcomes
open reduction has been associated with a greater loss of motion, increased rates of
osteonecrosis and synostosis compared with closed reduction.
Techniques
Closed reduction
o reduction techniques
Patterson maneuver
hold the elbow in extension and apply distal traction with the forearm supinated and pull
the forearm into varus while applying direct pressure over the radial head
Israeli technique
pronate the supinated forearm while the elbow is flexed to 90° and direct pressure
stabilizes the radial head
elastic bandage technique
tight application of an elastic bandage beginning at the wrist continuing over the forearm
and elbow may lead to spontaneous reduction
Closed Reduction and Percutaneous Pinning
o reduction technique
K-wire joystick technique
Metaizeau technique
involves retrograde insertion of a pin/nail across the fracture site
fracture is reduced by rotating the pin/nail
Open reduction
o approach
performed with lateral approach (Kocher interval) to radiocapitellar joint
avoid deep branch of radial nerve
o fixation
avoid transcapitellar pins
internal fixation only used for fractures that are grossly unstable
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
Complications
Decreased range of motion
o loss of pronation more common than supination
Radial head overgrowth
o 20-40% of fractures
o usually does not affect function
Osteonecrosis
o 10-20% of fractures
o up to 70% of cases occur with open reduction
Synostosis
o most serious complication
o occurs in cases of open reduction with extensive dissection or delayed treatment
6. Nursemaid's Elbow
Introduction
Also known as subluxation of radial head
Epidemiology
o most common in children from 2 to 5 years of age.
Pathophysiology
o mechanism
caused by longitudinal traction applied to an extended arm
o pathoanatomy
caused by subluxation of the radial head and interposition of the annular (orbicular) ligament
into the radiocapitellar joint.
Presentation
Symptoms
o a child with radial head subluxation tends to hold the elbow in slight flexion and the forearm
pronated.
Physical Exam
o pain and tenderness localized to the lateral aspect of the elbow.
Imaging
Radiographs
o recommended views
not routinely indicated in presence of
classic history and physical examination
o findings
radiographs are normal
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Differential
Pediatric Elbow Injury Frequency & Treatment
Fracture Type % elbow injuries Peak Age Requires OR
Supracondylar fractures 41% 7 majority
Radial Head subluxation 28% 3 rare
Lateral condylar physeal fractures 11% 6 majority
Medial epicondylar apophyseal
fracture 8% 11 minority
Radial Head and Neck fractures 5% 10 minority
Elbow dislocations 5% 13 rare
Medial condylar physeal fractures 1% 10 rare
Treatment
Nonoperative
o closed reduction
indications
acute cases
Operative
o open reduction
indications
chronic injuries
VIII:14 reduction technique: supination > flexion > hyperpronation
Techniques
Closed reduction of radial head subluxation
o reduction techniques
reduction is performed by manually supinating the forearm and flexing the elbow past 90
degrees of flexion.
while holding the arm supinated the elbow is then maximally flexed
during this maneuver the physician’s thumb applies pressure over the radial head and a
palpable click is often heard with reduction of the radial head.
alternative technique includes hyperpronation of the forearm while in the flexed position.
o followup
immobilization is not necessary and the child may immediately resume use of the arm.
follow up is only needed if the child does not resume normal use of his arm in the following
weeks.
Complications
Recurrence
o occurs in 5% to 39% of cases, but generally ceases after 5 years of age.
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
relatively small coronoid process in children cannot resist proximal and posterior
displacement of ulna
Associated conditions
o traumatic
child abuse
high index of suspicion for child abuse
avulsion of the medial epicondyle
is the most common associated fracture
incarcerated intra-articular bone fragment may block reduction
fractures of proximal radius, olecranon and coronoid process
neurovascular injury
brachial artery and median nerve
may be stretched over displaced proximal fragment
ulnar nerve
at risk with associated medial epicondyle avulsions
most common neuropathy
o congenital
dislocation of radial head
VIII:16 avulsion of the
Classification medial epicondyle
Anatomic classification
o based on the position of the proximal radio-ulnar joint in relation to the distal humerus
o includes
posterior or posterolateral (most common)
anterior (rare)
medial
lateral
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Presentation
Symptoms
o painful and swollen elbow
o attempts at motion are painful and restricted
Physical exam
o inspection
elbow held in flexion
forearm appears to be shortened from the anterior and posterior view
o palpation
distal humerus creates a fullness within the antecubital fossa
o essential to perform neurovascular examination
Imaging
Radiographs
o required views
AP and lateral radiograph of elbow
comparison radiographs of the contralateral elbow may be helpful
o findings
look for fractures of medial epidcondyle, coronoid, proximal radius
high index of suspicion for transphyseal (distal humerus epiphyseal separation) fractures in
very young children (<3 years old)
Treatment
Nonoperative
o closed reduction, brief immobilization with early range of motion
indications
dislocation that remains stable following reduction
indicated in the majority of cases
reduction technique (see below)
brief immobilization
immobilization should be minimized to 1- 2 weeks to minimize risk of stiffness
early therapy
encourage early active range of motion
Operative
o open reduction
indications
open dislocation
incarcerated medial epicondyle or coronoid process in the joint
failure to obtain or maintain an adequate closed reduction
significant joint instability
Technique
Closed reduction technique
o closed reduction performed using gradual traction and flexion for posterior dislocations
o post-reduction films should be reviewed to rule out presence of entrapped bone fragment
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Elbow Fractures
Open reduction
o approach
depends on reason for blocked reduction
elbow medial approach
indicated if medial epicondyle avulsion with incarcerated fragment is blocking
reduction
Complications
Stiffness
o most common
due to prolonged immobilization
Heterotopic ossification
Neurologic injuries
o usually transient
o ulnar nerve most commonly affected
Loss of terminal flexion or extension
Chronic instability (recurrent dislocations)
VIII:17 incarcerated medial epicondyle in the joint
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OrthoBullets2017 Pediatric trauma | Forearm Fractures
D. Forearm Fractures
Anatomy
Normal rotational alignment
o relationship of bicipital tuberosity and radial styloid should be 180 degrees from each other on
the AP radiograph
o relationship of coronoid process and ulnar styloid should be 180 degrees from each other on the
lateral radiograph
Classification
Greenstick fractures
o are incomplete fractures
o can be described as apex volar or apex dorsal
Complete fractures
o are categorized the same as adults
Presentation
Symptoms
o forearm pain and deformity
Physical exam
o swelling and focal tenderness
o should assess for neurovascular injury
o should rule out compartment syndrome
o open fracture
can be subtle poke-holes, and can often be missed if not evaluated
by an orthopaedic surgeon
Imaging
Radiographs
o help to describe apex dorsal vs apex volar injuries
o can help judge forearm rotation deformity based on relationship of bicipital
tuberosity and radial styloid which are 180 degees apart on the AP
view
o ulnar styloid and coronoid are 180 degrees apart on the lateral view
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Forearm Fractures
Treatment
Table of Acceptable Reduction (Tolerances)
Bayonet
Age Angulation (°) Malrotation (°)
Apposition
0-9 years <15 <45 Yes, if <1cm short
≥10y, mid to distal shaft <15 <30 No
≥10y, proximal shaft <10 0 No
Approaching skeletal maturity (<2y No
0 0
growth remaining)
Nonoperative
o closed reduction and immobilization
indications
most pediatric forearm fractures can be treated without surgery
greenstick injuries
bayonet apposition ok if <10 years
followup VIII:18 example of
Bayonet Apposition
weekly radiographs for first 3-4 weeks to monitor reduction
casting for 6-12 weeks total
Short arm cast vs above elbow cast
short arm for distal 1/3 BBFA
above elbow immobilization for any fracture proximal to distal 1/3
Operative
o percutaneous vs open reduction and nancy nailing
absolute indications
unacceptable alignment following closed reduction
angulation >15°, rotation >45° in children <10y
angulation >10°, rotation >30° in children >10y
bayonet apposition in children older than 10 years
both bone forearm fractures in children> 13
relative indications
highly displaced fractures
technique
allows smaller dissection and advantage of a load-sharing device allowing rapid healing
fixation of one bone often sufficient stability
considerations
shorter surgical time than ORIF
less blood loss than ORIF
equal union rates, radial bow and rotation as ORIF
o open reduction and internal fixation
absolute indications
unacceptable alignment following closed reduction
open fractures
refractures
angulation >15° and rotation >45° in children <10y
angulation >10° and rotation >30° in children >10y
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bayonet apposition in children older than 10 years
both bone forearm fractures in children> 13
relative indications
highly displaced fractures
technique
same technique as an adult
Techniques
Closed Reduction
o steady three point bending of immobilization depending on fracture type
apex volar fractures (supination injuries)
may be treated and reduced by forearm pronation
apex dorsal fractures (pronation injuries)
may be treated and reduced by forearm supination
o greenstick both bone fractures
most pediatric greenstick both bone fractures can be temporarily reduced by placing the palm
in the direction of the deformity (pronate arm for supination injury with apex-volar
angulation of fracture)
Casting
o usually long arm cast x 6-8wks, possible conversion to short arm cast after 4wks depending on
fracture type and healing response
o no increased risk of loss of reduction with short arm vs. long arm casting
o loss of reduction is associated with increasing cast index (sagittal width/coronal width) >0.8
Complications
Refracture
o occurs in 5-10% following both bone fractures
o is an indication for an ORIF
Malunion
o loss of pronation and supination is common but mild
Compartment syndrome
o may occur due to high energy injuries
o may occur due to multiple attempts at reduction and rod passage
if unsuccessful nail passage after 2-3 attempts, open the fracture site to visualize rod passage
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Forearm Fractures
peak incidence occurring from:
10-12 years of age in girls
12-14 years of age in boys
most common fracture in children under 16 years old
Pathophysiology
o mechanism
usually fall on an outstretched hand
VIII:20 Salter-Harris I
often during sports or play
o remodeling
remodeling greatest closer to physis and in plane of joint
(wrist) motion
sagittal plane (flexion/extension)
Anatomy
Distal radius physis
o contributes 75% growth of the radius VIII:21 Salter-Harris II
o contributes 40% of entire upper extremity
o growth at a rate of ~ 5.25mm per year
Classification
Relation to distal physis
o Physeal considerations
o Salter-Harris I
o Salter-Harris II
o Salter-Harris III
o Salter-Harris IV VIII:22 Salter-
o Salter-Harris V Harris III
Metaphysis (distal) (62%)
o complete (Distal Radius fracture)
apex volar (Colles' fracture)
apex dorsal (Smith's fracture)
o incomplete (Torus/Buckle fracture)
typically unicortical
Diaphysis (20%)
o both bone forearm fracture
o isolated radial shaft fracture VIII:23 Buckle
fracture
o isolated ulnar shaft fracture
o plastic deformation
incomplete fracture with deforming force resulting in shape change of bone without clear
fracture line
thought to be due to a large number of microfractures resulting from a relatively lower force
over longer time compared to mechanism for complete fractures
o greenstick fracture
incomplete fracture resulting from failure along tension (convex) side
typically plastic deformation occurs along compression side
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Fracture with dislocation / associated injuries
o Monteggia fracture
ulnar shaft fracture with radiocapitellar dislocation
o Galeazzi fracture
radius fracture (typically distal 1/3) with associated DRUJ
injury, often dislocation
Presentation
History
o wide range of mechanism for children, often fall during play or
other activity VIII:24 Galeazzi fracture
o rule out child abuse
mechanism or history appears inconsistent with injury
multiple injuries, especially different ages
child's affect
grip marks/ecchymosis
Symptoms
o pain, swelling, and deformity
Physical exam
o gross deformity may or may not be present VIII:25 Monteggia fracture
o ecchymosis and swelling
o inspect for puncture wounds suggesting open fracture
o although uncommon, compartment syndrome and neurovascular injury should be evaluated for
in all forearm fractures.
Imaging
Radiographs
o recommended views
AP and lateral of wrist
AP and lateral of forearm
AP and lateral of elbow
o findings
in addition to fracture must evaluate for associated injuries
scapholunate joint
DRUJ
ulnar styloid
elbow injuries
CT
o indications
useful characterize fracture if intra-articular
however use sparingly in children given concerns regarding increased longitudinal effects of
radiation
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Forearm Fractures
Treatment
"Classically" Acceptable Angulation for Closed Reduction in Pediatric Forearm Radius Fractures
(controversial with ongoing discussion)
Shaft / Both bone fx Distal radius/ulna
Acceptable
Age Acceptable Angulations Malrotation* Dorsal Angulation
Bayonetting
< 9 yrs < 1 cm 15-20° 45° 30 degrees
> 9 yrs. < 1 cm 10° 30° 20 degrees
Bayonette apposition, or overlapping, of less than 1 cm, does not block rotation and is acceptable in patients less than 10
years of age.
General guidelines are that deformities in the plane of joint motion are more acceptable, and distal deformity (closer to distal
physis) more acceptable than mid shaft.
The radius and ulna function as a single rotational unit. Therefore a final angulation of 10 degrees in the diaphysis can block
20-30 degrees of rotation.
*Rotational deformities do not remodel and are increasingly being considered as not acceptable.
Nonoperative
o immobilization in short arm cast for 2-3 weeks without reduction
indications
greenstick fracture with < 10 deg of angulation
torus/buckle fracture
studies ongoing to treat minimally displaced or torus fractures with pre-fabricated
removable wrist splint, no cast
o closed reduction under conscious sedation followed by casting
indications
greenstick fracture with > 10-20 degrees of angulation
Salter-Harris I with unacceptable alignment
Salter-Harris II with unacceptable alignment
technique (see below) : reduction technique determined by fracture pattern
acceptable criteria (see table above)
acceptable angulations are controversial in the orthopedic community.
accepted angulation is defined on a case by case basis depending on
the age of the patient
location of the fracture
type of deformity (angulation, rotation, bayonetting).
outcomes
short-arm (SAC) vs long-arm casting (LAC)
good SAC (proper cast index = sagital/coronal widths) considered equal to LAC for
distal radius fractures
conservative treatment though often utilizes LAC to reduce impact of variable cast
technique/quality
no increased risk of loss of reduction with (good) short arm vs. long arm casting
cast index : loss of reduction is associated with increasing cast index
follow-up
all forearm fractures serial radiographs should be taken every 1 to 2 weeks initially to
ensure the reduction is maintained.
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Operative
o closed reduction and percutaneous pinning (CRPP)
indications
unstable patterns with loss of reduction in cast
Salter-Harris I or II fractures in the setting of NV compromise
CRPP reduces need for tight casting in setting with increased concern for
compartment syndrome
any fractures unable to reduce in ED but are successfully reduced under anesthesia in the
OR
o open reduction and internal fixation
indications
displaced Salter-Harris III and IV fractures of the distal radial physis/epiphysis unable to
be closed reduced
irreducible fracture closed
often periosteum or pronator quadratus block to reduction
Treatment Techniques
Closed Reduction
o timing
avoid delayed reduction of greater than 1 week after injury
for physeal injuries, generally limit to one attempt to reduce growth arrest
o reduction technique
gentle steady pressure for physeal reduction
for complete metaphyseal fractures re-create deformity to unlock fragments, then use
periosteal sleeve to aid reduction
traction can be counter-productive due to thick periosteum
Casting
o usually consists of a long arm cast (conservative approach) for 6 to 8 weeks with the possibility
of conversion to a short arm cast after 2-4 weeks depending on the type of fracture and healing
response.
may utilize well molded short arm cast with adequate cast index instead of long arm cast
initially
CRPP
o approach
avoid dorsal sensory branch of radial nerve, typically with small incision
o reduction
maintain closed reduction during pinning
o fixation
radial styloid pins
usually 1 or 2 radial styloid pins, entry just proximal to physis preferred
if stability demands transphyseal pin, smooth wires utilized
for intra-articular fractures, may pin distal to physis transversely across epiphysis
dorsal pins
may also utilize dorsal pin, especially to restore volar tilt
for DRUJ injuries, or severe fractures unable to stabilize with radial pins alone, pin across
ulna and DRUJ
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Forearm Fractures
o postoperative considerations
followup in clinic for repeat imaging to assess healing and position
pin removal typically in clinic once callus formation verified on radiograph
may consider sedation or removal of pins in OR for children unable to tolerate in clinic
must immobilize radio-ulnar joints in long arm cast if stabilizing DRUJ
may supplement with external fixator for severe injuries
Complications
Casting Thermal Injury
o thermal injury may occur if:
dipping water temperature is > 24C (75F)
more than 8 layers of plaster are used
during cast setting, the arm is placed on a pillow. This decreases the dissipation of heat from
the exothermic reaction
fiberglass is overwrapped over plaster
Malunion
o most common complication
Physeal arrest
o from initial injury or repeated/late reduction attempts
o isolated distal radial physeal arrest can lead to ulnocarpal impaction, TFCC injuries, DRUJ injury
o distal ulnar physis most often to arrest
Ulnocarpal impaction
o from continued growth of ulna after radial arrest
TFCC injuries
Neuropathy
o Median nerve most commonly affected
Classification
Bado Classification
Type I Apex anterior proximal ulna fracture with anterior dislocation of the radial head
Type II Apex posterior proximal ulna fracture with posterior dislocation of the radial head
Type III Apex lateral proximal ulna fracture with lateral dislocation of the radial head
Type IV Fractures of both the radius and ulna at the same level with an anterior dislocation of
the radial head (1-11% of cases)
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Bado type I
Imaging
Radiographs
o obtain elbow radiographs for all forearm fractures to evaluate for
radial head dislocation
assess radiocapitellar line on every lateral radiograph of the
elbow
a line down the radial shaft should pass through the center
of the capitellar ossification center
o obtain forearm radiographs for all radial head dislocations
Treatment
Nonoperative
o closed reduction of ulna and radial head dislocation and long
arm casting
indications
Bado Types I-III with
radial head is stable following reduction
length stable ulnar fracture pattern
reduction technique
reduction technique uses traction
radial head will reduce spontaneously with reduction of the ulna and restoration of
ulnar length
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Forearm Fractures
immobilization
immobilize in 110° of flexion and full supination for Types I and III to tighten
interosseous membrane and relax biceps tendon
Operative
o plating of ulna + reduction of radial head ± annular ligament repair/reconstruction
indications
Bado Types I-III with
radial head is not stable following reduction
ulnar length is not stable (unable to maintain ulnar length)
acute Bado Type IV
open fractures
older patients ≥ 10y
technique
annular ligament reconstruction almost never required for acute fractures
open reduction of radial head through a lateral approach if needed
o ulnar osteotomy and annular ligament reconstruction
indications
chronic (>2-3 weeks old) Monteggia fractures where radial head still retains concave
structure
symptomatic individuals (pain, loss of forearm motion, progressive valgus deformity)
who had delayed treatment or missed diagnosis
technique
reduce surgically within 6-12 months postinjury
o ORIF similar to adult treatment
indications : closed physes
Complications
Neurovascular
o posterior interosseous nerve neurapraxia (10% of acute injuries)
almost always spontaneously resolves
Delayed or missed diagnosis
o common when evaluation not performed by an orthopaedic surgeon
o complication rates and severity increase if diagnosis delayed >2-3 weeks
Anatomy
DRUJ
o osteology
possesses poor bony conformity in order to allow some translation with rotatory movements
o ligamentous
ligament structures are critical in stabilizing the radius as it rotates about the ulna during
pronation and supination
triangular fibrocartilage complex (TFCC) is a critical component to DRUJ stability
o biomechanics
the joint is most stable at the extremes of rotation
Presentation
Symptoms
o wrist and forearm pain
o radial deformity
o limitation of wrist motion
o ulnar head prominence or deformity can sometimes be seen
Physical exam
o pain with movement or palpation of the wrist
o DRUJ instability may be appreciated by local tenderness and instability to testing of the DRUJ
compare to contralateral side
o careful examination for nerve injury
Imaging
Radiographs
o required views
AP and true lateral radiographs
true lateral radiograph is essential in determining the direction of displacement
o additional views
contralateral radiographs often helpful for comparison
o findings
displaced distal radial shaft fracture
DRUJ disruption
may be subtle and radiographs must be scrutinized
additional signs of DRUJ instability include
ulnar styloid fracture
widened DRUJ on posteroanterior view
greater than or equal to 5mm radial shortening
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Forearm Fractures
Treatment
Nonoperative
o closed reduction with long arm casting
indications
indicated as first line of treatment
in younger patients (higher likelihood of successful nonoperative treatment than in
adults)
reduction
requires anatomic reduction of both the radius fracture and the DRUJ
immobilization : place in above elbow cast in supination
Operative
o open reduction internal fixation +/- DRUJ pinning
indications
unable to obtain anatomic closed reduction
irreducible DRUJ due to interposed tendon or periosteum
technique
radial fixation can be done with volar plate of flexible IMN (see below)
o ORIF, soft tissue reconstruction of DRUJ and TFCC, +/- corrective osteotomy
indications
chronic DRUJ instability (a rare consequence of a missed injury)
o corrective osteotomy with soft tissue reconstruction of DRUJ and TFCC
indications
DRUJ subluxation is caused by a radial malunion
a corrective osteotomy is also required in addition to reconstruction, otherwise a soft
tissue reconstruction of the DRUJ alone will fail
Technique
ORIF with volar plating, +/- DRUJ pinning
o approach
dorsal approach to DRUJ to remove interposed material if unable to obtain closed reduction
volar approach for ORIF(with plate)
o open reduction
irreducible DRUJ requires an open reduction to remove interposed material
reduction can be blocked by interposed
tendon
ECU most common interposed tendon
periosteum
o DRUJ stability
following fixation, test DRUJ
if unstable, pin ulna to radius in supination
if unstable with large ulnar styloid fragment, fix ulnar styloid and splint in supination
ORIF with flexbile intramedullary nailing, +/- DRUJ pinning
o approach
percutaneous (with IMN) of radius fracture
o open reduction : same as above
o DRUJ stability : same as above
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Complications
Malunion/nonunion
Chronic DRUJ instability
o chronic DRUJ instability (a rare consequence of a missed injury)
Superficial radial nerve plasy
o can be seen with IMN
Extensor pollicus longus
o can be seen with IMN
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Hip & Femur Fractures
apparent dislocations (symphyseal, SI) may have periosteal tube that heals like
fracture
lower rate of hemmorhage secondary to
smaller vessels, which are more capable of vasoconstriction
injuries less commonly increase pelvic volume than in adult
o acetabular fractures
only 1-15% of pelvis fractures
more common after triradiate closure
differences from adult
triradiate cartilage injury can cause growth arrest and lead to deformity
fractures into triradiate cartilage occur with less force than adult acetabular fractures
transverse fracture pattern more common than both column
classified using Letournel
Associated conditions
o CNS and abdominal visceral injury
high rate (> 50%) in traumatic pelvic injuries, presumed secondary to higher energy required
to create fracture
o femoral head fractures/dislocations
associated with acetabular fractures
o GU injury
increased rate with Torode Type IV fractures
o life threatening hemmorhage
Prognosis
o complications are rare
o need for operative intervention increases after closure of triradiate cartilage
Anatomy
Pelvis undergoes endochondral ossification (like long bones) at 3 primary ossification centers
o ilium appears at 9 wks
o ischium appears at 16 wks
o pubis appears at 20 wks
all meet and fuse at 12yr in girls, 14yr in boys
Acetabular growth
o enlargement is a result of interstitial growth within triradiate cartilage
o concavity is a response to pressure from femoral head
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o depth of acetabulum results from
interstitial growth in acetabular cartilage
appositional growth in periphery of cartilage
periosteal new bone formation at acetabular margin
Puberty
o 3 secondary ossification centers of the acetabulum appear at 8-9yr and fuse at 17-18yr
os acetabuli (OA, forms anterior wall)
acetabular epiphysis (AE, forms superior acetabulum)
secondary ossification center of ischium (SCI, forms posterior wall)
o other secondary ossification centers (of the pelvis)
do not confuse with avulsion fractures
iliac crest
appears at 13-15y, fuses at 15-17y
used in Risser sign
ischial apophysis
appears at 15-17y, fuses at 19-25y
anterior inferior iliac spine
appears at 14y, fuses at 16y
pubic tubercle
angle of pubis
ischial spine
lateral wing of sacrum
Classification
Tile Classification
Type A • Stable injuries (rotationally & vertically)
Type B • Rotationally unstable
• Vertically stable
Type C • Unstable rotationally & vertically
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Hip & Femur Fractures
Torode/Zieg Classification (pediatric pelvic ring)
Presentation
History
o pediatric pelvic ring fractures often occur secondary to motor vehicle accidents or when a
pedestrian is struck by a motor vehicle
o pelvic avulsion injuries often occur during sporting activities such as sprinting, jumping or
kicking
Physical exam
o as in all trauma patients, initial evaluation should include ABC's followed by primary and
secondary surveys
o important to thoroughly complete a rectal/genitourinary evaluation in polytrauma patient
Imaging
Radiographs
o recommended views
AP
Judet views (45 degree internal and external oblique views, to better evaluate the
acetabulum),
Inlet/Outlet views (35 degree caudal and cranial tilt views, to better evaluate integrity of the
pelvic ring)
o sensitivity
plain radiographs will miss ~50% of all pediatric pelvic fractures
CT
o indications
negative plain films with increased suspicion
preoperative evaluation
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MRI
o indications
occasionally required to detect apophyseal avulsion injuries
apophyseal avulsion injuries are usually easily detected and adequately imaged with plain
radiographs
Treatment
Nonoperative
o protected weight bearing followed by therapy
indications
pelvic ring
dislocations of symphysis and SI joint
potential for periosteal healing
Type I Avulsion Injuries with < 2 cm displacement
Type II Iliac Wing Fractures with < 2 cm displacement
Type III pelvic ring fractures without segmental instability and non-displaced
acetabulum
acetabulum
few indications for non-op treatment
results often poor, especially with comminution, joint incongruity
if non-op chosen, needs close followup for 1-2yr to detect premature triradiate closure
technique
for Type I and II
protected weight bearing for 2-4 weeks
stretching and strengthening 4-8 weeks
return to sport and activity after 8 weeks and asymptomatic
Type III
weight bearing as tolerated for 6 weeks
o bedrest
indications : Type IV pelvic ring with instability AND < 2 cm pelvic ring displacement
Operative
o ORIF
principles
physis sparing where possible
where not possible, smooth pins across physis (especially triradiate) x 4-6wks with early
removal
indications
pelvis
Type I Avulsion Injuries with > 2-3 cm displacement
Type II Iliac Wing Fractures with > 2-3 cm displacement
Type III pelvic ring with displaced acetabular fractures > 2mm
Type IV pelvic ring with instability and > 2 cm pelvic ring displacement
acetabulum
comminuted acetabular fracture when traction does not improve position of fragments
joint displacement >2mm
joint incongruity
joint instability (persistent medial subluxation or posterior subluxation)
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Hip & Femur Fractures
central fracture dislocation
intra-articular fragments
open fractures
o temporizing external fixation followed by ORIF
indications
vertical shear with hemodynamic instability
Presentation
Symptoms
o pain, inability to bear weight
Physical exam
o posterior dislocation (most common)
slight flexion, adduction, and internal rotation of the limb
clinical limb length discrepancy
if large posterior wall acetabular fracture, can appear shortened without malalignment
o anterior dislocation
flexion, abduction, and external rotation
o neurovascular exam
check for sciatic or gluteal nerve palsy (rare)
Imaging
Radiographs
o recommended views
ap and lateral
VIII:29 post reduction xray of hip
most can be diagnosed on AP pelvis films dislocation showing medial joint space
lateral hip radiographs will confirm anterior vs posterior widening due to non concentric
reduction
dislocation
post reduction films
post-reduction radiographs are necessary to confirm concentric reduction
o findings
radiographs must be scrutinized in order to inspect for joint incongruity or nonconcentric
reduction
CT
o indications
post-reduction CT scan is utilized to further evaluate for any entrapped
osteochondral fragment
o findings
inspect for joint incongruity or nonconcentric reduction
entrapped labrum or capsule can produce a subtle asymmetry VIII:30 osteochondral
interposed soft-tissue can be difficult to appreciate on CT scan fragment
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Hip & Femur Fractures
osteochondral fragments can be seen in older children and are easily detected by CT
a non-concentric reduction requires exploration to remove entrapped labrum, capsule,
osteochondral fragment or ligamentum teres
MRI
o best for evaluating interposed soft tissue
Treatment
Nonoperative
o closed reduction under general anesthesia with fluoroscopy
indications
urgent attempt at closed reduction is first line treatment
most are successful reduced with closed means (85%)
Operative
o open reduction
indications
nonconcentric reduction
intra-articular fragment
unstable acetabular rim fracture
irreducible by closed means
technique
surgical approach is typically performed in direction of dislocation (most commonly
posterior)
Techniques
Closed reduction technique
o reduction
adequate anesthesia or sedation during reduction is mandatory in order to decrease the risk of
displacing the proximal femoral epiphysis
reduction under fluoroscopy has been recommended to decrease risk of displacement
o post-reduction
test hip stability before weaning sedation
obtain post-reduction imaging
some advocate spica cast in younger children or bracing in older children with 6 weeks
protected weight-bearing on crutches
Complications
Osteonecrosis
o reported in 3-15%
o less frequent than in adults if there is an absence of an associated femoral neck fracture
o if present, thought to be related to delayed reduction
Coxa magna
o common radiographic finding (20%)
o not associated with functional limitation
Redislocation
o rare sequela
o treatment
prolonged immobilization
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if recurrent and recalcitrant to immobilization: capsulorrhaphy
treatment based on age of patient and time elapsed since injury
Nerve injury
o sciatic or gluteal nerve injury can occur, usually resolves with prompt reduction
Anatomy
Growth centers of the proximal femur
o proximal femoral epiphysis
accounts for 13-15% of leg length
accounts for 30% length of femur
proximal femoral physis grows 3 mm/yr
entire lower limb grows 23 mm/yr
o trochanteric apophysis
traction apophysis
contributes to femoral neck growth
disordered growth
injury to the GT apophysis leads to shortening of the GT and coxa valga
overgrowth of the GT apophysis leads to coxa vara
Vascularity
o medial femoral circumflex artery
main blood supply to the head via the posterosuperior lateral epiphyseal branch and via
posteroinferior retinacular branch
becomes main blood supply after 4 years after regression of LFCA and artery of ligamentum
teres
o lateral femoral circumflex artery
regresses in late childhood
o artery of the ligamentum teres
diminishes after 4 years old
o metaphyseal vessels
also contribute to blood supply to the head < 3 years old and after 14-17years
between 3 to 14-17 years, the physis blocks metaphyseal supply
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Hip & Femur Fractures
after 14-17 years, anastomoses between metaphyseal-epiphyseal vessels develop
Neurovacular
o superior gluteal nerve (L5, S1, S2)
gluteus medius and gluteus minimus
Classification
Delbet Classification
Type Description Incidence AVN Nonunion
Type I Transphyseal (IA, without dislocation of <10% 38% (AVN 100%
epiphysis from acetabulum; IB, with in type IB)
dislocation of epiphysis)
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Imaging
Radiographs : AP pelvis and cross-table lateral
CT : for nondisplaced fractures and stress fractures
MRI : for nondisplaced fractures and stress fractures
Treatment
Nonoperative
o spica cast in abduction, weekly radiographs for 3wks
indications
Type IA, II, III, IV, nondisplaced, <4yrs
evaluate Type IA fractures for child abuse
Operative
o emergent ORIF, capsulotomy, or joint aspiration
indications
open hip fracture
vessel injury where large vessel repair is required
concomitant hip dislocation or significant displacement, especially type I
may decrease the rate of AVN (supporting data equivocal)
o closed reduction internal fixation (CRIF)/ percutaneous pinning (CRPP)
indications
Type II, displaced
postop spica (abduction and internal rotation) x 6-12wk
Type III and IV, displaced and older children
o open reduction and internal fixation (ORIF)
indications
Type IB
o pediatric hip screw / DHS
indications
Type IV
Techniques
Emergent reduction and capsulotomy
o timing of reduction
early reduction (<24h) may diminish risk of AVN by restoring
blood flow through kinked vessels
o reduction technique
radiolucent table for 0-10 years
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Hip & Femur Fractures
open capsulotomy through anterior incision
Closed reduction and percutaneous pinning (CRPP)
o reduction technique : see above
o fixation
smooth or threaded pins / K wires (use 2-3 pins or wires)
indications
younger patients
transphyseal
recommended when there is little metaphyseal bone available
cannulated screws
indications
short of the physis
less stable than transphyseal
for patients <4-6yrs
transphyseal
older patients close to skeletal maturity (>12yrs old)
where crossing the physis is necessary to achieve stable fixation
it is easier to treat leg length discrepancy from premature physeal closure than
nonunion
place within 5mm of subchondral bone
avoid anterolateral quadrant of epiphysis and posterior perforation of femoral neck
to prevent injury to vasculature
Closed reduction and internal fixation (CRIF)
o indications
type IV
appropriate if immediately available
o implants
pediatric hip screws
Open reduction and internal fixation (ORIF)
o approach
anterolateral (Watson-Jones) for types I, II, III
lateral (Hardinge) for type IV
Complications
AVN
o most common complication
VIII:32 Avascular necrosis (AVN)
risks = age + fracture type
most susceptible age = 3-8 years
highest for Delbet type I (nearly 100% for Delbet type IB)
o etiology
kinking/laceration of vessels
tamponade by intracapsular hematoma
o treatment
core decompression
vascularized fibular graft
Coxa vara (neck-shaft angle <130°) VIII:33 Coxa vara
o 2nd most common complication
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o more common if fracture is treated non-operatively
o more common for types I, II and III
incidence 25% for type III
o treatment
young patients (0-3yrs) will remodel
surgical arrest of trochanteric apophysis
indication
coxa vara in <6-8yrs
only works in younger patient
subtrochanteric or intertrochanteric valgus osteotomy
indication
coxa vara + nonunion
coxa vara with severe Trendelenburg limp or FAI signs and
symptoms
for the older patient
Nonunion
o can occur together with coxa vara (see above)
o etiology
nonoperative treatment of Type II or III
occult infection at fracture site
severe AVN of proximal femur VIII:34 Nonunion
malreduced fracture
o treatment
subtrochanteric or intertrochanteric valgus osteotomy
Coxa valga
o Type IV fractures involving GT in younger patient may have
premature GT apophysis closure, leading to coxa valga
Physeal arrest
o physeal arrest alone leads to <1.5cm leg length discrepancy
only in very young children
proximal femoral physis contributes to 15% of limb length
(3mm/yr)
Limb length discrepancy
o significant LLD occurs in combined AVN + physeal arrest
o treatment
shoe lift if projected LLD at skeletal maturity <2cm
epiphysiodesis of contralateral distal femur ± proximal tibia if projected LLD at skeletal
maturity 2-5cm
Chondrolysis
o usually associated with AVN
o etiology
poor vascularity to femoral head cartilage
persistent hardware penetration of joint
o presents as restricted hip motion, hip pain, radiographic joint space narrowing
Malreduction
o common with subtrochanteric fractures
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Hip & Femur Fractures
deforming forces on proximal fragment
displaced into flexion, abduction, and external rotation
Infection
o <1% incidence
o after ORIF or CRPP
o treatment
debridement, maintain fixation until union
o may lead to osteomyelitis, AVN, chondrolysis, premature physeal closure
Classification
Descriptive classification
o characteristics of the fracture
transverse
comminuted
spiral etc.
o integrity of soft-tissue envelope
open
closed fracture
Stability
o length stable fractures
are typically transverse or short oblique
o length unstable fractures
are spiral or comminuted fractures
Presentation
Symptoms : thigh pain, inability to walk, report of deformity or instability
Physical exam : gross deformity, shortening, swelling of the thigh
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Imaging
Radiographs
o AP and lateral of femur
typically allow complete evaluation of the fracture location, configuration and amount of
displacement
o ipsilateral AP and lateral of knee and hip
required to rule out associated injuries
Treatment
Based on age and size of patient and fracture pattern
Guidelines provided by AAOS
Treatment Guidelines
< 6 months Any fx pattern Pavlik harness
Early spica casting
7m - 5 years < 2 - 3 cm shortening Early spica casting
Surgical Technqiues
Pavlik harness
o indications
children up to 6 mos.
o technique
avoids the need for sedation or anesthesia
straps can be adjusted to manipulate fracture VIII:35 Spica cast
VIII:36 Pavlik harness
o complications
can compress femoral nerve if excessive hip flexion is used in presence of a swollen thigh
identified by decreased quadricep function
Immediate spica casting
o fewer complications than traction + later casting
o indications
children 7 m - 5 years with < 2 - 3 cm of shortening
relatively contraindicated with polytrauma, open fractures and shortening > 2-3 cm
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Hip & Femur Fractures
o technique
applied with reduction under sedation or with GA
single-leg spica or one-and-one-half spica (to control rotation)
the exception is distal femoral buckle fracture (stable) only requires long leg cast (not
spica)
hips flexed 60-90° and approximately 30° of abduction
knees in 90° of flexion
MUST limit compression and/or traction thru popliteal fossa
external rotation is typically needed to correct rotational deformity
molds along the distal femoral condyles and buttocks help to maintain reduction
acceptable limits are based on childs age
goal of reduction should include obtaining < 10° of coronal plane and < 20° of sagittal
plane deformity with no more than 2cm of shortening or 10° of rotational malalignment
a special car seat is needed for transport
o follow-up
weekly radiographs to monitor for loss of reduction for first 2 to 3 weeks
cast wedging can be used to correct deformities
healing times vary from 4 - 8 weeks based on age
o complications
compartment syndrome
decreased with applying smooth contours around popliteal fossa, limiting knee flexion to
< 90° and avoiding excessive traction
monitored for by observing the child's neurovascular exam and level of comfort
Traction + delayed spica casting
o indications
children 7 mos. - 5 yrs. of age with > 2 - 3 cm of shortening
o technique
placed in distal femur proximal to distal femoral physis
proximal tibial traction can cause recurvatum due to damage to the tibial tubercle
apophysis
used for 2-3 weeks to allow early callus formation
spica casting then applied until fracture healing
o complications
more complications than immediate spica casting
Flexible intramedullary nails
o indications
treatment of choice for most simple, length stable fracture patterns in children 6 - 10 years
adolescent patient weighing less than 100 lbs with a length stable fracture
o technique
allows load sharing and quick moblization of the patient
nail size determined by multiplying width of narrowest portion of femoral canal by 0.4
the goal is 80% canal fill
two nails of equal size are inserted retrograde beginning approximately 2 -2.5 cm above the
distal femoral physis
o follow up : time to union is typically 10 - 12 weeks
removal of the nail can be performed at 1 year
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o complications
most common complication is pain at insertion site near the knee
in up to 40% of patients
recommended that < 25mm of nail protrusion and minimal bend of the nail outside the
femur are present
Complications
Leg-Length Discrepancy
o overgrowth
0.7 - 2 cm is common in patients between of 2 - 10 years at time of fracture
typically presents within 2 years of injury
o shortening
is acceptable if less than 2 - 3 cm because of anticipated overgrowth
can be symptomatic if greater than 2 - 3 cm
temporary traction or internal fixation used to prevent persistent shortening
Osteonecrosis (ON) of femoral head
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o reported with both piriformis and greater trochanter entry nails
o femoral nailing through the piriformis fossa is contraindicated in adolescents with open physes
because of the risk of osteonecrosis of femoral head
o main supply to femoral head is deep branch of the medial femoral circumflex artery
branches into superior retinacular vessels that supply the femoral head
vulnerable as it lies near the piriformis fossa
Nonunion
o higher risk with load bearing devices
external fixator or submuscular plates
o can occur after flexible intramedullary nailing in patients
aged over 11 years old
who weigh >49 kg (>108 lb)
Malunion
o typical deformity is varus + flexion of the distal fragment
o remodeling is greatest in sagittal plane (ie flexion/extension deformity)
o rotational malalignment does not remodel
must be corrected at the initial surgery
rarely symptomatic
Refracture
o most common after external fixator removal with varus malalignment
o highest risk in transverse and short oblique fractures
less likelihood of secondary callus formation
Anatomy
Physeal considerations of the knee
o general assumptions
leg growth continues until
16 yrs in boys
14 yrs in girls
o growth contribution
leg grows 23 mm/year, with most of that coming from the knee (15 mm/yr)
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Hip & Femur Fractures
proximal femur - 3 mm / yr (1/8 in)
distal femur - 9 mm / yr (3/8 in)
proximal tibia - 6 mm / yr (1/4 in)
distal tibia - 5 mm / yr (3/16 in)
Presentation
Symptoms
o unable to bear weight
Physical exam
o pain and swelling
o tenderness along the physis in the presence of a knee effusion
o may see varus or valgus knee instability on exam
Imaging
MRI or ultrasound
o indications
diagnositic modality of choice to confirm physeal fracture
Radiographs
o Standard AP, lateral, and oblique radiographs of the knee should be done as initial evaluation
o indications
follow up radiographs after 2-3 weeks of casting if physeal injury is likely but not identifiable
on injury films initially
stress radiographs to look for physis opening if there was suspicion of physeal injury
have fallen out of favor due to patient discomfort and possible need for sedation in order
to properly stress the knee
Treatment
Nonoperative
o long leg casting
indications
stable nondisplaced fractures
close clinical followup is mandatory
Operative
o closed reduction and percutaneous pinning followed by casting
indications
displaced Salter-Harris I or II fractures
displaced fractures successfully reduced with closed methods should still be pinned
(undulating physis makes unstable following reduction)
technique
avoid multiple attempts at reduction
avoid physis with hardware if possible
if physis must be crossed (SH I and SH II with small Thurston-Holland fragments),
use smooth k-wires
SH II fracture, if possible, should be fixed with lag screws across the metaphyseal segment
avoiding the physis
postoperatively follow closely to monitor for deformity
o ORIF
indications
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Salter-Harris III and IV in order to anatomically reduce articular surface
irreducible SHI and SHII fractures
reduction often blocked by periosteum infolding into fracture site
techniques
If anatomic reduction cannot be obtained via closed techniques, incision over the
displaced physis to remove interposed periosteum is necessary.
Complications
Limb length discrepancy or angular deformity (most common)
o results from physeal disturbance
o correlates with fracture pattern
36% of SH 1 fractures
58% in SH 2 fractures
49% in SH 3 fractures
64% in SH 4 fractures
o prevent with
anatomic physeal alignment (critical)
close follow up following nonoperative or operative treatment
o treatment
physeal bridge excision
indication
deformity is present with a physeal bar of <50% and ≥ 2 years or 2 cm of growth
remaining
Popliteal artery injury
o rare and more common with anterior displacement of epiphysis
o most common with anterior, or posteriorly, displaced fracture patterns
Collected By : Dr AbdulRahman
AbdulNasser
June 2017
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Knee & Proximal Tibia
Anatomy
Osteology
o tibial eminence
non-articular portion of the tibia between the medial and lateral tibial plateau
Ligaments
o anterior cruciate ligament
inserts 10-14 mm behind anterior border of tibia and extends to medial and lateral tibial
eminence
Classification
Modified Meyers and McKeever Classification
Type I Nondisplaced (<3mm)
Type II Minimally displaced with intact posterior hinge
Type III Completely displaced
Type III+ Type III fracture with rotation
Type IV Completely displaced, rotated, comminuted
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OrthoBullets2017 Pediatric trauma | Knee & Proximal Tibia
Presentation
Symptoms
o pain in knee
Physical exam
o inspection
immediate knee effusion
o ROM
often limited secondary to pain
once pain is controlled, lack of motion may indicate
meniscal pathology
displaced/entrapped fracture fragment
positive anterior drawer
Imaging
Radiographs
o recommended views
standard knee radiographs
CT
o useful for pre-operative planning
MRI
o better at determining associated ligamentous/meniscal damage than CT or radiographs
Treatment
Nonoperative
o closed reduction, aspiration of hemarthrosis, immobilization in 0-20° of flexion
indications
non-displaced type I and reducible type II fractures
reduction maneuver = extend the knee to 20° short of full extension to observe for fragment
reduction
Operative
o ORIF vs. all-arthroscopic fixation
indications
Type III or Type II fractures that cannot be reduced
block to extension
Sugical Techniques
Arthroscopic fixation
o approach
standard arthroscopic portals
o technique
debride fracture
disengage entrapped meniscus or intermeniscal ligament
medial meniscus entrapment most common
reduce fracture
fracture fixation
suture fixation
pros
avoids physis
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Knee & Proximal Tibia
cons
technically demanding
screw fixation
pros
less demanding than suture fixation
possibly earlier mobilization
cons
hardware irritation
impingement from improperly placed screw
physeal damage
o post-operative care
early range of motion
length of limited weight bearing is controversial
Open fixation
o same principles as arthroscopic
Complications
Arthrofibrosis
o more common with surgical reconstruction
Growth arrest
ACL laxity
o incidence
10% of knees managed surgically
20% of knees managed non-operatively
o often not clinically significant
Anatomy
Osteology
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OrthoBullets2017 Pediatric trauma | Knee & Proximal Tibia
o proximaltibia has two ossification centers
primary ossification center (proximal tibial physis)
secondary ossification center (tibial tubercle physis or apophysis)
insertion of patellar tendon
physeal closure occurs from posterior to anterior and proximal to distal
places distal secondary center at greater risk of injury in older children
Muscles
o extensor mechanism can exert great force at secondary ossification center
Blood Supply
o recurrent anterior tibial artery can be torn with these injuries
Classification
Ogden Classification (modification of Watson-Jones)
Type I fracture of the secondary ossification center near the insertion of the patellar tendon
Type II fracture propagates proximal between primary and secondary ossification centers
Type III coronal fracture extend posteriorly to cross the primary ossification center
Modifier: A (nondisplaced), B (displaced)
Newer descriptions have been added to the original system
o Type IV is a fracture through the entire proximal tibial physis
o Type V is a periosteal sleeve avulsion of the extensor mechanism from the secondary ossification
center
Presentation
Symptoms
o sudden onset of pain
generally occurs during the initiation of jumping or sprinting
o extensor mechanism deficiency or lag with Type 2 and 3 injuries
o knee swelling
hemarthrosis with Type 3 injuries
Physical exam
o inspection & palpation
swelling at the knee
tenderness at the tibial tubercle
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Knee & Proximal Tibia
evaluate for anterior compartment firmness
o ROM & instability
extensor lag or extensor deficiency in Type 2 or 3 injuries
o neurovascular exam
monitor for increasing pain suggestive of compartment syndrome
Imaging
Radiographs
o recommended views
required
lateral of the knee
optional VIII:37 Ogden type IIIB
internal rotation view will bring the tibial tubercle into profile
consider contralateral knee views in pediatric fractures
o findings
widening or hinging open of the apophysis
fracture line may be seen extending proximally and variable distance posteriorly
anterior swelling may be the only sign in the setting of a periosteal sleeve avulsion (type 5
injury)
evaluate for possible patella alta
CT
o can be useful to evaluate for intra-articular or posterior extension
o arteriogram can be helpful if concern for anterior tibial artery injury
should not delay intervention in setting of compartment syndrome
MRI
o generally not indicated
o useful for determining fracture extension in a nondisplaced Type 2 injury
Treatment
Nonoperative
VIII:38 Ogden type IV B
o long leg cast in extension for 4-6 weeks
indications
usually Type 1 and 2 injuries
minimal displacement (< 2 mm)
acceptable displacement after closed reduction
Operative
o closed reduction and percutaneous fixation vs open reduction internal fixation
indications : Type 1, 2, and 4 fractures
o open reduction with arthrotomy and internal fixation
indications : Type 3 fractures - need to visualize joint surface for perfect reduction
o open reduction and soft tissue repair
indication
Type 5 (periosteal sleeve) fractures
Techniques
Closed reduction and percutaneous fixation
o approach
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OrthoBullets2017 Pediatric trauma | Knee & Proximal Tibia
closed reduction often done under anesthesia
percutaneous clamping
o technique
internal fixation with 4.0 cancellous partially threaded screws
larger screws can cause soft tissue irritation in the long-term
smooth K wires for younger child (>3y from skeletal maturity)
o postoperative care
immobilization
long leg cast or brace for 4-6 weeks
prolonged immobilization needed in Type 2 and 3 injuries
non-weight bearing
rehabilitation
progressive extensor mechanism strengthening
return to sports no sooner than 3 months
pros & cons
pros
no open reduction
excellent healing potential
cons
inability to clean fracture site or remove soft tissue interposition
hardware irritation can necessitate implant removal
Open reduction and internal fixation
o approach
midline incision to the fracture site
o technique
evaluate and clean fracture site
remove any soft tissue interposition (periosteum)
anatomic reduction of fracture fragments
internal fixation with 4.0 cancellous, partially threaded screws
larger screws can cause soft tissue irritation in the long-term
smooth K wires for younger child (>3y from skeletal maturity)
o postoperative care
immobilization
long leg cast or brace for 4-6 weeks
prolonged immobilization needed in Type 2 and 3 injuries
non-weight bearing
rehabilitation
progressive extensor mechanism strengthening
return to sports no sooner than 3 months
pros & cons
pros
anatomic reduction and stable fixation
excellent healing potential
may allow for earlier range of motion
cons
hardware irritation can necessitate implant removal
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Knee & Proximal Tibia
Open reduction with arthrotomy and internal fixation
o approach
midline approach or median parapatellar arthrotomy
joint surface must be visualized to assure anatomic reduction
alternatively, arthroscopy can be used to directly assess the articular reduction
o technique
same as above
evaluate for meniscal tears and repair or debride as appropriate
evacuate intraarticular hematoma
visualize joint surface to achieve anatomic reduction
o postoperative care
immobilization
long leg cast for 4-6 weeks
prolonged immobilization needed in Type 2 and 3 injuries
non-weight bearing
rehabilitation
progressive extensor mechanism strengthening
return to sports no sooner than 3 months
pros & cons
pros
addresses intraarticular extension and soft tissue injuries
cons
arthrotomy may require longer immobilization and/or rehabilitation
Open reduction and soft tissue repair
o approach
midline incision to the soft tissue injury site
o technique
evaluate soft tissue injury
remove any soft tissue interposition (periosteum)
heavy suture repair of periosteum back to the secondary ossification center
o postoperative care
immobilization
long leg cast for 8-10 weeks
prolonged immobilization needed due to soft tissue (rather than bone) healing
rehabilitation
progressive extensor mechanism strengthening
return to sports no sooner than 3 months
o pros & cons
cons
prolonged healing time due to soft tissue healing
Complications
Recurvatum deformity
o more common than leg length discrecancy
o growth arrest anteriorly as posterior growth continues leading to decrease in tibial slope
Compartment syndrome
o related to injury of anterior tibial recurrent artery
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OrthoBullets2017 Pediatric trauma | Knee & Proximal Tibia
Vascular injury
o to popliteal artery as it passes over distal metaphyseal fragment
Loss of range of motion
Bursitis
o due to prominence of screws and hardware about the knee
Anatomy
Ossification
o does not begin until 3 to 5 years of age.
o most patellar fractures occur in adolescents when ossification is nearly complete
o incomplete coalescence of a superolaterally located accessory center of ossification results in
bipartite patella (often confused with fracture)
Presentation
History
o indirect injury
o not associated with direct blow to the knee
Symptoms
o severe knee pain
Physical exam
o inspection
soft-tissue swelling
a high-riding patella implies that the extensor
mechanism has been disrupted
hemarthrosis of the knee joint is often present
o palpation
palpable gap at the lower end of the patella
o motion
active extension of the knee is difficult; especially
with resistance
inability to weightbear
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Knee & Proximal Tibia
Imaging
Radiographs
o recommended views
AP and lateral of knee
o findings
small flecks of bone adjacent to inferior pole
diagnosis may be missed because the distal bony fragment is not readily discernible on
radiographs
patella alta
for distal fractures (most common)
patella baja
for proximal fractures
MRI
o indications
may be useful for diagnosing a sleeve fracture when the diagnosis is not clear from the
clinical and plain radiographic findings
Treatment
Nonoperative
o cylinder cast for 6 weeks
indications
nondisplaced fractures with intact extensor mechanism
Operative
o open reduction and internal fixation (modified tension band technique)
indications
displacement more than 2-3mm
majority require ORIF
may be performed with sutures through drill holes
Technique
Open reduction and internal fixation
o approach
parapatellar to knee
approach the inferior pole of the patella through a 7-cm medial parapatellar incision
make incision over the distal aspect of the approach directly over the inferior pole of the
patella
o repair
repair of the torn medial and lateral retinaculum along with the use of sutures through the
cartilaginous and osseous portions of the patella often suffice
o fixation
once anatomic reduction of articular surface achieved, fracture can be stabilized using
modified tension band wiring around two longitudinally placed Kirschner wires
o post-operative care
place in cast with knee in mild degree of flexion
remove cast at ~3 weeks and start ROM exercises
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OrthoBullets2017 Pediatric trauma | Knee & Proximal Tibia
Complications
Patella alta
Extensor lag
Quadriceps atrophy
Anatomy
Physeal considerations of the knee
o general assumptions
leg growth continues until
16 yrs in boys
14 yrs in girls
o growth contribution
leg grows 23 mm/year, with most of that coming from the knee (15 mm/yr)
proximal femur - 3 mm / yr (1/8 in)
distal femur - 9 mm / yr (3/8 in)
proximal tibia - 6 mm / yr (1/4 in)
distal tibia - 5 mm / yr (3/16 in)
Presentation
Symptoms
o unable to bear weight
Physical exam
o inspection
pain and swelling
tenderness along the physis in the presence of a knee effusion
o motion
may see varus or valgus knee instability on exam
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Knee & Proximal Tibia
o neurovascular exam
physis is at same level of trifurcation of vessels and there is a risk of vascular compromise
with displacement
Imaging
Radiographs
o recommended views
AP and lateral
o optional views
oblique views
varus/valgus stress views
o findings
displacement of fracture fragments
Salter Harris classification
CT
o indications : assess fracture displacement
o findings : best modality for SH III or IV fractures
Treatment
Nonoperative
o immobilization in long leg cast
indications
non-displaced fracture
stable Salter-Harris Type I and Type II fractures
modalities
traction for fracture reduction
cast in slight flexion for 6 weeks
outcomes
redisplacement is common without internal fixation
Operative
o anatomic reduction and fixation with percutaneous pinning
indications
displaced fractures
unstable Salter-Harris Type I and Type II fractures
redisplacement following closed treatment
modalities
percutaneous pins parallel to physis
pins crossing perpendicular to physis if extra-articular fixation needed
outcomes
avoid displacement to affect trifurcation
o open reduction internal fixation
indications
displaced fractures
Salter-Harris Type III and Type IV fractures
modalities
screw parallel to physis
cast in slight flexion for 4-6 weeks
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OrthoBullets2017 Pediatric trauma | Knee & Proximal Tibia
Complications
Loss of reduction
Growth disturbances (25%)
o can lead to limb length discrepancy and/or angular deformities
Compartment syndrome
Ligamentous instability
Classification
Classification of pediatric proximal tibia metaphyseal fractures is descriptive.
o important radiographic parameters include:
complete versus incomplete fracture
majority are incomplete
displaced or nondisplaced
presence and location of associated fibula fracture
Presentation
Symptoms
o pain
o refusal to bear weight
Physical exam
o valgus deformity
o evaluate carefully for compartment syndrome
Imaging
Radiographs
o recommended views
required
AP and lateral
o findings
look for incomplete vs complete and presence of a proximal fibula fracture which may
indicate a more unstable fracture pattern
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Knee & Proximal Tibia
Treatment
Nonoperative
o long leg cast in extension with varus mold (aim for slight overcorrection)
indications
nondisplaced fracture
technique
casts are maintained for 6-8 weeks with serial radiographs
weight bearing may be allowed after 2-3 weeks.
o reduction followed by long leg cast in extension with varus mold (aim for slight
overcorrection)
indications
displaced fracture
technique
requires conscious sedation or general anesthesia
cast in near full extension (10 degrees flexion)
varus mold at fracture site
Operative
o open reduction
indications
inability to adequately reduce a displaced fracture
secondary to soft tissue interposition
technique
III:40 Valgus deformity
V
limited medial approach to proximal tibia
periosteum or tendons of pes anserinus may block reduction
internal fixation not commonly required
Complications
Valgus deformity (Cozen phenomenon)
o may be observed for 12-24 months with expectation of spontaneous correction
o parents should be counseled in advance
o etiology
incomplete reduction
concomitant injury to proximal tibia physis
infolded periosteum
injury to pes anserinus insertion, with loss of proximal tibia physeal tether, leading to
asymmetric physeal growth
o treatment
if deformity fails to resolve
medial hemi-epiphysiodesis in skeletally immature patient
corrective osteotomy in skeletally mature patient
osteotomies have significant complications
Limb length discrepancy
o affected tibia is often longer (average 9mm)
o typically does not require intervention however parents should be counseled that this does not
resolve
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OrthoBullets2017 Pediatric trauma | Leg & Ankle Fractures
Presentation
Symptoms
o pain
o bruising
o limping or refusal to bear weight
Physical exam
o warmth, swelling over fracture site
o tender over fracture site
o pain on ankle dorsiflexion
o always have high suspicion for compartment syndrome
Imaging
Radiographs
o views
AP and lateral views of the tibia and fibula are required
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Leg & Ankle Fractures
ipsilateral knee and ankle must be evaluated to rule out concomitant injury
o findings
Toddler's fracture are nondisplaced spiral tibial shaft fracture
Treatment Traumatic Tibia +/- Fibular fx
Nonoperative
o closed reduction and long leg casting
indications
almost all Toddler's fracture
most traumatic fractures
displaced with acceptable reduction
50% apposition
< 1 cm of shortening VIII:41 Toddler's fracture
< 5-10 degrees of angulation in the sagittal and coronal planes
followup
follow up xrays in 2 weeks to evaluate for callus in order to confirm diagnosis in
equivocal cases
serial radiographs are performed to monitor for developing deformity
Operative
o surgical treatment
indications (< 5% of tibia shaft fractures)
unacceptable reduction (see above)
marked soft tissue injury
open fractures
unstable fractures
compartment syndrome
neurovascular injury
multiple long bone fractures
>1cm shortening
unacceptable alignment following closed reduction (>10deg angulation)
techniques include
external fixation
plate fixation
percutaneous pinning
flexible IM nails
Techniques
Long Leg Casting
o immobilization is performed with a long leg cast with the knee flexed to provide rotational
control and prevent weight bearing.
External fixation
o open fractures with extensive soft tissue injury is most common indication
o most common complication is malunion
o nonunion (~2%)
Plate fixation
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OrthoBullets2017 Pediatric trauma | Leg & Ankle Fractures
Percutaneous pinning
o younger patients
Flexible or rigid intramedullary rods
o depending on the age of the patient and degree of soft tissue injury
o complications
nonunion (~10%)
malunion
infection
Complications
Compartment syndrome
o with both open and closed fractures
Leg-length discrepancy
Angular deformity
o varus for tibia only fractures
o valgus for tibia-fibula fractures
Associated physeal injury
o proximal or distal
Delayed union and nonunion
o usually only after external fixation
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Leg & Ankle Fractures
Anatomy
Physeal considerations
o distal tibial physis closes in predictable pattern
central to medial
anterolateral closes last
Classification
Anatomic classification
o Salter-Harris Classification
Diaz and Tachdjian classification (patterned off adult Lauge-Hansen classification)
o supination-inversion
o supination-plantar flexion
o supination-external rotation
o pronation/eversion-external rotation
Presentation
Symptoms
o ankle pain, inability to bear weight
Physical exam
o inspection : swelling, focal tenderness
Imaging
Radiographs
o recommended views
AP, mortise, and lateral
o optional views
full-length tibia, or proximal tibia, to rule out Maisonneuve-type fracture
o findings
triplane fractures
AP or mortise reveals intraarticular component
lateral reveals posterolateral metaphyseal fragment (Thurston-Holland fragment)
CT scan : indications
o assess fracture displacement
o assess articular step-off
Treatment
Nonoperative
o cast immobilization
indications
<2mm articular displacement
Operative
o CRPP vs ORIF
indications
>2mm displacement
intra-articular fractures
irreducible reduction by closed means
may have interposed periosteum, tendons, neurovascular structures
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OrthoBullets2017 Pediatric trauma | Leg & Ankle Fractures
Techniques
CRPP vs ORIF
o reduction
percutaneous manipulation with k-wires may aid reduction
open reduction may be required if interposed tissue
o fixation
transepiphyseal fixation best if at all possible
cannulated screws parallel to physis
tillaux and triplane fractures
2 parallel epiphyseal screws
medial malleolus shear fractures
transphyseal fixation
smooth wire fixation typically used
Complications
Ankle pain and degeneration
o high rate associated with articular step-off >2mm
Growth arrest
o medial malleolus SH IV have highest rate of growth disturbance of any fracture
o partial arrests can lead to angular deformity
distal fibular arrest results in valgus
medial distal tibia arrest results in varus
o complete arrests can result in leg-length discrepancy
can be addressed with contralateral epiphysiodesis
Extensor retinacular syndrome
o displaced fracture can lead to foot compartment syndrome
Rotational deformity
3. Tillaux Fractures
Introduction
Salter-Harris III fx of the distal tibia epiphysis
o caused by an avulsion of the anterior inferior tibiofibular ligament
Mechanism
o mechanism of injury is thought to be due to an external rotation force
Epidemiology
o typically occur within one year of complete distal tibia physeal closure.
older than triplane fracture age group
Pathoanatomy
o lack of fracture in the posterior distal tibial metaphysis in the coronal plane distinguishes this
fracture from a triplane injury
o transitional fractures (tillaux and triplane) occur in older children at the end of growth
variability in fracture pattern due to progression of physeal closure
a period of time exists when the lateral physis is the only portion not fused
leads to Tillaux and Triplane fractures
often associated with external rotation deformity of the ankle/foot
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Leg & Ankle Fractures
Anatomy
Ossification
o the distal tibial physis closes in the following order
central (first)
posterior
medial
anterolateral (last)
Imaging
Radiographs
o SH III fx of the anterolateral distal tibia epiphysis
CT scan
o delineate the fracture pattern
o determine degree of displacement
o identify intramalleolar or medial fracture variant patterns
Treatment
Nonoperative
o closed reduction, long leg cast x 4 weeks (control rotation), SLC x 2-3 weeks
indications
if < 2 mm of displacement (rare) following closed reduction
technique
reduction technique by internally rotating foot
CT scans sometimes needed to determine residual displacement (confirm < 2mm)
long leg cast initially to control rotational component of injury
Operative
o open reduction and internal fixation
indications
if >2 mm of displacement remains after reduction attempt
technique
closed reduction (by internal rotation) can be attempted under general anesthesia first
percutaneous screws can be placed if adequate reduction obtained
visualize joint line to optimize reduction
intra-epiphyseal screws
transphyseal screws can also be used as most patients are approaching skeletal
maturity
arthroscopically-assisted reduction has been described
Complications
Premature growth arrest
o rare as little physis remaining as closure is already occuring
o decrease risk with anatomic reduction
Early arthritis
o increase risk with articular displacement
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OrthoBullets2017 Pediatric trauma | Leg & Ankle Fractures
4. Triplane Fractures
Introduction
A complex SH IV fracture pattern with components in all three planes
o triplane fractures may be 2, 3, or 4 part fractures
epiphysis fractured in sagittal plane (same as tillaux fracture) and therefore is seen on the AP
radiograph
physis separated in axial plane
metaphysis fractured in coronal plane and therefore is seen on the lateral radiograph
Epidemiology
o Occur between ages 10-17 years, mean 13 years
juvenile ankle physis ossifies in specific order, which leads to transitional fractures such as
triplane and tillaux fractures
distal tibia physis order of
ossification
central > medial > lateral
Mechanism
o most are result of supination-external
rotation similar to tillaux fractures
(lateral triplane)
medial triplane is a result of
adduction
Classification
Parts - 2, 3, 4 part
Lateral triplane (more common) > medial triplane >> intramalleolar triplane (epiphyseal fracture
exits through medial malleolus)
Presentation
Symptoms
o ankle pain, inability to bear weight
Physical exam
o swelling, focal tenderness
Imaging
Radiographs
o AP radiograph shows Salter-Harris III
o lateral radiograph shows Salter-Harris II
CT scan
o usually required to delineate fracture pattern and access articular congruity
o fracture involvement seen in all 3 planes
Treatment
Nonoperative
o cast immobilization
indications
< 2 mm displacement
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By Dr, AbdulRahman AbdulNasser Pediatric trauma | Leg & Ankle Fractures
Operative
o CRPP vs ORIF
indications
> 2 mm displacement
techniques
epiphyseal screw placed parallel to physis
arthroscopic aided reduction can be used
Complications
Ankle pain and degeneration
o articular step-off >2mm
Collected By : Dr AbdulRahman
AbdulNasser
June 2017
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2
ORTHO BULLETS
Volume
two
Spine
2017
Collected By : Dr AbdulRahman AbdulNasser
[email protected]
OrthoBullets 2017
OrthoBullets 2017
Preface
Orthobullets.com is an educational resource for
orthopaedic surgeons designed to improve
training through the communal efforts of those
who use it as a learning resource. It is a simple but
powerful concept. All of our topics, technique
guides, cases, and user-generated videos are
free, and will stay that way.
Table of Contents
I. Spine Introduction .............................................................................................................. 0
A. Anatomy ........................................................................................................................ 1
1. Spinal Cord Anatomy ...................................................................................................... 1
2. Spine Biomechanics ....................................................................................................... 4
3. Cervical Spine Anatomy ................................................................................................. 9
4. Thoracic Spine Anatomy............................................................................................... 13
5. Lumbar Spine Anatomy ................................................................................................ 15
6. Intervertebral Disc ....................................................................................................... 20
B. Evaluation.................................................................................................................... 22
1. Neck & Upper Extremity Spine Exam ............................................................................ 22
2. Lower Extremity Spine & Neuro Exam .......................................................................... 25
3. Spinal Cord Monitoring ................................................................................................. 27
C. Infection ...................................................................................................................... 30
1. Adult Pyogenic Vertebral Osteomyelitis........................................................................ 30
2. Spinal Epidural Abscess ............................................................................................... 35
3. Spinal Tuberculosis ...................................................................................................... 37
4. Disk Space Infection - Pediatric .................................................................................... 42
II. Degenerative Spine .......................................................................................................... 45
A. Cervical Conditions ..................................................................................................... 46
1. Cervical Spondylosis .................................................................................................... 46
2. Cervical Stenosis.......................................................................................................... 48
3. Cervical Myelopathy ..................................................................................................... 49
4. Cervical Radiculopathy ................................................................................................ 60
5. Rheumatoid Cervical Spondylitis .................................................................................. 67
6. Ossification Posterior Longitudinal Ligament ............................................................... 71
B. Cervical Tested Procedures ........................................................................................ 73
1. Cervical Disc Replacement ........................................................................................... 73
C. Thoracolumbar Conditions .......................................................................................... 75
1. Low Back Pain - Introduction ........................................................................................ 75
2. Discogenic Back Pain ................................................................................................... 78
3. Thoracic Disc Herniation .............................................................................................. 80
OrthoBullets 2017
ORTHO BULLETS
I.Spine Introduction
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Anatomy
A. Anatomy
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Anatomy
Blood Supply
Spinal cord blood supply provided by
o anterior spinal artery
primary blood supply of anterior 2/3 of spinal cord, including both
the lateral corticospinal tract and ventral corticospinal tract
o posterior spinal artery (right and left)
primary blood supply to the dorsal sensory columns
o Artery of Adamkiewicz
the largest anterior segmental artery
typically arises from left posterior intercostal artery, which
branches from the aorta, and supplies the lower two thirds of the
spinal cord via the anterior spinal artery
significant variation exists
in 75% it originates on the left side between the T8 and L1
vertebral segments
Cerebral Spinal Fluid
Function
o a colorless fluid that occupies the subarachnoid space surrounding the brain, spinal cord, and
ventricular system
the subarachnoid space is between the arachnoid mater and pia mater
o provides mechanical and immunological protection for the brain, spinal cord, and thecal sac
Production
o location
most human cerebrospinal fluid (CSF) is produced by the choroid plexus in the third, fourth,
and lateral ventricles of the brain.
CSF is an ultrafiltrate of blood plasma through the permeable capillaries of the choroid
plexus
o volume
total CSF volume between brain, spinal cord, and thecal sac is ~150 mL
CSF formation occurs at rate of ~500mL per day
thus the total amount of CSF is turned over 3-4 times per day
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OrthoBullets2017 Spine Introduction | Anatomy
Nerve Root Anatomy
Cervical spine
o nerve roots exit above corresponding pedicle
C5 nerve root exits above the C5 pedicle
o nerve root travel horizontally to exit
o there is an extra C8 nerve root
that does not have a corresponding vertebral body
Thoracic spine
o nerve root travel below corresponding pedicle
T1 exits below T1 pedicle
T12 exits below T12 pedicle
Lumbar spine
o nerve roots descend vertically before exiting
o nerve root travel below corresponding pedicle
L1 exits below L1 pedicle
L5 exits below L5 pedicle
2. Spine Biomechanics
Introduction
Functional spinal unit (FSU)
o the cephalad and caudad vertebral body as well as the intervertebral disc and the corresponding
facet joints
o function is to provide physiologic motion and protect neural elements
o intradiscal pressure depends on position
Spinal stability
o defined when, under
physiologic loading, there is
neither abnormal strain or
excessive motion in the FSU
maintained by
FSU
muscular tension
abdominal and thoracic pressure
rib cage support
Three Column Theory
Denis three column system
o clinical relevance
only moderately reliable in determining clinical
degree of stability
o definitions
anterior column
anterior longitudinal ligament (ALL)
anterior 2/3 of vertebral body and annulus
middle column
posterior longitudinal ligament (PLL)
posterior 1/3 of vertebral body and annulus
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Anatomy
posterior column
pedicles
facets
ligamentum flavum
spinous process
posterior ligament complex (PLC)
instability defined by
injury to middle column
as evidenced by widening of interpedicular
distance on AP radiograph
loss of height of posterior cortex of vertebral body
disruption of posterior ligament complex combined with anterior and middle column
involvement
Ligaments
FSU is surrounded by 10 ligaments with the functions:
o protecting neural structures by restricting motion of the FSU
o absorb energy during high speed motions
Contents
o all ligaments are composed of type I collagen except ligamentum flavum (mostly elastin)
o are viscoelastic, with nonlinear behavior
Posterior Ligamentous Complex
Integerity of PLC now considered to be one of the most critical predictor of spinal fracture stability
o one of three primary factors in TLCIS scoring system. TLCIS measures as
intact
suspect/indeterminant
ruptured
Anatomy
o consists of
supraspinous ligament
interspinous ligament
ligamentum flavum
facet capsule
Evaluation
o determining the integrity of the PLC can be challenging
o conditions where PLC is ruptured
bony chance fracture
widening of interspinous distance
progressive kyphosis with nonoperative treatment
facet diastasis
o conditions where ambiguity
MRI shows signal intensity between spinous process
Treatment
o nonoperative
according to TLCIS, if PLC is intact (+0 points) in a compression (+1 point) burst fx (+1
point) than the patient should be treated with surgery
total score = 2 points (score < 4 points = nonoperative)
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OrthoBullets2017 Spine Introduction | Anatomy
o operative
according to TLCIS, if PLC is ruptured (+3 points) in a compression (+1 point) burst fx (+1
point) than the patient should be treated with surgery
total score = 2 point (score > 4 points = nonoperative)
Spinal Balance
Sagittal balance
o is due to the normal cervical lordosis, thoracic kyphosis and lumbar lordosis
cervical lordosis
normal range 20-40°
thoracic kyphosis
average 35°
normal range 20-50°
lumbar lordosis
average 60°
normal range 20-80°
as much as 75% of lumbar lordosis occurs between L4 and S1 with 47% occurring at
L5/S1
o normal alignment
the vertical axis runs from the center of C2 to the anterior border of T7 to the middle of the
T12/L1 disc, posterior to the L3 vertebral body, and crosses the posterior superior corner of
the sacrum.
on radiograph this is estimated by a plumb line dropped from the center of C7 to the
posterior-superior corner of S1
o negative sagittal balance
the axis is posterior to the sacrum and occurs in patients with lumbar hyperlordosis
o positive sagittal balance
The axis is anterior to the sacrum and occurs in patients with hip flexion contracture or flat-
back syndrome
Motion
The orientation of the facets (zygapophyseal) joints determines the degree and plane of motion at
that level
o varies throughout the spine to meet physiologic function
o cervical spine (C3-7)
planes
0° coronal
45° sagittal (angled superio-medially)
function
allows flexion-extension, lateral flexion, rotation
o thoracic spine
planes
20° coronal
55° sagittal (facets in coronal
plane)
6 degrees of freedom
function
allows some rotation, minimal
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Anatomy
flexion-extension (also limited by ribs)
prevents downward flexion on heart and lungs
o lumbar spine
plane
50° coronal
90° sagittal (facets in sagittal plane)
function
allows flexion-extension, minimal rotation
helps increase abdominal pressure
Instantaneous axis of rotation (IAR)
o axis about which the vertebra rotates at some instant in time
o normal FSU
I:1 Thoracic spine
is confined to a small area within the FSU
o abnormal FSU (e.g. degenerate disc)
shifts outside the physical space of the FSU
is enlarged dramatically
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OrthoBullets2017 Spine Introduction | Anatomy
Pedicle Anatomy
Cervical
o C2 : viable for pedicle screw placement
o C3-C6
pedicle small making pedicle screw instrumentation difficult
lateral mass scews placed at C3-C6 as alternative
o C7 : viable for pedicle screw placement
Thoracic
o pedicle diameter
the pedicle wall is twice as thick medially as laterally
T4 has the narrowest pedicle diameter (on average)
T7 can be irregular and have a narrow diameter on the concave side in AIS
T12 usually has larger pedicle diameter than L1
o pedicle length
pedicle length decreases from T1 to T4 and then increases again as you move distal in the
thoracic spine
T1: 20mm
T4: 14mm (shortest pedicle)
T10: 20 mm
o pedicle angle
transverse pedicle angle : varies from 10deg (mid thoracic spine) to 30deg (L5)
sagittal pedicle angle
15-17deg cephalad for majority of thoracic spine
neutral (0deg) for lumbar spine except L5 (caudal)
Lumbar-Sacral
o landmarks
midpoint of the transverse process used to identify midpoint of pedicle in superior-inferior
dimension
lateral border of pars used to identify midpoint in medial-lateral dimension
o pedicle angulation
pedicles angulate more medial as you move distal
L1: 12 degrees
L5: 30 degrees
S1: 39 degrees
o pedicle diameter Axial CT cuts showing :
L1 has smallest diameter in lumbar spine Level 1 through the pedicles
S1 has average diameter of ~19mm Level 2 through the vertebral body
Level 3 through the inter vertebral disc
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Anatomy
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OrthoBullets2017 Spine Introduction | Anatomy
o C1 to C7
have a transverse foramen
vertebral artery travels through transverse foramen of C1 to C6
o C2 to C6 : have bifid spinous process
o C7
despite having a transverse foramen, the vertebral artery does NOT travel through it in the
majority of individuals
there is no C8 vertebral body although there is a C8 nerve root
Alignment
Normal sagittal lordosis (measured from C2 to C7)
Spinal Canal
Spinal canal
o normal diameter is 17mm
<13mm indicates possible cord compression
Atlas (C1)
Has no vertebral body and no spinous process
Embryology
o three ossification centers
one for each lateral mass
lateral masses fuse to body at age 7
one for vertebral body
vertebral body does not appear until 1 year of age
Articulations
o occiput-C1
two superior concave facets that articulate with the occipital condyles
makes up 50% of neck flexion and extension
o C1-C2 (see below)
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Anatomy
Axis (C2)
Axis Osteology
o axis has odontoid process (dens) and body
o embryology
develops from five ossification centers
subdental (basilar) synchondrosis is an initial cartilagenous
junction between the dens and vertebral body that does not fuse
until ~6 years of age
the secondary ossification center appears at ~ age 3 and fuses to the dens at ~ age 12
Axis Kinetmatics
o CI-C2 (atlantoaxial) articulation
is a diarthrodal joint that provides
50 (of 100) degrees of cervical rotation
10 (of 110) degrees of flexion/extension
0 (of 68) degrees of lateral bend
o C2-3 joint
participates is subaxial (C2-C7) cervical motion which provides
C2 Blood Supply
o a vascular watershed exists between the apex and the base of the odontoid
apex is supplied by branches of internal carorid artery
base is supplied from branches of vertebral artery
the limited blood supply in this watershed area is thought to affect healing of type II odontoid
fractures.
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Anatomy
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Anatomy
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OrthoBullets2017 Spine Introduction | Anatomy
Pedicle diameter
o L1 has smallest diameter in lumbar spine (T4 has smallest diameter overall)
o S1 has average diameter of ~19mm
Lumbar Blood Supply
Lumbar vertebral bodies supplied by
o segmental arteries
dorsal branches supply blood to the dura & posterior
elements
Lumbar Neurologic Structures
Nerve roots
o anatomy
nerve root exits foramen under same numbered
pedicle
central herniations affect traversing nerve root
far lateral herniations affect exiting nerve root
dorsal rami
supplies muscles, skin
ventral rami
supplies anteromedial trunk
o key difference between cervical and lumbar spine is
pedicle/nerve root mismatch
cervical spine C6 nerve root travels under C5
pedicle (mismatch)
lumbar spine L5 nerve root travels under L5 pedicle (match)
extra C8 nerve root (no C8 pedicle) allows transition
horizontal (cervical) vs. vertical (lumbar) anatomy of nerve root
because of vertical anatomy of lumbar nerve root a paracentral and foraminal disc will
affect different nerve roots
because of horizontal anatomy of cervical nerve root a central and foraminal disc will
affect the same nerve root
Cauda equina
o begins at ~L1
I:4 Paracentral disc herniation ( blue ) vs far lateral disc herniation ( Red )
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Anatomy
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OrthoBullets2017 Spine Introduction | Anatomy
Lumbar-Pelvic Sagittal Alignment
Pelvic incidence
o pelvic incidence = pelvic tilt + sacral slope
o a line is drawn from the center of the S1 endplate to the center of the femoral head
o a second line is drawn perpendicular to a line drawn along the S1 endplate, intersecting the point
in the center of the S1 endplate
o the angle between these two lines is the pelvic incidence (see angle X in figure above)
o correlates with severity of disease
o pelvic incidence has direct correlation with the Meyerding–Newman grade
Pelvic tilt
o sacral slope = pelvic incidence - pelvic tilt
o a line is drawn from the center of the S1 endplate to the center of the femoral head
o a second vertical line (parallel with side margin of radiograph) line is drawn intersecting the
center of the femoral head
o the angle between these two lines is the pelvic tilt (see angle Z in figure above)
Sacral slope
o pelvic tilt = pelvic incidence - sacral slope
o a line is drawn parallel to the S1 endplate
o a second horizontal line (parallel to the inferior margin of the radiograph) is drawn
o the angle between these two lines is the sacral slope (see angle Y in the figure above)
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Anatomy
Facet joint injection
o indications
to confirm facet joint as pain generator (diagnostic)
also a therapeutic procedure
Epidural injection
o indications
lumbar spinal stenosis
Discography
o indications
very controversial
to prove that pain arises from the intervertebral disc ("concordant pain") rather than other
sources ("discordant pain")
o technique
small amount of dilute contrast injected into the disc and pain response is recorded
contrast helps assess disc morphology and diagnose annular tears
Surgical Approaches
Posterior
o posterior midline approach
can be used for PLIF or TLIF
o Wiltse paraspinal approach
Anterior
o retroperitoneal (anterolateral) approach
aorta bifurcation found at L4/5
superior hypogastric plexus on L5 body
damage causes retrograde ejaculation
Lateral
o transpoas approach
lumbar plexus moves dorsal to ventral moving down the lumbar spine
L4-L5 is lowest accessible disc space, highest risk of iatrogenic nerve injury
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OrthoBullets2017 Spine Introduction | Anatomy
6. Intervertebral Disc
Anatomy
Function
o allows spinal motion and provides stability
o links adjacent vertebral bodies together
o responsible for 25% of spinal column height
Composition
o annulus fibrosus
outer structure that encases the nucleus pulposus
composed of type I collagen that is obliquely oriented, water, and proteoglycans
characterized by high tensile strength and its ability to prevent intervertebral distraction
remains flexible enough to allow for motion
high collagen / low proteoglycan ratio (low % dry weight of proteoglycans)
fibroblast-like cells
responsible for producing type I collagen and proteoglycans
o nucleus pulposus
central portion of the intervertebral disc that is surrounded by the annulus fibrosis
composed of type II collagen, water, and proteoglycans
approximately 88% water
hydrophilic matrix is responsible for height of the intervertebral disc
characterized by compressibility
a hydrated gel due to high polysaccharide content and high water content (88%)
proteoglycans interact with water and resist compression
Aggrecan is a proteoglycan primarily responsible for maintaining water content of
the disc
viscoelastic matrix distributes the forces smoothly to the annulus and the end plates
low collagen / high proteoglycan ratio (high % dry weight of proteoglycans)
chondrocyte-like cells
responsible for producing type II collagen and proteoglycans
survive in hypoxic conditions
Blood Supply
o the disk is avascular with capillaries terminating at the end plates
o nutrition reaches nucleus pulposus through diffusion through pores in the endplates
annulus is not porous enough to allow diffusion
Innervation
o the dorsal root ganglion gives rise to the sinuvertebral nerve which innervates the superficial
fibers of annulus
no nerve fibers extend beyond the superficial fibers
o neuropeptides thought to participate in sensory transmission include
substance P
calcitonin
VIP
CPON
Fixation
o attached to vertebral bodies by hyaline cartilage
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Anatomy
Disc Biomechanics
Disc
o viscoelastic characteristics
demonstrates creep which allows for
deformity over time
demonstrates hysteresis which allows
for energy absorption with repetitive axial
compression
this property decreases with time
Stresses
o annulus fibrosus
highest tensile stresses
o nucleus pulposus
highest compressive stress
o intradiscal pressure is position dependent
pressure is lowest when lying supine
pressure is intermediate when standing
pressure is highest when sitting and flexed forward with weights in the hands
when carrying weight, the closer the object is to the body the lower the pressure
Stability
o following subtotal discectomy, extension is most stable loading mode
Pathoanatomy
Disc Herniation
o herniated disks are associated with a spontaneous increase in the production of
osteoprotegrin (OPG)
interleukin-1 beta
receptor activator of nuclear factor-kB ligand (RANKL)
parathyroid hormone (PTH)
Disc aging leads to an overall loss of water content and conversion to fibrocartilage. Specifically
there is a
o decrease in
nutritional transport
water content
absolute number of viable cells
proteoglycans
pH
o increase in
an increase keratin sulfate to chondroitin sulfate ratio
lactate
degradative enzyme activity
density of fibroblast-like cells
fibroblast-like cells reside in the annulus fibrosus only
o no change in
absolute quantity of collagen
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OrthoBullets2017 Spine Introduction | Evaluation
B. Evaluation
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Evaluation
Inspection, Palpation, ROM
Inspection
o alignment in sagittal and coronal plane (e.g., kyphotic cervical spine)
o prior surgical scars (e.g., prior ulnar nerve transposition or carpal tunnel surgery)
o skin defects (e.g., cafe au lait spots associated with neurofibromatosis)
o muscle atrophy (e.g., palsy will see decrease deltoid and biceps mass)
Palpation
o palpate local tenderness on the spinal axis, asymmetic
ROM
o document range of motion in flexion, extension, rotation, and bend
o may give absolute degrees or relative to anatomic landmark (e.g, chin rotates to right shoulder)
o normal range of motion of cervical spine
flexion: 50
extension: 60
rotation: 80
lateral bend: 45
Motor Testing
Grade key muscles groups from 0-5 using ASIA Grading System
o include at least one muscle from each nerve root group (C5 to T1)
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OrthoBullets2017 Spine Introduction | Evaluation
Sensory Exam
Grade sensory in C5 to T1 dermatomes
o score using ASIA Sensory Grading System
o score major sensory types in all patients
pain (prick with sharp object such as paper clip, broken cue tip)
light touch (stroke lightly with finger)
o score minor sensory types for focused exam
vibration (focused exam)
temperature (focused exam)
two-point discrimination (focused exam)
Provocative Tests
Spurlings Test
o foraminal compression test that is specific, but not sensitive, in diagnosing acute radiculopathy.
o it is performed by rotating head toward the affected side, extending the neck, and then applying
and axial load (applying downward pressure on the head)
o the test is considered positive if pain radiates into the ipsilateral arm when the test is performed
for 30 seconds.
Hoffman's Test
o a positive test is sensitive but not specific for cervical myelopathy
o performed in one of two ways
hold and secure the middle phalanx of the long finger and then flick the distal phalanx into an
extended position. Involuntary contraction of the thumb IP joint is a positive test.
hold and secure the distal phalanx of the long finger and then flick the distal phalanx into an
extended position. Involuntary contraction of the thumb IP joint is a positive test.
Lhermitte Sign
o a positive test is specific but not sensitive for cervical spinal cord compression and myelopathy
o test is positive cervical flexion or extension leads to shockline sensation radiating down spinal
axis and into arms and/or legs
Gait
Antalgic gait
o caused by guarding for pain in affected extremity due to
hip and knee pathology
severe radicular symptoms
Trendelenburg gait : caused by painful arthritis of hip or gluteus medius weakness
wide-based shuffling gait
o due to neurologic disorder including myelopathy
steppage or lateral swing gait
o a method of gait compensation for a foot drop (weakness ankle dorsiflexion and toe extension)
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Evaluation
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OrthoBullets2017 Spine Introduction | Evaluation
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Evaluation
Sensory Exam
Sensory Grading System (ASIA)
0 Absent
1 Impaired
2 Normal
NT Not Testable
Specific Tests
Special tests
o straight leg raise
Brachial Plexus Illustration (See figure in page 22)
Sensory Illustration (See figure in page 25)
Clinical Findings
Finding Description
1. Tenderness a. superficial - pain with light touch to skin
b. deep - nonanatomic widespread deep pain
2. Simulation a. pain with light axial compression on skull
b. pain with light twisting of pelvis
3. Distraction No pain with distracted SLR
4. Regional a.nonanatomic or inconsistent motor findings during entire exam
b. nonanatomic or inconsistent sensory findings during entire exam
5. Overreaction Overreaction noted at any time during exam
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OrthoBullets2017 Spine Introduction | Evaluation
spinothalamic tract
o motor (efferent)
lateral corticospinal tract
ventral corticospinal tract
Blood supply
o consists of
anterior spinal artery
primary blood supply of anterior 2/3 of spinal cord, including both the lateral
corticospinal tract and ventral corticospinal tract
posterior spinal artery (right and left)
primary blood supply to the dorsal sensory columns
Sensory evoked potenitals (SEPs)
Function
o monitor integrity of dorsal column sensory pathways of the spinal cord
Technique
o signal initiation
lower extremity usually involves stimulation of posterior tibial nerve
behind ankle
upper extremity usually involve stimulation of ulnar nerve
o signal recording
transcranial recording of somatosensory cortex
Advantages
o reliable and unaffected by anesthetics
Disadvantages
o not reliable for monitoring the integrity of the anterior spinal cord pathways
reports exist in literature of an ischemic injury leading to paralysis despite normal SEP
monitoring during surgery
Intraoperative considerations
o loss of signals during distraction mandates immediate removal of device and repeated assessment
of monitoring signals
Motor Evoked Potential (MEP)
Function
o monitor integrity of lateral and ventral corticospinal tract of the spinal cord
Technique
o signal initiation
transcranial stimulation of motor cortex
o signal recording
muscle contraction in extremity (gastroc, soleus, EHL of lower extremity)
Advantages
o effective at detecting a ischemic injury (loss of anterior spinal artery) in anterior 2/3 of spinal
cord
Disadvantages
o often unreliable due to effects of anesthesia
Intraoperative considerations
o loss of signals during distraction mandates immediate removal of device and repeated assessment
of monitoring signals
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Evaluation
Mechnical Electromyography (spontaneous)
Introduction
o monitor integrity of specific spinal nerve roots
Technique
o concept
microtrauma to nerve root during surgery causes deplorization and a resulting action potential
in the muscle that can be recorded
contact of a surgical instrument with nerve root will lead to "burst activity" and has no
clinical significance
significant injury or traction to a nerve root will lead to "sustained train" activity, which may
be clinically significance
o signal initiation
mechanical stimulation (surgical manipulation) of nerve root
o signal recording
muscle contraction in extremity
Advantages
o allows monitoring of specific nerve roots
Disadvantages
o may be overly sensitive (e.g., sustained train activity does not neccessary reflect nerve root
injury)
Electrical Electromyography (triggered)
Introduction
o allows detection of a breached pedicle screw
Technique
o concept
bone conducts electricity poorly
an electrically stimulated pedicle screw that is confined to bone will not stimulate the nerve
root
if there is a breach in a pedicle, stimulation of the screw will lead to activity of that specific
nerve root
o signal initiation
electrical stimulation of placed pedicle screw
o signal recording
muscle contraction in extremity
Advantages
o allows monitoring of specific nerve roots
Disadvantages
o may be overly sensitive (e.g., sustained train activity does not neccessary reflect nerve root
injury)
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OrthoBullets2017 Spine Introduction | Infection
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Infection
direct inoculation
can occur after penetrating trauma, open fractures, and following surgical procedure
contiguous spread from local infection
most commonly associated with retropharyngeal and retroperitoneal abscesses
o neurologic involvement
neurologic deficits present in 10-20%
results from
direct infectious involvement of neural elements
compression from an epidural abscess
compression from instability of the spine
Associated conditions
o epidural abscess
defined as a collection of pus or inflammatory granulation tissue between dura mater and
surrounding adipose tissue
epidemiology
usually associated with vertebral osteomyelitis
present in ~18% of patients with spondylodiskitis
50% of patients with an epidural abscess will have neurologic symptoms
Presentation
History
o history of UTI, pneumonia, skin infection, of organ transplant are common
Symptoms
o fever is only present in 1/3 of patients
o pain
pain is often severe and insidious in onset
pain is usually worse with activity and unrelenting in nature
pain that awakens patients at night should raise concern for malignancy and infection
o neurologic symptoms present in 10-20%
radiculopathy
myelopathy
Physical exam
o perform careful neurological exam
Imaging
Radiographs
o findings are usually delayed by weeks
o findings include
paraspinous soft tissue swelling (loss of psoas shadow)
I:8 disc space narrowin
seen if first few days
disc space narrowing and disc destruction
seen at 7-10 days
remember disc destruction is atypical of neoplasm
endplate erosion or sclerosis seen at 10-21 days
local osteopenia
CT
o useful to show bony abnormalities, abscess formation, and extent of bony involvement
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MRI
o MRI with gadolinium contrast
indications
gold standard for diagnosis and treatment
sensitivity and specificity
most sensitive (96%) and specific (93%) imaging modality for diagnosis of spinal
osteomyelitis
also most specific imaging modality to differentiate from tumor
findings include
paraspinal and epidural inflammation
disc and endplate enhancement with gadolinium
T2-weighted hyperintensity of the disk and endplate
rim enhancing
Bone scan
o Technetium Tc99m bone scans
indications
patients who can not obtain an MRI
sensitivity and specificity
90% sensitive but lack specificity
combined Technetium Tc99m and gallium 67 scan is both more specific and more
sensitive than Technetium Tc99m alone
o indium 111 labeled scan
not recommended due to poor sensitivity (17%)
Studies
Laboratory
o WBC
elevated only in ~ 50%
not a sensitive indicator for early infection
o ESR
elevated in 90% of cases
can be monitored serially to track success of treatment, however is considered less reliable
than CRP
o CRP
elevated in 90% of cases
can be monitored serially to track success of treatment and is considered more reliable than
ESR
o Blood cultures
identification of organism is mandatory for treatment
least invasive method to determine a diagnosis
sensitivity & specificity
~33% (reports show 25%-66%) of patients with spondylodiskitis have positive blood
cultures
when positive 85% are accurate for isolating the correct organism
blood culture yield is improved by withholding antibiotic and obtaining cultures when
patient is febrile
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Infection
CT guided biopsy
o indications
in patients who do not have indications for immediate open surgery and blood cultures are
negative
o sensitivity & specificity
can provide diagnosis in 68-86% of patients
o technique
can be guided by fluoroscopy or by CT scan
cultures should be sent for
aerobic
anaerobic
fungal
acid-fast cultures
Open biopsy
o indications : when tissue/organism diagnosis can not be made with noninvasive techniques
o technique : anterior, costotransversectomy, or transpedicular approach used
Differential
Spinal Tumors
o MRI is the most specific imaging modality to differentiate from tumor
features that weigh towards an infection include
disc space involvement
end-plate erosion
significant inflammation
Types of Spinal Osteomyelitis
o Bacterial
o Viral
o Tuberculosis
o Fungal
Treatment
Nonoperative
o bracing and long term antibiotic (6-12 weeks)
indications : most cases
bracing
helps improve pain and prevent deformity
rigid cervicothoracic orthosis or halo required for cervical osteomyelitis
antibiotics
indications
once organism has been identified via blood culture or biopsy
if patient is septic or critically ill then start broad spectrum antibiotics immediately
which include
vancomycin
for pencicillin-resistant and gram-positive bacteria
third-generation cephalosporin
for gram-negative coverage
technique once organism has been identified
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OrthoBullets2017 Spine Introduction | Infection
usually treated with IV culture directed antibiotics until signs of improvement (~ 4-6
weeks) and then converted to PO antibiotics
resistant strains
new antibiotic-resistant strains of microorganisms are becoming more common and
failure to diagnose can have negative consequences
organisms include
MRSA (methicillin-resistant Staph aureus)
VRSA (vancomycin resistant Staph aureus)
VRE (vancomycin resistant enterococcus)
treatment
newer generation antibiotics for antibiotic resistant organisms include linezolid
and daptomycin
outcomes : successful in 80%
Operative
o neurologic decompression, surgical debridement, and spinal stabilization
indications
refractory cases
neurologic deficits
progressive deformity & gross spinal instability
technique
dictated by characteristics of pathology
anterior debridement and strut grafting, +/- posterior instrumentation
considered to be gold standard
posterior debridement and decompression alone
usually ineffective for debridement
may be indicated in some cases
Techniques
Anterior debridement and strut grafting, +/- posterior instrumentation
o goals
identify organism
eliminate infection
prevent or improve neurologic deficits
maintain spinal stability
o techniques
strut graft selection
autogenous tricortical iliac crest, rib, or fibula strut grafts have proven safe and effective
in presence of acute infection
allograft being used with good results, but autogenous sources theoretically have better
incorporation
a recent study showed improved deformity correction with titanium mesh cages filled
with autograft (followed by posterior instrumentation)
instrumentation
spinal instrumentation in presence of active infection is controversial
some advocate I&D followed by staged instrumentation
some advocate a single procedure with bone graft and instrumentation in the presence
of an active infection
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Infection
titanium is preferred over stainless steel
posterior instrumentation
posterior instrumentation indicated when severe kyphotic deformity or a multilevel
anterior construct required
posterior instrumentation can be performed at same time or as a staged procedure
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OrthoBullets2017 Spine Introduction | Infection
o pain
pain is often severe and insidious in onset an occurs in 87%
Physical exam
o neurologic deficits present in ~33%
may present as a radiculopathy or a myelopathy
Labs
WBC
o mean leukocytosis 22,000 cells/mm3
o elevated in ~42%
ESR
o elevated in > 90% of cases (mean 86.3)
CRP
o elevated in 90% of cases
Imaging
Radiographs
o usually normal
CT
o poor sensitivity for epidural abscess
CT myelogram
o 90% sensitivity but invasive
MRI with gadolinium
o the imaging modality of choice for diagnosis of spinal epidural abscess
shows extent of abscess, presence of vertebral osteomyelitis, and allows evaluation of
neurologic compression
gadolinium allows differentiation of pus from CSF
a ring enhancing lesion is pathognomonic for abscess
Treatment
Nonoperative
o bracing and IV antibiotics
indications
small abscess with minimal compression on neural elements and
no neurologic deficits and
a patient capable of close clinical followup
those who are not candidates for surgery due to medical comorbidities
outcomes
historically presence of epidural abscess has been considered a surgical emergency
there has been a recent trend towards nonoperative management as new studies shows
nonoperative treatment effective in patients without neurologic deficit
Operative
o surgical decompression +/- spinal stabilization
indications
neurologic deficits present
evidence of spinal cord compression on imaging studies
persistent infection despite antibiotic therapy
progressive deformity or gross spinal instability
postoperative antibiotics
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Infection
indicated for 2-4 weeks if no bony involvement of infection
indicated for 6 weeks if bony involvement
Techniques
Decompressive laminectomy
o most common form of operative treatment
o indications
indicated when abscess is posterior and there is no contiguous spondylodiscitis
o avoid wide decompression and facetectomy as it will result in spinal instability
Anterior debridement and strut grafting
o indications
abscess is located anteriorly
anterior vertebral body and discs are involved (presence of spondylodiscitis)
3. Spinal Tuberculosis
Introduction
Epidemiology
o incidence
increasing incidence of TB in United States due to increasing immunocompromised
population
o demographics
HIV positive population (often seen in patients with CD4+ count of 50 to 200)
o location
15% of patients with TB will have extrapulmonary involvement
the spine, and specifically, the thoracic spine is the most common extrapulmonary site
5% of all TB patients have spine involvement
Pathoanatomy
o early infection
begins in the metaphysis of the vertebral body
spreads under the anterior longitudinal ligament and leads to
contiguous multilevel involvement
skip lesion or noncontiguous segments (15%)
paraspinal abscess formation (50%)
usually anterior and can be quite large (much more common in TB than pyogenic
infections)
initially does not involve the disc space (distinguishes from pyogenic osteomyelitis, but can
be misdiagnosed as a neoplastic lesion)
o chronic infection
severe kyphosis
mean deformity in nonoperative cases is 15°
in 5% of patients, deformity is >60°
infection is often diagnosed late, there is often much more severe kyphosis
in granulomatous spinal infections compared to pyogenic infections
in adults
kyphosis stays static after healing of disease
in children
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OrthoBullets2017 Spine Introduction | Infection
kyphosis progresses in 40% of cases because of growth spurt
classification of progression (Rajasekaran)
Type-I, increase in deformity until cessation of growth
should be treated with surgery
Type-II, decreasing progression with growth
Type-III, minimal change during either active / healed phases.
Presentation
Symptoms
o onset of symptoms of tuberculous spondylitis is typically more insidious than pyogenic infection
constitutional symptoms
chronic illness
malaise
night sweats
weight loss
back pain
often a late symptom that only occurs after significant boney destruction and deformity.
Physical exam
o kyphotic deformity
o neurologic deficits (present in 10-47% of patients with Pott's Disease)
mechanisms
mechanical pressure on cord by abscess, granulation tissue, tubercular debris, caseous
tissue
mechanical instability from subluxation/dislocation
paraplegia from healed disease can occur with severe deformity
stenosis from ossification of ligamentum flavum adjacent to severe
kyphosis
Imaging
CXR
o 66% will have an abnormal CXR
o should be ordered for any patients in which TB is a possibility
Spine radiographs
o early infection
shows involvement of anterior vertebral body with sparing of the disc space (this finding can
differentiate from pyogenic infection)
o late infection
shows disk space destruction, lucency and compression of adjacent vertebral bodies, and
development of severe kyphosis
o risk factors for buckling collapse ("spine
at risk signs")
retropulsion
subluxation
lateral translation
toppling
MRI with gadolinium contrast
o indications I:9 Spine at risk sign
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Infection
diagnose adjacent levels : multiple levels involved in 16-70%
o findings
low signal on T1-weighted images, bright signal on T2-weighted images
presence of a septate pre-/ paravertebral / intra-osseous smooth walled abscess with a
subligamentous extension and breaching of the epidural space
end-plate disruption
sensitivity 100%, specificity 81%
paravertebral soft tissue shadow
sensitivity 97%, specificity 85%
high signal intensity of the disc on the T2-
weighted image
sensitivity 81%, specificity 82%
spinal cord
edema
myelomalacia
atrophy
syringomyelia
CT
o indications
demonstrates lesions <1.5cm better than radiographs
inaccurate for defining epidural extension
o findings
types of destruction
fragmentary
osteolytic
subperiosteal
sclerotic
Nuclear medicine studies : obtain with combination of technetium and gallium
o shown to have highest sensitivity for detecting infection
Studies
CBC
o relative lymphocytosis
o low hemoglobin
ESR
o usually elevated but may be normal in up to 25%
PPD (purified protein derivative of tuberculin)
o positive in ~ 80%
Diagnosis
o CT guided biopsy with cultures and staining effective at obtaining diagnosis
should be tested for acid-fast bacilli (AFB)
mycobacteria (acid-fast bacilli) may take 10 weeks to grow in culture
PCR allows for faster identification (95% sensitivity and 93% accuracy)
smear positive in 52%
culture positive in 83%
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Differential
Other etiologies of granulomatous infection may have similar clinical picture as TB and include
o atypical bacteria
Actinomyces israelii
Nocardia asteroids
Brucella
o fungi
Coccidioides immitis
Blastomyces dermatitidis
Cryptococcus neoformans
Aspergillosis
o spirochetes
Treponema pallidum
Treatment
Nonoperative
o pharmacologic treatment +/- spinal orthosis
indications
no neurological deficit
drugs are the mainstay of treatment in most cases
pharmacologic
agents : isoniazid (H), rifampin (R), ethambutol (E) and pyrazanamide (Z) therapy
regimen : RHZE for 2 months, then RH for 9 to 18 months
spinal orthosis
indications : may be used for pain control and prevention of deformity
Operative
o anterior decompression/corpectomy, strut grafting ± posterior instrumented stabilization ±
posterior column shortening
indications
neurologic deficit
worsening neurological deficit
acute severe paraplegia
with panvertebral involvement with/without subluxation/dislocation
spinal instability
kyphosis correction
> 60° in adult
progressive kyphosis in child
≥3 vertebrae involved with loss of ≥1.5 vertebral bodies in thoracic spine
children ≤ 7 years with ≥3 vertebral bodies affected in T/TL spine and ≥ 2 at risk
signs are likely to have progression and should undergo correction
late onset paraplegia (from kyphosis)
cosmetic correction of kyphosis controversial
advanced disease with caseation preventing access by antibiotics
failure of nonoperative treatment after 3 to 6 months
diagnosis uncertain
panvertebral lesion
advantages of surgical treatment
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Infection
less progressive kyphosis
earlier healing
decreased sinus formation
in patients with neurologic deficits, early debridement and decompression led to
improved neurologic recovery
technical aspects
autogenous and allograft strut grafts are acceptable with good results
continue medical management with isoniazid, rifampin, and pyrazanamide
chronic implant colonization is less common in TB and other granulomatous infections
compared to more common pyogenic infections
o Halo traction, anterior decompression, bone grafting, anterior plating
indications
cervical kyphosis
o Pedicle subtraction osteotomy
indications
lumbar kyphosis
o Direct decompression / internal kyphectomy
indications
correction of healed thoracic/thoracolumbar kyphosis
allows spinal cord to transpose anteriorly
Surgical Technique
Anterior decompression/corpectomy, strut grafting ± posterior instrumented stabilization ±
posterior column shortening
o indications (see above)
kyphosis
active disease
o techniques
single-stage transpedicular
2-stage
anterior decompression with bone grafting
posterior kyphosis correction and instrumentation
single-stage extrapleural anterolateral
Complications
Deformity (kyphosis/gibbus)
o highest risk
after anterior decompression and grafting alone
slippage and breakage of graft (especially if ≥ 2 levels)
o lowest risk
after both anterior and posterior fusion
Retropharyngeal abscess affects swallowing/hoarseness
TB arteritis and pseudoaneurysm
Respiratory compromise if there is costopelvic impingement
Sinus formation
Pott's paraplegia
o spinal cord injury can be caused by abscess/bony sequestra or meningomyelitis
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OrthoBullets2017 Spine Introduction | Infection
o abscess/bony sequestra has a better prognosis than meningomyelitis as the cause of spinal cord
injury
Atypical Spinal Tuberculosis
definition
o compressive myelopathy without visible spinal deformity, without typical radiological
appearance
etiology
o intraspinal granuloma, neural arch involvement, concertina collapse of vertebra body ,
sclerotic vertebra with bridging of vertebral body
treatment
o laminectomy
indications
extradural extraosseous granuloma
subdural granuloma
o decompression and myelotomy
indications
intramedullary granuloma
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By Dr, AbdulRahman AbdulNasser Spine Introduction | Infection
o in pediatric patients, blood vessels extend from the cartilaginous end plate into the nucleus
pulposus
o in adult patients, blood vessels extend only to the annulus fibrosis
Presentation
Symptoms depend on age of child
o toddler
refusal to sit or walk, or painful limping
loss of appetite
fever (only 25% of patients will be febrile)
abdominal pain
o older children
back pain with point tenderness
Physical exam
o tender to palpation over involved level
o limited range of motion
Imaging
Radiographs
o radiographic findings are unreliable
o earliest manifestation is at 1 week
o findings
usually normal radiographs early in process
loss of lumbar lordosis may be earliest radiographic sign
disc space narrowing (10-21 days after infection begins)
endplate erosion (10-21 days after infection begins)
MRI
o diagnostic test of choice
I:10 disc space narrowing
Studies
Serum Labs
o ESR
high normal or mildly elevated
o C-reactive protein
high normal or mildly elevated
o WBC
high normal or mildly elevated
Blood Cultures
o blood cultures should be obtained to identify organism
Treatment
Nonoperative I:11 MRI showing pediatric
o bedrest, immobilization, and antibiotics for 4-6 weeks discitis
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OrthoBullets2017 Spine Introduction | Infection
Operative
o surgical debridement followed by antibiotic treatment
indications
late infection
paraspinal abscess in the presence of neurologic deficits
limited responsiveness to nonoperative measures
technique
important to obtain cultures
followed with antibiotics and bracing
Complications
Long term narrowing of disk space
Fusion between vertebra
Back pain
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Infection
ORTHO BULLETS
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OrthoBullets2017 Degenerative Spine | Cervical Conditions
A. Cervical Conditions
1. Cervical Spondylosis
Introduction
Cervical spondylosis represents the natural degenerative process of the cervical motion segement
(intervertebral disc and facets)
o often leads to the clinical conditions of
cervical radiculopathy
cervical myelopathy
discogenic neck pain
Epidemiology
o incidence
typically begins at age 40-50
85% of patients >65 years of age demonstrate spondylotic changes regardless of
symptomatology
o demographics
more common in men than women
o location
most common levels are C5-6 > C6-7 because they are associated with the most flexion and
extension in the subaxial spine
Pathophysiology
o pathoanatomy
see below
o risk factors include
excessive driving
smoking
lifting
professional athletes
Pathoanatomy
Spondylosis is a natural aging process of the spine
o characterized by degeneration of the disc and the four joints of the cervical motion segment
which include
two facet joints
two uncovertebral joints of Luschka)
Degenerative cycle includes
o disc degeneration
disc dessication, loss of disc height, disc bulging, and possible disc hernaition
o joint degeneration
uncinate spurring and facet arthrosis
o ligamentous changes
ligamentum flavum thickening and infolding secodary to loss of disc height
o deformity
kyphosis secondary to loss of disc height with resulting transfer of load to the facet and
uncovertebral joints, leading to further uncinate spurring and facet arthrosis
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Cervical Conditions
Mechanism of Neurologic Compression
Nerve root compression
o leads to the clinical condition of radiculopathy
o foraminal spondylotic changes
secondary to chondrosseous spurs of facet and uncovertebral joints
o posterolateral disc herniation or disc-osteophyte complex
between posterior edge of uncinate and lateral edge of posterior longitudinal ligament (PLL)
affects the exiting nerve root (C6/7 disease will affect the C7 nerve root)
o foraminal soft disc herniation
affects the exiting nerve root (C6/7 disease will affect the C7 nerve root)s
Central cord compression (central stenosis)
o leads to the clinical condition of myelopathy
o occurs with canal diameter is < 13mm (normal is 17mm)
o worse during neck extension whe central cord is pinched between
degenerative disc (anterior)
hypertrophic facets and infolded ligamentum (posterior)
Imaging
Radiographs
o common radiographic findings include
degenerative changes of uncovertebral and facet joints
osteophyte formation
disc space narrowing
endplate sclerosis
decreased sagital diameter (cord compression occurs with canal diameter is < 13mm)
o incidence
radiographic findings often do not correlate with symptoms
o lateral
important to look for sagital alignment and size of spinal canal
o oblique
important to look for foraminal stenosis which often caused by uncovertebral joint arthrosis
o flexion and extension views
important to look for angular or translational instability
look for compensatory subluxation above or below the spondylotic/stiff segment
MRI
o axial imaging is the modality of choice and gives needed information on the status of the soft
tissues. It may show
disc degeneration
spinal cord changes (myelomalacia)
preoperative planning
o has high rate of false positive (28% greater than 40 will have findings of HNP or foraminal
stenosis)
CT myelography
o can give useful information on bony anatomy
o most useful when combined with intrathecal injection of contrast (myelography) to see status of
neural elements
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o contrast given via C1-C2 puncture and allowed to diffuse caudally or given via a lumbar
puncture and allowed to diffuse proximally by putting patient in trendelenburg position.
o paricularly useful in patients that can not have an MRI (pacemaker) or has artifact (local
hardware)
Discography
o controversial and rarely indicated in cervical spondylosis
o approach is similar to that used with ACDF
o risks include esophageal puncture and disc infection
Clinical Presentation
Axial neck pain
Cervical radiculopathy
Cervical myelopathy
2. Cervical Stenosis
Introduction
Cervical stenosis may be
o congenital
o acquired (traumatic, degenerative)
Associated conditions
o Spear tackler's spine
a syndrome of cervical stenosis caused by repetitive microtrauma and improper tackling
techniques
is considered a contraindication to return to play
Prognosis
o cervical stenosis places a patient at increased risk for radiculopathy/myelopathy/SCI even from
minor trauma or cervical spondylosis
therefore congenital cervical stenosis is an important consideration in the athlete
Classification
Absolute cervical stenosis
o defined as canal diameter < 10mm
Relative cervical stenosis
o defined as canal diameter of 10-13mm
Imaging
Radiographs
o recommended views
ap, lateral, flexion/extension views of cervical spine
o radiographic risk factors for neurologic involvement on lateral radiograph include
canal diameter of < 13mm (normal is ~17mm)
Torg-Pavlov ratio (canal/vertebral body width) of < 0.8 (normal is 1.0)
Torg ratio is technique dependent, not predictive, and not accurate in large athletes
MRI : study of choice to evaluate soft tissue anatomy and neural impingement
Evaluation
Somatosensory evoked potentials
o may help identify cord compromise in absolute stenosis
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Cervical Conditions
Treatment
Nonoperative
o observation with possible activity restrictions
indications
patients without neurologic symptoms
contraindications to return to play (controversial)
loss of the CSF around the cord or deformation of the spinal cord documented by MRI
especially with
history of multiple episodes of transient quadriparesis
bilateral extremity symptoms
spear tackler's spine
Torg ratio of <0.8 alone is not considered a contraindication to return to play
Operative
o surgical decompression and stabilization
indications
radiculopathy
myelopathy
in some cases surgery may be indicated as a prophylactic measure
3. Cervical Myelopathy
Introduction
A clinical syndrome caused by compression on the spinal cord that is characterized by
o clumsiness in hands
o gait imbalance
Pathophysiology
o etiology
degenerative cervical spondylosis (CSM)
most common cause of cervical myelopathy
compression usually caused by anterior degenerative changes (osteophytes,
discosteophyte complex)
degenerative spondylolisthesis and hypertrophy of ligamentum flavum may contribute
congenital stenosis
symptoms usually begin when congenital narrowing combined with spondylotic
degenerative changes in older patients
OPLL
tumor
epidural abscess
trauma
cervical kyphosis
o neurologic injury
mechanism of injury can be
direct cord compression
ischemic injury secondary to compression of anterior spinal artery
Associated conditions
o lumbar spinal stenosis
tandem stenosis occurs in lumbar and cervical spine in ~20% of patients
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Prognosis
o natural history
tends to be slowly progressive and rarely improves with nonoperative modalities
progression characterized by steplike deterioration with periods of stable symptoms
o prognosis
early recognition and treatment prior to spinal cord damage is critical for good clinical
outcomes
Classification of Myelopathy
Nurick Classification
Grade 0 Root symptoms only or normal
Grade 1 Signs of cord compression; normal gait
Grade 2 Gait difficulties but fully employed
Grade 3 Gait difficulties prevent employment, walks unassisted
Grade 4 Unable to walk without assistance
Grade 5 Wheelchair or bedbound
Ranawat Classification
Class I Pain, no neurologic deficit
Class II Subjective weakness, hyperreflexia, dyssthesias
Class IIIA Objective weakness, long tract signs, ambulatory
Class IIIB Objective weakness, long tract signs, non-ambulatory
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Cervical Conditions
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OrthoBullets2017 Degenerative Spine | Cervical Conditions
Presentation of Myelopathy
Symptoms
o neck pain and stiffness
axial neck pain (often times absent)
occipital headache common
o extremity paresthesias
diffuse nondermatomal numbness and tingling
o weakness and clumsiness
weakness and decreased manual dexterity (dropping object, difficulty manipulating fine
objects)
o gait instability
patient feels "unstable" on feet
weakness walking up and down stairs
gait changes are most important clinical predictor
o urinary retention
rare and only appear late in disease progression
not very useful in diagnosis due to high prevalence of urinary conditions in this patient
population
Physical exam
o motor
weakness
usually difficult to detect on physical exam
lower extremity weakness is a more concerning finding
finger escape sign
when patient holds fingers extended and adducted, the small finger spontaneously abducts
due to weakness of intrinsic muscle
grip and release test
normally a patient can make a fist and release 20 times in 10 seconds. myelopathic
patients may struggle to do this
o sensory
proprioception dysfunction
due to dorsal column
involvement
occurs in advanced disease
associated with a poor prognosis
decreased pain sensation
pinprick testing should be done
to look for global decrease in
sensation or dermatomal changes
due to involvement of lateral
spinothalamic tract
vibratory changes are usually only found in severe case of long-standing myelopathy
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Cervical Conditions
o upper motor neuron signs (spasticity)
hyperreflexia
may be absent when there is concomitant peripheral nerve disease (cervical or lumbar
nerve root compression, spinal stenosis, diabetes)
inverted radial reflex
tapping distal brachioradialis tendon produces ipsilateral finger flexion
Hoffmann's sign
snapping patients distal phalanx of middle finger leads to spontaneous flexion of other
fingers
sustained clonus
> three beats defined as sustained clonus
sustained clonus has poor sensitivity (~13%) but high specificity (~100%) for cervical
myelopathy
Babinski test
considered positive with extension of great toe
o gait and balance
toe-to-heel walk
patient has difficulty performing
Romberg test
patient stands with arms held forward and eyes closed
loss of balance consistent with posterior column dysfunction
o provocative tests
Lhermitte Sign
test is positive when extreme cervical flexion leads to electric shock-like sensations that
radiate down the spine and into the extremities
Evaluation
Radiographs
o recommended views
cervical AP, lateral, oblique, flexion, and extension views
o general findings
degenerative changes of uncovertebral and facet joints
osteophyte formation
disc space narrowing
decreased sagittal diameter
cord compression occurs with canal diameter is < 13mm
o lateral radiograph
important to look for diameter of spinal canal
a Pavlov ratio of less than 0.8 suggest a congenitally narrow spinal canal predisposing to
stenosis and cord compression
sagittal alignment
C2 to C7 alignment
determined by tangential lines on the posterior edge of the C2 and C7 body on lateral
radiographs in neutral position
local kyphosis angle
the angle between the lines drawn at the posterior margin of most cranial and caudal
vertebral bodies forming the maximum local kyphosis
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o oblique radiograph
important to look for foraminal stenosis which often caused by uncovertebral joint arthrosis
o flexion and extension views
important to look for angular or translational instability
look for compensatory subluxation above or below the spondylotic/stiff segment
o sensitivity/specificity
changes often do not correlate with symptoms
70% of patients by 70 yrs of age will have degenerative changes seen on plain xrays
MRI
o indications
MRI is study of choice to evaluate degree of spinal cord and nerve root compression
o findings
effacement of CSF indicates functional stenosis
spinal cord signal changes
seen as bright signal on T2 images (myelomalacia)
signal changes on T1-weighted images correlate with a poorer prognosis following
surgical decompression
compression ratio of < 0.4 carries poor prognosis
CR = smallest AP diameter of cord / largest transverse diameter of cord
o sensitivity/specificity
has high rate of false positive (28% greater than 40 will have findings of HNP or foraminal
stenosis)
CT without contrast
o can provide complementary information with an MRI, and is more useful to evaluate OPLL and
osteophytes
CT myelography
o more invasive than an MRI but gives excellent information regarding degrees of spinal cord
compression
o useful in patients that cannot have an MRI (pacemaker), or have artifact (local hardware)
o contrast given via C1-C2 puncture and allowed to diffuse caudally, or given via a lumbar
puncture and allowed to diffuse proximally by putting patient in trendelenburg position.
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Cervical Conditions
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Cervical Conditions
Techniques
Goals
o optimal surgical treatment depends on the individual. Things to consider include
number of stenotic levels
sagittal alignment of the spine
degree of existing motion and desire to maintain
medical comorbidities (eg, dysphasia)
simplified treatment algorithm (see figures above)
Anterior Decompression and Fusion (ACDF) alone
o indications
mainstay of treatment in most patients with single or two level disease
fixed cervical kyphosis of > 10 degrees
anterior procedure can correct kyphosis
compression arising from 2 or fewer disc segments
pathology is anterior (OPLL, soft discs, disc osteophyte complexes)
o approach
uses Smith-Robinson anterior approach
o decompression
corpectomy and strut graft may be required for multilevel spondylosis
two level corpectomies tend to be biomechanically vulnerable (preferable to combine
single level corpectomy with adjacent level diskectomy)
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7% to 20% rates of graft dislodgement with cervical corpectomy with associated severe
complications, including death, reported.
o fixation
anterior plating functions to increase fusion rates and preserve position of interbody cage or
strut graft
o pros & cons
advantages compared to posterior approach
lower infection rate
less blood loss
less postoperative pain
disadvantages
avoid in patients with poor swallowing function
Laminectomy with posterior fusion
o indications
multilevel compression with kyphosis of < 10 degrees
> 13 degrees of fixed kyphosis is a contraindication for a posterior procedure
in flexible kyphotic spine, posterior decompression and fusion may be indicated if kyphotic
deformity can be corrected prior to instrumentation
o contraindications
fixed kyphosis of > 10 degrees is a contraindication to posterior decompression
will not adequately decompress spinal cord as it is "bowstringing" anterior
o pros & cons
fusion may improve neck pain associated with degenerative facets
not effective in patients with > 10 degrees fixed kyphosis
Laminoplasty
o indications
gaining in popularity
useful when maintaining motion is desired
avoids complications of fusion so may be indicated in patients at high risk of pseudoarthrosis
o contraindications
cervical kyphosis
> 13 degrees is a contraindication to posterior decompression
will not adequately decompress spinal cord as it is "bowstringing" anterior
severe axial neck pain
is a relative contraindication and these patients should be fused
o technique
volume of canal is expanded by hinged-door laminoplasty followed by fusion
usually performed from C3 to C7
open door technique
hinge created unilateral at junction of lateral mass and lamina and opening on opposite
side
opening held open by bone, suture anchors, or special plates
French door technique
hinge created bilaterally and opening created midline
o pros & cons
advantages
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Cervical Conditions
allows for decompression of multilevel
stenotic myelopathy without
compromising stability and motion (avoids
postlaminectomy kyphosis)
lower complication rate than multilevel
anterior decompression
especially in patients with OPLL
a motion-preserving technique
pseudoarthrosis not a concern in
patients with poor healing potential
(diabetes, chronic steroid users)
can be combined with a subsequent
anterior procedure
disadvantages
higher average blood loss than anterior procedures II:2 before and after open door technique
postoperative neck pain
still associated with loss of motion
o outcomes
equivalent to multilevel anterior decompression and fusion
Combined anterior and posterior surgery
o indications
multilevel stenosis in the rigid kyphotic spine
multi-level anterior cervical corpectomies
postlaminectomy kyphosis
Laminectomy alone
o indications
rarely indicated due to risk of post laminectomy kyphosis
o pros & cons
progressive kyphosis
11 to 47% incidence if laminectomy performed alone without fusion
Complications
Surgical Infection
o higher rate of surgical infection with posterior approach than anterior approach
Pseudoarthrosis
o incidence
12% for single level fusions, 30% for multilevel fusions
o treatment
treat with either posterior wiring or plating or repeat anterior decompression and plating if
patient has symptoms of radiculopathy
Postoperative C5 palsy
o incidence
reported to occur in ~ 4.6% of patients after surgery for cervical compression myelopathy
no significant differences between patients undergoing anterior decompression and fusion
and posterior laminoplasty
occurs immediately postop to weeks following surgery
o mechanism
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mechanism is controversial
in laminectomy patients, it is thought to be caused by tethering of nerve root with dorsal
migration of spinal cord following removal of posterior elements
o prognosis
patients with postoperative C5 palsy generally have a good prognosis for functional recovery,
but recovery takes time
Recurrent laryngeal nerve injury
o approach
in the past it has been postulated that the RLN is more vulnerable to injury on the right due to
a more aberrant pathway
recent studies have shown there is not an increased injury rate with a right sided approach
o treatment
if you have a postoperative RLN palsy, watch over time
if not improved over 6 weeks, then ENT consult to scope patient and inject teflon
if you are performing revision anterior cervical surgery, and there is an any suspicion of a
RLN from the first operation, obtain ENT consult to establish prior injury
if patient has prior RLN nerve injury, perform revision surgery on the same as the prior
injury/approach to prevent a bilateral RLN injury
Hardware failure and migration
o 7-20% with two level anterior corpectomies
o two-level corpectomies should be stabilized from behind
Postlaminectomy kyphosis
o treat with anterior/posterior procedure
Postoperative axial neck pain
Vertebral artery injury
Esophageal Injury
Dysphagia & alteration in speech
4. Cervical Radiculopathy
Introduction
A clinical symptom caused by nerve root compression in the cervical spine
o characterized by sensory or motor symptoms in the upper extremity
Pathophysiology
o causes
degenerative cervical spondylosis
discosteophyte complex and loss of disc height
chondrosseous spurs of facet and uncovertebral joints
disc herniation ("soft disc")
usually posterolateral
between posterior edge of uncinate and lateral edge of PLL
o neural compression
nerve root irritation caused by
direct compression
irritation by chemical pain mediators, including
IL-1
IL-6
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Cervical Conditions
substance P
bradykinin
TNF alpha
prostaglandins
affects the nerve root below
C6/7 disease will affect the C7 nerve root
Anatomy
Nerve root anatomy
o key differences between cervical and lumbar spine are
pedicle/nerve root mismatch
cervical spine C6 nerve root travels above C6 pedicle (mismatch)
lumbar spine L5 nerve root travels under L5 pedicle (match)
extra C8 nerve root (no C8 pedicle) allows transition
horizontal (cervical) vs. vertical (lumbar) anatomy of nerve root
because of vertical anatomy of lumbar nerve root, a paracentral and foraminal disc will
affect different nerve roots
because of horizontal anatomy of cervical nerve root, a central and foraminal disc will
affect the same nerve root
Symptoms
Symptoms
o occipital headache (common)
o trapezial or interscapular pain
o neck pain
may present with insidious onset of neck pain that is worse with vertebral motion
origin may be discogenic, or mechanical due to facet arthrosis
pain may radiate to shoulders
o unilateral arm pain
aching pain radiating down arm
often global and nondermatomal
o unilateral dermatomal numbness & tingling
numbness/tingling in thumb (C6)
numbness/tingling in middle finger (C7)
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o unilateral weakness
difficulty with overhead activities (C7)
difficulty with grip strength (C7)
Physical exam
o common and testable exam findings
C5 radiculopathy
deltoid and biceps weakness
diminished biceps reflex
C6 radiculopathy
brachioradialis and wrist extension weakness
diminished brachioradialis reflex
paresthesias in thumb
C7 radiculopathy
triceps and wrist flexion weakness
diminished triceps reflex
paresthesia in the index,middle, ring
C8 radiculopathy
weakness to distal phalanx flexion of middle and index finger (difficulty with fine motor
function)
paresthesias in little finger
o provocative tests
Spurling Test positive
simultaneous extension, rotation to affected side, lateral bend, and vertical compression
reproduces symptoms in ipsilateral arm
shoulder abduction test
shoulder abduction relieves symptoms
shoulder abduction (lifting arm above head) often relieves symptoms
valuable physical exam test to differentiate cervical pathology from other causes of
shoulder/arm pain
o myelopathy
check for findings of myelopathy in large central disc herniations
Imaging
Radiographs
o recommended views
AP, lateral, oblique views of cervical spine
obtain flexion and extension views if suspicion for instability
o findings
general
degenerative changes of uncovertebral and facet joints
osteophyte formation
disc space narrowing & endplate sclerosis
lateral radiograph
important to look for sagittal alignment and spinal canal diameter
oblique radiograph
best view to identify foraminal stenosis caused by osteophytes
flexion and extension views
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Cervical Conditions
important to look for angular or translational instability
look for compensatory subluxation above or below the spondylotic/stiff segment
o sensitivity & specificity
changes often do not correlate with symptoms
70% of patients by 70 yrs of age will have degenerative changes seen on plain xrays
MRI
o views
T2 axial imaging is the modality of choice and gives needed information on the status of the
soft tissues.
o findings
disc degeneration and herniation
foraminal stenosis with nerve root compression (loss of perineural fat)
central compression with CSF effacement
o sensitivity & specificity
has high rate of false positive (28% greater than 40 will have findings of HNP or foraminal
stenosis)
CT
o indications
gives useful information on bony anatomy including osteophyte
formation that is compressing the neural elements
useful as a preoperative planning tool to plan instrumentation
study of choice to evaluate for postoperative pseudoarthosis
CT myelography
o indications
largely replaced by MRI
useful in patients who cannot have an MRI due to pacemaker,
etc
useful in patients with prior surgery and hardware causing artifact on MRI
o technique
intrathecal injection of contrast given via C1-C2 puncture and allowed to diffuse caudally
lumbar puncture and allowed to diffuse proximally by putting patient in Trendelenburg
position.
Discography
o indications
controversial and rarely indicated in cervical spondylosis
o techniques
approach is similar to that used with ACDF
o risks include esophageal puncture and disc infection
Studies
Nerve conduction studies
o high false negative rate
o may be useful to distinguish peripheral from central process (ALS)
Selective nerve root corticosteroid injections
o may help confirm level of radiculopathy in patients with multiple level disease, and
when physical exam findings and EMG fail to localize level
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Differential
Carpal tunnel syndrome
Cubital tunnel syndrome
Parsonage-Turner Syndrome
Treatment
Nonoperative
o rest, medications, and rehabilitation
indications
75% of patients with radiculopathy improve with nonoperative management
improvement via resorption of soft discs and decreased inflammation around irritated
nerve roots
techniques (very few substantiated by evidence)
immobilization
immobilization for short period of time (< 1-2 weeks) may help by decreasing
inflammation and muscles spasm
medications
NSAIDS / COX-2 inhibitors
oral corticosteroids
GABA inhibitors (neurontin)
narcotics
muscle relaxants
rehabilitation
moist heat
cervical isometric exercises
traction/manipulation
avoid in myelopathic patients
return to play
indicated after resolution of symptoms and repeat MRI demonstrating no cord
compression
studies have shown return to play expedited with brief course of oral methylprednisolone
(medrol dose pack)
no increased risk of subsequent spinal cord injury
o selective nerve root corticosteroid injections
indications
may be considered as therapeutic or diagnostic option
outcomes
increased risk when compared to lumbar selective nerve root injections with the
following rare but possible complications, including
dural puncture
meningitis
epidural abscess
nerve root injury
Operative
o anterior cervical discectomy and fusion
indications
persistent and disabling pain that has failed nonoperative modalities
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Cervical Conditions
progressive and significant neurologic deficits
outcomes
remains gold standard in surgical treatment of cervical radiculopathy
single level ACDF is not a contraindication for return to play for athletes
o posterior foraminotomy
indications
foraminal soft disc herniation causing single level radiculopathy ideal
may be used in osteophytic foraminal narrowing
outcomes
91% success rate
reduces the risk of iatrogenic injury with anterior approaches
o cervical total disc replacement
indications (controversial)
single level disease with minimal arthrosis of the facets
outcomes
studies show equivalence to ACDF
effect on adjacent level disease remains unclear
some studies show 3% per year for all approaches
Techniques
Anterior Cervical Discectomy and Fusion (ACDF)
o approach
uses Smith-Robinson anterior approach
o techniques
decompression
placement of bone graft increases disk height and decompresses the neural foramen
through indirect decompression
corpectomy and strut graft may be required for multilevel spondylosis
fixation
anterior plating functions to increase fusion rates and preserve position of interbody cage
or strut graft
o pros and cons
complications of anterior surgery including persistent swallowing problems
Posterior foraminotomy
o approach
posterior approach
o technique
if anterior disc herniation is to be removed, then superior portion of inferior pedicle should be
removed
o pros & cons
advantages
avoids need for fusion
avoids problems associated with anterior procedure
disadvantages
more difficult to remove discosteophyte complex
disc height can not be restored
Total disc replacement
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o approach
uses Smith-Robinson anterior approach
o pros & cons
avoids nonunions
Complications
Pseudoarthrosis
o incidence
5 to 10% for single level fusions, 30% for multilevel fusions
risk factors
smoking
diabetes
multi-level fusions
o treatment
if asymptomatic observe
if symptomatic, treat with either posterior cervical fusion or repeat anterior decompression
and plating if patient has symptoms of radiculopathy
improved fusion rates seen with posterior fusion
Recurrent laryngeal nerve injury (1%)
o laryngeal nerve follows aberrant pathway on the right
although theoretically the nerve is at greater risk of injury with a right sided approach, there
is no evidence to support a greater incidence of nerve injury with a right sided approach.
o treatment
initial treatment is observation
if not improved over 6 weeks, than ENT consult to scope patient and inject teflon
Hypoglossal nerve injury
o a recognized complication after surgery in the upper cervical spine with an anterior approach
o tongue will deviate to side of injury
Vascular injury
o vertebral artery injury (can be fatal)
Dysphagia
o higher risk at higher levels (C3-4)
Horner's syndrome
o characterized by ptosis, anhydrosis, miosis, enophthalmos and loss of ciliospinal reflex on the
affected side of the face
o caused by injury to sympathetic chain, which sits on the lateral border of the longus coli muscle
at C6
Adjacent segment disease
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Cervical Conditions
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indications
goal is to prevent further neurologic progression and surgery may not reverse existing
deficits
Atlantoaxial Subluxation
Introduction
o present in 50-80% of patients with RA
o most common to have anterior subluxation of C1 on C2 (can have lateral and posterior)
Mechanism
o caused by pannus formation between dens and ring of C1 that leads to the destruction
of transverse ligament and dens
Radiographs
o controlled flexion-extension views to determine AADI and SAC/PADI
AADI (anterior atlanto-dens interval)
instability defined as > 3.5 mm of motion between flexion and extension views
instability alone is not an indication for surgery
> 7 mm of motion may indicate disruption of alar ligament
> 10 mm motion is indication for surgery
because of increased risk of neurologic injury
PADI / SAC (posterior atlanto-dens interval and space available for cord describe same
thing)
<14 mm is an indication for surgery
because of increased risk of neurologic injury
>13mm is the most important radiographic finding that may predict complete neural
recovery after decompressive surgery
Treatment
o nonoperative : indicated in stable atlantoaxial subluxation
o operative
posterior C1-C2 fusion
general indications for surgery
AADI > 10 mm (even if no neuro deficits)
SAC / PADI < 14 mm (even if no neuro deficits)
progressive myelopathy
indications for posterior C1-2 fusion
able to reduce C1 to C2 so no need to remove posterior arch of C1
technique
adding transarticular screws eliminated need for halo immobilization (obtain
preoperative CT to identify location of vertebral arteries)
occiput-C2 fusion ± resection of posterior C1 arch
indications
when atlantoaxial subluxation is combined with basilar invagination
resection of C1 posterior arch for complete decompression
leads to indirect decompression of anterior cord compression by pannus
may be required if atlantoaxial subluxation is not reducible
odontoidectomy : indications
rarely indicated
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Cervical Conditions
used as a secondary procedure when there is residual anterior cord compression due to
pannus formation that fails to resolve with time following a posterior spinal fusion
pannus often resolves following posterior fusion alone due to decrease in
instability
Basilar Invagination
Introduction
o also known as superior migration of odontoid (SMO)
tip of dens migrates above foramen magnum
o present in 40% of RA patients
o often seen in combination with fixed atlantoaxial subluxation
Mechanism
o cranial migration of dens from erosion and bone loss between occiput and C1&C2
Imaging
o radiographic lines
Ranawat C1-C2 index
center of C2 pedicle to a line connecting the anterior and posterior C1 arches
normal measurement in men is 17 mm, whereas in women it is 15 mm
distance of < 13 mm is consistent with impaction
most reproducible measurement
McGregor's line
line drawn from the posterior edge of the hard palate to the caudal posterior occiput curve
cranial settling is present when the tip of dens is more than 4.5 mm above this line
can be difficult when there is dens erosion
Chamberlain's line
line from dorsal margin of hard palate->posterior edge of the foramen magnum
abnormal if tip of dens > 5 mm proximal Chamberlain's line
normal distance from tip of dens to basion of occiput is 4-5 mm
this line is often hard to visualize on standard radiographs
McRae's line
defines the opening of the foramen magnum
the tip of the dens may protrude slightly above this line, but if the dens is below this line
then impaction is not present
o MRI : cervicomedullary angle < 135° suggest impending neurologic impairment
Treatment
o operative
C2 to occiput fusion
indications
progressive cranial migration (> 5 mm)
neurologic compromise
cervicomedullary angle <135° on MRI
transoral or anterior retropharyngeal odontoid resection
indications : brain stem compromise
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Cervical Conditions
Subaxial subluxation
Introduction
o present in 20% with RA
o often occurs at multiple levels
o often combined with upper c-spine instability
o lower spine involvement more common with
steroid use
males
seropositive RA
nodules present
severe RA
Pathophysiology
o pannus formation and soft tissue instability of facet joints and Luschka joints
Radiographs
o subaxial subluxation (of vertebral body) of >4mm or >20% indicates cord compression
o cervical height index (body height/width) < 2.0 is almost 100% sensitive and specific for
predicting neurologic compromise
Treatment
o operative
posterior fusion and wiring
indications
> 4mm / >20% subaxial subluxation + intractable pain and neurologic symptoms
Operative Complications
Failure to improve symptoms
o outcome less reliable in Ranawat Grade IIIB (objectively weak with UMN signs and
nonambulatory)
Pseudoarthrosis
o 10-20% pseudoarthrosis rate
o decreased by extension to occiput
Adjacent level degeneration
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Indications
Indications
o single and double level cervical radiculopathy
o single and double level cervical myelopathy
Preoperative Imaging
Radiographs
o AP and lateral of cervical spine
CT scan
o useful to determine positioning and sizing of THA
MRI
o required to evaluate central and foraminal stenosis.
Technique
Approach
o anterior approach to cervical spine
Biomechanics
o critical to align center of rotation in both coronal and saggital plane
especially important in two level CDA
Complications
Hardware failure
o may have catastrophic consequece in retropulsion into spinal canal
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Thoracolumbar Conditions
C. Thoracolumbar Conditions
1. Low Back Pain - Introduction
Introduction
Low back pain affects 50-80% of population in lifetime
o $100 billion in annual cost
o second only to respiratory infection as cause to visit doctors office
Etiology
o muscle strain
most common cause of low back pain
o most common degenerative disorders
lumbar spinal stenosis
lumbar disc herniation
discogenic back pain
Risk factors
o obesity, smoking, gender
o lifting, vibration, prolonged sitting
o job dissatisfaction
Red flags
o infection (IV drug user, h/o of fever and chills)
o tumor (h/o or cancer)
o trauma (h/o car accident or fall)
o cauda equina syndrome (bowel/bladder changes)
Outcomes : 90% of low back pain resolves within one year
Presentation
Symptoms
o axial pain
musculogenic
most common cause of back pain
associated with activity
characterized by stiffness and difficulty bending
discogenic pain
controversial
confirmed by discogram
mechanical pain
caused by
facet degeneration
micro and macro instability
worse with activity such as lifting objects and prolonged standing
sacroiliac symptoms
pain originating from sacroiliac joint
o peripheral / neurogenic
radicular pain
unilateral leg pain
usually dermatomal
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referred pain
buttocks
posterior thighs
inguinal region (think L5-S1)
neurogenic claudication
pain in buttock and legs that is worse with prolonged standing
fairly specific for spinal stenosis
myelopathy
clumsiness in hands
gait instability
due to injury of spinal cord (~ L1 or above)
conus medullaris syndrome
cauda equina syndrome
bilateral leg pain
LE weakness
saddle anesthesia
bowel/bladder symptoms
spinal cord injury
incomplete
complete
Wadell Signs
o system to evaluate non-organic back pain symptoms,
o clinically significant if three positive signs are present
superficial and non-anatomic tenderness
pain with axial compression or simulated rotation of the spine
negative straight-leg raise with patient distraction
regional disturbances which do not follow dermatomal pattern
overreaction to physical examination
Imaging
Radiographs
o indications for radiographs
pain lasting > one month and not responding to not nonoperative management
red flags are present
MRI
o highly sensitive and specific
o high rate of abnormal findings on MRI in normal people
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Thoracolumbar Conditions
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Differential
Neck and arm pain
o trauma
o cervical spondylosis
o metastatic disease / infection
o cervical radiculopathy
o cervical myelopathy
o ankylosing spondylitis
Thoracic back and rib pain
o trauma
o metastatic disease / infection
o thoracic disc herniation
o osteoporotic comression fracture
o trauma
Low back pain
o muscles strain
o disc herniation / discogenic pain
o degenerative spondylolithesis
o spinal stenosis
o lumbar radiculopathy
o abdominal aortic aneurism
Sacroiliac pain
o SI infection
o ankylosing spondylitis
Sacral pain
o coccydynia
o sacral insufficiency fracture
Treatment
Treatment dictated by cause of pain.
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Thoracolumbar Conditions
Imaging
Radiographs
o plain radiographs are the first diagnostic study to evaluate for disc degeneration
MRI
o shows degenerative discs without significant stenosis or herniation
Provocative Diskography
o criteria for a positive test
must have concordant pain response
must have abnormal disc morphology on fluoroscopy and postdiskography CT
must have negative control levels in lumbar spine
o outcomes
studies have show provocative diskography leads to accelerated disc degeneration including
increased incidence of lumbar disc herniations
loss of disk height
endplate changes
Treatment
Nonoperative
o NSAIDS, physical therapy, lifestyle
modifications
indications
treatment of choice of majority of patients
with low back pain in the abscence of leg
pain
Operative
o lumbar diskectomy with fusion
indications
controversial
outcomes
poor results when lumbar fusion is performed for discogenic back pain diagnosed with a
positive provocative discography
o lumbar total disc replacement
indications
controversial
most argue single level disc disease with disease-free facet joints is the only true
indication
outcomes
shown to have better 2-year patient outcomes than fusion
lower rates of adjacent segment disease with total disc replacement compared to fusion
complications
persistent back pain
thought to be facet joint in origin or subtle instability of prosthesis
if implant in good position, treat with posterior stabilization alone
dislocation of polyethylene inlay
treat with either revision arthroplasty or revision to arthrodesis
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Thoracolumbar Conditions
abnormal rectal tone
upper motor neuron findings
hyperreflexia
sustained clonus
positive Babinski sign
gait changes
wide based spastic gait
o Horner's syndrome
seen with HNP at T2 to T5
Imaging
Radiographs
o lateral radiographs
may show disc narrowing
may show calcification (osteophytes)
MRI
o most useful and important imaging method to demonstrate thoracic disc herniation
allows for identification of neoplastic pathology
can see intradural pathology
will show myelomalacia
may not fully demonstrate calcified component of herniated disc
o disadvantage is high false positive rate
in a study looking at asymptomatic individuals
73% had thoracic disk abnormalities
37% had frank herniations
29% of these had cord compression.
Treatment
Nonoperative
o activity modification, physical therapy, and symptomatic treatment
indications
the majority of cases
modalities include
immobilization and short term rest
analgesic
progressive activity restoration
injections may be useful for symptoms of radiculopathy
outcomes
majority improve with nonoperative treatment
Operative
o discectomy with possible hemicorpectomy or fusion
indications
surgery indicated in minority of patients
acute disc herniation with myelopathic findings attributable to the lesion, especially if
there is progressive neurologic deterioration
persistent and intolerable pain
technique
debate between discectomy with or without fusion is controversial.
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most studies do indicate that anterior or lateral (via costotransversectomy) is the best
approach
see below for different approaches
Surgical Techniques
Transthoracic discectomy
o indications
best approach from central disc herniations
o complications
intercostal neuralgia
o techniques
can be done with video assisted thoracic surgery (VATS)
Costotransversectomy
o indications
lateral disc herniation
extruded or sequestered disc
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Thoracolumbar Conditions
Nerve root anatomy
o key difference between cervical and lumbar spine is
pedicle/nerve root mismatch
cervical spine C6 nerve root travels under C5 pedicle (mismatch)
lumbar spine L5 nerve root travels under L5 pedicle (match)
extra C8 nerve root (no C8 pedicle) allows transition
horizontal (cervical) vs. vertical (lumbar) anatomy of nerve root
because of vertical anatomy of lumbar nerve root a paracentral and foraminal disc will
affect different nerve roots
because of horizontal anatomy of cervical nerve root a central and foraminal disc will
affect the same nerve root
Classification
Location Classification
o central prolapse
often associated with back pain only
may present with cauda equina syndrome which is a surgical emergency
o posterolateral (paracentral)
most common (90-95%)
PLL is weakest here
affects the traversing/descending/lower nerve root
at L4/5 affects L5 nerve root
o foraminal (far lateral, extraforaminal)
less common (5-10%)
affects exiting/upper nerve root
at L4/5 affects L4 nerve root
o axillary
can affect both exiting and descending nerve roots
Anatomic classification
o protrusion
eccentric bulging with an intact annulus
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o extrusion
disc material herniates through annulus but remains continuous with disc space
o sequestered fragment (free)
disc material herniates through annulus and is no longer continuous with disc space
Left sided paracentral L4-5 disc with compression Right sided far lateral L4-5 disc with compression
of descending L5 root of exiting L4 root
Presentation
Symptoms
o can present with symptoms of
axial back pain (low back pain)
this may be discogenic or mechanical in nature
radicular pain (buttock and leg pain)
often worse with sitting, improves with standing
symptoms worsened by coughing, valsalva, sneezing
cauda equina syndrome (present in 1-10%)
bilateral leg pain
LE weakness
saddle anesthesia
bowel/bladder symptoms
Physical exam
o see lower extremity neuro exam
o motor exam
ankle dorsiflexion (L4 or L5)
test by having patient walk on heels
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Thoracolumbar Conditions
EHL weakness (L5)
manual testing
hip abduction weakness (L5)
have patient lie on side on exam table and abduct leg against resistance
ankle plantar flexion (S1)
have patient do 10 single leg toes stands
o provocative tests
straight leg raise
a tension sign for L5 and S1 nerve root
technique
can be done sitting or supine
reproduces pain and paresthesia in leg at 30-70 degrees hip flexion
sensitivity/specificity
most important and predictive physical finding for identifying who is a good
candidate for surgery
contralateral SLR
crossed straight leg raise is less sensitive but more specific
Lesegue sign
SLR aggravated by forced ankle dorsiflexion
Bowstring sign
SLR aggravated by compression on popliteal fossa
Kernig test
pain reproduced with neck flexion, hip flexion, and leg extension
Naffziger test
pain reproduced by coughing, which is instigated by lying patient supine and applying
pressure on the neck veins
Milgram test
pain reproduced with straight leg elevation for 30 seconds in the supine position
o gait analysis
Trendelenburg gait
due to gluteus medius weakness which is innervated by L5
Imaging
Radiographs
o may show
loss of lordosis (spasm)
loss of disc height
lumbar spondylosis (degenerative changes)
MRI without gadolinium
o modality of choice for diagnosis of lumbar and cervical disc herniations
highly sensitive and specific
helpful for preoperative planning
useful to differentiate from synovial facet cysts
o however high rate of abnormal findings on MRI in normal people
o indications for obtaining an MRI
pain lasting > one month and not responding to nonoperative management or
red flags are present
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infection (IV drug user, h/o of fever and chills)
tumor (h/o or cancer)
trauma (h/o car accident or fall)
cauda equina syndrome (bowel/bladder changes)
MRI with gadolinium
o useful for revision surgery
o allows to distinguish between post-surgical fibrosus (enhances with gadolinium) vs. recurrent
herniated disc (does not enhance with gadolinium)
Treatment
Nonoperative
o rest and physical therapy, and antiinflammatory medications
indications
first line of treatment for most patients with disc herniation
90% improve without surgery
technique
bedrest followed by progressive activity as tolerated
medications
NSAIDS
muscle relaxants (more effective than placebo but have side effects)
oral steroid taper
physical therapy
extension exercises extremely beneficial
traction
chiropractic manipulation
o selective nerve root corticosteroid injections
indications
second line of treatment if therapy and medications fail
technique
epidural
selective nerve block
outcomes
leads to long lasting improvement in ~ 50% (compared to ~90% with surgery)
results best in patients with extruded discs as opposed to contained discs
Operative
o laminotomy and discectomy (microdiscectomy)
indications
persistent disabling pain lasting more than 6 weeks that have failed nonoperative options
(and epidural injections)
progressive and significant weakness
cauda equina syndrome
technique : can be done with small incision or through "tube" access
rehabilitation
patients may return to medium to high-intensity activity at 4 to 6 weeks
outcomes
outcomes with surgery compared to nonoperative
improvement in pain and function greater with surgery
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Thoracolumbar Conditions
positive predictors for good outcome with surgery
leg pain is chief complaint
positive straight leg raise
weakness that correlates with nerve root impingement seen on MRI
married status
negative predictors for good outcome with surgery
worker's compensation
WC patients have less relief from symptoms and less improvement in quality of
life with surgical treatment
o far lateral microdiskectomy
indications
for far-lateral disc herniations
technique
utilizes a paraspinal approach of Wiltse
Complications of Surgery
Dural tear (1%) : if have tear at time of surgery then perform water-tight repair
Recurrent HNP
o can treat nonoperatively initially
o outcomes for revision discectomy have been shown to be as good as for primary discectomy
Discitis (1%)
Vascular catastrophe : caused by breaking through anterior annulus and injuring vena cava/aorta
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Imaging
Radiographs
o recommended views
required
AP lateral, lateral, flexion and extension of spine
findings
usually normal
look for segmental instability
MRI
o indications
significant leg pain
o views
best seen on T2 axial and sagittal images
Treatment
Nonoperative
o NSAIDS, rest, immobilization
indications : mild symptoms
o CT guided aspiration
technically challenging and usually not effective
Operative
o laminectomy with decompression
indications
classical first line for symptomatic intraspinal synovial cysts
outcomes
high incidence of recurrent back pain and cyst formation within two years
o facetectomy and instrumented fusion
indications
some consider first line of surgical treatment due to high recurrance rates
symptomatic recurrance following laminectomy with decompression
outcomes
demonstrated to have the lowest risk of persistent back pain and recurrence of cyst
formation in recent studies
Complications
Cyst recurrence
o high incidence of recurrence with resection alone
o new studies favor facetectomy and fusion as first line of operative treatment
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Thoracolumbar Conditions
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pain relieved with flexion (sitting, leaning over shopping cart, sleeping in fetal position)
o leg pain (often unilateral)
o weakness
o bladder disturbances
recurrent UTI present in up to 10% due to autonomic sphincter dysfunction
o cauda equina syndrome (rare)
Physical Exam
o Kemp sign
unilateral radicular pain from foraminal stenosis made worse by extension of back
o Straight leg raise (tension sign)
is usually negative
o Valsalva test
radicular pain not worsened by Valsalva as is the case with a herniated disc
Differential
Important to differentiate symptoms of neurogenic claudication from vascular claudication
o flexion improves symptoms in neurogenic claudication because this posture increases the limited
area available for the neural elements in the spinal canal and foramen
ff Neurogenic Claudication Vascular Claudication
Postural changes Yes No
Walking upright Causes symptoms Causes symptoms
Standing stationary Causes symptoms Relieves symptoms
Sitting Relieves symptoms Relieves symptoms
Stair climbing Up easier (back flexed) Down easier (back extended)
Stationary bicycle (back Relieves symptoms Causes symptoms
flexed)
Pulses Normal Abnormal
Imaging
Radiographs
o standing AP and lateral may show
nonspecific degenerative findings (disk space narrowing, osteophyte formation)
degenerative scoliosis
degenerative spondylolisthesis
o flexion/extension radiographs may show
segmental instability and subtle degenerative spondylolisthesis
o myelogram
plain film myelography provides dynamic information such as degree of
cut off when a patient goes into extension
an invasive procedure
MRI
o findings include
central stenosis with a thecal sac < 100mm2
obliteration of perineural fat and compression of lateral recess or foramen
facet and ligamentum hypertrophy
o MRI findings of spinal stenosis may found in asymptomatic patients
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Thoracolumbar Conditions
Boden et al found that three of 14 asymptomatic patients and MRI findings of anatomic
spinal stenosis
CT myelogram
o more invasive than MRI
o findings include
central and lateral neural element compression
bony anomalies
bony facet hypertrophy
II:3 CT myelogram
Treatment
Nonoperative
o oral medications, physical therapy, and corticosteroid injections
indications
first line of treatment
o modalities include
NSAIDS, physical therapy, weight loss and bracing
steroid injections (epidural and transforaminal) effective and may obviate need for surgery
Operative
o wide pedicle-to-pedicle decompression
indications
persistent pain for 3-6 months that has failed to improve with nonoperative management
progressive neurologic deficit (weakness or bowel/bladder)
outcomes
improved pain, function, and satisfaction with surgical treatment
most common cause of failed surgery is recurrence of disease above or below
decompressed level
comorbid conditions are strongest predictor of clinical outcomes after decompression for
lumbar spinal stenosis
o wide pedicle-to-pedicle decompression with instrumented fusion
indications
presence of segmental instability (isthmic spondylolisthesis, degenerative
spondylolisthesis, degenerative scoliosis)
surgical instability created by complete laminectomy and/or removal of > 50% of facets
risk of adjacent segment degeneration greater than 30% at 10 years
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Surgical Techniques
Wide pedicle-to-pedicle decompression
o a single level decompression at L4/5 would include
resect inferior half of spinous process of L4
resect L4 lamina to the level of the insertion of the ligamentum flavum
resect ligamentum flavum
medial facetectomy and lateral recess decompression
undercutting of facets and removal of ligamentum flavum from lateral recess
exploration and decompression of the L4/5 and L5/S1 foramen
palpate L4 and L5 pedicle (pedicle-to-pedicle) and be sure nerve root is patent below it.
Wide decompression with posterolateral fusion
o technique
wide decompression with posterolateral fusion
instrumentation is controversial
circumferential fusion (with PLIF or TLIF) is accepted but no studies showing its superiority
Complications
Complications increase with age, blood loss, and levels fused
Major complication
o wound infection (10%)
deep surgical infections are to be treated with surgical debridement and irrigation
o pneumonia (5%)
o renal failure (5%)
o neurologic deficits (2%)
Minor complication
o UTI (34%)
o anemia requiring transfusion (27%)
o confusion (27%)
o dural tear
o failure for symptoms to improve
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Deformity & Instability
1. Degenerative Spondylolisthesis
Introduction
A condition characterized by lumbar spondylolithesis without a defect in the pars
o absent of pars defect differentiates from adult isthmic spondylolithesis
Epidemiology
o prevalence
~5% in men
~9% in woman
o demographics
more common in African Americans, diabetics, and woman over 40 years of age
~8 times more common in woman than men
increase in prevalence in women postulated to be due to increased ligamentous laxity
related to hormonal changes
o location :degenerative spondylolithesis is 5-fold more common at L4/5 than other levels
this is different that isthmic spondylolithesis which is most commonly seen at L5/S1
o risk factors
sacralization of L5 (transitional L5 vertebrae)
sagittally oriented facet joints
Pathoanatomy
o forward subluxation (intersegmental instability) of vertebral body is allowed by
facet joint degeneration
facet joint sagittal orientation
intervertebral disc degeneration
ligamentous laxity (possibly from hormonal changes)
o degenerative cascade involves
disc degeneration leads to facet capsule degeneration and instability
microinstability which leads to further degeneration and eventual macroinstability and
anterolithesis
instability is worsening with sagittally oriented facets (congenital) that allow forward
subluxation
o neurologic symptoms caused by
central and lateral recess stenosis
a degenerative slip at L4/5 will affect the descending L5 nerve root in the lateral recess
caused by slippage, hypertrophy of ligamentum flavum, and encroachment into the
spinal canal of osteophytes from facet arthrosis
foraminal stenosis
a degenerative slip at L4/5 will affect the L4 nerve root as it is compressed in the foramen
vertical foraminal stenosis (loss of height of foramen) caused by
loss of disk height
osteophytes from posterolateral corner of vertebral body pushing the nerve root up
against the inferior surface of the pedicle
anteroposterior foraminal stenosis (loss of anterior to posterior area) caused by
degenerative changes of the superior articular facet and posterior vertebral body
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Classification
Myerding Classification
Grade I < 25%
Grade II 25 to 50%
Grade III 50 to 75% (Grade III and greater are rare in degenerative
spondylolithesis)
Grade IV 75 to 100%
Grade V Spondyloptosis (all the way off)
Presentation
Symptoms
o mechanical/ back pain
most common presenting symptom
usually relieved with rest and sitting
o neurogenic claudication & leg pain
second most common symptoms
defined as buttock and leg pain/discomfort caused by upright walking
relieved by sitting
not relieved by standing in one place (as is vascular claudication)
may be unilateral or bilateral
same symptoms found with spinal stenosis
o cauda equina syndrome (very rare)
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Deformity & Instability
Physical exam
o L4 nerve root involvement (compressed in foramen with L4/5 DS)
weakness to quadriceps
best seen with sit to stand exam maneuver
weakness to ankle dorsiflexion (cross over with L5)
best seen with heel-walk exam maneuver
decreased patellar reflex
o L5 nerve root involvement
weakness to ankle dorsiflexion (cross over with L4)
best seen with heel-walk exam maneuver
weakness to EHL (great toe extension)
weakness to gluteus medius (hip abduction)
o provocative walking test
have patient walk prolonged distance until onset of buttock and leg pain
have patient stop but remain standing upright
if pain resolves this is consistent with vascular claudication
have patient sit
if pain resolves this is consistent with neurogenic claudication (DS)
o hamstring tightness
commonly found in this patients, and must differentiate this from neurogenic leg pain
Imaging
Radiographs
o recommended views
weight bearing lumbar AP, lateral neutral, lateral flexion, lateral
extension
o findings
slip evident on lateral xray
flexion-extension studies
instability defined as 4 mm of translation or 10° of angulation of
motion compared to adjacent motion segment
MRI
o indications
persistent leg pain that has failed nonoperative modalities
best study to evaluate impingement of neural elements
o views
T2 weighted sagittal and axial images best to look for compression of neurologic elements
CT
o useful to identify bony pathology
CT myelogram
o helpful in patients in which a MRI is contraindicated (pacemaker)
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Treatment
Nonoperative
o physical therapy and NSAIDS
indications
most patients can be treated nonoperatively
modalities include
activity restriction
NSAIDS
PT
o epidural steroid injections
indications
second line of treatment if non-invasive methods fail
Operative
o lumbar wide decompression with instrumented fusion
indications
most common is persistent and incapacitating pain that has failed 6 mos. of nonoperative
management and epidural steroid injections
progressive motor deficit
cauda equina syndrome
outcomes
~79% have satisfactory outcomes
improved fusion rates shown with pedicle screws
improved outcomes with successful arthrodesis
worse outcomes found in smokers
o posterior lumbar decompression alone
indications
usually not indicated due to instability associated with spondylolithesis
only indicated in medically frail patients who cannot tolerate the increased surgical time
of performing a fusion
outcomes
~69% treated with decompression alone are satisfied
~ 31% have progressive instability
o anterior lumbar interbody fusion (ALIF)
indications
reserved for revision cases with pseudoarthrosis
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Deformity & Instability
outcomes
injury to superior hypogastric plexus can cause retrograde ejaculation
Surgical Techniques
Posterior decompression and posterolateral fusion (+/- instrumentation)
o approach
posterior midline approach
multiple parasagittal incisions for minimally invasive approaches
o decompression
usually done with laminectomy, wide decompression, and foraminotomy
o fusion
posterolateral fusion with instrumentation most common
TLIF/PLIF growing in popularity and may increase fusion rates and decrease risk of
postoperative slip progression
o reduction of listhesis
limited role in adults
Complications
Pseudoarthrosis (5-30%)
o CT scan is more reliable than MRI for identifying failed arthrodesis
Adjacent segment disease (2-3%)
o incidence is approximately 2.5% a year
Surgical site infection (0.1-2%)
o treat with irrigation and debridement (usually hardware can be retained)
Dural tear
Positioning neuropathy
o LFCN
seen with prone positioning due to iliac bolster
o ulnar nerve or brachial plexopathy
from prone positioning with inappropriate position
Complication rates increase with
o older age
o increased intraoperative blood loss
o longer operative time
o number of levels fused
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Wiltse-Newman Classification
Type I • Dysplastic: a congenital defect in pars
Type II-A • Isthmic - pars fatigue fx
Type II-B • Isthmic - pars elongation due to multiple healed stress fx
Type II-C • Isthmic - pars acute fx
Type III • Degenerative: facet instability without a pars fx
Type IV • Traumatic: acute posterior arch fx other than pars
Type V • Neoplastic: pathologic destruction of pars
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Deformity & Instability
Myerding Classification
Grade I • < 25%
Grade II • 25-50%
Grade III • 50-75%
Grade IV • 75-100%
Grade V • spondyloptosis
Wiltse Type I
Wiltse Type II-C
High Grade Dysplastic
spondylolisthesis
Wiltse-Newman Classification
Myerding Classification
Wiltse Type III Degenerative: facet instability without a pars
fx
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Physical Exam
Symptoms
o axial back pain
most common presentation
pain usually has a long history with periodic episodes that vary in intensity and duration
o leg pain
usually a L5 radiculopathy usually caused by foraminal stenosis at the L5-S1 level
o neurogenic claudication
caused by spinal stenosis
characterized by buttock and leg pain worse with walking
symptoms of neurogenic claudication rare because these slips rarely progress beyond Grade
II
o cauda equina syndrome
rare because these slips rarely progress beyond Grade II
Physical exam
o L5 radiculopathy
ankle dorsiflexion and EHL weakness
Imaging
Radiographs
o recommended views
obtain AP, lateral, obliques, and flexion-extension views
o findings
AP
deformity in coronal plane
lateral
will see spondylolisthesis and pars defect
flexion-extension
instability defined as 4 mm of translation or 10° of angulation of motion compared to
adjacent motion segment
o measurements (See figures in pages 17 and 18)
pelvic incidence
pelvic incidence = pelvic tilt + sacral slope
a line is drawn from the center of the S1 endplate to the center of the femoral head
a second line is drawn perpendicular to a line drawn along the S1 endplate, intersecting
the point in the center of the S1 endplate
the angle between these two lines is the pelvic incidence (see angle X in figure above)
correlates with severity of disease
pelvic incidence has direct correlation with the Meyerding–Newman grade
pelvic tilt
sacral slope = pelvic incidence - pelvic tilt
a line is drawn from the center of the S1 endplate to the center of the femoral head
a second vertical line (parallel with side margin of radiograph) line is drawn intersecting
the center of the femoral head
the angle between these two lines is the pelvic tilt (see angle Z in figure above)
sacral slope
pelvic tilt = pelvic incidence - sacral slope
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Deformity & Instability
a line is drawn parallel to the S1 endplate
a second horizontal line (parallel to the inferior margin of the radiograph) is drawn
the angle between these two lines is the sacral slope (see angle Y in the figure above)
MRI
o views
T2 parasagittal images are best study to evaluate for foraminal stenosis and compression of
neural elements
Treatment
Nonoperative
o oral medications, lifestyle modifications, therapy
indications
most patients can be treated nonoperatively
techniques
activity restriction
NSAID
role of injections unclear
bracing may be beneficial especially in the acute phase
Operative
o L5-S1 decompression and instrumented fusion +/- reduction
indications
L5-S1 low-grade spondylolisthesis with persistent and incapacitating pain that has failed
6 months of nonoperative management (most common)
progressive neurologic deficit
slip progression
cauda equina syndrome
reduction
improved sagittal balance with reduction
risk of stretch injury to L5 nerve root with reduction
o L4-S1 decompression and instrumented fusion +/- reduction
indications
L5-S1 high-grade spondylolithesis with persistent and incapacitating pain that has failed 6
months of nonoperative management
o ALIF
indications
can be used successfully to treat low-grade isthmic spondylolisthesis even when radicular
symptoms are present
cannot be used to treat high grade isthmic spondylolisthesis due to translational and
angular deformity
outcomes
studies have shown good to excellent results in 87-94% at 2 years
Surgical Techniques
L5/S1 wide decompression and instrumented fusion
o approach
posterior midline
o decompression
indicated in adult with leg pain below knee
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usually involves Gill laminectomy and foraminal decompression
removal of loose lamina and scared pars defect allows decompression of nerve root
a Gill decompression is destabilizing and should be combined with fusion
o fusion
posterolateral fusion is standard
interbody fusion (PLIF/TLIF) commonly performed
posterior lumbar interbody fusion (PLIF) involves insertion of device medial to facets
transforaminal lumbar interbody fusion (TLIF) requires facetectomy and more lateralized
and transforaminal approach to the disc space
o cons
interbody fusion has increased operative time with greater blood loss and longer
hospitalizations
Anterior Lumbar Interbody Fusion (ALIF)
o approach
usually done through trans-retroperitoneal approach
o decompression
decompression of nerve root done indirectly by foraminal distraction via restoration of disc
height
o fusion
grafts used include autologous iliac crest, structural allograft, and cages of various materials
o pros
may increase chance of union by more complete discectomy and endplate preparation
allows improved restoration of disc height
o cons
retrograde ejaculation and sexual dysfunction
persistent radiculopathy due to inadequate indirect foraminal decompression
persistent low back pain may be caused by nociceptive pain fibers in pars defect that are not
removed in an anterior procedure alone
Complications
Psuedoarthrosis
Dural Tear
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Deformity & Instability
Pathoanatomy
o degenerative scoliosis results from the asymmetric degeneration of disc space and/or facet joints
in the spine.
o may occur in the coronal plane (scoliosis) or the sagittal plane (kyphosis/lordosis)
o factors contributing to loss of sagittal plane balance
osteoporosis
preexisting scoliosis
iatrogenic instability
degenerative disc disease
Prognosis
o worse prognosis with
if symptoms progress to the side of curve convexity
sagittal plane imbalance
sagittal plane balance is the most reliable predictor of clinical symptoms in adults with
spinal deformity
o progression
depends on curve type
thoracic > lumbar > thoracolumbar > double major
right thoracic curves (1 degree per year)
right lumbar curves (0.5 degree per year)
thoracolumbar curves (0.25 degree per year)
depends on curve magnitude
curves <30 deg rarely progress
curves >50 deg commonly progress
additional risk factors for progression
increased risk when intercrestal line is below L4-5
preexisting rotational changes exist
Classification
Coronal deformity can be broken down into
o idiopathic (residual) ASD
the result of untreated adolescent idiopathic scoliosis in the adult
o degenerative (de novo) ASD
defined as a progressive deformity in the adult caused by
degenerative changes
iatrogenic
paralytic
posttraumatic
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Presentation
Symptoms
o low back pain (40-90%)
commonest symptom is low back pain
caused by spondylosis, micro/macro instability, and discogenic pain
more severe and recurrent than general population
o neurogenic claudication
pain in lower extremities and buttocks
unlike classic claudication, patients with scoliosis + stenosis do not obtain relief with
sitting / forward flexion
caused by spinal stenosis
stenosis is located on the concave side of the curve
o radicular leg pain and weakness
caused by foraminal and lateral recess stenosis
worse in concavity of the deformity where there is vertebral body rotation and translation
Physical exam
o deformity with thoracic prominence seen with forward bending
o muscle weakness
Imaging
Radiographs
o recommended views
full length long 36-inch cassette standing scoliosis xrays in coronal (AP radiograph) and
sagittal plane (lateral radiograph), with right and left bending films
bending films help assess curve flexibility and possibility of correction with surgical
intervention
o measurements
AP radiograph
Cobb angle
coronal balance
using C7 plumb line (C7PL) and center sacral vertical
line (CSVL)
lateral radiograph
sagittal balance
using C7 plumb line (C7PL)
pelvic incidence
pelvic incidence = sacral slope + pelvic tilt
CT scan
o will help identify bony deformity such as facet arthrosis
CT myelogram
o most useful for assessing stenosis and bony anatomy as rotation makes
interpretation of MRI difficult
o better appreciation of bony anatomy and rotational deformity than MRI
MRI
o indicated when lower extremity pain is present
o can identify
central canal stenosis
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Deformity & Instability
facet hypertrophy
pedicular enlargement
foraminal encroachment
disc degeneration
DEXA scan
o important to determine bone density for surgical planning
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general indications
curve > 50 degrees of the following type
sagittal imbalance
curve progression
intractable back pain or radicular pain that has failed nonsurgical efforts
cosmesis (controversial)
cardiopulmonary decline
thoracic curves >60deg affect pulmonary function tests
thoracic curves >90deg affect mortality
technique
posterior only curve correction and instrumented fusion
indications
thoracic curves > 50 degrees
most double structural curves > 50 degrees
selecting technique is patient and surgeon specific
combined anterior/posterior curve correction with instrumented fusion
indications
isolated thoracolumbar
isolated lumbar curves
extremely rigid curves requiring anterior release
Techniques
General
o goals of surgery
restore spinal balance
sagittal plane balance is the most reliable predictor of clinical symptoms postoperatively
can be measured by C7 plumb line (C7 sagittal vertical axis)
correction of sagittal plane deformity requires intense preoperative planning
relieve pain
obtain solid fusion
Selecting Proximal and Distal fusion level
o proximal extension
extend to a neutral and horizontal vertebra above the main curve
o extend fusion to L5
indications
only indicated if no pathology at L5/S1
patients with normal C7 plumb line and normal sacral inclination have lowest risk of
future L5-S1 disc degeneration
outcomes
high failure rate if instrumentation does not extend to the sacrum if pathology at L5/S1
o extend fusion to sacrum (S1)
indications
extend to sacrum if any pathology at L5-S1 including
L5-S1 spondylolisthesis
L5-S1 spondylolysis
L5-S1 facet arthrosis
prior laminectomy
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Deformity & Instability
technique
may requires concomitant anterior release and anterior column support (through
anterior approach) for better deformity correction
outcomes
advantages
increased stability of long fusion construct
constructs less likely to fail if instrumentation extends to sacrum
disadvantages
increased risk of pseudoarthrosis
increased surgical time
increased reoperation rate
increased risk of sacral insufficiency fractures
altered gait postoperatively
o extend fusion to ilium (sacropelvic fusion)
indications : consider this if sacrum is included in fusion involving >3 levels
technique : using iliac screws or bolts
outcomes
advantage
increased stability of long fusion construct
increases success of lumbosacral fusion
disadvantage
prominent hardware
Osteotomies
o overview
useful to regain sagittal balance in severe angulation deformities
30deg or more correction can be obtained through Smith-Petersen or pedicle subtraction
osteotomies
intraoperative neuromonitoring preferred
o Smith-Petersen osteotomy (SPO)
indications
mild-moderate sagittal imbalance
requiring correction of up to 10deg (per level of osteotomy)
prerequisites
no anterior fusion at the level of osteotomy
adequate correction requires adequate disc height and mobility (correction is at the level
of the disc)
more correction in the lumbar spine (greater disc height and mobility)
less correction in the thoracic spine (lesser disc height and mobility)
o pedicle subtraction osteotomy (PSO)
indications
severe sagittal imbalance >12cm
requiring correction of 30-35deg in the lumbar spine, and 25deg in the thoracic spine
where anterior fusion is present (correction is at the level of the vertebral body and not at
the disc)
o vertebral column resection
indications
severe sagittal imbalance (provides more correction than PSO)
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requiring correction of up to 45deg
rigid angular thoracic spine kyphosis, such as associated with tumor, fracture or infection
severe rigid scoliosis
congenital kyphosis
hemivertebrae resection in thoracic/lumbar spines
Anterior Procedures
o indications
large curves >70deg
rigid curves (no flexibility on side bending films)
isolated lumbar or thoracolumbar curves
anterior interbody fusion at L5/S1 when fusing to sacrum
o technique
anterior release and fusion usually combined with posterior instrumentation and fusion
staged or same day
o outcomes
disadvantages
longer surgeries (if performed on the same day)
higher complication rates
more medically stressful
advantage
increases stability of L5-S1 long fusion constructs
helps restore and maintain sagittal and coronal balance
Complications (surgical)
Overall
o overall complication rate ~13.5%
o 10% major complications which often irreversibly affect long term health of patient
o complication rate is significantly higher when osteotomies, revision procedures, and combined
anterior/posterior approaches
o venous thromboembolism is most likely to result in poor clinical outcome following adult spinal
deformity surgery
Pseudoarthrosis
o incidence (~5-25%)
o most common surgical technique resulting in pseudoarthrosis is posterior only fusion (15%)
o commonest locations
L5-S1
thoracolumbar junction
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Sacral Conditions
o risks
age>55
kyphosis >20 degrees
positive sagittal balance >5cm
hip arthritis
smoking
thoracoabdominal approach
incomplete lumbopelvic fixation
Dural tear (~2.9%),
Infection
o deep wound infection (~1.5%)
o superficial wound infection (~0.9%)
Implant complication (~1.6%)
o instrumentation failure more likely in bone with lowest ratio of cortical to cancellous bone
(sacrum<vertebral bodies<lumbar pedicles<thoracic pedicles)
Neurologic deficits
o acute neurological deficits (~1.0%)
can occur intraoperatively after deformity correction maneuver
if identified on neurophysiologic monitoring, should remove instrumentation and consider
wake-up test
o delayed neurological deficits (~0.5%)
Epidural hematoma (~0.2%)
Pulmonary embolus (~0.2%)
Deep venous thrombosis (~0.2%).
Deaths (~0.3%)
E. Sacral Conditions
1. Sacroiliitis
Introduction
Epidemiology
o commonly part of ankylosing spodyliitis or Reiter's syndrome
o most commonly presents in teen to middle aged individuals
males > females
Pathophysiology
o can stem from traumatic event or infection
o pregnancy may lead to increased incidence in some females
o often stems from chronic inflammation of SI joints
o can lead to fibrosis and ossification within SI joint
Associated conditions
o ankylosing spodyliitis
associated with HLA-B27
1-2% of all individuals will have HLA-B27
o Reiter's syndrome
oligoarticular arthritis, conjunctivitis and urethritis
o joint arthritis
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Prognosis
o depends on cause but most patients will eventually resolve the episode and continue without
issues
Presentation
Symptoms
o pain with prolonged standing
o difficulty climbing stairs
o generalized low back pain
o weakness from hip musculature on affected side
o morning stiffness
Physical exam
o FABER test
pain with flexion, abduction, and external rotation of hip
o ankylosing spondylitis associated with
spinal flexion deformities
starting in T and L spines
Imaging
Radiographs
o may show some erosive changes in the bone, but it’s not specific
o may show calcifications or sclerosis within SI joint
MRI is study of choice
o use gadolinium
o T2’s show fluid/inflammation at the SI joint and maybe an abscess
Studies
Labs
o WBC
usually normal
can be elevated with infection
o ESR/CRP
usually elevated
o blood cultures
are positive in 50%
o HLA-B27
check for rheumatoid factor (should be negative for true Ankylosing spondylitis)
Treatment
Depends on cause
o infection
IV antibiotics
until symptoms and the CRP resolve
then put on orals antibiotic
surgery
may be necessary if this fails or if there is a large abscess
o trauma or overuse
rest, activity modification, NSAIDS, corticosteroid injections
indications
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By Dr, AbdulRahman AbdulNasser Degenerative Spine | Sacral Conditions
most resolve with soft tissue rest and activity modification
o pregnancy
observation
typically resolves after childbirth
o part of larger spondylopathy
aggressive PT, NSAIDs, TNF inhibitors
severe symptoms may require TNF inhibitors or other similar medications
2. Sacral Insufficiency Fx
This topic not written in Orthobullets.com until collecting this book in june 2017
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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ORTHO BULLETS
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By Dr, AbdulRahman AbdulNasser Tumors & Systemic Conditions | Systemic Conditions
A. Systemic Conditions
1. Ankylosing Spondylitis
Introduction
An systemic chronic autoimmune spondyloarthropathy characterized by
o HLA-B27 histocompatability complex positive (90%)
o RF negative (seronegative)
o primarily affect axial spine
Pathoanatomy
o exact mechanism is unknown, but most likely due to an autoimmune reaction to an
environmental pathogen in a genetically susceptible individual.
o theories of relation to HLA-B27 include
HLA-B27 aggregates with peptides in the joint and leads to a degenerative cascade
cytotoxic T-cell autoimmune reaction against HLA-B27
o enthesitis
entheses inflammation leads to bony erosion, surrounding soft-tissue ossification, and
eventually joint ankylosis
preferentially targets sacroiliac joints, spinal apophyseal joints, symphysis pubis
this differentiates from RA, which is a synovial process
o disc space involvement
inflammation of the annulus lead to bridging osteophyte formation (syndesmophytes)
Genetics
o there is a genetic predisposition, but mode of inheritance is unknown
o HLA-B27 is located on sixth chromosome, B locus
Epidemiology
o 4:1 male:female
o affects ~0.2% of Caucasian population
o usually presents in 3rd decade of life
juvenile form <16-years-old includes enthesitis
fewer than 10% of HLA-B27 positive patients have symptoms of AS
Diagnostic criteria
o bilateral sacroiliitis
o +/- uveitis
o HLA-B27 positive
Systemic manifestations
o acute anterior uveitis & iritis
o heart disease (cardiac conduction abnormalities)
o pulmonary fibrosis
o renal amyloidosis
o ascending aortic conditions (aortitis, stenosis, regurgitation)
o Klebsilella pneumoniae synovitis
HLA-B27 individuals are more susceptible to Klebsilella pneumoniae synovitis
Orthopaedic manifestations
o bilateral sacroiliitis
o progressive spinal kyphotic deformity
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o cervical spine fractures
o large-joint arthritis (hip and shoulder)
Anatomy
Enthesis
o defined as the insertion of tendon, ligaments, or muscle into bone
Presentation
Symptoms
o lumbosacral pain and stiffness
present in most patients
worse in morning
III:1 chin-on-chest
insidious onset in 3rd decade of life
o neck and upper thoracic pain
occurs later in life
acute neck pain should raise suspicion for
fracture
o sciatic
likely originates from sciatic nerve
involvement in the pelvic (piriformis spasm)
o loss of horizontal gaze
o shortness of breath
caused by costovertebral joint involvement,
leading to reduced chest expansion
Physical exam
o limitation of chest wall expansion
< 2cm of expansion is more specific than HLA-B27 for making diagnosis
o decreased spine motion
Schober test
used to evaluate lumbar stiffness
o kyphotic spine deformity
chin-on-chest (flexion) deformity of the spine
caused by multiple microfractures that occur over time
chin-brow-to-vertical angle (CBVA)
measured from standing exam of standing lateral radiograph
useful for preoperative planning
correction of this angle correlates with improved surgical outcomes
o hip flexion contracture
examining patient in supine and sitting position helps differentiate sagittal plane imbalance
due to hip flexion contractures or kyphotic spinal deformity
o sacroiliac provocative tests
Faber test
flexion abduction external rotation of the ipsilateral hip causes pain
Imaging
Radiographs
o spine
recommended views
standing full-length AP and lateral of axial spine
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findings
negative in 50% of cases with spine fractures
squaring of vertebrae with vertical or marginal syndesmophytes
late vertebral scalloping (bamboo spine)
measurements
chin-brow to vertical angle
used to measure chin-on-chest deformity
useful for preoperative planning for osteotomy
o pelvis & lower extremity
recommended views
Ferguson pelvic tilt view
allows for improved visualization of anterior SI joint
xray beam directed 10 to 15 degrees cephalad
findings
bilateral symmetric sacroiliac erosion
earliest radiographic sign is erosion of iliac side of sacroiliac joint
joint space narrowing
ankylosis
CT
o will show bony changes but not active inflammation
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Syndesmophytes are calcifications or heterotopic ossifications inside a spinal ligament or of the annulus fibrosus.
They are seen in only a limited number of conditions including ankylosing spondylitis ochronosis fluorosis
Source : https://radiopaedia.org/articles/syndesmophyte
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By Dr, AbdulRahman AbdulNasser Tumors & Systemic Conditions | Systemic Conditions
Syndesmophytes
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Spine Fractures
Introduction
o most occur in midcervical and cervicothoracic junction (some occur at thoracolumbar junction)
o often extension-type fracture that involved all three columns
o may be occult so if suspicious consider CT scan (best modality to make diagnosis)
o high mortality rate secondary to epidural hemorrhage
75% neurologic involvement
neurologic symptoms often present late
Treatment
o nonoperative
traction, orthotic or halo immobilization
indications : stable spine fractures with no neurologic deficits
technique : low-weight traction may facilitate reduction
o operative
spinal decompression with instrumented fusion
indications
progressive neurologic deficit
epidural hematoma with neurologic compromise
unstable fracture patterns
technique
decompression
decision to go anterior or posterior depends on fracture level, presence and
location of hematoma, and osteoporosis
instrumentation
need to obtain long fusion construct
multiple points of fixation above and below the fracture are necessary because of
osteoporosis
long lever arms of the ankylosed spine
do not make an effort to correct deformity
outcomes & complications
high rate of complications including
progressive deformity
nonunion
hardware failure
infection
Spinal Deformity
Introduction
o usually a kyphotic deformity of upper spine
o be sure to eliminate hip contractures as reason for deformity
Treatment
o lumbar osteotomy
indications : thoracolumbar kyphotic deformity
goals
goal is to restore sagittal balance and horizontal gaze
techniques
closing wedge (pedicle subtracting) osteotomy
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By Dr, AbdulRahman AbdulNasser Tumors & Systemic Conditions | Systemic Conditions
transpedicular decancelization procedure with removal of posterior elements
location of osteotomy determined by type of spine flexion deformity
hinge located on anterior vertebral body
considered procedure of choice due to
greater deformity correction (30 t0 40 degrees per level)
better fusion and stability due to direct bony apposition
vertebral body resection
entire vertebral body is removed and replaced with a cage
single-level opening wedge osteotomy
hinges on posterior edge of vertebral body
requires rupture of ALL
multi-segment opening osteotomy
advantage of less bone loss and preservation of ALL by distributing correction over
multiple levels
outcomes & complications
lumbar approach avoids complications of thoracic cage, spinal cord injury, and has
potential for greater correction due to long lever arm
o C7-T1 cervicalthoracic osteotomy
indications
cervicothoracic kyphotic (chin-on-chest) deformity
goals
slight under-correction with final brow-to-chin angle of 10 degrees
technique
osteotomy
advantage of C7-T1 osteotomy include
vertebral artery is external to transverse foremen
larger canal diameter
requires wide decompression with removal of C7 lateral mass and portions of C7-T1
pedicles to prevent iatrogenic SCI
instrumentation
usually a combination of lateral mass screws, pedicle screws, and sublaminar hooks
postoperative
postoperative halo immobilization often required in patients with poor bone quality
outcomes & complications
increased risk of venous air embolus (VAE) in the sitting operative position
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Large-Joint Arthritis
Introduction
o asymmetric involvement of large joints
o shoulder and hip most commonly involved
Treatment
o total hip replacement
indications
in patients with severe arthritis of this hips secondary to AS
technique
patients have more vertical and anteverted acetabulum (may lead to anterior dislocations
after total hip arthroplasty)
o bilateral total hip arthroplasty
indications
kyphotic deformity due to hip flexion contracture deformity
outcomes & complications
at risk for dislocation
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o preservation of disk height in the involved vertebral segment; relative absence of significant
degenerative changes (e.g. marginal sclerosis in vertebral bodies or vacuum phenomenon)
o absence of facet-joint ankylosis; absence of SI joint erosion, sclerosis or intraarticular osseous
fusion
Associated conditions
o lumbar spine
lumbar spinal stenosis
o cervical spine
dysphagia and stridor
hoarseness
sleep apnoea
difficulty with intubation
cervical myelopathy
o spine fracture and instability
because ankylosis of vertebral segments proximal and distal to the fracture creates long lever
arms that cause displacement even in low-energy injuries
hyperextension injuries are common
seemingly minor, low energy injury mechanisms may result in unstable fracture
patterns. One must have increase vigilance in patients with pain and an ankylosed spine
Presentation
Symptoms
o often asymptomatic and discovered incidentally
o thoracic and lumbar involvement
mild chronic back pain
usually pain is minimal because of stabilization of spinal segments through ankylosis
stiffness
worse in the morning
aggravated by cold weather
o cervical involvement (with large anterior osteophytes)
pain and stiffness
dysphagia
stridor
hoarseness
sleep apnea
Physical exam
o decreased ROM of the spine
o neurologic symptoms of myelopathy or spinal stenosis
Imaging III:3 cervical DISH causing dysphagia
Radiographs
o recommended views
AP and lateral spine radiographs of involved region
o findings
non-marginal syndesmophytes at three successive levels (4 contiguous vertebrae)
thoracic spine
radiographic findings on the right side
thoracic spine is often involved in isolation
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particularly T7-T11
radiographic examination of this area is helpful when attempting to establish a
diagnosis of DISH
cervical spine
anterior bone formation with preservation of disc space (best seen on lateral cervical
view)
lateral cervical radiographs useful to differentiate from AS
AS will demonstrate disc space ossification (fusion between vertebral bodies)
lumbar spine
symmetrical syndesmophytes (on left and right side of lumbar spine)
other joint involvement e.g. elbow
Technetium bone scan
o increased uptake in areas of involvement
may be confused with metastases
CT or MRI
o patients with DISH, neck pain and history of trauma must be evaluated for occult fracture with
CT
DISH Lumbar spine Thoracic DISH AP view Thoracic DISH lateral view Thoracic DISH AP view
Lateral elbow Cervical DISH Lumbar DISH AP view Lumbar DISH lateral view
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By Dr, AbdulRahman AbdulNasser Tumors & Systemic Conditions | Systemic Conditions
Differential
See figures in page 117
Treatment
Nonoperative
o activity modification, physical therapy, brace wear, NSAIDS and bisphosphonate therapy
indications
most cases
o cervical traction
indications
cervical spine fracture
use with caution because traction may result in excessive distraction due to lack of
ligamentous structures
Operative
o spinal decompression and stabilization
indications
reserved for specific sequelae (e.g., lumbar stenosis, cervical myelopathy, adult spinal
deformity)
Complications
Mortality
o for cervical spine trauma in DISH
15% for those treated operatively
67% for those treated nonoperatively
Heterotopic ossification
o increased risk of HO after THA
30-50% for THA in patients with DISH
<20% for THA in patients without DISH
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By Dr, AbdulRahman AbdulNasser Tumors & Systemic Conditions | Spinal Cord Lesions
o treatment
surgical resection
post-operative radiation for malignant tumors
Meningioma
o incidence
accounts for 25% of all primary spinal cord tumors
most often occurs in:
women (80%)
thoracic spine
peak incidence during 5th and 6th decades of life
risk factors include:
neurofibromatosis type II
previous history of radiation
o imaging
MRI
well-circumscribed, dura-based lesion
on T1, iso- or hypointense
on T2, slightly hypertensive with homogenous enhancement with contrast
o histology
lobulated architecture
may contain meningothelial whorls
o treatment
if symptomatic, surgical resection
can be curative with complete resection
for recurrence, radiation should be considered
Intradural Intramedullary Tumors
Epidemiology
o account for 20-30% of all intradural tumors in adults and 50% in children
o typically present with symptoms related to:
local or radicular pain
motor deficits (65%)
sensory deficits (60%)
sphincter dysfunction (38%)
often initial symptom
Ependymoma
o incidence
most common intradural intramedullary primary CNS tumor
classified as:
benign
myxopapillary (40-50%)
cellular (42%)
malignant
anaplastic
o imaging
myxopapillary
on MRI, encapsulated lesion in the filum terminale
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on T1, hypo- or isointense
on T2, hyper intense
heterogeneous on contrast enhancement
other features typically seen are:
vertebral body scalloping
neural foraminal enlargement
scoliosis
tumor seeding in the sacrum
cellular
III:4 polar cysts
on MRI, similar to myxopapillary
distinguishing characteristic
polar cysts
hemorrhage
o histology
cellular, monomorphic cells
characteristic rosettes and pseudorosettes
o treatment
gross total resection
good prognosis, especially if planes are maintained
Astrocytoma III:5 rosettes and pseudorosettes
o incidence
most are benign (30%)
peak incidence in third decade of life
most common in children (80-90% of intramedullary tumors)
o imaging
on MRI
fusiform appearance with irregular margins
On T1, hypo- or isointense
On T2, hyper intensive with variable contrast enhancement
typically found in cervicothoracic junction in children
o histology
hypercellular, mitotic figures
eosinophilic granules are common
o treatment
gross total resection difficult due to infiltrative nature
radiation typically used to supplement surgery
chemotherapy may be beneficial
Extradural Tumors
Metastasis
o extramedullary
representative of advancing systemic disease
'drop' metastases from cranial lesion possible
spread via CSF
o intramedullary
rare, <1% of all systemic malignancies
most commonly from : lung, breast
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By Dr, AbdulRahman AbdulNasser Tumors & Systemic Conditions | Spinal Cord Lesions
o imaging
rapidly expanding, progressive on MRI
intramedullary commonly found in cervical region and conus medullaris
o treatment
surgical resection rare
control burden with radiation and/or chemotherapy
intramedullary metastases associated with less than 3 month life expectancy
Lymphoma
o incidence
rare
o imaging
entire neuroaxis should be analyzed via MRI
on T2, ill-defined hyperintense lesion with marked homogeneous contrast enhancement
less cord enlargement
usually found in cervical spine
o treatment
methotrexate
2. Diastematomyelia
Introduction
A fibrous, cartilagenous, or osseous bar creating a longitudinal cleft in the spinal cord
o if the cord does not reunite distally to the spur, it is considered a diplomyelia (true duplication of
the cord)
Epidemiology
o demographics
typically presents in childhood
adult presentation is rare
o location
more common in lumbar spine (L1 to L3)
Pathoanatomy
o a congenital anomaly believed to be caused by persistence of neuroenteric canal
present during 3rd and 4th week of gestation
o leads to sagittal division of the spinal cord or cauda equina
Associated conditions
o congenital scoliosis
as high as 79% in some series
o tethering of cord
Presentation
Symptoms
o muscle atrophy
o weakness
o bladder or bowel incontinence
Physical exam
o sensory loss
o reflex asymmetry
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o spinal cutaneous manifestations (>50% of patients)
hairy patch (hypertrichosis)
dimple
subcutaneous mass
teratoma
o lower extremity deformity
cavus foot
club foot
claw toes
Imaging
Prenatal ultrasound
o may be diagnosed in utero, during the third trimester
Radiographs
o interpedicular widening is suggestive
CT
o helpful to delineate bony anatomy
Myelography
o spurs are often undetectable by plain radiographs or CT,
especially if they are fibrous or there is rotation from
concomitant scoliosis
o myelography is a useful adjuvant
MRI
o required to evaluate degree of neurologic compression
Treatment
Nonoperative
o observation alone
indications
may be observed if patient is asymptomatic and does not have neurologic sequelae
must watch closely for progressive neurological deterioration
Operative
o surgical resection
indications
surgery is indicated if patient is symptomatic or has neurologic deficits
must resect diastematomyelia before correction of spine deformity
must resect and repair the duplicated dural sac
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By Dr, AbdulRahman AbdulNasser Tumors & Systemic Conditions | Spinal Cord Lesions
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Presentation
Syringomyelia
o symptoms
symptoms usually begin insidiously between adolescence and age 45
occipital headache : sometimes exacerbated by Valsalva maneuver
back pain
radicular pain
neurologic deficits : syringomyelia often presents with a central cord syndrome
o physical exam
reflexes
asymmetric abdominal reflexes
asymmetric and/or hyperactive reflexes
asymmetric sweating
spasticity
motor
asymmetric muscle bulk
weakness
sensory
deficits in pain and temperature sensation in a capelike distribution over the back of the
neck
light touch and position and vibration sensation are usually not affected
deformity
lower extremity contracture and deformity
scoliosis
Syringobulbia
o symptoms related to cranial nerve involvment
tongue weakness and atrophy (CN XII)
sternocleidomastoid & trapezius weakness (CN XI)
dysphagia and dysarthia (CN IX, CN X)
facial palsy (CN VII)
Imaging
Radiographs
o relative lack of apical lordosis may indicate presence of syrinx
o scoliosis series for evaluation of scoliosis
CT
o not applicable for characterization of syrinx, only for associated scoliosis
MRI
o diagnosis of syrinx made by MRI
o obtain MRI with gadolinium enhancement to rule out associated tumor
o indications for MRI in patients with scoliosis
abnormal curve (e.g. double curve, apex left)
neurologic deficit
infantile or juvenile age at onset
male gender with atypical or large curve
thoracic kyphosis >30 degrees
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By Dr, AbdulRahman AbdulNasser Tumors & Systemic Conditions | Spinal Cord Lesions
Histopathology
Gross pathology
o cavitation of spinal cord gray matter
o syrinx in continuity with or adjacent to central canal
o inner layer of gliotic tissue
Differential Diagnosis
Hydromyelia
Glioependymal cysts
Myelomalacia
Cystic tumors
Persistent central canal
Treatment
Nonoperative
o observation
indications
if asymptomatic, non-elarging syrinx, most pediatric neurosurgeons recommend against
prophylactic surgery
orthopaedic management may include observation or bracing during neurosurgical and
neurologic evaluations but results of bracing mixed
Operative
o decompression of the foramen magnum and upper cervical cord +/- shunting
indications
cranial nerve deficits
extremity motor weakness
cerebellar findings
sensory deficit
technique
done prior to spinal arthrodesis
outcomes
effect of decompression on neurologic signs and symptoms is variable but supported due
to propensity of deficits to progess
some evidence shows neurosurgery alone may improve spinal deformity
but scoliosis still likely to progress in large curves or children >8 years old
o spinal fusion
indications
depends on age of presentation and curve characteristics
technique
timing of orthopaedic intervention debatable
most recommend waiting 3 to 6 months after neurosurgical decompression
Complications
In general, same as for idiopathic scoliosis
o Increased risk of neurologic deterioration including paralysis if fusion done with undiagnosed
syrinx
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ORTHO BULLETS
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Marchetti-Bartolozzi classification
Developmental • Includes Wiltse I and II
Acquired • Traumatic, postsurgical, pathologic, degenerative
Myerding Classification
Grade I • < 25%
Grade II • 25-50%
Grade III • 50-75%
Grade IV • 75-100%
Grade V • Spondyloptosis
Presentation
Symptoms
o most cases of spondylolysis are asymptomatic
o symptoms include insidious onset of activity related low back pain and/or buttock pain
o neurologic symptoms include
hamstring tightness (most common) and knee contracture
radicular pain (L5 nerve root)
bowel and bladder symptoms
cauda equina syndrome (rare)
o listhetic crisis
severe back pain aggravated by extension and relieved by rest
neurologic deficit
hamstring spasm - walk with a crouched gait
Physical exam
o palpation and motion
flattened lumbar lordosis
palpable step off of spinous process
limitation of lumbar flexion and extension
pain with single-limb standing lumbar extension
measure popliteal angle to evaluate for hamstring tightness
o neurologic exam
straight leg raise may be positive
rectal exam if bowel and bladder symptoms present
Imaging
Pars Stress Reaction & Spondylolysis
o radiographs
lateral radiograph : may show defect in pars in 80%
oblique radiograph
views may show sclerosis and elongation in pars interarticularis (scotty dog sign)
AP : may see sclerosis of the stress reaction
o bone scan
most sensitive (however lesion may be cold)
excellent screening tool for low back pain in children or adolescents
o CT
best study to diagnose and delineate anatomy of lesion
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By Dr, AbdulRahman AbdulNasser Pediatric Spine | Pediatric Spine Conditions
pars stress reaction will show up as sclerosis on xrays and CT scan
o Single photon emission computer tomography (SPECT)
best diagnostic adjunct when plain radiographs are negative
Spondylolisthesis
o radiograph
views
lateral xray used to measure slip angle and grade.
flexion and extension radiographs used to evaluate instability
measurements (See figures pages 17 & 18)
slip grade
slippage on plain lateral radiographic imaging measured in accordance to the vertebra
below
The caudal vertebra is divided into four parts
Grade I means a translation of the cranial vertebra of up to 25%
Grade II of up to 50%
Grade III of up to 75%
Grade IV up to 100%
Grade V describes the ptosis of the cranial vertebra
slip angles
methodology to determine slip angle
pelvic incidence (See figures pages 17 & 18)
pelvic incidence = pelvic tilt + sacral slope
a line is drawn from the center of the S1 endplate to the center of the femoral head
a second line is drawn perpendicular to a line drawn along the S1 endplate,
intersecting the point in the center of the S1 endplate
the angle between these two lines is the pelvic incidence (see angle X in figure above)
correlates with severity of disease
pelvic incidence has direct correlation with the Meyerding–Newman grade
pelvic tilt (See figures pages 17 & 18)
pelvic tilit = pelvic incidence - sacral slope
a line is drawn from the center of the S1 endplate to the center of the femoral head
a second vertical line (parallel with side margin of radiograph) line is drawn
intersecting the center of the femoral head
the angle between these two lines is the pelvic tilt (see angle Z in figure above)
sacral slope (See figures pages 17 & 18)
sacral slope = pelvic incidence - pelvic tilt
a line is drawn parallel to the S1 enplate
a second horizontal line (parallel to the inferior margin of the radiograph) is drawn
the angle between these two lines is the sacral slope (see angle Y in the figure above)
o CT
best study to diagnose and delineate anatomy of pars defect
o MRI
indicated if neurologic symptoms present
useful to diagnose associated stenosis central and foraminal
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Slip Grade
Slip Angle
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Non-Operative Treatment
Nonoperative
o observation with no activity limitations
indications
asymptomatic patients with low-grade spondylolisthesis or spondylolysis
may participate in contact sports
o physical therapy and activity restriction
indications
symptomatic isthmic spondylolysis
symptomatic low grade spondylolisthesis
technique
physical therapy should be done for 6 months and include
hamstring stretching
pelvic tilts
abdominal strengthening
watch low grade dysplastic carefully as there is a higher chance of progression
o TLSO bracing for 6 to 12 weeks
indications
acute pars stress reaction spondylolysis
isthmic spondylolysis that has failed to improve with physical therapy
low grade spondylolisthesis that has failed to improve with physical therapy
outcomes
brace immobilization is superior to activity restriction alone for acute stress
reaction spondylolysis
Operative
o par interarticularis repair
indications
L1 to L4 isthmic defect that has failed nonoperative management
multiple pars defects
o L5-S1 in-situ posterolateral fusion with bone grafting
indications
L5 spondylolysis that has failed nonoperative treatment
low grade spondylolisthesis (Myerding Grade I and II) that
has failed nonoperative treatment
is progressive
has neurologic deficits
is dysplastic due to high propensity for progression
o L4-S1 posterolateral fusion, +/- reduction, (+/- ALIF)
indications
high grade isthmic spondlylisthesis (Meyerding Grade III, IV, V)
reduction is extremely controversial with no accepted guidelines
Surgical Technique
Par interarticularis repair
o approach
posterior midline approach to lumbar spine
o technique
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repair pars defect with screw fixation, tension wiring, or screw and sublaminar hook
technique
decompression indicated if clinical symptoms of stenosis
L5-S1 in-situ posterolateral fusion with bone grafting
o approach
posterior midline approach to lumbar spine
o reduction
o technique
in-situ fusion with bone grafting / with or without instrumentation
postoperative immobilization in a TLSO
decompression only indicated if clinical symptoms of stenosis or radiculopathy
L4-S1 posterolateral fusion +/- reduction
o approach
posterior midline approach to lumbar spine
o reduction
reduction may be done with instrumentation or positioning
pros of reduction
can restore sagittal alignment and reduce lumbosacral kyphosis
cons
risk of significant complications (8-30%) including
L5 is the most common nerve root injury with reduction
sexual dysfunction
catastrophic neurologic injury
o fusion
usually instrumented
Complications
Neurologic deficits
Pseudoarthrosis
Progression of slippage
Hardware failure
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o increased physiologic motion due to
horizontally oriented facet joints
elevated ligamentous laxity
Presentation
Physical exam
o complete exam
is critical secondary to high incidence of associated injuries
always suspect cervical spine injuries when patients present with head trauma and facial
fractures
o careful neurologic exam
need to document sensation (including sacral sparing), motor function and
presence of reflexes
repeat exams are warranted considering that 20% of patients with spinal
fractures may have normal examinations
examinations can be difficult in unconscious patients
Imaging
Radiographs
o overview
pediatric cervical spine imaging interpretation complicated by
hypermobility
unique vertebral configurations
incomplete ossification
presence of apophyses
radiographic findings that could be considered abnormal in an adult,
may be normal in a pediatric patient
o mandatory trauma radiographs include
AP
odontoid open mouth
cross table lateral
normal findings include
prevertebral swelling < 2/3 of adjacent vertebral width
smooth contour lines of
anterior vertebral bodies
posterior vertebral bodies
spinolaminar line (inside lamina)
tips of spinous process
parallel facet joints
normal retropharyngeal space
< 6 mm at C2
< 22 mm at C6
retrotracheal space < 14 mm
atlanto-dens interval < 5 mm in children and < 3 mm adolescents
absent vertebral body wedging
7% of normal children have a wedge shaped C3 vertebral body
absence of cervical lordosis
loss of cervical lordosis may be found in 14% of normal children
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C2-3 or C3-4 pseudosubluxation < 4mm
considered normal as long as the posterior laminar line is contiguous
o additional xrays (optional)
oblique
can help visualize facet disruption
flexion-extension
problematic and should only be performed under physician supervision
CT scan
o useful to identify
fractures of upper cervical spine
atlantoaxial rotatory subluxation
o can help to assess the degree of spinal canal compromise
MRI
o indications
useful in obtunded patients or patients with closed head injuries
o findings
can help to assess the degree of spinal canal compromise
Treatment
Nonoperative
o initial Immobilization IV:1 pseudosubluxation
indications
all pediatric cervical spine trauma
modalities
on pediatric spine board with head "cutout" to compensate for large head size
commercial collars often do not fit properly, may use sandbags
using an adult backboard for pediatric patients creates a dangerous level of cervical
flexion
transporting patients less than 8 years of age requires a spine board with occipital
depression or enough thoracic elevation to align the cervical and thoracic segments of
the spine
o observation
indications
pseudosubluxation C2-3
o collar immobilization
some common indications include
stable odontoid fractures
atlantoaxial instability
acute atlantoaxial rotatory displacement (AARD)
stable subaxial cervical spine trauma
modalities
rigid collar vs. soft collar (depends on injury, often controversial)
o halo immobilization
some common indications include
unstable odontoid fractures
occipitocervical instability
atlantoaxial instability
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subacute atlantoaxial rotatory displacement (AARD)
C1 fractures (Jefferson fractures)
unstable subaxial cervical spine trauma
o surgical stabilization
some common indications
unstable cervical spine with spinal cord injury
atlantoaxial instability
chronic atlantoaxial rotatory displacement (AARD)
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absence of anterior soft-tissue swelling
o true traumatic subluxation may be caused by
Hangman's fx
Treatment
Nonoperative
o observation
indications
psuedosubluxation IV:3 Hangman's fx
outcomes
no association with increased morbidity or mortality has been associated with this
condition
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3 - To verbal stimulation or to touch
2 - To pain
1 - No response
Evaluation
Primary survey
o formation of a multi-disciplinary pediatric trauma team
o assessment as per Advanced Trauma and Life Support(ATLS) protocol for children
Airway
Breathing
Cardiovascular support
use of the Broselow pediatric emergency tape may be used for estimating children's
weight in the pediatric patient during trauma resusitation
Disability
spinal precautions with cervical spine immobilization and log-roll procedures should be
performed
pediatric spine board or an adult spine board with a torso pad/head cut out should be used
to prevent flexion of the cervical spine
evaluate neurologic response using the Pediatric Glasgow Coma Scale
Exposure
Secondary survey
o trauma specific history
mechanism of injury, last meal, PMHx, Allergies, medications
o full neurological examination
motor and sensory examination by myotome and dermatome, respectively
rectal and genital examination
bulbocavernosus reflex, when appropriate
o physical examination
inspection and palpation of the entire spine and paraspinous region
note step-offs, crepitus, bruising, pain, or open injuries
head-to-toe assessment for associated injuries
Imaging
Radiographs
o recommended views
AP and cross table lateral views of the C-T-L spine
o additional views
swimmer's view
open-mouth view
AP view of chest and pelvis
flexion-extension views
o findings
malalignment
fracture
relatively high chance of multilevel spinal involvement
dislocation
CT
o indications
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poly-trauma
high energy injuries
high clinical suspicion of spine injury
altered mental status
head and facial injuries
o findings
risk of radiation overexposure in young children
not to be used as a spine screening examination
MRI
o indications
neurological deficits without radiographic abnormalities
limits ionizing radiation exposure
o findings
spinal cord injury
soft-tissue edema
inferior to CT for evaluating osseous anatomy
Treatment
Nonoperative
o pain control and activity as tolerated
indications
stable fracture patterns
apophyseal fractures
spinous process fractures
transverse process fractures
o activity modification and spinal immobilization
indications
cervical collar immobilization (8 to 12 weeks)
fracture patterns
stable odontoid fractures
atlantoaxial instability
acute atlantoaxial rotatory displacement (AARD)
stable subaxial cervical spine trauma
thoracolumbosacral braces (8 to 12 weeks)
fracture patterns
compression fractures (<50% anterior height loss)
burst fracture (<50% retropulsion, no neurological deficit)
purely osseous flexion-distraction fracture
modalities
cervical collar
rigid collar vs. soft collar (depends on injury, often controversial)
halo collar
considered for unstable cervical spine fractures
thin calvaria increases risk of skull penetration
Operative
o surgical stabilization of cervical spine
indications
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occipitocervical instability
atlantoaxial instability
subaxial instability
techniques
occipitocervical fusion
transarticular screws
pedicle screws with rigid loops and plate or rod constructs
o surgical stabilization of thoracolumbar spine
indications
unstable burst fracture
spinal cord compression
irreducible fracture-dislocation
ligamentous flexion-distraction injury
techniques
pedicle instrumentation one to two levels above and below injury
Complications
Complete neurological deficits
Progressive spinal deformity
Poor wound healing with operative treatment
Cauda equina syndrome
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Classification
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Treatment
Nonoperative
o soft collar, anti-inflammatory
medications, exercise program
indications
subluxation present for < 1
week (traumatic or Grisel's disease)
many patients probably reduce
spontaneously before seeking medical
attention
o head halter traction and bracing
indications
subluxation persists > 1 week
technique
small amount (5 lbs.) usually enough
either in hospital or at home
muscle relaxants and analgesics may be
needed
o halo traction and bracing
indications
subluxation persists > 1 mos.
Operative
o posterior C1-C2 fusion
indications
subluxation persists > 3 mos (or late
diagnosis)
neurologic deficits present
Complications
Missed diagnosis
o diagnosis is often missed delayed
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metatarsus adductus
o traumatic delivery
o plagiocephaly (asymmetric flattening of the skull)
o congenital atlanto-occipital abnormalities
Physical Exam
Symptoms
o head tilt and rotation usually noticed by parents
Physical exam
o head tilt towards the affected side with chin rotation away from the affected side
o palpable neck mass (the contracted SCM) is noted within the first four weeks of life
gradually subsides, becoming a tight band as the patient ages
o not typically painful, if painful then suggestive of an alternative diagnosis
Imaging
Radiographs
o indicated if no palpable mass present to rule out other conditions that cause torticollis including
rotatory atlanto-axial instability
Klippel-Feil syndrome
Ultrasound
o indicated in the presence of a palpable mass
o can help differentiate congenital muscular torticollis from more serious underlying neurologic or
osseous abnormalities
CT Scan
o rules out atlantoaxial rotatory subluxation
o Scan at the C1-2 level with head straight, then in maximum rotation to the right, and then in
maximum rotation to the left
Differential
Atlantoaxial Rotatory Subluxation
o Post-traumatic
o Post-infectious (Grisel's disease)
o painful, patient will resist correction of deformity
Klippel-Feil syndrome
o has classic triad of:
short neck
low hairline
restricted neck motion
Ophthalmologic conditions
Vestibular conditions
Lesions of central and peripheral nervous system
Treatment
Nonoperative
o passive stretching
indications
condition present for less than 1 year
limitation less than 30°
stretching technique
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should include lateral head tilt away from the affected side and chin rotation toward the
affected side (opposite of the deformity)
outcomes
90% respond to passive stretching of the sternocleidomastoid in the first year of life
associated plagiocephaly does remodel and improve, but this process is delayed in older
children
Operative
o Z plasty lengthening or distal bipolar release of SCM
indications
failed response to at least 1 year of stretching
rotational limitation exceeds 30 degrees
good results reported even in older children (4-8 years)
Complications
Untreated may lead to
o permanent rotational deformity
o positional plagiocephaly
o facial asymmetry
o dysplasia of
skull base
atlas (articular facets, laminae, body)
axis
6. Klippel-Feil Syndrome
Introduction
Defined as multiple abnormal segments of cervical spine
o Congenital fusion of 2 or more cervical vertebrae
Pathophysiology
o due to failure of normal segmentation or formation of cervical somites at 3-8 weeks gestation
Genetics
o SGM1 gene (Chr 8)
o Notch and Pax genes
Associated conditions
o congenital scoliosis
o Sprengel's deformity (33%)
o renal disease (aplasia in 33%)
o deafness (30%)
o congenital heart disease / cardiovascular (5-30%)
o synkinesis (mirror motions)
o brainstem abnormalities
o congenital cervical stenosis
o basilar invagination
o atlantoaxial instability (~50%)
o adjacent level disease (100%)
degeneration of adjacent segments of cervical spine that has not fused is common due to
increased stress
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Classification
Several classifications have been proposed, none agreed upon
o Important to note extent and locations of fusions
Fusions above C3, especially those with occipitalization of the atlas are most likely to be
symptomatic and require abstaining from contact sports
Fusions below C3 are least likely to be symptomatic, and most likely to have a normal life
span
Presentation
Symptoms
o stiff neck
Physical exam
o classic triad (seen in fewer than 50%)
low posterior hair line
short webbed neck
limited cervical ROM
secondary to this, the condition may be confused with
muscular torticollis
o other findings
high scapula (Sprengel Deformity)
jaw anomalies
partial loss of hearing
torticollis
scoliosis
Imaging
Imaging
o recommended views : AP, lateral, and odontoid views
o findings
basilar invagination
is seen on lateral view
defined as dens elevation above McRae's line
atlantoaxial instability
is present when the atlanto dens interval is greater than 5 mm
cervical spinal canal stenosis is seen when spinal cord canal < 13 mm
degnerative changes
degnerative disease of the cervical spine is seen in 100%
calcifications
calcifications may be seen within the intervertebral space
resolution within 6 months is common
Treatment
Nonoperative
o observation, OK to participate in contact/ collision sports
indications : asymptomatic patients with fusions of 1-2 disc spaces below C3
o observation, abstain from contact / collision sports
indications
asymptomatic patients with fusion involving C2
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most common presentation
long fusions
o modalities
counseling important to avoid activities that place the neck at high risk of injury
contact sports, gymnastics, football, wrestling, trampoline, etc
Operative
o surgical decompression and fusion
indications
basilar invagination
chronic pain
myelopathy
associated atlantoaxial instability
adjacent level disease if symptomatic
C. Pediatric Deformity
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> 25° before skeletal maturity will continue to progress
after skeletal maturity
> 50° thoracic curve will progress 1-2° / year
> 40° lumbar curve will progress 1-2° / year
remaining skeletal growth
younger age
< 12 years at presentation
Tanner stage (< 3 for females)
Risser Stage (0-1)
Risser 0 covers the first 2/3rd of the pubertal growth spurt
correlates with the greatest velocity of skeletal linear growth
open triradiate cartilage
peak growth velocity
is the best predictor of curve progression
in females it occurs just before menarche and before Risser 1 (girls usually reach
skeletal maturity 1.5 yrs after menarche)
most closely correlates with the Tanner-Whitehouse III RUS method of skeletal
maturity determination
if curve is >30° before peak height velocity there is a strong likelihood of the need for
surgery
curve type
thoracic more likely to progress than lumber
double curves more likely to progress than single curves
Classification
King-Moe Classification
o five part classification to describe thoracic curve patterns and help guide surgeons implanting
Harrington instrumentation
o link to King-Moe classification (not testable)
Lenke Classification
o more comprehensive classification based on PA, lateral, and supine bending films
o helps to decide upon which curves need to be included within the fusion construct
o link to Lenke classification (not testable)
Presentation
School screening
o patients often referred from school screening where a 7° curve on scoliometer during Adams
forward bending test is considered abnormal
7° correlates with 20° coronal plane curve
Physical exam
o special tests
Adams forward bending test
axial plane deformity indicates structural curve
forward bending sitting test
can eliminate leg length inequality as cause of scoliosis
o other important findings on physical exam
leg length inequality IV:4 Adams forward bending test
midline skin defects (hairy patches, dimples, nevi)
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signs of spinal dysraphism
shoulder height differences
truncal shift
rib rotational deformity (rib prominence)
waist asymmetry and pelvic tilt
cafe-au-lait spots (neurofibromatosis)
foot deformities (cavovarus)
can suggest neural axis abnormalities and warrant a MRI
asymmetric abdominal reflexes
perform MRI to rule out syringomyelia
Imaging
Radiographs
o recommended views
standing PA and lateral
o Cobb angle
> 10° defined as scoliosis
intra-interobserver error of 3-5°
o spinal balance
coronal balance is determined by alignment of C7 plumb line to central sacral vertical line
sagittal balance is based on C7 plumb from center of C7 to the posterior-superior corner of
S1
o stable zone
between lines drawn vertically from lumbosacral facet joints
o stable vertebrae
most proximal vertebrae that is most closely bisected by central sacral vertical line
o neutral vertebrae
rotationally neutral (spinous process equal distance to pedicles on PA xray)
o end vertebrae
end vertebra is defined as the vertebra that is most tilted from the horizontal apical vertebra
o apical vertebrae
the apical vertebraeis the disk or vertebra deviated farthest from the center of the vertebral
column
o clavicle angle : best predictor of postoperative shoulder balance
MRI
o should extend from posterior fossa to conus
o purpose is to rule out intraspinal anomalies
o indications to obtain MRI
atypical curve pattern (left thoracic curve, short angular curve, apical kyphosis)
rapid progression
excessive kyphosis
structural abnormalities
neurologic symptoms or pain
foot deformities
asymmetric abdominal reflexes
a syrinx is associated with abnormal abdominal reflexes and a curve without significant
rotation
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Treatment
Based on skeletal maturity of patient, magnitude of deformity, and curve progression
Nonoperative
o observation alone
indications : cobb angle < 25°
technique
obtain serial radiographs to monitor for progression
o bracing
indication
cobb angle from 25° to 45°
only effective for flexible deformity in skeletally immature patient (Risser 0, 1, 2)
goal is to stop progression, not to correct deformity
outcomes
poor prognosis with brace treatment associated with
poor in-brace correction
hypokyphosis (relative contraindication)
male
obese
noncompliant (effectiveness is dose related)
Sanders staging system
predicts the risk of curve progression despite bracing to >50 degrees in Lenke type I
and III curves
uses anteroposterior hand radiograph and curve magnitude to assess risk of
progression despite bracing
Operative treatment
o posterior spinal fusion
indications
cobb angle > 45°
can be used for all types of idiopathic scoliosis
remains gold standard for thoracic and double major curves (most cases)
o anterior spinal fusion
indications : best for thoracolumbar and lumbar cases with a normal sagittal profile
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o anterior / posterior spinal fusion
indications
larges curves (> 75°) or stiff curves
young age (Risser grade 0, girls <10 yrs, boys < 13 yrs)
in order to prevent crankshaft phenomenon
Techniques
Bracing
o recommended for 16-23 hours/day until skeletal maturity or surgical intervention deemed
necessary (actual wear minimum 12 hours required to slow progression)
o brace types
curves with apex above T7
Milwaukee brace (cervicothoracolumbosacral orthosis)
extends to neck for apex above T7
apex at T7 or below
TLSO
Boston-style brace (under arm)
Charleston Bending brace is a curved night brace
o bracing success is defined as <5° curve progression
o bracing failure is defined
6° or more curve progression at orthotic discontinuation (skeletal maturity)
absolute progression to >45° either before or at skeletal maturity, or discontinuation in favor
of surgery
o skeletal maturity is defined as
Risser 4
<1cm change in height over 2 visits 6 months apart
2 years postmenarchal
Posterior spinal fusion
o fusion levels
goals
fusion should include enough levels to adequately maintain sagittal and coronal balance
while being as minimal as safely possible to preserve motion
typical fusion from proximal end vertebra to one or two levels cephalad to the stable
vertebra
double and triple major curves fuse to the distal end vertebra
Harrington technique
recommends one level above and two levels below the end vertebrae if these levels fall
wilthin the stable zone
Moe technique
recommends fusion to the neutral vertebrae
Lenke technique
recommends including all major curves in the fusion and minor curves that are not
flexible or are kyphotic
L5 level
Cochran found increase incidence of low back pain with fusion to L5, and to a lesser
extent L4.
therefore, whenever possible, avoid fusion to L4 and L5
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pelvis
it is almost never required to fuse to the pelvis in idiopathic scoliosis
o pedicle screw fixation
screw insertional torque correlates with resistance to screw pullout
resistance to screw pullout increases by
undertapping by 1mm
o curve correction
segmental pedicle screw fixation allows increased coronal plane correction while lessening
the need for anterior releases
ASF with instrumentation
o advantage
better correction while saving lumbar fusion levels
o disadvantage
increased risk of pseudarthrosis when thoracic hyperkyphosis is present
o fusion levels
typically fuse from end vertebra to end vertebra
Neurologic Monitoring
o monitoring with somatosensory-evoked potentials (SSEPs) and/or motor-evoked potentials
(MEPs) is now the standard of care
motor-evoked potentials can provide an intraoperative warning of impending spinal cord
dysfunction
o neurologic event defined as drop in amplitude of > 50%
o if neurologic injury occurs intraoperatively consider
check for technical problems
check blood pressure and elevate if low
check hemoglobin and transfuse as necessary
lessen/reverse correction
administer Stagnaras wake up test
remove instrumentation if the spine is stable
Complications
Neurologic injury
o paraplegia is 1:1000
o increased risk with kyphosis, excessive correction, and sublaminar wires
Pseudoarthrosis (1-2%)
o presents as late pain, deformity progression, and hardware failure
an asymptomatic pseudarthrosis with no pain and no loss of correction should be observed
Infection (1-2%)
o presents as late pain
o incision often looks clean
o Propionibacterium acnes most common organism for delayed infection (requires 2 weeks for
culture incubation)
o attempt I&D with maintenance of hardware if not loose and within 6 months
Flat back syndrome
o early fatigability and back pain due to loss of lumbar lordosis
o rare now that segmental instrumentation addresses sagittal plane deformities
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decreased incidence with rod contouring in the sagittal plane and compression/distraction
techniques
o treat with revision surgery utilizing posterior closing wedge osteotomies
anterior releases prior to osteotomies aid in maintenance of correction
Crankshaft phenomenon
o rotational deformity of the spine created by continued anterior spinal growth in the setting of a
posterior spinal fusion
can occur in very young patients when PSF is performed alone and the anterior column is
allowed continued growth
avoided by performing anterior diskectomy and fusion with posterior fusion in very young
patients
SMA syndrome (superior mesenteric artery [SMA] syndrome)
o compression of 3rd part of duodenum due to narrowing of the space between SMA and aorta
o SMA arises from anterior aspect of aorta at level of L1 vertebrae
o presents with symptoms of bowel obstruction in first postoperative week
associated with electrolyte abnormalities
nausea, bilious vomiting, weight loss
o risk factors
height percentile <50%; weight percentile < 25%
sagittal kyphosis
o treat with NG tube and IV fluids
Hardware failure
o late rod breakage can signify a pseudarthrosis
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TREATMENT
• this type of curve is usually fuse down to L4 (via a
posterior approach) or down to L3 (anterior approach)
Type II
DESCRIPTION
• S shaped or double curve in which both the
thoracic and lumbar curve cross the midline
• Thoracic curve larger and stiffer than the lumbar
curves.
TREATMENT
• often a thoracic fusion will suffice for these
patients (or down to L1)
Type III
DESCRIPTION
• Thoracic curve crosses midline and lumbar curve does
not cross midline
TREATMENT
• thoracic fusion
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Type IV
DESCRIPTION
• Long thoracic curve in which L5 is centered over
sacrum but L4 tilts into long thoracic curve
TREATMENT
• fuse thru L4
Type V
DESCRIPTION
Thoracic curve and T1 tilts to upper curve
TREATMENT
Use thru T2; do not assume that the upper (left) thoracic
curve is non-structural without proof, and if there is any
question, fuse the upper thoracic spine as well as the
lower thoracic spine;
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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Step 3: Assignment of Sagittal thoracic modifier (-, N, +)
Measure sagital Cobb from T5 to T12
Assign modifier
o hypokyphotic (-) if < 10°
o normal if 10-40°
o hyperkyphotic (+) if >40°
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o observation
indications
curves < 20°
technique
frequent radiographs to observe for curve progression
o bracing
indications
curves 20 - 50°
designed to prevent curve progression, not correct the curve
relative contraindication to bracing is thoracic hypokyphosis
technique
16-23h/day until skeletal growth completed or surgery indicated
Operative
o non-fusion procedures (growing rods, VEPTR)
indications
curves > 50° in small children with significant growth remaining
allows continued spinal growth over unfused segments
definitive PSF + ASF performed when the child has grown and is closer skeletal
maturity
o anterior / posterior spinal fusion
indications
curves > 50° in younger patients
required in order to prevent crankshaft phenomenon
o posterior spinal fusion
indications
curve > 50° in older patients near skeletal maturity
remains gold standard for thoracic and double major curves (most cases)
o anterior spinal fusion
indications
curve > 50°
best for thoracolumbar and lumbar cases with a normal sagittal profile
Complications
Crankshaft phenomenon
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> 20° is linked to high rate of progression
< 20° is associated with spontaneous recovery
MRI
o obtain MRI of spine first to rule out
tether
cyst
tumor
syrinx (20% incidence)
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6. Congenital Scoliosis
Introduction
Congenital scoliosis is the failure of normal vertebral development during 4th to 6th week of
gestation
o caused by developmental defect in the formation of the mesenchymal anlage
Epidemiology
o incidence
prevalence in general population estimated at 1% to 4%
Causes
o most cases occur spontaneously
o maternal exposures
diabetes
alcohol
valproic acid
hyperthermia
o genetic
uncertain
Associated conditions
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o may occur in isolation or with associated conditions
o with associated systemic anomalies, up to 61%
cardiac defects - 10%
genitourinary defects - 25%
spinal cord malformations
o with underlying syndrome or chromosomal abnormality
VACTERL syndrome
in 38% to 55%
characterized by vertebral malformations, anal atresia, cardiac malformations, tracheo-
esophageal fistula, renal, and radial anomalies, and limb defects
Goldenhar/OculoAuricularVertebral Syndrome
hemifacial microsomia and epibulbar dermoids
Jarcho-Levin Syndrome/Spondylocostal dysostosis
short trunk dwarfism, multiple vertebral and rib defects and fusion
most commonly autosomal recessive
often associated with thoracic insufficiency syndrome (TIS)
caused by shortening of the thorax and rib fusions
result is thorax is unable to support lung growth and respiratory decompensation
Klippel-Feil syndrome
short neck, low posterior hairline, and fusion of cervical vertebrae
Alagille syndrome
peripheral pulmonic stenosis, cholestasis, facial dysmorphism
Prognosis
o progression
most rapid in the first 3 years of life
determined by the morphology of vertebrae. Rate of progression from greatest to least is:
unilateral unsegmented bar with contralateral hemivertebra >
greatest potential for rapid progression (5 to10 degrees/year)
unilateral unsegmented bar >
fully segmented hemivertebra >
unsegmented hemivertebra >
incarcerated hemivertebra >
unincarcerated hemivertebra >
block vertebrae
little chance for progression (<2 degrees/year)
presence of fused ribs increases risk of progression
Outcomes
o dependent on potential for progression and early intervention
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Classification
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Imaging
Radiographs
o recommended views
AP and lateral plain films usually sufficient to confirm diagnosis
CT
o indications
judicious use recommended due to radiation exposure
3D CT useful to better delineate posterior bony anatomy and define type for surgical
planning
MRI
o indications
all patients with congenital scoliosis prior to surgery to evaluate for neural axis abnormality
(found in 20-40%) including
Chiari malformation
tethered cord
syringomyelia
diastematomyelia
intradural lipoma
o technique
sedation required in infants so may be delayed if no surgery is planned and no neuro deficits
Additional medical studies
o important to obtain studies for associated abnormalities
renal ultrasound or MRI
echocardiogram if suspicion for cardiac manifestations
Treatment
Nonoperative
o observation and bracing
indications for observation
absence of documented progression, ie:
incarcerated hemivertebrae
nonsegmental hemivertebrae
some partially segmented hemivertebrae
bracing
not indicated in primary treatment of congenital scoliosis (no effectiveness shown)
may be used to control supple compensatory curves, but effectiveness is unproven
Operative
o posterior fusion (+/- osteotomies and modest correction)
indications
hemi-vertebrae opposite a unlateral bar that does not require a vertebrectomy at any
age. this otherwise will relentlessly progress until fused.
older patients with significant progression, neurologic deficits, or declining respiratory
function
having many pedicle screws may decrease crankshaft phenomenon adn obviate the need
for an anterior fusion.
o anterior/posterior spinal fusion +/- vertebrectomy
indications
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young patients with significant progression, neurologic deficits, or declining respiratory
function
girls < 10 yrs
boys < 12 yrs
patients with failure of formation with contralateral failure of segmentation at any age
that requires hemi-vertebrectomy and/or significant correction. This may be done from a
posterior approach
technique
nutritional status of patient must be optimized prior to surgery
o distraction based growing rod construct
indications
may be used in an attempt to control deformity during spinal growth and delay
arthrodesis
outcomes
need to be lengthened approximately every 6 months for best
results
o osteotomies between ribs
indications
mulitple (>4) fused ribs wit potential for thoracic insufficiency
syndrome
outcomes
long-term follow up is needed to determine efficacy. the downside
is this may make the chest stiff and hurt pulmonary function.
o Hemi-Vertebrectomy - usally done from a posterior approach,
particularly with kyphosis.
indications - age 3-8 years (younger is difficult to get good anchor
purchase)
progressive or significant deformity
Techniques IV:12 osteotomies between
ribs
Spinal arthrodesis +/- vertebrectomy/osteotomy
o in situ arthrodesis, anterior/posterior or posterior alone
indications
unilateral unsegmented bars with minimal deformity
o hemiepiphysiodesis
indications
intact growth plates on the concave side of the deformity
patients less than 5 yrs. with < 40-50 degree curve
mixed results
o osteotomy
osteotomy of bar
o hemivertebrectomy
hemivertebrae with progressive curve causing truncal imbalance and oblique takeoff
often caused by a lumbosacral hemivertebrae
patients < 6 yrs. and flexible curve < 40 degrees best candidates
o spinal column shortening resection
indications
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deformities that present late and have severe decompensation
rigid, severe deformities
pelvic obliquity, fixed
Complications
Crankshaft phenomenon
o a deformity caused by performing posterior fusion alone
Short stature
o growth of spinal column is affected by fusion
younger patients affected more
Neurologic injury
o surgical risk factors include
overdistraction or shortening
overcorrection
harvesting of segmental vessels
o somatosensory and motor evoked potentials important
Soft-tissue compromise
o nutritional aspects of care essential to ensure adequate soft tissue healing
7. Neuromuscular Scoliosis
Introduction
Defined as an irregular spinal curvature caused by disorders of the brain, spinal cord, and muscular
system.
Neurogenic curves (relative to idiopathic curves) tend to be
o more rapidly progressive
o may progress after maturity
o associated with pelvic obliquity
o are longer and involve more vertebrae (may involve cervical vertebrae)
o have a higher rate of pulmonary complications with surgery
Classification & Treatment
Outcomes
o surgical correction of spinal fusion is only treatment that has a documented beneficial impact on
deformity
o parents and caretakers report excellent improvement in the child's quality of life after deformity
correction
o Increased risk of wound complications with:
Poor nutritional status (serum albumin <3.5 g/dL)
Immunocompromised status (WBC <1,500 cells/ucL)
Presence of a ventriculoperitoneal (VP) shunt
Severe spastic quadriplegia nonambulatory status with seizures
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Classification and Treatment
(for more detail go to disease content)
Category Disease Nonoperative Operative Treatment
Treatment
Upper Cerebral Boston-type Group I treat with PSF with instumentation
motor underarm bracing Group II treat with PSF +/- ASF with
neuron palsy until puberty (age instrumentation and fusion to pelvis (Luque-
10-12) and Galveston)
wheelchair Indications for surgery
modification o curve > 50°
o worsening pelvic obliquity with sitting
imbalance
Muscle Spinal muscular Boston-type Treat with PSF with fusion to pelvis for improved
Weakness underarm bracing wheelchair sitting
atrophy until puberty (age o address hip contractures before PSF
10-12) o may lead to temporary loss of upper
extremity function
Paralytic Spinal bifida and bracing is ASF/PSF with instumentation and pelvic fixation
Syndromes spinal cord contraindicated o anterior fusion required because minimal
posterior element to obtain fusion
injuries
Boston-type PSF
Polio underarm bracing
until puberty (age
10-12)
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o muscular-skeletal exam
motion, tone, and strength
hamstring contracture's (lead to decreased lumbar lordosis)
hip contractures (lead to excessive lumbar lordosis)
o spine exam
look at flexibility of curve
spinal balance and shoulder height
pelvic obliquity
Classification
Weinstein classification
o Group I - double curves with thoracic and lumbar component and minimal pelvic obliquity
o Group II - large lumbar or thoracolumbar curves with marked pelvic obliquity
Imaging
Radiographs
o introduction
important just to use same radiographic technique in patients over time
technique often determined by functional status of patient
do standing or erect films whenever possible
o standard AP & lateral
look for rib deformity, wedging, and spinal rotation
be sure to evaluate for spondylolisthesis on lateral (incidence of 4-21% in patients with
spastic diplegia)
o bending films
important to evaluate flexibility of curve
use push-pull radiographs or fulcrum bending radiographs if patient can not cooperate
MRI
o preoperative MRI is not routinely performed for patients undergoing spinal deformity surgery
o indications for MRI include
rapid curve progression
change in neurologic exam
Treatment
Nonoperative
o observation, custom seat and/or bracing, botox injections
indications
nonprogressive curves < 50°
early stages in patients < 10 years of age
goal is to delay surgery until an older age
outcomes
custom seat orthosis
helpful with seating but does not affect natural course of disease
bracing
TLSO is helpful to improve sitting balance but does not affect natural course of
disease
some studies have supported use as a palliative measure to slow progression in
skeletally immature patients only
botox
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OrthoBullets2017 Pediatric Spine | Pediatric Deformity
competitive inhibitor of presynaptic cholinergic receptor with a finite lifetime (usually
last 2-3 months)
provide some short term benefit in patients with spinal deformity
Operative
o goals of surgery
obtain painless solid fusion with well corrected, well balanced spine with level pelvis
decision to proceed with surgery must include careful assessment of family's goals and
careful risk-benefit analysis
o PSF with/without extension to the pelvis
indications
Group I curves 50° to 90° in ambulators that is progressive or interfering with sitting
position
patient > 10 yrs of age
adequate hip range of motion
stable nutritional and medical status
technique
treated as idiopathic scoliosis with selective fusion
can result in worsening pelvic obliquity and sitting imbalance
o PSF +/- ASF with/without extension to pelvis
indicated for
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By Dr, AbdulRahman AbdulNasser Pediatric Spine | Pediatric Deformity
Surgical Techniques
Fusion levels
o proximal fusion should extend to T1 or T2 (otherwise risk of proximal thoracic kyphosis)
o distal fusion depends on curve pattern
due to long curves in CP often extends to L4 or L5
extend to pelvis whenever pelvic obliquity is > 15°
Posterior fixation techniques
o Luque rod with sublaminar wires technique
o Unit rod with sublaminar wires technique
o Pedicle screw fixation technique
may provide better correction and eliminate need for anterior
surgery
Pelvic fixation techniques
o Galveston Technique
technique to fuse to pelvis with goal of a stability and truncal
balance and a level pelvis
caudal ends of rods are bent from lamina of S1 to pass into
the posterosuperior iliac spine and between the tables of the
ileum just anterior to the sciatic notch
o bilateral sacral screws
o iliosacral screws
o spinopelvic transiliac fixation
o Dunn-McCarthy technique (S-contoured rod that wraps over
sacral ala)
Anterior and Posterior Techniques
o use of anterior procedures decreasing with improved posterior
constructs
o higher complication rate in anterior surgery in CP spinal
deformity than idiopathic scoliosis
decrease complication rate if A/P done on same day verses
staging procedure (improved nutritional status, decreased
blood loss, short length of hospitalization)
Preoperative traction
o may be option in severe and rigid curve
Postoperative bracing
o usually not required
may be used in patients with osteoporosis or tenuous fixation
Complications
Implant failure
o sometimes may be asymptomatic and not require treatment
o includes penetration of pelvic limb of unit rod into pelvis
Pulmonary complications
o chronic aspiration
o pulmonary insufficiency most common complication in recent study
o pneumonia
GI complications
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OrthoBullets2017 Pediatric Spine | Pediatric Deformity
o GERD
o poornutrition and delayed growth
Neurologic complications
o seizures
Wound infection
o more common in CP than idiopathic scoliosis
o occurs in 3-5% and usually can be treated with local wound debridement alone
Death (0-7%)
9. Pathologic Scoliosis
Introduction
Painful, usually mild scoliosis resulting from a benign bone tumor most commonly located in the
posterior elements of the spine. Causes include
o osteoid osteomas
occur in the apex of the concavity of the curve
curves are typically rigid
can occur in the vertebral body or posterior elements
demonstrate same histology as osteoid osteomas in the peripheral
skeleton
o osteoblastomas IV:13 osteoid osteomas
larger lesion than osteoid osteoma
pain is usually less severe than osteoid osteoma
Epidemiology
o can occur in all age groups
Mechanics
o scoliosis is thought to develop in response to painful paraspinal muscle spasms
Prognosis
o outcomes good with treatment
most cases of scoliosis due to osteoid osteoma will resolve after resection of tumor if
performed within 15-18 months of onset of curvature
child is less than 11 years of age
Presentation
Symptoms
o back pain
most commonly at night
o pain relieved by anti-inflammatories
less relief reported with osteoblastomas
Physical exam
o posterior trunk
curvature of the spine
usually mild
o neurological exam
may have neurological deficits with osteoblastoma
findings dependent on level of lesion
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By Dr, AbdulRahman AbdulNasser Pediatric Spine | Pediatric Deformity
Imaging
Radiographs
o AP/Lateral of spine
can determine level and severity of curvature
o findings
lesion is defined by cortical thickening with radiolucent nidus
osteoid osteoma is less than 1 cm in diameter by definition
osteoblastoma is greater than 1.5 cm
CT scan
o fine cut best for outlining lesion and determining treatment plan
MRI
o good for showing proximity to neurovascular structures
o may only show soft tissue edema and not the nidus
Bone scan
o markedly increased uptake in area of lesion
Treatment
Non-operative
o NSAIDs, observation
indications
minimal curve
outcomes
may take up to 36 months to resolve
osteoblatomas usually do not respond to NSAIDS
Operative
o en bloc resection of lesion
indications
painful, progressive scoliosis
outcomes
resolution of curve if removed with 15-18 months of onset of curve in child less than 11
years old
o radiofrequency ablation of lesion
indications
usually not an option due to proximity of neurological structures of spine
case by case basis based on 3D studies (CT, MRI)
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By Dr, AbdulRahman AbdulNasser Pediatric Spine | Pediatric Deformity
normal thoracic kyphosis is between 20 degrees and 45 degrees
o may have a compensatory hyperlordosis of the cervical and/or lumbar spine
o tight hamstrings are common
o neurological deficits rare but need to evaluate neuro status
Imaging
Radiographs
o recommended : AP and lateral spine
o findings
anterior wedging across three consecutive vertebrae
disc narrowing
endplate irregularities
Schmorl's nodes (herniation of disc into vertebral endplate)
scoliosis
compensatory hyperlordosis
important to look for spondylolysis on lumbar films
o hyperextension lateral xrays
can help differentiate from postural kyphosis
Scheuermann's kyphosis usually relatively inflexible on bending xray
CT scan : usually not needed
MRI
o controversial as to if indicated prior to surgery or not to look for associated disc herniation,
epidural cyst, cord abnormalities, and spinal stenosis
o will show vertebral wedging, dehydrated discs, and Schmorl's nodes (herniation of disc into
vertebral endplate)
Treatment
Nonoperative
o stretching and observation
indications
kyphosis < 60° and asymptomatic (or pain is mild)
most patients fall in this group and can be treated with observation alone
o bracing with extension-type orthosis (jewitt type - with high chest pad)
indications
kyphosis 60°-80° msot effective in those with gorwth remaining
outcomes
patient compliance is often an issue
usually does not lead to correction but can stop progression
Operative
o PSF with dual rod instrumentation ± Smith-Petersen osteotomy ± anterior release and
interbody fusion
indications
kyphosis > 75 degrees
neurologic deficit
spinal cord compression
severe pain in adults
Smith-Petersen osteotomy
best for long sweeping, global kyphosis
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OrthoBullets2017 Pediatric Spine | Pediatric Deformity
10° sagittal plane correction per level
anterior release
uncommon now from improved pedicle screw posterior constructs
perhaps indicated in larger curves that are more rigid in nature
outcomes
studies show 60-90% improvement of pain with surgery (no correlation with amount of
correction)
Surgical Techniques
PSF with dual rod instrumentation
o approach
posterior midline to thoracic spine
o arthrodesis
current recommendation is to include entire kyphotic Cobb angle and stop distally to include
theStable Sagittal Vertebrae
o fixation technique
usually a combination of pedicle screws and hooks
intra canal hooks may be dangerous at apex of curve as they can potentially compress
spinal cord
do not always have to instrument at apex
o correction technique
Cantelever - usally two rods placed in top anchors then brought down to bottom pedicle
screws
Compression accross psoterior anchors
posterior spine shortening technique of Ponte
indicated in stiff curves where correction is needed
done by removing spinous processes at apex, ligamentum flavum, and
performing superior and inferior facet resection
goal is to obtain correction to final kyphosis from 40-50°
in situ bending usally not helpful
Anterior release and fusion
o thorascopic anterior discectomy may morbidity of thoracotomy, but usually not needed
Complications
Neurologic complications
o higher than idiopathic scoliosis corrective surgeries
o must monitor with motor and somatosensory evoked potentials
Distal Junctional kyphosis
o occurs in 20-30% of patient
o avoid by
making proper selection of fusion levels Collected By : Dr AbdulRahman
avoid overcorrection (correction should not AbdulNasser
exceed 50% of original curve) [email protected]
In June 2017
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3
ORTHO BULLETS
Volume
Three
Sports
2017
Collected By : Dr AbdulRahman AbdulNasser
[email protected]
OrthoBullets 2017
OrthoBullets 2017
Preface
Orthobullets.com is an educational resource for
orthopaedic surgeons designed to improve
training through the communal efforts of those
who use it as a learning resource. It is a simple but
powerful concept. All of our topics, technique
guides, cases, and user-generated videos are
free, and will stay that way.
ORTHO BULLETS
I.Shoulder
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By Dr, AbdulRahman AbdulNasser Shoulder | Anatomy & Examination
Glenohumeral Stability
Static restraints
o glenohumeral ligaments (below)
o glenoid labrum (below)
o articular congruity and version
o negative intraarticular pressure
if release head will sublux inferiorly
Dynamic restraints
o rotator cuff muscles
The primary biomechanical role of the rotator cuff is stabilizing the glenohumeral joint by
compressing the humeral head against the glenoid.
o rotator interval
o biceps long head
o periscapular muscles
SGHL
o from anteriosuperior labrum to humerus
o restraint to inferior translation at 0° degrees of abduction (neutral rotation)
o prevents anteroinferior translation of long head of biceps (biceps pulley)
MGHL
o resist anterior and posterior translation in the midrange of abduction (~45°) in ER
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OrthoBullets2017 Shoulder | Anatomy & Examination
IGHL
o posterior band IGHL
most important restraint to posterior subluxation at 90° flexion and IR
tightness leads to internal impingement and increased shear forces on superior labrum (linked
to SLAP lesions)
o anterior band IGHL
stability
primary restraint to anterior/inferior translation 90° abduction and maximum ER (late
cocking phase of throwing)
anatomy
anchors into anterior labrum
forms weak link that predisposes to Bankart lesions
o superior band IGHL
most important static stabilizer about the joint
100% increased strain on superior band of IGHL in presence of a SLAP lesion
Coracohumeral ligament (CHL)
o from coracoid to rotator cable
o limits posterior translation with shoulder in flexion,adduction, and internal rotation
o limits inferior translation and external rotation at adducted position
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By Dr, AbdulRahman AbdulNasser Shoulder | Anatomy & Examination
Glenoid Labrum (static)
Function
o helps create cavity-compression and creates 50% of the glenoid socket depth
Composition
o composed of fibrocartilagenous tissue
Blood supply
o suprascapular artery
o anterior humeral circumflex scapular
o posterior humeral circumflex arteries
o labrum receives blood from capsule and periosteal vessels and not from underlying bone
o anterior-superior labrum has poorest blood supply
Stability
o anterior labrum
anchors IGHL (weak link that leads to Bankart lesion)
o superior labrum
anchors biceps tendon (weak link that leads to SLAP lesion)
Anatomic variants
o normal variant
the labrum attached to the glenoid rim and a flat/broad middle glenohumeral ligament is the
most common “normal” variation. A cord-like middle glenohumeral ligament is often
present in 86% of population
o sublabral foramen
seen in ~12% if population
o sublabral foramen + cordlike MGHL
o Buford complex (absent anterosuperior labrum + cordlike MGHL)
seen in ~1.5% of population
cordlike middle glenohumeral ligament with attachment to base of biceps anchor and
complete absence of the anterosuperior labrum
attaching a Buford complex will lead to painful and restricted external rotation and elevation.
o meniscoid appearance (1%)
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OrthoBullets2017 Shoulder | Anatomy & Examination
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By Dr, AbdulRahman AbdulNasser Shoulder | Anatomy & Examination
Osteology
Humeral head
o greater and lesser tuberosities are attachment sites for the rotator cuff
o spheroidal in shape in 90% of individuals
o average diameter is 43 mm
o retroverted 30° from transepicondylar axis of the distal humerus
o articular surface inclined upward 130° from the shaft
Glenoid
o pear-shaped surface with average upward tilt of 5°
o average version is 5° of retroversion in relation to the axis of the scapular body and varies from
7° of retroversion to 10° of anteversion
Coracoid
o serves as an anatomic landmark or "lighthouse" for the deltopectoral approach
o coracobrachialis, pectoralis minor, and short head of the biceps attach to the coracoid
Acromion
o 3 ossification centers : meta (base), meso (mid), and pre-acromion (tip)
o acromiohumeral interval is 7-8mm
AHI may be normal on Xray but decreased on MRI when pt is supine and weight of arm is
removed. This usually signifies multiple tendon tear.
o acromial morphology
I=flat
II=curved
III=hooked
Blood Supply
Humeral head
o ascending branch of anterior humeral circumflex artery and arcuate artery
provides blood supply to humeral head
vessel runs parallel to lateral aspect of tendon of long head of biceps in the bicipital groove
beware not to injure when plating proximal humerus fractures
arcuate artery is the interosseous continuation of ascending branch of anterior humeral
circumflex artery and penetrates the bone of the humeral head
o posterior humeral circumflex artery
most current literature supports this as providing the main blood supply to humeral head
2. Acromioclavicular Joint
Osteology
o the AC joint is a diarthrodial joint
o fibrocartilaginous intraarticular disc is located
between the osseous segments
Motion
o majority of motion is from the bones, not through
the joint
clavicle rotates 40-50° posteriorly with shoulder
elevation
8° of rotation through AC joint
remainder from scapular rotation and
sternoclavicular motion
o joint itself is limited to gliding motions only
Stability
o acromioclavicular ligament
provides horizontal stability
has superior, inferior, anterior, and posterior components
superior ligament is strongest, followed by posterior
o coracoclavicular ligaments (trapezoid and conoid)
provides vertical stability
trapezoid inserts 3 cm from end of clavicle
stabilizer against horizontal and vertical loads
conoid inserts 4.5 cm from end of clavicle in the posterior border
more important ligament
vertical stabilizer of AC joint
normal CC distance (superior coracoid to inferior clavicle) is 11-13mm
o deltotrapezial fascia, capsule, deltoid and trapezius
act as additional stabilizers
3. Sternoclavicular Joint
Introduction
Diarthrodial saddle joint incongruous (~50% contact)
o fibrocartilage (not synovial cartilage)
o contains an intra-articular disc
Motion
o elevation of arm to 90° leads to rotation of the sternoclavicular joint of 30°
Imaging
o best assessed radiographically by Serendipity view
involves 40° cephalic tilt view of sternum and clavicle
CT scan is most sensitive and specific
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By Dr, AbdulRahman AbdulNasser Shoulder | Anatomy & Examination
Serendipity View
Stabilizing Ligaments of Sternoclavicular Joint
Posterior sternoclavicular capsular ligament
o primary restraint for anterior-posterior stability
Anterior sternoclavicular ligament
o primary restraint to superior displacement of medial clavicle
Costoclavicular (rhomboid) ligament
o anterior fasciculus resists superior rotation and lateral displacement
o posterior fasciculus resists inferior rotation and medial displacement
Intra-articular disk ligament
o prevents medial displacement of clavicle
o secondary restraint to superior clavicle displacement
4. Scapulothoracic Joint
Introduction
Function
o allows scapular motion against the rib cage
Osteology
o not a true joint; actually an articulation between the scapula and the thorax
o is a sliding "joint" between medial border of scapula and ribs 2-7
o resting position angulation (although these are variable even in healthy adults)
anteriorly 10-20°
internally rotated 30°-45° from the coronal plane
upward tilt of 3°
Biomechanics
Motion
o primary motion
elevation & depression
movement up and down along the rib cage
o secondary motions
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OrthoBullets2017 Shoulder | Anatomy & Examination
protraction & retraction
movement away from or toward the vertebral column
upward & downward rotation
upward rotation with arm elevation
downwared rotation with arm returning to side from raised position
internal & external rotation
anterior & posterior tipping
o shoulder abduction
the ratio of glenohumeral motion to scapulothoracic motion is 2:1
GH does 120°, then ST does 60°
Stability
o 17 different muscles attach to or originate from the scapula
trapezius
serratus anterior
deltoid
latisimus dorsi
levator scapulae
rhomboid major
rhomboid minor
omohyoid - inferior belly
pectoralis minor
teres major
teres minor
triceps brachii
biceps brachii
coracobrachialis
infraspinatus
subscapularis
supraspinatus
Clinical
Scapulothoracic dissociation
Scapular winging
Scapulothoracic dyskinesis
5. Os Acromiale
Introduction
An unfused secondary ossification center
o most common location is the junction of meso- and meta-acromion
o important to distinguish an os acromiale from fractures of the acromion
Epidemiology
o incidence 8%
o bilateral in 60%
o more common in males
o more common in African American
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By Dr, AbdulRahman AbdulNasser Shoulder | Anatomy & Examination
Associated conditions
o shoulder impingement
o rotator cuff disease
meso-acromion is associated with rotator cuff tendonitis
and full thickness tears (in 50%)
Prognosis
o poorer outcomes after rotator cuff repairs in patients with
meso-os acromiale
Anatomy
3 ossification centers
o meta-acromion (base)
origin of posterior portion of deltoid
o meso-acromion (mid)
origin of middle deltoid
o pre-acromion (tip)
origin of anterior deltoid fibers and coracoacromial ligament
Blood supply
o acromiale branch of thoracoacromial artery
Presentation
History
o pain
from impingement
reduction in subacromial space from flexion of the anteiror fragment with deltoid
contraction and arm elevation
from motion at the nonunion site (painful synchondrosis)
o incidental finding on radiographs
o trauma can trigger onset of symptoms from previously asymptomatic os acromiale
Imaging
Radiographs
o recommended views
best seen on an axillary lateral of the shoulder
CT : indications
o to better visualize the nonunion site
o to detect degenerative changes (cysts, sclerosis, hypertrophy)
Treatment
Nonoperative
o observation, NSAIDS, therapy, subacromial corticosteroid injections
indications
mild symptoms
Operative
o two-stage fusion
indications
symptomatic os acromiale with impingement
technique
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OrthoBullets2017 Shoulder | Anatomy & Examination
direct excision can lead to deltoid dysfunction
a two-stage procedure may be required
first stage - fuse the os acromiale ± bone graft
second stage - perform acromioplasty
preserve blood supply (acromiale branch of thoracoacromial artery)
tension band wires, sutures, cannulated screws
o arthroscopic subacromial decompression and acromioplasty
indications
impingement with/without rotator cuff tear (where the os acromiale is only incidental and
nontender)
o open or arthroscopic fragment excision
indications
symptomatic pre-acromion with small fragment
salvage after failed ORIF
results
arthroscopic has less periosteal and deltoid detachment
better excision results with pre-acromion
Complications
Deltoid weakness
o from fragment excision
Persistent pain/weakness
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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By Dr, AbdulRahman AbdulNasser Shoulder | Anatomy & Examination
6. Shoulder Exam
Introduction
This topic is broken down into
o general shoulder exam
inspection
palpation
ROM
neurovascular exam
o impingement tests
o rotator cuff tests
o labral injury tests
o biceps injuries tests
o AC joint
o instability
o other
Inspection
Skin
Scars
Symmetry
Swelling I:6 Shoulder Range of motion
Atrophy
Hypertrophy
Scapular winging
Palpation
All bony prominences around shoulder girdle (AC joint)
Muscles and soft tissues including
o deltoid
o rotator cuff tendon insertion / greater tuberosity
o trapezius
o biceps tendon in groove
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OrthoBullets2017 Shoulder | Anatomy & Examination
Neurovascular Exam
Sensation
o check dermatomes of following nerves
axillary
musculocutaneous
medial Brachial/Antebrachial Cutaneous
median
radial
ulnar
Motor
o Deltoid, Biceps, Triceps, Extensor Pollicis Longus, Flexor Digitorum Profundus, Dorsal
Interossei
Vascular : brachial, radial, ulnar artery pulses
Differential
o cervical radiculopathy
o suprascapular neuropathy
o brachial neuritits
1. Impingement
t Sign
o indicative of impingement of rotator cuff tendon/bursa against the coracoacromial arch
other abnormalities can produce a positive test including
stiffness
OA
instability
bone lesions
o technique
use one hand to prevent motion of the scapula
raise the arm of the patient with the other hand in forced elevation (somewhere between
flexion and abduction)
pain is elicited (positive test) as the greater tuberosity impinges against the acromion
(between 70-110°)
note you must have full range of motion for "positive" finding.
Neer Impingement Test
o positive when there is a marked reduction in pain from above impingement maneuver following
subacromial lidocaine injection
o technique
usually a combination of
4cc 1% Lidocaine
4cc 0.50% Bupivicaine (Marcaine)
2cc corticosteroid)
Hawkins Test
o positive with impingement
o technique
performed by flexing shoulder to 90°, flex elbow to 90°, and forcibly internally rotate driving
the greater tuberosity farther under the CA ligament.
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By Dr, AbdulRahman AbdulNasser Shoulder | Anatomy & Examination
Jobe‟s Test
o positive with supraspinatus weakness and or impingement
o technique
abduct arm to 90°, angle forward 30° (bringing it into the scapular plane), and internally
rotate (thumb pointing to floor).
then press down on arm while patient attempts to maintain position testing for weakness or
pain.
Internal Impingement
o patient supine or seated
o abduct affected side to 90° and maximally externally rotate (throwing position-late cocking
phase) with extension
o if this maneuver reproduces pain experienced during throwing (posteriorly located) considered it
is considered positive.
o further confirmed with relief upon performing relocation test
o re-perform test in abduction/max
o ER with elbow in front of plane of body and pain disappears.
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OrthoBullets2017 Shoulder | Anatomy & Examination
Supraspinatus Tests
Supraspinatus Strength
o strength is assessed using Jobe‟s Test (see below) – pain with this test is indicative of a
subacromial bursitis/irritation – not necessarily a supra tear. Only considered positive for tear
with a true drop arm. i.e. arm is brought to 90° and literally falls down.
Jobe‟s Test
o tests for supraspinatus weakness and/or impingement
o technique
abduct arm to 90°, angle forward 30° (bringing it into the scapular plane), and internally
rotate (thumb pointing to floor). Then press down on arm while patient attempts to maintain
position testing for weakness or pain.
Drop Sign
o tests for function/integrity of supraspinatus
o technique
passively elevate arm in scapular plan to 90°. Then ask the patient to slowly lower the arm.
The test is positive when weakness or pain causes them to drop the arm to their side.
Infraspinatus
Infraspinatus Strength
o external rotation strength tested while the arm is in neutral abduction/adduction
External Rotation Lag Sign
o positive when the arm starts to drift into internal rotation
o technique
passively flex the elbow to 90 degrees, holding wrist to rotate the shoulder to maximal
external rotation. Tell the patient to hold the arm in that externally rotated position. If the arm
starts to drift into internal rotation, it is positive.
Teres Minor
Teres Minor Strength
o external rotation tested with the arm held in 90 degrees of abduction
Hornblower's sign
o positive if the arm falls into internal rotation it may represent teres minor pathology
o technique
bring the shoulder to 90 degrees of abduction, 90 degrees of external rotation and ask the
patient to hold this position
Pectoralis
Axillary Webbing
o look for a defect in the normal axillary fold. A deformity may be indicative of an pectoralis
major muscle rupture
3. Labral Injuries and SLAP lesions
Active Compression test ("O'Brien's Test")
o positive for SLAP tear when there is pain is "deep" in the glenohumeral joint while the forearm
is pronated but not when the forearm is supinated. technique
patient forward flexes the affected arm to 90 degrees while keeping the elbow fully extended.
The arm is then adducted 10-15 degrees across the body. The patient then pronates the
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By Dr, AbdulRahman AbdulNasser Shoulder | Anatomy & Examination
forearm so the thumb is pointing down. The examiner applies downward force to the wrist
while the arm is in this position while the patient resists. The patient then supinates the
forearm so the palm is up and the examiner once again applies force to the wrist while the
patient resists.
Crank Test
o positive when there is clicking or pain in the glenohumeral joint
o technique
hold the patient's arm in an abducted position and apply passive rotation and axial rotation.
4. Biceps Injuries
Bicipital Groove Tenderness
o may be present with any condition that could lead to an inflamed long head biceps tendon and a
SLAP lesion
Speed's Test
o positive when there is pain elicited in the bicipital groove
o technique
patient attempts to forward elevate their shoulder against resistance while they keep their
elbow extended and forearm supinated.
Yergason's Sign
o positive when there is pain in the bicipital groove
o technique
elbow flexed to 90 degrees with the forearm pronated. The examiner holds the hand/wrist to
maintain pronated position while the patient attempts to actively supinate against this
resistance. If there is pain located along the bicipital groove the test is positive for biceps
tendon pathology.
Popeye Sign
o present when there is a large bump in the area of the biceps muscle belly. Consistent with long
head of biceps proximal tendon rupture.
5. AC Joint
Acromioclavicular joint tenderness
o tenderness with palpation of the acromioclavicular joint
Cross-Body Adduction
o positive when there is pain in the AC joint
o technique
patient forward elevates the arm to 90 degrees and actively adducts the arm across the body.
Obrien's Test (Active Compression test)
o positive when there is pain "superficial" over the AC joint while the forearm is pronated but not
when the forearm is supinated
o technique
patient forward flexes the affected arm to 90 degrees while keeping the elbow fully extended.
The arm is then adducted 10-15 degrees across the body. The patient then pronates the
forearm so the thumb is pointing down. The examiner applies downward force to the wrist
while the arm is in this position while the patient resists. The patient then supinates the
forearm so the palm is up and the examiner once again applies force to the wrist while the
patient resists.
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OrthoBullets2017 Shoulder | Anatomy & Examination
6. Instability
GRADING OF TRANSLATION OF HUMERAL HEAD
1+ translation to glenoid rim
2+ translation over glenoid rim but reduces
3+ translates and locks out of glenoid
Anterior Instability
Anterior Load and Shift
o positive when there is increased translation compared to the contralateral side
o technique
have the patient lie supine with the shoulder at 40-60 degrees of abduction and 90 degrees of
forward flexion. Axially load the humerus and apply anterior/posterior translation forces.
Compare to the contralateral side.
Apprehension and Relocation
o positive test if the patient experiences the sensation of instability
o technique
have the patient lie supine. Apprehension test performed by bringing the arm in 90 degrees of
abduction and full external rotation and patient experiences sense of instability. Relocation
test performed by placing examiner's hand on humeral head applying a posterior force on the
humeral head. Patient will experience reduction or elimination of sense of instability.
Anterior Release
o positive test if the patient experiences instability when examiner's hand is released
o technique
have the patient lie supine. Examiner places hand on humeral head to keep reduced as arm is
brought into abduction/external rotation. Examiner's hand is removed and the humeral head
subluxes causing sense of instability. NOTE: positive anterior release is really a "3 in 1" test -
if it is positive, apprehension and relocation are also positive.
Anterior Drawer
o positive if there is sense of instability when compared to the contralateral side
o technique
stablize the scapula and apply an anteriorly directed force against the humeral head with the
contralateral hand. NOTE: graded 1+, 2+, and 3+ but this only documents amount of laxity,
not pathologic unless causes symptoms.
Posterior Instability
Posterior Load and Shift
o positive if there is increased translation compared to contralateral side
o technique
lie the patient supine with the shoulder in 40-60 degrees of abduction and 90 degrees of
forward elevation. Load the humerus with an axial load and apply anterior/posterior forces to
the humeral head. Compare the amount of translation with the contralateral side.
Jerk Test
o positive if there is a 'clunk' or pain with the maneuver
o technique
have the patient sit straight up with the arm forward elevated to 90 degrees and internally
rotated to 90 degrees. Apply an axial load to the humerus to push it posteriorly.
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By Dr, AbdulRahman AbdulNasser Shoulder | Anatomy & Examination
Posterior Drawer
o positive if there is increased translation when compared to the contralateral side
o technique
stabilize the scapula and apply a posteriorly directed force against the humeral head with the
contralateral hand.
Posterior Stress Test
o positive if there is pain and sense of instability with the maneuver
o technique
Place the patient's arm in flexion, adduction, and internal rotation and apply a posteriorly
directed force.
Loss of External Rotation
o a shoulder that is locked in internal rotation may be subluxed posteriorly.
7. Other
Wright's Test
o test for thoracic outlet syndrome.
o positive if the patient losses their radial pulse
o technique
passively externally rotate and abduct the patient's arm while having the patient turn their
neck away from the tested extremity.
Medial Scapular Winging
o test for serratus anterior weakness or long thoracic nerve dysfunction.
o positive if the inferior border of the scapula migrates medially
o technique
while standing, have the patient forward flex their arm to 90 degrees and push against a wall
(or other stationary object).
Lateral Scapular Winging
o test for trapezius weakness or spinal accessory nerve (CNXI) dysfunction
o positive if the inferior boarder of the scapula migrates laterally
o technique
while standing, have the patient forward flex to 90 degrees and push against a wall (or other
stationary object).
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OrthoBullets2017 Shoulder | Anatomy & Examination
7. Shoulder Imaging
Radiographs
Shoulder trauma series includes at least:
o “true” anteroposterior view
o axillary lateral view
Computed Tomography
Overview
o provides better detail of cortical and trabecular bone structures than MRI at cost of higher
radiation exposure
o there for optimal for visualization of bony defects
o magnification artifacts that are associated with radiographs do not occur with CT
Axial Shoulder Images
o useful to visulaize Reverse Hill Sachs
Coronal Shoulder Images
o useful to visualize
fractures
Sagittal Shoulder Images
o useful to visualize
anterior-inferior glenoid insufficiency
3D Reconstructions
o useful to visualize
glenoid version for total shoulder arthroplasty
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By Dr, AbdulRahman AbdulNasser Shoulder | Anatomy & Examination
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OrthoBullets2017 Shoulder | Anatomy & Examination
Magnetic Resonance Imaging
Overview
o MRI is best for evaluating soft tissue structures and evaluating bone contusions or trabelcular
microfractures
o the stronger the magnet, the higher the intrinsic signal-to-noise ratio (e.g. a 3 Tesla MRI machine
has 9x the proton energy of a 1.5 Tesla MRI machine)
T1-weighted sequence
o uses a short repetition time (TR) and short echo time(TE)
bright= fat
dark= fluid, bone, ligament, bone marrow, and fibrocartilage
o often combined with MR arthrograms
o useful to visualize
Hill Sachs Lesion
T2-weighted sequence
o uses a long TR and long TE
bright= fluid (inflammation) and bone marrow
dark= bone, ligament, muscle, and fibrocartilage
o useful to visualize
rotator cuff pathology
full thickness tear
Short tau inversion recovery (STIR)
o Fat saturation (e.g. suppression) technique
technique that reduces signal from fat and increases signal from fluid and edema
helps to determe edema versus fatty infiltration in the rotator cuff muscles
o useful to visualize rotator cuff pathology
ABER (abduction external rotation) position
o sequence beyond the conventional 3 sequences (coronal, sagittal, and axial)
patient places affected hand behind their head instead of a true 90-90 degree abduction-
external rotation position
position tensions the anteroinferior glenohumeral ligament and labrum and relaxes the
capsule
o useful to visualize
Bankart lesions
partial- and full-thickness tears of the rotator cuff tendons
internal impingement
MR arthrogram
o commonly used to augment MRI to diagnose soft-tissue problems such as SLAP tears
dilute gadolinium-containing solution is percutaneously injected into the joint.
o optimal for
labral and ligament pathology
Bankart lesion
Superior labrum anterior-posterior tear (SLAP)
Glenoid labral articular disruption (GLAD)
Anterior labral periosteal sleeve avulsion (ALPSA)
Humeral avulsion of the glenohumeral ligament (HAGL)
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By Dr, AbdulRahman AbdulNasser Shoulder | Anatomy & Examination
8. Phases of Throwing
Phases of Throwing
There are 5 main phases of throwing
o wind up (see below)
o cocking
o acceleration
o deceleration
o follow-through
Biomechanics
o scapula must work in concert with humerus to maintain glenohumeral stability
o the entire throwing motion takes approximately 2 seconds
with wind up and acceleration phases taking approximately 75% of time (1.5 seconds)
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OrthoBullets2017 Shoulder | Impingement & Rotator Cuff
1. Wind Up
Description
o minimal force on the shoulder during first stage
Muscle activity
o rotator cuff muscles are inactive during this phase
2. Cocking
Sometimes described as 2 sub-phases
o early cocking
peak muscle activation
deltoid
o late cocking
high torque phase with maximal shoulder external rotation
peak muscle activation
supraspinatus
infraspinatus
teres minor
Associated pathology
o internal Impingement
o GIRD (glenohumeral internal rotation defect)
3. Acceleration
Description
o rotates ball to release point
Muscle activity
o early muscle activation
triceps
o late muscle activation
pectoralis major
latissimus dorsi
serratus anterior
4. Deceleration
Description
o center of gravity moves over plantar foot
Muscle activity
o eccentric contraction of all muscles is required to slow down arm motion
o highest torque phase
Associated pathology
o recognized as the most harmful phase of throwing
o associated injuries
superior labrum (SLAP lesion)
biceps tendon injury
brachialis injury
teres minor injury
5. Follow-through
Description
o phase where body rebalances and stops forward motion
Muscle activity : muscle activity returns to resting levels
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By Dr, AbdulRahman AbdulNasser Shoulder | Impingement & Rotator Cuff
1. Subacromial Impingement
Introduction
Subacromial impingement is the first stage of rotator cuff disease which is a continuum of disease
from
o impingement and bursitis
o partial to full-thickness tear
o massive rotator cuff tears
o rotator cuff tear arthropathy
Epidemiology
o incidence
subacromial impingement is the most common cause of shoulder pain
accounts for 44-65% of shoulder disorders
Pathophysiology
o subacromial impingement is thought to be a combination of
extrinsic compression
of the rotator cuff between the humeral head and
anterior acromion
coracoacromial ligaments
acromioclavicular joint
intrinsic degeneration
supraspinatus
attrition of the supraspinatus leads to inability to balance the humeral head on the
glenoid causing superior migration, impinging the subacromial space
o inflammatory process
inflammation of the subacromial bursa due to abutement between the humerus and rotator
cuff, and acromion and associated ligaments
Associated conditions
o hook-shaped acromion
o os acromiale
o posterior capsular contracture
o scapular dyskinesia
Anatomy
Acromion
o 3 ossification centers unite to form the acromion
meta-acromion (base)
meso-acromion (mid)
pre-acromion (tip)
o failure of the ossification centers to fuse results in an os acromiale
Classification
Bigliani classification of acromion morphology (based on a supraspinatus outlet view)
o classification types
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OrthoBullets2017 Shoulder | Impingement & Rotator Cuff
Type I - flat
Type II - curved
Type III - hooked
o studies have shown classification system has poor inter observer reliability
Presentation
Symptoms
o pain
insidious onset
exacerbated by overhead activities
night pain
poor indicator of successful nonoperative management
Physical exam
o strength
usually normal
o impingement tests (see complete physical exam of shoulder)
positive Neer impingement sign
positive if passive forward flexion >90° causes pain
positive Neer impingement test
if a subacromial injection relieves pain associated with passive forward flexion >90°
positive Hawkins test
positive if internal rotation and passive forward flexion to 90° causes pain
Jobe test
pain with resisted pronation and forward flexion to 90° indicates supraspinatus pathology
internal impingement test
positive if pain is elicited with abduction and external rotation of the shoulder
Imaging
Radiographs
o recommended views
true AP of the shoulder
useful in evaluating the acromiohumeral interval
normal distance is 7-14 mm
30° caudal tilt view
useful in identifying subacromial spurring
supraspinatus outlet view
useful in defining acromial morphology
o findings I:7 proximal migration of
common radiographic findings associated with impingement the humerus
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By Dr, AbdulRahman AbdulNasser Shoulder | Impingement & Rotator Cuff
MRI
o useful in evaluating the degree of rotator cuff pathology
o subacromial and subdeltoid bursisits often seen
CT arthography
o can also accurately image the rotator cuff tendons and muscle bellies
Ultrasound
o can also accurately image the rotator cuff tendons and muscle bellies
Studies
Histology
o tendinopathy histology shows
disorganized collagen fibers
mucoid degeneration I:8 supraspinatus outlet view
showing os acromiale
inflammatory cells
o inflammation of the subacromial bursa
high levels of metalloproteases and other inflammatory cytokines
Treatment
Nonoperative
o physical therapy, oral anti-inflammatory medication, subacromial injections
indications
first line and mainstay of treatment of subacromial impingement alone without rotator
cuff tear
techniques
aggressive rotator cuff strengthening and periscapular stabilizing exercises
an integrated rehabilitation program is indicated in the presence of scapular dyskinesia
which aims to regain full shoulder range of motion and coordinate the scapula with trunk
and hip motions
platelet-rich plasma injections
data is controversial at this point
Operative
o subacromial decompression / acromioplasty
indications
subacromial impingement syndrome that has failed a minimum of 4-6 months of
nonoperative treatment
outcomes
poor subjective outcomes have been observed after acromioplasty in patients with
workers' compensation claims
Technique
Subacromial decompression and acromioplasty
o acromioplasty
two-step procedure performed open or arthroscopically
an anterior acromionectomy is performed first
the anterior deltoid origin determines the extent of the acromionectomy when
performed arthroscopically and must remain intact
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OrthoBullets2017 Shoulder | Impingement & Rotator Cuff
an anteroinferior acromioplasty to smooth the undersurface of the acromion follows as
the second step of the procedure
a bone rasp is used if performed open
a shaver or burr is used if performed arthroscopically
the deltoid is meticulously repaired to bone in open procedures
o treatment of an os acromiale
a two-stage procedure may be required with the presence of an os
acromiale to avoid deltoid dysfunction caused by direct excision
the os acromiale is first fused with bone graft and allowed to
heal
an acromioplasty is then performed as a separate second
procedure
I:9 Os acromiale fixed
Complications by cannulated screws
and tension band
Deltoid dysfunction
o resulting from a failed deltoid repair following an open acromioplasty or an excessive
acromionectomy during an arthroscopic procedure
o secondary to direct excision of an os acromiale
Anterosuperior escape
o avoid acromioplasty and CA ligament release to preserve the coracoacromial arch in patients
with massive, irreparable rotator cuff tears
2. Subcoracoid Impingement
Introduction
Subcoracoid impingement is defined as impingement of the
subscapularis between the coracoid and lesser tuberosity
Pathoanatomy
o mechanism
position of maximal impingement is arm adduction,flexion, and internal rotation
o risk factors
patients with a long or excessively lateral coracoid process
prior surgery that caused posterior capsular tightening and
loss of internal rotation
Associated conditions
o combined subscapularis, supraspinatus, and infraspinatus tears
Anatomy
Glenohumeral joint anatomy and biomechanics
Coracoid
o muscle attachments
coracobrachialis, pectoralis minor, and short head of the biceps attach to the coracoid
o ligamentous attachments
coracohumeral ligament, coracoacromial ligament attach to coracoid
coracoclavicular ligament which is composed of the conoid and the trapezium
subscapularis tendon
o inserts onto lesser tuberosity
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By Dr, AbdulRahman AbdulNasser Shoulder | Impingement & Rotator Cuff
Presentation
Symptoms
o pain in anterior shoulder worsened by various degrees of flexion, adduction, and rotation
Physical exam
o tenderness over anterior coracoid
o position of maximal pain is 120-130° of arm flexion and internal rotation
Imaging
Radiographs
o recommended views
o findings
may show a decreased coracohumeral distance
CT scan
o views
obtained with the arms crossed on chest is helpful to make the diagnosis
o findings
a coracohumeral distance of < 6 mm is considered abnormal
normal is 8.7 mm in the adducted arm 6.7 mm in the flexed arm
MRI
o indications
used to evaluate degree of rotator cuff pathology
o findings
increased signal in subscapularis
increased signal in lesser tuberosity
o views
axial view also effective to look for a decreased coracohumeral distance
Studies
Diagnostic injection
o local corticosteroid injections should eliminate symptoms and can be diagnostic
Treatment
Nonoperative
o rest, ice, activity modification, NSAIDS, corticosteroid injections
indications : first line of treatment
techniques
local corticosteroid injections can be diagnostic and therapeutic
PT focuses on stretching
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OrthoBullets2017 Shoulder | Impingement & Rotator Cuff
Operative
o arthroscopic coracoplasty ± subscapularis repair
indications
symptoms refractory to conservative treatment
subscapularis tearing secondary to impingement
technique
resect posterolateral coracoid to create 7 mm clearance
between coracoid and subscapularis
if significant subscapularis tendon tear then repair
o open coracoplasty
indications
symptoms refractory to conservative treatment
subscapularis tearing secondary to impingement I:10 subscapularis tendon tear
technique
resect lateral aspect of coracoid process and reattach the conjoined tendon to the
remaining coracoid
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By Dr, AbdulRahman AbdulNasser Shoulder | Impingement & Rotator Cuff
3. Calcific Tendonitis
Introduction
Calcification and tendon degeneration near the rotator cuff insertion
o associated with subacromial impingement
Epidemiology
o demographics
typically affects patients aged 30 to 60
more common in women
o location
supraspinatus tendon is most often involved
o risk factors
association with endocrine disorders
diabetes
hypothyroidism I:11 Gartner type 1
Pathophysiology
o unknown etiology
o pathoanatomy
three stages of calcification
precalcific
fibrocartilaginous metaplasia of the tendon
clinically this stage is pain-free
calcific
subdivided into three phases
formative phase I:12 Gartner type 3
characterized by cell-mediated calcific deposits
+/- pain
resting phase
lacks inflammation or vascular infiltration
+/- pain
resorptive phase
characterized by a phagocytic resorption and vascular infiltration
clinically this phase is most painful
postcalcific
o cellular biology
key molecular pathways involved
osteopontin
cathepsin K
transglutaminase 2
Classification
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OrthoBullets2017 Shoulder | Impingement & Rotator Cuff
Presentation
History
o similar to the clinical presentation of subacromial impingement
Symptoms
o atraumatic pain (most severe in resorptive phase)
o catching, crepitus
o mechanical block
Physical exam
o inspection
supraspinatus fossa muscle atrophy
o motion
decreased active range of motion
scapular dyskinesia
may be associated with a decrease in rotator cuff strength
o provocative tests
subacromial impingement signs I:13 Example of calcification of
multiple tendons
Imaging
Radiographs
o views
AP, supraspinatus outlet, and axillary views show supraspinatus calcification
internal rotation view shows infraspinatus and teres minor calcification
external rotation view shows subscapularis calcification
o findings
deposits usually 1 to 1.5cm from supraspinatus tendon insertion
useful to monitor progression over time
allow assessment of location, density, extent, and delineation of deposit
CT
o indications
rarely required
may characterize the three-dimensional shoulder anatomy
MRI
o indications
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By Dr, AbdulRahman AbdulNasser Shoulder | Impingement & Rotator Cuff
limited utility in the diagnosis of calcific tendonitis
consider in patients with refractory pain as it can assess for concomitant pathology (e.g.,
rotator cuff tears)
o findings
cacific deposits have low signal intensity on all sequences
Ultrasound
o indications
may be useful to quantify the extent of the calcification
also utilized for guidance during needle decompression and injection
o findings
deposits are hyperechoic
Treatment
Nonoperative
o NSAIDs, physical therapy, stretching & strengthening, steroid injections
indications
first line of treatment for all phases
techniques
steroid injections
commonly used but controversial
duration of relief is variable
outcomes
resolution of symptoms in 60-70% of patients after 6 months
increased probability of failure when:
bilateral or large calcifications
deposits underlying the anterior third of acromion
deposits extending medial to the acromion
o extracorporeal shock-wave therapy
indications
adjunct treatment
most useful in refractory calcific tendonitis in the formative and resting phases
modalities
high- vs. low-energy therapy
outcomes
dose dependent outcomes
high-energy > low-energy in clinical outcome scores, and rate of calcific deposit
resorption
high-energy > low-energy in procedural pain and local reaction (e.g. ecchymosis)
o ultrasound-guided needle lavage vs. needle barbotage
indications
persistent symptomatic calcific tendonitis in the resorptive phase
outcomes
improved outcomes in patients with Type II/III calcific tendinitis vs Type I
Operative
o surgical decompression of calcium deposit
indications
progression of symptoms
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OrthoBullets2017 Shoulder | Impingement & Rotator Cuff
refractory to nonoperative treatments
interference with activities of daily living
outcome
good results in short term outcome studies
longer return to work with subacromial decompression and/or rotator cuff repair
risk of shoulder stiffness with operative treatment
Techniques
Ultrasound-guided needle lavage
o technique
two needles to maintain an outflow system for lavage
small amount of saline+/-anesthetic injected around the calcification
aspiration of calcific material with other needle
Needle barbotage
o technique
use needle to break up calcium deposit then follow with by corticosteroid injection
Surgical decompression of calcium deposit
o approach
may be done arthroscopically or with mini-open approach
o technique
+/- subacromial decompression
+/- rotator cuff repair
Complications
Recurrence
Persistent shoulder pain I:14 Ultrasound-guided needle lavage
Shoulder stiffness
Iatrogenic injury to rotator cuff with operative treatment
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By Dr, AbdulRahman AbdulNasser Shoulder | Impingement & Rotator Cuff
Pathophysiology
o mechanisms of tear includes
chronic degenerative tear ( intrinsic degeneration is the primary etiology)
usually seen in older patients
usually involves the SIT (supraspinatus, infraspinatus, teres minor) muscles but may
extend anteriorly to involve the superior margin of subscapularis tendon in larger tears
chronic impingement
typically starts on the bursal surface or within the tendon
acute avulsion injuries
acute subscapularis tears seen in younger patients following a fall
acute SIT tears seen in patients > 40 yrs with a shoulder dislocation
full thickness rotator cuff tears need to be repaired in throwing athletes
iatrogenic injuries
due to failure of surgical repair
often seen in repair failure of the subscapularis tendon following open anterior
shoulder surgery.
Associated conditions
o AC joint pathology
o proximal biceps subluxation
o proximal biceps tendonitis
o internal impingement
seen in overhead throwing athletes
associated with partial thickness rotator cuff tears
deceleration phase of throwing leads to tensile forces and potential for rotator cuff tears
Prognosis
o 50% of asymptomatic tears become symptomatic in 2-3 years
o 50% of symptomatic full-thickness tears progress at 2 years and bigger tears progress faster
Anatomy
Rotator cuff function
o the primary function of the rotator cuff is to provide dynamic stability by balancing the force
couples about the glenohumeral joint in both the coronal and transverse plane.
coronal plane
the inferior rotator cuff (infraspinatus, teres minor, subscapularis) functions to balance the
superior moment created by the deltoid
transverse plane
the anterior cuff (subscapularis) functions to balance the posterior moment created by the
posterior cuff (infraspinatus and teres minor)
this maintains a stable fulcrum for glenohumeral motion.
the goal of treatment in rotator cuff tears is to restore this equilibrium in all planes.
Rotator cuff footprint
o supraspinatus inserts on anterosuperior aspect of greater tuberosity
o medial-lateral width at insertion
supraspinatus is 12.7mm (covers superior facet of greater tuberosity)
6-7 mm tear corresponds to 50% partial thickness tear
infraspinatus is 13.4mm
subscapularis is 17.9mm
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OrthoBullets2017 Shoulder | Impingement & Rotator Cuff
Classification
Anatomic Classification
Supraspinatus, Make up majority of tears
infraspinatus, Associated with subacromial impingement
teres minor (SIT) Mechanism is often a degenerative tear in older patients or a
tears shoulder dislocation in patients > 40 yrs.
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OrthoBullets2017 Shoulder | Impingement & Rotator Cuff
Cuff Tear Shape
Crescent Usually do not retract medially, are quite mobile in the medial to lateral
.................... direction, and can be repaired directly to bone with minimal tension.
U-shape Similar shape to crescent but extend further medially with apex adjacent or
medial to the rim of the glenoid. Must be repaired side-to-side using margin
convergence first to avoid overwhelming tensile stress in the middle of the
rotator cuff repair margin.
L-shape Similar to U shape except one of the leaves is more mobile than the other. Use
margin convergence in repair.
Massive & May be u-shaped or longitudinal. Difficult to repair and often requires and
immobile interval slide.
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By Dr, AbdulRahman AbdulNasser Shoulder | Impingement & Rotator Cuff
Presentation
Symptoms
o pain
typically insidious onset of pain exacerbated by overhead activities
pain located in deltoid region
night pain, which is a poor indicator for nonoperative management
can have acute pain and weakness with an traumatic tear
o weakness
loss of active ROM with greater or intact passive ROM
Physical exam (complete exam of the shoulder see page 11)
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By Dr, AbdulRahman AbdulNasser Shoulder | Impingement & Rotator Cuff
Ultrasound
o indications
suspicion of rotator cuff pathology
need for dynamic examination
o advantages include
allows for dynamic testing
inexpensive
readily available at most centers
helpful to confirm intraarticular injections
o disadvantages include
highly user dependent
limited ability to evaluate other intraarticular pathology
o sensitivity/specificity
similar sensitivity, specificity, and overall accuracy for diagnosis of rotator cuff disease as
compared to MRI
23% of asymptomatic patients had a rotator cuff tear on ultrasound in one series
Treatment
Treatment considerations
o activity and age of patient
o mechanism of tear (degenerative or traumatic avulsion)
o characteristics of tear (size, depth, retraction, muscle atrophy)
partial thickness tears vs. complete tear
articular sided (PASTA lesion) vs. bursal sided
bursal sided tears treated more aggressively
Nonoperative
o physical therapy, NSAIDS, subacromial corticosteroid injections
indications
first line of treatment for most tears
partial tears often can be managed with therapy
technique
avoidance of overhead activities
physical therapy with aggressive rotator cuff and scapular-stabilizer strengthening over a
3-6 month treatment course
subacromial injections if impingement thought to be major cause of symptoms
Operative
o subacromial decompression and rotator cuff debridement alone
indications
select patients with a low-grade partial articular sided rotator cuff tear
o rotator cuff repair (arthroscopic or mini-open)
indications
acute full-thickness tears
bursal-sided tears >3 mm (>25%) in depth
release remaining tendon and debride degenerative tissue
partial articular-side tears>50% can be treated with tear completion and repair.
Partial articular-side tears <50% treated with debridement alone
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OrthoBullets2017 Shoulder | Impingement & Rotator Cuff
PASTA with >7mm of exposed bony footprint between the articular surface and intact
tendon represents significant (>50%) cuff tear (must have at least 25% healthy bursal
sided tissue)
younger patients with acute, traumatic tears
in situ repair leave bursal sided tissue intact
older patients with degenerative tears
tendon release, debridement of degenerative tissue and repair
postoperative
rate-limiting step for recovery is biologic healing of RTC tendon to greater tuberosity,
which is believed to take 8-12 weeks
peribursal tissue and holes drilled in greater tuberosity are major source of vascularity
to repaired rotator cuff
vascularity can increase with exercise
postop with limited passive ROM (no active ROM)
outcomes
Worker's Compensation patients report worse outcomes
higher postop disability and lower patient satisfaction
o tendon transfer
indications
massive cuff tears
techniques (see details below)
pectoralis major transfer
latissimus dorsi transfer
best for irreparable posterosuperior tears with intact subscapularis
o reverse total shoulder arthroplasty
indications
massive cuff tears with glenohumeral arthritis with intact deltoid
Surgical Technique
Mini-open rotator cuff repair
o once was gold standard but has been largely been replaced by arthroscopic techniques
o approach
small horizontal variant of shoulder lateral (deltoid splitting) approach
o advantages over open approach
decreased risk of deltoid avulsion
faster rehabilitation (do not need to protect deltoid repair)
may begin passive ROM immediately to prevent adhesive capsulitis
most surgeons wait ~6 weeks before initiating active ROM
Arthroscopic rotator cuff repair (See figures pages 43, 44)
o advantages
studies now show equivalent results to open or mini-open repair
o important concepts
margin convergence
shown to decrease strain on lateral margin in U shaped tears
anterior interval slide
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By Dr, AbdulRahman AbdulNasser Shoulder | Impingement & Rotator Cuff
release supraspinatus from the rotator interval (effectively incising coracohumeral
ligament). This increases the mobility of supraspinatus and allows it to be fixed to the
lateral footprint.
posterior interval slide
release supraspinatus from infraspinatus. This further increases the mobility of
supraspinatus and allows it to be fixed to the lateral footprint. Then repair supraspinatus
to infraspinatus with margin convergence.
subscapularis repair
although arthroscopic repair is technically challenging, new studies show superior
outcomes (motion and pain) compared to open repair
stabilize biceps tendon with tenodesis
superolateral margin of subscapularis identified by the "comma sign"
superior glenohumeral and coracohumeral ligaments attach to the subscapularis
tendon
long head biceps tendon repair
most studies show negligible difference between tenotomy vs. tenodesis after concurrent
rotator cuff repair
footprint restoration
it is hypothesized that a larger footprint will improve healing and the mechanical strength
of the rotator cuff repair
double row suture techniques (mattress sutures in medial row and simple sutures in lateral
row) have been shown to create a more anatomic repair of the footprint
lower retear rate compared with single row
no difference in functional score, pain score, time to healing (compared to single row)
addition of a trough in the greater tuberosity to allow tendon-to-cancellous bone
interface as opposed to tendon-to-cortical bone has NOT show increased repair strength
in animal models
coracoacromial ligament release
release leads to an increased anterior/inferior translation of the glenohumeral joint
Tendon transfer
o indicated for massive and irreparable rotator cuff tears
o pectoralis major transfer
indicated in chronic subscapularis tears
transferring pectoralis major under the conjoined tendon more closely replicates the vector
forces of the native subscapularis
requires 4-6 weeks of rigid immobilization
o latissimus dorsi transfer
indicated in large supraspinatus and infraspinatus tears
best candidate is young laborer
attach to cuff muscles, subscapularis, and GT
brace immobilize for 6 wks. in 45° abduction and 30° ER.
Biologic and synthetic grafts reconstruction
o some recent evidence of improved outcomes with the use of xenograft, allograft, or synthetic
patches for massive cuff tears
o limited human and long-term studies
o xenograft
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OrthoBullets2017 Shoulder | Impingement & Rotator Cuff
from bovine dermis or intestine
mixed functional outcomes and graft incorporation
o allograft
from human skin or muscular fascia
some evidence of good function and survival at short-term
o synthetics
concern for foreign body reaction
mixed functional results
Lateral acromionectomy
o historic significance only
o contraindicated due to high complication rate
Complications
Recurrence / repair failure
o most common cause of failed RCR is failure of cuff tissue to heal, resulting in suture pull out
from repaired tissue
o patient risk factors for repair failure
patient age >65 years is a risk factor for non-healing of rotator cuff repair and subsequent
failure
large tear size (>5 cm)
muscle atrophy
diabetes
smokers
tear retraction medial to glenoid
poor compliance with post-op protocol
no difference in clinical outcomes or healing with early vs. delayed motion protocols
multiple tendons involved
concomitant AC and/or biceps procedures performed at time of repair
o treatment
revision rotator cuff repair vs RTSA
variables to consider when choosing revision RCR vs RTSA
patient age (older age favors RTSA)
etiology of re-tear
quality of tissue / MRI findings
static proximal humeral migration (favors RTSA)
Deltoid detachment
o complication seen with open approach
AC pain
Axillary nerve injury
Suprascapular nerve injury
o may occur with aggressive mobilization of supraspinatus during repair
Infection
o less than 1% incidence
o Usually common skin flora: staph aureus, strep, p.acnes
o Propionoibacterium acnes is the most commonly implicated organism in delayed or indolent
cases
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By Dr, AbdulRahman AbdulNasser Shoulder | Impingement & Rotator Cuff
Stiffness
o Physical therapy and guided early range of motion exercises are not shown to reduce stiffness
one-year post-operatively
Pneumothorax
o Can be a complication of regional anesthesia (interscalene or supraclavicular block) or the
arthroscopy itself
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OrthoBullets2017 Shoulder | Impingement & Rotator Cuff
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By Dr, AbdulRahman AbdulNasser Shoulder | Impingement & Rotator Cuff
Anatomy
Glenohumeral joint
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OrthoBullets2017 Shoulder | Impingement & Rotator Cuff
Classification
Seebauer Classification of Rotator Cuff Arthropathy
Type IA • Intact anterior restraints
(centered, stable) • Minimal superior migration
• Dynamic joint stabilization
• Femoralization of the humeral head and acetabularization of
coracoacromial arch
Type IB • Intact or compensated anterior restraints
(centered, medialized) • Minimal superior migration
• Compromised joint stabilization
• Medial erosion of the glenoid
Type IIA • Compromised anterior restraints
(decentered, limited • Superior translation
stability) • Minimum stabilization by coracoacromial arch
Type IIB • Incompetent anterior restraints
(decentered, unstable) • Anterosuperior escape
• Nonexistent dynamic stabilization
• No coracoacromial arch stabilization
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By Dr, AbdulRahman AbdulNasser Shoulder | Impingement & Rotator Cuff
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OrthoBullets2017 Shoulder | Impingement & Rotator Cuff
Imaging
Radiographs
o recommended views
complete shoulder series; AP, axillary, Grashey (true AP)
o findings
acromial acetabularization (true AP)
femoralization of humeral head (true AP)
asymmetric superior glenoid wear
lack of osteophytes
osteopenia
"snowcap sign" due to subchondral sclerosis
anterosuperior escape
MRI
o indications
not necessary if humeral head is already showing anterosuperior escape on x-rays
o findings
shows an irreparable rotator cuff tear with
massive fatty infiltration
severe retraction
Treatment
Nonoperative
o activity modification, subacromial steroid injection, physical therapy
indications
first line of treatment
technique
physical therapy with a scapular and rotator cuff strengthening program
non-steroidal anti-inflammatories
subacromial steroid injections
Operative
o arthroscopic debridement
indications
controversial
outcomes
unpredictable results
must maintain coracoacromial arch without acromioplasty or release of CA ligament
o hemiarthroplasty
indications
anterior deltoid is preserved
coracoacromial arch intact
deficiency of the coracoacromial arch will lead to subcutaneous humeral escape
younger patients with active lifestyles
outcomes
will relieve pain but will not improve function (motion limited to 40-70 degrees of
elevation)
o reverse shoulder arthroplasty
indications
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By Dr, AbdulRahman AbdulNasser Shoulder | Impingement & Rotator Cuff
pseudoparalytic cuff tear arthropathy
preferred in elderly (>70) with low activity level
anterosuperior escape
requires functioning deltoid (axillary nerve) and good bone stock
deltoid is used to assist glenohumeral joint to act like a fulcrum in elevation
outcomes (short and intermediate at this point)
has the potential to improve both function and pain
risk of inferior scapular notching with poor technique
o latissimus dorsi transfer
indications
pseudoparesis with external rotation
combination with reverse total shoulder arthroplasty
o pectoralis transfer
indications
internal rotation deficiency and subscapularis insufficiency
techniques
upper portion or whole pectoralis tendon transferred near subscapularis insertion on lesser
tuberosity
complications
musculocutaneous nerve injury
o resection arthroplasty
indications
salvage only (chronic osteomyelitis, infections, poor soft tissue coverage)
o glenoid resurfacing
contraindicated
excess shear stress on superior glenoid leads to failure through loosening
o TSA
contraindicated
Complications
Infection
Neurovascular injury
Deltoid dysfunction
Instability (more common after hemiarthroplasty, rare after RTSA)
6. Biceps Subluxation
Introduction
A recognized cause of shoulder symptoms usually associated with a subscalaris tear
Pathophysiology
o most commonly associated with
subscapularis tears
most common associated pathology
coracohumeral ligament tear
disruption of the medial biceps sling
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OrthoBullets2017 Shoulder | Impingement & Rotator Cuff
Anatomy
Biceps tendon anatomy
o originates off supraglenoid tubercle and superior labrum
o stabilized by the biceps sling which is comprised of
fibers of the subscapularis
supraspinatus
coracohumeral
I:15 ultrasound
superior glenohumeral ligaments
Function
o acts as dynamic stabilizer
o involved in movement such as shoulder flexion, abduction
Complete glenohumeral anatomy
Presentation
Symptoms
o anterior shoulder pain
o may have sensation of clicking
I:16 MRII
Physical exam of shoulder
o strength
due to the association with subscapularis tears, strength of the subscapularis muscle should be
performed
o biceps provocation tests
Yergason's test
anterior shoulder pain with resisted forearm supination with the arm at the side and the
elbow flexed to 90 degrees.
Speed's test
anterior shoulder pain with resisted shoulder flexion with the shoulder flexed at 90
degrees, elbow in full extension and the palm facing upwards"
palpable click
may be produced with arm abduction and external rotation
occurs when tendon subluxes or dislocates out of groove
Imaging
Ultrasound
o can give dynamic test of bicep instability
MRI
o can show increased T2 signal, and displacement out of the bicipital groove
o coincides with subscapularis tears
Treatment
Nonoperative
o NSAIDS, PT strengthening, and steroid injections
indications
initial management I:17 tenodesis
technique
direct steroid injection in proximity, but not into tendon
Operative
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By Dr, AbdulRahman AbdulNasser Shoulder | Impingement & Rotator Cuff
o arthroscopic vs open biceps tenotomy vs tenodesis
indications
reserved for refractory cases for bicep pathology
technique
performed with or without subscapularis repair
can test instability intra-operatively
Anatomy
Glenohumeral anatomy
Bicep long head tendon
o originates off supraglenoid tubercle and superior labrum
o stabilized within bicipital groove by transverse humeral ligament
Presentation
Symptoms
o pain
anterior shoulder pain
may have pain radiating down the in the region of the biceps
symptoms may be simillar in nature and location to rotator cuff or subacromial impingement
pain
Physical exam
o tenderness with palpation over biceps groove
worse with arm internally rotated 10 degrees
o Speed test
pain elicited in bicipital groove when patient attempts to
forward elevate shoulder against examiner resistance
while elbow extended and forearm supinated.
may also be positive in patients with SLAP lesions.
o Yergason's test
pain elicited in biceps groove when patient attempts to
actively supinate against examiner resistance with elbow
flexed to 90-degrees and forearm pronated
o "popeye" deformity
indicates rupture
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OrthoBullets2017 Shoulder | Impingement & Rotator Cuff
Imaging
Ultrasound
o can show thickened tendon within bicipital groove
MRI
o can show thickening and tenosynovitis of proximal biceps tendon
increased T2 signal around biceps tendon
Treatment
Nonoperative
o NSAIDS, PT strengthening, and steroid injections
indications
first line of treatment
technique
direct steroid injection in proximity, but not into tendon
Operative
o arthroscopic tenodesis vs. tenotomy
indications
surgical release reserved for refractory cases for bicep pathology seen during arthroscopy
technique
repair vs. release/tenodesis
outcomes
tenotomy may be associated with arm cramping and cosmetic deformity ("Popeye
deformity")
tenodesis may be associated with "groove pain"
no difference in strength between two techniques
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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By Dr, AbdulRahman AbdulNasser Shoulder | AC Pathology
C. AC Pathology
Anatomy
AC Joint
o anatomy
the AC joint is a diarthrodial joint
o stability and ligaments
acromioclavicular ligament
provides horizontal stability
has superior, inferior, anterior, and posterior component
coracoclavicular ligaments (trapezoid and conoid)
provides vertical stability
trapezoid insert 3 cm from end of clavicle
conoid inserts 4.5 cm from end of clavicle in the posterior border
base of coracoid fracture can mimic a CC ligament disruption
o capsule, deltoid and trapezius act as additional stabilizers
Complete AC joint anatomy
Presentation
Symptoms
o pain
Physical exam
o palpate for lateral clavicle or AC joint tenderness
o observe for abnormal contour of the shoulder compared to contralateral side
o check for stability
AP stability assesses AC ligaments
vertical stability assesses CC ligaments
Imaging
Radiographs
o bilateral AP
compare displacement to contralateral side
measured as distance from top of coracoid to bottom of clavicle
1/3 penetration on AP to visualize AC joint
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OrthoBullets2017 Shoulder | AC Pathology
o axillary lateral (see page 19)
required to diagnose Type IV (posterior)
o zanca view(see page 19)
performed by tilting the x-ray beam 10° to 15° toward the cephalic direction and using only
50% of the standard shoulder anteroposterior penetration strength.
o weighted stress views
no longer used
helps differentiate Type II from Type III
Classification
Rockwood Classification of AC Joint Injuries
AC CC
Reducibility Displacement / Radiographs Tx
lig. lig.
Type sprain normal none
- sling
I
Type torn sprain AC joint is disrupted with a slight vertical separation and
reducible sling
II there is a slight increase in the CC interspace of <25%
Type torn torn CC distance of 25-100% of other side
reducible controversial
III
Type torn torn lateral end of the clavicle is displaced posterior through
not reducible surgery
IV trapezius as seen on the axillary X-ray
Type torn torn CC distance > 100% of other side (clavicle herniated
V not reducible through deltotrapezial fascia, resulting in subcutaneous surgery
distal clavicle)
Type torn torn rare injuries with the distal clavicle lying either in a
VI not reducible subacromial or subcoracoid position (infero-lateral under surgery
conjoined tendon)
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By Dr, AbdulRahman AbdulNasser Shoulder | AC Pathology
Differentials
Coracoid fracture
o has superiorly displaced distal clavicle, but normal CC distance (normal is 11-13mm)
Treatment
Nonoperative
o ice, rest and sling for 3 weeks
indications
Type I and II
Type III in most individuals
good results when clavicle displaced <2cm
rehab
early ROM
regain functional motion by 6 weeks I:19 Type V
return to normal activity at 12 weeks
complications
AC joint arthritis
chronic subluxation and instability
Operative
o CC interval fixation (within 3-4wk) using either AC fixation or CC fixation
indications
Type III in laborers / elite athletes and those with cosmetic concerns
chronic Type III
Type IV, V, VI
when clavicle displaced >2cm
contraindications
patient unlikely to comply with postoperative rehabilitation
skin problems over fixation approach site
rehabilitation
sling immobilization without abduction for 6 weeks
no shoulder ROM for 6 weeks
generally return to full activity after 6 months
o Tissue graft reconstruction (>3-4wk)
indicated for chronic tears (>3-4wk)
results
stronger than Weaver Dunn
Surgical Techniques
ORIF with Bosworth CC screw fixation (CC fixation)
o approach
proximal aspect of anterolateral approach to the shoulder
o technique
superior to inferior screw from distal clavicle into coracoid
o pros & cons
rigid internal fixation
danger of screw being too long and damage to critical structure below coracoid
routine screw removal at 8-12wk is advised to prevent screw breakage
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OrthoBullets2017 Shoulder | AC Pathology
because of normal movement between clavicle and scapula
o complications
hardware irritation
hardware failure at level of screw purchase in coracoid
ORIF with CC suture fixation (CC fixation)
o approach
proximal aspect of anterolateral approach to the shoulder
o technique
suture placed either around or through clavicle and around the base of the coracoid
can also use suture anchors for coracoid fixation
o pros & cons
no risk of hardware failure or migration
suture not as strong as screw fixation
requires careful suture passage inferior to coracoid due to proximity of crucial neurovascular
structures
o complications
suture erosion causing distal third clavicle fracture
ORIF with hook plate with subsequent plate removal (AC fixation)
o approach
exposure of distal and middle clavicle
o technique
use of standard hook plate over superior distal clavicle
o pros & cons
rigid fixation
generally require second surgery for plate removal
o complications
acromial erosion
hook pullout
CC ligament reconstruction (Modified Weaver-Dunn)
o approach
proximal aspect of anterolateral approach to the shoulder
arthroscopic technique also described
o technique
distal clavicle excision
transfer of coracoacromial ligament to the distal clavicle to recreate CC ligament
combined with internal fixation
o pros & cons
coracoacromial ligament only 20% as strong as normal CC ligament
lack of internal fixation risks failure of soft tissue repair
CC ligament reconstruction with free tendon graft
o approach
proximal aspect of anterolateral approach to the shoulder
wrist incision for palmaris harvest
o technique
figure-of--eight passage of graft from distal clavicle to coracoid
reinforce with internal fixation
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By Dr, AbdulRahman AbdulNasser Shoulder | AC Pathology
o pros & cons
graft reconstruction more closely recreates strength of native CC ligament
standard risks of allograft use or autograft harvest
lack of internal fixation risks failure of soft tissue repair
Primary AC joint fixation
o approach
can be done percutaneously
o technique
smooth wire or pin fixation directly across AC joint
o pros & cons
hardware irritation
o complications
high incidence of pin migration
generally not performed due to high complication rates
Complications
Residual pain at AC joint in 30-50%
AC arthritis
o more common with surgical management than with nonop
CC screw breakage/pullout
Anatomy
Osteology
o clavicle is
S-shaped bone
last bone to fuse
o medial growth plate fuses early 20s
Presentation
Symptoms
o pain at distal clavicle
Physical exam
o tenderness at distal end of clavicle
Imaging
Radiographs
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OrthoBullets2017 Shoulder | AC Pathology
o recommended views
AP clavicle
o findings
cysts at distal end of clavicle
osteopenia
resorption and erosion
tapering of distal clavicle
Treatment
Nonoperative
o activity modification, corticosteroid injections, NSAIDS
indications
first line of treatment
technique
(quit weight lifting or modify technique by moving arms farther apart)
Operative
o open or arthroscopic distal clavicle excision
indications
severe symptoms that have failed nonoperative treatment
outcomes
open vs. arthroscopic based on surgeon preference and comfort
arthroscopic resection has the advantage of allowing evaluation of the glenohumeral
joint
good results shown with arthroscopic treatment
open procedures require meticulous repair of deltoid-trapezial fascia
Techniques
Arthroscopic distal clavicle resection
o should resect only 0.5-1cm of distal clavicle
3. AC Arthritis
Introduction
AC joint arthritis is caused by transmission of large loads through a small contact area
Epidemiology
o demographics
more common with age but can occur by second decade of life
o risk factors
prior AC separations
commonly associated with individuals who engage in constant heavy overhead activities
especially in weight-lifters and overhead throwing athletes
Associated conditions
o distal clavicle osteolysis
Anatomy
Acromioclavicular Joint Anatomy
Diarthrodial joint
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By Dr, AbdulRahman AbdulNasser Shoulder | AC Pathology
o articulates scapula to clavicle
o contains a fibrocarilaginous disk
Ligaments
o AC ligaments
provide anterior-posterior stability
posterior and superior AC ligaments most important for stability
o Coracoclavicular ligaments
provide superior-inferior stability
Presentation
Symptoms
o activity related pain
with overhead activity
with arm adduction
Physical exam
o palpation
pain with direct palpation of AC joint
o provocative tests
pain with cross body adduction test
Imaging
Radiographs
o recommended views
best evaluated using Zanca view (15 degree cephalic tilt)
o findings
can show osteophytes and joint space narrowing
distal clavicle osteolysis
imaging findings do not always correlate with patient symptoms
MRI
o increased signal and edema in AC joint
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Treatment
Nonoperative
o activity modification and physical therapy
indications
indicated as a first line of treatment
technique
therapy should focus on strengthening and stretching of
shoulder girdle
o AC joint injection with corticosteroids
can be both a diagnostic and therapeutic modality
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By Dr, AbdulRahman AbdulNasser Shoulder | Instability
D. Instability
Associated injuries
Classification
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By Dr, AbdulRahman AbdulNasser Shoulder | Instability
Sulcus Test Grading Scheme
Grade 1 • Acromiohumeral interval <1cm
Grade 2 • Acromiohumeral interval 1-2cm
Grade 3 • Acromiohumeral interval >2cm
Presentation
Symptoms
o traumatic event causing dislocation
o feeling of instability
o shoulder pain complaints
caused by subluxation and excessive translation of the humeral head on the glenoid
Physical exam
o load and shift
Grade I - increased translation, no subluxation
Grade II - subluxation of humeral head to, but not over, glenoid rim
Grade III - dislocation of humeral head over glenoid rim
Instability in mid-ranges of motion is highly suggestive of concomitant glenoid bone loss
o apprehension sign
patient supine with arm in 90/90 position
o relocation sign
decrease in apprehension with anterior force applied on shoulder
o sulcus sign
tested with patient's arm at side
o generalized ligamentous laxity
assess via Beighton's criteria
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OrthoBullets2017 Shoulder | Instability
Imaging
Radiographs
o see imaging of shoulder
o a complete trauma series needed for evaluation
true AP
scapular Y
axillary
o other helpful views
West Point view : shows glenoid bone loss
Stryker view : shows Hill-Sachs lesion
CT scan
o helpful for evaluation of bony injuries
MRI
o best for visualization of labral tear
o addition of intraarticular contrast I:22 MRI showing anterior labral injury with
associated Hill Sachs defect
increases sensitivity and specificity
Treatment Indications
Nonoperative
o acute reduction, ± immobilization, followed by therapy
indications
management of first time dislocators remains controversial
reduction
simple traction-countertraction is most commonly used
relaxation of patient with sedation or intraarticular lidocaine is essential
immobilization
some studies show immobilization in external rotation decreases recurrence rates
thought to reduce the anterior labrum to the glenoid leading to more anatomic healing
subsequent studies have refuted this finding and the initially published results have
not been reproducible
physical therapy
strengthening of dynamic stabilizers (rotator cuff and periscapular musculature)
Operative
o Arthroscopic Bankart repair +/- capsular shift
indications
relative indications
first-time traumatic shoulder dislocation with Bankart lesion confirmed by MRI
in athlete younger than 25 years of age
high demand athletes
outcomes
results now equally efficacious as open repair with the advantage of less pain and greater
motion preservation
o Open Bankart repair +/- capsular shift
indications
Bankart lesion with glenoid bone loss < 20%
humeral avulsion of the glenohumeral ligament (HAGL)
can also be performed arthroscopically but is technically challenging
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By Dr, AbdulRahman AbdulNasser Shoulder | Instability
o Latarjet (coracoid transfer) and Bristow Procedures for glenoid bone loss
indications
bony deficiencies with >20% glenoid deficiency (inverted pear deformity to glenoid)
transfer of coracoid bone with attached conjoined tendon provides sling effect
Latarjet procedure performed more commonly than Bristow
o Autograft (tricortical iliac crest) or allograft (iliac crest or distal tibia) for glenoid bone loss
indications
bony deficiencies with >20-25% glenoid deficiency (inverted pear deformity to glenoid)
revision to failed latarjet
o Remplissage technique for Hill Sachs defects
indication
engaging large (>25%) Hill-Sachs defect
technique
posterior capsule and infraspinatus tendon sutured into the Hill-Sachs lesion
may be performed with concomitant Bankart repair
o Bone graft reconstruction for Hill Sachs defects
indication
engaging large (>25%) Hill-Sachs lesions
technique
allograft reconstruction
arthroplasty
rotational osteotomy
o Putti-Platt / Magnuson-Stack / Boyd-Sisk
indications
historic purposes only
led to over-constraint and arthrosis
Treatment Techniques
Arthroscopic Bankart repair +/- capsular plication
I:23 arthroscopic photo: Bankart repair with capsular
o approach : shoulder arthroscopic approach plication
o technique
drive through sign might be present prior to labral repair and capsulorraphy
studies support use of ≥ 3 anchors (< 3 anchors is a risk factor for failure)
o complications
recurrence, most often due to unrecognized glenoid bone loss
stiffness, especially in external rotation
axillary nerve injury
chondrolysis (from use of thermal capsulorraphy which is no longer used)
Open Bankart repair +/- capsular shift
o approach : shoulder anterior (deltopectoral) approach
o technique
subscapularis transverse split or tenotomy
open labral repair and capsulorraphy
o complications
recurrence, most often due to unrecognized glenoid bone loss
stiffness, especially in external rotation
axillary nerve injury
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Open Capsular shift
o approach : shoulder anterior (deltopectoral) approach
o technique
inferior capsule is shifted superiorly
o complications
subscapularis injury or failed repair
post-operative physical exam will show a positive lift off and excessive ER
overtightening of capsule
leads to loss of external rotation
treat with Z lengthening of subscapularis
axillary nerve injury
iatrogenic injury with surgery (avoid by abduction and ER of arm during procedure)
late arthritis
usually wear of posterior glenoid
may have internal rotation contracture
seen with Putti-Platt and Magnuson-Stack procedures
Latarjet and Bristow Procedure
o approach
shoulder anterior (deltopectoral) approach
can be performed arthroscopically
o technique
coracoid transfer to anterior inferior glenoid bone defect
traditional or congruent arc technique for coracoid graft placement
after harvest, coracoid is passed through a split in the proximal 1/3 subscapularis
o complications
nonunion
graft lysis
hardware problems
musculocutaneous nerve injury
axillary nerve injury
Putti-Platt & Magnuson-Stack
o approach
shoulder anterior (deltopectoral) approach
o technique
Putti-Platt is performed by lateral advancement of subscapularis and medial advancement of
the shoulder capsule
Magnuson-Stack is performed with lateral advancement of subscapularis (lateral to bicipital
groove and at times to greater tuberosity)
o complications
both lead to decreased external rotation and loading on posterior glenoid
which leads to degenerative joint disease (capsulorrhaphy arthropathy)
Boyd-Sisk
o historic value only
o technique
transfer of biceps laterally and posteriorly
o complications : high rate of recurrence
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By Dr, AbdulRahman AbdulNasser Shoulder | Instability
Complications
Recurrence
o often due to unrecognized glenoid bone loss treated with a soft tissue only procedure
o can be due to poor surgical technique (ie, < 3 suture anchors)
o increased risk with preoperative risk factors including age < 20, male sex, contact/collision sport
Shoulder pain
Nerve injury
o musculocutaneous
o axillary
Stiffness
o especially in external rotation
Infection
Graft lysis (Latarjet)
Hardware complications
o anchor pull-out (Bankart repair)
o screw pull-out (Latarjet)
Chondrolysis
o historically due to use of thermal capsulorraphy (now contraindicated) or intra-articular pain
pumps (now contraindicated)
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OrthoBullets2017 Shoulder | Instability
Lesions Associated with Posterior Instability
Avulsion of posterior band Associated with acute subluxations
of IGHL
Posterior Bankart lesions Characterized by detachment of posterior inferior capsulolabral
complex
Reverse Hill-Sachs lesions Associated with nonreducible and difficult to reduce dislocations
Posterior labral cyst Associated with chronic reverse Bankart lesion
Posterior glenoid rim Associated with chronic reverse Bankart lesion
fracture
Lesser tuberosity fracture Associated with posterior dislocation
Large capsular pouch Can see with MRI with contrast
Anatomy
Glenohumeral anatomy
Primary stabilizers of the posterior shoulder
o posterior band of IGHL
primary restraint in internal rotation
o subscapularis
primary dynamic restraint in external rotation
primary dynamic restraint against posterior subluxation
o superior glenohumeral ligament and coracohumeral ligament
primary restraint to inferior translation of the adducted arm and to external rotation
primary static stabilizer to posterior subluxation with shoulder in flexion, adduction, and
internal rotation
Static restraint
o labrum deepens the glenoid
Classification
Acute versus chronic
Voluntary versus involuntary
Presentation
History
o trauma with the arm in a flexed, adducted, and internally rotated position
Symptoms
o pain with flexion, adduction, and internal rotation of the arm
Physical exam
o inspection
prominent posterior shoulder and coracoid
o motion
limited external rotation
shoulder locked in an internally rotated position common in undiagnosed posterior
dislocations
pain on flexion, adduction and internal rotation for posterior instability
o provocative tests
posterior load & shift test
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By Dr, AbdulRahman AbdulNasser Shoulder | Instability
place patient supine with arm in neutral rotation with 40 to 60° abduction and forward
flexion, load humeral head and apply anterior and posterior translating forces noting
subluxation
Jerk test
place arm in 90° abduction, internal rotation, elbow bent
apply an axial force along axis of humerus and adduct the arm to a forward-flexed
position
a „clunk‟ is positive for posterior subluxation
97% sensitive for posterior labral tear when combined with a Kim test
Kim test
performed by having the patient seated, arm at 90° abduction, followed by flexing the
shoulder to 45 forward flexion while simultaneously applying axial load on the elbow &
posterior-inferior force on the upper humerus.
test is positive when pain is present
posterior stress test
stabilize scapula and look for posterior translation with a posterior direct force
pain is elicited often, but this is not a specific finding
Kim test
Imaging
Radiographs
o recommended views
AP
unreliable
may show a 'lightbulb' sign
axillary lateral
best view to demonstrate a dislocation
o optional
Velpeau view if patient is unable to abduct arm for axillary view
CT
o indications
analyze the extent and location of bone loss in a chronic dislocation (>2 to 3 weeks)
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MRI
o indications
evaluate for suspected associated rotator cuff tear
may show Kim lesion (concealed avulsion of the deep posteroinferior labrum, with
apparently intact superficial labrum)
The lightbulb sign refers to the
abnormal AP radiograph appearance of
the humeral head in posterior shoulder
dislocation.
When the humerus dislocates it also
internally rotates such that the head
contour projects like a lightbulb when
viewed from the front.
Source: Radiopedia.org
Treatment
Nonoperative
o acute reduction and immobilization in external rotation for 4 to 6 weeks
indications
should be initially attempted for all acute traumatic posterior dislocations
most dislocations reduce spontaneously
technique
immobilize in 10-20 degrees of external rotation with elbow at side
after 6 weeks advance to physical therapy (rotator cuff strengthening and periscapular
stabilization) and activity modification (avoid activities that place arm in high-risk
position)
Operative
o open or arthroscopic posterior labral repair (Bankart)
indications
recurrent posterior shoulder instability
continued pain with loading of arm in forward flexed position (bench press, football
blocking)
negative Beighton score
outcomes
80% to 85% success at 5- to 7-year follow-up after open repair
similar outcomes with arthroscopic repair after shorter follow-ups
o open or arthroscopic posterior capsular shift and rotator interval closure
indications
positive Beighton score
o posterior glenoid opening wedge osteotomy
indications
excessive glenoid retroversion
o open reduction with subscapularis and lesser tuberosity transfer to the defect
(McLaughlin)
indications
chronic dislocation < 6 months old
reverse Hill-Sachs defect < 50%
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By Dr, AbdulRahman AbdulNasser Shoulder | Instability
o hemiarthroplasty
indications
chronic dislocation > 6 months old
severe humeral head arthritis
collapse of humeral head during reduction
Surgical Techniques
Open or arthroscopic posterior labral repair (Bankart) and capsular shift
o goal is to repair any labral detachment or capsular tears, and/or reduce the posterior capsule
volume
o approach
arthroscopic approach to shoulder
high lateral portal is better than standard portal for posterior labral work
lateral decubitus position allows for improved visualization for arthroscopic stabilization
o posterior capsular shift
most common treatment
up to 50% failure rate
o closure of rotator interval
augments posterior capsular shift
controversial
o thermal shrinkage of capsule
contraindicated due to complications
mechanism
breaks collagen cross links
critical temp (65 to 75° C)
o complications
recurrence
capsular necrosis
axillary nerve injury
o postoperative care
rigid immobilizer with arm abducted to 30 degrees in neutral internal rotation and elbow
posterior to the plane of the body
early range of motion and strengthening
full heavy labor and contact sports after 6 month
Open reduction with subscapularis and lesser tuberosity transfer to defect (McLaughlin)
o approach
deltopectoral approach
o technique to repair defect
subscapularis and lesser tuberosity transfer
used by most (modified McLauglin procedure)
iliac crest bone graft
can be used for any glenoid bone loss
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disimpaction and bone grafting of the defect
if < 3 weeks the surgeon can try disimpaction and bone grafting of the defect
opening wedge glenoplasty
may be indicated with glenoid hypoplasia
o complications
stiffness
AVN
osteoarthritis
Complications
Stiffness
o most common complication after labral repair
Recurrence
o 2nd most common (7% to 50%)
Degenerative joint disease
o 3rd most common
Adhesive capsulitis
Overtightening of posterior capsule
o may lead to anterior subluxation or coracoid impingement
Nerve injury
o axillary or suprascapular
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By Dr, AbdulRahman AbdulNasser Shoulder | Instability
Anatomy
Glenohumeral stability
o static restraints
glenohumeral ligaments (below)
glenoid labrum (below)
articular congruity and version
negative intraarticular pressure
if release head will sublux inferiorly
o dynamic restraints
rotator cuff muscles
the primary biomechanical role of the rotator cuff is stabilizing the glenohumeral joint by
compressing the humeral head against the glenoid
biceps
periscapular muscles
Complete Glenohumeral anatomy
Presentation
Symptoms
o pain
o instability
o weakness
o paresthesias
o crepitus I:24 sulcus sign
o shoulder instability during sleep
Physical exam
o tests
sulcus sign
assesses rotator interval
apprehension/relocation test
load and shift test (posterior instability)
Neer and Hawkins test
impingement or rotator cuff tendonitis in <20 year old signals possible MDI
Imaging
Radiographs
o recommended views
complete trauma series needed for evaluation (AP-IR,AP-ER,AP-True, Axillary,Scapular Y)
o findings
may be normal in multidirectional instability
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MRI
o indications
to fully evaluate shoulder anatomy
o findings
patulous inferior capsule (IGHL anterior and posterior bands)
Bankart lesion
Kim lesion
bony erosion of glenoid
Arthroscopy
o drive through sign may be present
Differential Diagnosis
Unidirectional instability
Cervical spine disease
Brachial plexitis
Thoracic outlet syndrome
Treatment
Nonoperative
o dynamic stabilization physical therapy
indications
first line of treatment
vast majority of patients
technique
3-6 month regimen needed
strengthening of dynamic stabilizers (rotator cuff and periscapular musculature)
closed kinetic chain exercises are used early in the rehabilitation process to safely
stimulate co-contraction of the scapular and rotator cuff muscles
Operative
o capsular shift / stabilization procedure (open or arthroscopic)
indications
failure of extensive nonoperative management
pain and instability that interferes with ADLs of sports activities
contraindications
voluntary dislocators
o capsular reconstruction (allograft)
rare, described in refractory cases and patients with collagen disorders
Techniques
Capsular shift / stabilization procedure (open or arthroscopic)
o approach
arthroscopic approach to shoulder
o stabilization
must address capsule +/- rotator interval
inferior capsular shift (capsule shifted superiorly)
plication of redundant capsule in a balanced fashion
rotator interval closure (open or arthroscopic)
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By Dr, AbdulRahman AbdulNasser Shoulder | Instability
produces the most significant decrease in range of motion in external rotation with the
arm at the side
address any anterior or posterior labral pathology if present
thermal capsulorrhaphy (historical)
is contraindicated because of complications including capsular thinning/insufficiency and
attenuation, and chondrolysis
o post-operative rehabilitation
4-6 weeks: shoulder immobilizer or sling
6-10 weeks: ADL's with 45 degree limit on abduction and external rotation
10-16 weeks: gradual range of motion
>16 weeks: strengthening
>10 months: contact sports
patient should resume sports activities only after normal strength and motion have returned
Complications
Subscapularis deficiency
o more common after open anterior-inferior capsular shift
o may be caused by injury or failed repair
o postop physical exam will show a positive lift off test and excessive external rotation
Loss of motion
o may be due to asymmetric tightening or overtightening of capsule
o leads to loss of ER
o treat with Z-lengthening of subscapularis
o rare
Axillary nerve injury
o iatrogenic injury with surgery (abduction and ER moves axillary nerve away from glenoid)
o usually a neuropraxia that can be observed postoperatively
o can occur with anterior dislocation of shoulder
Late arthritis
o usually wear of posterior glenoid
o may have internal rotation contracture
o historically seen with Putti-Platt and Magnuson-Stack (non-anatomic) procedures
Recurrence
o high rate following thermal capsulorrhaphy
open revision indicated (not arthroscopic)
Presentation
Symptoms
o shoulder pain
o inability to move shoulder
o neurovascular injury
Physical exam
o presents with the arm overhead with shoulder in full abduction, and elbow in flexion
Imaging
Radiographs
o recommended views
complete shoulder series
o findings
inferior glenohumeral dislocation with arm fully abducted
MRI
o indications
can be obtained after shoulder is relocated to assess shoulder injuries
o findings
may show capsulolabral pathology
rotator cuff tears common
Treatment
Nonoperative
o closed reduction and immobilization
indications
good response to non-operative treatment
inactive elderly patients
technique
initial reduction and immobilization
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By Dr, AbdulRahman AbdulNasser Shoulder | Injuries in Throwing Athlete
followed by ROM exercises
physical therapy focusing on rotator cuff strengthening
Operative
o reconstruction with arthroscopic or open repair
indications
capsulolabral damage
rotator cuff tear
active younger patients
technique : repair vs reconstruction of shoulder pathology
Complications
Axillary nerve palsy
o usually resolves with relocation of shoulder
Axillary artery thrombosis
o may occur late
Rotator cuff tear
o especially in older patients
1. SLAP Lesion
Introduction
Superior Labrum from Anterior to Posterior tears
May occur as isolated lesion or be associated with
o internal impingement
o rotator cuff tears (usually articular sided)
o instability (may be subtle)
Mechanisms
o repetitive overhead activities (often seen in throwing athletes)
o fall on outstretched arm with tensed biceps
o traction on the arm
Pathophysiology
o in throwers may be due to tightness of the postero-IGHL which shifts the glenohumeral contact
point posterosuperiorly and increases the shear force on the superior labrum
o SLAP lesion increases the strain on the anterior band of the IGHL and thus compromises
stability of shoulder
Anatomy
Anatomy of glenohumeral joint
Biceps tendon attachment on glenoid (Tuoheti classification)
o Type I - completely posterior
o Type II - predominantly posterior
Type I and II together comprise >70%
o Type III - anterior + posterior (25%)
o Type IV - anterior (5%)
Glenoid labrum
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o function
chock block to subluxation
o composition
composed of fibrocartilagenous tissue
o blood supply
from suprascapular, circumflex scapular, posterior humeral circumflex arteries
labrum receives blood from capsule and periosteal vessels and not from underlying bone
anterior-superior labrum has poorest blood supply
o stability
superior labrum
anchors biceps tendon (weak link that leads to SLAP lesion)
most common pattern of biceps tendon attachment to the
superior labrum is posterior to the 12 o'clock position
o anatomic variants
sublabral recess
I:25 meniscoid appearance
can be confused with a tear on MRI
meniscoid appearance (1%)
Classification
SLAP Classification
Type Description %
I Labral and biceps fraying, anchor intact 11%
II Labral fraying with detached biceps tendon anchor 41%
III Bucket handle tear, intact biceps tendon anchor (biceps separates from 33%
bucket handle tear)
IV Bucket handle tear with detached biceps tendon anchor (remains attached to 15%
bucket handle tear)
V Type II + anterointerior labral extension (Bankart lesion) m
VI Type II + unstable flap m
VII Type II + MGHL injury m
VIII Type II + posterior extension
IX Circumferential
X Type II + posteroinferior extension (reverse Bankart)
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By Dr, AbdulRahman AbdulNasser Shoulder | Injuries in Throwing Athlete
Presentation
Symptoms
o vague deep shoulder pain (there is often a lag between the time of injury and the onset of
symptoms)
o mechanical symptoms of popping and clicking
o weakness, easy fatigue, and decrease athletic performance
Physical exam
o provocative tests
active compression test (O'Brien's test)
Crank test
Dynamic labral shear test
o biceps tendon tenderness
o patients commonly have GIRD
o apprehension positive in 85% of patients
o physical findings of suprascapular neuropathy secondary to a spinoglenoid cyst
Imaging
Radiographs
o should be normal
MRI
o T2 linear signal intensity between the superior labrum and the glenoid rim
o sensitivity ~50% and specificity ~90% which increases with arthrogram
o may see an associated paralabral ganglion cyst
usually in the spinoglenoid notch
may result in denervation changes to infraspinatus
Arthroscopy
o diagnosis can only be confirmed with arthroscopy
o look for erythema and tearing under labrum to differentiate from normal recess
o "peel back" test shows "peel back" of the labrum with 90° of external rotation and abduction
Treatment
Nonoperative
o physical therapy, NSAIDs
indications
first line of treatment
address GIRD, scapular dyskinesia, rotator cuff
incidental SLAP finding
in older patients (>45 years) having arthroscopic rotator cuff repair, it is not necessary
to repair a SLAP lesion that is found incidentally. It may actually lead to stiffness if it
is repaired.
Operative
o arthroscopic debridement and stabilization of the labrum and biceps tendon
indications
severe symptoms that have failed nonoperative management
complications
overdrilling the glenoid can injury the suprascapular nerve
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Techniques
Arthroscopic debridement and stabilization of the labrum and biceps tendon
o approach
standard arthroscopic approach to the shoulder
o technique
Type I - debride labrum
Type II - reattach labrum
Type III - debridement of flaps
Type IV
if tendon involvement < 1/3, then excise the bucket
if tendon involvement >1/3, same and perform biceps tenodesis or tenotomy.
decompress any cysts
o rehabilitation
week 1-4
sling with passive forward elevation. Avoid extremes of abduction and external rotation
passive and active assisted flexion in the scapular plane
week 4-6
progress to active ROM, isometrics
week 6-12
functional exercise and light strengthening
week 12+
advance strength and ROM, sport-specifics
typical return to sport around 6 months
2. Internal Impingement
Introduction
Internal impingement refers to pathology on undersurface of rotator cuff
o in contrast to subacromial or "external" impingement which occurs on bursal side of rotator cuff)
o internal impingement covers a spectrum of injuries including
fraying of posterior rotator cuff
posterior and superior labral lesions
hypertrophy and scarring of posterior capsule glenoid (Bennett lesion)
cartilage damage at posterior glenoid
Epidemiology
o major cause of shoulder pain in throwing athletes
Pathoanatomy
o caused by impingement of posterior under-surface of supraspinatus tendon on greater tuberosity
insertion on the posterosuperior glenoid rim
impingement occurs during maximum arm abduction and external rotation during late
cocking and early acceleration phases of throwing
causes"peel-back" phenomenon of posterosuperior labrum
o thought to be due to combination of
tightness of posterior band of IGHL
anterior micro instability
Associated conditions : associated with GIRD
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By Dr, AbdulRahman AbdulNasser Shoulder | Injuries in Throwing Athlete
Anatomy
Glenohumeral joint anatomy
Glenohumeral stability
o static restraints
glenohumeral ligaments
glenoid labrum
articular congruity and version
negative intraarticular pressure
o dynamic restraints
rotator cuff muscles
biceps
periscapular muscles
Glenohumeral ligaments
o Superior GHL
restraint to inferior translation at 0° degrees of abduction (neutral rotation)
o Middle GHL
resist anterior and posterior translation in the midrange of abduction (~45°) in ER
o Inferior GHL
posterior band
most important restraint to posterior subluxation at 90° flexion and IR
anterior band
primary restraint to anterior/inferior translation 90° abduction and maximum ER (late
cocking phase of throwing)
superior band
most important static stabilizer about the joint
Presentation
Symptoms
o diffuse pain in posterior shoulder along the posterior deltoid
shoulder pain worse with throwing
especially during late cocking and early acceleration
Physical exam
o increased external rotation
o decreased internal rotation
loss of > 20° of IR at 90°
must stabilize the scapula to get true measure of glenohumeral rotation
o often can demonstrate rotator cuff weakness
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Imaging
Radiographs
o recommended views
complete shoulder series
o findings
usually unremarkable
AP may show a Bennett lesion (glenoid exostosis)
MRI
o can show associated rotator cuff and/or labral pathology
such as partial articular sided supraspinatus tendon avulsion (PASTA) or tear
signal at greater tuberosity and/or posterosuperior labrum
Treatment
Nonoperative
o posterior capsule stretching PT for 6 months
indications
most internal impingement can be treated non-operatively
technique
posterior capsule stretching with sleeper stretches
rotator cuff stretching and strengthening
Operative
o arthroscopic debridement and/or repair of rotator cuff tear and labrum
indications
failed nonoperative treatment
partial thickness rotator cuff tear (PASTA) compromises the integrity of the rotator cuff
partial rotator cuff tears >50%
Bennett lesions
o posterior capsule release vs anterior stabilization
indications
failed nonoperative treatment
shoulder instability
technique
surgical techniques are controversial
some perform a posterior capsule release
some perform anterior stabilization
complications
inferior suprascapular nerve (infraspinatus) is at greatest risk during posterior capsule
release
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By Dr, AbdulRahman AbdulNasser Shoulder | Injuries in Throwing Athlete
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Anatomy
Glenohumeral joint
Presentation
Symptoms
o vague shoulder pain
o sometimes painless
o may report a decrease in throwing performance
Physical exam
o stabilize the scapula to obtain true measure of glenohumeral rotation
o increased sulcus sign
due to stretching of anterior structures that resist external rotation (coracohumeral ligament,
rotator interval)
o characterized by altered glenohumeral range of motion
decrease in internal rotation and increase in external rotation
if the GIRD (loss of internal rotation) is less than external rotation gain (ERG), the
shoulder maintains normal kinematics
if the GIRD exceeds external rotation gain (ERG), this leads to deranged kinematics
decrease in internal rotation is usually greater than a 25° difference as compared to
non-throwing shoulder
Imaging
Radiographs
o recommended views
AP and lateral of glenohumeral joint
o findings
usually normal
I:26 CT showing increased glenoid retroversion
CT
o may show increased glenoid retroversion
MRI
o ABER view on MRI can show associated lesions
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By Dr, AbdulRahman AbdulNasser Shoulder | Injuries in Throwing Athlete
Treatment
Nonoperative
o rest from throwing and physical therapy for 6 months
indications
first line of treatment
physical therapy
posteroinferior capsule stretching
sleeper stretch
performed with internal rotation stretch at 90 degrees abduction with scapular
stabilization
roll-over sleeper stretch
arm flexed 60° and body rolled forward 30°
doorway stretch
cross-body adduction stretch
pectoralis minor stretching
rotator cuff and periscapular strengthening
outcomes
90% of young throwers respond to sleeper stretches/PT
10% of older throwers do not respond, and will need arthroscopic release eventually
Operative
o posteroinferior capsule release vs. anterior stabilization
indications : only indicated if extensive PT fails
Techniques
Posterior capsule release vs. anterior stabilization
o some advocate posterior capsule release while others advocate anterior stabilization
o repair thinned rotator cuff if significantly thinned (transcuff or takedown and repair)
o technique controversial
for throwing athlete with posteroinferior capsular contracture, release posterior inferior
capsule and posterior band of IGHL
electrocautery inserted through posterior portal, camera from anterior portal
from 9 to 6 o'clock position
at level of glenoid rim
until rotator cuff fibers (behind the capsule) can be seen from within joint
insert arthroscopic shaver to widen gap in capsule (prevents recurrence)
gentle manipulation at the end completes release of any remaining fibers, maximizes IR and
flexion
o results : will immediately gain 65° of internal rotation postop
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Presentation
Symptoms
o arm and shoulder pain with throwing
worse in late cocking or deceleration phases
pain resolves with rest
o may be associated with decreased velocity and control
Physical exam
o point tenderness over shoulder physis
o pain reproduced with shoulder rotation
Imaging
Radiographs
o may be unremarkable
o findings
widened proximal humerus physis
metaphyseal bony changes
MRI
o shows edema around physis
o may be helpful to rule out other pathology
labral pathology
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By Dr, AbdulRahman AbdulNasser Shoulder | Injuries in Throwing Athlete
Treatment
Nonoperative
o rest, ice, PT, progressive throwing program
indications
mainstay of treatment
technique
refrain from pitching for 2-3 months
return to play only after asymptomatic
PT focuses on
rotator cuff strengthening
posterior shoulder capsule stretches
core strengthening and stretching
progressive throwing program
starts with short tosses at low velocity
slowly progresses distance and velocity
Prevention
o correction of pitching mechanics
using pitching coaches
o discourage breaking ball pitches
until skeletal maturity
o enforcement of pitch counts
Complications
Premature growth arrest of proximal humeral epiphysis
o can cause
growth arrest
angular deformity
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Pathophysiology
o mechanism
usually from a posteriorly directed force with arm flexed, adducted, and internally rotated
Associated injuries
o Kim lesion
is an incomplete and sometimes concealed avulsion of posterior labrum
Anatomy
Posterior labrum
o function
helps create cavity-compression and creates 50% of the glenoid socket depth
provides posterior stability
o anatomy
composed of fibrocartilagenous tissue
anchors posterior inferior glenohumeral ligament (PIGHL)
See complete Glenohumeral joint anatomy
Presentation
Symptoms
o shoulder pain
o sense of instability
o mechanical symptoms (clicking, popping) with range of motion
Physical exam
o posterior joint line tenderness
o provocative tests
Posterior Load and Shift
Jerk test
subluxation with posteriorly applied force while arm is in flexion and internal rotation
Kim test
subluxation with posteriorly applied force as arm is dynamically adducted by examiner
Imaging
Radiographs
o recommended views
complete shoulder series
o findings
are often normal
MRI
o diagnostic study of choice
o intra-articular contrast (MRI arthrogram) increases
sensitivity for labral pathology
Treatment
Nonoperative
o NSAIDs, PT
indications : first line of treatment
technique
rotator cuff strengthening and periscapular stabilization
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By Dr, AbdulRahman AbdulNasser Shoulder | Degenerative Conditions
Operative
o posterior labral repair with capsulorrhaphy
indications
extensive nonoperative management fails
technique
both open and arthroscopic techniques can be used
probing of posterior labrum is required to rule out a subtle Kim lesion
Complications
Axillary nerve palsy
o posterior branch of the axillary nerve is at risk during arthroscopic stabilization
travels within 1 mm of the inferior shoulder capsule and glenoid rim
is at risk during suture passage at the posterior inferior glenoid
F. Degenerative Conditions
1. Glenohumeral Arthritis
Introduction
Glenohumeral degenerative joint disease has many causes including
o osteoarthritis
o rheumatoid arthritis
is most prevalent form of inflammatory process affecting the shoulder with >90% developing
shoulder symptoms
is commonly associated with rotator cuff tears
25%-50% have full thickness tears
o connective tissue diseases
o spondyloarthropathies
Epidemiology
o demographics
more common in the elderly
may be associated with throwing athletes at younger age
Pathoanatomy
o primary osteoarthritis
no known cause
rotator cuff tears rare (5%-10%)
unlike RA shoulder, which has 30% incidence of full thickness cuff tears
posterior glenoid wear + posterior humeral subluxation (in 45% of cases)
anterior capsule and subscapularis contracture
limited external rotation
o secondary osteoarthritis
trauma
previous surgeries
overtightening of anterior capsule during reconstruction of shoulder
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hardware in and around shoulder
instability
rotator cuff disease
Associated conditions
o chondrolysis
which has been associated with the use of intra-articular local anesthetic infusion pumps after
surgery
Anatomy
Glenohumeral joint
Classification
Walch classification of glenoid wear associated with primary OA
Type A Concentric wear, no subluxation, well centered
A1 minor erosion
A2 deeper central erosion
Type B Biconcave glenoid, asymmetric glenoid wear and head subluxated posteriorly
B1 narrowing of posterior joint space, subchondral sclerosis, osteophytes
B2 posterior wear, biconcave glenoid
Type C C Glenoid retroversion of more than 25 degrees (dysplastic in origin) and posterior
subluxation of humerus
Presentation
Symptoms
o pain at night
o pain with activities involving shoulder motion
Physical exam
o tenderness at GH joint
o flattening of the anterior shoulder contour
due to posterior subluxation of the humeral head
o functional limitations at GH joint
decreased external rotation
o painful shoulder range of motion
Imaging
Radiographs
o recommended views
AP, true AP and axillary
o findings
subchondral sclerosis
osteophytes at inferior aspect of humeral head ("goat's beard")
superior migration of head to indicate cuff deficiency
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By Dr, AbdulRahman AbdulNasser Shoulder | Degenerative Conditions
look for evidence of previous surgery (staples)
look for medialization that occurs in inflammatory arthritis
may preclude glenoid resurfacing if severe
posterior glenoid (biconcave Walch B2) wear
posterior humeral head subluxation
CT
o study
of choice
o indications
inflammatory arthritis if large bony defects are present on radiographs
RA may have insufficient glenoid bone stock for glenoid prosthesis
preoperative planning
MRI
o may be indicated to evaluate rotator cuff tendon
Treatment
Nonoperative
o NSAIDS, DMARDs for RA, physical therapy, corticosteroid injections
first line of treatment in all cases
Operative
o total shoulder arthroplasty
indications
unresponsive to nonoperative treatment
progressive pain
decreased ROM
inability to perform activities of daily living
contraindications
deltoid dysfunction
insufficient glenoid stock
rotator cuff arthropathy
outcomes
literature shows decreased rate of revision surgery when compared to hemiarthroplasty
10 year survival 92-95%
commonest complication is rocking horse phoenomentn loosening
o hemiarthroplasty ± biologic resurfacing (Achilles allograft)
biologic resurfacing for young patients
indications
osteoarthritis
rheumatoid arthritis
when large, irreparable RC tears are present
insufficient glenoid bone to support glenoid prosthesis
post-traumatic arthritis
o reverse total shoulder arthroplasty (rTSA)
contraindications
deltoid deficiency
complication
most common is scapular notching
outcomes
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10 year survival 80-90%
higher complication rate than TSA
o fusion
indications
rotator cuff deficiencies
deltoid deficiencies
persistent deep infection
rarely indicated for OA
positioning
30°/30°/30°: flexion, internal rotation, abduction
o arthroscopic debridement
indications
temporizing measure
Techniques
Total shoulder arthroplasty
Hemiarthroplasty
Reverse ball prosthesis
Anatomy
Capsuloligamentous structures
o function
contribute to stability of the glenohumeral joint I:27 soft tissue scarring
and contracture
act as check reins at extremes of motion in their nonpathologic state
o include the glenohumeral ligaments
superior glenohumeral ligament (SGHL)
middle glenohumeral ligament (MGHL)
inferior glenohumeral ligament (IGHL) complex with the following components
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By Dr, AbdulRahman AbdulNasser Shoulder | Degenerative Conditions
anterior band
axillary fold
posterior band
Rotator interval
o a triangular region between the anterior border of supraspinatus and the superior border of
subscapularis
o contains the SGHL and coracohumeral ligament
Glenohumeral ligamints
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Classification
Clinical Stages
Painful Gradual onset of diffuse pain (6 wks to 9 mos)
Stiff Decreased ROM affecting activities of daily living (4 to 9 mos or more)
Thawing Gradual return of motion (5 to 26 mos)
Arthroscopic Stages
Stage 1 Patchy, fibrinous synovitis
Stage 2 Capsular contraction and fibrinous adhesions
Stage 3 Increasing contraction, synovitis resolving
Stage 4 Severe contraction
Presentation
Symptoms
o characterized by pain and stiffness
Physical exam
o painful arc of motion
o decreased ROM (especially external rotation)
examine and document all seven planes of motion
Imaging
Radiographs
o recommended views
AP in neutral rotation
AP in internal rotation
AP in external rotation
scapular-Y
axillary lateral
o findings
disuse osteopenia
concomitant osteoarthritis, calcific tendinitis, or hardware indicating prior surgery
MR arthrogram
o loss of axillary recess indicates contracture of joint capsule
Treatment
Nonoperative
o NSAIDs, physical therapy, and intra-articular steroid injections
physical therapy
program of gentle, pain-free stretching and moist heat
should be supervised and last for 3-6 months
results
successful in vast majority although patience is required
most common complication is decreased range of motion compared to contralateral
extremity
Operative
o manipulation under anesthesia (MUA)
indications
failure to improve with therapy and NSAIDs
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By Dr, AbdulRahman AbdulNasser Shoulder | Degenerative Conditions
surgical techniques
may be combined with arthroscopic surgical release
o arthroscopic surgical release
indications
only after extensive therapy has failed ( 3-6 months)
surgical techniques
arthroscopic lysis of adhesions (LOA)
arthroscopic rotator interval release will increase ER
when ER at the side is limited, the most likely diagnosis is contracture of the rotator
interval, including the superior glenohumeral and coracohumeral ligaments
arthroscopic posterior capsular release will increase IR
Complications
Axillary nerve injury
Rotator cuff tendon disruption
Iatrogenic chondral injury
Fracture or dislocation
o caution must be used with manipulation under anesthesia in osteoporotic bone
Recurrent stiffness
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Anatomy
Blood supply
o Humeral head
ascending branch of anterior humeral circumflex artery and arcuate artery
provides blood supply to humeral head
vessel runs parallel to lateral aspect of tendon of long head of biceps in the bicipital
groove
beware not to injure when plating proximal humerus fractures
arcuate artery is the interosseous continuation of ascending branch of anterior humeral
circumflex artery and penetrates the bone of the humeral head
provides 35% of blood supply to humeral head
posterior humeral circumflex artery
most current literature supports this as providing the main blood supply to humeral head
provides 65% of blood supply
Classification
Cruess Classification (stages)
Stage I Normal x-ray. Changes on MRI. Core decompression.
Stage II Sclerosis (wedged, mottled), osteopenia. Core decompression.
Stage III Crescent sign indicating a subchondral fracture. Resurfacing or hemiarthroplasty.
Stage IV Flattening and collapse. Resurfacing or hemiarthroplasty.
Stage V Degenerative changes extend to glenoid. TSA.
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By Dr, AbdulRahman AbdulNasser Shoulder | Degenerative Conditions
Presentation
Symptoms
o insidious onset of shoulder pain
often without a clear inciting event
o pain, loss of motion, crepitus, and weakness
Physical exam
o limited range of motion
o crepitus
o weakness of the rotator cuff and deltoid muscles
Imaging
Radiographs
o recommended views
five views of shoulder (shown best in neutral rotation AP)
o findings
no findings on radiograph at onset of disease process
osteolytic lesion develops on radiograph demonstrating resorption of subchondral necrosis
most common initial site is superior middle portion of humeral head
crescent sign demonstrates subchondral collapse
may progress to depression of articular surface and consequent arthritic changes.
MRI
o preferred imaging modality
~100% sensitivity in detection
o will demonstrate edema at the site of subchondral sclerosis
Treatment
Nonoperative
o pain medications, activity modification, physical therapy
indications
first line of treatment
technique
physical therapy
I:28 MRI showing AVN of humeral head
restrict overhead activity and manual labor
Operative
o core decompression + arthroscopy (confirm integrity of cartilage)
indications
early disease (precollapse Cruess Stage I and II)
o humeral head resurfacing
indications
Stage III disease with focal chondral defects, and sufficient remaining epiphyseal bone
stock for fixation.
o hemiarthroplasty
indications
moderate disease (Cruess Stage III and IV)
o total shoulder arthroplasty
indications
advance stage (Cruess V)
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OrthoBullets2017 Shoulder | Degenerative Conditions
4. Scapulothoracic Crepitus
Introduction
Scapulothoracic crepitus, or snapping scapula syndrome, manifests as pain at the scapulothoracic
junction with overhead activity.
Pathophysiology
o predisposing abnormal anatomy
6% of scapulae have some superomedial hooking
malunion of scapula or rib fractures
history of resection of 1st rib for thoracic outlet syndrome
o overuse with normal anatomy
o inflammation from overuse results in chronic inflammation, causing bursal fibrosis, bursitis,
snapping
o bony or soft tissue masses
osteochondroma
elastofibroma dorsi
a benign soft tissue tumor
scapular chondrosarcoma
Associated conditions
o Scoliosis, kyphosis
o scapulothoracic dyskinesis I:29 MRI : elastofibroma dorsi of scapula
Anatomy
Osteology - Scapula
o spans ribs 2 to 7
o three borders (superior, lateral, medial)
o three angles (superomedial, inferomedial, lateral)
o no direct bony articulation
o no true synovial articulation
Muscles
o trapezius
o serratus anterior
o subscapularis
o levator scapulae
o rhomboids
o supraspinatus
o infraspinatus
o teres minor
o teres major
o triceps brachii (long head)
o biceps brachii
o coracobracialis
o deltoid
o pectoralis minor
o latissimus dorsi (small slip of origin)
I:30 Blood supply around scapula
o omohyoid
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By Dr, AbdulRahman AbdulNasser Shoulder | Degenerative Conditions
Ligaments
o transverse scapular ligament - separates suprascapular artery (above) from suprascapular nerve
(below, in suprascapular notch)
Blood Supply
o dorsal scapular artery runs deep to rhomboids and levator 1 to 2 cm medial to scapula
Bursae
o Anatomic
infraserratus
supraserratus
o Adventitial (pathologic)
near superior or inferior angles
inconsistently identified
Presentation
History
o presentation ranges from mild discomfort to significant disability
o trauma and overuse have both been reported
Symptoms
o patient complains of "popping" of scapula
o painful crepitus with elevation of arm
o pain relieved with stabilization of scapula
Physical exam
o fixed or postural kyphosis may be present
o tenderness or fullness of symptomatic bursa
o ask patient to demonstrate symptomatic motions
o passive scapulothoracic motion by examiner may also reproduce crepitus
o scapulothoracic dyskinesis may be present
evaluate for winging
test muscle strength
trapezius
serratus
rhomboids
levator
latissimus
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OrthoBullets2017 Shoulder | Degenerative Conditions
Imaging
Radiographs
o recommended
AP, lateral and axillary
o findings
look for osseous abnormalities
CT scan
o indications
osseous lesion on plain radiographs
MRI
o indications
soft tissue masses
inflamed bursae
Studies
Diagnostic injections
o selective injection of local anesthetic and/or corticosteroid to point of maximal tenderness can be
diagnostic and therapeutic
Differential
Cervical pathology
o can be referred to shoulder girdle
Treatment
Nonoperative
o indications
first line of treatment
no mass or aggressive lesion
o modalities
NSAIDs
scapular strengthening exercises, postural training, activity modification
local corticosteroid injections
Operative
o bursectomy (open or arthroscopic), resection of osseous lesion, resection of scapular border
indications
cases refractory to nonoperative treatment
outcomes
improvement in symptoms reported with both open and arthroscopic
better results in patients who responded well to injection
incomplete resolution of symptoms common despite improvement
better results with addition of partial scapulectomy (vs bursectomy alone)
Techniques
Open
o position : prone, extremity draped free
o approach
vertical incision over medial border of scapula, centered on symptomatic bursa
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By Dr, AbdulRahman AbdulNasser Shoulder | Degenerative Conditions
trapezius split in line with fibers
rhomboids and levator elevated subperiosteally
o technique
bursa excised
angle of scapula can be excised
detached muscles repaired through drill holes
o postoperative care
sling immediate post op
must protect repaired muscle attachments
immobilize x 4 weeks
active motion at 8 weeks
strengthening at 12 weeks
o pros and cons
pros: wide exposure
cons: morbid
Arthroscopic
o position
prone, extremity draped free, arm in maximum internal rotation with hand over lumbar spine
o approach
portals: 3 cm medial to medial border of scapula (avoids dorsal scapular nerve and vessels)
and below scapular spine (avoids spinal accessory nerve)
superior (Bell's) portal: junction of medial one third and lateral two thirds of superior
border of scapula
trochar as parallel to chest wall as possible
o technique
skeletonize superomedial angle with cautery
resect superomedial angle if desired using burr
can place spinal needle at superior scapular border to mark lateral limit of resection
o postoperative care
sling immediate post op used for comfort x 1 week
active motion and strengthening based on tolerance
o pros and cons
pros: no muscle detachment
cons: technically demanding
Complications
Neurovascular injury
o suprascapular nerve and vessels
o dorsal scapular nerve and vessels
o spinal accessory nerve
Chest wall penetration
o Pneumothorax
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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OrthoBullets2017 Shoulder | Neurovascular Disorders
G. Neurovascular Disorders
1. Suprascapular Neuropathy
Introduction
Can be caused by
o suprascapular notch entrapment
weakness of both supraspinatus and infraspinatus
o spinoglenoid notch entrapment
weakness of infraspinatus only
Anatomy
Suprascapular nerve (C5,C6)
o emerges off superior trunk (C5,C6) of brachial plexus
o travels across posterior triangle of neck to scapula
o innervates
supraspinatus
infraspinatus
Suprascapular ligament
o arises from medial base of coracoid and overlies suprascapular notch
suprascapular artery runs above
suprascapular nerve runs below
Spinoglenoid ligament
o arises near spinoglenoid notch
overlies distal suprascapular nerve
weakness seen with shoulder abduction to 90 degree, 30 degrees forward flexion, and
with internal rotation (Jobe test positive)
weakness of infraspinatus
weakness to external rotation with elbow at side
atrophy along the posterior scapula
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By Dr, AbdulRahman AbdulNasser Shoulder | Neurovascular Disorders
Evaluation
o MRI
important to identify a compressive mass with associated cyst
o EMG/NCV
diagnostic
Treatment
o nonoperative
activity modification and organized shoulder rehab program
indications
no structural lesion seen on MRI
technique
rehab should be performed for a minimum of 6 months
o operative
surgical nerve decompression at suprascapular notch
indications
structural lesion seen on MRI (cyst)
failure of extended nonoperative management (~ 1 year)
2. Scapular Winging
Introduction
Two types based on direction of top-medial corner of scapula
o medial winging
serratus anterior (long thoracic nerve)
o lateral winging
trapezius (CN XI - spinal accessory nerve)
Differentiating medial and lateral winging
o history
medial winging
usually seen in young athletic patient
far more common
lateral winging
history of neck surgery (lateral is usually iatrogenic)
o physical exam
medial winging
medial spine of scapula moves upward and medial
lateral winging
medial spine of scapula moves downward and lateral
Anatomy
Scapula serves as the attachment site for 17 muscles
o function to stabilize the scapula to the thorax, provide power to the upper limb, and synchronize
glenohumeral motion.
Normal motion
o elevation and upward rotation
by trapezius muscle.
o scapular protraction (anterior and lateral motion)
by serratus anterior and pectoralis major and minor muscle
o scapular retraction (medial motion)
by rhomboid major and minor muscles.
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By Dr, AbdulRahman AbdulNasser Shoulder | Neurovascular Disorders
Medial Winging
Introduction
o caused by deficit in serratus anterior due to injury to the long thoracic nerve (C5,6,7)
o Mechanisms of injury to long thoracic nerve
iatrogenic from anesthesia
10% of patients with medial scapular winging had prior surgery
repetitive stretch injury (most common)
increased risk with head tilted away during overhead arm activity
e.g., weight lifters, volleyball players
compression injury
direct compression of nerve at any site, including the lateral chest wall seen with contact
sports and trauma
scapula fracture
Presentation
o symptoms
shoulder and scapula pain
weakness when lifting away from body or overhead activity
discomfort when sitting against chair
o physical exam
superior medial scapula elevates and migrates medial
wasting of anterior scalene triangle” due to wasting of sternocleidomastoid
Treatment
o nonoperative
observation, bracing, and serratus anterior strengthening
indications : observation for a minimal of 6 months- wait for nerve to recover
technique : bracing with a modified thoracolumbar brace
o operative
split pectoralis major transfer (sternal head)
indications : failure of spontaneous resolution after 1-2 years
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OrthoBullets2017 Shoulder | Neurovascular Disorders
Split pectoralis major transfer (medial winging) Eden-Lange transfer (lateral winging)
Lateral Winging
Introduction
o caused by deficit in trapezius due to spinal accessory nerve injury (CNXI)
o often caused by an iatrogenic injury (by general surgery or neurosurgery looking for lymph
nodes in posterior neck)
Physical exam
o superior medial scapula drops downward and lateral
shoulder girdle appears depressed or drooping
o anterior scalene triangle wasting
secondary to anterior scalene atrophy
Treatment
o nonoperative
observation and trapezius strengthening
o operative options include
nerve exploration
indications : iatrogenic nerve injury
Eden-Lange transfer
lateralize levator scapulae and rhomboids (transfer from medial border to lateral border)
scapulothoracic fusion
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By Dr, AbdulRahman AbdulNasser Shoulder | Neurovascular Disorders
bilateral in 10-30% of patients (16% simultaneously)
symptoms asymmetric
o demographics
age : 20-70 years
any age can be affected but typically middle aged individuals affected
males > females (between 1.5:1 and 11:1
o risk factors
viral infection
immunizations
medications
extreme stresses
autoimmune diseases
o nerves most commonly affected
suprascapular
axillary
musculocutaneous
long thoracic
radial
others : cervical roots, AIN, PIN, LABCN
Pathophysiology (INA)
o autoimmune process
lymphocytes increase blastogenic activity
transform from small lymphocytes into larger cells capable of mitosis
o infectious
viral triggers in 20-60%
EBV, VZV, Coxsackie B, HIV, parvovirus B19, mumps, smallpox
bacterial (Leptospira, TB, Yersinia, Salmonella, Borrelia burgdorferi)
immunization (tetanus, hepatitis B) in 15%
o stress
perioperative, peripartum, burns
strenuous exercise (in 8%)
hypothesis that mobility of upper trunk allows wear-and-tear of blood-nerve barrier that
normally prevents immune cells/factors from coming into contact with peripheral nervous
system
o drugs : abacavir, streptokinase, heroin, infliximab
o genetic
hereditary form (HNA) is autosomal dominant
extremely rare (200 families worldwide)
mutations in gene septin 9 (cytoskeletal protein) on chromosome 17q23
septin 9 is highly expressed in glial cells in neurons
mutations disrupt signaling
more recurrent episodes (average 3.5 episodes, vs 1.5 with INA)
younger onset (average 28yr, vs 41yr with INA)
more frequent involvment of nerves outside brachial plexus (56%, vs 17% with INA)
have dysmorphic features (hypotelorism, cleft palate, short stature, facial asymmetric,
unusual skin folds)
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OrthoBullets2017 Shoulder | Neurovascular Disorders
Prognosis
o females have worse functional outcome
o no relationship between recovery and age
o HNA more recurrence than INA
o upper trunk involvement has better prognosis than lower trunk
o may take up to 8 years for full recovery of strength
o excellent recovery in 36% at 1 yr, 75% at 2yr, and 89% at 3yr
o 33% have persistent pain/functional deficit
o 66% have recovery of motor function within 1 month
o prolonged pain/functional deficit has poor prognosis
Presentation
Symptoms
o sudden onset of intense, unrelenting shoulder pain (in 90%)
subsides in 1 to 2 weeks
lasts longer in males
typically awakens people from sleep
exacerbated by shoulder/elbow motion
o followed by flaccid paralysis
within 24h (33%) to 1 month (80%)
lasts up to 1 year in the muscle that is supplied by the involved nerve
usually involves upper brachial plexus +/- long thoracic nerve
Physical exam
o severe weakness of the external rotators and abductors
supraspinatus
infraspinatus
serratus anterior
biceps
deltoid
triceps
o muscle atrophy
o sensory loss in shoulder girdle (up to 75% of patients)
over deltoid, lateral upper arm, radial aspect of forearm (LABCN)
o commonly affects more than one nerve branch
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By Dr, AbdulRahman AbdulNasser Shoulder | Neurovascular Disorders
o autonomic dysregulation
trophic skin changes
temperature dysregulation
increased sweating
altered nail/hair growth
Imaging
MRI
o early changes
high T2-weighted signal in the affected muscle bellies
especially supraspinatus, infraspinatus, teres minor, deltoid
o late changes
high intramuscular T1-weighted signal suggesting atrophy with fatty infiltration
Studies
EMG
o first 3-4 weeks after initial symptoms
o findings
acute denervation with sharp waves and fibrillations
peripheral nerves
nerve roots
Treatment
Nonoperative
o observation for resolution and therapy
indications
mainstay of treatment
technique
follow patients monthly for improvement
no improvements noted with rehab and observation vs observation alone at one year after
diagnosis
outcomes
90% of patients recover full muscle strength and function by 3 years with no residual pain
or deficits
only 35% of patients recover at 1 year
o physical therapy
help alleviate traction on involved nerves
o NSAIDS and slow release opiates
o nerve transfer/decompression (neurolysis superior to neurorraphy and nerve grafting)
ulnar nerve transposition
radial tunnel release
carpal tunnel release
Guyon canal release
microneurolysis/decompression of long thoracic nerve
to reverse scapular winging
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OrthoBullets2017 Shoulder | Neurovascular Disorders
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By Dr, AbdulRahman AbdulNasser Shoulder | Neurovascular Disorders
Adson
extension of the arm with the neck extended and turned towards the affected side may
result in loss of radial pulse or reproduction of symptoms with inhaling
Roos
hands repeatedly opened and closed while holding them overhead for 1 minute can
reproduce symptoms
Imaging
Radiographs
o recommended views
c-spine x-ray to rule out cervical rib
chest x-ray to rule out Pancoast tumor
Angiography
o if etiology is vascular will show subclavian vessel disease or aneurysm
Studies
EMG and NCV
o studies usually equivocal
Treatment
Nonoperative
o physical therapy and activity modifications
indications : first line of treatment
technique
shoulder girdle strengthening, proper posture, and relaxation techniques
Operative
o neurologic decompression
indications
neurogenic etiology
nonoperative modalities have failed
progressive and severe neurologic deficits and pain
technique
address site of compression
repair clavicle malunion
transaxillary first rib resection (90% good to excellent results)
scalene takedown
pectoralis minor tenotomy
release of fibromuscular anomalous bands
o vascular reconstruction (open or interventionally)
indications
subclavian aneurysm present
persistent insufficient vascularity
Complications
Emboli to the hands
o treat with acute heparinization, embolectomy (or TPA if vessels too small), 7-10 days of heparin,
followed by three months of warfarin
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OrthoBullets2017 Shoulder | Neurovascular Disorders
Anatomy
Quadrangular space
o location
lateral to triangular space and medial to triangular interval
o boundaries
superior - subscapularis and teres minor
inferior - teres major
medial - long head of triceps brachii
lateral - surgical neck of the humerus
o contents
axillary nerve (C5 nerve root, posterior cord)
posterior circumflex humeral artery
Presentation
Symptoms
o poorly localized pain of the posterior/lateral shoulder
often worse at night
worse with overhead activity or late cocking/acceleration phase of throwing
o non-dermatomal distribution of paraesthesia along the lateral shoulder and arm
o shoulder external rotation weakness
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By Dr, AbdulRahman AbdulNasser Shoulder | Neurovascular Disorders
Physical examination
o inspection
may see atrophy of the teres minor and deltoid
o palpation
point tenderness over the quadrangular space
o motion and strength
external rotation weakness with the arm abducted in throwing position
pain exacerbated by active and resisted abduction and external rotation of the arm
o neurological examination
usually normal
have mild sensory changes in the axillary nerve distribution
Imaging
Radiographs
o recommended views
shoulder series (AP, lateral, axillary views)
o findings
usually normal
used to rule out pathologic entities
MRI
o indications
often used to rule out rotator cuff pathology
o findings
may show atrophy of teres minor (axillary innervation)
may show compression of the quadrilateral space
may show inferior paralabral cyst associated with labral tear
Arteriogram
o may shows lesion in posterior humeral circumflex artery
EMG
o indications
used to confirm diagnosis
o findings : will show axillary nerve involvement
Treatment
Nonoperative
o NSAIDS, activity restriction, physiotherapy
indications
first line of treatment
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OrthoBullets2017 Shoulder | Neurovascular Disorders
techniques
glenohumeral joint mobilization and strengthening
posterior capsule stretching
massage
outcomes
most people improve with 3-6 months of nonoperative treatment
o diagnostic lidocaine block
indications
will help to confirm diagnosis
technique
inject plain lidocaine directly into the quadrilateral space
starting point is 2 to 3 cm inferior to the standard posterior shoulder arthroscopy portal
outcomes
positive if no point tenderness or pain with full ROM of the shoulder following injection
Operative
o nerve decompression
indications
failure of nonoperative management
significant weakness and functional disability
decompression of space-occupying lesion
techniques
open release of quadrilateral space +/- arthroscopic repair of labral tear
Surgical Techniques
Open Quadrilateral Space Decompression
o approach
lateral decubitus position
3 - 4 cm incision over the quadrilateral space
identify posterior border of deltoid and reflect superolateral
expose fat in quadrilateral space between teres minor and teres major
o technique
identify the axillary nerve by using the humeral neck as reference
avoid cutting the posterior circumflex artery
free any fibrous lesions adhering to the nerve
ensure the nerve is completely free of compression by moving the arm into abduction and
external rotation
o postoperative care
immediate sling for comfort
early pendulum exercises to avoid new adhesions
progress to full active ROM with supervised physiotherapy
6. Scapulothoracic Dyskinesis
Introduction
Abnormal scapula motion leading to shoulder impingement and dysfunction
o cause are multifactorial including
neurologic injury
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By Dr, AbdulRahman AbdulNasser Shoulder | Neurovascular Disorders
pathologic thoracic spine kyphosis
periscapular muscle fatigue
poor throwing mechanics
secondary to pain (shoulder, neck)
Epidemiology
o demographics
seen in athletes
Pathoanatomy
o pathoanatomy
scapulothoracic power imbalance leads to protraction of scapula
leads to alteration of mechanics at glenohumeral joint
excessive stress placed on anterior capsule of shoulder and posterosuperior labrum
athletes have increased risk of injuring
labrum
rotator cuff
capsule
Anatomy
Scapulothoracic joint anatomy
Presentation
Symptoms
o shoulder pain and dysfunction worse with arm elevation
o loss of throwing velocity
Physical exam
o scapulothoracic crepitus
o affected scapula may be lower and protracted
o symptoms relieved with scapula stabilization
Imaging
Radiographs
o recommended views
complete shoulder series
o findings
usually unremarkable
Treatment
Nonoperative
o NSAIDs, PT, local injections
indications
main treatment
technique
physical therapy with emphasis on
core strengthening
scapular stabilizers, serratus anterior, trapezius
rotator cuff muscles
teaching proper core mechanics in throwers
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OrthoBullets2017 Shoulder | Muscle Ruptures
H. Muscle Ruptures
Anatomy
Pectoralis major
o innervation
by lateral and medial pectoral nerves
o two heads
clavicular head
sternocostal head
o one of four muscles connecting the upper limb to the thoracic wall
other muscles include
pectoralis minor
subclavius
serratus anterior
Biomechanics
o inferior fibers of sternal head at maximal stretch during final 30 degrees of humeral extension
position at which pectoralis major is most vulnerable to rupture (as with bench pressing)
Presentation
History
o patient may report a sharp tearing sensation with resisted adduction and internal rotation
Symptoms
o pain and weakness of shoulder
Physical exam
o swelling and ecchymosis
if localized to the anterior arm, then humeral attachment rupture is more likely than a
musculotendinous junction rupture
o palpable defect and deformity of the anterior axillary fold
o weakness with adduction and internal rotation
Imaging
Radiographs
o recommended views
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By Dr, AbdulRahman AbdulNasser Shoulder | Muscle Ruptures
standard shoulder trauma series (true AP, scapular Y, and axillary lateral)
o findings
often normal
MRI
o useful in identifying the site and extent of the rupture
may show avulsion of the pectoralis major tendon from the humerus
Treatment
Nonoperative
o initial sling immobilization, rest, ice, NSAIDs
indications
may be indicated for partial ruptures
tears in the muscle or musculotendinous junction
low-demand patients
Operative
o open exploration and repair of tendon avulsion
indications
tendon avulsion from the bone (will see ecchymosis down arm)
treatment of choice for high level athletes
outcomes
may show improvement regardless of location of tear
2. Deltoid rupture
Introduction
Deltoid ruptures are usually strains or partial tears
o complete ruptures are rare
Epidemiology
o incidence : rare
o risk factors
repeated corticosteroid injections about the shoulder
rotator cuff tear
trauma
Pathophysiology
o mechanism
secondary to repeated corticosteroid injections about the shoulder
massive rotator cuff tear
proximal migration of the humeral head leads to compression/abrasion of undersurface of
deltoid by greater tuberosity
iatrogenic injury
during open rotator cuff repair
trauma
sudden deltoid contracture
shoulder contusion
Associated conditions
I:36 depression over deltoid
o rotator cuff tear
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OrthoBullets2017 Shoulder | Muscle Ruptures
Anatomy
Deltoid anatomy
Presentation
Symptoms
o shoulder pain
Physical exam
o inspection
depression over deltoid
soft tissue mass distal to depression (contracted muscle)
Imaging
Radiographs
o recommended views
shoulder radiographs
o findings
associated with cuff tear arthropathy
proximal humeral head migration
Ultrasound
o indications
noninvasive method of detection
o findings
shows deltoid gap with intact surrounding fibers
MRI
o indications
differentiate partial vs complete deltoid tears
associated rotator cuff pathology
o findings
deltoid defect
associated rotator cuff tear
Ultrasound MRI
Treatment
Nonoperative
o observation only
indications
chronic injuries in elderly patients
Operative
o early surgical repair
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By Dr, AbdulRahman AbdulNasser Shoulder | Muscle Ruptures
indications
complete rupture
o deltoplasty with mobilization and anterior transfer of the middle third of the deltoid
indications
iatragenic injury during rotator cuff repair
Anatomy
Latissimus dorsi muscle
Presentation
Physical exam
o local tenderness and deformity over latissimus dorsi muscles
o pain with shoulder adduction and internal rotation
Imaging
MRI
o shows increased T2 signal and retraction of latissimus dorsi muscle
Treatment
Nonoperative
o short period of rest followed by PT
indications
allow resumption of activities in low demand patients
technique
physical therapy goals are to restore shoulder motion and strength
throwing can be allowed
after full, pain-free motion and good strength
balance of the rotator cuff and scapular rotator muscles
Operative
o primary repair vs reconstruction
indications
for high demand athletes (currently there are no defined indications for surgical repair)
technique
early primary repair is favored to prevent retraction and scarring
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OrthoBullets2017 Shoulder | Shoulder Procedures
I. Shoulder Procedures
1. Shoulder Hemiarthroplasty
Introduction
Humeral articular surface replaced with stemmed humeral component coupled with either
o standard humeral head
o extended-coverage head
Indications
Indications
o primary arthritis, if:
rotator cuff is deficient
glenoid bone stock is inadequate
risk of glenoid loosening is high
young patients
active laborers
o rotator cuff arthropathy
hemiarthroplasty > rTSA if able to achieve forward flexion > 90 degrees
o osteonecrosis without glenoid involvement
o proximal humerus fractures
three-part fractures with poor bone quality
four-part fractures
head-splitting fractures
fracture with significant destruction of the articular surface
Contraindications
o infection
o neuropathic joint
o unmotivated patient
o coracoacromial ligament deficiency
provides a barrier to humeral head proximal migration in the case of a rotator cuff tear
superior escape will occur if coracoacromial ligament and rotator cuff are deficient
Outcomes
Rotator cuff deficiency
o status of the rotator cuff is the most influential factor affecting postoperative function in shoulder
hemiarthroplasty
Proximal humerus fractures
o provides excellent pain relief in a majority of patients
o outcome scores inversely proportional to
patient age
time from injury to operation
Preoperative Imaging
I:37 Chest AP & true shoulder AP
Radiographs
o true (Grashey) AP of shoulder
taken 30-40 degrees oblique to the coronal plane of the body
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By Dr, AbdulRahman AbdulNasser Shoulder | Shoulder Procedures
findings
helps determine extent of DJD
delineation of fracture pattern
o axillary view
findings
look for posterior wear of glenoid
helps quantify displacement in cases of fracture
CT scan
o obtain CT scan to determine glenoid version and glenoid bone stock
o useful if fracture pattern is poorly understood after radiographic evaluation
MRI
o useful for evaluation of rotator cuff
Surgical Techniques
Approach
o deltopectoral approach
Shaft preparation and prosthesis placement
o humeral head resection
start osteotomy at medial insertion line of supraspinatus
o determine retroversion, implant height and head size
retroversion
30° of retroversion is ideal
lateral fin should be slightly posterior to biceps groove I:38 Axillary view: posterior
excessive anteversion leads to risk of anterior dislocation wear of glenoid
excessive retroversion leads to risk of posterior dislocation
implant height
greater tuberosity should be
5 to 8 mm below the top of the prosthetic humeral head
functions to
maintain cuff and biceps tension
recreate normal contour of medial calcar
technique to achieve
cement prosthesis proud
distance from top of prosthesis head to upper border of pectoralis major should
be 56mm.
head size
determine size by using
radiograph of contralateral shoulder or
measuring size of native head removed earlier in procedure
using too large of a head may "overstuff" joint
Fixation
o cemented prosthesis
standard of care
provides better quality of life, range of motion, and strength compared to uncemented
humeral component
Tuberosity reduction
o introduction
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tuberosity migration is one of the most common causes of failure for fractures treated with
hemiarthroplasty
o technique
strict attention to securing the tuberosities to each other and to the shaft
autogenous bone grafting from the excised humeral head will decrease the incidence of pull-
off and improve healing rates
tuberosity reduction must be anatomic or it may lead to a deficit in rotation
Rehab
Early passive motion until fracture has healed
o duration usually 6-8 weeks
Strengthening exercises begin once tuberosity has fully healed
Complications
Progressive glenoid arthrosis
o increased risk with
young patients
active patient
o treatment I:39 anterosuperior escape
Classification
Walch Classification of Glenoid Wear
Type A well-centered
A1 minor erosion
A2 deeper central erosion
Type B head subluxated posteriorly
B1 posterior wear
B2 severe biconcave wear
Type C glenoid retroversion of more than 25 degrees (dysplastic in origin)
Indications
Indications
o pain (anterior to posterior), especially at night, and inability to perform activities of daily living
o glenoid chondral wear to bone
preferred over hemiarthroplasty for osteoarthritis and inflammatory arthritis
o posterior humeral head subluxation
Contraindications
o insufficient glenoid bone stock
o rotator cuff arthropathy
o deltoid dysfunction
o irreparable rotator cuff (hemiarthroplasty or reverse total shoulder are preferable)
risk of loosening of the glenoid prosthesis is high ("rocking horse" phenomenon)
o active infection
o brachial plexus palsy
Preoperative Imaging
Radiographs
o true AP
determine extent of arthritis and look for superior migration of humerus
o axillary view
look for posterior wear of glenoid
CT scan : obtain CT scan to determine glenoid version and glenoid bone stock
MRI : evaluate rotator cuff condition
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Approach
Deltopectoral
o detach the subscapularis and capsule from anterior humerus
o dislocate shoulder anteriorly
o tight shoulders may require release of the upper half of the pectoralis tendon to increase exposure
and dislocation
pectoralis major tendon passes on top of the biceps tendon to attach to the humerus
Complications
o axillary nerve damage is the most common complication
axillary nerve and posterior humeral circumflex artery pass beneath the glenohumeral joint in
the quadrilateral space
Technical considerations
Capsule
o anterior capsule contracture (passive ER < 40°)
treatment
anterior release and Z-lengthening
o posterior capsule stretching
treatment
volume-reducing procedure (plication of posterior capsule)
Glenoid deficiency and retroversion
o glenoid deficiency
treatment
build up with iliac crest autograft or part of the resected humerus
do not use cement to build up the deficiency
o retroverted glenoid
treatment
build up posterior glenoid with allograft
eccentrically ream anterior glenoid
Glenoid component
o convex superior to flat
o recreate neutral version
o peg design is biomechanically superior to keel design
o polyethylene-backed components superior to metal-backed components
glenoid not large enough to accommodate both metal and PE
o uncemented glenoid has a lower rate of loosening
o conforming vs. nonconforming
both have advantages and neither is superior
conforming is more stable but leads to rim stress and radiolucencies
nonconforming leads to increased polyethylene wear
Humeral stem fixation
o cemented stem or uncemented porous-coated implants
o position of humeral stem should be 25-45° of retroversion
if position of glenoid retroversion is required, then the humeral stem should be less
retroverted to avoid posterior dislocation
o avoid valgus positioning of humeral stem
o avoid overstuffing the humeral head
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increases joint reaction forces and tension on the rotator cuff
the top of the humeral head should be 5 to 8 mm superior to the top of the greater tuberosity
o intraoperative humerus fracture
greater tuberosity fracture
treatment
if minimally displaced, insert a standard humeral prosthesis with suture fixation and
autogenous cancellous bone grafting of the greater tuberosity fracture
humeral shaft fracture
treatment
remove prosthesis and add longer stem with cement and reinforce with cerclage
wiring
Rehabilitation
Passive or active-assisted motion only during early rehab
o limiting factor in early postoperative rehabilitation is risk of injury to the subscapularis tendon
repair
Progress to ER isometrics
Limit passive external rotation
o risk of tear and pull-off of subscapularis tendon from anterior humerus
tear leads to anterior shoulder instability (most common form of instability after TSA)
treatment of subscapularis pull-off is early exploration and repair of tendon
test for pull-off of subscapularis
weak belly-press test
inability to put hand in back pants pockets or tuck shirt behind the back
avoid pushing out of chair during acute rehab
IR eccentric and isometric
Complications
Glenoid loosening
o most common cause of TSA failure (30% of primary OA revisions)
o risk factors
insufficient glenoid bone stock
rotator cuff deficiency
o 2.9% reoperation rate for loosening (28% with revision)
o radiographic lines
presence of radiographic lines does not correlate with symptoms
progression of a radiographic line does correlate with symptoms
progression present in 50% of patients as early as 3 to 4 years after TSA
radiolucency around the glenoid does not always correlate with clinical failure
at 3- and 7-year follow-up did not correlate with poor functional outcomes or pain
Humeral stem loosening
o more common in RA and osteonecrosis
o rule out infection
Subscapularis repair failure
Malposition of components
Improper soft tissue balancing
o failure due to undiagnosed presence of rotator cuff tears
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Iatrogenic rotator cuff injury
o can occur if humeral neck osteotomy is inferior to level of rotator cuff insertion
Stiffness
Infection
o may have normal aspiration results
o culture
arthroscopic tissue culture more sensitive (100% sensitive and specific) than fluoroscopically
guided aspiration (17% sensitivity, 100% specific)
o Propionibacterium acnes (P. acnes)
most common cause of indolent infections and implant failures
infection rate 1-2% after primary TSA
characteristics
gram positive, facultative, aerotolerant, anaerobic rod that ferments lactose to propionic
acid
has high bacterial burden around the shoulder
forms biofilm within 18-90h (found on implant surface and on synovial tissue) >>
planktonic (explains why aspiration is only 17% sensitive)
P. acnes PJI more common in males
presentation
initial pain & stiffness
later swelling & redness
diagnosis
use anaerobic culture bottles, keep for 10-14days (mean time to detection 6 days)
16s rRNA PCR
imaging (XR, CT, ultrasound) positive for subluxation/loosening in 24% of cases
if implant is removed, sonicate implant (to dislodge bacteria from surface) for sonication
culture
treatment
early infection (<6 weeks) can be treated with open irrigation and debridement
late infection (>6 weeks) should be treated by explant and 2-stage reimplantation after IV
antibiotic (penicillin G, ceftriaxone, clindamycin, vanco) x 6wk, followed by 2-6mths of
PO antibiotic
Neurologic injury
o axillary nerve is most commonly injured
o musculocutaneous nerve can be injured by retractor placement under conjoint tendon
Periprosthetic fracture
o acceptable fragment alignment ≤ 20° flexion/extension, ≤ 30° varus/valgus, ≤ 20° rotation
malalignment
o see table next page
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Indications
Indications
o clinical conditions
CTA
pseudoparalysis
an inability to actively elevate the arm in the presence of free passive ROM and in the
absence of a neurologic lesion
occurs secondary to irreparable rotator cuff tear in setting of glenohumeral arthritis
antero-superior escape
incompetent coracoacromial arch
humeral "escape" in subcutaneous tissue with hemiarthroplasty
acute 3 or 4-part proximal humerus fractures in the elderly
where GT has poor potential for healing and bone quality is poor for primary repair
rotator cuff insufficiency 'equvialent'
non-union or mal-union of the tuberosity following trauma or prior arthroplasty
failed arthroplasty
when all other options have been exhausted
rheumatoid arthritis
only if glenoid bone stock is sufficient
o patient characteristics (in clinical conditions above)
low functional demand patients
physiological age >70
sufficient glenoid bone stock
working deltoid muscle
intact axillary nerve
Contraindications
o deltoid deficiency (axillary nerve palsy)
I:40 Antero-superior escape
o bony acromion deficiency
o glenoid osteoporosis
o active infection
Biomechanics
Biomechanics
o the advantage of a reverse shoulder arthroplasty is that the center of rotation (COR) is moved
inferiorly and medialized
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By Dr, AbdulRahman AbdulNasser Shoulder | Shoulder Procedures
allows the deltoid muscle to act on a longer fulcrum and have more mechanical advantage to
substitute for the deficient rotator cuff muscles to provide shoulder abduction
allows increased (but not normal) shoulder abduction
does not significantly help shoulder internal or external rotation
o reverse shoulder arthroplasty can be combined with latissimus dorsi transfer to assist with
external rotation
Surgical Technique
Approaches
o superolateral
lower incidence of postoperative instability
lower risk of intraoperative scapular spine and acromion fractures
o deltopectoral
better preservation of active external rotation
better orientation of glenoid component
decreased risk of glenoid loosening and scapular notching
often used for revision surgery
Technique
o humeral preparation
humeral head typically osteotomized anywhere between 0 and 30 degrees of retroversion
more retroversion is gaining popularity as it may improve post-op external rotation
long head of biceps is tenotomized
ream and broach humerus similar to conventional TSA
o glenoid preparation
labrum is excised and capsule is released circumferentially
accurate central guidewire placement is dictated by availability of the best bone stock for
baseplate screw fixation
place baseplate as inferiorly as possible with an inferior tilt
shown to decrease implant loosening and scapular notching
mount glenosphere onto baseplate
Postoperative Care
o patient placed in sling post-op
may allow use of arm for light ADLs (brushing teeth and eating)
sling discontinued at 3 weeks if subscapularis is NOT repaired, and 6 weeks if subscapularis
is repaired
Outcomes
There are no high quality long-term outcome studies present in literature
Results are dependent on indication, with cuff tear arthropathy (CTA) having the best results
Some cases series' have noted 10 year survivability is approximately 90% for implant retention
Radiographic results deteriorate after 6 years and clinical results after 8 years
Complications
Scapular notching
o common
o related to impingement by the medial rim of the humeral cup during adduction
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o increased risk with superiorly placed glenoid component, or insufficient inferior tilt of glenoid
component on the native glenoid
Dislocation
o reported rate between 2% - 3.4%
o usually anterior instability
o increased risk with
irreparable subscapularis (strongest risk)
proximal humeral bone loss
failed prior arthroplasty
proximal humeral nonunion
fixed glenohumeral dislocation preop
NOT related to condition of rotator cuff I:41 Scapular notching
Glenoid Loosening
o glenoid prosthetic loosening is most common mechanism of failure
o treat using staged procedure to fill glenoid cavity with autogenous bone and await incorporation
with a hemiarthroplasty prior to reimplantation of a new glenosphere
Deep Infection
o susceptible to infection due to large subacromial dead space created by reverse prosthesis
o most common organisms include propionibacterium acnes and staphylococci
Acromion and Scapular Spine Fractures
Neurapraxia
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By Dr, AbdulRahman AbdulNasser Shoulder | Shoulder Procedures
4. Biologic Resurfacing
Prosthetic Resurfacing
Definition
o humeral head arthroplasty with a non-stemmed, metal prosthesis
o may or may not be mated with glenoid prosthesis or biologic resurfacing
Advantages over conventional stemmed prosthesis
o no osteotomy is needed
no change in anatomic offset or version
improved restoration of normal biomechanics
o minimal bone resection
o shorter operative time
o low prevalence of humeral periprosthetic fracture
o easy revision to conventional arthroplasty if needed
Indications
o cases in which the humerus anatomy is abnormal, causing:
difficulty with dislocation
difficulty with stem insertion
o examples
humeral dysplasia
developmental
secondary
Apert's disease
epiphyseal dysplasias
chronic Erb's palsy
prior humerus fracture
proximal, metaphyseal, or diaphyseal malunion
hardware in place which blocks stem implantation
Outcomes
o has demonstrated success in pain relief
o does not reliably improve motion
o at one year, considered inferior to outcomes of traditional stemmed prostheses
Complications
o implant loosening is most common
Biologic Resurfacing
Also known as interpositonal allografting
Concept of putting soft tissue in glenoid to reduce symptoms and obviate need for TSA
Frequently combined with hemiarthroplasty of the humerus or humeral prosthetic resurfacing
Indications
o young patients
o rotator cuff arthropathy
o GH narrowing following hemiarthroplasty
o GH arthritis following arthroscopic stabilization procedures
Interpositional allografts include
o fascia lata
o meniscal allograft
o achilles allograft
o acellular dermal matrix
Outcomes
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o short-term outcomes (2-year)
improvement:
VAS pain score
ASES score
questionable improvement:
active forward elevation
active external rotation
active internal rotation
o long-term outcomes : the rate of failure by 36-months has been reported at 44%
Complications
o difficulty converting to TSA due to scarring within the glenohumeral joint
5. Shoulder Arthrodesis
Introduction
The goal of shoulder arthrodesis is to provide a stable base for the upper extremity optimizing hand
and elbow function
o it remains an important treatment option in appropriately selected patients
Indications
o stabilization of paralytic disorders
o brachial plexus palsy
o irreparable deltoid and rotator cuff deficiency with arthropathy
o salvage of a failed total shoulder arthroplasty
o reconstruction after tumor resection
o painful ankylosis after chronic infection
o recurrent shoulder instability which has failed previous repair attempts
o paralytic disorders in infancy
Contraindications
o ipsilateral elbow arthrodesis
o contralateral shoulder arthrodesis
o lack of functional scapulothoracic motion
o trapezius, levator scapulae, or serratus anterior paralysis
o Charcot arthropathy during acute inflammatory stage (Eichenholtz 0-2)
o elderly patients
o progressive neurologic disease
Anatomy
Glenohumeral articulation
o a relatively small amount of surface area exists allowing for predictable fusion
o to increase the available fusion area, decortication of both the glenohumeral articular surface and
the articulation between the humeral head and the undersurface of the acromion is performed
o only the glenoid fossa and base of the coracoid provide sufficient strength for fixation
Presentation
Symptoms
o specific to the underlying condition necessitating arthrodesis
o symptomatic dysfunction of the glenohumeral joint
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By Dr, AbdulRahman AbdulNasser Shoulder | Shoulder Procedures
Imaging
Radiographs
o recommended views
AP, lateral, and axillary views to assess bone stock available for fusion and deformities
CT
o better to evaluate glenoid bone loss especially in the setting of failed arthroplasty
Studies
EMG
o indicated when the neurologic condition of the scapular muscles is ill-defined
Surgical Technique
Approach
o S-shaped skin incision beginning over the scapular spine, traversing anteriorly over the
acromion, and extending down the anterolateral aspect of the
arm
Fusion position
o goal is to allow patients to reach their mouths for feeding
think "30°-30°-30°"
20°-30° of abduction
20°-30° of forward flexion
20°-30° of internal rotation
Technique
o rotator cuff is resected from the proximal humerus and the
biceps tendon is tenodesed
o glenoid and humeral head articular surfaces and the undersurface of the acromion are
decorticated
o arm is placed into the position of fusion (30°-30°-30°)
o a 10-hole, 4.5 mm pelvic reconstruction plate is contoured along the spine of the scapula, over
the acromion, and down the shaft of the humerus
o compression screws are placed through the plate across the glenohumeral articular surface into
the glenoid fossa
o the plate is anchored to the scapular spine with a screw into the base of the coracoid
Postoperative care
o a thermoplastic orthosis is applied the day after surgery and is maintained for 6 weeks
o at 6 weeks, may transition to a sling if there are no radiographic signs of loosening
o at 3 months, mobilization exercises and thoracoscapular strengthening are commenced if no
radiographic signs of loosening are present
o expected recovery period is 6-12 months
Complications
Infection
Nonunion Collected By : Dr AbdulRahman
Malposition AbdulNasser
Prominent hardware [email protected]
Humeral shaft fracture In June 2017
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ORTHO BULLETS
II. Elbow
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By Dr, AbdulRahman AbdulNasser Elbow | Anatomy & Evaluation
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OrthoBullets2017 Elbow | Anatomy & Evaluation
the attachment of the brachialis 11 mm distal to the tip of the coronoid
the distal biceps attachment is at the level of the radial tuberosity
Extension
o triceps
Stability of Elbow
Static and dynamic stabilizers confer stability to the elbow
o static stabilizers (primary)
ulnohumeral joint (coronoid)
loss of 50% or more of coronoid height results in elbow instability
anterior bundle of the MCL
the MCL is composed of the anterior, posterior and transverse bundles
the MCL provides resistance to valgus and distractive stresses
anterior oblique fibers (of the anterior bundle)
these are the most important against valgus stresses
the posterior bundle forms the floor of the cubital tunnel
if this is contracted, flexion may be limited
in complex instability, repair/reconstruction of the MCL may be unnecessary because of
the secondary function of the radial head as a valgus stabilizer (especially if coronoid has
been repaired or is grossly intact)
LCL complex (includes the LUCL)
lateral ulnar collateral ligament
radial collateral ligament
annular ligament
provides stability to the proximal radioulnar joint
accessory collateral ligament
some believe that the the accessory collateral ligament and the radial collateral
ligament contribute substantially to lateral elbow stability
the LCL arises from isometric point on lateral aspect of capitellum
optimal stability is conferred with an appropriately tensioned LCL repair
o static stabilizers (secondary)
radiocapitellar joint
this functions as an important constraint to valgus stress
the radial head provides approximately 30% of valgus stability
this is most important at 0-30 deg of flexion/pronation
capsule
greatest contribution the capsule on stability occurs with the elbow extended
origins of the flexor and extensor tendons
o dynamic stabilizers
includes muscles crossing elbow joint
anconeus
brachialis
triceps
they provide compressive stability
o secondary varus stability
LCL, anconeus, and lateral capsule
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By Dr, AbdulRahman AbdulNasser Elbow | Anatomy & Evaluation
Nerve of the Elbow
4 major nerves
musculocutaneous nerve (lateral cord of the brachial plexus)
o innervates elbow joint
o it supplies the biceps and brachialis
the nerve runs between these muscles
it exits laterally, distal to the biceps tendon
it will terminate as the LABC (forearm), which is found deep to the cephalic vein
radial nerve (posterior cord of the brachial plexus )
o it leaves the triangular interval (teres major, long head of triceps and humeral shaft)
o found in spiral groove 13 cm above the trochlea
o pierces lateral intermuscular septum 7.5 cm above the trochlea
this is usually at the junction of the middle and distal third of the humerus
lies between the brachialis and the brachioradialis
o distally it is located superficial to the joint capsule, at the level of the radiocapitellar joint
median nerve (medial/lateral cords of the brachial plexus)
o it courses with brachial artery, running from lateral to medial
lies superficial to brachialis muscle at level of elbow joint
o it gives branches to elbow joint
o it has no branches in upper arm
ulnar nerve (medial cord)
o runs medial to brachial artery, pierces medial intermuscular septum (at the level of the arcade of
Struthers) and enters posterior compartment
o it traverses posterior to the medial epicondyle through the cubital tunnel
o it gives branches to elbow joint
o it has no branches in upper arm
first motor branch to FCU is found distal to the elbow joint
Kinematics
Functional ROM
o 30° to 130 flexion
total ROM is 0-150 degrees
o 50° supination
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o 50° pronation
Motion vectors
o flexion & extension
the axis of rotation is found at the center of trochlea
o pronation (pronator teres and quadratus) & supination (biceps and supinator)
the axis of motion is found at the capitellum through to the radial/ulnar heads
this effectively forms a cone
Joint reaction force
o there are large joint reaction forces due to short and inefficient lever arms around elbow (biceps
inserts not far from center of rotation)
o this contributes to degenerative changes of the elbow
Center of rotation
o is a line through isometric points on the capitellum about trochlea
o the axis of pronation / supination is a line drawn from capitellum, through radial head, to distal
ulna
Valgus alignment
o normal valgus carrying angle
7° for males
13° for females
this diminishes with flexion
Axial loading
o in extended elbow
40% of weight is through ulnohumeral joint
60% of weight is through radiohumeral joint
Arthrodesis
Optimal position
o in a unilateral arthrodesis
90° of flexion
0-7° of valgus
o in a bilateral arthrodesis
one elbow in 110 ° of flexion for feeding
one elbow in 65 ° of flexion for perineal hygiene
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By Dr, AbdulRahman AbdulNasser Elbow | Instability & Throwing Injuries
Anatomy
Medial collateral ligament (MCL)
o MCL is also called ulnar collateral ligament (UCL)
o MCL divided into three components
anterior oblique
strongest and most significant stabilizer to valgus stress
courses from medial epicondyle to the sublime tubercle
nearly isometric
anterior and posterior bands give reciprocal function throughout elbow range of motion
posterior band is tight in flexion and anterior band is tight in extension
posterior oblique
demonstrates the greatest change in tension from flexion to extension
tighter in flexion
transverse ligament : no contribution to stability
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Presentation
History
o acutely injuries may present with a "pop" associated with pain and difficulty throwing
Symptoms
o decreased throwing performance
loss of velocity
loss of control (accuracy)
o pain
medial or posterior elbow pain during late cocking and acceleration phases of throwing
many throwers also have posteromedial pain due to valgus extension overload felt during the
deceleration phase
o ulnar nerve symptoms
paresthesias down ulnar arm into ring and small fingers
Physical examination
o inspection
tenderness along elbow at or near MCL origin
posteromedial tenderness may be due to valgus extension overload
evaluate the integrity of the flexor-pronator mass
evaluate for cubital tunnel symptoms
o provocative tests
valgus stress test
flex elbow to 20 to 30 degrees (unlocks the olecranon), externally rotate the humerus, and
apply valgus stress
50% sensitive
milking maneuver
create a valgus stress by pulling on the patient's thumb with the forearm supinated and
elbow flexed at 90 degrees
positive test is a subjective apprehension, instability, or pain at the MCL origin
moving valgus stress test
place elbow in same position as the "milking maneuver" and apply a valgus stress while
the elbow is ranged through the full arc of flexion and extension
positive test is a subjective apprehension, instability, or pain at the MCL origin between
70 and 120 degrees
100% sensitive and 75% specific
Imaging
Radiographs
o recommended views
AP and lateral of the elbow
static x-rays are often normal
may show loose bodies
o optional views
oblique views to evaluate the olecranon
gravity stress : may show medial joint-line opening >3 mm (diagnostic)
o findings
assess for a posteromedial osteophyte (due to valgus extension overload)
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By Dr, AbdulRahman AbdulNasser Elbow | Instability & Throwing Injuries
MRI
o views
UCL pathology best seen on coronal T2-image
o findings
conventional MRI may identify a thickened ligament (chronic injury), calcifications, and
tears
o MR-arthrogram - diagnostic
can diagnosis full-thickness and partial undersurface tears
look for capsular "T-sign" with contrast extravasation
Dynamic ultrasound
o can evaluate laxity with valgus stress dynamically
o operator dependent
Differential
Varus Posteromedial Rotatory Instability Valgus Posterolateral Rotatory
(VPMRI) Instabiliy (VPLRI)
Radial head No radial head fracture Radial head fracture
Coronoid fracture >15% (anteromedial facet) <15% (tip fracture)
Posterior band of MCL ruptured, anterior
MCL Anterior band of MCL ruptured
band intact
LCL LCL complex (includes LUCL) avulsion LCL complex (includes LUCL) avulsion
Valgus stress, moving valgus, milking
Physical exam Varus stress, chair rise, lateral pivot shift
maneuver
Treatment
Nonoperative
o rest and physical therapy
indications : first line treatment in most cases
technique
6 weeks of rest from throwing
initial physical therapy for flexor-pronator strengthening and improving throwing
mechanics (after 6 weeks and symptoms have resolved)
progressive throwing program
outcomes
42% return to preinjury level of sporting activity at an average of 24 weeks
Operative
o MCL anterior band ligament reconstruction (Tommy John Surgery)
indications
high-level throwers that want to continue competitive sports
failed nonoperative management in patients willing to undergo extensive rehabilitation
technique (see below)
reconstruction is favored over direct repair
outcomes
90% return to preinjury levels of throwing
humeral docking associated with better patient outcomes and lower complication rate
compared to figure-of-8 fixation
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humeral docking and cortical button techniques are biomechanically stronger than figure-
of-8 and interference screw fixation
none of the reconstructive methods are stronger than native ligament
humeral docking with interference screw fixation of the ulnar side showed strength of
95% of the native MCL
Surgical Techniques
MCL anterior band ligament reconstruction
o approach
muscle-splitting approach (decreases morbidity to flexor-pronator mass)
in-situ ulnar nerve decompression
transposition reserved for patients with preoperative ulnar nerve symptoms, subluxating
ulnar nerve and patients with ulnar nerve motor weakness
o reconstruction
most techniques performed using autograft (palmaris longus, gracilis); allograft is also used
modified Jobe technique
figure-of-eight reconstruction (palmaris longus tendon commonly used)
graft passed through two tunnels in medial epicondyle of humerus and single tunnel in
ulnar sublime tubercle
graft sutured to itself in figure-of-8 configuration
docking technique
graft limbs are tensioned through single humeral docking tunnel
suture limbs passed through two bone punctures and sutured over bony bridge on medial
epicondyle
hybrid interference-screw technique
interference-screw fixation into the ulna
docking fixation on the humerus
Cortical suspensory fixation, ex. "Endo-button" (Smith & Nephew) reconstruction
stabilize the graft with an endobutton through the ulna
o postoperative care
early
early active wrist, elbow, and shoulder range of motion
strengthening exercises beginning four to six weeks post-op
mid-term
initiate a progressive throwing program at four months
avoid valgus stress until 4 months post-op
return to competitive throwing at 9-12 months post-op
Complications
Ulnar nerve injury
Medial antebrachial cutaneous (MABC) nerve injury
o nerve is present at distal aspect of the incision
Fracture of ulna or medial epicondyle
Elbow stiffness
Inability to regain preinjury level throwing ability
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By Dr, AbdulRahman AbdulNasser Elbow | Instability & Throwing Injuries
Presentation
Symptoms
o pain in posteromedial elbow with full extension of elbow
pain typically occurs in deceleration phase of pitch (sometimes during acceleration phase)
loss of terminal elbow extension
Physical exam
o tender to palpation over posteromedial olecranon
o crepitus
o pain with forced elbow extension
o flexion contracture
Imaging
Radiographs
o recommended views
AP, lateral, oblique of elbow II:1 osteophyte formation in
o findings posteromedial olecranon fossa
Treatment
Nonoperative
o NSAIDS, throwing rest, activity modification, steroid injections
indications : first line of treatment
technique
flexor-pronator strengthening
pitching instructions to correct poor technique
Operative
o resection of posteromedial osteophytes, removal of loose bodies, debridement of
chondromalacia
indications
persistent symptoms that fail to improve with nonoperative treatment
contraindications
MCL insufficiency is a relative contraindication for olecranon debridement alone
technique
may be arthroscopic or open
arthroscopy procedures can include debridement or drilling of chondromalacia,
debridement of lateral meniscoid lesion or posterolateral plica, osteophyte excision, loose
body excision
care must be taken to only remove osteophytes and not normal olecranon as this many
result in a loss of bony restraint and increase the tension in the MCL
Complications
Valgus instability
o resection of too much olecranon may cause valgus instability
Ulnar nerve damage
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By Dr, AbdulRahman AbdulNasser Elbow | Instability & Throwing Injuries
Risk factors
o Greater than 80 pitches per game
o More than 8 months of competitive pitching per year
o Fastball speed > 85mph
o Continued pitching despite arm fatigue/pain
o Participating in showcases
Presentation
Symptoms
o elbow pain in throwing arm
o decreased throwing speed, accuracy, and distance
Physical exam II:2 xray: widening of medial
o tenderness to palpation about medial elbow epicondyle physis
o pain with valgus stress
o instability with valgus stress notes more severe involvement
should be checked in varying degrees of elbow flexion to extension
Imaging
Radiographs
o recommended views
AP/lateral elbow
o findings
may show physeal widening
may show fragmentation or avulsion of the medial epicondyle
MRI
o will show increased edema of the medial epicondyle apophysis
o can be used to confirm UCL insufficiency
Treatment
Nonoperative
o rest, activity modifications, PT
indication
is the mainstay of treatment
technique
coach and parent education is critical to limit number of innings pitched per week
use minimal immobilization to maintain elbow ROM
Operative
o ORIF of medial epicondyle
indication
for medial epicondyle avulsion fractures
o UCL reconstruction
indication
for UCL disruption and insufficiency
Technique
Pediatric UCL reconstruction
o similar to adult treatment
o commonly using palmaris longus autograft
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OrthoBullets2017 Elbow | Instability & Throwing Injuries
Complications
Ulnar nerve neuropathy
Continued pain and instability
Loss of motion
Inability to return to same level of play
Presentation
Symptoms
o posteromedial olecranon pain of the throwing arm
improves with rest
worse with throwing movements
Physical exam II:3 lateral radiograph
o inspection
mild swelling over olecranon
localized tenderness
o motion
valgus instability stress test
may indicate associated UCL injury
Imaging
Radiographs
o recommended views
AP, lateral, oblique views of elbow
o optional views
valgus stress views
contralateral elbow for comparison
II:4 CT
o findings
physeal widening, delayed fusion, or fragmentation
widening of the medial joint space with UCL injuries
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By Dr, AbdulRahman AbdulNasser Elbow | Instability & Throwing Injuries
CT
o views: best seen on lateral views
o findings
typical fracture pattern
originates from the articular surface
runs toward the dorsal-proximal direction
MRI
o indications
suspected UCL tear
o views
coronal T2 fat-saturated views
o findings
T-sign indicative of UCL tears
Treatment
Nonoperative II:5 MRI : T-sign
o short-term administration of NSAIDS, rest +/- temporary splinting
indications : first-line treatment
modalities
initial 4-6 weeks of rest or splinting
progressive ROM exercises
avoiding valgus loading forces (e.g. throwing)
electrical bone stimulation may also be considered
Operative
o open internal fixation
indications : delayed fracture union
modalities
large compression screw
tension band wire
Anatomy
Lateral collateral ligament complex consists of 4 components
o accessory lateral collateral ligament
o annular ligament
o lateral radial collateral ligament (LCL)
o lateral ulnar collateral ligament (LUCL)
LUCL is the primary stabilizer to varus & ER stress
origin
lateral humeral epicondyle
insertion
the tubercle of the supinator crest of the ulna
Presentation
Symptoms
o pain is the primary symptom
o mechanical symptoms (clicking, catching, etc.)
often with elbow extension and when pushing off from arm of chair
Physical exam
o inspection and palpation
tenderness over LUCL
o motion and stability
varus instability
o provocative tests
lateral pivot-shift test
patient lies supine with affected arm overhead; forearm is supinated and valgus stress is
applied while bringing the elbow from full extension to 40 degrees of flexion
with increased flexion, triceps tension reduces the radial head
often more reliable on anesthetized patient
posterior drawer test
patient lies supine with affected arm overhead; forearm is supinated and the examiner's
index finger is placed under the radial head and the thumb over it.
application of a posterior force will cause posterior subluxation of the radial head
apprehension test
patient lies supine with affected arm extended overhead; forearm is supinated and valgus
stress is applied while flexing the elbow
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By Dr, AbdulRahman AbdulNasser Elbow | Instability & Throwing Injuries
chair rise test
table-top relocation test
floor push-up test
patient cannot do push-ups with forearm supinated
Imaging
Radiographs
o recommended views : AP and lateral views of elbow
o findings
important to rule out associated fractures and confirm concentric
reduction in setting of acute dislocation
standard radiographs are often of little value in evaluating PLRI
fluoroscopic imaging during provocative testing (e.g. pivot-shift) may demonstrate radial
head subluxation
MRI
o indications
may not be helpful in the setting of recurrent instability and LUCL attenuation as visualizing
ligament difficult due to oblique course
o findings
can identify acute avulsion of LUCL in acute instability
o sensitivity and specificity
LUCL pathology identifed in 50% of patients
Treatment
Nonoperative
o acute reduction followed by immobilization at 90° flexion for 5-7 days
indications
acute elbow dislocations
technique
following reduction assess post-reduction stability
place in posterior splint for 5-7 days, with elbow at 90 degrees of flexion and forearm
appropriately positioned based on post-reduction stability
LCL disrupted, but MCL intact
splint in full pronation (tightens lateral structures)
LCL + MCL disrupted
splint in neutral
will not splint in full supination (for MCL rupture only) as the LCL is always
disrupted in PLRI
early active ROM following splint removal (+/- extension block)
full supination/pronation from 90° to full flexion
progress with increasing extension by 30° weekly, but with the forearm in full
pronation; after 6 weeks full supination in extension allowed
o bracing, extensor strengthening, activity modification w/ avoidance of gravity varus
positions
indications
mild, chronic PLRI
low-demand patients
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OrthoBullets2017 Elbow | Instability & Throwing Injuries
Operative
o open reduction, fracture fixation, LUCL repair
indications
osteochondral fragment or soft-tissue entrapment prevents concentric reduction
complex dislocation (associated fractures are present)
acute instability
open & arthroscopic techniques described
o LUCL reconstruction w/ graft
indications : chronic PLRI
Techniques
Reconstruction of LUCL complex
o approach
posterior mid-line
Kocher approach
o graft types
II:6 docked technique
autograft or allograft tissue may be used
palmaris longus most common
gracilis and triceps fascia also utilized
o graft configuation
tendon graft tied to itself over lateral column after placing through tunnel in supinator crest &
then weaving through "Y" tunnel configuration in humerus
it is critical that the graft covers > posterior 25% of the radial head to create a sling
graft can be plicated to capsule to maintain position and capsule plicated to augment repair
graft secured with arm in neutral rotation and 45° of flexion
o graft fixation
graft may be "docked" on humerus with sutures exiting "Y" tunnels or on both humeral and
ulnar sides with interference screws (or sutures tied over bone - overlay technique)
o coronoid fracture ORIF / anterior capsular laxity
large fragments should be fixed with screw from dorsal ulnar surface (aided by ACL type
guide to improve accuracy
small fragments should be excised but a suture plication of the
anterior capsule to the broken tip increases stability and can be
placed with the aid of ACL type guide (Fig II:7)
o postoperative
protected from varus stress across the elbow and shoulder
abduction post-operatively (locked hinge brace)
early range-of-motion encouraged (+/- extension block with
progressive gain to full extension and supination by 6-8 weeks)
important to keep forearm in full pronation during ROM until
after 6 weeks (as above)
Complications
Recurrent instability : 3-8% incidence
II:7 Coronoid fixation tichneque
Infection
Cutaneous nerve injury : decreased risk with posterior mid-line approach
Decreased ROM
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By Dr, AbdulRahman AbdulNasser Elbow | Tendon Conditions
C. Tendon Conditions
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OrthoBullets2017 Elbow | Tendon Conditions
Anatomy
Biceps tendon inserts onto the radial tuberosity.
Contents of antecubital fossa (medial to lateral)
o median nerve (most medial structure), brachial artery, biceps tendon, radial nerve (most lateral
structure)
o radial recurrent vessels lie superficial to biceps tendon
Distal biceps tendon possesses two distinct insertions
o short head attaches distally on radial tuberosity (thin sliver)
origin is coracoid processs
is a better flexor
o long head attaches proximally on radial tuberosity (oval footprint)
origin is superior lip of humerus
is a better supinator as attachment is furthest from axis of rotation (attaches to apex of radial
tuberosity)
independent function to prevent anterior, inferior and superior translation of humeral head
against proximal pull of short head of biceps
Lacertus fibrosus
o distal to the elbow crease, the tendon gives off, from its medial side, the lacertus fibrosus
(bicipital aponeurosis or biceps fascia)
o originates from the distal short head of the biceps tendon
o lacertus passes obliquely across the cubital fossa, running distally and medially, helping to
protect the underlying brachial artery and median nerve
o it is continuous with the deep fascia of the flexor tendon origin, envelopes flexor muscle bellies
o may be mistaken for an intact distal biceps tendon on clincial exam
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By Dr, AbdulRahman AbdulNasser Elbow | Tendon Conditions
o motor exam
loss of more supination than flexion strength
loss of 50% sustained supination strength
loss of 40%% supination strength
loss of 30% flexion strength
o provocative tests
Hook test
performed by asking the patient to actively flex
the elbow to 90° and to fully supinate the
forearm
examiner then uses index finger to hook the
lateral edge of the biceps tendon. II:8 Hook test
with an intact / partially torn tendon, finger can be inserted
1 cm beneath the tendon
false positive
partial tear
intact lacertus fibrosis
underlying brachialis tendon
sensitivity and specificity 100%
Ruland biceps squeeze test (akin to the Thompson/Simmonds test for Achilles rupture)
elbow held in 60-80° of flexion with the forearm slightly pronated.
one hand stabilizes the elbow while the other hand squeeze across the distal biceps
muscle belly.
a positive test is failure to observe supination of the patient‟s forearm or wrist.
sensitivity 96%
challenge is to distinguish between complete tear and partial tear.
biceps tendon is absent in complete rupture and palpable in partial rupture (otherwise they
have a very similar clinical picture)
Evaluation
Radiographs
o usually normal
o occasionally show a small fleck or avulsion of bone from the radial tuberosity
MRI
o positioning in elbow flexion, shoulder abduction, forearm supination increases sensitivity
o is important to distinguish between
complete tear vs. partial tear
muscle substance vs. tendon tear
degree of retraction
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Treatment
Nonoperative
o supportive treatment followed by physical therapy
indications
older, low-demand or sedentary patients who are willing to sacrifice function
if the lacertus fibrosis is intact, the functional deficits of biceps rupture may be minimized
in a low-demand patient.
outcomes
will lose 50% sustained supination strength
will lose 40% supination strength
will lose 30% flexion strength
will lose 15% grip strength
Operative
o surgical repair of tendon to tuberosity
indications
II:9 Sliding kessler
young healthy patients who do not want to sacrifice function
repair
partial tears that do not respond to nonoperative management
timing
surgical treatment should occur within a few weeks from the date of injury
further delay may preclude a straightforward, primary repair.
a more extensile approach may be required in a chronic rupture to retrieve the
retracted and scarred distal biceps tendon.
Surgical Techniques
Anterior Single Incision Technique
o single incision technique was developed to reduce the incidence of HO and synostosis seen with
the double incision technique
o technique
limited antecubital fossa incision
interval between the brachioradialis and pronator teres
radial (lateral) retraction of the brachioradialis and medial retraction of the pronator teres
lateral antebrachial cutaneous nerve (LABCN) is identified as it exits between the biceps and
brachialis at antecubital fossa.
protect PIN by limiting forceful lateral retraction and maintaining supination
o complications
injury to the LABCN (lateral antebrachial cutanous nerve) is most common
more LABCN injury than 2-incision approach
radial nerve or PIN injury is most severe
risk has decreased with new tendon fixation techniques
that require less dissection in the antecubital fossa
synostosis and resulting loss of pronation/supination
avoid exposing periosteum of ulna
avoid dissection between the radius and ulna
heterotopic ossification II:10 LABCN
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By Dr, AbdulRahman AbdulNasser Elbow | Tendon Conditions
Dual Incision Technique
o developed to avoid injury to radial nerve/PIN
o technique
uses smaller anterior incision over the antecubital fossa and a second posterolateral elbow
incision
posterior interval is between ECU and EDC
avoid exposing ulna
do NOT use interval between ECU/anconeus (Kocher's interval) or anconeus and ulna
anterior dissection is same as single incision described above
after the biceps is identified, the radial tuberosity is palpated, and a blunt, curved hemostat is
placed in the interosseous space along the medial border of the tuberosity and palpated on the
dorsal proximal forearm
hemostat pierces anconeus and tents the skin indicating where the posterolateral incision
should be made
o complications
LABCN injury is most common
synostosis and heterotopic ossification more common with 2 incision than single incision
Recommended post incision Not recommended incision : interval between ECU/anconeus (Kocher's
interval) or anconeus and ulna
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Distal Biceps Fixation Techniques
o comparison
tolerances
elbow at 90°, no load, distal biceps sustains 50N
elbow at 90°, with 1kg load, distal biceps sustains 112N
force to rupture = 200N
repair needs to be able to withstand 50N
suture button (400N) > suture anchor (380N) > bone tunnel (310N) > interference screw
(230N)
combination technique (suture button + interference screw) stronger than single technique
o bone tunnel
2-incision approach
tuberosity is exposed and a guide pin drilled through the center of the tuberosity
acorn reamer is used to ream through anterior cortex to recreate a slot of varying depth
two or three 2-mm diameter holes are drilled 1 cm apart through the lateral, far side of the
radius
no. 2 sutures sown to the distal tendon are passed and tied across the bone bridge.
o suture anchors
single-incision approach
radial tuberosity is debrided to prepare for bone-to-tendon healing
2 suture anchors inserted into the biceps tuberosity, one distal and one proximal.
the distal anchor is tied first to bring the tendon out to length.
next, the sutures of the proximal anchor are tied
this repair sequence maximizes tendon-to-bone contact and surface area.
o intraosseous screw fixation
single-incision approach
similar to the bone tunnel technique, except the No. 2 suture (whip-stitched through the
tendon) is passed through a bioabsorbable tenodesis screw.
o suspensory cortical button
single-incision approach
tendon end is whip-stitched with the suture ends placed into two central holes of the button.
similar to bone tunnel technique, an acorn reamer is used to ream through the anterior cortex
after exposing tuberosity.
a smaller hole is then drilled through the far cortex to allow the button to be passed across the
far cortex.
button is flipped to lie on far cortex, and suture ends are tensioned (tension slide) to bring
tendon into tunnel
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By Dr, AbdulRahman AbdulNasser Elbow | Tendon Conditions
Chronic Rupture
Subacute/chronic ruptures may be treated successfully with direct repair (without allograft)
o may need to hyperflex elbow to achieve fixation
o hyperflexion does NOT lead to loss of elbow ROM or flexion contracture
Complications
LABCN injury
o most common complication overall
o because of overaggressive retraction
o more common with single incision technique
o usually resolved in 3-6mth
Radial nerve/PIN injury or radial sensory nerve injury
o more common in single incision than 2 incision technique
o usually resolve in 3-6mth
Heterotopic ossification
o if interosseous membrane and ulnar periosteum disrupted
o a risk of the 2 incision technique
Synostosis
Proximal radius fracture
o from large tunnels
Suture rupture (if bone tunnel method used)
2. Triceps Rupture
Introduction
Epidemiology
o demographics
usually males
age 30-50 most common
commonly seen in
competitive weightlifting
body building
football players
o risk factors
systemic illness (renal osteodystrophy)
anabolic steroid use
local steroid injection
flouroquinolone use
chronic olecranon bursitis
previous triceps surgery
Pathophysiology
o mechanism
usually forceful eccentric contraction
o pathoanatomy
rupture most common at the insertion of medial or lateral head
less frequently through muscle belly or musculotendinous junction
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Presentation
History
o patients often note a painful pop
Symptoms
o loss of ability to extend elbow against gravity
Physical exam
o may have palpable gap
o swelling, ecchymosis, and pain
Imaging
Radiographs
o recommended views
AP/lateral of elbow II:11 Flake sign
o findings
may show "flake sign" on lateral view
MRI
o useful for determining location and severity
Treatment
Non-operative
o supportive treatment
indications
partial tears and able to extend against gravity
low demand patients in poor health
Operative
o primary surgical repair
indications
acute complete tears
partial tears (>50%) with significant weakness
technique
delayed reconstruction may need tendon graft
Complications
Elbow stiffness
Ulnar nerve injury
Failure of repair
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By Dr, AbdulRahman AbdulNasser Elbow | Tendon Conditions
o demographics
up to 50% of all tennis players develop
risk factors
poor swing technique
heavy racket
incorrect grip size
high string tension
common in laborers who utilize heavy tools
workers engaged in repetitive gripping or lifting tasks
most common between ages of 35 and 50 years old
men and women equally affected
Pathophysiology
o mechanism
precipitated by repetitive wrist extension and forearm pronation
common in tennis players (backhand implicated)
o pathoanatomy
usually begins as a microtear of the origin of ECRB
may also involve microtears of ECRL and ECU
o pathohistology
microscopic evaluation of the tissue reveals
angiofibroblastic hyperplasia
disorganized collagen
Associated conditions
o radial tunnel syndrome
is present in 5%
Prognosis
o non-operative treatment effective in up to 95% of cases
Anatomy
Common extensor origin
o muscles that originate from lateral supracondylar ridge
extensor carpi radialis longus
o muscles that originate on lateral epicondyle
extensor carpi radialis brevis
extensor carpi ulnaris
extensor digitorum
extensor digiti minimi
anconeus
shares same attachment site as ECRB
Ligaments
o lateral ulnar collateral ligament
Nerves
o posterior interosseus nerve (PIN) enters the supinator just distal to the radial head
compression can lead to radial tunnel syndrome (may co-exist with lateral epicondylitis)
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OrthoBullets2017 Elbow | Tendon Conditions
Presentation
Symptoms
o pain with resisted wrist extension
o pain with gripping activities
o decreased grip strength
Physical exam
o palpation & inspection
point tenderness at ECRB insertion into lateral epicondyle
few mm distal to tip of lateral epicondyle
o neuromuscular
may have decreased grip strength
neurological exam helps to differentiate from entrapment syndromes
o provocative tests
the following maneuvers exacerbate pain at lateral epicondyle
resisted wrist extension with elbow fully extended
resisted extension of the long fingers
maximal flexion of the wrist
passive wrist flexion in pronation causes pain at the elbow
Imaging
Radiographs
o recommended views
AP/Lateral of elbow
o findings
usually normal
may reveal calcifications in the extensor muscle mass (up to 20% of patients)
may reveal signs of previous surgery
MRI
o not necessary for diagnosis
o increased signal intensity at ECRB tendon origin may be seen (up to 50% of cases)
thickening
edema
tendon degeneration
Ultrasonography
o requires experienced operator (variable sensitivity/specificity)
most useful diagnostic tool in experienced operator hands
o ECRB tendon appears thickened and hypoechoic
Studies
Histology
o histopathological studies of the ECRB tendon tissue shows
fibroblast hypertrophy
disorganized collagen
vascular hyperplasia
Diagnosis
o diagnosis is primarily based on symptoms and physical exam
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By Dr, AbdulRahman AbdulNasser Elbow | Tendon Conditions
Differential
Posterlateral plica
Posterlateral rotatory instability
Radial tunnel syndrome
o palpation 3-4 cm distal and anterior to the lateral epicondyle
o pain with resisted third-finger extension
o pain with resisted forearm supination
Occult fracture
Cervical radiculopathy
Capitellar osteochondritis dissecans
Triceps tendinitis
Radiocapitellar osteoarthritis
Shingles
Treatment
Nonoperative
o activity modification, ice, NSAIDS, physical therapy, ultrasound
indications : first line of treatment
techniques
tennis modifications (slower playing surface, more flexible racquet, lower string tension,
larger grip)
counter-force brace (strap)
steroid injections (up to three)
physical therapy regimen
acupuncture
iontophoresis/phonophoresis
extracoproeal shock wave therapy
outcomes : up to 95% success rate with nonoperative treatment, but patience is required
Operative
o release and debridement of ECRB origin
indications
if prolonged nonoperative (6-12 months) fails
clear diagnosis (isolated lateral epicondylitis)
intra-articular pathology
contraindications
inadequate trial of nonsurgical treatment
patient noncompliance with the recommended nonsurgical treatment
Techniques
Release and debridement of ECRB origin
o open
incision is positioned over the common extensor origin
lift ECRL off of ECRB (located deep and posterior to ECRL)
excise degenerative tissue
decorticate epicondyle
repair capsule if breached
side-to-side closure of tendon
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OrthoBullets2017 Elbow | Tendon Conditions
o arthroscopic
advantages include visualization and ability to address and intraarticular pathology
resect lateral capsule anteriorly (do not pass midradial head to protect LUCL)
release ECRB from origin (where muscle tissue begins)
decorticate lateral epicondyle
Complications
Iatrogenic LUCL injury
o excessive resection of the LUCL
o should not extend beyond equator of radial head
o may lead to posterolateral rotatory instability (PLRI)
Missed radial nerve entrapment syndrome
o common in up to 5% of patients with lateral epicondylitis
Iatrogenic neurovascular injury
o radial nerve injury
Heterotopic ossification
o decrease risk with thorough irrigation following decortication
Infection
Missed concomitant pathology (i.e. PLRI, radial tunnel)
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By Dr, AbdulRahman AbdulNasser Elbow | Tendon Conditions
jobs involving lifting >20kg, forceful grip, exposure to constant vibration at elbow
(plumbers, carpenters, construction workers)
can also occur post-traumatically
o pathoanatomy
micro trauma to insertion of flexor-pronator mass caused by repetitive activities
traditionally thought to affect pronator teres (PT) > flexor carpi radialis (FCR)
new studies show all muscles of common flexor tendon (CFT) affected except palmaris
longus
stages
peritendinous inflamation
angiofibroblastic hyperplasia
breakdown/fibrosis/calcification
Associated conditions
o ulnar neuropathy
inflammation may affect to ulnar nerve
o ulnar collateral ligament insufficiency
should rule this out especially in throwing athletes
o associated occupational conditions (present in 84% of occupational medial epicondylitis)
carpal tunnel syndrome
lateral epicondylitis
rotator cuff tendinitis
Anatomy
Common flexor tendon (CFT)
o 3 cm long
o attaches to medial epicondyle (anterior aspect), anterior bundle of MCL
o fibers run parallel to MCL
o ulnar head of PT becomes confluent with hyperplastic part of anteromedial joint capsule
Flexor-pronator mass includes
o Pronator Teres (median n.)
o Flexor Carpi Radialis (median n.)
o FDS (median n.)
o Palmaris Longus (median n.)
o Flexor Carpi Ulnaris (ulnar n.)
Presentation
History
o may include acute traumatic blow to elbow causing avulsion of CFT
o repetitive elbow use, repetitive gripping, repetitive valgus stress
o +/- numbness or tingling in ulnar digits
Symptoms
o insidious onset pain over medial epicondyle
worse with wrist and forearm motion
worse with gripping
during late cocking/early acceleration
Physical exam
o tenderness 5-10 mm distal and anterior to medial epicondyle
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o soft tissue swelling and warmth if inflammation present
o provocative tests
pain with resisted forearm pronation and wrist flexion
o examine for associated conditions
valgus instability in overhead athlete (milking maneuver, valgus stress, moving valgus stress
test)
ulnar neuritis (2-pt discrimination in ulnar distribution, hypothenar bulk, Tinel's along length
of nerve)
elbow flexion test involves maximal flexion, forearm pronation, wrist hyperextension x
30-60s
ulnar subluxation
o flexion contracture in chronic cases
Imaging
Radiographs
o usually unremarkable
o 25% have calcification of CFT or UCL
o can identify posterior-medial osteophytes or degenerative changes
o stress radiography used in some centers for assessing valgus instability
Ultrasound
o characteristics
>90% sensitivity, specificity, positive and negative predictive values
allows dynamic examination
o findings
hypoechoic/anechoic areas of focal degeneration
MRI
o standard of care
o indications
evaluate concomitant pathology e.g. UCL injury in overhead thrower
unclear source of medial elbow pain
evaluate for loose bodies
rule out rupture of flexor pronator origin
o findings
tendinosis / tendon disruption of CFT
increased signal on T2 images
peritendinous edema
UCL or osteochondral injuries
Studies
EMG/NCS
o may be used to further evaluate for ulnar nerve compression if identified on history and physical
Histology
angiofibroblastic hyperplasia, as described for lateral epicondylitis
inflammation uncommon
Differential
MCL injury
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By Dr, AbdulRahman AbdulNasser Elbow | Tendon Conditions
Cubital tunnel syndrome
Fracture
Cervical radiculopathy
Triceps tendinitis
Herpes zoster (shingles)
Treatment
Nonoperative
o rest, ice, activity modification (stop throwing x 6-12wks), PT (passive stretching), bracing,
NSAIDS
indications
first line of treatment
prolonged trial of conservative management appropriate due to less predictable success of
operative treatment (compared to lateral epicondylitis)
technique
counter-force bracing / kinesiology taping
ultrasound shown to be beneficial
multiple corticosteroid injections should be avoided
o extracorporeal shockwave therapy (ESWT)
no definitive recommendations at present
promotes angiogenesis, tendon healing, short term analgesia
o corticosteroid injections into peritendinous tissue
complications
skin depigmentation (if dark skinned)
subcutaneous atrophy
tendon weakening
ulnar nerve injury
o acupuncture
Operative
o open debridement of PT/FCR, reattachment of flexor-pronator group
indications
up to 6 months of nonoperative management that fails in a compliant patient
symptoms severe and affecting quality of life
clear diagnosis
outcomes
good to excellent outcomes in 80% (less than lateral epicondylitis)
worse outcomes when ulnar nerve symptoms present pre-operatively
Techniques
Open debridement and reattachment of flexor-pronator mass
o approach
medial approach to elbow
o technique
use the PT-FCR interval
excise regions of pathologic tissue near flexor-pronator mass
followed by side to side repair at site
can perform epicondyle microfracture to enhance vascular environment
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OrthoBullets2017 Elbow | Tendon Conditions
reattach flexor-pronator mass to medial epicondyle
if proximal origin involved
can also perform cubital tunnel release or transposition
for concomitant ulnar nerve symptoms
o rehabilitation
short period of immobilization x 1-2 weeks in sling
avoid volar flexion of wrist immediately postoperatively
ROM exercises after 2 weeks
strengthening at 6-8 weeks
return to sport at 3-6 months
Complications
Medial antebrachial cutaneous nerve neuropathy
o may result from avulsion or transection
if injury noticed during surgery, transpose nerve into brachialis muscle
Ulnar nerve injury
Infection
Anatomy
Flexor pronator mass provides dynamic support to the medial elbow against valgus stress
Flexor pronator mass includes (proximal to distal)
o Pronator Teres (median n.)
o Flexor Carpi Radialis (median n.)
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By Dr, AbdulRahman AbdulNasser Elbow | Tendon Conditions
o PalmarisLongus (median n.)
o FDS (median n.)
o Flexor Carpi Ulnaris (ulnar n.)
Presentation
History
o acute event of hitting the ground during golf, bat, or racquet swing
o history of throwing or racquet sports
o repetitive gripping and/or elbow valgus stress activities
Symptoms
o pain
medial elbow pain distal to the medial epicondyle
chronic pain during late cocking/early acceleration
Physical exam
o medial elbow swelling and ecchymosis in acute strain
o tenderness distal to medial epicondyle
o provocative tests II:12 T2 axial MRI demonstrating
edema in the flexor-pronator mass
pain with elbow extension and resisted wrist flexion or pronation
o examine for associated conditions
negative moving valgus stress test
normal neurovascular exam
Imaging
Radiographs : usually normal
MRI
o indications
unclear source of medial elbow pain
grade severity of muscle strain
rule out other causes of medial elbow pain such as UCL rupture
o findings
edema in flexor pronator mass
partial tearing or complete rupture of flexor pronator mass
Differential
Medial epicondylitis
UCL injury
Valgus extension overload with posteromedial olecranon impingement
Complications
Continued medial elbow pain and valgus instability
o unrecognized UCL insufficiency
D. Articular Conditions
Anatomy
Capitellum is supplied by 2 end arteries
o radial recurrent artery
o interosseous recurrent artery
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Classification
Radiographic and Arthroscopic Classification
Type I Intact cartilage
Bony stability may or may not be present
Type II Cartilage fracture with bony collapse or displacement
Type III Loose bodies present in joint
Presentation
Symptoms
o elbow pain
insidious, activity-related onset of lateral elbow pain in dominant arm
o mechanical symptoms
loss of extension
early sign
catching / locking / grinding
late signs if loose bodies present
Physical exam II:14 Type I
Imaging
Radiographs
o recommended views
AP and lateral of the elbow II:15 Type II
o findings
plain radiographs can confirm the diagnosis based on bone defect
capitellum is most commonly involved
Panner disease exhibits an irregular epiphysis, OCD a well-defined subchondral lesion
MRI
o most useful for assessing:
size
extent of edema
cartilage status
Treatment
Nonoperative
o cessation of activity +/- immobilization
indications
type I lesions (stable fragments) II:16 Type III
technique
3-6 weeks followed by slow progression back to activities over next 6-12 weeks
outcomes : >90% success rate
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Operative
o diagnostic arthroscopy and drilling of capitellum
indications (separated fragments)
unstable type I lesions
stable type II lesions
technique
arthroscopic reduction
microfracture of chondral lesion
extra- or transarticular drilling of defects
post op care
protected early range of motion
strengthening at 2 months
throwing and weight bearing at 4-6 months
outcomes
good success rate
o fixation of lesion
indications
large lesions that are not completely displaced
post op care
protected early range of motion
strengthening at 2 months
throwing and weight bearing at 4-6 months
outcomes
highly variable
o debridement and loose body excision
indications
unstable type II lesion
type III lesions
post op care
early range of motion +/- brace
begin strengthening when range of motion is painfree
no throwing or weight bearing activities X 3 months
Complications
Elbow stiffness
Pain
Unable to return to sports
Arthritis
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By Dr, AbdulRahman AbdulNasser Elbow | Articular Conditions
2. Elbow Arthritis
Introduction
Degenerative joint disease of the elbow articulation. Most common causes are
o primary osteoarthritis
o post-traumatic arthritis
o inflammatory arthritis (e.g., RA)
Osteoarthritis
o epidemiology
incidence
clinically symptomatic primary osteoarthritis rare (2% prevalence)
demographics
men to women 4:1
middle aged male laborers
can present from 20 to 70 years of age (average 50 years)
location
association with dominant hand
risk factors : strenuous manual labor
o pathophysiology
etiologies include
primary arthritis
secondary causes
post-traumatic arthritis
second most common form of elbow arthritis (after rheumatoid)
especially after nonoperatively treated radial head fractures or elbow dislocations with
coronoid fracture
history of osteochondritis dissecans
synovial osteochondromatosis
MUCL or ligamentous insufficiency, valgus extension overload
pathoanatomy
osteophytosis
capsular contracture
loose bodies
periarticular osteophytes block motion
preferentially involves radiocapitellar joint, sparing ulnohumeral articulation
Inflammatory Arthritis
o epidemiology
rheumatoid arthritis
most common inflammatory arthropathy in adults
most prevalent elbow arthritis
elbow affected in 20% to 50%
causes progressive bone resorption and osteopenia
other causes
psoriatic arthritis
systemic lupus erythematosius
pigmented villonodular synovitis
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o pathophysiology
inflammation, chronic synovitis, ligament attenuation, periarticular osteopenia, capsular
contracture
pathoanatomy
fixed flexion contracture
instability
ulnar or (less commonly) radial neuropathy
articular cartilage erosion
cyst formation
deformity
joint space loss
progressive instability
Anatomy
Primary stabilizing factors of elbow
o anterior band MCL
anterior oblique fibers most important
stabilizes to both valgus and distraction forces
o LCL
o coronoid
Secondary stabilizers
o radial head
most important
provides 30% of valgus stability
most important in 0-30° of flexion and pronation
o capsule
primary restraint to distraction forces in full extension
o aconeus, and lateral capsule
secondary stabilizer to varus force
Complete elbow anatomy and biomechanics
Presentation
Elbow osteoarthritis
o symptoms
progressive pain, typically at end range of motion, not mid-range
loss of terminal extension
painful locking or catching of elbow
night pain unusual
o physical exam
loss of elbow range of motion (terminal extension
forearm rotation relatively presereved early
ulnar neuropathy present in up to 50% of patients
Elbow inflammatory arthritis
o symptoms
hand and wrist involvement usually precedes elbow
pain and loss of motion
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o physical exam
may have fixed flexion contracture
ligamentous incompetence can be seen
+/- ulnar neuropathy
evaluate cervical spine in all rheumatoid arthritis patients
Imaging
Radiographs
o recommended views
ap/lateral of elbow, cervical plain films preop for RA
patients indicated for elbow surgery
o findings
elbow joint space narrowing
ulnohumeral joint space relatively preserved
osteophytes found at
coronoid process and fossa
radial head and fossa
olecranon tip and posteromedial olecranon fossa
loose bodies (underestimated on plain radiography)
periarticular erosions and cystic changes seen in RA
radiographic changes in RA graded by Larsen system
CT scan
o useful for surgical planning
o can help better define osteophytes and loose bodies
Treatment
Nonoperative
o NSAIDS, cortisone injections, resting splints, and activity modification
indications : mild to moderate symptoms
Operative
o arthroscopic debridement and capsular release
indications
mild disease with bone spurs
mechanical block to motion
preferred in patients with >90 degrees of motion
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contraindications
prior elbow surgery, especially ulnar nerve transposition
severe contracture or arthrofibrosis
technique
removal of osteophytes and loose bodies
often combined with soft tissue release
complications
neurologic injury
synovial fistula
o ulnohumeral distraction interposition arthroplasty II:17 olecranon fossa debridement
indications
young high demand patients with arthritis (OA, RA, post-traumatic arthritis)(who would
otherwise have received TEA if they were older)
technique
can use
autogenous tensor fascia lata
achilles tendon allograft
complications
patients with severely limited preoperative motion (extension > 60 degrees and flexion of
< 100 degrees are at risk for ulnar nerve dysfunction
postoperatively and should undergo a concomitant ulnar nerve
decompression/transposition
o olecranon fossa debridement (Outerbridge-Kashiwagi procedure)
indications : younger patients with decreased ROM
technique
burr hole through olecranon fossa
removes osteophytes and arthritic bone
increases range of motion
be sure to decompress the ulnar nerve if there is an extension contracture preoperatively
complications : failure to address anterior osteophytes
o total elbow arthroplasty
indications
older patients >65 years with severe elbow arthritis (Larsen stage 3-5)
complex distal humerus fracture in elderly with poor bone stock
contraindications
highly active patient <65
infection
Charcot joint
Complications (as high as 43%)
infection
instability
loosening
wound healing problems
triceps insufficiency
ulnar neuropathy
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Anatomy
ROM
o functional motion
30° - 130° (extension-flexion)
most activities require a 100 degree arc of motion at the elbow to be functional
a 30 degree loss of extension is well tolerated by most patients
50° - 50° (pronation/supination)
Elbow ligaments and biomechanics
o primary ligaments of elbow include
medial ulnar collateral ligament
anterior bundle
is most imporant stabilizer to both valgus and distraction forces
posterior bundle
posterior oblique portion of medial ulnar collateral ligament
radial collateral ligament
annular ligament
Nerves
o ulnar nerve
proximity to the elbow joint places nerve at risk if joint is contracted
Presentation
Symptoms
o pain
may or may not be painful
o decreased motion
often limits activities of daily living
Physical exam
o inspection
examine the skin around the elbow
look for scars from previous surgeries
inflammation
o range of motion
measure elbow
flexion/extension
if <90-100° of flexion, posterior band of MCL is likely contracted and should be
released
pronation/supination
o neurological
assess median, radial, and ulnar nerve function
Imaging
Radiographs
o recommended view
AP, lateral and oblique views
serial radiographs : if heterotopic ossification is noted
o findings
dependent on pathology causing stiffness/contractures
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By Dr, AbdulRahman AbdulNasser Elbow | Articular Conditions
CT scan
o indications
loose bodies in joint
non-unions
joint incongruity
abnormal bony anatomy
MRI
o rarely indicated
Treatment
Nonoperative
o NSAIDs, physical therapy with active and passive range of motion exercises
indications
first line of treatment in most cases
contractures <40°
o static splinting
indications
failed trial of physical therapy with
elbow flexion contractures greater than 30° OR
elbow flexion less than 130°
Operative
o capsular release +/- release of posterior band of MCL
indications
extrinsic capsular contractures with normal joint surface congruency
most predictable beneficial results
patients with arthritis
less predictable once joint surface is incongruous
outcomes
compliance with postoperative rehabilitation is critical
heterotopic ossifican can be resected once it reaches maturity
determine based on visualization of well-corticalized margins of new bone (with lack
of changes on serial radiographs)
contraindications
charcot elbow joint
neurologic elbow disorder
ankylosed elbow
poor skin
relative contraindication, may need plastic surgery (rotational flap)
o osteophyte excision
indications
intrinsic contractures with arthritis confined to olecranon fossa
o distraction interpositional arthroplasty
indications
intrinsic contractures with diffuse arthritis in high demand younger patients
o total elbow arthroplasty
indications
intrinsic contractures with diffuse arthritis in low demand elderly patients
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outcomes
high failure rate in young, active patients
permanent 5-lb lifting restriction
o musculocutaneous neurectomy
indications : neurogenic contractures with a flexion deformity of less than 90 degrees
Techniques
Capsular release +/- release of posterior band of MCL
o approaches
arthroscopic
technically demanding, radial nerve most at risk with portal placement, followed by ulnar
and median nerves
posterior compartment - debridement of olecranon fossa/osteophytes with posterior
capsular release; caution using suction medially due to proximity of ulnar nerve
anterior compartment - debridement of coronoid fossa/osteophytes with anterior
capsulotomy or capsulectomy
open
lateral column approach (Morrey)
medial "over the top" column approach (Hotchkiss)
perform with decompression or transposition of ulnar nerve
best for patients with extrinsic contractures, MCL calcifications, and/or ulnar nerve
symptoms
combined medial and lateral approach
if <90-100° of flexion, posterior band of MCL is likely contracted and should be
released with consideration of concomitant ulnar nerve decompression or
transposition
Complications
Post-operative heterotopic ossification
o may treat prophylactically with low-dose radiation therapy or indomethacin
Transient ulnar neuropraxia
Ulnar nerve damage : transpose nerve anteriorly during procedure
Recurrent contracture
E. Elbow Techniques
1. Elbow Arthroscopy
Introduction
Indications
o loose body removal
o osteophyte debridement
o synovectomy
o capsular releases for stiffness
o osteochondritis dissecans of capitellum
o lateral epicondylitis
o debridement for septic arthritis
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Contraindications
o prior trauma
o surgical scarring
o previous ulnar nerve transposition
ulnar nerve subluxation is not an absolute contraindication, but it should be identified prior to
surgery, especially with prior submuscular or intramuscular transposition
Advantages
o improved articular visualization
o decreased postoperative pain
o faster postoperative recovery
Disadvantages
o technically demanding
o high risk of damage to neurovascular structures due to proximity to the joint
Positioning
Patient position may be
o supine
o prone
o lateral decubitus
Anesthesia
o general anesthesia (allows muscle relaxation and placement of patient in prone or lateral
decubitus position)
o regional anesthesia may be used; it does not allow for immediate evaluation of nerve function
after surgery and patients may not tolerate the uncomfortable position for a prolonged period
Technique and Portals
Portal placement technique
o fully distend joint through lateral soft spot before placing portals
capsule distension moves NV structures away from the joint when trocar is introduced
o careful "nick and spread" technique using hemostat
o posterior medial portal usually avoided due to proximity to ulnar nerve
Elbow position
o establish anterior portals with elbow flexed 90deg
o establish posterior portals in some extension
Standard 30deg arthroscope
Tourniquet
Solid cannulas are helpful to maintain fluid distension and avoid fluid extravasation into soft tissue
(versus trephinated)
Landmarks: olecranon, lateral and medial epicondyles, radiocapitellar joint, ulnar nerve
o mark out before insufflating joint as distension can alter position
Summary of portals
o portal selection depends on the underlying pathology
o after joint insufflation, establish either medially- or laterally-based viewing portal, then establish
working portal under direct visualization via needle localization.
establishing a medially-based portal first, prior to joint/soft-tissue swelling, may be
advantageous to avoid neurovascular injury
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Portal Location Use Nerve at Risk
1-2cm proximal, 1cm Radial (risk decreases as
Proximal
anterior to lateral portal moved more
anterolateral
epicondyle proximally)
1 cm anterior and 1-3cm 1st portal for supine position Radial and
distal to lateral lateral antebrachial
Distal anterolateral epicondyle See radial head, medial side of cutaneous
elbow, coronoid, trochlea,
brachialis insertion, coronoid fossa
"soft spot" portal (in Initial site for joint distension
relatively safe, lateral
Direct lateral (or triangle formed by before scope is inserted, viewing
antebrachial cutaneous
midlateral) olecranon, radial head, posterior compartment (capitellum,
epicondyle) nerve
radial head, radioulnar articulation)
Anteromedial 2 cm anterior and 2cm Used most often to augment the medial antebrachial
distal to medial proximal anteromedial portal to cutaneous and
epicondyle. access medial recess. Place under median
direct visualization.
Proximal 2cm proximal to medial viewing entire anterior Medial antebrachial
anteromedial epicondyle, anterior to compartment, radial head, cutaneous, ulnar (3-4mm
(superomedial) intermuscular septum capitellum, coronoid, trochlea away) and median
3cm proximal to Elbow partially extended, good for posterior antebrachial
Straight posterior olecranon, triceps removing impinging olecranon cutaneous
(transtriceps) midline (musculotend. osteophytes and loose bodies from
junction) posteromedial compartment ulnar nerve
Elbow 20-30deg flexion (to relax
2-3 cm proximal to triceps) posterior antebrachial
olecranon and just cutaneous
lateral to triceps Best access to posterior
Posterolateral
compartment, radiocapitellar joint medial brachial cutaneous
center of anconeus (debridement of OCD capitellum),
triangle olecranon fossa and posterior ulnar
structures
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By Dr, AbdulRahman AbdulNasser Elbow | Elbow Techniques
Complications
Nerve palsy (1-5%)
o greatest risks for nerve palsy
underlying rheumatoid arthritis
elbow contracture
o nerves
transient ulnar nerve palsy (most common)
radial nerve palsy (second most common) - at risk from proximal anterolateral portal
medial antebrachial cutaneous - at risk from proximal anteromedial portal
o mechanism
direct injury
trocars and instrumentation
failure to use blunt dissection (neuromas)
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indirect injury
compartment syndrome (aggressive distension, fluid extravasation)
local anesthesia extravasation (transient)
Joint ankylosis/ heterotopic ossification
o less than open surgery
o minimize bleeding
Infection
o sinus tract formation (posterolateral portal)
Indications
Indications
o rheumatoid arthritis (RA)
indication
10-20% of patients with RA will have arthritic changes in the elbow
TEA considered for Larsen stages 3 to 5 with:
functional loss
pain
instability
ideally, patient should be older than 65 years old
outcomes
longest survivorship when TEA is performed for RA compared to other indications
most reliable with advanced, refractory RA
o primary osteoarthritis (advanced)
indication
patient should be older than 65 years old
mid-arc pain with activity resulting from ulnotrochlear joint cartilage loss
outcomes : 10-year implant survival about 80-85% for TEA for primary OA
o fracture
indication
physiologically elderly patient (e.g., > 70 years) with:
acute complex, unreconstructable intra-articular distal humerus fracture
missed elbow fracture dislocation
poor quality bone
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outcomes
faster recovery with more predictable functional outcomes compared to fixation strategies
limitations of lifting weight more than 5 to 10 pounds to avoid implant loosening
o posttraumatic osteoarthritis (advanced)
o chronic instability
Contraindications
o absolute
active infection (arthrodesis favored)
Charcot joint
o relative
poor neurologic control of affected extremity
active patient younger than <65 years old
olecranon osteotomy
Implants
Designs
o unconstrained or unlinked components
example : Ewarld capitella design II:18 Constrained
technical aspects
requires competent collateral ligaments
good bone quality as stability supplied by the soft tissue
outcomes
instability is most common complication (5-10% dislocation)
no proven superiority or clear indication compared with semiconstrained/linked
o semiconstrained or linked components
examples : Coonrad-Moorey design
technical aspects : "sloppy hinge" allows for some varus and valgus motion
outcomes
best results of all the designs
complication of early loosening with designs without an anterior flange
o constrained
example : Dee design
technical aspects : rigid hinged design
outcomes : highest loosening rates compared to semiconstrained and unconstrained designs
o approach
two main approaches to TEA
triceps "on" : eg, Alonso-Llamaes (paratricipital posterior approach) or triceps splitting
triceps "off" : eg, Bryan-Morrey
technique
approach (triceps "on")
direct midline, posterior incision
identify, release and protect the ulnar nerve
release the flexor-pronator mass and medial collateral ligament from medial
epicondyle
elevate the triceps off the posterior humerus towards the lateral intermuscular septum
release the common extensors and lateral collateral ligament complex
disarticulate the ulno-humeral joint
bone preparation
preparation of humeral component
resect the olecranon fossa of distal humerus
keep medial and lateral column intact
broaching to appropriate sized component
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preparation of ulnar component
resect the olecranon tip of proximal ulna
broaching to appropriate sized component
implant insertion
component design
semiconstrained most common
modern cement preparation and technique
humerus component
prepare a wedge-shaped piece of bone for placement behind the humeral flange
maintain component orientation relative to the posterior flat surface of the distal
humerus
ulnar component
orient the implant perpendicular to the dorsal flat surface of the olecranon
Postoperative care
o early period of immobilization
Early motion after TEA is associated with wound complications, instability, and hardware
loosening
Typically immobilize for 4 weeks after surgery
o lifelong weightlifting restriction of less than 5-10 lbs
Outcomes
Rheumatoid arthritis TEA outcomes
o 10 year survivorship
92.4% rate of survivorship free of revision at 10 years
however very high complication rate (14%)
triceps avulsion
deep infection
periprosthetic fracture
aseptic loosening
Post traumatic arthritis TEA outcomes
o 5 year survivorship
most achieve functional ROM and patient satisfaction
high complication rate (27-43%)
high re-operation rate (25%)
Complications
Aseptic loosening (radiographic 17%, clinical 6%)
o most common mode of failure for constrained
Infection (8%)
o acute infection (< 30 days)
treatment
aggressive serial irrigation and debridement and antibiotic bead placement
success depends on organism
staphylococcus epidermidis is associated with persistent infection because it is an
encapsulating organism, and it is best treated with implant removal and IV antibiotic
o chronic infection
treatment
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two staged reimplantation versus resection arthroplasty in medically ill patients or those
with inadequate bone stock.
Instability (7-19%)
o most common mode of failure for semiconstrained
Bushing wear (obtain AP xrays and varus/valgus angle of > 10 degrees is concerning)
o common mode of failure for constrained
Wound healing (higher with longterm steroid use)
Ulnar neuropathy
Triceps insufficiency
Bone loss
o from multiple revisions, fractures, osteolysis
o graded based on humeral bone stock
o treatment
up to 8cm of distal humeral loss can be replaced with longer
prosthesis with extended anterior flange or endoprosthesis (total
humerus)
salvage options include flail elbow, amputation, arthrodesis
Periprosthetic fracture
o in 5-30% of primary TEAs
o causes
trauma
osteoporosis
aseptic loosening
stress shielding
poor technique
non compliance with activity restriction
o classification based on that for periprosthetic femoral fractures (see table below)
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By Dr, AbdulRahman AbdulNasser Elbow | Elbow Techniques
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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OrthoBullets2017 Knee | Elbow Techniques
ORTHO BULLETS
III.Knee
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By Dr, AbdulRahman AbdulNasser Knee | Knee Introduction
A. Knee Introduction
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ACL
Function
o prevents anterior translation of the tibia relative to the femur
Anatomy
o intrasynovial
o origin
lateral femoral condyle
PL bundle originates posterior and distal to AM bundle (on femur)
o insertion
broad and irregular
anterior and between the intercondylar eminences of the tibia
o structure
33mm x 11mm in size
two bundles
anteromedial
fibers are parallel in extension
fibers are externally rotated in flexion
tight in both flexion and extension
posterolateral
PL bundle prevents pivot shift III:1 MRI showing 2 bundles of ACL
prevents internal tibial rotation with knee near extension
tight in extension, loose in flexion
Blood supply
o middle geniculate artery
Innervation
o contains significant innervation by posterior articular branches of tibial nerve
o contains mechanoreceptors (Ruffini, Pacini, Golgi tendon organs, free-nerve endings)
o function of innervation
proprioception
modulation of quadriceps function
Composition
o 90% Type I collagen
o 10% Type III collagen
Biomechanics
o tensile strength
native ACL 2200 N
BPTB 3000N
quadrupled hamstring 4000N
ACL PCL
Tight in flexion AM AL
Tight in extension PL PM
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PCL
Function
o prevents posterior translation of the tibia relative to the femur
o PCL and PLC work in concert to resist posterior translation and posterolateral rotatory instability
Anatomy
o origin
medial femoral condyle
o insertion
tibial sulcus
o structure
38mm x 13mm in size
two bundles
anterolateral
III:2 Tibial attachment of PCL
shorter, thicker and stronger
in double bundle reconstruction, tensioned in mid flexion
posteromedial
longer, thinner, weaker
in double bundle reconstruction, tensioned in extension and high flexion
tensioning in extension protects against hyperextension
insertions
medial intercondylar ridge
marks proximal border of femoral insertion
medial bifurcate ridge
separate the AL from PM bundle
variable meniscofemoral ligaments originate from the posterior horn of the lateral meniscus
and insert into the substance of the PCL. These include
Ligament of Humphrey (anterior to PCL)
Ligament of Wrisberg (posterior to PCL)
o blood supply
middle geniculate artery
Biomechanics
o strength: 2500 N (vs posterior translation)
Illustration: Arthroscopic view of tibial attachment of Illustration: Arthroscopic view of femoral attachment
PCL in right knee of PCL in right knee
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By Dr, AbdulRahman AbdulNasser Knee | Knee Introduction
PCL
------------------------------------------------------------------------------------------------------------------------------------------------
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By Dr, AbdulRahman AbdulNasser Knee | Knee Introduction
MCL
Function
o resists valgus angulation
o works in concert with ACL to provide restraint to axial rotation
Anatomy
o origin
MFC to medial tibia extending down several centimeters
o structure
two components
superficial portion (tibial collateral ligament)
lies just deep to gracilis and semitendinosus
originates from medial femoral epicondyle and inserts into periosteum of proximal
tibia (deep to pes anserinus)
the superficial portion of the MCL contributes 57% and 78% of medial stability at 5
degrees and 25 degrees of knee flexion, respectively.
the superficial MCL is the primary stabilizer to valgus stress at all angles
deep portion (medial capsular ligament)
separated from superficial portion by a bursa
attaches to medial meniscus (coronary ligament)
divided into meniscofemoral and meniscotibial portions
posterior fibers of the deep MCL blend with posteromedial capsule and POL
the deep MCL and posteromedial capsule act as secondary restraints to valgus stress
at full knee extension.
Biomechanics
o strength: 4000 N (vs valgus stress)
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Posteromedial corner
Function
o important for rotatory stability
Anatomy
o lies deep to MCL
o formed by
insertion of semimembranosus
posterior oblique ligament
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short oblique bundle, inserts on superior patellar pole
inferior straight bundle
o femoral insertion
medial femoral condyle, distal to adductor tubercle and proximal to MCL attachment
Schottle's point
1.3mm anterior to posterior femoral diaphyseal cortex
2.5mm distal to posterior origin of medial femoral condyle
proximal to the level of the posterior point of Blumensaat's line
o patellar attachment
fan-like structure inserting at junction between proximal-middle thirds of superomedial
border of patella
Pathoanatomy
o tears off femoral attachment > patellar attachment
some studies show otherwise
o risk of 2nd dislocation is 13%
risk of 3rd dislocation (after 2nd dislocation) is 50%
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Anterolateral Ligament
Function
o rotational stability
Anatomy
o lies in Layer 3 with LCL
o characteristics
width 7mm at midpoint/near joint line
femoral attachment width 8mm
tibial attachment width 11mm
length 59mm
o attachments
femoral
lateral femoral epicondyle
tibial
midway between Gerdy's tubercle and head of fibula
o attachments to middle third of lateral meniscus body
meniscotibial portion (asterisk)
meniscofemoral portion (dot)
o lateral inferior genicular artery and vein contained between lateral meniscus and ALL at level of
joint line
o NO connections to ITB
Pathoanatomy
o Segond's fracture (associated with ACL rupture) is avulsion fracture of ALL
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Inspection
Skin
o scars
o trauma
o erythema
Swelling
Muscle atrophy
o normal quadriceps circumference
10 cm (VMO)
15 cm (quadriceps)
Asymmetry
Gait
o antalgia
o stride length
o muscle weakness
Standing limb alignment
o neutral, varus, valgus
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Palpation
Joint line tenderness
Tenderness over soft tissue structures
o pes anserine bursae
o patellar tendon
o iliotibial band
Point of maximal tenderness
Effusion
o patella balloting
o milking
Neurovascular Exam
Sensation
o medial thigh - obturator
o anterior thigh - femoral
o posterolateral calf - sciatic
o dorsal foot - peroneal
o plantar foot - tibial
Motor
o thigh adduction - obturator
o knee extension - femoral
o knee flexion - sciatic
o toe extension - peroneal
o toe flexion - tibial
Vascular
o pulses
popliteal
dorsalis pedis
posterior tibial
o ankle-brachial index
ABI < 0.9 is abnormal
ACL Injury
Large hemarthrosis
Quadriceps avoidance gait (does not actively extend knee)
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Lachman's test
o most sensitive exam test
o grading
A= firm endpoint, B= no endpoint
Grade 1: <5 mm translation
Grade 2 A/B: 5-10mm translation
Grade 3 A/B: >10mm translation
o PCL tear may give "false" Lachman due to posterior subluxation
Pivot shift
o extension to flexion: reduces at 20-30° of flexion
o patient must be completely relaxed (easier to elicit under anesthesia)
o mimics the actual giving way event
KT-1000
o useful to quantify anterior laxity
o measured with knee in slight flexion and 10-30° externally rotation
PCL Injury
Posterior sag sign
o patient lies supine with hips and knees flexed to 90°, examiner supports ankles and observes for a
posterior shift of the tibia as compared to the uninvolved knee
Posterior drawer (at 90° flexion)
o with the knee at 90° of flexion, a posteriorly directed force is applied to the proximal tibia and
posterior tibial translation is quantified
the medial tibial plateau of a normal knee at rest is ~1 cm anterior to the medial femoral
condyle
o most accurate maneuver for diagnosing PCL injury
Quadriceps active test
o attempt to extend a knee flexed at 90° to elicit quadriceps contraction
o positive if anterior reduction of the tibia occurs relative to the femur
Posterior sag sign Posterior drawer (at 90° flexion) External rotation recurvatum test
PCL PCL PLC
MCL Injury
Valgus instability = medial opening
o 30° only - isolated MCL
o 0° and 30° - combined MCL and ACL and/or PCL
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o classification
Grade I: 0-5 mm opening
Grade II: 6-10 mm opening
Grade III: 11-15 mm opening
Anterior Drawer with tibia in external rotation
o grade III MCL tears often associated with ACL and posteriomedial corner tears
o postive test will indicate associated ligamentous injury
LCL Injury
Varus instability = lateral opening
o 30° only - isolated LCL
o 0° and 30° - combined LCL and ACL and/or PCL
Varus opening and increased external tibial rotatory instability at 30° - combined LCL and
posterolateral corner
PLC Injury
Gait
o varus thrust or hyperextension thrust
Varus stress test
o varus laxity at 0° indicates both LCL & cruciate (ACL or PCL) injury
o varus laxity at 30° indicates LCL injury
Dial test
o > 10° ER asymmetry at 30° only consistent with isolated PLC injury
o > 10° ER asymmetry at 30° & 90° consistent with PLC and PCL injury
Posterolateral drawer test
o performed with the hip flexed 45°, knee flexed 80°, and foot ER 15°
o a combined posterior drawer and ER force is applied to the knee to assess for an increase in
posterolateral translation (lateral tibia externally rotates relative to lateral femoral condyle)
Reversed pivot shift test
o with the knee positioned at 90°, ER and valgus forces are applied to tibia
o as the knee is extended, the tibia reduces with a palpable clunk
tibia reduces from a posterior subluxed position at ~20° of flexion to a reduced position in
full extension (reduction force from IT band transitioning from a flexor to an extensor of the
knee)
External rotation recurvatum test
o positive when the leg falls into ER and recurvatum when the lower extremity is suspended by the
toes in a supine patient
Peroneal nerve assessment
o injury present with altered sensation to foot dorsum and weak ankle dorsiflexion
Meniscus Injury
Joint line tenderness
Effusion
McMurray's test
o flex the knee and place a hand on medial side of knee, externally rotate the leg and bring the
knee into extension
o a palpable pop or click is a positive test and can correlate with a medial meniscus tear
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Patella Pathology
Large hemarthrosis
o absence of swelling supports ligamentous laxity and habitual dislocation mechanism
Medial-sided tenderness (over MPFL)
Increase in passive patellar translation
o measured in quadrants of translation (midline of patella is considered "0") and should be
compared to contralateral side
o normal motion is <2 quadrants of patellar translation
lateral translation of medial border of patella to lateral edge of trochlear groove is considered
"2" quadrants and is an abnormal amount of translation
Patellar apprehension
Increased Q angle
J sign
o excessive lateral translation in extension which "pops" into groove as the patella engages the
trochlea early in flexion
o associated with patella alta
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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By Dr, AbdulRahman AbdulNasser Knee | Knee Introduction
3. Knee Imaging
High yield findings
Finding Importance
Segond sign Small tibial avulsion fracture that indicates a
ACL tear
Patella alta Patellofemoral pathology
Pellegrini Stieda Sign Medial femoral condyle avulsion fx (Chronic
MCL injury)
Patella baja Arthrofibrosis
Fairbanks changes DJD - post meniscectomy (square condyle,
peak eminences, ridging, narrowing)
Lateral medial femoral condyle lesion osteochondritis dissecans
Square lateral femoral condyle, cupped Discoid meniscus
lateral tibial plateau, hypoplastic lateral tibial
spine
3 sagittal MRI images Discoid meniscus
Bipartate patella Must differentiate from fracture
Radiographic
Standard Radiographs
o Weight-bearing
Preferred for evaluation of joint space.
o 45 degree PA flexion view (Rosenberg view)
best for early tibio-femoral arthritis, posterior wear
o Merchant or sunrise view
to evaluate patello-femoral space, tilt and alignment.
Stress Radiographs
o Varus-valgus stress radiographs
two diagnostic indications
physeal fractures in children
MCL / LCL injuries
o Posterior stress radiographs
III:7 : 45 degree PA flexion view
isolated PCL injury (10-12 mm posterior displacement)
(Rosenberg view)
PCL and PLC injury (> 12 mm posterior displacement)
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By Dr, AbdulRahman AbdulNasser Knee | Knee Introduction
Discoid meniscus
MRI
Views
o sagittal
evaluate menisci, cruciates, cartilage, extensor mechanism
o coronal
evaluate menisci, cruciates, collaterals, cartilage
o axial
evaluate patellofemoral joint, cruciates, popliteal fossa
Sequences
o T1
water dark, fat bright
best for showing anatomy, but not pathology
o T2
fat dark, water bright
well suited for imaging edema and pathology
o STIR (Short T1 Inversion Recovery) Images
fat suppression technique
improved quality imaging in the presence of orthopedic prostheses
Excellent for
o meniscal injury
Medial meniscal extrusion >3mm is associated with severe meniscal degeneration, a large
meniscal tear, or tear of the root
Radial meniscal tears are more common in patients following prior meniscal surgery (32%
prevalence of radial meniscal tears in post-op knees compared to 14% in patients without
prior surgery)
3.0 T MRI has accuracy, sensitivity, and specificity of >90% for detecting medial and lateral
meniscus tears
o ligament tear
Increased signal intensity, thickening, and cysts within and adjacent to ACL are common
findings, and clinically insignificant (no instability)
o bone bruise
near sulcus terminalis
osteochondral injury
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o PLC corner injuries
can routinely visualize LCL and popliteus tendon with MRI, other structures are more rarely
seen
edema posterior to popliteus tendon can indicate an injury to the underlying structures of the
PLC
Ultrasound
Excellent for
o fluid collections
useful to evaluate bursae and fluid collections about the knee
o arthrofibrosis
effective in detecting arthrofibrosis of the knee following TKA
key findings for arthrofibrosis are synovial thickening and neovascularity
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By Dr, AbdulRahman AbdulNasser Knee | Knee Introduction
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By Dr, AbdulRahman AbdulNasser Knee | Meniscal Injuries
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OrthoBullets2017 Knee | Meniscal Injuries
B. Meniscal Injuries
1. Meniscus
Function
Force transmission
o the meniscus functions to optimize force transmission across the knee. It does this by
increasing congruency
increases contact area leads to decreased point loading
shock-absorption
the meniscus is more elastic than articular cartilage, and therefore absorbs shock
transmits 50% weight-bearing load in extension, 85% in flexion
Stability
o the meniscus deepens tibial surface and acts as secondary stabilizer
medial meniscus
posterior horn of medial meniscus is the main secondary stabilizer to anterior translation
lateral meniscus
is less stabilizing and has 2X the excursion of the medial meniscus
o the menisci become primary stabilizers in the ACL-deficient knee
Composition
Made of fibroelastic cartilage
o interlacing network of collagen, proteoglycan, glycoproteins, and cellular elements
o composed of 65-75% water
Collagen
o 90 % Type I collagen
Fibers
o composed of two types of fibers which allow the meniscus to expand under compressive
forces and increase contact area of the joint
radial
longitudinal (circumferential)
help dissipate hoop stresses
vertical mattress captures
Anatomy
Gross Shape
o medial meniscus
C-shaped with triangular cross section
avarage width of 9 to 10mm
average thickness of 3 to 5mm
o lateral meniscus
is more circular (the horns are closer together and approximate the ACL)
covers a larger portion of the articular surface
average width is 10 to 12mm
average thickness is 4 to 5mm
Attachment
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By Dr, AbdulRahman AbdulNasser Knee | Meniscal Injuries
o transverse (intermeniscal) ligament
connects the medial and lateral meniscus anteriorly
o coronary ligaments
connects the meniscus peripherally
medial meniscus has less mobility with more rigid peripheral fixation than the lateral
meniscus
o meniscofemoral ligament
connects the meniscus into the substance of the PCL
originate from the posterior horn of the lateral meniscus and has two components
Humphrey ligament (anterior)
Ligament of Wrisberg (posterior)
Blood supply
o medial inferior genicular artery
supplies peripheral 20-30% of medial meniscus
o lateral inferior genicular artery
supplies peripheral 10-25% of lateral meniscus
central 75% receive nutrition through diffusion
Innervation
o peripheral two-thirds innervated by Type I and II nerve endings
o posterior horns have highest concentration of mechanoreceptors
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2. Meniscal Injury
Introduction
Epidemiology
o most common indication for knee surgery
o higher risk in ACL deficient knees
Location
o medial tears
more common than lateral tears
the exception is in the setting of an acute ACL tear where lateral tears are more common
degenerative tears in older patients usually occur in the posterior horn medial meniscus
o lateral tears
more common in acute ACL tears
Anatomy
Anatomy of meniscus
Classification
Horizontal Radial Longitudinal
Descriptive classification
o location
red zone (outer third, vascularized)
red-white zone (middle third)
white zone (inner third, avascular)
o size Flap Parrotbeak Bucket handle
o pattern
vertical/longitudinal
common, especially with ACL tears
repair when peripheral
bucket handle
vertical tear which may displace into the notch
oblique/flap/parrot beak
may cause mechanical locking symptoms
radial
horizontal
more common in older population
may be associated with meniscal cysts
complex
Presentation
Symptoms
o pain localizing to medial or lateral side
o mechanical symptoms (locking and clicking)
o delayed or intermittent swelling
Exam
o joint line tenderness is the most sensitive physical examination finding
o effusion
o provocative tests
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By Dr, AbdulRahman AbdulNasser Knee | Meniscal Injuries
Apley compression
prone
Thessaly test
Standing at 20 degrees of knee flexion on the affected limb, the patient twists with knee
external and internal rotation with positive test being discomfort or clicking.
McMurray's test
Flex the knee and place a hand on medial side of knee, externally rotate the leg and bring
the knee into extension.
A palpable pop / click + pain is a positive test and can correlate with a medial meniscus
tear.
Imaging
Radiographs
o Should be normal in young patients with an acute meniscal injury
o Meniscal calcifications may be seen in crystalline arthropathy (ex. CPPD)
MRI
o indications
MRI is most sensitive diagnostic test, but also has a high false positive rate
o findings
MRI grade III signal is indicative of a tear
linear high signal that extends to either superior or inferior surface of the meniscus
parameniscal cyst indicates the presence of a meniscal tear
may see "double PCL" or "double anterior horn" sign that indicates a bucket-handle
meniscal tear
Treatment
Non-operative
o rest, NSAIDS, rehabilitation
indications
indicated as first line of treatment for degenerative tears
Operative
o partial meniscectomy
indications
tears not amenable to repair (complex, degenerative, radial tear patterns)
repair failure >2 times
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outcomes
>80% satisfactory function at minimum follow-up
50% have Fairbanks radiographic changes (osteophytes, flattening, joint space narrowing)
predictors of success
age <40yo
normal alignment
minimal or no arthritis
single tear
o meniscal repair
indications
best candidate for repair is a tear with the following
characteristics
peripheral in the red-red zone (vascularized region)
Rim width is the distance from the tear to the peripheral meniscocapsular junction
(blood supply).
rim width correlates with the ability of a meniscal repair to heal (lower rim width has
better blood supply)
vertical and longitudinal tear : rather than radial, horizontal or degenerative tear
1-4 cm in length
acute repair combined with ACL reconstruction
traditional literature report higher healing rates with concurrent ACL
reconstruction
current literature shows no difference in healing for 2nd generation all-inside
repairs with/without concomittant ACL reconstruction
technique (see below)
outcomes
70-95% successful
highest success when done with concomitant ACL reconstruction
poor results with untreated ACL-deficiency (30%)
o meniscal transplantation
indications : young patients with near-total meniscectomy, especially lateral
contraindications
inflammatory arthritis
instability
marked obesity
grade IV chondrosis (if not concurrently addressed)
malalignment (if not concurrently addressed)
diffuse arthritis
technique (see below)
outcomes
requires 8-12 months for graft to fully heal
III:8 Meniscal allograft
return to sports by 6-9 months
10 year follow-up showed:
persistent improvement in subjective pain and function scores
most had radiographic progression of degenerative changes
re-tears or extrusion are common
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By Dr, AbdulRahman AbdulNasser Knee | Meniscal Injuries
o total meniscectomy
of historical interest only
outcomes
20% have significant arthritic lesions and 70% have radiographic changes three years
after surgery
100% have arthrosis at 20 years
severity of degenerative changes is proportional to % of the meniscus that was removed
Techniques
Partial Meniscectomy
o approach
standard arthroscopic approach
o technique
minimize resection (DJD proportional to amount removed)
do not use thermal (heat probes)
o postoperative
early active range of motion
prolonged immobilization (10 weeks) is detrimental to healing in a dog model
Meniscal repair
o approach
inside-out technique
considered gold standard
medial approach to capsule
expose capsule by incising the sartorius fascia
retract pes tendons / semimembranosus posteriorly
developing plane between the medial gastrocnemius and capsule
lateral approach to capsule
develop plane between IT band and biceps tendon
then retract lateral head of gastrocnemius posteriorly
all-inside technique (suture devices with plastic or bioabsorbable anchors)
most common
many complications (device breakage, iatrogenic chondral injury)
outside-in repair : useful for anterior horn tears
open repair : uncommon except in trauma, knee dislocations
o technique
vertical mattress sutures are strongest because they capture circumferential fibers
healing is enhanced by rasping
o risks
saphenous nerve and vein (medial approach)
peroneal nerve (lateral approach)
popliteal vessels
Meniscal Transplantation
o technique
bone to bone healing with plugs at each horn or a bridge between horns
peripheral vertical mattress sutures
correct sizing of the allograft is essential (commonly based on radiographs, within 5-10%
error tolerated)
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Complications
Saphenous neuropathy (7%)
Arthrofibrosis (6%)
Sterile effusion (2%)
Peroneal neuropathy (1%)
Superficial infection (1%)
Deep infection (1%)
3. Meniscal Cysts
Overview
A condition characterized by a local collection of synovial fluid within or adjacent to the meniscus
Epidemiology
o incidence
no studies of the general population
found in 1-4% of MRI studies of the knee
o demographics
most commonly associated with a meniscal tear
no trend to increased age
o location
perimeniscal cysts
small lesions of fluid within the meniscus
medial cysts are slightly more common than lateral, 2:1 ratio (although literature data are
conflicting)
medial cysts = posterior horn
lateral cysts = anterior horn or mid-portion
parameniscal cysts (e.g., baker cysts)
extruded fluid outside the meniscus (most common)
usually located between semimembranosus and medial head of gastrocnemius
Pathophysiology
o mechanism of injury
meniscal tear functions as a one-way valve
synovial fluid extrudes and then concentrates to form gel-like material
o pathoanatomy
horizontal and complex tears, usually = parameniscal cysts
radial or vertical tears, usually = perimeniscal cysts
Associated conditions
o articular cartilage injury
o anterior cruciate ligament tear
Anatomy
Meniscus
o composition
fibroelastic cartilage
interlacing network of collagen, proteoglycan, glycoproteins, and cellular elements
composed of 65-75% water
Collagen : 90 % Type I collagen
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By Dr, AbdulRahman AbdulNasser Knee | Meniscal Injuries
o shape
medial meniscus
stretched-out, C-shape with triangular cross section
lateral meniscus
more circular in shape
covers larger area of articular surface
o Blood supply
medial inferior genicular artery
supplies peripheral 20-30% of medial meniscus
lateral inferior genicular artery
supplies peripheral 10-25% of lateral meniscus
synovial fluid
central 75% of meniscus' receive nutrition through diffusion
Presentation
History
o may have recent trauma
Symptoms
o asymptomatic
o pain
localized to medial/lateral joint line or back of knee
o mechanical symptoms
locking and clicking
o delayed or intermittent knee swelling
o weakness or claudication (neaurovascular impingement)
Examination
o inspection
popliteal mass
best visualized with the knee in extension
o palpation
joint line tenderness
palpable mass
o motion
crepitus
Imaging
Radiographs
o should be normal in young patients with an acute meniscal injury or cyst
MRI
o indications
MRI is most sensitive diagnostic test for meniscal cyst and meniscal tear
o findings
cyst with bright T2 signal
necrotic tissue, nerve sheath tissue, and pus can all resemble cysts on T2-weighted MRIs
IV contrast enhancement may be needed
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Treatment
Non-operative
o rest, NSAIDS, rehabilitation
indications
indicated as first line of treatment for small perimeniscal cysts and parameniscal cysts
outcomes
trial of medical therapy to observe patients pain response
may be effective in population with degenerative tears
o aspiration and steroid injection
indication
isolated baker's cysts in young patient
technique
cyst drainage
ultrasound guided injection into the cyst
outcomes
poor outcomes in older degenerative mensical tears with associated cysts
Operative
o arthroscopic debridement, cyst decompression and meniscal resection
indications
perimeniscal cysts with an associated tear that is not amenable to repair (e.g., complex,
degenerative, radial tear patterns)
technique
decompress cyst completely
perform partial meniscectomy
outcomes
incomplete meniscal resection may lead to recurrence
o cyst excision using open posterior approach
indications
symptomatic parameniscal cysts
outcomes
incomplete resection may lead to recurrence
Technique
Cyst excision using open posterior approach
o patient prone
o curved incision over popliteal fossa
o interval between medial head of gastrocnemius and semimembranosus
o sharp dissection of cyst margins to joint capsule
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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By Dr, AbdulRahman AbdulNasser Knee | Meniscal Injuries
4. Discoid Meniscus
Introduction
Abnormal development of the meniscus leads to a hypertrophic and discoid shaped meniscus
o discoid meniscus is larger than usual
o also referred to as "popping knee syndrome"
Epidemiology
o incidence
present in 3-5% of population
o location
usually lateral meniscus involved
25% bilateral
Classification
Watanabe Classification
Type I • Incomplete
Type II • Complete
Type III • Wrisberg (lack of posterior meniscotibial attachment to tibia
Presentation
Symptoms
o pain, clicking, mechanical locking
o often becomes symptomatic in adolescence
Physical exam
o mechanical symptoms most pronounced in extension
Imaging
Radiographs
o recommended views
AP and lateral of knee
o findings
widened joint space due to widened cartilage space (up to 11mm)
squaring of lateral condyle with cupping of lateral tibial plateau
hypoplastic lateral intercondylar spine
MRI
o indications
study of choice for suspected symptomatic meniscal pathology
o findings
diagnosis can be made with 3 or more 5mm sagittal images with meniscal continuity ("bow-
tie sign")
sagittal MRI will show abnormally thick and flat meniscus
coronal MRI will show thick and flat meniscal tissue extending across entire lateral
compartment
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Treatment
Nonoperative
o observation
indications
asymptomatic discoid meniscus without tears
Operative
o partial meniscectomy and saucerization
indications
pain and mechanical symptoms
meniscal tear or meniscal detachment
technique
obtain anatomic looking meniscus with debridement
repair meniscus if detached (Wrisberg variant)
III:9 diagnosis can be made with 3 or more 5mm sagittal images with meniscal continuity ("bow-tie sign")
III:11 sagittal MRI will show abnormally III:10 coronal MRI will show thick and flat
meniscal tissue extending across entire lateral
thick and flat meniscus
compartment
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By Dr, AbdulRahman AbdulNasser Knee | Ligament Injury
C. Ligament Injury
1. ACL Tear
Introduction
Incidence
o ~400,000 ACL reconstructions / year
Mechanism is a non-contact pivoting injury
o video showing ACL tear in elite athlete
Often associated with a meniscal tear
o lateral meniscal tears in 54% of acute ACL tears
Chronic ACL deficient knees associated with
o chondral injuries
o complex unrepairable meniscal tears
o relation with arthritis is controversial
Sex-related differences
o ACL injury more common in female athlete (4.5 :1 ratio) due to
o landing biomechanics and neuromuscular activation patterns (quadriceps dominant) play biggest
role
o females get ACL injuries at younger age than males
o females get more ACL injuries on the supporting leg (males get more ACL injuries on the
kicking leg)
o table of differences( see below)
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OrthoBullets2017 Knee | Ligament Injury
Anatomy
ACL Function
o provides 85% of the stability to prevent anterior translation of the tibia relative to the femur
o acts as secondary restraint to tibial rotation and varus/valgus rotation
ACL Anatomy
o 32mm length x 7-12mm width in size
o goes from LFC to anterior tibia (tibial insertion is broad and irregular and inserts just anterior
and between the intercondylar eminences of the tibia)
o two bundles
anteromedial bundle
more isometric
tight throughout knee ROM, but tightest in flexion
primarily responsible for restraining anterior tibial translation (anterior drawer test)
posterolateral bundle
greater length changes
tightest in extension, slack in mid-flexion
primarily responsible for rotational stability (pivot shift test)
ACL Blood supply : middle geniculate artery
ACL Innervation : posterior articular nerve (branch of tibial nerve)
ACL Composition
o 90% Type I collagen
o 10% Type III collagen
ACL Strength: 2200 N
(anterior)
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By Dr, AbdulRahman AbdulNasser Knee | Ligament Injury
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OrthoBullets2017 Knee | Ligament Injury
Presentation
Presentation
o felt a "pop"
o pain deep in knee
o immediate swelling (70%) / hemarthrosis
Physical exam
o effusion
o quadricep avoidance gait (does not actively extend knee)
o Lachman's test
most sensitive exam test
grading
A= firm endpoint, B= no endpoint
Grade 1: 3-5 mm translation
Grade 2 A/B: 5-10mm translation
Grade 3 A/B: > 10mm translation
PCL tear may give "false" Lachman due to posterior subluxation
o Pivot shift
extension to flexion: reduces at 20-30° of flexion
patient must be completely relaxed (easier to elicit under anesthesia)
mimics the actual giving way event
o KT-1000
useful to quantify anterior laxity
measured with knee in slight flexion and externally rotated 10-30°
Imaging
Radiographs
o usually normal
o Segond fracture (avulsion fracture of the proximal lateral tibia) is pathognomonic for an ACL
tear
represents bony avulsion by the anterolateral ligament (ALL)
associated with ACL tear 75-100% of the time
o deep sulcus (terminalis) sign
Depression on the lateral femoral condyle at the terminal sulcus, a junction between the
weight bearing tibial articular surface and the patellar articular surface of the femoral condyle
MRI
o findings of torn ACL
sagittal view
ACL fibers
discontinuity of fibers on T2
abnormal orientation
too "flat" compared with intercondylar roof / Blumensaat's line
this acute angle is common in chronic cases where ACL scars to the PCL
non-visualization of ACL
bone bruising in > half of acute ACL tears
middle 1/3 of LFC (sulcus terminalis)
posterior 1/3 of lateral tibial plateau
subchondral changes on MRI can persist years after injury
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By Dr, AbdulRahman AbdulNasser Knee | Ligament Injury
coronal view
discontinuity of fibers (do not reach the femur)
fluid against lateral wall ("empty notch sign")
o findings of normal ACL
fibers steeper than intercondylar roof
continuity of fibers all the way from tibia to femur
Segond fracture deep sulcus (terminalis) sign Sagittal view of ACL tear
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Treatment
Nonoperative
o physical therapy & lifestyle modifications
low demand patients with decreased laxity
increased meniscal/cartilage damage linked to
loss of meniscal integrity
frequency of buckling episodes
level I and II activity (e.g. jumping, cutting, side-to-side sports, heavy manual labor)
Operative
o ACL reconstruction
indications
younger, more active patients (reduces incidence of meniscal or chondral injury)
children (strongly consider operative as activity limitation is not realistic)
older active patients (age >40 is not contraindication if high demand athlete)
prior ACL reconstruction failure
associated injuries
MCL injury
allow MCL to heal (varus/valgus stability) and then perform ACL reconstruction
varus/valgus instability can jeopardize graft
meniscal tear
perform meniscal repair at same time as ACL reconstruction
increased meniscal healing rate when repaired at the same time as ACL
posterolateral corner injury
reconstruct at the same time as ACL or as 1st stage of 2 stage reconstruction
outcomes
return to play
largely influenced by psycholgical, demographic and functional outcomes
o ligament repair
traditionally has high failure rate
arthroscopic bridge-enhanced ACL repair (BEAR) trial with a bridging scaffold is ongoing
o revision ACL reconstruction
indications
failure of prior ACL reconstruction
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By Dr, AbdulRahman AbdulNasser Knee | Ligament Injury
Surgical Techniques
Femoral tunnel placement
o proper placement
sagittal plane
1-2 mm rim of bone between tunnel and posterior cortex of femur
coronal plane
tunnel should be placed on lateral wall (9-10 o'clock position) to create more horizontal
graft
Tibial tunnel placement
o proper placement
sagittal plane
center of tunnel entrance into joint should be 10-11mm in front of anterior border of PCL
insertion
coronal plane
tunnel trajectory of < 75° from horizontal
obtain by moving tibial starting point halfway between tibial tubercle and posterior
medial edge of tibia.
Graft placement
o graft preconditioning
can reduce stress relaxation up to 50%
o graft tensioning
graft tensioning at 20N or 40N had no clinical outcome effects in a level 1 study
fix graft in 20-30° of flexion
High tibial osteotomy
o limb malalignment in both the coronal and sagittal plane must be addressed before or at the same
time as ligament reconstruction
Revision ACL reconstruction
o technique
use high strength grafts (quad tendon, hamstring, allograft)
use dual fixation (suspension + interference screws)
bone grafting (tunnel dilation, decreased bone stock, staged prn)
reharvesting BTB contraindicated
o postoperative
conservative rehab
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Graft Selection
Bone patellar bone autograft
o advantage of autograft
using patient's own tissue
most common source of graft
faster incorporation
less immune reaction
no chance of acquiring someone else's infection
o pros and cons of bone-patella-bone
longest history of use, considered the "gold standard"
III:12 Bone patellar bone autograft
bone to bone healing
ability to rigidly fix at the joint line (screws)
highest incidence of anterior knee pain (up to 10-30%)
maximum load to failure is 2600 Newtons (intact ACL is 1725 Newtons)
o complications
patella fracture (usually postop during rehab), patellar tendon rupture
rerupture
associated with age < 20 years and graft size < 8mm
Quadruple hamstring autograft
o technique
may be taken from contralateral side in revision situation when allograft is not desirable or
available
o pros and cons
smaller incision, less periop pain, less anterior knee pain
fixation strength may be less than Bone-PT-Bone
maximum load to failure is approximately 4000 Newtons
decreased peak flexion strength at 3 years compared to Bone-PT-Bone
concern about hamstring weakness in female athletes leading to increased risk of re-rupture
o complications
"windshield wiper" effect (suspensory fixation away from joint line causes tunnel abrasion
and expansion with flexion/extension of knee)
residual hamstring weakness
Allograft
o pros & cons
useful in revisions
longer incorporation time
risk of disease transmission (HIV is < 1:1 million, hepatitis is even greater)
increased risk of re-rupture in in young athletes
odds of graft rerupture are 4.3 x higher in allograft for athletes aged 10-19
o graft processing
supercritical CO2: decreases the structural and mechanical properties
radiation: > 3 Mrads is required to kill HIV (this however decreases the structural and
mechanical properties)
2-2.8 Mrad decreases stiffness by 30%
1-1.2 Mrad decreases stiffness by 20%
deep freezing: destroys cells but does not affect strength of graft
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4% chlorhexidine gluconate: destroys cells but does not affect strength of graft
Quadriceps tendon autograft
o taken with patella bone plug
o much less common
Pediatric Considerations
Physis
o < 14 yrs with open physis
o onset of menarche is best determinant of skeletal maturity in females
Treatment
o Nonoperative
indications
compliant, low demand patient with no additional intra-articular pathologies
partial ACL tear (60% of adolescents have partial tears) with near normal Lachman and
pivot shift
o Surgery
indications
complete ACL tear
Techniques
o intra-articular
physis-sparing (all intra-epiphyseal)
transphyseal (males ≤13-16, females ≤ 12-14)
partial transphyseal
leave either distal femoral or proxiaml tibial physis undisturbed
no significant difference in growth disturbances between techniques
o combined intra- and extra-articular (males ≤12, females ≤ 11)
autogenous ITB harvested free proximally, left attached distally to Gerdy's tubercle
looped through the knee in over the top position
passed through the notch and under intermeniscal ligament anteriorly
sutured to lateral femoral condyle and proximal tibia
o adult type reconstruction (males >=16, females >=14)
Graft Selection
o transphyseal soft tissue grafts rarely lead to growth disturbances
Instrumentation
o Factors found to increase physeal injury include:
large tunnel diameter (>12mm) is most important
8mm tunnel corresponds to <3% physeal cross-sectional area
12mm tunnel corresponds to >7-9% of physeal cross sectional area is violated
oblique tunnel position
interference screw fixation
high-speed tunnel reaming
lateral extra articular tenodesis
dissection close to perichondral ring of LaCroix
suturing near tibial tubercle
Complications
o Physeal disruption without growth disturbance (10%)
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Rehabilitation
Early postoperative
o immediate
aggressive cryotherapy (ice)
immediate weight bearing (shown to reduce patellofemoral pain)
emphasize early full passive extension (especially if associated with MCL injury or patella
dislocation)
o early rehab
focus rehab on exercises that do not place excess stress on graft
appropriate rehab
eccentric strengthening at 3 weeks has been shown to result in increased quadriceps
volume and strength
isometric hamstring contractions at any angle
isometric quadriceps, or simultaneous quadriceps and hamstrings contraction
active knee motion between 35 degrees and 90 degrees of flexion
emphasize closed chain (foot planted) exercises
avoid
isokinetic quadricep strengthening (15-30°) during early rehab
open chain quadriceps strengthening
Injury prevention
o female athlete
neuromuscular training / plyometrics (jump training)
land from jumping in less valgus and more knee flexion
increasing hamstring strength to decrease quadriceps dominance ratio
o skier training
teach skiers how to fall
o ACL bracing
no proven efficacy except for ACL-deficient skiers
Complications
Failure due to Tunnel Malposition
o overview
is the most common cause of ACL failure
improper tunnel placement causes failure in 70%
o femoral tunnel malposition
coronal plane
vertical femoral tunnel placement
cause by starting femoral tunnel at vertical position in notch (12 o:clock) as opposed
to lateral wall (9 o:clock)
will cause continued rotational instability which can be identified on physical exam
by a positive pivot shift
sagittal plane
anterior tunnel placement
leads to a knee that is tight in flexion and loose in extension
occurs from failure to clear "residents ridge"
posterior misplacement (over-the-top)
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o treatment
immediate arthroscopic I&D
often can retain graft with multiple I&Ds and abx (6 weeks minimum)
graft retention more likely to be successful with S. epidermidis
graft retention less likely to be successful with S. aureus
Loss of motion & arthrofibrosis
o preoperative prevention
be sure patient has regained full ROM before you operate ("pre-hab")
wait until swelling (inflammatory phase) has gone down to reduce incidence of arthrofibrosis
o operative prevention
proper tunnel placement is critical to have full range of motion
o postop prevention : aggressive cryotherapy (ice)
o treatment
< 12 weeks, then treat with aggressive PT and serial splinting
> 12 weeks, then treat with lysis of adhesions / manipulation under anesthesia
Infrapatellar contracture syndrome
o an uncommon complication following knee surgery or injury which results in knee stiffness
o physical exam will show decreased patellar translation
Patella Tendon Rupture : will see patella alta on lateral radiograph
RSD (complex regional pain syndrome)
Patella fracture
o most fx occur 8-12 weeks postop
Hardware failure
Tunnel osteolysis : treat with observation
Late arthritis : related to meniscal integrity
Local nerve irritation : saphenous nerve
Cyclops lesion
o fibroproliferative tissue blocks extension
o "click" heard at terminal extension
2. PCL Injury
Introduction
Injuries may be isolated or combined and often go undiagnosed in the acutely injured knee
Epidemiology
o incidence
5-20% of all knee ligamentous injuries
Pathophysiology
o mechanism
direct blow to proximal tibia with a flexed knee (dashboard injury)
noncontact hyperflexion with a plantar-flexed foot
hyperextension injury
o pathoanatomy
PCL is the primary restraint to posterior tibial translation
functions to prevent hyperflexion/sliding
isolated injuries cause the greatest instability at 90° of flexion
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Associated conditions
o combined PCL and posterolateral corner
(PLC) injuries
o multiligamentous knee injuries
o knee dislocation
Prognosis
o chronic PCL deficiency
PCL deficiency leads to increased
contact pressures in
the patellofemoral and medial
compartments of the knee due to varus
alignment
controversial whether late patellar and
MFC chondrosis will develop
Anatomy
PCL anatomy
o origin
posterior tibial sulcus below the articular surface
o insertion
anterolateral medial femoral condyle
broad, crescent-shaped footprint
o dimensions
38 mm in length x 13 mm in diameter
PCL is 30% larger than the ACL
o PCL has two bundles
anterolateral bundle III:14 MeniscoFemoral Ligaments
tight in flexion
strongest and most important for posterior stability at
90° of flexion
mnemonic "PAL" - PCL has an AnteroLateral bundle
posteromedial bundle
tight in extension
reciprocal function to the anterolateral bundle
o lies between the meniscofemoral ligaments
ligament of Humphrey (anterior) and ligament of III:15 Tibial insertion of PCL
Wrisberg (posterior)
originate from the posterior horn of the lateral
meniscus and insert into PCL substance
Blood supply
o supplied by branches of the middle geniculate artery and fat
pad
Biomechanics
o strength is 2500 to 3000 N (posterior)
o Minimizes posterior tibial displacement (95%)
III:16 Femoral Insertion of PCL
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Classification
Classification based on posterior subluxation of tibia relative to femoral condyles (with knee in 90°
of flexion)
o Grade I (partial)
1-5 mm posterior tibial translation
tibia remains anterior to the femoral condyles
o Grade II (complete isolated)
6-10 mm posterior tibial translation
complete injury in which the anterior tibia is flush with the
femoral condyles
o Grade III (combined PCL and capsuloligamentous)
>10 mm posterior tibial translation III:17 Two bundles of PCL
tibia is posterior to the femoral condyles and often indicates an associated ACL and/or PLC
injury
Presentation
History
o differentiate between high- and low-energy trauma
dashboard injury
hyperflexion athletic injury with a plantar-flexed foot
o ascertain a history of dislocation or neurologic injury III:18 Posterior sag sign
Symptoms
o posterior knee pain
o instability
often subtle or asymptomatic in isolated PCL injuries
Physical exam
o varus/valgus stress
laxity at 0° indicates MCL/LCL and PCL injury
laxity at 30° alone indicates MCL/LCL injury
III:19 Posterior drawer test
o posterior sag sign
patient lies supine with hips and knees flexed to 90°, examiner supports ankles and observes
for a posterior shift of the tibia as compared to the uninvolved knee
the medial tibial plateau of a normal knee at rest is 10 mm anterior to the medial femoral
condyle
an absent or posteriorly-directed tibial step-off indicates a positive sign
o posterior drawer test (at 90° flexion)
with the knee at 90° of flexion, a posteriorly-directed force is applied to the proximal tibia
and posterior tibial translation is quantified
isolated PCL injuries translate >10-12 mm in neutral rotation and 6-8 mm in internal
rotation
combined ligamentous injuries translate >15 mm in neutral rotation and >10 mm in
internal rotation
most accurate maneuver for diagnosing PCL injury
o quadriceps active test
attempt to extend a knee flexed at 90° to elicit quadriceps contraction
positive if anterior reduction of the tibia occurs relative to the femur
o dial test
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> 10° ER asymmetry at 30° & 90° consistent with PLC and PCL injury
> 10° ER asymmetry at 30° only consistent with isolated PLC injury
o KT-1000 and KT-2000 knee ligament arthrometers
used for standardized laxity measurement although less accurate than for ACL
Imaging
Radiographs
o recommended views
AP and supine lateral
may see avulsion fractures with acute injuries
assess for posterior tibiofemoral subluxation
medial and patellofemoral compartment arthrosis may be present with chronic injuries
lateral stress view
apply stress to anterior tibia with the knee flexed to 70°
asymmetric posterior tibial displacement indicates PCL injury
contralateral knee differences >12 mm on stress views suggest a combined PCL and PLC
injury
becoming the gold standard in diagnosing and quantifying PCL injuries
kneeling stress radiographs of knee
MRI
o confirmatory study for the diagnosis of PCL injury
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By Dr, AbdulRahman AbdulNasser Knee | Ligament Injury
o technique
transtibial drilling anterior to posterior
fix graft in 90° flexion with an anterior drawer
results in knee biomechanics similar to native
knee
o pros & cons : risk to popliteal vessels
Open (tibial inlay)
o approach
uses a posteromedial incision between medial head
of gastrocnemius and semimembranosus
o technique : used for ORIF of bony avulsion
o pros & cons III:20 Rehabilitation : focus on quadriceps
biomechanical advantage with a decrease in the "killer turn" with less graft attenuation and
failure
screw fixation of the graft bone block is within 20 mm of the popliteal artery
Single-bundle technique
o approach : arthroscopic or open
o technique
reconstruct the anterolateral bundle
tension at 90° of flexion
Double-bundle technique
o approach : arthroscopic or open techniques may be utilized
o technique
anterolateral bundle tensioned in 90° of flexion
posteromedial bundle tensioned in extension
o pros & cons
biomechanical advantage with knee function in flexion and
extension
clinical advantage has yet to be determined
may be advantageous to perform with combined PCL/PLC
injuries for better rotational control as PLC reconstructions
typically loosen over time
Rehabilitation
Postoperative care
o immobilize in extension early and protect against gravity
o early motion should be in prone position III:21 Popliteal artery in relation to PCL
Rehabilitation
o focus on quadriceps rehabilitation
o avoid resisted hamstring strengthening exercises (ex. hamstring curls) in early rehab
this is because the hamstrings create a posterior pull on the tibia which increases stress on the
graft.
Complications
Popliteal artery injury: at risk when drilling the tibial tunnel
o lies just posterior to PCL insertion on the tibia, separated only by posterior capsule
Patellofemoral pain/arthritis : due to chronic PCL deficiency
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OrthoBullets2017 Knee | Ligament Injury
Anatomy
Ligaments of the knee
Medial capsulo-ligamentous complex of the knee
o function
resist valgus and external forces at the knee
o composition
it is composed of 3 layers which extend from the anterior midline to the posterior midline
it contains both static and dynamic stabilizers
static stabilizers
superficial MCL
primary restraint to valgus stress
deep MCL and posterior oblique ligaments
secondary restraints to valgus stress
dynamic stabilizers
semimembranosus complex
consists of 5 attachments
vastus medialis
medial retinaculum
pes anserine muscle group : sartorius, semitendinosus , gracilis
Blood supply : superior medial and inferior medial geniculate arteries
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By Dr, AbdulRahman AbdulNasser Knee | Ligament Injury
Classification
Classification of MCL Sprains
o Grade 1
mild severity
no loss of ligamentous integrity (stretch injury)
minimal torn fibers
o Grade II
moderate severity
incomplete tearing of MCL (partial tear)
increased joint laxity
end point found at 30 degrees of flexion with valgus stress
fibers remain apposed
o Grade III
severe
complete disruption of ligament (complete tear)
gross laxity
no end point with valgus stress at 30 degrees of knee flexion
Presentation
History : "pop" reported at time of injury
Symptoms
o medial joint line pain
o difficulty ambulating due to pain or instability
Physical exam
o inspection and palpation
tenderness along medial aspect of knee
ecchymosis
knee effusion
o ROM & stability
valgus stress testing at 30 degrees knee flexion
isolates the superficial MCL
medial gapping as compared to opposite knee indicates grade of injury
1- 4 mm = grade I
5-9 mm = grade II
> or equal to 10 mm = grade III
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valgus stressing at 0 degrees knee extension
medial laxity with valgus stress indicates posteromedial capsule or cruciate ligament
injury
o neurovascular exam
saphenous nerve exam
o evaluate for additional injuries
ACL
PCL
patellar dislocation
medial meniscal tear
Imaging
Radiographs
o recommended : AP and lateral
o optional view
stress radiographs in skeletally immature patient III:22 Valgus stress test
may indicate gapping through physeal fracture
o findings
usually normal
calcification at the medial femoral insertion site (Pellegrini-Stieda Syndrome)
MRI
o modality of choice for MCL injuries
o identifies location and extent of injury
o useful for evaluating other injuries
Treatment
Nonoperative
o NSAIDs, rest, therapy
indications
grade I
therapy
quad sets, SLRs, and hip adduction above the knee to begin immediately
cycling and progressive resistance exercises as tolerated
return to play
grade I may return to play at 5-7 days
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By Dr, AbdulRahman AbdulNasser Knee | Ligament Injury
o bracing, NSAIDs, rest, therapy
indications
grades II
grade III
if stable to valgus stress in full extension
no associated cruciate injury
technique
immobilizer for comfort
hinged knee brace for ambulation
return to play
grade II return to play at 2-4 weeks
grade III return to play at 4-8 weeks
outcomes : distal MCL injuries have less healing potential than proximal injuries
Operative
o ligament repair vs. reconstruction
relative indications
Acute repair in grade III injuries
in the setting of multi-ligament knee injury
displaced distal avulsions with "stener-type" lesion
entrapment of the torn end in the medial compartment
Sub-acute repair in grade III injuries
continued instability despite nonoperative treatment
>10 mm medial sided opening in full extension
Reconstruction
chronic injury
loss of adequate tissue for repair
technique
diagnostic arthroscopy recommended for all surgical candidates to rule out associated
injuries
Prevention
o knee bracing
functional bracing may reduce MCL injury in football players, particularly interior linemen
Techniques
MCL repair
o approach
medial approach to the knee
o indications
acute injuries
o techniques
ligament avulsions
should be reattached with suture anchors in 30 degrees of flexion
interstitial disruption
anterior advancement of the MCL to femoral and tibial origins
MCL reconstruction
o approach
medial approach to the knee
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o indications
chronic instability
insufficient tissue for repair
o graft type
can use semitendinosus autograft or hamstring, tibialis anterior or Achilles tendon allograft
Complications
Loss of motion
Neurological injury : saphenous nerve
Laxity : associated with distal MCL injuries
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Blood supply
o superolateral and inferolateral geniculate arteries
Biomechanics
o function
primary restraint to varus stress at 5° and 25° of knee flexion
provides 55% of restraint at 5°
provides 69% of restraint at 25°
secondary restraint to posterolateral rotation with <50° flexion
resists varus in full extension along with ACL and PCL
o located behind the axis of knee rotation
tight in extension and lax in flexion
o tensile strength: 750 N (valgus)
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Classification
LCL/PLC injury
o based on quantification of lateral joint opening as compared with the normal contralateral knee
with varus stress
grade 1+: 0-5 mm lateral opening
grade 2+: 6-10 mm lateral opening
grade 3+: >10 mm lateral opening without an endpoint
o sprains classified according to amount of ligamentous disruption
grade I: minimal
grade II: partial
grade III: complete
Imaging
Radiographs
o recommended views : AP, lateral, and varus stress radiographs
MRI
o imaging modality of choice
o provides information about severity (complete vs. partial rupture) and location (avulsion vs.
midsubstance tear)
Treatment
Nonoperative
o limited immobilization, progressive ROM, and functional rehabilitation
indications : isolated grade I or II LCL injury (no instability at 0°)
outcomes
return to sport expected in 6-8 weeks
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progressive varus/hyperextension laxity can occur with unrecognized associated injuries
to the PLC
Operative
o LCL repair/reconstruction +/- PLC/ACL/PCL reconstruction
indications
grade III LCL injury
rotatory instability involving LCL/PLC
posterolateral instability (LCL/PLC) at 0° (ACL/PCL rupture)
outcomes : more favorable outcomes with surgery when injuries are acute
Surgical Techniques
Acute LCL repair
o approach
lateral approach to the knee
uses the interval between iliotibial band (superior gluteal nerve) and biceps femoris
(sciatic nerve)
incise the fascia between ITB and biceps to expose the LCL insertion on the fibular head
develop a second interval proximally within ITB to identify the lateral femoral
epicondyle
o techniques
suture anchors for repair of avulsed ligament
direct suture repair for midsubstance ruptures
repair torn or avulsed ligament within 2 weeks of injury (reconstruct if native tissue is
irreparable)
LCL +/- PLC reconstruction
o approach
lateral approach to the knee : between ITB and biceps femoris as detailed above
o techniques
single-stranded graft (bone-patellar tendon-bone) for isolated LCL injuries
fibular-based reconstruction (Larson technique) for LCL and popliteofibular ligament
reconstruction
hamstring graft passed through bone tunnel in fibular head
limbs crossed to create figure-of-eight which is then fixed to lateral femur
transtibial double-bundle reconstruction of LCL and popliteofibular ligament
split Achilles tendon is fixed to the isometric point of the femoral epicondyle
one limb is fixed to the fibular head with a bone tunnel and transosseous sutures to
reconstruct the LCL
second limb is brought through the posterior tibia to reconstruct the popliteofibular
ligament
anatomic reconstruction of multiple injured structures (LCL, popliteus tendon, and
popliteofibular ligament) using bifid graft (split Achilles tendon)
Complications
Persistent varus or hyperextension laxity
Peroneal nerve injury
Stiffness
Hardware irritation
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Anatomy
PLC structures
o static structures
LCL (most anterior structure inserting on the fibular head)
popliteus tendon
popliteofibular ligament
lateral capsule
arcuate ligament (variable)
fabellofibular ligament (variable)
o dynamic structures
biceps femoris (inserts on the posterior aspect of the fibula posterior to LCL)
popliteus muscle
iliotibial tract
lateral head of the gastrocnemius
Function
o popliteus works synergistically with the PCL to control external rotation, varus, and posterior
translation
o popliteus and popliteofibular ligament function maximally in knee flexion to resist external
rotation
o LCL is primary restraint to varus stress at 5° (55%) and 25° (69%) of knee flexion
Definitions
o arcuate complex includes the static stabilizers: LCL, arcuate ligament, and popliteus tendon
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Classification
Grade I (0-5mm of lateral opening and minimal ligament disruption)
Grade II (5-10mm of lateral opening and moderate ligament disruption)
Grade III (>10mm of lateral opening and severe ligament disruption and no endpoint)
Presentation
Symptoms
o often have instability symptoms when knee is in full extension
difficulty with reciprocating stairs, pivoting, and cutting
Physical exam
o gait exam : varus thrust or hyperextension thrust
o varus stress
varus laxity at 0° indicates both LCL & cruciate (ACL or PCL) injury
varus laxity at 30° indicates LCL injury
o dial test
> 10° external rotation asymmetry at 30° only consistent with isolated PLC injury
> 10° external rotation asymmetry at 30° & 90° consistent with PLC and PCL injury
o external rotation recurvatum
positive when lower leg falls into external rotation and recurvatum when leg suspended by
toes in supine patient
o posterolateral drawer test
performed with the hip flexed 45°, knee flexed 80°, and foot is ER 15°.
a combined posterior drawer and external rotation force is then applied to the knee to assess
for an increase in posterolateral translation (lateral tibia externally rotates relative to lateral
femoral condyle)
o reverse pivot shift test
knee positioned at 90° and external rotation and valgus force applied to tibia
as the knee is extended the tibia reduces with a palpable clunk
tibia reduces from a posterior subluxed position at ~20° of flexion to a reduced position in
full extension (reduction force from IT band transitioning from a flexor to an extensor of
the knee)
o peroneal nerve injury
altered sensation to dorsum of foot and weak ankle dorsiflexion
approximately 25% of patients have peroneal nerve dysfunction
Arcuate fracture
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Imaging
Radiographs
o may see avulsion fracture of the fibula (arcuate fracture ) or
femoral condyle
o stress radiography can be done but MRI is diagnostic study of
choice
MRI
o look for injury to the LCL, popliteus, and biceps tendon
o in acute injury may see bone bruising of medial femoral
III:27 Stress I II:26 Bone contusions of
condyle and medial tibial plateau radiography tibial plateau and medial
femoral condyle
Treatment
Nonoperative
o immobilize knee in full extension with protected weightbearing for ~2 weeks
indications
in isolated PLC Grade I or II injuries
followed by progressive functional rehabilitation focusing on quad strengthening with return
to sports in 8 weeks
Operative
o PLC repair
indications
only in isolated PLC injuries with bony or soft tissue avulsion
able to operate within 2 weeks of injury
techniques
may need to augment PLC repair with free graft
avulsion fx of fibular head can be treated with screws or suture anchors
o PLC reconstruction
indications
used for most grade III isolated injuries
when repair not possible or has poor tissue quality
techniques
goal is to reconstruct LCL and the popliteofibular ligament using a free tendon graft
(semitendinosus or achilles)
fibular-based reconstruction (Larson)
hamstring graft passed through bone tunnel in fibular head
limbs crossed to create figure-of-eight and fixed to lateral femur
trans-tibial double-bundle reconstruction
split achilles tendon is fixed to isometric point of the femoral epicondyle.
one branch is fixed to the fibular head with a bone tunnel and transosseous sutures to
reconstruct the LCL.
second limb is brought through the posterior tibia to reconstruct the popliteofibular
ligament
postop : 4 weeks of postop cast controls leg ER better than knee brace
outcomes
operative treatment has improved outcomes compared to nonoperative treatment
repair has higher failure rate than reconstruction
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improved outcomes with early treatment
Complications
Arthrofibrosis
Missed PLC injury
o failure to identify a PLC injury combined with an ACL injury will lead to failure of the ACL
reconstruction
Peroneal nerve injury (15-29%)
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Anatomy
Arthrology
o proximal fibula articulates with a facet of the lateral cortex of the tibia
distinct from the articulation of the knee
o joint is strengthened by anterior and posterior ligaments of the fibular head
Nerves
o common peroneal nerve lies distal to the proximal tibiofibular joint on the posterolateral aspect
of the fibular neck
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Anatomy: joint is strengthened by anterior and posterior ligaments of the fibular head
Ogden classification
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Classification
Ogden classification
o subluxation and 3 types of dislocation
anterolateral - most common
posteromedial
superior
Presentation
Symptoms
o lateral knee pain
symptoms can mimic a lateral meniscal tear III:29 Anterolateral dislocation, the arrow indicate the
o instability original site of the fibular head
Physical exam
o tenderness about the fibular head
o comparison of bilateral knees with palpation of normal anatomic landmarks and their relative
positions can clarify the diagnosis
Imaging
Radiographs
o recommended views
AP and lateral of both knees
comparison views of the contralateral knee are essential
CT scan
o clearly identifies the presence or absence of dislocation
Treatment
Nonoperative
o closed reduction
indications
III:30 Closed reduction and pinning
acute dislocations
technique
flex knee 80°-110° and apply pressure over the fibular head opposite to the direction of
dislocation
post-reduction immobilization in extension vs. early range of motion (controversial)
outcomes
commonly successful with minimal disadvantages
Operative
o surgical soft tissue stabilization vs. open reduction and pinning vs. arthrodesis vs. fibular
head resection
indications
chronic dislocation with chronic pain and symptomatic instability
Complications
Recurrence
Common peroneal nerve injury : usually seen with posterior dislocations
Arthritis : rarely occurs and is usually minimally symptomatic
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OrthoBullets2017 Knee | Knee Overuse Injuries
1. Patellar Tendinitis
Introduction
Definition
o activity-related anterior knee pain associated with focal patellar-tendon tenderness
o also known as "jumper's knee"
Epidemiology
o incidence
up to 20% of jumping athletes
o demographics / risk factors
males > females
volleyball most common
more common in adolescents/young adults
quadriceps tendinopathy is more common in older adults
poor quadriceps and hamstring flexibility
Pathophysiology
o mechanism
repetitive, forceful, eccentric contraction of the extensor mechanism
o histology
degenerative, rather than inflammatory
micro-tears of the tendinous tissue are commonly seen
Classification
Blazina classification system
o phase I
pain after activity only
o phase II
pain during and after activity
o phase III
persistent pain with or without activities
deterioration of performance
Presentation
Symptoms
o insidious onset of anterior knee pain at inferior border of patella
initial phase
pain following activity
late phase
pain during activity
pain with prolonged flexion ("movie theater sign")
Physical exam
o inspection
may have swelling over tendon
o palpation
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By Dr, AbdulRahman AbdulNasser Knee | Knee Overuse Injuries
tenderness at inferior border of patella
o provocative tests
Basset's sign
tenderness to palpation at distal pole of patella in full extension
no tenderness to palpation at distal pole of patella in full flexion
Imaging
Radiographs
o recommended views
AP, lateral, skyline views of knee
o findings
usually normal
may show inferior traction spur (enthesophyte) in chronic cases
Ultrasound
o findings
thickening of tendon
hypoechoic areas
MRI
o indications
chronic cases
surgical planning
o findings
tendon thickening
more diagnostic than presence of edema
increased signal intensity on both T1 and T2 images
loss of the posterior border of fat pad in chronic cases
Treatment
Nonoperative
o ice, rest, activity modification, followed by physical therapy
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indications
most cases
technique
physical therapy
stretching of quadriceps and hamstrings
eccentric exercise program
ultrasound treatment may be helpful
taping or Chopat's strap can be used to reduce tension
across patellar tendon
o cortisone injections
are contraindicated due to risk of patellar tendon rupture
Operative
o surgical excision and suture repair as needed
indications
Blazina Stage III disease
chronic pain and dysfunction not amendable to conservative treatment
partial tears
technique
can be done open or arthroscopic
resect angiofibroblastic and mucoid degenerative area
follow with bone abrasion at tendon insertion and suture repair/anchors as needed
postoperative rehab
initial immobilization in extension
progressive range-of-motion and mobilization exercises as tolerated
weight bearing as tolerated
outcomes
return to activities is achieved by 80% to 90% of athletes
there may be activity-related aching for 4 to 6 months after surgery
2. Quadriceps Tendonitis
Introduction
Inflammation of the suprapatellar tendon of the quadriceps muscle
Epidemiology
o demographics
8:1 male-to-female ratio
more common in adult athletes
o risk factors
jumping sports
basketball
volleyball
athletics (e.g., long jump, high jump, etc)
Pathophysiology
o mechanism of injury
occurs as the result of repetitive eccentric contractions of the extensor mechanism
o pathoanatomy : microtears of the tendon most commonly at the bone-tendon interface
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Associated conditions
o Jumper's knee
patellar tendonitis
more commonly affects the insertion of the patella tendon at the patella.
less commonly the insertion at the tibial tubercle
o Quadriceps tendinosis
chronic quad tendon degeneration with no inflammation
Anatomy
Knee extensor mechanism
o quadriceps muscles
rectus femoris, vastus medialis, vastus lateralis, vastus intermedius
o quadriceps tendon
common trilaminar tendon of quadriceps muscles
anterior layer = rectus femoris
middle layer = vastus medialis and vastus lateralis
deep layer = vastus intermedius
Vascular supply
o medial, lateral and peripatellar arcades
Innervation
o innervated by muscular branches of the femoral nerve (L2, L3, L4)
Presentation
History
o overuse injury in a jumping athlete
o recent increase in athletic demands or activity
o often a recurring injury
Symptoms
o pain localized to the superior border of patella
o worse with activity
o associated swelling
Physical examination
o inspection
knee alignment
swelling
o palpation
tenderness to deep palpation at quadriceps tendon insertion at the patella
palpable gap would suggest a quads tendon tear
patellar subluxation
o motion
pain with resisted open chain knee extension
able to actively extend the knee against gravity
Imaging
Radiographs
o recommended views
AP and lateral of knee
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o optional views
Sunrise or Merchant views for patella instability
o findings
usually normal
may see tendon calcinosis in chronic degeneration
o measurement
evaluate knee alignment for varus/valgus angle
evaluate for patellar height (patella alta vs baja) for suspected quadriceps tendon rupture
Blumentsaat's line should extend to inferior pole of the patella at 30 degrees of knee
flexion
Insall-Salvati method
normal between 0.8 and 1.2
Ultrasound
o indications
suspected acute or chronic
o findings
effective at detecting and localizing disruption in tendon
operator and user-dependent
MRI
o indications
most sensitive imaging modality
o findings
intrasubstance signal and thickening of tendon
Treatment
Nonoperative
o activity modification, NSAIDS, and physical therapy
indications
mainstay of treatment
technique
rest until pain is improved
physical therapy starting with range of motion and progressing to eccentric exercises
cortisone injections contraindicated due to risk of quadriceps tendon rupture
Operative
o quadriceps tendon debridement
indications
very rarely required
3. Semimembranosus Tendinitis
Introduction
Epidemiology
o demographics
most common in male athletes
often occurs in patients in their early thirties
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Presentation
History
o of report recent increase in endurance activities (running or cycling)
Symptoms
o pain in the posteromedial knee
may radiate into the posterior thigh or into the distal-medial calf
may be exacerbated with traversing down stairs or in deep knee flexion
Physical exam
o tenderness to palpation at the tibial insertion of the semimembranosus
the tendon may be more prominent with resisted knee flexion at 90 degrees
o provocative tests
passive deep flexion of the knee or internal rotation of the tibia at 90 degrees of knee flexion
may increase pain
Imaging
MRI
o may be helpful in making the diagnosis
Nuclear imaging
o may be helpful in making the diagnosis
Treatment
Nonoperative
o physical therapy
indications : mainstay of treatment
modalities
usually responds to stretching & strengthening of the hamstrings
o steroid injection
indications
used as an adjunctive measure
it may be utilized if there is limited improvement with physical therapy
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Anatomy
Prepatellar bursa
o the prepatellar bursa is a potential space
o function to enhance gliding of tissue over patella
Presentation
History
o often patients have a history of kneeling
Symptoms
o pain
o swelling
Physical exam
o can be warm to touch, especially if septic
Studies
Aspiration with gram stain and culture
o indicated to distinguish between septic versus aseptic
on physical exam a septic presentation is difficult to distinguish from an aspetic presentation
the collection is extra-articular so the patient does not have the pain one has with septic
arthritis
Treatment
Nonoperative
o compressive wrap, NSAIDs, +/-aspiration and immobilization for 1 week
indications
most cases
technique
corticosteroid use is controversial
Operative
o bursal resection
indications
rare
open or arthroscopic
arthroscopic bursal resection
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training errors
sudden change in training intensity
poor shoe support
anatomical factors
genu recurvatum or genu varum
limb length discrepancies
excessive foot pronation
weak hip abductors
tight iliotibial band
biomechanical factors
disparity between quadriceps and hamstring strength
increased landing forces
increased angle of knee flexion at heel strike
Pathophysiology
o mechanism of injury
iliotibial band is repetitively shifted forward and backwards across the lateral
femoral condyle causing
friction, iliotibial band tensioning and inflammation
impingement zone = 30 degress of knee flexion
o pathoanatomy
compression and irritation of the underlying connective tissues beneath the iliotibial band
may result in cysts or bursitis in the lateral synovial recess
may be associated with femoral condyle osseous edema
pathologic changes in the iliotibial band are less common
Associated conditions
o patellofemoral syndrome
may be due to tightness of ITB
o medial compartment osteoarthritis
reduced medial joint space causes varus knee deformities
o greater trochanteric pain syndrome
alters biomechanics of the ITB
Prognosis
o 50-90% of patients will improve with 4-8 weeks of non-operative modalities
Anatomy
Iliotibial band
o origin
continuation of tensor fascia lata
o insertion
Gerdy tubercle
o innervation
superior gluteal nerve (L1-3)
o primary synergistic muscles
hip aBDuctors
Presentation
History
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o endurance athletes presenting with activity related knee pain
Symptoms
o pain predominantly localized over the lateral femoral condyle
o pain may be exacerbated by changes in running terrain or mileage
o usually relieved with rest
Physical exam
o inspection
may have swelling over iliotibial band
foot and knee malalignment
o palpation
localized tenderness over the lateral femoral condyle
o motion
joint crepitus
reduced hip and/or knee motion
weakness of hip aBDuction
pain reproduced with single leg squat
o provocative tests
Ober test
detects iliotibial band tightness
positioning
lateral with symptomatic side up with knee flexed to 90deg
hip is brought from flexion and abduction into extension and adduction
findings
positive if pain, tightness, or clicking over the iliotibial band
Radiography
Radiographs
o recommended views : AP, lateral views of knee
o additional views : oblique or skyline views
o findings
usually normal
may show associated bone pathology
medial joint compartment narrowing
patellar malalignment
fracture
MRI
o indications
rule out associated soft-tissue pathology in the same region (e.g., lateral meniscal tear, LCL
sprain/tear, etc) with normal radiographs
o findings
may reveal signal changes in the lateral synovial recess, iliotibial band or periosteum
Treatment
Nonoperative
o rest, ice, NSAIDs, corticosteroid injections
indications : initial treatment to reduce pain and swelling
modalities
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ice
oral or topical anti-inflammatory medications
corticosteroids injection
when conservative measures fail
o physical therapy and training modifications
indications
mainstay of treatment that follows initital treatment phase aimed at reducing pain and
swelling
modalities
therapy
stretching of the iliotibial band, lateral fascia and gluteal muscles
deep transverse friction massage
strengthening hip aBDuctors
proprioception exercises to improve neuromuscular coordination
training modifications
change shoes every 300-500 miles
avoid sudden increases in mileage
Operative
o excision of a cyst, burse or lateral synovial recess
indications
failed nonoperative management
soft-tissue pathology with no signal change in the iliotibial band
techniques : arthroscopic vs. open
outcome
may cause chronic synovial fluid effusion and pain
o elipitical surgical excision of iliotibial band
indications : failed nonoperative therapy with chronic presentation
techniques
open technique
lateral distal femur incision
expose posterior portion of the band over lateral femoral epicondyle
incise 2 x4 cm ellipse of band tissue
o Z plasty of iliotibial band
indications : only indicated in refractory cases
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1. Patellofemoral Joint
Overview
Biomechanically complex articulation between the patella and distal femoral condyles
Associated clinical conditions
o trauma
patella dislocation
fracture
patella tendon rupture
quadriceps tendon rupture
OCD lesions
o chondromalacia patellae
o patellofemoral joint arthritis
o patella instability
Anatomy
Osseous
o bony constraint of the patella within the trochlear groove
intracondylar groove
diameter of lateral femoral condyle > medial femoral condyle
bony constraint of groove is the primary constraint to lateral patellar instability when
knee flexion is > 30 degrees
Ligaments
o static stability of the patella within the trochlear groove
medial patellofemoral ligament (MPFL)
originates from the adductor tubercle to insert onto the superomedial border of the
patella
primary constraint to lateral patellar instability with knee flexion 0 to 20 degrees
patellotibial ligament
retinaculum
Muscles
o dynamic stability of the patella within the trochlear groove
vastus medialis = medial restraint to lateral translation
vastus lateralis = lateral restraint to medial translation
Tendon
o angular difference between the quadriceps tendon insertion and patella tendon insertion creates
a valgus axis (Q angle)
o creates a laterally directed force across the patellofemoral joint
Blood supply
o superior, medial and lateral, geniculate arteries
o inferior, medial and lateral, geniculate arteries
o anterior geniculate artery
o descending geniculate artery
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Patella moves 7cm caudally during full flexion Note the increase in resultant force
with knee flexion
Biomechanics
Function
o transmits tensile forces generated by the quadriceps to the patellar tendon
o increases lever arm of the extensor mechanism
patellectomy decreases extension force by 30%
Biomechanics
o patellofemoral joint reaction force
up to 7x body weight with squatting
2-3x body weight when descending stairs
Motion
o "sliding" articulation
patella moves 7cm caudally during full flexion
o maximum contact between femur and patella is at 45
degrees of flexion
Stability
o passive restraints to lateral subluxation
medial patellofemoral ligament
primary passive restraint to lateral translation in
20 degrees of flexion
60% of total restraining force
medial patellomeniscal ligament
13% of total restraining force
medial retinaculum
10% of total restraining force
o dynamic restraint
quadriceps muscles
o Q angle
definition
line drawn from the anterior superior iliac spine --
> middle of patella --> tibial tuberosity
normal Q angle
males = 13 degrees III:31 Q angle
females = 18 degrees
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III:32 Joint reaction force across the patellofemoral joint with different exercises
Imaging
Radiographs
o recommended views of the knee
AP, lateral, axial views
o findings
AP = joint alignment, fracture, knee arthritis
lateral = patella alta vs baja, femoral condyle dysplasia, arthritis, transverse patellar fracture
axial = patella malalignment, trochlear groove depth, arthritis, vertical patellar fracture
o measurements
patellar height (e.g. Insall-Salvati ratio)
lateral patellofemoral angle (normal is an angle that opens laterally )
congruence angle (normal is -6 degrees)
CT
o indications
better visualization of the patellofemoral joint alignment
fracture
o findings
trochlear geometry
TT-TG distance
MRI
o indications
best modality to assess articular cartilage
o views
T2 best sequence to assess cartilage
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2. Patellar Instability
Introduction
Can be classified into the following
o acute traumatic
occurs equally by gender
may occur from a direct blow (ex. helmet to knee collision in football)
o chronic patholaxity
recurrent subluxation episodes
occurs more in women
associated with malalignment
o habitual
usually painless
occurs during each flexion movement
pathology is usually proximal (e.g. tight lateral structures - ITB and vastus lateralis)
Epidemiology
o demographics
most commonly occurs in 2nd-3rd decades of life
o risk factors
general factors
ligamentous laxity (Ehlers-Danlos syndrome)
previous patellar instability event
"miserable malalignment syndrome"
a term named for the 3 anatomic characteristics that lead to an increased Q angle
femoral anteversion
genu valgum
external tibial torsion / pronated feet
anatomical factors
osseous
patella alta
causes patella to not articulate with sulcus, losing its constraint effects
trochlear dysplasia
excessive lateral patellar tilt (measured in extension)
lateral femoral condyle hypoplasia
muscle
dysplastic vastus medialis oblique (VMO) muscle
overpull of lateral structures
iliotibial band
vastus lateralis
Pathophysiology
o mechanism
usually on noncontact twisting injury with the knee extended and foot externally rotated
patient will usually reflexively contract quadriceps thereby reducing the patella
osteochondral fractures occur most often as the patella relocates
direct blow : less common
ex. knee to knee collision in basketball, or football helmet to side of knee
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Anatomy
Passive stability
o medial patellofemoral ligament (MPFL)
femoral insertion origin is between medial epicondyle and adductor tubercle
is usual site of avulsion of MPFL
is primary restraint in first 20 degrees of knee flexion
o patellar-femoral bony structures account for stability in deeper knee flexion
trochlear groove morphology, patella height, patellar tracking
Dynamic stability
o provided by vastus medialis (attaches to MPFL)
Presentation
Symptoms
o complaints of instability
o anterior knee pain
Physical exam
o acute dislocation usually associated with a large hemarthrosis
absence of swelling supports ligamentous laxity and habitual dislocation mechanism
o medial sided tenderness (over MPFL)
o increase in passive patellar translation
measured in quadrants of translation (midline of patella is considered "0"), and also should be
compared to contralateral side
normal motion is <2 quadrants of patellar translation
lateral translation of medial border of patella to lateral edge of trochlear groove is
considered "2" quadrants and is considered abnormal amount of translation
o patellar apprehension
passive lateral translation results in guarding and a sense of apprehension
o increased Q angle
o J sign
excessive lateral translation in extension which "pops" into groove as the patella engages the
trochlea early in flexion
associated with patella alta
Imaging
Radiographs
o rule out fracture or loose body
medial patellar facet (most common)
lateral femoral condyle
o AP views
best to evaluate overall lower extremity alignment and version
o lateral views
best to assess for trochlear dysplasia
evaluate for patellar height (patella alta vs baja)
Blumensaat's line should extend to inferior pole of the patella at 30 degrees of knee
flexion
Insall-Salvati method
normal between 0.8 and 1.2
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Blackburne-Peel method
normal between 0.5 and 1.0
Caton Deschamps method
normal between 0.6 and 1.3
Plateau-patella angle
normal between 20 and 30 degrees
o Sunrise / Merchant views III:34 Lateral patellofemoral angle
best to assess for lateral patellar tilt
lateral patellofemoral angle (normal is an angle that opens laterally )
congruence angle (normal is -6 degrees)
CT scan
o TT-TG Distance
measures the distance between 2 perpendicular lines from the
posterior cortex to the tibial tubercle and the trochlear groove
>20mm usually considered abnormal
MRI
o help further rule out suspected loose bodies
osteochondral lesion and/or bone bruising
medial patellar facet (most common)
lateral femoral condyle
o tear of MPFL
tear usually at medial femoral epicondyle
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indications
patella alta
techniques
distal displacement of osteotomy and fixation
o lateral release
indications
isolated release no longer indicated for instability
only indicated if there is excessive lateral tilt or tightness after medialization
technique
arthroscopic
o trochleoplasty
indications
rarely addressed (in the USA) even if trochlear dysplasia present
may consider in severe or revision cases
techniques
arthroscopic or open trochlear deepening procedure
Pediatric Treatment
Same principles as adults in general but
o must preserve the physis
do not do tibial tubercle osteotomy (will harm growth plate of proximal tibia)
Complications
Recurrent dislocation
o redislocation rates with nonoperative treatment may be high (15-50%) at 2-5 years
Medial patellar dislocation and medial patellofemoral arthritis
o almost exclusively iatrogenic as a result of prior patellar stabilization surgery
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Presentation
Presentation
o pain with stair climbing
o theatre sign (pain with sitting for long periods of time)
Physical exam
o pain with compression of patella and moderate lateral facet tenderness
o inability to evert the lateral edge of the patella
Imaging
Radiographs
o patellar tilt in lateral direction
Treatment
Nonoperative
o NSAIDS, activity modification, and therapy
indications
mainstay of treatment and should be done for extensive period of time
technique
therapy should emphasize vastus medialis strengthening and closed chain short arc
quadriceps exercises
Operative
o arthroscopic lateral release
indications
objective evidence of lateral tilting (neutral or negative tilt)
pain refractory to extensive rehabilitation
inability to evert the lateral edge of the patella
ideal candidate has no symptoms of instability
medial patellar glide of less than one quadrant
lateral patellar glide of less than three quadrants
o patellar realignment surgery
Maquet (tubercle anteriorization)
indicated only for distal pole lesions III:36 lateral tilting
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indicated only for instability with lateral translation (not isolated lateral tilt)
avoid if medial patellar facet arthrosis
Fulkerson alignment surgery (tubercle anteriorization and medialization)
indications (controversial)
lateral and distal pole lesions
increased Q angle
contraindications
superior medial arthrosis (scope before you perform the surgery)
skeletal immaturity
Techniques
Arthroscopic lateral release
o technique
viewing through superior portal will show medial facet does not articulate with trochlea at 40
degrees of knee flexion
be sure adequate hemostasis is obtained
postoperatively the patella should be able to be passively tilted 80°
o complications
persistent or worsened pain
patellar instability with medial translation
Anatomy
Patellofemoral joint
o articulation between patella and intracondylar groove of femur
Pain receptors of the knee
o subchondral bone has weak potential to generate pain signals
o anterior fat pad and joint capsule have highest potential for pain signals
Classification
Outerbridge Classification of Chondromalacia
Type I Softening
Type II Fissures
Type III Crabmeat changes
Type IV Exposed subchondral bone
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Presentation
Symptoms
o diffuse pain in the peripatellar or retropatellar area of the knee (major symptom)
o insidious onset and typically vague in nature
o aggravated by specific daily activities including
climbing or descending stairs
prolonged sitting with knee bent (known as theatre pain)
squatting or kneeling
o always consider the physical, mental and social elements of knee pain
Physical exam
o quadricep muscle atrophy
o signs of patella maltracking
increased femoral anteversion or tibial external rotation
lateral subluxation of patella or loss of medial patellar mobility
positive patellar apprehension test
o palpable crepitus
o pain with compression of patella with knee range of motion or resisted knee extension
Imaging
Radiographs
o recommended views
AP, lateral and notch radiographs of knee
o findings
may see chondrosis on xray
shallow sulcus, patella alta/baja, or lateral patella tilt
CT scan
o indications
patellofemoral alignment
fracture
o findings
trochlear geometry
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TT-TG distance
torsion of the limb
MRI
o indications
best modality to assess articular cartilage
o views
T2 best sequence to assess cartilage
abnormal cartilage is usually of high signal compared to
normal cartilage
Differential
Quadriceps or patellar tendinitis
Saphenous neuroma
Post-operative neuromas
Treatment
Nonoperative
o rest, rehab, and NSAIDS
indications
mainstay of treatment and should be done for a minimum of one year
technique
NSAIDS are more effective than steroids
activity modification
rehabilitation with emphasis on
vastus medialis obiquus strengthening
core strengthening
closed chain short arc quadriceps exercises
Operative
o arthroscopic debridement
indications
Outerbridge grade 2-3 chondromalacia patellofemoral joint
techniques
mechanical debridement
radiofrequency debridment
o lateral retinacular release
indications
tight lateral retinacular capsule, loose medial capsule and lateral patellar tilt
techniques
open arthrotomy
arthroscopy
o patellar realignment surgery
indications
severe symptoms that have failed to improve with extensive physical therapy
techniques
Maquet (anterior tubercle elevation)
only elevate 1 cm or else risk of skin necrosis
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Fulkerson (anterior-medialization)
indications (controversial)
increased Q angle
patellar instability
contraindications
superior medial arthrosis (scope before you perform the surgery)
skeletal immaturity
Elmslie-Trillat osteotomy
MPFL reconstruction
Classification
Rupture classified as either
o partial
o complete
Anatomy
Quadriceps tendon
o has been described as having 2 to 4 distinct layers
important when distinguishing between partial and complete tear and when repairing tendon
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Presentation
History
o often report a history of pain leading up to rupture consistent with an underlying tendonopathy
Symptoms
o pain
Physical exam
o tenderness at site of rupture
o palpable defect usually within 2 cm of superior pole of patella
o unable to extend the knee against resistance
o unable to perform straight leg raise with complete rupture
Imaging
Radiographs
o recommended views
AP and lateral of knee
o findings
will show patella baja
MRI
o indications
when there is uncertainty regarding diagnosis
helps differentiate between a partial and complete tear
Treatment
Nonoperative
o knee immobilization in brace
indications
partial tear with intact knee extensor mechanism
patients who cannot tolerate surgery
Operative
o primary repair with reattachment to patella
indications
complete rupture with loss of extensor mechanism
Techniques
Primary repair of acute rupture
o approach
midline incision to knee
o repair
longitudinal drill holes in patella
nonabsorbable sutures in tendon in a running locking fashion with ends free to be passed
through osseous drill holes
retinaculum is repaired with heavy absorbable sutures
ideally the knee should flex to 90 degrees after repair
o postoperative care
initial immobilization in brace, cast, or splint
eventual progressive flexibility and strengthening exercises
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Primary repair of chronic rupture
o approach
midline to knee
o repair
often the tendon retracts proximally
ruptures >2 weeks old can retract 5cm
repaired with a similar technique to acute ruptures but a tendon lengthening procedure may
be necessary
Codivilla procedure (V-Y lengthening)
auto or allograft tissue may be needed to secure quadriceps tendon to patella
Complications
Strength deficit
o 33%-50% of patients
Stiffness
Functional impairment
o 50% of patients are unable to return to prior level of activity/ sports
Anatomy
Extensor mechanism of the knee
o quadriceps femoris muscles
o quadriceps tendon
o patella
o patellar tendon
o tibial tubercle
Forces in patellar tendon
o ascending stairs is 3x body weight
o to rupture a normal tendon is 17x body weight
Blood supply
o infrapatellar fat pad
o retinacular structures (medial and lateral inferior geniculate arteries)
Presentation
History
o sudden quadriceps contraction with knee in a flexed position (e.g., jumping sports, missing step
on stairs)
Symptoms
o infrapatellar pain
o popping sensation
o difficulty weight-bearing
Physical exam
o inspection
elevation of patella height
usually associated with a large hemarthrosis and ecchymosis
localized tenderness
palpable gap below the inferior pole of the patella
o motion
unable to perform active straight leg raise or maintain passively extended knee
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reduced ROM of knee (and difficulty bearing weight) due to pain
if only tendon is ruptured and retinaculum is intact, active extension will be possible but
will have extensor lag of a few degrees
Imaging
Radiographs
o recommended views
AP and lateral of the knee
o optional views
merchant or skyline
o findings
patella alta seen in complete rupture
knee in flexion, the Insall-Salvati ratio is > 1.2
Ultrasound
o indications
suspected acute and chronic injuries III:37 Patella Alta
o findings
effective at detecting and localizing disruption
operator and user-dependent
MRI
o indications
differentiate partial from complete tendon rupture
most sensitive imaging modality
o findings
site of disruption, tendon degeneration, patellar position, and associated soft tissue injuries
Treatment
Nonoperative
o immobilization in full extension with a progressive weight-bearing exercise program
indications
partial tears with intact extensor mechanism
modalities
application of a removable knee splint
early knee range of motion
Operative
o primary repair
indications
complete patellar tendon ruptures
ability to approximate tendon at site of disruption
techniques
end-to-end repair
transosseous tendon repair
suture anchor tendon repair
o tendon reconstruction
indications
severely disrupted or degenerative patella tendon
techniques
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semitendinosus or gracilis tendon autograft
free ends of the tendons are passed through transosseous hole of the patella, and then
through a transosseous hole within the tibial tubercle to make a complete circle graft.
other options
central quadriceps tendon-patellar bone autograft
contralateral bone-patellar tendon-bone autograft
allograft
o rehabilitation
may weight bear early with protected knee extension brace
exercises to optimize range of motion and minimizes stress on the repair include
passive extension and active closed chain flexion (heel slides)
prone open chain knee flexion
Techniques
Direct primary repair
o approach
longitudinal midline incision
expose rupture and adjacent retinacula
debride the ends of the rupture
o end-to-end technique
approximate tendon at site of rupture
nonabsorbable sutures are woven with locking stitch
o transosseous tendon repair
suture the patellar tendon to the patella with a no.5 nonabsorbable transosseous suture
can be protected with a cerclage wire or nonabsorbable tape between patella and tibial
tuberosity
o postoperative care
immediate immobilization
weight-bearing status
rehabilitation
Complications
Stiffness (loss of knee flexion)
o prevent this by starting early ROM and quads strengthening
o treat this with MUA if flexion is <120° at 6-8wks
Decreased quadriceps strength
Quadriceps atrophy (does not compromise return of strength)
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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By Dr, AbdulRahman AbdulNasser Knee | Knee Lesions
F. Knee Lesions
Anatomy
See Articular Cartilage Basic Science
Classification
Outerbridge Arthroscopic Grading System
Grade 0 Normal cartilage
Grade I Softening and swelling
Grade II Superficial fissures
Grade III Deep fissures, without exposed bone
Grade IV Exposed subchondral bone
Presentation
History
o commonly present with history of precipitating trauma
o some defects found incidentally on MRI or arthroscopy
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Symptoms
o asymptomatic vs. localized knee pain
o may complain of effusion, motion deficits, mechanical symptoms (e.g., catching, instability)
Physical exam
o inspection
look for background factors that predispose to the formation of articular defects
joint laxity
malalignment
compartment overload
o motion
assess range of motion, ligamentous stability, gait
Imaging
Radiographs
o indications
used to rule out arthritis, bony defects, and check alignment
o recommended views
standing AP, lateral, merchant views
o optional views
semiflexed 45 deg PA views
most sensitive for early joint space narrowing
long-leg alignment views
determine the mechanical axis
CT scan
o indications : better evaluation of bone loss
o findings III:38 long-leg alignment
views
used to measure TT-TG when evaluating the patello-femoral joint
MRI
o indication
most sensitive for evaluating focal defects
o views
Fat-suppressed T2, proton density, T2 fast spin-echo (FSE) offer improved sensitivity and
specificity over standard sequences
dGEMRIC (delayed gadolinium-enhanced MRI for cartilage) and T2-mapping are evolving
techniques to evaluate cartilage defects and repair
Treatment
Nonoperative
o rest, NSAIDs, physiotherapy, weight loss
indications
first line of treatment when symptoms are mild
o viscosupplementatoin, corticosteroid injections, unloader brace
indications
controversial
may provide symptomatic relief but healing of defect is unlikely
Operative
o debridement/chondroplasty vs. reconstruction techniques
indications
failure of nonoperative management
acute osteochondral fractures resulting in full-thickness loss of cartilage
technique
treatment is individualized, there is no one best technique for all defects
decision-making algorithm is based on several factors
patient factors
age
skeletal maturity
low vs. high demand activities
ability to tolerate extended rehabilitation
defect factors
size of defect
location
contained vs. uncontained
presence or absence of subchondral bone involvement
basic algorithm (may vary depending on published data)
femoral condyle defect
correct malaligment, ligament instability, meniscal deficiency
measure size
< 4 cm2 = microfracture or osteochondral autograft transfer (pallative if older/low
demand)
> 4 cm2 = osteochondral allograft transplantation or autologous chondrocyte
implantation
patellofemoral defect
address patellofemoral maltracking and malalignment
measure size
< 4 cm2 = microfracture or osteochondral autograft transfer
> 4 cm2 = autologous chondrocyte implantation (microfracture if older/low
demand)
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Surgical Techniques
Debridement / Chondroplasty
o overview
goal is to debride loose flaps of cartilage
removal of loose chondral fragments may relieve mechanical symptoms
short-term benefit in 50-70% of patients
o benefits
include simple arthroscopic procedure, faster rehabilitation
o limitations
problem is exposed subchondral bone or layers of injured cartilage
unknown natural history of progression after treatment
Fixation of Unstable Fragments
o overview
need osteochondral fragment with adequate subchondral bone
o technique
debride underlying nonviable tissue
consider drilling subchondral bone or adding local bone graft
fix with absorbable or nonabsorbable screws or devices
o benefits
best results for unstable osteochondritis dissecans (OCD) fragments in patients with open
physis
o limitations
lower healing rates in skeletally mature patients
nonabsorbable fixation (headless screws) should be removed at 3-6 months
Marrow Stimulation Techniques
o overview
goal is to allow access of marrow elements into defect to stimulate the formation of
reparative tissue
includes microfracture, abrasion chondroplasty, osteochondral drilling
o microfracture technique
defect is prepared with stable vertical walls and the calcified cartilage layer is removed
awls are used to make multiple perforations through the subchondral bone 3 - 4 mm apart
protected weight bearing and continuous passive motion
(CPM) are used while mesenchymal stem cells mature
into mainly fibrocartilage
o benefits
include cost-effectiveness, single-stage, arthroscopic
best results for acute, contained cartilage lesions less than
2 cm x 2cm
o limitations
poor results for larger defects >2 cm x 2cm
does not address bone defects
requires limitation of weight bearing for 6 - 8 weeks
Osteochondral autograft / Mosaicplasty
o overview III:39 Microfracture technique
goal is to replace a cartilage defect in a high weight bearing area with normal autologous
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By Dr, AbdulRahman AbdulNasser Knee | Knee Lesions
cartilage and bone plug(s) from a lower weight bearing area
Chondrocytes remain viable, bone graft is incorporated into subchondral bone and overlying
cartilage layer heals.
o technique
a recipient socket is drilled at the site of the defect
a single or multiple small cylinders of normal articular cartilage with underlying bone are
cored out from lesser weight bearing areas (periphery of trochlea or notch)
plugs are then press-fit into the defect
o limitations
size constraints and donor site morbidity limit usage of this technique
matching the size and radius of curvature of cartilage defect is difficult
fixation strength of graft initially decreases with initial healing response
weight bearing should be delayed 3 months
o benefits
include autologous tissue, cost-effectiveness, single-stage, may be performed
arthroscopically
Osteochondral allograft transplantation
o overview
goal is to replace cartilage defect with live chondrocytes in mature matrix along with
underlying bone
fresh, refrigerated grafts are used which retain chondrocyte viability
may be performed as a bulk graft (fixed with screws) or shell (dowels) grafts
o technique
match the size and radius of curvature of articular cartilage with donor tissue
a recipient socket is drilled at the site of the defect
an osteochondral dowel of the appropriate size is cored out of the donor
the dowel is press-fit into place
o benefits
include ability to address larger defects, can correct significant bone loss, useful in revision
of other techniques
o limitations
limited availability and high cost of donor tissue
live allograft tissue carries potential risk of infection
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Autologous chondrocyte implantation (ACI)
o overview
cell therapy with goal of forming autologous "hyaline-like" cartilage
o technique
arthroscopic harvest of cartilage from a lesser weight bearing area
in the lab, chondrocytes are released from matrix and are expanded in culture
defect is prepared, and chondrocytes are then injected under a periosteal patch sewn over the
defect during a second surgery
o benefits
may provide better histologic tissue than marrow stimulation
long term results comparable to microfracture in most series
include regeneration of autologous tissue, can address larger defects
o limitations
must have full-thickness cartilage margins around the defect
open surgery
2-stage procedure
prolonged protection necessary to allow for maturation
Patellar cartilage unloading procedures
o Maquet (tibia tubercle anteriorization) III:40 Autologous
indicated only for distal pole lesions chondrocyte implantation
(ACI)
only elevate 1 cm or else risk of skin necrosis
contraindications
superior patellar arthrosis (scope before you perform the surgery)
o Fulkerson alignment surgery (tibia tubercle anteriorization and medialization
indications (controversial)
lateral and distal pole lesions
increased Q angle
contraindications
superior medial patellar arthrosis (scope before you perform the surgery)
skeletal immaturity
Matrix-associated autologous chondrocyte implantation
o overview
example is "MACI"
cells are cultured and embedded in a matrix or scaffold
matrix is secured with fibrin glue or sutures
III:41 MACI
o benefits
include ability to perform without suturing, may be performed arthroscopically
o limitations
2-stage procedure
in worldwide use/evaluation- not available in the USA
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By Dr, AbdulRahman AbdulNasser Knee | Knee Lesions
Physical Exam
Symptoms
o pain with weightbearing, especially sitting to standing
Imaging
Radiographs
o first line imaging studies
AP knee
lateral knee
merchant view knee
o findings
wedge-shaped lesion on imaging
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MRI
o most useful study
o findings
highest sensitivity and specificity
T1: dark
T2: bright (marrow edema)
Differential
Osteochondritis dissecans (OCD)
o more commonly found at lateral aspect of medial femoral condyle of 15 to 20-year-old males
Transient osteoporosis
o more common in young to middle-aged men
o multiple joint involvement found in 40% of patients (transient migratory osteoporosis)
Occult fractures and bone bruises
o associated with trauma, weak bones, or overuse
Treatment
Nonoperative
o NSAIDs, limited weightbearing, quadriceps strengthening, activity modification
indications : first-line of treatment
outcomes : favorable, but less so than nonoperative management for SONK
Operative
o diagnostic arthroscopy
indications
remove small, unstable fragments from the joint
o core decompression
indications
extra-articular lesions
o osteochondral allograft
indications
large symptomatic lesions in younger patients that failed nonoperative management
o total knee arthroplasty (TKA)
indications
large area of involvement
collapse
osteonecrosis in multiple compartments
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By Dr, AbdulRahman AbdulNasser Knee | Knee Lesions
o location
99% of patients have only one joint involved
usually epiphysis of medial femoral condyle
Pathophysiology
o may represent a subchondral insufficiency fracture
o also believed to be caused by a meniscal root tear
Presentation
Symptoms
o sudden onset of severe knee pain
o effusion
o limited range of motion secondary to pain
o tenderness over medial femoral condyle
Imaging
Radiographs
o recommended views
standing AP and lateral of hip, knee and ankle
MRI
o most useful study
o is helpful to confirm the diagnosis and assist in determining the extent of disease helping guide
treatment considerations
o lesion is crescent shaped
Differential
Must differentiate from
o osteochondritis dissecans
more common on lateral aspect of medial femoral condyle in adolescent males
o transient osteoporosis
more common in young to middle age men
o bone bruises and occult fractures
associated trauma, bone fragility or overuse
o idiopathic osteonecrosis of the knee
lesion is not crescent shaped
Treatment
Nonoperative
o NSAIDs, narcotics, protected weight bearing
indications
mainstay of treatment as most cases resolve
technique
physical therapy directed at quadriceps strengthening
outcomes
initial conservative measure and has shown good results
Operative
o arthroplasty
indications
when symptoms fail to respond to conservative treatment
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outcomes
successful results reported with TKA (larger lesions or bone collapse) and UKA (smaller
lesions) when properly indicated
o high tibial osteotomy
indications
when angular malalignment present
4. Plicae
Introduction
Plica syndrome
o defined as a painful impairment of knee function resulting from the thickened and
inflamed synovial folds
usually only medial plica
o 50% present with history of blunt trauma to the anterior knee
Plica
o are embryologic remnant synovial folds. Most common plicae are
ligamentum mucosum
most common plica
located in the intercondylar notch
suprapatellar plica
located in the suprapatellar space, extending from the medial wall of the knee toward the
lateral wall
medial plica
extends from the infrapatellar fat pad to the medial wall of the knee
most commonly irritated from the abrading the medial femoral condyle
Presentation
Symptoms
o snapping sensations
o buckling
o knee pain on sitting
o pain with repetitive activity
Physical exam
o tenderness in the medial parapatellar region
o painful, palpable medial parapatellar cord
can be rolled and popped beneath the examiners
finger
o provacative test
hold the knee in full extension while examiner tries to
flex against the patient‟s resistance.
the examiner again pushes the patella medially while palpating its medial border.
pain produced with or without a click is considered a positive test.
Imaging
MRI
o can detect plica but has low sensitivity
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By Dr, AbdulRahman AbdulNasser Knee | Pediatric Knee
Treatment
Nonoperative
o activity restriction, NSAIDS, and physical therapy
indications
most cases can be treated nonoperatively
physical therapy
moist heat applications
hamstring stretching
resistive strengthening exercises are avoided in early rehabilitation phases
Operative
o arthroscopic resection of lesion
indications
only utilized in rare cases of plica band syndrome not responding to nonoperative
treatment
G. Pediatric Knee
1. Osteochondritis Dissecans
Introduction
A pathologic lesion affecting articular cartilage and subchondral bone with variable clinical patterns
Epidemiology
o demographics
juvenile form (open physes)
occurs at age 10-15 while the physis is still open
adult form (skeletal maturity)
o location
knee (most common)
posterolateral aspect of medial femoral condyle (70% of lesions in knee)
capitellum of humerus
talus
Pathophysiology
o mechanism/etiology may be
hereditary
traumatic
vascular
cause of adult form is thought to be vascular
o pathoanatomic cascade
softening of the overlying articular cartilage with intact
articular surface
early articular cartilage separation
partial detachment of lesion
osteochondral separation with loose bodies
Prognosis
o juvenile form
prognosis correlates with
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age
younger age correlates with better prognosis
open distal femoral physes are the best predictor of successful non-operative
management
location
lesions in lateral femoral condyle and patella have poorer prognosis
appearance
sclerosis on xrays correlates with poor prognosis
synovial fluid behind the lesion on MRI correlates with a worse prognosis
o adult form
worse prognosis
usually symptomatic and leads to DJD if untreated
Classification
Clanton Classification of Osteochondritis (Clanton and DeLee)
Type I Depressed osteochondral fracture
Type II Fragment attached by osseous bridge
Type III Detached non-displaced fragment
Type IV Displaced fragment
Presentation
Symptoms
o pain
activity related pain that is vague and poorly localized
o mechanical symptoms
indicates advanced disease
o recurrent effusions of the knee
Physical exam
o localized tenderness
o stiffness
o swelling
o Wilson‟s test
pain with internally rotating the tibia during extension of the knee between 90° and 30°, then
relieving the pain with tibial external rotation
Imaging
Radiographs
o recommended views
weight-bearing anteroposterior, lateral radiographs
obtain tunnel (notch) view
knee bent between 30 and 50 degrees
MRI
o useful for characterizing
size of lesion
status of subchondral bone and cartilage
signal intensity surrounding lesion
presence of loose bodies
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By Dr, AbdulRahman AbdulNasser Knee | Pediatric Knee
Treatment
Nonoperative
o restricted weight bearing and bracing
indications
stable lesions in children with open physes
asymptomatic lesions in adults
outcomes
50-75% will heal without fragmentation
Operative
o diagnostic arthroscopy
indications
impending physeal closure
clinical signs of instability
expanding lesions on plain films
failed non-operative management
o subchondral drilling with K-wire or drill
indications
stable lesion seen on arthroscopy
performed either transchondral or retrograde
outcomes
leads to formation of fibrocartilagenous tissue
improved outcomes in skeletally immature patients
o fixation of unstable lesion
indications
unstable lesion seen on arthroscopy or MRI >2cm in size
outcomes
85% healing rates in juvenile OCD
o chondral resurfacing
indications
large lesions, >2cm x 2cm
o knee arthroplasty
indications : patients > 60 years
Surgical Techniques
Microfracture
o technique
tap awl to a depth of 1-1.5cm below articular surface III:42 Herbert screws
o post-operative : NWB for 4-6 weeks with CPM
Internal fixation
o technique
options for fixation
cannulated screws
Herbert screws
bone pegs
Kirschner wires
o cons : may require hardware removal
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Osteochondral grafting
o arthrotomy (vs. arthroscopy) indicated in lesions > 3cm
technique
open vs. arthroscopic
arthroscopy generally used for lesions <3cm
arthrotomy used for lesions > 3cm
allograft plugs
autograft OATS
Periosteal patches
Anatomy
Tibial tubercle is a secondary ossification center
o age <11y, tubercle is cartilaginous
o age 11-14y, apophysis forms
o age 14-18y, apophysis fuses with tibial epiphysis
o age >18y, epiphysis (and apophysis) is fused to rest of tibia
Presentation
Symptoms
o pain on anterior aspect of knee
o exacerbated by kneeling
Physical exam
o inspection
III:44 Anatomy
enlarged tibial tubercle
tenderness over tibial tubercle
o provocative test
pain on resisted knee extension
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By Dr, AbdulRahman AbdulNasser Knee | Pediatric Knee
Imaging
Radiographs
o recommended views
lateral radiograph of the knee
o findings
irregularity and fragmentation of the
tibial tubercle
MRI
o indications
not essential for diagnosis
diagnosis can be made based on
history, presence of tender swelling
and radiographs alone
o findings
soft tissue swelling
thickening and edema of inferior patellar tendon
fragmentation and irregularity of ossification center
Differential
Sinding-Larsen-Johansson syndrome
o chronic apophysitis or minor avulsion injury of inferior
patella pole
o occurs in 10-14yr old children, especially children with
cerebral palsy
Osteochondroma of the proximal tibia
III:46 Sinding- III:45 Osteochondroma
Tibial tubercle fracture Larsen-Johansson of the proximal tibia
Jumpers knee syndrome
Treatment
Nonoperative
o NSAIDS, rest, ice, activity modification, strapping/sleeves to decrease tension on the
apophysitis and quadriceps stretching
indications : first line of treatment
outcomes
90% of patients have complete resolution
o cast immobilization x 6 weeks
indications
severe symptoms not responding to simple conservative management above
Operative
o ossicle excision
indications
refractory cases (10% of patients)
in skeletally mature patients with persistent symptoms
Complications
Complications of cast immobilization
o quadriceps wasting
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3. Sinding-Larsen-Johansson Syndrome
Introduction
Overuse injury causing anterior knee pain at the inferior pole of patella at the proximal patella
tendon attachment
o similar to Osgood-Schlatter's disease which is at the distal attachment of the patella tendon
o differnt from Jumper's Knee which is tendonitis of the patella tendon
Epidemiology
o demographics : more common in adolescence
o Location : patellar tendon insertion at the inferior pole of the patella
Pathophysiology
o chronic injury
o similar pathogenesis to Osgood-Schlatter
o overuse causes a traction apophysitis
Classification
Blazina Classification
Stage 1 Pain occurs after activity
Stage 2 Pain present while performing activity and persists after activity
Stage 3 Pain affecting/limiting function during activity
Presentation
History : insidious onset of pain on anterior aspect of knee after or during activity
Physical exam
o tenderness over inferior patella
o swelling
Imaging
Radiographs
o recommended views : AP and lateral of knee
o findings : may be normal
may show spur at inferior pole of patella
MRI
o indications : if diagnosis unclear
o views
inflammation best seen on T2 sagitals
bony spurs best seen on T1 sagitals
Treatment
Nonoperative
o activity modifications, NSAIDS, physical therapy
indications
mainstay of treatment
usually a self limiting process
Operative
o debridement of damaged tissue/stimulation of healing response
in some cases refractory to nonoperative treatment
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Pediatric Knee
ORTHO BULLETS
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OrthoBullets2017 Lower Extremity | Pelvis
A. Pelvis
Anatomy
Iliac crest is origin of several muscles any of which can be involved
o sartorius
o tensor fascia lata
o gluteus medius
o abdominal muscles
transverse or oblique muscles
Presentation
Symptoms
o pain near iliac crest
Physical exam
o contusion and hematoma near iliac crest
o affected hip weakness
o decreased range of motion
Imaging
Radiographs
o usually unremarkable
MRI
o usually unremarkable
o can show large hematoma
Treatment
Nonoperative
o rest, NSAIDS, steroid injections, and therapy
indications : main line of treatment
technique
medications : NSAIDs and muscle relaxants may be beneficial
therapy
focused on stretching the muscles about the iliac crest
place affected leg on maximum stretch
steroid injections : corticosteroid injection directed near iliac crest
return to play : additional padding during return to play
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Pelvis
Anatomy
Muscles that originate from ASIS
o sartorius (femoral n.)
o tensor fascia lata (superior gluteal n.)
Presentation
History
o athlete will often report a pop or snap at the time of injury
Symptoms
o may complain of weakness
may be confused or misdiagnosed as an acute muscle strain
Physical exam
o may see weakness to hip flexion and knee extension
o severe injuries may result in a limp
Imaging
Radiographs
o displaced fractures usually can be seen on radiographs
may be missed due to location and small size of bony
fragment
CT or MRI
o can be obtained to confirm the diagnosis
Treatment
Nonoperative
o rest, protected weight bearing with crutches, and early ROM and stretching
indications
most cases
Operative
o ORIF of avulsion fracture
indications
fractures with displacement of > 3 cm
painful nonunions
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Epidemiology
o demographics
most often in adolescent between the ages 14-17
males more often than females
occurs most often in sports involving kicking
Pathophysiology
o mechanism
typically occurs due to eccentric contraction of the rectus femoris (femoral n.)
as hip extends and knee is flexed
causes avulsion of its anatomic origin off the pelvis
Anatomy
Anterior inferior iliac spine
o a bony prominence just above acetabulum
o is the origin of the direct head of the rectus femoris (femoral n.)
Presentation
History
o sudden "pop" in pelvis
Symptoms
o pain and weakness
Physical exam
o antalgic gait
o anterior hip pain and hip flexion weakness
Imaging
Radiographs : show avulsion of AIIS
Treatment
Nonoperative
o bed-rest, ice, activity modification
indications
almost all treated nonoperatively
technique
hip flexed for 2 weeks
position lessens stretch of affected muscle and apophysis
follow with guarded weight bearing for 4 week
Complications
Loss of reduction
Delayed union
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Pelvis
Epidemiology
o demographics
males > females
common in hockey players and soccer players
o location
muscles of abdominal wall or adductor longus
Pathophysiology
o mechanism of injury
may be caused by acute trauma or microtrauma caused by overuse
thought to be a caused by abdominal hyperextension and thigh abduction
Presentation
Symptoms
o lower abdominal pain and inguinal pain at extremes of exertion
Physical exam
o inspection
tenderness to adductor longus
o provocative tests
pain with valsalva and situps
Imaging
Obtain radiographs, MRI, and bone scan to rule out other cause of symptoms
Differential
Must be differentiated from subtle true inguinal hernia
Treatment
Nonoperative
o rest and physical therapy for 6-8 weeks
indications
first line of treatment
Operative
o pelvic floor repair (hernia operation) vs. adductor / rectus recession
indications
after extensive nonoperative treatment fails
o decompression of the genital branch of the genitofemoral nerve
indications
after extensive nonoperative treatment fails
5. Osteitis Pubis
Introduction
Inflammation of the pubic symphysis caused by repetitive trauma
Epidemiology
o demographics
common in soccer, hockey, football and running
Pathophysiology
o mechanism
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repetitive microtrauma to the pubic symphysis by
sports involving repetitive kicking
sports involving hip repetitive adduction/abduction
Anatomy
Pubic symphysis
o osteology
located at the anterior articulation between each hemipelvis
composed of articular cartilage-covered rami separated by fibrocartilage disc
o muscles
regional attachments
adductors
adductor magnus
adductor brevis
adductor longus
gracilis
rectus abdominis
pectineus
o ligaments
superior pubic ligament
inferior pubic ligament
anterior pubic ligament
posterior pubic ligament
o biomechanics
very stable joint
strong ligamentous support limits motion
Presentation
Symptoms
o vague, ill-defined pain is anterior pelvic region
worse with activities involving hip adduction/abduction at the anterior pelvis
may have spasms with hip adduction
Physical exam
o palpation
localized tenderness directly over the pubic symphysis
Imaging
Radiographs
o recommended views : AP of pelvis
o findings
AP pelvis shows osteolytic pubis with bony erosions and often times diastasis of the
symphysis
degenerative changes within the joint can be seen
MRI
o bone marrow edema found early
Bone scan
o increased activity in area of pubic symphysis
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Pelvis
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o chronic medial thigh pain
Evaluation
o nerve conduction studies can help establish diagnosis
Treatment
o nonoperative
nonoperative treatment indicated in most cases
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Pelvis
Anatomy
Sciatic nerve
o exits
inferior to piriformis
superior to superior gemellus
Muscles
o external rotators of the thigh include (superior to inferior)
piriformis
superior gemellus
obturator internus
inferior gemellus
obturator externus
quadratus femoris
Presentation
Symptoms
o pain in the posterior gluteal region and migrating down the back
of the leg
o pain may be burning or aching in nature similar to sciatica
symptoms
Physical exam
o FAIR test
Flexion, Adduction, and Internal Rotation of hip can
reproduce symptoms
maneuver places piriformis muscle on tension
Imaging
Radiographs
o unremarkable
MRI
o usually unremarkable
o lumbar MRI helpful to rule out spine as cause of compression of
sciatic nerve
Electrodiagnostic studies
o can document functional impairment of sciatic nerve
Treatment
Nonoperative
o rest, NSAIDS, muscle relaxants, PT, steroid injections
indications : first line of treatment
technique
focused on stretching the piriformis muscle and short external rotators
corticosteroid injection directed near the piriformis muscles
Operative
o piriformis muscle release and external sciatic neurolysis
indications
only indicated in refractory cases after failed conservative measures
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OrthoBullets2017 Lower Extremity | Hip
B. Hip
Treatment
Nonoperative
o often internal and external snapping are painless and require no treatment
o activity modification
indications
acute onset (<6 months) of painful internal or external snapping hip
o physical therapy, injection of corticosteroid
indications
persistent, painful snapping interfering with activities of daily living
Operative
o excision of greater trochanteric bursa with Z-plasty of iliotibial band
indications
painful external snapping hip that has failed nonoperative management
snapping after total hip replacement
o release of iliopsoas tendon
indications
painful internal snapping hip that has failed of nonoperative management
o hip arthroscopy with removal of loose bodies or labral debridement/repair
indications
intra-articular snapping hip that has failed nonoperative management and has MRI
confirmation of
loose bodies
labral tear
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Surgical Techniques
Excision of greater trochanteric bursa with Z-plasty of iliotibial band
o technique
lengthen the iliotibial band by Z-plasty
may be done endoscopically
Iliopsoas tendon release
o approach
variety of open approaches have been described
anterior
medial
ilioinguinal
iliofemoral
o technique
tendon is either partially or completely released
may be done with the arthroscope
trans-capsular from the central compartment
endoscopically off of the lesser trochanter)
o post-operative care
avoid hip flexion strengthening for 6 weeks
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Hip
Anatomy
Structure
o horse-shoe shaped structure continuous with transverse acetabular ligament
o 2 parts
articular
fibrocartilage
capsular
dense connective tissue
Vascularity
o capsule and synovium at acetabular margin
Innervation
o branch of nerve to the quadratus femoris
o obturator nerve
Presentation
Symptoms
o mechanical hip pain and snapping
o may have vague groin pain
o may be associated with a sensation of locking
Physical exam
o provocative tests
anterior labral tear
pain if hip is brought from a fully flexed, externally rotated, and abducted position to a
position of extension, internal rotation, and adduction
posterior labral tear
pain if hip is brought from a flexed, adducted, and internally rotated position to one of
abduction, external rotation, and extension.
Imaging
Radiographs
o useful to exclude other types of hip pathology
o may show
hip dysplasia
arthritis
acetabular cysts
MRI arthrogram
o imaging study of choice
92% sensitive for detecting labral tears
may be combined with intra-articular injections of lidocaine and steroid for diagnostic and
therapeutic purposes
Treatment
Nonoperative
o rest, NSAIDS, physical therapy, steroid injections
indications : initial treatment of choice for all patients with labral tears
outcomes
no long-term follow-up data on conservative management
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Operative
o arthroscopic labral debridement
indications
symptoms that have failed to improve with nonoperative modalities
labral tear not amenable to repair
technique
remove any unstable portions of the labrum and associated synovitis
underlying hip pathology (e.g. FAI) should also be addressed at time of surgery
post-operative care
limited weight-bearing x4 weeks
flexion and abduction are limited for 4 to 6 weeks
outcomes
70-85% experience short-term relief of symptoms following arthroscopic debridement
long-term follow-up data not available
o arthroscopic labral repair
indications
symptoms that have failed to improve with nonoperative modalities
full-thickness tears at the labral-chondral junction
outcomes
unknown at this time
3. Femoroacetabular Impingement
Introduction
A common cause of
o early onset hip dysfunction
o secondary osteoarthritis
Epidemiology
o Cam impingement
refers to femoral based disorder is usually in young athletic males
and includes
decreased head-to-neck ratio
aspherical femoral head
decreased femoral offset
femoral neck retroversion
can be due to previous SCFE deformity
o Pincer impingement
refers to acetabular based disorder usually in active middle-aged women and includes
anterosuperior acetabular rim overhang
acetabular retroversion
acetabular protrusio
coxa profunda
o combined Cam/Pincer impingement
can include both patient populations
refers to combinations of above (up to 80%)
Mechanism : result of impingement of the femoral neck against anterior edge of acetabulum
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Presentation
Symptoms
o activity related groin or hip pain, exacerbated by hip
flexion
o difficulty sitting
o mechanical hip symptoms
o can present with gluteal or trochanteric pain
due to aberrant gait mechanics
Exam
o limited hip flexion (<90 degrees), especially with internal
rotation (<5 degrees)
o anterior impingement test (flexion, adduction, internal
rotation) elicits pain
o externally rotated extremity
can be due to post-SCFE deformity
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Imaging
Radiographs
o radiographic views
false profile view
to assess anterior coverage of the femoral head
standing position at an angle of 65° between the pelvis and the film
o characteristic findings
asphericity and contour of femoral head and neck
pistol grip deformity: indicates Cam impingement
examine for acetabular protrusio, retroversion, and coxa profunda
crossover sign: indicates acetabular retroversion in Pincer impingement
o measurements
alpha angle
method
measured frog-leg lateral radiograph
first line is drawn connecting the center of the femoral head and the center of the
femoral neck.
second line is drawn from the center of the femoral head to the point on the
anterolateral head-neck junction where prominence begins
the intersection of these two lines forms the alpha angle
normal values
values of >42° are suggestive of a head-neck offset deformity
head-neck offset ratio
method : measured from lateral radiographs
line #1 is drawn through the center of the long axis of the femoral neck
line #2 is drawn parallel to line 1 through the anteriormost aspect of the femoral neck
line #3 is drawn parallel to line 2 through the anteriormost aspect of the femoral head
the head-neck offset ratio is calculated by measuring the distance between lines 2 and
3, and dividing by the diameter of the femoral head
normal values : If the ratio is <0.17, a cam deformity is likely present
CT : can be used as adjunct to assess for structural abnormalities
MRI
o best modality to evaluate for articular cartilage, and labral degeneration and tears
o can assess anatomy of femoral head/neck junction abnormalities
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Treatment
Nonoperative
o observation
indications
minimally symptomatic patient
no mechanical symptoms
Operative
o arthroscopic hip surgery
indications
symptomatic patient
mechanical symptoms
IV:3 periacetabular osteotomy
outcomes
recent literature supports arthroscopy shows equivalent results to open hip surgery
o open surgical hip dislocation
indications
gold standard for management of FAI for patients with clinical signs and structural
evidence of impingement and
preserved articular cartilage, correctable deformity, reasonable expectations
contraindications
age >55, morbid obesity, advanced joint disease
o periacetabular osteotomy
indications
structural deformity of acetabulum with poor coverage of femoral head
technique
osteotomy and fixation
o total hip arthroplasty
indications
age >60 years and end-stage hip
degeneration
Techniques
Arthroscopic hip surgery
o approach : arthroscopic approach to the hip
o technique
trim femoral head/neck in Cam impingement
acetabular rim labral debridement vs repair
isolated labral debridement will not solve problem
without treatment of underlying pathology
Open surgical hip dislocation
o approach
anterior (Smith-Peterson) approach
best for isolated femoral head/neck pathology due to
limited exposure, although it is possible that acetabular
side could be treated
acetabular treatment involves take down of rectus femoris reflected head
femoral osteotomy and fixation
o technique
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uses a "trochanteric flip" for safe access to proximal femur and acetabulum
provides best visualization for hip surgery
preserves all external rotators and blood supply to femoral head (medial circumflex
femoral artery)
no increase in AVN risk
provides wide exposure of femoral head and acetabulum
Complications
Femoral neck fracture
o at risk during open or arthroscopic debridement of Cam lesions
o risk is minimized by limiting depth of femoral head-neck osteochondroplasty to <30% of femoral
neck diameter
Heterotopic Ossification
Failure to preserve
4. Trochanteric Bursitis
Introduction
Epidemiology
o demographics
often occurs in female runners
o risk factors
Is associated with training on banked surfaces
Pathophysiology
o pathoanatomy
repetitive trauma caused by iliotibial band tracking over trochanteric
bursa
can irritate the bursa causing inflammation
Anatomy
Trochanteric bursa is superficial to the hip abductor muscles and deep to the
iliotibial band
Presentation
Symptoms
o lateral sided hip pain, although hip joint is not involved
Physical exam
o pain with palpation over greater trochanter
Imaging
Radiographs
o will be unremarkable
MRI
o will show increased signal in bursa due to inflammation on T2 sequence
Treatment
Nonoperative
o NSAIDS, stretching, PT including modalities, corticosteroid injections
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indications
first line treatment is always conservative
Operative
o open vs arthroscopic trochanteric bursectomy
indications
is done only after conservative measures fail
5. Hip Arthroscopy
Introduction
Technically difficult because of deep location of hip joint
Lower morbidity than open arthrotomy with easier post-operative course
Indications
o FAI
o labral tears
o AVN (diagnosis and staging)
o loose bodies
o synovial disease
o chondral injuries
o ligamentum teres injuries
o snapping hip
o mechanical symptoms
o impinging osteophytes
Contraindications
o advanced DJD
o hip ankylosis
o joint contracture
o severe osteoporotic bone
o significant protrusio acetabuli
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Portals
Anterolateral portal
o function
primary viewing portal
anterolateral hip joint access
o location and technique
located 2 cm anterior and 2 cm superior to anterosuperior border of greater trochanter
typically established first under fluoroscopic guidance
Posterolateral portal
o function : posterior hip joint access
o location and technique
located 2 cm posterior to the tip of the greater trochanter
Anterior portal
o function
anterior hip joint access
o location and technique
located at intersection between
superior ridge of greater trochanter
ASIS
flexion and internal rotation of hip loosens capsule and assists scope insertion
Distal anterolateral portal
o function
provides access to the peripheral compartment in the region of the femoral neck
o location and technique
used in conjunction with the anterolateral portal to visualize the peripheral compartment
traction is removed and the hip is placed in either neutral flexion and extension or in 45
degrees of flexion to relax the anterior capsule
fluoroscopy and direct arthroscopic visualization is used to guide portal placement
portal is established 3 to 5 cm distal to the anterolateral portal, just anterior to the lateral
aspect of the proximal femoral shaft and neck
o structures visualized within the peripheral compartment
femoral head
labrum
zona orbicularis
provides a landmark for the iliopsoas tendon
medial synovial fold
femoral neck
peripheral capsular attachments
Rehabilitation
Immediate post-operative period
o NWB or PWB for ~ one week
o with gradual progression to full weight bearing
Rehabilitation
o strengthening is started after full ROM is achieved
Return to full activity : at ~ 3 months
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Complications
Direct injuries
o can occur from scope or cannula placement
o most commonly reported complication
chondral injuries
Neurovascular injury
o traction related
pudendal nerve injury
most common neurovascular complication
due to traction post in groin for traction
neuropraxia or compression injury
peroneal nerve injury
traction neuropraxia
may prevent traction injuries with
intermittent release of traction
adequate anesthesia
o anterolateral portal
risks superior gluteal nerve
o posterolateral portal
risks sciatic nerve
increased risk with external rotation of hip
o anterior portal
risks lateral femoral cutaneous nerve injury
risks femoral neurovascular bundle
risks ascending branch of lateral femoral circumflex artery
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C. Thigh
1. Adductor Strain
Introduction
A common injury to the adductor muscle group
Epidemiology
o incidence
occurs in 10-30% of soccer and hockey players due to strong eccentric contraction of
adductors during play
Pathophysiology
o mechanism : a “pulled groin,” is caused by forceful external rotation of an abducted leg.
Classification
1st degree
o pain with minimal loss of strength and motion
2nd degree
o compromised strength
3rd degree
o complete disruption with loss of muscle function
Anatomy
Hip joint adductor complex
o adductor longus (most common muscle injured in complex)
o adductor magnus
o adductor brevis
o gracilis
o obturator externus
o pectineus
All have obturator nerve innervation
Presentation
Symptoms
o Pain is immediate and severe in the groin region.
Physical exam
o Tenderness is at the site of injury along the subcutaneous border of the pubic ramus.
o pain and/or decreased strength with resisted leg adduction compared to the other leg
Imaging
Radiographs
o recommended views
AP pelvis
lateral of hip
o findings : if injury is due to an avulsion then fleck of bone may be visible
MRI
o May show avulsion injury of the adductor muscle from the pubic ramus with muscle edema and
hemorrhage.
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Treatment
Nonoperative
o rest, ice, protected weight bearing as needed
indications
mainstay of treatment
modalities
dictated by the severity of the symptoms but generally consists of of a period of rest
follow with a rehabilitation program that begins with gentle stretching and progresses
to resistance exercise and core strengthening with a gradual return to sports
immobilization should be avoided because this promotes muscle tightness and
scarring
Operative
o open repair
indications
no data exist to suggest that open repair yields a better outcome than nonsurgical
management.
2. Hamstring Injuries
Introduction
Hamstring injuries can occur at any level in hamstring
o myotendinous junction
is the most common site of rupture
often occurs during sprinting
o avulsion of ischial tuberosity
less common
seen in skeletally immature
seen in water skiers
Mechanism
o occurs as a result of hip flexion and knee extension
Pathophysiology
o satellite cell plays a role in muscle healing following muscle injury
Relevant Anatomy
"Hamstring" muscles include
o semimembranosus
most lateral attachment
o semitendinosus
semitendinosus and biceps femoris (long head) attach medial to semimembranosus
o biceps femoris
long head : attaches medial to semimembranosus
short head : origin from linea aspera
Common characteristics of hamstring muscles include
o originate on ischial tuberosity
o innervated by sciatic (tibial) nerve
o blood supply from inferior gluteal artery and profunda femoral artery
o cross and act upon 2 joints: the hip and knee (except short head of biceps femoris)
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Presentation
Physical exam
o ecchymosis in posterior thigh
o may have palpable mass in middle 1/3 of posterior thigh
(myotendinous rupture)
o normal hamstring/quadricep ratio is 65%
o stiff legged gait (avoiding knee and hip flexion)
Imaging
Radiographs
o may show avulsion off ischial tuberosity
MRI
o may show avulsion off ischial tuberosity
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Treatment
Nonoperative
o rest, ice, NSAIDS, protected weightbearing for 4 weeks followed by stretching and
strengthening
indications
most hamstring injuries
single tendon, retraction ≤1-2cm
rupture at myotendinous junction
return to play
only when strength is 90% of contralateral side to avoid
further injury
Operative
o operative repair
indications
proximal avulsion ruptures
partial avulsion that has failed nonoperative management
for 6mths (persistent symptoms)
at least 2 tendons but > 2cm retraction in young, active
patients
surgical technique
transverse incision at gluteal crease
protection of the sciatic nerve
mobilization of the ruptured tendons
repair to the ischial tuberosity with the use of suture
anchors
results
easier to mobilize acute ruptures than chronic ruptures
repair of acute ruptures has less sciatic nerve scarring
chronic ruptures may require sciatic neurolysis
Complications
Weakness in knee flexion, hip extension
Hamstring syndrome
o posterior buttock and ischial tuberosity pain
o treatment
surgical release and sciatic nerve decompression
Sciatic nerve scarring and sciatic neuralgia
3. Quadriceps Contusion
Introduction
An injury commonly seen in athletes
o occurs as a result of direct trauma
o common in contact sports
Presentation
Symptoms
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Thigh
o pain at anterior thigh
Physical exam
o tenderness at anterior thigh
o limited active knee flexion due to pain
o possible knee effusion
o peform straight leg raise to ensure extensor mechanism is intact
o test sensory branches of femoral nerve (lateral, intermediate, and medial cutaneous nerves)
during evaluation for compartment syndrome
Imaging
Radiographs
o imaging not necessary if mild contusion and extensor mechanism intact
o plain radiograph to evaluate for myositis ossificans in chronic injuries
MRI
o has the highest sensitivity and specificity for disorders of the quadriceps
o MRI helpful in moderate to severe contusions or if quadriceps tendon competency in doubt
Treatment
Nonoperative
o immobilize in 120 degrees of knee flexion for 24 hours followed by therapy
indications
acute injuries
technique
acute phase
cold therapy
ACE bandage or hinged knee brace
subacute phase
begin active pain-free quadriceps stretching several times a day thereafter
weight bearing as tolerated with use of crutches often needed initially
close monitoring for compartment syndrome
o Angiotensin II receptor blockade (e.g. Losartan)
indications
increase muscle regeneration after contusion
decrease fibrosis
mecahnism
blockade of insulin-like growth factor
reduces apoptotic cascade of muscle
Operative
o thigh fasciotomies
indications
compartment syndrome present
Complications
Compartment syndrome
o usually rupture of deep perforating branches of the vastus intermedius
Myositits ossificans
o incidence of 5-9% rate with quadriceps contusion
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Anatomy
Osteology
o anterior inferior iliac spine (AIIS)
origin of direct head of rectus femoris muscle
Muscles
o rectus femoris
crosses hip and knee joint
flexes hip and extends knee
Presentation
Symptoms
o pain in the anterior aspect of the hip
strain or avulsion at insertion on AIIS
o pain midthigh
strain in muscle fibers
o pain distally
most common finding
Physical exam
o inspection and palpation
tenderness to palpation in the injured area
proximally at origin of rectus femoris muscle
muscle belly midthigh region
distally at knee
feel for defect in muscle indicating a full tear (unusual finding)
o provocative maneuvers
pain elicited with resisted hip flexion or extension
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Imaging
MRI
Ultrasound
Radiographs
o indications
concern for avulsion at insertion site on anterior
inferior iliac spine in adolescent athletes
o findings
normal in most cases
Treatment
Nonoperative
o NSAIDS, rest, ice, stretching/strengthening
indications
definitive treatment for vast majority
outcomes
usually resolves within 4-6 weeks
D. Leg
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40% of people with exertional compartment syndrome have these facial defects, only
5% of asymptomatic people have such defects
most common location is near the intramuscular septum of the anterior and lateral
compartments, where the superficial peroneal nerve exits
Presentation
Symptoms
o aching or burning pain in leg
patients can often predict how long the pain will last for after they stop exercise
o paresthesias over dorsum of foot
o symptoms are reproduced by exercise and relieved by rest
symptoms begin ~ 10 minutes into exercise and slowly resolve ~30-40 minutes after exercise
Physical exam
o may be normal
o decreased sensation 1st web space
o decreased active ankle dorsiflexion
Imaging
Radiographs
o useful to eliminate other pathology
MRI
o not very helpful in establishing diagnosis
o can help eliminate other pathology
Evaluation
Compartment pressure measurement
o limb should be in relaxed and consistant position
o required to establish diagnosis
o three pressure should be measured
resting pressure
immediate post-exercise pressure
continuous post-exercise pressure for 30 minutes
o diagnostic criteria
resting (pre-exercise) pressure > 15 mmHg
immediate (1 minute) post-exercise is >30 mmHg and/or
post-exercise pressure >20mmHg at 5 minutes
post-exercise pressure >15 mmHg at 15 minutes
Near-infrared spectroscopy
o can show deoxygenation of muscle
showed return to normal within 25 minutes of exercise cessation
Treatment
Nonoperative
o activity modification
indications
rarely effective
o anti-inflammatories
o attempt these treatments for 3 months prior to operating
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Operative
o two incision fasciotomy
indications
refractory cases
technique
two incision approach
lateral incision
release anterior and lateral compartments
12-15 cm above lateral malleolus
identify and protect superficial peroneal nerve
may see fascial hernia
medial incision
used to release posterior compartments
perform if needed based on measurements
release at middle of tibia at posterior border
endoscopic
smaller incisions, similar complications
outcomes
not a "home run" procedure because symptoms are often multi-variable
no studies directly comparing operative to non-opertative treatment options
surgery is successful in >80% of cases for the anterior compartment
Deep posterior compartment success is lower (around 60%)
Complications
Nerve injury
o most commonly the SPN
DVT
Recurrence
o up to 20% at a mean of 2 years after fasciotomy
o because of fibrosis/scar formation
Presentation
Symptoms
o swelling
patients often report limb swelling as primary complaint
o paresthesias
foot numbness and paresthesias also common
tingling sensation of toes following vigorous exercise
o cramping
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Imaging
Radiographs
o usually normal
Doppler ultrasound
o less invasive than arteriogram
o useful during physical exam to detect changes in pulse
when active plantar flexion or passive dorsiflexion is
performed
Arteriogram
o used to confirm diagnosis
o close to 100% sensitivity
o will show stenosis, obliteration and post-stenotic dilation
MRI/MRA and CT/CTA
o studies ongoing to evaluate usefulness for detection of popliteal artery entrapment
Treatment
Nonoperative
o activity modification and observation
indications
mild symptoms with rigorous exercise only
Operative
o vascular bypass with saphenous vein vs endarterectomy
indications
if damage to the popliteal artery or vein
most patients eventually require surgery
technique
can perform posterior or medial approach to popliteal fossa
posterior approach provides improved exposure
medial approach used more when bypass is indicated
structures released depend on the type of entrapment
Complications
Surgical failure
o 30% rate of return of entrapment
o can result in need for amputation
Wound infection
o <5%
DVT
o around 10%
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Epidemiology
o incidence
10-15% of running injuries
60% of leg pain syndromes
o location
distal and posteromedial tibia
o risk factors
runners without enough shock absorption (running on
cement or uneven surfaces, improper running shoes)
training errors (sudden increase in training intensity
and duration)
running >20 miles/week
hill training early in the season
history of previous lower extremity injuries
over-pronation or increase internal tibial rotation
Pathophysiology
o caused by a traction periostitis
anterolateral
traction periostitis of tibialis anterior on
tibia and interosseous membrane
posteromedial
traction periostitis of tibialis posterior and
soleus
Associated conditions
o female athlete triad
critical to diagnose and treat
o tibial stress fractures
females have 1.5-3.5 increased risk of
progression to stress fractures
Presentation
Symptoms
o vague, diffuse pain along middle-distal tibia that
decreases with running (early stage)
differentiate from exertional compartment
syndrome, for which pain increases with
running
o earlier onset of pain with more frequent training (later stages)
Physical exam
o tenderness along posteromedial border of tibia
4cm proximal to medial malleolus, extending proximally up to 12cm
o pes planus
o tight Achilles tendon
o weak core muscles
o provocative test
pain on resisted plantar flexion
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Imaging
Radiographs
o indications
exclude stress fracture
o findings
conventional radiographs are normal in first 2-3weeks
long-term changes include periosteal exostoses
differentiate from stress fracture, which shows "dreaded
black line"
3-phase bone scan
o indications
exclude stress fracture
o findings
diffuse, longitudinal increased uptake along posteromedial border of tibia
in delayed phase (Phase 3)
normal findings on Phase 1 (flow phase) and blood pool phase (Phase 2)
differentiate from stress fracture, which has focal, intense hyperperfusion
and hyperemia in Phase 1 and 2, and focal, fusiform uptake in Phase 3
MRI
o indications
identify other soft tissue injuries
o findings
periosteal edema
progressive marrow involvment
Differential
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Treatment
Nonoperative
o activity modification with nonoperative modalities
indications
first line of treatment and successful in vast majority
techniques
activity modification
decreasing running distance, frequency and intensity by 50%
use low-impact and cross-training exercises during rehab period
regular stretching and strengthening
run on synthetic track
avoid running on hills, uneven or hard surfaces
shoe modifications
change running shoes every 250-500miles as shoes lose shock absorbing capacity at
this distance
orthotics may be helpful in patients with pes planus
therapy
focus on strengthening of invertors and evertors of the calf
other
local phonophoresis with corticosteroids may be effective
Operative
o deep posterior compartment fasciotomy + release of painful portion of periosteum
indications
failed nonoperative treatment
outcomes
variable results, not likely to cause complete resolution of symptoms
Complications
Recurrence
o common after resumption of heavy activity
E. Stress Fractures
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crack "initiation"
o continued repetitive loading does not allow for healing response and stress fracture occurs
crack "propagation"
Associated conditions
o "female athlete triad"
amenorrhea, eating disorder, and osteoporosis
must be considered in any female athlete with stress fracture
Prognosis
o dependent upon patient compliance
Anatomy
Muscle insertions around femoral neck
o iliopsoas
o quadratus femoris
o gluteus medius
o piriformis
Blood supply to femoral neck
o provided by two branches of the femoral artery including
medial femoral circumflex artery
lateral femoral circumflex artery
Biomechanics of femoral neck
o compression side
inferior medial neck with weight bearing
o tension side
superior lateral neck with weight bearing
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Presentation
History
o history of overuse or increase in normal training regimen
Symptoms
o insidious onset of pain
improves with cessation of activity
high impact activities increase pain
o anterior thigh or groin pain with weight bearing
Physical exam
o usually benign exam
o may have tenderness directly over femoral neck region
with deep palpation
Imaging
Radiographs
o recommended views
AP pelvis, AP and lateral of hip
o findings
usually negative
later findings include linear lucency and cortical
changes
MRI
o sensitive and specific for diagnosis
o detects early changes
o modality of choice for stress fractures when radiographs are normal
Bone scan
o has good sensitivity but very poor specificity (therefore MRI is better)
Treatment
Nonoperative
o non-weight bearing, crutches and activity restriction
indications
compression side stress fractures with fatigue line <50% femoral neck width
Operative
o ORIF with percutaneous screw fixation
indications
tension side stress fractures
compression side stress fractures with fatigue line >50% femoral neck width
progression of compression side stress fractures
technique
use three 6.5mm or 7.0mm cannulated screws
postoperative weightbearing as tolerated
Complications
Fracture progression/completion
o if fracture is unrecognized and the athlete continues to train
o fracture completion is associated with severe, disabling complications
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o precludes return to prior activity level (elite athletes will not be able to return to prior level
following displaced fracture)
Varus settling
AVN
Nonunion
Refracture
Presentation
Symptoms
o often a history of overuse
o insidious onset of pain
o pain during activity is localized to the involved bone
o pain improves with rest
Physical exam
o focal tenderness and swelling
o three point fulcrum test elicits pain
examiner's arm is used as a fulcrum under the patient's thigh as gentle pressure is applied to
the dorsum of the knee with the opposite hand
test is positive if pain and apprehension is experienced at the point of the fulcrum
Imaging
Radiographs
o recommended views
AP and lateral
o findings
linear cortical radiolucency
periosteal reaction
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endosteal and cortical thickening
CT
o findings
cortical lucency
benign-appearing periosteal reaction
MRI
o most sensitive and replacing bone scan for diagnosis
o views
T2-weighted images
findings
periosteal high signal is the earliest finding
broad area of increased signal
T1-weighted images
reveal linear zone of low signal
Technetium Tc 99m bone scan
o findings
focal uptake in cortical and/or trabecular bone
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Treatment
Nonoperative
o rest, activity modification, protected weight bearing
indications
most femoral shaft stress fractures
technique
restrict weight bearing until the fracture heals
incorporate cross-training into running programs
Operative
o locked intramedullary reconstruction nail
indications
prophylactic fixation
patients with low bone mass
patients >60 years old
fracture completion or displacement
technique
reamed insertion is preferred
Presentation
History
o change in exercise routine
Symptoms
o onset of symptoms often insidious
o symptoms initially worse with running, then may develop symptoms with daily activities
Physical exam
o pain directly over fracture
Imaging
Radiographs
o recommended views
AP and lateral
o findings
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OrthoBullets2017 Lower Extremity | Stress Fractures
lateral xray may show "dreaded black line" anteriorly indicating tension fracture from
posterior muscle force
endosteal thickening
periosteal reaction with cortical thickening
Technetium Tc 99m bone scan
o findings
focal uptake in cortical and/or trabecular region
MRI
o replacing bone scan for diagnosis and is most sensitive
o findings
marrow edema
earliest findings on T2-weighted images
periosteal high signal
T1-weighted images show linear zone of low signal
Treatment
Nonoperative
o activity restriction with protected weightbearing
indications IV:5 MRI: Stress fracture shaft tibia
most cases with bone marow oedema
technique
avoids NSAIDs (slows bone healing)
consider bone stimulator
Operative
o intramedullary tibial nailing
indications
if "dreaded black line" is present, especially if it violates the anterior cortex
fractures of anterior cortex of tibia have highest likelihood of delayed healing or non-
union
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By Dr, AbdulRahman AbdulNasser Lower Extremity | Stress Fractures
o risk factors
amenorrhea
osteopenia / osteoporosis
extreme overuse / repetitive use
repetitive coughing paroxysms
Pathophysiology
o pathoanatomy
repetitive contraction
stress placed on a rib during repetitive
contraction of an attached muscle
accentuated during training because
muscles strengthen more rapidly than
bone
muscle fatigue during prolonged activity
places a bone at risk for fracture by lessening the ability of a muscle to absorb and
dissipate opposing forces
anatomic sites of weakness
first rib stress fx
groove for subclavian artery is site of weakness due to superiorly directed forces from
the scalene muscles and inferiorly directed forces from the serratus anterior and
intercostal muscles
Presentation
History
o in cases of acute injury may hear "snap" (complete fracture of fatigued bone) while performing
activity (i.e., throwing, batting, lifting)
Symptoms
o pain
insidious onset
worse with coughing, deep inspiration and overhead activities
Physical exam
o palpation
focal tenderness directly over affected rib
with advanced injuries, palpable callus may develop
Imaging
Radiographs
o recommended views
AP chest
o findings
x-rays are negative for fracture in as many as 60% of patients with rib fracture of any
etiology
Bone scan
o indications
when x-rays are negative and clinical suspicion remains
o findings
increased activity
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OrthoBullets2017 Lower Extremity | Stress Fractures
CT scan
o indications
can be helpful when there is concern for pathologic fx
can help localize an uptake abnormality in the costotransverse region, where the anatomy is
complex
o findings
clear delineation of fracture pattern
MRI
o indications
when x-rays are negative and clinical suspicion remains
avoids the use of radiation
used more commonly than bone scans in athletes
o findings
marrow edema consistent with stress response; fracture line may or may not be seen
Treatment
Nonoperative
o rest, analgesia, cessation of inciting activity for ~4-6 weeks, correction of training errors or
faulty mechanics
indications
majority of rib stress fx
outcomes
majority heal uneventfully
Complications
Non-union
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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By Dr, AbdulRahman AbdulNasser Team Physician | Stress Fractures
ORTHO BULLETS
V. Team Physician
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OrthoBullets2017 Team Physician | Head and Spine
Anatomy
Layers of the spinal cord include the
o dura mater (outside)
epidural hematoma
subdural hematoma
o arachnoid (middle)
subarachnoid hematoma
o pia mater (inside)
Classification
American Academy of Neurology (AAN) guidelines
Grade Definition
Grade I No loss of consciousness and symptoms of confusion last less than
15 minutes
No loss of consciousness and symptoms of confusion last greater than
Grade II
15 minutes
Grade IIIa Brief loss of consciousness (measured in seconds)
Grade IIIb Brief loss of consciousness (measured in minutes)
Presentation
Symptoms
o headache and dizziness most common symptoms
o amnesia (memory loss)
Imaging
CT
o usually normal
o rule out intracranial hemorrhage
subdural hematoma most common
epidural, subarachnoid, intracerebral bleeds also possible
CT required if patient is unconscious for greater than 5 minutes
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By Dr, AbdulRahman AbdulNasser Team Physician | Head and Spine
Evaluation
Standard Assessment of Concussion Test (SAC)
o orientation, memory, concentration, exertional delayed recall
Immediate Post-Concussion Assessment and Cognitive Testing battery (ImPACT)
o a computer-based test that assess the users attention, memory, and processing speed
o comparison is made to baseline scores or historical controls
o useful tool in guiding treatment and return to play decisions
Memory testing
o antegrade and retrograde must be tested
Balance error scoring system (BESS)
Treatment
Nonoperatve
o same day return to play is NOT indicated in patients diagnosed with concussion
o graduated return to play
indications
any athlete <18 years of age
elite athletes of any age without team physicians experienced in concussion management
technique (see table below)
each step should take 24 hours, so an athlete should take one week to proceed through the
full protocol and return to play
o return to play contraindicated until further evaluation
indications
LOC
prior Grade 1 concussion in same season
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OrthoBullets2017 Team Physician | Head and Spine
symptoms > 15 minutes
positive exertional stress test
amnesia
postconcussion syndrome
Prevention
o includes enforcing proper head gear
o minimizing premature return to play
Complications
Second impact syndrome
o second minor blow to head before initial symptoms resolve
o due to loss of autoregulation of the brain's blood supply
o 50% mortality rate
o affects adolescent males
Epidural bleeding
o commonly have a lucid period before neurologic decline
o neurosurgical decompression and seizure prophylaxis indicated
Cumulative effects
o cumulative effects of repeated concussions is controversial
Postconcussion syndrome
o headache, confusion
o RTP contraindicated
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By Dr, AbdulRahman AbdulNasser Team Physician | Head and Spine
spear tackler's spine
definition
developmental narrowing (stenosis) of the cervical canal
persistent straightening or reversal of the normal cervical lordotic curve
concomitant posttraumatic roentgenographic abnormalities of the cervical spine
documentation of having employed spear tackling techniques
treatment : contraindication to play in contact sports
cervical fxs
transient quadriplegia
neuropraxia of the cervical cord
bilateral upper and lower extremity pain, parasthesias, and weakness
symptoms resolve within minutes to hours
quadriplegia
Epidemiology
o injuries to the cervical spine are primarily seen in contact sports
common among football and rugby players
evolution of protective gear has decreased incidence
Mechanism
o axial load (compression) with flexion of the spine
o most injuries in contact sports occur during tackling of another player
"spear tackling"
is the most common mechanism of neck injury in football
can lead to gradual cervical stenosis and loss of cervical lordosis
Associated conditions
o underlying conditions of the cervical spine can increase the severity of neck injuries and be
contraindications to play. They include
previous trauma to cervical spine (fractures, ligamentous injuries)
cervical stenosis
congenital odontoid hypoplasia
os odontoideum
Klippel-Feil anomalies
Anatomy
Cervical spine
Presentation
History
o evaluate mental status
o spinal injuries should be assumed in the athlete with loss of or altered consciousness
Symptoms
o neck pain
o neurological symptoms such as numbness, tingling or weakness
Physical exam (on-field evaluation)
o when cervical spine injury is suspected in the field
stabilize the head and neck
log roll to supine position
remove facemask to protect airway as needed
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OrthoBullets2017 Team Physician | Head and Spine
do not remove helmet or shoulder pads
CPR as indicated
log roll place on backboard
transport to location to perform complete physical exam
o inspection
look for deformities of cervical spine
o palpate
spinous processes for step off or pain
o neurological exam
muscle testing of all 4 extremities
test sensation throughout extremities
test reflexes
Imaging
Radiographs
o indications
burner / stingers with recurring symptoms
neurologic symptoms and transient quadriplegia
o recommended views
cervical spine trauma series
o findings
canal diameter of < 13mm (normal is ~17mm)
Torg-Pavlo ratio (canal/vertebral body width) of < 0.8 (normal is 1.0)
Torg ratio is technique dependent, not predictive, and not accurate in large athletes
MRI
o indications : bilateral neurologic symptoms
o findings : look for spinal stenosis or loss of CSF around the spinal cord
Treatment
Nonoperative
o return to play criteria
indications
specific to diagnosis
burners/stingers
may return to play when
complete resolution of symptoms
normal strength and range of motion
o NO to return to play
indications (contraindications to return to play)
transient quadriplegia with severe stenosis
spear tackler's spine
cervical neuropraxia with ligamentous instability
odontoid hypoplasia and os odontoideum
are absolute contraindications to play
Klippel-Feil anomalies : mass fusion of the cervical and thoracic vertebrae is an absolute
contraindication to play
Operative : treatment is the same as for other traumatic injuries to the spine
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By Dr, AbdulRahman AbdulNasser Team Physician | Head and Spine
Anatomy
Brachial plexus
o with motor and sensory innervations
Presentation
Symptoms
o unilateral tingling in arm not typically isolated to a single dermatome
o usually resolve quickly in 1-2 minutes
Physical exam
o full cervical ROM
o no tenderness
o unilateral transient weakness in C5, C6 muscles (deltoid, biceps)
o can have positive Spurling test
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OrthoBullets2017 Team Physician | Head and Spine
Imaging
Radiographs
o usually unremarkable
o C-spine images indicated with recurring symptoms
to rule out fx and cervical stenosis
MRI
o indicated whenever symptoms are bilateral (inconsistent with stinger)
to rule out cervical spine pathology such as herniated disc or cervical stenosis
EMG
o indicated if symptoms persist after 3 weeks
will show abnormalities in roots, cords, trunks, and peripheral nerves
Treatment
Nonoperative
o return to play
a player may return to play when
complete resolution of symptoms
normal strength and range of motion
contraindications to return to play include
recurring symptoms
until cervical spine xrays are obtained
Prevention
o try different neck collars for football players
Heat Syncope
Definition
o Transient loss of consciousness with peripheral vasodilation and decreased cardiac output with
normal body temperature.
Pathophysiology
o results from sever orthostatic event secondary to elevated temperatures
Treatment
o fluid replacement
o lying supine with leg elevation
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By Dr, AbdulRahman AbdulNasser Team Physician | Team Physician
Heat Exhaustion
Definition
o Defined as a core temperature of less than 102.2 degrees F (39 degrees C) and an absence of
central nervous system dysfunction.
Epidemiology
o the most common heat-induced condition
Pathophysiology
o Hypernatremic heat exhaustion results from inadequate water replacement.
Symptoms
o consist of profuse sweating and nausea/vomiting
Treatment
o table salts
o IV hydration
o cooling
Heat Illness
Treatment
o drink fluids
o Low osmolarity solution (<10%)
o carbs and stimulate GI fluid absorption
Monitor weight
5% loss - not able to return to play
7% loss - see physician
Heat Stroke
Introduction
o a medical emergency with a high death rate that results from failure of the thermoregulatory
mechanisms of the body.
Definition
o hyperthermia
o tachycardia/tachypnea
o central nervous system dysfunction
o cessation of sweating with hot, dry skin
o anhidrosis
o Body temperature above 40.5 degrees Celsius
Epidemiology
o second most common cause of death in football players
Treatment
o rapid reduction in body core temperature
lower temp below 39°C (102° F) with
ice immersion
cooling blanket
fanning
internal cooling if needed
IV hydration
Complications
o heat sensitivity : may last 1 year
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OrthoBullets2017 Team Physician | Team Physician
B. Team Physician
1. Exercise Science
Types of Contractions/Movements
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By Dr, AbdulRahman AbdulNasser Team Physician | Team Physician
Exercise Programs Definitions
Periodization
o strength and conditioning term for planned variation in intensity and duration of a specific
workout over a predefined duration of time
Dynamic exercise improves cardiac output by increasing cardiac stroke volume
Endurance (aerobic) Training
o results in changes in circulation and muscle metabolism
o contractile muscle adapts by increasing energy efficiency
o increases in mitochondrial size, number, and density
o increases in enzymes involved in Krebs cycle, fatty acid processing, and respiratory chain
o over time, increased use of fatty acids > glycogen
o over time, oxidative capacity of Type I, IIA, and IIB fibers increase
percentage of more highly oxygenated IIA fibers increases
o Aerobic Threshold: level of effort at which anaerobic energy pathways become significant
energy producer
o Anaerobic (lactate) Threshold: level of effort at which lactate production > lactate removal
Strength Training
o typically high-load, low-repetition activities
o results in increased cross-sectional area of muscle due to muscle hypertrophy
hyperplasia (increased number of fibers) less likely
o results in increased motor unit recruitment +/- improved synchronization of muscule activity
o maximal force production is proportional to muscle physiologic cross-sectional area
o adolescents can safely participate in appropriate strength training programs
gains in strength largely due to improved neuromuscular activation and coordination rather
than muscle hypertrophy
gains for adolescents are reversible if training is discontinued
Aquatic training
Benefits
o decreases joint stress by lowering vertical component of the ground reaction force through
buoyancy
o unique advantages in cardiorespiratory fitness when compared to land training
o less abrupt increases in heart rate
o increased oxygen consumption
o prevents secondary injuries to the lower limb
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By Dr, AbdulRahman AbdulNasser Team Physician | Team Physician
Weight training
Effects on muscles
o increased cross-sectional area
o increased strength
o increased mitochondria
o increased capillary density
o thickened connective tissue
Adult strength gains are associated with muscle hypertrophy
Adolescent strength gains occur more from increased muscle firing efficiency and coordination
Nutritional training
Carbohydrate loading
o involve increase carbohydrates three days prior to an event and decreasing physical activity to
build up carbohydrates stores
o increases the stores of muscle glycogen to provide improved endurance, especially in events
lasting > 90 minutes when the bodies normal supply of glycogen runs low
o best technique for athlete is to instead maintain normal diet
Fluid loading and replacement
o magnitude of core temperature and heart rate increase accompanying work are proportional to
the magnitude of water debt at the onset of exercise
o best technique is to replace enough water to maintain prepractice weight
Fluid carbohydrate and electrolyte replacement
o best done with low osmolarity (< 10%) fluids of carbohydrates and electrolyties which enhances
absorption in the gut
glucose polymers decrease osmolarity
Muscle Injury
Muscles soreness
o caused by edema and inflammation in the connective tissue
leads to increased intramuscular pressure
occurs primarily in Type IIB fibers
o worse with unaccustomed eccentric exercise
o often with delayed onset: Delayed-Onset Muscle Soreness (DOMS)
peaks at 24-72 hours
o elevated CK levels seen in serum
Muscles strain
o occurs commonly at myotendinous junction (off during eccentric contraction which produces
highest forces in skeletal muscle)
o pathoanatomy in inflammation followed by fibrosis
Muscle contusion
o non-penetrating blunt injury
o leads to hematoma and inflammation
o extracellular connective tissue forms within 2 days, peaks between 5-21 days
o healing characterized by late scar formation, variable muscle regeneration
o myositis ossificans (bone formation within the muscle tissue)
most apparent 4 weeks post-injury
Muscle laceration (complete tear)
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OrthoBullets2017 Team Physician | Team Physician
o typicallyoccur near myotendinous junction
o characterized by abnormal muscle countour
o fragments heal by dense connective scar tissue
mediated by myofibroblasts
TGF-beta stimulates differentiation and proliferation of myofibroblasts
o regeneration and renervation: unpredictable and likely incomplete
Muscle Immobilization
Can result in shorter muscle position and atrophy
Leads to decreased ability to generate tension and increased fatigability
Results in fatty infiltration
Atrophy occurs faster in muscles crossing a single joint
Atrophy occurs at a non-linear rate
o most changes occur during initial days of disuse
o seen at cellular level: loss of myofibrils within the fibers
o related to duration of immobilization
Atrophy is more prominent if immobilization occurs without tension
o quadriceps atrophy greater than hamstrings with knee immobilization in extension
Treatment
Local treatments designed to assist with soft tissue recovery or rehabilitation
Goals of treatment
o decrease inflammation
o increase local blood flow
o increase tissue compliance
Modalities include
o cryo or heat treatments
o massage
o ultrasound
o electrical stimulation
o Iontophoresis
use of an electrical current to drive charged molecules of medicine through the skin to the
deep tissues
medications including steroids, local anesthetics, salicylates, and non-steroidal anti-
inflammatory drugs (see table below)
indications - see table below
contraindications
susceptibility to applied currents e.g. cardiac pacemakers
hypersensitivity/allergy to drug used
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By Dr, AbdulRahman AbdulNasser Team Physician | Team Physician
Indication Iontophoresis Drug/Solution
Hyperhydrosis Tap water, glycopyrrolate
Muscle spasm Magnesium sulfate, calcium chloride
Edema Hyaluronidase
Adhesive conditions Iodine
Inflammation Dexamethasone, hydrocortisone, prednisone, lidocaine, salicylates
Calcific tendinitis Acetic acid
Myositis ossificans Acetic acid
Open wounds Zinc oxide, tolazoline hydrochloride
2. Pre-Participation Physical
Introduction
AAOS, AOSSM, AFP, and AAP have collaborated to form the "Preparticipation Physical
Examination Task Force"
Goal is to identify conditions that may predispose an athlete to injury or illness.
o often is the only medical encounter for adolescent athletes that don't have routine physician
check-ups
Should be performed in all athletes
Legal necessity for high school and collegiate participation
Orthopaedic history and questionnaire most useful tool for identifying musculoskeletal problems
o identifies 75% of problems
o should include complete list of current and past illnesses and injuries along with prior treatments
o all current OTC and prescription medications and supplements should be listed
o family history and past symptoms are paramount for identifying potentially lethal conditions
o document instances of only a solitary remaining organ in a paired-organ system (e.g., single
kidney, single enucleation).
Physical examination
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OrthoBullets2017 Team Physician | Team Physician
o height, weight, and body mass index (BMI) , vital signs
o visual acuity
o lung exam
o musculoskeletal exam with focus on regions of prior injury or surgery
o male genital examination for inguinal hernia, testicular mass, and undescended testis
o scoliotic curve
EKG's, urinalysis, CBC, ferritin, or chest radiographs presently not indicated for routine screening in
the USA
athletes are then assigned one of the following:
o clearance without restriction
o cleared with further evaluation recommended
o cleared with restrictions
o not cleared for participation
Cardiac Screening
History
o hypertrophic cardiomyopathy, sudden death, murmurs, marfan syndrome, long QT syndrome
o athletes who suffer a sudden cardiac death most commonly have no history of prodromal
symptoms
Physical exam
o exertional symptoms with activity
may include dyspnea, angina, dizziness, palpitations
o cardiac murmur that increases with valsalva indicates hypertrophic cardiomyopathy
participation contraindicated with outflow obstruction
Neurologic Screening
History
o concussions, loss of consciousness, seizures, transient quadriplegia
Physical exam
o neuropsychiatric testing at baseline is encouraged to serve as comparative data post-head injury
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By Dr, AbdulRahman AbdulNasser Team Physician | Team Physician
o common in wrestlers
o use proper headgear
o treatment
aspiration
wrapping
Eye Injuries
Common in baseball, basketball, racketball, boxing, martial arts
Injuries include
o traumatic mydriasis
a transient phenomenon during which the iris fails to constrict properly, resulting in a dilated
pupil
caused by contusion to iris sphincter
treated with bedrest
o corneal abrasion
diagnosed with fluorescent stain and UV light
treat with topical antibiotics, topical NSAIDS, eye patch, and nonurgent referral
to ophthalmologist
o hyphema
blood in the anterior chamber
treat with eye patch and to ER or emergent ophthalmologist
o ruptured globe
sunken appearance
vitreous exudate
requires referral to ER or emergent ophthalmologist
o orbital wall fracture
may cause occular muscle entrapment
requires referral to ER or emergent ophthalmologist
o retinal detachment
Bright flashes, stabbing pain, visual field cut
requires referral to ER or emergent ophthalmologist
Presentation
o vision loss
o decreased acuity
o floaters or flashers
o double vision
Physical exam
o hyphema
blood in anterior chamber
may represent vitreous or retinal injury
Dental injuries
An avulsed tooth is a medical emergency and should be replaced immediately
o the likelihood of survival of the tooth depends on the length of time that the tooth is out of the
socket and the degree to which the periodontal ligament is damaged.
Tooth handling includes
o the tooth should be handled only by the crown end and not the root end
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OrthoBullets2017 Team Physician | Team Physician
o it can be rinsed of debris with water or normal saline solution
o then place temporarily in buccal fold or pour normal saline solution on the teeth and then place
them in milk
Treatment
o the tooth and the athlete should be transported to the dentist for reinsertion as soon as possible
and preferably within an hour
4. Cardiac Conditions
Introduction
Epidemiology
o cardiac pathology is the most common cause of sudden death in young athletic patients
Common conditions include
o syncope
o hypertrophic cardiomyopathy
o CAD
o commotio cordis
o long QT syndrome
Presentation
Symptoms
o history and physical exam is the best screening tool to identify cardiovascular problems in high
school athletes
o chest pain
o palpitations
o syncope
Physical exam
o pre-participation physicals
diastolic murmur warrants further workup
II/VI systolic murmur
Evaluation
EKG
o normal EKG findings in endurance athletes
ventricular hypertrophy
primary AV block
nonspecific STT wave changes in the lateral leads on ECG
resting sinus bradycardia at 40 beats per minute
Syncope
Overview
o a syncopal episode in a young athlete is a red flag for a serious cardiac condition.
Treatment
o medical evaluation
requires a medical evaluation prior to returning to athletic activity
Hypertrophic Cardiomyopathy
Overview
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By Dr, AbdulRahman AbdulNasser Team Physician | Team Physician
o most common cause of cardiac sudden death in young athletic patients
Presentation
o symptoms
dyspnea on exertion
chest pain
positive family history
o physical exam
II/VI systolic murmur
a murmur that increases with standing or Valsalva maneuver should raise concern for
hypertrophic cardiomyopathy
increase in murmur caused by dynamic obstruction of blood outflow caused by enlarged
ventricle
Evaluation
o echocardiogram
study of choice to make diagnosis
will show nondilated, thickened left ventricular wall thickness compared to normal
individuals of the same age.
Treatment
o avoid vigorous exercise
considered an absolute contraindication to vigorous exercise and sports
Commotio Cordis
A rare but catastrophic condition that is caused by blunt chest trauma
o it results in cardiac ventricular fibrillation and is universally fatal unless immediate defibrillation
is performed
Epidemiology
o most common in children and adolescents due to high number of athletes
Treatment
o CPR vs.cardiac defibrillation
best method of treatment is cardiac defibrillation
Prevention
o chest protectors in baseball and hockey have not yielded the protective results desired
Long QT Syndrome
An abnormality of ventricular repolarization that can lead to
o ventricular tachycardia
o torsades de pointes
o sudden cardiac death if not recognized and treated
Symptoms
o syncope or near-syncope with exercise
o often times asymptomatic
Diagnosis : ECG is gold standard
Treatment
o sports return to play
determination of play by genetic makeup, presentation, and need for pacemaker
5. Pulmonary Conditions
Tension pneumothorax
Introduction
o a life-threatening emergency where air is trapped between the pleura and the lung, which
prevents expansion of the lung.
this causes hypoxia and cardiopulmonary compromise.
o caused include
trauma
infection
Symptoms
o acute-onset, unilateral, pleuritic chest pain
o dyspnea / acute respiratory distress
o syncope
Physical exam
o tachypnea
o unilateral decreased or absent breath sounds
o deviated trachea
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By Dr, AbdulRahman AbdulNasser Team Physician | Team Physician
Treatment
o emergent needle decompression followed by chest tube
the first line of treatment is to place a needle into the second intercostal space in the
midclavicular line.
then the athlete should then be transported to the emergency department for chest tube
placement.
Exercise-induced Asthma
Symptoms
o coughing, SOB, wheezing
o often occurs 15 minutes after stopping
Pathophsiology
o drying and cooling of mucosa leads to edema and constriction
worse in winter sports
Treatment
o beta-agonist inhaler prior to exercise
o steroid inhaler
Diaphragmatic Spasm
Commonly known as "wind knocked out"
o caused by a direct blow to epigastrium causing diaphragmatic spasm
Treatment
o observation
resolves spontaneously
may continue play
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OrthoBullets2017 Team Physician | Team Physician
Treatment
o nonoperative
ice and rest
indications
most cases
o operative
surgery decompression
indications
required if persistent progression and pain
Kidney Injuries
Introduction
o more common in boxers and football players
Presentation
o look / ask for hematuria but not always present
Evaluation V:4 Contrast enhanced CT:
extravasation of contrast from
o diagnosis can be made with CT renal laceration
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By Dr, AbdulRahman AbdulNasser Team Physician | Team Physician
Treatment
o operative
urgent surgery
indications
extensive bleeding with renal fx or vascular pedicle injury
Penile & Testicular Injuries
Pudendal nerve neuropraxia
o introduction
common in bicyclists
o presentation
causes penile shaft numbness
o treatment
nonoperative
seat modifications
Testicular Injury
o introduction
mechanism is usually a kick
leads to rupture of tunica albuginea (outer covering)
causes a hematocoele
o presentation :5 Ultrasound showing hematocele (h) with
V
painful firm scrotal mass that does not transilluminate septation and debris. There is thickening of the
scrotal wall (w). The testis is normal (T).
o diagnosis
ultrasound by urology
o treatment
observation
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OrthoBullets2017 Team Physician | Team Physician
indications
initial treatment of small lesions
o operative
irrigation & debridement with oral trimethoprim/sulfa and rifampin
indications
larger lesions
irrigation & debridement and IV antibiotics
indications
more severe infections
Herpes Gladiatorum
Herpes infections are a group of viral infections which manifest on the skin and/or in the nervous
system
Epidemiology
o common in wrestlers and rugby players
o occurs in approximately 2% to 7% of wrestlers
Pathophysiology
o caused by herpes simplex type 1 virus
o transmitted via direct skin to skin contact
o incubation 2-14 days
o head, neck and shoulders primary areas of infection
o if contacts the eye herpetic conjunctivitis can develop
Presentation
:6 Herpes Gladiatorum
V
o physical exam
clusters of fluid-filled blisters
rash
Treatment
o nonoperative
acyclovir, valacyclovir, and no wrestling until lesions have scabbed over
indications
any active lesions
return to play
when no new lesions within the preceding 72 hours and
at least 5 days of anti-viral medications
Tinea Infections
A common fungal infection of the skin
o include tinea pedis, corporis, capitis, and cruris (describes areas of body affected)
Epidemiology
o common in wrestlers
Pathophysiology
o tinea infections are caused by dermatophytes
o transmitted by direct contact of fungus with skin
o broken areas of skin can facilitate infection
Presentation
o physical exam
scaly red patches in circular formation
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By Dr, AbdulRahman AbdulNasser Team Physician | Team Physician
example of tinea corporis (body) aka "ringworm"
Studies
o diagnosis
scrapings from lesions are examined under microscope after preparation with potassium
hydroxide
positive for tinea if hyphae are found
Treatment
o nonoperative
topical antifungals
indications
tinea cruris, pedis and corporis
systemic antifungals
indications
tinea capitis
more severe cases of all forms tinea
no sports participation
V:7 Tinea Infections
indications
active infection
can return to play when
48 hours of treatment
must be screened prior to competition
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OrthoBullets2017 Team Physician | Team Physician
Impetigo
A highly contagious bacterial infection of the skin
Epidemiology : common in wrestlers
Pathophysiology
o common pathogens include
streptococcus pyogenes
staphylococcus aureus
Presentation
o initially present as fluid filled blister-like lesions
o crusting noted after a few days
Treatment
o erythromycin, topical bactroban
first line of treatment
o no sports participation
indications : active infection V:9 Impetigo
return to play
may return to play when all lesions are clear of crusting
Mononucleosis
A viral infectious condition characterized by fatigue and splenomegaly
Pathophysiology
o caused by Epstein-Barr Virus (a herpes virus)
o incubation period of 30-50 days
o spread through saliva (kissing, sharing cups)
Presentation
o symptoms
resolve in 4-8 weeks
3-5 day prodromal period includes
malaise
myalgia
nausea
headache
Hoagland's triad
V:10 CT scan demonstrating splenomegaly which can be
fever characteristic of mononucleosis
pharyngitis (in 30%)
Group A streptococcus is responsible
exudative (white/grey pseudomembrane) in 50%
lymphadenopathy
posterior cervical chain
lasts 2-3 weeks
rash
petechial/maculopapular/urticarial
common if treated with ampicillin/amoxicillin
o physical exam
splenomegaly
pharyngitis
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By Dr, AbdulRahman AbdulNasser Team Physician | Team Physician
Studies
o heterophile Ab test (Mono-spot test)
87% sensitive, 91% specific
o viral capsid antigen (VCA) IgG and IgM
97% sensitive, 94% specific
o lab tests
absolute and relative lymphocytosis with >10% atypical lymphocytes
Imaging
o generally unnecessary
o ultrasound
if imaging is obtained, order ultrasound
noninvasive, reliable, has no radiation
o CT : to exclude rupture
Treatment
o nonoperative
fluids, hydration, acetaminophen, rest
isolation is unnecessary as transmissibility is low
no contact sports for 3-5 weeks
some take up to 3 months
indications
indicated in athletes until splenomegaly is completely resolved
most splenic rupture occurs in first 3 weeks
IM penicillin (one time) or PO penicillin (10 days)
erythromycin if allergic to PCN
indications
for strep pharyngitis
do NOT use amoxicillin
corticosteroids
decrease tonsillar size if there is difficulting swallowing/dehydration
advanced airway management
if there is respiratory distress
stool softener : decreases straining/Valsalva during bowel movements
Complications
o splenic rupture
risk is 0.1-0.5%
most common in first 3 weeks
due to sudden increase in portal venous pressure
50% atraumatic from Valsalva maneuver (rowing, weightlifting)
50% from external trauma
o aplastic anemia
o Guillain-Barre syndrome
o meningitis/encephalitis
o neuritis
o lymphoma
o hemolytic uremic syndrome
o disseminated intravascular coagulation
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OrthoBullets2017 Team Physician | Team Physician
HIV and AIDS
AIDS is an immune deficiency condition caused by infection with the Human Immunodeficiency
Virus (HIV)
Epidemiology
o HIV can occur in any population
increased prevalence in hemophiliacs, IV drug abusers, and homosexual men
Pathophysiology
o the CD4 cells (T-helper cells) are affected
Diagnosis
o the diagnosis of AIDS requires an HIV positive test plus one of the following
CD4 count less than 200
diagnosis of an opportunistic infection
Treatment
o no difference in treatment as compared to other athletes
use of universal precautions at all times
wound care
in the event of bleeding, compressive dressings should be used
participation in sport is restricted until all bleeding has ceased
participation in sports
HIV infection alone is insufficient grounds to prohibit an athlete from competition
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By Dr, AbdulRahman AbdulNasser Team Physician | Team Physician
ACL injury
Risk of injury is 2-10x greater than males
o especially with pivoting sports
ACL injury is more common in females due to
o landing biomechanics and neuromuscular control differences
conditioning and strength play the biggest role
females land with their knees in more extension and valgus due
to hip internal rotation
o smaller notches
o smaller ACL size
o cyclic hormonal levels
ACL at greater risk for injury during the first half (preovulatory
phase) of the menstrual cycle
o leg alignment
o genetic predisposition
underrepresentation of CC genotype of a COL5A1 gene
sequence in females with ACL ruptures V:13 The female athlete depicted
in this clinical photograph
Preventions displays landing biomechanics
o incidence can be reduced with neuromuscular training (jump consistent with valgus medial
knee collapse.
training)
Female athlete triad (anorexia athletica)
A condition seen in female athletes that consists of:
o amenorrhea
resulting from energy imbalance, low body fat, and hypothalamic-pituitary axis changes
secondary amenorrhea (cessation of menses for 6 months after at least one normal cycle) is
often caused by hormonal disturbances
incidence in elite runners is nearly 50%
leads to bone demineralization and stress fractures
o disordered eating
insufficient caloric intake
is the most common cause of amenorrhea in female athletes
o osteoporosis
obtain a DEXA scan in female athletes with a history of amenorrhea and stress fractures
Treatment
o a multidisciplinary approach should include
psychological counseling as the core
education and counseling for eating behaviors
dietary management should begin by establishing an energy balance
increase weight/food intake and decrease exercise
increase calcium and vitamin D in diet
reduced training intensity and cross-training to decrease risk of stress fractures
calcium and vitamin D supplements should be taken for osteoporosis
may consider cyclic estrogens or progesterones in treating osteoporosis
oral contraceptive pills may be beneficial in treating amenorrhea
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OrthoBullets2017 Team Physician | Team Physician
Pregnancy
Increased estradiol
o leads to ligamentous laxity
Increased oxygen
o increased body weight leads to a 16-32% increase in oxygen consumption
Title IX
Law stating that females have equal access to training rooms
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By Dr, AbdulRahman AbdulNasser Team Physician | Team Physician
can lead to decreased bone mineral density
oligospermia or azoospermia
o growth retardation
o gynecomastia
Type of steroids
o Human Growth hormone (HGH)
the most abundant substance produced by the pituitary gland. Growth hormone has a direct
anabolic effect by accelerating the incorporation of amino acids into proteins. It is becoming
an increasingly popular anabolic steroid substitute;
similar effects from insulin-like growth factor (IGF-1)
increased muscle size but not strength
Side effects:
myopathic muscles development
carpal tunnel syndrome
insulin resistance
o Androstenedione
an androgen produced by the adrenal glands and gonads
acts as a potent anabolic steroid and is converted in the liver directly to testosterone with a
resultant increase in levels after administration.
o DHEA
is a naturally occurring hormone made by the adrenal cortex.
it is converted to androstenedione, which in turn is converted to testosterone.
the beneficial and adverse effects of DHEA can be correlated directly with those of
testosterone.
o Erythropoietin (EPO)
stimulates hemoglobin production and increases O2 carrying capacity
side effects
increased blood viscosity which can lead to stroke or myocardial infarctions
o Somatotropin
a growth hormone that causes hypertrophy of type 1 muscles and atrophy of type 2 muscle
Catabolic Hormones
Glucagon
o has a catabolic effect on skeletal muscle
Supplements
Creatine
o Introduction
derived from glycine, arginine, and methionine
a muscle and power building supplement (not an anabolic steroid)
mechanism is that creatinine is converted to phosphocreatine, which acts as a source of ATP
for muscle
studies have shown although it can increase work in anaerobic trials, it cannot increase
peak force
widely used in conjunction with off-season weight lifting programs
o Outcomes
studies show mixed results with regard to enhanced sports performance
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OrthoBullets2017 Team Physician | Team Physician
o Risks
pulls water from blood vessels into cells, creating a theoretical risk of dehydration
o Reports of
cramps
increased muscle injury
renal insufficiency (rare)
Stimulants
Includes
o caffeine
doses of 2 to 3 mg/kg have been shown to improve performance
works by reducing fatigue and increasing alertness
previously banned by the International Olympic Committee (IOC)
now allowed up to 12 micrograms per milileter of urine
o ephedra
o ephedrine
o "ma huang"
often included in energy drink
o amphetamines
Risks include
o dehydration
o impaired heat management
o high blood pressure
o nervous system impairment
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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4
ORTHO BULLETS
Volume
Four
Pediatrics
2017
Collected By : Dr AbdulRahman AbdulNasser
[email protected]
OrthoBullets 2017
OrthoBullets 2017
Preface
Orthobullets.com is an educational resource for
orthopaedic surgeons designed to improve
training through the communal efforts of those
who use it as a learning resource. It is a simple but
powerful concept. All of our topics, technique
guides, cases, and user-generated videos are
free, and will stay that way.
Table of Contents
I. Pediatric Conditions ..................................................................................... 0
A. Infection ................................................................................................... 1
1. Transient Synovitis of Hip ......................................................................... 1
2. Osteomyelitis - Pediatric ........................................................................... 4
3. Hip Septic Arthritis - Pediatric ................................................................. 10
4. SI Joint Infection ..................................................................................... 15
5. Chronic Recurrent Multifocal Osteomyelitis (CRMO) ................................ 16
6. Lyme Disease ......................................................................................... 18
B. Upper Extremity Conditions .................................................................... 20
1. Sprengel's Deformity .............................................................................. 20
2. Congenital Pseudoarthrosis of Clavicle ................................................... 22
3. Congenital Amputations .......................................................................... 23
4. Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy) ........................... 24
C. Hip & Pelvis Conditions ........................................................................... 29
1. Developmental Dysplasia of the Hip ........................................................ 29
2. Legg-Calve-Perthes Disease (Coxa plana) ............................................... 38
3. Slipped Capital Femoral Epiphysis .......................................................... 44
4. Developmental Coxa Vara ....................................................................... 49
5. Sacral Agenesis ..................................................................................... 51
6. Bladder Extrophy .................................................................................... 53
D. Leg Conditions ....................................................................................... 54
1. Proximal Femoral Focal Deficiency ......................................................... 54
2. Hemihypertrophy .................................................................................... 56
3. Leg Length Discrepancy (LLD) ................................................................ 58
E. Pediatric Knee........................................................................................ 61
1. Congenital Dislocation of the Knee .......................................................... 61
2. Congenital Dislocation of Patella ............................................................. 62
3. Popliteal Cyst in Children ........................................................................ 65
4. Bipartite Patella ...................................................................................... 66
F. Varus & Valgus Deformities .................................................................... 71
1. Infantile Blount's Disease (tibia vara) ...................................................... 71
OrthoBullets 2017
ORTHO BULLETS
I.Pediatric Conditions
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Infection
A. Infection
Presentation
History
o key questions
site of pain
groin vs. hip (or referred pain)
timing (intermittent vs constant)
lack of mechanical symptoms (locking, catching, giving way)
associated limp
constitutional symptoms
recent infection or trauma
Symptoms
o mild or absent fever
o acute or insidious onset of groin/thigh pain
pain is typically worse on awakening
refusal to bear weight on affected extremity
usually improves during day (child can walk with a limp later in the day)
o muscle spasms
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OrthoBullets2017 Pediatric Conditions | Infection
Physical exam
o inspection
hip presents in flexion, abduction and external rotation (position with least amount of
intracapsular pressure)
usually child does not have toxic appearance
o motion
mild to moderate restriction of hip abduction is the most sensitive range-of-motion
restriction
log-rolling leg can detect involuntary muscle guarding
painless arc of motion is more likely synovitis vs. septic arthritis
non-tender motion of lumbar spine and ipsilateral knee
o neurovascular
toe-walking, cavus foot, or clawing of the toes may suggest neurological cause of childs limp
Imaging
Radiographs
o recommended views
AP, lateral, frog leg
o findings
usually has a normal appearance
may show medial joint space widening
Ultrasonography
o indications
history and physical examination suspicious for infection
o findings
accurate for detecting intracapsular fluid/effusion
may show synovial membrane thickening
difficult to distinguish transient synovitis from septic arthritis
MRI
o indications
when hip aspiration has not been performed
o findings
can differentiate transient synovitis from septic arthritis
requires general anesthesia and is not recommended as first-line imaging in patients
Differential
Transient synovitis is a diagnosis of exclusion
o Table - Differential diagnosis of Hip Pain in Children
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OrthoBullets2017 Pediatric Conditions | Infection
Treatment
Nonoperative
o NSAIDS and close observation
indications
low clinical suspicion of septic arthritis
patient is afebrile for the past 24 hours with mild symptoms
improved ambulation
Kocher score < 2
modalities
treat patient with IV or PO NSAIDS and observe over 24 hours
early weight-bearing with physiotherapy
outcomes
if symptoms improve with NSAIDS, more likely to be transient synovitis
symptom resolution in under 1 week from date of presentation
Operative
o joint aspiration, then initiation of IV antibiotics
indications
high clinical suspicion for septic arthritis
worsening hip pain despite treatment with NSAIDs
systemic infection
Kocher score >2
concurrent infectious process (otitis media, URI)
modalities
ultrasound guided aspiration
MR guided aspiration
o irrigation and debridement of hip
indications
documented infection
severe systemic infection with suspected septic hip
Kocher criteria = 4/4
outcomes
treatment of infection with I&D is time sensitive
prolonged infection will affect cartilage survival
Complications
Legg-Calvé-Perthes (1-3%)
Coxa magna
Hip dysplasia
2. Osteomyelitis - Pediatric
Introduction
Epidemiology
o incidence
1 in 5000 children younger than 13 years old
o demographics
mean age 6.6 years
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Infection
2.5 times more common in boys
more common in first decade of life due to rich metaphyseal blood supply and immature
immune system
not uncommon in healthy children
o location
typically metaphyseal via hematogenous seeding
o risk factors
diabetes mellitus
hemoglobinopathy
rheumatoid arthritis
chronic renal disease
immune compromise
varicella infection
Pathophysiology
o mechanism
local trauma and bacteremia lead to increased susceptibility to bacterial seeding
o microbiology
Staph aureus
is the most common organism in all children
recent strains of community acquired (CA) MRSA have genes encoding for Panton-
Valentine leukocidin (PVL)
PVL-positive strains are more associated with complex infections
MRSA is associated with increased risk of DVT and septic emboli
Group B strep
is most common organism in neonates
Kingella kingae
becoming more common in younger age groups
Pseudomonas
is associated with direct puncture wounds to the foot
H. influenza
has become much less common with the advent of the haemophilus influenza vaccine
Mycobacteria tuberculosis
children are more likely to have extrapulmonary involvement
biopsy with stains and culture for acid-fast bacilli is diagnostic
Salmonella
more common in sickle cell patients
o pathoanatomy
acute osteomyelitis
most cases are hematogenous
initial bacteremia may occur from a skin lesion, infection, or even trauma from tooth
brushing
microscopic activity
sluggish blood flow in metaphyseal capillaries due to sharp turns results in venous
sinusoids which give bacteria time to lodge in this region
the low pH and low oxygen tension around the growth plate assist in bacterial growth
infection occurs after the local bone defenses have been overwhelmed by bacteria
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OrthoBullets2017 Pediatric Conditions | Infection
spread through bone occurs via Haversian and Volkmann canal systems
purulence develops in conjunction with osteoblast necrosis, osteoclast activation,
release of inflammatory mediators, and blood vessel thrombosis
macroscopic activity
subperiosteal abscess develops when the purulence breaks through the metaphyseal
cortex
septic arthritis develops when the purulence breaks through an intra-articular
metaphyseal cortex (hip, shoulder, elbow, and ankle)
Infants <1 year of age can have infection spread across the growth plate via capillaries
causing osteomyelitis in the epiphysis
chronic osteomyelitis
periosteal elevation deprives the underlying cortical bone of blood supply leading to
necrotic bone (sequestrum)
an outer layer of new bone is formed by the periosteum (involucrum)
chronic abscesses may become surrounded by sclerotic bone and fibrous tissue leading to
a Brodie's abscess
o definitions
involucrum
a layer of new bone growth outside existing bone seen in osteomyelitis
sequestrum
necrotic bone which has become walled off from its blood supply and can present as a
nidus for chronic osteomyelitis
Prognosis
o mortality has decreased from 50% to <1% due to new antibiotic treatment
Classification
Acute osteomyelitis
o see pathoanatomy above
Subacute osteomyelitis
o uncommon infection with bone pain and radiographic changes without systemic symptoms
o increased host resistance, decreased organism virulence, and/or prior antibiotic exposure
o radiographic classification
types IA and IB show lucency
type II is a metaphyseal lesion with cortical bone loss
type III is a diaphyseal lesion
type IV shows onion skinning
type V is an epiphyseal lesion
type VI is a spinal lesion
Chronic osteomyelitis
o see pathoanatomy above
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Infection
Presentation
History
o limb pain
o recent local infection or trauma
o obtain immunization history regarding H. influenza
o ask about prior antibiotic use, as it may mask symptoms
Symptoms
o limp or refusal to bear weight
o generally not toxic appearing
o +/- fever
Physical exam
o inspection & palpation
edematous, warm, swollen, tender limb
evaluate for point tenderness in pelvis, spine, or limbs
o range of motion
restricted motion due to pain
Imaging
Radiographs
o early films may be normal or show loss of soft tissue planes and soft tissue edema
o new periosteal bone formation (5-7 days)
o osteolysis (10-14 days)
o late films (1-2 weeks) show metaphyseal rarefaction (reduction in metaphyseal bone density) or
possible abscess
CT
o indication
more helpful later in the disease course to demonstrate boney changes or abscesses
MRI
o detects abscesses and early marrow and soft tissue edema
o indications
Can assist with decision making when a poor clinical response to antibiotics or surgical
drainage experienced
o views
T1 signal decreased
T1 with gadolinium signal increased
T2 signal increased
o 88% to 100% sensitivity
Bone scan
o indications
nondiagnostic x-ray
localize pathology in infant or toddler with non focal exam
technetium-99m can localize the focus of infection and show a multifocal infection
92% sensitivity
cold bone scan may be associated with more aggressive infections
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OrthoBullets2017 Pediatric Conditions | Infection
Studies
WBC count
o elevated in 25% of patients and correlates poorly with treatment response
C-reactive protein
o elevated in 98% of patients with acute hematogenous osteomyelitis
o becomes elevated within 6 hours
o most sensitive to monitor therapeutic response
o declines rapidly as the clinical picture improves
o CRP is the best indicator of early treatment success, and normalizes within a week
failure of the C-reactive protein to decline after 48 to 72 hours of treatment should indicate
that treatment may need to be altered
ESR
o elevated in 90% of patients with osteomyelitis
o rises rapidly and peaks in three to five days, but declines too slowly to guide treatment
o less reliable in neonates and sickle cell patients
Plasma procalcitonin
o new serologic test that rises rapidly with a bacterial infection, but remains low in viral infections
and other inflammatory situations
o elevated in 58% of pediatric osteomyelitis cases
Bone aspiration
o required for definitive diagnosis
o 50% to 85% of affected patients have positive cultures
Blood culture
o is positive only 30% to 50% of the time and will likely be negative soon after antibiotics are
administered, even if treatment is not progressing satisfactorily
Treatment
Nonoperative treatment
o aspiration
indications
helps guide medical management when organism identified (50% of the time)
cultures allow for better antibiotic management with knowledge of susceptibility
technique
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Infection
large bore needle utilized to aspirate the subperiosteal and intraosseous spaces under
fluoroscopic or CT-guidance
start antibiotics after aspiration
o antibiotic treatment
indications
early disease, no abscess
surgery is not indicated if clinical improvement obtained within 48 hours
technique
Controversial duration. typically treat with IV antibiotics for four to six weeks
empiric therapy generally nafcillin or oxacillin, unless high local prevalence of MRSA
(then use clindamycin or vancomycin)
Mechanism of action for vancomycin involves binding to the D-Ala D-Ala moiety in
bacterial cell walls
if gram stain shows gram-negative bacilli - add a third generation cephalosporin
when treating subacute osteomyelitis, obtain biopsy and culture initially to rule out tumor
mycobacterium tuberculosis
treatment for initial 1 year is multiagent antibiotics and rarely surgical debridement
due to risk of chronic sinus formation
Operative Treatment
o surgical drainage, debridement and antibiotic therapy
indications
deep or subperiosteal abscess
failure to respond to antibiotics
chronic infection
contraindications
hemodynamic instability, as patients should be stabilized first
technique
evacuate all purulence, debride devitalized tissue, and drill as needed into intraosseous
collections
remove the sequestrum in chronic cases
send tissue for culture and pathology to rule out neoplasm
close wound over drains or pack and redebride in two to three days
follow with IV abx and then PO abx until ESR or CRP has returned to normal
Complications
DVT
o is an infrequent complication
risk factors
CRP > 6
surgical treatment
age > 8-years-old
MRSA
Meningitis
Chronic osteomyelitis
Septic arthritis
Growth disturbances and limb-length discrepancies : may result in gait abnormalities
Pathologic fractures
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OrthoBullets2017 Pediatric Conditions | Infection
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Infection
most common organism following varicella infection
o Group B streptococcus
most common in neonates with community-acquired infection
o Staph aureus
most common in children over 2 years of age
gram positive cocci in clusters
most common in nosocomial infections of neonates
o HACEK organisms
Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella
fastidious
Kingella is best isolated on blood culture media
Prognosis
o usually good unless diagnosis is delayed
o poor prognostic indicators
age < 6 months
associated osteomyelitis
hip joint (versus knee)
delay >4 days until presentation
Presentation
History
o similar to history of osteomyelitis
o history of rash and swollen lymph nodes are associated with other conditions in the differential
diagnosis and are not expected findings of septic arthritis
o vaccination history must be obtained
Symptoms
o presents more acutely than osteomyelitis
o often associated with fever and other systemic symptoms causing toxic appearance
o children refuse to walk or move their hip
Physical exam
o inspection and palpation
localized swelling
effusion, tenderness, and warmth
hip rests in a position of flexion, abduction, and external rotation
hip capsular volume is maximized with flexion, abduction, and
external rotation and is the position of comfort for hip septic
arthritis
o range of motion
severe pain with passive motion
unwillingness to move joint (pseudoparalysis)
examine adjacent joints
must rule out adjacent joint involvement I:2 The clinical photograph reveals a
right septic hip resting in a position of
flexion, abduction, and external
rotation to maximize joint volume.
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OrthoBullets2017 Pediatric Conditions | Infection
Imaging
Radiographs
o recommended views
AP and frog-leg lateral pelvic x-rays
o findings
may be normal, especially in early stages of disease
often see widening of the joint space, subluxation, or dislocation
in infants, prior to ossification of the femoral head, widening of joint space can be seen
by lateral displacement of the proximal femur
may see bone involvement with associated osteomyelitis
Ultrasound
o may be helpful to identify effusion
o can be used to guide aspiration
MRI
o difficult to obtain emergently
o identifies a joint effusion and adjacent osseous involvement
Evaluation
Must distinguish from transient synovitis
o Probabilty of septic arthritis ranged as high as 99.6% when all four criteria below are present
WBC > 12,000 cells/µl
inability to bear weight
fever > 101.3° F (38.5° C)
ESR > 40 mm/h
o CRP > 2.0 (mg/dl) is an independent risk factor (not included in studies of the previous 4
criteria)
CRP > 2.0 (mg/dl) in combination with refusal to bear weight yields a 74% probability of
septic arthritis
o Order of sensitivity of above criteria:
Fever > CRP > ESR > refusal to bear wieght > WBC
Hip aspiration
o indicated whenever a high suspicion for infection
o required to confirm diagnosis
o joint fluid studies should include
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Infection
cell count with differential
Gram stain, culture, and sensitivities
glucose and protein levels
o a septic joint aspirate will show
3
high WBC count (> 50,000/mm with >75% PMNs)
glucose 50 mg/dl less than serum levels
high lactic acid level with infections due to gram positive cocci or gram negative rods
Blood cultures
Lumbar puncture : consider in a septic joint caused by H. influenzae due to risk of meningitis
Differential diagnosis
Table - Differential diagnosis of Hip Pain in Children
Psoas abscess
o presents like hip septic arthritis with hip pain and limp, with the limb held flexed
o commonest organism is Staph aureus
o may spread to hip joint causing septic arthritis because of
indirect passage via psoas bursa
lies between hip joint and psoas
connects psoas directly to hip joint in 15% of cadavers
direct passage between the iliofemoral and iliopubic ligaments
o treatment
percutaneous ultrasound or CT-guided drainage
open drainage
useful for secondary psoas abscess e.g. spread from the bowel
can simultaneously address intraabdominal source
Treatment
Nonoperative
o antibiotics alone
indications
adolescent Neisseria gonorrhoeae infection
can be treated with large doses of penicillin alone and usually does not require
surgical debridement
Operative
o emergent surgical I&D
indications
standard of care for almost all septic joints
considered a surgical emergency due to chondrolytic effect of pus
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OrthoBullets2017 Pediatric Conditions | Infection
Surgical Techniques
Emergent incision and drainage
o approach
most commonly one of the following approaches is utilized
anterolateral approach to the hip
anterior approach through the Smith-Peterson interval
o technique
an arthrotomy is performed to remove all purulent fluid and to irrigate the joint
synovial culture and drain placement is recommended
follow with IV antibiotics targeting pathogens based on age and medical comorbidities
convert to PO antibiotics once the clinical picture improves and definitive sensitivities are
obtained
duration of antibiotic therapy is generally 3-4 weeks
terminate antibiotics once the CRP or ESR return to normal
o postoperative care
range of motion exercises of the affected joint may be started within the first few days after
surgery
Complications
Femoral head destruction
o complete destruction of the femoral head and neck, easily visible on x-ray
o salvage operations exist including varus/valgus proximal femoral osteotomies
Deformity
o physeal damage leads to late angular deformity and leg length discrepancy
Joint contracture
Hip dislocation
Growth disturbance
Gait abnormalities
Osteonecrosis
I :4 The AP pelvic radiograph reveals a right hip valgus osteotomy I:3 The AP pelvic radiograph demonstrates complete destruction of
for subluxation and a 2-cm leg length discrepancy following failed
the right hip joint secondary to failed treatment of septic arthritis.
treatment for septic arthritis.
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Infection
4. SI Joint Infection
Introduction
Epidemiology
o incidence
rare and only accounts for 1-2% of cases of septic arthritis
o demographics
more common in children over the age of 10 than adults
o risk factors in adults
intravenous drug abuse
immune suppression
pregnancy
trauma
infective endocarditis
sepsis
Pathophysiology
o microbiology
staphylococcus aureus
is the causative organism in most of these infections
mycobacterium tuberculosis
skeletal tuberculosis accounts for 3–5 % of all tuberculosis, of which approximately 10 %
occurs at the SIJ
Presentation
Symptoms
o progressive low back and right buttock pain
o unable to bear weight on affected side secondary to pain
o fever
Physical exam
o pain worsened by
compression of the iliac wings
palpation of the right sacroiliac (SI) joint
Faber test
positive flexion, abduction and external rotation (FABER) test of the hip joint that
dramatically aggravates the pain
o normal hip range of motion
Imaging
MRI
o is the most sensitive diagnostic study for SIJ infection
o findings in the acute phase
intra-articular fluid or gas
subchondral bone marrow edema
articular and periarticular post-gadolinium enhancement and soft tissue edema
o findings in chronic phase
periarticular bone marrow reconversion
replacement of articular cartilage by pannus
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OrthoBullets2017 Pediatric Conditions | Infection
bone erosion
subchondral sclerosis
joint space widening or narrowing and ankylosis
Studies
Serum labs
o elevated WBC
o elevated ESR (>50)
o elevated CRP (>70)
Blood cultures
o may be positive and should be obtained prior to starting antibiotics
Treatment
Nonoperative
o antibiotics targeted towards the specific organsim
indications
first line of treatment
technique
target staph aureus in children if no organism is identified from blood cultures
Operative
o surgical debridement
indications
acute cases with abscess present
failed antibiotic treatment
the presence of sequestered bone
o debridement and SI joint arthrodesis
indications
rare
may be considered in chronic cases
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Infection
Associated conditions
o Pustulosis palmoplantaris syndrome
a rare chronic relapsing condition causing red patches and pustules on the soles of the
feet and palms of the hands
considered a rheumatologic condition and no infectious agents have been identified
following the outbreak o the lesions, desquamation occurs several days later
associated with CRMO
o SAPHO Syndrome : CRMO associated with: synovitis, acne, pustulosis, hypersotosis, osteitis
Prognosis
o natural history
characterized by periods of remission and exacerbation
typically resolves in 3-5 years
o prognosis
traditionally thought as having a relatively benign sequelae
several case reports of growth disturbance have been reported.
Presentation
Symptoms
o episodic fever
o malaise
o localized pain, swelling
Physical exam : focal tenderness in region of involvement
Imaging
Plain radiography
o eccentric metaphyseal lesions with sclerosis and new bone formation
Bone scan : Can help determine other sites of disease
MRI
o If concerned for malignancy, MRI can help determine presence or absence of soft tissue
involvement
Studies
Laboratory values
o WBC typically normal
o ESR and CRP may be elevated
Biopsy
o biopsy and bone cultures negative
o important to establish diagnosis which is one of exclusion
Treatment
Nonoperative
o symptomatic treatment with NSAIDS and pamidronate
indications : treat during exacerbations
medications
pamidronate can provide symptomatic improvement and stimulate vertebral remodling
Complications
Growth disturbance : rare but may occur
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OrthoBullets2017 Pediatric Conditions | Infection
6. Lyme Disease
Introduction
Systemic infection with Borrelia burgdorferi spirochete following bite of deer tick (Ixodes)
Epidemiology
o northeast, midwest, western US (areas with heavy deer population)
Maryland to Maine (Ixodes scapularis)
Wisconsin, Minnesota (Ixodes scapularis)
northern California (Ixodes pacificus)
o less than 1% of Ixodes bites result in Lyme disease
o peak incidence May to November
Body locations : affects skin, heart, CNS, joints, eyes
Organism
o spirochete Borrelia burgdorferi
o survives in the absence of iron
o takes 24 hours of tick attachment for transfer of the spirochete
regular "tick checks" may prevent infection
o can survive intracellularly in fibroblast even with antibiotics in extracellular fluid
o host
nymphs feed on white-footed mouse
nymphs responsible for 90% of disease transmission
adults feed on white-tailed deer
o reinfection is common (different serotype of B burgdorferi) but relapse is uncommon
Arthritis
o susceptible patients have HLA DR4 or DR2, or HLA-DRB1*40 and antibodies to OspA and
OspB proteins in joint fluid
o immune mediated, persistent auto-immune inflammation even after organism is eradicated
Classification
Stage 1 (rash) - early localized
o 1 to 30 days after bite
o erythema migrans
o fatigue, myalgia, arthralgia, headache, fever, chills, neck stiffness
Stage 2 (neurologic) - early disseminated
o weeks to months after bite
o progresses to stage 2 in 50% of untreated disease
o musculoskeletal and neurologic symptoms
migratory polyarthritis or monoarthritis, tendonitis, bursitis
CN VII neuropathy and meningitis
Stage 3 (arthritis) - chronic disseminated
o months to years after bite
o joints and neurologic symptoms
arthritis (usually the knee) : swelling disproportionate to tenderness
intermittent arthritis
chronic monoarthritis
o acrodermatitis chronica atrophicans
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Infection
Presentation
Symptoms
o tick bite in May through November
o fever, headache, myalgia, arthralgia, fatigue
o neurologic symptoms
headache, neck stiffness, encephalitis
facial CN VII palsy
bilateral in 50% (unlike Bell's palsy)
polyradiculoneuropathy
numbness, paresthesia, weakness, cramps
o carditis (complete heart block)
o acute joint pain
o acute or chronic arthritis
Physical exam
o erythema migrans ("bullseye rash") in 60-80% of patients
expanding rash >5cm diameter 1 to 3 weeks after tick bite
itching or burning
fades after 1 month
at axillary or gluteal folds, hairline, near elastic bands (bra strap or underwear)
o acute, self limiting joint effusions
knee and shoulder
recurrent
o acrodermatitis chronica atrophicans
"cigarette paper" skin
dorsum of hands, feet, knees, elbows
in older patients
Laboratory
Serum
o WBC normal or elevated
o ESR, CRP elevated
ELISA (sensitive)
o 2 step test - if ELISA positive, proceed to Western blot (specific)
o seroconversion takes weeks to become positive
o prior Lyme disease might have persistently positive results
o vaccination gives positive ELISA, negative Western blot
CSF (patients with polyradiculitis and CN VII neuropathy)
o increased protein
o lymphocytic pleocytosis
Synovial fluid
o 10,000-25,000 WBC/mm3
lower than baterial septic arthritis
o PMN predominance
PCR
Culture on Barbour-Stoenner-Kelly medium
o use skin edge punch biopsy from erythema migrans lesion
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OrthoBullets2017 Pediatric Conditions | Upper Extremity Conditions
Differential
Bacterial septic arthritis
o features that differentiate Lyme's diseae from bacterial septic arthritis include
ability to bear weight
normal serum WBC
lower synovial fluid WBC count
Treatment
Non-operative
o oral antibiotics for mild disease
indications
in endemic regions, if erythema migrans is present, start antibiotics without blood tests
medications
doxycycline (not in children <8 years) x 10 days
28-30 days for arthritis, CN VII palsy or acrodermatitis
amoxicillin
cefuroxime
o IV antibiotics
indications
for carditis, meningoencephalitis and arthritis
medications
IV ceftriaxone or cefotaxime
IV penicillin G
Operative
o synovectomy
indications
chronic arthritis not responding to IV antibiotics
1. Sprengel's Deformity
Introduction
Congenital condition with a small and undescended scapula often associated with
o scapular winging
o hypoplasia
o omovertebral connection between superior medial angle of scapula and cervical spine (30-50%)
Epidemiology
o incidence
most common congenital shoulder anomaly in children
o location : bilateral in 10-30% of cases
Etiology
o interruption of embryonic subclavian blood supply
at level of subclavian, internal thoracic or suprascapular artery
in contrast, Poland syndrome is subclavian artery interruption proximal to internal thoracic
and distal to vertebral artery
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Upper Extremity Conditions
Associated diseases
o Klippel-Feil (approximately 1/3 have Sprengel deformity)
o congenital scoliosis
o upper extremity anomalies
o diastematomyelia
o kidney disease
Anatomy
Osteology
o scapula consists of
body
spine
acromion
coracoid process
glenoid
Articulations
o AC joint and glenohumeral diarthrodial articulations of the scapula
Muscles
o muscles that insert on medial border of scapula
levator scapulae
rhomboids major and minor
teres major
small portion just proximal to inferior angle
latissimus dorsi
small slip of origin at inferior angle
Presentation
Symptoms
o often referred for evaluation of scoliosis
Physical exam
o high riding medially rotated scapula
o loss of long medial border
o equilateral triangle like shape
o shoulder abduction most limited due to loss of normal scapulothoracic motion and glenoid
malpositioning
o forward flexion limited as well
Treatment
Nonoperative
o observation
indications : no severe cosmetic concerns or loss of shoulder function
Operative
o surgical correction
indications
severe cosmetic concerns or functional deformities (abduction < 110-120 degrees)
best to perform surgery from 3 to 8 yrs of age
risk of nerve impairment after the age of 8
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OrthoBullets2017 Pediatric Conditions | Upper Extremity Conditions
pre-operative planning
MRI or CT to identify omovertebral bar
procedures
Woodward procedure
detachment and reattachment of medial parascapular muscles at spinous process
origin to allow scapula to move inferiorly and rotate into more shoulder abduction
modified Woodward includes resection of superiormedial border of scapula in
conjunction with surgical descent
Schrock, Green procedure
extraperiosteal detachment of paraspinal muscles at the scapular insertion and
reinsertion after inferior movement of scapula with traction cables
Clavicle osteotomy
in conjunction with above procedures for severe deformity to avoid brachial plexus
injury, performed before movement of clavicle.
Bony resection
extraperiosteal resection of proximal scapular prominence for cosmetic concerns, may
be done with other procedures or alone
outcomes
Woodward and Green procedures can improve abduction by 40-50 degrees
Presentation
Symptoms
o usually asymptomatic
Physical exam
o inspection
painless, nontender mass on clavicle
may be associated with winging of scapula
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Upper Extremity Conditions
Imaging
Radiographs
o recommended views
AP of clavicle
o findings
show rounded sclerotic bone at pseudoarthrosis site
Treatment
Nonoperative
o observation
indications
minimal symptoms and cosmetic deformity
Operative
o ORIF with iliac crest bone grafting at age 3-6 years
indications
pain
functional impairment
cosmesis
outcomes
successful union is usually obtained
avoid bone graft substitute, higher rates of non-union
3. Congenital Amputations
Introduction
Epidemiology
o incidence : rare
o body location
transradial is the most common location
Pathophysiology
o due to failure of formation
Genetics
o no clear genetic involvement
Risk factors
o amniotic band constriction
Associated conditions
o typically not associated with systemic conditions
Presentation
Symptoms
o usually painless
o functional deficits
Physical exam
o varies depending on location of amputation
Imaging
Radiographs : AP and lateral of affected extremity
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OrthoBullets2017 Pediatric Conditions | Upper Extremity Conditions
Treatment
Nonoperative
o prosthesis placement
indications
fitting with passive terminal prosthesis recommended at the age of 6 months ("fit when
they sit")
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Upper Extremity Conditions
complete recovery possible if biceps and deltoid are M1 by 2 months
early twitch biceps activity suggests a favorable outcome
poor
lack of biceps function by 3 months
preganglionic injuries (worst prognosis)
avulsions from the cord, which will not spontaneously recover motor function
loss of rhomboid function (dorsal scapular nerve)
elevated hemidiaphragm (phrenic nerve)
Horner's syndrome (ptosis, miosis, anhydrosis)
less than 10% recover spontaneous motor function
C5-C7 involvement
Klumpke's Palsy
Anatomy
Brachial plexus diagram
Classification
Narakas Classification
Group Roots Characteristics
Paralysis of deltoid and biceps. Intact wrist and
Group I (Duchenne-Erb's Palsy) C5-C6
digital flexion/extension.
Group II (Intermediate Paralysis) C5-C7 Paralysis of deltoid, biceps, and wrist and digital
extension. Intact wrist and digital flexion.
Group III (Total Brachial Plexus C5-T1 Flail extremity without Horner's syndrome
Palsy)
Group IV (Total Brachial Plexus C5-T1 Flail extremity with Horner's syndrome
Palsy with Horner's syndrome)
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OrthoBullets2017 Pediatric Conditions | Upper Extremity Conditions
Presentation General
Symptoms
o lack of active hand and arm motion
Physical exam
o upper extremity exam
arm hangs limp at side in an adducted and internally rotated position
decreased shoulder external rotation
affected shoulder subluxates posteriorly
o provocative testing
stimulate neonatal reflexes including Moro, asymmetric tonic neck and Votja reflexes
o Toronto Scale muscle strength grading system
0 - no motion
1- motion present but limited
2- normal motion
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Upper Extremity Conditions
Total Plexus Palsy
Physical exam
o flaccid arm
o both motor and sensory deficits
Prognosis
o worst prognosis
Treatment
Nonoperative
o observation & daily passive exercises by parents
indications
first line of treatment for most obstetric brachial plexopathies
technique
key to treatment is maintaining passive motion while waiting for nerve function to returr
o Elbow Flexion Contracture
Serial nighttime extension splinting
for contracture <40 degrees
prevents progression, does not correct contracture
Serial extension casting
for contracture >40 degrees
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OrthoBullets2017 Pediatric Conditions | Upper Extremity Conditions
Operative
o early surgical attempt at nerve restoration
microsurgical nerve repair or nerve grafting
indications
complete flail arm at 1 month of age
Horner's syndrome at 1 month of age
lack of antigravity biceps function between 3-6 months of age
neurotization (nerve transfer)
indications
root avulsion at 3 months of age
donor nerves
sural
intercostal
spinal accessory
phrenic
cervical plexus
contralateral C7
hypoglossal
o posterior glenohumeral dislocation - late surgery
open reduction and capsulorrhaphy
indications
early recognition with minimal glenoid deformity
proximal humeral derotation osteotomy
indications
late recognition, no glenoid present
o Internal rotation contractures and glenohumeral joint dysplasia - late surgery
latissimus dorsi and teres major transfer to rotator cuff
indications
persistent external rotation and abduction weakness, internal rotation contractures,
and mild-to-moderate glenohumeral joint dysplasia
pectoralis major and +/- subscapularis lengthening
indications : <5 years of age
proximal humeral derotation osteotomy
indications : > 5 years of age
o forearm supination contractures - late surgery
biceps tendon transfers
indications
supination contractures with intact forearm passive pronation
forearm osteotomy (radius +/- ulna) +/- biceps tendon transfer
indications
supination contractures with limited forearm passive pronation
o elbow flexion contractures - late surgery.
Consider Anterior capsular release, biceps/brachialis tendon lengthening for severe,
persistent contracture
May have High recurrence rate
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Hip & Pelvis Conditions
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Hip & Pelvis Conditions
Imaging
Radiograph
o become primary imaging modality at 4-6 mo after the femoral head begins to ossify
hip dislocation
Hilgenreiner's line
horizontal line through right and left triradiate cartilage
femoral head ossification should be inferior to this line
Perkin's line
line perpendicular line to Hilgenreiner's through a point at lateral margin of
acetabulum
femoral head ossification should be medial to this line
Shenton's line
arc along inferior border of femoral neck and superior margin of obturator foramen
arc line should be continuous
delayed ossification of the femoral head is seen in cases of dislocation
hip dysplasia
acetabular index (AI)
angle formed by a line drawn from point on the lateral triradiate cartilage to point on
lateral margin of acetabulum and Hilgenreiners line
should be less than 25° in patients older than 6 months
center-edge angle (CEA) of Wiberg
angle formed by a vertical line from the center of the femoral head and a line from the
center of the femoral head to the lateral edge of the acetabulum
less than 20° is considered abnormal
reliable only in patients over the age of 5 years
acetabular teardrop not typically present prior to hip reduction
development of teardrop after reduction is thought to be good prognostic sign for hip
function
Shenton line
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OrthoBullets2017 Pediatric Conditions | Hip & Pelvis Conditions
Ultrasound
o evaluates for acetabular dysplasia and/or the presence of a hip dislocation
useful before femoral head ossification (<4-6 mos)
may produce spurious results if performed before 4-6 weeks of age
o allows view of bony acetabular anatomy, femoral head, labrum, ligamentum teres, hip capsule
alpha angle
angle created by lines along the bony acetabulum and the ilium
normal is greater than 60°
beta angle
angle created by lines along the labrum and the ilium
normal is less than 55°
femoral head is normally bisected by a line drawn down from the ilium
o the AAP recommends a US study at 6 weeks in patients who are considered high risk (family
history or breech presentation) despite normal exam
o normal ultrasound in patients with soft-tissue 'clicks' will have normal acetabular development
o allows for monitoring of reduction during Pavlik harness treatment
o is not cost effective for routine screening
Arthrogram
o used to confirm reduction after closed reduction under anesthesia
o help identify possible blocks to reduction
inverted labrum
labrum enhances the depth of the acetabulum by 20% to 50% and contributes
to the growth of the acetabular rim
in the older infant with DDH the labrum may be inverted and may mechanically block
concentric reduction of the hip
inverted limbus
represents a pathologic response of the acetabulum to abnormal pressures caused by
superior migration of the head
consists of fibrous tissue
transverse acetabular ligament
hip capsule is constricted by iliopsoas tendon causing hour-glass deformity of the capsule
pulvinar
ligamentum teres
CT
o CT study of choice to evaluate reduction of the hip after closed reduction and spica casting
MRI : does not play significant role in primary diagnosis
Treatment in Children
Nonoperative
o abduction splinting/bracing (Pavlik harness)
indications
DDH < 6 months of age and reducible hip
Pavlik harness treatment is contraindicated in teratologic hip dislocations
is a dynamic splint that requires normal muscle function for successful outcomes
contraindicated in patients with spina bifida or spasticity
outcomes
overall Pavlik harness has success rate of 90%
dependent upon age at initiation of treatment and time spent in the harness
abandon pavlik harness treatment if not successful after 3-4 weeks
If pavlik harness fails, convert to semi-rigid abduction brace with weekly ultrasounds for
an addition 3-4 weeks before considering further intervention
o closed reduction and spica casting
indications
DDH in 6 - 18 months of age
failure of Pavlik treatment
Operative
o open reduction and spica casting
indications
DDH in patient >18 months of age
failure of closed reduction
o open reduction and femoral osteotomy
indications
DDH > 2 yr with residual hip dysplasia
anatomic changes on femoral side (e.g., femoral anteversion, coxa valga)
femoral head should be congruently reduced with satisfactory ROM, and reasonable
femoral sphericity
best in younger children (< 4 yr)
after 4 yr, pelvic osteotomies are utilized
o open reduction and pelvic osteotomy
indications
DDH > 2 yr with residual hip dysplasia
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OrthoBullets2017 Pediatric Conditions | Hip & Pelvis Conditions
severe dysplasia accompanied by significant radiographic changes on the acetabular side
(increased acetabular index)
used more commonly in older children (> 4 yr)
decreased potential for acetabular remodeling as child ages
Techniques
Abduction splinting/bracing (Pavlik harness)
o goals
treatment is based on early concentric reduction in order to prevent future degeneration of the
hip
risk, complexity and complications are increased with delays in diagnosis
o position in bracing
goal is 90-100° flexion (controlled by anterior straps) and abduction of 50° (controlled
by posterior straps)
o extreme positions can cause
AVN due to impingement of the posterosuperior retinacular branch of the medial femoral
circumflex artery
seen with extreme abduction (> 60°)
placement of abduction within 'safe zone'
transient femoral nerve palsy
seen with hyperflexion
o discontinue if hip is not reduced by 3-4 weeks to prevent Pavlik disease
erosion of the pelvis superior to the acetabulum and prevention of the development of the
posterior wall of the acetabulum
o worn for 23 hours/day for at least 6 weeks or until hip is stable
wean out of harness over 6-8 weeks after hip has stabilized until normal anatomy develops
o confirm position with ultrasound or xray and monitor every 4-6 week
Closed reduction and spica casting
o performed under general anesthesia
excessive force can result in AVN
o arthrogram used to confirm reduction
concentric reduction must be obtained with less than 5mm of contrast pooling medial to
femoral head and the limbus must not be interposed
the arthrogram will also help identify anatomic blocks to reduction:
o spica casting
following reduction immobilize in a spica cast with hip flexion of 100 deg. and abduction of
45 deg with neutral rotation for 3 months
'human position'
change cast at 6 weeks
adductor tenotomy performed if patient has an unstable safe zone
used if excessive abduction required to maintain the reduction
confirm reduction with CT scan in spica cast with selective cuts to minimize radiation to the
child
Open reduction
o anterior approach (Smith-Peterson) most common to decrease risk to medial femoral circumflex
artery
capsulorrhaphy can be performed after reduction
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Hip & Pelvis Conditions
used if patient is older than 12 months
o other possible approaches include
medial adductor approach, variation of Ludloff
Pros
directly addresses block to reduction
can be used in patients under 12 months of age
less blood loss
Cons
unable to perform a capsulorrhaphy
higher association of AVN
anteromedial approach
posteromedial approach
o remove possible anatomic blocks to reduction
iliopsoas contracture, capsular constriction, inverted labrum, pulvinar, hypertrophied
ligamentum teres
o adductor tenotomy performed if patient has an unstable safe zone
if excessive abduction required to maintain the reduction
o immobilize in functional position of 15° of flexion, 15° of abduction and neutral rotation
Femoral Osteotomy
o used to correct excessive femoral anteversion and/or valgus
o femoral osteotomy and shortening may be needed to prevent AVN
decrease tension produced by reduction of a previously dislocated hip
Pelvic Osteotomies
o increase anterior or anterolateral coverage
o used after reduction is confirmed on abduction-internal rotation views and satisfactory ROM has
been obtained
See table of Reconstructive Pelvic Osteotomies next page
Complications
Osteonecrosis
o seen with all forms of treatment
o increased rates associated with
excessive or forceful abduction
previous failed closed treatment
repeat surgery
o diagnosis based on radiographic findings that include
failure of appearance or growth of the ossific nucleus 1 year after reduction
broadening of femoral neck
increased density and fragmentation of ossified femoral head
residual deformity of proximal femur after ossification
Delayed diagnosis
o bilateral dislocations
patients typically functions better if hips are not reduced if 6 years of age or older
o unilateral dislocation
better outcomes without surgical treatment if patient is 8 years of age or older
epiphysiodesis can be performed for treatment of limb length discrepancy
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OrthoBullets2017 Pediatric Conditions | Hip & Pelvis Conditions
Recurrence
o approximately 10% with appropriate treatment
o requires radiographic follow-up until skeletal maturity
Transient femoral nerve palsy
o seen with excessive flexion during Pavlik bracing
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Hip & Pelvis Conditions
PAO (Ganz)
Shelf Chiari
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OrthoBullets2017 Pediatric Conditions | Hip & Pelvis Conditions
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Hip & Pelvis Conditions
Prognosis
o important prognostic variables
age of patient (bone age) at presentation
sphericity of femoral head and congruency at skeletal maturity (Stulberg classification)
o bad prognosis
age (bone age) > 6 years at presentation
chronological age 5-7y better than age 8-9y
female sex
decreased hip range of motion (abduction) with adduction contracture
heavy patient
longer duration from onset to completion of healing
stiffness with progressive loss of ROM
o good prognosis
younger age (bone age) < 6 years at presentation
preservation of ROM
o natural history
long-term studies show that most patients do well until fifth or sixth decade of life in which
degenerative changes of the hip become present
approximately 1/2 of patients develop premature osteoarthritis secondary to an aspherical
femoral head
Stages of Legg-Calves-Perthes (Waldenström)
Initial • Infarction produces a smaller, sclerotic • Radiographs may remain occult for 3 to 6
epiphysis with medial joint space widening mos
Fragmentation •Femoral head appears to fragment or • Hip related symptoms are most prevalent
dissolve •Lateral pillar classification based on this stage
• Result of a revascularization process and
bone resorption producing collapse and
subsequent increased density
Reossification •Ossific nucleus undergoes reossification • May last up to 18m
as new bone appears as necrotic bone is
resorbed
Healing or •Femoral head remodels until skeletal • Begins once ossific nucleus is completely
remodeling maturity reossified trabecular patterns returns
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OrthoBullets2017 Pediatric Conditions | Hip & Pelvis Conditions
Classification
Lateral Pillar (Herring) Classification
Group A • lateral pillar maintains full height with no • uniformly good outcome
density changes identified
Group B • maintains >50% height • poor outcome in patients with bone age > 6
years
B/C Border • lateral pillar is narrowed (2-3mm) or poorly • recently added to increase consistency &
ossified with approximately 50% height prognosis of classification
Group C • less than 50% of lateral pillar height is • poor outcomes in all patient
maintained
Determined at the beginning of fragmentation stage
o usually occurs 6 months after the onset of symptoms
Based on the height of the lateral pillar of the capital femoral epiphysis on AP imaging of the pelvis
Has best interobserver agreement
Designed to provide prognostic information
Limitation is that final classification is not possible at initial presentation due to the fact that the patient needs to
have entered into the fragmentation stage radiographically
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Hip & Pelvis Conditions
Catterall Classification
Group I • involvement of the anterior epiphysis only
Group II • involvement of the anterior epiphysis with a clear sequestrum
Group III • only a small part of the epiphysis is not involved
Group IV • total head involvement
Based on degree of head involvement
At risk signs (indicate a more severe disease course)
o Gage sign
V-shaped radiolucency in the lateral portion of
the epiphysis and/or adjacent metaphysis
o calcification lateral to the epiphysis
o lateral subluxation of the femoral head
o horizontal proximal femoral physis
o metaphyseal cyst I:7 Gage sign
added later to the original four at risk signs
described by Catterall
Salter-Thompson classification
Class A • crescent sign involves < 1/2 of femoral head
Class B • crescent sign involves > 1/2 of femoral head
Based on radiographic cresent sign
Stulberg classification
Gold standard for rating residual femoral head deformity and joint congruence
Recent studies show poor interobserver and intraobserver reliability
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OrthoBullets2017 Pediatric Conditions | Hip & Pelvis Conditions
Presentation
Symptoms
o insidious onset
o may cause painless limp
o intermittent knee, hip, groin or thigh pain
Physical exam
o hip stiffness with loss of internal rotation and abduction
o gait disturbance
Trendelenburg gait (head collapse leads to decreased tension of abductors)
antalgic limp
o limb length discrepancy is a late finding
hip contracture can exacerbate the apparent LLD
Imaging
Plain radiographs
o AP of pelvis and frog leg laterals
critical in diagnosis and prognosis
o early findings include
medial joint space widening (earliest)
irregularity of femoral head ossification
cresent sign (represents a subchondral fracture)
Bone scan
o can confirm suspected case of LCP
o decreased uptake (cold lesion) can predate changes on radiographs
Contrast enhanced MRI
o early diagnosis revealing alterations in the capital femoral epiphysis and physis
o more sensitive than radiograph
o perfusion studies predict maximum extent of lateral pillar involvement
Arthrogram
o a dynamic arthrogram can demonstrate coverage and containment of the femoral head
Histology
Femoral epiphysis and physis exhibit areas of disorganized cartilage with areas of hypercellularity
and fibrillation
Differential Diagnosis
Radiographic differential diagnosis
o multiple epiphyseal dysplasia
o spondyloepiphyseal dysplasia
o sickle cell disease
o Gaucher disease
o hypothyroidism
o Meyers dysplasia
Treatment
Nonoperative
o literature does not support use of orthotics
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Hip & Pelvis Conditions
o observation alone, activity restriction (non-weightbearing), and physical therapy (ROM
exercises)
indications
children < 8 years of age : (young patient do not benefit from any surgery)
children with lateral pillar A
consider activity restriction and protected weight-bearing during earlier stages until
reossification is complete
technique
main goals of treatment are to keep the femoral head contained and maintain good motion
containment limits deformity and minimizes loss of sphericity and
lessen subsequent degenerative changes
bracing and casting for containment have not been found to be beneficial in a large,
prospective study
all patients require periodic clinical and radiographic followup until completion of disease
process
outcomes
good outcome correlates with spherical femoral head
60% do not require operative intervention
good outcomes associated with lateral pillar A and Catterall I groups
Operative
o femoral and/or pelvic osteotomy
indications : children > 8 years of age, especially lateral pillar B and B/C
technique
proximal femoral varus osteotomy : to provide containment
pelvic osteotomy
Salter, triple innominate, Dega or Pemberton osteotomy
Shelf arthroplasty may be performed to prevent lateral subluxation and resultant
lateral epiphyseal overgrowth
outcomes
children with lateral pillar A and those with B under 8 years did well regardless of
treatment
large recent studies show improved outcomes with surgery for lateral pillar B and B/C in
children > 8 years (bone age >6 years)
studies sugggest earlier surgery before femoral head deformity develops may be best.
poor outcome for lateral pillar C regardless of treatment
o valgus and shelf osteotomies
indications
hinge abduction
lateral extrusion of the capital femoral epiphysis producing a painful hinge effect on
the lateral acetabulum during abduction
osteotomies will
reposition the hinge segment away from the acetabular margin
correct shortening from fixed adduction
improve abductor mechanism by improving abductor muscle contractile length
shelf or Chiari osteotomies are also considered when the femoral head is no longer
containable
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OrthoBullets2017 Pediatric Conditions | Hip & Pelvis Conditions
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Hip & Pelvis Conditions
Classification
Imaging
Radiographs
o recommended views
AP & frog-leg lateral of right and left hip
lateral radiograph is best way to identify a subtle slip I:8 Klein's line
o findings on AP of pelvis
Klein's line
line drawn along superior border femoral neck will not intersect femoral head in a child
with SCFE (does in a normal hip)
epiphysiolysis (growth plate widening or lucency)
an early radiographic findings
blurring of proximal femoral metaphysis (metaphyseal blanch sign of Steel)
seen on AP due to overlapping of the metaphysis and posteriorly displaced epiphysis
MRI
o indications
can help diagnose a preslip condition when radiographs are negative
o findings
shows growth plate widening and increased signal of the metaphysis
Treatment
Operative
o percutaneous in situ fixation
indications
both stable and unstable slips
technique
one vs. two cannulated screws is controversial
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Hip & Pelvis Conditions
2 screw constructs have greater biomechanically stable than the single screw
constructs
benefit of 2 screws needs to be considered in the face of greater violation of the physis
+/- articular surface
o contralateral in situ prophylactic pinning (bilateral in situ fixation)
indications
remains controversial
Current indications are high risk patients (contralateral slip ~ 40-80%)
obese males
endocrine disorders (e.g. hypothyroidism)
initial slip at younger age (<10 years old or have open triradiate cartilage)
o epiphyseal reduction and pinning
indications
reduction remains controversial
unstable, high grade SCFEs
o proximal femoral osteotomy
indications
correction of painful or function-limiting
proximal femoral deformities associated
with severe, chronic slip
Techniques
Percutaneous in situ fixation
o goal
stabilize the epiphysis from further slippage and promote closure of the proximal femoral
physis
o technique
reductions
forceful reduction is not indicated and increases risk of osteonecrosis
"serendipitous reduction" is often obtained with positioning
screw fixation
single cannulated screw sufficient and decreases risk of osteonecrosis (compared to
multiple pins) in unstable SCFE
screw must start on the anterior surface of the neck in order to cross perpendicular to the
physis enter into the central portion of the femoral head (which has slipped
posteriorly) on both the AP and lateral views
minimum of 3 threads crossing the physis
screws should be at least 5mm from subchondral bone in all views
imaging
use fracture table to obtain good radiographic visualization
rotate under live fluoroscopy to confirm that pin is not penetrating the hip joint
o postoperative
stable slips are able to bear weight after in situ pinning
unstable slips are made non-weight bearing
Open reduction with capital realignment
o techniques
surgical dislocation with epiphyseal reorientation
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modified Dunn procedure with formation of a epiphyseal vascular flap
Proximal femoral osteotomy
o techniques
can be performed at the subcapital, femoral neck, intertrochanteric and subtrochanteric
regions
subcapital and femoral neck osteotomies provide the most correction but are associated with
the highest risks of osteonecrosis and should be avoided
o typical correction consists of flexion, valgus and derotation
Complications
Osteonecrosis of femoral head (4-6%)
o may occur as the result of
initial trauma
increased risk with high grade slips (~45-50%)
operative complication (4-6%)
hardware placement in posteriosuperior femoral neck has the greatest risk of disrupting
the vascular supply
Contralateral hip SCFE
o most common complication after unilateral surgical fixation (20-80%)
risk factors for contralateral slip include
male, obesity, young age of initial slip, endocrine disorders
Chondrolysis (0-2%)
o associated with
unrecognized implant penetration of the articular surface (0-2%)
spica cast immobilization
decreased prevalence with modern fluoroscopy
Residual proximal femoral deformity & limb length discrepancy
o increased α-angle associated with symptomatic impingement
o caused by failure of proximal femur to remodel
o treatment
intertrochanteric osteotomy (Imhauser)
produces flexion, internal rotation and valgus
subtrochanteric osteotomy (Southwick's)
cuneiform osteotomy (controversial due to high rate of osteonecrosis and arthritis)
Slip progression
o occurs in 1-2% of cases following single screw fixation
Infection (0-2%)
Chronic pain (5-10%)
Degenerative arthritis
Pin associated proximal femur fracture
Labral tearing and degeneration
o seen with high anterior and medial 2nd screw in-situ fixation
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Hip & Pelvis Conditions
Classification
Etiologies of Coxa Vara
o congenital
o acquired
o dysplasia
o developmental
o cretinism
Presentation
History
o previous hip trauma or infection
o associated skeletal abnormalities
o prenatal and developmental history
o family history of similar deformity
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Symptoms
o usually painless
o gait abnormality
waddling or limp (trendelenburg gait)
caused by abductor weakness from tension abnormality
Physical exam
o inspection
leg length discrepancy
high riding greater trochanter
limb shortening
excessive lumbar lordosis
o motion : restricted hip range of motion in all planes that is usually non-tender
Imaging
Radiographs
o recommended views: AP hip with limb internally rotated + lateral hip
o findings
neck shaft angle <125 degrees
increased Hilgenreiner's epiphyseal angle (normal <25 degrees)
determined on AP as angle between Hilgenreiner's line and a line through the proximal
femoral physis
triangular metaphyseal fragment in inferior femoral neck (looks like inverted-Y
radiolucency)
decreased femoral anteversion
CT
o indications
surgical planning
delineate proximal femur defects
orientation of deformity
o views
consider all views including 3D reconstructions
o findings
deformity configuration
bone stock
physeal widening
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Hip & Pelvis Conditions
Treatment
Nonoperative
o observation alone
indications
Hilgenreiner's physeal angle < 45
20% correct spontaneously without surgery
Operative
o corrective valgus derotation osteotomy (VDRO)
indications
Hilgenreiner's physeal angle > 60°
45-60° with limp & progression of varus
(neck shaft angle < 110 °)
technique (see below)
aftercare
hip-spica or abduction pillow x 4-6 weeks depending on fixation and healing
Technique
Corrective valgus derotation osteotomy (VDRO)
o goals of treatment
Over-correct neck shaft angle
correct leg length discrepancy
correct hip anteversion/retroversion
re-establish abductor muscle tensioning
o approach
typically a hip direct lateral approach is used
o procedure
protect periosteum and physis
perform valgus producing osteotomy in sub-trochanteric
may need to transfer greater trochanter to properly tension abductor muscles
Complications
Loss of correction
Premature closure of the proximal femoral physis
Overgrowth of proximal femur
Dysplasia of acetabulum
5. Sacral Agenesis
Introduction
Condition characterized by partial or complete absence of sacrum and lower lumbar spine
Epidemiology
o incidence
1 - 2.5 per 100,000 newborns
o risk factors
highly associated with maternal diabetes
Pathophysiology
o neurologic involvement
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motor deficit corresponds to level
protective sensation is usually intact
important in that there is a lesser rate of decubiti ulcers
this differentiate from myelodysplasia
Associated conditions
o caudal regression syndrome
gastrointestinal disorders (imperforate anus)
genitourinary disorders
cardiovascular disorders
lower extremity deformities
progressive kyphosis
Classification
Renshaw Classification
Type I Partial or total unilateral sacral agenesis
Type II Partial sacral agenesis with a bilaterally symmetrical defect
Type III Ilium articulating with the sides of the lowest vertebra present
Type IV Caudal endplate of vertebra resting above fused ilia or an iliac amphiarthrosis
Presentation
Symptoms
o clinical presentation is based on the severity of disease
Physical exam
o inspection
prominence of the last vertebral segment
classic sign of buttock dimping
postural abnormalities (e.g. sitting buddha)
limb and joint contractures
Extended knees, flexed hips, and equinovarus feet.
o motion
flexion and extension may occur at the junction of the spine rather than hips
o neurovascular examination
motor and sensory deficits are common in severe disease
Treatment
Nonoperative
o physical therapy
indications
Renshaw type 1/2
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Hip & Pelvis Conditions
outcomes
most become community ambulators
foot and knee deformities to be addressed
Operative
o spinal stabilization procedures
indications
Renshaw type 3/4 with progressive kyphosis or scoliosis
outcomes
progressive kyphosis and/or scoliosis may develop between the spine and pelvis
child must use his or her hands to support the trunk, and therefore is unable to use his or
her hands for other activities
o limb amputation
indication
non-fuctional lower limb deformities
outcomes
better mobility
6. Bladder Extrophy
Introduction
A congenital disorder that involves the musculoskeletal and genitourinary systems
Epidemiology
o 1/40,000 infants diagnosed with this condition (classic exstrophy)
o 1/200,000 infants with intestinal track involved as well (cloacal exstrophy)
Pathology
o abnormal anterior rupture of the cloacal membrane early in the embryonic period
o mesenchymal ingrowth into abdominal wall is also inhibited
o altered migration of sclerotomes that comprise the anterior elements (pubis)
Associated conditions
o family history should be sought out as often associated with other conditions
Presentation
Symptoms
o a thorough history and a complete examination are essential
o urinary system infection(s)
Physical exam
o genitourinary system
exposed bladder
o musculoskeletal
acetabuli are ~12 degrees externally rotated
without pubis to tether the anterior ring, the posterior elements externally rotate
waddling gait with external foot progression
Imaging
Radiographs
o recommended views
obtain AP pelvic radiograph
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o findings
pubic rami diastasis
Shortened pubic rami
Acetabular retroversion
Treatment
Goal = close abdominal wall, achieve urinary continence, normal renal function
Operative
o staged multidisciplinary reconstruction
management should be multidisciplinary and involve pediatric urologist and general surgeon
Reconstruction sequence may vary by preference of urologist
technique
stage I: primary closure of bladder (newborn)
stage II: epispadias repair in males (1-2 y/o)
stage III: bladder neck reconstructions (4 y/o)
pelvic osteotomies for closure of pelvic ring may be performed at any stage of process (in
order to decrease tension on bladder and repaired abdominal wall to decrease dehiscence)
Pelvic osteotomy fixaiton depends on age
not required in newborns (skin traction and hips flexed 90 degrees)
External fixation in younger patients
Augment correction of diastasis with plate fixation in > 8 y/o
D. Leg Conditions
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Leg Conditions
o nonorthopaedic manifestations
dysmorphic facies found in rare autosomal dominant type
Classification
Aitken classification
Class Femoral Head Acetabulum
A present normal
B present mildly dysplastic
C absent severely dysplastic
D absent absent
Presentation
Physical exam
o severe shortening of one or both legs
percentage of shortening remains constant with growth
o short bulky thigh that is flexed, abducted, and externally rotated
o normal feet (most common)
Treatment
Goals of treatment
o treatment must be individualized based on
ultimate leg length discrepancy
presence of foot deformities
adequacy of musculature
proximal joint stability
Nonoperative
o observation
indications
often in children with bilateral deficiency
o extension prosthesis
indications
less attractive option due to large proximal segment of prosthesis
assists patient when attempting to pull self up to stand
Operative
o ambulation without prosthesis
limb lengthening with or without contralateral epiphysiodesis
indications
predicated limb length discrepancy of <20 cm at maturity
stable hip and functional foot
femoral length >50% of opposite side
femoral head present (Aitken classifications A & B)
contraindications
unaddressed coxa vara, proximal femoral neck pseudoarthrosis, or acetabular
dysplasia
o ambulation with a prosthesis
knee arthrodesis with foot ablation
indications:
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ipsilateral foot is proximal to the level of contralateral knee
prosthetic knee will not be below the level of the contralateral knee at maturity
need for improved prosthetic fit, function, and appearance
femoral-pelvic fusion (Brown's procedure)
indications
femoral head absent (Aiken classifications C & D)
Van Ness rotationplasty
indications
ipsilateral foot at level of contralateral knee
ankle with >60% of motion
absent femoral head (Aiken classifications C & D)
surgical technique
180 degree rotational turn through the femur
ankle dorsiflexion becomes knee flexion
allows the use of a below-knee prosthesis to improve gait and efficiency
amputation
indications
femoral length <50% of opposite side
surgical technique
preserve as much length as possible
amputate through the joint, if possible, in order to avoid overgrowth which can lead to
difficult prosthesis fittingfit for prosthesis for lower extremity after 1 year
2. Hemihypertrophy
Introduction
Asymmetry between the right and left sides of the body to a greater degree than can be attributed to
normal variation
o abnormal asymmetry defined as a 5% or greater difference in length and/or circumference
Epidemiology
o incidence
varies from 1:14,000 to 1:86,000
o demographics
male:female = 2:3
o location
slightly more common on the right side
may also involve head, trunk and internal organs
Pathophysiology
o most common causes are
idiopathic (non-syndromic)
syndromic
neurofibromatosis
Beckwith-Wiedemann syndrome
Klippel-Trenauney syndrome
Proteus syndrome
Associated conditions
o orthopaedic manifestations
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Leg Conditions
scoliosis (compensatory)
peripheral nerve entrapment (rare)
o medical conditions & comorbidities
malignant intra-abdominal tumors
Wilm's tumor (most common)
perform serial abdominal ultrasounds (every 3 months) until age 7 to rule out Wilm's
tumor
then physical exam every 6 months until skeletal maturity
adrenal carcinoma
hepatoblastoma
genitourinary abnormalities
medullary sponge kidneys
polycystic kidney
inguinal hernias
Classification
Congenital classification
o congenital
total
involvement of all organ systems
limited
only muscular, vascular, skeletal, or neurologic involvement
classic (ipsilateral upper and lower limbs)
segmental (a single limb)
facial
crossed
o acquired
very rare
can result from injury, infection, radiation or inflammation
Syndromic classification
o non-syndromic (isolated)
o syndromic (part of a clinical syndrome)
Presentation
Physical exam
o findings rarely apparent at birth, manifest during growth
o skin often thicker on involved side
o more hair on corresponding side of the head
o limb circumference asymmetric
o leg-length discrepancy (LLD)
Imaging
Radiographs
o AP + lateral of affected limb may demonstrate enlargement of bone and soft tissue
osseous maturation may be seen
Abdominal ultrasound
o indications
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perform serial abdominal ultrasounds (every 3 months) until age 7 to rule out Wilm's tumor
Studies
Renal function tests
Serum alpha-fetoprotein
o screen for embryonal tumors
Treatment
Nonoperative
o observation, shoelift, corrective shoes
indications
< 2 cm projected LLD at maturity
Operative
o surgical correction
indications
based on principles of leg length discrepancies
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Leg Conditions
Classification
Static
o malunion of femur or tibia
Progressive
o physeal growth arrest
o congenital
absolute discrepancy increases
proportion stats the same
Presentation
Symptoms
o usually asymptomatic
Physical exam
o block testing
with the patient standing, add blocks under the short leg until the pelvis is level, then measure
the blocks to determine the discrepancy
block testing is considered the best initial screening method
o tape measurement
measure from the anterior superior iliac spine to the medial malleolus with a tape measure
o evaluate for hip, knee and ankle contractures
affect apparent limb length
hip adduction contracture causes apparent shortening of adducted side
Imaging
Radiographs
o teleoroentgenography (scanography)
measure discrepancy with single exposure from 2m away
o bone age hand films
determine bone age with bone age xray (hand)
CT Scanography
o CT scanography is the most accurate diagnostic test with contractures of the hip, knee, or ankle
LLD Projections
General assumptions
o growth continues until 16 yrs in boys and until 14 yrs in girls
Methods to project LLD at maturity
o Mosley graph
o estimation technique
leg grows 23 mm/year, with most of that coming from the knee (15 mm/yr)
proximal femur - 3 mm / yr (1/8 in)
distal femur - 9 mm / yr (3/8 in)
proximal tibia - 6 mm / yr (1/4 in)
distal tibia - 5 mm / yr (3/16 in)
Can be tracked with
o Green-Anderson tables
uses extremity length for a given age
o Moseley straight line graph
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improves on Green-Anderson method by reformatting data in a graph form
accounts for differences between skeletal and chronologic age
minimizes error
averages serial measurements
o Multiplier method
prediction based on multiplying the current discrepancy by a sex and age specific factor
most accurate for congenital LLD
1/2 of final leg length
girls at age 3
boys at age 4
Treatment
Nonoperative
o shoe lift or observation only
indications
< 2 cm projected LLD at maturity Green-Anderson tables
outcomes
not associated with scoliosis or back pain
Operative
o shortening of long side via epiphysiodesis of femur, tibia, or both
indications
2-5 cm projected LLD
o limb lengthening of short side
indications
> 5 cm projected LLD
lengthening often combined with a shortening procedure (epiphysiodesis, ostectomy) on
long side
o physeal bar excision
indications
bony bridge involves <50% of physis
at least 2 years left of growth
o amputation and prosthetic fitting
indications
non-reconstructable limb
> 20 cm projected LLD
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Pediatric Knee
Surgical Techniques
Distraction osteogenesis (Ilizarov principles)
o initiation
perform osteotomy and place fixator
metaphyseal corticotomy to preserve medullary canal and blood supply
o distraction
wait 5-7 days then begin distraction
distract ~ 1 mm/day
following distraction keep fixator on for as many days as you lengthened
o concurrent procedures
may lengthen over a nail so ex-fix can be removed sooner
lengthening often combined with a shortening procedure (epiphysiodesis, ostectomy) on long
side
Complications
Incomplete arrest/ angular deformity
o open technique
o percutaneous technique
Pin site infections
Fracture
Delayed union
Premature cessation of lengthening
Joint subluxation/dislocation
Mechanical axis deviation (MAD)
o lengthening along the anatomical axis of the femur leads to lateral MAD
o shortening along the anatomical axis of the femur leads to medial MAD
E. Pediatric Knee
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o clubfoot,
o metatarsus adductus
Presentation
Presents with hyperextened knee at birth
Treatment
Nonoperative treatment
o reduction with manual manipulation and casting
indications
most cases can be treated nonoperatively
if both knee and hip dislocated, then treat knee first
can't get Pavlik harness on hip if knee dislocated
technique
long leg casting on weekly basis
Operative treatment
o surgical soft tissue release
indications
failure to gain 30° of flexion after 3 months of casting
goal of surgery is to obtain 90° of flexion
quadriceps tendon lengthening (V-Y quadricepsplasty or Z lengthening)
anterior joint capsule release
hamstring tendon posterior transposition
collateral ligaments mobilization
postoperative
cast in 45 to 60° flexion for 3 to 4 weeks
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Pediatric Knee
Associated conditions
o Larson syndrome
o arthrogryposis
o diastrophic dysplasia
o nail-patella syndrome
o Down syndrome
o Ellis-van Creveld syndrome
Anatomy
Osteology
o the patella is the largest sesamoid bone
o ossification
males at 4-5 yrs. old
females at 3 yrs. old
accessory ossification center appears between 8-12 years
separate fragment attached to patella by fibrocartilaginous tissue
Function
o fulcrum for the quadriceps
o protects the knee joint
articular cartilage of patella is thickest in body (up to 1cm)
o enhances lubrication of the knee
o see complete knee biomechanics
Blood supply
o blood supply to patella is predominantly from distal to proximal
o 6 arteries contribute
from popliteal artery
superior lateral geniculate artery
superior medial geniculate artery
inferior lateral geniculate artery
inferior medial geniculate artery
from superficial femoral artery
supreme geniculate artery
from anterior tibial artery
recurrent anterior tibial artery
Presentation
History
o associated syndromes present
Symptoms
o delayed walking : can mimic cerebral palsy
Physical exam
o inspection
genu valgum
knee flexion contractures
"smiley face" appearance of knee caps
femoral condyles abnormally prominent
small patella which is difficult to palpate laterally
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o motion
limited active flexion
as genu valgum worsens, patella subluxes posteriorly causing quadriceps to act as knee
flexor
Imaging
Radiographs
o recommended views
not helpful in children younger than 3 years old because patella is not ossified
in children > 3 years of age
AP lateral and sunrise
o findings
dislocated patella
hypoplastic trochlea
Ultrasound or MRI
o indications
children <3 years of age
can help diagnose non-ossified, dislocated patella
AP xray showing Lateral xray: note it has Sunrise view of the knee showing a
congenitally dislocated dislocated laterally and dislocated patella with hypoplastic
patella posteriorly, it is not visible on trochlea.
the lateral
Treatment
Nonoperative
o observation
indications
for most part not recommended as the condition impairs long term function if left
untreated
Operative
o surgical reduction (Andrish technique)
indications
perform early to allow for trochlear intervention
technique (below)
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Pediatric Knee
Techniques
Surgical reduction (Andrish technique)
o soft tissue reduction steps
divide and lengthen lateral retinaculum between oblique and transverse layers
dissect vastus lateralis from intermuscular septum and advance proximally on quadriceps
tendon
release distal patellomeniscal ligaments
lengthen quadriceps tendon, shorten patellar tendon to correct patellar alta
tighten medial structures via medial patellofemoral reconstruction
reroute semitendinosus through medial collateral ligament and attach to patella
o osseous realignment
distal realignment usually not needed with adequate release
if needed, realignment limited due to tibial tubercle apophysis
Roux-Goldthwait is preferred
Complications
Recurrence
Anatomy
Muscles posterior to medial knee capsule
o semimembranosus
o medial head of gastrocnemius
Presentation
Symptoms
o usually asymptomatic
Physical exam
o located in popliteal fossa
usually located medially and distal to knee crease
most pronounced with knee extended
o mass will transilluminate
Imaging
Radiographs : are normal
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Ultrasound : consistent with cystic lesion
MRI : show fluid filled cyst
Treatment
Nonoperative
o observation
indications
mainstay of treatment
with majority of cases resolving spontaneously
Operative
o excision
indications
only if cyst causes significant discomfort
failure of spontaneous resolution
4. Bipartite Patella
Introduction
Normal patellar variant representing a failure of fusion
o often confused with patellar fractures
Epidemiology
o incidence
2-8% of the population
o demographics
male:female ratio = 9:1
o location
most often found in the superolateral region (Type III)
bilateral in 50%
Pathophysiology
o painful bipartite patella following injury
direct or indirect injury results in disruption in fibrocartilaginous zone between main patella
and accessory fragment
fibrocartilaginous zone cannot heal by bony union, resulting in persistent pain
vastus lateralis contributes to traction force in fragment separation and nonunion
Associated conditions
o nail-patella syndrome
o patella fracture
compared with patellar fractures, bipartite patellas
are located superolaterally
have rounded borders
may have similar findings on a contralateral knee radiograph
Anatomy
Osteology
o the patella is the largest sesamoid bone
o ossification
males at 4-5 yrs. old
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Pediatric Knee
females at 3 yrs. old
accessory ossification center appears between 8-12 years
separate fragment attached to patella by fibrocartilaginous tissue
Function
o fulcrum for the quadriceps
o protects the knee joint
articular cartilage of patella is thickest in body (up to 1cm)
o enhances lubrication of the knee
o see complete knee biomechanics
Blood supply
o blood supply to patella is predominantly from distal to proximal
o 6 arteries contribute
from popliteal artery
superior lateral geniculate artery
superior medial geniculate artery
inferior lateral geniculate artery
inferior medial geniculate artery
from superficial femoral artery
supreme geniculate artery
from anterior tibial artery
recurrent anterior tibial artery
Classification
Saupe Classification
Type Incidence Location
Type I 5% Inferior pole
Type II 20% Lateral margin
Type III 75% Superolateral pole
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Imaging
Radiographs
o recommended views
AP knee radiograph
best view to visualize bipartite patella
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Pediatric Knee
skyline view
prone position (non-weightbearing)
squatting position (weightbearing)
radiograph of contralateral knee
o findings
smooth edges (differentiate from fracture)
weightbearing skyline (squatting) demonstrates increased separation of fragments compared
with non-weightbearing skyline (prone)
50% have bilateral bipartite patella
MRI
o indications
assessment of painful bipartite patella to determine if pain is attributable to the bipartite
patella
o findings
edema around the fragment
Bone scan
o indications
equivocal radiographs with high suspicion for bipartite patella
o findings
increased uptake along superolateral aspect
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Studies
Histology
o the interposed tissue between accessory and main fragment
is composed of fibrocartilage > fibrous > hyaline cartilage
complete lack of blood vessels
o adjacent bone
scalloped surface with numerous osteoclasts
numerous blood vessels in bone marrow
Treatment
Nonoperative
o rest, immobilization, NSAIDS, and physical therapy
indications
nonoperative symptomatic management indicated for bipartite patella for at least 6
months
modalities
rest and restriction of sports activities
NSAIDS
isometric strengthening exercises of the quadriceps muscle in extension
immobilization with the knee braced in 30° of flexion
local corticosteroid injection
Operative
o open excision of the accessory fragment
indications
failed nonoperative treatment >6mths
irregular articular surface of accessory fragment (on radiographs)
most common treatment technique
o lateral retinacular release
indications
superolateral fragment (to remove traction force of vastus lateralis on the fragment)
o vastus lateralis release
indications
superolateral fragment
to avoid long lateral retinacular release
o ORIF
indications : for large fragments
lateral retinacular release vastus lateralis release Open reduction & internal fixation
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Varus & Valgus Deformities
Anatomy
Genu varum is a normal physiologic process in children I:9 Rickets
o physiologic genu varum
genu varum (bowed legs) is normal in children less than 2 years
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genu varum migrates to a neutral at ~ 14 months
continues on to a peak genu valgum (knocked knees) at ~ 3 years of age
genu valgum then migrates back to normal physiologic valgus at ~ 7 years of age
Classification
Langenskiold Classification
o type I thru IV consist of increasing medial metaphyseal beaking and sloping
o type V and VI have an epiphyseal-metaphyseal bony bridge (congenital bar across physis)
o provides prognostic guidelines
Presentation
Physical exam
o genu varum/flexion/internal rotation deformity
usually bilateral in infants
may exhibit positive 'cover-up test'
o often associated with internal tibial torsion
o leg length discrepancy
o usually NO tenderness, restriction of motion, effusion
o lateral thrust on walking
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Varus & Valgus Deformities
o findings suggestive of Blounts disease
varus focused at proximal tibia
severe deformity
asymmetric bowing
medial and posterior sloping of proximal tibial epiphysis
progressing deformity
sharp angular deformity
lateral thrust during gait
metaphyseal beaking
different than physiologic bowing which shows a symmetric flaring of the tibia and femur
o measurements
metaphyseal-diaphyseal angle (Drennan)
angle between line connecting metaphyseal beaks and a line perpendicular to the
longitudinal axis of the tibia
>16 ° is considered abnormal and has a 95% chance of progression
<10 ° has a 95% chance of natural resolution of the bowing
tibiofemoral angle
angle between the longitudinal axis of the femur and tibia
metaphyseal beaking
Treatment
Nonoperative
o brace treatment with KAFO
indications
Stage I and II in children < 3 years
technique
bracing must continue for approximately 2 years for resolution of bony changes
outcomes
improved outcomes if unilateral
poor results associated with obesity and bilaterality
if successful, improvement should occur within 1 year
Operative
o proximal tibia/fibula valgus osteotomy
overcome the varus/flexion/internal rotation deformity
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indications
Stage I and II in children > 3 years
Stage III, IV, V, VI
age ≥ 4y (all stages)
failure of brace treatment
progressive deformity
metaphyseal-diaphyseal angles > 20 degrees
technique
perform osteotomy below tibial tubercle
staged procedures may be required for Stage IV, V, VI
epiphysiolysis required in stage V and VI
outcomes
risk of recurrence is significantly lessened if performed before 4 years of age
o growth modulation
technique
tension band plate and screws
o physeal bar resection
indication
at least 4y of growth remaining
technique
perform together with osteotomy
interpositional material is usually fat or PMMA
o hemiplateau elevation
technique
may be performed together with osteotomy
Surgical Techniques
Proximal tibia/fibula valgus osteotomy
o goals of correction
overcorrect into 10-15° of valgus because medial physeal growth abnormalities persist
distal segment is fixed in valgus, external rotation and lateral translation
o technique
staples and plates function by increasing compression forces across the physis which slows
longitudinal growth (Heuter-Volkmann principle)
temporary lateral physeal growth arrest with staples or plates can be used
increasing use for correction in younger patients
include a bar resection (epiphysiolysis) when a physeal bar is present (Langenskiold V and
VI)
consider hemiepiphysiodesis if bar > 50%
medial tibial plateau elevation is required at time of osteotomy if significant depression is
present
consider prophylactic anterior compartment fasciotomy
Complications
Compartment syndrome (with high tibial/fibular osteotomy)
o prophylactic release of anterior compartment
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Varus & Valgus Deformities
Presentation
Physical exam
o hallmark is genu varum deformity
o obesity
o usually unilateral (compared to bilateral in infantile Blount's)
o limb-length discrepancy secondary to deformity
o mild to moderate laxity of medial collateral ligament
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OrthoBullets2017 Pediatric Conditions | Varus & Valgus Deformities
Imaging
Radiographs
o views
standing long-cassette AP radiograph of both lower extremities
ensure patellas are facing forward (commonly associated with internal tibial torsion)
o findings suggestive of adolescent Blount's disease
narrowing of the tibial epiphysis
widening of the medial tibial growth plate
occasional widening of the lateral distal femoral physis
o metaphyseal beaking less commonly seen with adolescent Blount's
o measurements
metaphyseal-diaphyseal angle (Drennan)
angle between line connecting metaphyseal beaks and a line perpendicular to the
longitudinal axis of the tibia
>16 degrees is considered abnormal
tibiofemoral angle
angle between the longitudinal axis of the femur and tibia
Treatment
Nonoperative
o observation or bracing is unlikely to be successful - treatment is always surgical
indications : mild cases only
outcomes
poor outcomes - will progresse and cause medial joint pain and altered kinematics
early onset arthritis is common in untreated cases
Operative
o lateral tibia and fibular epiphysiodesis
indications
mild to moderate deformity with growth remaining
outcomes
up to 25% may require formal osteotomy due to residual deformity
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Varus & Valgus Deformities
o proximal tibia/fibula osteotomy
indications
more severe cases in the skeletally mature
outcomes
multiplanar external fixation following osteotomy allows gradual angle and length
correction and decreases risk on neurovascular structures
o distal femoral osteotomy or epiphysiodesis
indications
for distal femoral varus deformity of 8 degrees or greater
Surgical Techniques
Lateral tibia and fibular epiphysiodesis
o transient hemiepiphysiodesis
technique
tether physis with 8-plates or staple
may remove implant once correction is achieved
pros
simple
allows for gradual correction is children with adequate
growth remaining I:11 lateral tibia and fibular
implants may be removed epiphysiodesis
cons
requires significant growth remaining
close observation is necessary following operation as growth plate may stop functioning
or have a rebound period of accelerated growth
o permanent hemiepiphysiodesis
technique
obliteration of physis through small, lateral incision
pros
limited surgery
overcorrection is uncommon
does not limit ability to perform corrective osteotomy in future
cons
cannot correct rotational deformity
up to 25% may require formal corrective osteotomy
Proximal tibia/fibula osteotomy
o goals of correction
overcorrection to valgus not indicated (as is the case in infantile Blount's)
strive for neutral mechanical axis
o high tibial osteotomy with rigid internal fixation
technique
variety of techniques, including closing wedge, opening wedge, dome, serrated and
inclined osteotomies
variety of fixation devices including cast, pins and wires, screws, plates and screws
post-op
limited weight bearing with use of crutches for 6-8 weeks
pros : immediate correction
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OrthoBullets2017 Pediatric Conditions | Varus & Valgus Deformities
cons
potential for neurologic injury due to acute lengthening
potential for compartment syndrome
consider prophylactic fasciotomies
o osteotomy with external fixation and gradual correction
technique
perform osteotomy, and connect frame that allows for gradual correction
Taylor Spatial Frame or Ilizarov ring external fixator
post-op
usually 12-18 weeks of treatment are needed
pros
gradual correction limits neurovascular compromise and risk for compartment syndrome
allows for correction of deformity in all planes
cons
pin site infection
duration of treatment
bulk of construct
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Varus & Valgus Deformities
Anatomy
Normal physiologic process of genu valgum
o between 3-4 years of age children have up to 20 degrees of genu valgum
o genu valgum rarely worsens after age 7
o after age 7 valgus should not be worse than 12 degrees of genu valgum
o after age 7 the intermalleolar distance should be <8 cm
Treatment
Nonoperative
o observation
indications
first line of treatment
genu valgum <15 degrees in a child <6 years of age
o bracing
indications
rarely used
ineffective in pathologic genu valgum and unnecessary in physiologic genu valgum
Operative
o hemiepiphysiodesis or physeal tethering (staples, screws, or plate/screws) of medial side
indications
> 15-20° of valgus in a patient <10 years of age
if line drawn from center of femoral head to center of ankle falls in lateral quadrant of
tibial plateau in patient > 10 yrs of age
technique
to avoid physeal injury place them extraperiosteally
to avoid overcorrection follow patients often
growth begins within 24 months after removal of the tether
o distal femoral varus osteotomy
indications
insufficient remaining growth for hemiepiphysiodesis
complications
peroneal nerve injury
perform a peroneal nerve release prior to surgery
gradually correct the deformity
utilize a closing wedge technique
I:13 hemiepiphysiodesis
I:12 distal femoral varus osteotomy
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OrthoBullets2017 Pediatric Conditions | Tibial Bowing
G. Tibial Bowing
1. Neurofibromatosis
Introduction
Neurofibromatosis is an autosomal dominant disorder of neural crest origin characterized by
o extremity deformities
congenital anterolateral bowing and pseudoarthrosis of tibia/ fibula and forearm
hemihypertrophy
o spine involvement
scoliosis & kyphosis
atlantoaxial instability
Epidemiology : 1:3,000 births for NF1
Genetics
o autosomal dominant (AD)
o mutation in NF1 gene on chromosome 17q21
codes for neurofibromin protein
negatively regulates Ras signaling pathway
neurofibromin deficiency leads to increased Ras activity
affects Ras-dependent MAPK activity which is essential for osteoclast function and
survival
o neurofibromatosis is the most common genetic disorder caused by a new mutation of a single
gene
Associated conditions
o scoliosis (see below)
o anterolateral bowing of tibia
o bowing of forearm bones with obliteration of medullary cavity
ulnar pseudoarthrosis
radius pseudoarthrosis
o neoplasias
Prognosis
o normal life expectancy
o high incidence of malignancy and hypertension
Diagnostic criteria
o according to the NIH Consensus Development Conference Statement (1987) the diagnostic
criteria for NF-1 are met in an individual if two or more of the following are found
six or more café-au-lait macules over 5 mm in greatest diameter in prepubertal individuals
and over 15 mm in postpubertal individuals.
two or more neurofibromas of any type or one plexiform neurofibroma.
freckling in the axillary or inguinal region.
optic glioma.
two or more Lisch nodules (iris hamartomas).
a distinctive osseous lesion such as sphenoid dysplasia or thinning of long bone cortex with
or without pseudarthrosis.
a first-degree relative (parent, sibling, or offspring) with NF-1 by the above criteria.is based
on presence of both
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Tibial Bowing
Classification
NF1 (von Recklinghaussen disease) : most common
NF2 : associated with bilateral vestibular schwannomas
Segmental NF : features of NF1 but involving a single body segment
Presentation General
Presentation
o often presents with anterolateral bowing of tibia
I:14 anterolateral
o often presents with radial bowing bowing of tibia
Physical exam
o verrucous hyperplasia
o hemihypertrophy
o cafe-au-lait spots
o axillary freckling
o scoliosis Pigmented hamartomas
o anterolateral bowing or pseudoarthrosis of tibia
o dermal Plexiform-type neurofibroma may be seen
o Lisch nodules are benign pigmented hamartomas of the iris Cafe-au-lait spots Hemihypertrophy
Neoplasias (Neurofibromatosis)
Neurofibromas (plexiform-type)
o is pathognomonic for NF1
o present in 4% of NF1
o may be dermal or in deep tissues
o often associated with limb overgrowth
o can undergo malignant transformation to neurofibrosarcoma
Wilms Tumor
Scoliosis (Neurofibromatosis)
Introduction
I:15 Neurofibroma
o spine is most common site of skeletal involvement in NF-1
scoliosis is NOT associated with NF-2
o can take two forms
idiopathic-like form (nondystrophic)
longer curve and treatment resembles that for idiopathic scoliosis
dystrophic form
curve is typically thoracic kyphoscoliosis with a short segmented and
sharp curve with distorted ribs and vertebrae
usually recognized earlier than nondystrophic form
generally characterized by a sharp angular curve involving 4 to 6 vertebrae
Imaging
o radiographs show
vertebral scalloping
penciling of ribs (penciling of 3 or more ribs is a poor prognostic finding and associated
with rapid curve progression)
enlarged foramina
o MRI : always obtain preoperative MRI to identify dural ectasia and dumbbell
lesion (neurofibroma on nerve root)
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OrthoBullets2017 Pediatric Conditions | Tibial Bowing
paraspinal masses are useful to distinguish from idiopathic scoliosis
Treatment
o nonoperative
observation vs. bracing
bracing is not effective for dystrophic form
nondystrophic scoliosis in NF is treated like adolescent idiopathic scoliosis
o operative
decompression, ASF & PSF with instrumentation
indications
dystrophic scoliosis
perform early in young children (< 7 yrs) with dystrophic curves
complications
High rate of pseudoarthrosis with PSF alone (40%)
Pseudoarthrosis rate still high with ASF&PSF (10%)
some recommend augmenting the PSF with repeat iliac crest bone grafting 6
months after the primary surgery
Anterolateral Tibial Bowing (Neurofibromatosis)
Introduction
o epidemiology
anterolateral bowing is often associated with neurofibromatosis (NF1)
50% with anterolateral bowing have NF1
10% of NF1 have anterolateral bowing
o pathophysiology
may progress to pseudoarthrosis
o differentials for tibia bowing
anteromedial
associated with fibular hemimelia and congenital loss of lateral rays of the foot
posteromedial
usually congenital due to
abnormal intrauterine positioning
dorsiflexed foot pressed against anterior tibia
will develop leg length discrepancy
associated with calcaneovalgus deformity
Imaging
o radiographs
obtain AP and lateral of tib/fib
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Tibial Bowing
Anterolateral bowing progress to pseudoarthrosis Posteromedial bowing
Treatment
o nonoperative
bracing in total contact orthosis
indications
bowing without pseudoarthrosis or fracture (goal is to prevent further bowing and
fractures)
spontaneous remodeling is not expected
osteotomy for bowing alone is contraindicated
o operative
bone grafting with surgical fixation
indications
in bowing with pseudoarthrosis or fracture
amputation with prosthesis fitting
indications
three failed surgical attempts
Syme's often superior to BKA due to atrophic and scarred calf muscle in these
patients
Techniques
o intramedullary nailing with bone grafting
resect pseudoarthrosis
insert Charnley-Williams rod
antegrade through resection site, then retrograde through the heel
< 4 y.o., extend fixation to calcaneus
5-10 y.o., extend fixation to talus
2 yrs. postop, typically a 2nd surgery to push rod proximally to free the ankle joint
o free fibular graft
often need to take fibula from contralateral side because ilpsilateral fibula is not normal
Illizarov's external fixation
Classification
Achterman & Kalamchi
o based on amount of fibula present
Birch Classification
o based on limb length and foot function
o directs treatment
Presentation
Physical exam
o classic findings
short limb
skin dimpling over midanterior tibia
equinovalgus foot
o other findings
often missing lateral toes
genu valgum
Imaging
Radiographs
o fibula is either absent or shortened
o tibial spines are underdeveloped
o intercondylar notch is shallow
o ball and socket ankle joint
secondary to tarsal coalitions
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OrthoBullets2017 Pediatric Conditions | Tibial Bowing
Treatment
Goals
o treatment determined by the stability and level of foot and ankle function, as well as the degree
of limb shortening
not based on amount of fibula present
Nonoperative
o observation
shoe lift
bracing
Operative
o contralateral epiphysiodesis alone
indications
mild projected LLD (<5cm or <10%)
stable, plantigrade foot
o limb lengthening procedure alone
indications
plantigrade, functional foot with a stable ankle
LLD < 10%
technique
involves resection of fibular anlage to avoid future foot problems
o contralateral epiphysiodesis + limb lengthening procedure
indications
Moderate LLD (10-30%)
o Syme amputation (preferred to Boyd amputation)
Boyd is more bulbous and only about 1cm longer
indications
nonfunctional, deformed, unstable foot
LLD > 30%
unable to cope psychologically with multiple limb lengthening procedures
cosmesis
technique
amputation usually done at ~1 year of age to allow early prosthesis fitting, better
psychosocial acceptance
results : 88% satisfaction with amputation vs 55% satisfaction with limb lengthening
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Tibial Bowing
Definition
o A congenital bowing of the tibial diaphysis (anterolateral apex), associated with diaphyseal
pseudoarthrosis
o Pseudoarthrosis in not congenital, but in fact develops post-natally due to fracture non-union
Epidemiology
o Incidence
Extremely rare
1:140,000-190,000
o Risk Factors
Up to 55% associated with Neurofibromatosis Type 1
15% associated with Fibrous Dysplasia
Classification
Numerous classification systems have been proposed (Boyd, Andersen, Crawford) however none
guide management or are predictive of outcome
Two classification criteria have been proposed to guide treatment:
o The presence or absence of fracture
o The age at which fracture occurs
"Early onset" < 4 years old
"Late onset" > 4 years old
Presentation
Symptoms
o majority present with bowing in the first year of life
Physical exam
o deformity
o careful skin examination for cafe-au-lait spots and other signs of neurofibromatosis
Treatment
The lesion does not self-resolve, and once fracture occurs there is low likelihood of spontaneous
resolution
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OrthoBullets2017 Pediatric Conditions | Tibial Bowing
Nonoperative
o bracing in clamshell orthosis or patellar tendon bearing (PTB) orthosis
indications
Children of ambulatory age (weight bearing)
bowing without pseudarthrosis or fracture
spontaneous remodeling is not expected
goal is to prevent further bowing and fractures
osteotomy for bowing alone is contraindicated
technique
maintained until skeletal maturity
Operative
o surgical fixation
indications
bowing with pseudarthrosis or fracture
o amputation
indications
typically indicated after multiple failed
surgical attempts at union
severe limb length discrepancy
dysfunctional angular deformity
Method- Syme or Boyd amputation
Techniques
Surgical fixation
I:19 intramedullary nailing with bone grafting
o goals
resection of pseudarthrosis to grossly normal bone
correction of alignment
bone grafting and stabilization of the remaining segments
intramedullary splinting of the bone is desired
o techniques
intramedullary nailing with bone grafting
Resect the pseudarthrosis
Tibial shortening
Fixation with intramedullary rod
Bone graft
free vascularized fibular graft (Farmer's Procedure) I:20 Free vascularized fibular graft
Complications
Recurrent fracture : seen in 50% or more of patients even after initial union
Valgus deformity
Limb length discrepancy at skeletal maturity (average 5cm)
No treatment is considered to produce results in a predictable and acceptable fashion
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Tibial Bowing
Presentation
Symptoms
o presents at birth
Physical exam
o posteromedial bowing
apex of deformity is in the distal tibia
o calcaneovalgus foot deformity
apex of deformity is at the ankle
I:21 A, Photograph demonstrating calcaneovalgus deformity. Note that the
Imaging apex of the deformity is in the joint. B, Photograph demonstrating
posteromedial bowing of the tibia. Note that the apex of the deformity is in
Radiographs the tibia.
o recommended views
AP and lateral of tibia
o findings
will see posterior medial bowing
Treatment
Nonoperative
o observation
indications
observation is indicated for bowing deformity which usually spontaneously corrects over
5-7 years
make sure to follow clinically to monitor for leg length discrepancy
associated calcaneovalgus foot treated with observation and parental stretching
Operative
o age-appropriate epiphysiodesis of long limb
indications : projected leg length discrepancy
Complications
Leg length discrepancy
o patient may have residual 2-5 cm leg length discrepancy at maturity
o may require age-appropriate epiphysiodesis of long limb
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OrthoBullets2017 Pediatric Conditions | Tibial Bowing
5. Tibial Deficiency
Introduction
A longitudinal deficiency of the tibia with varying degrees of tibial absence
o previously known as tibial hemimelia
Genetics
o autosomal dominant inheritance pattern
obtain genetic counseling
Associated conditions
o musculoskeletal conditions present in 75% of patients
ectrodactyly
preaxial polydactyly
ulnar aplasia
Classification
Jones classification: types I- IV
1a: No proximal tibia visible on radiograph. Extensor mech absent. Hypoplastic distal femoral
epiphysis
1b- Proximal tibia eventually ossifies and extensor mechanism will function. Distal femoral epiphysis
appears normal
2- Proximal tibia present at birth but short tibia
3- diaphyseal and distal tibia present but proximal tibia absent
4- short tibia, fibula migrated proximal, diastasis of distal tib-fib joint
Alternate system is Kalamachi and Dawe (types 1-3)
Presentation
Physical exam
o deformity
shortening of the affected extremity
anterolateral bowing of the tibia
prominent fibular head
o ROM & stability
the knee is usually flexed with an associated knee flexion contracture
it is important to evaluate for active knee extension
check stability of the knee joint in all planes
treatment is based primarily on the stability of the knee joint
o foot deformity
there is often a rigid equinovarus and supination deformity of the foot
sole of foot faces perineum
Imaging
Radiographs
o recommended : AP and lateral tibia/fibula
o findings : show deficiency of the tibia
early radiographs may show small and minimally ossified distal femoral epiphysis
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Rotational Deformities
Treatment
Operative
o knee disarticulation followed by prosthestic fitting
indications
complete absence of the tibia
no active knee extension present (most cases)
o tibiofibular synostosis with modified Syme amputation
indications
proximal tibia present with intact extensor mechanism and minimal flexion contracture
o Syme/Boyd amputation
indications
ankle diastasis
o Brown Procedure (centralization of fibula under femur)
no longer recommended due to high failure rate
H. Rotational Deformities
1. Femoral Anteversion
Introduction
There are three main causes of intoeing including
o femoral anteversion (this topic)
o metatarsus adductus (infants)
o internal tibial torsion (toddlers)
Femoral anteversion is characterized by
o increased anteversion of the femoral neck relative to the femur
o compensatory internal rotation of the femur
o lower extremity intoeing
Epidemiology
o demographics
seen in early childhood (3-6 years)
twice as frequent in girls than boys
can be hereditary
o location
often bilateral : be cautious of asymmetric abnormalities
Pathophysiology
o a packaging disorders caused by intra-uterine positioning
o most spontaneously resolve by age 10
Associated conditions
o can be seen in association with other packaging disorders
DDH
metatarsus adductus
congenital muscular torticollis
Prognosis
o multiple studies have been unable to reveal any association with degenerative changes in the hip
and knee when increased anteversion persists into adulthood
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OrthoBullets2017 Pediatric Conditions | Rotational Deformities
Anatomy
Is based on degree of anteversion of femoral neck in relation to the femoral condyle
o at birth, normal femoral anteversion is 30-40°
o typically decreases to normal adult range of 15° by skeletal maturity
o minimal changes in femoral anteversion occur after age 8
Presentation
Symptoms
o parents complain of an intoeing gait in early childhood
o child classically sits in the W position (see above image)
I:23 decreased
o knee pain when associated with tibial torsion
external rotation
o awkward running style
o when extreme in an older child occasional functional limitations in sports and activities of daily
living can occur
difficulty with tripping during walking or running activities
o can be more symptomatic in those with neuromuscular diseases and brace-dependent walkers
secondary to lever-arm dysfunction and decreased compensatory mechanisms
Physical exam
o evaluation for intoeing
femoral anteversion
hip motion (tested in the prone position)
increased internal rotation of >70° (normal is 20-60°)
decreased external rotation of < 20° (normal 30-60°)
anteversion estimated on degree of hip IR when greater trochanter is most prominent
laterally
trochanteric prominence angle test
patella internally rotated on gait evaluation
tibial torsion
look at thigh-foot angle in prone position
normal value in infants- mean 5° internal (range, −30° to +20°)
normal value at age 8 years- mean 10° external (range, −5° to +30°)
metatarsus adductus
adducted forefoot deformity, lateral border should be straight
a medial soft-tissue crease indicates a more rigid deformity
evaluate for hindfoot and subtalar motion
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Rotational Deformities
Imaging
Radiographs
o recommended views
none required typically
CT or MRI
o may be useful in measuring actual anteversion
Treatment
Nonoperative
o observation and parental reassurance
indications
most cases usually resolve spontaneously by age 10
technique
bracing, inserts, PT, sitting restrictions do not change natural history
Operative
o derotational femoral osteotomy
indications
< 10° of external rotation on exam in an older child (>8-10 yrs)
rarely needed
technique
typically performed at the intertrochanteric level
amount correction needed can be calculated by (IR-ER)/2
Presentation
History
o commonly noticed once child begins walking
o parents report that the legs are "turning in"
o increased tripping and/or falling
Symptoms
o usually asymptomatic
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OrthoBullets2017 Pediatric Conditions | Rotational Deformities
Physical exam
o Foot progression angle directed internal
Product of hip rotation, tibial torsion and shape of foot.
measure angle between foot position and imaginary straight line while walking
normal is -5 to +20 degrees
o thigh-foot angle directed internal
technique
prone position
angle formed by a line bisecting the foot and line bisecting the thigh
normal values
infants- mean 5° internal (range, −30° to +20°)
age 8 years- mean 10° external (range, −5° to +30°)
o transmalleolar axis > 15 degrees internal
technique
Measure the angle formed by an line from the lateral to the medial malleolus, and a
second line from the lateral to the medial femoral condyles.
normal
average = 0 to -10 degrees internal rotation in childhood
abnormal = greater than 15 degrees internal rotation
Imaging
Radiographs
o usually not indicated unless other conditions present (see above)
Advanced imaging
o CT or MRI can be utlized for surgical planning (in the few cases that require surgery)
Differential
Causes of Intoeing
Condition Key findings
Tibial Torsion Thigh-foot angle > 10 degrees internal
Femoral Anteversion Internal rotation >70 degrees and < 20 degrees of external
rotation
Metatarsus Adductus Medial deviation of the forefoot (abnormal heel bisector), normal
hindfoot
In-toeing associated with the following necessitates further work-up
o pain
o limb length discrepancy
o progressive deformity
o family history positive for rickets/skeletal dysplasias/mucopolysaccharidoses
o limb rotational profiles 2 standard deviations outside of normal
Treatment
Nonoperative
o observation and parental education
indications : most cases
outcomes
usually resolves spontaneously by age 6
bracing/orthotics do not change natural history of condition
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Rotational Deformities
Operative
o indications
rarely required
child > 6-8 years of age with functional problems and thigh-foot angle >15 degrees
o derotational supramalleolar tibial osteotomy
associated with lower complications than proximal osteotomy
fixaton with plate or smooth K wires
intramedullary nail fixation if skeletally mature
Anatomy
Normal development
o tibia externally rotates on average 15 degrees during early childhood
o femoral anteversion decreases on average 25 degrees during this time as well
Presentation
Symptoms
o anterior knee pain
caused by patellofemoral malalignment
Physical Exam
o thigh-foot axis measurement
best way to evaluate tibial torsion
average during infancy is 5 degrees internal rotation, that slowly derotates
average at 8 years of age is 10 degrees external, ranging from -5 to +30 degrees
technique
lie patient prone with knee flexed to 90 degrees
thigh-foot-axis is the angle subtended by the thigh and the longitudinal axis of the foot
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OrthoBullets2017 Pediatric Conditions | Rotational Deformities
o transmalleolar axis measurement
another way to evaluate tibial torsion
average at infancy is 4-5 degrees internal rotation
average at adulthood is 23 degrees external (range 0-40 degrees external)
technique
lie patient supine
an imaginary line from medial malleolus to lateral malleolus and another imaginary
line from medial to lateral femoral condyle is made
the axis is the angle made at the intersection of these two lines
this helps to determine the direction and extent of tibial torsion present
Imaging
Usually none required.
Treatment
Nonoperative
o rest, rehab, and activity modifications
indications : first line of treatment
Operative
o supramalleolar derotational osteotomy or proximal tibial derotational osteotomy
indications
Surgery is reserved for children older than 8 years of age with external tibial torsion
greater than three standard deviations above the mean ( >40 degrees external).
more likely to require surgery than internal tibial torsion
Techniques
Supramalleolar rotational osteotomy
o technique
osteotomy
supramalleolar rotational osteotomy is most commonly performed
fibula is obliquely osteotomized if the deformity is severe
proximal tibial osteotomies are avoided secondary to higher risk factors associated with
this procedure
plate fixation
cross pin fixation or plate fixation
intramedullary fixation
IM fixation with rotational osteotomy is reserved for skeletally mature adolescents
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Rotational Deformities
4. Metatarsus Adductus
Introduction
Adduction of forefoot (at tarsometatarsal joint) with normal hindfoot alignment
o mechanism thought to be related to packaging disorder caused by intra-uterine positioning
Epidemiology
o incidence
occurs in approximately 1 in 1,000 births
equal frequency in males and females
bilateral approximately 50% of cases
o increased incidence in
late pregnancy
first pregnancies
twin pregnancies
oligohydramnios
o associated conditions
DDH (15-20%)
torticollis
Prognosis
o long-term studies show that residual metatarsus adductus is not related to pain or decreased foot
function
o associated with late medial cuneiform obliquity (not hallux valgus)
Serpentine Foot (complex skew foot)
o a condition that can be considered on the axis of severity of metatarsus adductus
o residual tarsometatarsal adductus, talonavicular lateral subluxation, and hindfoot valgus
o different from metatarsus adductus in that nonoperative treatment and casting are ineffective at
correcting deformity
Presentation
Symptoms : parents complain of intoeing, usually in first year of life
Physical exam
o tickling to foot can allow evaluation of active correction
o evaluation for intoeing
metatarsus adductus
forefoot is adducted
lateral foot border is convex instead of straight
a medial soft-tissue crease indicates a more rigid deformity
normal hindfoot and subtalar motion
femoral anteversion
hip motion shows >70° internal rotation (normal is 30-60°)
and decreased external rotation
patella internally rotated
tibial torsion
observe foot-thigh angle in prone position
> 10° of internal rotation is indicative of tibial torsion (normal is 0-20° of external
rotation)
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OrthoBullets2017 Pediatric Conditions | Rotational Deformities
Classification
Bleck classification by heel bisector method (Beck, JPO 1983)
o normal - heel bisector line through 2nd and 3rd toe webspace
o mild - heel bisector line through 3rd toe
o moderate - heel bisector through 3rd and 4th toe webspace
o severe - heel bisector through 4th and 5th toe webspace
Berg classification
Berg Classification
Simple MTA MTA
Complex MTA MTA, lateral shift of midfoot
Skew foot MTA, valgus hindfoot
Complex skew foot (serpentine foot) MTA, lateral shift, valgus hindfoot
Imaging
Radiographs
o only indicated in older children
Differential diagnosis
Causes of Intoeing
Condition Key findings
Internal Tibial Torsion Thigh-foot angle < -10 degrees
Femoral Anteversion Internal rotation >70 degrees and < 20 degrees of external
rotation (tested in prone position)
Metatarsus Adductus Medial deviation of the forefoot with normal alignment of the
hindfoot
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By Dr, AbdulRahman AbdulNasser Pediatric Conditions | Rotational Deformities
Treatment
Nonoperative
o a benign condition that resolves spontaneously in 90% of cases by age 4
o another 5% resolve in the early walking years (age 1-4 years)
corrected to midline
Flexible deformities that can passively be Serial stretching by parents at home
corrected to midline
Serial casting with the goal of obtaining a
Rigid deformity with medial crease straight lateral border of foot
Operative
o metatarsus adductus
tarsometatarsal capsulotomies
indications
aged 2-4yr with failed nonop management
lateral column shortening and medial column opening osteotomies, multiple metatarsal
osteotomies
indications
age > 5yrs (as the deformity may correct with growth until this age)
resistant cases that fail nonoperative treatment (usually with medial skin crease)
severe deformity produces difficulty with shoeware and pain
technique
lateral column shortening done with cuboid closing wedge osteotomy
medial column lengthening includes a cuneiform opening wedge osteotomy with
medial capsular release and abductor hallucis longus recession (for atavistic first toe)
o serpentine foot
opening wedge and closing wedge osteotomies
indications
indicated if serpentine deformity is symptomatic and significantly limits function
operative treatment is difficult and often times deformity is accepted and observed
technique
calcaneal osteotomy for hindfoot valgus
possible midfoot osteotomies to correct midfoot and forefoot deformities
multiple metatarsal osteotomies with forefoot pinning and tarsometatarsal capsular
release (Hamen procedure)
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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OrthoBullets2017 Pediatric Foot | Rotational Deformities
ORTHO BULLETS
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Cavus Deformities
A. Cavus Deformities
Anatomy
Muscles contractures lead to the characteristic deformity that includes (CAVE)
o midfoot Cavus (tight intrinsics, FHL, FDL)
o forefoot Adductus (tight tibialis posterior)
o hindfoot Varus (tight tendoachilles, tibialis posterior, tibialis anterior)
o hindfoot Equinus (tight tendoachilles)
Bony deformity consists of
o talar neck is medially and plantarly deviated
o calcaneus is in varus and rotated medially around talus
o navicular and cuboid are displaced medially
Table of foot deformity muscle imbalances ( see below)
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OrthoBullets2017 Pediatric Foot | Cavus Deformities
Simple Deformities
Deformity Strong Muscle Weak Muscle
equinus gastrocnemius-soleus complex dorsiflexors
cavus plantar fascia, intrinsics dorsiflexors
varus posterior tibialis and anterior tibialis peroneal brevis
supination anterior tibialis peroneus longus
flatfoot peroneus brevis posterior tibialis
Complex Deformities
equinovarus + gastroc-soleus complex, posterior tibialis, peroneus brevis & longus
supination anterior tibialis
equinovalgus gastroc-soleus complex, peroneals posterior tibialis, anterior
tibialis
calcaneovalgus foot dorsiflexors/evertors (L4 and L5) plantar flexors /inverters
(S1 and S2)
Presentation
Physical exam
o inspection
small foot and calf
shortened tibia
medial and posterior foot skin creases
foot deformities
hindfoot in equinus and varus
differentiated from more common positional foot deformities by rigid equinus and
resistance to passive correction
midfoot in cavus
forefoot in adduction
Imaging
Radiographs
o recommended views
dorsiflexion lateral (Turco view)
shows hindfoot parallelism between the talus and calcaneus
will see talocalcaneal angle < 35° and flat talar head (normal is talocalcaneal angle >35°)
AP
talocalcaneal (Kite) angle is < 20° (normal is 20-40°)
talus-first metatarsal angle is negative (normal is 0-20°)
also shows hindfoot parallelism
Ultrasound
o helpful in prenatal diagnosis (high false positive rate)
o can be diagnosed as early as 12 weeks of gestational age
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Cavus Deformities
The dorsiflexion lateral radiograph shows 25-year-old man with a unilateral The clubfoot is diagnosed by ultrasound in
hindfoot parallelism between the talus and right clubfoot. Standing utero when there is persistent medial
calcaneus characteristic of clubfoot anteroposterior radiograph of deviation and equinus of the foot relative
deformity both feet shows an AP to the tibia.
talocalcaneal angle measurement
of 25° on the left and 15° on the
right.
Treatment
Nonoperative
o serial manipulation and casting (Ponseti method)
indications
there has been a trend away from surgery and
towards the nonoperative Ponseti method due to
improved long term results
outcomes
Ponseti method has 90% success rate
Operative
o posteromedial soft tissue release and tendon
lengthening
indications
resistant feet in young children
"rocker bottom" feet that develop as a result of
serial casting
syndrome-associated clubfoot
delayed presentation >1-2 years of age
performed at 9-10 months of age so the child can be ambulatory at one year of age
outcomes
requires postoperative casting for optimal results
extent of soft-tissue release correlates inversely with long-term function of the foot and
patient
o medial column lenthening or lateral column-shortening osteotomy, or cuboid
decancellation : older children from 3 to 10 years
o triple arthrodesis
indications
in refractory clubfoot at 8-10 years of age
contraindicated in insensate feet due to rigidity and resultant ulceration
o talectomy
indications
salvage procedure in older children (8-10 yrs) with an insensate foot
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o multiplanar supramalleolar osteotomy
indications
salvage procedure in older children with complex, rigid, multiplanar clubfoot deformities
that have failed conventional operative management
o gradual correction by means of ring fixator (Taylor Spatial Frame) application
complex deformity resistant to standard methods of treatment
Techniques
Serial manipulation and casting (long leg cast)
o goal is to rotate foot laterally around a fixed talus
o order of correction (CAVE)
midfoot cavus
forefoot adductus
hindfoot varus
hindfoot equines
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Cavus Deformities
Ponseti Method
Month Weekly serial casting (with knee • First correct cavus with forefoot SUPINATED (NOT pronation)
1-4 in 90° of flexion ) with forefoot by aligning the plantar-flexed 1st MT with the remaining
supination, then forefoot metatarsals (forcible pronation would increase cavus deformity
abduction as the 1st MT is plantar-flexed further)
• Secondly correct adduction and heel varus by rotating
calcaneus and forefoot around talus (head of talus acts as a
fulcrum) into forefoot ABDUCTION
Tendoachilles lengthening • Equinus correction last with tendinoachilles lengthening (TAL)
(TAL) at week 8 required in 80% • Perform when foot is 70° abducted and heel is in valgus
• Ponseti method uses a complete transverse cut of achilles
• Cast in maximal dorsiflexion after TAL
Month Foot abduction orthosis (FAO) • With Denis-Brown bar in external rotation (70° in clubfoot and
4-8 • 23 hours a day for 3 months 40° in normal foot)
after correction • Fit FAO on day of TAL
• night time/nap time only until
age 4 years
2-4 Tibialis anterior tendon transfer • 10-20% will need TA transfer with or without repeat TAL for
years (TA transfer) at 2 yrs of age (10- recurrent supination, varus, and/or equinus
20% will require) • Indicated if the patient demonstrates supination of the foot
during dorsiflexion (a dynamic intoeing gait)
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this causes lateral rotation of navicular, together w/ cuboid & anterior aspect of
calcaneus, w/o pronation of foot;
o to correct the varus and adduction, the foot in supination is abducted while counter pressure
is applied with the thumb against the head of the talus;
foot is abducted in flexion and slight supination to stretch the medial tarsal ligaments,
while counter pressure applied on the lateral aspect of the head of the talus;
this allows the calcaneus to abduct under the talus which correction of the heel varus;
heel must not be touched during this manipulation;
o calcaneus abducts by rotating and sliding under the talus;
noted that the calcaneus can evert only when it is abducted (laterally rotated) under the
talus.
as the calcaneus abducts it simultaneously extends and everts which corrects the heel
varus;
note that the calcaneus cannot evert unless it is abducted;
o casting involves a toe-to-groin plaster cast w/ knee flexed 90 degrees and the foot in
maximum external rotation;
maintenance of correction of varus deformity of hind part of foot which requires external
rotation of foot distal to talus;
o radiographs may be taken at this point inorder to confirm that the talonavicular joint is
reduced, prior to managing equinus;
cautions:
o avoid forced external rotation of the foot to correct adduction while the calcaneus is in varus;
this causes a posterior displacement of the lateral malleolus by externally rotating the
talus in the ankle mortice.
o avoid abducting the foot against pressure at the calcaneocuboid joint the abduction of the
calcaneus is blocked, thereby interfering with correction of the heel varus.
correction of equinus:
o equinus is corrected last, by dorsiflexion of foot w/ heel in valgus angulation;
o if foot is dorsiflexed prior to correction of the hindfoot varus, rocker bottom foot may be
created;
o equinus is corrected by dorsiflexing the fully abducted foot;
o correction entails stretching of the tight posterior capsules and ligaments of ankle and
subtalar joints and the tendo achillis;
o lateral x-ray are helpful in assessing quality of cast correction;
o percutaneous tenotomy of the achillis tendon:
may be necessary inorder to avoid rocker bottom deformity;
dorsiflexion of ankle to > 10 to 15 degrees is rarely possible because of talar and
calcaneal malformations and tight ligaments;
o cautions:
care should be taken not to cause a rocker-bottom deformity, which can occur when
dorsiflexion of foot is attempted w/ pressure under metatarsals rather than under the mid-
part of foot, particularly when varus deformity of heel has not been corrected;
do not to exert excessive upward force on metatarsals, because this can result in midfoot
break (rocker-bottom deformity);
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Cavus Deformities
Complications:
1. increased cavus deformity;
2. rocker-bottom deformity;
3. longitudinal breach
4. flattening of the proximal surface of the talus
5. lateral rotation of the ankle
6. increased stiffness of the ligaments and joints;
7. recurrence: Ponsetti advocates use of shoes attached to a bar in external rotation for three
months full-time and at night for 2-4 years Source: wheelessonline.com
French Method
Correction • Daily corrective • Begin with derotation of the calcaneopedal block and correction
Phase manipulations of the of forefoot adduction through massage of the Achilles tendon
clubfoot are performed by and gastrocnemius muscle
an experienced physical
therapist and the correction • Next, medial soft tissues are stretched to allow the navicular to
is held with elastic move away from the medial malleolus and its medial position on
taping and splints until the the head of the talus. Distraction of the forefoot and midfoot
next day's session. helps to loosen the tightened structures, and derotation of the
foot facilitates reduction of the talus
• Family participation is
integral to the success of • To maintain the gain achieved in passive range of motion, the
this treatment program as toe extensors and peroneals are recruited by stimulating
the family must be able to (tickling) the lateral border of the foot and leg and the tops of the
bring the infant to therapy toes
during the week for 1-3
months • Once the talonavicular joint has been reduced, attention is
directed toward the correction of varus and equinus. With the
• Each session lasts valgus maneuver, the calcaneus gradually moves to a neutral
approximately 30 mins per and eventually valgus position. The ankle is externally rotated at
foot and manipulations are the same time that the calcaneus is being mobilized into valgus.
performed in a progressive The knee should be kept at 90° during these maneuvers
gentle pattern
• Equinus is corrected with gradual dorsiflexion of the foot.
Correction of equinus can be augmented with a percutaneous
heel cord tenotomy
Maintenance • Fewer visits to the • Periodic follow-up is needed to monitor the range of motion of
Phase therapist are needed as the the foot and the development of the infant and to fabricate new
parents assume the daily splints
treatment exercises and
taping • Once the patient is walking, taping is discontinued and a
resting ankle-foot orthosis is used during nighttime and naps
until the age of two years.
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Complications
Complications with nonoperative treatment
o deformity relapse
relapse in child < 2 years
early relapse usually the result of noncompliance with FAO
treat with repeat casting
relapse in child > 2 years
treat initially with casting
consider tibialis anterior tendon transfer to lateral cuneiform (can only perform if lateral
cuneiform is ossified)
consider repeat Achilles tendon lengthening
o dynamic supination
treat with whole anterior tibial tendon transfer (preferred in OITE question over split anterior
tibial tendon transfer)
Complications with surgical treatment
o residual cavus
result of placement of navicular in dorsally subluxed
position
o pes planus
results from overcorrection
o undercorrection
o intoeing gait
o osteonecrosis of talus II:4 Dorsal bunion
results from vascular insult to talus resulting in osteonecrosis and collapse
o dorsal bunion
caused by dorsiflexed first metatarsal (FHB and abductor hallucis overpull secondary to weak
plantar flexion) and overactivity of anterior tibialis
treat with capsulotomy, FHL lengthening, and FHB flexor to extensor transfer at MTP joint
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Cavus Deformities
Associated conditions
o orthopaedic
Charcot-Marie-Tooth
Freidreich's ataxia
Cerebral palsy
Polio
spinal cord lesions
Prognosis
o depends on severity and etiology
o full neurologic workup is mandatory
Presentation
Symptoms
o painful calluses under head of 1st metatarsal, 5th metatarsal, and medial heel due to plantar
flexed first ray
Physical exam
o Coleman block test
helps guide treatment
evaluates flexibility of hindfoot
by putting block under lateral foot you eliminate the contribution by the first ray
a first ray that is overly flexed can contribute to a varus deformity
flexible hindfoot will correct to neutral or valgus when block placed under lateral aspect of
foot
a rigid hindfoot will not correct into neutral
o always remove shirt and look for spinal dysraphism
Treatment
Nonoperative
o full-length semi-rigid insole orthotic with a depression for the first ray and a lateral wedge
indications
mild cavus foot deformities in adults
nonoperative management usually not effective in treatment of more severe pediatric
cavus deformities
Operative
o plantar fascia release, posterior tibial tendon transfer, tendoachilles lengthening (TAL),
and +/- 1st metatarsal dorsiflexion osteotomy
indications
flexible hindfoot cavus deformities (normal Coleman block test)
surgical intervention should be delayed until progression of the deformity begins to cause
symptoms and/or weakness of the muscular units resulting in contractures of the
antagonistic muscle units.
technique
+/- transfer posterior tibialis to dorsum of foot to improve foot drop (augment weak
tibialis anterior)
+/- transfer of peroneus longus to brevis
+/- lateral ankle ligament reconstruction (e.g. Broström ligament reconstruction)
dorsiflexion 1st metatarsal osteotomy sometimes performed
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1st metatarsal osteotomy and transfer of EHL to neck of 1st MT when hallux
clawing combined with cavus foot
o calcaneal valgus producing osteotomy
indications
rigid hindfoot cavus deformities (abnormal Coleman block test)
technique
combine with soft tissue procedure discussed above, and
dorsiflexion 1st metatarsal osteotomy
o triple arthrodesis
indications
severe rigid deformities
may be helpful in select cases but is falling out of favor
3. Equinovarus Foot
Introduction
Epidemiologyincidence
o common foot deformity seen with
cerebral palsy (usually spastic hemiplegia)
Duchenne muscular dystrophy
residual clubfoot deformity
tibial deficiency (hemimelia)
Pathophysiology
o pathomechanics
spasticity of
tibialis posterior and/or tibialis anterior
gastoc-soleus complex
absence of ligamentous laxity
o foot deformity muscle imbalance overview
Presentation
Symptoms
o painful weight bearing over the lateral border of the foot
o instability during stance phase
o poor shoe fitting and shoe wear problems
Physical Exam
o inspection
intoed gait
inverted heel (tib post)
supinated forefoot (tib ant)
callous and pain along lateral border
o provocative tests
confusion test
helps to distinguish TA vs TP as the primary muscle involved
patient performs active hip flexion against resistance while seated
in a positive confusion test, the tibialis anterior fires with active hip flexion and is
typical in patients with CP
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Cavus Deformities
if the foot supinates with dorsiflexion, tibialis anterior is most likely contributing
to the equinovarus deformity
Imaging
Radiographs
o recommended views
AP + lateral of ankle
o findings
forefoot adduction is seen on the AP radiograph
stress fractures along the base of the fifth metatarsal can develop
secondary to repetitive load along the lateral border of the foot.
Studies
EMG II:5 Adduction deformity of
the forefoot. A stress fracture
o useful in distinguishing whether tibialis anterior or tibialis posterior is
(white arrow) of the base of
causing the varus the fifth metatarsal has
developed
Treatment
Nonoperative
o AFO / serial casting / botulinum toxin injection into tibialis posterior and gastrocnemius
indication
flexible or dynamic deformities
Operative
o TAL with split-posterior tibialis tendon transfer [SPOTT]
indications
spastic hemiplegia in patient ages 4 to 7
flexible equinovarus hindfoot
tibialis posterior spastic in both stance and swing phase (continous activity)
technique
reroute half of tendon dorsally and insert into peroneus brevis
o split-anterior tibialis tendon transfer [SPLATT]
indications
overactive anterior tibialis
flexible equinovarus deformity
technique
split anterior tibialis transfer to cuboid with TAL and intramuscular lengthening of the
posterior tibial tendon
o calcaneal osteotomy
indications
is required in a rigid hindfoot varus deformity
technique
lateral closing wedge osteotomy to incur valgus to the heel
Complications
Overcorrection (resultant valgus deformity)
o increased risk in
children who undergo surgery at younger age
children with diplegia (as oppose to hemiplegia)
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4. Equinovalgus Foot
Introduction
Epidemiologyincidence
o common foot deformity seen with
cerebral palsy (spastic diplegic and quadriplegic)
fibular hemimelia
o body location
typically bilateral
Pathophysiology
o deformities
midfoot abduction
hindfoot valgus
equinus contracture
o muscle imbalances
spasticity of
peroneals
gastoc-soleus complex
weakness of
ligamentous laxity
posterior tibialis
anterior tibialis
o pathomechanics
creates lever arm dysfunction during gait and ankle rocker function
patient is bearing weight on the medial border of the foot and talar head
external rotation of the foot creates instability during push off
Presentation
Symptoms
o painful callus over talar head secondary to weightbearing
o shoe wear problems
Physical exam
o inspection
typically seen bilaterally
valgus heel deformity seen when viewing feet from posterior II:6 Weight-bearing lateral radiograph
of a patient with equinovalgus foot
prominent talar head appreciated in the arch deformity.
compensatory midfoot supination is typically seen
midfoot break occurs in attempt to keep foot plantigrade
hallux valgus typically develops over time
o motion
the hindfoot valgus deformity must be manually corrected first before testing for achilles
contracture
a valgus heel can mask an equinus contracture by allowing a shortened path for the
Achilles
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Cavus Deformities
Imaging
Radiographs
o recommended views
weight-bearing AP radiographs of the ankles must be obtained to rule out ankle valgus as
cause of deformity
o findings
collapse of the medial longitudinal arch as seen by a decrease in the calcaneal pitch.
talus tilted inferiorly
Treatment
Nonoperative
o bracing and physical therapy
indications
flexible deformities
technique
ankle foot orthosis or supramalleolar orthosis
o botox injections
indications
flexible deformities with mild spasticity
delays need for surgery II:7 Pre- and post-operative images following
Operative subtalar arthroeresis
Techniques
Calcaneal osteotomy with soft tissue procedure
o soft tissue procedures
TAL
peroneus brevis lengthening
o bony procedures
calcaneal osteotomy
medial slide osteotomy or calcaneal lengthening osteotomy
lateral column lengthening procedure
performed through calcaneus or cuboid
Grice procedure
extra-articular subtalar arthrodesis via a lateral approach
place ICBG in lateral subtalar joint to block valgus
does not interfere with tarsal bone growth
subtalar arthroereisis
stabilizes subtalar joint in correct alignment without fusion
implant or spacer is placed laterally in the subtalar joint to prop open
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Complications
Overcorrection (resultant varus deformity)
o most common complication
Sural nerve injury
o at risk during calcaneal osteotomy procedures
Overlengthening of lateral column
o results in a painful lateral forefoot secondary to overload
B. Planus Deformity
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Planus Deformity
due to contracture of the Achilles and peroneal tendons
rigid midfoot dorsiflexion
secondary to the dislocated navicular
forefoot abducted and dorsiflexed
due to contractures of the EDL, EHL and tibialis anterior tendons
o prominent talar head
can be palpated in medial plantar arch on exam
produces a convex plantar surface
o gait abnormality
patient may demonstrate a "peg-leg" or a calcaneal gait due to poor push-off power
limited forefoot contact, excessive heel contact
o neurologic deficits
a careful neurologic exam needs to be performed due to frequent association with
neuromuscular disorders
Imaging
Radiographs
o recommended views : AP, oblique and lateral foot
o findings
lateral
vertically positioned talus & dorsal dislocation of navicular
line in long axis of talus passes below the first metatarsal-cuneiform axis
before ossification of navicular at age 3, the first metatarsal is used as a proxy for
the navicular on radiographic evaluation
AP : talocalcaneal angle > 40° (20-40° is normal)
o alternative views
forced plantar flexion lateral radiograph is diagnostic
shows persistent dorsal dislocation of the talonavicular joint
oblique talus reduces on this view
Meary's angle > 20° (between line of longitudinal axis of talus and longitudinal axis
of 1st metatarsal)
forced dorsiflexion lateral
reveals fixed equinus
MRI
o neuraxial imaging should be performed to rule out neurologic disorder
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Differential Diagnosis
Oblique talus
o reduces with forced plantar flexion
o treatment is observation vs casting
Calcaneovalgus foot deformity
Tarsal coalition
Paralytic pes valgus
Pes planovalgus
II:9 Surgical release and talonavicular
Treatment reduction and pinning
Nonoperative
o serial manipulation and casting for three months
indications
indicated preoperatively to stretch the dorsolateral soft-tissue structures
typically followed by surgical release and pinning of the talonavicular joint with
percutaneous achilles tenotomy
Operative
o surgical release and talonavicular reduction and pinning
indications
indicated in most cases
performed at 12-18 months of age
technique
involves pantalar release with concomitant lengthening of peroneals, Achilles, and toe
extensors
talonavicular joint is reduced and pinned while reconstruction of the plantar
calcaneonavicular (spring) ligament is performed
concomitant tibialis anterior transfer to talar neck
o minimally invasive correction
indications
new technique performed in some centers to avoid complications associated with
extensive surgical releases
technique
principles for casting are similar to the Ponseti technique used clubfoot
serial casting utilized to stretch contracted dorsal and lateral soft tissue structures and
gradually reduced talonavicular joint
once reduction is achieved with cast, closed or open reduction is performed and secured
with pin fixation
percutaneous achilles tenotomy is required to correct the equinus deformity
o talectomy
indicated in resistant case
o triple arthrodesis
as salvage procedure
Complications
Missed vertical talus
o reconstructive options are less predictable after age 3, and patients may require triple arthrodesis
as salvage procedure
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Planus Deformity
2. Calcaneovalgus Foot
Introduction
A soft tissue contracture foot deformity characterized by excessively dorsiflexed hindfoot
o hindfoot valgus
o no dislocation or bony deformity
Etiology
o usually a positional deformity caused by intrauterine "packaging"
Epidemiology
o more common in females and first born children
Similar or related conditions
o posteromedial tibial bowing
calcaneovalgus foot is often confused with posteromedial tibial bowing, another condition
caused by intrauterine positioning
calcaneovalgus foot is USUALLY accompanied by posteromedial bowing of the tibia
o vertical talus
clinically it looks similar to vertical talus but you can differentiate on physical exam and with
plantar flexion radiographs
o paralytic foot deformity
deformity is caused by
spasticity of
foot dorsiflexors (L4 and L5)/evertors (S1)
weakness of
plantar flexors (S1 and S2) /inverters (L5)
this muscle imbalance can be caused by an L5 spinal
bifida, which is a one cause of this deformity
Presentation
Physical exam
o excessively dorsiflexed hindfoot that is passively correctable to neutral
dorsal surface of foot rests on anterior tibia
o looks similar to vertical talus
differs on exam in that vertical talus has a rigid hindfoot equinus/valgus and rigid
dorsiflexion through midfoot
Imaging
Radiographs
o AP and lateral tibia : used to determine presence of posteromedial bowing
o plantar flexion radiographs
useful to differentiate from vertical talus
before ossification of navicular at age 3, the first metatarsal is used as a proxy for the
navicular on radiographic evaluation
calcaneovalgus foot
first metatarsal will line up with talus with calcaneovalgus foot
vertical talus
the axis of the talus is plantar to the 1st metatarsal (and navicular if visible yet) on
both standard lateral and plantar flexion lateral radiographs
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Treatment
Nonoperative
o observation & passive stretching exercises
typically resolves spontaneously
resolution may be expedited by stretching performed by parents
Complications
Leg Length Discrepancy
o LLD a possible complication when associated with posteromedial bowing of the tibia
3. Tarsal Coalition
Introduction
Structural anomaly between two or three tarsal bones causing a rigid flatfoot
o two types
congenital : most common
acquired : less common and caused by
trauma
degenerative
infections
Epidemiology
o demographics
age of onset
calcaneonavicular usually 8-12 years old
talocalcaneal usually 12-15 years old
o prevalence : varies from 1%-2%
o location
calcaneonavicular (most common)
talocalcaneus
Pathophysiology
o embryology
failure of mesenchymal segmentation leading to coalition between two or three tarsal bones
develops into a fibrous coalition, or undergoes metaplasia to cartilage +/- bone
o pathoanatomy
gait mechanics
subtalar joint will normally rotate 10 degrees internally during stance phase
in presence of coalition, internal rotation does not occur
deformity
flattening of longitudinal arch
abduction of forefoot
valgus hindfoot
peroneal spasticity (also known as peroneal spastic flatfoot)
pain generator theories
ossification of previously fibrous or cartilaginous coalition
microfracture at coalition bone interface
secondary chondral damage or degenerative changes
increased stress on other hindfoot joints
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Planus Deformity
Associated conditions
o nonsyndromic : autosomal dominant
o syndromic
fibular hemimelia
carpal coalition
FGFR-associated craniosynostosis (FGFR-1, FGFR-2, FGFR-3)
Apert syndrome, Pfeiffer, Crouzon, Jackson-Weiss and Muenke
Classification
Anatomic classification
o calcaneonavicular
between calcaneus and navicular bones (most common)
o talocalcaneal
middle facet of talocalcaneal joint
Pathoanatomic classification
o 3 types
fibrous coalition (syndesmosis)
cartilagenous coalition (synchondrosis)
osseous coalition (synostosis) II:10 hindfoot valgus
Presentation
History
o history of prior recurrent ankle sprains
Symptoms
o asymptomatic
most coalitions are found incidentally
75% of people are asymptomatic
o pain
location of pain
sinus tarsi and inferior fibula suggests calcaneonavicular
distal to medial malleolus or medial foot suggests talocalcaneal
pain worsened by activity
onset of symptoms correlates with age of ossification of coalition
calf pain
secondary to peroneal spasticity
Physical exam
o inspection
hindfoot valgus
forefoot abduction
pes planus
o range of motion
limited subtalar motion
heel cord contractures
arch of foot does not reconstitute upon toe-standing
hindfoot remains in valgus (does not swing into varus) upon toe-standing
o special tests
reverse Coleman block test : evaluate for subtalar rigidity
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OrthoBullets2017 Pediatric Foot | Planus Deformity
Imaging
Radiographs
o recommended views
required
anteroposterior view
standing lateral foot view
45-degree internal oblique view
most useful for
calcaneonavicular coalition
Harris view of heel
o findings
calcaneonavicular coalition
"anteater" sign II:11 Size of tarsal coalition relative to
posterior facet
elongated anterior process of calcaneus
talocalcaneal coalition
talar beaking on lateral radiograph
occurs as a result of limited motion of the subtalar joint
irregular middle facet joint on Harris axial view
c-sign
c-shaped arc formed by the medial outline of the talar dome and posteroinferior aspect
of the sustentaculum tali
dysmorphic sustentaculum
appears enlarged and rounded
CT scan
o necessary to
rule-out additional coalitions
incidence approx. 5%
determine size, location and extent of coalition
size of talocalcaneal coalition based on size of posterior facet using coronal slices
MRI
o may be helpful to visualize a fibrous or cartilaginous coalition
o STIR sequences help to differentiate inflammatory changes (e.g. tendinitis) in local structures
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Planus Deformity
CT scan
Treatment
Nonoperative
o observation, shoe inserts
indications
incidental finding or asymptomatic flatfoot patients
techniques
medial arch support and preserved hindfoot alignment
outcomes
75% of cases are asymptomatic
o immobilization with casting, analgesics
indications
initial treatment for symptomatic cases
techniques : below-knee walking cast for six-weeks
outcomes
approximately 30% of symptomatic patients will become pain-free with a short period of
immobilization
Operative
o coalition resection with interposition graft, +/- correction of associated foot deformity
indications
persistent symptoms despite prolonged period of nonoperative management
coalition involves <50% of joint surface area
techniques
open vs arthroscopic coalition resection
interposition material
extensor digitorum brevis (calcaneonavicular coalition)
split flexor hallucis longus tendon (talocalcaneal coalition)
interposed fat graft
bone wax
correction of associated hindfoot, midfoot or forefoot deformities
calcaneal osteotomy for hindfoot valgus
heel cord lengthening if intraoperative ankle dorsiflexion is not past neutral
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outcomes
80-85% will experience pain relief
poor outcomes
coalition resection >50% size of joint surface area
uncorrected hindfoot valgus
associated degenerative changes
o subtalar arthrodesis
indications
role has not been well established
consider if coalition involves >50 % of the joint surface of a talocalcaneal coalition
technique
open vs. arthroscopic
consider an associated calcaneal osteotomy with severe hindfoot malalignment
o triple arthrodesis (subtalar, calcaneocuboid, and talonavicular)
indications
advanced coalitions that fail resection
diffuse associated degenerative changes affecting calcaneocuboid and talonavicular joints
technique
open vs. arthroscopic
Surgical Techniques
Calcaneonavicular coalition resection
o approach
lateral or sloppy lateral position
anterolateral approach over coalition
o incision
oblique incision just distal to subtalar joint
between extensor tendons and peroneal tendons
o technique
protect branches of superficial peroneal and sural nerves
reflect fibrofatty tissues in sinus tarsi anterior and extensor digitorum brevis distally
identify coalition between anterior process of calcaneus and navicular bones and confirm
with fluorscopy
excise bar with saw or osteotomes, which leaves defect ~1cm in size
interpose fat, bone wax or portion of extensor digitorum brevis muscle into defect
o post-operative
short-leg, non-weight bearing cast for 3-4 weeks
Talocalcaneal coalition resection
o approach
positioned supine
medial approach to hindfoot
o incision
horizontal or curved incision centered over sustentaculum tali
between flexor digitorum longus and neurovascular bundle
o technique
sustentaculum tali usually just plantar to the talocalcaneal coalition
identify normal subtalar joint cartilage by dissecting out the anterior and posterior facets
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Planus Deformity
this will help determine location and size of coalition resection
confirm with two needles immediately anterior and posterior to coalition clinically
and confirm with fluorscopy
resect coalition with high speed-burr, ronguers and curettes
invert and evert subtalar joint to demonstrate improvement in subtalar motion
interpose fat, bone wax or portion of flexor hallucis longus tendon into defect
o post-operative
short-leg non-weight bearing cast for three weeks
Complications
Incomplete resection
Recurrence of the coalition
Residual pain or stiffness
o due to malalignment or associated arthritis
Classification
Hypermobile flexible pes planovalgus (most common)
o familial
associated with generalized ligamentous laxity and lower extremity rotational problem
usually bilateral
o associated with an accessory navicular
correlation is controversial
Flexible pes planovalgus with a tight heel cord
Rigid flatfoot & tarsal coalition (least common)
o no correction of hindfoot valgus with toe standing due limited subtalar motion
Presentation
Symptoms
o usually asymptomatic in children
o may have arch pain or pretibial pain
Physical exam
o inspection
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foot is only flat with standing and reconstitutes with toe walking, hallux dorsiflexion, or foot
hanging
valgus hindfoot deformity
forefoot abduction
o motion
normal and painless subtalar motion
hindfoot valgus corrects to a varus position with toe standing
evaluate for decreased dorsiflexion and tight heel cord
Imaging
Radiographs
o indications
painful flexible flatfoot to rule out other mimicking conditions
tarsal coalition (sinus tarsi pain)
congenital vertical talus (rocker bottom foot)
accessory navicular (focal pain at navicular)
rigid flatfoot
o recommended views
required
weightbearing AP foot
evaluate for talar head coverage and talocalcaneal
angle
weightbearing lateral foot
evaluate Meary's angle
weightbearing oblique foot
II:12 Meary's angle
rule out tarsal coalition
optional
plantar-flexed lateral of foot
rules out vertical talus with a line through the long axis of the talus passing above the
first metatarsal axis
AP and lateral of the ankle
if concerned that hindfoot valgus may actually be ankle valgus (associated
with myelodysplasia)
o findings
Meary's angle will be apex plantar
angle subtended from a line drawn through axis of the talus and axis of 1st ray
Differential
Tarsal coalition
Congenital vertical talus
Accessory navicular
Treatment
Nonoperative
o observation, stretching, shoewear modification, orthotics
indications
asymptomatic patients, as it almost always resolves spontaneously
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Planus Deformity
counsel parents that arch will redevelop with age
techniques
athletic heels with soft arch support or stiff soles may be helpful for symptoms
orthotics do not change natural history of disease
UCBL heel cups may be indicated for symptomatic relief of advanced cases
rigid material can lead to poor tolerance
stretching for symptomatic patients with a tight heel cord
Operative
o Achilles tendon or gastrocnemius fascia lengthening
indications
flexible flatfoot with a tight heelcord with painful symptoms refractory to stretching
o calcaneal lengthening osteotomy (with or without cuneiform osteotomy)
indications
continued refractory pain despite use of extensive conservative management
rarely indicated
technique
calcaneal lengthening osteotomy (Evans)
with or without a cuneiform osteotomy and peroneal tendon lengthening
sliding calcaneal osteotomy
corrects the hindfoot valgus
plantar base closing wedge osteotomy of the first cuneiform
corrects the supination deformity
5. Accessory Navicular
Introduction
Epidemiology
o incidence
accessory navicular is a normal variant seen in up to 12% of population
majority of patients are asymptomatic
o demographics
more commonly symptomatic in females
Pathophysiology
o pathoanatomy
occurs as a plantar medial enlargement of the navicular bone
exists as accessory bone or as completely ossified extension of the navicular
Genetics
o inheritance pattern
autosomal dominant
Associated conditions
o flat feet
o posterior tibial tendon insufficiency
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OrthoBullets2017 Pediatric Foot | Planus Deformity
Anatomy
Osteology
o navicular bone normally has a single center of ossification
ossifies at age 3 in girls and 5 in boys and fuses at 13 years of age
o an accessory navicular is a normal variant from which the tuberosity of the navicular develops
from a secondary ossification center that fails to unite during childhood
the accessory navicular does not begin to ossify prior to age 8
Muscles
o tibialis posterior inserts onto the tuberosity (medial) of the navicular bone
innervated by tibial nerve
Ligament
o plantar calcaneonavicular (spring) ligament originates from sustentaculum tali and inserts on to
navicular
plantar support for head of talus
o bifurcate ligament attaches the anterior process of the calcaneus to the navicular and cuboid
bones
lateral support
o dorsal talonavicular ligament connects the neck of the talus to the dorsal surface of the navicular
bone
dorsal support
Blood Supply
o dorsalis pedis artery (dorsal aspect)
o medial plantar artery (plantar aspect)
o anastomosis between dorsalis pedis and medial plantar arteries (medial surface of tuberosity)
Classification
Radiographic Classification
Type 1 Sesamoid bone in the substance of the tibialisposterior insertion
Type 2 Separate accessory bone attached to native navicular via synchondrosis
Type 3 Complete bony enlargement
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Planus Deformity
Imaging
Radiographs
o recommended views
AP, lateral, external obliques
best seen with an external oblique view
o findings
will see bony enlargement or accessory bone
MRI
o indications
II:13 lateral xray
evaluation for other pathology
Treatment
Nonoperative
o activity restriction, shoe modification, and non-narcotic analgesics
indications
first line of treatment
modalities
the use of arch supports or pads over the bony prominence may be helpful
a UCBL orthosis may invert the heel during walking and decrease symptoms
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OrthoBullets2017 Pediatric Foot | Osteochondroses
orthotics must offload pressure from the accessory navicular or they will exacerbate
symptoms
outcomes
most children and adolescents who have a symptomatic accessory tarsal navicular bone
become asymptomatic when they reach skeletal maturity
o short period of cast immobilization
indications
pain is refractory to activity modification and shoe modifications
Operative
o excision of accessory navicular
indication
recalcitrant cases that have failed extended nonoperative management
Technique
Excision of accessory navicular
o approach
medial approach to the foot
incision made dorsal to prominence of navicular from medial cuneiform to sustenaculum tali
reflect the posterior tibialis tendon plantar in order to excise the navicular
o resection technique
bone should be resected flush with the medial cuneiform
most common cause of persistent symptoms after surgery is inadequate bone resection
o flatfoot deformity correction
advancing the posterior tibialis will not correct flatfoot deformity
lateral column lengthening or medial displacement calcaneus osteotomy if flatfoot correction
is needed
Complications
Persistant symptoms following resection
o most common cause of persistent symptoms after surgery is inadequate bone resection
o other patients may have persistent pain from scar tissue or other causes
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Osteochondroses
C. Osteochondroses
1. Kohler's Disease
Introduction
Avascular necrosis of the navicular bone of unclear etiology
Epidemiology
o demographics
occurs in young children (usually age 4-7 yrs)
four times more common in boys than girls
80% of cases in boys
o locations
can be bilateral in up to 25% of cases
Pathophysiology
o the blood supply of the central one third of the navicular is a watershed zone
accounts for the susceptibility to avascular necrosis and stress fractures
o the navicular is the last bone to ossify
increases its vulnerability to mechanical compression and injury
Associated conditions
o infection
Kohler's disease is often misdiagnosed as infection
Prognosis
o typically a self-limiting condition
o intermittent symptoms for 1-3 years after diagnosis
typically associated with activity
Classification
There is no widely used classification system for this condition
Presentation
History
o patient may not have complaints as disease can be asymptomatic
o characteristically described as midfoot pain with an associated limp
Symptoms
o pain in dorsomedial midfoot
o may have swelling, warmth, and redness
o point tenderness over the navicular
Physical exam
o antalgic limp (may place weight on lateral side of foot)
Imaging
Radiographs
o characteristic sclerosis, fragmentation, and flattening of
tarsal navicular
o most tarsal navicular bones reorganize after disease has run its course
some continue to be deformed but almost all of those remain asymptomatic
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Treatment
Nonoperative
o NSAIDs
short course can be used to decrease symptoms
o immobilization with short leg walking cast
indications
pain with activities
outcomes
studies have shown treatment in a short leg walking cast will decrease the duration of
symptoms
radiographs improve at around 6-48 months from onset of symptoms
no reports of long-term disability
Operative
o surgery
indications
not indicated for this disease
2. Iselin's
Introduction
Iselin's disease is a traction apophysitis of the tuberosity of the fifth metatarsal
Epidemiology
o demographics
most often seen in physically active boys and girls between the ages of 8 and 13 years of age
common in soccer players, basketball players, gymnasts, and dancers
Pathophysiology
o due to repetitive traction of peroneus brevis tendon at the site of its attachment
Presentation
Symptoms
o pain on lateral foot
worse with activity and improves with rest
Physical exam
o tenderness over base of 5th metatarsal
Imaging
Radiographs : usually normal
Differential
Normal apophysis
Base of 5th metatarsal fractures
o may be difficult to differentiate in adolescents
Treatment
Nonoperative
o rest, activity modification, icing
indications : standard of care as conditions resolves with time
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Osteochondroses
3. Sever's disease
Introduction
Overview
o common cause of heel pain
o thought to be an overuse injury of the calcaneal apophysis in a growing child
Epidemiology
o commonly seen in immature athletes participating in running & jumping sports
frequently seen just before or during peak growth
Mechanism
o exact etiology is unknown
o thought to be due to traction apophysitis and repetitive microtrauma experienced during
gait (similar to Osgood Schlatter's Disease)
Natural history
o self-limiting entity that resolves with maturation and the closure of the apophysis
Relevant Anatomy
The calcaneal apophysis experience significant force from combination of both
o direct impact onto the heel during the heel strike phase of gait
o opposing tension forces generated by the plantar fascia and the pull of the gastrocsoleus complex
Presentation
Symptoms
o pain in the area of the calcaneal apophysis in an immature athlete
o pain increased with activity or impact
o stretch of the triceps surae exacerbates heel pain
o can display warmth, erythema, & swelling
Physical exam
o tight Achilles tendon
o positive squeeze test (pain with medial-lateral
compression over the tuberosity of the calcaneus)
o pain over the calcaneal apophysis
Imaging
Radiographs
o diagnosis is clinical as there is no established diagnostic criteria
o sclerosis can be present in both patients with and without calcaneal apophysitis
o fragmentation is more frequently seen in patients with Sever's disease
o helpful to rule out other causes of heel pain (osteomyelitis, calcaneal bone cysts)
MRI
o can help localize inflammation to apophysis
o can rule out disorders of the body of the os calcis (stress fracture, lytic lesion, osteomyelitis)
Other
o bone scan can show increase uptake at the apophysis, but is typically not helpful in diagnosis
Treatment
Nonoperative
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OrthoBullets2017 Pediatric Foot | Toe Conditions
o symptomatic treatment
modalities include
activity modification
Achilles tendon stretches (can help decrease recurrence)
ice application before and after athletic endeavors
use of heel cups or heel pads
NSAIDs
short leg cast immobilization of persistent pain
outcomes
recurrence is common
Operative
o there is no role for operative treatment
D. Toe Conditions
Presentation
Symptoms
o painless deformity
Imaging
Radiographs
o recommended views of the foot
AP
lateral
oblique
o findings
short, thick 1st metatarsal
Differential
Must be differentiated from metatarsus adductus
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Toe Conditions
II:14 (A) Preoperative photograph showing marked medial deviation of the broad great toe and widening of the first web space. (B)
Preoperative radiograph showing varus angulation of the first metatarsophalangeal joint and accessory bone of the great toe. (C)
Treatment
Nonoperative
o observation alone
indications
first line of treatment as most cases resolve with age
Operative
o abductor hallucis muscle release
indications
resistant cases
o excision of central portion of epiphyseal bracket
indicated if epiphyseal bracket found to be the cause of Hallux Varus
resumption of longitudinal growth common if performed at a young age
secondary corrective realignment or lengthening is sometimes needed
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Classification
Two types
o simple : if soft tissue only
o complex : if bony fusion present
Presentation
Symptoms
o usually painless with cosmetic concerns only
Imaging
Radiographs
II:15 Pre & post operative syndactyly
o AP of the foot
Treatment
Nonoperative
o observation
indications
simple syndactyly
rarely requires treatment as this is an aesthetic deformity
complications include contractures and painful scar tissue
Operative
o digit release
indications : complex syndactyly
3. Polydactyly of Foot
Introduction
Extra digits of the toe
Epidemiology
o incidence
occurs in 1 in 500 births
postaxial (lateral side of the foot) polydactyly is most
common
o demographics
more common in African-Americans than caucasians
Pathophysiology
o failure of differentiation in the apical ectodermal ridge during
first trimester of pregnancy
Genetics
o usually transmitted as autosomal dominant (positive family
history)
Associated conditions
o orthopaedics manifestations II:16 duplicated ray
may involve extra phalanges or even duplicated rays
Prognosis
o natural history of disease
may cause problems with shoe fitting and angular deformity of the toes
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Toe Conditions
Classification
Venn-Watson Classification of Polydactyly
o post-axial (lateral side of the foot)
'Y' metatarsal
'T' metatarsal
wide metatarsal head
complete duplication
o central (not part of the original classification)
duplication of the second, third or fourth toe
o pre-axial (medial side of the foot)
short block first metatarsal
wide metatarsal head
Presentation
Physical exam
o extra digits in the foot
Imaging
Radiographs
o metatarsals are present on radiographic views at birth, but generally
radiographic evaluation delayed to allow full ossification of the phalanges for
surgical planning
Treatment
Nonoperative
o observation II:17 postaxial polydactyly
indications
postaxial or central polydactyly
with proper alignment of the digit may remain in place unless the foot is significantly
widened (rare)
Operative
o ablation of extra digit (usually border digit)
indications
malaligned toe, particularly preaxial polydactyly
perform at 9-12 months of age if possible
small skin tags can be removed in newborn nursery
4. Oligodactyly
Introduction
Congenital absence of one or more toes
Epidemiology
o incidence
less common than polydactyly
o body location
lateral rays are affected more often than the hallux
Pathophysiology
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OrthoBullets2017 Pediatric Foot | Toe Conditions
o pathoanatomy
due to improper differentiation of the apical ectodermal ridge during development
o thought to be caused by
teratogenic insults
impaired blood flow
amniotic bands
Genetics
o positive family history in some cases
o sporadic in others
Associated conditions
o orthopaedic
fibular hemimelia
tarsal coalition
hand & foot abnormalities
polydactyly
syndactyly
constriction rings
brachdactyly
o medical
associated with a number of syndromes including
VACTERL
Fanconi
Presentation
Physical exam
o absent digits
Symptoms
o usually painless
o may present with discomfort during shoe wear
Imaging
Radiographs
o recommended views
AP of the foot
Treatment
Nonoperative
o observation alone
indications : mainstay of treatment as there is usually no limitation in function
5. Overlapping Toe
Introduction
A congenital deformity characterized by a digit that overlaps another
Epidemiology
o demographics
evenly distributed between males and females
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Toe Conditions
o body location
the fifth toe most commonly affected
usually bilateral
Pathophysiology
o pathoanatomy
due to contraction of the extensor digitorum longus
Genetics
o often familial
Butler procedure
Presentation
Symptoms
o may cause problems with shoe wear
Physical Exam
o adduction and slight external rotation of the
affected digit
o metatarsophalangeal joint is dorsiflexed
o the nail plate is smaller than the contralateral
digit
Treatment
Nonoperative
o passive stretching and buddy taping
indications
first line of treatment
Operative
o surgical correction
indications
fails nonoperative treatment and remains
symptomatic
technique
Butler procedure
perform racket handle incision then
release the extensor digitorum longus
tenotomy vs. dorsal capsulotomy
vs. syndactylization with fourth toe
(McFarland procedure)
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Presentation
Symptoms
o usually asymptomatic
Imaging
Radiographs
o not indicated
Treatment
Nonoperative
o observation
indications : usually asymptomatic and requires no treatment
toe strapping not found to be beneficial
Operative
o soft tissue release e.g. flexor tenotomy
indications
FDL release reserved for severe toe deformity or nail bed deformity in children
typically > 3 years old
outcomes
85-90% effective
flexor tenotomy is as effective as flexor tendon transfer
Techniques
Surgical soft tissue release
o open tenotomy of both slips of the flexor digitorum brevis (FDB) and FDL tendon
o open tenotomy of one slip of the flexor digitorum brevis (FDB) tendon only
o flexor digitorum longus (FDL) transfer to the extensor hood
7. Brachymetatarsia
Introduction
A congenital hypoplasia of one or more metatarsals
Epidemiology
o location
shortening of the fourth metatarsal is the most common
often bilateral
o demographics
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By Dr, AbdulRahman AbdulNasser Pediatric Foot | Toe Conditions
female:male 25:1
Pathophysiology
o cellular biology
due to premature epiphyseal closure of the metatarsals
Associated conditions
o Down’s Syndrome
o Turner’s Syndrome
o Larsen’s Syndrome
o Albright’s Syndrome
o Diastrophic Dwarfism
Presentation
Symptoms
o discomfort with shoe wearing
Imaging
Radiographs
o recommended views
AP and lateral weight-bearing views
o findings
shortening of the affected metatarsals
discontinued metatarsal parabola
Treatment
Nonoperative
o shoe modifications
indications
first line of treatment and will generally will
improve symptoms
technique
extra-depth or extra-wide shoes
taping and manipulative reduction attempts are
ineffective
Operative
o metatarsal lengthening
indications II:18 A) Image of congenital brachymetatarsia of the
fourth toe. (B) Depicts a transverse osteotomy which
if symptoms persist in the older child is distracted gradually by a bone spreader. (C) The
o amputation bone graft is placed.(D) A K wire is passed through
the metatarsal shaft up to the toe.
indications
if symptoms persist in the older child
o extensor tenotomy and capsulotomy
indications
none: not likely to sufficiently correct the deformity
o fusion
Indications
result in complications and generally are not indicated.
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OrthoBullets2017 Pediatric Foot | Toe Conditions
8. Local Gigantism
Introduction
Overview
o form of gigantism usually isolated to fingers or toes "macrodactyly" but may affect an entire
limb
Epidemiology & Incidence
o rare
o congenital causes:
neurofibromatosis
proteus syndrome
klippel-Trenaunay-Weber
o acquired causes:
amyloidosis
elephantiasis (filariasis)
av malformation
tumor
acromegaly
Physiology
o unknown
Relevant Anatomy
Growth plate consists of three principal layers:
o resting zone
o proliferative zone
o hypertrophic zone
Presentation
Symptoms
o pain
Physical exam
o enlarged digit or limb
Imaging
Radiograhs
o needed for reconstruction or amputation planning
Treatment
Nonoperative
o observation
monitor growth of affected region
Operative
o epiphysiodesis vs. bony and soft-tissue reduction procedures
indications
individualized based on etiology, location of affected area, skeletal growth left, and
severity
o amputation
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Toe Conditions
ORTHO BULLETS
III.Pediatric Syndromes
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OrthoBullets2017 Pediatric Syndromes | Cerebral Palsy
A. Cerebral Palsy
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Cerebral Palsy
(dyskenesias such as chorea and athetosis)
secondary (growth and spasticity related)
contractures
starts as dynamic contractures, become static with time (continuous muscle
contraction results in shortening) and growth (growth of bones occurs at a faster
longitudinal rate than muscles in spastic cerebral palsy)
upper extremity deformities
hip subluxation and dislocation
spinal deformity
foot deformities
gait disorders
fractures
often associated with non-ambulators secondary to low bone mineral density
bisphosphonates may be useful
IV pamidronate considered with >3 fractures and a DEXA z-score <2 SD
Prognosis
o most reliable predictor for ability to walk is independent sitting by age 2
Classification
Physiologic Classification
Spastic (most Velocity-dependent increased muscle tone and hyperreflexia with slow,
common) restricted movement due to simultaneous contraction of agonist and
antagonist muscles. Most amenable to operative treatments.
Athetoid Characterized by constant succession of slow, writhing, involuntary
movements
Ataxic Characterized by inability to coordinate muscle movements. Results in
unbalanced, wide based gait.
Mixed Usually mixed spastic and athetoid features and involves the entire body
Hypotonic Usually precedes spastic or ataxic for 2-3 years
Anatomic Classification
Quadriplegic Total body involvement and nonambulatory
Diplegic Legs more than arms but usually still ambulatory. IQmay be normal (injury
in brain is midline)
Hemiplegic Arms and legs on one side of the body, usually with spasticity; will
eventually be able to walk, regardless of treatment
Gross Motor Function Classification Scale (GMFCS)
Level I Near normal gross motor function, independent ambulator
Walks independently, but difficulty with uneven surfaces, minimal ability to
Level II
jump
Level III Walks with assistive devices
Level IV Severely limited walking ability, primary mobility is wheelchair
Level V Nonambulator with global involvment, dependent in all aspects of care
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OrthoBullets2017 Pediatric Syndromes | Cerebral Palsy
Evaluation
History
o clinical history
perinatal history
growth & development
prior medical treatments
o functional status
sitting/standing posture
upper and lower extremities function
communication skills
acuity of hearing and vision
Physical exam
o general musculoskeletal exam
motion, tone, and strength
Rotational limb profiles for torsional deformities
o gait
gait lab analysis
plantigrade feet
crouch
stiff knee gait
o spine exam
presence and flexibility of scoliosis
spinal balance and shoulder height
pelvic obliquity
resting head posture
hamstring contractures (lead to decreased lumbar lordosis)
o hips
hip contractures
flexion contracture (lead to excessive lumbar lordosis)
adduction contracture
hip instability and dislocations are common, may be looked over as a contracture alone
observe thigh length in sitting, leg length when supine, or galleazzi test
adductor contracture can make examination difficult
o foot and ankle
equinovarus and planovalgus deformities common
observe wear patterns, callouses
note hypertonicity
toe walking or absent heel strike during gait secondary to gastrosoleus spasticity and
contracture
may hyperextend knee to obtain heel contact
provacative Silverskiold test to differentiate gastrocnemius contracture vs achilles contracture
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Cerebral Palsy
Imaging
Radiographs : standard radiographs should include
o AP and lateral of hips
o standing spine radiographs as baseline
MRI
o MRI of brain shows a spectrum of changes including
periventricular leukomalacia (PVL) white matter lesions most frequent (56%)
while grey matter lesions (18%)
brain malformations are less frequent (9%)
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nonambulatory patients with spastic quadriplegia (associated with significant spinal
deformities)
falling out of favor due to limited functional gains and no reduced risk of subsequent
musculoskeletal surgeries
o bony procedures/deformity correction
indications
usually performed in later childhood / adolescence
static contractures, progressive joint breakdown, and certain patterned gait-deterioration
can be treated with combinations of myotendonous unit lengthening, tendon transfers, and
osteotomies
SEMLS surgery (Single-Event, Multi-Level Surgery)
concept arose to limit multiple surgeries, anesthetics, and rehabilitation time for children
most successful when combined with a thorough gait lab assessment that predicts
improvemenet in function with multiple level surgical interventions
simple lengthenings can cause deterioration in gait when other contractures are
"uncovered"; SEMLS management seeks to avoid these iatrogenic complications
can be done on bilateral lower extremities in efforts to improve gait
specific procedures
see Cerebral Palsy Upper Extremity Conditions
see Cerebral Palsy Spine Conditions
see Cerebral Palsy Hip Conditions
see Cerebral Palsy Gait Disorders
see Cerebral Palsy Foot Disorders
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Classification
Stages of Hip Deformity in Cerebral Palsy
Hip at risk Hip abduction of <45° with partial Botox A into spastic muscles (age <3) to
uncovering of the femoral head delay surgery
on radiographs Attempt to prevent dislocation with adductor
Reimers index <33% release, psoas release, hamstring
lengthening (age 3-4)
Avoid obturator neurectomy
Windswept Abduction of one hip with Brace adducted hip with or without tenotomy
hips adduction of the contralateral hip and release abduction contracture of
abducted hip
Complications
Osteonecrosis of femoral head : incidence 1-11%
Heterotopic Ossification
o prevention
radiation on the second or third postoperative day more effective than anti-inflammatory
medications
Insufficiency factures
o incidence : ranges from 4-29%
o may be seen in distal femur following postoperative Spica casting
Abduction contracture
o may occur with neurectomy of anterior branch of obturator nerve during adductor releases
Classification
Descriptive (Qualitative) classification
o useful for simplification, though high variability of segmental deviations in each pattern
o descriptive classifications have been unsuccessful at classifying up to 40% of CP gait patterns
o common descriptive classifications are shown in table in next page.
III:2 descriptive classifications have been unsuccessful at classifying up to 40% of CP gait patterns
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Cerebral Palsy
Descriptive Classification
Equinus Term "equinus" used to refer to the isoloated abnormality in foot position relative to the
Gait tibia, i.e. a one-level deviation (e.g. no knee/hip involvement)
o characterized by absence of heal strike during gait
o isolated equinus gait is common in hemiplegics
Equinus is either:
o true equinus
defined by the foot position in relationship to the tibia being less than
plantigrade
o apparent equinus
defined by a foot position that is normal in relationship to the tibia, however
heel strike does not occur due to more proximal deviations (flexion of the
knee most common)
Jump Deformity includes hip flexion, knee flexion, and equinus ankle deformity ( could result in
Gait apparent ankle equinus)
Multi-level gait deviations where treatment of underlying spasticity should be considered
Crouch A combination of hip flexion, knee flexion, and excessive ankle dorsiflexion (the latter may
Gait be represented by flatfoot or calcaneus)
Common in diplegic CP
Pathophysiology
o often an iatrogenic consequence of isolated lengthening the achilles in a jump gait
pattern if the other levels of gait deviations are not addressed properly
Levels of deviation
o Calcaneal contact pattern throughout stance phase
o Increased knee flexion throughout stance phase due to disruption of the ankle
plantar flexion-knee extension couple
Compensated crouch gait
o refers to tertiary deviations that allow the knee extensor mechanism to be off-
loaded during stance phase (e.g. pelvic or truncal forward tilt) - this may be well-
tolerated by younger children with CP and low body mass
Uncompensated crouch gait
o occurs secondary to persistent overloading of the extensor mechanism. This
occurs in all crouch eventually, if untreated
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Quantitative classification
o uses technology to better characterize the pathoanatomy of abnormal gait, particularly when
multiple planes and segments of deformity exist
o characterizes gait into 3 planes of deformity
sagittal plane
includes:
anterior or posterior pelvic tilt
hip flexion/extension
knee flexion/extension
ankle dorsiflexion/plantarflexion
coronal plane
includes:
pelvic elevation/depression
hip abduction/adduction
transverse plane
transverse plane is least reliable plane described in instrumented gait analysis
includes:
pelvic and hip internal and external rotation deformities, foot progression angle
Treatment
Nonoperative
o physical therapy
indications
plays an important role in both operative an nonoperatively treated patients
o chemodenervation (botulinum neurotoxin A)
may be used to temporize certain muscle groups in order to delay surgical management or as
a primary treatment modality
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indications
hamstring spasticity without fixed deformity in ambulatory patient
o orthoses
solid ankle foot orthosis (AFO)
indications
flexible equinus deformities
ankle is passively correctable to neutral while
maintaining a subtalar neutral position
posterior leaf-spring (or hinged) orthoses
III:3 AFO & leaf spring orthoses
indications
used in presence of excessive ankle plantar flexion in the swing phase
Operative
o single-event, multi-level surgery (SEMLS)
overview
SEMLS approach has become the gold-standard of CP gait surgery
goal is to address all primary (spasticity) and secondary (i.e. contractures) deviations at
multiple levels during a single surgery ( see table page 151)
addressing multiple deviations at once is essential to avoiding iatrogenic worsening of
gait
procedures used during a SEMLS
lever arm dysfunction due to increased femoral anteversion: external rotation proximal
femur osteotomy
hip flexion contracture: intramuscular psoas lengthening
knee contractures
medial hamstring lengthening (lateral may result in excessive weakness) if minimal
fixed contracture
guided growth
distal femur extension osteotomy
rectus transfer for stiff knee gait
equinus: tendo-achilles lengthening or gastrocnemius recession
flatfoot reconstruction
rehabilitation
AFOs and aggressive physical therapy for re-training and strengthening following
releases is an essential component of SEMLS intervention
expect one year for recovery
Techniques
External rotation proximal femur osteotomy
o indications
femoral anteversion / hip internal rotation deviation
Rectus Transfer
o indications
stiff knee gait
o technique
create knee flexion vector with rectus activation by transferring it posterior to the center of
rotation of the knee
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Medial hamstring lengthening
o indications
for mild knee dysfunction, usually younger patients with less than 5 degrees knee flexion
deformity
o technique
fractional lengthening at the myotendinous junction is ideal
o complications
hamstring contractures often recur, especially in jump gait
Guided growth surgery
o indications
knee flexion deformities of 10-25 degrees in the patients with at least two years of growth
remaining
Supracondylar femur extension osteotomy +/- patellar tendon advancement or shortening
o indications
for knee flexion deformities of 10-30 degrees, with severe quadriceps lag close to or already
at skeletal maturity
Gastrocnemius recession
o indications
Silfverskiöld test positive
o technique
horizontal or vertical incision at the level of the myotendinous junction of the gastroc
identify and protect the sural nerve (superficial to fascia)
sharply divide the tendon only, preserving the muscle fibers not yet joined to the tendon
incise all deeper bands that prevent release of contracture (small raphes may be present in the
tendon
manipulate the ankle
goal of treatment is 10 degrees of dorsiflexion
Tendo-achilles lengthening
o indications
rigid deformities - ankle is not passively correctable to neutral
true equinus
Silfverskiöld negative
o techniques
multiple hemi-lengthenings or a Z-lengthening can be performed
avoid overlengthning
Complications
Recurrent hamstring contracture
Worsening crouch gait secondary to isolated and overlengthening of achilles
Patella alta
o elongated patellar tendon (patellar alta) is another complication of this condition that is difficult
to treat
o Multiple simultaneous soft tissue releases without careful gait analysis
Knee pain
o tendo-achilles lengthening may worsen knee pathology if careful gait analysis isn't performed
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Cerebral Palsy
Equinus
Epidemiology
o most common deformity in cerebral palsy
Pathophysiology
o imbalance of ankle dorsiflexors and plantarflexors, resulting in plantar flexion of the hindfoot
relative to the ankle, with normal mid- and forefoot alignment
o spasticity/contracture of the gastrocsoleus complex
Presentation
o symptoms
shoe fitting / wear and tear
tripping secondary to poor foot clearance
instability due to decreased base of support
o physical exam
inspection
forefoot callosities
toe walking or absent heel strike during gait
hyperextended knee with heel contact III:4 hyperextended
knee with heel
provacative tests contact
Silverskiold test
improved ankle dorsiflexion with knee flexed = gastrocnemius tightness
equivalent ankle dorsiflexion with knee flexion and extension= achilles tightness
Treatment
o nonoperative
serial manipulation and casting
indications : mild spasticity, dynamic, younger patients
botulinum toxin A intramuscular injection into gastrocnemius
indications
mild spasticity, may delay need for surgery
mechanism of action
blocks presynaptic release of acetylcholine
articulated or hinged AFO
indications
mild and passively correctible deformity with mild spasticity and no myostatic
contractures.
contraindication
presence of excessive ankle dorsiflexion in midstance
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solid AFO
indications
mild to moderate foot deformities that are partially correctible with mild to moderate
spasticity and with mild myostatic contractures
contraindications
excessive ankle dorsiflexion during midstance in heavy patients, >=12 years of age
and significant rigid foot malalignment
o operative
tendo-Achilles lengthening (TAL)
indications
rarely indicated as an isolated procedure, except in hemiplegia
Hallux Valgus
Epidemiology
o most common in diplegics with planovalgus feet
o associated with equinovalgus and external tibial torsion
Pathophysiology
o caused by combination of adductor hallucis overactivity and
externally applied forces, such as inadequate clearance resulting
from equinovalgus deformity, forcing the great toe into valgus.
Presentation
o symptoms
pain and difficulty wearing proper shoes
o physical Exam
inspection
painful bunion/callosity over 1st MT head III:5 painful bunion/callosity over 1st
Treatment MT head
o nonoperative
observation
indications
no pain or difficulty with footwear
o operative
first metatarsophalangeal joint arthrodesis
indications
painful hallux valgus
outcomes
has the highest overall success rate compared to other
surgeries in ambulatory and nonambulatory children with
cerebral palsy.
the recurrence rate is unacceptably high with the other
procedures
proximal phalanx (Akin) osteotomy
indications
hallux valgus with associated valgus interphalangeus
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Cerebral Palsy
EquinoPlanoValgus
Epidemiology
o incidence
common foot deformity seen with
cerebral palsy (spastic diplegic and quadriplegic)
o body location
typically bilateral
Pathophysiology
o equinus with pronation deformity
o pathomechanics
creates lever arm dysfunction during gait
leads to bearing weight on the medial border of the foot and
talar head
external rotation of the foot creates instability during push off
Presentation
o Symptoms
painful callus over talar head secondary to weightbearing
shoe wear problems
o Physical exam
inspection
typically bilaterally
valgus heel deformity seen when viewing feet from posterior
prominent talar head appreciated in the arch
midfoot break occurs in attempt to keep foot plantigrade
hallux valgus typically develops over time
motion
the hindfoot valgus deformity must be manually corrected first before testing for achilles
contracture
a valgus heel can mask an equinus contracture by allowing a shortened path for the
achilles
Imaging
o Radiographs
recommended views
weight-bearing AP radiographs of the ankles must be obtained to rule out ankle valgus as
cause of deformity
findings
decrease in the calcaneal pitch
negative talo-first metatarsal angle on lateral view
Weight-bearing lateral radiograph of a patient with Grice extra-articular subtalar arthrodesis. A bone block
equinovalgus foot deformity. (graft) is placed into the sinus tarsi.
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Treatment
o Nonoperative
bracing
indications
flexible deformities
o Operative
calcaneal osteotomy with soft tissue procedure
indications
pain or pressure sores despite bracing
subtalar arthroereisis
indications
controversial
technique
stabilizes subtalar joint in correct alignment without fusion
Techniques
o Calcaneal osteotomy with soft tissue procedure
soft tissue procedures
achilles lengthening
peroneus brevis lengthening
posterior tibial tendon advancement
bony procedures
calcaneal osteotomy
medial slide osteotomy
lateral column lengthening procedure
Grice procedure
extra-articular subtalar arthrodesis via a lateral approach
place ICBG in lateral subtalar joint to block valgus
does not interfere with tarsal bone growth
subtalar arthroereisis
Complications
o Overcorrection (resultant varus deformity)
most common complication
o Sural nerve injury
at risk during calcaneal osteotomy procedures
o Overlengthening of lateral column
results in a painful lateral forefoot secondary to overload
EquinoCavoVarus
Epidemiology
Pathophysiology
o equinus deformity of the hindfoot coupled with supination deformities of the midfoot and
forefoot
o pathomechanics
creates lever arm dysfunction during gait
disrupts the second rocker by blocking ankle dorsiflexion, thus compromising stability
function in midstance
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Cerebral Palsy
shortens the length of the plantar flexor muscles, compromising their ability to generate
tension
Presentation
o Symptoms
o Physical exam
inspection
motion
Imaging
o Radiographs
Treatment
o Nonoperative
o Operative
Gastrocsoleus complex lengthening
Split Posterior Tibial Tendon Transfer
Techniques
o Split Posterior Tibial Tendon Transfer
between ages of 4 and 7 years with flexible equinovarus deformities. Tendon transfers in
patients with athetosis are unpredictable
o Complications
Shoulder IR Contracture
Overview
o characterized by glenohumeral internal rotation contracture
Treatment
o shoulder derotational osteotomy and/or subscapularis and pectoralis lengthening
with biceps/brachialis lengthening capsulotomy
indications
severe contracture (>30 degrees) interfering with hand function
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Forearm-Pronation / Elbow-Flexion Deformity
Overview
o usually consists of a combination of a
forearm pronation deformity and
elbow flexion contracture
Treatment
o lacertus fibrosis release, biceps and brachialis lengthening, brachioradialis origin release
indications : elbow flexion contracture
o pronator teres release
indications
forearm pronation deformity
technique
transfer to an anterolateral position
complication
supination deformity
this is less preferable than a pronation deformity
o FCU transfer
transfer of the FCU to the ECRB
indications
another option for pronation deformity
Wrist-Flexion Deformity
Overview
o wrist is typically flexed and in ulnar deviation
o associated with weak wrist extension and pronation of the forearm
Treatment
o FCU or FCR lengthening
indications
when there is good finger extension and little spasticity on wrist flexion
o FCU to ECRB transfer or FCU to EDC transfer
indications
as a functional procedure in patients with voluntary control, IQ of 50-70 or higher, and
better sensibility
technique
with good grasp ability
transfer FCU to EDC
with poor grasp ability
transfer FCU to ECRB
o flexor release
indications
weakening of the wrist flexors
technique
release of the flexors of the wrist and pronator teres from the medial epicondyle
o wrist arthrodesis
indications
as a hygienic procedure in low functioning patients
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Cerebral Palsy
Thumb-in-Palm Deformity
Introduction
o flexed thumb into palm prevents grasping and pinching activities
can preclude appropriate hygiene
Classification (House)
House Classification
Type Characteristics Treatment
adductor release
1st metacarpal adduction possible 1st dorsal interosseous release
Type I
contracture z-plasty of the skin contracture in the 1st web
Treatment
o release of the adductor pollicis, transfer of tendons, and stabilization of the MCP joint
indications
as a functional procedure in patients with voluntary control, IQ of 50-70 or higher, and
better sensibility
Finger-Flexion Deformity
Introduction
o a result of intrinsic muscle tightness along with extrinsic overpull of the finger extensors
Treatment
o swan-neck deformities can often be helped with correction of the wrist flexion deformity
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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B. Neuromuscular
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o ability to ambulate
L3 or above are mostly confined to a wheelchair
L5 level patients have a good prognosis for independent ambulation
Special considerations
o IgE mediated latex allergy
results in profound anaphylaxis
present in 20 to 70% of patients with this disorder
Classification
Forms of myelodysplasia
o spinal bifida oculta
defect in vertebral arch with confined cord and meninges
o meningocele
protruding sac without neural elements
o myelomeningocele
protruding sac with neural elements III:9 rachischisis
o rachischisis
neural elements exposed with no covering
Function level (described by lowest functioning level)
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Imaging
Radiographs
o useful for monitoring
scoliosis/kyphosis
hip dysplasia
pathologic fractures
MRI
o change in neurologic exam prompts urgent MRI to rule out cord tethering
Studies
Labs
o alpha-fetoprotein (AFP)
elevated in 75% of children with open spina bifida
obtain during second trimester
Pathologic Fractures
Introduction
o fractures of the long bones are common due to osteopenia
o frequency increases with the higher the level of the defect
o common in hip and knee in children ages 3 to 7 years of age
o fractures are often confused with
infection
osteomyelitis
cellulitis
Treatment
o short period of immobilization in a well-padded splint
indications
fractures in satisfactory alignment
technique
well-padded cast
avoid long-term casting
may lead to
osteopenia
repeat fractures
Scoliosis
Introduction
o may result from
muscle imbalance (neurogenic) or
congenital malformation (e.g., hemivertebrae)
defined as curve > 20°
o higher the functional level, the greater the incidence of scoliosis
100% scoliosis rate with defects in thoracic levels
o consider cord tethering in rapidly progressing deformities
Treatment
o nonoperative
bracing not effective
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Neuromuscular
o operative
ASF and PSF with pelvic fixation
indications
progressive curve
indicated in most situations as bracing is not effective
technique
anterior fusion required due to dysplastic posterior elements that may impair posterior
fusion
complications
high psuedoarthrosis rate
high incidence of infection (15 to 25%)
due to poor soft tissue coverage of posterior spine
Congenital Kyphosis
Introduction
o present in 10-15% with myelodysplasia
o usually congenital and progressive
Physical exam
o Gibbus deformity may cause recurrent skin breakdown due to
pressure points when sitting
Treatment
o operative
kyphectomy with fusion and posterior instrumentation
indications
III:10 Gibbus deformity
progressive deformity
technique
check shunt function prior to kyphectomy
shunt failure during surgery may result in death
Hip Disorders
Hip dislocation
o introduction
most common at L3 level due to unopposed hip flexion and adduction
L1 L2 L3 L4 L5 S1
HIP FLEXION HIP EXTENSTION
HIP ADDUCTION HIP ABDUCTION
o treatment
nonoperative
indications
all levels
technique
close observation
operative
indications
surgical treatment of dislocated hips is controversial
Hip abduction contracture
o introduction : can cause pelvic obliquity and scoliosis
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o treatment
proximal division of fascia lata and distal iliotibial band release (Ober-Yount procedure)
indications
contractures interfere with sitting or bracing
Hip flexion contracture
o introduction
common in high lumbar or thoracic defects
o treatment
anterior hip release with tenotomy of the iliopsoas, sartorius, rectus femoris, and tensor
fascia lata
indications
contractures greater than 40 degrees
Knee Disorders
Weak quadriceps
o introduction
common condition affecting children with myelodysplasia
o treatment
KAFO (knee-ankle-foot orthotic)
Flexion contracture
o introduction
not as important to treat in wheelchair bound patients
o treatment
hamstring lengthening +/- posterior capsulotomy
indications
greater than 20 degrees of knee flexion contracture
supracondylar extension osteotomy
indications
older patients
those who have failed soft tissue procedures
Extension contracture
o introduction
less common than flexion contractures
o treatment
serial casting
indications
extension contracture limiting ambulation or sitting
technique
goal is to reach 90 degrees of flexion
Tibial rotational deformities (torsion)
o treatment
observation and orthotics
Indications
children less than 5 years old
distal tibial derotational osteotomy
indications
children older than 5 years
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Neuromuscular
Foot and Ankle deformities
Introduction
o very common
60 - 90% incidence
due to high incidence of lower nerve root involvement
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Classification
Classification of CMT
Type I A demyelinating condition that slows nerve conduction velocity
Characteristics:
1. autosomal dominant
2. onset in first or second decade of life
3. most commonly leads to cavus foot
Type II Direct axonal death caused by Wallerian degeneration (not demyelination)
Characteristics:
1. Usually less disabled than Type I
2. onset in second decade of life or later
3. most commonly leads to flaccid foot
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Neuromuscular
Presentation
Symptoms
o lateral foot pain
o sensory deficits are variable
o clumsiness
o frequent ankle sprains
o difficulty climbing stairs
Physical exam
o lower extremity
rigid cavovarus foot (similar to Freidreich's ataxia) with hammer toes or clawing of toes
atrophied EDB and EHB
calf atrophy
weak dorsiflexion and eversion due to weak tib ant and peroneals (foot drop during swing
phase)
lower limb areflexia
Coleman block test
test to evaluate flexibility of hindfoot
flexible hindfoot will correct to neutral when block placed under lateral aspect of foot
a rigid hindfoot will not correct into neutral
o upper extremity
intrinsic wasting of hands
Studies
EMG
o low nerve conduction velocities with prolonged distal latencies are noted in peroneal, ulnar, and
median nerves
Genetic Testing
o DNA analysis
PCR analysis used to detect peripheral myelin protein 22 (PMP22) gene mutations
o chromosomal analysis
duplication on chromosome 17 seen in autosomal dominant (most common) form
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Neuromuscular
Hip dysplasias
Introduction
o hip dysplasia is sometimes associated with CMT
may present during adolescence in ambulatory patients
Treatment
o pelvic osteotomy
indications
end-stage osteoarthritis
outcomes
higher rate of sciatic nerve palsy after surgery
Scoliosis
Introduction
o often occurs in children with CMT
o characteristic left thoracic and kyphotic curve distinguish from idiopathic scoliosis
Treatment
o nonoperative
bracing
indications : bracing rarely effective
o operative
fusion and instrumentation
indications : progressive deformity
3. Friedreich's Ataxia
Introduction
The most common form of spinocerebellar degenerative diseases
o characterized by lesions in the
dorsal root ganglia
corticospinal tracts
dentate nuclei in the cerebellum
sensory peripheral nerves
Epidemiology
o 1 in 50,000 births
o onset usually between 7 and 25 years
age of onset related to number of GAA repeats
Genetics
o autosomal recessive
o repeat mutation leads to lack of frataxin gene
frataxin is a mitochondrial protein involved in iron metabolism and oxidative stress
mutation is GAA repeat at 9q13
Associated conditions
o pes cavovarus foot
o scoliosis
predictors of progression
onset of disease is less than 10 years of age
onset of scoliosis is before 15 years of age
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o cardiomyopathy
cardiology evaluation before surgery
antioxidants (Coenzyme Q) have been shown to decrease rate of cardiac deterioration but
have no effect on ataxia
Prognosis
o usually wheelchair bound by age 30
o usually die by age 50 from cardiomyopathy
Presentation
Symptoms
o ataxia
staggering wide based gait (spinocerebellar)
Physical exam
o classic triad
ataxia
areflexia
positive plantar response
o weakness
o nystagmus
o cavovarus foot
very high arch
rigid deformity
associated claw toes
o scoliosis
Imaging
Radiographs
o recommended views
standing scoliosis series
AP and lateral of foot if pes cavovarus present
Studies
EMG
o shows defects in motor and sensory with an increase in polyphasic potentials
o nerve conduction velocities are decreased in upper extremities
Treatment
Cavovarus foot
o nonoperative
observation
indications
only indicated in nonambulatory patient
deformity is rigid and progressive and resistant to bracing and stretching as treatment
o operative
plantar release, transfers, +/- metatarsal and calcaneal osteotomy
indications : early disease in ambulatory patient
triple arthrodesis
indications : late disease in nonambulatory patients
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Neuromuscular
Scoliosis
o nonoperative
observation
indications
curves < 40 degree without predictors of progression (see above)
o operative
PSF and instrumentation
indications
curve > 60 degrees
rapid progression with positive predictors of progression (see above)
usually does not need to be extended to pelvis
4. Arthrogryposis
Introduction
Nonprogressive congenital disorder involving multiple rigid joints (usually symmetric) leading to
severe limitation in motion
Epidemiology
o incidence 1:3000 live births
Mechanism
o symmetry of contractures due to immobilization in utero
neurogenic (90%)
myopathic (10%)
Pathophysiology
o exact mechanism unknown
some mothers have serum antibodies inhibiting the fetal acetylcholine receptors leading to
a decreased number of anterior horn cells
Associated conditions
o orthopaedic manifestations
upper extremity deformity (see below)
teratologic hip subluxation and dislocation
knee contractures
foot conditions
clubfoot
vertical talus
Neuromuscular C-shaped scoliosis (33%)
Fractures (25%)
Prognosis
o Nonambulatory (25%)
Classification
Type Characteristics
Type I Single localized deformity (e.g., forearm pronation)
Type II Full expression (absence of shoulder muscles, thin limbs, elbows extended, wrists
flexed and ulnarly deviated, intrinsic plus deformity of hands, adducted thumbs, no
flexion creases)
Type III Full expression (type II) with polydactyly and involvement of non-neuromuscular
systems
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Presentation
Physical exam
o inspection & palpation
shoulders adducted and internally rotated (absense of shoulder muscles)
elbows extended (no flexion creases)
wrists flexed and ulnarly deviated
hands with intrinsic plus deformity
thumb adducted
hips flexed, abducted, and externally rotated
subluxation or teratologic dislocation common
knees extended (classical), most of the time flexed
clubfeet
normal intelligence, facies, sensation, and viscera
o range of motion
severely limited usually involving all four extremities
Studies
Perform at 3-4 months of age
o neurologic studies
o enzyme tests
o muscle biopsies
Deformity Procedure
Elbow extension Triceps V-Y lengthening and posterior capsulectomy at 1.5 to 3
years (4 yrs and older?)
Wrist palmar flexion and Flexor carpi ulnaris release, lengthening and/or transfer to wrist
ulnar deviation extensors; dorsal carpal closing wedge osteotomy
Thumb in palm contracture Z-plasty syndactly release
and syndactyly
Finger defomity PIP arthrodesis
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Neuromuscular
Teratologic Hip Subluxation & Dislocation
Introduction
o present in 68-80% of patients with arthrogryposis
Treatment
o nonoperative
observation alone
observe alone while addressing other hand/foot deformities
indications
bilateral dislocations (controversial)
unilateral dislocation in older child (controversial)
Pavlik harness and rigid abduction brace are unlikely to succeed
o operative
closed reduction
indications
rarely successful
medial open reduction with possible femoral shortening
done at ≥ 6 months of age
indications
unilateral teratologic dislocation
may lead to worse function if it leads to a hip flexion contracture because flexion
deformities worsen the patient's gait
Knee Contractures
Treatment
o operative
soft tissue releases (especially hamstrings)
indications
flexion contracture >30 degrees
best performed early (6-9 months of age)
perform before hip reduction to assist in maintenance of reduction
femoral angulation through guided growth (epiphysiodesis)
indications
useful in conjunction with osteotomies
outcomes
may not effectively correct chronic poor quadriceps function
supracondylar femoral osteotomy
indications
may be needed to correct residual deformity at skeletal maturity
Foot Conditions
Clubfoot
o treatment
nonoperative
Ponseti casting
indications
useful in many patients
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operative
soft tissue release
indications
first line of treatment in rigid clubfoot
failed Ponseti casting in more flexible types
talectomy vs. triple arthorodesis
indications
failed soft tissue releases
triple arthrodesis in adolescence
Vertical Talus
o treatment
operative
soft tissue releases
indications : first line of treatment
talectomy
indications : if deformities recur despite soft tissue releases
5. Marfan Syndrome
Introduction
A connective tissue disorder associated with
o long narrow limbs (dolichostenomelia)
o skeletal abnormalities
o cardiovascular abnormalities
o ocular abnormalities
Epidemiology
o incidence : 1/10,000
o demographics
no ethnic or gender predilection known
Genetics
o autosomal dominant
mutation in fibrillin-1 (FBN1) gene
located on chromosome 15 (locus CH 15q21)
multiple mutations identified
Sporadic mutation may also occur (30%)
Associated conditions
o orthopaedic conditions
arachnodactyly (long, slender digits)
scoliosis (50%)
protrusio acetabuli (15-25%)
ligamentous laxity
recurrent dislocations (patella, shoulder, fingers)
pes planovalgus
dural ectasia (>60%)
meningocele
pectus excavatum or carinatum
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Neuromuscular
o nonorthopaedic conditions
cardiac abnormalities
aortic root dilatation
aortic dissection
mitral valve prolapse
superior lens dislocations (60%)
spontaneous pneumonthorax
Skin striae, recurrent hernias
Presentation
History
o scoliosis is usually the first manifestation to be diagnosed
o may be a history of ankle sprains secondary to ligamentous laxity
Symptoms
o asymptomatic in most cases
Physical exam
o dolichostenomelia (arm span greater than height (>1.05 ratio)
o arachnodactyly (long, thin toes and fingers)
o Thumb sign- Tip of thumb extends beyond small finger when thumb clasped in palm under four
fingers
o Wrist sign- distal phalanges of thumb and index fingers overlap when wrapped around opposite
wrist
o ligamentous hyperlaxity
o scoliosis
o Pes planus
Imaging
Radiographs
o recommended
scoliosis series of spine
o findings
scoliosis
kyphosis
MRI
o MRI of spine prior to surgery
look for dural ectasia
Cardiac studies
o cardiac evaluation prior to surgery
cardiac consult
echocardiogram
Studies
Diagnosis
o orthopaedist may be the first provider to identify manifestations and suspect diagnosis
o refer to cardiology or genetics if multiple manifestations are found
o Ghent nosology used to assist in diagnosis.
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Treatment General
Nonoperative
o beta blockers
indications
medications decrease risk of aortic dilatation
o observation and orthotics
indications
for generalized joint laxity
Operative
o preoperative evaluation
cardiology consultation required before any surgery
Scoliosis Treatment
Nonoperative
o bracing
indications
early treatment of mild curve
outcomes
less effective than for idiopathic scoliosis
Operative
o PSF +/- ASF with instrumentation
indications
rapidly progressing curve in a skeletally immature patient
large curve in a skeletally mature patient
Extend construct to avoid "adding-on", fuse to pelvis for distal curves with pelvic
oblquity or poor distal fixation
Growing rod construct may be required in younger patients
Obtain MRI to identify dural ectasia prior to surgery
outcomes
higher complication rate than idiopathic scoliosis surgery
Complications
Postoperative Complications after Scoliosis Surgery
o overall higher complication rate compared to idiopathic scoliosis
o fixation failure
is the most common complication secondary to thin laminae, thin pedicles and osteopenia.
higher risk of fixation failure than AIS
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Neuromuscular
o infection
higher risk of infection than AIS
o pseudarthrosis
higher risk of pseudarthrosis than AIS
o dural tear and intraoperative CSF leak (8%)
higher risk than AIS
o curve decompensation and need for reoperation
higher risk than AIS
o blood loss
same complication rate as AIS
o postoperative neurologic deficits
same complication rate as AIS
o length of hospital stay
same complication rate as AIS
6. Larsen's Syndrome
Introduction
A rare genetic disorder with characteristic findings of ligamentous hyperlaxity, abnormal facial
features, and multiple joint dislocations
o dislocations include
hips
knees (usually bilateral)
shoulders
elbows (radial head)
Epidemiology
o estimated to be 1 in 100,000 live births
Genetics
o autosomal dominant (AD) and recessive (AR) inheritance patterns
AD linked to a mutation of the gene encoding filamin B
AR linked to carbohydrate sulfotransferase 3 deficiency
Associated conditions
o orthopaedic manisfestations
hand deformities
scoliosis
clubfeet
cervical kyphosis
may present with extremity weakness secondary to myelopathy
caused by hypoplasia of the cervical vertebrae
Presentation
Symptoms
o patients have normal intelligence
Physical exam
o hypotonia
uncommon but may be due to cervical compression
o abnormal facial features
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flattened nasal bridge
hypertelorism
prominent forehead
o hands
long cylindrical fingers that do not taper
wide distal phalanx at the thumb
o elbows
bilateral radial head dislocations may be present
o knees
look for bilateral knee dislocations
o foot deformities
equinovarus
eqinovalgus
clubfeet
Imaging
Radiographs
o recommended
AP and lateral of cervical spine
during first year of life
AP pelvis and lateral of hips
ultrasound if less than 3 months
o findings
hypoplasia of vertebrae
cervical kyphosis with subluxation
hip dislocation
MRI
o recommended
cervical kyphosis
myelopathy
Treatment
Cervical kyphosis
o operative
posterior cervical fusion
indications
patients with significant kyphosis but no neurologic deficits
recommended to be performed during the first 18 months of life to prevent
neurological deterioration
anterior/posterior cervical decompression and fusion
indications
cervical kyphosis with neurologic deficits
Hip dislocations
o nonoperative
closed reduction under anesthesia
indications
may be attempted but rarely successful
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Neuromuscular
o operative
open reduction of hip dislocation
indications
failed closed reduction
decreased range of motion secondary to contractures around hip
unilateral hip dislocation
bilateral hip dislocation
controversial
if considering, perform early and only once
Knee dislocations
o nonoperative
closed reduction and casting
indications : may be attempted but rarely successful
o operative
open reduction with femoral shortening and collateral ligament excision
indications : knee dislocations that remain unstable after closed reduction
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Classification
Type Name Presentation Prognosis
Type I Acute Werdnig-Hoffman • Present at < 6 months Poor, usually die by 2 yrs.
disease • Absent DTR
• Tongue fasciculations
Type II Chronic Werdnig- • Present at 6-12 months May live to 5th decade
Hoffman disease • Muscle weakness worse in LE
• Can sit but cant walk
Type III Kugelberg-Welander • Present at 2-15 years Normal life expectancy - may need
disease • Proximal weakness respiratory support
• Walk as children, wheelchair as
adult
Presentation
Symptoms
o symmetric progressive weakness that is
more profound in lower-extremity than upper extremity
more profound proximally than distally
Physical exam
o absent deep tendon reflexes
distinguishes from Duchenne's muscular dystrophy where DTR are present
o fasciculations present
Imaging
Radiographs
o scoliosis series
o pelvis
Evaluation
Diagnosis based on
o DNA analysis
o muscle biopsy
o prenatal diagnosis is possible
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Neuromuscular
Treatment
Nonoperative
o Nusinersen has been FDA approved for treatment of SMA. It is administered intra-thecally.
Operative
o treat associated orthopaedic disorders (details below)
hip dislocation
scoliosis
lower extremity contractures
Hip Dislocation
Overview
o Hip subluxation and dislocation occur in 62% with type II SMA, and less frequently in Type III.
Treatment
o nonoperative
observation alone (leave dislocated)
indications
standard of care as dislocations typically remain painless and high recurrence rate if
open reduction attempted
Scoliosis
Overview
o the development of scoliosis is almost universal
o usually occurs by age 2 to 3 years
o often progressive
Treatment
o nonoperative
bracing
indications
devices may delay but not prevent surgery in children younger than ten years
o operative
PSF with fusion to pelvis
indications
progressive curve
technique
address hip contractures and any other lower extremity contractures before PSF to
ensure seating balance
outcomes
for improved wheelchair sitting
may lead to temporary loss of upper extremity function
Combined PSF with anterior releases/fusion
indications
curves >100 degrees
very young child with high risk of crankshaft phenomenon
contraindications
pulmonary compromise
typically not necessary due to the high flexibility of SMA curves
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Hip, knee, and ankle contractures
Overview
o Common in the hip and knee
o Nonambulators also develop ankle equinus
Treatment
o Physical therapy
o Surgical release is controversial as function in nonwalkers is rarely improved and recurrence is
common
C. Muscular Dystrophies
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Muscular Dystrophies
later onset with slower progression and longer life expectancy (average diagnosis occurs
at age 8 compared to 2 years of age with Duchenne's)
more prone to cardiomyopathy
Prognosis
o most are unable to ambulate independently by age 10
o most are wheelchair dependent by age 15
o most die of cardiorespiratory problems by age 20
Physical Exam
Symptoms
o progressive weakness affecting proximal muscles first
(begins with gluteal muscle weakness)
o gait abnormalities
delayed walking
toe walking
clumsy, waddling gait
difficulty climbing stairs, hopping, or jumping
o decreased motor skills
Physical exam
o calf pseudohypertrophy (infiltration of normal muscle
with connective tissue)
o deep tendon reflexes present (unlike spinal muscular
atrophy) III:15 The illustration depicts a positive Gower's sign
that is present with proximal muscle weakness in
o lumbar lordosis Duchenne muscular dystrophy.
compensates for gluteal weakness
o Gower's sign
rises by walking hands up legs to compensate for gluteus maximus and quadriceps weakness
o Trendelenburg sign
Evaluation
Labs
o markedly elevated CPK levels (10-200x normal)
CPK leaks across defective cell membrane
Muscle biopsy
o will show connective tissue infiltration and foci of necrosis
o will show absent dystrophin with staining
DNA testing
I II:16 The muscle biopsy reveals absence of
o shows absent dystrophin protein dystrophin staining in Duchenne muscular
EMG dystrophy (right image) compared with normal
dystrophin staining (left image) and partial
o myopathic dystrophin staining as seen in Becker's muscular
decreased amplitude, short duration, polyphasic motor dystrophy (middle image).
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Differential Diagnosis
Similar traits to Duchenne's Distinguishing traits from Duchenne's
Becker's • calf pseudohypertrophy • Becker's has slower progression of weakness
• markedly elevated CPK with diagnosis made later (~8 yrs)
• x-linked transmission • prone to cardiomyopathy
Spinal muscular • proximal weakness • onset of weakness is earlier in childhood
atrophy • absent deep tendon reflexes and fasciculations
• CPK levels are normal
• pseudohypertrophy is absent
Emery-Dreifuss • similar clinical picture • no calf pseudohypertrophy
dystrophy • CPK levels near normal
• elbow and ankle contractures develop early
Limb girdle dystrophy • progressive motor weakness • no calf pseudohypertrophy
• CPK levels are only mildly elevated
Guillain-Barre • acute onset of weakness • absent deep tendon reflexes
syndrome • CPK levels are normal
Treatment
Nonoperative
o corticosteroid therapy (prednisone 0.75 mg/kg/day)
indications
5 to 7-year-old child with progressive disease
goals
to maintain ambulatory capacity as long as possible
outcomes
significant positive effect on disease progression
acutely improves strength, slows progressive weakening, prevents scoliosis formation,
and prolongs ambulation
delays deterioration of pulmonary function
side effects
osteonecrosis
weight gain
cushingoid appearance
GI symptoms
mood lability
headaches
short stature
cataracts
o pulmonary care with nightly ventilation
o rehabilitation
techniques
physical therapy for range of motion exercises
adaptive equipment
power wheelchairs
KAFO bracing (controversial)
Operative
o soft tissue releases to prolong ambulation
indications : ambulatory child with Duchenne's
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Muscular Dystrophies
techniques
hip abductor and hamstring releases
Achilles tendon and posterior tibialis lengthenings
postoperative care
early mobilization and ambulation to prevent deconditioning
o scoliosis surgery (see below)
Scoliosis
Introduction
o considered a neurogenic curve
o occurs in 95% of patients after becoming wheelchair dependent
o curve progresses rapidly from age 13 to 14 years
begins with mild hyperlordosis
progresses with general kyphosis and scoliosis with varying degrees of pelvic obliquity
progresses 1° to 2° per month starting at age 8 to 10 years
o patients may become bedridden by age 16
o treatment is complicated by restrictive pulmonary disease (significant decrease in forced vital
capacity)
o cardiac and pulmonary function studies should be obtained pre-operatively as significant declines
in function of both organ systems may make spinal fusion too high-risk
Treatment
o nonoperative
bracing is contraindicated
may interfere with respiration
o operative
early PSF with instrumentation
indications
curve 20-30° in nonambulatory patient
treat early before pulmonary function declines
can wait longer ~ 40° if responding well to corticosteroids
FVC drops ≤ 35%
rapidly progressive curve
PSF with instrumentation to pelvis
indications
curves ≥ 40°
pelvic obliquity ≥ 10°
lumbar curve where apex is lower than L1
complications
malignant hyperthermia is common intraoperatively
pretreat with dantrolene
intraoperative cardiac events
anterior and posterior spinal fusion
indications
rarely for stiff curves
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Equinovarus Foot
Introduction
o common foot deformity seen with Duchenne muscular
dystrophy
Pathoanatomy
o muscle imbalance secondary to muscle replacement with
fibrofatty tissue
Diagnosis
o made upon clinical exam
Treatment
o nonoperative
stretching, physical therapy, and night time AFO use
o operative
Tendinoachilles lengthening with posterior tibialis tendon transfer, toe flexor
tenotomies
Classification
Type 1A (FSHD1A)
o most common form
o also referred to as chromosome 4 linked
Type 1B (FSHD1B)
o rare
o also referred to as non-chromosome 4 linked
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Muscular Dystrophies
Infantile
o more severe subtype of Type 1A and 1B and symptoms present earlier (~ 5 years old)
o most patients become wheelchair bound during the 2nd decade of life
o marked lumbar lordosis is progressive and is pathognomonic for infantile FSHD
o hearing loss, vision problems and seizures have been documented
o have severely compromised pulmonary function and succumb in early adolescence
Presentation
Symptoms
o slow muscular weakness over time
Physical Exam
o inspection
scapular winging with limited arm abduction
causing prominent shoulder blades
incomplete eye closure
transverse smile
absence of eye and forehead wrinkles
selective sparing of deltoid, distal part of pectoralis major, and erector
spinae muscles
o motion
I II:17 Marked
marked decrease in shoulder flexion and abduction lumbar lordosis
Studies
Labs
o CPK levels usually normal
Electrodiagnostic
o EMG usually shows mild myopathic changes
Muscle Biopsy
o nonspecific chronic myopathic changes
o performed only in those individuals in whom FSHD is suspected
but not confirmed by molecular genetic testing
Genetic Testing
o 95% sensitive and highly specific for FSHD III:18 Transverse smile sign
Treatment
Nonoperative
o PT/OT, speech therapy
indications
shoulder girdle and upper arm weakness
to maintain strength and range of motion of affected muscles
outcomes
although their arms become gradually weaker from adolescence on, patients can usually
work into later life
Operative
o scapulothoracic fusion
indications
scapular winging
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technique
wiring of the medial border of the scapula to ribs three through seven
internal fixation is achieved with 16-gauge wire
wires ensure firm fixation and eliminate the need for postoperative immobilization and
subsequent rehabilitation
child uses a sling for 3 to 4 days postoperatively, and then begins a physical therapy
program
outcomes
increased active abduction and forward flexion of the shoulder, and improved function as
well as cosmesis
D. Disproportionate dwarfism
1. Achondroplasia
Introduction
Epidemiology
o most common skeletal dysplasia
Genetics
o autosomal dominant (AD)
o a sporadic mutation in >80%
risk increases with advanced paternal age
o caused by G380 mutation of FGFR3 (fibroblast growth factor receptor 3, on chromosome 4P)
gain of function mutation that increases inhibition of chondrocyte proliferation in
the proliferative zone of the physis
results in defect in endochondral bone formation
a quantitative cartilage defect
Associated conditions
o medical conditions
weight control problems
hearing loss
tonsillar hypertrophy
frequent otitis media
o spinal manifestations
lumbar stenosis
patients at risk due to short pedicles, thick facets and ligamentum flavum
most likely to cause disability
thoracolumbar kyphosis
foramen magnum stenosis
may cause periods of apnea or suddent death in infants
Presentation
Symptoms
o history
normal intelligence
delayed motor milestones
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o symptoms of spinal stenosis
pseudoclaudication and standing discomfort
numbness and paresthesias
subjective weakness
Physical exam
o rhizomelic dwarfism
humerus shorter than forearm and femur shorter than tibia
normal trunk
adult height ~ 50 inches
o facial features
frontal bossing
o extremities
trident hands (fingers same length with divergent ring and middle
Imaging
Radiographs
o lumbar spine findings
shortened pedicles
decreased interpedicular distance from L1-S1 (pathognomonic)
vertebral wedging in thoracolumbar kyphosis
posterior vertebral scalloping
o pelvis and extremities
recommended views
AP pelvis and weight-bearing hip-to-ankle AP
III:20 a trident hand
findings characterized by splaying of
champagne glass pelvis (pelvis is wider than deep) the 2nd through 4th digits
along the AP axis of the hand
Squared iliac wings in the plane of the palm with
Inverted V in distal femur physis relatively normal positioning
of the 1st and 5th digits.
MRI
o indications
to evaluate spinal stenosis
adjunct to sleep study for screening foramen magnum stenosis in infants
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AP and lateral xray spine A cone down radiographic view of the The lateral radiograph of a lumbar
(achondroplasia) showing lumbar spine reveals shortened spine in achondroplasia reveals the
thoracolumbar kyphosis and a pedicles with resultant lumbar characteristic feature of posterior
progressive decrease in stenosis characteristic of vertebral scalloping
interpedicular distance in the achondroplasia
lumbar spine in a caudad
direction.
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Disproportionate dwarfism
Treatment - Spine Conditions
Thoracolumbar kyphosis
o nonoperative
observation
90% improve
bracing
if persitent vertebral wedging after age 3 years
may be poorly tolerated
o operative
anterior strut corpectomy with posterior fusion or isolated posterior fusion
indications
bracing has failed
kyphosis of > 45-60°
Lumbar stenosis
o nonoperative
weight loss, physical therapy, corticosteroid injections
indications : first line of treatment and frequently effective
o operative
multilevel laminectomy and fusion
indications
spinal stenosis with severe symptoms
nonoperative management has failed
Lumbar hyperlordosis
o nonoperative
observation
treatment typically not required
Foramen magnum stenosis
o operative
surgical decompression of foramen magnum
indications : sleep apnea or cord compression
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Presentation
Symptoms
o short-limbed, disproportionate dwarfism
o joint pain
o waddling gait
Physical exam
o joint deformities from joint incongruity
hips are most common joint involved
valgus knee deformity common
early OA
o joint contractures
o short, stubby fingers and toes
o normal neurologic exam
o normal intelligence
o spine is normal
o normal facies
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Disproportionate dwarfism
Imaging
Radiographs
o demonstrate irregular, delayed ossification at multiple epiphyses
o may also demonstrate multiple osteochondritis dissecans lesions
o cervical spine
flexion-extension films may show instability of upper cervical spine
o hip
may show bilateral proximal femoral epiphyseal defects
distinguished from Leg-Calve-Perthes disease by its symmetric and bilateral
presentation, early acetabular changes, and lack of metaphyseal cysts
when bilateral Leg-Calve-Perthes is suspected, perform skeletal survey of other joints to
rule out MED
concurrent avascular necrosis of femoral head
acetabular dysplasia
o knee
valgus knee
flattened femoral condyles
double layer patella
o hand
may show short, stunted metacarpals
hyperextensible fingers
o foot
short metatarsals
Differential Diagnosis
Spondyloepiphyseal dysplasia
o distinct in that it also involves the spine
o typically with a sharp curve
o atlantoaxial instability
o cervical myelopathy
o mutation in type II collagen
Treatment
Nonoperative
o NSAIDS and physical therapy
indications
early OA
o childhood hip deformities such as acetabular dysplasia often resolve by skeletal maturity
Operative
o realigning osteotomy or hemiepiphysiodesis at the knee
indications
progressive genu varum or valgum
o total hip arthroplasty
indications
severe arthritis may present by age 30
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Classification
Two forms of SED exist
o SED congenita
autosomal dominant
more severe than SED tarda
o SED tarda
X-linked recessive
clinicallly less severe and does not have the lower extremity angular deformities that are
present in the congenita form
Presentation
Symptoms
o cervical myelopathy
due to atlantoaxial instability
o respiratory difficulty
due to respiratory insufficiency secondary to thoracic dysplasia
o problems with vision
due to myopia or retinal detachment
o hip pain
due to coxa varus
o decreased walking distance
due to poor muscular endurance and skeletal deformities
Physical exam
o inspection
short stature
flatened facies
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kyphoscoliosis
lumbar lordosis
coxa vara
genu valgum
o motion
decreased ROM of hips
waddling gait
Imaging
Radiographs
o recommended views
AP, lateral, open mouth views of cervical spine
III:21 Xray.Cervical.Lat: Odontoid
hypoplasia or os odontoideum leading
AP, lateral views of thoracolumbar spine to atlantoaxial instability is common in
SED. This image shows an ununited
AP, lateral views of hips
odontoid process. Flexion-extension
o alternative views lateral cervical radiographs may
reveal anterior, posterior, or
flexion-extension views of cervical, thoracolumbar spine
anteroposteri
o findings
cervical spine
upper cervical spine instability
odontoid hypoplasia or os odontoideum
thoracolumbar spine
platyspondyly (flattened vertebral bodies) is evident in
lumbar spine
incomplete fusion of spinal ossification centers
end plate irregularities and narrowed intervertebral disk
spaces
kyphoscoliosis
excessive lumbar lordosis
hips
horizontal acetabular roofs and delayed ossification of the
pubis
wide Y cartilage III:22 Xray.Spine.Lat: In SED varying
coxa vara of varying severity degrees of platyspondyly are present,
with posterior wedging of vertebral
delayed ossification of the femoral head
bodies giving rise to oval, trapezoid, or
MRI pear-shaped vertebrae, as seen in the
image below. The ossification of the
o indications
bodies may be incompletely fuse
cervical instability
symptoms of myelopathy
o findings
spinal cord signal changes
delayed ossification centers
Differential
Achondroplasia
Diastrophic dysplasia
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Treatment
Nonoperative
o multidisciplinary rehabilitation
indications
all patients to improve and maintain function
technique
should integrate
physiotherapy
monitor for weakness, increasing spine curvature, worsening hip pain
occupational therapist
ophthalmologist
obtain yearly eye examination
pulmonologist
monitor for declining lung function
orthopaedic surgeon
possible bracing for mild scoliosis
Operative
o posterior atlantoaxial fusion
indications
atlantoaxial instability measuring 8 mm or more
myelopathy
techniques
posterior instrumentation
o posterior thoracolumbar instrumentation
indications
spinal scoliosis curvatures >50 degrees
techniques
distraction spinal rods (younger aged patients)
posterior instrumented spinal fusion (older aged patients)
o valgus intertrochanteric osteotomy
indications
coxa vara angle <100 degrees
progressive coxa vara
symptomatic hip arthritis
techniques
valgus + extension osteotomy may help to decrease an associated hip flexion deformity
reconstructive measures may be indicated in patients with subluxation, hinge abduction,
or osteoarthritis.
open reduction and fixation of proximal femur and acetabulum to treat hip dislocations.
Complications
Cervical spine instability
Spinal deformity
o including scoliosis, kyphosis, lordosis
Ocular abnormalities
Hip deformities
Degenerative joint disease
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Disproportionate dwarfism
4. Diastrophic Dysplasia
Introduction
A form of short-limbed dwarfism caused by failure of formation of secondary ossification center
(epiphysis)
o associated with progressive deformity
Epidemiology
o more common Finland
o rare in rest of world
Genetics
o autosomal recessive
o mutation in DTDST gene (SLC26A2) on chromosome 5
encodes for sulfate transporter protein
mutation is present in 1 in 70 Finnish citizens III:23 Cauliflower ears
leads to undersulfation of cartilage proteoglycan
Presentation
Physical exam and syndrome features
o short stature ("twisted dwarf")
rhizomelic shortening
o cleft palate (60%)
o cauliflower ears (80%)
o poorly developed UE
III:24 Hitchhikers thumb
o hitchhikers thumb
o thoracolumbar scoliosis
o severe cervical kyphosis
o hip and knee contractures
o genu valgum
o skewfoot (serpentine or Z foot)
tarsometatarsal adductus and valgus hindfoot
o rigid clubfeet (equinocavovarus)
Imaging
Radiographs III:25 Severe cervical kyphosis
o recommended views
AP and lateral of cervical spine and thoracolumbar spine
three joint standing lower extremity films to assess alignment
Ultrasound
o can be used to make diagnosis prenatally
Treatment
Nonoperative
o observation and supportive treatment
indications : most patients
modalities
III:26 Rigid clubfeet
cauliflower ears frequently repsond to early treatment with compressive bandages
cervical kyphosis frequently resolves spontaneously
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Operative
o occipital-cervical fusion
indications
atlantoaxial instability with neurologic symptoms: risk of quadriplegia is a concern
o posterior cervical fusion
indications
cervical kyphosis that does not resolve spontaneously
o thoracolumbar fusion
indications
kyphoscoliosis of thoracolumbar spine
if progressive may require ASF / PSF
o soft tissue surgical release
indications
early foot ankle deformity after initial period of casting
severe joint contractures (hip and knee)
o osteotomies for correction
indications
progressive valgus deformity of lower extremities (with dislocated patellae)
resistant or recurrent clubfeet
distal femoral extension osteotomies for fixed knee flexion contractures
valgus intertrochanteric osteotomies +/- acetabuloplasty for early hip subluxation
o total joint arthroplasty
indications : end stage osteoarthritis of hips
5. Kniest's Dysplasia
Introduction
Form of disproportionate short-trunk dwarfism
o a Type II collagenopathy
Genetics
o autosomal dominant
o defect in COL2A1 (missense, splice or deletion)
o defect leads to abnormal Type II collagen, chondrocyte degeneration, cytoplasmic inclusions
Associated conditions
o orthopaedic manifestations
short stature
disproportionate short-trunk dwarfism
joint stiffness / contractures
dumbell-shaped femora
hypoplastic pelvis and spine
scoliosis & kyphosis
early osteoarthritis
o medical conditions
respiratory problems
cleft palate
retinal detachment and myopia
otitis media with hearing loss
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Presentation
Physical exam
o disproportionate short-trunk dwarfism
o joints enlarged and stiff
o scoliosis & kyphosis
o cleft lip
o round face with central depression
o prominent eyes
o bell-shaped chest
Imaging
Radiographs
o osteopenia
o dumbbell-shaped metaphyseal bone
o coxa vara
o genu valgum
6. Metaphyseal Chondrodysplasia
Introduction
Heterogeneous group of disorders characterized by metaphyseal changes of the tubular bones with
normal epiphyses
Epidemiology
o incidence : skeletal dysplasias occur at a rate of 2 to 3 newborns per 10,000 births
Pathophysiology
o metaphyseal dysplasia involving the proliferative and hypertrophic zone of the physis (epiphysis
is normal)
Genetics
o three main subtypes
Jansen (rare, most severe form)
autosomal dominant
genetic defect in parathryoid hormone-related peptide (PTHrP)
Schmid (more common, less severe form)
autosomal dominant
genetic defect in type X collagen
McKusick
autosomal recessive
most commonly occurs in Amish and Finnish populations
cartilage-hair dysplasia (hypoplasia of cartilage and small diameter of hair)
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Associated conditions
o birth defects : can be mimicked by teratogenic
o rickets
Schmid type often confused for rickets
Classification
Table of Metaphyseal Chondrodysplasias
Type Genetics Characteristic Comments
Jansen's autosomal dominant mental retardation ostebulbous metaphyseal
defect in parathyroid short limbed dwarfism expansion of long bones seen
hormone related peptide wide eyes on xray
(PTHRP) receptor monkey like stance
Schmid's autosomal dominant short limbed dwarfism diagnosed when patient older
defect in Type X collagen excessive lumbar lordosis due to coxa vara and genu
severe thigh and leg bowing, varum
genu varum often confused with Ricketts
wrist swelling, elbow
contractures
trendelenburg gait
McKusicks autosomal reccessive cartilage hair dysplasia (hair seen in Amish population and
had small diameter) in Finland
atlantoaxial instability
ankle deformity due to fibular
overgrowth
immunologic deficiency and
increased risk for malignancy
Presentation
Jansen type
o mental retardation
o markedly-short limbed dwarfism with:
wide eyes
monkey-like stance
hypercalcemia
Schmid type
o often not diagnosed until older age due to marked coxa vara and genu varum
o short-limbed dwarf involving:
Trendelenburg gait
predominate proximal femur involvement
increased lumbar lordosis
normal laboratory results
McKusick type
o common associated with
atlantoaxial instability secondary to odontoid hypoplasia
ankle deformity due to fibular overgrowth
associated with:
abnormal immunocompetence
increased risk for malignancies
intenstinal malabsorption
megacolon
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Imaging
Radiographs
o Jansen type
AP pelvis, hip, knee, and upper extremity radiographs
reveals bulbous expansion of metaphysis
o Schmid type
AP pelvis and hip radiographs
rule out coxa vara
standing lower extremity films
rule out genu varum
o McKusick type
cervical AP, lateral, flexion and extension views
rule out atlantoaxial instability
ankle AP, oblique and lateral views
surveillance of potential distal fibular overgrowth
o Metaphyseal dysplasia involving the proliferative and hypertrophic zone of the physis (epiphysis
is normal)
Treatment
Operative
o posterior atlantoaxial fusion
indications
atlantoaxial instability measuring 8 mm or more
myelopathy
techniques : posterior instrumentation
o valgus intertrochanteric osteotomy
indications
coxa vara angle <100 degrees
progressive coxa vara
symptomatic hip arthritis
techniques
valgus + extension osteotomy may help to decrease an associated hip flexion deformity
reconstructive measures may be indicated in patients with subluxation, hinge abduction,
or osteoarthritis.
open reduction and fixation of proximal femur and acetabulum to treat hip dislocations.
o tibial osteotomies or hemiepiphysiodeses : indications
symptoms are severe
nonoperative modalities have failed
o limb lengthening through a metaphyseal corticotomy
indications : controversial due to high rate of complications
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E. Proportionate dwarfism
Presentation
Symptoms
o usually asymptomatic
Physical exam
o hypermobility of the shoulders
o frontal bossing
o hand deformities
examine middle phalanges for shortening
o delayed formation of permanent teeth
o abnormal range of motion at hips
if severe coxa vara may be present
Imaging
Radiographs
o recommended
AP chest
to identify clavicular dysmorphism
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Proportionate dwarfism
lateral skull
look for delayed closure of sutures
AP pelvis
look for coxa vara
look for failure of pubis to ossify
AP hands
short middle phalanges
Treatment
Nonoperative
o observation
indications : clavicular hypoplasia
outcomes
most manifestations associated with this disease do not need intervention
Operative
o intertrochanteric osteotomy
indications
coxa vara with a neck shaft angle of less than 100 degrees
2. Mucopolysaccharidoses
Introduction
A group of 13 metabolic syndromes caused by the absence or malfunctioning of lysosomal
enzymes which break down glycosaminoglycans
o main forms include
Morquio syndrome and Sanfilippo syndrome most common
Hurler syndrome
Hunter syndrome
Pathophysiology
o lysosomal storage disorders due to incomplete glycosaminoglycan breakdown products
(mucopolysaccharides) accumulating and causing dysfunction in various organs
glycosaminoglycans are long sugar carbohydrate chains that help
build bone, cartilage, tendons, corneas, skin and connective tissue
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Associated conditions
o orthopaedic manifestations
proportionate dwarfism
increased rate of carpal tunnel syndrome
C1-C2 instability
delayed hip dysplasia
abnormal epiphyses
bullet-shaped phalanges
genu valgum
o nonorthopaedic conditions
complex sugars in the urine
visceromegaly
corneal clouding
cardiac disease
deafness
mental retardation (except Morquio syndrome)
enlarged skull
Prognosis
o bone marrow transplant improves life expectancy, but doesn't alter orthopaedic manifestations
Studies
Labs
o urine test (toluidine blue-spot test) to analyze the excess mucopolysaccharides
o skin fibroblast culture to test enzyme activity
o chorionic villous sampling
Morquio Syndrome
Characterized by accumulation of keratan sulfate
o interferes with the cartilage at the growth plate
o presents at 18-24 months
Pathophysiology
o Type A (galactosamine-6-sulfate-sulphatase deficiency)
o Type B (beta-galactosidase deficiency)
Genetics
o autosomal recessive
Prognosis
o Type A is more severe
o Type A and B survive into adulthood
Presentation
o proportionate dwarfism
o normal intelligence
o waddling gait
o genu valgum
o thoracic kyphosis
o corneal clouding
Radiographs
o thickened skull
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o wide ribs
o vertebral beaking
o coxa vara with unossified femoral head
o bullet-shaped metacarpals
o odontoid hypoplasia leading to cervical instability (obtain flexion-extension x-rays)
o thoracic kyphosis with platyspondia
Studies
o keratan sulfate in urine
Treatment
o decompression and cervical fusion
indications
myelopathy with C1-C2 instability
o realignment osteotomies
restores plumb alignment to limb
malalignment commonly recurs
o guided growth
attractive alternative to osteotomies, but there is a lack of evidence
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o multiple enzyme deficiencies
Genetics
o autosomal recessive
Prognosis
o death in second decade of life
Presentation
o mental retardation
o proportionate dwarfism
o clear cornea
Studies
o heparan sulfate in the urine
Treatment
o bone marrow transplant
has increased lifespan
Hunter Syndrome
A mucopolysacharidosis characterized by accumulation of dermatan/heparan sulfate
Pathophysiology
o sulpho-iduronate-sulphatase deficiency
Genetics
o X-linked recessive
Prognosis
o death by 2nd decade of life
Presentation
o mental retardation
o proportionate dwarfism
o clear cornea
Studies
o dermatan/heparan sulfate in urine
1. Osteogenesis Imperfecta
Introduction
A hereditary condition resulting from a decrease in the amount of normal Type I collagen
Pathophysiology
o can result from
decreased collagen secretion
production of abnormal collagen
o leads to insufficient osteoid production
physeal osteoblasts cannot form sufficient osteoid
periosteal osteoblasts cannot form sufficient osteoid and
therefore cannot remodel normally
Genetics
o 90% have an identifiable genetic mutation
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Collagen & Bone
COL 1A1 and COL 1A2
causes abnormal collagen cross-linking via a glycine substitution in the procollagen
molecule
o autosomal dominant and autosomal recessive forms
milder autosomal dominant forms (Types I and IV)
severe autosomal recessive forms (Types II and III)
o CRTAP and LEPRE1 genes associated with severe, lethal forms of OI not associated with
primary structural defect of type I collagen
Orthopaedic manifestations
o bone fragility and fractures
fractures heal in normal fashion initially but the bone does not remodel
can lead to progressive bowing
o ligamentous laxity
o short stature
o scoliosis
o codfish vertebrae (compression fx)
o basilar invagination
o olecranon apophyseal avulsion fx
o coxa vara (10%)
Non-Orthopaedic manifestations
o blue sclera
o dysmorphic, triangle shaped facies
o hearing loss
50% of adults with OI
may be conductive, sensorial and mixed
o brownish opalescent teeth (dentinogenesis imperfecta)
alteration in dentin
brown/blue teeth, soft, translucent, prone to cavities
affects primary teeth > secondary teeth
o wormian skull bones (puzzle piece intrasutural skull bones)
o hypermetabolism
increased risk of malignant hyperthermia
hyperhidrosis, tachycardia, tachypnoea, heat intolerance
o thin skin prone to subcutaneous hemorrhage
o cardiovascular
mitral valve prolapse
aortic regurgitation
Anatomy
Type I collagen is the most important structural protein of bone, skin, tendon, dentin, sclera
triple helix structure
o two alpha-1 chains coded by genes COL1A1
o one alpha-2 chain coded by gene COL1A2
o triple helix structure is possible because of glycine at every 3rd amino acid residue
genetic mutations alter triple helix by substitution of glycine with another amino acid
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Classification
Sillence originally classified into four types
o however most likely a continuum of disease
o additional types have been added
o 90% of patients can be grouped into the Sillence Type I and IV
Presentation
Symptoms
o mild cases
multiple fractures during childhood
o severe cases
present with fractures at birth and can be fatal
number of fractures typically decreases as
patient ages and usually stops after puberty
o basilar invagination
presents with apnea, altered consciousness,
ataxia, or myelopathy
usually in third or fourth
decade of life, but can be as
early as teenage years
Physical exam
o multiple fractures leads to
saber shin appearance of tibia
bowing of long bones
o trendelenburg gait
if coxa vara present
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Collagen & Bone
Imaging
Radiographs
o thin cortices
o generalized osteopenia
o saber shins
o skull radiographs reveal wormian bones
o coxa vara
Evaluation
Labroratory
o mildly elevated ALP
Histology
o increased diameter of haversion canals and osteocyte lacunae
o replicated cement lines
o increased number of osteoblasts and osteoclasts
o decreased number of trabeculae III:29 Saber shins
xray
o decreased cortical thickness
Diagnosis
o diagnosis is based on family history associated with typical radiographic and clinical features
o Labs
no commercially available diagnostic test due to variety of genetic mutations
laboratory values are typically within normal range
o possible methods diagnosis include
skull radiographs to look for wormian bones
fibroblast culturing to analyze type I collagen (positive in 80% of type IV)
can be used for confirmation of diagnosis in equivocal cases
biopsy
collagen analysis of a punch biopsy
iliac crest biopsy which shows a decrease in cortical widths and cancellous bone volume,
with increased bone remodeling.
Treatment of Fractures
Fracture prevention
o early bracing
indicated to decrease deformity and lessen fractures
o bisphosphonates
indicated in most cases of OI to reduce fracture rate, pain, improve ambulation
marked improvement in pain at 1-6wk after initiation
inhibits osteoclasts
increases cortical diameter 88%
increases cancellous bone volume 46%
does not affect development of scoliosis
chronic use causes horizontal metaphyseal bands seen on radiographs
growth arrest lines
maintain bisphosphonate-free period around the time of IM rodding
interferes with osteotomy healing >> fracture healing
o growth hormone
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o bone marrow transplantation
has been used with some success
Fracture treatment
o nonoperative
observation
indications
indicated if child is <2 years (treat as child without OI)
o operative
fixation with telescoping rods
indications
consider in patients > 2 years
allow continued growth
Treatment of Scoliosis
Vital capacity drops to 40% of expected for a 60° curve
Nonoperative
o observation
indications: if curve is <45 °
o bracing is ineffective and not recommended
because of fragility of ribs
Operative
III:30 Sofield-Miller procedure
o posterior spinal fusion
indications
for curves > 45 ° in mild forms and > 35 ° in severe forms
technique
challenging due to fragility of bones
use allograft instead of iliac crest autograft due to paucity of bone
ASF only indicated in very young children to prevent crankshaft
associated with a large blood loss
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2. Osteopetrosis
Introduction
A metabolic bone disease caused by defective osteoclastic resorption of immature bone
Epidemiology
o prevalence
approximately 1 in 3.3 million
o demographics
genetic inheritance (3 types)
malignant autosomal recessive
intermediate autosomal recessive
benign autosomal dominant (most common)
penetrance
may skip generations
75% gene penetrance
Pathophysiology
o pathoanatomy
osteoclast dysfunction leads to dense bone and obliterated medullary canals
caused by osteoclast inability to acidify Howship's lacuna
leads to predisposition to fracture
lower extremity > upper extremity > axial skeleton
lifelong prevalence of fracture ~ 40-50%
o Associated conditions
head
cranial nerve palsies
from overgrowth of skull foramina
optic n. > auditory n. > trigeminal n. > facial n.
osteomyelitis
due to lack of marrow vascularity and impaired WBC function
spine
lower lumbar pain
increased prevalence of spondylolysis
pelvis
coxa vara
commonly due to femoral neck fracture nonunion or repeated stress fractures
increased risk of degenerative joint arthritis
extremities
increased tendency for long bone fractures
often low energy
transverse
increased risk of delayed union and malunion
carpal tunnel syndrome
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Classification
Genetic Forms
Type Genetic Clinical Presentation
proton pump or chloride channel dysfunction
Malignant Autosomal recessive pancytopenia, hepatosplenomegaly and infection
fatal at an early age without bone marrow transplant
carbonic anhydrase II dysfunction or chloride channel
Intermediate Autosomal recessive dysfunction
usually live into adulthood
chloride channel dysfunction
Type I does not have increased fracture risk
Type II is known as Albers-Schonberg disease (anemia,
Benign Autosomal dominant pathologic fractures, and premature osteoarthritis)
general health, life span, mental function, and physique are
normal
most common form to be managed by orthopaedic surgeon
Presentation
Autosomal recessive forms
o symptoms
frequent fractures
progressive deafness and blindness
severe anemia (caused by encroachment of bone on marrow) beginning in early infancy or in
utero
bleeding risk
frequent infections
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Collagen & Bone
o physical exam
macrocephaly
hepatosplenomegaly (caused by compensatory extramedullary hematopoiesis)
dental abscesses and osteomyelitis of the mandible
Autosomal dominant form
o symptoms
usually asymptomatic
fractures
first learn of disease after fracture
usually a low energy pathologic fracture to lower extremity
anemia (fatigue)
joint pain
lower back pain common
early hip osteoarthritis
o physical exam
general
normal height and appearance
generalized osteosclerosis
range of motion
usually normal unless underlying osteoarthritis
head and neck
high risk of cranial nerve palsy
Imaging
Radiographs
o recommended views
AP and lateral of bone of interest
o general findings
increased cortical thickening
increased overall bone density
loss of medullary canal diameter
bone-in-bone appearance
o additional findings
"erlenmeyer flask" proximal humerus and distal femur
"rugger jersey spine" with very dense bone
block femoral metaphysis
coxa vara
Studies
Histology
o histology shows defective osteoclasts
lack ruffled border and clear zone
islands of calcified cartilage within mature trabeculae
o empty lacunae and plugging of the haversian canals also seen
Laboratory studies
o autosomal recessive
increases acid phosphatase
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may have increased PTH +/- calcium
o autosomal dominant
usually normal
Treatment
Medical management
o bone marrow transplant
indications
autosomal recessive (infantile-malignant) form
o high dose calcitriol (1,25 dihydroxy vitamin D), bone marrow transplant
indications
autosomal recessive (infantile-malignant) form
o interferon gamma-1beta
indications
autosomal dominant form
Cranial nerve impingment
o Neurosurgical decompression
Fracture management
o nonoperative
indications
diaphyseal long bone fractures
upper extremity fractures
techniques
prolonged casting and non-weight bearing
acceptable bone alignment, rotation and length
outcomes
healing may be delayed
fracture remodeling limited
increased risk of malunion and refracture
o operative
indications
proximal femur fractures
techniques
plate and screws
avoid intramedullary devices
slow steady drilling
constant cooling and change of drill bit
outcomes
increased risk of hardware failure
higher union rates and lower malunion rates compared to non-operative management
decreased risk of coxa vara
Degenerative joint disease
o total hip arthroplasty
indication
end stage osteoarthritis
techniques
femur
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Chromosomal Syndromes
cannulated reamers under fluoroscopy
short stemmed implants
usually uncemented components are used
acetabulum
small, sharp reamers
irrigation
multiple screws
o total knee arthroplasty indication
indications
end stage osteoarthritis
technique
consider navigation
Complications
Refracture
o caused by
hard brittle bones
hardware failure
Infection
o increased risk due to reduced tissue vascularity
Malunion
Non-union
G. Chromosomal Syndromes
1. Down Syndrome
Introduction
Definition
o genetic disorder of childhood caused by the presence of an extra chromosome 21
Epidemiology
o incidence
most common chromosomal abnormality in the United States
1:700 live births
o risk factors
advanced maternal age. 1 in 250 if mother > 35 yo, 1 in 5000 if < 30 yo
Genetics
o maternal duplication of chromosome 21, yielding a trisomy 21
o chromosome 21 codes for Type VI Collagen (COL6A1, COL6A2)
critical component of skeletal muscle extracellular matrix
dysfunction may contribute to generalized joint laxity
Associated conditions
o orthopaedic manifestations
generalized ligamentous laxity and hypotonia
short stature
C1-2 instability
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Occipitocervical Instability
delayed motor milestones (walk at 2-3 years of age)
hip subluxation and dislocation
patellofemoral instability and dislocation
scoliosis & spondylolisthesis
pes planus
metatarsus primus varus
SCFE
o medical conditions and comorbidities
mental retardation
cardiac disease (50%)
endocrine disorders (hypothyroidism)
premature aging
duodenal atresia
hypothyroidism
Alzheimer's disease
Presentation
Symptoms
o determining degree of symptoms can be difficult
Physical exam
o HEENT
flattened facies
upward slanting eyes
epicanthal folds
o upper extremity
single palmar crease (simian crease)
ligamentous laxity
o spine
scoliosis
o neuro
mental retardation of varying degrees
hearing loss
Spine Conditions
Atlantoaxial Instability
o epidemiology
instability is present in 17.5%
o presentation
may be subtle
manifests as a loss or change in gait or bowel/bladder symptoms
o radiographs
may obtain flexion-extension cervical spine radiographs (indications vary, routine screening
radiographs likely not needed)
flexion-extension films are needed to confirm stability prior to intubation
atlantodens interval (ADI) of <5mm is normal
In general, 5-10mm of motion can be considered normal in this population
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o treatment
nonoperative
routine follow up with neurologic evaluation and repeat imaging
indications
for ADI 5-10, no neurologic findings, and imaging with >14mm space available
for the cord.
operative
C1-2 posterior spinal fusion
general indications
ADI >5mm and symptomatic/myelopathic or ADI >10mm
<14mm space available for the cord
complications
reported complication rate up to 50%
sports participation
asymptomatic patients with instability should avoid contact sports, diving, and gymnastic
Occipitocervical Instability
o imaging
Powers ratio
used to diagnosis occipitocervical instability
o treatment
observation with limitation of contact sports activity
indications
vast majority of patients
posterior occipitocervical fusion
indications
progressive neurologic deficits and myelopathy
Lumbar Spondylolithesis
o present in 6% of patients with Down's Syndrome
Scoliosis
o treatment
bracing for Curves 25-30 degrees
spinal Fusion for curves >50 degrees
o complications
complication rate with surgical treatment likely greater than idiopathic scoliosis
Knee Conditions
Patellofemoral instability
o radiographs
lower extremity to evaluate for genu valgum
sunrise or Merchant view to evaluate degree of subluxation or dislocation
o treatment
nonoperative
observation only
indications
in skeletally mature patient with no pain
patellar stabilizing brace
indicated if symptomatic
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operative
lateral release, medial reefing, semitendiniosus tenodesis, or tibial tubercle
osteotomy
indications
symptomatic patients
osteotomy for skeletal mature patients
Hip Conditions
Hip instability
o introduction
may be subluxation of dislocation
caused by ligamentous laxity and muscle hypotonia
occurs between 2-10 years of age
occurs in 5% of patients
o treatment
nonoperative
abduction bracing
indications
younger child without bony changes or dislocation
operative
capsulorrhaphy and pelvic and femoral varus osteotomies
indications
symptomatic older children
surgery associated with high complication rate
Slipped capital femoral epiphysis
o introduction
evaluate for concomitant hypothyroidism
o radiographs
AP and Frog Pelvis
o treatment
operative
pinning of affected and contralateral hip
Foot Conditions
Pes Planus and Planovalgus
o introduction
seen in 50% of patients
o treatment
orthotics
indications
if symptomatic
surgery correction
indications
if refractory symptoms
Metatarsus primus varus
Hallux valgus
o seen in 25% of patients
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Chromosomal Syndromes
2. Prader-Willi Syndrome
Introduction
Epidemiology
o incidence
1 in 25,000 births
Genetics
o partial chromosome 15 deletion
Associated conditions
o orthopaedic
growth retardation
hip dysplasia
juvenile onset scoliosis
genu valgum
pes planus
leg length difference
o medical
hypotonic
obese
intellectually impaired
insatiable appetite
hypoplastic genitalia
Presentation
Symptoms
o failure to thrive in infancy
o weak cry
o aggressive behavior
o abnormal facial features
almond-shaped eyes
small, down-turned mouth
Physical exam
o small for gestational age
o hypoplastic or undescended testicles
o delayed onset of puberty
o truncal obesity at 1-4 years of age
o slow motor development
o may show signs of right-sided heart failure
o knee and hip instability
Imaging
Radiographs
o recommended views
scoliosis films
consider AP pelvis to identify hip dysplasia
Evaluation
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Diagnosis is based primarily on physical exam at infancy
Labs
o glucose intolerance
o high insulin level
o failure to respond to LHrF
o high CO2, low O2
Genetic testing
o may identify missing portion of chromosome 15 to confirm diagnosis
Treatment
Nonoperative
o bracing
indications: curves over 20°-25° in children less than 10 years of age
efficacy may be compromised by obesity
Operative
o growth rods
indications
children under the age of 10 who cannot maintain a curve under 50°
o posterior spinal fusion
indications- older children with curves greater than 50°
complications may be higher than in idiopathic scoliosis
3. Turner's Syndrome
Introduction
Epidemiology
o incidence
1 in every 2,000 live births
o demographics
only in females
Less than 10% of cases are diagnosed antenatally
Largest proportion are diagnosed between ages 10 to 16
Genetics
o mutation
45 XO gentoype
Associated condtitions
o medical
sexual infantilism
malignant hyperthermia common with anethesia
o orthopaedic
cubitus valgus
idiopathic scoliosis (may be exacerbated by growth hormone therapy)
genu valgum
short 4th metacarpals
congenital hip dislocation
web neck
osteoporosis
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Other Syndromes
Presentation
Symptoms
o amenorrhea
o short stature
o webbed neck
Physical exam
o amenorrhea with present uterus
o coarctation of the aorta may be evident on auscultation
o low hairline in back
o low-set ears
o extremity edema
o hypertension
o signs of thyroid dysfunction
o stool guaiac may identify GI bleeding
Imaging
Radiographs
o recommended views
triplanar films of the hand
biplanar knee films
o findings
short fourth metacarpal on AP view
genu valgum on AP of knees
Treatment
Nonoperative
o monitor for osteoporosis
H. Other Syndromes
1. Rett Syndrome
Introduction
Progressive impairment and developmental delays seen in girls 6-18 months
Epidemiology
o incidence : 1 in 10,000 births
o demographics
male fetuses (only 1 X chromosome) do not survive to term
female fetuses (1 mutated gene, 1 normal gene) survive and manifest disease
Pathophysiology
o affects the grey matter of the brain
Genetics
o inheritance pattern : X-linked dominant pattern
o mutation
MECP2 gene mutation
this gene encodes the methyl-CpG-binding protein-2, which methylates DNA
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95% de novo mutation
mutation is on male copy of X chromosome
Associated conditions
o medical conditions
development delay
seizures : 80% of cases
behavioral abnormalities
screaming and crying
loss of speech
gastrointestinal
constipation
o orthopaedic
spasticity and joint contractures
ataxia
hypotonia
bruxism (grinding of teeth)
chorea (abnormal hand movement)
scoliosis with C-shaped curve
develops at the age of 10
occurs in more than 50% of patients
does not respond to bracing
instrumentation must include entire scoliotic and kyphotic curve
Prognosis
o half of children unable to walk after the age of ten due to deterioration of motor function
development is normal until 6 to 18 months then progressive impairment and development
delays occur
regression is rapid until the age of three
a more stable phase of progression occurs until age of 10
Presentation
Symptoms
o normal development for first 6-18 months of life
o when symptoms present, they range widely from mild to severe including
apraxia
loss of purposeful movements in the hands
often the first sign of the disease
mental slowing (i.e. signs of dementia)
abnormal breathing
difficulty ambulating
seizures
Physical exam
o apraxia
o abnormal gait
o scoliosis
o decreased head circumference
usually starts to become evident at 5-6 months
o poor circulation indicated by cold, blue extremities
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Imaging
Radiographs
o recommended views
AP pelvis
findings
coxa vara
scoliosis films
findings : C-shaped curve
Studies
Diagnosis is based primarily on patient development history and clinical observations
Genetic testing
o may identify genetic mutation responsible for disease, though not in all cases
Treatment
Nonoperative
o symptom management
there is no specific treatment for Rett's syndrome
assistance with feeding and hygeine
treat seizures
o physical therapy
indicated to avoid hand contracture
Operative
o posterior spinal fusion
indications
thoracic curve that interferes with sitting and balance
C-shaped curve does not respond to bracing
technique
instrumentation must include entire scoliotic and kyphotic curve
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o one of the following must be present to make diagnosis
rash
presence of RF
iridocyclitis
C-spine involvement
pericarditis
tenosynovitis
intermittent fever
morning stiffness
Associated conditions
o C-spine involvement
may lead to kyphosis, facet ankylosis, and atlantoaxial subluxation
o Ocular involvement
typically consists of iridocyclitis, a type of anterior uveitis
frequently indolent and requires immediate ophthalmologic evaluation for slit lamp
examination
can lead to rapid loss of vision if untreated
increase risk with positive ANA titer
o Stills disease
acute-onset JRA with multiple joint involvement, fever, rash, and splenomegaly
infection must be ruled out
male = female
usually presents at age 5-10 years
Prognosis
o 50% patients symptoms resolve without sequelae
o 25% are slightly disabled
o 25% have crippling arthritis or blindness
best prognosis pauciarticular > polyarticular > systemic
Classification
Onset
o early onset denotes onset before teens
o late onset denotes onset during teens or later
Classification of Juvenile Rheumatoid Arthritis
Polyarticular (30%) > 5 joints involved hand/wrist involvement most common.
small joint involvement o deformity is wrist ulnar deviation and flexion with MCP
symmetric findings stiffness in extended, swollen & radially deviated digits
position
Pauciarticular < 5 joints involved most common type
(50%) (oligoarticular) large joint involvement early-onset ssociated with iridiocyclitis in 50% and chronic
asymmetric findings uveitis.
o obtain opthalmology consult; requires frequent
ophthalmologic exams
o girls are affected four times more often than boys in early-
onset
o peak age 2-3 yrs
late-onset seen more frequent in boys
typical finding is a limp that improves during day
Systemic (20%) systemic symptoms includes Stills disease
poorest prognosis
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Other Syndromes
Presentation
Symptoms
o morning stiffness and joint pain
o visual changes
o fever
Physical exam
o rash
o iridocyclitis (can lead to rapid loss of vision if untreated)
Imaging
Radiographs
o often negative at presentation
o juxta-articular, late osteopenia and joint destruction can be seen if disease progressive
o obtain flexion-extension neck radiographs to rule out atlantoaxial instability
Studies
Laboratory
o rheumatoid factor
RF seropositive in <15%
associated with higher incidence of chronic, active, and progressive disease
often results in more destructive DJD
more likely to progress into adult RA
RF seronegative is more common
o ANA
ANA positive is diagnostic
o basic serology
values often normal and are not diagnostic
Treatment
Nonoperative
o immunomodulating drugs (DMARDs) and frequent ophthalmologic exams
indications
first line of treatment
medications
DMARDs (disease modifying antirheumatic drugs)
new class of medications that have had significant impact on outcomes
includes but not limited to
etanercept
TNF inhibitor
rituximab
chimeric monoclonal antibody against CD20 on B cell surface
azathioprine
purine synthesis inhibitor
high dose aspirin/NSAIDs
salicylates are now used less frequently secondary to DMARD success
occasionally, gold may be used
intra-articular steroid injections
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frequent ophthalmologic exams
slit-lamp examination twice yearly if ANA(-), every 4 months if ANA(+)
progressive iridocyclitis can lead to rapid loss of vision if untreated
Operative
o synovectomy
o epiphysiodesis
indications
LLD
affected leg typically longer
o corrective osteotomies
indications
extremity deformity
deferred until skeletal maturitity
o arthrodesis and arthroplasty
indications
for severe disease
3. Beckwith-Wiedemann Syndrome
Introduction
An overgrowth syndrome characterized by spectrum of clinical manisfestations, highlighted by:
o major criteria:
overgrowth
abdominal wall defects, incl. omphalocele
macroglossia or large tongue
o minor criteria
hemihypertrophy (10-20%)
ear anomalies
neonatal hypoglycemia
nephromegaly
Epidemiology
o incidence : 1 in 13,700 births
o demographics
1:1 male to female
Pathophysiology
o pancreatic islet cell hypertrophy causes repeated bouts of infantile
hypoglycemia resulting in spasticity
Genetics
o inheritance
sporadic in 85% of cases
autosomal dominant with incomplete penetrance in remaining 15%
o mutation
chromosome 11p15.5
Associated conditions
III:31 Left lower limb
o orthopaedic manifestations
hemihypertrophy and
hemihypertrophy prominent tongue
o medical conditions
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Other Syndromes
patients have a predisposition for embryonal tumors, i.e. Wilm's tumor, and should be
screened with US every 3-6 months until 5-8 years of age
Presentation
Physical exam
o macroglossia
o midface hypoplasia
o infraorbital creases
o anterior linear ear lobe creases
o visceromegaly
o hemihypertrophy
Imaging
Radiographs
o recommended views
comparison view of affected limb with contralateral limb
Treatment
Operative
o epiphysiodesis I II:32 AP showing hemihypertrophy
of the left femur and tibia.
indications
growth arrest of the affected limb
4. Ehlers-Danlos Syndrome
Introduction
Connective tissue disorder characterized by
o hyperelastic/fragile skin
o joint hypermobility and dislocation
o generalized ligamentous laxity
o poor wound healing
o early onset arthritis
o additional features
soft tissue and bone fragility
soft tissue calcification
mitral valve prolapse
aortic root dilatation
developmental dysplasia of the hip
clubfoot
pes planus
scoliosis
high palate
gastroparesis
Genetics
o COL5A1 or COL5A2 mutation in 40-50%
gene for type V collagen
important in proper assembly of skin matrix collagen fibrils and basement membrane
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o less common mutations identified below
Classification
Berlin Classification (1988) - revised
o Types I - XI exist
Types II and III - most common and least disabling
Villefranche Classification (1998)
o Classical - Type I (gravis) and Type II (mitis)
autosomal dominant
hyperextensible skin, widened atrophic scars, joint hypermobility
COL5A1 or COL5A2 mutation; type V collagen (co-expressed with type I collagen)
o Hypermobility - Type III (hypermobile)
autosomal dominant
large and small joint hypermobility, recurring joint subluxations/dislocations, velvety soft
skin, chronic pain, scoliosis
unknown mutation
o Vascular - Type IV (vascular)
autosomal dominant, rarely autosomal recessive
translucent skin, arterial/intestinal/uterine fragility and spontaneous rupture, extensive
bruising
COL3A1 mutation; abnormal type III collagen
o Kyphoscoliosis - Type VI (ocular scoliotic)
autosomal recessive
severe hypotonia at birth, generalized joint laxity, progressive infantile scoliosis, scleral
fragility may lead to globe rupture
mutation in PLOD gene; lysyl hydroxylase deficiency (enzyme important in collagen cross-
linking)
o Arthrochalasis - Type VIIA, VIIB
autosomal dominant
bilateral congenital hip dislocation, severe joint hypermobility, skin hyperextensibility
deletion of type I collagen exons encoding N-terminal end of COL1A1 or COL1A2
o Dermatosparaxis - Type VIIIC
autosomal recessive
severe skin fragility and substantial bruising, sagging or redundant skin
mutation in ADAMTS2 gene; type I procollagen N-terminal peptidase deficiency
Presentation
Symptoms
o double-jointedness
o easily damaged, bruised, & stretchy skin
o easy scarring & poor wound healing
o increased joint mobility, joint popping, early arthritis
especially shoulders, patellae, ankles
o chronic musculoskeletal pain (50%)
Physical exam
o a score of 5 or more on 9-point Beighton-Horan scale defines joint hypermobility; however this
threshold varies in the literature
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Other Syndromes
passive hyperextension of each small finger >90° (1 point each)
passive abduction of each thumb to the surface of forearm (1 point each)
hyperextension of each knee >10° (1 point each)
hyperextension of each elbow >10° (1 point each)
forward flexion of trunk with palms on floor and knees fully extended (1 point)
joint hypermobility with small finger hypermobility of the thumb with The weight-bearing AP radiograph
dorsiflexion in an individual with apposition to the flexor surface of of bilateral feet: severe bilateral
Ehlers-Danlos syndrome. the forearm hallux valgus deformities with
incongruent first MTP joints and
bilateral metatarsus adductus.
Imaging
Radiographs
o look for joint dislocations/subluxations
o kyphoscoliosis
Echocardiogram
o cardiac evaluation with echo is mandatory in the workup
o up to 1/3 of patients have aortic root dilatation
Labs
Diagnosed by collagen typing of skin biopsy
Treatment
Nonoperative
o physical therapy, orthotics, supportive measures for pain
indications
mainstay of treatment
Operative
o arthrodesis
indications
joints recalcitrant to non-operative management
technique
soft tissue procedures are unlikely successful in hypermobile joints
o posterior spinal fusion
indications
progressive scoliosis (most common in Kyphoscoliosis Type)
technique
longer fusions needed to prevent junctional problems
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OrthoBullets2017 Pediatric Syndromes | Other Syndromes
5. Gaucher Disease
Introduction
Autosomal recessive deficiency in B-glucocerebrosidase
Epidemiology
o incidence
most common lysosomal storage disase
incidence of ~1 in 40,000 people in general population
o demographics : more common in Ashkenazi Jewish origin
Pathophysiology
o cell biology
enzyme deficency leads to disturbances in cell metabolism with accumulation of
sphingolipids in the
liver
spleen
bone marrow
Genetics
o inheritance pattern
autosomal recessive
o classification
Type 1 (B-glucocerebrosidase deficency) is most common
Type 2
Type 3 (with CNS involvement)
Classification
Classification
Type Clinical Features Prognosis
Type 1 • Easy bruising • Treatable with enzyme replacement therapy
(Adult Type) • Anemia, fractures (fatal if enzyme substitute is not given)
Type 2 • Lethal by age 3 • Untreatable and lethal during infancy
(InfantileType) • Brain and organ involvement
• Onset in teen years
• Thrombocytopenia, anemia, • Type 3 is clinically diverse.
Type 3
enlarged liver • The non-CNS effects respond well to enzyme
(JuvenileType)
• Fractures replacement therapy
• Gradual brain involvement
Presentation
Symptoms (will depend on the type of Gaucher's disease)
o Systemic Manifestations
fatigue (anemia)
prolonged bleeding (thrombocytopenia)
fever, chills, sweats (infection)
seizure, developmental delay (CNS involvement)
o Orthopaedic Manifestations
bone pain (fracture, osteomyelitis)
joint pain or contracture
bone crisis (osteonecrosis)
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Physical exam
o inspection
abnormal skin and bruising
o palpation
hepatosplenomegaly
o auscultation
cardiac mumur
o musculoskeletal
bone deformities (80% of patients with Gaucher will develop
deformities of the distal femur or proximal tibia)
joint contractures
pathologic fractures
Evaluation
Labs
o Full blood count
anemia and thrombocytopenia are common
o diagnosis confirmed by elevated plasma levels of glucocerebrosides
Histology
o bone marrow aspirate shows a giant binucleate storage cell filled with glucocerebrosides
which accumulate because of an hereditary deficiency of Beta-glucocerebrosidase
Imaging
o radiographs
chest
may reveal cardiac involvement (e.g. cardiac enlargement, etc)
skeletal
may reveal pathologic fractures, osteonecrosis, abnormal bone remodeling or joint
deformity
almost all patients have diffuse osteopenia
o CT/MRI
visceral
abdomen may reveal organomegaly
skeletal
increased prevalence of osteomyelitis in patients with Gaucher's disease
chronic vascular insults may lead to osteonecrosis in the proximal and distal femur,
proximal tibia and proximal humerus most commonly
Treatment
Nonoperative
o observation and supportive therapy
indications
unaffected patients (e.g., no blood result irregularities, minimal organ enlargement, no
bony lesions on MRI)
modalities
extended multidisciplinary approach is essential
o enzyme replacement therapy
indications
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all children and symptomatic patients
not effective in Type 2 Gaucher's disease
modalities
imiglucerase
velaglucerase alfa
taliglucerase alfa
o substrate reduction therapy
indications
less severely affected patients that cannot tolerate IV replacement therapy
modalities
miglustat
Operative
o bone marrow transplant
if performed early may be curative
Complications
Fracture management
o preoperative optimization with enzyme therapy is critical
o availability of additional blood, clotting factors and platelets due to increased bleeding risk
o anesthisologist to maintain oxygenation to avoid precipitating bone crisis
o increased risk of infection
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Other Syndromes
Presentation
Symptoms
o physical and mental disability
o poor motor coordination
o classic facial deformities
Physical exam
o short palpebral fissures
o epicanthal folds
o thin upper lip with smooth groove
o developmental delay
o microcephaly
o micrognathia
o decreased muscle tone
Differential
Other teratogen exposure
Intrauterine trauma
Cerebral palsy without FAS
7. Hemophilia
Introduction
A bleeding disorder that results from
o Hemophilia A
decreased or absent factor VIII
o Hemophilia B
decreased or absent factor IX
Epidemiology
o incidence
Hemophilia A
approx. 1 in 5000 boys/men
Hemophilia B:
approx. 1 in 30,000 boys/men
o location
excessive bleeding into joints and muscle
hemarthrosis most commonly affects the knee
other joints affected include
elbow, ankle, shoulder, and spine
Pathophysiology
o Factors VIII and IX required for the generation of thrombin in the intrinsic coagulation pathway
o results in unstable clot formation and excessive bleeding
Genetics
o inheritence pattern
congential hemophilia
X-linked recessive disorder (typically affects males only)
aquired hemophila
rare condition with autoimmune ethiology, with no genetic inheritence
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Orthopaedic manifestations
o hemophilic arthropathy
synovitis
cartilage destruction
joint deformity
pseudotumor
o intramuscular hematoma (pseudotumor)
may lead to nerve compression
iliacus hematoma may compress femoral nerve and presentswith paresthesias in the L4
distribution
o leg length discrepancy
due to epiphyseal overgrowth
o fractures
due to generalized osteopenia
will heal in normal time
o compartment syndrome
Prognosis
o natural history of diease
Disease severity determined by degree of coagulation factor deficiency
mild: 5-25%
moderate: 1-5%
severe: 0-1%
o prognositc variables
treatment related inhibitors (e.g. Immunoglobulin G antibody inhibitors)
IgG antibody to clotting factor proteins
inhibits response of therapeutic factor replacement
present in 4-20% of hemophillia patients and can develop at any time
presence is a relative contraindication for surgery
blood borne infections
high risk of viral transmission
prevalence of HIV in hemophiliacs is approx. 10-15%
allergic reaction to infused blood products
Presentation
History
o male gender
o family history of hemophilia, usually maternal uncles
Symptoms
o recurrent or severe bleeding
o bleeding in unusual places (e.g. joints)
o mucocutaneous bleeding (e.g. gums, nose, easy bruising)
Physical Examination
o inspection
pallor
joint effusions
bruising
o movement
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Other Syndromes
joint tenderness
decreased ROM
focal neurological deficits
muscle pain (bleeding most commonly in quadriceps, hamstrings, iliopsoas, biceps, triceps)
Imaging
Radiographs
o recommended views of knee
AP, lateral, oblique and skyline
o general findings
epiphyseal overgrowth
generalized osteopenia
fractures
irregularity of the joint space
joint effusion
o specific findings
squaring of patella and femoral condyles (Jordan's sign)
ballooning of distal femur
widening of intercondylar notch
patella appear long and thin on lateral
CT scan
o indication
evaluate pseudotumors
characterize fracture pattern
o findings
determine the location of pseudotumor in soft-tissue or bone
better visualization of fracture pattern and characteristic
MRI better than CT at visualizing soft tissue characteristics
MRI
o indication
soft tissue evaluation
evaluate cartilage
o findings
hemarthrosis, synovitis, and hemosiderin deposition in the joint
best visualization modality of soft-tissue anatomy
Ultrasound
o indication
differentiate effusion from pseudotumor
often helpful to prospectively follow intramuscular hematomas
Studies
Labs:
o CBC (check Hb levels)
o aPTT prolonged, PT normal
o plasma factor VIII or IX inhibitor assay
o LFTs normal
Screening
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o Bethesda assay
performed is blood factor VIII or IX inhibitor are positive
measures the amount of factor VIII or IX antibody in the blood
measurements=no titre, <5 BU (low levels), >5BU (high levels)
Treatment
Nonoperative
o analgesics, pain team evaluation, physiotherapy,
indications
non-life threatening bleeds into joint or muscle
adjunct measures
modalities
codiene in children should be moderated by local prescriber
joint immobilization and joint paracentesis are not routinely recommended
o factor VIII or IX administration
indications
relavent factor is administered for Hemophilia A (Factor VIII) and B (Factor IX)
estabilished bleed with decreased factor VIII and IX or increased Bethesda assay (>5 BU)
modalities
increase factor levels by risk of potential blood loss and bleeding
acute hematomas
increase blood factor levels to 30%
acute hemarthrosis and soft tissue surgery
increase blood factor levels to 40-50%
skeletal surgery
increase blood factor levels to 100% for first week following surgery then
maintain at > 50% for second week following surgery
Operative treatment
o synovectomy and/or contracture release
indications
may be indicated for recurrent bleeding into a specific joint causing:
chronic synovitis
recurrent hemarthrosis
technique
radioactive synoviorthesis (destruction of synovial tissue with intra-articular injection fo
radioactive agent)
surgical synovectomy
outcomes
synoviorthesis has been shown to reduce incidence of recurrence greater than surgical
synovectomy
o total joint arthroplasties
indications
for end stage arthropathy
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Other Syndromes
Imaging General
Radiographs
o recommended
AP and lateral standard of involved area
o findings
bone infarcts common
biconcave "fishtale" vertebrae III:34 bone infarcts - biconcave "fishtale" vertebrae
MRI
o recommended for differentiating bone infarction from osteomyelitis
obtain gadolinium enhanced T1 sequences which will identify infection
Bone Scan
o helps differentiate infarct from infection
Studies General
Labs
o serum : CBC, ESR, CRP
may be elevated in both osteomyelitis and sickle cell crisis
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o joint aspiration and culture
may be necessary to determine if diagnosis is osteomyelitis or sickle cell crisis
Sickle Cell Crisis
Presentation
o severe bone pain
o usually begins near age 2-3 years
o caused by substance P
o may lead to bone infarcts
Treatment
o nonoperative
hydroxyurea provides
pain relief during bone crisis
Osteomyelitis
Introduction
o often in diaphysis
o organism
increased incidence of salmonella (may spread from gallbladder infection), but staph
aureus is still the most common
staph aureus is the most common cause of osteomyelits in all children, including those
with sickle cell disease
salmonella osteomyelitis occurs most commonly in children with sickle cell disease, but
is still less common than Staph aureus in these patients
Imaging
o radionuclide bone scan and radionuclide bone marrow scan can differentiate bone infarct from
osteomyelitis
osteomyelitis: normal marrow uptake, abnormal bone scan
infarct: decreased marrow uptake, abnormal bone scan
Evaluation
o aspirate and culture to differentiate from a bone infarct
Septic arthritis
Sickle cell patients are susceptible to infection due to
o hyposplenia
o sluggish circulation
o decreased opsonization of bacteria
Presentation
o bone pain
o fever
Labs
o elevated CRP and ESR
Studies
o aspirate joint and culture to identify organism
Treatment
o irrigation & debridement
consider preoperative oxygenation and exchange transfusion prior to surgery
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By Dr, AbdulRahman AbdulNasser Pediatric Syndromes | Other Syndromes
Avascular Necrosis of Femoral Head
Osteonecrosis of the femoral head
o can be bilateral in sickle cell disease
Presentation
o hip pain with weight bearing
Treatment
o Nonoperative
partial weight bearing and range of motion
indications : initial treatment
o Operative
total hip arthroplasty
indications
failed non operative
intractable pain
outcomes
results of total joint arthroplasty are poor due to ongoing remodeling of bone
Presentation
Symptoms
o asymmetrical limb deformity
o joint symptoms
Physical exam
o decreased motion
o joint line tenderness
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Imaging
Radiographs
o may see calcification at the joint line
CT
o useful for assessing cortical continuity with the epiphysis
Studies
Histology
o similar to osteochondroma
o diagnosis of DEH is made with the location of the osteochondroma, specifically located in the
epiphysis of the involved bone
Treatment
Operative
o excision of overgrowth
indications
symptomatic early disease
o osteotomies
indications
symptomatic late stage disease
Complications
Recurrence
o a common complication following excision
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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5
ORTHO BULLETS
Volume
Five
Recon
2017
Collected By : Dr AbdulRahman AbdulNasser
[email protected]
OrthoBullets 2017
OrthoBullets 2017
Preface
Orthobullets.com is an educational resource for
orthopaedic surgeons designed to improve
training through the communal efforts of those
who use it as a learning resource. It is a simple but
powerful concept. All of our topics, technique
guides, cases, and user-generated videos are
free, and will stay that way.
Table of Contents
I. Recon Science.............................................................................................................................. 0
A. Joint Conditions ....................................................................................................................... 1
1. Hip Osteoarthritis...................................................................................................................... 1
2. Knee Osteoarthritis ................................................................................................................... 5
3. Hip Osteonecrosis..................................................................................................................... 9
4. Adult Dysplasia of the Hip ........................................................................................................ 14
5. Idiopathic Transient Osteoporosis of the Hip (ITOH) ................................................................ 19
6. Prosthetic Joint Infection ........................................................................................................ 21
B. Implant Science ..................................................................................................................... 30
1. Wear & Osteolysis Basic Science ............................................................................................ 30
2. Catastrophic Wear & PE Sterilization ....................................................................................... 32
C. Clinical Evaluation ................................................................................................................. 35
1. Knee Biomechanics ................................................................................................................ 35
2. Hip Biomechanics ................................................................................................................... 38
3. Physical Exam of the Hip ......................................................................................................... 41
II. Hip Reconstruction ..................................................................................................................... 43
A. THA Techniques .................................................................................................................... 44
1. THA Prosthesis Design ............................................................................................................ 44
2. THA Implant Fixation ............................................................................................................... 49
3. THA Templating ...................................................................................................................... 54
4. THA Approaches ..................................................................................................................... 57
5. THA Stability Techniques ........................................................................................................ 59
6. THA Acetabular Screw Fixation ............................................................................................... 62
7. THA Rehabilitation .................................................................................................................. 63
B. THA Complications ................................................................................................................ 66
1. THA Dislocation ...................................................................................................................... 66
2. THA Periprosthetic Fracture ................................................................................................... 68
3. THA Aseptic Loosening ........................................................................................................... 75
4. THA Sciatic Nerve Palsy .......................................................................................................... 76
5. THA Leg Length Discrepancy .................................................................................................. 78
6. THA Iliopsoas Impingement ..................................................................................................... 79
7. THA Other Complications ........................................................................................................ 80
C. THA Revision ......................................................................................................................... 82
1. THA Revision .......................................................................................................................... 82
D. Hip Arthroplasty Related Procedures ..................................................................................... 90
OrthoBullets 2017
ORTHO BULLETS
I.Recon Science
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By Dr, AbdulRahman AbdulNasser Recon Science | Joint Conditions
A. Joint Conditions
1. Hip Osteoarthritis
Introduction
Definition
o degenerative disease of synovial joints that causes progressive loss of articular cartilage
Epidemiology
o incidence
hip OA (symptomatic)
88 per 100,000 per year
knee OA (symptomatic)
240 per 100,000 per year
Risk factors
o modifiable
articular trauma
muscle weakness
I:1 Cartilage changes in aging vs. osteoarthritis.
heavy physical stress at work
high impact sporting activities
o non-modifiable
gender
females >males
increased age
genetics
developmental or acquired deformities
hip dysplasia
slipped capital femoral epiphysis
Legg-Calvé-Perthes disease
Pathophysiology
o pathoanatomy
articular cartilage ( see table above)
increased water content
alterations in proteoglycans
eventual decrease in amount of proteoglycans
collagen abnormalities
organization and orientation are lost
binding of proteoglycans to hyaluronic acid
synovium and capsule
early phase of OA
mild inflammatory changes in synovium
middle phase of OA
moderate inflammatory changes of synovium
synovium becomes hypervascular
late phases of OA
synovium becomes increasingly thick and vascular
bone
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OrthoBullets2017 Recon Science | Joint Conditions
subchondral bone attempts to remodel
forming lytic lesion with sclerotic edges (different than bone cysts in RA)
bone cysts form in late stages
Cell biology
o proteolytic enzymes
matrix metalloproteases (MMPs)
responsible for cartilage matrix digestion
examples
stromelysin
plasmin
aggrecanase-1 (ADAMTS-4)
tissue inhibitors of MMPS (TIMPs)
control MMP activity preventing excessive degradation
imbalance between MMPs and TIMPs has been demonstrated in OA tissues
inflammatory cytokines
secreted by synoviocytes and increase MMP synthesis
examples
IL-1
IL-6
TNF-alpha
Genetics
o inheritance
non-mendilian
o genes potentially linked to OA
vitamin D receptor
estrogen receptor 1
inflammatory cytokines
IL-1
leads to catabolic effect
IL-4
matrilin-3
I:2 Illustration showing an overview of the molecules involved in the
osteoarthritic process.
BMP-2, BMP-5
Presentation
History
o identify age, functional activity, pattern of arthritic involvement, overall health and duration of
symptoms
Symptoms
o function-limiting hip pain
effect on walking distances
o pain at night or rest
o hip stiffness
o mechanical
instability, locking, catching sensation
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By Dr, AbdulRahman AbdulNasser Recon Science | Joint Conditions
Physical exam
o inspection
body habitus
gait
leg length discrepancy
skin (e.g. scars)
o range of motion
lack of full extension (>5 degrees flexion contracture)
lack of full flexion (flexion < 90-100 degrees)
limited internal rotation
Neurovascular exam
o straight leg test negative
Imaging
Radiographs
o recommended views
standing AP pelvis
AP + lateral hip
o optional views I:3 False profile view hip radiograph
false profile view (e.g. hip dysplasia)
o findings
osteoarthritis
joint space narrowing
osteophytes
subchondral sclerosis
subchondral cysts
pelvic obliquity
may be secondary to spinal deformity
may cause leg-length issues I:4 Crossover sign
acetabular retroversion
makes appropriate positioning of acetabular component more difficult intraoperatively
Studies
Histology
o loss of superficial chondrocytes
o replication and breakdown of the tidemark
o fissuring
o cartilage destruction with eburnation of subchondral bone
Treatment
Nonoperative
o NSAIDs and/or tramadol
indications
first line treatment for all patients with symptomatic arthritis
technique
NSAID selection should be based on physician preference, patient acceptability and cost
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o walking stick
decreases the joint reaction force on the affected hip when used in the contralateral upper
extremity
o weight loss, activity modification and exercise program/physical therapy
indications
first line treatment for all patients with symptomatic arthritis
BMI > 25
technique
exercise aimed at increasing flexibility and aerobic capacity
o corticosteroid joint injections
indications
can be therapeutic and/or diagnostic of symptomatic hip osteoarthritis
o controversial treatments
acupuncture
viscoelastic joint injections
glucosamine and chondroitin
Operative
o arthroscopic debridement
indications
controversial
degenerative labral tears
o periacetabular osteotomy +/- femoral osteotomy
indications
symptomatic dysplasia in an adolescent or young adult with concentrically reduced hip
and mild-to-moderate arthritis
outcomes
mixed results
literature suggest this can delay need for arthroplasty
o femoral head resection
indications
pathological hip lesions
painful head subluxation
o hip resurfacing
indications
young active, male, patients with hip osteoarthritis
o total hip arthroplasty (THA)
indications
end-stage, symptomatic or severe osteoarthritis arthritis
preferred treatment for older patients (>50) and those with advanced structural changes
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By Dr, AbdulRahman AbdulNasser Recon Science | Joint Conditions
2. Knee Osteoarthritis
Introduction
Definition degenerative disease of synovial joints that causes progressive loss of articular cartilage
Epidemiology
o incidence
hip OA (symptomatic)
88 per 100,000 per year
knee OA (symptomatic)
240 per 100,000 per year
Risk factors
o modifiable
articular trauma
occupation, repetitive knee bending
muscle weakness
large body mass
metabolic syndrome
central (abdominal) obesity, dyslipidemia (high triglycerides and low-density
lipoproteins), high blood pressure, and elevated fasting glucose levels.
o non-modifiable
gender
females >males
increased age
genetics
race
African American males are the least likely to receive total joint replacement when
compared to whites and Hispanics
Pathophysiology
o pathoanatomy
articular cartilage
increased water content
alterations in proteoglycans
eventual decrease in amount of proteoglycans
collagen abnormalities
organization and orientation are lost
binding of proteoglycans to hyaluronic acid
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By Dr, AbdulRahman AbdulNasser Recon Science | Joint Conditions
Genetics
o inheritance
non-mendilian
o genes potentially linked to OA
vitamin D receptor
estrogen receptor 1
inflammatory cytokines
IL-1
leads to catabolic effect
IL-4
matrilin-3
BMP-2, BMP-5
Presentation
History
o identify age, functional activity, pattern of arthritic
involvement, overall health and duration of symptoms
Symptoms
o function-limiting knee pain
effect on walking distances I:6 Neutral aligment - Varus aligment
o pain at night or rest
o activity induced swelling
o knee stiffness
o mechanical
instability, locking, catching sensation
Physical exam
o inspection
body habitus
gait
often an increased adductor moment to the limb during gait
limb alignment
effusion
I:7 Sunrise view
skin (e.g. scars)
o range of motion
lack of full extension (>5 degrees flexion contracture)
lack of full flexion (flexion <110 degrees)
o ligament integrity
Imaging
Radiographs
o recommended views
weight-bearing views of affected joint
o optional views
knee
sunrise view
PA view in 30 degrees of flexion
I:8 PA view in 30 degrees of
flexion (Knotch view)
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o findings
pattern of arthritic involvement
medial and/or lateral tibiofemoral, and/or patellofemoral
characteristics
joint space narrowing
osteophytes
eburnation of bone
subchondral sclerosis
subchondral cysts
Studies
Histology
o loss of superficial chondrocytes
o replication and breakdown of the tidemark
o fissuring I:9 arthritic knee vs. normal radiograph
o cartilage destruction with eburnation of subchondral bone
Treatment
Nonoperative
o non-steroidal anti-inflammatory drugs
indications
first line treatment for all patients with symptomatic arthritis
technique
Non-steroidal anti-inflammatory drugs (first choice)
selection should be based on physician preference, patient acceptability and cost
duration of treatment based on effectiveness, side-effects and past medical history
outcomes
AAOS guidelines: strong evidence for
o rehabilitation, education and wellness activity
indications
first line treatment for all patients with symptomatic arthritis
technique
self-management and education programs
combination of supervised exercises and home program have shown the best results
these benefits lost after 6 months if exercises are stopped
outcomes
AAOS guidelines strong evidence for
o weight loss programs
indications
patients with symptomatic arthritis and BMI > 25
technique
diet and low-impact aerobic exercise
outcomes
AAOS guidelines: moderate evidence for
o controversial treatments
acupuncture
AAOS guidelines: strong evidence against
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By Dr, AbdulRahman AbdulNasser Recon Science | Joint Conditions
viscoelastic joint injections
AAOS guidelines: strong evidence against
glucosamine and chondroitin
AAOS guidelines: strong evidence against
needle lavage
AAOS guidelines: moderate evidence againnst
lateral wedge insoles
AAOS guidelines: moderate evidence against
Operative
o high-tibial osteotomy
indications
younger patients with medial unicompartmental OA
technique
valgus producing proximal tibial oseotomy
outcomes
AAOS guidelines: limited evidence for
o unicompartmental arthroplasty (knee)
indications
isolated unicompartmental disease
outcomes
TKA have lower revision rates than UKA in the setting of unicompartmental OA
o total knee arthroplasty
indications
symptomatic knee osteoarthritis
failed non-operative treatments
techniques
cruciate retaining vs. crucitate sacrificing implants show no difference in outcomes
patellar resurfacing
no difference in pain or function with or without patella resurfacing
lower reoperation rates with resurfacing
drains are not recommended
3. Hip Osteonecrosis
Introduction
Also known as avascular necrosis
Epidemiology
o incidence
20,000 new cases per year in the United States
accounts for 10% of total hip arthroplasties performed
o demographics
male > females
average age at presentation is 35 to 50
o location
bilateral hips involved 80% of the time
multifocal osteonecrosis
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disease in three or more different joints
3% of patients with osteonecrosis have multifocal involvement
o risk factors
direct causes
irradiation
trauma
hematologic diseases (leukemia, lymphoma)
dysbaric disorders (decompression sickness, "the bends") - Caisson disease
marrow-replacing diseases (e.g. Gaucher's disease)
sickle cell disease
indirect causes
alcoholism
hypercoagulable states
steroids (either endogenous or exogenous)
systemic lupus erythematosus (SLE)
transplant patient
virus (CMV, hepatitis, HIV, rubella, rubeola, varicella)
protease inhibitors (type of HIV medication)
idiopathic
Pathophysiology
o idiopathic AVN
intravascular coagulation is the final common idiopathic pathway
pathoanatomic cascade
coagulation of the intraosseous microcirculation →
venous thrombosis →
retrograde arterial occlusion →
intraosseous hypertension →
decreased blood flow to femoral head →
AVN of femoral head →
chondral fracture and collapse
o AVN associated with trauma
due to injury of femoral head blood supply (medial femoral circumflex)
Associated conditions
o AVN rates of specific traumatic injuries
femoral head fracture: 75-100%
basicervical fracture: 50%
cervicotrochanteric fracture: 25%
hip dislocation: 2-40% (2-10% if reduced within 6 hours of injury)
intertrochanteric fracture: rare
o higher risk of AVN with greater initial displacement and poor reduction
o decompression of intracapsular hematoma may reduce risk
o quicker time to reduction may reduce risk
Prognosis
o risk of femoral head collapse with osteonecrosis is based on the modified Kerboul combined
necrotic angle
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By Dr, AbdulRahman AbdulNasser Recon Science | Joint Conditions
calculated by adding the arc of the femoral head necrosis on a mid-sagittal and mid-coronal
MR image
Low-risk group = combined necrotic angle less than 190°
Moderate-risk group = combined necrotic angle between 190° and 240°
High-risk group = combined necrotic angle of more than 240°
Classification
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Presentation
Symptoms
o insidious onset of pain
o pain with stairs, inclines, and impact
o pain common in anterior hip
Physical exam
o mostly normal initially
o advanced stages similar to hip OA (limited motion, particularly internal rotation)
Imaging
Radiographs
o recommended views
AP hip
frog-lateral of hip
AP and lateral of contralateral hip
o classification systems based largely on radiographic findings (see below)
MRI
o highest sensitivity (99%) and specificity (99%)
o double density appearance
T1: dark (low intensity band)
T2: focal brightness (marrow edema)
o order when radiographs negative and osteonecrosis still suspected
o presence of bone marrow edema on MRI is predicitve of worsening pain and future progression
of disease
Bone scan
Treatment
Nonoperative
o bisphosphonates
indicated for precollapse AVN (Ficat stages 0-II)
trials have shown that alendronate prevents femoral head collapse in osteonecrosis with
subchondral lucency
However, other studies have also shown no benefit of preventing collapse with
bisphosphonates
Operative
o core decompression with or without bone grafting
indications
for early AVN, before subchondral collapse occurs
reversible etiology
technique
traditional method
drill an 8-10 mm hole through the subchdonral necrosis
alternative method
pass a 3.2 mm pin into the lesion two to three times for decompression
relieves intraosseous hypertension equals less pain
stimulates a healing response via angiogenesis
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By Dr, AbdulRahman AbdulNasser Recon Science | Joint Conditions
o rotational osteotomy
indications
only for small lesions (<15%) in which the lesion can be rotated away from a weight
bearing surface
technique
typically performed through intertrochanteric region
for medial disease
perform varus rotational osteotomy
for anterolateral disease
perform valgus flexion osteotomy
outcomes
reported success rate of 60% to 90%, mainly in Japan
distorts the femoral head making THA more difficult
o curettage and bone grafting through Mont trapdoor technique or Merle D'Aubigne
lightbulb technique
indications
preferably pre-collapse
technique
lightbulb - through the cortex of the femoral neck-head junction to access the necrotic
area of the femoral head and place bone graft
trapdoor - through articular surface
o vascularized free-fibula transfer
indications
for both pre-collapse and collapsed AVN in young patient
reversible etiology preferred
technique
remove the necrotic area with large core hole
fibular strut is placed under subchondral bone to help prevent collapse or tamp up small
areas of collapse
outcomes
some centers demonstrating 80% success at 5 to 10-year follow-up
less predictable in patients >40
complications
related to donor site morbidity
sensory deficit
motor weakness
FHL contracture
tibial stress fracture from side graft is taken
o total hip replacement
indications
younger patient with crescent sign or more advanced femoral head collapse, +/-
acetabular DJD
irreversible etiology (chronic steroid use)
patients >40 with large lesions
techniques
cementless cup and stem
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care must be taken while preparing the femur as there are high rates of femoral canal
perforation
outcomes
in young patients with osteonecrosis, there is a higher rate of linear wear of the
polyethylene liner and a higher rate of osteolysis than compared to older patients who
have THA for osteoarthritis
provides good pain relief and function
o total hip resurfacing
indications
in advanced DJD with small, isolated focus of AVN
requires adequate bone to support resurfacing component
contraindicated in underlying disease process or chronic steroid use causing AVN (poor
bone quality) and renal disease (metal ions from metal-on-metal implant)
outcomes
medium-term follow-up showing problems with acetabular erosion and pain
o hip arthrodesis
indications
only consider in the very young patient in a labor intensive occupation
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By Dr, AbdulRahman AbdulNasser Recon Science | Joint Conditions
Hartofilakidis Classification
Dysplasia Femoral head within acetabulum despite some subluxation. Segmental
(Type A) deficiency of the superior wall. Inadequate true acetabulum depth.
Low Femoral head creates a false acetabulum superior to the true acetabulum.
dislocation There is complete absence of the superior wall. Inadequate depth of the true
(Type B) acetabulum.
High Femoral head is completely uncovered by the true acetabulum and has
dislocation migrated superiorly and posteriorly. There is a complete deficiency of the
(Type C) acetabulum and excessive anteversion of the true acetabulum.
Presentation
Symptoms
o hip or groin pain, especially in flexion activities
o often insidious onset
Physical exam
o increased internal rotation before arthritis sets in
due to increased femoral anteversion
o decreased internal rotation may represent osteoarthritis
o increased external rotation with ambulation
o positive anterior impingement test (pain with passive flexion, internal rotation and adduction)
o may have instability with extension, abduction and external rotation
Imaging
Radiographs
o recommended views
standard a/p and lateral radiographs
o findings
abnormalities with the femoral head
decreased sphericity
decreased head:neck offset
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abnormalities with the pelvis
increased retroversion (Crossover sign) (see figure page 3)
acetabular protrusio
false profile view (see figure page 3)
lateral center edge angle
angle formed by a vertical line and a line connecting the center of the femoral head with
the lateral edge of the acetabulum
<20 degrees associated with dysplasia
o measurements
Tonnis angle
measures inclination of weight bearing zone
angle greater than 10 is abnormal
CT
o useful in accessing structural abnormalities of the femoral head and neck
PAO
(Ganz, Bernese)
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Complications
Sciatic nerve palsies
o 10 times increased incidence of sciatic nerve palsy (5-15%)
o lengthening of greater than 4 cm can lead to sciatic nerve palsy that will present clinically as a
foot drop.
Hip Dislocation
o increased risks of hip dislocation after arthroplasty (5-10%)
Periprosthetic femur fx
Infection
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By Dr, AbdulRahman AbdulNasser Recon Science | Joint Conditions
Presentation
Symptoms
o progressive, atraumatic hip and groin pain over several weeks
o may be unable to bear weight
Physical exam
o local tenderness
o reduced ROM
Labs
Elevated ESR
Imaging
Radiographic changes
o xray findings in femoral head and neck lag behind clinical signs by 4-8wks
o subchondral cortical loss
o diffuse osteopenia of femoral head and neck
o joint effusion
o joint space is always preserved
MRI
o imaging modality of choice
o shows marrow edema of femoral head and neck
o T1 : decreased signal, loss of fatty marrow
o T2
high signal of marrow edema
joint effusion
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Bone scan
o increased uptake in femoral head
o preceeds Xray changes
Differential
ITOH is a diagnosis of exclusion. Exclude
o femoral neck stress fracture
o infection
o malignancy
o AVN
Treatment
Nonoperative
o symptomatic with avoidance of weightbearing
indications : first line of treatment
protected weightbearing to avoid stress fractures
resolves spontaneously in 6-8mths
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o screening
screen and optimize risk factors
nasal mupirocin for decolonization of nasal MSSA/MRSA
routine urine cutures NOT warranted pre-operatively, unless history or symptoms of UTI
stop DMARDs 4-6 weeks prior to surgery
revision joint replacement
normalized ESR, CRP off antibiotics
o operatively
pre-operative skin cleansing with antiseptic wash
systemic antibiotics
administered within 30 minutes to incision, and >10 minutes prior to tourniquet
continued for 24 hours after surgery
operative room
vertical laminar airflow systems
limit hospital personal OR traffic in-and-out of room
o post-operatively
antibiotics prior to dental work is dependant on host risk factors
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By Dr, AbdulRahman AbdulNasser Recon Science | Joint Conditions
consequence
no method exists to safety remove biofilm and eradication is difficult
prosthetic explant indicated with infection >4 weeks due to biofilm
infection has invaded prosthetic-bone interface
Source of infection
o Direct invasion
sinus tract into joint capsule
wound dehiscence
o Hematogenous infection
infection in a longstanding infection-free joint secondary to another infection (eg. dental
work, infected gallbladder)
Presentation
History
o may have history of the following
recent or active bacteremia
multiple local surgeries
skin/epithelial tissue penetration (eg. IV drug use, colonoscopy, dental work, ulceration,
wound complication)
Symptoms
o persistent pain and stiffness at site of arthroplasty is associated with infection in >90% of patients
o acute onset with swelling, tenderness, and drainage
o chronic infections show pain and more subtle symptoms
function deteriorates over time
pain worsens over time
Physical exam
o inspection
sinus tract to the joint is a definite infection
warmth, redness, or swelling
low grade fever
o motion
limited by pain and swelling
Imaging
Radiographs
o findings
periosteal reaction
scattered patches of osteolysis
generalized bone resorption without implant wear
transcortical sinus tracts
implant loosening
Bone scan
o modalitity
Tc-99m (technetium) detects inflammation and In-111 (indium) detects leukocytes
triple scan can differentiate infection from fracture or bone remodeling
o indications
if infection is suspected, but cannot be confirmed by aspiration or blood work
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o sensitivity and specificity
99% sensitivity and 30% to 40% specificity
Positron emission tomography (PET)
o indication
may help to identify areas of high metabolic activity using fluorinated
glucose
o sensitivity and specificity
98% sensitivity and 98% specificity
MSIS Criteria
Musculoskeletal Infection Society (MSIS) analyzed the available evidence to
propose a new definition for prosthetic joint infections
o Major criteria (diagnosis can be made when [1] major criteria exist)
sinus tract communicating with prosthesis, or
pathogen isolated by culture from 2 separate tissue/fluid samples from the affected joint
o Minor criteria (diagnosis can be made when [4/6] of the following minor criteria exist)
elevated ESR (>30mm/h) or CRP (>10mg/L)
elevated synovial WBC (>1,100cells/ul for knees, >3,000cells/ul for hips)
elevated synovial PMN (>64% for knees, >80% for hips)
purulence in affected joint
this finding alone is insufficient
fluid from metal-metal articulation, gout, etc. can resemble pus
pathogen isolation in 1 culture
>5 PMN per hpf in 5 hpf at x400 magnification (intraoperative frozen section of
periprostehtic tissue)
Studies
Labs
o Blood panel
WBC : not specific or sensitive
o ESR and CRP
CRP
physiology
peaks 2-3days after surgery
returns to normal at 21 days (3 weeks)
normal range I:12 positive gram stain
acute (< 6 weeks from surgery) = <100 mg/L
chronic (> 6 weeks from surgery)= <10 mg/L
ESR
physiology
peaks 5-7 days after surgery
returns to normal 90 days (3 months)
normal range
acute (< 6 weeks from surgery) = no consences
chronic (> 6 weeks from surgery)= <30 mm/hr
o Serum interleukin-6 (IL-6, normal <10pg/mL)
physiology
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By Dr, AbdulRahman AbdulNasser Recon Science | Joint Conditions
peaks 8-12h after surgery
returns to normal 48-72h after surgery (3 days)
less commonly followed, but can monitor and follow the progress of infection
outcomes
has been shown to have the highest correlation with periprosthetic joint infection
sensitivity 100%, specificity 95%
false positives
RA
multiple sclerosis
AIDS
Paget's disease of bone
Joint aspiration
o indications : whenever there is a strong suspicion in order to confirm the diagnosis
o lab order request
cell count and differential
crystals
gram stain
cultures and specificity
o outcomes
cell count and differential
lowest serologic values suggestive of infection
synovial WBC >1,100 cells/ul and PMN >64% in knees
WBC >3,000 cells/ul and PMN >80% for hips
gram stain
stain for bacteria in sample
specificity > sensitivity
positive test would be indicative of infection, however a negative test does not rule
out infection
repeat aspiration : indicated in cases of inconclusive aspirate and peripheral lab data
o other tests
alpha-defensin immunoassay test
leukocyte esterase colorimetric strip test
Peri-operative analysis
o microbiology
definitive diagnosis can be made if the same organism is
obtained by repeat aspirations or at least 3 of 5
periprosthetic specimens obtained at surgery
complications I:13 Frozen section: This is a frozen section
false-positive rate is 8% under 40X magnification taken from a
intraoperative joint biopsy. The presence of
tissue sample better than swabs
>5 PMNs above indicate a deep joint
o histology infection.
Intraoperative frozen section
indications
equivocal cases with elevated ESR and CRP or suspicion for infection
sensitivity 85% and specificity 90% to 95%
>5 PMNs/hpf x 5 hpf is probable for infection
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Treatment
Nonoperative
o chronic suppressive antibiotic therapy
indications
unfit for surgery
refuse surgery
systemic spread and maintain joint motion with symptomatic relief
outcomes
10% to 25% success rate of eradication
8% to 21% complication rate
Operative
o polyethylene exchange with component retention, IV abx for 4-6 weeks
indications
acute infection (<3 weeks after surgery)
acute hematogenous infection (weak literature, ideally <48-72hrs from symptom onset)
techniques
thorough tissue debridement and irrigation with large-volume of irrigant
outcomes
50% to 55% success rate
implants must be removed if reinfection documented
Dependant of bacteria speciation
o one-stage replacement arthroplasty
indications
used more commonly in Europe for infected THA
no sinus tract, healthy patient and soft tissue, no prolonged antibiotic use, no bone graft
low-virulence organism with good antibiotic sensitivity
technique
use antibiotic-impregnated cement
advantages
lower cost and convenience with single procedure
earlier mobility
disadvantages
higher risk of continued infection from residual microorganisms
outcomes
variable success of 75-100%
o two-stage replacement arthroplasty
indications
gold standard for an infected joint >4 weeks after arthroplasty
must be medically fit for multiple surgeries
requires adequate bone stock
requires confirmation of microbial eradication
benign clinical exam
normal labs (WBC, ESR, and CRP)
negative aspiration cultures
obtain repeat cultures at least two weeks after planned antibiotic course has been
completed
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By Dr, AbdulRahman AbdulNasser Recon Science | Joint Conditions
techniques (see section below)
prosthesis removal, antibiotic spacer, IV antibiotics for 4-6 weeks and delayed
reconstruction
outcomes
bilateral TKA resection arthroplasty followed by 6 weeks of antibiotics and bilateral
reimplantation has excellent results at 2-year follow-up
early reimplantation within 2 weeks has 35% success rate
delayed reimplantation >6 weeks has a 70-90% success rate
cementless reimplantation in the hip has better outcomes than cemented
o resection arthroplasty
indications
poor bone and soft tissue quality
recurrent infections with multi-drug resistant organisms
medically unfit for multiple surgeries
failure of multiple previous reimplantations
elderly nonambulatory patients
disadvantages
short limb, poor function, and patient dissatisfaction
technique
remove all infected tissue and components with no subsequent
reimplantation
outcomes
total knee success rate is 50% to 89%
total hip success rate is 60% to 100%
o arthrodesis
indications
reimplantation is not feasible due to poor bone stock I:14 Knee arthrodesis
recurrent infections with virulent organisms
outcomes
71% to 95% success rate with bony fusion and infection eradication
o amputation
indications
total knee infections recalcitrant to other options
severe pain, soft tissue compromise, severe bone loss, or vascular damaged
technique : AKA
Techniques
Surgical debridement and polyethylene exchange
o debridement
modular parts should be removed to remove fibrin layer between plastic and metal parts
which acts as a nidus of infection
o polyethylene exchange
be sure component available
Two-stage replacement arthroplasty
o prosthetic explant
o surgical debridement
must debride bone implant interface and soft tissues
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o antibiotic spacer and IV antibiotics
advantages of spacers
reduce joint dead space, provide stabilty, and deliver high dose antibiotics
disadvantages of spacers
potential local or systemic allergic reactions
increased chance of developing antibiotic-resistant organisms
only heat-stable antibiotics can be added to cement
static or dynamic (articulating) spacers can be used
advantages of static spacers
allow delivery of higher doses of antibiotics (not premade)
better wound healing (no joint motion)
advantages of articulating spacers
decreased reimplantation exposure time
better maintenance of joint space and motion I:15 THA articulating
cement spacer
decreased quad shortening
better patient satisfaction
both spacer types have equivalent functional outcomes and rate of infection recurrence
spacer antibiotics
each 40 g bag of cement should have 3 g of vancomycin and 4 g of tobramycin added
gentamycin may be substituted for tobramycin
elution of antibiotics depends on cement porosity, surface area (beads increase area), and
antibiotic concentration
must use heat stable antibiotics (vancomycin, tobramycin, gentamicin)
IV antibiotics
wait to administer intraoperatively until aspiration and cultures taken
must be administered for 4 to 6 weeks after explant
initial empiric regimen
first-generation cephalosporin
vancomycin (if any of the following are true)
true allergic sensitivity to penicillin
prior history of or documented exposure to MRSA
unidentified organism
tailor the regimen based on microorganism and susceptibility testing
o reimplantation
send tissue specimens for culture and frozen section pathology
implant only if all preoperative and intraoperative measures are acceptable
if intraoperative frozen section demonstrate acute inflammation, debride the wound, reapply
cement spacer, and return later
when using cement, use antibiotic-impregnated cement
Local Antibiotics
Properties
o active against the organism
o can be incorporated into delivery vehicle (PMMA)
o thermo stable (will not denature during exothermic polymerisation reaction)
Choices
o aminoglycosides (gentimicin, tobramycin)
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By Dr, AbdulRahman AbdulNasser Recon Science | Joint Conditions
effective against gram-negative bacilli
synergistic against gram-positive cocci (Staphylococcus, Enterococcus)
low risk of systemic toxicity
o Vancomycin
effective against gram-positive cocci
excellent elution properties
Doses
o low dose = 2g antibiotics:40g of cement
commercial antibiotic cement is low dose
Cobalt G-HV (Biomet)
Palacos R+G (Zimmer)
Simplex P (Stryker)
Cemex Genta (Exactech)
SmartSet GMV (Depuy)
VersaBone AB (Smith & Nephew)
o high dose ≥ 3.6g antibiotics:40g of cement
highest doses without systemic toxicity
12.5g tobramycin:40g cement
10.5 vancomycin:40g cement
o practical dose
vancomycin is 1g per vial, tobramycin is 1.2g per vial
use 3g vanco and/or 3.6g tobramycin in 40g cement
use extra liquid monomer (1.5-2 ampoules monomer : 1 bag cement)
Elution properties
o rapid release in initial 24h
o followed by rapidly decline in release rate
combination dosing (both tobramycin+vancomycin) increases release rate of antibiotics
(more than if each were used alone)
o low levels at 5 weeks
o experimental models do NOT show difference in elution/concentrations in conventional wound
closure vs negative-pressure wound therapy (NPWT)
Mixing
o vacuum mixing
removes air bubbles
enhances mechanical properties
may increase/decrease antibiotic elution rates
o hand mixing
may lead to uneven distribution of antibiotics within cement and inconsistent release
o sequence of ingredients
adding vancomycin powder after cement powder + liquid monomer mixed for 30s results in
greater elution
Newer techniques
o vancomycin powder directly into wounds (mostly in spine literature)
o antibiotic cement coated IM nails
o local antibiotics bonded to implant surface
B. Implant Science
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By Dr, AbdulRahman AbdulNasser Recon Science | Implant Science
thickness < 6mm
malalignment of components
patients < 50 yo
men
higher activity level
femoral head size between 22 and 46mm in diameter does not influence wear rates of
UHMWPE
ceramics
ceramic bearings have the lowest wear rates of any bearing combination (0.5 to 2.5 µ per
component per year)
ceramic-on-polyethylene bearings have varied, ranging from 0 to 150 µ.
has a unique complication of stripe wear occurring from lift-off separation of the head
gait
recurrent dislocations or incidental contact of femoral head with metallic shell can cause
"lead pencil-like" markings that lead to increased femoral head roughness and
polyethylene wear rates.
metals
metal-on-metal produces smaller wear particles as well as lower wear rates than those for
metal-on-polyethylene bearings (ranging from 2.5 to 5.0 µ per year)
titanium used for bearing surfaces has a high failure rate because of a poor resistance to
wear and notch sensitivity.
metal-on-metal wear stimulates lymphocytes
metal-on-metal serum ion levels greater with cup abduction angle >55 degrees and
smaller component size
Particulate Type
o UHMWPE
most common
o PMMA
o Co-Cr
o Ti
o third-body
Particulate size
o is < 1 micron
PE thickness
Introduction
o PE insert width is usually defined as the maximal thickness of the PE insert and metal tray
o therefore a PE insert labeled as 8mm, may only have a "true" PE of only 4-5 mm at the thinnest
point, assuming the metal tray is ~ 2 mm thick
Cause of Failure
o PE thickness <8mm
leads to loads transmitted to localized area of PE which exceed PE's inherent yield strength
thickness of < 8mm associated with catastrophic PE failure
Solution
o keep thinnest portion of PE >8mm
avoid having to use a PE insert of less than 8mm by making a more aggressive tibial cut
in younger more active patients surgeons may tend to try to preserve more bone for future
revision but the increased activity combined with thinner PE will increase risk of
catastrophic failure
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By Dr, AbdulRahman AbdulNasser Recon Science | Implant Science
Articular surface design
Introduction
o two general designs in total knee prosthesis include
a deeper congruous joint (deeper cut PE) without rollback
less anatomic
maximizes contact loads
decreases contact stress
a flat tibial PE that improves femoral rollback and optimizes flexion,
more anatomic
PCL sparing
increases contact stress and catastrophic failure
Cause of Failure
o flat designs of tibia PE
low contact surface area leads to high contact stress load in areas of contact
Solution
o increase congruency of articular design
higher contact surface area leads to lower contact stress load
newer prosthesis designs sacrifice rollback and have a more congruent or "dished" fit
between the femoral condyle and the tibial insert in both the sagittal and coronal plane in
order to decrease the contact stress
Kinematics
Introduction
o variables that affect kinetics include
knee alignment
varus alignment of knee associated with catastrophic PE failure
femoral rollback
optimizes flexion at the cost of increasing contact stress and increased risk of catastrophic
failure
Cause of failure
o excessive femoral rollback
dyskinetic sliding movements of femur on tibia causes surface cracking and wear
Solution
o Perform medial release to avoid varus malalignment
o Decrease contact stress by minimizing femoral rollback
use a more congruous joint design
increase posterior slope of tibia
use PCL substituting knee for incompetent PCL or dyskinetic femoral rollback
to compensate for the lack of rollback, newer designs move the point of contact (where
femoral condyle rests) more posterior and have a steeper posterior slope to aid with flexion
PE Sterilization
Radiation
o gamma radiation is the most common form of polyethylene sterilization
o oxidation vs. cross linking
presence of oxygen determines pathway following free radical formation
oxygen rich environment
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PE becomes oxidized
leads to early failure due to
subsurface delamination
pitting
fatigue cracking
oxygen depleted environment
PE becomes cross linked
improved resistance to adhesive and abrasive wear
decrease in mechanical properties (decreased ductility and fatigue resistance) and
is at greater risk of catastrophic failure under high loads
methods to obtain
packing via argon, nitrogen
packing in vacuum environment
Solution
o irradiate PE in inert gas or vacuum to minimize oxidation
PE Fabrication
Introduction
o cutting tools can disrupt chemical bonds of PE
Fabrication methods
o ram bar extrusion and machining
UHMWPE powder fed into heated chamber, ram pushes powed into heated cylinder barrel,
forming a cylindrical rod, cut into 10ft lengths for sale
implants are machined from the cylindrical bar stock
o sheet compression molding
UHMWPE powder introduced into large 4' x 8' rectangular container to make sheets up to 8"
thick
implants are machined from these molded sheets
o direct compression molding/net shape
UHMWPE powder placed into a mold the shape of the final component, which is heated
the net shape implant is removed and packaged
no external machining involved, implants have highly glossy surface finish
lower wear rates (50% wear rate of machined products)
slow, expensive
Cause of failure
o machining shear forces cause subsurface region (1-2mm) stretching of PE chains
especially in amorphous regions > crystalline regions
o leads to subsurface delamination and fatigue cracking
can show classic white band of oxidation in subsurface 1-2mm below articular surface
Solution
o use direct-compression molding of PE
performed by molding directly from PE powder to the desired product
results in less fatigue crack formation and propagation compared to ram bar extrusion
o avoid machining of articular surface
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By Dr, AbdulRahman AbdulNasser Recon Science | Clinical Evaluation
C. Clinical Evaluation
1. Knee Biomechanics
Introduction
The knee is comprised of 2 joints
o tibiofemoral joint
o patellofemoral joint
Patellofemoral Articulation
Function
o transmits tensile forces generated by the
quadriceps to the patellar tendon
o increases lever arm of the extensor
mechanism I:16 Patellofemoral Articulation
patellectomy decreases extension force by 30%
Biomechanics
o patellofemoral joint reaction force
up to 7x body weight with squatting
2-3x body weight when descending stairs
Motion
o "sliding" articulation
patella moves 7cm caudally during full flexion
o maximum contact between femur and patella is at 45 degrees of flexion
Joint reaction force across the patellofemoral joint with different exercises.
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Stability
o passive restraints to lateral subluxation
medial patellofemoral ligament
primary passive restraint to lateral translation in 20
degrees of flexion
60% of total restraining force
medial patellomeniscal ligament
13% of total restraining force
lateral retinaculum
10% of total restraining force
o dynamic restraint
quadriceps muscles
o Q angle
definition
line drawn from the anterior superior iliac spine -->
middle of patella --> tibial tuberosity
normal Q angle
in extension
males
13 degrees
females
18 degrees I:17 The Q-angle is a line drawn from the
in flexion anterior superior iliac spine --> middle of
patella --> tibial tuberosity
8 degrees
Pathology
Note the lateral retinaculum, which is an The MPFL is the primary passive restraint to
important stabilizer to lateral subluxation. lateral translation of the patella.
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By Dr, AbdulRahman AbdulNasser Recon Science | Clinical Evaluation
Tibiofemoral Articulation
Function
o transmission of body weight from femur to tibia
Biomechanics
o tibiofemoral joint reaction force
3x body weight with walking
4x body weight with climbing
Motion in sagittal plane
o range of motion
3 degrees of hyperextension to 155 degrees of flexion
thigh-calf contact is usually the limiting factor to full flexion I:18 As the knee flexes, the instant
center of rotation moves posteriorly.
normal gait requires ROM from 0 to 70 degrees
Rotation
o instant center of rotation
definition
point at which the joint surfaces are in direct contact
relevance
posterior rollback
as the knee flexes, the instant center of rotation on the
femur moves posteriorly
allows for increased knee flexion by avoiding I:19 The medial tibial plateau is longer
impingement than the lateral tibial plateau, leading to
external rotation of the tibia during
o "screw home" mechanism terminal flexion.
definition
tibial externally rotates 5 degrees in the last 15 degrees of extension
cause
medial tibial plateau articular surface is longer than lateral tibial plateau
relevance
"locks" knee decreasing the work performed by the quadriceps while standing
Stability
o varus stress
lateral collateral ligament
o valgus stress
superficial portion of medial collateral ligament
o anterior translation
anterior cruciate ligament
attachments
origin
semicircular area on the posteromedial
aspect of lateral femoral condyle
insertion
just anterior to and between the
intercondylar eminences of the tibia
components
anteromedial bundle I:20 The lateral collateral ligament is the primary
restraint to varus stress.
tight in flexion
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OrthoBullets2017 Recon Science | Clinical Evaluation
posterolateral bundle
tight in extension
function
primary static restraint to anterior translation
also plays a roll in axial rotation
o posterior translation
posterior cruciate ligament
attachments
origin
anterolateral medial femoral condyle
insertion
tibial sulcus below articular surface
components
anterolateral
tight in flexion I:21 Anatomic views of the superficial and deep MCL.
posteromedial
tight in extension
function
primary static restraint to posterior translation
o external rotation
posterolateral corner is the primary stabilizer of external tibial rotation
Femoral insertion of ACL, both Tibial insertion of ACL, both During flexion, the anteromedial bundle of
anteromedial and bundles included. the ACL tightens.
posterolateral bundles.
2. Hip Biomechanics
Joint Biomechanics Definitions
Joint reaction force defined as force generated within a joint in response to forces acting on the joint
o in the hip, it is the result of the need to balance the moment arms of the body weight and
abductor tension (see diagram to right)
o maintains a level pelvis
Coupled forces
o when two movements and associated forces are coupled
Joint congruence
o relates to fit of two articular surfaces
o high congruence increases joint contact area
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By Dr, AbdulRahman AbdulNasser Recon Science | Clinical Evaluation
Instant center of rotation
o point about which a joint rotates
o often changes during rotation due to joint translation
o center of gravity of human is just anterior to S2
Friction and lubrication
o not a function of contact area
o lubrication decreases friction
o examples
coefficient of friction of human joints is .002 to .04
TJA (metal on PE) is .05 to .15
Clinical Implications
Actions that decrease joint reaction force include
o increase in ratio of A/B (shift center of rotation medially)
acetabular side
moving acetabular component medial, inferior,
and anterior
I:22 The Trendelenburg gait is an involuntary
femoral side compensatory mechanism that results in a
increasing offset of femoral component reduction of lower extremity muscle force
required to stabilize the injured or paralyzed
long stem prosthesis leg.
lateralization of greater trochanter
by using increased offset neck/prosthesis
varus neck-shaft angulation : increases shear across joint
patient's gait
shifting body weight over affected hip
this results in Trendelenburg gait
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By Dr, AbdulRahman AbdulNasser Recon Science | Clinical Evaluation
cane in contralateral hand
reduces abductor muscle pull and decreases the moment arm between the center of
gravity and the femoral head
carrying load in ipsilateral hand
produces additional downward moment on same side of rotational point
Actions that increase joint reaction force include
o valgus neck-shaft angulation : decreases shear across joint
Palpation
Greater Trochanter / Bursea
o Pain can be attributable to bursitis, tendonitis, infection, or fracture
o Snapping Iliotibial band : ITB can snap over GT and cause pain
Anterior Superior Iliac Spine
o pain with sartorius avulsions / injuries
Ischial tuberosity
o pain with hamstring avulsions / tendinopathy
Iliac crest
o pain with oblique avulsions / hip pointers
Iliotibial band / TFL
Neurovascular
Motor
o hip adduction - obturator nerve
o thigh abduction - superior gluteal nerve
o hip flexion - femoral nerve
o hip extension - inferior gluteal nerve
Sensory
o proximal anteromedial thigh - genitofemoral nerve
o inferomedial thigh - obturator nerve
o lateral thigh - lateral femoral cutaneous nerve
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o anteromedial thigh - femoral nerve
o posterior thigh - posterior femoral cutaneous nerve
Pulses
o femoral
Reflexes
o none
ROM
Flexion
o 120-135 deg
o Thomas test FADIR test FABER test
evaluates hip flexion contractures
Extension
o 20-30 deg
Abduction
o 40-50 deg
Adduction
o 20-30 deg
Internal rotation
o 30 deg
Stinchfield resisted Ober's test
External rotation
hip flexion test
o 50 deg
Special Tests
FADIR test
o hip Flexed to 90 deg, ADducted and Internally Rotated
o positive test if patient has hip or groin pain
o can suggest possible labral tear or FAI
FABER test (aka Patrick's test)
o hip Flexed to 90 deg, ABducted and Externally Rotated
o positive test if patient has hip or back pain or ROM is limited
o can suggest intra-articular hip lesions, iliopsoas pain, or sacroiliac disease (posteriorly located
pain)
Log roll test
o passive maximal internal and external rotation of lower extremity while supine
o clicking or popping suggest acetabular labral tear
o increased total ROM compared to contralateral side suggests ligament or capsular laxity
Thomas test
o with patient supine, fully flex one hip.
o if contralateral hip lifts off table, there is likely a fixed flexion deformity
Ober's test
o patient placed in lateral position with affected side up
o with hip in slight extension, abduct the leg then allow it to drop into adduction
o if unable to adduct leg, suspect tight ITB
Stinchfield resisted hip flexion test
o with patient supine and extended knee, examiner resists active hip flexion past 30-45 deg
o a positive test ellicits pain which is likely to be associated with an intraarticular hip pathology
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | Clinical Evaluation
ORTHO BULLETS
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OrthoBullets2017 Hip Reconstruction | THA Techniques
A. THA Techniques
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Techniques
History
1891
o Dr. Gluck performs first reported attempt at a hip replacement
with ivory used to replace the femoral head
1940
o Austin Moore performs first metallic hip replacement surgery
(hemiarthroplasty) with a proximal femoral replacement bolted
to the femur
1952
o Austin Moore prosthesis developed
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Junctional corrosion is
depicted here at the head-
M/L Taper (Zimmer) VerSys Full Coat (Zimmer) ZMR (Zimmer) neck junction.
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Techniques
Bearing Surfaces
Metal-on-polyethylene
o metal (cobalt-chrome) femoral head on polyethylene acetabular liner
o benefits
longest track record of bearing surfaces
lowest cost
most modularity
o disadvantages
higher wear and osteolysis rates compared to metal-on-metal and ceramics
smaller head (compared to metal-on-metal) leads to higher risk of impingement
Metal-on-metal
o benefits
better wear properties than metal-on-polyethylene
lower linear wear rate
decreased volume of particles
larger head allows for increased ROM before impingement
o disadvantages
more expensive than metal-on-polyethylene
increased metal ions in serum and urine (5-10x normal)
serum metal ion concentration highest at 12-24 months
correlates with the initial "wear in" or "run-in" phase of increased particle generation,
but then followed by a "steady state" phase of decreased particle generation
no proven cancer link
may form pseudotumors
hypersensitivity (Type IV delayed type hypersensitvity)
mediated by T-cells
metals sensitize and activate T-cells (nickel > cobalt and chromium)
however, most participating cells are macrophages (only 5% are lymphocytes)
antigen-activated T-cells secrete cytokines that activate macrophages
activated macrophages have increased ability to present class II MHC and IL-2, leads
to increased T-cell activation
the cycle continues
contraindications
pregnant women
renal disease
metal hypersensitivity due to metal ions
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OrthoBullets2017 Hip Reconstruction | THA Techniques
An example of a pseudotumor is Because ceramic heads are brittle, they stripe wear
shown here on MRI following a may fracture (as shown here). Rates of
metal-on-metal hip replacement. fracture have decreased with newer
developments in recent years.
Ceramic on Ceramic
o benefits
best wear properties of all bearing surfaces
lowest coefficient of friction of all bearing surfaces
inert particles
no concern for cancer risk
o disadvantages
more expensive than metal-on-polyethylene
worst mechanical properties (alumina is brittle, low fracture toughness)
small 28mm heads only exist in zirconia because of alumina's inferior mechanical
properties
squeaking
increased risk with
edge loading
impingement and acetabular malposition
third-body wear
loss of fluid film lubrication
thin, flexible (titanium) stems
less modularity with fewer neck length options
stripe wear
caused by contact between the femoral head and rim of the cup during partial subluxation
results in a crescent shaped line on the femoral head
Ceramic on polyethylene
o disadvantages
zirconia undergoes tetragonal to monoclinic phase transformation with time
increased with
prolonged in vivo implantation >8yr
pressure
temperature
has lower heat conductivity than alumina (joint temperature can reach 99oC for
zirconia, and 50oC for alumina)
Titanium on Polyethylene
o not recommended due to high wear rates
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Techniques
Indications
Dorr classification attempts to guide indications for cemented or uncemented femoral component
fixation.
Ratio
(inner canal diameter at Suggested Femoral
Dorr Classification Characteristics
midportion of lesser trochanter Component Fixation
divided by diameter 10 cm distal)
Cortices seen on both
Type A <0.5 Uncemented
AP and lateral XR
Thinning of posterior
Type B 0.5 to 0.75 Uncemented
cortex on lateral XR
Thinning of cortices on
Type C >0.75 Cemented
both views
Cement Fixation
Mechanism
o acts as grout by producing interlocking fit between surfaces
Indications
o femoral component
elderly patients
deeper penetration of cement in osteopenic patients provides excellent fixation
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irradiated bone
bone ingrowth potential is limited with press-fit components in irradiated bone
"stovepipe femur"
also known as Dorr C femur
enlarged metaphyseal region and lack of supporting isthmus make cementless fixation
difficult
o acetabular component
controversial
cemented acetabular component fails at a higher rate than press-fit
cement resists shear poorly
Technique
o cementing techniques have evolved with time
1st generation
hand-mixed cement
finger packed cement
no canal preparation or cement restrictor
2nd generation
cement restrictor placement
cement gun
femoral canal preparation
brush and dry
3rd generation
vacuum-mixing to reduce cement porosity
cement pressurization
femoral canal preparation
pulsatile lavage
o cement fixation optimized by
limited porosity of cement
leads to reduced stress points in cement
cement mantle > 2mm II:9 The Dorr Classification is shown. Type C shows
increased risk of mantle fractures if < 2mm mantle thin cortices and loss of the tapered metaphysis.
stiff femoral stem
flexible stems place stress on cement mantle
stem centralization
avoid malpositioning of stem to decrease stress on cement mantle
smooth femoral stem
sharp edges produce sites of stress concentration
absence of mantle defects
defined as any area where the prosthesis touches cortical bone with no cement between
creates an area of higher concentrated stress and is associated with higher loosening rates
proper component positioning within femoral canal
varus or valgus stem positioning increases stress on cement mantle
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Techniques
Radiographic analysis
o Barrack and Harris grading system
grade A
complete filling of medullary canal
"white-out" of cement-bone interface
grade B
slight radiolucency of cement-bone interface
grade C
radiolucencies > 50% of bone-cement interface or incomplete cement mantles
grade D
gross radiolucencies and/or failure of cement to surround tip of stem
Biologic Fixation
Mechanism
o 2 different types
ingrowth
bone grows into porous structure of implant
ongrowth
bone grows onto the microdivots in the grit blasted surface
Indications
o femoral component
younger patients
older patients with good bone stock
revision total hip arthroplasty
cemented femoral stems have lower success rates in the revision setting
o acetabular component
all situations except
poor acetabular bone stock
irradiated bone
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Technique
o methods
press fit technique
slightly larger implant than what was reamed/broached is wedged into position
line-to-line technique
size of implant is the same as what was reamed/broached
screws often placed in acetabulum if reamed line-to-line
o biologic fixation is optimized with
pore size 50-300um
preferably 50-150um
porosity of 40-50%
increased porosity may lead to shearing of metal
gaps < 50um
defined as gap space between bone and prosthesis
micromotion < 150um
increased micromotion may lead to fibrous ingrowth
maximal contact with cortical bone
o types of coating
porous-coated metallic surfaces
allows bone ingrowth fixation
extent of coating
proximal coating only
less distal stress shielding
extensively coated stem
produces more stress shielding of proximal bone
useful for revision arthroplasty where proximal bone stock may be compromised
grit blasted metallic surface
allows bone ongrowth fixation
all grit blasted stems are extensively coated
fixation strength is less than with porous coated stems, necessitating greater area of
surface coating
hydroxyapatite (HA)
osteoconductive agent used as an adjunct to porous-coated and grit blasted surfaces
may allow more rapid closure of gaps between bone and prosthesis
has shown shorter time to biologic fixation in animal models, but no advantage
clinically in humans
Radiographic analysis
o signs of a well-fixed cementless femoral component
spot-welds : new endosteal bone that contacts porous surface of implant
absence of radiolucent lines around porous portion of femoral stem
proximal stress shielding in extensively-coated stems
absence of stem subsidence on serial radiographs
o signs of a well-fixed cementless acetabular component II:10 Arrows point to
lack of migration on serial radiographs spot-welds indicating
a well-fixed femoral
lack of progressive radiolucent lines
prosthesis.
intact acetabular screws
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Techniques
Complications of Implant Fixation
Aseptic loosening
o causes
poor initial fixation
mechanical loss of fixation over time
particle-induced osteolysis
o clinical presentation
acetabular loosening
groin/buttock pain
femoral loosening
thigh pain
start-up pain
o evaluation
sequential radiographs
bone scan
o treatment
II:11 Radiograph shows progressive loss of bone in the calcar region consistent
revision of loose components with stress shielding.
Stress shielding
o definition
proximal femoral bone loss in the setting of a well-fixed stem
o risk factors
stiff femoral stem
most important risk factor
large diameter stem
extensively porous coated stem
greater preoperative osteopenia
o clinical implications
clinical implications of proximal stress shielding unknown
o treatment
no specific treatment is necessary
Intraoperative fracture
o risk factors
use of press fit technique
o treatment
acetabular fracture
stable cup : add screws for additional fixation
unstable cup : remove cup, stabilize fracture, and reinsert cup with screws
femur fracture
proximal femur fracture
stable prosthesis
limit weight-bearing
consider cerclage cables/wires
unstable prosthesis
remove prosthesis, stabilize fracture, reinsert new stem that bypasses fracture by
two cortical diameters
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OrthoBullets2017 Hip Reconstruction | THA Techniques
3. THA Templating
Introduction
Definition : the process of anticipating the size and position of implants prior to surgery
Importance
o allows surgeon to anticipate potential difficulties
o to reproduce hip biomechanics
o minimizes leg length inequality
Accuracy
o 52-98% accurate +/- one size
o related to experience and practice
Steps
o obtain appropriate radiographs
o record vital patient information on template (age, height, weight, etc)
o establish radiographic landmarks
o establish limb length discrepancy
o template acetabular component
do this first to determining center of rotation of new hip
o template femoral component
Tips
o best to achieve a good template with sizes in the middle range of the component system
o different system may be a better choice if this cannot be achieved
Radiographic Analysis
Necessary radiographs
o AP pelvis
centered over pubic symphysis
o AP hip
taken with 10-15 degrees of internal rotation
places femoral neck parallel to cassette
external rotation on radiographs will
falsely decrease offset
create valgus appearing femoral neck
falsely decrease femoral canal diameter
o frog lateral hip
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Techniques
Magnification
o 20% is standard
most templates account for this
o magnification markers are helpful
Secondary assessment of radiographs
o pelvic obliquity
may be secondary to spinal deformity
may cause leg-length issues
o acetabular retroversion
makes appropriate positioning of acetabular component more difficult intraoperatively
Radiographic Landmarks
Femoral side
o medullary canal
o greater trochanter
o lesser trochanter
o saddle point
most distal part of the junction between the superior aspect of the femoral neck and the
greater trochanter
Acetabular side
o acetabular roof
o tear drop
created by superposition of the most distal part of the medial wall of the acetabulum and the
tip of the anterior/posterior horn of acetabulum
Pelvis
o ischial tuberosities
important to determine limb length discrepancy
Saddle point is indicated by red Acetabular roof is Teardrop is marked in Ischial tuberosities are
arrow. marked in black. black. shown by black arrows
Notice the deformity
secondary to arthritis.
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4. THA Approaches
Introduction
Surgical approach may be dictated by
o surgeon preference
o prior incisions
o obesity
o risk for dislocation
o implant selection
o degree of deformity
Standard approaches
o direct anterior
o anterolateral
o direct lateral
o posterolateral
Extensile approaches
o trochanteric osteotomy
"Minimally invasive" approaches
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Disadvantages
o steep learning curve : complication rates decrease after 100+ procedures
o surgical site infection rates increased in obese patients with large abdominal panni
o femoral exposure can be challenging
may require a special operating room table for increased exposure
o lateral femoral cutaneous nerve paresthesias
o intraoperative fracture rate may be higher
Anterolateral Approach
Overview
o less commonly used approach for arthroplasty secondary
to violation of abductor mechanism and post-operative
limp
o uses interval between tensor fascia lata and gluteus
medius
Advantages
o lower dislocation rate than posterior approach
Disadvantages
o violates abductor mechanism
may lead to postoperative limp
Posterolateral Approach
Overview
o most common approach for primary and revision arthroplasty
o no true interval
Advantages
o abductor mechanism not violated
o excellent exposure of both femur and acetabulum
o easily converted to more extensile exposures both proximally and distally
Disadvantages
o dislocation rates may be higher than anterior exposures
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Techniques
Extensile Approaches
Trochanteric osteotomy
o overview
3 types
standard trochanteric osteotomy
trochanteric slide
extended trochanteric osteotomy
useful for difficult primary and revision hip arthroplasty
o advantages
excellent acetabular exposure
useful for component removal
o disadvantages
complications include
non-union
heterotopic ossification
trochanteric bursitis
abductor weakness
extended trochanteric osteotomy requires diaphyseal engaging stem
Component Design
Femoral component design II:13 Diagram showing how
o large femoral heads increasing the head/neck ratio by
increasing the femoral head size
decreased dislocation rates due to improves range of motion and
head-neck ratio increased decreases impingement prior to
dislocation.
definition
diameter of femoral head/diameter of femoral neck
importance
larger head-neck ratios allow greater arc range of motion prior to impingement
skirts can be avoided
definition : skirts are attachments used to extend the length of the femoral neck
importance : skirts decrease the head-neck ratio
jump-distance is increased
definition
amount of translation prior to dislocation
importance
large femoral heads are seated deeper within the acetabulum, increasing jump-
distance
increase in jump-distance increases joint stability
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A regular liner versus an elevated rim liner is A lateralized liner is shown in comparison to a
shown. standard liner.
o femoral offset
see "soft tissue tensioning" below
Acetabular component design
o elevated rim liner
a posteriorly placed elevated rim liner may increase joint stability
o lateralized liner
increases soft-tissue tension by increasing offset
II:14 Measurement of acetabular
Component Position component version is shown.
Acetabular position
o recommendations
anteversion
5° - 25°
abduction
30° - 50°
o caveats
surgical approach may affect optimal position of implants II:15 Measurement of the inclincation
angle (abduction angle, theta angle) is
posterior approach should err towards more anteversion shown.
anterior approach should err towards less anteversion
Hypertrophy of the anterior inferior iliac spine may cause component impingement
and instability
o complications
excessive retroversion
posterior dislocation
excessive anteversion
anterior dislocation
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Techniques
excessive abduction (high theta angle, vertical cup)
posterior superior dislocation
eccentric polyethylene wear and late instability
excessive adduction (low theta angle, horizontal cup)
impingement in flexion
inferior dislocation
Femoral stem position
o recommendations
10°- 15° of anteversion
II:16 excessive
o caveats
retroversion II:17 posterior superior dislocation
more difficult to adjust femoral component version in uncemented femoral components
Combined version
o definition
femoral component anteversion plus acetabular component anteversion
o recommendations
37 degrees
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OrthoBullets2017 Hip Reconstruction | THA Techniques
MS
Parkinson's
myelopathy
delirium
alcoholism
o peripheral nervous system
pathology that affects the peripheral nervous system
spinal stenosis (gluteus medius is L5)
peripheral neuropathy
radiculopathy
paralysis/paresis
o local soft tissue integrity
trauma
myoligamentous disruption
deconditioning
aging process
poor health
irradiation
osteolysis
collagen abnormalities
myopathy
malignancy
infection
Exceptions
o in the "high hip" the structures in the anterosuperior and anteroinferior quadrants are often found
in the posterosuperior quadrant
Avoiding Prosthesis Impingement
Leaving the anterior rim of the acetabular component proud above the native acetabulum may result
in anterior iliopsoas tendon impingement
o evaluate with cross-table lateral radiograph and anesthetic injection of the iliopsoas tendon
sheath
Causes of impingement
o medializing and raising acetabulum cup center of rotation will increase risk of bone-on-bone
impingement by decreasing femoral offset
o lateralizing cup will increase risk of metal femoral neck-on-metal acetabulum impingement
o femoral head-to-neck ratio (<2:1) will increase risk of impingement
femoral head skirts
small femoral head
7. THA Rehabilitation
Introduction
Rehabilitation requires coordinated effort from
o orthopaedic surgeon
o physical therapist
o occupational therapist
o case manager
o nursing staff
o patient and patient's family
Care can be broken down into different phases including
o preoperative teaching
o inpatient acute care (hospital)
o inpatient extended care (rehab/SNF)
o outpatient home care
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OrthoBullets2017 Hip Reconstruction | THA Techniques
Preoperative Teaching
Physical therapy
o preoperative physical therapy has not been shown to improve postoperative outcomes
Hip precautions
o useful if discussed before surgery
o types of hip precautions
posterolateral approach
avoid
flexion past 90 degrees
extreme internal rotation
adduction past body's midline
anterolateral approach
avoid
extension
extreme external rotation
adduction past the body's midline
direct anterior approach
avoid
bridging
extension
extreme external rotation
adduction past body's midline
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Techniques
multimodal oral drug therapy
gold standard
Physical therapy goals
o sitting upright -->
o gait training, ambulation with walker, out of bed to chair -->
o transfers, gait normalization -->
o independence
Discharge home criteria
o independent ambulation with assistive device
o independent transfers
o independent ADLs
o stairs with supervision
o appropriate home assistance (spouse, family, visiting nurses)
Outpatient Care
Return to sport
o low-impact exercises are preferred
golf
handicap shows minimal change after THA
handicap shows increase after TKA
o high-impact exercises increase revision rates in patients less than 55 years-old
Driving recommendations
o 3-4 weeks after right THA
o less than 3-4 weeks after a left THA
o reaction time returns to preoperative levels at 4-6 weeks
Return to work
o within a month if no manual labor
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In July 2017
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OrthoBullets2017 Hip Reconstruction | THA Complications
B. THA Complications
1. THA Dislocation
Introduction
Dislocation following THA is a common reason for revision
Epidemiology
o incidence 1-3%
o 70% occur within first month
o 75-90% posterior
Mechanism
o anterior
extension and external rotation of hip
o posterior
flexion, internal rotation, adduction of hip
Risk factors
o prior hip surgery (greatest risk factor)
o female sex
o >70-80 years of age
o posterior surgical approach
repairing capsule and reconstructing external rotators brings dislocation rate close to anterior
approach
o malpositioning of components
ideal positioning of acetabular component is 40 degrees of abduction and 15 degrees
anteversion give or take 10 degrees in each position
in general, excessive anteversion increases risk of anterior hip dislocation; excessive
retroversion increases risk of posterior hip dislocation
o spastic or neuromuscular disease (Parkinson's)
o drug or alcohol abuse
o decreased femoral offset (decreases tissue tension and stability)
o decreased femoral head to neck ratio
Presentation
History
o often reports activity that puts patient in a position that provokes dislocation (hip flexion,
adduction, internal rotation)
shoe tying
sitting in low seat or toilet
Imaging
Radiographs
o recommended views
AP pelvis, AP and true lateral of hip
o findings
look for eccentric position of femoral head as an indication of polyethylene wear and risk for
impending dislocation
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Complications
Treatment
Nonoperative
o closed reduction and immobilization
indications
two-thirds of early dislocations can be treated with closed reduction and immobilization
technique
immobilize with hip spica cast, hip guide brace, or knee immobilizer
Operative
o polyethylene exchange
indications
stable well-aligned implants with extensive polyethylene wear thought to be sole reason
for dislocation
o revision THA
indications
indicated if 2 or more dislocations with evidence of
implant malalignment
vertical acetabular component may require revision
acetabular retroversion is also a common reason
implant failure
polyethylene wear
techniques : see below
o conversion to hemiarthroplasty with larger femoral head
indications
for soft tissue deficiency or dysfunction
contraindicated if acetabular bone is compromised
older technique rarely used with development of dual mobility implants
o resection arthroplasty
indications
when all options have been exhausted
significant bone loss and soft tissue deficiency
psychiatric patients who are dislocating for secondary gain
Technique
Revision THA
o techniques to prevent future dislocation during THA include
realign components
indicated if malalignment explains dislocation
retroverted acetabulum
vertical acetabulum
femoral neck shortening
lack of femoral neck offset
retroversion of the femoral component
head enlargement
optimize head-neck ratio
trochanteric osteotomy and advancement
places abductor complex under tension which increases hip compression force
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OrthoBullets2017 Hip Reconstruction | THA Complications
conversion to a constrained acetabular component
indications
recurrent instability with a well positioned acetabular component due to soft tissue
deficiency or dysfunction
advantage
can be used when there is bony deficiency of the acetabulum
disadvantages
limited range of motion
if patient is not compliant the prosthesis will fail by fracture of the constrained
ring or cup loosening from the pelvis
conversion to dual mobility implant
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Complications
o risk factors
underreaming >2mm
elliptical modular cups
osteoporosis
cementless acetabular components
dysplasia
radiation
Evaluation
o must determine stability of implant II:20 elliptical modular cups
Treatment
o observation alone
indications
if evaluated intraoperatively and found to be stable
postoperative care II:21 The use of a jumbo acetabular
consider protected weight-bearing for 8-12 weeks cup (seen above) may be considered
if there is bone loss or instability
o acetabular revision with screws vs. ORIF associated with fractured
indications acetabulum.
if evaluated intraoperatively and found to be unstable
technique
addition of acetabular screws
may consider upgrading to "jumbo" cup
ORIF of acetabular fracture with revision of acetabular component
if posterior column is compromised, ORIF + revision is most stable construct
may add bone graft from reamings if patient has poor bone stock
postoperative care
consider protected weight-bearing for 8-12
weeks
Intraoperative Femur Fractures
Introduction
o incidence
primary THA
0.1-5%
revision THA
3-21%
o mechanism II:22 Intraoperative proximal and distal femur fractures
proximal fractures
usually occur with bone preparation (ie aggressive rasping) and prosthetic insertion
may occur during implant insertion from dimension mismatch
middle-region fractures
usually occur when excessive force is used during surgical exposure or bone preparation
distal fractures
usually occur when tip of a straight-stem prosthesis impacting at femoral bow
o risk factors
impaction bone grafting
female gender
technical errors
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OrthoBullets2017 Hip Reconstruction | THA Complications
cementless implants
osteoporosis
revision
minimally invasive techniques (controversial)
Presentation
o change in resistance while inserting stem should raise suspicion for fracture
Classification
o Vancouver classification (intraoperative)
considerations
location
pattern
stability of fracture
types
A - proximal metaphysis
B - diaphyseal
C - distal to stem tip (not amenable to insertion of longest revision stem)
subtypes
1 - cortical perforation
2 - nondisplaced crack
3 - displaced unstable fracture pattern
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Complications
Imaging
o intraoperative radiographs are required when there is a concern for fracture
Treatment
o stem removal, cabling, and reinsertion
indications
intraoperative longitudinal calcar split
II:23 In this revision
o trochanteric fixation with wires, cables, or claw-plate for a B2 periprosthetic
indications fracture, an
intraoperative
intraoperative, proximal femur fractures fracture of the greater
o removal of implant, insertion of longer stem prosthesis trochanter was noted
and fixed with
indications cerclage wiring
complete (two-part) fractures of middle region technique.
technique
distal tip of stem must bypass distal extent of fracture by 2 cortical diameters
may use cortical allograft struts for added stability
o removal of implant, internal fixation with plate, reinsertion of prosthesis
indications
distal fractures that cannot be bypassed with a long-stemmed prosthesis
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OrthoBullets2017 Hip Reconstruction | THA Complications
B2 B3 C2 C2
C3 C3 C3
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Complications
o risk factors
poor bone quality
cementless prostheses
compromised bone stock
revision procedures
Classification
o Vancouver classification (postoperative)
considerations
stability of prosthesis
location of fracture
quality of surrounding bone
pros
simple
validated
cons
often difficult to differentiate between B1 and B2 fractures based on radiographs alone
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OrthoBullets2017 Hip Reconstruction | THA Complications
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Complications
Presentation
o often result after low-energy trauma
Treatment
o nonoperative treatment with protected weight-bearing
indications
non-displaced periprosthetic fractures of greater trochanter
non-displaced fractures of lesser trochanter
technique
limiting abduction may decrease chances of displacement with greater trochanter
fractures
o ORIF greater trochanter with wires, cables, or claw-plate
indications
displaced periprosthetic fractures of the greater trochanter
technique
if osteolysis is present, use cancellous allograft to fill defects
o ORIF femoral shaft with locking plate and cerclage wires
indications
Vancouver B1 fractures
Vancouver C fractures
technique
typically place cerclage wires/cables proximally and bicortical
screws distal to stem
may use unicortical locking screws proximally
may add cortical strut allografts
o femoral component revision with long-stem prosthesis
II:24 Example of a claw plate used
indications to treat a Vancouver A, displaced
Vancouver B2 fractures greater trochanter fracture.
some Vancouver B3 fractures
o femoral component revision with proximal femoral allograft
indications
Vancouver B3 fractures in young patients
o femoral component revision with proximal femoral replacement
indications
Vancouver B3 fractures in elderly, low-demand patients
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OrthoBullets2017 Hip Reconstruction | THA Complications
Presentation
Symptoms
o pain
location
groin pain
thigh pain
knee pain
aggrevating factors : often activity related
Physical exam
o may have minimal pain with ROM
o increased pain with weight bearing
Imaging
Basic radiographs
o with show radiolucent area around implant or cement
o subsidence of implant
Studies
Serum labs
o ESR will be normal
o CRP will be normal
Treatment
Nonoperative
o observation
indications : stable implant with minimal symptoms
Operative
o revision THA
Indications
pain due to aseptic loosening
pain with evidence of osteolysis
extensive osteolysis that would compromise revision surgery in the future.
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Complications
o causes
direct trauma
stretch
compression due to hematoma
heat from polymethylmethacralate polymerization
Unknown (40%)
o risk factors
for motor nerve palsies include
developmental dysplasia of the hip
revision surgery
female gender
limb lengthening
posttraumatic arthritis
surgeon self-rated procedure as difficult
o prognosis
only 35% to 40% recover full strength after complete palsy
Presentation
Post-operative complaints of numbness, paresthesias, or weakness
Imaging
Post-operative CT
o may be helpful if hematoma suspected
Ultrasound
o may be helpful if hematoma suspected
Studies
EMGs
o may be used post-operatively to confirm level of injury and guide discussion with patient
regarding prognosis
Treatment
Intraoperative
o adult hip dysplasia undergoing THA
subtrochanteric osteotomy
downsizing components
Immediate postoperative
o place hip in extension and knee in flexion
indications
immediate post-operative palsy
technique
decreases tension along sciatic nerve
o immediate excavation in operating room
indications
post-operative hematoma
Persistent foot drop
o AFO orthosis
indications : first line of treatment for persistent foot drop
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OrthoBullets2017 Hip Reconstruction | THA Complications
Presentation
Symptoms
o patient may feel perceived LLD despite anatomic equality
Physical exam
o post-operative assessment of limb-length discrepancy
true limb length
measured from anterior superior iliac spine to medial malleolus
apparent limb length
determined by adding effect of soft-tissue contractures and pelvic obliquity
difficult to truly measure
Imaging
Radiographs
o radiographic measurement of leg-length discrepancy
o increasing neck length will increase limb length
o increasing femoral offset will not increase limb length
Treatment
Nonoperative
o shoe-lift
indications II:25 Radiographic measurement of leg-length
discrepancy pre-operatively. Begin by drawing a line
shoe-lift adequate in most cases parallel to the floor at the bottom of the obturator rings.
wait 6 months until treatment to allow Next, mesure the distance from this line to the top of
each lesser trochanter. The leg-length differe
adequate relaxation of muscles
Operative
o revisions THA - rare
indications
significant LLD that affect quality of life and has not resolved over 6 to 12 months.
concern for dislocation with revision surgery especially if attempting to shorten limb
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Complications
Presentation
Symptoms
o groin pain
Physical Exam
o findings are subtle and may include
slight limp
Tenderness in the groin.
II:26 CT image showing anterior acetabular overhang in a
palpable snap may be detected (rare) patient with anterior groin pain after a total hip replacement.
o provocative tests
pain may be reproduced or exacerbated by resisted seated hip flexion or straight leg raise
Imaging
Radiographs
o required views
AP pelvis
AP and lateral of hip
CT scan
o helpful to determine postition of prosthesis and rule out other caused of symtpoms
MRI
o usually not valuable due to artifact.
Studies
Diagnostic injection
o diagnostic cortisone injection into iliopsoas sheath is helpful in diagnosis
Treatment
Nonoperative
o indications
rare - most patients require operative intervention for complete resolution of symptoms
Operative
o iliopsoas tenotomy or resection
indications
in cases of normal post-op radiographs
o acetabular component revision
indications
in cases of excessive anterior cup overhang
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OrthoBullets2017 Hip Reconstruction | THA Complications
Postoperative Anemia
Low preoperative hemoglobin
o is the best predictor of the need for a blood transfusion postoperatively
Prevention
o TXA
Treatment
o postoperative transfusion
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Complications
indications
most centers have dropped to a hemoglobin of 7-8
Squeaking
Defined as a high pitched audible sound occurring during hip movement
Incidence
o ceramic-on-ceramic
0.5-10%
o metal-on-metal
4-5%
o incidence of revision because of squeaking is 0.5%
Risks
o impingement
o edge loading
o component malposition
o loss of fluid film lubrication
o third body particles
o thin, flexible (titanium) femoral stem
Vascular Injury
Incidence
o 0.1%-0.2%
Risk factors
o acetabular screw placement in anterior-superior quadrant
o inappropriate retractor placement
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In July 2017
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OrthoBullets2017 Hip Reconstruction | THA Revision
C. THA Revision
1. THA Revision
Introduction
Indications
o osteolysis
o loosening
o instability
o infection
o mal-alignment
o polyethylene wear
o fracture or implant failure
Options include
o acetabular component revision
most common reason for revision in the Charnley "low-friction" total hip arthroplasty
o femoral head and polyethylene exchange
o femoral component revisions
o conversion from a hip arthrodesis
Complications
o significantly higher than primary hip reconstruction
o include
dislocation (even in simple procedures)
infection
nerve palsy
cortical perforation
fractures
DVT
limb length inequalities
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Revision
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OrthoBullets2017 Hip Reconstruction | THA Revision
Femur
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Revision
Imaging
Radiographs
o required views
AP pelvis
orthogonal views of involved hip
full-length femur radiographs
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Revision
o additionalviews
pre-operative radiographs
immediate post-operative radiographs
Judet views
useful for assessment of columns
CT scan
o useful for determining extent of osteolysis
radiographs frequently underestimate extent of osteolysis
o assessment of component position
Evaluation
Laboratory analysis
o infectious laboratories
ESR
CRP
CBC
Aspiration
o recommended if infectious laboratories are suggestive of infection II:28 example of an extensively
porous coated long-stem prosthesis
Treatment used for revision of a
hemiarthroplasty.
Femoral revision
o primary total hip arthroplasty components
indications
minimal metaphyseal bone loss, Paprosky I
o uncemented extensively porous-coated long stem prosthesis (or porous-coated/grit blasted
combination) or modular tapered stems
indications
most Paprosky II and IIIa defects
outcomes
95% survival rate at 10-years
o impaction bone grafting
indications
large ectactic canal and thin cortices
Paprosky IIIb and IV defects
outcomes
most common complication is stem
subsidence
o allograft prosthetic composite
indications II:29 An illustration of an
II:30 Radiograph showing a
Paprosky IV defects modular tumor prosthesis used allograft prosthetic
for revision total hip composite used for massive
o modular oncology components
arthroplasty. metadiaphyseal damage
indications with thin cortices and a
widened femoral canal.
massive bone loss with a non-supportive diaphysis
Paprosky IV defects
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OrthoBullets2017 Hip Reconstruction | THA Revision
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | THA Revision
Surgical Techniques
Femoral revision with uncemented extensively porous-coated long stem prosthesis
o technique
femoral stem must bypass most distal defect by 2 cortical diameters
prevents bending moment through cortical hole
cavitary lesions are grafted with particulate graft
allograft cortical struts may be used to reinforce cortical defects
II:31 Allograft cortical strut secured with cerclage wires. II:32 Illustration explaining impaction
bone grafting. Typically, femoral head
allograft or autograft is impacted into the
canal maintaining the original cortices.
Femoral impaction bone grafting Next, the femoral component is cemented
o technique into the canal.
morselized fresh frozen allograft packed into canal
smooth tapered stem cemented into allograft
Acetabular revision with porous-coated hemisphere cup with screws
o technique
cavitary lesions are filled with particulate graft
cup placement should be inferior and medial
lowers joint reactive forces
metallic wedge augmentation may be used if cup in good position and rigid internal fixation
is achieved
jumbo cups may be used when larger reamer is needed to make cortical contact
structural allografts may be used to provide stability while bone grows into cementless cup
Acetabular revision with reconstruction cage and structural bone allograft
o technique
polyethylene cup is cemented into reconstruction cage
bone graft placed behind cage
Femoral head and polyethylene exchange
o technique
exchange both head and liner
osteolytic defects may be bone grafted through screw holes to fill bony defects
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OrthoBullets2017 Hip Reconstruction | Hip Arthroplasty Related Procedures
1. Hip Resurfacing
Introduction
History
o prior versions of resurfacing failed in the past due to
larger femoral head on polyethylene -> increased
volumetric wear -> high osteolysis rate
o modern resurfacing techniques (approved by FDA in
2006) have made the following changes
metal-on-metal components
larger femoral head
o very popular 10 years ago particularly in younger patients
due to less femoral bone resection
Indications II:33 Birmingham hip prosthesis. Metal-on-metal
prosthesis with a porous coated acetabular cup and
Indications (controversial) cemented femoral stem. The Birminghan prosthesis
o patients with advanced arthritis and good proximal is one of the most common hip resurfacing
prostheses used.
femoral bone stock
best outcomes in younger males with good bone stock
o patients with proximal femoral deformity making total hip arthroplasty difficult
Contraindications
o absolute
bone stock deficiency of the femoral head or neck (e.g., cystic degeneration of the femoral
head)
abnormal acetabular anatomy (small)
o relative
coxa vara
increased risk for neck fractures
significant leg length discrepancies (resurfacing does
not allow leg length corrections)
female sex (controversial)
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | Hip Arthroplasty Related Procedures
Outcomes
Variable outcome findings in the literature (79% to 98% success rate)
Better results found in patients young, larger males with excellent bone stock treated for
osteoarthritis than for dysplasia or osteonecrosis
Some case series have shown survival comparable to conventional THA, while others have reported
higher rates of early revision
o some products have been removed from the market due to early failure
More recent prospective trials have shown few differences between resurfacing and THA
Complications
Periprosthetic femoral neck fracture
o incidence of 0% to 4% (more common than in THA)
o frequent cause for revision in acute post-operative period
(<20 weeks)
o mechanism thought to be related to osteonecrosis
o fracture pattern
vertical fracture line from neck down to lesser trochanter
o risk factors:
femoral neck notching II:34 Femoral neck
prevent by placing implant in slight valgus (rather than slight varus) fracture after hip
resurfacing
osteoporotic bone
large areas of preexisting AVN
femoral neck impingement (from malaligned acetabular component)
female sex
varus positioning of femoral component
o presents as groin pain
o treatment
convert to a primary THA
place cerclage wire above lesser trochanter to prevent fracture propagation during stem
insertion
Implant loosening (aseptic)
o early loosening of the cemented femoral resurfacing component
Heterotopic ossification
o higher incidence of heterotopic ossification compared to THA (from wider exposure)
Elevated metal ion levels
o found in blood and urine from metal debris (unknown significance)
Dislocation
o risk is <1% (lower than conventional THA)
Pseudotumor
o risk
metal-on-metal implants (like resurfacing)
young
female sex
o may be asymptomatic
o symptomatic patients require revision surgery
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OrthoBullets2017 Hip Reconstruction | Hip Arthroplasty Related Procedures
2. Hip Arthrodesis
Introduction
Used for management of advanced hip arthritis in a select group of patients
o its utility has decreased with advances in THA technology
Biomechanics
o pathomechanics
reduces efficiency of gait by ~50%
increases pelvic rotation of contralateral hip
increases stress at adjacent joints
o biochemistry
increases oxygen consumption
requires 30% more energy expenditure for ambulation
Prognosis
o provides pain relief and reasonable clinical results in most patients
o success may be limited by adjacent joint degeneration in 60% of patients
lumbar spine, ipsilateral knee or contralateral hip may be affected
low back pain and arthritic ipsilateral knee pain are the most common symptoms
may start within 25 years of hip arthrodesis
Treatment
Primary hip arthrodesis
o indications
salvage for failed THA (most common)
young active laborers with painful unilateral ankylosis after infection or trauma
neuropathic arthropathy
tumor resection
o contraindications
active infection
severe limb-length discrepancy greater than 2.0 cm.
bilateral hip arthritis
adjacent joint degenerative changes
lumbar spine
contralateral hip
ipsilateral knee
severe osteoporosis
degenerative changes in lumbar spine
contralateral THA
increased failure rate (40%) in THA when there is a contralateral hip arthrodesis
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By Dr, AbdulRahman AbdulNasser Hip Reconstruction | Hip Arthroplasty Related Procedures
a constrained acetabular component is
required if the abductor complex is
nonfunctional
o outcomes
clinical outcome is dependent on abductor
complex function
the presence of hip abductor complex
weakness or dysfunction
requires prolonged rehabilitation
severe lurching gait may develop
Surgical Techniques
Hip arthrodesis
o goals
achieve apposition of arthrodesis surfaces,
obtain rigid internal fixation and promote early
mobilization
o optimal position
optimal positioning for function and limited
effect on adjacent joints II:35 This illustration demonstrates the lateral approach to
20-35° of flexion the hip with a trochanteric osteotomy to perform a hip
arthrodesis with a cobra plate
0°-5° adduction
5-10° external rotation
avoid abduction as it creates pelvic obliquity and increased back pain
o approach
lateral approach with trochanteric osteotomy is preferred
important to preserve the abductor complex
avoid injury to the superior gluteal nerve
anterior approach to hip is also popular
o instrumentation
cobra plating
Complications
Low back pain
o can be improved by taking down hip
arthrodesis, but overall improvement depends
on abductor function
Ipsilateral knee degeneration and laxity
Contralateral hip degeneration
II:36 Anterior approach to the hip to perform a hip arthrodesis
can be performed. This will avoid disruption of the abductor
musculature.
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OrthoBullets2017 Knee Reconstruction | Hip Arthroplasty Related Procedures
ORTHO BULLETS
III.Knee Reconstruction
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Techniques
A. TKA Techniques
History
19th century
o interposition of soft tissues for reconstruction of articular surfaces
1950s
o Walldius designs first hinged knee replacement
1958
o MacIntosh and McKeever introduce acrylic tibial plateau prosthesis to correct deformity
1960s
o Gunston introduces first cemented surface arthroplasty of knee joint
1970
o Guepar develops a new hinged prosthesis based on design by Walldius that increases motion and
decreases bone loss
~1973
o "total condylar prosthesis" is introduced which is first to resurface all three compartments (PCL
sacrificing)
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OrthoBullets2017 Knee Reconstruction | TKA Techniques
Concepts in Prosthetic Design
Femoral rollback
o definition
the posterior translation the femur with progressive flexion
o importance
improves quadriceps function and range of knee flexion by preventing posterior impingement
during deep flexion
o biomechanics
rollback in the native knee is controlled by the ACL and PCL
o design implications
both PCL retaining and PCL substituting designs allow for femoral rollback
PCL retaining
native PCL promotes posterior displacement of femoral condyles similar to a native
knee
PCL substituting
tibial post contacts the femoral cam causing posterior displacement of the femur
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Techniques
o options include
metal tibial baseplate with modular polyethylene insert
more expensive than all-polyethylene tibial component
has an equivalent rate of aseptic loosening compared with all-polyethylene tibia
component
metal augmentation for bone loss
modular femoral and tibial stems
o advantages
ability to customize implant intraoperatively
o disadvantages
increased rates of osteolysis in modular components
backside polyethylene wear
micromotion between tibial baseplate and undersurface of polyethylene insert that occurs
during loading
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Techniques
Constrained Nonhinged Design
Design
o constrained prosthesis without axle connecting tibial and femoral components (nonhinged)
o large tibial post and deep femoral box provide
varus/valgus stability
rotational stability
Indications
o LCL attenuation or deficiency
o MCL attenuation or deficiency
o flexion gap laxity
o moderate bone loss in the setting of neuropathic arthropathy
Radiographs
Advantages
o prosthesis allows stability in the face of soft tissue (ligamentous) or bony deficiency
Disadvantages
o more femoral bone resection
necessary to accommodate large box
o aseptic loosening
as a result of increased constraint
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OrthoBullets2017 Knee Reconstruction | TKA Techniques
Disadvantages
o aseptic loosening
as a result of increased constraint
large amount of bone resection required
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Techniques
2. TKA Templating
Introduction
Definition
o the process of anticipating the size and position of implants prior to surgery
Importance
o allows prediction of implant sizes needed to be available in operating room
o provides a reliable starting point in determining size and position of implants
Accuracy
o up to 92-100% accurate +/- one size
Steps
o obtain appropriate radiographs
o analyze radiographs for appropriate planning
o ensure scale is correct between templates and radiographs
o template femoral component
o template tibial component
Radiographic Views
Necessary radiographs
o AP weight-bearing radiograph of the knee
o lateral view of the knee
most important view for templating
o patellofemoral joint view
not necessary for templating
Optional radiographs
o full-length hip-to-ankle AP weight-bearing view
can be used for templating
useful for
ruling-out extra-articular deformity
estimating coronal laxity
planning bony cuts with respect to mechanical axis
Magnification
o 20% is standard
most templates account for this
o magnification markers are helpful
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Radiographic Analysis
Step 1
o assess the mechanical axis
draw a line of the hip-to-ankle view that shows the overall mechanical axis
neutral mechanical axis should bisect the center of knee
Step 2
o estimate magnitude of coronal deformity
measure the tibiofemoral angle
Step 3
o determine the femoral resection angle
difference between mechanical and anatomic axis of the femur
Step 4
o determine tibial bone cut
perpendicular to mechanical axis
Step 5
o assess bony defects and osteophytes
easiest to do on AP weight-bearing view
Step 6
o assess tibial slope
completed on lateral radiograph
Step 7
o assess patellar height
completed on lateral radiograph
assess for patella baja
this will make exposure more difficult
Step 8
o assess patellar shift/tilt
completed on skyline view of patella
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Techniques
The mechanical axis of This is the angle between Your distal femoral cut
the limb should bisect the anatomic axis of the angle should be the
the center of the knee. femur and tibia. difference between the
A standard tibial bone cut is
anatomic and mechanical
perpendicular to the
axis of the femur.
mechanical axis.
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Choose an appropriate This is an appropriately An appropriately sized On the AP, ensure there is
sized component so sized femoral component. tibial component. no medial/lateral
posterior condylar offset is An oversized femoral overhang.An oversized
restored and there is no component can lead to tibial component in the
notching. Increasing the post-operative pain. medial/lateral plane can
posterior condylar offset, lead to post-operative
as seen here, can tighten pain. This is especially
your flexion gap. true if the overhang is
medial.
3. TKA Approaches
Introduction
Surgical approach may be dictated by
o surgeon preference
o prior incisions
o degree of deformity
o patella baja
o patient obesity
Incision planning
o if multiple incision, choose more lateral
blood supply comes from medial side
o generally safe to cross previous transverse incisions at right angles
o ensure adequate skin bridge
exact length of skin bridge needed is controversial
Approaches
o "simple" primary knee arthroplasty approaches
medial parapatellar
midvastus
subvastus
minimally invasive
o "complex" primary or revision total knee arthroplasty
medial parapatellar
quadriceps snip
V-Y turndown
tibial tubercle osteotomy
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Techniques
Standard Medial Parapatellar Approach
Overview
o most commonly completed through a straight midline incision
Advantages
o familiar for most orthopaedic surgeons
o excellent exposure even in challenging cases
Disadvantages
o possible failure of medial capsular repair
o development of lateral patellar subluxation
o access to lateral retinaculum less direct
o may jeopardize patellar circulation if lateral release is performed
III:2 The medial parapatellar approach is noted by the black line. III:3 The lateral parapatellar approach is shown by the black line.
Note that various surgeons use differing levels of curvature when
completing their arthrotomy.
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Midvastus
Overview
o similar approach to medial parapatellar that spares VMO insertion and may lead to quicker
recovery
Advantages
o vastus medialis insertion on quad tendon is not disrupted
o potentially allows accelerated rehab due to avoiding disruption of extensor mechanism
o patellar tracking may be improved compared to medial parapatellar approach
Disadvantages
o less extensile
o exposure difficult in obese patients
o exposure difficult with flexion contractures
Relative contraindications
o ROM <80 degrees
o obese patient
o hypertrophic arthritis
o previous HTO
Subvastus Approach
Overview
o muscle belly of vastus medialis is lifted off
intermuscular septum
Advantages III:4 The midvastus approach spares the quadriceps
o patellar vascularity preserved tendon but is carried through the muscle belly of the
VMO.
o extensor mechanism remains intact
o minimal need for lateral retinacular release
Disadvantages
o least extensile
o potential for denervation of VMO
Relative contraindications
o revision TKA
o large quadriceps
o previous HTO
o obese patient
o previous parapatellar arthrotomy
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o staged
one surgeon performing each TKA under a separate anesthetic
timing ranges from 3 days to one year in between each side
Other
Antibiotic loaded bone cement
o routine use in all TKA increases the risk of aseptic loosening
o reduces deep infection in revision TKA
o indications for use in primary TKA are controversial
Preoperative Evaluation
Radiographs
o standing AP and lateral of knee
to evaluate for
joint space narrowing
collateral ligament insufficiency
lateral gapping in varus & medial gapping in valgus deformities
subluxation of femur on tibia
bone defects
o standing full-length radiographs (AP and Lateral)
are indicated to determine an accurate valgus cut angle when the patient has
femoral or tibial deformity
very tall or short stature
o extension and flexion laterals
o sunrise view
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Techniques
Femoral Alignment
Anatomic axis femur (AAF)
o a line that bisects the medullary canal of the femur
o determines entry point of femoral medullary guide rod
o intramedullary femoral guide goes down anatomic axis of the femur
Mechanical axis femur
o defined by line connecting center of femoral head to point where anatomic axis meets
intercondylar notch
o obtaining a neutral mechanical axis allows even load sharing between the medial and lateral
condyles of a knee prosthesis
Valgus cut angle (~5-7° from AAF )
o difference between AAF and MAF
o perpendicular to mechanical axis
o jig measures 6 degrees from femoral guide (anatomic axis)
o will vary if people are very tall (VCA < 5°) or very short (VCA > 7°)
o can measure on a standing full length AP x-ray
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Tibial alignment
Anatomic axis of tibia (AAT)
o a line that bisects medullary canal
o tibia medullary guide (internal or external) runs parallel to it
o determines entry point for tibial medullary guide rod
Mechanical axis of tibia
o line from center of proximal tibia to center of talus
o proximal tibia is cut perpendicular to mechanical axis of tibia
o usually mechanical axis and anatomic axis of tibia are coincident and therefore you can usually
can cut the proximal tibia perpendicular to anatomic axis (an axis determined by
an intramedullary jig)
o if there is a tibia deformity and the mechanical and anatomic axis are not the same, then the
proximal tibia must be cut perpendicular to the mechanical axis (therefore an extramedullary
tibial guide must be used)
Patellofemoral Alignment
Q angle
o Abnormal patellar tracking, although not the most serious, is the most common complication of
TKA.
o The most important variable in proper patellar tracking is preservation of a normal Q angle (11
+/- 7°)
the Q angle is defined as angle between axis of extensor mechanism (ASIS to center of
patella) and axis of patellar tendon(center of patella to tibial tuberosity)
o Any increase in the Q angle will lead to increased lateral subluxation forces on the patella
relative to the trochlear groove, which can lead to pain and mechanical symptoms, accelerated
wear, and even dislocation.
It is critical to avoid techniques that lead to an increased Q angle. Common errors include:
internal rotation of the femoral prosthesis
medialization of the femoral component
internal rotation of the tibial prosthesis
placing the patellar prosthesis lateral on the patella
o Q angle management in TKA
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Techniques
Varus Deformity
Anatomy
o medial side is tight (concave), lateral side stretched (convex)
Goals
o create precise bone cuts
o release the tight medial ligaments
o tighten the lax lateral ligaments
o balance flexion and extension gaps by adjustment of polyethylene bearing thicknesss
Steps of medial release
o Step 1
Deep MCL Release To Mid-Coronal Plane Of Tibia
o Step 2
Medial Osteophyte Removal
o Step 3
Release Posteromedial Corner (Posterior Oblique Ligament)
o Step 4
Medial Tibial Reduction Ostectomy
o Step 5:
Consider PCL Release/Substitution If Imbalance Persists At This Point (If Substitution Not
Initially Chosen)
o Step 6
Release Semimembranosis (Especially If There Is An Associated Flexion Contracture)
o Step 7
Pie Crust Superficial MCL (Favor Use Of 18 Gauge Needle)
o Step 8
Complete Superficial MCL Release / Pes Anserinus
Rarely Required Even In Severe Cases
Destabilizes Medial Flexion Gap / Consider A Constrained Prosthesis
Differential release: performed with two components of superficial MCL
posterior oblique portion is tight in extension (release if tight in extension)
anterior portion is tight in flexion (release if tight in flexion)
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Lateral tightening
o use a prosthesis that is sized to "fill up" the gap and make the stretched lateral ligaments taut
o if a polyethylene bearing thickness of >15mm is required to gain appropriate lateral ligamentous
tension, consider use of a constrained prosthesis to avoid excessive joint line elevation
Valgus Deformity (lateral side is concave/tight)
Anatomy
o lateral side is tight (concave), medial side stretched (convex)
Goals
o create precise bone cuts
o release the tight lateral ligaments
o tighten the lax medial ligaments
o balance flexion and extension gaps by adjustment of polyethylene bearing thicknesss
Lateral release in order
o Step 1
osteophytes
o Step 2
posterolateral capsule
o Step 3
iliotibial band if tight in extension
with pie crust or release off Gerdy's tubercle
o Step 4
popliteus if tight in flexion (release if tight in flexion)
release the anterior part of its insertion
for severe deformities release both the iliotibial band and the popliteus
o Step 5
LCL
some authors prefer to release this structure first if tight in both flexion and extension
other authors prefer to release the LCL last
if LCL & Popliteus require release, flexion gap stability is lost so consider constrained
prosthesis
o differential release: performed by differentially release the IT band and popliteus
Medial tightening
o fill up medial side until medial ligament complex is taut
o In severe cases, if a polyethylene bearing thickness >15mm is required to obtain appropriate
medial tension, consider a constained prosthesis to avoid excessive joint line elevation
Flexion / Contracture Deformity
Anatomy
o concave side is posterior- needs to be released
Posterior release order
o 1) posterior femoral & posterior tibial osteophytes
o 2) posterior capsule
o 3) additional resection of distal femur
o 4) gastronemius muscles (medial and lateral)
All releases are performed with knee at 90 degrees of flexion
o allows the popliteal artery to fall posteriorly to decrease risk of injury
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Techniques
You do not want to address a contracture by removing more tibia
o will change the joint line and lead to patella alta
Complications
Peroneal nerve palsy
o correction of valgus and flexion contracture deformity has highest risk of peroneal nerve palsy
o if patient presents with a peroneal palsy in recovery room then
then take off dressing and flex the knee
watch for three months to see if function returns
if function does not return, consider nerve conduction studies or operative exploration to
access for damage
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Tight in Flexion Balanced in Loose in Flexion
(can not fully flex) Flexion (large drawer test)
Tight in Extension, Tight in Flexion Tight in Extension, Balanced in Tight in Extension, Loose in Flexion
Problem: Flexion
Did not cut enough tibia Problem: Problem:
Tight in
Solution: Did not cut enough distal femur or Distal femur too long.
Extension
Cut more proximal tibia did not release enough posterior Solution:
(can not fully
capsule 1) Resect more distal femur or use
extend)
Solution: thinner distal femoral augmentation
1) Release posterior capsule wedge (revision scenario)
2) Cut more distal femur 2) Upsize femoral component
Balanced in Extension, Tight in Balanced in Extension, Loose in
Flexion Flexion
Problem:
Did not cut enough posterior Problem:
femur, PCL scarred and too tight. Cut too much posterior femur.
Solution: Solution:
1) Decrease femoral component 1) Increase size of femoral
size which required an increase in component (AP only)
resection of the posterior femoral 2) Posteriorize femoral component
condyle Recess vs. release of PCL (augment posterior femur).
Release posterior capsule
Balanced in
Decrease femoral component size Balanced in extension, Balanced in
Extension
which required an increase in Flexion (Perfect)
resection of the posterior femoral
condyle
2) Recess vs. release of PCL
3) Release posterior capsule
Solution:
1) Decrease femoral component
size which required an increase in
resection of the posterior femoral
condyle
2) Recess vs release of PCL
3) Release posterior capsule
Loose in Extension, Tight in Loose in Extension, Balanced in Loose in Extension, Loose in
Flexion Flexion Flexion
Solution: Problem: Problem:
Loose in 1) Downsize femur and use thicker Cut too much distal femur. Cut too much tibia.
Extension tibial insert until balanced. Solution: Solution:
(recurvatum) 1) Augment distal femur 1) Use thicker tibia PE
2) Add medial & lateral metal
augments to tibial tray
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Techniques
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In July 2017
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Anatomy
Q Angle
o the Q angle is defined as angle between
axis of extensor mechanism (ASIS to center of patella)
axis of patellar tendon (center of patella to tibial tuberosity)
Imaging
CT scan
o malrotation of components is best diagnosed with CT scan of the knee
Femoral Prosthesis
There are three reference axis that one may use:
o anteroposterior axis
defined as a line running from the center of the
trochlear groove to the top of the intercondylar notch
a line perpendicular to this defines the neutral
rotational axis
o transepicondylar axis
defined as a line running from the medial and lateral
epicondyles
the epicondylar axis is parallel to the cut tibial
surface
A posterior femoral cut parallel to the epicondylar
axis will create the appropriate rectangular
flexion gap
o posterior condylar axis
defined as a line running across the tips of
the two posterior condyles
this line is in ~ 3 degrees of internal rotation
from the transepicondylar axis, the femoral
prosthesis should be externally rotated 3
degrees from this axis to produce a rectangular flexion gap
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Techniques
if the lateral femoral condyle is hypoplastic, use of the posterior condylar axis may lead to
internal rotation of the femoral component
WARNING: the average posterior condylar twist angle is 3º but the range is 1-10º. Therefore
vary angle of femoral rotation based on variances in femoral anatomy.
Therefore vary angle of femoral rotation
Based on variances in femoral anatomy.
Internal Rotation of Femoral Prosthesis will Increase Q angle
o by internally rotating the femoral prosthesis, you are effectively bringing the groove and the
patella medially. This will increase the Q angle to the tibial tubercle
o will also make the medial compartment tight in flexion with subsequent TKA stiffness
Medialization of the Femoral Prosthesis will Increase Q angle
o a medialized femoral prosthesis will bring the trochlear groove to a more medial position, and
thus bring the patella medial with it, thus increasing the Q angle
o therefore, you want the femoral component to be slighly lateral if anything
Tibial Prosthesis
The preferred rotation of the tibial component is neutral,
with no internal or external rotation.
o the best way to obtain this is to have the tibial
component centered over the medial third of the tibial
tubercle
o this may leave a portion of the posteromedial tibia
uncovered and some overhang of the prosthesis over
the tibia on the posterolateral tibia.
Internal Rotation of Tibial Prosthesis will increase Q angle
o internal rotation of the tibial component effectively
results in relative external rotation of the tibial tubercle
and an increase in the Q angle
Medialization of tibia will increase Q angle
Patellar Prosthesis
The preferred position of the patellar prosthesis is to be either centered over the patella or medialized
o Medializing the patellar component is one strategy to decrease the Q angle.
o Results in uncoverage of lateral facet. Consider removing to lessen risk of lateral facet syndrome.
o Another alternative is use of an oval shaped patella with the
apex medialized.
Lateralization of the patellar prosthesis will increase the Q angle
and increase maltracking
Intraoperative lateral subluxation of the patella
o if patella laterally subluxes intraoperatively during trialing,
deflate tourniquet and recheck before performing a lateral
release
Indications for resurfacing
o absolute
inflammatory arthritis
patella maltracking
patellofemoral arthritis as the main indication for TKA
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Options for resurfacing during TKA
o always resurface
o never resurface
option to perform patelloplasty
excision of marginal osteophytes, reshaping of patella
o selective resurfacing
Patella resurfacing vs. Non-resurfacing
o less anterior knee pain with resurfacing
o less revision rates with resurfacing
o inferior results with secondary resurfacing
o increase complications (fx, tendon injury, etc.) with resurfacing
o similar patient satisfaction rates
o trochlear design important: “patellar friendly”
thinner anterior flange
anatomic trochlear groove
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Techniques
Imaging
Radiographs
o recommended views
AP and lateral views of the knee
lateral view of the knee in 30 degrees of flexion
used to measure Insall-Salvati ratio
measures ratio patellar tendon length to patellar bone
length
normal Insall-Salvati is 1:1 between length of the patellar
tendon length to patellar bone length
o findings
lateral view in extension
distal positioning of the patella in relation to the trochlear
groove III:9 Insall-Salvati ratio
Insall-Salvati ratio of < 0.8 is consistent with patella baja
Treatment
Nonoperative
o activity modifications, physical therapy
indications
mild symptoms in younger patients
Operative
o total knee replacement
indications
severe impingement in older patients with osteoarthritis
Techniques
Total knee arthroplasty in patient with patella baja
o methods to address patella infera during TKA
place patellar component superiorly
indications
mild patella baja
technique
use a smaller patellar dome placed on superior aspect of patella
trim inferior bone to decrease flexion impingement
lower joint line
indications
moderate patella baja
technique
add distal femoral augmentation
cut more proximal tibia to lower joint line (lower tibial cut)
avoid bone cuts that raise the joint line
raising the joint line will effectively increase the patella baja deformity
may require revision knee system
transfer tibial tubercle to cephalad position
indications
moderate patella baja
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technique
technique is difficult due to complexity of a tibial transfer in proximity to a cemented
tibial component
outcomes
unpredictable bone healing leads to variable, and often poor, outcomes
patients may be left with extensor lag
patellectomy
indications
severe patella baja
techniques
alters the tension in the anterior knee mechanism
therefore recommended to use use a cruciate substituting system
consider partial patellectomy in which patella is resected to a width of 10-12mm.
lessens impingement & crepitus while maintaining some of the fulcrum of the
patella.
9. TKA Rehabilitation
Introduction
Rehabilitation requires coordinated effort from
o orthopaedic surgeon
o physical therapist
o occupational therapist
o case manager
o nursing staff
o patient and patient's family
Care can be broken down into different phases including
o inpatient acute care (hospital)
o inpatient extended care (rehab/SNF)
o outpatient home care
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Techniques
III:11 Multimodal therapy is defined as altering the pain pathway in various ways.
NSAIDs
inhibit COX-1 and COX-2
inhibition of inflammatory
mediators (PGs, TXA, AA)
selective COX-2 inhibitors
inhibits transformation of AA to PG precursors
minimizes GI effects
may inhibit bone healing
gabapentin/pregabalin
reduce hyper-excitability of voltage dependent Ca2+ channels in activated
neurons.
pregabalin= better oral bioavailability.
SNRIs
inhibition of serotonin and noradrenergic reuptake in the CNS
Range of motion
o requirements
swing phase of gait
65° of flexion
activities of daily living
90° of flexion
stairs
95° of flexion
rise from a chair
105° of flexion
o continuous passive motion (CPM) machine
improve early knee flexion
has not been shown to have a long-term benefit
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Discharge home criteria
o medically stable
o 80-90° AROM knee flexion
o ambulate 75-100 feet
o ascend or descend stairs
Outpatient Care
Physical therapy
o 2-3 times per week for at least 2 weeks
o focused on closed-chain concentric exercises
o gradually advance from crutches to cane to unassisted
o other modalities include but not limited to
aquatic therapy
buoyancy attenuates gravity/compressive forces in joint; provides resistance
balance training
proprioception and postural control
cryotherapy
correlation between local temp and synovial PGE2
neuromuscular electrical stimulation (NMES)
may override deficits in muscle activation caused by CNS impairments
Return to activities
o low-impact closed chain exercises preferred
eliptical
biking
golf
handicap will show rise after TKA (stays same with THA)
o impact activities may decrease longevity of implant
running is discouraged
Driving recommendations
o 4 weeks after a right total knee
o < 4 weeks after a left total knee
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In July 2017
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Complications
B. TKA Complications
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Neer and Associates (1967)
Type I Nondisplaced (<5 mm displacement and/or <5 degrees angulation)
Type II Displaced > 1 cm
Type IIa Displaced > 1 cm with lateral femoral shaft displacement
Type IIb Displaced > 1 cm with medial femoral shaft displacement
Type III Displaced and comminuted
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Complications
Su and Associates' Classification of Supracondylar Fractures of the Distal Femur
Type I Fracture is proximal to the femoral component
Type II Fracture originates at the proximal aspect of the femoral component and extends
proximally
Type III Any part of the fracture line is distal to the upper edge of anterior flange of the
femoral component
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nail must be inserted deep enough (not protrude) to not abrade on patella/patellar
component
indications
intact/stable prosthesis with open-box design to accommodate nail
fracture proximal to femoral component (Su Type I)
fracture that originates at the proximal femoral component and extends proximally
(Su Type II)
ORIF with fixed angle device
indications
intact/stable prosthesis
Lewis-Rorabeck II or Su Types I or II (described above) unable to accommodate
intramedullary device
fracture distal to flange of anterior femoral component (Su Type III)
techniques
condylar buttress plate (non-locking)
does not resist varus collapse
locking supracondylar / periarticular plate
polyaxial screws allow screws to be directed into best bone before locking into
plate, and can avoid femoral component
blade plate / dynamic condylar screw
difficult to get adequate fixation around PS implants
complications
nonunion
increased risk in plating via extensile lateral approach compared with submuscular
approach
malunion
increased risk with minimally-invasive approach/MIPO
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revision to a long stem prosthesis
indications
loose femoral component
Lewis-Rorabeck III or Su Type III (described above) with poor bone stock
distal femoral replacement
indications
elderly patients with loose (Su type III) or malpositioned components and poor bone
stock
advantages
immediate weight-bearing
decreased operative time of procedure
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I II:17 An example of a
central single peg patellar
component.
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Complications
Classification
Goldberg Classification
Type I Fracture not involving implant/cement interface or quadriceps mechanism
Type II Fracture involving implant/cement interface and/or quadriceps mechanism
Type III Type A: inferior pole fracture with patellar ligament rupture
Type B: inferior pole fracture without patellar ligament rupture
Type IV All types with fracture dislocations
Treatment
o nonoperative
casting or bracing in extension
indications
stable implants with intact extensor mechanism
non-displaced fractures
o operative
indications
loose patellar component
extensor mechanism disruption
techniques (indications for each have not been clearly defined)
ORIF with or without component revision
partial patellectomy with tendon repair
patellar resection arthroplasty and fixation
total patellectomy
Radiograph showing a grossly Inferior pole fracture with This periprosthetic patellar
loose patellar component. extensor mechanism disruption. fracture was treated with ORIF
that eventually failed. Revision
ORIF was performed.
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Presentation
Symptoms
o painless
early disease
o pain
location
localized to the tissues around the loose components
aggrevating factors
weightbearing
often activity related
Physical exam
o may have minimal pain with ROM
o increased pain with weight bearing
Imaging
Radiographs
o required views
AP
tibial osteolysis readily visible on AP
femoral osteolysis may be difficult to detect on AP as lesions are typically located in
posterior condyles and are obscured by the femoral component
oblique x-rays
often more helpful for identifying femoral osteolysis
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Complications
Lateral radiograph
demonstrating significant AP and lateral radiograph and CT scans showing osteolysis of the
osteolysis of tibia distal femur and the tibia
o findings
radiolucent area around implant or cement
change in position of the implant
varus or valgus subsidence of tibial component
CT Scan & MRI
o viable options for assessing larger osteolytic lesions to aid in preoperative planning
Studies
Serum labs
o ESR normal
o CRP normal
Differential
Critical to rule out periprosthetic joint infection
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Treatment
Nonoperative
o observation
indications
stable implant with minimal symptoms
Operative
o revision TKA
indications
pain due to aseptic loosening
pain with evidence of osteolysis
3. TKA Instability
Instability
Introduction
o incidence
common cause of early failure following total knee arthroplasty
accounts for 10-20% of revisions
o types
extension (varus-valgus) instability
flexion (anteroposterior) instability
mid-flexion instability
genu recurvatum
global, multiply-operated instability
Presentation
History
o previous operations
o indication for initial replacement
o original implant information
o comorbidities including
connective tissue disease
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inflammatory diseases
diabetes, Charcot arthropathy
o history of trauma
Symptoms
o pain, instability or both
o timeline as to start of symptoms, what worsens/improves
Physical Examination
o overall gait, observe for valgus/varus thrust
o ligamentous examination throughout range of motion, attempt to reproduce symptoms
o flexion instability test
positive posterior sag with the knee flexed to 90 degrees
o overall strength
o extensor mechanism competency
o patellar tracking
Imaging
Plain radiographs
o weight bearing radiographs may reveal joint line asymmetry
o full limb length radiographs will offer overall mechanical alignment
o lateral radiographs can reveal:
tibial slope
tibial subluxation
recurvatum
Computed tomography
o can offer information regarding component rotation
Studies
Serum labs
o CBC, ESR, CRP, must rule out infection as potential cause
Knee aspiration
o to rule out infection via cell count and culture
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OrthoBullets2017 Knee Reconstruction | TKA Complications
controlled release of soft tissue on contracted side
if ligamentously insufficient, varus/valgus constrained device needed
if caused by, intraoperative MCL transection/deficiency
suture repair or suture anchor reattachment, use of either CR or PS implant, hinged knee
brace for 6 weeks postoperatively
use of unlinked constrained prosthesis
Mid-flexion instability
Causes
o controversial topic, poorly understood
o associated with modification of the joint line
o involves malrotation when the knee is flexed between 45 and 90 degrees
o potential contributing factors
femoral component design in sagittal plane
attenuation of anterior MCL
overall geometry of the tibiofemoral joint
Treatment
o typically, full revision is required
o goals
restoration of joint line
equalize flexion and extension gaps
Genu recurvatum
Definition
o fixed valgus deformity and iliotibial band contracture
Causes
o associated with poliomyelitis, rheumatoid arthritis, or Charcot arthropathy
o poliomyelitis
patient walks with knee locked in hyperextension, ankle in equinus due to quadriceps
weakness
Treatment
o typically long-stemmed posterior stabilized, or varus/valgus constrained implant
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Complications
o rotating-hinge reserved for salvage as residual hyperextension may occur, leading to early failure
Global, multiply-operated instability
Definition
o laxity of both flexion and extension gaps, as well as varus/valgus instability
o can be associated with severe bone loss
Presentation
o multidirectional ligamentous instability with recurvatum gait
Treatment
o varus/valgus constrained prosthesis at minimum
o typically, hinged prosthesis with or without augments, sleeves, cones
o severe bone loss situations may require endoprosthetic replacements
Presentation
Symptoms
o knee pain and weakness
Imaging
Radiographs
o patella alta or baja
Treatment
Nonoperative
o knee immobilizer x6 weeks
indications
partial quadriceps tendon rupture
Operative
o direct repair with suture
indications
patellar tendon avulsion < 30%
complete quadriceps tendon rupture with adequate soft tissues
risk of failure increases with prior lateral release, complete excision of prepatellar fat pad
o primary repair and augmentation with graft
indications
complete laceration of patellar tendon with adequate patellar bone stock
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OrthoBullets2017 Knee Reconstruction | TKA Complications
o extensor mechanism allograft
indications
complete laceration of patellar tendon without adequate patellar bone stock and deficient
soft tissues
Presentation
Symptoms
o complaints may include
feelings of subluxation
frank dislocation
peri-patellar pain
limited flexion
Imaging
Radiographs
o merchant view
may show a laterally subluxed patella
CT
o best to assess for rotational malalignment
Treatment
Must appropriately address etiology
Presentation
Symptoms
o persistnent knee pain
Imaging
Imaging
o radiographs
lateral view
show patellar component adjacent/superficial to patella
show loss of radiolucent space in patellofemoral joint and contact between patella bone
and femoral component
Treatment
Operative
o revision of patellar component
indications : if revision fails, resection of patellar component
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OrthoBullets2017 Knee Reconstruction | TKA Complications
patellar component placed low on the patella
exposes unresurfaced superior pole and quadriceps tendon to contact with femoral
component
patellar overresection and thin patellar button
reduces offset of quadriceps tendon from top of trochler groove
exposure of cut patellar bone that is not covered by patellar component
resect uncovered lateral patellar facet
femoral component
PS design
increased posterior femoral condylar offset
smaller femoral component
femoral component in flexed position
causes by more posterior entry point for intramedullary distal femoral cutting jig,
because of anterior bow of femur
femoral component with higher intercondylar box ratio (trochlear groove extended more
proximal and anterior)
thick polyethylene insert : raises joint line, creates relative patella baja
Pathophysiology
o cause of scar tissue is unknown, but may be related to:
direct trauma to quadriceps tendon during patella resection during TKA
impingement of the quadriceps tendon on the femoral component due to an undersized
patellar component
o scar is entrapped within the intercondylar notch during flexion
o the scar is forced out of the notch during active knee extension
o the painful snap or clunk is usually felt between 30-45 degrees
Presentation
Presents an average of 12 months after TKA
Symptoms
o patellofemoral knee pain
o complaints of knee "popping" and "catching"
Physical exam
o painful, palpable "pop" or "catch" as knee extends (~40° of flexion)
Imaging
US : shows suprapatellar fibrous tissue
Differential
Patellar crunch syndrome
o occurs when scar accumulates around the patellar component, causing
a crunching sensation when bringing the knee from extension to flexion III:22 arthroscopic vs open
resection of fibrous nodule
Treatment
Operative
o arthroscopic vs open resection of fibrous nodule
indications : severe symptoms
outcomes of arthroscopic resection are good, with very low rates of recurrence and
improvement in knee society scores
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Complications
8. TKA Stiffness
Introduction
Definition
o flexion contracture 10-15 degrees
o flexion < 90 degrees
Incidence
o 1.3%-12%
Risk factors
o preoperative factors
poor preoperative ROM
most important factor
patella baja
increased medical comorbidities
low pain tolerance
o technical factors
overstuffing patellofemoral joint
malrotation
tight flexion and/or extension gaps
joint line elevation
excessive tightening of extensor mechanism during closure
closure in flexion (as opposed to extension) may limit this complication
tight PCL in cruciate-retaining prosthesis
o postoperative factors
delayed rehabilitation
infection
HO
hamstring spasms
usually resolves within 6 months
Presentation
Symptoms
o difficulty kneeling
Physical exam
o check preoperative ROM from records
Studies
Serum labs
o ESR/CRP
must rule-out infection
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Treatment
Nonoperative
o manipulation under anesthesia
indications
flexion <90 degrees within first 12 weeks of operation (timing is controversial)
over aggressive manipulation
fracture
extensor mechanism disruption
contraindications
stiffness >3 months postoperatively
manipulation associated with greater risk and lower benefit
Operative
o arthroscopic lysis of adhesions with manipulation under anesthesia
indications
persistent late stiffness
o revision total knee arthroplasty
indications
identifiable technical cause for stiffness
Anatomy
Popliteal artery
o origin before knee
a continuation of the superficial femoral artery
transition is at hiatus of adductor magnus muscle
anchored by insertion of adductor magnus as enters region of posterior knee
o course in posterior knee
relation to anatomy structures of knee
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Complications
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OrthoBullets2017 Knee Reconstruction | TKA Complications
lies posterior to the posterior horn of the lateral horn of the lateral meniscus
lies directly behind posterior capsule
o branches within knee
at supracondylar ridge gives branches the provide blood supply to the knee
above knee joint branches include
medial and lateral sural arteries
cutaneous branch
middle genicular artery
at level of knee joint branches include
medial genicular artery
lateral genicular artery
o exit of knee
anchor
as artery exits knee it is anchored by soleus tendon (originates form medial aspect of
tibial plateau)
distal branches
branches into anterior and posterior tibial arteries at distal popliteus muscles
Presentation
Intraoperative
o brisk bleeding
o loss of pulses
Postoperative
o ischemia
o sensory changes
I II:24 Intraoperative angiogram noting popliteal
o loss of distal pulses pseudoaneurysm following injury during TKA. Left
o skin mottling image exhibits the psuedoaneurysm, right image exhibits
complete occlusion without distal run-off
III:25 CT angiogram s/p TKA
Imaging noting occlusion without run-off
distal to the popliteal artery
Intraoperative
o angiogram
indications
if brisk intraoperative bleeding and/or loss of pulses than obtain immediate vascular
surgery consultation.
vascular consultation will dictate intraoperative imaging, including angiogram.
Postoperative
o CT angiogram
indications
signs of ischemia
loss of pulses
skin mottling
sensory changes
Treatment
Immediate vascular surgery consultation III:26 Angiograms depicting before and
o indications after placement of a popliteal artery stent
exhibiting re-established flow
whenever a concern for injury to the popliteal artery
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Complications
o modalities may include
nonoperative and observation
closed suction drainage is associated with increased incidence of transfusion
stent placement
bypass
endarterectomy
prophylactic fasciotomy
may be indicated to avoid reperfusion compartment syndrome
Complications
Compartment syndrome
Amputation
Mortality
Socioeconomic consequences
o increased length of stay
o increased cost
Presentation
History
o multiply operated knee
o prior infection
Symptoms
o persistent knee pain
o persistent drainage beyond the early postoperative period (7 days)
Physical exam
o wound breakdown
o erythema
o warmth
o drainage
o peri-incisional eschar
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Complications
Imaging
Radiographs
o may help rule-out deep infection. looks for bone resorption
Bone scan
o radionuclide studies if infection suspected but aspiration and serology not confirmatory
Angiography
o if flow through sural arteries in question and gastrocnemius flap planned
Treatment
Nonoperative
o local wound care +/- antibiotics
indications
may be appropriate for some small superficial wounds
patients who are not surgical candidates
Operative
o debridement and coverage with rotational flap
indications
full-thickness necrosis
medial gastrocnemius rotational flap (medial sural artery): anterior and medial defects
lateral gastrocnemius rotational flap (lateral sural artery): lateral defects
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OrthoBullets2017 Knee Reconstruction | TKA Complications
o lymphocyte transformation test (LST)
o T-lymphyocyte rich immunohistopathology
o negative work-up for chronic/acute infection (must be ruled out)
Diagnosis
o exact definition is controversial
some argue combination of a positive patch test, positive immunohistopathology, and relief
of symptoms upon implant exchange is only way to confirm diagnosis
others argue that metal hypersensitivity is a diagnosis of exclusion, only arrived upon when
infection and aseptic loosening is ruled out
Treatment
Operative
o implant exchange
indications : persistent symptoms affecting quality of life
technique
hypoallergenic femoral component with all-polyethylene tibial component if possible
at time of surgery, chronic inflammatory synovitis typically present
Classification
Furia and Pellegrini classification system
o 2 Classes and 2 Grades
o Class I: island of bone localized to suprapatellar soft tissues
o Class II: bone organized into areas of ossification contiguous with the anterior distal femur
o Grade A: less than or equal to 5 cm
o Grade B: greater than 5 cm
Presentation
Symptoms (rare)
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Revision
o loss of motion
o pain
o quadriceps muscle snapping
o patellofemoral instability
Imaging
Radiographic evaluation
o typically visible 3-4 weeks post-operatively and matures within 1-2 years
o anterior distal aspect of femur and within quadriceps mechanism
Prevention
High-risk patients, generally those undergoing THA and not TKA
o external beam radiation therapy
o pharmaceutical prophylaxis with NSAIDs
no literature regarding these therapies in TKA patients
Treatment
Nonoperative
o observation
indications : in majority cases as HO rarely impacts clinical outcome
Operative
o surgical excision
indications
quadriceps muscle snapping
patellofemoral tracking difficulties
patellofemoral instability
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OrthoBullets2017 Knee Reconstruction | TKA Revision
C. TKA Revision
1. TKA Revision
Introduction
Most common causes of failure
o aseptic component loosening (~39%)
aseptic loosening is the most common reason for late revision (>2 years from primary)
tibial loosening more common than femoral
femoral loosening more difficult to detect due to obscured view of posterior femoral condyles
where lesions typically occur
oblique radiographs may help identify
detected on serial radiographs
osteolytic wear
most common in uncemented technique
motion between modular tibial insert and metal tray (backside wear)
o septic failure (~27%)
must rule out infection prior to any revision
infection is the most common failure mechanism for early revision (< 2 years from primary)
o ligament/flexion instability (~8%)
MCL/LCL incompetence can to lead to laxity
flexion instability
PCL attenuation (in CR knees)
unbalanced flexion gap
excessive posterior slope
undersized femoral component
femoral component placed in excessive extension
o periprosthetic fracture (~5%)
most commonly supracondylar femur region
need for revision due to combination of excessive comminution/bone loss with loose
component
o arthrofibrosis (~5%)
o patellofemoral maltracking
most commonly caused by component malpositioning
o abnormal joint line problems
o patellar clunk
fibrotic scar tissue that 'clunks' as the knee moves from flexion into extension and patella
jumps the femoral notch
arthroscopic treatment to remove fibrotic tissue
o metal hypersensitivity
Presentation
History
o original etiology and indications for TKA
o preoperative range of motion, ambulatory status
o history of infection, thrombophlebitis, recent falls
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | TKA Revision
o history of THA
o comorbidities
o type of implant, review of prior records and imaging
Symptoms
o temporal course is crucial:
pain
persistent since index procedure or new onset pain (may indicate potential acute vs.
chronic infection)
pain with weight bearing indicates likely mechanical etiology
stiffness
instability
environment of instability (i.e. stairs, level ground, rising from chair)
Physical Exam
o gait (stiff legged gait, inability to fully extend during stance phase)
o range of motion (passive or active)
o skin changes, presence of effusion, warmth (infection vs. complex regional pain syndrome
(CRPS))
o ligamentous exam for laxity
o patellar tracking
Imaging
Radiographs
o Serial AP and lateral radiographs to provide timeline of TKA
o Weight bearing radiographs can provide evaluation of any asymmetric wear
o Skyline view to assess patellar tracking
o Standing leg length views to assess overall alignment
o AP pelvis to rule out any hip pathology
Computed tomography
o Femoral version study can aide in assessing component rotation when also compared to the
femoral neck
o Can also aide in assessing severity and location of bony defects
Bone scan
o Can be positive for up to 2 years after primary TKA
o Positive scan
nonspecific
can indicate loosening, infection, or stress fracture
o Negative scan
rules out loosening
o Diffuse uptake can indicate CRPS
Studies
Serum labs
o CBC, ESR, CRP to rule out infection
Knee aspiration to rule out infection via cell count and culture
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OrthoBullets2017 Knee Reconstruction | TKA Revision
o indicated if PCL is intact
always have a PCL substituting implant available as it is difficult to evaluate the integrity of
the PCL prior to surgery
Unconstrained Posterior Cruciate Substituting
o indicated if there is a PCL deficiency
Constrained Nonhinged
o large central post substitutes for MCL/LCL function
o indicated for varus/valgus instability
LCL attenuation or deficiency
MCL attenuation or deficiency (controversial because load may lead to breaking of central
post)
flexion gap laxity
can be made stable with a tall post
Constrained Hinged with rotating platform
o tibial component is allowed to do internal/external rotation within a yoke
reduces rotational forces that would otherwise be on prosthesis-bone interface
o indicated for global ligament deficiency
LCL attenuation or deficiency
MCL attenuation or deficiency (deficiency of MCL is controversial
because load may lead to breaking of central post)
flexion gap laxity with component mismatch
post-traumatic or multiply revised TKR
hyperextension instability seen in polio
resection of the knee for tumor or infection
relatively indicated for charcot arthropathy
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OrthoBullets2017 Knee Reconstruction | TKA Revision
cemented:
advantages
can use in scenarios of excessive femoral bow
ability to delivery antbiotics
useful in severely osteopenic bone
disadvantages
increases complexity of any future revision
o cavity defect filling
cavitary defect <1cm
cement is adequate for small defects, structurally better than allograft
cavitary defect >1cm
metaphyseal sleeves
advantages
encouraging mid-to-long term data
efficient, simple, can be used as cutting guides
instrumented
morse taper interface with implant
disadvantages
expensive III:28 metaphyseal sleeves
difficult to remove
specific to each implant manufacturer
not useful for uncontained defects
trabecular metal cones
advantages
short-to-mid term data encouraging
variety of shapes/sizes with custom shaping/contouring is possible
trials/specific instrumentation available
compatible with several different implant companies
disadvantages
expensive
difficult to remove
cemented interface to implant
can be irritant to soft tissues
structural allograft
advantages
custom shaping available
satsifactory survivorship in mid-to-long term
potential biologic interface with host III:29 trabecular metal cones
disadvantages
time-consuming
disease transmission risk
long-term failure due to graft resorption
infection risk
technically demanding
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | Knee Arthroplasty Related Conditions
Complications
Pain
o pain scores less favorable than primary TKR
o activity related pain can be expected for 6 months
Stiffness
Neurovascular problems
o peroneal nerve subject to injury with correction of valgus and flexion deformity
Infection
o upwards of 4-7%, double the risk of primary TKA
Skin necrosis
o prior scars should be incorporated into skin incision whenever possible
o bloody supply to anterior knee is medially based, so lateral skin edge is more hypoxic
if multiple previous incisions, use most lateral skin incision
o can use wound care, skin grafting, or muscle flap coverage (gastroc) for full thickness defects
Extensor mechanism disruption
o can use extensor mechanism allograft using achilles tendon bone block
residual lag due to attenuation is common
o extensor mechanism reconstruction with mesh may offer better mid-term results in function and
survivorship
Indications
Indications
o young, active patient (<50 years) in whom an arthroplasty would fail due to excessive wear
o healthy patient with good vascular status
o non-obese patients
o pain and disability interfering with daily life
o only one knee compartment is affected
o compliant patient that will be able to follow postop protocol
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OrthoBullets2017 Knee Reconstruction | Knee Arthroplasty Related Conditions
General contraindications
o inflammatory arthritis
o obese patient BMI>35
o flexion contracture >15 degrees
o knee flexion <90 degrees
o procedure will need >20 degrees of correction
o patellofemoral arthritis
o ligament instability
o varus thrust during gait
Anatomy
Mechanical axis of lower extremity
o can be assessed by drawing straight line from center of femoral head to the
center of the ankle joint
o line axis should pass just medial to the medial tibial spine
Presentation
Symptoms
o pain on medial or lateral side of knee
Exam
o knee malalignment
III:30 Mechanical
Imaging axis of lower
extremity
Radiographs
o show knee malalignment using mechanical axis line
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | Knee Arthroplasty Related Conditions
lateral tibial subluxation >1cm
medial compartment bone loss >2-3mm
varus deformity >10 degrees
Technique
o lateral closing wedge technique
most common technique
wedge of bone removed with tibia via an anterolateral approach
ORIF of wedge
has advantages
more inherent stability allows for faster rehab and weight bearing
no required bone grafting
o medial opening wedge technique
III:32 lateral
transverse bone cut made in proximal tibia, and wedged open on medial side closing wedge
ORIF of wedge technique
has advantages
of maintaining posterior slope
avoids proximal tibiofibular joint
avoids peroneal nerve in anterior compartment
o focal dome osteotomy (concavity proximal)
the center of the dome is located at the center of rotation of angulation
(CORA)
has advantages
corrects limb alignment with the least translation of bone ends
least translation of anatomical axis
minimal shortening
Complications
Recurrence of deformity
o 60% failure rate after 3 years when
III:33Medial opening
failure to overcorrect wedge technique
patients are overweight
Loss of posterior slope
Patella baja
o refers to a shortened patellar tendon which decreases the distance of the patellar tendon from the
inferior joint line
can be caused by raising tibiofemoral joint line in opening wedge osteotomies
can be caused by retropatellar scarring and tendon contracture
can cause bony impingement of patella on tibia
Compartment syndrome
Peroneal nerve palsy
o more common in lateral opening wedge osteotomy
Malunion or nonunion
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OrthoBullets2017 Knee Reconstruction | Knee Arthroplasty Related Conditions
Indications
Indications
o controversial and vary widely
o as an alternative to total knee arthroplasty or osteotomy for unicompartmental disease
o classicaly reserved for older (>60), lower-demand, and thin (<82 kg) patients
6% of patient's meet the above criteria with no contraindications
o new effort to expand indications to include younger patients and patients with more moderate
arthrosis
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | Knee Arthroplasty Related Conditions
Contraindications
o inflammatory arthritis
o ACL deficiency
absolute contraindication for mobile-bearing UKA and lateral UKA
controversial for medial fixed-bearing
o fixed varus deformity > 10 degrees
o fixed valgus deformity >5 degrees
o restricted motion
arc of motion < 90°
flexion contracture of > 5-10°
o previous meniscectomy in other compartment
o tricompartmental arthritis (diffuse or global pain)
o younger high activity patients and heavy laborers
o overweight patients (> 82 kg)
o grade IV patellofemoral chondrosis (anterior knee pain)
Technique
Procedural tips
o avoid overcorrections
undercorrect the mechanical axis by 2-3 degrees
overcorrection places excess load on unresurfaced compartment
o remove osteophytes (peripheral and notch)
o resect minimal bone
o avoid extensive releases
o avoid edge loading
o prevent tibial spine impingement with proper mediolateral placement
o avoid making a varus tibial cut which increases the chance for loosening
o use caution when placing the proximal tibial guide pins to avoid stress fractures
o correct varus deformity to 1-5 degrees of valgus
Complications
Stress fractures
o always involve tibia
o associated with high activity and patient weight
o clinically there will be a pain free interval followed by spontaneous pain with activity
o blood commonly found on joint aspiration
Tibial component collapse
o poor mechanical properties of bone
Outcomes
Fixed-bearing
o 1st decade results
10-year survivorship from studies done in 1980s and 1990s ranges from 87.4% to 96%
the standard faliure rate in the first decade is 1%
o 2nd decade results : rapid decline in survivorship ranging from 79% to 90%
Mobile-bearing
o excellent clinical results with 15-year survivorship reported at 93%
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OrthoBullets2017 Knee Reconstruction | Knee Arthroplasty Related Conditions
Long-term results
o lateral compartment arthroplasties have equivalent results to medial
o revision rates are worse than total knee revision rates
o causes of late failure
other compartment degeneration (idiopathic, over-correction, more common with mobile-
bearing)
component failure (overload due to under-correction)
component loosening (common in fixed-bearing)
patella impingement on femoral component (patella pain)
polyethylene wear
3. Knee Arthrodesis
Introduction
Indications
o painful ankylosis after infection or trauma
o neuropathic arthropathy
o tumor resection
o salvage for failed TKA (most common)
o loss of extensor mechanism
Contraindications
o absolute
active infection
o relative
bilateral knee arthrodesis
contralateral leg amputation
significant bone loss
ipsilateral hip or ankle DJD
Optimal Position
o 5-8° valgus
o 0-10° of external rotation (match other leg)
o 0-15° of flexion
o some limb shortening advantageous for patient self-care
Surgical Technique
Intramedullary rod fixation
o technique
can be one long antegrade device or a two part device connected at the knee
patella can be left alone or incorporated into arthrodesis
External fixation
o technique
must allow compression of arthrodesis site
done with unilateral external fixation, Ilizarov, or Taylor Spatial Frame
Plate fixation
o technique
can be done alone in combination with intramedullary nailing
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By Dr, AbdulRahman AbdulNasser Knee Reconstruction | Knee Arthroplasty Related Conditions
Complications
Nonunion
Infection
Low back pain
Ipsilateral hip degenerative changes
Contralateral knee degenerative changes
Fracture
o supracondylar femur or proximal tibial metaphysis fractures
these occur from increased stress in these regions after arthrodesis
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In July 2017
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6
ORTHO BULLETS
Volume
Six
Hand
2017
Collected By : Dr AbdulRahman AbdulNasser
[email protected]
OrthoBullets 2017
OrthoBullets 2017
Preface
Orthobullets.com is an educational resource for
orthopaedic surgeons designed to improve
training through the communal efforts of those
who use it as a learning resource. It is a simple but
powerful concept. All of our topics, technique
guides, cases, and user-generated videos are
free, and will stay that way.
ORTHO BULLETS
I.Hand Introduction
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
A. Anatomy
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OrthoBullets2017 Hand Introduction | Anatomy
Extensor Ligaments
Lumbrical tendon passes volar to transverse metacarpal ligament
Interossei tendons pass dorsal to transverse metacarpal ligament
Retinacular Ligaments
Function
o retain and position common extensor mechanism during PIP and DIP flexion
o similar to sagittal band function
Anatomic Components
o oblique band (oblique retinacular ligament of Landsmeer)
function
links motion of DIP and PIP
lies volar to axis of PIP, but dorsal to axis of DIP
anatomy
origin: from lateral volar aspect of proximal phalanx,
insertion: to lateral terminal extensor dorsally (crosses collateral ligaments)
biomechanics
with PIP flexion, ligament relaxes to allow DIP flexion
with PIP extension, ligament tights to facilitate DIP extension
pathology
contracture causes volar displacement of lateral bands and a resulting Boutonniere
Deformity
reconstruction of oblique retinacular ligament used to treat swan neck deformity
if ORL is tight,
resting finger position is DIP extended, PIP flexed
unable to flex DIP if PIP is extended
able to flex DIP only after PIP is flexed
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
- 3 -
OrthoBullets2017 Hand Introduction | Anatomy
Anatomic Components
o Cleland's ligaments (remember "C" for ceiling)
dorsal to digital nerves
not involved in Dupuytren's disease
o Grayson's ligament (remember "G" for ground)
volar to digital nerves
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
Expansion Hood
Function
o works to extend PIP and DIP joint
Anatomic Components
o central slip
functions to extend PIP
inserts into base of middle phalanx
o lateral band
functions to extend DIP
inserts into distal phalanx
lumbricals, extensor indicis, dorsal and palmar
interossei insert on lateral band
MCP Joint Collateral Ligaments
Function
o stabilize MCP joint during motion
MCP joint "cam" nature leads to inconstant arc of motion because of joint asymmetry
caused by "snoopy head" configuration of metacarpal head
collaterals looser in extension, tighten during increasing flexion
as MP joint flexes, proximal phalanx moves further away from metacarpal head,
tightening all the ligaments
I:2 Figure - showing shape of metacarpal head I:3 Red, dorsal - proper ligament Green, volar - accessory ligament
Anatomic Components
o radial collateral ligaments (RCL) are more horizontal than ulnar collateral ligaments (UCL)
o RCL and UCL have 2 parts each: proper and accessory ligaments
accessory ligament
fan shaped
more volar
tight in extension
attachment
from metacarpal head at center of rotation
to palmar plate and deep transverse metacarpal ligament
clinical test
adduction/abduction stress in extension
proper ligament
cord like
more dorsal
tight in 30 degrees of flexion
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OrthoBullets2017 Hand Introduction | Anatomy
attachment
from posterior tubercle of metacarpal head (dorsal to mid axis)
to proximal phalanx base
clinical test : adduction/abduction stress in 30 degrees flexion to isolate proper ligaments
Sagittal Bands
Function
o keep extensor mechanism tracking in the midline during flexion of MP joint
Anatomy
o origin: palmar plate
o insertion: extensor mechanism (curves around radial and ulnar side of MP joint)
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
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OrthoBullets2017 Hand Introduction | Anatomy
Triangular ligament
Function
o counteracts pull of oblique retinacular ligament,
preventing lateral subluxation of the common
extensor mechanism
Anatomy
o triangular in shape
o located on dorsal side of extensor mechanism, distal
to PIP joint
Pathology
o contracture leads to swan neck deformity
Volar Plate
Function
o prevent hyperextension
Anatomy
o thickening of joint capsule volar to the MP joint
o in the thumb, sesamoid bones are located here
o origin: metacarpal head
o insertion: periarticular surface of proximal phalanx , via checkrein ligaments
Biomechanics
o loose in flexion
folds into metacarpal neck during flexion
o tight in extension
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
Annular ligaments
o A2 and A4 are critical to prevent bowstringing
most biomechanically important
o A1, A3, and A5 overlie the MP, PIP and DIP joints respectively
originate from palmar plate
o A1 pulley most commonly involved in trigger finger
Cruciate pulleys
o function to prevent sheath collapse and expansion during digital motion
o facilitates approximation of annular pulleys during flexion
o 3 total at the level of the joints
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OrthoBullets2017 Hand Introduction | Anatomy
Flexor Pulley System-Thumb
Types of
annular
variable pulley:
Type 1
Type 2
Type3
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OrthoBullets2017 Hand Introduction | Anatomy
Pulley Reconstruction
Goals
o preserve or reconstruct 3 or more pulleys
o A2 is important
o unclear if A4 reconstruction is absolutely necessary (can be sacrificed during acute flexor tendon
surgery)
Graft material
o extensor retinaculum
synovialized pulley surface, provides least gliding resistance
o excised tendon material
o palmaris or plantaris
o FDS
o flexor tendon allograft I:9 Bunnell single loop
Techniques
o first excise all scar dorsal to the flexor tendon
o around-the-bone (encircling technique)
single-loop (Bunnell)
triple loop (Okutsu)
biomechanically strongest construct
complications
most worrisome is phalangeal fracture
stiffness I:10 Okutsu triple loop
persistent bowstringing
inadequate tensioning
failure to remove scar tissue dorsal to tendon (tendon is not pressed against bone)
o nonencircling reconstruction
ever-present-rim (Kleinert)
belt-loop (Karev)
extensor retinaculum (Lister)
palmaris longus transplantation through volar plate (Doyle and Blythe)
Location Specific
o proximal phalanx (for A2 pulley)
use 3 loops (around-the-bone) - strongest reconstruction
pass DEEP to extensor mechanism
o middle phalanx (for A4 pulley)
use 2 loops (around-the-bone)
pass SUPERFICIAL to extensors
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
Superficial Arch
Anatomy
o deep to palmar fascia
o distal to the deep arch I:13 Superficial Arch
o surface marking
at the level of a line drawn across the palm parallel to the distal edge of the fully abducted
thumb
Blood supply
o predominant supply is ulnar artery
o minor supply from superficial branch of radial artery
Branches of superficial arch (from ulnar to radial)
o 1st branch
is the deep branch that provides the minor supply to the deep palmar arch
o 2nd branch
is the ulnar digital artery of the little finger
the proper digital artery to the ulnar side of the little finger arises directly from the
superficial arch
o 3rd, 4th, 5th, and 6th branches
are the common palmar digital arteries
in the palm, the digital arteries are volar to the digital nerves
in the digits, the digital arteries are dorsal to the digital nerves
in the digits, the neurovascular bundle is volar to Cleland's ligament
o multiple branches to intrinsic muscles and skin
The superficial arch is complete (branches to all digits) in 80% of individuals
Deep Arch
Anatomy
o deep to the flexor tendons (FDS, FDP)
o proximal to the superficial arch
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OrthoBullets2017 Hand Introduction | Anatomy
o at the level of the base of the metacarpals
o surface marking
1 fingerbreadth proximal to a line drawn
across the palm parallel to the distal edge of
the fully abducted thumb
1 fingerbreadth proximal to the superficial
arch
Blood supply
o predominant supply is the deep branch of the
radial artery
o minor supply from the deep branch of the ulnar
artery
Branches of the deep arch (from radial to ulnar)
I:14 Deep Arch
o princeps pollicis
runs between 1st dorsal interosseus and adductor pollicis
o branch to the radial side of the index finger
the proper digital artery to the radial side of the IF arises directly from the deep arch
o branches to the 3 common digital arteries in the 2nd, 3rd, and 4th web spaces
The deep arch is complete (branches to all digits) in 97% of individuals
Anatomic Landmarks
Arch Kaplan's cardinal line Distal Wrist Crease
Superficial 15mm distal 50mm distal
Deep 7mm distal 40mm distal
- 14 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
Digital Arteries
Common digital arteries arise from the superficial palmar arch
Divide into proper digital arteries at the web spaces
Gives dorsal branches distal to the PIP joints
Dominant arteries are found on the median side of the digit (closer to midline)
o in the index finger, the ulnar digital artery is dominant
o in the little finger, the radial digital artery is dominant
in the middle and ring fingers, ulnar and radial digital
arteries are dominant respectively, but dominance is less obvious
Dorsal Arteries
Blood supply
o posterior interosseous artery
o dorsal perforating branch of anterior interosseous artery
Form a dorsal carpal arch which gives rise to dorsal metacarpal arteries
o useful for dorsal metacarpal artery flaps
o 1st and 2nd dorsal metacarpal artery are more consistent than 3rd and 4th
Veins
Deep veins
o veins follow the deep arterial system as venae comitantes
Superficial veins
o found at the hand dorsum
o contribute to the basilic and cephalic vein system
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OrthoBullets2017 Hand Introduction | Anatomy
Wrist Biomechanics
Three biomechanic concepts have been proposed:
Link concept
o three links in a chain composed of radius, lunate and capitate
head of capitate acts as center of rotation
proximal row (lunate) acts as a unit and is an intercalated
segment with no direct tendon attachments
distal row functions as unit
o advantage
efficient motion (less motion at each link)
strong volar ligaments enhance stability
o disadvantage
I:16 Link Concept
more links increases instability of the chain
scaphoid bridges both carpal rows
resting forces/radial deviation push the scaphoid into flexion and push the triquetrum into
extension
ulnar deviation pushes the scaphoid into extension
Column concept
o lateral (mobile) column
comprises scaphoid, trapezoid and trapezium
scaphoid is center of motion and function is mobile
o central (flexion-extension) column
comprises lunate, capitate and hamate
luno-capitate articulation is center of motion
motion is flexion/extension
o medial (rotation) column
comprises triquetrum and distal carpal row
motion is rotation
Rows concept I:17 Rows concept I:18 Column concept
o comprises proximal and distal rows
scaphoid is a bridge between rows
o motion occurs within and between rows
Carpal Relationships
Carpal collapse
o normal ratio of carpal height to 3rd metacarpal height is 0.54
Ulnar translation
o normal ratio of ulna-to-capitate length to 3rd metacarpal height is 0.30
Load transfer
o distal radius bears 80% of load
o distal ulna bears 20% of load
ulna load bearing increases with ulnar lengthening
ulna load bearing decreases with ulnar shortening
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
Wrist Ligaments
The ligaments of the wrist include
o extrinsic ligaments
bridge carpal bones to the radius or metacarpals
include volar and dorsal ligaments
o intrinsic ligaments
originate and insert on carpal bones
the most important intrinsic ligaments are the scapholunate interosseous ligament and
lunotriquetral interosseous ligament
Characteristics
o volar ligaments are secondary stabilizers of the scaphoid
o volar ligaments are stronger than dorsal ligaments
o dorsal ligaments converge on the triquetrum
Space of Poirier
o center of a double "V" shape convergence of ligaments
o central weak area of the wrist in the floor of the carpal tunnel at the level of the proximal capitate
o between the volar radioscaphocapitate ligament and volar long radiolunate ligament
(radiolunotriquetral ligament)
wrist palmar flexion
area of weakness disappears
wrist dorsiflexion
area of weakness increases
o in perilunate dislocations, this space allows the distal carpal row to separate from the lunate
o in lunate dislocations, the lunate escapes into this space
I:21 Volar ligaments of the wrist I:20 Dorsal ligaments of the wrist
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
Sagittal MR arthrogram showing short radiolunate Cadaveric specimen showing short radiolunate ligament
ligament (3) (3)
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OrthoBullets2017 Hand Introduction | Anatomy
- 20 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Anatomy
Intrinsic (Interosseous) ligaments
Proximal row
o scapholunate ligament
primary stabilizer of scapholunate joint
composed of 3 components
dorsal portion
thickest and strongest
prevents translation
volar portion
prevents rotation
proximal portion
no significant strength
disruption leads to lunate extension when the scaphoid flexes
creating DISI deformity
o lunotriquetral ligament
composed of 3 components
dorsal
volar
proximal
disruption leads to lunate flexion when the scaphoid is normally aligned
creating VISI deformity (in combination with rupture of dorsal radiotriquetral rupture)
Distal row
o trapeziotrapezoid ligament
o trapeziocapitate ligament
o capitohamate ligament
Palmar midcarpal
o scaphotrapeziotrapezoid
o scaphocapitate
o triquetralcapitate
o triquetralhamate
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OrthoBullets2017 Hand Introduction | Anatomy
v Flexion Extension
MCP 70% Interosseous Extensor Digitorum sagittal band
o palmar adductors
o dorsal interosseous
30% lumbricals
o 2nd & 3rd digit by median n.
o 4th & 5th digit by ulnar n.
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Clinical Evaluation
7. Thumb Motion
- 23 -
OrthoBullets2017 Hand Introduction | Clinical Evaluation
B. Clinical Evaluation
Inspection
Skin
o discoloration
erythema (cellulitis)
white (arterial insufficiency)
blue/purple (venous congestion)
black spots (melanoma) I:22 Clinical photo of a
patient with thenar atrophy
o trophic changes (i.e. increased hair growth or altered sweat production)
secondary to carpal tunnel
can represent derangement of sympathetic nervous system syndrome
o scars/wounds
Swelling
Muscle atrophy
o thenar atrophy
median nerve involvement : caused by carpal tunnel
syndrome
o interossei atrophy
ulnar nerve involvement
I:23 Clinical photo of a patient with interossei muscle
caused by cubital tunnel or cervical radiculopathy atrophy secondary to cubital tunnel syndrome
o subcutaneous atrophy
locally post-steroid injection
Deformity
o asymmetry
o angulation
o rotation
o absence of normal anatomy (previous amputation)
o cascade sign
fingers converge toward the scaphoid tubercle when flexed at the MCPJ and PIPJ
if one or more fingers do not converge, then trauma to the digits has likely altered normal
alignment
- 24 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Clinical Evaluation
Palpation
Masses (ganglions, nodules)
Temperature
o warm: infection, inflammation
o cool: vascular pathology
Tenderness
Crepitus (fracture)
Clicking or snapping (tendonitis)
I :24 A clinical picture of a patient with a
Joint effusion (infection, inflammation, trauma)
dorsal wrist ganglion
Range of Motion
Active and passive
o Finger
MCP: 0° extension to 85° of flexion
PIP: 0° extension to 110° of flexion
DIP: 0° extension to 65° of flexion
o Wrist
60° flexion
60° extension
50° radioulnar deviation arc
- 26 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Clinical Evaluation
Special Tests
Palpation
o grind test
used to test for pathology at the thumb carpometacarpal
joint (CMC)
examiners applies axial load to first metacarpal and rotates
or "grinds" it
positive findings: pain, crepitus, instability
o Finkelstein's
used to test for DeQuervain's tenosynovitis
patient makes fist with fingers overlying thumb
examiner gently ulnarly deviates the wrist
positive findings: pain along the 1st compartment
Range of motion
o flexor profundus
used to test continuity of FDP tendons
MCP + PIP joints held in extension while patient asked to flex FDP,
thereby isolating FDP (from FDS) as the only tendon capable of
flexing the finger
o flexor sublimus
used to test for continuity of FDS tendon
MCP, PIP and DIP of all fingers held in extension with hand flat
and palm up; the finger to be tested is then allowed to flex at PIP
joint.
o Bunnel's test
examiner passively flexes PIPJ twice
first with MCP in extension
next with MCP held in flexion
intrinsic tightness present if PIP can be flexed
easily when MCP is flexed but NOT when
MCP is extended
extrinsic tightness present if PIP can be flexed
easily when MCP is extended but NOT when MCP is flexed
Stability assessment
o scaphoid shift test (Watson's test)
tests for scapholunate ligament tear
examiner places thumb on distal pole of scaphoid on palmar side of wrist and applies
constant pressure as the wrist is radially and ulnarly deviated
dorsal wrist pain or "clunk" may indicate instability
o lunotriquetral ballottement
tests for lunotriquetral ligament tear
examiner secures the pisotriquetral unit with the thumb and index finger of one hand and the
lunate with the other hand
anterior and posterior stresses are placed on the LT joint
positive findings are increased laxity and accompanying pain
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OrthoBullets2017 Hand Introduction | Clinical Evaluation
o midcarpal instability
examiner stabilizes distal radius and ulna with non-dominant hand and moves patients wrist
from radial deviation to ulnar deviation, whilst applying an axial load
a positive test occurs when a clunk is felt when the wrist is ulnarly deviated
o ulnar carpal abutement
tests for TFCC tear or ulnar-carpal impingement
examiner ulnarly deviates wrist with axial compression
positive if test reproduces pain or a 'pop' or 'click' is heard
o Gamekeeper's
tests for ulnar collateral ligament tear at MCP of thumb
examiner stresses first MCPJ into radial deviation with MCPJ in fully
flexed and extended positions
positive test if > 30 degrees of laxity in both positions (or gross laxity
compared to other side)
Nerve assessment
o Tinel's
tests for carpal tunnel syndrome
examiner percusses with two fingers over distal palmar crease in the
midline
positive if patient reports paresthesias in median nerve distribution
o Phalen's
tests for carpal tunnel syndrome
with the hands pointed up, the patient's wrist is allowed to flex by gravity
in palmar flexion for 2 minutes maximum
positive if patient reports paresthesias in median nerve distribution
o Froment's sign
tests for ulnar nerve motor weakness
patient asked to hold a piece of paper between thumb and radial side of
index
positive if as the paper is pulled away by the examiner the patient flexes
the thumb IP joint in an attempt to hold on to paper
o Wartenberg's sign
tests ulnar nerve motor weakness
patient asked to hold fingers fully adducted with MCP, PIP, and DIP
joints fully extended
positive if small finger drifts away from others into abduction
o Jeanne's sign
tests for ulnar nerve motor weakness
ask patient to demosntrate key pinch
positive finding if patients first MCP joint is hyperextended
- 28 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Clinical Evaluation
Introduction
Definition
o comprises nerve conduction velocity (NCV) studies and electromyography (EMG)
o used to localize areas of compression and neuropathy
o distinguish
lower vs upper motor neuron lesions
spinal root, trunk, division, cord or peripheral nerve lesion
o determine severity and prognosis
neuropraxia has good prognosis
axonotmesis/neurotmesis has poor prognosis
o demonstrate denervation, reinnervation, aberrant reinnervation, motor end plate lesion
o valuable in worker's compensation patients with secondary gain issues
Indications
o carpal tunnel syndrome
o cubital tunnel syndrom
o cervical radiculopathy
o lumbar radiculopathy
o nerve dysfunction of the shoulder (e.g., scapular winging)
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OrthoBullets2017 Hand Introduction | Clinical Evaluation
Nerve Conduction Velocity
Definition
o tests performed on peripheral nerves to determine their response to electrical stimuli
Technique
o constant voltage electric stimulator evokes a response from muscle (motor nerve study) or along
the nerve (sensory nerve study)
standard stimulus is 0.1 to 0.2ms square wave
o for motor nerve studies, an additional stimulus is measured along the proximal segment between
2 points on the nerve
to overcome inherent delay across neuromuscular junction if the recording electrode were
placed on the muscle
Measures
o NCV = distance divided by latency
distance traveled is from the cathode of the stimulating electrode to the recording electrode
latency is the time from the onset of stimulus to the onset of response
onset latency = time from site of stimulation + time to activate postynaptic terminal
(neuromuscular transmission time) + time for action potential to propagate along muscle
membrane to recording potential
NCV is determined by
myelin thickness
internode distance
temperature
age
NCV in newborns are 50% of adult values
NCV in 1 year olds are 75% of adult values
NCV in 5year olds are 100% of adult values
o Amplitude
from baseline to negative peak (in mV)
area under peak is proportional to number of muscle fibers depolarized
provides estimate of number of functioning axons and muscles
o Duration
reflects range of conduction velocities and synchrony of contraction of muscle fibers
if there are axons with different CVs (acute demyelination), duration will be greater
o Late responses evaluate proximal nerve lesions (near spinal cord, e.g. Guillain-Barre syndrome)
F-wave amplitude
H-reflex
stimulate Iα fibers at knee, with recording at the soleus (S1 root)
affected by sensory neuropathies, motor neuropathies of the tibial or sciatic nerves, and
S1 root lesions
Demyelination leads to
o increase latencies (slowing) of NCV
distal sensory latency of > 3.2 ms are abnormal for CTS
motor latencies > 4.3 ms are abnormal for CTS
o decreased conduction velocities less specific than latencies
velocity of < 52 m/sec is abnormal
- 30 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Clinical Evaluation
Findings on NCV
Condition Latency Conduction Velocity Amplitude Evoked Response
Upper limb (>45m/s),
Normal Normal Normal Normal
lower limb (>40m/s)
Axonal Normal Normal Decreased Prolonged
Demyelinating Increased Decreased Normal/decreased Absent/prolonged
Anterior horn cell Normal or polyphasic,
Normal Normal Decreased
disease prolonged duration
Myopathy Normal Normal Decreased Normal
Neuromuscular
Normal Normal Decreased Normal
junction
Neuropraxia
Absent Absent Absent Absent
proximal to lesion
Neuropraxia distal to
Normal Normal Normal Normal
lesion
Axonotmesis
Absent Absent Absent Absent
proximal to lesion
Axonotmesis distal to
Absent Absent Absent Normal
lesion
Neurotmesis
Absent Absent Absent Absent
proximal to lesion
Neurotmesis distal to
Absent Absent Absent Absent
lesion
Electromyography
Definition
o to study electrical activity of individual muscle fibers and motor units
o differentiate between diseases of nerve roots, peripheral nerves or skeletal muscles
o determine if disease is acute or chronic, and if there is reinnervation
o determine if there is nerve continuity
Technique
o insert needle electrode through the skin into muscle to determine insertional and spontaneous
activity
Types of activity
o insertional activity
shows state of muscle and innervating nerve as needle is inserted
normal muscle has baseline electrical activity
abnormal insertional activity (>300-500ms) shows early denervation
polymyositis
myotonic disorders
myopathies
reduced insertional activity occurs after prolonged denervation
muscle undergoes fibrosis
o contraction activity
patient is asked to contract muscle and shape/size/frequency of motor unit potentials are
recorded
o spontaneous activity
normal spontaneous activity includes end plate potentials and end plate spikes
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OrthoBullets2017 Hand Introduction | Clinical Evaluation
abnormal spontaneous activity indicates some nerve/muscle damage
sharp waves
fibrillations
spontaneous action potentials from single muscle fibers caused by oscillations in
resting membrane potential of denervated fibers
seen 3-5wk after nerve lesion begins, and stays until it resolves or muscle becomes
fibrotic
also seen in muscle disorders e.g. muscular dystrophy
fasciculations
spontaneous discharge of group of muscle fibers
found in amyotrophic lateral sclerosis, progressive spinal muscle atrophy and anterior
horn degenerative diseases e.g. polio, syringomyelia
seen as "undulating bag of worms" on physical exam
complex repetitive discharges
myokimic discharges
Findings on EMG
Insertional
Condition Spontaneous Activity Minimal Activity Interference
Activity
Biphasic/triphasic
Normal Normal Silent Complete
potentials
Fibrillations/positive sharp Biphasic/triphasic
Axonal neuropathy Increased Incomplete
waves potentials
Biphasic/triphasic
Demyelinating neuropathy Normal Silent Incomplete
potentials
Fibrillations/fasciculations, Large polyphasic
Anterior horn cell disease Increased Incomplete
positive sharp waves potentials
Small polyphasic
Inflammatory Myopathy Increased Fibrillations, myotonia Early
potentials
Small polyphasic
Noninflammatory Normal Normal Early
potentials
Biphasic/triphasic
Neuromuscular junction potentials
Normal Normal Early/normal
disorder (decreased
amplitude/duration)
Neurapraxia Normal Silent None None
Fibrillations/positive sharp
Axonotmesis Increased None None
waves
Fibrillations/positive sharp
Neurotmesis Increased None None
waves
- 32 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Hand Infections
C. Hand Infections
All hand trauma topics moved to volume one of trauma except hand infections
1. Paronychia
Introduction
A soft tissue infection of the proximal or lateral nail fold
Epidemiology
o incidence
most common hand infection (one third of all hand infections)
o demographics
usually in children
more common in women (3:1)
o location
most commonly involve the thumb
Pathophysiology
o organism
acute infection
adults - usually caused by Staphylococcus aureus
children - usually mixed oropharyngeal flora
diabetics - mixed bacterial infection
chronic infection
Candida albicans (more common in diabetics)
often unresponsive to antibiotics
Classification
Acute paronychia
o minor trauma from nail biting, thumb sucking, manicure
Chronic paronychia
o occupations with prolonged exposure to water and irritant acid/alkali chemicals e.g. dishwashers,
florists, gardeners, housekeepers, swimmers, bartenders
o risk factors for chronic paronychia
diabetes
psoriasis
steroids
retroviral drugs (indinavir and lamivudine)
indinavir is most common cause of paronychia in HIV positive patients
resolves when medication is discontinued
Anatomy
Nail organ
o adds to stability of finger tip by acting as counterforce to finger pulp
o thermoregulation (glomus bodies of nail bed and nail matrix)
o allows "extended precision grip" (using opposed thumbnail and index fingernail to pluck out a
splinter)
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OrthoBullets2017 Hand Introduction | Hand Infections
Nail plate
o made of keratin, grows at 3mm/month, faster in summer
o fingernails grow faster than toenails (fingernails take 3-6 months to regrow, and toenails take 12-
18 months)
o growing part is under proximal eponychium
Perionychium
o comprises hyponychium, eponychium and paronychium
Presentation
Symptoms
o acute paronychia
pain and
nail fold tenderness
erythema I:28 Green discoloration from
Pseudomonas
swelling
o chronic paronychia
recurrent bouts of low-grade inflammation (less severe than acute paronychia)
Physical exam
o acute paronychia
fluctuance
nail plate discoloration (green discoloration suggests Pseudomonas)
o chronic paronychia
nail plate hypertrophy (fungal infection)
nail fold blunting and retraction after repeated bouts of inflammation
prominent transverse ridges on nail plate
Differentials
Herpetic whitlow
Felon
Onychomycosis
Psoriasis
Glomus tumor
Mucous cyst
- 34 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Hand Infections
Treatment
Acute paronychia
o nonoperative
warm soaks, oral antibiotics and avoidance of nail biting
indications
swelling only, but no fluctuance
medications : augmentin or clindamycin
o operative
I&D with partial or total nail bed removal followed by oral abx
indications
fluctuance (indicates abscess collection)
nail bed mobility (indicates tracking under the nail)
follow with oral antibiotics and routine dressing change
Chronic paronychia
o nonoperative
warm soaks, avoidance of finger sucking, topical antifungals
indications
first line of treatment
medications
miconazole is commonly used
o operative
marsupialization (excision of dorsal eponychium down to level of germinal matrix)
indications
severe cases that fail nonoperative treatment
technique
combine with nail plate removal
leave to heal by secondary intention
Techniques
I&D with partial or total nail bed removal
o approach
may be done in emergency room
incision into sulcus between lateral nail plate and lateral nail fold
o technique
preserve eponychial fold by placing materials (removed nail) between skin and nail bed
if abscess extends proximally over eponychium (eponychia), a separate counterincision is
needed over the eponychium
obtain gram stain and culture
Complications
Eponychia : spread into eponychium
Runaround infection : involvement of both lateral nail folds
Felon
o spread volarward to pulp space
o I&D of finger pulp is necessary
Flexor tenosynovitis : volar spread into flexor sheath
Subungual abscess ("floating nail") : nail plate removal is necessary
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OrthoBullets2017 Hand Introduction | Hand Infections
2. Felon
Introduction
Infection of finger tip pulp
o usually thumb and index finger
Pathophysiology
o mechanism
penetrating injury including
blood glucose needle stick
splinters
local spread
may spread from paronychia
no history of injury in 50% of patients
o pathoanatomy
swelling and pressure within micro-compartments, leading to "compartment syndromes" of
the pulp
o organism
Staphylococcus aureus
most common organism
gram negative organisms
found in immunosuppressed patients
Eikenella corrodens
found in diabetics who bite their nails
Anatomy
Fingertip micro-compartments
o pulp fat is separated by fibrous vertical septae running
from distal phalanx bone to dermis
Presentation
Symptoms
o pain, swelling
Physical exam
o tenderness on distal finger
Treatment
Operative
o I&D in emergency room followed by IV antibiotics
indications
most cases due to risk of finger tip compartment syndrome
Techniques
Fingertip irrigation & debridement
o approach
keep incision distal to DIP crease
to prevent DIP flexion crease contracture and prevent
extension into flexor sheath I:29 Felon drainage - mid lateral
approach
- 36 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Hand Infections
mid-lateral approach
indicated for deep felons with no foreign body and not
discharging
incision on ulnar side for digits 2,3 and 4 and radial side for
thumb and digit 5 (non-pressure bearing side of digit)
volar longitudinal approach
most direct access
indicated for superficial felons, foreign body penetration or
visible drainage
incisions to avoid
fishmouth incisions - leads to unstable finger pulp
double longitudinal or transverse incision - injury to digital
nerve and artery I:30 Mid lateral incision
o debridement
avoid violating flexor sheath or DIP joint to avoid spread into
these spaces
break up septa to decompress infection and prevent compartment
syndrome of fingertip
obtain gram stain and culture
hold antibiotics until culture obtained
o postoperative
routine dressing changes
Complications
Finger tip compartment syndrome
Flexor tenosynovitis
Osteomyelitis
Digital tip necrosis I:31 longitudinal incision
I:32 RECOMMENDED: "J shaped" lateral or volar longitudinal. NOT RECOMMENDED: fishmouth and double lateral incisions
- 37 -
OrthoBullets2017 Hand Introduction | Hand Infections
- 38 -
By Dr, AbdulRahman AbdulNasser Hand Introduction | Hand Infections
o anatomy
variations common
sheaths extends from
index, middle, and ring fingers
from DIP to just proximal to A1 pulley
thumb (flexor pollicus longus sheath)
from IP joint to as proximal as radial bursa (in wrist)
little finger
from DIP joint to as proximal as ulnar bursa (in wrist)
Presentation
Symptoms
o pain and swelling
typically present in delayed fashion (over last 24-48 hours)
usually localized to palmar aspect of one digit
Physical exam
o Kanavel signs (4 total)
flexed posturing of the involved digit
tenderness to palpation over the tendon sheath
marked pain with passive extension of the digit
fusiform swelling of the digit
o increased warmth and erythema of the involved digit
Imaging
Radiographs
o recommended views
radiographs usually not required, but may be useful to
rule out foreign object
MRI
o cannot distinguish infectious flexor tenosynovitis from
inflammatory but may help determine the extent of the
ongoing process
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OrthoBullets2017 Hand Introduction | Hand Infections
Treatment
Nonoperative (rare)
o hospital admission, IV antibiotics, hand immobilization, observation
indications : early presentation
modalities
splinting
outcomes
if signs of improvement within 24 hours, no surgery is required
Operative
o I&D followed by culture-specific IV antibiotics
indications
low threshold to operative once suspected (orthopaedic emergency)
late presentation
no improvement after 24 hours of non-operative treatment (confirmed diagnosis)
technique (see below)
Technique
I&D of flexor tendon
o approach
full open exposure using long midaxial or Bruner incision
two small incisions placed distally at A5 pulley and proximally at A1 pulley and using an
angiocatheter
Complications
Stiffness
Tendon or pulley rupture
Spread of infection
Loss of soft tissue
Osteomyelitis
Anatomy
Thenar space
o a bursa (potential space) just palmar to adductor pollicis and dorsal to flexor tendons
o separated from midpalmar potential space by a fascial septum
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Hand Infections
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OrthoBullets2017 Hand Introduction | Hand Infections
Midpalmar space
o located dorsal and radial to hypothenar space
Hypothenar space
o located palmar to fifth metacarpal, dorsal and radial to hypothenar fascia, ulnar to hypothenar
septum
Presentation
History
o may or may not have penetrating trauma
Symptoms
o pain
o swelling
Physical exam
o pain with flexion of fingers
thenar
pain with thumb flexion
hypothenar
pain with small finger flexion
midpalmar
pain with small, ring, and small finger flexion
o thenar and midpalmar spaces
often have loss of palmar concavity secondary to swelling
Imaging
Radiographs
o indicated if there is suspicion for a foreign body
MRI
o indications
help define extent of infection
Treatment
Operative
o incision and drainage in conjunction with IV
antibiotics
indications I:33 Abscess in the Thenar Space: Debridement of infection
is best approached in the style of tumor management -
standard of care for deep space infections excision, rather than scrubbing. The abscess margins were
and collar button abscesses not well defined. The infection involved a volume from the
skin, superficial palmar fascia, down through the carpal
technique tunnel to the adductor muscle. Branches of the median nerve
use volar and dorsal incisions for collar and the superficial palmar arch are visible here. Excisional
debridement, wound care, intravenous antibiotics, and
button abscesses delayed closure at five days resulted in cure. Courtesy of Dr.
avoid skin in actual web space Charles Eaton
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Hand Infections
5. Herpetic Whitlow
Introduction
A viral infection of the hand caused by herpes simplex virus (HSV-1)
Epidemiology
o demographics
occurs with increased frequency in medical and dental personnel
most common infection occurring in a toddler’s and preschooler’s hand
Pathophysiology
o viral shedding occurs while vesicles are forming bullae
Presentation
Symptoms
o intense burning pain followed by erythema
o malaise
Physical exam
o erythema followed by small, vesicular rash
over the course of 2 weeks, the vesicles may come together to form bullae
the bullae will crust over and ultimately lead to superficial ulceration
o fever and lymphadenitis may be found
Studies
Tzank smear
o diagnosis confirmed by culture, antibody titers or Tzank smear
Treatment
Nonoperative
o observation +/- acyclovir
indications
standard of treatment
outcomes
self limiting, with resolution of symptoms in 7-10 days
acyclovir may shorten the duration of symptoms
recurrence may precipitated by fever, stress and sun exposure
Operative
o surgical debridement
indications
none
surgical treatment associated with superinfections, encephalitis, and death and should
be avoided
Complications
Superinfections
o often the result of surgical intervention
in pediatric patients, an infection of the digits may occur and require treatment with an oral
antibiotic (penicillinase resistant) ifor 10 days
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OrthoBullets2017 Hand Introduction | Hand Infections
Presentation
Symptoms
o cutaneous rash with discomfort
Physical exam
o papules, ulcers, and nodules are common, especially on the hands
many times presents with a single nodule that may ultimately spread
to the lymph nodes
indistinguishable from tuberculous mycobacterial infection
Studies
Histology I:34 Lowenstein-Jensen
o granulomas may or may not demonstrate acid-fast bacilli on AFB stain Agar growing M. Marinum
Cultures and sensitivities are key to diagnosis
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Hand Infections
o Lowenstein-Jensen culture agar
M. marinum incubated specifically at 30 to 32° C
M. avium intracellulare incubated at room temperature
Treatment
Nonoperative
o oral antibiotics
indications
if diagnosed at early stage
medications
ethambutol, tetraycline, trimethoprim-sulfamethoxazole, clarithromycin, azithromycin
add rifampin if osteomyelitis present
Operative
o surgical debridement + oral antibiotics in combination for 3 to 6 months
indications
later stage disease
use a combination of above medications
7. Fungal Infections
Introduction
Cutaneous fungal infections of the hand are rare and usually mild
o more common to have fungal infection in macerated skin areas (skin folds)
Prognosis
o usually resolve spontaneously
o May have serious infection in immunocompromised host
Classification
Infections divided into three categories
o cutaneous : includes nail bed infections (onychomycosis)
o subcutaneous : includes sporothrix schenckii from rose thorn prick
o deep
orthopaedic manifestation
tenosynovial
septic arthritis
osteomyelitis
organisms include
endemic
coccidiomycosis
histoplasmosis
blastomycosis
opportunistic include
candidiasis
mucormycosis
cryptococcocis
asperfillosisi
requires surgical debridement
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OrthoBullets2017 Hand Introduction | Hand Infections
Onychomycosis
Introduction
o defined as fungal infection in vicinity of nail bed (cutaneous)
o most common organisms are
trichophyton rubrum
a destructive nail plate infection
candida
chronic infection of nail fold
Treatment
o topic antifungal treatment & nail plate removal
indications : first line of treatment
o systemic griseofulvin or ketoconazole
indications
recalcitrant cases
Sporothrix schenckii
Introduction I:35 Sporothrix schenckii: local ulceration
o Sporothrix schenckii a common soil organism (papule) at site of penetration with additional
lesions in region on lymphatic vessels.
o a subcutaneous infection
o rose thorn in classic mechanism of subcutaneous transmission
Presentation
o physical exam
will show local ulceration (papule) at site of penetration
with time additional lesions form in region on lymphatic vessels
may show proximal lymph node involvement
Evaluation
o S schenckii isolated at room temperature on Sabouraud dextrose agar
Treatment
o oral itraconazole for 3 to 6 months
indications
mainstay of treatment
has replaced potassium iodide due to side effects which included
thyroid dysfunction
rash
GI symptoms
Coccidiomycosis
Introduction
o found in southwest arid regions (e.g., new mexico)
o often a deep infection
Presentation
o manifestations include
subclinical pulmonary involvement
orthopaedic manifestations
synovitis
arthritis
periarticular osteomyelitis
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By Dr, AbdulRahman AbdulNasser Hand Introduction | Hand Infections
Treatment
o amphotericin B & surgical debridement
Histoplasmosis
Introduction
o histoplasma capsulatum infection
o found in Mississippi River Valleys and Ohio
Presentation
o usually subclinical
o often found incidentally on CXR
o may present with tenosynovial infection
Evaluation
o diagnosed by skin testing
Treatment
o amphotericin B & surgical debridement / tenosynovectomy
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In July 2017
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OrthoBullets2017 Microsurgery | Hand Infections
ORTHO BULLETS
II. Microsurgery
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By Dr, AbdulRahman AbdulNasser Microsurgery | Replantation
A. Replantation
Anatomy
Fingertip anatomy
o eponychium
soft tissue on the dorsal surface just proximal to the nail
o paronychium
lateral nail folds
o hyponychium
plug of keratinous material situated beneath the distal edge of the nail where the nail bed
meets the skin
o lunula
white portion of the proximal nail
demarcates the sterile from germinal matrix beneath
o nail bed
sterile matrix
where the nail adheres to the nail bed
germinal matrix
proximal to the sterile matrix
responsible for 90% of nail growth
Presentation
History
o mechanism
avulsion
laceration
crush
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Physical exam
o inspection
often, characteristics of laceration will guide management
presence or absence of exposed bone
o range of motion : flexor and extensor tendon involvement
Imaging
Radiographs
o required imaging : AP/lateral radiographs to assess for bony involvement
Treatment
Nonoperative
o healing by secondary intention
indications
adults and children with no bone or tendon exposed with < 2cm of skin loss
children with exposed bone
Operative
o primary closure (revision amputation)
indications
finger amputation with exposed bone and the ability to rongeur bone proximally without
compromising bony support to nail bed
o full thickness skin grafting from hypothenar region
indications
fingertip amputation with no exposed bone and > 2cm of tissue loss
o flap reconstruction
indications
exposed bone or tendon where rongeuring bone proximally is not an option
Surgical Techniques
Secondary intention
o technique
initial treatment with irrigation and soft dressing
after 7-10 days, soaks in water-peroxide solution daily followed by application of soft
dressing and fingertip protector
complete healing takes 3-5 weeks
Full thickness skin grafting from hypothenar region
o technique
split thickness grafts not used because they are
contractile
tender
less durable
donor site is closed primarily
graft is sutured over defect
cotton ball secured over graft helps maintain coaptation with underlying tissue
o post-operative care
cotton ball removed after 7 days
range of motion encouraged after 7 days
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By Dr, AbdulRahman AbdulNasser Microsurgery | Replantation
Primary closure with removal of exposed bone (revision amputation)
o technique
must ablate remaining nail matrix
prevents formation of irritating nail remnants
if flexor or extensor tendon insertions cannot be preserve, disarticulate DIP joint
transect digital nerves and remaining tendons as proximal as possible
palmar skin is brought over bone and sutured to dorsal skin
Flap reconstruction (see below)
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Flap Reconstruction Techniques
V-Y advancement flap
o indications
straight or dorsal oblique finger tip lacerations
Digital island artery
o indications
straight or dorsal oblique finger tip lacerations II:1 V-Y advancement flap
volar oblique finger tip lacerations
o advantages : best axial pattern flap
Cross finger flap
o indications
volar oblique finger tip lacerations in
patients > 30 years
o advantages
leads to less stiffness
Reverse cross finger flap
o indications
II:2 Cross finger flap
dorsal finger & MCP lacerations
Thenar flap
o indications
volar oblique finger tip lacerations to
index or middle finger in patients < 30
years
o advantages
improved cosmesis
Axial flag flap from long finger
o indications
II:3 Axial flag flap from long finger
volar proximal finger
dorsal proximal finger & MCP lacerations
Moberg advancement volar flap
o indications : volar thumb if < 2 cm
Neurovascular island flap
o indications : volar thumb up to 4 cm
First dorsal metacarpal artery flap
II:4 Moberg advancement volar flap
o indications
dorsal thumb lacerations
volar thumb lacerations if > 2 cm
o technique
based on 1st dorsal metacarpal artery
Z-plasty with 60 degrees flaps
o indications : first web space lacerations
o technique : can lead up to 75% increase in length
Posterior interosseous fasciocutaneous flap
o indications : first web space lacerations
Groin flap
II:5 Neurovascular island flap
o indications : lesions to dorsal hand
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By Dr, AbdulRahman AbdulNasser Microsurgery | Replantation
Thenar flap
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OrthoBullets2017 Microsurgery | Replantation
Classification
Urbaniak Classification
Class Description Treatment
Standard bone and soft tissue
Class I Circulation adequate
care
Class II Circulation inadequate Vessel repair
Class III Complete degloving or complete amputation Amputation
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Kay, Werntz and Wolff Classification
Class Description Treatment
Standard bone and soft
Class I Circulation adequate
tissue repair
Class II Arterial compromise only Vessel repair
Inadequate circulation with bone, tendon, or nerve
Class III Amputation
injury.
Class IV Complete degloving or complete amputation. Amputation
Class I injury. Class IIA injury. Only tendons and bone Class III injury. Complete amputation of
Circumferential skin remained intact. DIPJ was dislocated the ring finger at the PIPJ level (A).
injury with laceration and all neurovascular structures were Successful replantation was achieved
of extensor tendon, severed, leaving the digit avascular (B) but the patient had limited range of
FDS, FDP and open
with no capillary refill. motion and was out of work for 18
dislocation of PIPJ
and injury to volar months.
plate. One intact
neurovascular bundle
maintained good
circulation.
Presentation
History
o may have history of working with machinery, getting caught in door
Symptoms
o pain
o bleeding
o lack of sensation at tip
Physical exam
o inspection
irrigate wound and inspect for visible avulsed vessel,
nerve, tendon, damaged skin edges
staggered injury pattern
proximal skin avulsion (from PIPJ to base of digit)
distal bone fracture or dislocation (distal to PIPJ, II:8 Urbaniak Class III avulsion. Note trailing
often at DIPJ level) flexor tendon avulsed proximally at
musculotendinous junction
Imaging
Radiographs
o recommended views
Xray both segments (the amputated part, if present, and the remaining digit)
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By Dr, AbdulRahman AbdulNasser Microsurgery | Replantation
II:9 Radiograph of amputate shows level of amputation. Bone fracture/dislocation is distal to level of skin avulsion
Treatment
Initial
o place amputated part, if present, in bag with saline-moistened gauze, followed by bag of ice
water
o antibiotics and tetanus prophylaxis
Operative
o replantation +/- vein graft, DIPJ fusion
indications
disruption of venous drainage only
disruption of venous and arterial flow (requires revascularization)
requires intact PIPJ and FDS insertion
contraindication
complete amputation (especially proximal to PIPJ and FDS insertion) is relative
contraindication to replantation
outcomes
survival
lower overall survival for avulsed digits replantation (60%) than finger replantation in
general (90%)
lower survival for complete (66%) vs incomplete avulsion replantation (78%)
lower survival for avulsed thumb (68%) than finger (78%) replantation
surgeons more likely to attempt technically difficult avulsed thumb replantation
where conditions not favorable because of importance of thumb to hand function
(unlike other digits, where revision amputation would be performed instead)
sensibility
most achieve protective sensibility (2PD 9mm)
better sensibility with incomplete avulsion replantation (8mm) than complete (10mm)
range of motion
average total arc of motion (TAM) of 170-200 degrees
better TAM with incomplete avulsion replantation (199 degrees) than complete (174
degrees)
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o revision amputation
indications
complete degloving
bony injury with nerve and vessel injury
bony amputation proximal to FDS insertion or proximal to PIPJ
replantation likely to leave poor hand function
consider revision amputation or ray amputation
Surgical Technique
Replantation/revascularization
o approach
under operating microscope mid-lateral approach to digit
o technique
arteries
thorough debridement of nonviable tissue
thorough arterial debridement (inadequate debridement leads to failure)
repair using vein grafts because of significant vascular damage
may need another step-down vein graft because of difficulty in arterial size matching
(small artery, large vein graft)
may reroute arterial pedicle from adjacent digit
disadvantage is this sacrifices major artery from adjacent digit
veins
repair at least 2 veins
important factor in revascularization failure
bone
if amputation occurs at DIPJ, perform primary arthrodesis of DIPJ
skin
perform full-thickness skin grafts or venous flaps to prevent tight closure or may utilize
commercially available synthetic acellular dermal matrix.
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By Dr, AbdulRahman AbdulNasser Microsurgery | Replantation
Complications
Complications of replantation
o cold intolerance (70%)
o revascularization/replantation failure
factors include
most significant factor is repair of <2 veins
vascular damage up to digital pulp
smoking and level of bone injury have not been found to affect survival
o flexion contracture
o malunion
o revision surgery
Complications of revision amputation
o hyperaesthesia
3. Replantation
Introduction
Trauma is the most common etiology for upper extremity replantation
Epidemiology
o incidence
90% of upper extremity amputation occurred after trauma
o demographics
4:1 male-to-female ratio
o location
most amputations occur at the level of the digits
Pathophysiology
o mechanism of traumatic amputation
sharp dissection
blunt dissection
avulsion
crush
Presentation
History
o timing of injury
o type and location of amputation
number of digits involved
o preservation of amputated tissue
o associated injury
o past medical history
Examination
o stump examined for
zone of injury
tissue viability
supporting tissue structures
contamination
o amputated portion inspected
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segmental injury
bone and soft tissue envelope
contamination
Indications
Indications for replantation after trauma
o primary indications
thumb at any level
multiple digits
through the palm
wrist level or proximal to wrist
almost all parts in children
o relative indications
individual digits distal to the insertion of flexor digitorum superficialis [FDS] (Zone I)
ring avulsion
through or above elbow
Contraindications to replantation
o primary contraindications
severe vascular disorder
mangled limb or crush injury
segmental amputation
prolonged ischemia time with large muscle content (>6 hours)
o relative contraindications
single digit proximal to FDS insertion (Zone II)
medically unstable patient
disabling psychiatric illness
tissue contamination
prolonged ischemia time with no muscle content (>12 hours)
Treatment
Transport of amputated tissue
o indications
any salvageable tissue should be transported with the patient to hospital
o modality
keep amputated tissue wrapped in moist gauze in lactate ringers solution
place in sealed plastic bag and place in ice water (avoid direct ice or dry ice)
wrap, cover and compress stump with moistened gauze
Operative
o time to replantation
proximal to carpus
warm ischemia time < 6 hours
cold ischemia time < 12 hours
distal to carpus (digit)
warm ischemia time < 12 hours
cold ischemia time < 24 hours
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By Dr, AbdulRahman AbdulNasser Microsurgery | Replantation
Postoperative Care
Environment
o keep patient in warm room (80°F)
o avoid caffeine, chocolate, and nicotine
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Replant monitoring
o skin temperature most reliable
concerning changes include a > 2° drop in skin temp in less than one hour or a temperature
below 30° celsius
o pulse oximetry
< 94% indicates potential vascular compromise
Anticoagulation
o adequate hydration
o medications (aspirin, dipyridamile, low-molecular weight dextram, heparin)
Arterial Insufficiency
o treat with
release constricting bandages
place extremity in dependent position
consider heparinization
consider stellate ganglion blockade
early surgical exploration if previous measures unsuccessful
o thrombosis secondary to vasospasm is most common cause of early replant failure
Venous congestion
o treatment
elevate extremity
leech application
releases Hirudin (powerful anticoagulant)
Aeromonos hydrophila infection can occur (prophylax with Bactrim or ciprofloxacin)
heparin soaked pledgets if leeches not available
Complications
Replantation failure
o most frequently cause within 12 hours is arterial thrombosis from persistent vasospasm
Stiffness
o replanted digits have 50% of total motion
o tenolysis is most common secondary surgery
Myonecrosis
o greater concern in major limb replantation than in digit replantation
Myoglobinuria
o caused by muscle necrosis in larger replants (forearm and arm)
o can lead to renal failure and be fatal
Reperfusion injury
o mechanism thought to be related to ischemia-induced hypoxanthine conversion to xanthine
o allopurinol is the best adjunctive therapy agent to decrease xanthine production
Infection
Cold intolerance
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By Dr, AbdulRahman AbdulNasser Microsurgery | Replantation
4. Thumb Reconstruction
Introduction
Region A
Primary closure
Toe to Thumb (wrap
around)
Local flaps
Region B
Web deepening
Metacarpal lengthening
Toe to thumb
Region C
Toe to thumb
Osteoplastic thumb
reconstruction
Dorsal rotational flap
Region D
Pollicization
Reconstruction of the thumb requires an intact carpometarcarpal joint that not only is stable, but is
appropriately functional.
Treatment
Toe to thumb procedure
o great toe receives blood supply from the first dorsal metatarsal artery and dorsalis pedis
The Morrison/wrap around flap allow for maintenance of length of the hallux. Size and
appearance are best replicated.
o second toe is not as stable for transfer
Vascular pedicle can be based on
dorsalis pedis /1st dorsal metatarsal artery
2nd dorsal metatarsal artery
Web deepening
o Z plasty (2 or 4 flap)
2 flaps provide greater depth
if completed at 45 degrees, relative length is increased by 50%; 60 degrees leads to an
increase in length of 75%
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o Brand flap
index finger is used to provide a full thickness (dermoepidermal flap)
can close the donor site primarily
o Dorsal rectangular flaps
Take from dorsum of metacarpals
May require skin grafting
o Arterialized palmar flap
o May use axial or island flaps (locally vs distally)
Osteoplastic reconstruction
o Iliac crest is used to establish mechanical length to the thumb
o an island flap from the radial aspect of the 4th ray is combined with a reverse radial forearm flap
to aid in coverage
B. Reconstruction
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By Dr, AbdulRahman AbdulNasser Microsurgery | Reconstruction
o regeneration process after transection
distal segment undergoes Wallerian degeneration (axoplasm and myelin are degraded distally
by phagocytes)
existing Schwann cells proliferate and line up on basement membrane
proximal budding (occurs after 1 month delay) leads to sprouting axons that migrate at
1mm/day to connect to the distal tube
o variables affecting regeneration
contact guidance with attraction to the basal lamina of the Schwann cell
neurotropism
neurotrophism
neurotrophic factors (factors enhancing growth and preferential attraction to other nerves
rather than other tissues)
Prognosis
o factors affecting success of recovery following repair
age
is single most important factor influencing success of nerve recovery
level of injury
is second most important (the more distal the injury the better the chance of recovery)
sharp transections
have better prognosis than crush injuries
repair delay
worsen prognosis of recovery (time limit for repair is 18 months)
o return of function
pain is first modality to return
Anatomy
Highly organized structure consisting of nerve fibers, blood vessels, and connective tissue
Functional structures
o epineural sheath
surrounds peripheral nerve
o epineurium
surrounds a group of fascicles to form peripheral nerve
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o neuron cell
cell body - the metabolic center that makes up < 10% of cell mass
axon - primary conducting vehicle
dendrites - thin branching processes that receive input from surrounding nerve cells
Blood supply
o extrinsic vessels
run in loose connective tissue surrounding nerve trunk
o intrinsic vessels
plexus lies in epineurium, perineurium, and endoneurium
Physiology
o presynaptic terminal & depolarization
electrical impulse transmitted to other neurons or effector organs at presynaptic terminal
resting potential established from unequal distribution of ions on either side of the neuron
membrane (lipid bilayer)
action potential transmitted by depolarization of resting potential
caused by influx of Na across membrane through three types of Na channels
voltage gate channels
mechanical gated channels
chemical-transmitter gated channels
o nerve fiber types
Classification
Seddon Classification
o neurapraxia
same as Sunderland 1st degree, "focal nerve compression"
nerve contusion leading to reversible conduction block without Wallerian degeneration
histology
histopathology shows focal demyelination of the axon sheath (all structures remain intact)
usually caused by local ischemia
electrophysiologic studies
nerve conduction velocity slowing or a complete conduction block
no fibrillation potentials
prognosis
recovery prognosis is excellent
o axonotmesis
same as Sunderland 2nd degree
axon and myelin sheath disruption leads to conduction block with Wallerian degeneration
endoneurium remains intact
fibrillations and positive sharp waves on EMG
o neurotmesis
complete nerve division with disruption of endoneurium
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By Dr, AbdulRahman AbdulNasser Microsurgery | Reconstruction
no recovery unless surgical repair performed
fibrillations and positive sharp waves on EMG
Sunderland Classification
o 1st degree
same as Seddon's neurapraxia
o 2nd degree
same as Seddon's axonotmesis
o 3rd degree
included within Seddon's neurotmesis
injury with endoneurial scarring
most variable degree of ultimate recovery
o 4th degree
included within Seddon's neurotmesis
nerve in continuity but at the level of injury there is complete scarring across the nerve)
o 5th degree
included within Seddon's neurotmesis
Sunderland Myelin
Axon Endoneurim Perineurium Epineurium
Grade Sheath
I Disrupted Intact Intact Intact Intact
II Disrupted Disrupted Intact Intact Intact
III Disrupted Disrupted Disrupted Intact Intact
IV Disrupted Disrupted Disrupted Disrupted Intact
V Disrupted Disrupted Disrupted Disrupted Disrupted
Evaluation
EMG
o often the only objective evidence of a compressive neuropathy (valuable in workcomp patients
with secondary gain issues)
o characteristic findings
denervation of muscle
fibrillations
positive sharp waves (PSW)
fasiculations
neurogenic lesions
fasiculations
myokymic potentials
myopathies
complex repetitive discharges
myotonic discharges
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NCV
o focal compression / demyelination leads to
increase latencies (slowing) of NCV
distal sensory latency of > 3.2 ms are abnormal for CTS
motor latencies > 4.3 ms are abnormal for CTS
decreased conduction velocities less specific that latencies
velocity of < 52 m/sec is abnormal
motor action potential (MAP) decreases in amplitude
sensory nerve action potential (SNAP) decreases in amplitude
Treatment
Nonoperative
o observation with sequential EMG
indications
neuropraxia (1st degree)
axonotmesis (2nd degree)
Operative
o surgical repair
indications
neurotomesis (3rd degree)
o nerve grafting
indications
defects > 2.5 cm
type of autograft (sural, saphenous, lateral antebrachial, etc)
no effect on functional recovery
Surgical Techniques
Direct muscular neurotization
o insert proximal nerve stump into affected muscle belly
o results in less than normal function but is indicated in certain cases
Epineural Repair
o primary repair of the epineurium in a tension free fashion
o first resect proximal neuroma and distal glioma
o it is critical to properly align nerve ends during repair to maximize potential of recovery
Fasicular repair
o indications
three indications exist for grouped fascicular repair
median nerve in distal third of forearm
ulnar nerve in distal third of forearm
sciatic nerve in thigh
o technique
similar to epineural repair, but in addition repair the perineural sheaths (individual fascicles
are approximated under a microscope)
o outcomes
no improved results have been demonstrated over epineural repair
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By Dr, AbdulRahman AbdulNasser Microsurgery | Reconstruction
Nerve grafting
o autologous graft
indications
≥ 3cm gap
digital nerve defects
at wrist to common digital nerve bifurcation - use sural nerve
at MCP to DIP level - use lateral antebrachial cutaneous nerve
at DIP level - use AIN, PIN or medial antebrachial cutaneous nerve
outcomes
gold standard for segmental defects > 5cm
o collagen conduit
tensioned closures inhibit Schwann cell activation and axon regeneration, compromise
perfusion and lead to scarring
collagen conduits allow nutrient exchange and accessibility to neurotrophic factors to the
axonal growth zone during regeneration
indications
defects ≤ 2cm
outcomes
equal results to autologous grafting when gap ≤5mm
quality of nerve recovery drops with gaps >5mm
o allograft
off-the-shelf option for defects up to 5cm
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By Dr, AbdulRahman AbdulNasser Microsurgery | Reconstruction
Techniques
Fingertips & Hand
See Finger amputation and Flaps
Arm Flaps
Lateral arm flap • Lateral arm defects
• Blood supply by posterior radial collateral artery (branch of profunda brachii)
Leg Muscle Flaps
Medial Gastroc flap • Used for medial and midline defects over proximal third of tibia
• Pedicle supplied by medial sural artery
Lateral Gastroc
• Used for lateral defects over proximal third of tibia
flap
Soleus • Used for wounds over middle third of tibia
• Supplied by branches of the popliteal artery trunk, the posterior tibial artery
(medial), and the peroneal artery (proximal)
Gracilis • Most common donor for free muscle transfer
• Nerve is anterior division of obturator nerve
• Artery is branch of medial femoral circumflex artery
Free flaps • Used for wound coverage over distal third of tibia, or in the middle and
proximal leg when soleus and gastrocnemius are damaged
Groin flap • Axial flap that has been a mainstay of providing soft-tissue coverage of the
upper extremity
• Based on the superficial circumflex iliac artery
Bone Flaps
Free iliac crest • Based on deep circumflex iliac vessels
• Useful for metaphyseal reconstruction
Free fibula • Useful for diaphyseal reconstruction
• Based on peroneal artery pedicle
Vascular bone • Gaining popularity osteonecrosis of scaphoid fractures
graft from radius • Harvested from dorsal aspect of distal radius
• Based on 1-2 intercompartmental superretinacular artery (branch of radial
artery)
• Indicated to reduce the space left between the index and ring finger following
Index metacarpal
middle ray amputation. An alternative technique is deep transvers
transposition
intermetacarpal ligament reconstruction.
Little metacarpal • Indicated to reduce the space left between the middle and little finger
transposition following ring ray amputation.
Technique
Ladder of reconstruction
o in order of increasing complexity
primary closure
secondary closure
healing by secondary intention
skin graft
local flap
regional flap
free tissue transfer
Complications
Flap Failure
o inadequate arterial flow
treatment II:10 Clinical photograph showing venous congestion after
immediate return to operating room free anterolateral thigh flap to the forearm.
o inadequate venous outflow
treatment
loosen dressings, removal of selected sutures
return to operating room if not relieved by above measure
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By Dr, AbdulRahman AbdulNasser Microsurgery | Reconstruction
Donor site morbidity
o may be cosmetically unacceptable
o pain related to grafting
o seroma
treatment
aspiration
excision if encapsulated
Nonunion for vascularized bone transfer
o incidence
may be as high as 32% if no additional bone graft is used
3. Skin Grafting
Introduction
A skin graft is an avascular graft and consists of
o partial-thickness dermal tissue
o full-thickness dermal tissue
Donor site
o most commonly autologous
Goals of treatment
o cover deep structures
o create a barrier to bacteria,
o restore dynamic function of the limb
o prevent joint contractures
Indications
o well-perfused wound beds over muscle or subcutaneous tissue
Contraindications
o wounds with exposed bone, tendon, nerves, or blood vessels
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By Dr, AbdulRahman AbdulNasser Microsurgery | Reconstruction
should transfer motor grade 5
o appropriate tensioning
o appropriate excursion
can adjust with pulley or tenodesis effect
Smith 3-5-7 rule
3 cm excursion - wrist flexors, wrist extensors
5 cm excursion - EDC, FPL, EPL
7 cm excursion - FDS, FDP
o surgical priorities
elbow flexion (musculocutaneous n.)
shoulder stabilization (suprascapular n.)
brachiothoracic pinch (pectoral n.)
sensation C6-7 (lateral cord)
wrist extension and finger flexion (lateral and posterior cords)
o selection
determine what function is missing
determine what muscle-tendon units are available
evaluate the options for transfer
o basic principles
donor must be expendable and of similar excursion and power
one tendon transfer performs one function
synergistic transfers rehabilitate more easily
it is optimal to have a straight line of pull
one grade of motor strength is lost following transfer
Prognosis
o age
leading prognostic factor
worse after age 30
o location
distal is better than proximal
Presentation
Physical exam
o brachial plexus injury
Horner's sign
correlates with C8-T1 avulsion
often appears 2-3 days following injury
severe pain in anesthetic limb
indication of root avulsion
loss of rhomboid function
indication of root avulsion
o radial nerve palsy
classified according to location of lesion proximal or distal to the origin of PIN
low radial nerve palsy
PIN syndrome
high radial nerve palsy
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OrthoBullets2017 Microsurgery | Reconstruction
loss of radial nerve proper function (triceps, brachioradialis, ECRL plus muscles
innervated by PIN)
o median nerve palsy
classified according to location of lesion proximal or distal to the origin of AIN
low median nerve palsy
loss of thumb opposition (APB function)
high median nerve palsy
loss of thumb opposition
loss of thumb, index finger, and middle finger flexion
o ulnar nerve palsy
low ulnar nerve palsy
loss of power pinch
II:11 Wartenberg sign
abduction of the small finger (Wartenberg sign)
clawing
results from imbalance between intrinsic and extrinsic muscles
high ulnar nerve palsy
loss of ring and small finger FDP function
primary distinguishing deficit
clawing less pronounced because extrinsic flexors are not functioning
Studies
Sensory and motor evoked potentials
o better than standard EMG/NCS
Treatment
Nonoperative
o physical therapy, splinting, and antispasticity medications
indications
decreased passive range of motion
spasticity
Operative
o early surgical intervention (3 weeks to 3 months)
indications
total or near-total brachial plexus injury
high energy injury
o late surgical intervention (3 to 6 months)
indications
partial upper-level brachial plexus palsy
low energy injury
postoperative care
protect for 3-4 weeks then begin ROM
continue with protective splint for 3-6 weeks
synergistic transfers are easier to rehabilitate (synergistic actions occur together in normal
function, e.g., finger flexion and wrist extension)
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By Dr, AbdulRahman AbdulNasser Microsurgery | Reconstruction
Specific Transfers & Indications
Goal to regain FROM: Donor tendon (working) TO: Recipient Tendon (deficient)
Axillary nerve palsy
Shoulder stability glenohumeral arthrodesis glenohumeral arthrodesis
(flail shoulder)
Musculocutaneous nerve palsy
Elbow flexion pectoralis major, latissimus dorsi to biceps
Elbow flexion common flexor mass point more proximal on humerus
(Steindler flexorplasty)
Radial nerve & PIN palsy
Elbow extension deltoid, latissimus dorsi, or biceps to triceps
Wrist extension PT ECRB
Finger extension FDS, FCR, or FCU EDC
Thumb extension PL or FDS EPL
Low median nerve palsy
Thumb opposition FDS (ring) base proximal phalanx or APB tendon
and abduction (use FCU as pulley - classic Bunnell
opponensplasty)
EIP APB (pulley around ulnar side of wrist)
High median nerve palsy
Thumb IP flexion BR FPL
Index and long FDP of ring and small finger (ulnar FDP of index and middle (side-to-side
finger flexion nerve) transfer)
Ulnar nerve palsy
Thumb adduction FDS or ECRB adductor pollicis
Finger abduction APL, ECRL, or EIP 1st dorsal interosseous
(index most
important)
Reverse clawing FDS, ECRL (must pass volar to lateral bands of ulnar digits
effect transverse metacarpal ligament to flex
proximal phalanx)
Complications
Adhesions
o necessitate aggressive therapy and possible secondary tenolysis
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OrthoBullets2017 Neuropathies | Reconstruction
ORTHO BULLETS
III.Neuropathies
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By Dr, AbdulRahman AbdulNasser Neuropathies | Median Neuropathies
A. Median Neuropathies
Presentation
Symptoms
o numbness and tingling in radial 3-1/2 digits
o clumsiness
o pain and paresthesias that awaken patient at night
o self administered hand diagram
the most specific test (76%) for carpal tunnel syndrome
Physical exam
III:1 thenar atrophy
o inspection may show thenar atrophy
o carpal tunnel compression test (Durkan's test)
is the most sensitive test to diagnose carpal tunnels syndrome
performed by pressing thumbs over the carpal tunnel and holding pressure for 30 seconds.
onset of pain or paresthesia in the median nerve distribution within 30 seconds is a
positive result.
o Phalen test
wrist volar flexion for ~60 sec produces symptoms
less sensitive than Durkin compression test
o Tinel's test
provocative tests performed by tapping the median nerve over the volar carpal tunnel
o Semmes-Weinstein testing
most sensitive sensory test for detecting early carpal tunnel syndrome
measures a single nerve fiber innervating a receptor or group of receptors
o innervation density test
static and moving two-point discrimination
measures multiple overlapping of different sensory units and complex cortical integration
the test is a good measure for assessing functional nerve regeneration after nerve repair
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By Dr, AbdulRahman AbdulNasser Neuropathies | Median Neuropathies
Imaging
Radiographs
o not necessary for diagnosis
Studies
Diagnostic criteria
o numbness and tingling in the median nerve distribution
o nocturnal numbness
o weakness and/or atrophy of the thenar musculature
o positive Tinel sign
o positive Phalen test
o loss of two point discrimination
EMG and NCV
o overview
often the only objective evidence of a compressive neuropathy (valuable in work comp
patients with secondary gain issues)
not needed to establish diagnosis (diagnosis is clinical) but recommended if surgical
management is being considered
o demyelination leads to
NCV
increase latencies (slowing) of NCV
distal sensory latency of > 3.2 ms
motor latencies > 4.3 ms
decreased conduction velocities less specific than latencies
velocity of < 52 m/sec is abnormal
EMG
test the electrical activity of individual muscle fibers and motor units
detail insertional and spontaneous activity
potential pathologic findings
increased insertional activity
sharp waves
fibrillations
fasciculations
complex repetitive discharges
Histology
o nerve histology characterized by
edema, fibrosis, and vascular sclerosis are most common findings
scattered lymphocytes
amyloid deposits shown with special stains in some cases
Treatment
Nonoperative
o NSAIDS, night splints, activity modifications
indications
first line of treatment
modalities
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OrthoBullets2017 Neuropathies | Median Neuropathies
Technique
Open carpal tunnel release
o antibiotics
prophylactic antibiotics, systemic or local, are not indicated for patients undergoing a clean,
elective carpal tunnel release
o technique
internal neurolysis, tenosynovectomy, and antebrachial fascia release do not improve
outcomes
Guyon's canal does not need to be released as it is decompressed by carpal tunnel release
lengthened repair of transverse carpal ligament only required if flexor tendon repair
performed (allows wrist immobilization in flexion postoperatively)
o complications
correlate most closely with experience of surgeon
incomplete release
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By Dr, AbdulRahman AbdulNasser Neuropathies | Median Neuropathies
progressive thenar atrophy due to injury to an unrecognized transligamentous motor branch
of the median nerve
Endoscopic carpal tunnel release
o advantage is accelerated rehabilitation
o long term results same as open CTR
o most common complication is incomplete division of transverse carpal ligament
Presentation
Symptoms
o motor deficits only
o no complaints of pain, unlike other median compression
neuropathies (carpal tunnel syndrome and pronator syndrome)
Physical exam
o weakness of grip and pinch, specifically thumb, index and middle finger flexion
o patient unable to make OK sign (test FDP and FPL)
o pronator quadratus weakness shown with weak resisted pronation with elbow maximally flexed
o distinguish from FPL attritional rupture (seen in rheumatoids) by passively flexing and extending
wrist to confirm tenodesis effect in intact tendon
if tendons intact, passive wrist extension brings thumb IP joint and index finger DIP joint into
relatively flexed position
Evaluation
NCV / EMG
o helpful to make diagnosis
o may reveal abnormalities in the FPL, FDP index and middle finger and pronator quadratus
muscles
o assess severity of neuropathy
o may rule out more proximal lesions
Treatment
Nonoperative
o observation, rest and splinting in 90° flexion
indications
in vast majority of patients, unless clear space occupying mass
majority will improve with nonoperative management
technique : elbow splinting in 90 degrees of flexion (8-12 weeks)
Operative
o surgical decompression of AIN
indications
if nonoperative treatment fails after several months
approximately 75% success rate of surgical decompression
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By Dr, AbdulRahman AbdulNasser Neuropathies | Median Neuropathies
Techniques
Surgical decompression of AIN
o technique
release of superficial arch of FDS and lacertus fibrosus
detachment of superficial head of pronator teres
ligation of any crossing vessels
removal of any space occupying lesion
Complications
Recurrence
3. Pronator Syndrome
Introduction
A compressive neuropathy of the median nerve at the level of the elbow
Epidemiology
o more common in women
o common in 5th decade
o has been associated with well-developed forearm muscles (e.g.
weight lifters)
Pathoanatomy
o 5 potential sites of entrapment include
supracondylar process
residual osseous structure on distal humerus present in 1% of
population
ligament of Struthers
travels from tip of supracondylar process to medial epicondyle
not to be confused with arcade of Struthers which is a site of ulnar compression
neuropathy in cubital tunnel syndrome
bicipital aponeurosis (a.k.a. lacertus fibrosus)
between ulnar and humeral heads of pronator teres
FDS aponeurotic arch
Associated conditions
o commonly associated with medial epicondylitis
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OrthoBullets2017 Neuropathies | Median Neuropathies
Presentation
Symptoms
o paresthesias in thumb, index, middle finger and radial half of ring finger as seen in carpal tunnel
syndrome
in pronator syndrome paresthesias often made worse with repetitive pronosupination
o should have characteristics differentiating from carpal tunnel syndrome (CTS)
aching pain over proximal volar forearm
sensory disturbances over the distribution of palmar cutaneous branch of the median
nerve (palm of hand) which arises 4 to 5 cm proximal to carpal tunnel ( see photos next page)
lack of night symptoms
Physical exam
o provocative tests are specific for different sites of entrapment
positive Tinel sign in the proximal anterior forearm but no Tinel sign at wrist nor provocative
symptoms with wrist flexion as would be seen in CTS
resisted elbow flexion with forearm supination (compression at bicipital aponeurosis)
resisted forearm pronation with elbow extended (compression at two heads of pronator teres)
resisted contraction of FDS to middle finger (compression at FDS fibrous arch)
o possible coexisting medial epicondylitis
Imaging
Radiographs
o recommended views
elbow films are mandatory
o findings
may see supracondylar process
Studies
EMG and NCV
o may be helpful if positive but are usually inconclusive
o may exclude other sites of nerve compression or identify double-crush syndrome
Treatment
Nonoperative
o rest, splinting, and NSAIDS for 3-6 months
indications
mild to moderate symptoms
technique
splint should avoid forearm rotation
Operative
o surgical decompression of median nerve
indications
only when nonoperative management fails for 3-6 months
technique
decompression of the median nerve at all 5 possible sites of compression
outcomes
of surgical decompression are variable
80% of patients having relief of symptoms
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By Dr, AbdulRahman AbdulNasser Neuropathies | Ulnar Neuropathies
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OrthoBullets2017 Neuropathies | Ulnar Neuropathies
B. Ulnar Neuropathies
Anatomy
Ulnar nerve
o pierces intramuscular septum at arcade of Struthers 8 cm proximal to the medial epicondyle as it
passes from the anterior to posterior compartment of the arm
o enters cubital tunnel
Cubital tunnel
o roof
formed by FCU fascia and Osborne's ligament (travels from the medial epicondyle to the
olecranon)
o floor
formed by posterior and transverse bands of MCL and elbow joint capsule
o walls
formed by medial epicondyle and olecranon
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By Dr, AbdulRahman AbdulNasser Neuropathies | Ulnar Neuropathies
Presentation
Symptoms
o paresthesias of small finger, ulnar half of ring finger, and ulnar dorsal hand
exacerbating activities include
cell phone use (excessive flexion)
occupational or athletic activities requiring repetitive elbow flexion and valgus stress
o night symptoms
caused by sleeping with arm in flexion
Physical exam
o inspection and palpation
interosseous and first web space atrophy
ring and small finger clawing
observe ulnar nerve subluxation over the medial epicondyle as the elbow moves through a
flexion-extension arc
o sensory
decreased sensation in ulnar 1-1/2 digits
o motor
loss of the ulnar nerve results in paralysis of intrinsic muscles (adductor pollicis, deep head
FPB, interossei, and lumbricals 4 and 5) which leads to
weakened grasp
from loss of MP joint flexion power
weak pinch
from loss of thumb adduction (as much as 70% of pinch strength is lost)
Froment sign
compensatory thumb IP flexion by FPL (AIN) during key pinch
compensates for the loss of MCP flexion by adductor pollicis (ulna n.)
adductor pollicis muscle normally acts as a MCP flexor, first metacarpal
adductor, and IP extensor
Jeanne sign
compensatory thumb MCP hyperextension and thumb adduction by EPL (radial n.)
with key pinch
Compensates for loss of IP extension and thumb adduction by adductor pollicis
(ulna n.)
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OrthoBullets2017 Neuropathies | Ulnar Neuropathies
Studies
EMG / NCV
o helpful in establishing diagnosis and prognosis
o threshold for diagnosis
conduction velocity <50 m/sec across elbow
low amplitudes of sensory nerve action potentials and compound muscle action potentials
Treatment
Nonoperative
o NSAIDs, activity modification, and nighttime elbow extension splinting
indications
first line of treatment with mild symptoms
technique
night bracing in 45° extension with forearm in neutral rotation
outcomes
management is effective in ~50% of cases
Operative
o in situ ulnar nerve decompression without transposition
approach
elbow medial approach
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By Dr, AbdulRahman AbdulNasser Neuropathies | Ulnar Neuropathies
indications
when nonoperative management fails
before motor denervation occurs
technique
open release of cubital tunnel retinaculum
endoscopically-assisted cubital tunnel release
favorable early results but lacks long-term data
outcomes
meta-analyses have shown similar clinical results with significantly fewer complications
compared to decompression with transposition
80-90% good results when symptoms are intermittent and denervation has not yet
occurred
poor prognosis correlates most with intrinsic muscle atrophy
o ulnar nerve decompression and anterior transposition
indications
failed in situ release
throwing athlete
patient with poor ulnar nerve bed from tumor, osteophyte, or heterotopic bone
technique
subcutaneous, submuscular, or intramuscular transposition
outcomes
similar outcomes to in situ release but increased risk of creating a new point of
compression
o medial epicondylectomy
indications
visible and symptomatic subluxating ulnar nerve
technique
in situ release with medial epicondylectomy
outcomes
risk of destabilizing the medial elbow by damaging the medial ulnar collateral ligament
Complications
Recurrence
o secondary to inadequate decompression, perineural scarring, or tethering at the intermuscular
septum or FCU fascia
o higher rate of recurrence than after carpal tunnel release
Neuroma formation
o iatrogenic injury to a branch of the medial antebrachial cutaneous nerve may cause persistent
posteromedial elbow pain
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OrthoBullets2017 Neuropathies | Ulnar Neuropathies
Anatomy
Guyon’s canal
o course
is approximately 4 cm long
begins at the proximal extent of the transverse carpal ligament and ends at the aponeurotic
arch of the hypothenar muscles
o contents
ulnar nerve bifurcates into the superficial sensory and deep motor branches
o boundaries and zones (see table below)
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By Dr, AbdulRahman AbdulNasser Neuropathies | Ulnar Neuropathies
III:2 Zones of the ulnar tunnel (Zone 1: ulnar nerve, motor and sensory. Zone 2: deep motor branch. Zone 3: superficial sensory branch.)
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OrthoBullets2017 Neuropathies | Ulnar Neuropathies
Deep branch of the ulnar nerve
o innervates all of the interosseous muscles and the 3rd and 4th lumbricals.
o Innervates the hypothenar muscles, the adductor pollicis, and the medial head (deep) of the
flexor pollicis brevis (FPB)
Classification
Presentation varies based on location of compression within Guyon's canal and may be
o Motor only
o Sensory only
o Mixed Motor & Sensory
Presentation
Presentation varies based on location of compression within Guyon's canal and may be
o pure motor
o pure sensory
o mixed motor and sensory
Symptoms
o pain and paresthesias in ulnar 1-1/2 digits
o weakness to intrinsics, ring and small finger digital flexion or thumb adduction
Physical exam
o inspection & palpation
clawing of ring and little fingers
caused from loss of intrinsics flexing the MCPs and extending the IP joints
Allen test
helps diagnose ulnar artery thrombosis
o neurovascular exam
ulnar nerve palsy results in paralysis of the intrinsic muscles (adductor pollicis, deep head
FPB, interossei, and lumbricals 4 and 5)
weakened grasp
from loss of MP joint flexion power
weak pinch
from loss of thumb adduction (as much as 70% of pinch strength is lost)
Froment sign
IP flexion compensating for loss of thumb adduction when attempting to hold a piece of
paper
loss of MCP flexion and adduction by adductor pollicis (ulnar n.)
compensatory IP hyperflexion by FPL (AIN)
Jeane's sign
a compensatory thumb MCP
hyperextension and thumb adduction by EPL (radial
n.)
compensates for loss of IP extension and thumb
adduction by adductor pollicis (ulna n.)
Wartenberg sign
abduction posturing of the little finger III:3 Wartenberg sign
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By Dr, AbdulRahman AbdulNasser Neuropathies | Ulnar Neuropathies
Imaging
Radiographs
o useful to evaluate hook of hamate fractures
CT scan
o useful to evaluate hook of hamate fractures
MRI
o useful to evaluate for a ganglion cysts
Studies
NCS and EMG
o helpful in establishing diagnosis and prognosis
o threshold for diagnosis
conduction velocity <50 m/sec across elbow
low amplitudes of sensory nerve action potentials and compound muscle action potentials
Differential
How to differentiate ulnar tunnel syndrome from cubital tunnel syndrome
o cubital tunnel demonstrates
less clawing
sensory deficit to dorsum of the hand
motor deficit to ulnar-innervated extrinsic muscles
Tinel sign at the elbow
positive elbow flexion test
Treatment
Nonoperative
o activity modification, NSAIDS and splinting
indications
as a first line of treatment when symptoms are mild
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OrthoBullets2017 Neuropathies | Radial Neuropathies
Operative
o local decompression
indications
severe symptoms that have failed nonoperative treatment
o tendon transfers
indications
correction of clawed fingers
loss of power pinch
Wartenberg sign (abduction of small finger)
o carpal tunnel release
indications
patients diagnosed with both ulnar tunnel syndrome and CTS
Techniques
Local surgical decompression
o release hypothenar muscle origin
o decompress ganglion cysts
o resect hook of hamate
o vascular treatment of ulnar artery thombosis
o explore and release all three zones in Guyon's canal
Tendon transfers
o correct claw fingers
possible grafts include ECRL, ECRB, palmaris longus
tendons must pass volar to transverse metacarpal ligament in order to flex the proximal
phalanx
attach with either a two or four-tailed graft to the A2 pulley of the ring and small fingers
o restore power pinch
Smith transfer using ECRB or FDS of ring finger
o restore adduction of small finger
transfer ulnar insertion of EDM to A1 pulley or radial collateral ligament of the small finger
Complications
Recurrance
C. Radial Neuropathies
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By Dr, AbdulRahman AbdulNasser Neuropathies | Radial Neuropathies
o mechanism of injury
microtrauma
from repetitive pronosupination movements
trauma
fracture/dislocation (e.g., monteggia fx, radial head
fx, etc)
space filling lesions
e.g. ganglion, lipomas, etc
inflammation
e.g. rheumatoid synovitis of radiocapitellar joint
iatrogenic (surgery)
o pathoanatomy:
five potential sites of compression include
fibrous tissue anterior to the radiocapitellar joint
between the brachialis and brachioradialis
“leash of Henry”
are recurrent radial vessels that fan out across
the PIN at the level of the radial neck
extensor carpi radialis brevis edge
medio-proximal edge of the extensor
carpi radialis brevis
"arcade of Fröhse"
which is the proximal edge of the superficial portion of the supinator
supinator muscle edge
distal edge of the supinator muscle
Anatomy
PIN
o origin
PIN is a branch of the radial nerve that provides motor innervation to the extensor
compartment
o course
passes between the two heads of origin of the supinator muscle
direct contact with the radial neck osteology
passes over abductor pollicis longus muscle origin to reach interosseous membrane
transverses along the posterior interosseous membrane
o innervation
motor
common extensors
ECRB (often from radial nerve proper, but can be from PIN)
Extensor digitorum communis (EDC)
Extensor digiti minimi (EDM)
Extensor carpi ulnaris (ECU)
deep extensors
Supinator
Abductor pollicis longus (APL)
Extensor pollicus brevis (EPB)
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OrthoBullets2017 Neuropathies | Radial Neuropathies
III:4 Bifurcation of the radial nerve (R) into the PIN and superficial radial nerve (SR). The PIN passes between the superficial (Ss) and deep
(Sd) heads of the supinator before entering the posterior compartment of the forearm.
Presentation
Symptoms
o insidious onset, often goes undiagnosed
o defining symptoms
pain in the forearm and wrist
location depends on site of PIN compression
e.g., pain just distal to the lateral epicondyle of the elbow may be caused by
compression at the arcade of Frohse
weakness with finger, wrist and thumb movements
Physical exam
o inspection
chronic compression may cause forearm extensor compartment muscle atrophy
o motion
weakness
finger metacarpal extension weakness
wrist extension weakness
inability to extend wrist in neutral or ulnar deviation
the wrist will extend with radial deviation due to intact ECRL (radial n.) and absent
ECU (PIN).
o provocative tests
resisted supination
will increase pain symptoms
normal tenodesis test
tenodesis test is used to differentiate from extensor tendon rupture from RA
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By Dr, AbdulRahman AbdulNasser Neuropathies | Radial Neuropathies
Evaluation
Radiographs
o indications
not commonly needed for the diagnosis of PIN compression syndrome
MRI
o indications
not commonly needed for the diagnosis of PIN compression syndrome
may be help to site and delineate the soft tissue mass responsible for compression
helpful for surgical planning of mass resection
Studies
EMG
o indications
may help identify the level of nerve compression
may be used to rule out differential diagnoses of neuropathy
Differential
Cervical spine nerve compression
Brachial plexus compression
Peripheral neuropathy
Treatment
Nonoperative
o rest, activity modification, stretching, splinting, NSAIDS
indications
recommended as first-line treatment for all cases
o lidocaine/corticosteroid injection
indications
a compressive mass, such as lipoma or ganglion, has been ruled out
isolated tenderness distal to lateral epicondyle
trial of rest, activity modification, anti-inflammatories were not effective
technique
single injection 3-4 cm distal to lateral epicondyle at site of compression
o surgical decompression
indications
symptoms persist for greater than three months of nonoperative treatment
compressive mass detected on imaging
outcomes
results are variable
spontaneous recovery of motor function was seen in 75 - 97% of non-traumatic case
series
may continue to improve for up to 18 months
Technique
Surgical decompression
o approach
anterolateral approach to elbow is most common approach
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OrthoBullets2017 Neuropathies | Radial Neuropathies
may also consider posterior approach
o decompression
decompression should begin with release of
fibrous bands connecting brachialis and brachioradialis
leash of Henry
fibrous edge of ECRB
radial tunnel, including arcade of Frosche and distal supinator
Complications
Neglected PIN compression syndrome
o muscle fibrosis of PIN innervated muscles
o resulting in tendon transfer procedures to re-establish function
Chronic pain
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By Dr, AbdulRahman AbdulNasser Neuropathies | Radial Neuropathies
Anatomy
Radial Tunnel
o 5cm in length
o from the level of the radiocapitellar joint, extending distally past the proximal edge of the
supinator
o boundaries
lateral
brachioradialis
ECRL
ECRB
medial
biceps tendon
brachialis
floor
capsule of the radiocapitellar joint
III:5 leash of Henry
PIN
o origin
PIN is a branch of the radial nerve that provides motor innervation to the extensor
compartment
o course
passes between the two heads of origin of the supinator muscle
direct contact with the radial neck osteology
passes over abductor pollicis longus muscle origin to reach interosseous membrane
transverses along the posterior interosseous membrane
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OrthoBullets2017 Neuropathies | Radial Neuropathies
o innervation
motor
common extensors
ECRB (often from radial nerve proper, but can be from PIN)
Extensor digitorum communis (EDC)
Extensor digiti minimi (EDM)
Extensor carpi ulnaris (ECU)
deep extensors
Supinator
Abductor pollicis longus (APL)
Extensor pollicus brevis (EPB)
Extensor pollicus longus (EPL)
Extensor indicis proprius (EIP)
sensory
sensory fibers to dorsal wrist capsule
provided by terminal branch which is located on the floor of the 4th extensor
compartment
no cutaneous innervation
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By Dr, AbdulRahman AbdulNasser Neuropathies | Radial Neuropathies
Presentation
Symptoms
o deep aching pain in dorsoradial proximal forearm
from lateral elbow to wrist
increases during forearm rotation and lifting activities
o muscle weakness
because of pain and not muscle denervation
Physical exam
o tenderness
over mobile wad over the supinator arch
maximal tenderness is 3-5cm distal to lateral epicondyle
more distal than lateral epicondylitis
o provocative tests
resisted long finger extension test
reproduces pain at radial tunnel (weakness because of pain)
resisted supination test (with elbow and wrist in extension)
reproduces pain at radial tunnel (weakness because of pain)
passive pronation with wrist flexion
reproduces pain at radial tunnel
passive stretch of supinator muscle increases pressure inside radial tunnel to 250mmHg
(normal 50mmHg)
radial tunnel injection test
diagnostic if injection leads to a PIN palsy and relieves pain
o sensory
may have paresthesias in the first dorsal web space
o motor
no motor manifestations
Imaging
Axial fat suppressed T2 MRI Transverse T1-weighted MRI Transverse T1-weighted MRI
demonstrates fluid anterior to showing hypertrophic leash of showing normal leash of Henry
the radius (arrow) and edema in Henry (arrows) (SRN, superficial (arrows)(SRN, superficial radial
the supinator (arrowheads). radial nerve; PIN, posterior nerve; PIN, posterior
interosseous nerve) interosseous nerve)
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OrthoBullets2017 Neuropathies | Radial Neuropathies
MRI
o usually negative
o indications
to identify muscle changes in muscles innervated by PIN
denervation edema/atrophy within the supinator/extensor
to evaluate compression sites
may show thickened edge of ECRB, prominent radial recurrent vessels (leash of Henry),
swelling of PIN
to identify other causes of entrapment (rare)
tumors, ganglia, radiocapitellar synovitis, bicipital bursitis, radial head fractures and
dislocations
Studies
Electrodiagnostic studies
o EMG/NCV are inconclusive because
PIN carries unmyelinated Group IV fibers (C-fibers, nociception) and small myelinated
Group IIA afferent fibers (temperature)
pressure on these fibers produces pain
these fibers cannot be evaluated by EMG/NCV
the large myelinated fibers of PIN remain normal, producing normal EMG/NCV
Diagnostic injection
o injection of local anesthetic (LA) into the area of localized tenderness
o ensure that LA does not spread to lateral epicondyle
Differential Diagnosis
Lateral epicondylitis
o both conditions coexist in 5% of patients
o in lateral epicondylitis, tenderness is directly over the lateral epicondyle
o in RTS, tenderness is 3-5cm distal to the lateral epicondyle
Cervical radiculopathy at C6-7
o electrodiagnostic studies may show denervation
Treatment
Nonoperative
o activity modification, temporary splinting, NSAIDS
indications
first line of treatment for at least one year
technique of activity modification
avoid prolonged elbow extension with forearm pronation and wrist flexion
o corticosteroid injection
indications
both diagnostic and therapeutic
outcomes
70% improvement at 6 weeks
60% pain free at 2 years
Operative
o radial tunnel release
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By Dr, AbdulRahman AbdulNasser Neuropathies | Radial Neuropathies
Techniques
Radial tunnel release
o approach
dorsal approaches to the PIN
3 planes have been described
between ECRB and EDC
between brachioradialis and ECRL
transmuscular brachioradialis-splitting
anterior approach to the PIN
between brachioradialis and biceps
o technique
release arcade of Frohse
release distal edge of supinator
release fibrous bands superficial to the radiocapitellar joint
o outcomes
success rate of surgical decompression is 70-90%
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OrthoBullets2017 Neuropathies | Radial Neuropathies
3. Wartenberg's Syndrome
Introduction
Definition
o compressive neuropathy of the superficial sensory radial nerve (SRN)
o also called "cheiralgia paresthetica"
o sensory manifestation only
o no motor deficits
Epidemiology
o incidence
rare
o demographics
male:female ratio is 1:4, more common in women
age bracket is 20-70 years
Pathoanatomy
o SRN compressed by scissoring action
of brachioradialis and ECRL tendons during forearm
pronation
o also by fascial bands at its exit site in the subcutaneous III:7 With the forearm SUPINATED, SRN lies
plane between BR and ECRL without compression.
With the forearm PRONATED, ECRL crosses
Associated conditions
beneath BR, creating scissoring (pinching) of the
o associated with De Quervain's disease in 20-50% SRN.
Prognosis
o spontaneous resolution of symptoms is common
o treatment outcomes
74% success after surgical decompression
Anatomy
The superficial sensory branch of the radial nerve
o arises from the bifurcation of the radial nerve in the proximal forearm
o travels deep to the brachioradialis in the forearm
o emerges from between brachioradialis and ECRL 9cm proximal to radial styloid
o bifurcates proximal to the wrist
dorsal branch lies 1-3cm radial to Lister's tubercle
supplies 1st and 2nd web space
palmar branch passes within 2cm of 1st dorsal compartment, directly over EPL
supplies dorsolateral thumb
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By Dr, AbdulRahman AbdulNasser Neuropathies | Radial Neuropathies
Presentation
History
o may have history of trauma
forearm fracture
handcuffs
tight wrist band, wristwatch band, bracelet or plaster cast
Symptoms
o ill-defined pain over dorsoradial hand (does not like to wear watch)
o paresthesias over dorsoradial hand
o numbness
o symptom aggravation by motions involving repetitive wrist flexion and ulnar deviation
o no motor weakness
Physical exam
o provocative tests
Tinel's sign over the superficial sensory radial nerve (most common exam finding)
wrist flexion, ulnar deviation and pronation for one minute
Finkelstein test increases symptoms in 96% of patients
because of traction on the nerve
Imaging
Radiographs
o of limited value
o may demonstrate old forearm fracture
Studies
Electrodiagnostic tests
o EMG and NCV of limited value
Diagnostic injection III:8 Palmar ulnar flexion of the wrist
puts maximum traction on the nerve
o diagnostic wrist block may temporarily relieve pain
Differential
De Quervain's tenosynovitis
o pain is not aggravated by wrist pronation, unlike Wartenberg Syndrome
Lateral antebrachial cutaneous nerve (LACN) neuritis
o positive Tinel's sign over LACN can be mistaken for positive Tinel's over superficial sensory
radial nerve
Intersection syndrome
o may have dorsoradial forearm swelling
o symptom exacerbation and "wet leather" crepitus on repeated wrist flexion/extension
Treatment
Nonoperative
o rest, activity modification, NSAIDS, and wrist splints
indications : first line of treatment
techniques
avoid aggravating activities
remove inciting factors (e.g. tight wristwatch band)
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OrthoBullets2017 Neuropathies | Radial Neuropathies
o corticosteroid injection
although evidence to support this is limited
Operative
o surgical decompression
indications
symptoms persist after 6 months
Surgical Technique
Surgical Decompression
o approach
longitudinal incision volar to Tinel's sign
to avoid injury to LACN
to avoid tethering of incision scar over SRN
o decompression technique
neurolysis and release of fascia between brachioradialis and ECRL
Complications
Failed decompression
Persistent pain and numbness
Wound dehiscence
Infection
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In July 2017
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Radial Neuropathies
ORTHO BULLETS
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OrthoBullets2017 Degenerative Conditions | Hand Deformities
A. Hand Deformities
Pathoanatomy
Pathoanatomic components
o loss of intrinsics
leads to loss of baseline MCP flexion and loss of IP extension
o strong extrinsic EDC
leads to unopposed extension of the MCP joint
remember the EDC is not a significant extensor of the PIP joint
most of the MCP extension forces on the terminal insertion of the central slip come from
the interosseous muscles
o strong FDP and FDS
leads to unopposed flexion of the PIP and DIP
Presentation
Symptoms
o decreased hand function
Physical exam
o MCP hyperextension and IP joint flexion
with an ulnar nerve palsy, the deformity will be worse in the 4th and 5th digits (lumbricals
innervated by the ulnar nerve)
not as severe in the 2nd and 3rd digits (lumbricals innervated by the median nerve)
o functional weakness
unable to perform prehensile grasp
diminished grip and pinch strength
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hand Deformities
o provocative tests
if MCP joints are brought out of hyperextension, the flexion deformity of the DIP & PIP will
correct
Treatment
Operative
o contracture release and passive tenodesis vs. active tendon transfer
indications
progressive deformity that is affecting quality of life
technique
goal is to prevent MCP joint hyperextension
Presentation
Symptoms
o difficulty gripping large objects
Physical exam
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OrthoBullets2017 Degenerative Conditions | Hand Deformities
o inspection
MCP joint flexion and IP joint extension
o provocative tests
Bunnell test (intrinsic tightness test)
differentiates intrinsic tightness and extrinsic tightness
positive test when PIP flexion is less with MCP extension than with MCP flexion
Imaging
Radiographs
o no radiographs required in diagnosis or treatment
Treatment
Nonoperative
o passive stretching
indications
mild cases
Operative
IV:1 Note the MCP flexion and IP joint extension.
o proximal muscle slide This makes grasping large objects challenging.
indications
less severe deformities when there is some remaining function of the intrinsics (e.g.,
spastic intrinsics)
o distal instrinsic release (distal to MP)
indications
more severe deformity involving both MCP and IP joints
dysfunctional intrinsic muscles (e.g., fibrotic)
Surgical Techniques
Proximal muscle slide
o techinque
subperiosteal elevation of interossei lengthens muscle-tendon unit
Distal intrinsic release
o technique
resection of intrinsic tendon distal to the transverse fibers responsible for MCP joint flexion
3. Boutonniere Deformity
Introduction
A Zone III extensor tendon injury characterized by
o PIP flexion
o DIP extension
Mechanism
o caused by rupture of the central slip over PIP joint from
laceration
traumatic avulsion (jammed finger)
capsular distension in rheumatoid arthritis
Pathoanatomy
o pathoanatomic sequence includes
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hand Deformities
rupture of central slip
causes the extrinsic extension mechanism from the EDC to be lost
prevents extension at the PIP joint
attenuation of triangular ligament
causes intrinsic muscles of the hand (lumbricals) to act as flexors at the PIP joint
lumbricals also extend the DIP joint without an opposing or balancing force
palmar migration of collateral bands and lateral bands
the lumbricals' pull becomes unopposed, pulling through the base of the distal phalanx
and volar to the PIP
causes PIP flexion and DIP extension
o bone deformity
injury involves all three phalanges
the middle phalanx flexes on the proximal phalanx at the PIP joint
the distal phalanx is hyperextended relative to the middle phalanx at the DIP joint
Associated conditions
o rheumatoid arthritis
o pseudo-boutonniere
refers to PIP joint flexion contracture in the absence of DIP extension
Anatomy
Muscle
o lumbrical muscles
originate from the FDP and insert on the lateral bands
Ligament anatomy
o extensor hood and central slip
the extrinsic extensor tendon joins the extensor hood at the MCP
the central portion of the extensor hood forms the central slip
the central slip inserts onto the middle phalanx and acts to extend the PIP joint
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OrthoBullets2017 Degenerative Conditions | Hand Deformities
o lateral bands
the lateral bands are formed from the deep head of the dorsal interossi combining with the
volar interossi
the lateral bands insert onto the base of the distal phalanx to extend the DIP joint
o triangular ligament
spans the two lateral bands, preventing them from subluxing volarly
o transverse retinacular ligament
prevents dorsal subluxation of the lateral bands
Blood supply
o interosseous muscles
receive blood from vessels formed by a combination of the deep palmer arch and the ulnar
artery
Presentation
Physical exam
o deformity
characterized by PIP flexion DIP extension
o Elson test
is the most reliable way to diagnose a central slip
injury before the deformity is evident
bend PIP 90° over edge of a table and extend middle phalanx
against resistance.
in presence of central slip injury there will be
weak PIP extension
the DIP will go rigid
in absence of central slip injury DIP remains floppy because the
extension force is now placed entirely on maintaining extension
of the PIP joint; the lateral bands are not activated
Imaging
Radiographs
o recommended view
radiographs are not required in evaluation and treatment of Boutonniere deformity
Treatment
Nonoperative
o splint PIP joint in full extension for 6 weeks
indications : acute closed injuries (< 4 weeks)
technique
encourage active DIP extension and flexion in splint to avoid contraction of oblique
retinacular ligament
complete part-time splinting for an additional 4-6 weeks
Operative
o primary central band repair
indications
acute displaced avulsion fx (proximal MP avulsion seen on x-ray)
open wound that needs I&D
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hand Deformities
o lateral band relocation vs. terminal tendon tenotomy vs. tendon reconstruction
indications
in chronic injuries after FROM is obtained with therapy or surgical release
technique
terminal tendon tenotomy (modified Fowler or Dolphin tenotomy)(never central slip
tenotomy)
secondary tendon reconstruction (tendon graft, Littler, Matev)
triangular ligament reconstruction
o PIP arthrodesis
indications
rheumatoid patients
painful, stiff and arthritic PIP joint
Pathoanatomy
Primary lesion is lax volar plate that allows hyperextension of PIP. Causes include
o trauma
o generalized ligament laxity
o rheumatoid arthritis
Secondary lesion is imbalance of forces on the PIP joint (PIP extension forces that is greater than the
PIP flexion force). Causes of this include
o mallet injury
leads to transfer of DIP extension force into PIP extension forces
o FDS rupture
leads to unopposed PIP extension combined with loss of integrity of the volar plate
o intrinsic contracture
tethering of the lateral (collateral) bands by the transverse retinacular ligament as a result of
PIP hyperextension.
if the lateral (collateral) bands are tethered, excursion is restricted and the extension force is
not transmitted to the terminal tendon, and is instead transmitted to the PIP joint
o MCP joint volar subluxation
caused by rheumatoid arthritis
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OrthoBullets2017 Degenerative Conditions | Hand Deformities
Presentation
Symptoms
o snapping and locking of the fingers
Physical exam
o hyperextension of PIP
o flexion of DIP
Imaging
Radiographs
o recommended views
AP and lateral view of the affected hand
Treatment
Nonoperative
o double ring splint
indications
can prevent hyperextension of PIP
Operative
o volar plate advancement and PIP balancing with central slip tenotomy
indications
progressive deformity
technique
address volar plate laxity with volar plate advancement
correct PIP joint muscles imbalances with either
FDS tenodesis indicated with FDS rupture
spiral oblique retinacular ligament reconstruction
central slip tenotomy (Fowler)
5. Quadriga Effect
Introduction
The quadriga effect is characterized by an active flexion lag in fingers adjacent to a digit with a
previously injured or repaired flexor digitorum profundus tendon.
Mechanism
o most commonly caused by a functional shortening of the FDP tendon due to
over-advancement of the FDP during tendon repair
>1 cm advancement associated with quadriga
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hand Deformities
adhesions
retraction of the tendon
"over-the-top" FDP repair of the distal phalanx after amputation
Pathoanatomy
o FDP tendons of long, ring, and little fingers share a common muscle belly
therefore excursion of the combined tendons is equal to the shortest tendon
improper shortening of a tendon during repair results in inability to fully flex adjacent
fingers
Anatomy
Flexor digitorum profundus
Zones of the flexor tendons
o most injuries resulting in quadrigia involve Zone I
Presentation
Symptoms
o inability to fully flex the fingers of the hand adjacent to the injured finger
o patient may complain of "weak grip"
Physical exam
o upon making a fist the fingers adjacent to the injured digit will not reach full flexion
o grip strength decreased
Imaging
Radiographs
o usually not required
Treatment
Nonoperative
o observation
indications
mild symptoms not affecting quality of life
Operative
o release FDP of injured digit
indications
severe symptoms limiting function
IV:2 Conditions causing lumbrical plus: (1) FDP transection, (2) FDP avulsion, (3) too long tendon graft, (4) amputation through middle
phalanx
Pathophysiology
o mechanism
FDP disruption distal to the origin of the lumbicals (most common)
can be due to
FDP transection
FDP avulsion
DIP amputation
amputation through middle phalanx shaft
"too long" tendon graft
o pathoanatomy
lumbricals originate from FDP
with FDP laceration, FDP contraction leads to pull on lumbricals
lumbricals pull on lateral bands leading to PIP and DIP extension of involved digit
with the middle finger, when the FDP is cut distally, the FDP shifts ulnarly (because of the
pull of the 3rd lumbrical origin)(bipennate)
this leads to tightening of the middle finger lumbrical (2nd lumbrical, unipennate), and
amplifies the "lumbrical plus" effect
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hand Deformities
Anatomy
Lumbricals
o 1st and 2nd lumbricals
unipennate
median nerve
originate from radial side of FDP2 and FDP3 respectively
o 3rd and 4th lumbricals
bipennate
ulnar nerve
3rd lumbrical originates from FDP 3 & 4
4th lumbrical originates from FDP 4 & 5
o all insert on radial side of extensor expansion
Presentation
History
o recent volar digital laceration (FDP transection) or sudden axial traction on flexed digit (FDP
avulsion)
Symptoms
o notices that when attempting to grip an object or form a fist, 1 digit sticks out or gets caught on
clothes
Physical exam
o paradoxical IP extension with grip (fingers extend while holding a beer can)
Treatment
Operative
o tenodesis of FDP to terminal IV:5 LEFT: With the fingers relaxed, the affected finger can be passively flexed
tendon or reinsertion to distal into the palm. RIGHT: With gripping, the affected middle finger extends at the IP
phalanx joints.
indications
FDP lacerations
do NOT suture flexor-extensor mechanisms over bone
o lumbrical release
indications
if FDP is retracted or segmental loss makes it impossible to fix
NOT done in the acute setting as it does not occur consistently enough to warrant routine
lumbrical sectioning acutely
contraindications
do not transect lumbricals 1 & 2 if there is concomitant ulnar nerve palsy
with ulnar nerve paralysis, the interosseous muscles are also lost
(interosseus muscles extend the IP joints)
technique
transect at base of flexor sheath (in the palm)
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OrthoBullets2017 Degenerative Conditions | Flexor Tendon Conditions
1. Trigger Finger
Introduction
Stenosing tenosynovitis caused by inflammation of the flexor tendon sheath
Epidemiology
o more common in diabetics
o ring finger most commonly involved
Mechanism
o caused by entrapment of the flexor tendons at the level of the A1 pulley
o fibrocartilaginous metaplasia of tendon and pulley found in pathology
Associated conditions
o diabetes mellitus
o rheumatoid arthritis
o amyloidosis
Anatomy
Flexor pulleys of finger
o A1 overlie the MP joints
Muscles
o FDP
o FDS
Classification
Green Classification
Grade I Palm pain and tenderness at A-1 pulley
Grade II Catching of digit
Grade III Locking of digit, passively correctable
Grade IV Fixed, locked digit
Imaging
Radiographs
o not required in diagnosis and treatment
Presentation
Symptoms
o finger clicking
o pain at distal palm near A1 pulley
o finger becoming "locked in flexed position
Physical exam
o tenderness to palpation over A1 pulley
o a palpable bump may be present near the same location
Treatment
Nonoperative
o night splinting, activity modification, NSAIDS
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Flexor Tendon Conditions
indications : first line of treatment
o steroid injections
indications
best initial treatment for fingers, not for thumb
technique
give 1 to 3 injections in flexor tendon sheath
diabetics do not respond as well as non-diabetics
Operative
o surgical debridement and release of the A-1 pulley
indications
in cases that fail nonoperative treatment
o release of A1 pulley and 1 slip of FDS (usually ulnar slip)
indications
pediatric trigger finger
presents with Notta's nodule (proximal to A1 pulley), flexion contracture and
triggering
may need to release remaining FDS slip and A3 pulley as well
Techniques
Surgical debridement and release of the A-1 pulley
o approach
longitudinal or transverse incision
o release technique
in children, in addition to A-1 pulley release, may also need to release
one or both limbs of the sublimus tendon
A-2 pulley
A-3 pulley
o postoperative
early passive and active ROM 4 times a day
if patient does not have FROM at first post-op visit then send to PT
Complications
Radial digital nerve injury
2. Dupuytren's Disease
Introduction
A benign proliferative disorder characterized by fascial nodules and contractures of the hand
Epidemiology & genetics
o genetics
autosomal dominant with variable penetrance
o age
5-7th decade of life
o sex
2:1 male to female ratio
presents earlier in men (mean 55y) than women (mean 65y)
more severe disease in men than women
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o ethnicity
Caucasian males of northern European descent
uncommon in south Europe, south America
rare in Africa and China
o location
ring > small > middle > index
Pathophysiology
o myofibroblast is the dominant cell type
differs from fibroblast as the myofibroblast has INTRACELLULAR ACTIN filaments
aligned along long axis of cell
adjacent myofibroblasts connect via EXTRACELLULAR FIBRONECTIN to act together to
create contracted tissue
o type III collagen predominates (> type I collagen)
o cytokines have been implicated
TGFbeta1, TGFbeta2, epidermal growth factor, PDGF, connective tissue growth factor
o ectopic manifestations
Ledderhose disease (plantar fascia) 10-30%
Peyronie's disease (dartos fascia of penis) 2-8%
Garrod disease (knuckle pads) 40-50%
Associated conditions
o HIV, alcoholism, diabetes, antiseizure medications
Pathoanatomy
Nodules and Cords make up the pathologic anatomy
o nodules appear before contractile cords
Normal fascial bands become pathologic cords
o Palmar IV:6 This clinical photo demonstrates a pad at the PIP
pretindinous cord joint consistent with Garrod disease
o Palmodigital transition
natatory cord
spiral cord
o Digital
central cord - distal extent of the pretendinous cord
lateral cord
digital cord
retrovascular cord
Different named cords include but are not limited to
o spiral cord
most important cord
cause of PIP contracture
IV:7 Spiral Cord
typically inserts distally into the lateral digital sheet then into Grayson's ligament
components
pretendinous band
spiral band
lateral digital sheet
Grayson's ligament
travels under the neurovascular bundle displacing it central and superficial
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Flexor Tendon Conditions
at risk during surgical resection
best predictors of displacement are
PIP joint flexion contracture (77% positive predictive value)
interdigital soft-tissue mass (71% positive predictive value)
o central cord
from disease involving pretendinous band
inserting into flexor sheath at PIPJ level and causes MCP contracture
forms palmar nodules and pits between distal palmar crease and palmar digital crease
NOT involved with neurovascular bundle
o retrovascular cord
runs dorsal to the neurovascular bundle distally
originates from proximal phalanx, inserts on distal phlanx
causes DIP contracture
o natatory cord (from natatory ligament)
causes web space contracture
NOT involved in Dupuytren's disease
o Cleland's ligament
o transverse ligament of the palmar aponeurosis
disease only involves longitudinally oriented structures
Histopathology
Stages of Dupuytren's (Luck)
Proliferative stage Hypercellular with large myofibroblasts and immature fibroblasts
- this is a nodule
Very vascular with many gap junctions
Minimal extracellular matrix
Involutional stage Dense myofibroblast network
Fibroblasts align along tenion lines and produce more collagen
Increase ratio of type III to type I col
Residual stage Myofibroblast disappear (acellular) leaving fibrocytes as the
predominate cell line
Leaves dense collagen-rich tissue/scar
Presentation
Symptoms
o decreased ROM affecting ADL
o painful nodules
Physical exam
o nodule in the pretendinous bands of the palmar fascia
nodule beyond MCPJ is strong clue suggesting spiral
cord displacing digital nerve midline and superficial
o most commonly involve small or ring finger
o Hueston's tabletop test IV:8 Hueston's tabletop test with a PIP flexion
ask patient to place palm flat on table contracture of the ring finger
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OrthoBullets2017 Degenerative Conditions | Flexor Tendon Conditions
Treatment
Nonoperative
o range of motion exercises
o injection of Clostridium histolyticum collagenase (Xiaflex)
indications : may be attempted but condition will not spontaneously resolve
technique/characteristics
has low activity against type IV collagen (in basement membrane of blood vessels and
nerves) explaining the low neurovascular complication rate
minimum dose is 10,000 units
use 0.25ml for MCP, and 0.20ml for PIP
followed by stretch manipulation within 24-48h under local anesthesia
repeat at 1mth if desired result not achieved
modalities
early efficacy seen with injections of clostridial collagenase into Dupuytren's cords
causes lysis and rupture of cords
outcomes
able to correct MCP/PIP contracture to <5°
more successful at MCP correction than PIP correction
PIP recurrence more severe than MCP recurrence
complications
minor
edema/contusion, skin tear, pain are most common
major (1%)
flexor tendon rupture, CRPS, pulley rupture
o needle aponeurotomy
indications
mild contractures (at the MCP > PIP)
medical co-morbidities that preclude surgery
technique IV:9 This clinical photo demonstrates the
perform in office using 22G or 25G needle McCash technique in which the transverse
limb is left open
followed by manipulation and night orthosis wear
outcomes
more successful for MCP contracture than PIP
less improvement and higher recurrence rate than surgery (open partial fasciectomy)
Operative
o surgical resection/fasciectomy
indications
MCP flexion contractures > 30°
PIP flexion contractures
painful nodules are not an indication for surgery
o with skin graft
rarely needed for primary cases
indications
severe, diffuse disease
multiple joint involvement
recurrences
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Flexor Tendon Conditions
technique : full thickness skin graft
outcomes
rarely fail to "take" even if placed directly over neurovascular bundles/flexor sheath
Dupuytrens recurrence is uncommon beneath a graft
Surgical Techniques
Regional/limited/ partial palmar fasciectomy
o technique
removal of all diseased tissue only in involved digits
dissect from proximal to distal
incision options - Brunner zigzag, multiple V-Y, sequential Z-plasties
o pros
most widely used surgical treatment
overlying skin is preserved
o postoperative care
early active range of motion (starting postoperative day 5-7)
night-time extension brace or splint
Total/radical palmar fasciectomy
o infrequently used
o technique
release/excision of all palmar and digital fascia including non-diseased fascia
o cons
high complication rate
little effect on recurrence rate (also high)
Open palm technique (McCash technique)
o approach
leave a transverse skin incision open at the distal palmar crease
o pros
reduced hematoma formation
reduced risk for stiffness
o outcome
longer healing
greater recurrence than if the palmar defect were covered with transposition flap or FTSG
Salvage techniques (for recurrent/advanced disease)
o Hueston dermofasciectomy (excise skin + fascia)
o arthrodesis
o amputation
Outcomes
Recurrence
o 30% at 1-2y, 15% at 3-5y, 10% at 5-10y, and <10% after 10y
o higher recurrence with non-operative measures (needle aponeurotomy and collagenase injection)
o PIP develop contratures of secondary structures that may need more comprehensive surgical
release
volar plate
accessory collateral ligaments
flexor sheath
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OrthoBullets2017 Degenerative Conditions | Flexor Tendon Conditions
o risks
Dupuytren diathesis (age <50, white men, bilateral hands DD, family history, ectopic disease
outside the palm including Ledderhoses, Peyronies, Garrods pads)
patients with Dupuytren diathesis may need more aggressive followup and treatment
PIP disease
small finger contracture
Complications
Wound edge necrosis/slough
Hematoma
o most common surgical complication
o can lead to flap necrosis
Flare reaction
o pain syndrome with diffuse swelling, hyperesthesia, redness and stiffness
o treatment
cervical sympathetic blockage, progressive stress-loading in therapy
A1 pulley release
o no increase risk of CRPS with fasciectomy + carpal tunnel release
Neurovascular injury
o because of midline + superficial displacement of NV bundle by spiral cord
o identify prior to excising cord
o risk is 5-10x higher for recurrent disease
o treatment
immediate neurorrhaphy (nerve repair)
Digital ischemia
o most common reason is correction of longstanding joint contracture and vessels have inadequate
elasticity
o less commonly traction, transection, spasm, intimal hemorrhage, rupture
o treatment
allow joint to relax, warm the digit
topical lidocaine and papaverine
if thrombosed segment is identified, use interpositional vein graft
Postop swelling
o contributes to stiffness, poor wound healing
PIP complications
o stiffness, instability, flexion contracture
Infection
o increased risk with DM and PVD
o oral antibiotics for superficial infection
o surgical drainage for deep infection
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Flexor Tendon Conditions
Anatomy
Flexor carpi radialis musculotendinous unit
o FCR muscle
IV:10 FCR musculotendinous unit.
bipennate The tendon begins 15cm proximal
o FCR tendon to the radiocarpal joint, is
musculotendinous for 8cm proximal
enveloped by sheath from musculotendinous origin to trapezium to the RC joint, and is completely
no fibrous sheath distal to trapezium tendinous distal to that.
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OrthoBullets2017 Degenerative Conditions | Flexor Tendon Conditions
IV:11 FCR tunnel at the level of the distal trapezium. Boundaries are the trapezial crest palmarly, IV:12 FCR insertion into the base of
trapezial body radially, trapezium-trapezoid joint and trapezoid dorsally, and retinacular septum the 2nd and 3rd metacarpals, with a
ulnarly. small slip (1-2mm) into the trapezial
crest
Presentation
Symptoms
o volar radial aspect of the wrist
Physical exam
o tenderness over volar radial forearm along FCR tendon at distal wrist flexion crease
o provocative test
resisted wrist flexion triggers pain
resisted radial wrist deviation triggers pain
Imaging
Radiographs
o findings
in primary tendinitis, radiographs are unremarkable
in secondary tendinitis, the following may be present
healed scaphoid fracture IV:13 Axial T2 MRI shows increased signal
healed distal radius fracture around FCR tendon sheath.
exostosis or arthritis of scaphotrapezoid joint or thumb CMC
MRI
o views : best seen on T2
o findings
increased signal around FCR sheath on T2 image
may find associated conditions in secondary tendinitis
ganglion
scaphoid cyst
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Flexor Tendon Conditions
Studies
Diagnostic injection
o injection of local anesthetic along FCR sheath relieves symptoms
Differentials
Thumb CMC arthritis
Scaphoid cyst
Ganglion
De Quervain's tenosynovitis
Treatment
Nonoperative
o immobilization, NSAIDS, steroid injection
indications
first line of treatment
technique
direct steroid injection in proximity, but not into tendon
outcomes
usually effective for primary tendinitis
unsuccessful in secondary tendinitis if other lesions are present (e.g. osteophytes)
Operative
o surgical release of FCR tendon sheath
indications
rarely needed but can be effective in recalcitrant cases
Surgical Technique
Surgical release of FCR tendon sheath
o approach
volar longitudinal incision starting proximal to the wrist crease,
extending over proximal thenar eminence
care taken to avoid
palmar cutaneous branch of median nerve
lateral antebrachial cutaneous nerve
superficial sensory radial nerve IV:14 Longitudinal incision
o technique radial to FCR, extending over
proximal thenar eminence
elevate and reflect thenar muscles radially
expose FCR sheath
open FCR sheath proximally in the distal forearm, and extend to the trapezial crest
at the trapezial crest, the tendon enters the FCR tunnel
at this point, incise the sheath along the ulnar margin, taking care not to injure the tendon
mobilize tendon from trapezoidal groove (releasing trapezial insertion)
Complications
Complications of disease
o FCR attrition and rupture
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OrthoBullets2017 Degenerative Conditions | Extensor Tendon Conditions
Complications of surgical release
o cutaneous nerve injury
palmar cutaneous branch of median nerve
lateral antebrachial cutaneous nerve
superficial sensory radial nerve
o injury to deep palmar arch
o injury to FPL tendon (lies superficial to FCR tendon)
o injury to FCR tendon within the tunnel
decompression is easy proximal to the tunnel (incision of FCR sheath)
within FCR fibroosseous tunnel, take care to avoid cutting FCR tendon
Anatomy
Extensor tendon compartments
o Compartment 1 (De Quervain's Tenosynovitis)
APL
EPB
o Compartment 2 (Intersection syndrome)
ECRL
ECRB
o Compartment 3
EPL
o Compartment 4
EIP
EDC
o Compartment 5 (Vaughn-Jackson Syndrome)
EDM
o Compartment 6 (Snapping ECU)
ECU
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Extensor Tendon Conditions
1. De Quervain's Tenosynovitis
Introduction
A stenosing tenosynovial inflammation of the 1st dorsal compartment which includes
o abductor pollicis longus (APL)
o extensor pollicis brevis (EPB)
Epidemiology
o demographics
woman > men
30 - 50 years old
o body location
most commonly in the dominant wrist
o risk factors
overuse
golfers and racquet sports
post-traumatic
postpartum
Pathophysiology
o pathoanatomy
thickening and swelling of extensor retinaculum causes increased tendon friction
NOT considered an inflammatory process
may be related to accumulation of mucopolysaccharides
Prognosis
o most cases resolve with non-operative management
o high recurrence rate
Anatomy
Extensor tendon compartments See page 130
Presentation
Symptoms
o gradual onset
o radial sided wrist pain
o pain exacerbated by gripping and raising objects with wrist in neutral
Physical exam
o inspection
tenderness over 1st dorsal compartment at level of radial styloid
o motion
usually normal wrist motion
pain with resisted radial deviation
o neurovascular exam
normal
o provocative tests
Finkelstein maneuver
On grasping the patient’s thumb and quickly abducting the hand ulnarward, the pain over
the styloid tip is painful
more indicative of EPB > APL tendon pathology
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OrthoBullets2017 Degenerative Conditions | Extensor Tendon Conditions
Eichhoff maneuver
ulnar deviated wrist while patient clenches thumb in fist, followed by relief of pain once
the thumb is extended even if the wrist remains ulnar deviated
Imaging
Radiographs
o recommended views
AP, lateral views of wrist
o indications
radiographs usually not indicated
o findings
may be used to rule out
basilar arthritis of the thumb
carpal arthritis
Treatment
Nonoperative
o rest, NSAIDS, thumb spica splint, steroid injection
indications
first line of treatment
technique
NSAIDS, rest and immobilisation usually first step
steroid injections into first dorsal compartment usually second step
outcomes
overall corticosteriods found to be superior to splinting
concomitant splinting and/or NSAIDs after steriods injection does not improve outcomes
Operative
o surgical release of 1st dorsal compartment
indications
severe symptoms
usually consider after 6 months of failed nonoperative management
technique
radial based incision proximal to the wrist
protect the superficial radial sensory nerve
Surgical Techniques
Surgical release of 1st dorsal compartment
o approach
transverse incision with release on dorsal side of 1st compartment to prevent volar
subluxation of the tendon
has variable anatomy with APL usually having at least 2 tendon slips and its own fibro-
osseous compartment
a distinct EPB sheath is often encountered dorsally
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Extensor Tendon Conditions
Complications
Sensory branch of radial nerve injury
Neuroma formation
Failure to decompress with recurrence
o may be caused by failure to recognize and decompress EPB or APL lying in separate
subsheath/compartment
Complex regional pain syndrome
2. Intersection Syndrome
Introduction
Due to inflammation at crossing point of 1st dorsal compartment (APL and EPB ) and 2nd dorsal
compartment (ECRL, ECRB)
Epidemiology
o common in
rowers
weight lifters
Pathophysiology
o mechanism is repetitive wrist extension
Anatomy
Extensor tendon compartments See page 130
Presentation
Symptoms
o pain over dorsal forearm and wrist
Physical exam
o tenderness on dorsoradial forearm
approximately 5cm proximal to the wrist joint
o provocative tests
crepitus over area with resisted wrist extension and thumb extension
Imaging
Radiographs
o not required for the diagnosis or treatment of intersection syndrome
MRI
o indications
to confirm diagnosis when clinical findings unclear
o views
fluid sensitive sequences (short tau inversion recovery, STIR; fat suppressed proton density,
FS PD; T2-weighted)
o findings
most characteristic is peritendinous edema or fluid surrounding the 1st and 2nd extensor
compartments
other findings - tendinosis, muscle edema, tendon thickening, loss of the normal comma
shape of the tendon, and juxtacortical edema may also be seen
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Treatment
Nonoperative
o rest, wrist splinting, steroid injections
indications
first line of treatment
technique
injection aimed into 2nd dorsal compartment (ECRL, ECRB)
Operative
o surgical debridement and release
indications
rarely indicated in recalcitrant cases
technique
release of the 2nd dorsal compartment approximately 6 cm proximal to radial styloid
3. Snapping ECU
Introduction
Overuse of wrist can lead to spectrum of ECU tendonitis and instability
Pathoanatomy
o ECU subluxation is secondary to attenuation or rupture of the ECU
subsheath (6th dorsal compartment)
o attenuation
remains intact but is stripped at ulnar/palmar attachment to produce a
false pouch that the ECU tendon can subluxate/dislocate into
o rupture IV:15 Attenuation
ulnar sided ECU subsheath tears
ECU subluxates on supination, and reduces on pronation
radial sided ECU subsheath tears
ECU subluxates on supination, and lies on top of the torn
subsheath on pronation
o subluxation and snapping can lead to ECU tendonitis
Risks
o tennis IV:16Rupture
o golf
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Extensor Tendon Conditions
ECU subsheath is part of the TFCC that is most critical to ECU subluxates during ulnar deviation,
ECU stability supination, wrist flexion
Anatomy
Extensor tendon compartments See page 130
ECU tendon
o ECU subsheath is part of the TFCC that is most critical to ECU stability
o ECU subluxates during ulnar deviation, supination, wrist flexion
this position has the greatest angulation of the ECU tendon with respect to the ulna
Presentation
Symptoms
o pain and snapping over dorsal ulnar wrist
Physical exam
o extension and supination of the wrist elicit a painful snap
o ECU tendon reduces with pronation
Imaging
Radiographs
o unremarkable
Ultrasound IV:17 Axial T2 MRI of the wrist shows tearing and
subluxation of the ECU tendon consistent with
o can dynamically assess ECU stability snapping ECU tendon.
MRI
o can show tendonitis, TFCC pathology, or degenerative tears of ECU
Treatment
Nonoperative
o wrist splint or long arm cast
indications
first line of treatment
technique
arm immobilized in pronation and slight radial deviation
Operative
o ECU subsheath reconstruction +- wrist arthroscopy
indications
if nonoperative management fails
technique
direct repair in acute cases
chronic cases may require a extensor retinaculum flap for ECU subsheath reconstruction
wrist arthroscopy shows concurrent TFCC tears in 50% of cases
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OrthoBullets2017 Degenerative Conditions | Wrist Conditions
D. Wrist Conditions
1. Ulnar Variance
Introduction
Definition
o length of the ulna compared to the radius
o measured in shoulder abducted 90deg, elbow flexed 90deg,
forearm neutral, hand aligned with forearm axis
Epidemiology
o demographic
male:female relationship
UV is lower in males than females
age bracket
UV increases with age
o risk factors IV:18 Neutral Ulnar Variance
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Conditions
Ulnar Variance
Ulnar Length Difference Load Passing Through Load Passing Through
Variance (ulnar - radial length) Radius Ulna
Positive +2mm 60% 40%
Positive +1mm 70% 30%
Neutral 0 (<1mm) 80% 20%
Negative -1mm 90% 10%
Negative -2mm 95% 5%
Anatomy
Neutral ulnar variance (ulnar zero)
o difference between ulnar and radial length is <1mm
Positive ulnar variance
o ulnar sided wrist pain from increased impact stress on the lunate and triquetrum
o UV becomes more positive in pronation
o UV becomes more positive during grip
Negative ulnar variance
o UV decreases in supination
Imaging
Radiographs
o recommended view
PA of the wrist with shoulder abducted 90 deg, elbow flexed 90 deg, neutral forearm rotation
Method to determine ulnar variance
o draw 2 lines
1 line tangential to the articular surface of the ulna and perpendicular to its shaft
1 line tangential to the lunate fossa of the radius and perpendicular to its shaft.
o measure the distance between these 2 lines (normal is 0mm)
o if the ulnar tangent is distal to the radial tangent = positive UV
o if the ulnar tangent is proximal to the radial tangent = negative UV
MRI
o can estimate but not quantify degree of UV
o because specific wrist position cannot be duplicated in MRI
Treatment
Depends on specific condition
o ulnar abutment syndrome
o TFCC tears
o Kienbock's disease
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OrthoBullets2017 Degenerative Conditions | Wrist Conditions
Presentation
Symptoms
o pain on dorsal side of DRUJ
o increased pain with ulnar deviation of wrist
o pain with axial loading
o ulna sided wrist pain
Physical exam
o Ballottement test
dorsal and palmar displacement of ulna with wrist in ulnar deviation
positive test produces pain
o Nakamura's ulnar stress test
ulnar deviation of pronated wrist while axially loading, flexing and extending the wrist
positive test produces pain
o fovea test
used to evaluate for TFCC tear or ulnotriquetral ligament tear
performed by palpation of the ulnar wrist between the styloid and FCU tendon
Imaging
Radiographs
o recommended views
AP radiograph with wrist in neutral supination/pronation and zero rotation
required to evaluate ulnar variance
pronated grip view
increases radiographic impaction
arthrography can show TFCC tear and lunotriquetral ligament tear
o findings
ulna positive variance
sclerosis of lunate and ulnar head
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Conditions
MRI
o evaluate for TFCC tears which may be caused by ulnocarpal impingement and often influences
treatment
Differential
Ulnar sided wrist pain
o DRUJ instability or arthritis
o TFCC tear
o LT ligament tear
o pisotriquetral arthritis
o ECU tendonitis or instability
Treatment
Nonoperative
o supportive measures
indications
may attempt supportive measures as first line of treatment
Operative
o ulnar shortening osteotomy
indications
most cases of ulnar positive variance
most cases of DRUJ incongruity
o Wafer procedure
technique
2 to 4mm of cartilage and bone removed from under TFCC arthroscopically
o Darrach procedure (ulnar head resection)
indications
reserved for lower demand patients
complications
risk of proximal ulna stump instability
o Sauvé-Kapandji procedure
indications
good option for manual laborers
technique
creates a distal radioulnar fusion and a ulnar pseudoarthrosis proximal to the fusion site
through which rotation can occur
o ulnar hemiresection arthroplasty
indications
usually requires an intact or reconstructed TFCC
appropriate treatment option in the presence of post-traumatic DRUJ with concomitant
distal ulnar degenerative changes
o ulnar head replacement
indications
severe ulnocarpal arthrosis
salvage for failed Darrach
outcomes
early results are promising, long-term results pending
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OrthoBullets2017 Degenerative Conditions | Wrist Conditions
Techniques
Ulnar shortening osteotomy
o approach
subcutaneous to ulna
o technique
often combined with arthroscopic TFCC repair
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Conditions
Anatomy
Ulnocarpal joint
o transmits about 20% of the load through the wrist
increasing ulnar length by 2.5mm relative to the radius increases this load up to 50%
pronation and hand grasp both increase elative ulnar variance and transmission forces across
the wrist
Classification
Ulnar Variance
Ulnar Length Difference Load Passing Through Load Passing Through
Variance (ulnar - radial length) Radius Ulna
Neutral 0 (<1mm) 80% 20%
Positive +2.5mm 60% 40%
Negative -2.5mm 95% 5%
Treatment
Nonoperative
o activity modifications, NSAIDS, steroid injections
indications
first line of treatment
technique
rest should be tried for a minimum of 6-12 weeks
Operative
o ulnar shortening osteotomy
currently, the gold standard
o partial ulnar styloidectomy (Wafer procedure)
can be done open or arthroscopically
encouraging early results, but no superiority established
Complications
Non-union
Tendon rupture
Persistent pain/hardware irritation
Infection
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Conditions
4. Kienbock's Disease
Introduction
Avascular necrosis of the lunate leading to abnormal carpal motion
Epidemiology
o incidence
most common in males between 20-40 years old
o risk factors
history of trauma
Pathophysiology
o thought to be caused by multiple factors
biomechanical factors
ulnar negative variance
leads to increased radial-lunate contact stress
decreased radial inclination
repetitive trauma
anatomic factors IV:21 Ulnar variance refers to the position of the
cortical margin of the distal ulna relative to that
geometry of lunate of the distal radius.
vascular supply to lunate
patterns of arterial blood supply have differential incidences of AVN
disruption of venous outflow leading to increased intraosseous pressure
Prognosis
o progressive and potentially debilitating condition if unrecognized and untreated
Anatomy
Blood supply to lunate
o 3 variations
Y-pattern
X-pattern
I-pattern
31% of patients
postulated to be at the highest risk for avascular necrosis
IV:22 There are three patterns of blood supply to the lunate, X, Y and I. The I pattern is thought to be at the highest risk for AVN.
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OrthoBullets2017 Degenerative Conditions | Wrist Conditions
Classification
Lichtman Classification
Stage Description Treatment
Stage I No visible changes on xray, Immobilization and NSAIDS
changes seen on MRI
Stage II Sclerosis of lunate Joint leveling procedure (ulnar negative
patients)
Radial wedge osteotomy or STT fusion (ulnar
neutral patients)
Distal radius core decompression
Revascularization procedures
Stage IIIA Lunate collapse, no scaphoid Same as Stage II above
rotation
Stage IIIB Lunate collapse, fixed scaphoid Proximal row carpectomy, STT fusion, or SC
rotation fusion
Stage IV Degenerated adjacent intercarpal Wrist fusion, proximal row carpectomy, or
joints limited intercarpal fusion
Stage I: A. No visible changes on xray B. Changes seen Stage II: Sclerosis of lunate.
on MRI.
Stage IIIA: A. Radiographic view of lunate Stage IIIB: A. Radiographic view of lunate collapse
collapse with no scaphoid rotation. B. CT with fixed scaphoid rotation. B. CT scan showing
scan showing lunate collapse, with no lunate collapse, with fixed scaphoid rotation.
scaphoid rotation.
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Conditions
Presentation
Symptoms
o dorsal wrist pain
usually activity related
more often in dominant hand
Physical exam
o inspection and palpation
IV:23 CT scan of the lunate showing
+/- wrist swelling trabecular destruction and
often tender over radiocarpal joint degenerative cystic changes.
o range of motion
decreased flexion/extension arc
decreased grip strength
Imaging
Radiographs
o recommended views
AP, lateral, oblique views of wrist
o findings (see table above)
CT
o most useful once lunate collapse has already occurred IV:24 T1 weighted MRI scan showing
decreased signal intensity throughout
o best for showing the lunate.
extent of necrosis
trabecular destruction
lunate geometry
MRI
o best for diagnosing early disease
o rule out ulnar impaction
o findings
decreased T1 signal intensity
reduced vascularity of lunate
IV:25 Post-operative radiograph after
STT pinning in an adolescent with
Kienbock's Disease.
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OrthoBullets2017 Degenerative Conditions | Wrist Conditions
Treatment
Nonoperative
o observation, immobilization, NSAIDS
indications
initial management for Stage I disease
outcomes
a majority of these patients will undergo further degeneration and require operative
management
Operative
o temporary scaphotrapeziotrapezoidal pinning
indications
adolescent with radiographic evidence of Kienbock's
and progressive wrist pain
o joint leveling procedure
indications
Stage I, II, IIIA disease with ulnar negative variance
initial operative managment
technique
can be radial shortening osteotomy or ulnar lengthening
more evidence on radial shortening
o radial wedge osteotomy
indications
Stage I, II, IIIA disease with ulnar positive or neutral
variance IV:26 Post-operative radiograph after STT
o vascularized bone grafts pinning in an adolescent with Kienbock's
Disease.
indications : Stage I, II, IIIA, IIIB disease
outcomes
early results promising, but long-term data lacking
best results in Stage III patients
o distal radius core decompression
indications : Stage I, II, IIIA disease
technique : creates a local vascular healing response
o partial wrist fusions
STT
capitate shortening osteotomy +/- capitohamate fusion
scaphocapitate
indications
Stage II disease with ulnar neutral or positive variance
Stage IIIA or IIIB disease
must address internal collapse pattern (DISI)
o proximal row carpectomy (PRC)
indications
stage IIIB disease
stage IV disease
outcomes
some studies have shown superior results of STT fusion over PRC for stage IIIB disease
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Conditions
o wrist fusion
indications
stage IV disease
technique
must remove arthritic part of joint
o total wrist arthroplasty
indications
Stage IV disease
outcomes
long-term results not available
Techniques
Vascularized bone grafts
o technique
many options have been described including
transfer of pisiform
transfer of distal radius on a vascularized pedicle of pronator quadratus
transfers of branches of the first, second, or third dorsal metacarpal arteries
4 + 5 extensor compartment artery (ECA)
temporary pinning of the STT joint, SC joint or external fixation may be used to unload
lunate after revascularization
IV:27 transfers of branches of the first, second, or third dorsal metacarpal arteries
Impact of surgical procedure on radiolunate contact stress
Operative Procedure % decrease on radiolunate contact stress
STT fusion 3%
Scaphocapitate fusion 12%
Capitohamate fusion 0%
Ulnar lengthening of 4mm 45%
Radial shortening of 4mm 45%
Capitate shortening and capitohamate fusion 66%, but 26% increase in radioscaphoid load
Complications
pending
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OrthoBullets2017 Degenerative Conditions | Wrist Conditions
Presentation
Symptoms
o dorsoradial wrist pain
Imaging
Radiographs
o show sclerosis and fragmentation of proximal pole
without evidence of fracture
MRI
o can further allow classification into complete vs partial
IV:28 Radiograph shows sclerosis and proximal
involvement collapse of scaphoid consistent with Preiser's
disease.
Treatment
Nonoperative
o immobilization
is effective in 20% of cases
Operative
o microfracture drilling, revascularization procedure, or
allograft replacement
indications
when nonoperative management fails
techniques include
drilling
IV:29 Hand.MRI.Coronal.T1: T1
revascularization MRI image showing Preiser's Disease.
allograft replacements
o proximal row carpectomy or scaphoid excision with four corner fusion
indications
considered salvage procedures
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Conditions
o microtrauma can lead to premature closure of distal radial physis resulting in secondary
overgrowth of ulna
Associated conditions
o orthopaedic
distal ulnar overgrowth
positive ulnar variance
Prognosis
o good outcomes associated with early treatment
Presentation
Symptoms IV:30 AP and lateral radiographs demonstrating widening
o wrist pain of the distal radial physis found in "gymnast's wrist"
Imaging
Radiographs
o recommended views
AP and lateral of the wrist
o findings
widened distal radial growth plate with ill-defined borders
IV:31 AP radiograph demonstrates late
positive ulnar variance with chronic cases findings of physeal closure of the distal radius
MRI and positive ulnar variance.
o indications
chronic or cases non-responsive to treatment
o findings
paraphyseal edema
early physeal bridging
bruising of radius
Treatment
Nonoperative
o NSAIDS, rest, immobilization for 3-6 months
indications
first line of treatment
IV:32 Coronal fat suppressed proton-density
Operative weighted image demonstrates widening and
o resection of physeal bridge irregularity of the distal radial physis found in
distal physeal stress syndrome; "gymnast's
indications wrist"
small physeal closures
o ulnar epiphysiodesis and shortening with radial osteotomy as needed
indications : large physeal closures (roughly 50% of physis)
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OrthoBullets2017 Degenerative Conditions | Wrist Instability & Collapse
Anatomy
Scaphoid anatomy
o blood supply
major blood supply is dorsal carpal branch (branch of the radial artery)
enters scaphoid in a nonarticular ridge on the dorsal surface and supplies proximal 80%
of scaphoid via retrograde blood flow
minor blood supply from superficial palmar arch (branch of volar radial artery)
enters distal tubercle and supplies distal 20% of scaphoid
o motion
both intrinsic and extrinsic ligaments attach and surround the scaphoid
the scaphoid flexes with wrist flexion and radial deviation and it extends during wrist
extension and ulnar deviation (same as proximal row)
o also see Wrist Ligaments and Biomechanics for more detail
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Instability & Collapse
Classification
Radiographic Classification
Stage I • Arthrosis localized to the radial side of the scaphoid and radial styloid
Stage II •Scaphocapitate arthrosis in addition to Stage 1
Stage III • Periscaphoid arthrosis (proximal lunate and capitate may be maintained)
Presentation
Symptoms
o weakness
reduced grip and pinch strength
o stiffness
stiffness with extension and radial deviation
Physical exam
o palpation
localized tenderness of the radioscaphoid articulation
o motion
decreased wrist motion on extension and radial deviation
Imaging
Radiographs
o recommended view
ap and lateral of wrist
o findings
see radiographic classification above
Treatment
Nonoperative
o observation alone
indications
medically frail and low functioning patients only
Operative
o radial styloidectomy plus scapholunate reduction and stabilization
indications : stage I
o proximal row corpectomy
indications : stage II and III
outcomes
disadvantages
reduction of wrist motion and grip strength
procedure should be avoided if there are capitate head degenerative changes
o four-corner fusion
indications
stage II and III
outcomes
retains 60% of wrist motion and 80% of grip strength
o wrist arthrodesis
indications
stage II and III
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Instability & Collapse
Anatomy
Scapholunate interosseous ligament
o location
c-shaped structure connecting the dorsal, proximal and volar surfaces of the scaphoid and
lunate bones
dorsal fiber thickened (2-3mm) compared to volar fibers
o biomechanics
dorsal component provides the greatest constraint to translation between the scaphoid and
lunate bones
proximal fibers have minimal mechanical strength
Overview of wrist ligaments and biomechanics
Presentation
History
o acute FOOSH injury vs. degenerative rupture
age, nature of injury, duration since injury, degree of underlying arthritis, level of activity
Symptoms
o usually dorsal and radial-sided wrist pain
o pain increased with loading across the wrist (e.g. push up position)
o clicking or catching in the wrist
o may be associated with wrist instability or weakness
Physical exam
o inspection
may see swelling over the dorsal aspect of the wrist
o palpation
tenderness in the anatomical snuffbox or over the dorsal scapholunate interval (just distal to
Lister's tubercle)
o motion
pain increased with extreme wrist extension and radial deviation
o provocative tests
Watson test
when deviating from ulnar to radial, pressure over volar aspect of scaphoid produces a
clunk secondary to dorsal subluxation of the scaphoid over the dorsal rim of the radius
dorsal wrist pain or a clunk during this maneuver may indicate instability of
scapholunate ligament
Imaging
Radiographs
o recommended views
AP and lateral views of the wrist
o additional views
radial and ulnar deviation views
flexion and extension views
clenched fist (can attenuate the diastasis)
o findings
AP radiographs
SL gap > 3mm with clenched fist view (Terry Thomas sign)
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OrthoBullets2017 Degenerative Conditions | Wrist Instability & Collapse
cortical ring sign (caused by scaphoid malalignment)
humpback deformity with DISI associated with an unstable scaphoid fracture
scaphoid shortening
Lateral radiographs
dorsal tilt of lunate leads to SL angle > 70° on neutral rotation lateral
capitolunate angle > 20°
DISI
normal carpal alignment
increased SL angle
Arthrography
o indications : may be used as screening tool for arthroscopy
o views
radiocarpal and midcarpal views
always assess the contralateral wrist for comparison
o findings
may demonstrate the presence of a tear but cannot determine the size of the tear
positive finding of a tear may indicate the need for wrist arthroscopy
MRI
o indications : often overused as a screening modality for SLIL tears
o findings
requires careful inspection of the SLIL by a dedicated radiologist to confirm diagnosis
low sensitivity for tears
Arthroscopy
o indications : considered the gold standard for diagnosis
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Instability & Collapse
Treatment
Nonoperative
o NSAIDS, rest +/- immobilization
indications
acute, undisplaced SLIL injuries
chronic, asymptomatic tears
technique
splinting and close follow-up with repeat imaging and clinical response with acute
injuries
outcomes
most people feel casting alone is insufficient
may be effective with incomplete tears
Operative
o scapholunate ligament repair
indications
acute scapholunate ligament injury without carpal malalignment
chronic but reducible scapholunate ligament injuries (can peform if < 18 months from the
time of injury)
ligament pathoanatomy is ammenable to repair
o scapholunate reconstruction
indications
acute scapholunate ligament injury without carpal malalignment where pathoanatomy is
not ammenable to repair
reducible scapholunate ligament injuries > 18 months from the time of injury
o scaphoid ORIF vs. CRPP (+/- arthroscopic assistance)
indications
f pathoanatomy of SL ligament injury is a scaphoid fx than repair with ORIF vs.
CRPP (+/- arthroscopic assistance)
o stabilization with wrist fusion (STT or SLC)
indications
rigid and unreducible DISI deformity
DISI with severe DJD
technique
scaphotrapezialtrapezoidal (STT) fusion
scapholunocapitate (SLC) fusion
scapholunate fusion alone has highest nonunion rate
Technique
Scapholunate ligament direct repair SLIL with k-wires
o approach
small incision is made just distal to the radial styloid
care to avoid cutting the radial sensory nerve branches
o methods
SL joint pinning with k-wires
suture anchors with k-wires
Blatt dorsal capsulodesis
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often added to a ligament repair and remains a viable alternative for a chronic instability
when ligament repair is not feasible
o repair technique
place two k-wires in parallel into the scaphoid bone
reduce the SL joint by levering the scaphoid into extension, supination and ulnar deviation
and lunate into flexion and radial deviation
pass the k wires into the lunate
confirm reduction of the SL joint under fluoroscopy
place patient in short arm cast
o post-operative care
remove k-wires in 8-10 weeks
no heavy labor for 4-6 months
Scapholunate ligament reconstruction
o approach
same as for repair
o reconstruction
FCR tendon transfer (direct SL joint reduction)
ECRB tendonosis (indirect SL joint reduction)
weave not recommended due to high incidence of late failure
Complications
Disease progression (e.g. SLAC wrist)
Arthritis
Post-operative pain, stiffness, fatigue
Reduced grip strength
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Instability & Collapse
o VISI may occasionally be seen in uninjured wrists in patients with ligamentous laxity
this is in contrast to DISI deformity, which is always a pathologic condition
Anatomy
Lunotriquetral ligament
o C-shaped intrinsic ligament spanning the dorsal, proximal and palmar edges of the joint
o comprised of thick dorsal and volar regions and weak membranous portion
dorsal LT ligament
most important as a rotational constraint
volar LT ligament
thickest and strongest portion of the LT ligament
transmits extension moment of the triquetrum
Dorsal radiocarpal ligament (aka dorsal radiotriquetral ligament)
o extrinsic ligament that serves as a secondary restraint to VISI deformity, and loss of integrity
allows lunate to flex more easily
Volar long and short radiolunate ligaments
o extrinsic ligament that may be torn in advanced injury
Presentation
Symptoms
o ulnar sides pain that is worse with pronation and ulnar deviation (power grip)
Physical exam
o LT shuck test (aka ballottement test)
grasp the lunate between the thumb and index finger of one hand while applying alternative
dorsal and palmar loads across the triquetrum with the thumb and index of the other hand
positive test elicits pain, crepitus or increased laxity, suggesting LT interosseous injury
o Kleinman's shear test
stabilize the radiolunate joint with the forearm in neutral rotation and with the contralateral
hand load the triquetrum in the AP plane, producing shear across the LT joint
positive test produces pain or a clunk
o Lunotriquetral compression test
displacement of triquetrum ulnarly during radioulnar deviation which is associated with pain
Imaging
Radiographs
o lateral
volar flexion of lunate leads to SL angle < 30° (normal is 47°) and VISI deformity
capitolunate zigzag deformity seen with capitolunate angle increase to > 15° (lunate and
capitate normally co-linear)
o AP
unlike scapholunate dissociation, may not be widening of LT interval
break in Gilula's arc
may see proximal translation of triquetrum and/or LT overlap
Arthroscopy
o helpful in making diagnosis, as radiographs may be normal
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Instability & Collapse
scapholunate angle > 70 degrees
lunate extended > 10 degrees past neutral
o resultant scaphoid flexion and lunate extension creates
abnormal distribution of forces across midcarpal and radiocarpal joints
malalignment of concentric joint surfaces
o initially affects the radioscaphoid joint and progresses to capitolunate joint
Classification
Watson classification
o describes predictable progression of degenerative changes from the radial styloid to the entire
scaphoid facet and finally to the unstable capitolunate joint, as the capitate subluxates dorsally on
the lunate
o key finding is that the radiolunate joint is spared, unlike other forms of wrist arthritis, since there
remains a concentric articulation between the lunate and the spheroid lunate fossa of the distal
radius
Watson Stages
Stage I Arthritis between scaphoid and radial styloid
Stage II Arthritis between scaphoid and entire scaphoid facet of the radius
Stage III Arthritis between capitate and lunate
note: radiolunate joint spared
While original Watson classification describes preservation of radiolunate joint in all stages of
SLAC wrist, subsequent description by other surgeons of "stage IV" pancarpal arthritis observed in
rare cases where radiolunate joint is affected
o validity of "stage IV" changes in SLAC wrist remains controversial and presence pancarpal
arthritis should alert the clinician of a different etiology of wrist arthritis
Evaluation
Radiographs
o obtain standard PA and lateral radiographs
PA radiograph will reveal greater than 3mm diastasis between the scaphoid and lunate
Stage I SLAC wrist
PA radiograph shows radial styloid beaking, sclerosis and joint space narrowing
between scaphoid and radial styloid
Stage II SLAC wrist
PA radiograph shows sclerosis and joint space narrowing between scaphoid and the
entire scaphoid fossa of distal radius
Stage III SLAC wrist
PA radiograph shows sclerosis and joint space narrowing between the lunate and
capitate, and the capitate will eventually migrate proximally into the space created by
the scapholunate dissociation
lateral radiograph
will reveal DISI deformity and subluxation of capitate dorsally onto lunate
o stress radiographs unnecessary
MRI
o unnecessary for staging, but will show
thinning of articular surfaces of the proximal scaphoid
scaphoid facet of distal radius and capitatolunate joint with synovitis in radiocarpal and
midcarpal joints
Treatment
Nonoperative
o NSAIDs, wrist splinting, and possible corticosteroid injections
indications
mild disease
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Instability & Collapse
Operative
o radial styloidectomy and scaphoid stabilization
indications
Stage I
technique
prevents impingement between proximal scaphoid and radial styloid
may be performed open or arthroscopically via 1,2 portal for instrumentation
o PIN and AIN denervation
indications
Stage I
technique
since posterior and anterior interosseous nerve only provide proprioception and sensation
to wrist capsule at their most distal branches, they can be safely dennervated to provide
pain relief
can be used in combination with below procedures for Stage II or III
o proximal row carpectomy
indications
Stage II
contraindicated if there is an incompetent radioscaphocapitate ligament
contraindicated with caputolunate arthritis (Stage III) because capitate articulates with
lunate fossa of the distal radius
technique
excising entire proximal row of carpal bones (scaphoid, lunate and triquetrum) while
preserving radioscaphocapitate ligament (to prevent ulnar subluxation after proximal row
carpectomy)
outcomes
provides relative preservation of strength and motion
o scaphoid excision and four corner fusion
indications
Stage II or III
technique
also provides relative preservation of strength and motion
wrist motion occurs through the preserved articulation between lunate and distal radius
(lunate fossa)
outcomes
similar long term clinical results between scaphoid excision/ four corner fusion and
proximal row carpectomy
o wrist fusion
indications
Stage III
any form of pancarpal arthritis
outcomes
wrist fusion gives best pain relief and good grip strength at the cost of wrist motion
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OrthoBullets2017 Degenerative Conditions | Wrist Instability & Collapse
Anatomy
Volar extrinsic ligaments
o radioscaphocapitate (RSC)
o long radiolunate
o short radiolunate
o radioscapholunate
Classification
Overview table of wrist instability
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Wrist Instability & Collapse
Presentation
History
o usually no history of trauma (midcarpal)
o high energy trauma (radiocarpal)
Symptoms
o subluxation that may or may not be painful
o complain of wrist giving way
o irritating clunking sign
"clunk" when wrist is moved ulnarly from flexion to extension with an axial load
Physical exam
o generalized ligamentous laxity
Imaging
Radiographs
o recommended views
required
AP and lateral of the wrist
optional
cineradiographs
o findings
sudden subluxation of proximal carpal row with active radial or ulnar deviation on
cineradiograph
ulnar translation
diagnosis made when >50% of lunate width is ulnarly translated off the lunate fossa of
the radius
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Treatment
Nonoperative
o immobilization +/- splinting
indications
first line of treatment
midcarpal instability is most amenable to splinting
Operative
o immediate open repair, reduction, and pinning
indications
ulnar translation associated with styloid fractures
outcomes
poor results with late repair
ligament reconstruction has poor long term results
o midcarpal joint fusion
indications
midcarpal instability (preferred over ligamentous reconstruction)
late diagnosis that failed nonoperative management
outcomes
will lead to 20-35% loss of motion
o osteotomy with malunion correction
indications
distal radius malunion
o wrist arthrodesis
indications : failure of above treatments
outcomes
fusion of radiocarpal joint leads to a 55-60% loss of motion
F. Arthritic conditions
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Arthritic conditions
Anatomy
Trapezial metacarpal joint is a biconcave saddle joint
Trapezium has a palmar groove for flexor carpi radialis (FCR) tendon
Ligaments
o anterior oblique ligament (Beak ligament)
primary stabilizing restraint to subluxation of CMC joint
o intermetacarpal ligaments
o posterior oblique ligament
o dorsal-radial capsule (injured in dorsal CMC dislocation)
Biomechanics
o CMC joint reactive force is 13X applied pinch force
IV:34 Illustration shows volar (A) and dorsal (B) ligaments of CMC joint.
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Classification
Eaton and Littler Classification of Basilar Thumb Arthritis
Stage I slight joint space widening (pre-arthritis)
Stage II slight narrowing of CMC joint with sclerosis, osteophytes <2mm
Stage III marked narrowing of CMC joint with osteophytes, osteophytes >2mm
Stage IV pantrapezial arthritis (STT involved)
Imaging
Radiographs
o technique
X-ray beam is centered on trapezium and metacarpal with thumb flat on cassette and thumb
hyperpronated
o findings
joint space narrowing
osteophytes
may show MCP hyperextension
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Arthritic conditions
IV:36 Clinical image shows correct thumb IV:35 Thumb MCP hyperextension
positioning for radiograph of basilar thumb deformity associated with late basilar thumb
arthritis. arthritis.
Differential Diagnosis
de Quervains tenosynovitis
STT arthritis
scaphoid nonunion/SNAC
radioscaphoid arthritis
Treatment
Nonoperative
o NSAIDS, thumb spica bracing, symptomatic treatment, steroid injections
indications
indicated as first line of treatment for mild symptoms
o hyaluronic acid injections
show no difference for the relief of pain and improvement in function when compared to
placebo and corticosteroids
Operative
o closing wedge dorsal extension osteotomy of 1st metacarpal
indications
for early Stage I disease
technique
redirects the force to the dorsal, more uninvolved
portion of the first carpometacarpal joint
outcomes
gained in popularity
93% have symptom improvement at 7 years
o ligament reconstruction with FCR
indications
Stage I disease when joint is hypermobile and unstable (pain with varus valgus stress)
o trapeziectomy + LRTI (ligament reconstruction and tendon interposition)
indications
Stage II-IV disease
most common procedure and favored in most patients
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technique
there are many different surgical options available
trapezial excision is most important, regardless of other specifics of CMC arthroplasty
FCR tendon most commonly used in reconstruction to suspend metacarpal
alternatively, ECRL or APL may be used for suspension
or PL around FCR to correct subluxation
outcomes
can expect ~25% subsidence postoperatively
postoperatively
with no change in outcomes
results in improved grip and pinch strengths
o hematoma arthroplasty (trapezial resection alone without LRTI)
indications
Stage II-IV disease
technique
trapezium resection and pinning of thumb metacarpal without LRTI
outcomes
comparable outcomes to trapeziectomy + LRTI
o excision of proximal third of trapezioid
indications
concomitant scaphotrapezioid arthritis (present in 62%), especially in Eaton-Littler stage
IV
o CMC arthroscopy and debridement
indications
early stages of disease
o trapeziometacarpal (CMC) arthrodesis
indications
Stage II-III disease in young male heavy laborers
preserves grip strength
contraindications
scaphotrapeiotrapezoidal (STT) arthritis
technique
CMC joint fused in
35° radial abduction
30° palmar abduction IV:37 CMC arthrodesis with plate & screws
15° pronation
outcomes
good pain relief, stability, and length preservation
decreased ROM; inability to put hand down flat
nonunion rate of 12%
o volar capsulodesis, EPB tendon transfer, sesamoid fusion, or MCP fusion
indications
thumb MCP hyperextension instability (hyperextension > 30°) otherwise a Swan neck
deformity will arise
see below (Complications) for algorithm
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Arthritic conditions
o silicone replacements
indications
not recommended
complications of prosthesis fracture, subluxation, or silicone synovitis
Complications
1st metacarpal subsidence and narrowing of trapezial space height
o after trapeziectomy ± tendon suspension
o salvage treatment
LRTI with ECRL tendon or APL tendon
if FCR is already used /ruptured
MCP hyperextension deformity
o treatment depends on degree of hyperextension
<10° - no surgical intervention
10-20° - percutaneous pinning of MCP in 25-35° flexion x 4wk ± EPB tendon transfer
20-40° - volar capsulodesis or sesamoidesis
>40° - MCP fusion
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nail ridging
Presentation
Symptoms of primary osteoarthritis
o pain
o deformity
Symptoms of erosive osteoarthritis
o intermittent inflammatory episodes
o articular cartilage and adjacent bone destroyed
o synovial changes similar to RA but not systemic
Imaging
Radiographs
o recommended views
AP, lateral and oblique of hand
o findings
erosive osteoarthritis will show cartilage destruction,
osteophytes, and subchondral erosion (gull wing
deformity)
Treatment
DIP Arthritis
o nonoperative
observation, NSAIDs
indications
first line of treatment for mild symptoms
o operative
fusion
indications
debilitating pain and deformity
technique
fusion with headless screw has highest fusion rate (nonunion in 10%)
2nd and 3rd digit fused in extension
4th and 5th digit fused in 10-20° flexion
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Arthritic conditions
Mucous Cyst
o nonoperative
observation
indications
first line of treatment as 20-60% spontaneously resolve
o operative
mucous cyst excision + osteophyte resection
indications
impending rupture
may need to do local rotational flap for skin coverage
outcome
osteophytes MUST be debrided or mucous cyst will recur
PIP Arthritis
o nonoperative
observations, NSAIDs
indications : first line of treatment in mild symptoms
o operative
collateral ligament excision, volar plate release, osteophyte excision
indications
predominant contracture with minimal joint involvement
fusion
indications
border digits (index and small PIP)
middle and ring finger OA if there is angulation/rotation deformity, ligamentous
instability or poor bone stock
technique
headless screw fixation has highest fusion rates
recreate normal cascade of fingers / PIPJ flexion angles
index- 30°, long- 35°, ring- 40°, small- 45°
silicone arthroplasty for middle and ring PIPJ
radial collateral ligament should be intact to tolerate pinch grip
indications
central digits (long and ring finger)
good bone stock
no angulation or deformity
outcomes
results are similar for both dorsal and volar approaches
Erosive osteoarthritis
o nonoperative
splints, NSAIDs
indications : tolerable symptoms
o operative
fusion
indications : intolerable deformity
technique
position of fusion same as above
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3. Wrist Arthritis
Introduction
Various forms of wrist arthritis based on location
o SLAC wrist (scapholunate advanced collapse)
most common
o STT arthrosis
second most common
o SNAC (scaphoid nonunion advanced collapse)
o DRUJ arthrosis
o Pisotriquetrial arthrosis
Mechanism
IV:39 STT Arthritis
o degenerative
primary OA
o posttraumatic
leads to SLAC/SNAC/DRUJ
o inflammatory
Rheumatoid arthritis
o congenital
may be secondary to Madelung's deformity
o idiopathic
may secondary to Kienbock's or Preiser's disease
Pathoanatomy IV:40 DRUJ Arthitis
o SLAC
Injury to SL ligament --> palmar rotary subluxation of
scaphoid --> incongruency of joint surfaces --> arthrosis
of radiocarpal joint --> arthrosis of capitolunate joint
radiolunate typically spared
o SNAC
proximal portion of scaphoid remains attached to lunate
while distal scaphoid flexes
leads to early arthritis between radial styloid and distal
scaphoid
like SLAC, radiolunate typically spared
o Rheumatoid arthritis
wrist becomes supinated, palmarly dislocated, radially
IV:41 Pisotriquetrial arthrosis
deviated, and ulnarly translocated
early disruption of DRUJ leads to dorsal subluxation of ulna (Caput-ulna)
Anatomy
Wrist ligaments and biomechanics
Imaging
Radiographs
o obtain standard hand series with additional views to visualize specific joints
o pisotriquetral joint (pisotriquetral arthrosis) obtain lateral in 30 degrees of supination
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Arthritic conditions
Treatment
Nonoperative
o NSAIDs, bracing, intra-articular steroid injections
indications
first line of treatment for mild to moderate symptoms
Operative
o aimed at addressing diseased area
SLAC
SNAC
Pisotriquetrial arthritis
excision of pisiform in refractory cases
DRUJ abutment syndrome & arthrosis
I V:42 Post-operative
distal ulna resection (Darrach procedure) radiograph of an
Sauvé-Kapandji procedure ulnar head
replacement.
partial ulna resection and interposition
ulnar head replacement
can be used as primary procedure, or as salvage for failed Darrach
early results are promising, long-term results pending
Rheumatoid arthritis
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In July 2017
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OrthoBullets2017 Pediatric Hand | Arthritic conditions
ORTHO BULLETS
V. Pediatric Hand
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Arm
A. Congenital Arm
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OrthoBullets2017 Pediatric Hand | Congenital Arm
Presentation
Physical exam
o deformity of hand with perpendicular relationship between forearm and wrist
o absent thumb
o perform careful elbow examination
Imaging
Radiographs
o entire radius and often thumb is absent
Laboratory
o must order CBC, renal ultrasound, and echocardiogram to screen for associated conditions
Treatment
Nonoperative
o passive stretching
target tight radial-sided structures
o observation
indicated if absent elbow motion or biceps deficiency
hand deformity allows for extra reach to mouth in presence of a stiff elbow
Operative
o hand centralization
indications
good elbow motion and biceps function intact
done at 6-12 months of age
followed by tendon transfers
contraindications
older patient with good function
patients with elbow extension contracture who rely on radial deviation
proximate terminal condition
technique
involves resection of varying amount of carpus, shortening of ECU, and, if needed, an
angular osteotomy of the ulna (be sure to spare ulnar distal physis)
may do as two stage procedure in combination with a distraction external fixator
if thumb deformity then combine with thumb reconstruction at 18 months of age
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Arm
o orthopaedic conditions
PFFD
fibula deficiency
scoliosis
phocomelia
multiple hand abnormalities
almost all patients have absent ulnar sided digits
Presentation
Symptoms
o limited function
o usually painless
Physical exam
o shortened, bowed forearm
o decrease in elbow function
o loss of ulnar digits
Classification
Bayne Classification
Type 0 • Deficiencies of the carpus and/or hand only
Type 1 • Undersized ulna with both growth centers present
Type II • Part of the ulna is missing (typically the distal ulna is absent)
Type III • Absent ulna
Type IV • Radiohumeral synostosis
There is a subtype of each classification that is based on the first webspace
• A = Normal
• B = Mild deficiency of the webspace
• C = Moderate to severe deficiency of the webspace
• D = Absent webspace
Type II
Type I
Type 0
Anatomy
Elbow Anatomy & Biomechanics
Presentation
Symptoms
o patients often asymptomatic
o limited elbow ROM
Physical exam
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Arm
o radialhead prominence
o can have limited elbow ROM
especially in extension and supination
usually painless
Imaging
Radiographs
o radial head posterior to capitellum
o radial head can be large and convex
o radius is short and bowed
Treatment
Nonoperative
o observation
indications V:3 2 views of elbow demonstrate congenital dislocation of
head, including a convex and posteriorly dislocated radial head.
first line of treatment
Operative
o radial head resection
indications
usually done in adulthood if patient has
significant pain
restricted motion
cosmetic concern of elbow
outcomes
reduces pain
may improve some elbow ROM
4. Madelung's Deformity
Introduction
A congenital dyschondrosis of the distal radial physis that leads to
o partial deficiency of growth of distal radial physis
o excessive radial inclination and volar tilt
o ulnar carpal impaction
Epidemiology
o occurs predominantly in adolescent females
common in gymnasts
Pathophysiology
o caused by disruption of the ulnar volar physis of the distal radius
repetitive trauma or dysplastic arrest
o one hypothesis is due to tethering by Vickers ligament
Vickers ligament is a fibrous band running from the distal radius to the lunate on the volar
surface of the wrist (radio-lunate ligament)
may be accompanied by anomalous palmar radiotriquetral ligament
Genetics
o autosomal dominant
Associated conditions
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o Leri-Weill dyschondrosteosis
rare genetic disorder caused by mutation in the SHOX gene
SHOX stands for short-statute homeobox-containing gene
anatomically at the tip of the sex chromosome
causes mesomelic dwarfism (short stature)
associated Madelung's deformity of the forearm
Presentation
Symptoms
o most are asymptomatic until adolescence
o symptoms include
symptoms of ulnar impaction
median nerve irritation
Physical exam
o leads to radial and volar displacement of hand
o restricted forearm rotation
The wrists on this patient The increased volar tilt in The wrists on this patient appear to be
appear to be subluxed volar Madelung's deformity leads the subluxed volar however this is due to
however this is due to the clinical appearance of the wrist the increased volar tilt which is
increased volar tilt which is to seem subluxed in a volar characteristic of Madelung's deformity.
characteristic of Madelung's direction.
deformity.
Imaging
Radiographs
o can see proximal synostosis
o characteristic undergrowth of the volar, ulnar corner
of the radius
o increased radial inclination
o increased volar tilt
MRI
o indications
concern for pathologic Vickers ligament :4 The thick dark band
V
seen on the T1 MRI is a
o views pathologically thick short
thickening ligament from the distal radius to the lunate radio-lunate ligament
(Vickers ligament) which
Treatment can cause tethering of the
volar, ulnar radial physis
Nonoperative and cause Madelung's
deformity.
o observation
indications : if asymptomatic
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Arm
o restricted activity
indications
activities with repetitive wrist impaction
recommend cessation of weight-bearing activities until pain decreases
Operative
o physiolysis with release of Vickers ligament
indications
wrist pain or decreased range of motion
efficacy of prophylactic release of Vickers ligament in mild deformity in skeletally
immature patients unknown
o radial corrective osteomy +/- distal ulnar shortening osteotomy
indications
wrist pain or decreased range of motion
cosmetic deformity
functional limitations
o DRUJ arthroplasty
indications
highly controversial
painful DRUJ instability and limited supination/pronation
significant deformity may require staged procedures
Techniques
Physiolysis and release of Vickers ligament
o approach
volar approach to the distal radius
o technique
V:5 In this patient the distal radius
has undergone a distal radio-ulnar
release a pathologically thick ligament joint fusion to stabilize the wrist. The
ligament approximately 0.5 to 1.0 cm in diameter ulnar variance has been corrected to
neutral by ulnar osteotomy to
bar resection and fat grafting in the physis decrease the pressure on the ulnar
aspect of the wrist joint.
Corrective radial osteotomy +/- distal ulnar shortening osteotomy
o goals
restore mechanics of distal radius
o approach
volar approach to the distal radius
o technique
severe deformities may benefit from a staged procedure with initial distraction external
fixation to avoid neurovascular stretching injury of a single procedure
codome osteotomy allows correction of coronal and sagittal deformity
Complications
Incomplete physiolysis or premature growth arrest
Violation of radiocarpal or ulnocarpal joint
Incomplete deformity correction
Recurrent deformity
Nonunion of the osteotomy site
Continued ulnar impaction (if radial osteotomy done alone)
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Presentation
Physical exam
o children often present at 3-5 years of age
no pronation or supination
fixed in varying degree of pronation (50% of patients have > 50° of pronation)
Imaging
Radiographs
o recommended view
AP and lateral of forearm and elbow
o findings
can see proximal synostosis
radius is heavy and bowed
Studies
Chromosome analysis
o to identify duplication in sex chromosomes
Treatment
Nonoperative
o observation
indications : usually preferred treatment, especially if deformity is unilateral
Operative
o osteotomy with fusion
surgery rarely indicated
indications
indicated to obtain functional degree of pronation
unilateral : fix the forearm in pronation of 30°
bilateral
fix dominant forearm in pronation (10-20°)
nondominan forearm in neutral
technique
use percutaneous pins to aid fusion
perform at ~ 5 years of age
cannot recreate proximal radial-ulnar joint with excision alone as it will reossify and
recur
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
B. Congenital Hand
1. Cleft Hand
Introduction
Definition
o typical (central) cleft hand is characterized by absence of 1 or more central digits of the hand or
foot
also known as lobster-claw deformity
o Swanson type I failure of formation (longitudinal arrest) of central ray,
leaving V-shaped cleft in the center of the hand
o types
unilateral vs bilateral
isolated vs syndromic
Epidemiology
o incidence
rare (1:10,000 to 1:90,000)
o demographics
male:female ratio is 5:1 (more common in male)
o location
hands, usually bilateral
associated with absent metacarpals (helps differentiate from symbrachydactyly)
missing middle finger
on the ulnar side, small finger is always present
often involves feet as well
Pathogenesis
o theory is wedge-shaped degeneration of central part of apical ectodermal ridge (AER) because of
loss of function of certain genes expressed in that part of the AER
Genetics
o inheritance pattern
Autosomal dominant with reduced penetrance (70%)
inherited forms become more severe with each generation
o mutations
deletions, inversions, translocations of 7q
split hand-split foot syndrome
o affected families should undergo genetic counseling
Associated conditions
o Ectrodactyly-ectodermal dysplasia-cleft (EEC) syndrome
o sensorineural hearing loss
o syndactyly and polydactyly
Prognosis
o functional limitation dependent on involvement of 1st webspace
o aesthetically displeasing, but not functionally limiting
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Classification
Type I cleft hand showing Type IIA cleft hand with Type IIB cleft hand with
absent middle ray with mildly narrowed thumb- severely narrowed
normal thumb-index web index web space prior to Z- thumb-index web space
space plasty.
Type III cleft hand with Type IV cleft hand with Type V cleft hand with
syndactyly of thumb and merging of the web space absent thumb web space
index rays and cleft (absent index and resulting from absent
middle rays) middle, index and thumb
rays.
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
Presentation
History
o may have family history
Symptoms
o aesthetic limitation
o functional limitation
Physical exam
o absent or shortened central (third) ray
o may have absent radial digits
o may have syndactyly of ulnar digits
may involve feet
Imaging
Radiographs
o recommended views
AP, lateral, oblique views of bilateral hands
foot radiographs if involved
Treatment
Nonoperative
o observation
indications
types I (normal web) and IV (merged web), no functional impairment
Operative
o thumb web space, thumb, and central cleft reconstruction
indications
types IIA, IIB, III and V webs
Technique
Thumb, thumb web space reconstruction
o web space deepening, tendon transfer, rotational osteotomy, toe-hand transfer
o thumb web reconstruction has greater priority over correction of central cleft
o thumb reconstruction should not precede cleft closure as it might compromise skin flaps
Central cleft reconstruction
o depends on characteristic of thumb web space
o close the cleft proper with local tissues from the cleft and stabilize and close intermetacarpal
space
2. Symphalangism
Introduction
Congenital digital stiffness that comes in two forms
o hereditary symphalangism
o nonherediatry symphalangism
Epidemiology
o location
more common in ulnar digits
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Pathophysiology
o failure of IP joint to differentiate during development
Genetics
o inheritance pattern (hereditary type)
autosomal dominant
Associated conditions
o syndactyly (nonhereditary type)
o Apert's syndrome (nonhereditary type)
o Poland's syndrome (nonhereditary type)
o correctable hearing loss (hereditary type)
Presentation
Physical exam
o inspection
absence of flexion and extension creases
o motion
stiff digits
Imaging
Radiographs
o IP joint space may appear narrow
Treatment
Nonoperative
o observation
no indication for surgery in children
Operative
o capsulectomy
outcome
limited success
o IP joint arthroplasty
outcome : limited success
o angular osteotomy
indications
rarely needed due to adequate digital function
o arthrodesis
indications
may be considered during adolesence to improve function and cosmesis
rarely needed due to adequate digital function
3. Camptodactyly
Introduction
Congenital digital flexion deformity that usually occurs in the PIP joint of the small finger
Epidemiology
o prevalence
less than 1%
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
o location
Unilateral (33%) or bilateral (66%)
if bilateral, can be symmetric or asymmetric
Pathophysiology
o typically caused by either
abnormal lumbrical insertion/origin
abnormal (adherent, hypoplastic) FDS insertion
other less common causes include
abnormal central slip
abnormal extensor hood
abnormal volar plate
skin, subcutaneous tissue, or dermis contracture
Genetics
o most often sporadic
o can be inherited with autosomal dominant inheritance with incomplete penetrance/variable
expressivity
Associated conditons
o can be associated with more widespread developmental dysmorphology syndromes
Classification
If full PIP extension can be achieved actively with MCP held in flexion, digit can be explored and
abnormal tendon transferred to radial lateral band
Benson Classification
Type Characteristics Treatment
Type I • Isolated anomaly of little finger, presents
in infancy and affects males and females equally Stretching/splinting
• Most common form
Type II • Same clinical features as Type I, presents in If full PIP extension can be
adolescence achieved actively with MCP
• Affects girls more often than boys held in flexion, digit can be
From abnormal lumbrical insertion, abnormal FDS explored and abnormal
origin or insertion FDS tendon transferred
to radial lateral band
Type III • Severe contractures, multiple digits involved, Non-operative (unless
presents at birth functional deficit exists
• Usually associated with a syndrome after skeletal maturity),
then consider corrective
osteotomy/fusion
Kirner's • Specific deformity of small finger distal phalanx with
Deformity volar-radial curvature (apex dorsal-ulnar)
• Often affects preadolescent girls
• Often bilateral
• Usually no functional deficits
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OrthoBullets2017 Pediatric Hand | Congenital Hand
Imaging
Radiographs
o often normal, especially in early stages
o later stages: possible decrease in P1 head convexity; possible volar subluxation and flattening of
base of P2
Treatment
Nonoperative
o passive stretching, splinting
indications
nonoperative treatment is favored in most cases
best for PIP contracture < 30 degrees
technique
passive stretching + static splinting
outcomes
variable outcomes
best outcomes with early intervention
Operative
o FDS tenotomy +/- FDS transfer
indications
progressive deformity leading to functional impairment
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
technique
must address all abnormal anatomy
passive (correctable) deformities
FDS tenotomy, or
FDS transfer to radial lateral band if full active PIP extension can be achieved with
MCP flexion
o osteotomy vs. arthrodesis
indications
severe fixed deformities
outcomes
variable outcomes
4. Clinodactyly
Introduction
Congenital curvature of digit in radioulnar plane
o found in 25% of children with Down's syndrome and 3% of general population
Pathoanatomy
o autosomal dominant inheritance
o middle phalanx of small finger most commonly affected
Anatomy
Anatomy of ligaments of the fingers
Classification
Clinodactyly Classification
Type I • Minor angulation with normal length (most common)
Type II • Minor angulation with short length
Type III • Significant angulation and delta phalanx (c-shaped epiphysis and longitudinal
bracketed diaphysis)
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Presentation
Physical exam
o function rarely significantly compromised
o daily activities can be affected if deformity reaches 30-40 degrees
Imaging
Radiographs
o C-shaped physis can result in a delta phalanx
Treatment
Nonoperative
o observation
indications V:6 delta phalanx
favored in most cases
splinting is not indicated
Operative
o phalanx opening wedge osteotomy +/- bone excision
indications
Type III (delta phalanx)
when deformity (delta phalanx) encroaches digit space of neighboring short digit
technique
excision of extra bone
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
5. Syndactyly
Introduction
Most common congenital malformation of the limbs
Epidemiology
o incidence : 1 in 2,000 - 2,500 live births
o demographics
M>F
Caucasians > African Americans
o ray involvement
50% long-ring finger
30% ring-small finger
15% index-long finger
5% thumb-index finger
Pathophysiology
o failure of apoptosis to separate digits
Genetics
o autosomal dominant in cases of pure syndactyly
reduced penetrance and variable expression
V:7 Clinical photograph
positive family history in 10-40% of cases demonstrating an example of
Associated conditions acrosyndactyly.
o acrosyndactyly
digits fuse distally and proximal digit has fenestrations (e.g., constriction ring syndrome)
o Poland Syndrome
o Apert Syndrome
o Carpenter syndrome
acrocephalopolysyndactyly
Classification
Syndactyly Classification
Simple Only soft tissue involvement, no bony connections
Complex Side to side fusion of adjacent phalanges
Complicated Accessory phalanges or abnormal bones involved in fusion
Complete vs. Complete syndactyly the skin extends to finger tips; with
Incomplete incomplete, skin does not extend to fingertips
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complicated syndactyly.
Treatment
Operative
o digit release
indications
syndactyly
perform at ~ 1 year of age
acrosyndactyly
perform in neonatal period
Technique
Digit Release
o if multiple digits are involved perform procedure in two stages (do 1 side of a finger at a time) to
avoid compromising vasculature
o release digits with significant length differences first to avoid growth disturbances
release border digits first (ring-little, and thumb-index) at <6mths because of differential
growth rates between ring-little and between thumb-index digits
middle-ring syndactyly can be released later (2yr old) as because middle and ring digits have
similar growth rates
thus if syndactyly involving index-middle-ring-small digits, releae index-middle and ring-
small first, and leave the central syndactyly (middle-ring) for 6months later
do all releases before school age
o bilateral hand releases
perform simultaneously if child is <18mths (less active)
perform staged if child is >18mths (more active, hard to immobilize bilateral limbs
simultaneously)
o interdigitating zigzag flaps are created during release to avoid longitudinal scarring
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
o dorsal fasciocutaneous flaps to reconstruct the web
o use only absorbable sutures (5-0 chromic catgut) which have less inflammation
Complications
Web creep
o most common complication of surgical treatment (8-60%)
o causes
early creep is most commonly caused by necrosis of the
tip of the dorsal quadrilateral flap and loss of full-
thickness skin graft placed in the web
late creep (adolescence) is caused by discrepant growth
between scar/skin graft and surrounding tissue during the :8 Intraoperative photo of the zigzag
V
growth spurt technique used to release digits.
o treatment
reconstruct web space with local skin flaps
Nail deformities
6. Poland Syndrome
Introduction
A congenital disorder characterized by
o unilateral chest wall hypoplasia
due to absence of sternocostal head of pectoralis major
o hypoplasia of the hand and forearm
o symbrachydactyly and shortening of middle fingers
result of absence or shortening of the middle phalanx
simple complete syndactyly of the short digits
Epidemiology
o 1 in 32,000 live births
o occurs in 10% of syndactyly cases :9 symbrachydactyly and shortening
V
Etiology of middle fingers
o thought to be linked to subclavian artery hypoplasia
Presentation
Physical exam
o extent of hand and chest involvement varies
o chest deformities
hypoplasia or absence of the pectoralis major, pectoralis minor, deltoid, serratus anterior,
external oblique, and latissimus dorsi
Sprengel’s deformity
scoliosis
dextrocardia
absence or underdevelopment of the breast
o hand deformities
syndactyly
hypoplasia or absence of metacarpals or phalanges
absence of extensors or flexor tendons
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carpal coalition or hypoplasia
radioulnar synostosis
nail agenesis
Imaging
CT scan
o will show absent perctoralis major
Treatment
Operative
o syndactyly release
indications
performed in most patients
technique
complete syndactyly release produces skin deficiency that requires skin grafting
perform only one side of the digit at a time to avoid vascular complications
local flap is created for commisure reconstruction followed by interdigitating zigzag
dorsal and palmar flaps along the medial and lateral aspect of the digit
Complications
Skin graft failure
Excessive tension
Improper flap planning
Digital artery injury
Web creep
Nail deformity
7. Apert Syndrome
Introduction
Syndrome characterized by
o bilateral complex syndactyly of hands and feet
index, middle, and ring fingers most affected
o symphalangism
o premature fusion of cranial sutures (craniosynostosis) results in flattened skull and broad
forehead (acrocephaly)
o hypertelorism (increased distance between paired body parts, as in wide set eyes)
o normal to moderately disabled cognitive function
o glenoid hypoplasia
o radioulnar synostosis
Genetics
o autosomal dominant, but most new cases are sporadic
o mutation of FGFr2 gene
Epidemiology
o incidence is 1/80,000 live births
Prognosis
o spectrum of normal to moderately disabled cognitive function
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
Presentation
Physical exam
o dysmorphic face
craniosynostosis results in flattened skull and facial features
o rosebud hands (complex syndactyly where the index, middle, and ring finger share a common
nail)
Imaging
Radiographs
o will show complex syndactyly
Treatment
Operative
o surgical release of border digits
indications
perform ~ 1 year of age
o digit reconstruction
indications : perform ~ 1.5 years of age
to convert central three digits into two digits
8. Polydactyly of Hand
Introduction
A congential malformation of the hand
Three forms exist
o preaxial polydactlyly
thumb duplication
o postaxial polydactlyly
small finger duplication
o central polydactlyly
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
Epidemiology
o commonly associated with syndactyly
extra digit may lead to angular deformity or impaired motion
Treatment
o osteotomy and ligament reconstructions
indications
perform early to prevent angular growth deformities
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
Classification
Functional Classification
Static Present at birth and growth is linear with other digits
Progressive Not as noticable at birth but shows disproportionate growth over time
Presentation
History
o asymmetry to digits can be present at birth or appearing over time
Symptoms
o pain
o inability to use digits
o complaints of cosmetic issues
Physical exam
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o inspection & palpation
thick, fibrofatty tissue involving enlarged digits
o ROM & instability
often limited ROM due to soft tissue constraints
Imaging
Radiographs
o recommended views
biplanar hand radiographs
o findings
enlarged phalanges to involved digits
may see malalignment of joints or angled phalanges
CT, MRI
o not typically needed
Studies
Angiography
o only needed if used for surgical planning
Treatment
Nonoperative
o observation
in mild cases
Operative
o epiphysiodesis
indications
single digit
perform once digit reaches adult length of same sex parent
most common approach
postoperative care
soft tissue care
early ROM
o osteotomies and shortening procedures
indications
thumb involvement
multiple digit involvement
severe deformity
postoperative care
local soft tissue care
early ROM
o amputations
indications
severe involvement of digit
non-reconstructable digit
Complications
Digital stiffness
Chronic digital pain or edema
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
Classification
Degrees of Constrictive Ring Syndrome
Simple constriction rings Mild ring with no distal deformity or lymphedema
Rings with distal deformity Ring may cause distal lymphedema in association with
deformity
Acrosyndactyly Fusion between the more distal portions of the digits with the
space between the digits varying from broad to pinpoint in
size.
Amputations Loss of limb distal to ring
Presentation
Symptoms
o most patients get diagnosed at birth
Physical exam
o check for distal pulses and perfusion
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Amputations
Imaging
Ultrasound
o intrauterine diagnosis can be made with ultrasound at end of first trimester
Treatment
Operative
o surgical release with multiple circumferential Z-plasties
indications
if circulation is compromised by edema or limb has contour deformity
perform early (neonatal)
technique
acrosyndactyly is treated with distal release early in neonatal period
intrauterine band release can be done if limb is found to be at risk of amputation (rare)
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Hand
Classification
Patterson Classification
Type I • Simple constriction ring
Type II • Deformity distal to ring (hypoplasia, lymphedema)
• Edema may or may not be present
Type III • Fusions distally (syndactyly, acrosyndactyly)
Type D • Amputation
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Treatment
Nonoperative
o observation
indications
Type I (simple constriction ring)
Operative
o excision or release of constriction band
indications
Type I with compromise of digital circulation
o circumferential Z-plasties
indications
Type II
distal deformities present
o surgical release of syndactyly
indications
Type III with distal fusions
o reconstruction of involved digits or limb (i.e., lengthening of bone, deepening of web space)
indications
Type IV to improve function
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In July 2017
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Thumb
C. Congenital Thumb
1. Thumb Hypoplasia
Introduction
Congenital underdevelopment of the thumb frequently associated with
partial or complete absence of the radius
Epidemiology
o incidence : 1/100,000 live births
o demographics
male = female
o location
bilateral involvement in ~60% of patients
right hand more common than left
Pathophysiology
o exact cause during embryologic development has yet to be elucidated
Associated anomalies
o greater than 80% of patients will have associated anomalies including
VACTERL
Holt-Oram
thrombocytopenia-absent radius (TAR)
Fanconi anemia
Blauth Classification
Type Description Treatment
Type I Minor hypoplasia No surgical treatment
All musculoskeletal and neurovascular required
components of the digit are present, just small
in size
Type II All of the osseous structures are present (may Stabilization of MCP joint
be small) Release of first web space
MCP joint ulnar collateral ligament instability Opponensplasty
Thenar hypoplasia
Type IIIA Musculotendinous and osseous deficiencies
CMC joint intact
Absence of active motion at the MCP or IP joint
Type IIIB Musculotendinous and osseous deficiencies. Thumb amputation &
Basal metacarpal aplasia with deficient CMC pollicization
joint
Absence of active motion at the MCP or IP joint.
Type IV Floating thumb
Attachment to the hand by the skin and digital
neurovascular structures
Type V Complete absence of the thumb
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Presentation
Physical exam
o inspection
extrinsic tendon abnormalities
pollex abductus
flexor pollicus longus attaches to normal insertion
and the extensor tendon
hypoplasia of thenar musculature
absence of skin creases indicates muscle or tendon
abnormalities :12 Pollex abductus is considered an extrinsic
V
tendon abnormality where the FPL also attaches
excessive abduction of MCP joint to the extensor tendon.
o range of motion and instability
ulnar collateral ligament laxity
web-space tightness
o evaluation for associated anomalies is essential
cardiac
auscultation
echocardiography
kidneys
ultrasound
abdomen : ultrasound
V:13 Arrow pointing to atrophy of the
Imaging thenar musculature.
Radiographs
o recommended views
bilateral films of hand, wrist and forearm
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Thumb
Studies
Labs
o peripheral blood smear and complete blood count
important to rule out Fanconi anemia
Additional studies
o chromosomal challenge test : detects Fanconi anemia before bone marrow failure
Treatment
Nonoperative
o observation
indications
Type I hypoplasia where augmentation of thenar musculature (thumb abduction) is not
necessary
Operative
o opposition tendon transfer (opponensplasty)
indications
Type I hypoplasia with insufficient thumb abduction
o release of first web space, opposition transfer, stabilization of MCP joint
indications : Type II and IIIA hypoplasia
o pollicization
indications : Type IIIB, IV, V hypoplasia
Surgical Techniques
Opponensplasty (opposition transfer)
o technique
performed using
flexor digitorum superficialis or
abductor digiti minimi
First web space deepening
o technique
usually performed with Z-plasty
Stabilization of MCP joint
o technique
three options V:14 Pollicization
fusion
reconstruction of UCL with FDS
reconstruction of UCL with free tendon graft
Pollicization
o technique
plan skin incision to avoid skin grafts
isolate index finger on its neurovascular bundles
detach first dorsal and palmar interosseous muscles
shorten digit by removing index finger metacarpal and epiphyseal plate
stabilize index MCP joint
reattach and balance musculotendinous units
reconstruct long extensor tendons
rebalance flexor tendons
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Blauth Classification
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Thumb
Presentation
History
o presenting complaint is usually fixed thumb flexion deformity at the IP joint
o history of trauma is rare
o family history of disease is rare
Symptoms
o usually painless
o may be bilateral
Physical exam
o inspection
flexion deformity at the IP joint
o motion
prominence of the flexor tendon nodule, referred to as "Notta's
node"
deformity may be fixed with loss of IP joint extension
o neurovascular
usually preserved
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Imaging
Radiographs
o recommended views
AP and lateral views of the hand
o additional views
dedicated thumb views
o indications
recommended only if history of trauma
o findings
usually diagnosed based on clinical presentation
radiographs are usually normal
Treatment
Nonoperative
o passive extension exercises and observation
indications
not recommended for fixed deformities in older children
technique
passive thumb extension exercises
duration based on clinical response
outcomes
30-60% will resolve spontaneously before the age of 2 years old
<10% will resolve spontaneously after 2 years old
o intermittent extension splinting
indications
first line of treatment
more successful than observation alone
consider alongside stretching regime
flexible deformity
not recommended with fixed deformity in older children
technique
splints maintain IP joint hyperextension and prevent MCP joint hyperextension
duration for 6-12 weeks
outcomes
50-60% resolution in all age groups
high drop out rate from therapy
Operative
o A1 pulley release
indications
fixed deformity beyond age of 12 months of age
failed conservative treatment
outcomes
65-95% resolution in all age groups
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Thumb
Techniques
A1 Pulley Release
o open release
small transverse incision in the thumb MCP flexion crease, extending over the A1 pulley
protect the radial digital nerve
sharp dissection of the A1 pulley
identify the Notta nodule in the FPL tendon
watch nodule under direct vision during passive IP extension of the thumb to ensure there is
smooth FPL tendon gliding
Complications
Digital nerve injury
o caution must be performed during release as digital nerves at high risk due to proximity to flexor
tendon and A1 pulley
Wound complications
o scar contracture
o abscess
o infection
IP flexion deficit
Bow-stringing of flexor tendon
o usually related to release of the oblique pulley
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Orthopedic considerations
o common manifestations associated with disease
lower limb anomalies
congenital vertical talus
congenital talipes equinovarus (bilateral)
upper limb anomalies
flexion deformities of the four fingers
Associated conditions
o arthrogryphosis (congenital joint contractures affect two or more areas in the body)
o digitotalar dysmorphisms
o Freeman-Sheldon syndrome
o X-linked MASA syndrome
Classification
Tsuyuguchi Classification of Clasped Thumb
Type Feature
Type I (Supple clasped Thumb can be passively abducted and extended against
thumb) resistance of thumb flexors. No other digital anomaly present.
Type II (Clasped thumb with Thumb cannot be passively extended and abducted. This may
contracture) occur with or without other digital anomaly.
Type III (Rigid clasped Clasped thumb that is associated with arthrogryposis and
thumb) marked soft-tissue deficits.
Presentation
History
o persistent flexion-adduction deformity beyond 3rd or 4th month of life, usually bilateral
o family history
o pre-natal history
Symptoms
o pain usually with a contracture
o associated with other musculo-skeletal deformities
Examination
o type of clasped thumb
o associated anomalies
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By Dr, AbdulRahman AbdulNasser Pediatric Hand | Congenital Thumb
Treatment
Nonoperative
o serial splinting and stretching for 3-6 months
indications
first-line treatment for all types
begin treatment around the age of 6 month old
outcome
good definitive results with Type I congenital deformities when one of the EPL or EPB
tendons are present
poor results with Type I deformities when both EPL/EPB tendons are absent
poor results with Type II or III deformities
Operative
o EIP tendon transfer to EPL
indications
Type I or II with residual deficiency in active extension
technique
EIP transfer to remnant of extensor tendon
o thumb reconstruction
indications
failed conservative treatment
soft-tissue deficiency in the thumb-index finger webspace (Type III)
Type II or III deformity with significant MCP joint contractures
technique
o arthrodesis
indications
severe deformities when skin release and tendon trasnfer cannot overcome joint
deformity.
Techniques
Thumb reconstruction
o delayed until the age of 3 to 5 years old
o procedure based on amount of contracture and may include
1st web widening
transposition flap of skin (dorsal rotational advancement flap)
four-flap or five-flap Z plasty
deepening the first webspace by releasing soft-tissue
releasing origins of thenar musculature from transverse carpal ligmant
releasing joint capsule of first MP joint
tendon transfer
FPL Z-lengthening in the forearm
EPB and EPL absence is best reconstructed with tendon transfer
isolated EPB absence will not usually require tendon transfer
Complications
Cosmetic appearance
Instability of the MP joint
Reduced thumb function
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OrthoBullets2017 Hand Tumors & Lesions | Congenital Thumb
ORTHO BULLETS
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Tumors of the hand
1. Ganglion Cysts
Introduction
A mucin-filled synovial cyst caused by either
o trauma
o mucoid degeneration
o synovial herniation
Epidemiology
o incidence
It is the most common hand mass (60-70%)
o location
Dorsal carpal (70%)
originate from SL articulation
Volar carpal (20%) VI:1 Ganglion Cyst
originate from radiocarpal or STT joint
Volar retinacular (10%)
originate from herniated tendon sheath fluid
dorsal DIP joint (mucous cyst, associated with Heberden's nodes)
Pathophysiology
o filled with fluid from tendon sheath or joint
o no true epithelial lining
Associated conditions
o median or ulnar nerve compression
may be caused by volar ganglion
o hand ischemia due to vascular occlusion
may be caused by volar ganglion
Presentation
Symptoms
o usually asymptomatic
o may cause issues with cosmesis
Physical exam VI:2 mucous cyst
o inspection
transilluminates (transmits light through tissue)
o palpation
firm and well circumscribed
often fixed to deep tissue but not to overlying skin
o vascular exam
Allen's test to ensure radial and ulnar artery flow for volar wrist ganglions
Imaging
Radiographs
o Normal
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OrthoBullets2017 Hand Tumors & Lesions | Tumors of the hand
MRI
o indications
not routinely indicated
o findings
shows well marginated mass with homogenous fluid signal intensity
Ultrasound
o useful for differentiating cyst from vascular aneurysm
o may provide image localization for aspiration while avoiding artery
Histology
Biopsy
o indications
not routinely indicated
o findings
will show mucin-filled synovial cell lined sac
Treatment
Nonoperative
o observation
indications
first line of treatment in adults
children
76% resolve within 1 year in pediatric patients
o closed rupture
home remedy
high recurrence
o aspiration
indications
second line of treatment in adults with dorsal ganglions
aspiration typically avoided on volar aspect of wrist due to radial artery
outcomes
higher recurrence rate (50%) than surgical resection but minimal risk so reasonable to
attempt
Operative
o surgical resection
indications
severe symptoms or neurovascular manifestations
technique
requires adequate exposure to identify origin and allow resection of stalk and a portion of
adjacent capsule
at dorsal DIP joint: must resect underlying osteophyte
results
volar ganglions have higher recurrence after resection than dorsal ganglions (15-20%
recurrence)
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Tumors of the hand
Complications
With aspiration
o infection (rare)
o neurovascular injury
With excision
o infection
o neurovascular injury (radial artery most common)
o injury to scapholunate interosseous ligament
o stiffness
Presentation
Symptoms
o painless mass, most commonly occurring in the fingertip
o although less common, erythematous, painful lesions have been reported
Physical exam
o inspection & palpation
flesh-colored, yellow, or white in appearance
well-circumscribed, firm, slightly mobile lesions
lesions are firmer than ganglion cysts and do not transilluminate
often superficial and tethered to overlying skin
o range of motion
there may be loss of ROM when lesions are large and occur near IP joints
o neurovascular exam
sensory deficits may be evident with 2-point discrimination testing secondary to digital nerve
compression
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OrthoBullets2017 Hand Tumors & Lesions | Tumors of the hand
an epidermal inclusion
cyst on the dorsal
an epidermal inclusion cyst on well-circumscribed surface of the PIP joint of
the palmar surface of the epidermal inclusion cyst the ring finger which is
hand. on the palmar surface of adherent to the overlying
the small finger. skin.
Imaging
Radiographs
o recommended views
AP, lateral, and oblique views of the involved digit or hand
o findings
soft tissue mass may be evident
a lytic lesion of the distal phalanx may be present if the cyst erodes
into bone
may mimic a malignant or infectious process
VI:3 The AP radiograph of a
Studies distal phalanx reveals an
interosseous epidermal inclusion
Biopsy cyst with lytic bony erosion.
o indications
should be considered before surgical excision to rule out neoplasm or infection if a lytic bony
lesion is present in the distal phalanx
Histology
o gross appearance
cysts contain a thick, white keratinous material
o characteristic findings
cysts filled with keratin and lined with epithelial cells
The low-power
histology slide
reveals an epidermal
inclusion cyst where
the red arrow marks
lamellated keratin
and the green arrow
identifies stratified
squamous epithelium. The medium-power histology slide
reveals an epidermal inclusion cyst
characterized by a stratified squamous
epithelial lining and abundant keratin.
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Tumors of the hand
Differential
Tophaceous gout
Foreign body granuloma
Sebaceous cyst
Giant cell tumor
Ganglion cyst
Enchondroma
Glomus tumor
Treatment
Nonoperative
o observation
indications
not recommended
Operative
o marginal excision
indications
diagnosis of epidermal inclusion cyst
painful lesions
loss of function
cosmetic concerns
technique
careful dissection to remove the entire capsule
local curettage and bone graft may be required for lesions eroding bone
amputation is an alternative with advanced bony destruction in rare circumstances
outcomes
marginal excision is curative
low recurrence rate
Complications
Wound complications
Infection
Digital neurapraxia
Recurrence
o recurrence rate is low even with bony involvement
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OrthoBullets2017 Hand Tumors & Lesions | Tumors of the hand
Mechanism
o symptoms arise because of increased muscle volume within small muscle compartment
pain from synovitis or ischemia
Anatomy
Normal EIP
o occupies 4th dorsal extensor compartment (8-10mm wide)
o ratio of 1:1 for muscle:tendon length
o origin - posterior surface of distal third of ulna and adjacent interosseous membrane
o insertion - dorsal expansion of index finger on ulnar side of EDC
Classification
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Tumors of the hand
Presentation
Symptoms
o usually asymptomatic
discovered incidentally during surgery (e.g. ganglion removal)
o mass on the dorsum of the hand
o intermittent dorsal wrist pain if muscle bellies impinge on and occupy the narrow dorsal
compartments of the wrist
Physical Exam
o inspection
mass does not transilluminate
moves with movement of local muscles (flexion and extension of
hand and wrist)
becomes firmer with grasp
o provocative tests
resisted extension triggers pain
Imaging
MRI
VI:4 aEIP presenting as
painful dorsal wrist mass
o indications (arrow)
exclude other more common conditions e.g. ganglion
o findings
mass is isointense with muscle tissue
anomalous extensor indicis proprius (aEIP)
extensor digitorum brevis manus (EDBM)
extensor medii proprius (EMP)
extensor indicis et medii communis (EIMC)
Differential
Ganglion
Synovitis
o both produce dorsal wrist pain
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OrthoBullets2017 Hand Tumors & Lesions | Tumors of the hand
Presentation
Symptoms
o enlarging mass
o pain, worse with activity (or wearing shoes, for foot lesions)
Physical exam
o firm, nodular mass that does not transilluminate
Differential diagnosis
o ganglion cyst
cystic component
o pigmented villonodular synovitis
histologically identical
involves larger joints
o desmoid tumor
o fibroma/fibrosarcoma
o glomangioma
Imaging
Radiographs
o pressure-type bone erosion can be seen in up to 5% of patients on radiographs
Ultrasound
o able to demonstrate relationship of lesion with adjacent tendon
o homogeneously hypoechoic, although some heterogeneity may be seen in echo-texture in a
minority of cases
o most have some internal vascularity
MRI
o MRI may be helpful diagnostically
o appearance of the focal form is generally decreased signal intensity on both T1-and T2-weighted
MR imaging
Histology
Characterized by
o proliferating histiocytes, moderately cellular (sheets of rounded or polygonal cells)
o hemosiderin (brown color) may be present, but typically less than seen with PVNS
o multinucleated giant cells are common
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Tumors of the hand
Treatment
Operative
o marginal excision
5-50% recurrence rate
more common if tumor extends into joints and deep to the volar plate
local recurrence is usually treated with repeat excision
operative approach is dependant on location and extent of the tumor
VI:7 32 y/o female with a painful R long finger mass. MRI and intraoperative
findings consistent with Giant Cell tumor of tendon sheath.
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OrthoBullets2017 Hand Tumors & Lesions | Vascular Conditions
B. Vascular Conditions
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Vascular Conditions
Anatomy
Ulnar artery
o ulnar artery branches into 2 branches as it exits Guyon's canal
deep branch
superficial palmar arch in Guyon's canal
o relation to hook of hamate
over distal 2cm, the artery is directly anterior to the hook of the hamate, covered by palmaris
brevis, subcutaneous tissue and skin
Presentation
History
o occupational or sporting risks (see above)
Symptoms
o pain over hypothenar eminence and ring finger
may involve small, middle and index fingers
o cold sensitivity
o paresthesia
Physical exam
o inspection
blanching, mottling, cyanosis, pallor, gangrene
tenderness over hypothenar eminence
prominent callus (calloused skin over hypothenar eminence)
pulsatile mass if aneurysm is present
fingertip ulcerations over ulnar digits
splinter hemorrhages over ulnar digits
o provocative tests
Allen's test VI:8 CT angiogram showing
positive if occlusion is present aneurysm at hook of hamate
Imaging
Doppler ultrasound
o indications
first line test
measure digital brachial index
<0.7 necessitates reconstruction
Angiogram, CT angiogram or MR angiogram
o indications
mandatory for diagnosis
o findings
tortuous "corkscrew" ulnar artery VI:9 Angiogram showing aneurysm
at hook of hamate
occlusion or aneurysm at the hook of the hamate
Differential
Raynaud's disease involves the thumb but hypothenar hammer syndrome does not
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OrthoBullets2017 Hand Tumors & Lesions | Vascular Conditions
Treatment
Nonoperative
o lifestyle modifications, symptomatic treatment, and vascular consult
indications
thrombosis without aneurysm > 2 weeks
asymptomatic
no threat of digital loss
lifestyle modifications
smoking cessation
avoid recurrent trauma
outcomes
80% success
Operative
o endovascular fibrinolysis I:10 Resection of ulnar artery aneurysm in
V
indications hypothenar hammer syndrome
2. Raynaud's Syndrome
Introduction
Raynaud's Syndrome consists of both
o Raynaud's Phenomenon
vasospastic disease with a known cause
o Raynaud's Disease
vasospastic disease with no known cause (idiopathic)
Raynaud's Phenomenon
Vasospastic disease with a known underlying disease
o epidemiology
demographics
occasional female predominance
age >40 years (generally older than patients with Raynaud's disease)
location
affects the distal aspect of digits
o pathophysiology
periodic digital ischemia induced by cold temperature or sympathetic stimuli including pain
or emotional stress
triphasic color change (white-blue-red progression)
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Vascular Conditions
digits turn white from vasospasm and interruption of blood flow
blue discoloration follows from cyanosis and venous stasis
finally digits turn red as a result of rebound hyperemia
dysesthesias often follow color changes
o associated conditions
connective tissue disease
scleroderma (80-90% incidence of Raynaud's phenomenon)
SLE (18-26%)
dermatomyositis (30%)
RA (11%)
CREST syndrome
calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, telangiectasias
neurovascular compression (thoracic outlet syndrome)
Presentation
o symptoms
asymmetric findings
rapid progression
o physical exam
peripheral pulses often absent
frequent trophic skin changes (including ulceration and gangrene)
abnormal Allen test
Studies
o labs
blood chemistry - often abnormal
o invasive studies I:11 The clinical photograph
V
demonstrates gangrene in a
microangiology - often abnormal patient with Raynaud's
angiography - often abnormal phenomenon.
Treatment
o nonoperative
lifestyle modifications, treat underlying cause
indications
mainstay of treatment
modalities
smoking cessation and avoidance of cold exposure is critical
Raynaud's Disease
Vasospastic disease with no known cause (idiopathic)
VI:12 The imaging study
o epidemiology represents an angiogram with
seen in young premenopausal women (age <40 years) incomplete ulnar artery
obstruction in a patient with
o pathophysiology Raynaud's phenomenon.
similar to Raynaud's phenomenon
Presentation
o symptoms
often bilateral
slow progression
o physical exam
peripheral pulses usually present
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OrthoBullets2017 Hand Tumors & Lesions | Vascular Conditions
trophic skin changes are uncommon
normal Allen test
Studies
o labs usually normal
o invasive studies usually normal
o diagnosis
based on Allen and Brown criteria
Treatment
o nonoperative
medical management
indications
first line of treatment
modalities
smoking cessation and avoidance of cold exposure is critical
thermal biofeedback techniques
medications include
calcium channel blockers
ASA
intra-arterial reserpine
dipyridamole (Persantine)
pentoxifylline (Trental)
o operative
digital sympathectomy
indications
severe cases that fail conservative treatment
microvascular reconstruction
indications
may be indicated in rare situations
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By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Vascular Conditions
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OrthoBullets2017 Hand Tumors & Lesions | Vascular Conditions
Presentation
Symptoms
o early disease
intermittent claudication of feet, legs, hands or arms
numbness and/or tingling in the limbs
o late disease
symptoms of critical limb ischemia
rest pain
Physical exam
VI:13 Ulcerations are usually present prior to
o inspection the onset of necrosis.
ulcerations
large, erythematous, superficial blood vessels
necrotic distal digits in hands and feet
o palpation
decreased temperature in hands and feet
o neurovascular
diminished or absent pulses
sensory findings in up to 70% of patients VI:14 Necrotic distal digits in a
patient with Buerger's disease.
o provocative tests
positive Allen test in young smoker with digital ischemia is suggestive of disease
Imaging
Arteriography
o indications
useful for ruling-out other conditions that may mimic
Buerger's disease
o findings
"corkscrew" vessels
collateral circulation giving a "spider leg" appearance
Studies
Labs
I:15 Arteriogram showing classic
V
o used to exclude alternative diagnoses "corkscrew" arteries in a patient with
Echocardiogram Buerger's disease.
o used to exclude proximal source of emboli
Treatment
Nonoperative
o smoking cessation and symptomatic treatment
indications
all patients with Buerger's disease that use tobacco
techniques
smoking cessation
patient education
pharmacotherapy
smoking cessation groups
symptomatic treatment
- 230 -
By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Vascular Conditions
avoid exposure to cold
gentle exercise
daily aspirin
vasodilators
outcomes
smoking cessation is the only treatment known to decrease the risk of future amputation
Operative
o surgical sympathectomy
indications (controversial)
refractory pain and digital ischemia
technique
cut nerves to the affected areas
o amputation
indications
gangrene
non-healing ulcers
refractory pain
Presentation
History
o recent blunt or penetrating hand trauma VI:16 Palpable palmar mass secondary
Symptoms to penetrating trauma
o slow-growing painful mass
o many be sensory disturbance due to compression of adjacent digital nerve
Physican exam
o palpable mass
o may be pulsatile in ~ 50% of cases
o may occur in any of the 5 digits
most common in thumb > index > ring finger
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OrthoBullets2017 Hand Tumors & Lesions | Vascular Conditions
Imaging
Radiographs
o indication
usually not helpful
concern of destructive lesion
o findings : usually normal
Doppler ultrasound or angio–computed tomography (CT) scan
o indication : pre-operative confirmation
o findings
size and location of lesion
thrombus formation
collateral circulation
VI:17 angio–computed tomography (CT) scan:
Differential Arrow pointing to narrow artery causing decrease
in flow into second webspace
Often misdiagnosed as
o epidermoid cysts
o arteriovenous fistulas
o forieign body granulomas
o ganglions
o neurilemmomas
Treatment
Nonoperative
o observation and analgesics
indications : small, asymptomatic lesions
o ultrasound-guided thrombin injection
indications
Some reports use this techique in lesions arising more
proximal in the hand or wrist.
Operative
o surgical exploration and ligation
indications
symptomatic lesions with adequate collateral circulation
technique
ligation performed proximal and distal
o repair with interpositional grafting
indications
symptomatic lesions with inadeaquate collateral circulation
VI:18 Intraoperative photograph
Techniques demonstrating the digital artery
(white arrow), which lies dorsal to the
Digital artery aneurysm repair digital nerve (black arrow) in the
finger
o end-to-end anastomosis and an autogenous interpositional vein or
arterial graft
Complications
digital ischemia
chronic pain
- 232 -
By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Nail Bed
C. Nail Bed
Anatomy
Perionychium
o consists of
nail bed
soft tissue beneath the nail includes
germinal matrix (proximal)
produces 90% of the nail
scarring causes absence
sterile matrix (distal) VI:19 Split nail
keeps nail adherent to nail bed
injury causes deformity
nail fold
most proximal portion of the perionychium consists of
ventral floor - germinal matrix portion of the nail bed
dorsal roof
eponychium
skin proximal to the nail that covers the nail fold
paronychium
skin on each side of the nail
hyponychium
skin distal to the nail bed
Presentation
History
o patient will report fingertip injury in the form of trauma or infection in the past
Symptoms
o common symptoms
painless
complaint is typically cosmetic in nature
Physical exam
o careful inspection of the nail to identify any 'blank' areas of nail
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OrthoBullets2017 Hand Tumors & Lesions | Nail Bed
Imaging
Radiographs
o not typically warranted
o obtain if suspicious of underlying bony etiology
Treatment
Nonoperative
o observation alone
indications
majority of patients not concerned about cosmesis
Operative
o scar resection and primary closure
indications
size < 2mm
patients have strong desire to improve cosmesis
o scar resection and full thickness nail bed graft from second toe
indications
germinal matrix and size >2mm
sterile matrix, any size
resection and primary closure rarely successful
patients have strong desire to improves cosmesis
Techniques
Scar resection and primary closure
o indicated for germinal matrix if size <2mm
Scar resection and full thickness nail bed graft from second toe
o preferred for geminal matrix if size > 2mm
Scar resection and full thickness nail bed graft from second toe
Complications
Recurrence of split nail
Persistent cosmetic deformity
Donor site morbidity
- 234 -
By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Nail Bed
Anatomy
Perionychium
o consists of
nail bed
soft tissue beneath the nail includes
germinal matrix (proximal)
produces 90% of the nail
scarring causes absence
sterile matrix (distal)
keeps nail adherent to nail bed
injury causes deformity
nail fold
most proximal portion of the perionychium consists of
ventral floor - germinal matrix portion of the nail bed
dorsal roof
eponychium
skin proximal to the nail that covers the nail fold
paronychium
skin on each side of the nail
hyponychium
skin distal to the nail bed
Presentation
History
o patient will report fingertip injury in the form of trauma or infection in the past
Symptoms
o common symptoms
painless
complaint is typically cosmetic in nature
can become painful if it becomes in-grown
Physical exam
o careful inspection of the nail to identify any 'hooking' of the nail
Imaging
Radiographs
o typically needed to assess the bone stock/deformity of the distal phalanx tuft
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OrthoBullets2017 Hand Tumors & Lesions | Nail Bed
Treatments
Nonoperative
o observation alone
indications
majority of patients not concerned about cosmesis
o prosthetic replacement
Operative
o indications
improving cosmesis
painful, in-grown hook nail
soft tissue manipulation - shorten bone, do not maintain nail bed length
indications
majority of distal tuft maintained
when the distal nail bed has been closed/pulled over the distal tuft
soft tissue + bony support - lengthen bone, maintain nail bed length
indications
lack of distal tuft/bony support
Technique
Soft tissue manipulation
o shorten bone, perform soft tissue procedure to correct 'hooking' of nail bed that advances soft
tissue and reattach to dorsum of bone
V-Y advancement
cross-finger flap
full-thickness skin graft
Bony support procedure to maintain nail length
o options
bone graft to distal tip
free, vascularized bone graft from second toe
Complications
Lack of complete correction VI:20 example of a prosthetic that can be
fitted and placed on the end of a hook nail
Recurrence of deformity to cover the cosmetic deformity
Necrosis/flap failure, loss of distal tip
- 236 -
By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Tested Procedures
D. Tested Procedures
1. Wrist Arthroscopy
Introduction
Plays an important therapeutic and diagnostic role
Indications
o TFCC injuries
o interosseous ligament injuries
o anatomic reduction assistance (distal radius, scaphoid fxs)
o ulnocarpal impaction
o debridement of chondral lesions
o removal of loose bodies
o synovectomy
o excision of dorsal wrist ganglia
o assistance in treatment of SNAC and or SLAC wrist
o septic wrist irrigation and debridement
o diagnosis in unexplained mechanical wrist pain
Portals
Portals named for relation to extensor wrist compartments
Created with sharp skin incision followed by hemostat dissection
Photograph of right
wrist undergoing
arthroscopy showing
scope in 3-4 portal and
appropriate
positioning of 6U portal
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OrthoBullets2017 Hand Tumors & Lesions | Tested Procedures
Radiocarpal Portals
Portal Location, Function Structures at Risk
Located just distal to Lister tubercle, between EPL and EPL and EDC tendons
3-4
EDC; Established first, primary viewing portal
Located in line with ring finger metacarpal, between EDC and EDC and EDM
4-5
EDM; Portal for instrumentation, visualization of TFCC tendons
Located just radial to ECU tendon; Primary adjunct for visualization Dorsal sensory branch
6R
and instrumentation, ulnar-sided TFCC repairs of ulnar nerve
Located just ulnar to ECU tendon; Primary adjuct for visualization Dorsal sensory branch
6U
and instrumentation, ulnar-sided TFCC repairs of ulnar nerve
Located between APL and ECRB, along dorsal aspect of Superficial branch of
1-2 snuffbox; Not often utilized, provides access to radial styloid and radial nerve; Radial
radial aspect of joint, sometimes used for inflow artery
Midcarpal Portals
(necessary for complete carpal visualization, evaluating for wrist instability, and advanced
techniques)
Located 1 cm distal to 3-4 portal along axis of radial border of ECRB and EDC
middle finger metacarpal, between ECRB and EDC. Allows tendons
MCR
visualization of scapholunate, scaphocapitate, and
scaphotrapezoid joints.
Located 1 cm distal to 4-5 portal along axis of ring finger EDC and EDM
MCU metacarpal, between EDC and EDM. Allows visualization of tendons
lunocapitate, lunotriquetral, and triquetrohamate joints.
Located along axis of index finger metacarpal just ulnar to EPL at ECRB and ECRL
STT level of STT joint. Allows visualization of scaphotrapezial and tendons
scaphotrapezoid joints.
First CMC Portals
Located on ulnar aspect of EPL at level of first CMC joint (basal
Superficial sensory
1U joint). Allows diagnosis of DJD of first CMC joint and arthroscopic
branch of radial nerve
debridement.
Located on radial aspect of EPL at level of thumb CMC joint, just
Superficial sensory
1R volar to APL tendon. Allows diagnosis of DJD of first CMC joint and
branch of radial nerve
arthroscopic debridement.
Rehabilitation
Immediate post-operative period
o cast, splint or soft dressing depending on specific procedure(s) performed
Rehabilitation
o progression depending on specific procedure(s) performed
Return to full activity
o timing depending on specific procedure(s) performed
- 238 -
By Dr, AbdulRahman AbdulNasser Hand Tumors & Lesions | Tested Procedures
Complications
Incidence
o overall complication rate is 1-2%
Dorsal sensory branch of ulnar nerve
o averages 8mm from 6R portal
o at risk with establishment of 6U and 6R portals
to a lesser extent main ulnar nerve and artery also at risk
o When performing a TFCC repair, small open incision is typically made prior to knot tying to
prevent injury to this nerve.
Superficial sensory branch of radial nerve
o averages 16mm from 3-4 portal
o at risk during arthroscopy of basal joint, as 1U and 1R portals are on either side of the first
branch of this nerve
o at risk during placement of 1-2 portal
Radial artery Injury
o Associated with establishment 1-2 portal, used for arthroscopic radial styloidectomy.
Extensor tendon injury
o most commonly EPL and EDM due to improper portal placement
Chondral injuries
o iatrogenic from scope or instrument placement
Portal site infection
Stiffness
MCPJ pain
o typically caused by over-distraction
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In July 2017
Wrist Portals
- 239 -
7
ORTHO BULLETS
Volume Seven
Foot
&
Ankle
2017
Collected By : Dr AbdulRahman AbdulNasser
[email protected]
OrthoBullets 2017
OrthoBullets 2017
Preface
Orthobullets.com is an educational resource for
orthopaedic surgeons designed to improve
training through the communal efforts of those
who use it as a learning resource. It is a simple but
powerful concept. All of our topics, technique
guides, cases, and user-generated videos are
free, and will stay that way.
Table of Contents
I. Introduction ................................................................................................. 0
A. Foot and Ankle Anatomy ........................................................................... 1
1. Ankle Ligaments ....................................................................................... 1
2. Foot Anatomy and Biomechanics .............................................................. 9
3. Blood Supply to the Foot ......................................................................... 13
4. Layers of the Plantar Foot ....................................................................... 17
5. Nerves of the Foot .................................................................................. 18
6. Foot Muscle Forces & Deformities ........................................................... 19
7. Lower Extremity Os ................................................................................ 20
B. Foot and Ankle Evaluation ...................................................................... 27
1. Gait Cycle ............................................................................................... 27
C. Infection ................................................................................................. 30
1. Puncture Wound Infections ..................................................................... 30
II. Degenerative Conditions ............................................................................ 32
A. Tendon Conditions ................................................................................. 33
1. Posterior Tibial Tendon Insufficiency (PTTI) ............................................ 33
2. Achilles Tendonitis ................................................................................. 41
3. FHL Tendonitis & Injuries ........................................................................ 45
4. Plantar Fasciitis ...................................................................................... 47
B. Hallux Disorders ..................................................................................... 51
1. Hallux Valgus .......................................................................................... 51
2. DJD & Hallux Rigidus .............................................................................. 58
3. Sesamoid Injuries of the Hallux ............................................................... 62
4. Turf Toe.................................................................................................. 65
5. Hallux Varus ........................................................................................... 68
C. Lesser Toe Deformities ........................................................................... 70
1. Claw Toe ................................................................................................ 70
OrthoBullets 2017
ORTHO BULLETS
I.Introduction
- 0 -
By Dr, AbdulRahman AbdulNasser Introduction | Foot and Ankle Anatomy
1. Ankle Ligaments
Ankle Joint Osteology
Ankle Joint
o consists of
tibial plafond
medial malleolus
lateral malleolus
talus
o motion
main motion
plantar flexion
dorsiflexion
secondary motions
inversion/eversion
rotation
Distal tibiofibular joint
o consists of
distal fibula
incisura fibularis
concave surface of distal lateral tibia
o motion
fibular rotates within incisura during gait
mortise widens when ankl e goes from plantar to dorsiflexion
syndesmosis screws limit external rotation
Joint reaction force
o ankle joint
5 times body weight with walking on level surfaces
- 1 -
OrthoBullets2017 Introduction | Foot and Ankle Anatomy
Syndesmosis
Function
o responsible for integrity of ankle mortise
Anatomy
o Syndesmosis components
Anterior-inferior tibiofibular ligament (AITFL)
Posterior-inferior tibiofibular ligament (PITFL)
deep portion of this ligament sometimes reffered to as the
inferior transverse ligament
I:2 external rotation test
Transverse tibiofibular ligament (TTFL)
Interosseous ligament (IOL)
Physical Exam
o test to identify a syndesmosis injury include
external rotation test
squeeze test
Imaging
o AP and mortise ankle radiographs
used to evaluate the tibiofibular clear space and tibiofibular
overlap
tibiofibular clear space should be < 5 mm
tibiofibular overlap for AP view > 10 mm
weight bearing mortise view is most accurate radiograph for
diagnosis I:3 Squeeze test
CT scan is most accurate for assessment but true normals have not been validated and
comparison to the uninjured side are helpful
Clinical conditions
o high ankle sprain & syndesmosis injury
o ankle fracture
- 2 -
By Dr, AbdulRahman AbdulNasser Introduction | Foot and Ankle Anatomy
Anterior Talofibular Ligament (ATFL)
Function
o primary restraint to inversion in plantar flexion
o resists anterolateral translation of talus in the mortise
o weakest of the lateral ligaments
Anatomy
o extends from the anteroinferior border of the fibula to the neck of the
talus
origin is 10mm proximal to tip of fibula
inserts directly distal to articular cartilage of the talus (18mm distal
to joint line)
runs 45°-90° to longitudinal axis of the tibia
Physical exam
o anterior drawer in 20° of plantar flexion
test competency by anterior drawer in 20° of plantar flexion and
compare to uninjured side
forward shift of more than 8 mm on a lateral radiograph is
considered diagnostic for an ATFL tear
Imaging
o stress radiographs
more accurate in chronic injuries
o MRI
can diagnose injury
o arthroscopic findings
can confirm MRI imaging
o ultrasound
more accurate than radiographs I:4 Arthroscopy
Clinical Conditions
o low ankle sprains
MRI Ultrasound
- 3 -
OrthoBullets2017 Introduction | Foot and Ankle Anatomy
- 6 -
By Dr, AbdulRahman AbdulNasser Introduction | Foot and Ankle Anatomy
- 7 -
OrthoBullets2017 Introduction | Foot and Ankle Anatomy
Clinical conditions
o ankle fracture
injury occurs with pronation (eversion) trauma leading to forced external rotation and
abduction of ankle
may occur with fracture of the medial malleolus
o high ankle sprain & syndesmosis injury
I:9 Medial view of the anatomic dissection of the main components of the
medial collateral ligament. 1 Tibionavicular ligament; 2 tibiospring ligament; 3
tibiocalcaneal ligament; 4 deep posterior tibiotalar ligament; 5 spring ligament
complex (superomedial
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By Dr, AbdulRahman AbdulNasser Introduction | Foot and Ankle Anatomy
Hindfoot
Overview
o consists of articulation between
talus
calcaneus
Joints
o subtalar joint
has 3 facets
posterior facet
this is the largest facet
middle facet
located medially and sits on the sustentaculum of the calcaneus
anterior facet
continuous with the talonavicular joint
motion
inversion/eversion
plays no role in plantar and dorsiflexion
o transverse tarsal joint (Chopart joint)
consists of two components
talonavicular joint
ligament support
supported by the spring ligament which consist of
superior medial calcaneonavicular ligament
inferior calcaneonavicular ligament
calcaneocuboid joint
anatomy
saddle shaped
ligament support
plantar support is by the superficial and deep inferior calcaneocuboid ligaments
superior support is by the lateral limb of the bifurcate ligamant
motion
inversion of subtalar joint locks the transverse tarsal joint
allows for a stable hindfoot/midfoot for toe-off
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OrthoBullets2017 Introduction | Foot and Ankle Anatomy
Midfoot
Overview
o starts at the articulation between the navicular and cuneiforms
o consists of
articulations between the cuboid and fourth and fifth metatarsals
tarsometatarsal joint (TMT joint)
Midfoot joints
o naviculocuneiform and intercuneiform joints
connected by a dense ligamentous structure that permits little motion between the joints
o tarsometatarsal joint(Lisfranc joint)
consists of
1st, 2nd and 3rd metatarsocuneiform joints
4th and 5th metatarsocuboid joints
divided into three columns
medial column
first metatarsal
medial cuneiform
navicular
middle column
second and third metatarsals
middle cuneiform
lateral cuneiform
lateral column
forth and fifth metatarsals
cuboid
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By Dr, AbdulRahman AbdulNasser Introduction | Foot and Ankle Anatomy
The medial column of the foot The middle column of the foot The lateral column of the foot
consists of the first metatarsal, consists of the second and third consists of the fourth and fifth
the medial cuneiform and the metatarsals, the middle cuneiform metatarsals and the cuboid.
navicular. and the lateral cuneiform.
ligament support of the TMT joint
composed of three layers
interosseus layer
contains the Lisfranc ligament
origin
plantar aspect of the medial cuneiform
inserts
base of the second metatarsal
this is the strongest layer
plantar layer
next strongest
dorsal layer
this is the weakest layer
motion
lateral column is the most mobile
allows for flexibility when walking on uneven ground
middle column is the least mobile
allows for rigidity during push-off
medial column carries most of load while standing
function
functions as a transverse roman arch in the axial plane
dorsal surface of the arch is wider than the plantar surface
second metatarsal base
acts as a keystone
Forefoot
Overview
o extends from tarsal-metatarsal joint to tips of toes
o bones consists of
phalanges
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OrthoBullets2017 Introduction | Foot and Ankle Anatomy
metatarsals
first metatarsal
shortest and widest
takes 50% of weight during the gate cycle
second metatarsal
is the longest
Joints consists of
o metatarsophalangeal joints
o proximal interphalangeal joints
o distal interphalangeal joints
Ligaments and tendons
o transverse metatarsal ligament
function
holds hallucal sesamoids in place as 1st MT head moves medially
can lead to false image of sesmoid subluxation
head is moving, not the sesmoids
o conjoined tendon of the adductor hallucis muscles
broad insertion over the lateral aspect of the lateral sesamoid and lateral aspect of the base of
the proximal phalanx
o plantar plate
made up of a dense phalangeosesamoidal complex
plantar plate of 2nd MTP
must become lax before abnormal dorsal translation of proximal phalanx can occur
once attenuated, most deforming force is EDL
weakest at origin of metatarsal neck
Joint reaction forces
o second metatarsal experiences more stress during gait
most commonly metatarsal to have a stress fracture
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By Dr, AbdulRahman AbdulNasser Introduction | Foot and Ankle Anatomy
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OrthoBullets2017 Introduction | Foot and Ankle Anatomy
Posterior Tibial Artery
Origin
o largest of the two terminal branches of the popliteal artery
o its most proximal part is referred to as the tibioperoneal trunk
Course in leg
o it passes between the superficial and deep muscles of the posterior compartment of the lower leg
o as it courses down the lower leg it becomes more medial and is palpable behind the medial
malleolus
Branches at the ankle
o posterior medial malleolar artery
o communicating branch
o artery of tarsal canal : dominant blood supply to the talar body
Branches in foot
o beneath sustentaculum posterior tibial artery bifurcates into
lateral plantar arteries
branches
medial calcaneal branch (first branch)
is the major vascular supply to the heel pad
heel pad avulsions are severe injuries associated with high-energy trauma and
often carry a poor prognosis because of the potential for heel pad necrosis
branches to adductor digiti minimi (second branch)
digital branch to fifth toe (third branch)
terminal branch : plantar branch (see below)
medial plantar arteries
branches
terminal branch
anastomoses with the first dorsal metatarsal branch of the dorsalis pedis artery
superficial digital branches join plantar metatarsal arteries of first three intermetatarsal
spaces
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By Dr, AbdulRahman AbdulNasser Introduction | Foot and Ankle Anatomy
Anterior Tibial Artery
Origin the other, smaller, terminal branch of the popliteal artery
Course in leg
o descends anterior to the interosseous membrane and supplies
the muscles of the anterior compartment of the lower leg
o it becomes superficial at the ankle midway between the
malleoli
o supplies muscles of the anterior compartement of the lower leg
Branches at ankle
o anterior medial malleolar artery
o anterior lateral malleolar artery
Branches in foot
o dorsalis pedis artery
a continuation of the anterior tibial artery in the foot
palpable over the dorsum of the foot just lateral to the
extensor hallicus longus tendon
branches
arcuate (see below)
lateral tarsal
medial tarsal arteries
terminates at the first intermetatarsal space into
first dorsal metatarsal artery
deep plantar arch (see below)
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OrthoBullets2017 Introduction | Foot and Ankle Anatomy
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By Dr, AbdulRahman AbdulNasser Introduction | Foot and Ankle Anatomy
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OrthoBullets2017 Introduction | Foot and Ankle Anatomy
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By Dr, AbdulRahman AbdulNasser Introduction | Foot and Ankle Anatomy
Injury
o injury leads to weak or absent EDB and EHB function
this can be seen with trauma or CMT
Saphenous Nerve
Supplies sensation to
o medial side of foot
Simple Deformities
Complex Deformities
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OrthoBullets2017 Introduction | Foot and Ankle Anatomy
Introduction
Equinovarus foot
o most common deformity following stroke
use AFO and physical therapy for at least 6 months to await for possible neuro recovery
overactivity of the tibialis anterior, with contributions from the FHL, FDL, and tibialis
posterior
o treatment
nonoperative
AFO fitting
physical therapy
Phenol or botox injections
surgical
split anterior tibial tendon transfer (SPLATT)
flexor hallucis longus tendon transfer to the dorsum of the
foot and release of the flexor digitorum longus and brevis
tendons at the base of each toe
gastrocnemius or achilles lengthening
Physical Exam
Silfverskiöld test
I:11 Silfverskiöld test
o improved ankle dorsiflexion with knee flexed = gastrocnemius tightness
o equivalent ankle dorsiflexion with knee flexion and extension= achilles tightness
7. Lower Extremity Os
Introduction
Up to 40 accessory ossicles and multiple sesamoids have been described in the foot and ankle
Definition
o accessory ossicles
are secondary ossification centers that remain separated from the normal bone
o sesamoids
are bones that are incorporated into tendons and move with normal and abnormal tendon
motion
Most common ossicles
o os trigonum
o accessory navicular (os tibiale externum)
o os intermetatarseum
Most common sesamoids
o os peroneum
located in the peroneus longus tendon
o hallux sesamoids
located in the flexor hallucis brevis tendon at the base of the 1st metatarsal head
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By Dr, AbdulRahman AbdulNasser Introduction | Foot and Ankle Anatomy
Classification
Os Trigonum
Definition
o accessory ossicle representing the separated posterolateral
tubercle of the talus
o usually asymptomatic, but can become symptomatic and cause
os trigonum syndrome
Epidemiology
o incidence
10-25% of the population have os trigonum
commonly symptomatic in ballet dancers due to extreme
plantar flexion ("en pointe" toe position)
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OrthoBullets2017 Introduction | Foot and Ankle Anatomy
Pathophysiology of os trigonum syndrome
o repetitive microtrauma (ankle plantarflexion)
may present as a stress fracture
o acute forced plantarflexion
may present as an acute fracture
Associated conditions
o FHL tenosynovitis or entrapment
Anatomy
o osteology
the secondary ossification center forms posterior to the talus between 8-13yrs
normally fuses with talus within 1yr
if the ossicle fails to fuse, it articulates with the talus through a synchondrosis
the os lies lateral to FHL, tibial nerve, PTT, and posterior tibial artery
Presentation
o symptoms
pain in "en pointe" position
o physical exam
posterolateral ankle pain with passive ankle plantar flexion
differentiate from FHL tendinitis where ankle pain is posteromedial and there may be
triggering
may have swelling and tenderness over FHL if associated with FHL tendinitis
Imaging
o radiographs
recommended views
lateral radiograph with foot in plantar flexion
findings
shows os trigonum impinged between posterior tibial malleolus and calcaneal tuberosity
os trigonum can be round, oval or triangular and of variable size
o MRI
findings : shows os trigonum and associated inflammation and edema in FHL tendon
Lateral radiograph Sagittal MRI showing edema Fracture of the posterior process of the
showing os trigonum around the os trigonum, talus
(arrow) with surrounding suggesting abnormal motion
edema between the os and talus
related to os trigonum
syndrome
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By Dr, AbdulRahman AbdulNasser Introduction | Foot and Ankle Anatomy
Differential diagnosis
o fracture of the posterior process of the talus (Shepherd's fracture)
o FHL and posterior tibialis tendinitis
produce posterior medial ankle pain and tenderness
Treatment
o nonoperative
NSAIDS, rest, immobilization, restricted weightbearing
o operative
surgical excision
indications
Os Subfibulare
Definition
o small piece of bone adjacent to inferior fibula
Epidemiology
o incidence
1-2% of population
Pathoanatomy
I:12 Ossicle covered with fibrocartilage, with
o may represent avulsion fx of ATFL that secondarily ossifies no ligamentous ATFL attachment, supporting
o or accessory ossification center the theory of the os subfibulare being
anaccessory ossification center
Presentation
o symptoms
may be asymptomatic
may have ankle pain (symptomatic os subfibulare)
may be associated with chronic ankle instability and present with recurrent ankle sprains
o signs
focal tenderness and swelling at the site of the ossicle
laxity with anterior drawer and inversion/eversion stress testing
Imaging
o radiographs
recommended views
standard ankle series (weightbearing AP, lateral, mortise)
varus stress view
findings
accessory ossicle
talar tilt on varus stress view
suggesting ankle instability
increased separation of os fragment from fibula tip
Differential diagnosis
o acute lateral malleolus avulsion fracture (by the ATFL)
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OrthoBullets2017 Introduction | Foot and Ankle Anatomy
Treatment
o nonoperative
NSAIDS, rest, immobilization, restricted weightbearing
indications
initial treatment for symptomatic os subfibulare
o operative
surgical excision
indications
failed nonoperative management
Os Peroneum
Definition
o sesamoid bone found within the peroneus longus tendon near the base of the 5th MT
o may represent avulsion or rupture of peroneus longus
Epidemiology
o incidence
9-20% of adults
bilateral in 60%
bipartite in 30%
Pathophysiology of injury or fracture
o direct trauma
o indirect trauma (sudden inversion and supination)
associated with peroneus longus tendon rupture
Imaging
o radiographs
findings
normal os peroneum
acute os peroneum fracture
peroneus longus rupture
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By Dr, AbdulRahman AbdulNasser Introduction | Foot and Ankle Anatomy
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OrthoBullets2017 Introduction | Foot and Ankle Anatomy
o MRI
findings
normal os peroneum
acute os peroneum fracture
peroneus longus rupture
Differential diagnosis
o painful os vesalianum
o bipartite os peroneum
Treatment
o nonoperative
NSAIDS, rest, immobilization, restricted weightbearing
indications
initial treatment for painful os peroneum syndrome
minimally displaced os peroneum fractures
o operative
surgical excision
indications
painful os peroneum syndrome (with minimal tendon involvement) refractory to
conservative treatment
os peroneum fracture with displaced fragments
surgical excision and repair of peroneus longus tendon or tenodesis to peroneus brevis
indications
os peroneum associated with peroneus longus tendon rupture
Hallux Sesamoids
See Sesamoid Injuries of the Hallux
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By Dr, AbdulRahman AbdulNasser Introduction | Foot and Ankle Evaluation
1. Gait Cycle
Overview
One gait cycle is measured from heel-strike to heel-strike
o consists of
stance phase
period of time that the foot is on the ground
~60% of one gait cycle is spent in stance
during stance, the leg accepts body weight and provides single limb support
swing phase
period of time that the foot is off the ground moving forward
~40% of one gait cycle is spent in swing
the limb advances
Stride
o is the distance between consecutive inital contacts of the same foot with the ground
Step
o is the distance between initial contacts of the alternating feet
Stance Phase
Initial contact (heel strike)
o definition
occurs when foot contacts the ground
o muscular contractions
hip extensors contract to stabilize the hip
quadriceps contract eccentrically
tibialis anterior contracts eccentrically
Loading response (initial double limb support)
o marks the beginning of the initial double limb stance
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OrthoBullets2017 Introduction | Foot and Ankle Evaluation
o definition
occurs after initial contact until elevation of opposite limb
bodyweight is transferred on to the supporting limb
o muscular contractions
ankle dorsiflexors (tibialis anterior) contract eccentrically to control plantar flexion moment
quads contract to stabilize knee and counteract the flexion moment (about the knee)
Mid-stance (single limb support)
o initial period of single leg support
o definition
from elevation of opposite limb until both ankles are aligned in coronal plane
o muscular contractions
hip extensors and quads undergo concentric contraction
Terminal stance (single limb support)
o definition
begins when the supporting heel rises from the ground and continues until the opposite heel
touches the ground
o muscular contractions
toe flexors and tibialis posterior contract and are the most active during this phase
Pre-swing (second double limb support)
o is the start of the second double limb stance in the gait cycle
o definition
from initial contact of opposite limb to just prior to elevation of ipsilateral limb
o muscular contractions
hip flexors contract to propel advancing limb
Swing Phase
Initial swing (toe off)
o start of single limb support for opposite limb
o definition
from elevation of limb to point of maximal knee flexion
o muscular contractions
hip flexors concentrically contract to advance the swinging leg
Mid-swing (foot clearance)
o definition
following knee flexion to point where tibia is vertical
o muscular contractions
ankle dorsiflexors contract to ensure foot clearance
Terminal swing (tibia vertical)
o definition
from point where tibia is vertical to just prior to initial contact
o muscular contractions
hamstring muscles decelerate forward motion of thigh
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By Dr, AbdulRahman AbdulNasser Introduction | Infection
Pelvic tilt
o pelvis drops 4 degrees on swing side
lowers COG at midstance
Knee flexion in stance
o early knee flexion (15 degrees) at heel strike
lowers COG, decreasing energy expenditure
also absorbs shock of heel strike
Foot mechanisms
o ankle plantar flexion at heel strike and first part of stance
Knee mechanisms
o at midstance, the knee extends as the ankle plantar flexes and foot supinates
o restores leg to original length
o reduces fall of pelvis at opposite heel strike
Lateral displacement of pelvis
o pelvis shifts over stance limb
COG must lie over base of support (stance limb)
Center of gravity (COG)
o in standing position is 5cm anterior to S2 vertebral body
o vertical displacement
during gait cycle COG displaces vertically in a rhythmic pattern
the highest point is during midstance phase
lowest point occurs at the time of double limb support
o horizontal displacement
COG displaces 5cm horizontally during adult male step
Muscle Activity
Figure showing muscle activity through different phases of gait cycle
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OrthoBullets2017 Introduction | Infection
C. Infection
All trauma topics moved to volume one of trauma
1. Puncture Wound Infections
Introduction
Epidemiology
o common injury in certain work-places (i.e. construction sites)
approximately 10% develop infection
approximately 1-2% develop osteomyelitis
Pathophysiology
o mechanism of injury
usually stepping on a nail or stick through a sock/sole of foot
o microbiology
most common cause of soft tissue infection is Staph aureus
most common cause of osteomyelitis is pseudomonas
Presentation
Presentation
o often present weeks to a month after initial injury
o limp
Physical exam
o swollen and tender foot
o obvious wound, with or without tract
o well-demarcated erythema
o may present with lymphadenopathy
Imaging
Radiographs
o required views
ap and lateral
o findings
normal early
bone destruction seen later
exclude presence of foreign body
MRI
o indications
obtain prior to operative irrigation and debridement
used to rule out osteomyelitis
may occur in 1-2%
Treatment
Nonoperative
o tetanus booster, prophylactic antibiotics (controversial)
indications
recent (within hours) puncture wound with no evidence of infection
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By Dr, AbdulRahman AbdulNasser Introduction | Infection
if open wound, bedside irrigation and debridement
no standard prophylactic abx for acute (within hours) injury, but should cover for
Pseudomonas
Operative
o surgical debridement
indications
late/delayed presentation with deep infection with/without osteomyelitis
foreign body removal
no improvement with PO antibiotics
technique
tract and soft tissue debridement
deep culture
bony curretage (if osteo)
packing with wick to allow for healing by secondary intention
postoperative
follow with IV antibiotics (coverage for pseudomonas)
convert to PO antibiotics once clinical picture improves
antibiotic choice
preferred antibiotics
ciprofloxacin or levofloxacin (except in children)
alternative antibiotics: ceftazidime or cefepime
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In July 2017
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OrthoBullets2017 Degenerative Conditions | Infection
ORTHO BULLETS
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Tendon Conditions
A. Tendon Conditions
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OrthoBullets2017 Degenerative Conditions | Tendon Conditions
II:2 The illustration demonstrates the anatomy of the medial side of the ankle
with the posterior tibial tendon coursing posteriorly to the medial malleolus.
II:3 The illustration demonstrates the plantar aspect of the foot with the insertions of the posterior tibial tendon.
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Tendon Conditions
Anatomy
Muscle
o tibialis posterior
originates from posterior fibula, tibia, and interosseous membrane
innervated by tibial nerve (L4-5)
Tendon
o posterior tibial tendon (PTT) lies posterior to the medial malleolus before dividing into 3 limbs
anterior limb
inserts onto navicular tuberosity and first cuneiform
middle limb
inserts onto second and third cuneiforms, cuboid, and metatarsals 2-4
posterior limb : inserts on sustentaculum tali anteriorly
Blood supply
o branches of the posterior tibial artery supply the tendon distally
o a watershed area of poor intrinsic blood supply exists between the navicular and distal medial
malleolus (2-6 cm proximal to navicular insertion)
Biomechanics
o PTT lies in an axis posterior to the tibiotalar joint and medial to the axis of the subtalar joint
functions as a primary dynamic support for the arch
acts as a hindfoot invertor
adducts and supinates the forefoot during stance phase of gait
acts as secondary plantar flexor of the ankle
o major antagonist to PTT is peroneus brevis
o activation of PTT allows locking of the transverse tarsal joints creating a rigid lever arm for the
toe-off phase of gait
Classification
Deformity Physical exam Radiographs
Stage I • Tenosynovitis • (+) single-heel raise • Normal
• No deformity
Stage IIA • Flatfoot deformity • (-) single-leg heel raise • Arch collapse deformity
• Flexible hindfoot • Mild sinus tarsi pain
• Normal forefoot
Stage IIB • Flatfoot deformity
• Flexible hindfoot
• Forefoot abduction ("too
many toes", >40%
talonavicular uncoverage)
Stage III • Flatfoot deformity • (-) single-leg heel raise • Arch collapse deformity
• Rigid forefoot abduction • Severe sinus tarsi pain • Subtalar arthritis
• Rigid hindfoot valgus
Stage IV • Flatfoot deformity • (-) single-leg heel raise • Arch collapse deformity
• Rigid forefoot abduction • Severe sinus tarsi pain • Subtalar arthritis
• Rigid hindfoot valgus • Ankle pain • Talar tilt in ankle mortise
• Deltoid ligament
compromise
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OrthoBullets2017 Degenerative Conditions | Tendon Conditions
The weight bearing lateral foot radiograph Weight bearing lateral radiograph of the foot
reveals no abnormalities which is reveals stage IIB PTTI with longitudinal arch
characteristic of stage I PTTI collapse
Weight bearing lateral radiograph of the foot The mortise view of a right ankle reveals stage
reveals stage III PTTI with longitudinal arch IV PTTI with arch collapse, peritalar
collapse and subtalar arthritis. subluxation and arthritis, and talar tilt within
the ankle mortise.
Presentation
Symptoms
o medial ankle/foot pain and weakness is seen early
o progressive loss of arch
o lateral ankle pain due to subfibular impingement is a late symptom
Physical exam
o inspection & palpation
pes planus
collapse of the medial longitudinal arch
hindfoot valgus deformity
flexible stage II
rigid stage III, IV
forefoot abduction (Stage IIB disease)
"too many toes" sign
>40% talonavicular uncoverage
forefoot varus II:4 The clinical photograph demonstrates adult-
acquired flatfoot deformity with collapse of the
place flexible heel in neutral position medial longitudinal arch secondary to posterior
observe the relationship of metatarsal heads tibial tendon insufficiency.
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Tendon Conditions
flexible = MT heads perpendicular to long axis of tibia and calcaneus
fixed = lateral border of foot is more plantar flexed than medial border
tenderness just posterior to tip of medial malleolus
often associated with an equinus contracture
o range of motion
single-limb heel rise
unable to perform in stages II, III, and IV
PTT power
foot positioned in plantar and full inversion
unable to maintain foot position when examiner
applies eversion force
determine whether deformity is flexible or fixed
flexible deformities are passively correctable to a II:5 The clinical photograph demonstrates adult-
acquired flatfoot deformity with forefoot abduction
plantigrade foot (stage II) characterized by "too many toes" sign.
rigid deformities are not correctable (stages III
and IV)
Imaging
Radiographs
o recommended views
weight bearing AP and lateral foot
ankle mortise
o findings
AP foot
increased talonavicular uncoverage
increased talo-first metatarsal angle (Simmon angle)
seen in stages II-IV
weight bearing lateral foot
increased talo-first metatarsal angle (Meary angle)
angles >4° indicate pes planus
seen in stages II-IV
decreased calcaneal pitch
normal angle is between 17-32°
indicates loss of arch height
decreased medial cuneiform-floor height
indicates loss of arch height
subtalar arthritis
seen in stages III and IV
ankle mortise
talar tilt due to deltoid insufficiency
seen in stage IV
MRI
o findings
variable amounts of tendon degeneration and arthritic changes in the talonavicular, subtalar,
and tibiotalar joints
Ultrasound
o increasing role in the evaluation of pathology within the PTT
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OrthoBullets2017 Degenerative Conditions | Tendon Conditions
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Tendon Conditions
Differential
Pes planus secondary to
o midfoot pathology (osteoarthritis or chronic Lisfranc injury)
treat with midfoot fusion and a realignment procedure
o incompetence of the spring ligament (primary static stabilizer of the talonavicular joint) in the
absence of PTT pathology
treat with adjunctive spring ligament reconstruction in addition to standard flatfoot
reconstruction
Treatment
Nonoperative
o ankle foot orthosis
indications
initial treatment for stage II, III, and IV
also for patients who are not operative candidates,
sedentary/low demand (age > 60-70)
II:6 The clinical photograph illustrates
technique an Arizona brace which is used in the
AFO family of braces (Arizona, molded, articulating) treatment of adult-acquired flatfoot
deformity.
AFO found to be most effective
want medial orthotic post to support valgus collapse
Arizona brace is a molded leather gauntlet that provides stability to the tibiotalar joint,
hindfoot, and longitudinal arch
o immobilization in walking cast/boot for 3-4 months
indications
first line of treatment in stage I disease
o custom-molded in-shoe orthosis
indications
stage I patients after a period of immobilization
stage II patients II:7 Shows University of California
Biomechanics Laboratory (UCBL) foot
technique orthotic
medial heel lift and longitudinal arch support
medial forefoot post indicated if fixed forefoot varus is present
UCBL with medial posting
Operative
o tenosynovectomy
indications
indicated in stage I disease if immobilization fails
o FDL transfer, calcaneal osteotomy, TAL, ± forefoot correction osteotomy ± spring ligament
repair ± lateral column lengthening ± medial column arthrodesis ± PTT debridement
indications
stage II disease
lateral column lengthening for talonavicular uncoverage
medial column arthrodesis if deformity is at naviculocuneiform joint
contraindications
hypermobility
neuromuscular conditions
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OrthoBullets2017 Degenerative Conditions | Tendon Conditions
severe subtalar arthritis
obesity (relative)
age >60-70 (relative)
o first TMT joint arthrodesis, calcaneal osteotomy, TAL ± lateral column lengthening ± PTT
debridement
indications
stage II disease with 1st TMT hypermobility, instability or arthritis
o isolated subtalar arthrodesis
indications
absence of fixed forefoot deformity
contraindications
fixed forefoot supination/varus
otherwise will overload lateral border of foot
joint hypermobility
o triple arthrodesis and TAL
indications
II:8 The postoperative lateral radiograph of the foot
stage III disease
demonstrates a triple arthrodesis performed for
stage II disease with severe subtalar arthritis stage III posterior tibial tendon insufficiency.
Isolated subtalar arthrodesis can be considered
o triple arthrodesis and TAL + deltoid ligament reconstruction
indications
stage IV disease with passively correctable ankle valgus
o tibiotalocalcaneal arthrodesis
indications
stage IV disease with a rigid hindfoot, valgus angulation of the talus, and tibiotalar and
subtalar arthritis
Surgical Techniques
FDL transfer
o indications
FDL is synergistic with tibialis posterior and therefore transfer can augment function of
deficient PT
Stage II disease
o relative contraindications
rigidity of subtalar joint (<15 degrees of motion)
fixed forefoot varus deformity (>10-12 degrees)
o technique
find FDL and FHL at knot of Henry
insert FDL into navicular near insertion of PT
II:9 medial displacement calcaneal osteotomy
vs. FHL transfer (MDCO)
FHL is more complicated to mobilize and has not shown improved results
in the midfoot, FHL runs under FDL
Calcaneal osteotomy
o indicated to correct hindfoot valgus
o techniques include
medial displacement calcaneal osteotomy (MDCO)
used in stage IIA (insignificant forefoot abduction)
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Tendon Conditions
Evans lateral column lengthening osteotomy
used in stage IIB (significant forefoot abduction)
may require additional MDCO to correct the deformity
overlengthening may be corrected by a first TMT fusion or medial cuneiform osteotomy
TAL or gastrocnemius recession
o indicated for equinus contracture
Forefoot correction osteotomy
o indicated for fixed forefoot supination/varus (stage IIC)
o techniques
plantarflexion (dorsal opening-wedge) medial cuneiform (Cotton) osteotomy
used with a stable medial column (navicular is colinear with first MT)
corrects residual forefoot varus after hindfoot correction is made surgically
medial column fusion (isolated first TMT fusion, isolated navicular fusion, or combined
TMT and navicular fusions)
used with an unstable medial column (plantar sag at first TMT and/or naviculocuneiform
joint)
Spring ligament repair
o indicated with spring ligament rupture in some cases
PTT debridement
o may also be required
Triple arthrodesis
o triple arthrodesis includes calcaneocuboid, talonavicular, subtalar joints
o additional medial column stabilization may be required
2. Achilles Tendonitis
Introduction
A family of conditions that include
o insertional Achilles tendonitis
o retrocalcaneal bursitis & Haglund deformity
o Achilles tendonitis
Achilles Tendonopathy
Mechanism
o overuse
o imbalance of dorsiflexors and plantar flexors
o poor tendon blood supply
o genetic predisposition
o fluoroquinolone antibiotics
o inflammatory arthropathy
Pathophysiology
o theorized to be due to abnormal vascularity 2 to 6 cm proximal to Achilles insertion in response
to repetitive microscopic tearing of the tendon
Classification
o Achilles tendinosis
tendon thickening
thought to be caused by anaerobic degeneration in portion of tendon with poor blood supply
o Achilles peritendonitis
involves inflammation of tendon sheath
o inflammation of paratenon
Presentation
o symptoms
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pain, swelling, warmth
worse symptoms with activity
difficulty running
o physical exam
tendon thickening and tenderness 2 to 6 cm proximal to Achilles insertion
pain throughout entire range of motion
Imaging
o MRI
disorganized tissue will show up as intrasubstance intermediate signal intensity
thickened tendon
chronic rupture will show a hypoechoic region between tendon ends
Treatment
o nonoperative
activity modification, shoe wear modification, therapy, NSAIDs
indications
first line of treatment
techniques
therapy
physical therapy with eccentric training
modalities (iontophoresis, phonophoresis, and ultrasound)
shoewear
heel lifts
cast or removable boot (severe disease)
outcomes
nonoperative management is 65% to 90% successful
glyceryl trinitrate patches, prolotherapy, and aprotinin injections
indications
evolving indications due to lack of evidence at this time
o operative
percutaneous tenotomies
indications
mild to moderate disease
techniques
longitudinal tenotomy made in the degenerative area
strip the anterior Achilles tendon with a large suture to free any adhesions
open excision of degenerative tendon with tubularization
indications
moderate to severe disease
outcomes
70% to 100% successful
tendon transfer (FHL, FDL, or PB)
indications
degeneration of >50% of the Achilles tendon
>55 years of age
MRI evidence of diffuse tendon thickening without a focal area of disease
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Tendon Conditions
Anatomy
Muscle
o FHL
originates from posterior fibula
travels between posteromedial/posterolateral tubercles of the talus
contained within fibro-osseous tunnel
passes beneath the sustentaculum tali
crosses dorsal to FDL (at the Knot of Henry)
FHL is "higher" at Knot of Henry
FDL is "down" at Knot of Henry
multiple connections exist between the FDL and FHL
distally it stays dorsal to the FDL and neurovascular bundle
inserts on the distal phalanx of the great toe
Biomechanics
o primary action
plantarflexion of the hallux IP and MP joints
o secondary action
plantarflexion of the ankle
Presentation
Symptoms
o posteromedial ankle pain
o great toe locking with active range of motion
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o crepitus along the posterior medial ankle
Physical exam
o pain with resisted flexion of the IP joint
o pain with forced plantarflexion of the ankle
o motion
great toe triggering with active or passive motion but no tenderness at the level of the first
metatarsal head
Imaging
MRI
o findings
fluid around the tendon at level of ankle joint
intra-substance tendinous signal
Differentials
Os trigonum syndrome
o pain is posterolateral in os trigonum syndrome
Treatment
Nonoperative
o rest/activity modification, NSAIDS
indications
first line of treatment
modalities II:10 This T2-weighted sagittal MRI sequence of the ankle
arch supports shows signal around the FHL tendon. This is consistent with
tenosynovitis.
physical therapy
Operative
o release of the FHL from the fibro-osseous tunnel, tenosynovectomy, possible tendinous
repair
indications
recalcitrant symptoms
in athletes when symptoms persist despite rest and nonsurgical management
technique
approach
arthroscopic
open, posteromedial
FHL Laceration
Introduction
o direct trauma to the FHL tendon in an acute setting
Pathophysiology
o mechanism of injury
acute laceration
most common form of injury
Presentation
o physical exam
range of motion II:11 FHL laceration seen on this axial
MRI sequence
loss of active interphalangeal joint flexion
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Tendon Conditions
Imaging
o MRI
findings
tendon ends may be retracted
Treatment
o operative
acute surgical repair of the laceration
indications
lacerations of both the FHL and the FHB II:12 FHL laceration seen on this sagittal MRI sequence
4. Plantar Fasciitis
Introduction
A condition caused by inflammation of the aponeurosis at its origin on the calcaneus
Epidemiology
o demographics
affects men and women equally
o location
affects the posteromedial heel
o risk factors
obesity (high BMI)
decreased ankle dorsiflexion in a non-athletic population (tightness of the foot and calf
musculature)
weight bearing endurance activity (dancing, running)
Pathophysiology
o pathoanatomy
chronic overuse leads to microtears in the origin of the plantar fascia
repetitive trauma leads to recurrent inflammation and periostitis
abductor hallucis, flexor digitorum brevis, and quadratus plantae share the origin on medial
calcaneal tubercle and may be inflamed as well
Associated conditions
o calcaneal apophysitis
o gastrocnemius-soleus contracture
o heel pain triad
plantar fasciitis
posterior tibial tendon dysfunction
tarsal tunnel syndrome
o anatomic variations
femoral anteversion
pes cavus
pes planus
Anatomy
The plantar fascia is a thin layer of connective tissue supporting the arch of the foot
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Presentation
Symptoms
o sharp heel pain
insidious onset of heel pain, often when first getting out of bed
may prefer to walk on toes initially
worse at the end of the day after prolonged standing
o relieved by ambulation
o common to have symptoms bilaterally
Physical exam
o inspection
tender to palpation at medial tuberosity of calcaneus
dorsiflexion of the toes and foot increases tenderness with palpation
limited ankle dorsiflexion due to a tight Achilles tendon
tenderness at origin of abductor hallucis
small subset of patients
indicative of entrapment or irritation of the first branch of the lateral plantar nerve
(Baxter's nerve)
Imaging
Radiographs
o not necessary on initial visit
often normal
may show plantar heel spur
o optional films
weight bearing axial and lateral films of hindfoot
may show structural changes
MRI
o indications
may be useful for surgical planning
Bone Scan
o can quantify inflammation and guide management
o useful to rule out stress fracture
Lateral radiograph of the foot At the proximal/medial origin This bone scan demonstrates the
demonstrates a calcaneal bone of the plantar fascia, Increased signal in the plantar heel
spur. Although this was thickening and edema can be consistent with plantar fasciitis.
previously thought to be the appreciated on this sagittal T2
cause of plantar fasciitis, this has weighted MRI scan.
been disproven.
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Tendon Conditions
Studies
Labs
o not routinely indicated
o useful if other causes of heel pain are suspected
inflammatory arthritis
infection
EMG
o useful to rule out entrapment
Treatment
Nonoperative
o pain control, splinting & therapy (stretching) programs
indications
first line of treatment
modalities
plantar fascia-specific stretching and Achilles tendon stretching
anti-inflammatories or cortisone injections
corticosteroid injections can lead to fat pad atrophy or plantar fascia rupture
foot orthosis
examples include cushioned heel inserts, pre-fabricated shoe inserts, night splints,
walking casts
short leg casts can be used for 8-10 weeks
outcomes
pre-fabricated shoe inserts shown to be more effective than custom orthotics in relieving
symptoms when used in conjunction with achilles and plantar fascia stretching
dorsiflexion night splint most appropriate for chronic plantar fasciitis
a non-weight bearing, plantar fascia specific stretching program is more effective than
weight bearing Achilles tendon stretching programs
stretching programs have equally successful satisfaction outcomes at 2 years
o shock wave treatment
indications
second line of treatment
chronic heel pain lasting longer than 6 months when other treatments have failed
FDA approved for this purpose
technique
painful for patients
outcomes
efficacious at 6 month followup
Operative
o gastrocnemius recession
indications
no clear indications established
o surgical release with plantar fasciotomy
indications : perisistent pain after 9 months of failed conservative measures
outcomes
complications common and recovery can be protracted
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o surgical release with plantar fasciotomy and distal tarsal tunnel decompression
indications
concomitant compression neuropathy (tibial nerve in tarsal tunnel)
technique
open procedure must be completed
outcomes
success rates are 70-90% for dual plantar fascial release and distal tarsal tunnel
decompression
Technique
Surgical release with plantar fasciotomy
o approach
can be done open or arthroscopically
open procedure is indicated if tarsal tunnel syndrome is present as well
o release
release medial one-third to two-thirds
avoid complete release as it may lead to
destabilization of the longitudinal arch
overload of the lateral column
dorsolateral foot pain
consider simultaneous release of Baxter's nerve
release the deep fascia of abductor hallucis
may improve outcomes
Complications
Lateral plantar nerve injury
Complete release of the plantar fascia with destabilization of medial longitudinal arch
Increased stress on the dorsolateral midfoot
Chronic pain
Plantar fascia rupture
o risk factors = athletes, minimalist runners, corticosteriod injections
o treat with cast immobilization
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hallux Disorders
B. Hallux Disorders
1. Hallux Valgus
Introduction
Not a single deformity, but rather a complex deformity of the first ray
o often accompanied by deformities and symptoms in lesser toe
o two forms exist
adult hallux valgus
adolescent & juvenile hallux valgus
Epidemiology of adult hallux valgus
o more common in women
o 70% of pts with hallux valgus have family history
genetic predisposition with anatomic anomalies
o risk factors
intrinsic
genetic predisposition
increased distal metaphyseal articular angle (DMAA)
ligamentous laxity (1st tarso-metatarsal joint instability)
convex metatarsal head
2nd toe deformity/amputation
pes planus
rheumatoid arthritis
cerebral palsy
extrinsic
shoes with high heel and narrow toe box
Pathoanatamy
o valgus deviation of phalanx promotes varus position of metatarsal
o the metatarsal head displaces medially, leaving the sesamoid complex laterally translated relative
to the metatarsal head
o sesamoids remain within the respective head of the flexor hallucis brevis tendon and are attached
to the base of the proximal phalanx via the sesamoido-phalangeal ligament
o this lateral displacement can lead to transfer metatarsalgia due to shift in weight bearing
o medial MTP joint capsule becomes stretched and attenuated while the lateral capsule becomes
contracted
o adductor tendon becomes deforming force
inserts on fibular sesamoid and lateral aspect of proximal phalanx
o lateral deviation of EHL further contributes to deformity
o plantar and lateral migration of the abductor hallucis causes muscle to plantar flex and pronate
phalanx
o windlass mechanism becomes less effective
leads to transfer metatarsalgia
Associated conditions
o hammer toe deformity
o callosities
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OrthoBullets2017 Degenerative Conditions | Hallux Disorders
Juvenile and Adolescent Hallux valgus
o factors that differentiate juvenile / adolescent hallux valgus from adults
often bilateral and familial
pain usually not primary complaint
varus of first MT with widened IMA usually present
DMAA usually increased
often associated with flexible flatfoot
o complications
recurrence is most common complication (>50%), also overcorrection and hallux varus
Anatomy
Presentation
Symptoms
o presents with difficulty with shoe wear due to medial eminence
o pain over prominence at MTP joint
o compression of digital nerve may cause symptoms
Physical exam
o Hallux rests in valgus and pronated due to deforming forces illustrated above
o examine entire first ray for
1st MTP ROM
1st tarsometatarsal mobility
callous formation
sesamoid pain/arthritis
o evaluate associated deformities
pes planus
lesser toe deformities
midfoot and hindfoot conditions
Imaging
Radiographs
o views
standard series should include weight bearing AP, Lat, and oblique views
sesamoid view can be useful
o findings
lateral displacement of sesamoids
joint congruency and degenerative changes can be evaluated
radiographic parameters (see below) guide treatment
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hallux Disorders
Radiographic Measurements in Hallux Valgus
Hallux valgus (HVA) Long axis of 1st MT and prox. phal. Identifies MTP Normal
deformity < 15°
Intermetatarsal angle Between long axis of 1st and 2nd MT < 9°
(IMA)
Distal metatarsal articular Between 1st MT long. axis and line Identifies MTP joint < 10°
(DMAA) through base of distal articular cap incongruity
Hallux valgus Between long. axis of distal phalanx and < 10 °
interphalangeus (HVI) proximal phalanx
DMAA
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OrthoBullets2017 Degenerative Conditions | Hallux Disorders
Treatment - Juvenile and Adolescent Hallux valgus
Nonoperative
o shoe modification
indications : pursue nonoperative management until physis closes
Operative
o surgical correction
indications
best to wait until skeletal maturity to operate
can not perform proximal metatarsal osteotomies if physis is open (cuneiform
osteotomy OK)
surgery indicated in symptomatic patients with an IMA > 10° and HVA of > 20°
severe deformity with a DMAA > 20 consider a double MT osteotomy to correct
orientation of MT head articular cartilage
technique
soft tissue procedure alone not successful
similar to adults if physis is closed (except in severe deformity)
Techniques
Soft Tissue Procedures
o modified McBride
indications
goal is to correct an incongruent MTP joint (phalanx not lined up with articular cartilage
of MT head). Usually done in patients with
a HVA less than 25 degrees
IMA deformity less than 15 degrees
usually in patient 30-50 years of age
rarely appropriate in isolation
usually performed in conjunction with
medial eminence resection
MT osteotomy
1st TMT arthrodesis (Lapidus procedure)
technique
includes
release of adductor from lateral sesamoid/proximal phalanx
lateral capsulotomy
medial capsular imbrication
(original McBride included lateral sesamoidectomy)
Metatarsal Osteotomies
o distal metatarsal osteotomy
indications
mild disease (HVA ≤ 40, IMA < 13)
distal metatarsal osteotomies include
Chevron
biplanar Chevron (corrects DMAA)
Mitchell
may be combined with proximal phalanx osteotomy (Akin-medial closing wedge
osteotomy)
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hallux Disorders
o proximal metatarsal osteotomy
indications
moderate disease (HVA >40°, IMA >13°)
proximal metatarsal osteotomies include
crescentic osteotomy
Broomstick osteotomy
Ludloff
Scarf
o double (proximal and distal) osteotomy
indications
severe disease (HVA 41-50°, IMA 16-20°)
o first cuneiform osteotomy
indications
severe deformity in young patient with open physis
Proximal phalanx osteotomies
o Akin osteotomy
indications
hallux valgus interphalangeus
congruent joint with DMAA <10°
as a secondary procedure if a primary procedure (e.g., chevron or distal soft-tissue
procedure) did not provide sufficient correction due to a large DMAA or HVI
some authors perform Akin together with/at the time of proximal osteotomy+distal soft
tissue correction because this results in progressive increase in HVI
Fusion procedures
o Lapidus procedure (1st metatarsocuneiform arthrodesis with modified McBride)
indications
severe deformity (very large IMA)
arthritis at 1st TMT
metatarsus primus varus
hypermobile 1st TMT joint
concomitant pes planus
o MTP Arthrodesis
indications are hallux valgus in
cerebral palsy
Down's syndrome
Rheumatoid arthritis
Gout
Severe DJD
Ehler-Danlos
Resection arthroplasty
o proximal phalanx (Keller) resection arthroplasty
indications
largely abandoned
rarely indicated in some elderly patient with reduced function demands
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Surgical Indications for Various Techniques to treat Hallux Valgus
HVA IMA Modifier Procedure
Mild < 25° <13° Distal osteotomy Chevron osteotomy. Biplanar if DMAA >
10° usually with mod McBride
Moderate 26- 13- Proximal osteotomy +/- distal Chevron/mod McBride + Akin osteotomy
40° 15° osteotomy Proximal MT osteotomy and mod McBride
Severe 41- 16- Double osteotomy DMAA > - Proximal MT osteotomy plus biplanar
50° 20° 15° chevron, mod McBride
Lapidus procedure plus Akin
Elderly/very low demand Keller
patient
Juvenile/Adolescent with Double osteotomy of first ray
DMAA > 20
Chevron Distal 1st MT osteotomy (intra- reserved for mild to -AVN of MT head
articular). Can perform in two moderate deformities in -recurrence
planes (Biplanar distal Chevron) adults and children, -dorsal malunion with
biplanar chevron-->correct
transfer
increased DMAA
metatarsalgia
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hallux Disorders
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Complications
Recurrence
o most common cause of failure is insufficient preoperative assessment and failure to follow
indications
e.g., failure to recognize DMAA > 10°
inadequate correction of IMA
e.g., failure to do adequate distal soft tissue realignment
o more common in juvenile/adolescent population
o noncompliant patient that bears weight
Avascular necrosis
o medial capsulotomy is primary insult to blood flow to metatarsal head
o distal metatarsal oseotomy and lateral soft tissue release inconjunction do not increase risk for
AVN (Chevron plus lateral release thought to increase risk in the past)
Dorsal malunion with transfer metatarsalgia
o due to overload of lesser metatarsal heads
o risk associated with shortening of hallux MT
Lapidus
proximal crescentric osteotomies
Hallux Varus
o caused by
overcorrection of 1st IMA
excessive lateral capsular release with overtightening of
medial capsule II:13 Hallux Varus
overresection of medial first metatarsal head
lateral sesamoidectomy
Cock up toe deformity
o due to injury of FHL
o most severe complication with Keller resection
2nd MT transfer metatarsalgia
o often seen concomitant with hallux valgus
o shortening metatarsal osteotomy (Weil) indicated with extensor tendon
and capsular release II:14 Cock up toe deformity
Neuropraxia
o Painful incisional neuromas after bunion surgery frequently involve the medial branch of the
dorsal cutaneous nerve-a terminal branch of the superficial peroneal nerve. It is most commonly
injured during the medial approach for capsular imbrication or metatarsal osteotomy.
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hallux Disorders
Classification
Coughlin and Shurnas Classification
Exam Findings Radiographic Findings
Grade 0 Stiffness Normal
Grade 1 mild pain at extremes of motion mild dorsal osteophyte, normal joint space
Grade 2 moderate pain with range of motion moderate dorsal osteophyte, <50% joint
increasingly more constant space narrowing
Grade 3 significant stiffness, pain at extreme severe dorsal osteophyte, >50% joint space
ROM, no pain at mid-range narrowing
Grade 4 significant stiffness, pain at extreme same as grade III
ROM, pain at mid-range of motion
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Presentation
Symptoms
o first ray and 1st MTP pain and swelling worse with push off or forced dorsiflexion of great toe
o shoe irritation due to dorsal osteophytes and compression of dorsal cutaneous nerve may lead to
paresthesias
o pain becomes less severe as the disease progresses
Physical exam
o limited dorsiflexion
o pain with grind test
Imaging
Radiographs
o recommended views
AP, lateral, and oblique views
o findings
osteophytes, especially dorsal
joint space narrowing
subchondral sclerosis and cysts
Treatment
Nonoperative
o NSAIDS, activity modification & orthotics
indications : grade 0 and 1 disease
activity modifications II:15 dorsal cheilectomy
avoid activities that lead to excessive great toe dorsiflexion
types of orthotics
Morton's extension with stiff foot plate is the mainstay of treatment
stiff sole shoe and shoe box stretching may also be used
Operative
o joint debridement and synovectomy
indications
patients with acute osteochondral or chondral defects
o dorsal cheilectomy
indications
grade 1 and 2 disease II:16 Morton's extension
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hallux Disorders
technique
increases dorsiflexion by decreasing the plantar flexion arc of motion
o Keller Procedure (resection arthroplasty)
indications
elderly, low demand patients with significant joint degeneration and loss of motion
contraindicated in patients with pre-existing rigid hyperextension deformity of 1st MTP
joint
technique
involves removing the base of the first proximal phalanx
risk of hyperextension (cock-up deformity), weakness with push-off, and transfer
metatarsalgia (decreased with capsular interposition)
o MTP arthroplasty
indications
indications controversial
technique
capsular interpositonal arthroplasty gaining popularity
silicone implants are not recommended due to poor long-term results
outcomes
silicone implants may have a good short term satisfaction rate
osteolysis and synovitis cause mid to long term pain and joint destruction
o MTP joint arthrodesis
indications
grade 3 and 4 disease (significant joint arthritis)
most common procedure for hallux rigidus
outcomes
70% to 100% fusion rate
15% of patients experience degeneration of IP joint after surgery (mostly asymptomatic)
o MTP joint arthrodesis with structural bone graft
indications for structural bone graft
1st MT shortening that cannot be adequately rebalanced with a lesser metatarsal
osteotomy (usually shortening > 5 mm)
most commonly seen with failed MTP arthroplasty
significant proximal phalanx bone loss with inadequate remaining bone for fixation
without compromising IP joint,
1st MT shortening with loss of medial support of the 2nd toe predisposing to varus at the
2nd MTP joint.
Techniques
MTP joint arthrodesis
o dorsal plate with compression screw is biomechanically strongest construct
o preferred surgical alignment
10 to 15 degrees of valgus in relation to the metatarsal shaft
15 degrees of dorsiflexion in relation to the floor
o fusion in excessive dorsiflexion causes pain at tip of the toe, over the IP joint, and under the 1st
metatarsal with excessive dorsiflexion
o fusion in excessive plantar flexion causes increased pressure at the tip of the toe
o fusion in excessive valgus increases the risk of IP joint degeneration
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Complications
Failed arthroplasty
o treatment
implant resection, synovectomy if there is isolated great toe pain
implant resection, bone grafting, and arthrodesis if there is great toe pain with lesser toe
metatarsalgia
Anatomy
Osteology
o sesamoids play important role in function of great toes by
absorbing weight-bearing pressure
reducing friction at MT head
protect FHL tendon
glides between sesamoids
provide fulcrum for flexor hallucis brevis that increases MTP flexion power
o bipartite sesamoid present in 10-25%
97% are in the tibial sesamoid
25% bilateral
Attachments
o FHB attaches to both tibial and fibular sesamoid
o sesamoids are connected to each other by intersesamoid ligament and plantar plate
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hallux Disorders
o adductor hallucis is connected to tibial sesamoid
o abductor hallucis is connected to fibular sesamoid
Biomechanics
o sesamoid function is analogous to the patella as they increase the mechanical advantage of the
FHB
Presentation
Symptoms
o generalized big toe pain
worse in terminal part of stance phase
Physical exam
o possible plantar-flexed MTP with cavus foot
Treatment
Nonoperative
o NSAIDs, reduced weightbearing, activity modification, orthoses
indications
indicated as first line of treatment
o short leg cast with toe extension
indication : acute fracture (controversial)
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o shaving keratotic lesion
indications
keratotic lesion present increasing pressure on sesamoids
Operative
o partial or complete sesamoidectomy
indications
nonoperative management fails after 3-12 months
technique (see below)
o autologous bone grafting
indications
nonunion or fracture
o dorsiflexion osteotomy
indication II:17 approach to tibial sesamoid
plantar-flexed first ray with sesamoid injury
Surgical Techniques
Complete or Partial Sesamoidectomy
o approaches
approach to tibial sesamoid
medial-plantar approach
high risk of injuring proper branch of medial plantar nerve
approach to fibular sesamoid
plantar approach
beware for
proper branch to lateral side of hallux
first common branch to first web space
o technique II:18 approach to fibular
sesamoid
may be partial or complete sesamoidectomy
sesamoid shaving (contraindicated in a patient with a plantar flexed 1st MT)
Complications
Cock-up deformity
o removal of both sesamoids is associated with a high incidence of cock-up deformity of the great
toe
o caused by weakening of the flexor hallucis brevis tendon, which should be meticulously repaired
after sesamoid excision
o excision of both sesamoids should be avoided
Hallux valgus
o may be caused from tibial sesamoid excision
Hallux varus
o may be caused by fibular sesamoid excision
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hallux Disorders
4. Turf Toe
Introduction
Hyperextention injury to plantar plate and sesamoid complex of the hallux metatarsophalangeal
(MTP) joint
Epidemiology
o demographics
more prevalent in contact athletic sports played on rigid surfaces
Pathophysiology
o mechanism of injury
forefoot is fixed to the ground
hallux MTP joint positioned in hyper-extension
axial load is applied to the heel
combination of force and joint positioning causes attenuation or tearing of the
plantar capsular-ligamentous complex
o pathoanatomy
tear to capsular-ligamentous-seasmoid complex
tear occurs off the proximal phalanx, not the metatarsal
Associated injuries
o varus, valgus injuries to hallux MTP
o sesamoid fracture
o proximal migration of sesamoid
o cartilaginous injury or loose body in hallux MTP joint
o stress fracture of proximal phalanx
o hallux rigidus (late sequelae)
Prognosis
o can be a devastating injury to the professional athlete
Classification
Grade I
o sprain of plantar plate
Grade II
o partial tear of plantar plate
Grade III
o complete tear of plantar plate
Anatomy
Hallux metatarsophalangeal (MTP) joint
o stabilized by
osseous structures
articulation between MT and proximal phalanx
tendons
flexor hallucis brevis
contains tibial and fibular seasmoids
abductor hallucis attaches to medial sesamoid
adductor hallucis attaches to lateral sesamoid
ligaments
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medial and lateral collateral ligaments
intermetatarsal ligament
plantar plate
composed of the joint capsule
attaches to the transverse head of adductor hallucis, flexor tendon sheath and deep
transverse intermetatarsal ligament
Presentation
History
o circumstances of injury
mechanism of injury consistent with hyper-extension and axial loading of hallux MTP
type of athletic shoe and surface
Symptoms
o primary symptoms
acute pain
stiffness
swelling
o defining characteristics
inability to push-off
reduced agility
Physical exam
o inspection
plantar swelling and ecchymosis
alignment of hallux MTP joint
o motion
active and passive range of motion
inability to hyperextend the joint without significant symptoms
vertical Lachman test (positive if greater laxity compared to contralateral side)
varus/valgus instability
o gait : shorten time spent after heel rise
Imaging
Radiographs
o recommended views
weightbearing AP, lat, oblique foot
o additional views
sesamoid axial views
forced dorsiflexion view
o findings
comparison of the sesamoid-to-joint distances
medial sesamoid may be displaced proximally
may show a sesamoid fracture
often does not show a dislocation of the great toe MTP joint because it is concentrically
located on both radiographs
Bone scan
o indications
negative radiograph with persistent pain, swelling, weak toe push-off
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hallux Disorders
o findings
increased signal at 1st MTP joint
stress fracture of the proximal phalanx
MRI
o indications
positive bone scan
persistent pain, swelling, weak toe push-off
not recommended routinely
o findings
will show disruption of volar plate
used to rule out stress fracture of the proximal phalanx
Treatment
Nonoperative
o rest, NSAIDS, taping, stiff-sole shoe or walking boot II:19 disruption of volar plate
indications
nonoperative modalities indicated in most injuries (Grade I-III)
technique
early icing and rest
taping not indicated in acute phase due to vascular compromise with swelling
stiff-sole shoe or rocker bottom sole to limit motion
more severe injuries may require walker boot or short leg cast for 2-6 weeks
physiotherapy
progressive motion once the injury is stable
Operative
o surgical repair
indications (usually Grade III injuries)
failed conservative treatment
retraction of sesamoids
fracture of sesamoids with diastasis
traumatic bunions
loose fragments in the joint
hallux toe deformity
technique
medial plantar incision
repair or excision of sesamoid depending on fragmentation
headless screw or suture repair of sesamoid fracture
joint synovitis or osteochondral defect often requires debridement or cheilectomy
abductor hallucis transfer may be required if plantar plate or flexor tendons cannot be
restored
outcomes
immediate post-operative non-weight bearing
progressive ROM and physiotherapy
expected return to sport 3-4 months
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Complications
Hallux rigidus
o a late sequela
o treat with cheilectomy versus arthrodesis, depending on severity
Proximal phalanx stress fracture
o may be overlooked
5. Hallux Varus
Introduction
Characterized by medial deviation of great toe relative to the 1st metatarsal bone
Epidemiology
o incidence
varies between 2-14% after corrective surgery for hallux valgus deformities
o demographics
more commonly seen in women
Pathophysiology
o causes
congenital
acquired
iatogenic (overcorrection from surgery)
trauma
inflammatory (e.g. rheumatoid arthritis, ankylosis spondylitis)
neurological (e.g. Charcot-Marie-Tooth, post-polio)
o pathoanatomy
loss of osseous support
excessive resection of the medial eminence
excision of fibular (lateral) sesamoid
overrelease of lateral capsular structures
overplication of medial capsule
overtranslation of intermetatarsal angle or hallux valgus interphalangeus
Orthopaedic manifestations
o hallux varus usually presents with three possible components
medial deviation of the hallux relative to first MTP
joint
supination of the phalanx
claw toe deformity
Prognosis
o natural history of disease
in established hallux varus, the role of nonoperative
management is limited
Presentation
History
o main complaint
appearance of the great toe as being "too straight" to excessive medial deviation
difficulty wearing shoes
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Hallux Disorders
Symptoms
o often asymptomatic
o pain indicates underlying joint arthritis or trauma
o may also complain of decreased ROM, instability, weakness with push-off
Physical exam
o inspection
varus anglulation of great toe
dorsal contracture of the MTP joint with or without IP joint contracture
EHL may be medially displaced, creating a "bowstring" deformity
tibial (medial) sesamoid may be medially displaced
o motion
determine if fixed or flexible deformity
Imaging
Radiographs
o recommended views
weight-bearing AP & lateral views of the foot,
o additional views
non-weightbearing oblique views, and sesamoid axial views
o findings
hallux valgus angle < 0 degrees (normal 5-15 degrees)
excessive medial eminence resection
overcorrection osteotomies
reduced IMA between first and second metatarsals
medial subluxation of tibial seasmoid
absent lateral seasmoid
degenerative changes at MTP or IP joint
CT scan or MRI
o indications
not usually required
may be considered if underlying osteonecrosis of first metatarsal
Treatment
Nonoperative
o shoe modifications to accommodate the deformity
indications
flexible, longstanding and asymptomatic deformities
patient preference
modalities
wider and more flexible toe box shoes
padding boney prominences
outcomes
mild flexible and stable deformities are usually well tolerated
o taping or splinting the deformity
indications
early post-operative varus deformities after hallux correction surgery
modalities
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frequent taping and follow-up
duration should be maintained for up to 3 months or until soft-tissues have healed
outcomes
may correct deformity if initiated within the first few weeks from surgery
Operative
o lateral closing wedge osteotomy
indications
overcorrection of proximal/distal metatarsal osteotomy, or proximal phalangeal
osteotomy
techniques
revision osteotomy to re-establish alignment
consider release of scar tissue and repair of the lateral ligaments
o tendon transfer with medial release
indications
flexible first MTP joint deformities
techniques
aDDuctor hallucis tendon re-attachment with medial release
may be difficult in cases of previous McBride-type surgery
aBDuctor hallucis tendon transfer on the base of the lateral base of proximal phalanx
combined with the reattachment or reefing of the conjoined tendon in the web space
transfer or EHL or EHB, medial release, with or without IP joint arthrodesis
transfer portion of EHL or EHB under the transverse intermetatarsal ligament to the
distal metatarsal neck (from lateral to medial)
o first MTP arthrodesis
indications
absolute
fixed (not passively correctable) first MTP joint with significant deformity and non-
functioning hallux
painful joint arthritis
relative
excessive medial eminence resection beyond tibial seasmoid sulcus
1. Claw Toe
Introduction
A claw toe deformity is characterized by MTP hyperextension and resulting PIP and DIP flexion
o analogous to intrinsic minus deformity in the hand
Epidemiology
o location
typically involves multiple toes
often bilateral
Pathophysiology
o MTP hyperextension is the primary pathology
chronic MTP hyperextension leads to unopposed flexion of the DIP and PIP by FDL
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Lesser Toe Deformities
o theMTP plantar plate becomes insufficient over time
o base of proximal phalanx translates dorsally
o interossei and lumbricals move dorsally
shifts flexion moment arm to the wrong side of the center of rotation
Etiology
o synovitis is the most common cause
o trauma
o delayed or missed compartment syndrome involving the deep posterior compartment of the leg
or foot
Associated conditions
o cavus deformity
o neuromuscular disease affecting intrinsic and extrinsic muscle balance
clawing of all 4 lesser toes implicates a neurologic abnormality
o inflammatory arthropathies
lead to soft tissue structure attenuation and MTP joint instability
Classification
Presentation
Symptoms
o pain at the level of the unstable MTP joint
o metatarsalgia
Physical exam
o inspection & palpation
claw-type deformity of the toe is present
depressed metatarsal head with callus formation
and tenderness I I:20 The clinical photograph demonstrates severe claw toe
flexed IP joints with callosities and tenderness deformity involving the four lesser toes with callosities
visible on the IP joints of the fourth toe.
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Treatment
Nonoperative
o taping and shoe modification
indications
first line of treatment
techniques
provide adequate plantar padding using metatarsal and/or crest pads or orthotics to
offload plantarly-subluxed metatarsal heads
wear a shoe with a high toe box
use a sling to hold the proximal phalanx parallel to the ground
Operative
o EDB tenotomy, EDL lengthening, FDL flexor-to-extensor transfer (Girdlestone)
indications
painful, flexible deformities without contractures
ulcerations caused by shoe wear
o Girdlestone (above), MTP capsulectomy, and proximal phalanx head and neck resection
indications
fixed contracture
o Girdlestone and distal MT shortening osteotomy (Weil lesser MT osteotomy)
indications
claw toe deformity of all four lesser toes
technique
oblique shortening osteotomy
translates metatarsal head proximal and plantar
Complications
Floating toe
o most common complication of a Weil osteotomy
o caused by intrinsics migrating dorsal to the joint and acting as
MTP extensors II:21 The illustration demonstrates a
Recurrence Weil metatarsal shortening osteotomy
with the osteotomy made parallel to the
o caused by persistent plantar plate dysfunction plantar surface of the foot to prevent
joint depression and dorsiflexion
deformity of the MTP joint.
2. Hammer Toe
Introduction
Hammer deformity characterized by
o PIP flexion
o DIP extension
o MTP neutral (or extended)
o deformity can be rigid or flexible
Epidemiology
o most common deformity of lesser toes
o more common in older women
o 2nd toes usually affected
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Lesser Toe Deformities
Pathoanatomy
o overpull of EDL
o imbalance of intrinsics
Associated conditions
o painful corns at dorsal PIP joint
Classification
Presentation
Symptoms
o pain on dorsal surface with shoe wear
o deformity
Physical exam
o flexion deformity of the PIP joint of the lesser toes with extension of DIP
o ankle plantar flexion
flexible deformity corrects
fixed deformity does not correct with ankle plantar flexion
o push up test
flexible deformity is reducible with dorsal directed pressure on the plantar aspect of the
involved metatarsal
effect of over active extrinsics is removed
Imaging
Imaging not required in diagnosis and treatment
Treatment
Nonoperative
o shoes with high toe boxes, foam or silicone gel sleeves
indications
pain and or corns on dorsal PIP
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Operative
o flexor tendon (FDL) to EDL tendon transfer
indications
flexible deformity that has failed nonoperative management
o PIP resection arthroplasty +/- tenotomy and tendon transfers
indications
rigid deformity that has failed nonoperative management
o Girdlestone procedure with FDL to EDL transfer
indications
MTP involvement
similar to claw toe treatment
o EDL Z-lengthening or tenotomy
indications
mild MTP hyperextension
o EDL Z-lengthening and dorsal capsular release
ndications
moderate to severe MTP hyperextension
o PIPJ arthrodesis
indications
an option in rigid deformity
outcomes
high nonunion rate
o treat concurrent forefoot deformities
correct hallux valgus (for 2nd hammer toe)
arthrodesis for severe hallux valgus
amputation for severe hallux valgus touching 3rd toe
indications
elderly
poor health
does not want hallux reconstruction
Surgical Techniques
Resection arthroplasty +/- tenotomy and tendon transfers
o resection of head and neck of proximal phalanx to create a fibrous joint
+/- FDL to EDL transfer
o hold in place with K-wire for 2-3 weeks
o postoperative
protect for additional 3 weeks with taping of PIP in extension
Girdlestone procedure (flexor to extensor transfer)
o extensor tendon lengthening with Z plasty
o perform MTP capsule release
o +/- metatarsal shortening with oblique osteotomy
o FDL to EDL transfer
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Lesser Toe Deformities
3. Mallet Toe
Introduction
Mallet deformity is characterized by
o hyperflexion of the DIP joint
Deformity may be
o flexible or fixed
Pathoanatomy
o contracture (or spasm) of FDL because of pressure of toe against the end of shoe
> 70% of patients have a longer digit
o rupture of EDL at DIP joint
Congenital mallet toe
o associated with flexion and lateral deviation of the DIP joint
Anatomy
Claw Toe Hammer Toe Mallet Toe
Presentation
Physical exam
o callosities on toe
dorsum of the DIP
tip of toe; pain results from impacting the ground with gait
Treatment
Nonoperative
o shoes with high toe boxes, Silicone/foam toe sleeves
indications : first line of treatment
Operative
o percutaneous/open FDL tenotomy
indications
flexible deformities that have failed nonoperative management
o FDL transfer to dorsum of phalanx
indications
to prevent unopposed extensor with FDL tenotomy and cock-up deformity
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o DIPJ fusion or middle phalangeal distal condylectomy (excisional arthroplasty of DIP)
indications
rigid deformities that have failed nonoperative management
technique
repair attenuated extensor tendons
K wire placement used to hold affected digit in extension
Anatomy
Imaging
Radiographs
o recommended views
weight-bearing AP and lateral views of foot
o findings
widening or medial-lateral joint space imbalance of second MTP joint
dorsal subluxation of MTP joint
may appear like joint space narrowing or overlapping of the proximal phalanx on distal
metatarsal head
varus or valgus deformity of toe
MRI
o indications
if diagnosis unclear
quantify the extent of plantar plate or ligamentous disruption
Differential
Morton's neuroma
o may mimic Mortons neuroma
o important to differentiate MTP synovitis from interdigital neuroma because a steroid injection
into the interdigital space may weaken the capsuloligamentous structures at MTP joint leading to
progressive deformity
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Weil procedure
Treatment
Nonoperative
o activity/shoe wear modifications, NSAIDs, external support of MTP joint
indications
first line treatment
technique
external support with crossover taping or Budin-type toe splint
nonoperative treatment should last 10 to 12 weeks
subsequently avoid shoes that aggravate symptoms
Operative
o synovectomy
indications
no deformity
failure of nonoperative treatment
o distal oblique shortening MT osteotomy (Weil procedure)
indications
fixed deformity with long second metatarsal
technique
preserves joint
rebalances metatarsal cascade
relaxes plantar plate and rebalances alignment
o FDL-to-EDL tendon transfer (Girdlestone-Taylor) or MTP capsular release with extensor
tendon lengthening
indications
fixed deformity and NO long second metatarsal
sagittal deformity
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Lesser Toe Deformities
Complications
Vascular compromise
o if correcting a chronic dislocation the soft tissue, including vasculature, can contract
o stretching of the vasculature can compromise flow
o procedure may need to be reversed to save digit
5. MTP Dislocations
Introduction
A condition characterized by multiplanar instability of MTP joint
o often seen with "crossover toe"
o dorsomedial subluxation
Pathoanatomic stages
o plantar plate disrupted
can be caused by
traumatic rupture
chronic inflammation (more common)
o lateral collateral ligament fails
leads to medial deviation of the second toe
plantar plate, with its flexor tendon attachments, displace medially
medial displacement of the proximal phalanx relative to the metatarsal
o medial structures become contracted
lumbrical and interosseous tendons, medial collateral ligament (MCL), and medial capsule
become tight and contracted creating adduction force
o plantar plate subsequently fails
hyperextension forces on the proximal phalanx result in dorsal instability
Associated conditions
o MTP synovitis, deformity often accelerated by cortisone injection done for either misdiagnosed
Morton's neuroma or into the MPJ for synovitis.
Anatomy
Plantar plate ( see photos page 76)
o anatomy
broad, thick ligamentous structure that spans the plantar aspect of the MTP joint
origin
on the metatarsal head via a thin synovial attachment, just proximal to the metatarsal
articular surface
insertion
plantar base of the proximal phalanx
o function
resists tensile loads in the sagittal plane (particularly in dorsiflexion of the joint)
cushion the joint and support weightbearing forces
Presentation
Symptoms
o pain
o walking on “marble in the ball of their foot”
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o early instability (prior to deformity) may be confused with Morton's neuroma, deformity often
follows cortisone injection for presumed neuroma
Physical exam
o callus under the metatarsal head
o dorsomedial deviation of the toe in relation to the metatarsal
o hammertoe (flexion at the PIPJ, extension at the MPJ)
o dorsal instability found on "drawer test "
grip toe (proximal phalanx) with one hand and the metatarsal head with the other and move
toe dorsally
Imaging
Radiographs
o recommended views
weightbearing AP, oblique, and lateral
o findings
AP shows dislocation of the proximal phalanx (medial more often than lateral)
weightbearing lateral shows hyperextension and dorsal dislocation of the proximal phalanx
MRI
o indications
rule out other pathology
elucidate pathology of surrounding structures
o used in early stages of MTP synovitis to evaluate plantar plate but not necessarily useful in
dislocation
Treatment
Nonoperative
o taping, shoe modification, metatarsal pads, Budin splint, and NSAIDS
indications
first line of treatment
will not correct deformity
Operative
o distal oblique shortening MT osteotomy (Weil procedure)
indications
significant pain and loss of function
fixed deformity
o plantar plate repair
performed with metatarsal osteotomy
sutures passed through distal plantar plate and then through drill holes in proximal phalanx
o flexor to extensor tendon transfer
FDL split and brought over top of proximal phalanx to stabilize joint
o EDB transfer under intermetatarsal ligament
Surgical Techniques
Distal oblique shortening MT osteotomy (Weil procedure)
o soft tissue balancing
dorsal and medial capsular release with lateral capsular reefing can be used in combination
with Weil osteotomy
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Lesser Toe Deformities
EDB tendon transfer after rerouting tendon through transverse intermetatarsal ligament
results in a dynamic stabilizer of incompetent lateral structures
flexor digitorum longus (FDL)–to–extensor digitorum longus (EDL) tendon transfer
(Girdlestone-Taylor procedure)
resection arthroplasty of the metatarsal head (DuVries)
plantar plate repair as above
o osteotomy
intra-articular osteotomy that achieves longitudinal decompression through shortening and
allows joint reduction.
metatarsal (MT) is exposed and the direction of shortening in the original Weil procedure
runs mostly parallel to the plantar aspect of the foot.
o fixation
osteotomy is fixed by means of a screw running perpendicular to the osteotomy line.
Complications
Floating toe deformity
o inability to flex MTP joint causing 2nd digit dorsiflexion deformity (ie. floating toe)
o most common complication
Toe vascular compromise
o if correcting a chronic dislocation, the soft tissue (including vasculature) can contract
o stretching of the vasculature can compromise flow
o procedure may need to be reversed to save digit
6. Bunionette Deformity
Introduction
Prominence on the lateral aspect of the 5th metatarsal head : commonly called "tailor's bunion"
Epidemiology
o demographics
commonly seen in adolescents and adults
2-4x more common in women
often bilateral deformities
Pathophysiology
o mechanism of disease
extrinsic causes
compression of forefoot (e.g. tight shoes)
abnormal loading on the lateral aspect of the foot
intrinsic causes
congenital deformities (e.g. splayfoot, brachymetatarsia)
inflammatory arthropathies
residual malalignments from surgery
o pathoanatomy
boney prominence +/- bursitis over lateral aspect of 5th metatarsal head
increased 4-5 intermetatarsal angle (normal 6.5-8 degrees)
increased lateral deviation angle (normal 0-7 degrees)
increased width of MT head (normal <13mm)
lateral bowing of the 5th metatarsal bone
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Type 1 lesion. Note Type 2 lesion. Note Type 3 lesion. Note the increased angle
enlarged head without the abnormal bowing between the fourth and fifth metatarsals.
marked angulation. of the metatarsal and The angulation at the metatarsophalangeal
the secondary joint is secondary to medial pressure on
angulation of the the phalanx.
metatarso phalangeal
joint.
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Lesser Toe Deformities
Associated conditions
o varus MTP joint
o pes planus
Classification
Description
Type I Enlarged 5th MT head or lateral exostosis
Type II Congenital bow of 5th MT, normal 4-5 IMA
Type III Increased 4-5 IMA (most common)
Presentation
History
o effect on activities and employment
Symptoms
o cosmetic deformity
medial deviation of 5th toe
prominence of the 5th metatarsal head
o pain
lateral bunion
plantar callous
worse with constrictive shoe wear
Physical exam
II:22 hyperkeratosis
o inspection
plantar or lateral hyperkeratosis
widened forefoot
erythema and swollen 5th bunion
check shoe wear
o motion
often painless passive ROM of 5th MTP joint
Imaging
Radiographs
o recommended views
standard weight-bearing films, dorsoplantar, lateral & oblique films
o characteristic findings
increased 4-5 IMA (normal 6.5-8 degrees)
increased lateral deviation angle (normal 0-7 degrees)
increased width of MT head (normal <13mm)
CT scan
o indications
ancillary studies rarely required
may be used if there is associated trauma or malignancy
Treatment
Nonoperative
o NSAIDS, shoe wear modification, orthotics, keratosis padding, callous shaving
indications
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indicated as first-line treatment of all types
asymptomatic deformities
techniques
semi-rigid shoe inserts
wide based shoes
stretching the forefoot of existing shoes
outcomes
75-90% success rate
Operative
o lateral condylectomy
indications
symptomatic Type I deformities
technique
resection of lateral third of the 5th MT head
combine with tightening of lateral MTP joint capsule
outcome
does not require extended period of immobilization
o distal metatarsal osteotomy
indications
long-standing or severely symptomatic Type I deformity
Type 2 and 3 deformities if IMA is < 12 degrees
technique
different techniques described
chevron-medializing osteotomy (most common)
distal transverse osteotomy
peg-and-slot type osteotomy
stepcut osteotomy
better stability of fragments with internal fixation (e.g. K-wire or screw)
may be combined with distal condylectomy and tightening of lateral capsule
outcomes
chevron osteotomy is biomechanically the strongest construct compared to the other
proximal osteotomies
o oblique diaphyseal rotational osteotomy
indications
symptomatic Type 2 and 3 if IMA is > 12 degrees
technique
shave plantar aspect 5th MT head if plantar callosity present
proximal osteotomy should be avoided due to poor blood supply in this region of the
metatarsal
fixation achieved with screw
outcomes
may produce 5th MT shortening
o metatarsal head resection
indications
salvage procedure only
leads to unacceptable instability of MTP joint
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Lesser Toe Deformities
Complications
Recurrence
o is the most common complication with condylectomy alone
Transfer metatarsalgia
o seen with isolated metatarsal head resection
Claw toe
7. Freiberg's Disease
Introduction
A condition characterized by infarction and fracture of the metatarsal head.
o also known as Freiberg's infraction
Epidemiology
o demographics
female to male = ~ 4:1
most commonly seen in patients 13-18 years
more common in female adolescent athletes
o body location
most often seen in 2nd metatarsal (MT) head, particularly the dorsal aspect
4th and 5th MT rarely affected
o risk factors : more common in patients with long 2nd metatarsals
Pathophysiology
o thought to be related to a disruption in the blood supply due to microtrauma or osteonecrosis
and stress overloading
leads to eventual collapse of 2nd MT head
Classification
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Smillie Classification
Stage 1 Subchondral fracture visible only on MRI
Stage 2 Dorsal collapse of articular surface on plain radiographs
Stage 3 Collapse of dorsal MT head, with plantar articular portion intact
Stage 4 Collapse of entire MT head, joint space narrowing
Stage 5 Severe arthritic changes and joint space obliteration
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Lesser Toe Deformities
Presentation
Symptoms
o forefoot pain, swelling and stiffness localized to head of the second MT
worse with weight bearing activities
Physical exam
o inspection
peri-articular swelling
o motion
exacerbated by distraction (early stages) and compaction (later stages)
limitation of motion in 2nd MTP joint
Imaging
Radiographs
o recommended views
AP, lateral, obliques of foot
o findings (see Smillie classification)
subchondral sclerosis in early disease
flattening of involved MT head
joint destruction in late disease
defect is usually located in the upper half of the articular surface of the MT head
MRI
o findings
can show patchy edema in metatarsal head
Plain radiograph shows Joint destruction of the 2nd T2 coronal MRI shows
example of Freiberg's metatarsal head from Freiberg's example of Freiberg's
disease of 2nd MT head. disease disease with patchy edema in
2nd MT head.
Treatment
Nonoperative
o activity limitations, NSAIDS, immobilization
indications : early stage of disease
technique
short leg walking cast or boot for 4-6 weeks
can be used if symptoms are severe and do not improve with orthotics
stiff-soled shoe with MT bars or pads
typically used after period of casting
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Operative
o metatarsophalangeal arthrotomy with removal of loose bodies
indications
very rarely indicated
only if extensive nonoperative management fails
o dorsal closing-wedge osteotomy
indications
dorsal disease involvement of bone and cartilage
o DuVries arthroplasty (partial MT head resection)
indications
severe stage 4 or 5 disease
plantar cartilage is not sufficient to reconstruct joint
can consider adding capsular interposition after joint debridement
Techniques
Metatarsophalangeal arthrotomy with removal of loose bodies
o approach : lesser toe MTP joint approach
o technique
may be combined with drilling of metatarsal head, subchondral bone grafting, and
interposition arthroplasty using EDL tendon
metatarsal head resection should be avoided due to increased loads on adjacent metatarsal
heads
Dorsal closing-wedge osteotomy
o goals
shortening offloads stress on metatarsal head
resects collapsed dorsal diseased bone and cartilage
o approach
lesser toe MTP joint approach
o technique
bring less affected plantar cartilage into contact with
proximal phalanx
Complications
II:23 Duvries arthroplasty at 3yr (left) and 5yr (right)
Degenerative joint disease
o of 2nd MTP joint in adulthood
D. Arthritic Conditions
Classification
Berndt and Harty Radiographic Classification
Stage 1 • Small area of subchondral compression
Stage 2 • Partial fragment detachment.
Stage 3 • Complete fragment detachment but not displaced.
Stage 4 • Displaced fragment.
Presentation
Symptoms
o pain, swelling, and mechanical symptoms such as catching or
locking
Physical exam
o effusion
Imaging
Radiographs
o may be normal
o may see subtle lucency or bone fragmentation
CT
o helpful in evaluating lesions seen on radiographs
MRI
o indicated in ankle sprains that do not heal with time
Treatment
Nonoperative
o short leg cast and non weight bearing for 6 weeks
indications
acute injury
nondisplaced fragment with incomplete fracture
Operative
o arthroscopy with removal of the loose fragment and microfracture or antegrade drilling of
the base
indications
chronic fractures
size < 1 cm
displaced smaller fragment with minimal bone on the osteochondral fragment (poor
healing potential)
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Arthritic Conditions
o retrograde drilling and or bone grafting
indications
size > 1 cm with intact cartilage cap
o ORIF vs. osteochondral grafting
indications
size > 0.5 cm and displaced
rehabilitation
emphasize peroneal strengthening, range of motion, and proprioceptive training
2. Ankle Arthritis
Introduction
Defined as osteoarthritis of the tibiotalar joint
Epidemiology
o less common than OA of knee and hip
Pathophysiology
o causes include
post-traumatic arthritis
most common etiology, accounting for greater than 2/3 of all ankle arthritis
primary osteoarthritis
accounts for less than 10% of all ankle arthritis
other etiologies include rheumatoid arthritis, osteonecrosis, neuropathic, septic, gout, and
hemophiliac
o pathoanatomy
nonanatomic fracture healing alters the joint contact forces of the ankle and changes the load
bearing mechanics of the ankle joint
loss of cartilage on the talar body and tibial plafond results in joint space narrowing,
subchondral sclerosis and eburnation
Anatomy
Osteology
o a ginglymus joint that includes the tibia, talus, and fibula
o talar dome is biconcave with a central sulcus
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Range of motion
o ankle dorsiflexion: 20 degrees
o ankle plantar flexion: 50 degrees
Classification
Takakura Classification
Stage I Early sclerosis and osteophyte formation, no joint space narrowing
Stage II Narrowing of medial joint space (no subchondral bone contact)
Stage Obliteration of joint space at the medial malleolus, with subchondral bone
IIIA contact
Stage Obliteration of joint space over roof of talar dome, with subchondral bone
IIIB contact
Stage IV Obliteration of joint space with complete bone contact
Stage IIIB - obliteration of joint space Stage IV - obliteration of joint space with
advanced to roof of talar dome, with complete bone contact
subchondral bone contact
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Arthritic Conditions
Presentation
Symptoms
o pain with weight bearing
o loss of motion
Physical exam
o joint effusion
o pain with ROM testing, loss of ROM compared to the contralateral side
o angular deformity may be present depending on the history of trauma
Imaging
Radiographs
o recommended views : weight bearing AP, lateral, and obliques
o radiographic findings include
loss of joint space
subchondral sclerosis and cysts
eburnation
possible angular deformity
Treatment
Nonoperative
o activity modification, bracing to immobilize the ankle, and NSAIDS
indications
indicated as first line of treatment in mild disease
single rocker sole shoe modification can improve gait and pain symptoms
Operative
o surgical management
indications
indicated upon failure of conservative treatment in a patient with radiographic evidence
of ankle arthritis
Surgical Techniques
Ankle debridement with anterior tibial/dorsal talar exostectomy
o indications : mild disease with pain during push off
Distraction arthroplasty
o controversial
o ideal candidate younger than 45 yrs with post-traumatic arthritis
o indications
well-preserved ankle ROM
moderate to severe arthritis
congruent tibiotalar surface
also for partial AVN talus
Supramalleolar osteotomy
o indications
near-normal ROM
minimal talar-tilt or varus heel alignment
medially focused ankle arthritis
stage 2 or 3a according to the Takakura-Tanaka classification for varus-type osteoarthritis
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Arthrodesis
o indications
ideal for the elderly, less active patient
o outcomes
reliable relief of pain and return to activities of daily living
o complications
long term studies demonstrate subtalar arthrosis
50% of patients demonstrated subtalar arthrosis 10 years following ankle arthrodesis in
one study
Risk factors for nonunion include smoking, adjacent joint fusion, history of failed previous
arthrodesis, and avascular necrosis
Arthroplasty
o indications
patient selection is crucial
indications
posttraumatic or inflammatory arthritis, elderly patient
contraindications
uncorrectable deformity, severe osteoporosis, talus osteonecrosis, charcot joint, ankle
instability, obesity, and young laborers increase the risk of failure and revision
o techniques
new generation arthroplasty minimizes bony resection, retains soft tissue stabilizers, and
relies on anatomic balancing
o outcomes
recent 5-10 year outcome studies demonstrate up to 90% good to excellent clinical results,
long-term studies are still pending on the newest generation of ankle arthroplasty
increased gait speed and stride length
o complications
syndesmosis nonunion
include wound infection, deep infection, and osteolysis
3. Tibiotalar Impingement
Introduction
Most often caused by osteophyte impingement in anterior tibiotalar joint
can also be caused by excessive anterolateral soft tissues or posterior soft tissue or osseous
abnormalities
Epidemiology
o common in athletes who play on turf or on grass including
rugby
football
dancers
soccer
Mechanism
o repetitive overuse injuries
o trauma
o degenerative sequelae
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Arthritic Conditions
Presentation
Symptoms
o pain in anterior ankle
Physical exam
o pain with forced dorsiflexion
o limited dorsiflexion
o soft tissue swelling and effusion may be evident
o subtalar joint is pain free
Imaging
Radiographs
o recommended views
AP, lateral, and oblique
o findings
spurs seen in anterior distal tibia or dorsal aspect of the talus
oblique views are beneficial in revealing anteromedial talar spurs
CT
o delineates extent of bony osteophytes
MRI
o shows spurring and fluid in joint
Treatment
Nonoperative
o therapy, lifestyle modifications, NSAIDS
indications
first line of treatment
Operative
o arthroscopic excision
indications
nonoperative modalities fail
Techniques
Arthroscopic excision
o supine position with external traction device and leg over a padded bump
o use knife to only cut the skin and use hemostat to spread to avoid neurovascular injury while
making portals
o ensure adequate field of view prior to burring or shaving anterior distal tibia to avoid iatrogenic
dorsal NV bundle injury
Complications
Superficial peroneal nerve injury during anterolateral portal creation
Saphenous vein injury during anteromedial portal creation
Dorsal neurovascular bundle injury during tibiotalar spur removal
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4. Midfoot Arthritis
Introduction
Defined as arthritis of the midfoot which includes the following joints
o naviculocuneiform joint
o intercuneiform joint
o metatarsal cuneiform
Pathophysiology
o etiology
idiopathic (primary) : osteoarthritis is most common form of midfoot arthritis
posttraumatic
inflammatory
o pathoanatomy
large forces seen by joints that have limited motion
soft tissues that support joints see abnormally high forces over time
results in midfoot collapse
Presentation
Symptoms
o midfoot pain (and in arch) with push off
Physical exam
o inspection
deformity shows
longitudinal arch collapse with weight bearing
midfoot collapse (look like PTTI)
forefoot abduction
hindfoot valgus
equinuus contracture of achilles tendon
halux valgus
o palpation
palpation of arch/midfoot leads to pain
Imaging
Radiographs II:24 Note the bilateral midfoot arthritis,
o lateral with the right foot being more severe than
the left. As the midfoot collapses, the
loss of co-linearity between talus-1st MT (Meary's line)
forefoot will abduct in an attempt to
apex of deformity is at the level of the midfoot restore the mechanical tripod of the foot
may show collapse of longitudinal arch
o AP
arthritic signs in midfoot
inflammatory etiology consistent with symmetric degeneration across midfoot
abduction of forefoot
Differential
PTTI
post-traumatic Lis-Franc injury
Lateral ankle instability
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By Dr, AbdulRahman AbdulNasser Degenerative Conditions | Arthritic Conditions
Treatment
Nonoperative
o NSAIDS, activity modification, orthotic/bracing
indications
first line of treatment
modalities
steroid injections under radiographic guidance
can be diagnostic and therapeutic
orthotics
cushioned heel
longtidunal arch supports
stiff sole with a rocker bottom
Operative
o midfoot arthrodesis, +/- TAL, +/- hindfoot realignment
indications
failure of non operative management
outcomes
midfoot joints are non-essential joints
arthrodesis results in close to normal foot function
o Achilles tendon lengthening/hindfoot realignment
may need to be done concomitantly
Technique
Midfoot arthrodesis
o approach
realignment arthrodesis
close to full physiologic foot function, especially during push-off, can be established
tarsometatarsal joints are 2-3 cm deep and warrant appropriate preparation prior to fusion
o realignment arthrodesis
fusion of the first ray via the first tarso-metatarsal joint
fusion of the second/third rays via the naviculocuneiform/intercuneiform joints
do not fuse the 4th/5th tarsometatarsal joints
the lateral ray mobility facilitates foot accomodation during stance
interpositional arthroplasties of the 4th/5th tarsometatarsal joints
select cases
will maintain length of lateral column
can assist with gait accommodation
o instrumentation
may use screws, staples, plates designed for midfoot fusions
o concomitant procedures
Achilles tendon lengthening
hindfoot realignment
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ORTHO BULLETS
III.Neurologic Conditions
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By Dr, AbdulRahman AbdulNasser Neurologic Conditions | Diabetic Conditions
A. Diabetic Conditions
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By Dr, AbdulRahman AbdulNasser Neurologic Conditions | Diabetic Conditions
Studies
Transcutaneous oxygen pressures (TcpO2)
o considered Gold Standard to assess wound healing potential
o > 30 mm Hg (or 40mmHg depending on review source cited) is a good sign of healing potential
ABI's and ischemic index
o calcification in the arteries can result in inaccurate doppler flow readings
calcifications falsely elevate the ABI's due to decreased compliance of the calcified vessels
index of > 0.45 and toe pressure >40mm Hg are needed to heal ulcer
Imaging
Radiographs
o recommended views
AP, lateral, and oblique of foot and ankle
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MRI
o best for differentiating abscess from soft tissue swelling
o difficult to differentiate infection from Charcot arthropathy on MRI
Bone scan
o views
obtain with technetium Tc99m, gallium (Ga)67, or indium (In) 111
o useful to differentiate between
soft tissue infection
osteomyelitis
Charcot arthropathy
Treatment
General
o factors important in deciding a treatment plan include
angiopathic vs. neuropathic
deep vs. superficial
+/- osteomyelitis, antibiotics based on bone biopsy culture sensitivities
+/- pyarthrosis
Nonoperative
o shoe modification
indications
prevention when signs of potential ulcers are present
Includes deep or wide shoes, custom insoles, rocker bottom soles, etc.
of the available shoe only modifications, rocker sole shoes best reduce the plantar pressure on
the forefoot
medicare will cover modifications and custom shoes/insoles yearly
o wound care
indications
first line of treatment
goals of wound care and dressings
provide moist environment
absorb exudate
act as a barrier
off-load pressure at ulcer
o total contact casting (TCC)
indications
gold standard for mechanical relief plantar ulcerations
contraindications
absolute
infection
relative
marginal arterial supply to affected area
patients unable to comply with cast care
patients unable to tolerate a cast (cast claustrophobia)
outcomes
if ulcer recurs, it is typically 3-4 weeks after cast removal
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Operative
o surgical debridement, antibiotics, local wound care, contact casting
indications
grade 3 or greater ulcers should undergo I&D with antibiotic treatment before casting
outcomes
high rates of associated osteomyelitis if bone is able to be probed, or is exposed at the
base of the ulcer
o ostectomy +/- TAL
indications
bony prominence causing internal pressure
technique
TAL indicated if tight Achilles
several studies have shown TAL to be effective to help heal and prevent recurrence of
plantar forefoot ulcers
o partial calcanectomy +/- TAL
indications
large heel ulcers with associated calcaneal osteomyelitis
outcomes
preserves limb length and decreases morbidity compared to higher level amputations
o Syme amputation
indications
forefoot gangrene and a palpable posterior tibial artery pulse
o Keller resection arthroplasty
indications
IPJ plantar neuropathic ulcer with hypomobile/stiff MTPJ that has failed total contact
casting
Techniques
Total Contact Casting
o often necessary for up to 4 months
o TCC followed by Charcot restraint walker then custom shoe
o pneumatic walking brace
alternative to TCC, same principal
allows better wound surveillance
significant deformity and/or extremely large girth often requires custom pneumatic walkers
patient compliance with offloading can be an issue because the pneumatic walker is
removable
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neurotraumatic
insensate joints subjected to repetitive microtrauma
body unable to adopt protective mechanisms to compensate for microtrauma due to
abnormal sensation
neurovascular
autonomic dysfunction increases blood flow through AV shunting
leads to bone resorption and weakening
o molecular biology
inflammatory cytokines may cause destruction
IL-1 and TNF-alpha lead to increased production of
transcription factor-kB
RANK/RANKL/OPG triad pathway
Associated conditions
o orthopaedic manifestations
foot ulcerations
III:4 example of charcot shoulder
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By Dr, AbdulRahman AbdulNasser Neurologic Conditions | Diabetic Conditions
Classification
Brodsky Classification
Type 1 • Involves tarsometatarsal and naviculocuneiform joints 60%
• Collapse leads to fixed rocker-bottom foot with valgus angulation
Type 2 • Involves subtalar, talonavicular or calcaneocuboid joints 10%
• Unstable, requires long periods of immobilization (up to 2 years)
Type 3A • Involves tibiotalar joint 20%
• Late varus or valgus deformity produces ulceration and osteomyelitis of
malleoli
Type 3B • Follows fracture of calcaneal tuberosity < 10%
• Late deformity results in distal foot changes or proximal migration of the
tuberosity
Type 4 • Involves a combination of areas < 10%
Type 5 • Occurs solely within forefoot < 10%
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Eichenholtz Classification
Stage 0 • Joint edema
• Radiographs are negative
• Bone scan may be positive in all stages
Stage 1 • Joint edema
fragmentation • Radiographs show osseous fragmentation with joint
dislocation
Stage 2 • Decreased local edema
coalescence • Radiographs show coalescence of fragments and absorption
of fine bone debris
Stage 3 • No local edema
reconstruction • Radiographs show consolidation and remodeling of fracture
fragments
Stage 0 - hot foot, normal Xrays. MR shows bone oedema and fractures
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By Dr, AbdulRahman AbdulNasser Neurologic Conditions | Diabetic Conditions
Stage 3 - Remodelling
Presentation
Symptoms
o swollen foot and ankle
o pain in 50%, painless in 50%
o loss of function
Physical exam
o acute Charcot neuropathy
inspection
swollen
warm
average of 3.3 degrees C warmer than contralateral side
erythema
often confused with infection
erythema will decrease with elevation in Charcot arthropathy, but is unchanged in
infection
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Note the significant swelling An example of a rocker bottom foot Example of a collapsed
in the left foot in comparison deformity in Charcot arthropathy. medial longitudinal arch in
to the unaffected right side. Charcot arthropathy.
o chronic Charcot neuropathy
inspection
structurally deformed foot
bony prominences
rocker bottom deformity
collapse of medial arch
motion
may be ligamentously unstable
neurovascular
Semmes-Weinstein monofilament testing III:5 The erythematous foot in Charcot arthropathy is
frequently confused for infection. In contrast to
Imaging infection, the erythema will resolve with elevation of
the foot in Charcot.
Radiographs
o views
obtain standard AP and lateral of foot, complete ankle series
o findings
early changes
degenerative changes may mimic osteoarthritis
late changes
obliteration of joint space
fragmentation of both articular surfaces of a joint leading to subluxation or dislocation
scattered "chunks" of bone in fibrous tissue
surrounding soft tissue edema
joint distension by fluid
heterotopic ossification
Bone scan
o Indications: useful to help determine presence of superimposed osteomyelitis
o type of study
technetium bone scan
may be positive for a neuropathic joint and osteomyelitis
indium WBC scan
negative (cold) for neuropathic joints and positive (hot) for osteomyelitis
MRI
o indications
best for differentiating abscess from soft-tissue swelling
most sensitive in diagnosing soft tissue and/or osteomyelitis
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o limitations
difficult to differentiate infection from Charcot arthropathy on MRI
Studies
Laboratory
o inflammatory markers
ESR and WBC
elevated in both infection and Charcot arthropathy
o wound healing levels
absolute lymphocyte count >1500/mm3 III:6 detritic synovitis
serum albumin >3.0g/dL
Biopsy
o may be used to guide antibiotic therapy in cases of associated osteomyelitis or soft tissue abscess
Histology
o synovial hypertrophy
o detritic synovitis (cartilage and bone distributed in synovium)
Treatment
Nonoperative
o total contact casting, shoewear modifications, medications
indications
first line of treatment
technique
contact casting
casts changed every 2-4 weeks for 2-4 months III:7 An example of a total
contact cast.
orthotics
Charcot restraint orthotic walker (CROW) boot can be used after contact casting
shoe modifications
in Eichenholtz stage 3 double rocker shoe modifications will best reduce risk for
ulceration at the plantar apex of the deformity
medications
bisphosphonates
neuropathic pain medications
antidepressants
topical anesthetics
outcomes
75% success rate
Operative
o resection of bony prominences (exostectomy) and TAL
III:8 A CROW walking boot.
indications
"braceable" foot with equinus deformity and focal bony prominences causing skin
breakdown
technique
goal is to achieve plantigrade foot that allows ambulation without skin compromise
o deformity correction, arthrodesis +/- osteotomies
indications : severe deformity that is not "braceable"
Outcomes: very high complication rate (up to 70%)
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o amputations
indications
failed previous surgery (unstable arthrodesis)
recurrent infection
technique
goal is for a partial or limited amputation if vascularity
allows
Surgical Techniques
Arthrodesis III:9 Example of a tibiocalcaneal nail used
for arthrodesis in Charcot arthropathy.
o technique
fixation techniques
internal fixation
srew, pins, plates, tibiocalcaneal nail
external fixation
used when bone quality is poor or soft tissues are
compromised
o post-operative care
minimal weight-bearing for three months
o cons
high complication rate (up to 70%) III:10 Example of an external fixator used for
infection Charcot arthropathy.
hardware malposition
recurrent ulceration
fracture
Total contact casting (TCC) is a specially designed cast designed to take weight off of the foot (off-
loading) in patients with diabetic foot ulcers (DFUs). Reducing pressure on the wound by taking
weight of the foot has proven to be very effective in DFU treatment. DFUs are a major factor leading
to lower leg amputations among the diabetic population in the US with 85% of amputations in
diabetics being preceded by a DFU.[1] Furthermore, the 5 year post-amputation mortality rate among
diabetics is estimated at around 45% for those suffering from neuropathic DFUs.[2]
TCC has been used for off-loading DFUs in the US since the mid-1960s and is regarded by many
practitioners as the “reference standard” for off-loading the bottom surface (sole) of the foot.[3]
TCC involves encasing the patient’s complete foot, including toes, and the lower leg in a specialist
cast that redistributes weight and pressure in the lower leg and foot during everyday movements. This
redistributes pressure from the foot into the leg, which is more able to bear weight, to protect the
wound, letting it regenerate tissue and heal.[4] TCC also keeps the ankle from rotating during
walking, which prevents shearing and twisting forces that can further damage the wound.[5]
Effective off loading is a key treatment modality for DFUs, particularly those where there is
damage to the nerves in the feet (peripheral neuropathy). Along with infection management and
vascular assessment, TCC is vital aspect to effectively managing DFUs.[6] TCC is the most effective
and reliable method for off-loading DFUs
Source : Wikipedia.org
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By Dr, AbdulRahman AbdulNasser Neurologic Conditions | Neurologic Conditions
B. Neurologic Conditions
Presentation
Symptoms
o deformity and difficulty with gait
Physical exam
o most common physical finding is spastic equinovarus deformity
o increased tone
o hyperreflexia
Imaging
Radiographs
o recommended views
AP, lateral, oblique of foot and ankle
Treatment
Nonoperative
o physical therapy, injections, orthoses
indications
as first line of treatment
modalities
therapy
focus on stretching and strengthening, maintenance of joint range of motion
injections
phenol blocks and botulinum toxin injections are used
AFO
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should be used while the patient is in bed or wheelchair
Operative
o Achilles tendon lengthening with split anterior tibialis tendon transfer (SPLATT)
indications
fixed contractures persist after the period of neurologic recovery and are not braceable.
functional deficits
skin problems secondary to deformity
technique
equinus deformity is treated with lengthening of the Achilles tendon
varus deformity is treated with a split anterior tibialis tendon transfer (SPLATT)
o osteotomies and fusions
indications
recurrence of deformity despite proper soft tissue procedures
Surgical Techniques
Split anterior tibialis tendon transfer (SPLATT)
o often done in conjunction with
achilles lengthening (open or percutaneous)
gastrocnemius recession
lengthening or dorsal transfer of the posterior tibialis tendon (PTT) may also be necessary
o the tibialis anterior is split and the lateral half is attached to the cuboid through a drill hole and
sutured in place
Complications
Hindfoot valgus
o inadvertent lengthening of PTT can result in over correction
Anatomy
Interdigital nerve
o location
lies plantar to the transverse intermetatarsal ligament between the metatarsal heads
o components
confluence branches of the lateral and medial plantar nerves
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Presentation
Symptoms
o pain
worse with weight-bearing or wearing narrow toe box shoes (e.g. high heels)
relief of symptoms by removing shoes and massaging foot
o paresthesia
most commonly on the plantar aspect of web space
Physical exam
o palpation
neuroma may be palpable
positive web-space compression test
o provocative tests
Mulder's click
bursal click may be elicited by squeezing metatarsals together
Drawer test at metatarsal phalangeal joint (MTPJ)
assess for MTPJ instability
Imaging
Radiographs
o recommended views
weight bearing AP/lateral/oblique views
o findings
usually normal
may see bony deformity
Ultrasound
o indication
non-palpable neuroma with clear clinical presentation
o findings
oval, hypoechoic mass oriented parallel to the metatarsal bones
o outcomes
highly operator dependent
MRI
o indication
not usually required for diagnosis
may be used to rule out other pathologies
Studies
Common digital nerve block
o indication
confirmatory for accurate diagnosis of interdigital neuroma
o findings
numbness over lateral surface of toe with relief of patient reported pain
Differential diagnosis
MTP synovitis
o consider if there is no relief of pain after well positioned digit nerve block
Metatarsalgia
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By Dr, AbdulRahman AbdulNasser Neurologic Conditions | Neurologic Conditions
Stress fracture
MTPJ arthritis
Metatarsal head osteonecrosis
Neoplasm
Lumbar radiculopathy
Treatment
Nonoperative
o wide shoe box with firm sole and metatarsal pad
indications
first line of treatment
outcomes
results are unpredictable
approximately 20% of patients will have complete resolution of symptoms
adding anti-inflammatory medications rarely provide any benefit
o corticosteroid injection
indications
symptomatic benefit
modality
usually approached dorsal after isolating the neuroma with palpation or ultrasound
outcomes
evidence for its effectiveness is weak
suggested to provide symptomatic benefit in short term randomized control studies
Operative
o neurectomy
indications
failure of nonoperative management
techniques
dorsal or plantar approach (dorsal most common)
neurectomy with nerve burial (bury proximal stump within intrinsic muscles)
transverse intermetatarsal ligament release
Surgical Technique
Dorsal neurectomy
o approach
3 to 4 cm incision just proximal to the involved webspace
blunt dissection to avoid injury to branches of superficial peroneal nerve
o technique
spread the metatarsal bones to visualize the webspace, as well as tension the transverse
intermetatarsal ligament
protecting the neurovacular bundle, transect the transverse intermetatarsal ligament
identify the interdigital nerve proximal and distal to the nerve bifurcation
resect the nerve as far proximal as possible
reapproximate and repair the transverse intermetatarsal ligament to avoid intermetatarsal
head instability
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Complications
Stump neuroma
o causes include
inadequate retraction (traction neuritis)
most common
caused by tethering of plantar neural branches that prevent retraction following resection
inadequate resection (not proximal enough)
o resect through plantar or dorsal incision
Painful plantar scar
o increased risk (5%) with plantar incision
Anatomy
Posterior tarsal tunnel
o an anatomic structure defined by
flexor retinaculum (laciniate ligament)
calcaneus (medial)
talus (medial)
abductor hallucis (inferior)
o contents include
tibial nerve
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posterior tibial artery
FHL tendon
FDL tendon
tibialis posterior tendon
Tibial nerve
o has 3 distal branches
medial plantar
lateral plantar
medial calcaneal
the medial and lateral plantar nerves can be
compressed in their own sheath distal to
tarsal tunnel
bifurcation of nerves occurs proximal to
tarsal tunnel in 5% of cases
Anterior tarsal tunnel
o flattened space defined by
inferior extensor retinaculum
fascia overlying the talus and navicular
o contents include
deep peroneal nerve and branches
EHL
EDL
dorsalis pedis artery
Presentation
History
o may have previous trauma or surgery
Symptoms
o pain
pain with prolonged standing or walking
often vague and misleading medial foot pain
III:11 Anterior Tibial Tunnel - EHL
sharp, burning pains in the foot extensor hallucis longus, EDL extensor
o numbness digitorum longus, EHB extensor hallucis
brevis, dpn deep peroneal nerve, ier
intermittent paresthesias and numbness in the plantar foot inferior extensor retinaculum
o may present as part of the "heel pain triad"
posterior tibial tendon deficiency (adult-acquired flatfoot), plantar fasciitis, tarsal tunnel
syndrome
believed to be due to loss of static and dynamic stabilizers of the medial arch and susequent
traction neuropathy on the tibial nerve
Physical exam
o tenderness of tibial nerve (tinel's sign)
o sensory exam equivocal
o pes planus
o muscle wasting of foot intrinsics
abductor digiti quinti or abductor hallucis
o pain with dorsiflexion and eversion of the ankle
o compression test
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plantar flexion and inversion of ankle
digital pressure over tarsal tunnel
highly senstitive and specific
Imaging
Radiographs
o weight-bearing radiographs provide osseous structure
MRI
o may be helpful to rule out accessory muscle or soft-tissue tumor
Studies
EMG
o positive finding include
distal motor latencies of 7.0 msec or more
prolonged SENSORY latencies of more than 2.3 msec
sensory (SAP) more likely to be abnormal than motor
decreased amplitude of motor action potentials of
abductor hallucis
or abductor digiti minimi
Diagnosis
o history is often most useful diagnostic aid
Treatment
Nonoperative
o lifestyle modifications, medications
indications
usually ineffective
medications
anti-inflammatory medications
SSRIs have been used
bracing
orthosis or foot wear changes to address alignment of hindfoot
can try a period of short-leg cast
Operative
o surgical release of tarsal tunnel
indications
after 3-6 months of failed conservative management and
compressive mass (ganglion cyst) identified
positive EMG
reproducible physical findings
outcomes
best results following surgery are in cases where a compressing anatomic
structure (ganglion cyst) is identified and removed
traction neuritis does not respond as well to surgery
Technique
Tarsal Tunnel Surgical Release
o approach
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By Dr, AbdulRahman AbdulNasser Neurologic Conditions | Neurologic Conditions
identify the nerve proximally
o decompression
layers that must be released include
flexor retinaculum
deep investing fascia of lower leg
superficial and deep fascia of abductor hallucis
Complications
Recurrence
o usually caused by inadequate release
o repeat tarsal tunnel release not recommended
Imaging
Radiographs
o recommended views
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By Dr, AbdulRahman AbdulNasser Neurologic Conditions | Neurologic Conditions
lateral view of foot and ankle
o findings
dorsal osteophytes
sequelae of prior fracture
CT
o to define bony anatomy of canal
MRI
o best for evaluation of mass lesions
Treatment
Nonoperative
o shoe modifications
indications III:13 Note the dorsal bony prominence caused by navicular
first line of treatment nonunion
techniques
NSAIDs
PT (if ankle instability contributing)
injection
well padded tongue on shoe
alternative lacing configurations
full length rocker-sole steel shank
night splint (to prevent natural tendency for ankle to assume plantar flexion)
diuretic if chronic peripheral edema is implicated
Operative
o surgical release of DPN by releasing inferior extensor retinaculum and osteophyte /
ganglion resection
indications
failure of nonoperative treatment
symptoms of RSD are a contraindication to release
outcomes
80% satisfactory
Technique
Surgical release of DPN by releasing inferior extensor retinaculum and osteophyte / ganglion
resection
o approach
S-shaped incision over dorsum of foot from ankle joint proximally to base of first and second
metatarsals distally
o decompression
start distal, identify nerve, and release both branches proximally (nerve lies lateral to EHL)
resect osteophytes, debulk hypertrophic muscle bellies
o postoperative
no compressive shoe wear
Complications
Persistent symptoms following decompression
o warn patient that recovery is prolonged
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OrthoBullets2017 Neurologic Conditions | Neurologic Conditions
Obturator nerve
Found in patients with well-developed hip adductors (skaters)
Can cause chronic medial thigh pain
Nerve conductions studies help establish diagnosis
Treatment
o nonoperative
supportive
Sciatic nerve
Can occur anywhere along the course of the nerve
Most common locations
o at level of ischial tuberosity
o at the piriformis muscle (piriformis syndrome)
Saphenous neuritis
Compression of the saphenous nerve, usually at Hunter's canal
o also known as surfer's neuropathy
Caused by kneeling for long periods of time
Symptoms
o pain inferior and medial to knee
Treatment
o nonoperative
knee pads
indications
first line of treatment
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By Dr, AbdulRahman AbdulNasser Neurologic Conditions | Neurologic Conditions
Common peroneal nerve
Can be compressed behind fibula by a ganglion cyst or injured by a direct blow
Fusion of the proximal tibiofibular joint may be needed to prevent cyst recurrence
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OrthoBullets2017 Neurologic Conditions | Neurologic Conditions
Sural nerve
Can occur anywhere along the course of the nerve
Most vulnerable 12-15mm distal to the tip of the fibula as the foot rests in equinus position
Treatment
o operative
surgical release
Interdigital neuroma
Also known as Morton's neuroma
6. Poliomyelitis
Introduction
A disease caused by viral destruction of the anterior horn cells in the spinal cord and brain stem
motor nuclei
o hallmark is motor weakness with normal sensation
Epidemiology
o has been eradicated in the United States with the use of a vaccine
Associated conditions
o Postpolio syndrome
an aging phenomenon where more nerve cells become inactive with time
it does not represent reactivation of the virus
occurs after middle age
occurs in up to 50% of polio cases
leads to increasing difficulty performing activities of daily living
patients should exercise at sub-exhaustion levels to tone affected muscle groups without
causing muscle breakdown
Presentation
Physical Exam
o hallmark is muscle weakness with normal sensation
Treatment
Postpolio Syndrome
o nonoperative
limited exercise with periods of rest, +/- lightweight orthosis
indications
first line of treatment
technique
goal is to maintain but not overuse muscles
o operative
tendon transfers, contracture releases, and arthrodesis
indications
used to optimize functional capacity
Polio foot deformities
o nonoperative
lightweight orthoses
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By Dr, AbdulRahman AbdulNasser Neurologic Conditions | Neurologic Conditions
indications
first line of treatment
help patient remain functionally independent
o operative
contracture release, tendon transfer, and arthrodesis
indication
if orthoses do not achieve satisfactory standard of living
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In July 2017
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OrthoBullets2017 Procedures | Neurologic Conditions
ORTHO BULLETS
IV. Procedures
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By Dr, AbdulRahman AbdulNasser Procedures | Tested Procedure Review
1. Ankle Arthroscopy
Indications
Indications
o osteochondral lesions of the talus
o microfracture of OCD
o debridement of post-traumatic synovitis
o ATFL anterolateral impingement
o AITFL anterolateral impingement
o resection of anterior tibiotalar spurs
such as anterior bony impingement
o os trigonum excision
o removal of loose bodies
o cartilage debridement in conjunction with ankle fusions
Portals
Anteromedial
o function
primary viewing portal
typically established first
access to anteromedial joint
o location and technique
medial to tibialis anterior and lateral to medial malleolus
make portal between tibialis anterior and saphenous vein
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OrthoBullets2017 Procedures | Tested Procedure Review
Anterolateral
o function
primary viewing portal
access to anterolateral joint
o location and technique
located just lateral to peroneus tertius and superficial peroneal nerve and medial to lateral
malleolus
can trace out superficial peroneal nerve prior to incision
Anterocentral
o function
anterior viewing portal
o location and technique
not commonly utilized due to danger to dorsal pedis artery
medial to EDC and lateral to EHL
Posterolateral
o function
posterior viewing portal for access to os trigonum
o location and technique
located 2cm proximal to tip of lateral malleolus
medial to peroneal tendons and lateral to achilles tendon
Posteromedial
o function
posterior viewing portal for access to os trigonum
o location and technique
just medial to achilles tendon
Complications
Synovial cutaneous fistula
o avoid by immobilization to allow portal skin
healing and closure
Neurovascular injury from portal placement
o neuropraxia most common complication
o Anterolateral portal
risks superficial peroneal nerve
most common neurovascular injury
specifically, the dorsal intermediate
cutaneous branch
o Anteromedial portal
risks saphenous nerve and vein
o Anterocentral portal
risks dorsalis pedis artery
o Posterolateral portal
risks sural nerve and short saphenous vein
o Posteromedial portal
risks posterior tibial artery
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By Dr, AbdulRahman AbdulNasser Procedures | Tested Procedure Review
2. Ankle Arthrodesis
Indications
Indications
o painful arthritis following
infection
trauma (most common cause)
chronic instability
AVN of the talus
inflammatory arthropathy
primary OA
o neuropathic arthropathy
o tumor resection
o salvage for failed ORIF
o salvage for failed TAA
Technique
Optimal Position
o neutral dorsiflexion
o 5-10° of external rotation
o 5° of hindfoot valgus
Arthroscopic arthrodesis
o only indicated if minimal deformity present
Open arthrodesis
o transfibular approach often used when deformity present
screw fixation
plate and screw construct
external fixation
Tibiotalocalcaneal (TTC) fusion with retrograde intramedullary nail
o Load-sharing device with improved bending stiffness and rotational stability compared to plate-
and-screw constructs
o Indications:
End-stage ankle and subtalar arthritis
Charcot neuroarthropathy
Significant hindfoot bone loss (failed total ankle arthroplasty, failed arthrodesis)
Osteonecrosis of the talus
Severe acute trauma
o Contraindications:
Active infection
Profound vascular disease
Severe tibia malalignment
Complications
Nonunion
o incidence
10% non union rate
tobacco users have 2.7x risk
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OrthoBullets2017 Procedures | Tested Procedure Review
Lateral plantar nerve injury
Superficial peroneal nerve
o injury to superficial peroneal nerve during transfibular approach
Hindfoot arthritis
o adjacent hindfoot arthritis commonly occurs following fusion
o isolated hindfoot arthritis due to chronic pes planus is treated with subtalar joint arthrodesis
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By Dr, AbdulRahman AbdulNasser Procedures | Tested Procedure Review
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OrthoBullets2017 Procedures | Tested Procedure Review
Indications
Indications
o diagnosis
unilateral or bilateral end-stage ankle OA
o favorable patient factors
older (middle- to old-aged), low demand, reasonably mobile patient with no significant
co-morbidities
normal or low body mass index
well-aligned and stable hindfoot
good soft tissues conditions
Contraindications
o active infection
o peripheral vascular disease
o inadequate soft-tissue envelope
o Charcot arthropathy
o insufficient bone stock
o severe osteoporosis
o osteonecrosis of the talus
Preoperative Imaging
Radiographs
o recommended views
weight-bearing AP and lateral views of the ankle
o findings
extent of arthritis
MRI
o findings
presence of osteonecrosis, amount of involvement, bone loss,and size of subchondral cysts
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OrthoBullets2017 Procedures | Tested Procedure Review
Complications
Delayed wound healing
o most common
o reported in 4% to 17% of cases in the literature
Superficial wound infection
Deep wound infection
o ranges from 0.5% to 3.5% of cases
Sensory deficits
o secondary to anterior incision and its proximity to the superficial and deep peroneal nerves
o reported rates are as high as 21%
Intraoperative Fracture
o medial > lateral malleolus
o occur in the narrow bone bridge between the ankle joint and the outer cortex of the tibia or
fibula
o causes
overextending the plafond cut too medially or laterally
making a cut too proximal in the tibia
using an over-sized tibial component
distraction of the ankle with an external fixator
o prevention (see photo previous page)
prophylactic K-wire pinning (or screw fixation) prior to osteotomy cut
Component loosening
o talar component fails more commonly than the tibial component
Subsidence
o may need to convert to ankle fusion
decide if there is infection
decide whether to fuse across subtalar joint (TTC fusion)
decide what bone graft to use
particulate cancellous graft (<2cm talar bone loss)
bulk allograft (>2cm bone loss)
femoral head allograft
graft of choice if TTC fusion is chosen
Cambell allograft graft (wedges of tricortical iliac crest)
fresh-frozen distal tibial allograft
decide what type of fixation
nail
plate
nail and plate
Osteolysis
o polyethylene wear results in osteolysis, with large, expansive cystic lesions in the tibia or talus
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In July 2017
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8
ORTHO BULLETS
Volume
Eight
Pathology
2017
Collected By : Dr AbdulRahman AbdulNasser
[email protected]
OrthoBullets 2017
OrthoBullets 2017
Preface
Orthobullets.com is an educational resource for
orthopaedic surgeons designed to improve
training through the communal efforts of those
who use it as a learning resource. It is a simple but
powerful concept. All of our topics, technique
guides, cases, and user-generated videos are
free, and will stay that way.
Table of Contents
I. Pathology ..................................................................................................... 0
A. Introduction ............................................................................................. 1
1. Bone Tumor Staging Systems ................................................................... 1
2. Impending Fracture & Prophylactic Fixation .............................................. 2
3. Biopsy Principles ...................................................................................... 5
4. Chemotherapy .......................................................................................... 6
5. Radiation Therapy .................................................................................... 7
6. Differential Groups ................................................................................... 9
B. Infection ................................................................................................. 16
1. Osteomyelitis - Adult ............................................................................... 16
2. Septic Arthritis - Adult............................................................................. 21
3. Wound & Hardware Infection .................................................................. 26
4. Necrotizing Fasciitis ............................................................................... 28
5. Gas Gangrene ........................................................................................ 31
II. Bone Tumors .............................................................................................. 34
A. Osteogenic Tumors ................................................................................ 35
1. Osteoid Osteoma .................................................................................... 35
2. Osteoblastoma ....................................................................................... 39
3. Intramedullary Osteosarcoma ................................................................. 41
4. Parosteal Osteosarcoma ........................................................................ 44
5. Periosteal Osteosarcoma........................................................................ 45
6. Telangiectatic Osteosarcoma ................................................................. 47
B. Chondrogenic Tumors ............................................................................ 49
1. Enchondromas ....................................................................................... 49
2. Periosteal Chondromas .......................................................................... 54
3. Osteochondroma & Multiple Hereditary Exostosis ................................... 55
4. Chondroblastoma ................................................................................... 59
5. Chondromyxoid Fibroma ......................................................................... 61
6. Chondrosarcoma .................................................................................... 63
C. Hematopoietic ........................................................................................ 66
1. Multiple Myeloma .................................................................................... 66
2. Lymphoma.............................................................................................. 71
3. Leukemia................................................................................................ 73
D. Fibrogenic and Histiocytic ...................................................................... 75
OrthoBullets 2017
ORTHO BULLETS
I.Pathology
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By Dr, AbdulRahman AbdulNasser Pathology | Introduction
A. Introduction
Tumor Compartments
o intracompartmental
bone tumors are confined within the cortex of the bone
o extracompartmental
bone tumors extend beyond the bone cortex
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OrthoBullets2017 Pathology | Introduction
Tumor Grade
o histologically, tumors are graded based on the percentage of cellular atypia
low grade tumors
low metastatic potential
e.g. parosteal osteosarcoma
high grade tumors
greater metastastatic potential
e.g. intramedullary osteosarcoma, Ewing's sarcoma, dedifferentiated chondrosarcoma
- 2 -
By Dr, AbdulRahman AbdulNasser Pathology | Introduction
Harington's criteria
Harington's criteria
> 50% destruction of diaphyseal cortices
> 50-75% destruction of metaphysis (> 2.5 cm)
Permeative destruction of the subtrochanteric femoral region
Persistent pain following irradiation
Mirels' criteria
Mirels criteria
score > 8 suggests prophylactic fixation
Score 1 2 3
Site upper limb lower limb peritrochanteric
Pain mild moderate functional
Lesion blastic mixed lytic
Size < 1/3 1/3 to 2/3 > 2/3
Treatment algorithm
Obtain tissue diagnosis
o unless patient has a known primary neoplasm with bone biopsy proven skeletal metastasis, the
treating surgeon should biopsy the lesion in question
biopsy may require separate incision than the incision used for IM nailing of bone
if biopsy suggests primary neoplasm of bone (like sarcoma) that may benefit from
neoadjuvant chemo/radiotherapy then close wound and refer to local sarcoma center prior to
surgical stabilization
surgical treatment of primary sarcoma will contaminate entire bone with sarcoma
and affect ability to perform limb-salvage surgery
Radiation therapy
o indications : low Mirels' score
Surgical fixation
o do not proceed with fixation until primary neoplasm of bone has been ruled out with biopsy
o goals of fixation
maximize ability for immediate mobilization and weight-bearing
protect the entire bone in setting of systemic or metastatic disease
optimize implant choice in the context of the patient's overall prognosis
o type of fixation depends on location of lesion and type of disease
humerus
proximal humerus lesions
endoprosthesis
diaphysis
intramedullary nail
resection and intercalary spacer
plates and screws (less preferred)
distal humerus lesions
flexible nails
elbow replacement
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OrthoBullets2017 Pathology | Introduction
femur
peritrochanteric lesions
intramedullary nail
femoral neck and head lesions
hemiarthroplasty
Postoperative radiation
o following surgery refer the patient to radiation oncology for post-operative radiotherapy
treatment to
decrease pain
slow progression
treat remaining tumor burden not removed at surgery
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
- 4 -
By Dr, AbdulRahman AbdulNasser Pathology | Introduction
3. Biopsy Principles
Introduction
Purpose of the biopsy is to confirm a suspected diagnosis
The biopsy is not a substitute for a thorough history, physical exam, and laboratory investigation
o prerequisites for a biopsy
CBC, platelets, coagulation studies
cross-sectional imaging to evaluate local anatomy
treatment center performing biopsy must be capable of proper diagnosis and treatment
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OrthoBullets2017 Pathology | Introduction
Biopsy
o perform through the involved compartment of the tumor
o for bone lesions with a soft tissue mass, it is ok to perform the biopsy using the soft tissue mass
Closure
o if using a drain, bring drain out of the skin in line with surgical incision
allows drain site to be removed with definitive surgical extensile incision
4. Chemotherapy
Introduction
Mechanism
o induces apoptosis
o may target specific proteins over-expressed in cancer cells
e.g. tyrosine kinase inhibitors
imatinib (Gleevec) for chronic myelogenous leukemia
gefitinib (EGFR inhibitor, Iressa) for lung, breast cancer
erlotinib (EGFR inhibitor, Tarceva) for NSCLC and pancreatic cancer
o eliminates micrometastasis in lungs
o >98% necrosis with chemotherapy is good prognostic sign
Resistance
o expression of multi-drug resistance (MDR) gene portends very poor prognosis
cells can pump chemotherapy out of cell
present in 25% of primary lesions and 50% of metastatic lesions
Indications
Integral component of treatment
along with surgical resection in
o osteosarcoma (intramedullary
and periosteal)
o Ewing's sarcoma/primative
neuroectodermal tumor
o malignant fibrous histiocytoma
o dedifferentiated chondrosarcoma
o chemotherapy for soft tissue
sarcoma is controversial
Administration
Preoperative chemotherapy given for
8-12 weeks
Maintenance chemotherapy for 6-12
months
Specific Agents & Antidotes
Doxorubicin (Adriamycin)
o mechanism
doxorubicin is an anthracycline antibiotic commonly used in oncological protocols
functions as a cytostatic agent
- 6 -
By Dr, AbdulRahman AbdulNasser Pathology | Introduction
o side effects
cardiac toxicity
leads to congestive heart failure
dexrazoxane used to mitigate toxicity
Agents and Antidotes
o mechlorethamine/cisplatin - give sodium thiosulfate
o doxorubicin/epirubicin - give dexrazoxane
o vinca alkaloids (vincristine/vinblastine) - give hot compress and hyaluronidase
give cold compress for all other vesicants
5. Radiation Therapy
Introduction
Two mechanisms of action
o production of free radicals
o direct genetic damage
Indications
Indications of external beam irradiation
o definitive control (primary malignant bone tumors)
Ewing sarcoma/primative neuroectodermal tumor
primary lymphoma of bone
hemangioendothelioma
solitary plasmacytoma of bone
o adjuvant to surgical excision
soft tissue sarcomas
may be given pre or post-operatively as adjuvant to surgical excision
no difference exists in overall survival and the timing of radiation
o palliative care and impending fracture fixation
metastatic bone disease
needed after fixation of impending/pathologic fractures to reduce overall tumor burden
prostate tumors are very radiosensitive
breast cancer is 70% sensitive, 30% resistant
GI and renal tumors are not radiosensitive
Technique
1 rad = 1 centiGray
Typical dose is 180-200 cGy/day
o radiation is given in "fractions" as radiotherapy is cumulative
o the total dose of therapy is the summation of all the separate fractions given during treatment
Total dose
o < 45 Gray: usually leads to uncomplicated tissue healing
o 45 - 55 Gray: tissue usually heals but with problems
o > 60 Gray: tissue will likely not he
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OrthoBullets2017 Pathology | Introduction
Preoperative vs. Postoperative
Preoperative RT (neoadjuvant) Postoperative RT (adjuvant)
More wound complications (up to
Wound complications Less wound complications (<20%)
40%)
Edema, fibrosis, joint More edema, fibrosis, joint stiffness
Less (<15%)
stiffness (>20%) (usually temporary)
Radiation field Smaller field Larger field
Allows formation of pseudocapsule
Pseudocapsule No pseudocapsule advantage
to facilitate close-margin resection
Tumor shrinkage Helps shrink tumor prior to surgery No tumor shrinkag advantage
Local recurrence Lower local recurrence rates Higher local recurrence rates
Complications
Soft tissue complications
o early effects
delayed wound healing
infection
desquamation
o late effects
fibrosis
joint stiffness
secondary sarcoma (below)
fractures (below)
Post-radiation sarcoma
o defined by the development of a sarcoma in a region previously radiated for malignancy
o incidence is ~13%
more frequent in patients with prior chemotherapy
o overal patient prognosis is very poor
Post-radiation fractures
o approximately 25% incidence following soft tissue sarcoma resection and external
beam irradiation
risk factors for post radiation fracture
radiation dose ≥ 59Gy
weight bearing bones esp. femur
female
volume of bone receiving it
anterior femoral compartment resection
age
periosteal stripping
some advocate prophylactic fixation if periosteal stripping is performed
osteoporosis
- 8 -
By Dr, AbdulRahman AbdulNasser Pathology | Introduction
6. Differential Groups
Introduction
When answering questions with regard to orthopaedic pathology it is very useful to have an
understanding of the different differential groups. This topic is broken down into the following
differentials by
o Age
o Location
o Imaging
o Tumor Grade
o Histology
o Treatment
Differentials by Age
NOF
Young patient Osteosarcoma
Osteoid osteoma
(10-40 years) Giant cell tumor Ewing's
ABC Desmoplastic fibroma
UBC Leukemia
Osteochondroma & MHE Lymphoma
Chondroblastoma
Fibrous dysplasia
Osteomyelitis
Eosinophillic granuloma
Older patient Enchondroma Metastatic bone disease
(40-80 years) Bone infarct Myeloma
Bone island Lyphoma
Paget's disease Chondrosarcoma
Hyperparathyroidism MFH
Secondary sarcoma (Paget's,
irradiation)
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OrthoBullets2017 Pathology | Introduction
Differential by Location
Location in Bone
EG
Multiple lesions in Young Patient
Fibrous dysplasia
Leukemia
Lymphoma
Hemangioendothelioma
Enchondroma / Olliers / Marfucci's
Osteochondroma / MHE
NOF / Jaffe-Campanacci syndrome
Multiple lesions in Older Patient Paget's
Metastatic bone disease
Multiple myeloma
Lymphoma
Hyperparathyroidism
Bone infarcts
Chondroblastoma
Epiphyseal / Subchondral Lesions
Giant cell tumor
Clear cell chondrosarcoma
Osteochondroma / MHE
Surface Lesions
Parosteal osteosarcoma
Periosteal osteosarcoma
Periosteal chondroma
Florid reactive periostitis
Post Traumatic Surface Lesions
BPOP
Turret exostosis
Subungal exostosis
Location in Body
Giant cell tumor
Sacrum in young patients (10-40)
ABC
Ewing's
Osteosarcoma
Chordoma
Sacrum in older patients (40-80)
Metastasis
Myeloma
Lymphoma
Chondrosarcoma
MFH
Tibial lesions Adamantinoma
Osteofibrous dysplasia
Fibrous dysplasia
Osteomyelitis
- 10 -
By Dr, AbdulRahman AbdulNasser Pathology | Introduction
Imaging Differential
Radiographs
NOF
"Bubbly" lesion on xray
ABC
UBC
Bone scan is cold Multiple myeloma
Melanoma
Eosinophillic granuloma
Well defined "punched out" lesion
Giant Cell Tumor
Multiple myeloma
Differential by Grade
ORIGIN BENIGN LOW GRADE HIGH GRADE
Bone tumors
Notochordal • Chordoma
Lipogenic • Lipoma
- 11 -
OrthoBullets2017 Pathology | Introduction
ORIGIN BENIGN LOW GRADE HIGH GRADE
• Fibrosarcoma
Fibrogenic & • Fibroma x
• Myxofibrosarcoma
Fibrohistiocytic • Fasciitis (nodular • Malignant fibrous
or proliferative) histiocytoma
• Fibrous
histiocytoma
- 12 -
By Dr, AbdulRahman AbdulNasser Pathology | Introduction
Differential by Histology
Histology
Bone marrow aspiration and biospy required for • Lymphoma
diagnosis and staging • Ewings
Small round cell tumor • Lymphoma
• Leukemia
• Ewing's sarcoma
• Metastatic carcinoma (small cell lung)
• Rhabdomyosarcoma
• Neuroblastoma
Epithelial Glands seen on histology • Synovial sarcoma (biphasic)
• Metastatic carcinoma
• Glomus tumor
Bimorphic histology • Dedifferentiated chondrosarcoma
• Synovial sarcoma
• Osteosarcoma with chondroblastic features
Multi-nucleated Giant cells present • Giant cell tumor
• Chondroblastoma
• Aneurysmal bone cyst
Hemosiderin pigmentation • NOF
• PVNS
• UBC
Immunostains
Leukocyte common antigen • Lymphoma
CD138 • Myeloma
CD99 • Ewing's
CD1A • EG
CD31 and 34 • DFSP
• Angiosarcoma
CD20 and CD45 (B cell) • Lymphoma
S100 • EG
• Chordoma
• Melanoma
• Clear cell sarcoma
• Nerve sheath tumors (Schwanoma)
Elastin • Elastofibroma
Keratin • Metastatic bone disease
• Synovial sarcoma
• Chordoma
• Epitheloid sarcoma
• Adamantinoma
Factor VIII • Angiosarcoma
Smooth muscle actin • Leiomyosarcoma
Desmin • Rhabdomyosarcoma
Myoglobin • Rhabdomyosarcoma
CK7 • Breast CA
• Lung CA
CK125 • Ovarian CA
CK20 • Colon CA
TTF1 • Lung CA
Vimentin • synovial sarcoma, rhabodymosarcoma, and leiomyosarcoma
EMA • Synovial sarcoma
- 13 -
OrthoBullets2017 Pathology | Introduction
Differential by Treatment
Non Operative
Bisphosphonate therapy Metastatic bone disease (with wide resection and radiation)
Myeloma (with chemotherapy)
Paget's disease (with observation)
Fibrous dysplasia (with observation)
Operative
Periosteal chondroma
Marginal Resection
Neurilemoma (soft tissue)
Nodular fasciitis (soft tissue)
Epidermal inclusion cyst
Glomus tumor
• Chondrosarcoma
Wide Resection Alone
• Parosteal osteosarcoma
• Chordoma
• Adamantinoma
• Squamous cell (if no mets)
• Metastatic Bone Disease
Wide Resection + Irradiation
• Soft tissue sarcoma-high grade (angiosarcoma, synovial sarcoma,
liposarcoma, desmoid tumor, MFH/fibrosarcoma)
• Osteosarcoma
Wide Resection + Chemotherapy
• Periosteal osteosarcoma
• Ewing's
• MFH / fibrosarcoma
• Secondary sarcoma
• Dedifferentiated chondrosarcoma
• Rhabdomyosarcoma (exception to soft tissue sarcoma tx)
- 14 -
By Dr, AbdulRahman AbdulNasser Pathology | Introduction
- 15 -
OrthoBullets2017 Pathology | Infection
B. Infection
1. Osteomyelitis - Adult
Introduction
Infection of bone characterized by progressive inflammatory destruction and apposition of new
bone
Epidemiology
o risk factors
recent trauma or surgery
immunocompromised patients
illicit IV drug use
poor vascular supply
systemic conditions such as diabetes and sickle cell
peripheral neuropathy
Pathophysiology
o mechanism of spread
hematogenous
originated or transported by blood
etiology of 20% of osteomyelitis
vertebrae most common site
S. aureus is most common organism
contiguous-focus
associated with previous surgery, trauma, wounds, or poor vascularity
can be bacterial (most common), mycobacterial, or fungal in nature
direct-inoculation
penetrating injuries
surgical contamination
o biofilm formation
bacteria produce biofilm that covers necrotic bone and hardware
made of an extracellular polymeric substance or exopolysaccharide
antibiotics have difficulty penetrating biofilm
o organism : organism varies by age of patient
S. aureus is most common in adults
- 16 -
By Dr, AbdulRahman AbdulNasser Pathology | Infection
Prognosis
o philosophy of treatment
infection elimination
bone union
o despite surgical debridement and long-term antibiotics, recurrence rate of chronic osteomyelitis
in adults is 30%
Classification
Timing classification
o acute : within 2 weeks
o subacute : within one to several months
o chronic : after several months
Cierny classification
- 17 -
OrthoBullets2017 Pathology | Infection
Presentation
Symptoms
o pain
o fever
more common in acute osteomyelitis
Physical exam
o erythema, tenderness, and edema are commonly seen
o limp and/or pain inhibition with weight-bearing or motion may be
present
o draining sinus tract
more common in chronic osteomyelitis
Imaging
Radiographs
o recommended views
orthogonal plain radiographs of the affected extremity
o findings
I:6 Draining sinus
often shows a lytic region surrounded by an area of sclerosis
may mimic a neoplastic processes
bone loss must be 30-40% before evident on plain films
sequestrum: devitalized bone that serves as a nidus for infection
involucrum: formation of new bone around an area of bony necrosis
CT
o useful for surgical planning and determining extent of bony destruction
MRI
o useful for soft tissue evaluation
Bone Scan
o sensitivity comparable to MRI, but specificity is poor
I:7 sequestrum
I:8 involucrum
- 18 -
By Dr, AbdulRahman AbdulNasser Pathology | Infection
Studies
Laboratory analysis
o leukocyte count (WBC)
often elevated in acute osteomyelitis
may be normal in chronic osteomyelitis
o erythrocyte sedimentation rate (ESR)
usually elevated in both acute and chronic osteomyelitis
decrease in ESR after treatment is a favorable prognostic indicator
o C-reactive protein
decreases faster than ESR in successfully treated patients
Microbiology
o blood cultures
may be used to guide therapy for hematogenous osteomyelitis
o sinus tract cultures
not reliable for guiding antibiotic therapy
o bone biopsy
gold-standard for guiding antibiotic therapy
Treatment
Goals
o success in the treatment is dependent on various factors
patient factors
immunocompetence of patient
nutritional status
injury factors
severity of injury as demonstrated by segmental bone loss
infection location
metaphyseal infections heal better than mid-diaphyseal infections
other factors affecting prognosis and treatment include:
residual foreign materials and/or ischemic and necrotic tissues
inappropriate antibiotic coverage
lack of patient cooperation or desire
Nonoperative Treatment
o IV or oral antibiotic therapy for 4-6 weeks
indications : initial therapy in almost all situations
outcomes : rate of recurrence can be as high as 30%
o hyperbaric oxygen therapy
indications : can be used as adjunct in refractory osteomyelitis
Operative treatment
o irrigation and debridement followed by organism specific antibiotics
indications
stage III and IV osteomyelitis
abscess formation
draining sinus
surgical fixation techniques
Ilizarov technique
- 19 -
OrthoBullets2017 Pathology | Infection
intramedullary nail with or without external fixation
Masquelet technique
free tissue transfer
in situ reconstruction
outcomes
when combined with postoperative antibiotics tailored to specific organism, treatment is
often successful
Surgical Techniques
Antibiotic therapy
o technique
antibiotics should be tailored to specific organism, preferably after a bone biopsy is obtained
chronic suppressive antibiotics may be useful in patients who are immunocompromised or
in whom surgery is not feasible
Irrigation & Debridement
o technique
debridement
all devitalized and necrotic tissue should be removed
extensive debridement is essential to eradicate infection
sequestrum must be eliminated from the body, or infection is likely to recur
hardware removal
any non-essential hardware should be removed
dead space management
goal is to replace dead bone and scar tissue with vascularized tissue
options include
vascularized bone grafts
local tissue flaps or free flaps
antibiotic-impregnated acrylic beads (PMMA)
vacuum-assisted closure
stabilization
bony stability is required for successful eradication of infection
external fixation preferred to internal
fixation
mechanism is thought to be related to
improved angiogenesis
Complications
Persistence or extension of infection
Amputation
Sepsis
Malignant transformation (Marjolin's ulcer)
o most commonly squamous cell carcinoma
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By Dr, AbdulRahman AbdulNasser Pathology | Infection
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OrthoBullets2017 Pathology | Infection
Classification
By organism
o staphylococcus species
staphylococcus aureus
most common and accounts for >50% of cases
MRSA
staphylococcus epidermis
o neisseria gonorrhea
account for ~20% of cases
most common organism in otherwise healthy sexually active adolescents and young adults
manifests as a bacteremic infection
arthritis-dermatitis syndrome in ~60% of cases
localized septic arthritis in ~40% cases
o gram-negative bacilli
account for 10-20% of cases
pathogens include
E coli, proteus
klebsiella
enterobacter
risk factors
neonates
IV drug users
elderly
immunocompromised patients with diabetes
o streptococcus
streptococcus pyogenes (Group A)
most common
Group B streptococcus (e.g., agalactiae)
predilection for infants, elderly and diabetic patients
o propionibacterium acnes
associated with shoulder surgery
o salmonella or streptococcus pneumoniae
seen in patients with sickle cell disease
o bartonella henselae
seen in patients with HIV
o pseudomonas aeruginosa
seen in patients with history of IV drug abuse
o pasteurella multocida
seen in patients after dog or cat bite
o eikenella corrodens
seen in patients after human bite
o fungal/candida
found in immunocompromised host
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By Dr, AbdulRahman AbdulNasser Pathology | Infection
Presentation
Symptoms
o pain in affected joint
o fevers (only present in 60% of cases)
o may appear toxic
Physical exam
o inspection
erythema
effusion
extremity tends to be in position of maximum joint volume
hip would be in FABER position (flexed, abducted, externally rotated)
o palpation
warmth
tender
o motion
inability to bear weight
inability to tolerate PROM
Imaging
Radiographs
o recommended views
AP and lateral of the joint in question
o findings I:10 FABER position
may show joint space widening or effusion
periarticular osteopenia
Ultrasound
o indications
may help in confirming joint effusion in large joint such as hip
can be used in guiding aspirations
MRI
o indications :detects joint effusion, and may detect adjacent bone involvement such as
osteomyelitis
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OrthoBullets2017 Pathology | Infection
Studies
Serum labs
o WBC >10K with left shift
o ESR >30
ESR is often elevated but may be normal early in process
rises within 2 days of infection and can rise 3-5 days after initiation of appropriate
antibiotics, and returns to normal 3-4 weeks
o CRP >5
most helpful
best way to judge efficacy of treatment, as CRP rises within few hours of infection, and may
normalize within 1 week of treatment
Joint fluid aspirate
o gold standard for treatment and allows directed antibiotic treatment
o should be analyzed for
cell count with differential (see table above)
gram stain
culture
glucose level
crystal analysis
septic arthritis occurs concurrently with gout or pseudogout in < 5% of cases
o characteristic findings
joint fluid appears cloudy or purulent
cell count with WBC > 50,000 is considered diagnostic for septic arthritis, however lower
counts may still indicate infection
prosthetic joint with WBC >1,100 is considered septic
gram stains only identifies infective organism 1/3 of time
glucose less than 60% of serum level
Saline load test
o utilized to determine if wound near a joint communicates with the joint
o for the knee, 155 mL of saline is needed to reach 95% sensitivity
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By Dr, AbdulRahman AbdulNasser Pathology | Infection
Differential
Crystal arthropathy
o gout
o pseudogout
Cellulitis
Bursitis
o prepatellar bursitis
Treatment
Operative
o IV abx, operative irrigation and drainage of the joint
indications
considered an orthopaedic surgical emergency
IV antibiotic therapy
initiate empiric therapy prior to definitive cultures based on patient age and or risk factors
young, healthy adults
staphylococcus aureus and neisseria gonorrhea
immunocompromised patients
staphylococcus aureus and pseudomonas aeruginosa
transition to organism-specific antibiotic therapy based once obtain culture sensitivities
outcomes
treatment can be monitored by following serum WBC, ESR, and CRP levels during
treatment
Technique
Operative irrigation and drainage of the joint
o approach
can be performed open or arthroscopically (depending on joint)
o irrigation
remove all purulent fluid and irrigate joint
o debridement
synovectomy can be performed as needed
o cultures
obtain joint fluid and tissue for culture
Complications
Arthritis
Fibrous ankylosis
Osteomyelitis
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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OrthoBullets2017 Pathology | Infection
Presentation
History
o history of trauma must be detailed
extent of soft tissue injury
extent of bony injury
previous or current hardware
previous or current surgery at the same site
history of previous skin or deep infections
Symptoms
o pain at previous fracture site
may indicate infected non-union
o fevers, chills, and night sweats may be present
Physical exam
o inspection
erythema, drainage, or purulence
tenderness
o motion gross : motion at fracture site is suggestive of non-union
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By Dr, AbdulRahman AbdulNasser Pathology | Infection
Imaging
Radiographs
o recommended views
biplanar images of afflicted area
45 degree orthogonal views can also be obtained to evaluate for union
o findings
acute infection
radiographs may be normal
sub-acute and chronic infections
peri-implant lucency can be seen
involucrum
reactive bone surrounding active infection
sequestrum
retained nidus of infected necrotic bone
CT
o indications
pre-operative planning
MRI
o indications
useful adjunct for diagnosis and delineating extent of disease
to assess soft-tissue masses and fluid collections
o sensitivity and specificity
98% sensitive
78% specific
WBC-labeled scans
o can help determine infection from other similar appearing etiologies
Studies
Labs
o WBC
may be normal in chronic or indolent infections
o erythrocyte sedimentation rate
may remain elevated for months following initial injury or surgery in absence of infection
o C-reactive protein
most predictive for postoperative infection in the first week after fracture fixation
should decrease from a plateau after postoperative day 2 (after fixation of fractures)
will increase further or fail to decrease if a hematoma or infection is present
Cultures
o in-office cultures swabs or aspirations of wounds or sinus tracts are unreliable
o intraoperative deep cultures are most reliable method of isolated causative organisms
multiple specimens from varying locations should be obtained
Treatment
Nonoperative
o chronic suppression with antibiotics
indications
risk of surgical treatment outweighs the benefit to the host
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OrthoBullets2017 Pathology | Infection
immunosuppressed, elderly, etc.
presence of an infected but incompletely healed fracture following internal fixation
technique
ESR and CRP levels used to assess adequacy of treatment
outcomes
32% rate of chronic infected nonunion persisting or worsening despite suppression
Operative
o surgical debridement
indications
any active infection
technique
hardware should be maintained if stability at risk with removal
low-pressure irrigation with normal saline may be superior to other methods of irrigation
thorough identification and debridement of infection key to success
deep bony specimens should be obtained for culture as well as biopsy
outcomes
71% success seen with debridement and antibiotics for early acute postoperative infection
Risk factors for failure include intramedullary nail and open fracture
4. Necrotizing Fasciitis
Introduction
Necrotizing fasciitis is a life threatening infection that spreads along soft tissue planes
Risk factors
o immune suppression
diabetes
AIDS
cancer
o bacterial introduction
IV drug use
hypodermic therapeutic injections
insect bites
skin abrasions
abdominal and perineal surgery
o other host factors
obesity
Associated conditions
o cellulitis
overlying cellulitis may or may not be present
Prognosis
o life threatening infection
mortality rate of 32%
mortality correlates with time to surgical intervention
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By Dr, AbdulRahman AbdulNasser Pathology | Infection
Classification
Necrotizing Fasciitis Classification
Type Organism Characteristics
Type 1 Polymicrobial • Most common (80-90%)
Typical 4-5 aerobic and • Seen in immunosuppressed (diabetics and
anaerobic species cultured: cancer patients)
• non-Group A Strep • Postop abdominal and perineal infections
• anaerobes including Clostridia
• facultative anaerobes
• enterobacteria
• Synergistic virulence between
organisms
Type 2 Monomicrobial • 5% of cases
• Group A β-hemolytic Streptococci • Seen in healthy patients
is most common organism isolated • Extremities
Type 3 Marine Vibrio vulnificus • Marine exposure
(gram negative rods)
Type 4 MRSA
Presentation
Symptoms
o early
localized abscess or cellulitis with rapid
progression
minimal swelling
no trauma or discoloration
o late findings
severe pain
high fever, chills and rigors
tachycardia
Physical exam
o skin bullae
o discoloration
ischemic patches
cutaneous gangrene
o swelling, edema
o dermal induration and erythema
o subcutaneous emphysema (gas producing
organisms)
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OrthoBullets2017 Pathology | Infection
Imaging
Radiographs
o not required for diagnosis or treatment
Differentials
Gas gangrene
Studies
Biopsy
o indications
emergent frozen section can confirm diagnosis in
early cases
o technique
take 1x1x1cm tissue sample
can be performed at bedside or in operating room
surgical intervention should not be delayed to
obtain
o histological findings
necrosis of fascial layer
microorganisms within fascial layer
PMN infiltration
fibrinous thrombi in arteries and veins and necrosis
of arterial and venous walls
LRINEC Scoring system
o score > 6 has PPV of 92% of having necrotizing fasciitis
CRP (mg/L)
≥150: 4 points
3 3
WBC count (×10 /mm )
<15: 0 points
15–25: 1 point
>25: 2 points
Hemoglobin (g/dL)
>13.5: 0 points
11–13.5: 1 point
<11: 2 points
Sodium (mmol/L)
<135: 2 points
Creatinine (umol/L)
>141: 2 points
Glucose (mmol/L)
>10: 1 point
Treatment
Operative
o emergency radical debridement with broad-spectrum IV antibiotics
indications
whenever suspicion for necrotizing fasciitis
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By Dr, AbdulRahman AbdulNasser Pathology | Infection
operative findings
liquefied subcutaneous fat
dishwater pus
muscle necrosis
venous thrombosis
technique
hemodynamic monitoring with systemic resuscitation is critical
hyperbaric oxygen chamber if anaerobic organism identified
antibiotics
initial antibiotics
start empirically with penicillin, clindamycin, metronidazole, and an aminoglycoside
definitive antibiotics
penicillin G
for strep or clostridium
imipenem or doripenem or meropenem
for polymicrobial
add vancomycin or daptomycin : if MRSA suspected
o amputation
indications
low threshold for amputation when life threatening
5. Gas Gangrene
Introduction
Definition
o also called clostridial myonecrosis
Epidemiology
o demographics
male:female ratio
no sexual predilection
o location
buttocks, thigh, perineum
o risk factors
posttraumatic (associated with C perfringens)
car accidents (most common)
crush injuries
gunshot wounds with foreign bodies
burns and frostbite
IV drug abuse
postoperative
bowel resection or perforation
biliary surgery
premature wound closure
spontaneous
colon cancer (associated with C. septicum)
neutropenia
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OrthoBullets2017 Pathology | Infection
Pathophysiology
o Clostridial species
Clostridium perfringens (most common), Clostridium novyi, Clostridium septicum
found in soil and gut flora
gram-positive obligate anaerobic spore-forming rods that produce exotoxins (e.g. C.
perfringens alpha toxin)
causes muscle necrosis and vessel thrombosis
can cause hemolysis and shock
incubation period <24h
gas produced by fermentation of glucose
main component is nitrogen
o other bacteria include E. coli, Pseudomonas aeruginosa, Proteus species, Klebsiella pneumoniae
Prognosis
o overall 25% mortality
o 50% mortality if bacteremic
o 100% mortality if treatment is delayed
o poorer prognosis for older patients with comorbidities
Presentation
History
o recent surgery to GI or biliary tract
Symptoms
o triad
sudden progressive pain out of proportion to injury
from thrombotic occlusion of large vessels
tachycardia not explained by fever
feeling of impending doom
Physical exam
o sweet smelling odor
o swelling, edema, discoloration and ecchymosis
o blebs and hemorrhagic bullae
o "dishwater pus" discharge
o crepitus
o altered mental status
Imaging
Radiographs
o findings
linear streaks of gas in soft tissues
Studies
Labs
o Elevated LDH
o Elevated WBC
o Metabolic acidosis and renal failure
Histology
o Gram stain reveals Gram-positive bacilli
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By Dr, AbdulRahman AbdulNasser Pathology | Infection
o absence of neutrophils
lack of acute inflammatory response is hallmark of gas gangrene
Culture
o blood culture rarely grows Clostridial species
Differentials
Necrotizing fasciitis
Treatment
Nonoperative
o high dose IV antibiotics
1st line is penicillin G and clindamycin
alternative treatment is erythromycin, tetracycline or ceftriaxone
clindamycin and tetracycline inhibit toxin synthesis
o hyperbaric O2
indications
useful adjunct
outcomes
effectiveness of HBO2 is inconclusive
Operative
o radical surgical debridement with fasciotomies
indications
1st line treatment is surgical
Complications
Shock
Renal failure
o both mediated by TNF alpha, IL-1, IL-6
I:11 Gram positive spore forming rods (C. perfringens ) I:12 Gas pockets between muscle fibers
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OrthoBullets2017 Bone Tumors | Infection
ORTHO BULLETS
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Osteogenic Tumors
A. Osteogenic Tumors
1. Osteoid Osteoma
Introduction
A small, discrete, painful, benign bone lesion
Epidemiology
o incidence
cause of painful scoliosis in the adolescent population
o demographics
3:1 male to female ratio
persons aged 5-25 years (>80% present before age of 30)
o location
most common
lower extremity (>50%)
proximal femur > tibia diaphysis
usually found within the bone cortex
spine (10-15%)
thoracic and lumbar regions > cervical and sacral
majority involve the posterior elements
usually found on the side of concavity in scoliosis
hand (5-10%)
scaphoid and proximal phalanx
foot (<5%)
predominantly involves the talar neck
Pathophysiology
o pathoanatomy
nidus
central nodule of woven bone and osteoid with osteoblastic rimming
reactive zone
area of thickened bone and fibrovascular tissue
o cellular biology
pain
attributed to increased local concentration of prostaglandin E2 and COX1 & 2 expression
increased number and size of unmyelinated nerve fibers within the nidus
Associated conditions
o orthopaedic manifestations
painful scoliosis
growth disturbance
flexion contractures
Prognosis
o pain from lesions usually resolves after an average of 3 years
o the lesion spontaneously resolves in 5-7 years
o in the spine, early resection (within 18 months) leads to resolution of scoliosis in young children
(<11years)
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OrthoBullets2017 Bone Tumors | Osteogenic Tumors
Classification
Enneking Classification of Benign Lesions
Stage Grade Examples
Stage 1 Latent lesions enchondroma, non-ossifying fibroma
Stage 2 Active lesions osteoid osteoma, UBC
Stage 3 Aggressive giant cell tumor of bone, ABC, chondroblastoma, chondromyxoid
lesions fibroma,
Symptoms
Symptoms
o pain
constant and progressive
worse at night and with drinking ETOH
relieved by NSAIDS
may be adjacent to joint and mimic arthritis
o hand lesions may present with painless swelling
Physical exam
o inspection
palpable bone
deformity, swelling, erythema, tenderness
proximity to a joint
effusion, contracture, limp, muscle atrophy
spine
postural scoliosis, paravertebral muscle spasm
Imaging
Radiographs
o recommended views
3 views of affected bone or joint
o findings
intensely reactive bone around radiolucent nidus
CT
o indication
cross-sectional imaging is the study of choice
o findings
to help identify the location and size of nidus
usually < 1.5 cm (otherwise think osteoblastoma)
Bone scan
o indication
concerning features on radiograph or advanced imaging
o findings
intense hot area of focal uptake at the nidus
low uptake in reactive zone
known as the 'double-density sign'
MRI
o indications
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Osteogenic Tumors
usually not recommended as it can mimic aggressive lesions
o findings
must be interpreted with reference to x-ray or CT scan
Histology
Histology
o distinct demarcation between nidus and reactive bone
nidus
contains uniform osteoid seams of immature osteoid trabeculae (woven bone) with a
sharp border of osteoblastic rimming
uniform plump osteoblasts have regularly shaped nuclei with abundant cytoplasm
reactive zone
region surrounding the sclerotic border
Differentials
Long bone osteoid osteomas need to be differentiated from
o stress fx
o osteomyelitis
o Ewing's sarcoma
Posterior spinal element lesions need to be differentiated from
o aneurysmal bone cyst
o osteoblastoma (see table below)
Treatment
Nonoperative
o clinical observation and NSAID administration
indications
NSAIDS are 1st line and will lead to a dramatic decrease in symptoms
~50% can be treated with NSAIDS alone
also indicated for painful spine lesions without scoliosis
fingertip lesions (distal phalanx) may not respond to NSAIDS
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OrthoBullets2017 Bone Tumors | Osteogenic Tumors
Operative
o percutaneous radiofrequency ablation
relative indications
failure of medical management
periarticular lesions, which increase the risk of cartilage injury and premature
degenerative disease.
spinal lesions (controversial) - depends on the location of the lesion and proximity to
neural elements
contraindications
lesions close to spinal cord or nerve roots
technique
done under CT guidance
probe at 80-90 deg C for 6 minutes to produce a 1cm zone of necrosis
outcomes
90% of patients are successfully treated with 1-2 sessions of RFA
10-15% recurrence rate
o surgical resection/currettage
indications
location of lesion is not amenable to CT guided percutaneous radiofrequency ablation
e.g. close to skin or nerve
spine lesion associated with painful scoliosis
digital lesions
RFA carries risk of thermal skin necrosis and injury to digital neurovascular bundle
technique
successful treatment depends on complete marginal resection of nidus (sclerotic bone is
normal and can be left behind)
percutaneous approach
open approach
outcomes
94% success with local excision
associated scoliosis rarely requires treatment
Complications
Recurrance
o 10-15% recurrence rate with percutaneous radiofrequency ablation
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Osteogenic Tumors
2. Osteoblastoma
Introduction
Aggressive benign osteoblastic tumor of bone
o "big brother" of osteoid osteoma (nidus > 2cm)
Epidemiology
o incidence
relatively rare
less common than osteoid osteoma
o demographics
males > females (2:1)
majority of patients 10-30 years of age
o location
most common in posterior elements of spine
Genetics
o unknown
Associated conditions
o oncogenic osteomalacia
o secondary ABC
10%-40% associated with secondary ABC
Presentation
Symptoms
o pain
slowly progressive dull aching pain
not relieved by NSAIDS
o may see neurologic symptoms with spine involvement
Physical exam
o swelling
o muscle atrophy
o limp
Imaging
Radiographs
o recommended views
AP and lateral of symptomatic area
o findings
lytic or mixed lytic-blastic lesion with radiolucent nidus > 2cm
reactive sclerotic bone
66% cortically based, 33% medullary based
often expansile with extension into soft tissues with rim of reactive bone
25% appear very aggressive and often mistaken for malignant lesion
CT
o indications
necessary to fully evaluate lesion
Bone scan : hot with intense focal uptake
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OrthoBullets2017 Bone Tumors | Osteogenic Tumors
Studies
Histology
o similar to osteoid osteoma but with more giant cells
o distinct demarcation between nidus and reactive bone
nidus of immature osteoid and osteoblasts with abundant cytoplasm and normal nuclei
o fibrovascular stroma that merges with normal trabeculae of bone
o rim of osteoblasts surrounds osteoid
o numerous mitotic figures, but not atypical
Differential
Radiographic differential for osteoblastoma includes
o osteosarcoma
o ABC
o osteomyelitis
o osteoid osteoma
Differentiating from osteoid osteoma
o characteristics specific to osteoblastoma
rare and locally aggressive but benign (not self limiting)
over 40% occur in posterior elements of spine or sacrum
dull pain unresponsive to NSAIDs
larger
Differential for lesions of the posterior spinal elements elements includes
o aneurysmal bone cyst
o osteod osteoma (see table below)
o osteoblastoma
Treatment
Nonoperative
o observation
indications : rarely, if ever, indicated as the lesion will continue to grow
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Osteogenic Tumors
Operative
o curettage or marginal excision with bone grafting
indications
standard of care
recurrence 10-20%
3. Intramedullary Osteosarcoma
Introduction
Intramedullary osteosarcoma is the most common primary sarcoma of bone
o the most common malignancy of bone is metastatic disease
o the most common primary malignancy of bone is myeloma
Age & location
o usually occurs in children and young adults
bimodal distribution of occurrence
majority occur in the second decade of life
second peak in occurrence is in elderly patients with Paget's disease
o most common site is the distal femur and proximal tibia II:1 Rothmund Thomson
o other common sites include proximal humerus, proximal femur, and pelvis syndrome
Malignancy
o most commonly diagnosed as Stage IIB (high grade, extra-compartmental, no metastases)
o 10-20% of patients present with pulmonary metastases (obtain CT of chest)
lung is most common site of metastasis
bone is second most common site
Genetics
o patients who carry the Retinoblastoma tumor suppressor gene (Rb) are predisposed to
osteosarcoma
o risk increased in Rothmund Thomson syndrome
AR inheritance, mutations in RECQL4 gene, chr 8q24.3
sun-sensitive facial poikiloderma rash (pigmentation, thinned skin, prominent blood vessels)
absent eyelashes, eyebrows, hair
juvenile cataracts, teeth abnormalities
osteosarcoma, fibrosarcoma, gastric adenocarcinoma, cutaneous BCC and SCC
Prognosis
o 76% long-term survival with modern treatment
o poor prognostic factors include
advanced stage of disease (most predictive of survival)
response to chemotherapy (as judged by percent tumor necrosis of resected specimen)
tumor site and size
expression of P-glycoprotein
high serum alkaline phosphatase
high lactic dehydrogenase
vascular involvement
surgical margins
type of chemotherapy regimen
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OrthoBullets2017 Bone Tumors | Osteogenic Tumors
Symptoms
Symptoms
o rapidly progressive pain, fever, and swelling
Physical exam
o may feel mass on examination
Imaging
Radiographs
o characteristic blastic and destructive lesion
sun-burst or hair on end pattern of matrix mineralization
o periosteal reaction (Codman's triangle)
o large soft tissue mass with maintenance of bone cortices
MRI
o must include entire involved bone to determine
soft tissue involvement
neurovascular involvement
presence skip metastases
if skip metastases are found, this is equivalent to metastatic (stage III) disease
Bone scan
o very hot in osteosarcoma
o useful to evaluate extent of local disease and presence of bone metastases
CT
o chest CT is required at presentation to evaluate for pulmonary metastases
Labs
Elevated alkaline phosphatase
o may be 2-3 times normal value
Histology
Characteristics
o tumor cells show significant atypia, and produce "lacey" osteoid
o stroma cells show malignant characteristics with atypia, high nuclear to cytoplasmic ratio, and
abnormal mitotic figures
May have mixed histology with different combinations of chondroblastic,osteoblastic, or fibroblastic
looking cells
o depends on the subtype of osteosarcoma
Giant cells may be present in giant cell rich osteosarcoma
o often confused with giant cell tumor of bone
Diagnosis
o biopsy is required to obtain tissue diagnosis and institute therapy
o improper biopsy techniques are associated with increased rates of complications
biopsy should be performed by the surgeon responsible for definitive treatment of the
sarcoma, or after discussion with this surgeon
Treatment
Operative
o multi-agent chemotherapy and limb salvage resection
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Osteogenic Tumors
indications
high grade osteosarcoma
chemotherapy
preoperative chemotherapy given for 8-12 weeks followed by maintenance chemotherapy
for 6-12 months after surgical resection
98% necrosis after neo-adjuvant chemotherapy is good prognostic sign
expression of multi-drug resistance (MDR) gene tends to have a poor prognosis
tumor cells can pump chemotherapy out of cell with MDR expression
present in 25% of primary lesions and 50% of metastatic lesions
surgical technique
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OrthoBullets2017 Bone Tumors | Osteogenic Tumors
4. Parosteal Osteosarcoma
Introduction
A low grade osteosarcoma
Epidemiology
o demographics
more common in females, age 30-40
o location
occurs on surface of metaphysis of long bones
most common sites include posterior distal femur, proximal tibia, and proximal humerus
80% cases occur in the femur
marrow invasion occurs in 25% of cases
Prognosis
o 95% long term survival when local control has been achieved
dedifferentiation of parosteal osteosarcoma is a poor prognostic factor
invasion into the medullary cavity does not affect long-term survival
Symptoms
Presentation
o often presents as a painless mass
o limited joint motion can also be a presenting complaint for characteristic large posterior distal
femoral lesions
Imaging
Radiographs
o heavily ossified, lobulated mass arising from cortex
o appears stuck onto cortex
CT chest
o mandatory staging study
o used to evaluate for pulmonary metastasis
MRI
o mandatory and must include entire involved bone
o helps determine soft tissue/marrow involvement and skip lesions
Bone scan
o mandatory imaging study
o always hot
Histology
Characteristic histology
o low grade lesion
o regularly arranged normal osseous trabeculae
o most prominent histologic feature are the atypical spindle cells seen between regularly arranged
osseous trabeculae
o some cellular atypia should be seen to make diagnosis
Histology can be mistaken for fibrous dysplasia
high rate of MDM2 amplification and ring chromosome
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Osteogenic Tumors
Treatment
Operative
o wide local surgical excision
indications
standard of care in most patients
technique
many consider geometric osteotomy of involved bone to decrease long term morbidity
and retain native joint
chemotherapy
chemotherapy not indicated unless there is a high grade component
outcomes
often curative
Bone surface lesion Similar Histology Treated with surgery alone (2)
(cortex)
Parosteal osteosarcoma • •
Periosteal osteosarcoma •
Periosteal chondroma • •
Osteochonroma / MHE • •
Developmental defect •
Myositis ossifican •
Chondrosarcoma •
Adamantinoma •
Chordoma • (controversial)
Fibrous Dysplasia •
ASSUMPTIONS: (1) Older patient is > 40 yrs; (2) assuming no impending fracture
5. Periosteal Osteosarcoma
Introduction
Epidemiology
o incidence
extremely rare intermediate grade surface osteosarcoma
o demographics
usually occurs in patients 15 to 25 years of age
more common in females than males
o location
occurs most commonly in the diaphysis of long bones
femur and tibia are most common
Genetics
o germ-line mutation of p53 found in 15-20% of cases
Prognosis
o 20-35% chance of pulmonary metastasis
o intermediate prognosis between parosteal and intramedullary osteosarcoma
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OrthoBullets2017 Bone Tumors | Osteogenic Tumors
o 98% necrosis with chemotherapy is good prognostic sign
o expression of multi-drug resistance (MDR) gene portends very poor prognosis
cells can pump chemotherapy out of cell
present in 25% of primary lesions and 50% of metastatic lesions
Presentation
Symptoms
o pain is the most common presenting symptom
o 25% present with pathologic fracture
Physical exam
o regional swelling and tenderness
Imaging
Radiographs
o lesion has a classic "sunburst" or "hair on end" periosteal reaction
often sunburst periosteal reaction occurs in a saucerized cortical depression
o typically there is no involvement of the medullary canal
Chest CT scan
o required for staging
o evaluates for the presence of pulmonary metastasis
Bone scan
o required for staging
o usually very hot
Histology
Classically
o grossly tumor appears lobular and cartilaginous
o while tumor produces osteoid, histology reveals areas of chondroblastic matrix
if histology shows no osteoid production, tumor would be classified as a chondrosarcoma
Treatment
Operative (same as intramedullary osteosarcoma)
o multi-agent chemotherapy and limb salvage resection
indications
standard of care in most patients
chemotherapy
preoperative chemotherapy given for 8-12 weeks followed by maintenance chemotherapy
for 6-12 months after surgical resection
surgical resection
trend towards limb salvage whenever possible
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Osteogenic Tumors
6. Telangiectatic Osteosarcoma
Introduction
A malignant osteogenic tumor
o similar to classic osteosarcoma in epidemiology and genetics
o similar in ABC in presentation (must differentiate)
Epidemiology (similar to classic osteosarcoma)
o incidence
rare (4% of osteosarcomas)
o demographics
male > female
o location
proximal humerus, proximal femur, distal femur, proximal tibia
occur in same location as ABC
o risk factors
history of prior radiation
Genetics
o associated with the following mutations
tumor suppressor genes
Rb-1
p53
oncogenes
HER2/neu
c-myc
c-fos
Prognosis
o prognostic variables
poor
advanced tumor stage is most important indicator
increased lactate dehydrogenase (LDH) and alkaline phosphatase (ALP)
expression of multi-drug resistance (MDR) gene
pathologic fractures increased risk of recurrence
favorable
98% necrosis with chemo is good prognostic sign
o survival
more chemosensitive but same survival as intramedullary osteosarcoma
5 year survival with tumor localized to an extremity is ~70%
5 year survival with metastases is ~20%
Presentation
Symptoms
o pain
o 25% present with pathologic fracture
Physical exam
o soft tissue swelling
o local tenderness
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Imaging
Radiographs
o lytic, destructive, and expansile lesion; entire cortex may be compromised
Bone scan
o shows increased uptake
MRI
o indications
indicated in all cases to determine soft tissue involvement
o findings
fluid-fluid levels
extensive edema in surrounding tissue
Studies
Histology
o characterized by
high grade sarcoma with mitotic figures is seen in intervening cellular areas
Differential
ABC (aneurysmal bone cyst)
ABC
o differentiating ABC from telangietic osteosarcoma is difficult and critical
both have similar radiographic appearance
both have large blood filled spaces
both have similar location (proximal humerus, proximal femur, distal femur, proximal tibia)
o diagnosis needs to be confirmed by an experienced musculoskeletal pathologist
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Chondrogenic Tumors
ABC vs Telangietic Osteosarcoma
Aneurysmal Bone Cyst Telangietic Osteosarcoma
Epidemiology • 75% of patient < 20 years. • Locations (proximal humerus, proximal
• Locations (proximal humerus, proximal femur, distal femur, proximal tibia)
femur, distal femur, proximal tibia)
Radiographs • Expansive, eccentric and lytic lesion • Expansive, eccentric and lytic lesion
with bony septae with bony septae
MRI • Clear fluid levels • Fluid levels less defined
• May extend into soft tissue. • Edema in surrounding tissue
Histology • Blood-filled spaces, spindle cells, benign • Lakes of blood mixed with malignant
giant cells, no evidence of malignant cells cells with mitotic bodies
Treatment
Operative
o multi-agent (neoadjuvant) chemotherapy and limb salvage resection
indications
standard of care in most patients
surgical resection
trend towards limb salvage whenever possible
can be performed in close to 90% of cases
chemotherapy
preoperative chemotherapy given for 8-12 weeks followed by maintenance chemotherapy
for 6-12 months after surgical resection
doxorubicin/cisplatin/methotrexate/ifosamide
98% necrosis with chemo is good prognostic sign
expression of multi-drug resistance (MDR) gene portends very poor prognosis
cells can pump chemo out of cell
present in 25% of primary lesions and 50% of metastatic lesions
outcomes
risk of recurrence is decreased with good cellular response/wide surgical margins
Complications
Local recurrence
o uncommon (~5%)
o associated with poor prognosis
o increased risk of recurrence in patients with displaced, pathologic fracture
B. Chondrogenic Tumors
1. Enchondromas
Introduction
A benign chondrogenic tumor composed of hyaline cartilage
o located in the medullary cavity
o caused by an abnormality of chondroblast function in the physis
Epidemiology
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o incidence
2nd most common benign cartilage lesion (osteochondroma is most common)
o demographics
male:female ratio is 1:1
age bracket
most common in 20-50 year olds
location
usually found in the medullary cavity of the diaphysis or metaphysis
the most common locations hand (60%) > feet
the most common bone tumor in the hand is the enchondroma
other locations include distal femur (20%) > proximal humerus (10%) > tibia
rare in the pelvis, scapula, ribs
suspect chondrosarcoma in these locations
Pathophysiology
o enchondromas represent incomplete endochondral ossification
chondroblasts and fragments of epiphyseal cartilage escape from the physis, displace into the
metaphysis and proliferate there
Associated conditions
o solitary enchondroma
o Ollier's disease (multiple enchondromatosis)
sporadic inheritance with no genetic predisposition
skeletal dysplasia with failure of normal endochondral ossification
enchondromas throughout the metaphyses and diaphyses of long
bones
involved bones are dysplastic, with shortening and bowing
risk of malignant transformation <30%
o Maffucci's syndrome
sporadic inheritance with no genetic predisposition
multiple enchondromas and soft-tissue angiomas
radiographically, enchondromas in Maffucci's syndrome markedly expand the bone and
angiomas are seen as small, round calcified phleboliths
risk of malignant transformation up to 100%
also has increased risk of visceral malignancies (astrocytoma, GI malignancy)
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Chondrogenic Tumors
Classification
Enneking Classification of Benign Lesions
Stage Grade Examples
Stage 1 Latent lesions enchondroma, non-ossifying fibroma
Stage 2 Active lesions ABC, UBC, chondromyxoid fibroma, chondroblastoma
Stage 3 Aggressive lesions giant cell tumor of bone
Presentation
Symptoms
o asymptomatic, discovered incidentally on radiographs
usually true for enchondromas in long bones and foot
o pathologic fracture
often seen with enchondromas in the hand
o pain
pain is uncommon
when a patient presents with an enchondroma and pain in the adjacent joint, the cause of pain
is often unrelated to the tumor
unlike enchondroma, most chondrosarcomas have non-mechanical pain (rest pain and
nocturnal pain)
Physical exam
o shortening and angular deformities
enchondromas may disrupt the growth plate
o multiple bluish angiomas in Maffucci's syndrome
Imaging
Radiographs
o recommended views
skeletal survey if polyostotic disease is suspected
o findings
well defined, lucent, central medullary lesions that calcify over time
1 to 10cm in size
metaphyseal location when they first appear
appear more diaphyseal as the long bone grows
"pop-corn" stippling, arcs, whorls, rings
minimal endosteal erosion (<50% width of cortex)
cortical expansion and thinning may be present in hands, feet
but not in long tubular bones (femur, tibia)
may have purely lytic appearance (especially in hand)
Ollier's disease
enchondromas markedly expand the bone
bones are dysplastic, with shortening and bowing
Maffucci's syndrome
enchondromas markedly expand the bone
angiomas are visible as calcified phleboliths
unlike enchondromas, chondrosarcomas display
cortical thickening and destruction
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endosteal erosions and scalloping >50% of the width of the cortex
are larger (>5cm)
Bone scan
o indications
to help differentiate chondrosarcoma from enchondroma
to identify polyostotic disease
rarely adds useful information
only 20% have more uptake than ASIS
most enchondromas are small, and easily identified as
benign
o findings
increased uptake, but less than chondrosarcoma
because of continued remodeling within the lesion
MRI
o indications
usually not necessary for diagnosis
identify size and intramedullary extent and soft tissue extension
differentiate from chondrosarcoma
o findings
lobular and bright on T2-weighted images
no bone marrow edema or periosteal reaction
may show steak of cartilage or "sled runner tracks"
medullary fill >90% suggests chondrosarcoma instead
Studies
Core needle-biopsy
o from areas of bone scalloping or lysis
o prone to sampling error due to tumor heterogeneity
chondrosarcomas may contain areas of benign hyaline cartilage
o often impossible to differentiate from low-grade chondrosarcoma
Histology
o gross appearance
blue gray, lobulated hyaline cartilage, with scattered calcifications
o microscopic
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Chondrogenic Tumors
solitary lesions in long bones
hypocellular with bland, mature hyaline cartilage (blue balls of cartilage) separated by
normal marrow
differentiates from chondrosarcoma
endochondral ossification encases cartilage with lamellar bone
abundant extracellular matrix with no myxoid component
solitary lesions in small tubular bones and fibula, Ollier's and Maffucci's syndromes
hypercellular, with mild chondrocytic atypia
characteristics of chondrocytes
small, bland chondroid cells in lacunar spaces
uniform staining nuclei
no pleomorphism, mitoses, anaplasia, hyperchromasia or multinucleate cells
o unlike enchondromas, chondrosarcomas display
hypercellularity, with plump nuclei
multiple binucleate cells: giant cells with clumps of chromatin
Differential
Bone infarct
o "smoke up the chimney" radiographic appearance
o MRI does not give high T2 signal
enchondromas have high T2 signal because of high water
content of cartilage
Chondrosarcoma
II:2 Bone infarct xray
o worsening pain
o large size
o deep endosteal scalloping >2/3 of cortical thickness
o periosteal reaction, cortical breakthrough
o rare in hands, feet, more common in pelvis, scapula, ribs
the converse is true for enchondroma
o radiographic appearance differentiating low grade chondrosarcoma from enchondroma (see
below)
Treatment
Nonoperative
o observation
indications
treatment for vast majority of asymptomatic enchondromas
follow up
serial radiographs at 6 months and 12 months to confirm radiographic stability
long term follow-up for patients with multiple enchondroma syndromes
Operative
o intralesional curettage and bone grafting
indications
lesion that shows any change on serial xrays
radiographs suspicious for low-grade chondrosarcoma
large lesions at risk for recurrent fracture
outcomes
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local recurrence is unusual
o immobilization, followed by currettage and bone grafting
indications
pathologic fracture in small tubular bones (hand lesions) because repeated fractures will
usually occur
technique
immobilize until fracture union, followed by currettage and grafting
Complications
Malignant transformation
o risk of transformation of enchondroma to chondrosarcoma
solitary enchondroma
risk of malignant transformation is 1%
Ollier's disease
risk of malignant transformation is 25-30%
Maffucci's syndrome
risk of malignant transformation is 25-30%, but up to 100% risk of other visceral and
CNS malignancies as well
2. Periosteal Chondromas
Introduction
A rare type of chondroma (benign chondrogenic lesion) which occur on surface of long bones
Epidemiology
o demographics
occur in 10-20 year-olds
o locationsurface of long bones (under periosteum) in distal femur, proximal humerus, and
proximal femur
59% of lesions in proximal humerus
other locations in the hand (metacarpal or phalanges)
Presentation
Symptoms
o many are painful secondary to irritation of tendons
Imaging
Radiographs
o well-demarcated, shallow cortical defect
o punctate mineralization (calcification) in 1/3.
o saucerization of underlying bone
o radiographs important to differentiate from chondrosarcoma (histology may be similar)
Studies
Histology
o similar to enchondroma except for increased cellularity and more malignant looking cells (can
look like chondrosarcoma)
bland hyaline cartilage
small chondroid cells in lacunar spaces
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Chondrogenic Tumors
Treatment
Operative
o marginal excision including underlying cortex
indications
severe symptoms interferring with function
technique
lesion will recur if cartilage is left behind
bone graft any large defects
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o pathoanatomy
hamartomatous proliferation of bone and cartilage
possibly arise from growth plate cartilage that grows through the cortex by endochondral
ossification under the periosteum
perichondral node of Ranvier defect may allow growth from the physis to extend from the
surface
the stalk of the lesion is cortical and cancellous bone formed from ossified cartilage
Genetics
o inheritance : autosomal dominant
o mutation
mutation in EXT gene affects prehypertrophic chondrocytes of growth plate
loss of regulation of Indian hedgehog protein is currently being investigated in the
pathogenesis of this disease
Associated conditions
o secondary chondrosarcoma
a malignant condition that results from malignant transformation of a solitary
osteochondroma or MHE
most commonly a low-grade tumor (90%)
epidemiology
occurs in older patients (tested ages: 50)
rare in the pediatric population (< 1%)
most common location of secondary chondrosarcoma is the pelvis
Prognosis
o risk of malignant transformation is
<1% with solitary osteochondroma
~5-10% with MHE develop secondary chondrosarcoma
Presentation
Osteochondroma
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Chondrogenic Tumors
o symptoms
most lesions are asymptomatic
usually present with painless mass
may have mechanical symptoms or symptoms of neurovascular compression
they continue to grow until skeletal maturity
o physical exam
palpable mass
may have mechanical symptoms secondary to mass
Multiple hereditary exostosis (MHE)
o symptoms
limb deformities
most common sites of deformity include the knee, forearm, and ankle
femoral shortening and limb-length discrepancy
coxa valga
knee valgus (because of shortened fibula) and patellar dislocation
ankle valgus (because of shortened fibula)
upper extremity deformities are well tolerated and lead to little loss of function
ulnar shortening
radial bowing and radial head dislocation
may be treated with exostosis excision, ulnar lengthening and radial closing wedge
osteotomy
joint pain
may have symptoms of premature OA
o physical exam
most common deformities include
ulnar shortening and radial bowing
radial head dislocation
ulnar deviation of the hand
Secondary chondrosarcoma
o acute onset of pain in adults with MHE should raise suspicion for malignancy
Imaging
Radiograph
o sessile (broad base) or pedunculated (narrow stalk) lesions found on the surface of bones
higher risk of malignant degeneration in sessile lesions
pedunculated lesions point away from the joint
o continuity with native tissue
cortex of the lesion continuous with cortex of the native bone
medullary cavity of lesion continuous with medullary cavity of
native bone
o cartilage cap is usually radiolucent and involutes at skeletal maturity
o nodules of metaplastic cartilage can occur within the bursa over
cartilage caps
CT or MRI
o used to better characterize lesions
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Histology
Characteristic histology
o is similar to a normal physis with
cartilage cap consists of hyaline cartilage
well defined perichondrium around the cartilage cap
normal primary trabeculae
linear clusters of active chondrocytes
o may have thin cartilage cap covers lesion
only 2-3 mm thick
thick cartilage caps imply growth but are not a reliable indicator of malignant degeneration in
children
if cartilage cap becomes thicker as an adult, need to be concerned for chondrosarcoma
transformation
Treatment
Osteochondromas
o nonoperative
observation alone
indications : asymptomatic or minimally symptomatic cases
o operative
marginal resection at base of stalk, including cartilage cap
indications
symptomatic lesions
lesion may cause inflammation to surrounding tissue
lesion may be cosmetically displeasing
try to delay surgery until skeletal maturity
Multiple hereditary exostosis (MHE)
o nonoperative
observation
indications : most patients do not require intervention prior to reaching skeletal maturity
o operative
surgical excision of the osteochondroma
indications
dislocated radial heads
loss of forearm rotation
outcomes
simple excision of the osteochondroma optimizes chance of improved motion
Secondary chondrosarcoma
o operative : wide surgical resection : treat same as typical chondrosarcoma
Complications
Pseudoaneurysm of the popliteal artery in the popliteal fossa
o other vascular complications
vascular compression
true aneurysm
arterial thrombosis
venous thrombosis
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Chondrogenic Tumors
Nerve compression
o sciatic nerve
o common peroneal nerve
atrophy of anterior and lateral compartment muscles of the leg
o radial nerve
Tendon compression
o lesions around the shoulder can give rise to
rotator cuff impingement
subscapularis tear
bicipital tendinitis
Chondrosarcoma
o in adults, cartilage cap >2cm is associated with increased chance of malignancy
o mean age of diagnosis, 31yrs : seldom in 1st decade or after 5th decade of life
Bursa formation
Recurrence
o 2-5% of cases after resection
o Short-term X-ray surveillance is adequate unless symptomatic later
4. Chondroblastoma
Introduction
A rare, benign chondrogenic lesion (differs from giant cell tumor by its chondroid matrix)
Epidemiology
o demographics
M:F = 2:1
80% of patients under 25 years of age
o body location
epiphyseal lesion in young patients (usually around 12 years of age)
common locations include distal femur and proximal tibia >>> proximal humerus, proximal
femur, calcaneus, flat bones and apophysis or triradiate cartilage of the pelvis
typically epiphyseal but may occasionally cross the physis
Pathophysiology
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o thought to arise from cartilaginous epiphyseal plate
o categorized as cartilage tumor due to its areas of chondroid matrix, but type II collagen is not
expressed by tumor cells
Genetics
o mutations
may have genetic abnormalities on chromosome 5 and 8
Associated Conditions
o medical conditions & comorbidities
< 1% develop benign pulmonary metastasis (similar to giant cell tumor)
Prognosis
o local recurrence rate is 10-15% after treatment
Presentation
Symptoms
o progressive pain at tumor site
o limping
Physical examination
o inspection
muscle atrophy
tenderness over affected bone
o motion
decreased ROM
Imaging
Radiographs
o recommended views
AP, lateral, and oblique of involved area
o findings
well-circumscribed epiphyseal lytic lesion with thin rim of sclerotic bone that is sharply
demarcated from normal medullary cavity
lesions often cross physis into metaphysis
stippled calcifications within the lesion may or may not be present (25%-45%)
cortical expansion may be present
soft tissue expansion rare
o differential with radiographs
giant cell tumor
osteomyelitis
clear cell chondrosarcoma
CT
o indications
not required
defines bony extent of lesion
MRI
o findings
extensive edema surrounding lesion
Studies
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Chondrogenic Tumors
Histology
o findings
chondroblasts arranged in "cobblestone" or "chickenwire" pattern may be present
scattered multinucleated giant cells with focal areas of chondroid matrix
occasional multinucleated giant cells may be present
mononuclear stromal cells are distinct, S100+ cells with large central nuclei
nuclei have longitudinal groove resembling coffee bean
1/3 of chonroblastomas have areas of secondary ABC
Treatment
Operative
o extended intralesional curettage and bone grafting
indications
standard of treatment in symptomatic individuals
technique
may do local adjuvant treatment with phenol or cryotherapy to decrease local recurrence
o surgical resection
indications
pulmonary metastasis
Differential Groups
Epiphyseal Benign lesion that may Treatment is curretage and bone
lesion metastasize to lung grafting (1)
Chondroblastoma • • •
Giant Cell Tumor • • •
Aneurysmal bone cyst •
Osteoblastoma •
Chondromyoid fibroma
•
(CMF)
ASSUMPTIONS: (1) assuming no impending fracture
5. Chondromyxoid Fibroma
Introduction
A rare and benign chondrogenic lesion characterized by variable amounts of chondroid, fibromatoid
and myxoid elements
Epidemiology
o demographics
more common in males
most common in second and third decades of life
may affect patients up to 75 years old
o location
long bones (ie. tibia, distal femur)
often affects metaphyseal (proximal tibia) regions
pelvis
feet or hands
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Pathophysiology
o may arise from physeal remnants
Genetics
o mutations
a genetic rearrangement may affect chromosome 6 (postion q13)
Prognosis
o natural history
recurrence in CMF is not uncommon
may occur in 20-30% of cases
o negative prognostic variables
children
tumor is more lobulated with abundant myxoid material
o metastasis
has not been reported
Presentation
History
o long standing pain (months to years)
o may be incidentally identified
Symptoms
o pain and mild swelling
Imaging
Radiographs
o findings
lytic, eccentric metaphyseal lesion
sharply demarcated from adjacent bone
scalloped and sclerotic rim
calcifications are rare
cortical expansion may be seen
lesion size may range from two to ten centimeters
MRI
o findings
low signal on T1-weighted images
high signal on T2-weighted images
Bone scan
o findings
increased signal uptake will be seen
Studies
Histology
o findings
low-power
biphasic appearance
hypercellular area with lobules of fibromyxoid tissue
spindle-shaped cells or stellate-shaped cells
the cells contain hyperchromatic nuclei
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Chondrogenic Tumors
multinucleated giant cells and fibrovascular tissue are located between lobules
hypocellular area with chondroid material
high power
myxoid stroma with stellate cells
regions of pleiomorphic cells with bizarre nuclei may be seen
Diagnostic criteria
o histopathologic examination is mandatory for confirmation of the diagnosis
Differential
Radiographic
o aneurysmal bone cyst (ABC)
o chondroblastoma
o non-ossifying fibroma
Histologic
o chondroblastoma
o enchondroma
o chondrosarcoma
Treatment
Operative
o intralesional curretage and bone grafting (or PMMA)
indications
mainstay of treatment
Complications
Recurrence
o occurs in 25% of cases
6. Chondrosarcoma
Introduction
Malignant chondrogenic lesions can occur in two forms
o primary chondrosarcoma
which includes
low-grade, high-grade, dedifferentiated chondrosarcoma
clear cell chondrosarcoma (see below)
mesenchymal chondrosarcoma (see below)
o secondary chondrosarcoma
arises from benign cartilage lesions including
osteochondroma (<1% risk of malignant transfomation)
multiple hereditary exostosis (1-10% risk of malignant transformation)
enchondromas (1% risk of malignant transformation)
Ollier's disease (25-40% risk of malignant transformation)
Maffucci's (100% risk of malignant transformation)
Age & location
o typically, chondrosarcomas are found in older patients (40-75 yrs)
o there is a slight male predominance
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o most common locations include the pelvis, proximal femur, scapula
o tumor location is important for diagnosis as the same histology may be diagnosed as benign in
the hand but malignant if located in the long bones
Grade
o 85% of chondrosarcomas are grade 1 or 2
o 15% of chondrosarcomas are grade 3 or dedifferentiated chondrosarcoma
de-differentiated chondrosarcomas are high grade lesions which develop from low grade
chondroid lesions
Prognosis
o axial and proximal extremity lesions have a more aggressive course
o histologic grade correlates with survival
Grade I: 90% survival
Grade II: 60-70% survival
Grade III: 30-50% survival
De-differentiated chondrosarcoma: 10% survival
o increased telomerase activity in chondrosarcoma, as determined by reverse transcriptase-
polymerase chain reaction (RT-PCR), has been shown to directly correlate with the rate of
recurrence
Chondrosarcoma sub-types
o Clear cell chondrosarcoma
malignant immature cartilaginous tumor accounting for <2% of all chondrosarcomas
most common in 3rd and 4th decades of life
commonly presents with insidious onset of pain
presents as an epiphyseal lesion and can be mistaken for low-grade chondroblastoma
locally destructive with potential to metastasize
o Mesenchymal chondrosarcoma
chondrosarcoma variant which presents with a biphasic pattern of neoplastic cartilage with
associated neoplastic small round blue cell component
occurs in younger patients than typical chondrosarcomas
may occur at several discontinuous sites at presentation and can occur in the soft tissues
treatment includes neo-adjuvant chemotherapy followed by wide surgical resection
Presentation
Symptoms
o pain is the most common symptom
o may present with slowly growing mass or symptoms of bowel/bladder obstruction due to mass
effect in the pelvis
o 50% of de-differentiated chondrosarcomas present with a pathologic fracture
Imaging
Radiographs
o lytic or blastic lesion with reactive thickening of the cortex
low-grade chondrosarcomas show
similar appearance to enchondromas with additional cortical thickening/expansion and
endosteal erosion
high-grade chondrosarcomas show
cortical destruction and a soft tissue mass
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o intra-lesional"popcorn" mineralization may be seen
described as rings, arcs, and stipples of mineralization
o de-differentiated chondrosarcomas radiographically show a lower grade chondroid lesion
with superimposed highly destructive area consistent with the high grade transformed
dedifferentiated chondrosarcoma
MRI or CT
o helpful to determine cortical destruction, marrow involvement, and the soft tissue involvement
Bone scan
o is usually very hot in all grades of chondrosarcoma
"popcorn"
lytic lesion mineralization de-differentiated chondrosarcomas MRI
Histology
Chondrosarcoma
o needle biopsy is not indicated for cartilage tumors due to difficulties with diagnosis
it is often difficult to determine malignancy based on histology alone
o characteristic histology
low-grade chondrosarcomas show
few mitotic figures with a bland histologic appearance
enlarged chondrocytes with plump multinucleated lacunae
high-grade chondrosarcomas show
hypercellular stroma consisting of characteristic "blue-balls" of a cartilage lesion which
permeate the bone trabeculae
o enchondromas of hand, Ollier's disease, Maffucci's disease, periosteal chondromas, and
chondrosarcoma may all have similar histology
De-differentiated chondrosarcomas
o characterized by a bimorphic histology
low grade chondroid component
high grade spindle cell component (similar histology to osteosarcoma, fibrosarcoma, MFH)
Treatment
Operative
o intra-lesional curettage
indications
Grade 1 lesions
treatment of grade 1 lesions located in the pelvis or axial skeleton is controversial
many authors recommend wide excision of all chondrosarcomas (even grade 1) if
located in the pelvis
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o wide surgical excision
indications
grade 2 or 3 lesions
some say grade 1 lesions in pelvis
historically, there is no significant role for radiation or chemotherapy in typical
intramedullary chondrosarcoma
o wide surgical excision combined with multi-agent chemotherapy
indications
mesenchymal chondrosarcoma
the role of chemotherapy in de-differentiated chondrosarcoma is very controversial
C. Hematopoietic
1. Multiple Myeloma
Introduction
A neoplastic proliferation of plasma cells that presents with skeletal lesions
o neoplastic plasma cells produces immunoglobulins
heavy chains: IgG (52%), IgA (21%), IgM (12%)
light chains: kappa or lambda
aka Bence Jones proteins
Disease forms
o disease takes multiple forms that vary in treatment and prognosis and includes
multiple myeloma (see below)
solitary plasmacytoma
osteosclerotic myeloma
Epidemiology
o incidence
most common primary bone malignancy
o demographics
patients > 40 years of age
affects males more than females
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twice as common in African-americans
Prognosis
o prognosis is variable
o data suggests 5 year survival of 30% and 10 year survival of 11%
overall survival is related to stage of disease and secondary factors like renal failure or
hypercalcemia
median survival is 3 years from diagnosis
shortest survival is seen in patients with renal failure
o poor prognostic factors in multiple myeloma
chromosome 13 deletion or translocation (t4;14), 4(14;16)
circulating plasma cells
increased beta 2 microgloblulin (indicates elevated tumor burden)
decreased serum albumin
increased marrow microvessels
o solitary plasmacytoma has best prognosis
Classification
Multiple Myeloma
o most common form
o Clonal bone marrow plasma cells ≥10% or biopsy-proven bony or extramedullary
plasmacytoma and any one or more of the following CRAB features and myeloma-defining
events:
o Evidence of end organ damage that can be attributed to the underlying plasma cell
proliferative disorder, specifically:
HyperCalcemia: serum calcium >0.25 mmol/L (>1mg/dL) higher than the upper limit of
normal or >2.75 mmol/L (>11mg/dL)
Renal insufficiency: creatinine clearance <40 mL per minute or serum creatinine
>177µmol/L (>2mg/dL)
Anemia: hemoglobin valure of >20g/L below the lowest limit of normal, or a hemoglobin
value <100g/L
Bone lesions: one or more osteolytic lesion on skeletal radiography, CT, or PET/CT. If bone
marrow has <10% clonal plasma cells, more than one bone lesion is required to distinguish
from solitary plasmacytoma with minimal marrow involvement
o Any one or more of the following biomarkers of malignancy (MDEs):
60% or greater clonal plasma cells on bone marrow examination
Serum involved / uninvolved free light chain ratio of 100 or greater, provided the absolute
level of the involved light chain is at least 100mg/L (a patient’s ―involved‖ free light chain—
either kappa or lambda—is the one that is above the normal reference range; the
―uninvolved‖ free light chain is the one that is typically in, or below, the normal range)
More than one focal lesion on MRI that is at least 5mm or greater in size.
Solitary Plasmacytoma
o plasma cell tumor occurring in a single skeletal location and lacking appropriate criteria for
diagnosis of multiple myeloma
o sensitive to radiation
o progress to multiple myeloma in over 50% of patients
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OrthoBullets2017 Bone Tumors | Hematopoietic
o diagnostic criteria
solitary lesion on skeletal survey
histologic biopsy confirmation of plasmacytoma
negative bone marrow biopsy (i.e. no plasma cells in bone marrow)
o do MRI and FDG-PET
additional lesions identified in one third of patients
Osteosclerotic Myeloma
o a rare syndrome characterized by POEMS:
Polyneuropathy, Organomegaly, Endocrinopathy, M protein, Skin changes
o neurologic symptoms are symmetric and begin distal and migrate proximally
sensory symptoms manifest first and then are followed by motor
weakness
neurological symptoms usually do not improve
o skin lesions are characteristic and occur predominantly in the trunk
up to 25-50% of skin lesions occur in the extremities
o sclerotic bone lesions occur in both the axial and appendicular skeleton
Presentation
Symptoms
o usually present with localized bone pain (usually spine or ribs) or pathologic fracture
o fatigue secondary to anemia, renal insufficiency, hypercalcemia
Imaging
Radiographic
o show multiple "punched-out" lytic lesions
lytic lesions caused by osteoclastic bone resorption via RANKL, IL-6 and MIP-1alpha
lack of osteoblastic activity in myeloma cause the "punched out lesions" on radiographs
which lack a sclerotic border
o skeletal survey
if there is a suspicion for multiple myeloma obtain a skeletal survey as bone scans are cold in
30%
MRI
o shows multiple lesions that are bright on T2 and dark on
T1
o more sensitive than XR for pelvis, spine
Bone scans
o are cold in 30% so obtain a skeletal survey
o bone scans are "hot" due to radio-tracer integration into
the inorganic phase of bone caused by osteoblastic activity
o multiple myeloma often lacks osteoblastic activity
FDG PET
o sensitivity 93%, more sensitive than plain radiographs in diagnosing/screening for MM
o may uncover additional sites in "solitary" plasmacytoma
Labs
Serum labs
o anemia
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Hematopoietic
o elevated creatinine
o hypercalcemia
present in 30% of patients due to excessive resorption of bone
o ESR often elevated
o SPEP (serum protein electrophoresis)
M spike present (50% IgG, 25% IgA)
Urine
o proteinuria
o UPEP (urine protein electrophoresis)
may show Bence Jones proteins (secreted immunoglobulin kappa and lambda light chains)
Histology
Distinctive histology
o round plasma cells with an eccentric nucleus, prominent nucleolus, and clock face organization
of chromatin
o characteristic clear area (Hoffa clear zone) next to the nucleus represents the prominent Golgi
apparatus involved in immunoglobulin (protein) production
Bone marrow aspirate
o percentage of plasma cells on bone marrow aspirate is one major criteria used to distinguish
plasmacytoma (10-30% plasma cells) vs. multiple myeloma (>30% plasma cells)
o normal amount of plasma cells on bone marrow aspirate is < 2%
Immunohistochemical stains
o CD38+
Treatment
Monoglonal gammopathy of unknown significant or asymptomatic myeloma
o annual surveillance
Multiple myeloma
o nonoperative
multiagent chemotherapy
indications
is the mainstay of treatment
used alone for nontransplant candidates
advanced age >65y
poor physical condition
cytotoxic chemotherapy combined with steroids
melphalan + prednisone + thalidomide or bortezomib
lenalidomide + dexamethasone
thalidomide + dexamethasone
autologous and allogeneic stem cell transplantation
not curative but increases disease free survival by 2-3y
induction
dexamethasone + lenalidomide
bortezomib + dexamethasone
bortezomib + lenalidomide + dexamethasone
bortezomib + thalidomide + dexamethasone
bisphosphonates
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OrthoBullets2017 Bone Tumors | Hematopoietic
help reduce number of skeletal events in multiple myeloma patients
o operative
surgical stabilization and irradiation
indications
for complete or impending fractures
when life expectancy >3mths
vertebral compression fractures with instability or neural compression resistant to
radiation
technique
kyphoplasty / vertebroplasty an option for painful vertebral compression fractures
currettage, PMMA and modified Harrington pins
periacetabular lesions with intact acetabular subchondral plate
complex THA with acetabular cage
periacetabular lesions where acetabular subchondral plate is violated
Solitary plasmacytoma
o nonoperative
external beam irradiation alone (45 - 50 Gy)
indications
is the mainstay of treatment
o operative
surgical stabilization
indications
for complete or impending fractures
Osteosclerotic myeloma
o nonoperative
chemotherapy, radiotherapy, and plasmapheresis
indications
is the mainstay of treatment
outcomes
neurologic changes usually do not improve with treatment
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Hematopoietic
2. Lymphoma
Introduction
Malignant hematopoietic tumor uncommonly found primarily in bone that occurs in three forms
o primary lymphoma of bone (solitary site)
most primary lymphomas of bone are Non-Hodgkin's B-cell lymphomas rather than T-cell
variants
diagnosed when there is only a single node of disease for six months
o multiple bony sites (no visceral sites)
o bone and soft tissue lymphoma
Epidemiology
o incidence
10-35% of non-Hodgkin's lymphoma patients have extranodal disease
primary lymphoma of bone is very rare
o demographics
males > females
can occur in all age groups
most common in patients aged 35 to 55
o location
bones with persistent red marrow
most common sites are pelvis, spine, and ribs
other common sites include knee (distal femur and proximal tibia), proximal femur, and
shoulder girdle
o risk factors
immunodeficiency (HIV, hepatitis)
viral or bacterial infections
Prognosis
o primary lymphoma of bone has a better prognosis than secondary involvement of bone in
lymphoma
Presentation
Symptoms
o pain unrelieved by rest
o 25% present with a pathologic fracture
o neurologic symptoms from spinal compression
o fever, nightsweats, weight loss (B-cell symptoms)
Physical Exam
o inspection
warm and swollen large soft tissue masses are common
Imaging
Radiographs
o large ill-defined diffuse lytic lesions with a subtle mottled appearance
o more common in the diaphysis of long bones
o 25% show cortical thickening
o "ivory" vertebrae
o multiple sites of disease is common
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OrthoBullets2017 Bone Tumors | Hematopoietic
o differentialdiagnosis
metastatic disease
multiple myeloma
osteomyelitis
CT
o CT of chest, abdomen, and pelvis required for staging
MRI
o extensive marrow involvement with large soft-tissue mass
Bone scan
o intensely positive
PET
o useful to stage and follow the disease
Studies
Biopsy
o bone marrow aspiration and biopsy are required for staging
Histology
o diagnosis difficult to make with needle biopsy alone because tissue is often crushed
o mixed small round blue cell infiltrate (different sizes and shapes)
o diffuse infiltration of trabeculae (as opposed to nodular)
o immunohistochemical stains positive
CD20 positive
CD45 positive
lymphocyte common antigen positive
Treatment
Nonoperative
o multi-agent chemotherapy +/- local irradiation
indications
mainstay of treatment
radiation may be added to obtain local control in persistent disease
techniques
cyclophosphamide, doxorubicin, prednisone and vincristine
outcomes
chemotherapy alone is effective for most lesions
70% 5-year survival in disseminated disease
Operative
o fracture stabilization
indications
stabilization of pathologic fractures or prophylactic fracture management
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Hematopoietic
Differentials & Groups
Destructive lesion in Malignant lesion Malignant small Treatment is
young patients(1) in older patient(2) cells tumor chemotherapy
alone(3)
Lymphoma • • • •
Leukemia • •
Osteosarcoma •
Ewing's sarcoma • •
Eosinophilic granuloma •
Osteomyelitis •
Desmoplastic fibroma •
Metastatic disease • •
Myeloma • •
Chondrosarcoma •
MFH •
Secondary sarcoma •
Rhabdomyosarcoma •
Neuroblastoma •
ASSUMPTIONS: (1) Younger patient is < 40 yrs; (2) older patient > 40 (3) assuming no impending fracture
3. Leukemia
Introduction
The most common malignancy of childhood
Forms include
o acute lymphocytic leukemia (ALL)
neoplastic proliferation of lymphocytes
o actue myeloblastic leukemia (AML)
neoplastic proliferation of myeloblasts
o chronic myelocytic leukemia (CML)
neoplastic mature myeloid cells (granulocytes)
o chronic lymphocytic leukemia (CLL)
neoplastic proliferation of naive B cells II:3 myeloblasts with Auer rods
Classification
ALL
o represents 80% of cases of leukemia
o peak incidence of 4 years of age
o causes dimeralization of bones, periostitis, and lytic lesions
o positive TdT nuclear staining
o T-ALL
proliferation of T-lymphocytes
presents in teenagers
o B-ALL II:4 Philadelphia chromosome
proliferation of B-lymphocytes
12;21 translocation most commonly seen in children
9;22 translocation most commonly seen in adults
AML
o most commonly seen in older adults (5th-6th decade)
o marrow failure secondary to crowding out of normal hematopoeisis by neoplastic proliferation
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OrthoBullets2017 Bone Tumors | Hematopoietic
o myeloblasts with Auer rods
o Acute Promyelocytic Leukemia (APL)
caused by 15;17 translocation
disrupts retinoic acid receptor (RAR) required for myeloblast maturation
o Acute megakaryoblastic leukemia
associated with Down syndrome
younger than 5 years
o Acute monocytic leukemia
infiltration of the gums
CML
o onset usually in older adults (5th-6th decade)
o 9;22 translocation II:5 smudge cells on peripheral smear
known as the Philadelphia chromosome
results in a fusion tyrosine kinase with increased activity (bcr-abl)
increased levels of bcr-abl leads to ↑ cell division and inhibition of apoptosis
CLL
o commonly seen in older adults (5th-6th decade)
o insidious onset of symptoms
o smudge cells on peripheral smear
Presentation
Symptoms
o recurrent infections
o bleeding
o fatigue
o lymphadenopathy (more common in CLL)
Physical exam
o hepatosplenomegaly
secondary to leukemic infiltrate
o lymphadenopathy
secondary to leukemic infiltrate
Treatment
Nonoperative
o chemotherapy
T-ALL & B-ALL
may predispose to pathologic fractures
all-trans-retinoic acid for APL (AML subtype)
imatinib for CML
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Fibrogenic and Histiocytic
1. Non-ossifying Fibroma
Introduction
Non-ossifying Fibroma (NOF) is a benign fibrogenic lesion that is the most common benign bone
tumor in childhood
o related to dysfunctional ossification
o other names
metaphyseal fibrous defect
nonosteogenic fibroma
cortical desmoid
fibrous cortical defect
fibromatosis
fibroxanthoma
Epidemiology
o demographics
common in children 5-15 years old
30% of children with open physis have a NOF
o locations
metaphysis of long bones
80% in lower extremity
distal femur > proximal tibia > proximal fibula > distal tibia
uncommon in proximal femur, proximal humerus
Pathophysiology
o possibly due to abnormal osteoclastic resorption at the subperiosteal level during remodeling of
the metaphysis
Associated conditions
o Jaffe-Campanacci syndrome
congenital syndrome of multiple non-ossifying fibromas and
cafe au lait pigmentation
mental retardation
heart, eyes, gonads involved
o neurofibromatosis
o familial multifocal NOF
o ABC
Presentation
Symptoms
o asymptomatic and found incidentally
o painless
o may present with pathologic fracture
Imaging
Radiographs
o diagnostic
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OrthoBullets2017 Bone Tumors | Fibrogenic and Histiocytic
o metaphyseal eccentric "bubbly" lytic lesion surrounded by sclerotic rim
o cortex may be expanded and thin
o as bone grows
migrates to diaphysis
lesions enlarge (1-7cm)
o lesions become sclerotic as patient approaches skeletal maturity
o avulsion of adductor magnus insertion in the posteromedial aspect of the distal femur may
produce a similar looking lesion.
CT
o quantitative CT shown to be useful in predicting fracture risk
Studies
Histology
o classic characteristics are
fibroblastic spindle cells in whirled or storiform pattern (helicopter in wheat field)
fibroblastic connective tissue background
numerous lipophages and giant cells
hemosiderin pigmentation
occasional ABC component
Differential
Giant cell tumor
o painful
o rare in skeletally immature
o no mineralization
Osteosarcoma
o painful
o irregular zone of bony destruction with less defined zone of transition
o periosteal reaction
o mineralized soft tissue mass
Treatment
Nonoperative
o observation
indications
first line of treatment
most lesions resolve spontaneously and progressively reossify as child enters 2nd and 3rd
decade of life
technique
radiographs at 6, 12months, then annually until reossified
o casting
indication
pathologic fracture
can be treated as per the fracture alone (long leg casting for distal femur pathologic fx)
Operative
o curettage and bone grafting
indication
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Fibrogenic and Histiocytic
symptomatic and large lesion
increased risk of fracture shown on quantitative CT
Differentials & Groups
"Bubbly" lytic lesion on Hemosiderin seen on Treatment is Observation
xray Histology alone (1)
NOF • • •
ABC •
UBC •
PVNS •
Fibrous dysplasia •
Enchondroma •
Osteochondroma •
Eosinophillic granuloma •
Paget's •
ASSUMPTIONS: (1) assuming aymptomatic and no impending fracture
Symptoms
Presentation
o pain and swelling
Imaging
Radiographic characteristics
o lytic lesion with sclerotic border
Histology
Characteristic findings
o spindle cells
o foamy macrophages
o storiform pattern (helicopter in wheat field)
Treatment
Operative
o curettage and bone grafting
Prognosis
Recurrence rare
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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OrthoBullets2017 Bone Tumors | Fibrogenic and Histiocytic
3. Desmoplastic Fibroma
Introduction
Low-grade malignant fibrogenic tumor of bone
Epidemiology
o incidence
extremely rare
o demographics
usually occurs in adolescence and young adults (15-25)
o body location
mandible and metaphysis of long bones
Prognosis
o recurrence rate of 40%
Symptoms
Presentation
o painful lesion
Imaging
Radiographs
o findings
purely lytic lesion
soap bubble appearance (internal pseudotrabeculatins)
endosteal scalloping
may involve cortex
may have soft tissue mass
Histology
Classic characteristics are
o dense swirling fibrous spindle cells
o mature fibroblasts without cellular atypia
o abundant bundles of collagen
Treatment
Operative
o wide surgical resection vs. intralesional curretage
indications
wide surgical resection recommended to avoid recurrence
Presentation
History
o new, painful mass
o can present with pathologic fracture
Symptoms
o pain
o constitutional symptoms
fevers, chills, night sweats and weight loss
Physical exam
o inspection
swelling
limp
o motion
decreased range of motion
Imaging
Radiographs
o recommended views
AP and lateral of affected area
o findings
lytic and destructive lesion often in the metaphysis
variable periosteal reaction
cortical destruction with soft tissue extension
radiographs often non-specific
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OrthoBullets2017 Bone Tumors | Fibrogenic and Histiocytic
MRI
o indications
necessary to better characterize lesion
o findings
deep seated heterogeneous mass
often associated with internal hemorrhage
T1- low signal
T2- high signal
CT scan
o indications
to assess the amount and character of bone destruction
Bone scan
o indications
may be ordered as part of pre-treatment staging
o findings
shows increased uptake in adjacent cortex
Studies
Labs
o elevated WBC
o eosinophilia
o abnormal LFTs
o hypoglycemia
Histology
o pleomorphic spindle cells and histiocytic cells in storiform pattern
o malignant multinucleated giant cells with grooved or indented nuclei
o areas of chronic inflammatory cells
o variable collagen production
o fibrous fascicles radiate from focal hypocellular areas
o hemorrhagic and necrotic regions not infrequent; suggest high-grade lesion
Treatment
Operative (similar to osteosarcoma)
o neoadjunctive chemotherapy, wide resection, postoperative chemotherapy +/- radiation
indications : standard of care
chemotherapy
preoperative chemotherapy given for 8-12 weeks followed by maintenance chemotherapy
for 6-12 months after surgical resection
surgical resection
correct surgical option is based on the location of the tumor and the feasibility of
obtaining a wide surgical margin
wide excision or amputation have been found to have a higher 5-year survival rate
than those who received intralesional or marginal excision
trend towards limb salvage whenever possible
options include arthroplasty, resection arthrodesis, allograft reconstruction and
rotationplasty
radiation
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Fibrogenic and Histiocytic
indications
incomplete or questionable margins in order to reduce risk of local recurrence
adjunct to traditional chemotherapy and surgical regimens
5. Fibrosarcoma of Bone
Introduction
MFH and fibrosarcoma are now considered the same entity
A malignant fibrogenic tumor of the bone that usually affects older patients (> 50 yrs), although it
may occur in all age groups
o the majority are high grade
Prognosis is poor
o high grade has 30% survival at 5 years
o low grade has 80% survival at 10 years
Symptoms
Presentation
o pain and swelling
Imaging
Radiographic characteristics
o purely lytic lesion with bone destruction in a permeative pattern
o ill defined features
o looks like osteosarcoma
Bone scan is very hot
Histology
Same as soft tissue sarcoma
o atypical spindle cells
o herringbone pattern
o variable levels of collagen production
Treatment
Operative
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OrthoBullets2017 Bone Tumors | Notochordal & Vascular
o wide surgical resection and multiagent chemotherapy
indications : all malignant cases
chemotherapy
multiagent chemotherapy only if high grade (most cases)
1. Chordoma
Introduction
A malignant tumor of primitive notochordal origin
o slow growing and frequently misdiagnosed as low back pain
Epidemiology
o incidence
most common primary malignant spinal tumor in adults
o demographics
3:1 male to female ratio
usually in patients > 50 years
o location
50% occur in the sacrum and coccyx
35% in spheno-occiptal region
15% in mobile spine
Pathoanatomy
o forms from malignant transformation in residual notochordal cells
resulting in midline location
Prognosis
o metastasis
metastatic disease in 30-50%
occurs late in the course of the disease so long term follow up required
may spread to lung and rarely to bone
o survival
60% 5-years survival
25% long term survival
local extension may be fatal
Symptoms
Presentation
o pain
insidious onset of pain
may be mistaken for low back or hip pain
o neurologic
often complain of bowel or bladder changes
sensory deficits rare due to distal nature of tumor
o gastrointestinal
constipation
fecal incontinence
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Notochordal & Vascular
Physical exam
o neurologic
motor deficits rare because most lesions at S1 or distal
bowel and bladder changes are common
o rectal exam
more than 50% of sacral chordomas are palpable on rectal exam
Imaging
Radiographs
o often difficult to see lesion due to overlying bowel gas
CT
o will show midline bone destruction and soft tissue mass
o calcifications often present within the soft tissue lesion
MRI
o bright on T2
o useful to evaluate soft tissue extension
Histology
Biopsy
o transrectal biopsy is contraindicated
Gross
o lobular and gelatinous
Histology
o findings
characterized by foamy, vacuolated, physaliferous cell
grows in distinct nodules
o histochemical staining
keratin positive
important to distinguish from chondrosarcoma, which is not keratin positive
weakly S100 positive
Treatment
Nonoperative
o radiation treatment
indications
inoperable tumors
Operative
o wide margin surgical resection +/- radiation
indications
standard of care in most patients
technique
must be willing to sacrifice sacral nerve roots to obtain adequate surgical margins
add radiation if margin not achieved
outcomes
long-term survival 25-50%
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OrthoBullets2017 Bone Tumors | Notochordal & Vascular
Complications
Local recurrence
o 50% local recurrence common
o some newer evidence that radiation with proton-photon beams may be beneficial for recurrence
Loss of bowel/bladder function postoperatively
o to preserve near normal bowel/bladder function
preserve bilateral S2 nerve roots (at least)
preserve unilateral S2, S3, S4 roots
2. Hemangioma
Introduction
A benign vascular tumor of bone that often occurs in the vertebral bodies and cranio-facial bones
Presentation
Symptoms
o may be asymptomatic
o may present with pain or pathologic fx
Imaging
Radiographs
o lytic lesion characteristic vertical striations giving a "honey-comb" or "jail-bar" appearance
o may be multi-focal
Bone scan is warm to hot
Histology
Characteristic histology
o cavernous lesions with numerous thin walled blood vessels
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Notochordal & Vascular
Treatment
Nonoperative
o observation along is indicated if the patient is asymptomatic
Operative
o curettage and bone grafting
indicated if the lesion is symptomatic and accessible
o low dose radiation (25 to 40 Gy)
indicated if the lesion is symptomatic and inaccessible
3. Hemangioendothelioma (hemangiosarcoma)
Introduction
Hemangioendothelioma (or epitheliod hemangioendothelioma in soft tissue) is considered a rare
sarcoma showing endothelial differentiation
o distinct histologically and molecularly from benign hemangioma and high-grade angiosarcoma
Epidemiology
o demographics
occurs most commonly in 4th - 5th decade
women affected more than men
o location
more commonly in soft-tissue > bone
usually occurs in the lower extremity
o risk factors
exposure to arsenic
Pathophysiology
o pathoanatomy
arise from the lining of blood vessels
o cellular biology
stratifed into two groups based on size of tumor and mitotic activity
classic
malignant
Prognosis
o natural history of disease
malignant
tumor > 3cm and >3 mitoses/50 HPFs have 5 year survival of 59%
classic
100% survival if lack these features
o prognostic features
20 - 30% of tumors metastasize
visceral involvement is considered the most important criterion in predicting survival
Presentation
Symptoms
o local pain
o not usually associated with swelling
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OrthoBullets2017 Bone Tumors | Notochordal & Vascular
Imaging
Radiographs
o recommended views
2 or 3 views of affected bone
o findings
lytic lesion with no reactive bone
areas of cortical destruction and cortical expansion are common
CT
o indication
cross-sectional imaging to better define the area of concern
o findings
multifocal eccentric lytic lesions in bone
matrix mineralization may be present
calcification and periosteal reaction is rare
MRI
o indication
cross-sectional imaging to better define the area of concern
o findings
high signal intensity on T2-weighted images
edematous bone reaction surrounding the lesion
Histology
Macroscopic
o angiocentric growth expanding the vessel wall
o obliterating the lumen and spreading centrifugally into surrounding tissue
o induce a sclerotic response
Microscopic
o arranged in single files, cords and small nests
o typically lack well-formed vascular channels, with only immature, intracytoplasmic lumina
Differential diagnosis
Langerhans cell histiocytosis (LCH), angiosarcoma, infection, myeloma, metastasis, and lymphoma
o the diagnosis of hemangioednthelioma requires histopathologic analysis
Treatment
Nonoperative
o radiation therapy alone
indications
low grade lesion (classic)
o chemotherapy
the role of chemotherapy is not yet clear
Operative
o surgical resection +/- radiotherapy
indications
high grade lesion (malignant)
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Reactive lesions
F. Reactive lesions
Presentation
Symptoms
o most asymptomatic unless fracture occurs (usually with minor trauma)
o presents with pain from a pathologic fracture in ~50%
Imaging
Radiographs
o central, lytic, well-demarcated metaphyseal lesion (2-3% cross physis)
o cystic expansion with symmetric thinning of cortices
o "fallen leaf" sign (pathologic fracture with fallen cortical fragment in base of empty cyst is
pathognomonic)
o trabeculated appearance after multiple fractures
MRI
o very dark on T1
o very bright on T2
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OrthoBullets2017 Bone Tumors | Reactive lesions
o gadolinium shows classic rim enhancement of a cystic lesion
Bone scan
o is variable, but usually warm
Labs
Specific laboratory tests
o usually not required
Histology
Characteristic findings
o cyst with thin fibrous lining containing fibrous tissue, giant cells, and hemosiderin pigment
o chronic inflammatory cells may be found in small numbers
o cementum spherules (calcified eosinophilic fibrinous material) in 10%
o uniform population of spindle cells without nuclear atypia
Biopsy usually indicated for questionable diagnosis
Differential
ABC
o is more expansive than UBC (UBC lesion usually not wider than physis)
Telangiectatic osteosarcoma
Treatment
Nonoperative
o immobilization alone
indications
proximal humerus lesions with pathologic fracture (15% of lesions fill in with native bone
after acute fracture)
o aspiration/methylprednisolone acetate injection
indications
active cysts (communicates with physis) in the proximal humerus
technique
usually requires several injections, especially in very young children
bone marrow injections have recently been reported to be effective
Operative
o curettage and bone grafting +/- internal fixation based on tumor location
indications
symptomatic latent cysts that have not responded to steroid injections
latent cysts in the proximal femur that are a structural concern and at risk for fracture and
osteonecrosis
proximal femoral lesions with a pathologic fracture have a high rate of refracture and
malunion when treated nonoperatively therefore, internal fixation is recommended
contraindications
avoid in active lesions as communication with physis may lead to growth arrest
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Reactive lesions
Differentials & Groups
"Bubbly" lytic lesion on xray Treatment is USUALLY Treatment is
Aspiration and OCCASIONALLY
Injection curettage and bone
grafting.
UBC • • •
ABC •
NOF • •
Enchondroma •
Presentation
Symptoms
o pain and swelling
o may present with pathologic fracture
Physical exam
o neurologic deficits possible with spine lesions
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OrthoBullets2017 Bone Tumors | Reactive lesions
Imaging
Radiographs
o expansile, eccentric and lytic lesion with bony septae ("bubbly appearance")
o usually in metaphyseal
o classic cases have thin rim of periosteal new bone surrounding lesion
o no matrix mineralization
MRI or CT scan
o will show multiple fluid lines
o lesion can expand into soft tissue
Studies
Histology
o Characteristic findings
cavernous space
blood-filled spaces without endothelial lining
o cavity lining
numerous benign giant cells
spindle cells
thin strands of woven (new) bone present
Differential
Radiographic differential includes
o UBC
o telangiectatic osteosarcoma
Histologic differential includes
o telangiectatic osteosarcoma
o giant cell tumor
Treatment
Nonoperative
o nonoperative fracture management
indications
ABC with acute fracture
indicated until fracture has healed. Once healed, treat as an ABC without fracture
unless the fracture has led to spontaneous healing of the ABC
Operative
o aggressive curettage (+/- adjuvant) and bone grafting
indications
symptomatic ABC without acute fracture
technique
possible adjuvants
phenol
argon beam
liquid nitrogen
outcomes
local recurrence in up to 25% and more common in children with open physes
G. Tumor-like Lesions
1. Fibrous Dysplasia
Introduction
A developmental abnormality caused by failure of the production of normal lamellar bone
o areas of the skeleton remain poorly mineralized trabeculae
Epidemiology
o demographics
male:female ratio
females > males
age bracket
found in any and all ages
onset for 75% of patients at <30 years of age
o location
any bone can be involved
the proximal femur is most common site, followed by rib, maxilla, and tibia
Genetics
o GS alpha protein (chromosome 20q13) activating mutation (affects cAMP signaling pathway
leading to increased production of cAMP)
o not inherited
o high production of FGF-23 which may lead to hypophosphatemia
Associated conditions
o orthopedic manifestations
McCune Albright syndrome
condition defined by the presence of
skin abnormalities (cafe au lait spots in coast of Maine pattern)
endocrine abnormalities (precocious puberty)\
renal phosphate wasting due to FGF-23 (oncogenic osteomalacia)
unilateral polyostotic fibrous dysplasia
obtain AP spine radiographs to look for scoliosis
Mazabraud syndrome
polyostotic fibrous dysplasia
soft-tissue intramuscular myxomas
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OrthoBullets2017 Bone Tumors | Tumor-like Lesions
Osteofibrous dysplasia
rare form that primarily affects the tibia and is confined to the cortices
o nonorthopedic manifestations
severe cranial deformities with blindness
Prognosis
o 1% risk of malignant transformation to osteosarcoma, fibrosarcoma, or malignant fibrous
histiocytoma
poor prognosis
Presentation
Symptoms
o usually asymptomatic and discovered as an incidental finding
o may have swelling or deformity
o bone lesions may be monostotic (80%) or polystotic (20%)
o pain from stress fractures
Physical exam
o inspection
cafe au lait spots
II:6 cafe au lait spots
larger and more irregular borders than neurofibromatosis
may or may not be present with fibrous dysplasia
by definition present with McCune-Albright syndrome
swelling around lesion
Imaging
Radiographs
o hip/pelvis radiograph
central lytic lesions in medullary canal (diaphysis or metaphysis)
may have cortical thinning with expansile lesion
highly lytic lesions or a ground glass appearance
"punched-out" lesion with well defined margin of sclerotic bone is common
modest expansion of bone
Shepherd's crook deformity
o AP spine radiograph
vertebral collapse
kyphoscoliosis
Bone scan
o usually warm
Studies
Gross - yellow-white gritty tissue
Histology
o characteristic look of "alphabet soup" or "chinese letters"
o fibroblast proliferation surrounding islands of woven bone
woven bone lacks osteoblastic rimming (osteofibrous dysplasia has osteoblastic rimming)
o trabeculae of osteoid and bone in fibrous stroma with metaplastic cartilage or areas of cyst
degeneration
o mitotic figures are common
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Tumor-like Lesions
Treatment
Nonoperative
o observation
indications
asymptomatic patients
o Bisphosphonate therapy
indications
symptomatic polyostotic fibrous dysplasia
effective in decreasing pain and reducing bone turnover
Operative
o internal fixation and bone grafting
indications
symptomatic lesions
impending/actual fractures through lesions in areas of high stress (femoral neck)
severe deformity
neurologic compromise in the spine
technique
never use autogenous cancellous bone, as the transplanted bone will quickly turn into
fibrous dysplastic woven bone
use cortical or cancellous allografts
intramedullary device more effective than a plate in the lower extremity
o osteotomies
indications
coxa vara deformity
intertrochanteric osteotomy
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OrthoBullets2017 Bone Tumors | Tumor-like Lesions
Multiple lesions Treatment is Benefits from
in young patients Observation alone Bisphonate therapy
(1) (2)
Fibrous dysplasia • • •
Eosinophilic granuloma • •
Lymphoma •
Leukemia •
Enchondroma / Olliers / Marfucci's • •
Osteochondroma / MHE • •
NOF / Jaffe-Campanacci syndrome • •
Hemangioendothelioma •
Paget's • •
Metastatic Disease •
Myeloma •
ASSUMPTIONS: (1) Younger patient is < 40 yrs; (2) assuming aymptomatic and no impending fracture
2. Osteofibrous Dysplasia
Introduction
Rare form of fibrous dysplasia that primary affects the tibia and is confined to the cortices
o also known as ossifying fibroma and Campanacci lesion
Epidemiology
o demographics
usually found in younger children (< 10 years old)
males>females
o location
primarily in anterior tibia
Genetics
o trisomy 7, 8, 12, 22 have been reported
o does NOT have Gs alpha activating mutation like fibrous dysplasia has
Prognosis
o lesions usually regress and do not cause problems in adulthood
Presentation
Symptoms
o may be asymptomatic
o painless swelling
o anterior or anterolateral bowing of the tibia
o pseudoarthrosis develops in 10-30% of patients
Physical exam
o may have local tenderness over the tibia
Imaging
Radiographs
o recommended views
AP and lateral of affected area
o findings
anterior eccentric lytic tibial lesion in child that often leads to tibial bowing
usually diaphyseal
no periosteal reaction
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Tumor-like Lesions
confined to anterior cortex
o radiographic differential includes adamantinoma
Studies
Histology
o histology similar to fibrous dysplasia EXCEPT osteoblastic rimming is present
fibroblast proliferation surrounding islands of woven bone with osteoblastic rimming
mitotic figures are common
may have giant cells
Treatment
Nonoperative
o observation
indication
first line of treatment
alone is the treatment for most patients
o bracing
indication
if deformity significant and interfering with walking
Operative
o deformity correction with osteotomy
indication
rarely needed
significant deformity
perform after skeletal maturity
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OrthoBullets2017 Bone Tumors | Tumor-like Lesions
3. Paget's Disease
Introduction
A condition of abnormal bone remodeling
o original osseous tissue is reconstructed through active interplay between excessive bone
resorption and abnormal new bone formation
Pathophysiology
o increased osteoclastic bone resorption is the primary cellular abnormality
o cause is thought to be a slow virus infection (intra-nuclear nucleocapsid-like structure)
paramyxovirus
respiratory syncytial virus
Epidemiology
o peak incidence in the 5th decade of life
o common in Caucasians (northern European / Anglo-Saxon descent)
o males = females
o location
may be monostotic or polyostotic
common sites include femur > pelvis > tibia > skull > spine
Genetics
o inheritance
most cases are spontaneous
hereditary
familial clusters have been described with ~40% autosomal dominant transmission
o genetics
most important is 5q35 QTER (ubiquitine binding protein sequestosome
1) SQSTM1 (p62/Sequestosome)
tend to have severe Paget disease
also insertion mutation in TNFRSF11A for gene encoding RANK
Orthopaedic manifestations
o bone pain
o long bone bowing
o fractures, due to brittle bone and tend to be transverse
o large joint osteoarthritis
excessive bleeding during THA
malalignment during TKA
o secondary sarcoma
Associated conditions : high output heart failure
Prognosis & malignancy
o Paget's sarcoma
less than 1% will develop malignant Paget's sarcoma (secondary sarcoma)
osteosarcoma > fibrosarcoma and chondrosarcoma
most common in pelvis, femur, and humerus
poor prognosis
5-year survival for metastatic Paget's sarcoma < 10%
treatment includes chemotherapy and wide surgical resection
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Tumor-like Lesions
Classification
Phases
o lytic phase
intense osteoclastic resorption
o mixed phase
resorption and compensatory bone formation
o sclerotic phase
osteoblastic bone formation predominates
o all three phases may co-exist in the same bone
Presentation
Symptoms
o asymptomatic II:7 enlargement of left hemipelvis with cortical
frequently asymptomatic and found incidentally thickening of left pubic rami
o pain
pain may be the presenting symptom due to
stress fractures
increased vascularity and warmth
new intense pain and swelling
suspicious for Paget's sarcoma in a patient with history of Paget's + new intense pain and
swelling
o cardiac symptoms
can present with high-output cardiac failure particularly if large/multiple lesions & pre-
existing diminished cardiac function
Imaging
Radiographs
o coarsened trabeculae which give the bone a blastic appearance
both increased and decreased density may exist depending on phase of disease
lytic phase
lucent areas with expansion and thinned, intact cortices
'blade of grass' or 'flame-shaped' lucent advancing edge
mixed phase
combination of lysis + sclerosis with coarsened trabeculae
sclerotic phase
bone enlargement with cortical thickening, sclerotic and lucent areas
o remodeled cortices
loss of distinction between cortices and medullary cavity
o long bone bowing
bowing of femur or tibia
o fractures
o hip and knee osteoarthritis
o osteitis circumscripta
(cotton wool exudates) in skull
o Paget's secondary sarcoma
shows cortical bone destruction II:8 bowing of tibia
Evaluation
Laboratory findings
o elevated serum ALP
o elevated urinary collagen cross-links
o elevated urinary hydroxyproline (collagen breakdown marker)
o increased urinary N-telopeptide, alpha-C-telopeptide, and deoxypyridinoline
o normal calcium levels
Histology
Characteristic histology
o woven bone and irregular broad trabeculae with disorganized cement lines in a mosaic pattern
o profound bone resorption - numerous large osteoclasts with multiple nuclei per cell
virus-like inclusion bodies in osteoclasts
Paget's osteoclasts larger, more nuclei than typical osteoclasts
o fibrous vascular tissue interspersed between trabeculae
Treatment
Nonoperative
o observation and supportive therapy
treatment for asymptomatic Paget's disease
physiotherapy, NSAIDS, oral analgesics
o medical therapy aimed at osteoclast inhibition
bisphosphonates are 1st line treatment for symptomatic Pagets
oral
alendronate and risedronate
etidronate disodium (Didronel)
older generation medication
inhibits osteoclasts and osteoblasts
cannot be used for more than 6 months at a time
intravenous
pamidronate, zoledronic acid (Zometa)
newer generation medications that only inhibit osteoclasts
disadvantageous in that they only come in IV form
II:9 bone scan
calcitonin are 2nd line (after bisphosphonates)
causes osteoclasts to shrink in size and decreases their bone resorptive activity within
minutes
administered subcutaneously or intramuscularly
teriparatide is contraindicated in Paget's disease due to risk of secondary osteosarcoma
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Tumor-like Lesions
Operative
o THA / TKA
indications
affected patients with degenerative joint disease
technique
treat Paget's with pharmacologic agents prior to arthroplasty to reduce bleeding
outcomes
greater incidence of suboptimal alignment secondary to pagetoid bone
the most common complications include
malalignment with knee arthroplasty
bleeding with hip arthroplasty
o metaphyseal osteotomy and plate fixation
indications
fractures through pathologic bowing of long bones
impending pathologic fracture of long bone with bowing
4. Eosinophilic Granuloma
Introduction
Histiocytosis X or Langerhans cell histiocytosis is a spectrum of diseases of the reticuloendothelial
system with one of three general presentations
o Eosinophilic granuloma (EG)
usually a single self-limited lesion found in younger patients
o Hand-Schuller-Christian disease (HSC)
chronic, disseminated form with bone and visceral lesions
also known as Langerhans cell histiocytosis with visceral involvement
o Letterer-Siwe disease (LSD)
fatal form that occurs in young children
Epidemiology
o demographics
most commonly occurs in children (80% of afflicted < 20 years of age)
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HSC disease presents in children > 3 years of age
LSD occurs in children < 3 years of age
Male to female ratio of 2:1
o location
eosinophilic granuloma
commonly presents in the skull, ribs, clavicle, scapula, mandible
isolated lesions of the spine (thoracic most common)
can also occur in diaphyseal regions of long bones and the pelvis
HSC
multiple bony sites
multiple lytic skull lesions
visceral involvement of the lungs, spleen, liver, skin, lymph nodes
Genetics
o no clear genetic pattern of inheritance or locus has been determined
Prognosis
o EG
isolated involvement generally treatable with local management
spine lesions can spontaneously resolve
o HSC
prognosis depends on response to chemotherapy
worsening prognosis with increasing extraskeletal involvement
o LSD
generally fatal in children < 3 years of age
Presentation
Symptoms
o skeletal involvement
pain and swelling at the region of involvement
limping can be seen with pelvic or lower extremity involvement
o vertebral involvement
localized or diffuse back pain
increasingly kyphotic posture
radiculopathy can occur with more aggressive lesions
o HSC
classic triad of
multiple lytic skull lesions
diabetes insipidus
increased thirst and water intake
exopthalmos
II:10 exopthalmos
visceral involvement
diffuse or nonspecific abdominal or chest pain
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Tumor-like Lesions
Imaging
Radiographs
o general
known as "the great mimicker" as it appears similar to many lesions
radiographic differential includes osteomyelitis, leukemia, lymphoma, fibrous dysplasia, or
Ewing's sarcoma
o diaphyseal lesions
well defined intramedullary lytic or "punched-out" lesion
cortex may be thinned, expanded, or destroyed
may have periosteal reaction
o metaphyseal lesions
extend up to but not through the physis
less central location than diaphyseal lesions
o spinal lesions
vertebra plana (flattened vertebrae) in spine
increased kyphosis
o cranial involvement
multiple "punched-out" lytic lesions
MRI
o may show a soft tissue mass adjacent to boney lesions
Bone scan
o generally shows increased uptake in the region of boney lesion
Studies
Histology
o Langerhan's cells
mononuclear histiocyte-like cells with oval nuclei with well-defined round or oval cytoplasm.
a prominent nuclear groove (coffee bean nuclei) can be seen in most of the nuclei
eosinophilic cytoplasm (pink generally)
stain with CD1A
electronmicroscopy
birbeck granules seen inside Langerhan's cells
o mixture of inflammatory cells also present
o giant cells are present
o lack of nuclear atypia and atypical mitoses
differentiates this condition from malignant conditions such as Ewings sarcoma, lymphoma
of bone, and metastatic neuroblastoma, which may look similar based on the round cells
alone
Treatment
Nonoperative
o observation alone
indications
a self-limited process and it is reasonable to treat with observation alone
o bracing
indications
to prevent progressive kyphosis of the spine
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OrthoBullets2017 Bone Tumors | Tumor-like Lesions
outcomes
will correct deformity in 90% of patients
vertebral lesions generally regain 50% of their height
o low dose irradiation (600-800 cGy)
indications
indicated for lesions in the spine that compromise stability, neurologic status
lesions not amenable to injection or open treatment
outcomes
effective for most lesions
o chemotherapy
indications
diffuse HSC
outcomes
prognosis is improved with less severe extraskeletal involvement
o corticosteroid injection
indications
isolated lesions
can be performed after curettage as well
Operative
o curettage and bone grafting
indications
for lesions that endanger the articular surface or are a risk for impending fractures
o spinal deformity correction
indications
progressive spine deformity refractory to bracing
approximately 10% of patients with spine lesion will need operative intervention for
deformity correction
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Tumor-like Lesions
5. Myositis Ossificans
Introduction
A reactive process that is characterized by a well-circumscribed proliferation of fibroblasts,
cartilage, and bone within muscle
A form of heterotopic ossification that is the result of
o direct trauma
o intramuscular hematoma
most common location is the diaphysis of long bones
Must differentiate from tumors
Fibrodysplasia ossificans progressiva (FOP) is a rare subtype of heterotopic ossification
o involves mutation of the ACVR1 gene (activin A type I receptor gene, a BMP type-1 receptor)
Epidemiology
o demographics
most common in young active males (15 to 35 years old)
o body locations
quadriceps, brachialis and gluteal muscles
Genetics
o almost always a posttraumatic condition
Prognosis
o usually self limiting
mass usually begins to decrease in size after 1 year
Presentation
Symptoms
o pain, tenderness, swelling and decreased range of motion that usually presents within days of the
injury
pain and size of the mass decrease with time
o mass increases in size over several months (usually 3 to 6 cm)
after the mass stops growing, it becomes firm
Physical exam
o palpable soft tissue mass
o restricted range of motion
Imaging
Radiographs
o peripheral bone formation with central lucent area
o may appear as "dotted veil" pattern
MRI with gadolinium
o rim enhancement is seen within the first 3 weeks
CT scan
o lesion has an eggshell appearance
Histology
Characteristic histology shows zonal pattern
o periphery of lesion
mature trabeculae of lamellar and woven bone
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calcification seen on xray
o center of the lesion
irregular mass of immature fibroblasts
cartilage component may be present
(no calcification seen on xray)
no cellular atypia seen
Treatment
Nonoperative
o rest, range of motion exercises, and activity modification
passive stretching is contraindicated (makes it worse)
physical therapy
utilized to maintain range of motion
o radiographic monitoring
obtained to confirm maturation of the lesion
Operative
o surgical excision
indicated only if it remains a problem after it matures
do not operate in acute phase, wait at least six months
excision of the lesion within 6 to 12 months predisposes to local recurrence
6. Melorheostosis
Introduction
Rare benign painful disorder of the extremities characterized by formation of periosteal new bone
Epidemiology
o demographics
usually presents before age 40
no sex predilection
o location
more common in the lower extremities, but can occur in any bones
Genetics
o non-hereditary
Presentation
Symptoms
o pain
o reduced range of motion
o joint contractures
Physical exam
o fibrosis of the skin with significant induration and erythema is common
o reduced range of motion
o painful hyperostoses
Imaging
Radiographs
o cortical hyperostosis
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Tumor-like Lesions
―dripping candle wax‖ appearance with dense hyperostosis that flows along the cortex of the
bone
hyperostosis may flow across joints
Studies
Histology
o normal haversian systems with enlarged bone trabeculae and without cellular atypia or mitotic
figures
Treatment
Nonoperative
o symptomatic treatment
indications
mild symptoms with adeqate motion
Operative
o hyperostotic bone resection with contracture release
indications
severe contractures, limited mobility, and pain
7. Heterotopic Ossification
Introduction
Formation of bone in atypical, extraskeletal tissues
o usually occurs
spontaneously or following trauma
within 2 months of neurologic injury (brain or spinal cord)
following THA and TKA
o most common location is between muscle and joint capsule
Epidemiology
o incidence
(see table below)
o demographics
male:female = 2:1
especially men with hypertrophic osteoarthritis, and women >65y
o location
traumatic brain injury or stroke
hip > elbow > shoulder > knee
elbow HO more common following brain trauma
occurs on affected (spastic) side
rarely in the knee (TBI)
spinal cord injury
hip > knee > elbow > shoulder
hip flexors and abductors > extensors or adductors
medial aspect of the knee
o risk factors (see table below)
Pathophysiology
o exact cause of HO is not known but there appears to be a genetic disposition
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o experimental HO associated with
tissue expression of BMP
Associated conditions
o orthopaedic manifestations
pathologic fractures
from decreased joint ROM and osteoporotic bone
nerve impingement
soft tissue contractures, contributing to the formation of decubitus ulcers
CRPS (more common in patients with HO)
joint ankylosis
HO after THA adversely affects outcome of THA
o nonorthopaedic conditions
skin maceration and hygiene problems
Classification
Subtypes
o neurogenic HO (discussed here)
o traumatic myositis ossificans
o fibrodysplasia ossificans progressiva (Munchmeyer's Disease)
Presentation
Symptoms
o painless loss of ROM
o interferes with ADL
o CRPS symptoms
o fever
Physical exam
o inspection
warm, painful, swollen joint
may have effusion
skin problems
decubitus ulcers
from contractures around skin, muscles, ligaments
skin maceration and hygiene problems
o motion
decreased joint ROM
joint ankylosis
with HO after TKA, might develop quad muscle snapping or patella instability
o neurovascular
peripheral neuropathy
HO often impinges on adjacent NV structures
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Tumor-like Lesions
Risk Factors for Heterotopic Ossification
Injury severity score (ISS) High ISS is a risk 11%
Higher incidence in the spastic limbs of the
Traumatic brain injury (TBI) 11%
patient
Spinal cord injury Complete SCI produces more HO than 20%
incomplete SCI. Cervical and thoracic SCI
produces more HO than lumbar SCI.
Younger age produces more HO (20-30yo).
Higher incidence in the spastic limbs of the
patient.
Prolonged coma in young patient (20-
Neurologic compromise
30yo), and prolonged ventilator use
DISH, ankylosing spondylitis, hypertrophic
Other diseases
osteoarthritis (prominent osteophytes)
70% (with
Worse with concomitant decubitus ulcers
Decubitus ulcers concomitant
and SCI or TBI
SCI)
Antegrade femoral nail entry site Worse with piriformis fossa entry point. 25%
HO in distal quadriceps. Higher incidence rare
Distal femur traction pins in patients with other concomitant injuries,
use of large diameter Steinmann pins
(5mm) because of hematoma, soft tissue
injury from percutaneous insertion.
Amputation through zone of Worse with blast mechanism 63%
injury
Surgical approaches Extended iliofemoral > Kocher-Langenbeck 25%
> ilioinguinal approach (acetabular (acetabular
fracture). Anterior approach > posterior fracture
approach for femoral head fracture fixation. fixation)
Total hip arthroplasty THA Complications : Increased risk with 53%
psoas tenotomy and cementless (significant
components (more particulate debris and in only 5%)
marrow spillage, muscle trauma from
difficult broaching). Smith-Petersen and
Hardinge > transtrochanteric > posterior
(posterior has lowest risk of HO).
Total knee arthroplasty TKA complications : Increased risk with
notching anterior femur, surgical trauma to
quadriceps, distal femur exposure and
periosteal stripping, and postop
manipulation under anesthesia, and high
lumbar BMD
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OrthoBullets2017 Bone Tumors | Tumor-like Lesions
Imaging
Radiographs
o recommended views
Judet view valuable for evaluation of hip HO
o findings
ossification usually easy to visualize
maturity of HO
the appearance of a bony cortex suggests mature HO
sharp demarcation from surrounding tissue
trabecular pattern
o sensitivity and specificity
not useful for early diagnosis
only useful at 1 week after onset of symptoms
calcium is deposited 7-10 days later than symptom onset
Ultrasound
o indications
for early diagnosis of hip HO
o findings
echogenic surfaces with posterior acoustic shadowing
CT II:11 U/S showing HO (Large black
arrow) at the distal patellar tendon in
o indications a patient with Osgood Shlatter
useful for preoperative planning disease (small black arrows)
Studies
Labs
o elevated serum alkaline phosphatase (>250IU/L)
ALP removes inhibitors of mineralization
nonspecific, may be elevated with skeletal trauma
cannot determine maturity of HO
elevated 12wks after surgery is predictor
o elevated CRP
correlates with inflammatory activity of HO better than ESR
II:12 CT
normalization of CRP may correlate with maturity of HO
o elevated ESR (>35mm/h)
12wks after THA is predictor
o elevated CK
correlates with involvement of muscle, extent of muscle involvement
Histology
o mature fatty bone marrow
o mature trabecular bone
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Tumor-like Lesions
Treatment
Prophylaxis
o bisphosphonates & NSAIDS
indications
although no literature supports, are commonly used
technique
indomethacin is most commonly used
dose is 75mg/day for 10days to 6 weeks
o perioperative radiation
indications
although no literature supports, commonly used
is thought to be effective by blocking osteoblast differentiation
technique
a single perioperative dose of 700cGy can be given either 4 hours preop or within 72
hours postoperatively
<550cGy not effective
Posttraumatic
o wide exposure and surgical resection
indications
severe loss of motion and decreased function
technique
wide exposure required to identify all neurovascular structures that may be involved
timing of resection (controversial)
marked decrease in bone scan activity AND normalization of ALP
6 months following general trauma
1 year following SCI
1.5 years following TBI
some data suggests equivalent results when comparing early versus late resection
postop
follow with 5 day course of indomethacin
early gentle joint mobilization
Arthroplasty
o treatment for HO following THA
o treatment for HO following TKA
Complications
Hematoma and intraoperative bleeding
Infection
o higher rate of infection following joint arthroplasty if HO is present
Fractures of osteoporotic bone
o osteopenic from disuse
o during surgery or physiotherapy
Recurrence
o recurrence rate correlates with neurological injury
greater recurrence if severe neurological compromise
AVN : if extensive dissection or stripping is required
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8. Tumoral Calcinosis
Introduction
Rare and poorly understood hereditary metabolic dysfunction of phosphate regulation associated
with massive periarticular calcinosis in the extra-capsular soft tissues
Epidemiology
o demographics
more common in females and African-Americans
onset in childhood or early adolescence
o location
around joints, primarily the hip (trochanteric bursa is most common location) > shoulder
Pathophysiology
o unknown
inborn abnormality of phosphorus metabolism
Presentation
Symptoms
o mass or swelling typically around joints
o pain secondary to compression of normal surrounding structures
Physical exam
o inspection
palpable mass around joint
Imaging
Radiographs
o amorphous, cystic, lobular (circular or oval) well-demarcated calcification in periarticular
location
o direct involvement of the bones or joints is rare
CT
o findings
may demonstrate fluid-fluid levels within some of these masses
calcium layering ("sedimentation sign")
or may have homogenous appearance
reduced metabolic activity, lower likelihood of growth
MRI
o findings
diffuse, low signal intensity
bright, nodular pattern with alternating areas of high signal intensity and signal void
may demonstrate fluid-fluid levels (as with CT)
Bone scan
o radionuclide bone scan may reveal intense uptake in the calcific masses
Studies
Labs
o normal or slightly elevated renal and parathyroid function
o normal or slightly elevated serum calcium, phosphorus, uric acid, and alkaline phosphatase
Histology
o lobulated soft tissue masses with well-defined capsules and thick septae
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Tumor-like Lesions
o masses are filled with calcareous material (calcium phosphate, calcium carbonate and calcium
hydroxyapatite) and fluid
Differentials
Calcinosis of renal failure (secondary tumoral calcinosis)
o approximately 1% prevalence of periarticular masses
o may occur independent of concomitant hyperparathyroidism
o no radiologic/histologic differences with primary tumoral calcinosis
diagnosis is based on vitamin D levels, GFR, hyperphosphatemia, and history of chronic
renal failure/long term dialysis
Calcific tendinitis
o shoulder > hip > elbow > wrist > knee
o occurs within tendon
o no sedimentation of calcium (makes it different from tumoral calcinosis)
Synovial osteochondromatosis
o occurs within joint/tendon sheath
o "rings and arcs" and intra-articular location (makes it different from tumoral calcinosis)
Myositis ossificans and heterotopic ossification
o not lobular
o evolves rapidly from faint calcification to organized cartilage and bone in 6 weeks
o late lesions of HO have well developed cortex and medullary cavity
Gout
o may have hyperuricemia
o focal erosions of underlying bone
Treatment
Nonoperative
o observation
indications
treatment of choice for non-symptomatic lesions
Operative
o complete surgical excision
indications
treatment of choice for symptomatic lesions
technique
complete surgical excision is required to decrease the rate of local recurrence
results
risk of recurrence
if lesion is poorly circumscribed
if excision is performed while lesion is actively growing
9. Bone Infarct
Introduction
Overview
o bone infarcts are often thought to be in the same spectrum of disease as osteonecrosis
o occurs within the metaphysis or diaphysis of long bone
Epidemiology & Incidence
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o similarrisk factors as those seen in osteonecrosis
trauma, sickle cell disease, connective tissue disorders, Gaucher's disease, steroid use
Mechanism
o interruption of blood supply by intrinsic or extrinsic factors
Presentation
Symptoms
o usually asymptomatic
often found when imaging the extremities for other reasons
Imaging
Radiographs
o medullary lesion of sheet-like central lucency surrounded by sclerosis with a serpiginous border
"smoke up the chimney"
MRI
o key feature is that central signal remains of normal marrow
o T1 weighted images
peripheral low signal due to grannulation tissue and to lesser extent sclerosis
periphery may enhance post gadolinium
o T2 weighted images
acute infarct may show ill-defined non-specific area of high signal
intense inner ring of granulation tissue and a hypointense outer ring of sclerosis
Bone Scan
o cold in early phases
o hot in late resorptive and revascularisation phase
Treatment
Nonoperative
o observation
indications
usually asymptomatic and do not require treatment
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Unknown Origin
Presentation
Physical exam
o unilateral tibia vara
o knee hyperextension with lateral thrust can be seen
Imaging
Radiographs
o abrupt varus at the metaphyseal–diaphyseal junction of the tibia
o cortical sclerosis at the medial cortex
o radiolucency may appear just proximal to area of cortical
sclerosis corresponding to the fibrocartilaginous tissue
Studies
Histology
o prominent layers of collagenic fibrous tissue with thick dense fibrocartilaginous tissue
Treatment
Nonoperative
o observation
indications
majority spontaneously correct because of the normal proximal tibial physeal growth
Operative
o deformity correction
indications
may be necessary if the deformity progresses or fails to resolve during a period of
observation or orthotic management
H. Unknown Origin
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metastatic to lung in 2-5%
hand lesions have greater chance of metastasis
o secondary malignant giant cell tumor
occurs following radiation or multiple resections of giant cell tumor
Symptoms
Symptoms
o pain referable to involved joint
Physical exam
o palpable mass
o decreased range of motion around affected joint
Imaging
Radiographs
o eccentric lytic epiphyseal/metaphyseal lesion that often extends into the distal
epiphysis and borders subchondral bone
o "neo-cortex" is characteristic of benign aggressive lesions, and not unique to
GCT
Chest radiograph or chest CT
o pulmonary metatases occurs in 1-6%
o lung metastases are usually benign (histologically similar to primary bone
tumor)
Bone scan : is very hot
MRI
o shows clear demarcation on T1 image between fatty marrow and tumor
Histology
Characteristic cells
o Type I cell
mononucleur stromal cell that
resembles interstitial fibroblasts
this is the neoplastic/tumor cell
has features of mesenchymal stem cells
o Type II cell
from monocyte/macrophage family
recruited from peripheral blood
precursors of giant cells
o Type III cell
numerous giant cells are the hallmark
of this lesion
nuclei
nuclei of giant cell appears same as stromal cells
multiple nuclei (up to 50 per cell)
similar characteristics as osteoclasts and resorb bone
have same enzymes (tartrate resistant acid phosphatase, carbonic anhydrase II, cathepsin
K, vacuolar ATPase)
o secondary ABC degeneration is not uncommon
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Unknown Origin
Molecular biology
o Type II and III cells have IGF-I and IGF-II activity
o 80% of patients with GCT have telomeric associations (tas) abnormality in half the cells
o RANK pathway is important : denosumab acts on this pathway
Treatment
Nonoperative
o radiation alone
indications
only indicated for inoperable or multiply recurrent
lesions
outcomes
leads to 15% malignant transformation
o medical management
indications
medical therapy can be used to augment or replace surgical management depending on
the specific clinical scenario
medications
bisphosphonates
osteclast inhibitors which may decrease the size of the defect in giant cell tumors
denosumab
monoclonal antibody against RANK-ligand
recent clinical trials suggest denosumab can decrease the size of the bone defect in
giant cell tumor
90% tumor necrosis
shows dramatic sclerosis and reconstitution of cortical bone
after treatment
Operative
o extensive curettage and reconstruction (with adjuvant treatment)
indications
lesions amenable to currettage
hand lesion treatment is controversial
if no cortical breakthrough treat with curettage and cementing
if significant cortical breakthrough consider intercalary resection (with free fibular
graft) vs. amputation
technique
challenge of treatment is to remove lesion while preserving joint and providing support to
subchondral joint
extensive exterioration (removal of a large cortical window over the lesion) is required
can fill lesion with bone cement or autograft/allograft bone
outcomes
10-30% recurrence with curettage alone verses 3% with
adjuvant treatment (phenol, hydrogen peroxide, argon beam,
etc)
o amputation
indications
hand lesions with cortical breakthrough who are not amendable to intercalary resection
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OrthoBullets2017 Bone Tumors | Unknown Origin
Complications
Malignant transformation (<1% prevalence)
o to high grade sarcoma (poor prognosis)
o latency
9 years for previous radiation treatment
19 years for spontaneous transformation
Secondary ABC (≤14%)
o differentiate from primary ABC because of enhancing soft-tissue component in GCT (not present
in primary ABC)
Recurrence (15-25%)
o lucency at bone-cement interface
diagnose with CT guided biopsy
Pathologic fracture
o poorer outcome
Postoperative infection
o increased risk with en bloc resection + endoprosthesis
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Unknown Origin
2. Ewing's Sarcoma
Introduction
A distinctive small round cell sarcoma
Epidemiology
o demographics
typically found in patients from 5-25 years of age
second most common malignant bone tumor in children
uncommon in African Americans and Chinese
o locations
~50% are found in the diaphysis of long bones
most common locations pelvis, distal femur, proximal tibia, femoral diaphysis, and
proximal humerus
5% metaphysis
Genetics
o t(11:22) translocation
found in 95% of cases
leads to the formation of a fusion protein (EWS-FLI1)
can be identified with PCR and useful to differentiate Ewing sarcoma from other round
cell lesions
Staging : almost all tumors are MSTS stage IIB or III
Prognosis
o survival
5 yr survival
65-80% for localized disease
25-40% for metastatic disease
10 yr survival
60% for localized disease
30% for metastatic disease
o poor prognostic factors
tumor size/location
tumors greater than 100cm3 or >8cm in size
spine and pelvic tumors (worst) > proximal extremities > distal extremities (best
prognosis)
age and sex
older age (>14) worse prognosis
male worse prognosis
laboratory parameters
elevated lactic dehydrogenase levels (>200IUml) indicates large tumors/metastatic
disease
anemia and elevated WBC indicates extensive disease
molecular pathology
p53 mutation in addition to t(11:22) translocation
overexpression of cell proliferation antigen Ki-67
overexpression of HER-2/neu
metastases (most important prognostic indicator)
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OrthoBullets2017 Bone Tumors | Unknown Origin
presence of mets has poor prognosis
lung metastases better prognosis than bone/bone marrow mets
skip metastases (same bone) better pronosis than metastases to another site
chemotherapy response
< 90% necrosis with chemotherapy
Symptoms
Presentation
o pain often accompanied by fever
o often mimics an infection
Physical exam
o swelling and local tenderness
Imaging
Radiographs
o required images
AP and lateral of affected area
o findings
large destructive lesion in the diaphysis or metaphysis with a permeative moth-eaten
appearance
lesion may be purely lytic or have variable amounts of reactive new bone formation
Studies
Labs
o ESR is elevated
o WBC is elevated
o anemia is common
o lactic dehydrogenase
Bone marrow biopsy
o required as part of workup for Ewing's to rule out metastasis to the marrow
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Unknown Origin
Histology
Gross appearance
o may have liquid consistency mimicking pus
Characteristic findings
o sheets of monotonous small round blue cells
o prominent nuclei and minimal cytoplasm
o may have pseudo-rosettes (circle of cells with necrosis in center)
Immunostaining
o positive
CD99 (in 95%)
MIC2
vimentin
PAS positive (intracellular glycogen)
neuron specific enolase (NSE)
S100
Leu7
o negative
cytokeratin
reticulin (positive in lymphoma)
neurofilament (positive in neuroblastoma)
o see complete immonostaining chart
Differentials
Small-round-cell tumor differential (by age)
o < 5 yrs: neuroblastoma or leukemia
o 5-10 yrs: eosinophilic granuloma
o 5-30 yrs: Ewing's sarcoma
o >30 yrs: lymphoma
o > 50 yrs: myeloma
Osteosarcoma
Osteomyelitis
Treatment
Nonoperative
o chemotherapy + radiation therapy
indications
non-resectable tumors (eg. large spinal tumors)
sites where functional deficit is unacceptable
trend is towards surgical resection / away from RT because of morbidity associated with
radiation and risk of secondary malignancies
Operative
o chemotherapy + limb salvage resection ± adjuvant radiation
indications
standard of care in most patients
where primary tumor can be completely removed (expendable and surgically
reconstructible sites)
chemotherapy
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OrthoBullets2017 Bone Tumors | Unknown Origin
vincristine, doxorubicin, cyclophosphamide, and dactinomycin
preoperative chemotherapy given for 8-12 weeks followed by surgical resection and
maintenance chemotherapy for 6-12 months
adjuvant radiation
not necessary if margins are adequate and there is good response to chemotherapy
indications
positive post-resection surgical margins
patients who present with widely metastatic disease
where chemotherapeutic response has been poor
Complications
Secondary neoplasms
o bone sarcoma (from radiation therapy)
risk is 10-20% at 20y
arises in prior RT treatment field
dose dependant
≥ 60Gy of RT confers 20% risk
50-60Gy confers 5% risk
<48Gy has no risk
o treatment related acute myeloid leukemia / myelodysplasia (tMDS/AML)(from chemotherapy)
in 2% of survivors of ES
arises at ~5y after diagnosis
Recurrence/progression
o extremely poor prognosis (<10% 5YS)
Metastases
o 25-30% have macrometastases on presentation (lungs, bone, bone marrow)
o 10% have bone mets on presentation
o cure rates with chemotherapy
30% cure rate for lung mets alone
20% cure rate for bone mets alone
15% cure rate for combined bone and lung mets
Radiation therapy complications
o limb length discrepancy (especially in skeletally immature)
o joint contracture
o muscle atrophy
o pathologic fracture
o secondary sarcoma
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Unknown Origin
Destructive lesion Treatment is Wide
in young Resection &
patients(1) Small round cell tumors Chemotherapy (2)
Ewing's sarcoma • • •
Osteosarcoma • •
Lymphoma • •
Leukemia • •
Eosinophilic granuloma • •
Osteomyelitis •
Desmoplastic fibroma •
Metastatic disease
Neuroblastoma (soft tissue) •
Rhabdomyosarcoma (soft tissue)
Secondary sarcoma
Dediff. Chondrosarcoma •
MFH / fibrosarcomaa
Myeloma •
ASSUMPTIONS: (1) Younger patient is < 40 yrs; (2) assuming no impending fracture
3. Adamantinoma
Introduction
Rare low-grade malignant tumor of unknown etiology that is almost always located in the mid-tibia
Epidemiology
o incidence
less than 300 cases have been documented
o demographics
occurs in young adults (20 - 40 years of age)
Associated conditions
o osteofibrous dysplasia
historically, it was thought that osteofibrous dysplasia (OFD) was a precursor to this
adamantinoma, however current studies have cast doubt on this theory
Prognosis
o may metastasize to lungs (25%), therefore long-term followup is recommended
o recurrence is uncommon with negative margin excision
Presentation
Symptoms
o pain of months to years duration
Physical exam
o bowing deformity or a palpable mass of tibia is common
Imaging
Radiographs
o multiple sharply circumscribed lucent lesions ("soap bubble" appearance) with interspersed
sclerotic bone in mid tibia
some lesions may destroy cortex
o may see bowing of the tibia
o radiographic evolution of lesions is helpful in the diagnosis as lesions may continue to grow and
erode thru the cortex
o unlike other primary bone tumors, adamantinoma typically shows no periosteal reaction
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OrthoBullets2017 Bone Tumors | Unknown Origin
Studies
Histology
o biphasic
o contains both epithelial and fibrous mesenchymal cells
nests of epithelial-like cells arranged in palisading or glandular pattern
stain for keratin
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Metastatic Disease
I. Metastatic Disease
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OrthoBullets2017 Bone Tumors | Metastatic Disease
Principles of metastasis
Mechanism of metastasis
o tumor cell intravasation
E cadherin cell adhesion molecule (CAM) on tumor cells modulates release from primary
tumor focus into bloodstream
PDGF promotes tumor migration
o avoidance of immune surveillance
o target tissue localization
chemokine ligand 12 (CXCL12) in the stromal cells bone marrow acts as homing chemokine
to certain tumor cells and promote targeting of bone
attaches to target organ endothelial layer via integrin cell adhesion molecule (expressed on
tumor cells)
o extravasation into the target tissue
uses matix metalloproteinases (MMPs) to invade basement membrane and ECM
o induction of angiogenesis
via vascular endothelial growth factor (VEGF) expression
o genomic instability
o decreased apoptosis
thrombospondin inhibits tumor growth
Vascular spread
o Batson's vertebral plexus
valveless venous plexus of the spine that provides a route of metastasis from organs to axial
structure including vertebral bodies, pelvis, skull, and proximal limb girdles
o arterial tree metastasis
mechanism by which lung and renal cancer spread to the distal extremities
Mechanism of bone lysis
o oncogenic cell releases cytokines IL-6, IL-11, PTHrP, TGF-beta
o PTHrP and TGF-beta activate osteoblasts
o osteoblasts secrete RANKL, that binds to RANK on osteoclasts and activates osteoclasts
Mechanism of bone sclerosis (prostate and breast mets)
o prostate cancer cells secrete endothelin 1 (ET-1)
o ET-1 binds to endothelin A receptor (ETAR) on osteoblasts and stimulates osteoblasts
o ET-1 decreasesWNT suppressor DKK-1
activates WNT pathway, increasing osteoblast activity
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Metastatic Disease
Symptoms
Symptoms
o pain
may be mechanical pain due to bone destruction or tumorigenic pain which often occurs at
night
o pathologic fracture
occurs at presentation in 8-30% of patients with metastatic disease
o metastatic hypercalcemia
confusion
muscle weakness
polyuria & polydipsia
nausea/vomiting
dehydratio
Physical exam
o neurologic deficits
caused by compression of the spinal cord with metastatic disease to the spine
Evaluation
Workup for older patient with single bone lesion and unknown primary includes
o imaging
plain radiographs in two planes of affected limb
CT of chest / abdomen / pelvis
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technetium bone scan to detect extent of disease
myeloma and thyroid carcinoma are often cold on bone scan -
evaluate with a skeletal survery
o labs
CBC with differential
ESR
basic metabolic panel
LFTs, Ca, Phos, alkaline phosphatase
serum and urine immunoelectrophoresis (SPEP, UPEP)
o biopsy
in patients where a primary carcinoma is not identified, obtaining a biopsy is necessary to
rule out a primary bone lesion
should not treat a bone lesion without tissue diagnosis of the lesion
metastatic adenocarcinoma not identified by CT of the chest, abdomen, and pelvis is most
likely from a small lung primary tumor
Imaging
Radiographic
o recommended views
AP and lateral of involved area
o findings
purely lytic or mixed lytic/blastic lesions
lung, thyroid, and renal are primarily lytic
60% of breast CA is blastic
90% of prostate CA is blastic
cortical metastasis are common in lung cancer
lesions distal to elbow and knee are usually from lung or renal primary
CT scan
o helpful to identify metastatic lesions to the spine
MRI
o useful to show neurologic compromise of the spine
Studies
Histology
o characteristic findings
epithelial cells in clumps or glands in a fibrous stroma
o immunohistochemical stains positive
Keratin
CK7 (breast and lung cancer)
TTF1 (lung cancer)
Receptor status
o can provide therapeutic targets during concomitant medical management
o Estrogen, Progesterone, and HER2/neu receptor status is essential for treating metastatic breast
cancer
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Metastatic Disease
Treatment General
Nonoperative
o bisphosphonate therapy
indications
symptomatic care by preventing osteoclatic bone destruction
technique
IV pamidronate most commonly used
o chemotherapy, radiotherapy, and hormone therapy
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OrthoBullets2017 Bone Tumors | Metastatic Disease
Table of fixation methods by location:
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Metastatic Disease
Table of treatment based on cancer type :
THA
indications
acetabular involvement
cephalomedullary nail + currettage + cement
pertrochanteric / subtrochanteric fractures
Techniques
o prophylactic IM nailing of proximal femur lesions
indications
impending and complete peritrochanteric fractures that do not involve the femoral head
technique
statically locked cephalomedullary IM nail for peritrochanteric fractures
o hemiarthroplasty vs.Total Hip Arthroplasty
indications
both impending and complete pathologic fractures of the femoral head and neck can be
management with replacement arthroplasty
Complications
o dislocation of prosthesis
THA > hemiarthroplasty
o infection
higher for THA and hemiarthroplasty than nails
o nonunion of fracture
for cephallomedullary nails
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OrthoBullets2017 Bone Tumors | Metastatic Disease
Differentials & Groups
Malignant Multiple lesion Epithelial Benefits from Treatment is wide
lesion in older in older glands on Bisphonate resection and
patient(1) patient(1) histology therapy radiation(2)
Metastatic bone disease • • • • •
Myeloma • • •
Lymphoma • •
Chondrosarcoma •
MFH / fibrosarcoma •
Secondary sarcoma •
Pagets disease • •
Fibrous dysplasia •
Synovial sarcoma •
Hyperparathyroidism •
Gomus tumor •
Soft tissue sarcomas (3) •
ASSUMPTIONS: (1) Older patient is > 40 yrs; (2) assuming no impending fracture (3) High-grade soft tissue sarcomas
includes angiosarcoma, synovial sarcoma, liposarcoma, desmoid tumor, MFH/fibrosarcoma: exception is
rhabdomysarcoma which is treated with chemotherapy and wide resection
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Metastatic Disease
PTHrP positive breast cancer cells activate osteoblastic RANKL production
osteoblastic bone metastases are due to tumor-secreted endothelin 1
Prognosis
o median survival in patients with metastatic bone disease
thyroid: 48 months
prostate: 40 months
breast: 24 months
kidney: variable depending on medical condition but may be as short as 6 months
lung: 6 months
Associated conditions
o metastatic hypercalcemia
a medical emergency
symptoms include
confusion
muscle weakness
polyuria & polydipsia
nausea/vomiting
dehydration
treatment
hydration (volume expansion)
loop diuretics
bisphosphonates
Principles of metastasis
Mechanism of metastasis
o tumor cell intravasation
E cadherin cell adhesion molecule (on tumor cells) modulates release from primary tumor
focus into bloodstream
o avoidance of immune surveillance
o target tissue localization
attaches to target organ endothelial layer via integrin cell adhesion molecule (expressed on
tumor cells)
o extravasation into the target tissue
o induction of angiogenesis
via vascular endothelial growth factor (VEGF) expression
o genomic instability
o decreased apoptosis
Vascular spread
o Batson's vertebral plexus
valveless venous plexus of the spine that provides a route of metastasis from organs to axial
structure including vertebral bodies, pelvis, skull, and proximal limb girdles
Mechanism of bone lysis
o oncogenic cell releases cytokines IL-6, IL-11, PTHrP, TGF-beta
o PTHrP and TGF-beta activate osteoblasts
o osteoblasts secrete RANKL, that binds to RANK on osteoclasts and activates osteoclasts
Mechanism of bone sclerosis (prostate and breast mets)
o prostate cancer cells secrete endothelin 1 (ET-1)
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OrthoBullets2017 Bone Tumors | Metastatic Disease
o ET-1 binds to endothelin A receptor (ETAR) on osteoblasts and stimulates osteoblasts
o ET-1 decreasesWNT suppressor DKK-1
activates WNT pathway, increasing osteoblast activity
Symptoms
Symptoms
o pain
axial night pain
may be mechanical pain due to bone destruction or tumorigenic pain which often occurs
at night
metastatic hypercalcemia
Physical exam
o neurologic deficits
caused by compression of the spinal cord with metastatic disease to the spine
Evaluation
Workup for older patient with single bone lesion and unknown primary includes
o imaging
AP and lateral of spine in region of pain
CT of chest / abdomen / pelvis
technetium bone scan to detect extent of disease
myeloma and thyroid carcinoma are often cold on bone scan - evaluate with a skeletal
survery
o labs
CBC with differential
ESR
basic metabolic panel
LFTs, Ca, Phos, alkaline phosphatase
serum and urine immunoelectrophoresis (SPEP, UPEP)
o biopsy
in patients where a primary carcinoma is not identified, obtaining a biopsy is necessary to
rule out a primary bone lesion
should not treat a bone lesion without tissue diagnosis of the lesion
metastatic adenocarcinoma not identified by CT of the chest, abdomen, and pelvis is most
likely from a small lung primary tumor
See table of evaluation algorithms based on patient factors (see next page)
Imaging
Radiographic
o recommended views
AP and lateral of involved area off spine
o findings
purely lytic or mixed lytic/blastic lesions
lung, thyroid, and renal are primarily lytic
60% of breast CA is blastic
90% of prostate CA is blastic
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By Dr, AbdulRahman AbdulNasser Bone Tumors | Metastatic Disease
CT scan
o helpful to identify metastatic lesions to the spine
MRI
o useful to show neurologic compromise of the spine
Studies
Histology
o characteristic findings
epithelial cells in clumps or glands in a fibrous stroma
o immunohistochemical stains positive
Keratin
CK7 (breast and lung cancer)
TTF1 (lung cancer)
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OrthoBullets2017 Bone Tumors | Metastatic Disease
metastatic lesions to spine with neurologic deficits in patients with life expectancy of > 6
months.
technique
preoperative embolization indicated in metastatic renal CA to spine
Complications
Recurrance
Hardware failure and spinal instability
Nonunion of fracture
Table 1 Takuhashi scoring system
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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By Dr, AbdulRahman AbdulNasser Soft Tissue Tumors | Metastatic Disease
ORTHO BULLETS
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OrthoBullets2017 Soft Tissue Tumors | Introduction
A. Introduction
Classification
Over 50 histological types of soft tissue sarcomas exist
o previously tested soft tissue sarcomas include
synovial sarcoma
liposarcoma
rhabdomyosarcoma
fibrosarcoma
leiomyosarcoma
angiosarcoma
Presentation
Symptoms
o enlarging painless mass
Physical exam
o palpable soft tissue mass
differentiation of whether mass is above or below fascia has prognostic importance
size greater than 5cm in cross-section is a poor prognostic factor
Imaging
Radiographs
o obtain plain radiographs in two planes
MRI
o is mandatory to evaluate soft tissue lesions in the extremities and determine treatment algorithm
o diagnostic MRI
MRI is typically diagnostic for the following benign lesions
lipoma
neurilemoma (schwanoma)
intramuscular myxoma
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By Dr, AbdulRahman AbdulNasser Soft Tissue Tumors | Introduction
if MRI is diagnostic and the mass is benign and symptomatic, then it can be removed without
a biopsy
o indeterminate MRI
if MRI is indeterminate or suggestive of sarcoma, then a core needle or open biopsy must be
obtained before further treatment is initiated
soft tissue sarcomas can look similiar to hematomas so be cautious of a "hematoma" which
occurs without trauma
Evaluation
Histology
o detemined by type of sarcoma
synovial sarcoma
liposarcoma
rhabdomyosarcoma
fibrosarcoma
Treatment
Treatment overview
o treatment must be based on a tissue diagnosis unless images are diagnostic (e.g. lipoma)
Operative
o radiation therapy & wide surgical resection
indications
standard of care in most cases
radiation therapy
an important adjunct to surgery decreasing local recurrence
50-60 Gy is the standard dose for soft-tissue sarcomas
radiotherapy may be given pre- or post-operatively
pre-operative radiotherapy is associated with a 30% risk for wound complications
post-operative radiotherapy is associated with greater radiation induced morbidity and
an increased risk for radiation induced sarcoma
chemotherapy
controversial for soft tissue sarcomas
surgical resection
must confirm border free of disease with histology
o surgical resection of lung metastases (wedge resection or lobectomy)
indications
first line for pulmonary metastases if preop evaluation shows that complete resection is
possible
resuts
long-term survival is possible with selected patients
Complications
Recurrence
o following resection the most common location for recurrence of a low grade, soft tissue sarcoma
is locally
Unplanned excision
o CT chest, abdomen, pelvis to exclude metastasis
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OrthoBullets2017 Soft Tissue Tumors | Synovial Tissue
o MRI of the limb to determine degree of contamination, post-operative changes, and to assess
margins
o revision surgery
limb salvage + radiation therapy
amputation
B. Synovial Tissue
Presentation
History
o 50% of patients will have a prior history of trauma to the area
Symptoms
o pain and swelling
o mechanical pain and limited motion
o recurrent atraumatic hemarthrosis is hallmark of disorder
Physical exam
o intra-articular form (classic PVNS)
evaluate for joint effusion and erythema
o extra-articular form (giant cell tumor of tendon sheath)
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By Dr, AbdulRahman AbdulNasser Soft Tissue Tumors | Synovial Tissue
palpable masses seen along tendon sheath
painless
soft
Characteristic Localized PVNS Diffuse PVNS
Hands > knees (anterior
Location Knee (75%)
compartment) > ankle
Age 30-50y <40
Gender Male = female Female > male
Painful, swollen, tender, limited
Presentation Painless, swollen joint, longstanding
mobility
Osseous erosion from localized Degenerative changes on both
Radiograph
pressure sides of the joint
Ill-defined (poorly
MRI Well circumscribed soft tissue mass
circumscribed) soft tissue mass
Recurrence 8% after synovectomy 30% after synovectomy
Imaging
Radiographs
o may show cystic erosion with sclerotic margins on both sides of the joint
CT
o may show cystic erosions on both sides of the joint
MRI
o provides excellent delineation of intra-articular and extra-articular disease
o low signal intensity on both T1 and T2 : due to hemosiderin deposits
o "blooming artifact"
signal loss on gradient-echo sequences
because of iron in hemosiderin
o presence of fat signal (T1) within the lesion
o can evaluate extra-articular extension of an intra-articular process
commonly see posterior extension outside of the knee joint
Studies
Arthrocentesis
o grossly bloody effusion
Arthroscopy (gross appearance)
o brownish or reddish inflamed synovium is typical of PVNS
o frond like pattern of papillary projections
Biopsy
o synovial biopsy should be performed if there is any doubt of the diagnosis
Histology
o mononuclear stromal cells infiltrating the synovium
o highly vascular villi with hyperplastic synovial cells
o hemosiderin stained multinucleated giant cells
o pigmented foam cells (lipid-laden histiocytes)
o mitotic figures common
Treatment
Nonoperative
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OrthoBullets2017 Soft Tissue Tumors | Synovial Tissue
o observation
indications
minimal role for nonoperative treatment if disease is symptomatic
Operative
o total synovectomy (anterior arthroscopic, posterior open, for the knee)
classified as marginal excision
preferred technique
indications
in grossly symptomatic and painful disease
technique
intra-articular disease
techniques range from arthroscopic partial synovectomy to fully open total
synovectomy
dependent on extent and location of disease
frequent recurrence is common
mostly due to incomplete synovectomy
extra-articular
marginal excision is adequate for giant cell tumor of tendon sheath
recurrence (which is common) is treated with repeat excision
o external beam irradiation
when combined with total synovectomy, reduces rate of recurrence to 10-20%
30-35Gy in 15 fractions, or 50Gy in 25 fractions
Differential Diagnosis
Synovial chondromatosis
Hemophilia
Inflammatory synovitis
Techniques
Arthroscopic synovectomy for localized PVNS
o routine arthroscopic portals for knee, ankle, and shoulder
o technique
perform as thorough resection of synovium as possible
excellent for focal or limited PVNS
o postoperative
generally treat with some rest after procedure
o pros
minimally invasive approach
quick return to function
o cons
unable to access the posterior portions of the joint
unable to address extraarticular disease
Arthroscopic synovectomy combined with open posterior synovectomy (knee) for diffuse
PVNS
o preferred method for diffuse
o approach
posterior approach to the knee via transverse or S-shape incision across popliteal fossa
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By Dr, AbdulRahman AbdulNasser Soft Tissue Tumors | Synovial Tissue
approach between heads of gastrocnemius
retract neurovascular bundle to access posterior joint capsule
o technique
disease is often seen posterior and extra-articular to the knee
complete posterior synovectomy and resection of extra-articular disease
o pros
allows surgeon to fully address all diseased sections
allows for thorough synovectomy
o cons
posterior approach to the knee requires approaching neurovascular bundle
Total joint arthroplasty and synovectomy
o indicated in advanced disease with severe degenerative joint changes
o applicable to knee, hip, shoulder
Total synovectomy and arthrodesis
o indicated in severe disease of the ankle
Complications
Recurrence
o recurrence is the most frequent complication for both intra-articular and extra-articular disease
30% recurrence rate despite complete synovectomy
same rates for complete open vs open+arthroscopic
rates can be reduced with addition of external beam radiation
Skin necrosis, radiation induced sarcoma
o complications of radiation therapy
2. Synovial Chondromatosis
Introduction
A proliferative disease of the synovium
o associated with cartilage metaplasia
o results in multiple intra-articular loose bodies
o ranges from synovial tissue to firm nodules of cartilage
Epidemiology
o demographics
usually affects young adults 30-50 years of age
2:1 male to female ratio
o location
knee is most common location
Genetics
o occasional chromosome 6 abnormalities have been found
Presentation
Symptoms
o slow progression of symptoms
o pain and swelling
pain worse with activity
o mechanical symptoms including stiffness
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OrthoBullets2017 Soft Tissue Tumors | Synovial Tissue
o can occur in the bursa overlying an osteochondroma
Physical exam
o decreased range of motion
o can have warmth, erythema, or tenderness
Imaging
Radiographs
o recommended views
standard AP/lateral of affected joint
o findings
variable depending on stage of disease
may show stippled calcification
MRI
o initially cartilage nodules are only visible on MRI
o lobular appearance
o in later stage, signal drop out consistent with calcification
Studies
Histology
o discrete hyaline cartilage nodules in various stages of calcification and ossification
o chondrocytes
mild atypia
binucleate cells
occasional mitoses
Treatment
Nonoperative
o observation
indications : mild symptoms not affecting range of motion
Operative
o open or arthroscopic synovectomy and loose body resection
indications
severe symptoms affecting range of motion
outcomes
treatment is symptomatic but may help prevent degenerative joint changes
3. Synovial Sarcoma
Introduction
Malignant soft tissue sarcoma which arises near joints, but rarely within the joint
o cellular origin of synovial sarcoma is unknown, but it is not the synovial cell or any cell involved
in the synovium
the name synovial sarcoma is a misnomer.
Epidemiology
o demographics
most common sarcoma found in young adults (15-40 years)
affects more males than females
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o location
it is the most common malignant sarcoma of the foot
Genetics
o chromosomal translocation t(X;18) is observed in more than 90% of cases
o translocation forms the SYT-SSX1, 2, or 4 fusion protein
SYT-SSX4 is rare
SYT-SSX1 SYT-SSX2
Frequency More common (60% of tumors Less common (40% of tumors)
Histology type Biphasic Monophasic
Gender M:F = 1:1 M:F = 1:2
Presentation Larger, with metastases Smaller, without metastases
Survival Worse Better
Metastases
o synovial sarcoma typically shows high histologic grade
o metastasis may develop in 30-60% of patients
like other sarcomas, the lung is most common site of metastasis
synovial sarcoma is one of the rare soft tissue sarcomas which can metastasize to lymph
nodes
the other sarcomas which can metastasize to lymph nodes include, epitheliod sarcoma,
angiosarcoma, rhabdomyosarcoma, clear cell sarcoma
can stage with lymph node biopsy
while lymph node metastasis is a poor prognostic sign, it is not as bad as lung
metastasis
o metastasis is more common with large, deep, and high grade sarcomas
Prognosis
o overall prognosis is poor
5 year survival is approximately 50%
10 year survival is approximately 25%
o SYT-SSX fusion type is most important prognostic factor
SYT-SSX2 better survival
Presentation
Symptoms
o typically present as a growing mass in proximity to a joint
o may be painless or painful
o most commonly occur in periarticular locations
knee, shoulder, elbow, foot
60% are found in the lower extremity
Physical exam
o examine for regional lymphadenopathy
Imaging
Radiographs
o can show soft tissue mineralization (calcification) in these tumors
o may resemble heterotopic ossification
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CT
o can show calcification in the soft tissue mass
MRI
o MRI reveals a heterogenous mass that is typically dark on T1 weighted images and bright on T2
weighted images
Histology
Characteristic findings
o classical synovial sarcoma shows a biphasic appearance with two typical cell types
spindle cells (fibrous type of cells)
relatively small and uniform and found in sheets of malignant appearing cells with
minimal cytoplasm and dark atypical nuclei
epithelial cells
gland, nest, or cyst like cells
o rarely, synovial sarcoma can also present with poorly differentiated or monophasic fibrous cell
histology, consisting only of sheets of spindle cells
o cellular origin of synovial sarcoma is unknown, but it is not the synovial cell or any cell involved
in the synovium. The name SYNOVIAL sarcoma is a misnomer
Immunostaining for
o synovial sarcoma stains positive for
vimentin
epithelial membrane antigen
sporadic S-100
epithelial cells stain positive for keratin
Treatment
Operative
o wide surgical resection with adjuvant radiotherapy
indications
standard of care in most patients
technique
radiotherapy
may be delivered either pre-surgery or post-surgery
chemotherapy
data regarding chemotherapy in synovial sarcoma suggests that chemotherapy may
improve both local control and overall survival
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By Dr, AbdulRahman AbdulNasser Soft Tissue Tumors | Peripheral Nerves
C. Peripheral Nerves
1. Neurilemmoma
Introduction
A benign encapsulated tumor composed of Schwann cells
o tumor is well encapsulated on the surface of a peripheral nerve
o also known as Schwannoma
Age & location
o peak incidence is in the 3rd to 6th decades
previous test question ages: 40, 45
o affect males and females equally
o often occurs on flexor surfaces of extremities and head and neck
o larger lesions may occur in the pelvis
Pathoanatomy
o can affect motor or sensory nerves
Genetics
o often associated with mutations affecting NF2 gene
Malignant transformation
o extremely rare
Presentation
Symptoms
o usually asymptomatic III:1 String sign
o may have paresthesia in the distribution of the peripheral nerve
Physical exam
o may have positive Tinel’s sign in the distribution of the nerve affected may be present
Imaging
MRI
o sequences
low intensity (dark) T1
high intensity (bright) on T2
diffuse enhancement with gadolinium
o findings
may show ―string sign‖
difficult to differentiate from neurofibroma
Histology
Gross pathology
o the lesion is well encapsulated in a nerve sheath
o gray in color
Histology
o Antoni A structure
a pattern of spindle cells arranged in intersecting bundles (spindle cell battle formation)
o Antoni B : areas with less cellularity with loosely arranged cells
o Verocay bodies
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pathognomonic
composed of two rows of aligned nuclei in a palisading formation
Immunochemistry
o strongly uniform S100 antibody staining
Treatment
Nonoperative
o observation
indications
asymptomatic lesions
Operative
o marginal excision
indications
symptoms or interfering with quality of life
technique
nerve function may be preserved by careful dissection, excising the lesion parallel to the
nerve fascicles so the lesion may be extruded.
complications
small risk of sensory deficits
outcomes
recurrence is rare
2. Neuroma
Introduction
Common neuromas include
o Interdigital (Morton's) Neuroma
o Recurrent neuroma
Treatment
Targeted muscle reinnervation
o a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and
improve patient use of myoelectric prostheses
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By Dr, AbdulRahman AbdulNasser Soft Tissue Tumors | Peripheral Nerves
Presentation
Presentation
o soft-tissue mass
o most arise from large nerves (sciatic, brachial plexus)
o motor and sensory deficit of the affected nerve
Imaging
Radiograph : usually normal or non-specific soft-tissue mass
MRI
o low-intensity on T1-weighted images
o high intensity on T2-weighted images
o serial MRI may show enlargement of previous benign nerve sheath lesion suggesting malignant
transformation
Bone scan : mildly positive
Studies
Histology
o classic characteristics are
spindle cells with wavy nuclei resembling fibrosarcoma
o Immunohistochemistry
positive S100 stain
keratin staining is negative
Treatment
Operative
o wide surgical resection + radiation
indications
standard of care in most patients
in general, treated as high-grade sarcoma
technique : wide resection should include entire affected nerve
radiation : perform preoperative adjuvant radiation
chemotherapy not useful
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4. Neurofibroma
Introduction
Benign nerve sheath tumors with multiple cell types
o fibroblasts (predominant cell)
o nonmyelinating Schwann cells
cell of origin, arises from this cell
o perineural cells
o differentiate from Schwannoma, which involves Schwann cell alone
Molecular biology
o arise in nonmyelinating Schwann cells with biallelic inactivation of NF1 tumor-suppressor gene
o loss of expression of protein neurofibromin
neurofibromin negatively regulates RAS-mediated pathway
loss of neurofibromin leads to increased RAS activity
affects RAS-dependent MAPK activity which is essential for osteoclast function and survival
o rapid hyperplasia of nonmyelinating Schwann cells into neurofibromas after NF1 inactivation
recruits perineural cells, fibroblasts, mast cells, endothelial cells
Age
Location Inheritance
group
Sporadic
Peripheral PNS tumors of the extremities - 20-40y
neurofibromas
Neurofibromatosis Tendency to be found near spinal cord/brain (CNS) and AD, chr
<20y
(NF1) uncommon locations (parotid glands, tongue) 17q11.2
Classification
Subtypes of
Origin Description Associations Onset Malignancy
neurofibroma
Arise from
single Fusiform swelling of 90% sporadic, Do not become
Dermal At puberty
peripheral nerve 10% arise in NF1 malignant
nerve
"Bag of worms"
Arise from 10% become
(tortuous Pathognomic of Early
Plexiform multiple nerve malignant
enlargement of NF1 childhood
bundles (MPNST)
nerves)
Types of Schwann
Axons Disease process
cells
Myelinating Covers large diameter PNS axons with myelin -
Covers small diameter PNS axons with cytoplastic Responsible for
Nonmyelinating
processes neurofibromatosis
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By Dr, AbdulRahman AbdulNasser Soft Tissue Tumors | Peripheral Nerves
Presentation
Symptoms
o asymptomatic
o stinging, itching, pain, disfiguration
Physical exam
o reduced sensation
o cutaneous lesions
can "button hole" through skin defect using finger pressure
o signs of neurofibromatosis (2 of 7) (NIH criteria)
2 or more neurofibromas, or 1 plexiform neurofibroma
axillary or groin freckling (Crowe's sign)
III:3 cafe-au-lait
6 or more coast of California cafe-au-lait spots
5mm diameter in prepubertal
>15mm diameter in postpubertal
sphenoid wing dysplasia or thinning of long bone cortex
(anterolateral tibial bowing)
2 or more Lisch nodules (iris hamartomas)
on slit lamp
optic glioma
1st degree relative with NF1 III:4 (iris hamartomas)
o associated with NF1
dystrophic kyphoscoliosis
rib penciling
intraspinal neurofibromas and dumbbell lesions
dural ectasia
meningiomas
Imaging
MRI with and without contrast
o findings
III:5 optic glioma
differentiate Schwannoma from neurofibroma
Schwannoma are found ECCENTRIC to the nerve fibers
Solitary neurofibromas are found CENTRAL to the nerve fibers
o nerve continuity sign
fusiform tumor in continuity with the neurovascular bundle
o split fat sign
fusiform tumor surrounded by a thin margin of fat because the mass within the neurovascular
bundle enlarges and displaces the adjacent intramuscular fat
o target sign
lesion of high signal intensity peripherally and low signal centrally (on coronal STIR)
Histology
Characteristics
o cells
hypocellular
predominantly fibroblasts
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Differential
MPNST (malignant peripheral nerve sheath tumor or neurofibrosarcoma)
o 5% of patients with NF, 10-25% lifetime risk
o symptoms include painful, enlarging soft tissue mass
o usually from plexiform neurofibroma
10% of plexiform neurofibromas transform into MPNST
o associated with loss of expression of CDKN2A or TP53 genes in non-myelinating Schwann cells
(that also have biallelic inactivation of NF1)
o poor prognosis
widespread metastasis
high rate of local recurrence
Schwannoma
Wilms tumor
melanoma
leukemia
rhabdomyosarcoma
pheochromocytoma
Treatment
Nonoperative III:6 MRI with and without contrast
o observe
if asymptomatic
Operative
o surgical excision
if symptomatic
may require nerve grafting
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By Dr, AbdulRahman AbdulNasser Soft Tissue Tumors | Peripheral Nerves
5. Neuroblastoma
Introduction
Neuroblastoma is a malignant tumor which develops from sympathetic neural tissue
o it is the most common solid tumor of childhood
o most cases of neuroblastoma arise in the adrenal gland or near the spinal cord
Epidemiology
o occurs in approximately 1 out of 100,000 children
o slight male predominance
o the majority of cases occur in children younger than 2 years of age
Metastasis
o metastasis to the bone are common and a poor prognostic sign
Prognosis
o the majority of children are cured
III:7 abdominal mass
o metastatic disease is a poor prognostic factor
o in very young children, spontaneous regression of the tumor without treatment is known to occur
Presentation
Symptoms
o fever, malaise, weight loss, diarrhea
o if the adrenal glands are affected, the child may present with significant
tachycardia
o abdominal mass
Exam
o may reveal abdominal mass or hepatosplenomegaly
Biopsy
o needle or open incisional biopsy is required to obtain lesional tissue
and make the histological definitive diagnosis
Imaging
Radiographs
o may show bone lesions in cases of metastatic disease
o bone lesions are often permeative and lytic in nature
o may occur anywhere in the skeleton
CT
o chest/abd/pelvis is the most common initial imaging sequence for
evaluation of the extent of disease
o helpful in determining the extent of visceral metastasis
MRI
o MRI scan of the chest/abdomen may be useful to delineate anatomic
structures
Bone scan
o helpful in determining the extent of metastatic bone disease
Histology
Small round blue cells forming rosette patterns
o other small round blue cell tumors of childhood include
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rhabdomyosarcoma
non-Hodgkin's lymphoma
Ewing's sarcoma/PNET
blastemic component of Wilms’ tumor
Treatment
Nonoperative
o observation
indications
very young infants with low risk tumors
a significant portion of neuroblastomas can spontaneously regress
o chemotherapy and stem cell transplant alone
indications
children with high grade or metastatic neuroblastomas in a location not amenable to surgical
resection
technique
treat with chemotherapeutics like platinum (cisplatin) or alkylating agents (ifosfamide) followed
by stem cell transplant
Operative
o surgical excision
indications
low grade tumors which can be easily excised with a wide surgical margin while not damaging
critical neurovascular structures
o chemotherapy, stem cell transplant, and surgical excision
indications
high grade tumors which arise in close proximity to critical neurovascular structures and
therefore cannot be easily excised with a wide surgical margin
D. Muscle Tumors
1. Leiomyosarcoma
Introduction
Leiomyosarcoma (LMS) is an aggressive sarcoma thought to arise from the smooth muscle cells
lining small blood vessels
o it may either occur in the soft tissue (uterus) or in the bone
Epidemiology
o incidence
fewer than 100 case reports of extra-facial leiomyosarcoma of bone
o demographics
the mean age of presentation is in 5th and 6th decades of life
o location
most frequently occurs in the metaphysis of long bones, but can occur in diaphyseal
locations.
the most frequent sites of boney presentation are the femur, tibia, ilium, and humerus
Prognosis
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o LMS of bone in adults
25% recurrence rate and 25% metastasis rate
75% survival at 3 years with treatment
Presentation
Symptoms
o bone pain
o palpable mass
o typical duration of symptoms prior to diagnosis is 6 months
Physical exam
o pelvic masses can be difficult to appreciate on inspection exam
o can be tender or nontender to palpation
o masses will be firm
Imaging
Radiographs
o involved extremity
purely osteolytic lesions with ill-distinct margins, moth-eaten, or permeative pattern of bone
destruction.
primarily intra-medullary but may extend into the soft tissues.
o chest
indicated for all staging of tumors to evaluate for lung metastasis
CT
o indications
help evaluate bone loss of involved extremity or pelvis
chest CT indicated in all patients as part of staging workup to
evaluate for metastasis
MRI
o indications
differentiate from benign soft tissue tumors
evaluate size, depth, and surrounding anatomy
o views
appears dark on T1, similar to muscle tissue
appears heterogeneous on T2 with areas of increased signal intensity
contrast causes diffuse enhancement of signal within the lesion
Studies
Histology
o a spindle cell neoplasm with similar characteristics shared between the osseous and soft tissue
forms of this disease
o cigar-shaped nuclei
o cells arranged into fascicles along with myofibrils running parallel
o presence of actin and vimentin immunoreactivity
Staging
o all tumors should be staged appropriately prior to treatment initiation
Treatment
Nonoperative
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o chemotherapy
indications
diffuse metastatic disease to the lungs
large pelvic masses with neurovascular involvement that preclude safe resection
outcomes
variable response to chemotherapy
better survival when chemotherapy combined with surgery than surgery alone
o radiation
indications
controversial
contaminated resection bed
outcomes
variable response, difficult to predict
Operative
o early wide resection of the primary lesion and secondary reconstruction
indications
standard of care in localized disease
technique
clean margin is an important goal of surgical resection
chemotherapy
Neo-adjuvant or adjuvant chemo/radiotherapy in the treatment of leiomyosarcoma of
bone is controversial
radiation
if unable to obtain wide margin consider adjuvant radiation
2. Rhabdomyosarcoma
Introduction
A malignant tumor of the primitive mesenchyme
o it is the most common sarcoma in children
Four sub-types of rhabdomyosarcoma
o Embryonal
occurs in infants and young children
o Alveolar
occurs in adolescents and young adults
o Botryoid
occurs in infants and young children, typically in the vagina
aka Sarcoma botryoides or "bunch of grapes"
o Pleomorphic
tends to occur in older patients 40-70yrs
Genetics
o alveolar rhabdomyosarcoma has a common t(2;13) translocation
forms Pax3-FKHR fusion protein
associated with a high risk metastatic disease
Metastasis
o nodal metastasis are known to occur with rhabdomyosarcoma
consider sentinel lymph node biopsy as part of treatment
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o bone marrow biopsy is required for staging
bone marrow metastases have been shown to portend a worse prognosis
Prognosis
o 5-year survival
Embryonal - 80%
Alveolar - 60%
Botryoid - uniformly fatal, less than 30% of patients live 5 years from the time of diagnosis
Pleomorphic - 25%
Symptoms
Presentation
o rapidly growing painless mass
o most lesions occur in the head/neck, genitourinary system, or retroperitoneum
Imaging
CT
o CT of the chest is required for staging of disease
MRI
o non-diagnostic but crucial for treatment planning
o rhabdomyosarcoma images appear like many other soft tissue sarcomas
dark on T1, bright on T2
Histology
Characteristic histology includes
o Embryonal
Treatment
Nonoperative
o chemotherapy alone
indications : only indicated in select patients with widespread metastatic disease.
o radiation therapy alone
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indications : can be used for unresectable tumors or close/positive margins
Operative
o wide surgical excision with chemotherapy
indications
pediatric rhabdomyosarcoma
chemotherapy is not effective for adult rhabdomyosarcoma
technique
common agents include vincristine, dactinomycin, cyclophosphamide
o wide surgical excision with radiation therapy
indications
adult pleomorphic rhabdomyosarcoma
E. Fibrogenic Tumors
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By Dr, AbdulRahman AbdulNasser Soft Tissue Tumors | Fibrogenic Tumors
Symptoms
Presentation
o usually an enlarging mass
o nerve compression : numbness, tingling, motor weakness, stabbing pain
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Physical exam
o has a distinctive "rock hard" feel on palpation
because tumor is fixed to surrounding tissues
o poorly circumscribed
o may be painful and limit motion around joint
Imaging
Radiographs
o play minimal role in diagnosis
o some tumors encroach on/erode bone or trigger periosteal reaction that extends into tumor as
"frond like" spicules of bone
MRI
o Indications
best means to diagnose
exclude multicentric lesions (in the same extremity)
o findings
low signal intensity on T1-weighted images
low to medium intensity on T2-weighted images
Gadolinium enhances appearance
infiltrates muscle
5-10cm in size
may erode bone locally
Studies
Gross specimen
o gritty
o white
o poorly encapsulated
Histology
o Classic
characteristics are
well differentiated fibroblasts
uniform spindle cells with elongated nuclei and occasional mitoses
abundant collagen
tumor infiltrates adjacent tissues
Molecular Genetics/Immunohistochemisty
o positive
100% positive for estrogen receptor-beta
somatostatin
cathepsin D
Ki-67
c-Kit
o negative
estrogen receptor-alpha
progesterone receptor
HER2
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Treatment
Nonoperative
o low dose-chemotherapy only / tamoxifen
indications
inoperable lesions
tamoxifen favored for failed/poor candidates for standard chemotherapy
works because most lesions occur in women and are more aggressive in women,
especially premenopausal
tamoxifen works via an estrogen receptor blockage
Operative
o wide surgical resection with radiotherapy
indications
symptomatic lesion
recurrent lesion
local recurrence is common (reduced recurrence with radiotherapy)
external beam radiation dose 50-60Gy
Complications
Recurrence
o margin negative
28% recurrence with surgery alone
6% recurence with surgery + radiation
o margin positive
39% recurence with surgery alone
25% recurrnce with surgery + radiation
4. Nodular Fasciitis
Introduction
A common reactive lesion that usually occurs in upper extremities of young people (ages 15-35)
o Incidence
most common fibrous soft tissue lesion
half of the cases occur in the upper extremities
o Demographics
males and females equally affected
o Body locations
volar forearm, back, chest wall, head and neck
Presentation
Symptoms
o may be painless or painful
painful in half of patients
o often rapidly enlarging mass over 1 to 2 weeks
o lesions 1 to 2 cm
Imaging
Radiograph : usually normal
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MRI
o shows deep seated inhomogeneous mass
o nodularity with extension along the fascial planes
o avid enhancement with gadolinium
o most commonly is superficial but can occur intramuscularly or along the superficial plane
Histology
Classic characteristics are
o short irregular bundles and fascicles
o dense reticulum network
o small amounts of mature collagen
Treatment
Operative : marginal resection
Symptoms
Presentation
o usually and enlarging painless mass
o usually symptoms develop after mass reaches ten cm
Imaging
Radiograph are usually normal
MRI shows deep seated inhomogeneous mass
Histology
Classic characteristics are
o spindle and histiocytic cells arranged in stroiform (cartwheel) pattern
o chronic inflammatory cells may be present
Treatment
Operative
o wide local resection and adjuvant radiation
technique
add radiation if tumor is > 5 cm (5000 cGy before resection and 2000 cGy after resection)
may do local adjuvant treatment with phenol or cryotherapy
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Symptoms
Presentation
o usually and enlarging painless mass
o usually symptoms develop after mass reaches ten cm
Imaging
Radiograph
o are usually normal
MRI
o shows deep seated inhomogeneous mass
Histology
Classic characteristics are
o fasiculated growth pattern
o spindle-shaped cells with scant cytoplasm and indistinct borders
o cells separated by interwoven collagen fibers
o tissue may be organized in herringbone fashion
Treatment
Operative
o wide local resection with perioperative radiation
indications
most cases
radiation
add radiation if tumor is > 5 cm (5000 cGy before resection and 2000 cGy after resection)
local adjuvant treatment
may do local adjuvant treatment with phenol or cryotherapy
7. Dermatofibrosarcoma Protuberans
Introduction
A rare low-grade fibrogenic cutaneous sarcoma that occurs in early to midadult life.
rarely metastasizes distally
has a tendency to recurr locally
occurs in upper or lower extremities in 40%
Symptoms
Presentation
o usually and enlarging painless mass
Histology
Classic characteristics are
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o uniform fibroblasts arranged in storiform pattern around an inconspicuous vasculature
Treatment
Operative
o wide surgical resection
F. Lipogenic Tumors
1. Lipomas
Introduction
A common benign tumor of mature fat
o may be subcutaneous, extramuscular, or intramuscular
Epidemiology
o demographics
slightly more common in men
affects predominantly patients between 40-60 years old
develops in sedentary individuals
o location
superficial/subcutaneous location is common
superficial lesions are common in the upper back, thighs, buttocks, shoulders and arms
deep lesions are affixed to surrounding muscle, in the thighs, shoulders and arms
~5-10% of patients with a known superficial lipoma, will have multiple lesions
Prognosis : size typically plateaus after initial growth
Classification
Common variants of lipoma include
o spindle cell lipoma
common in male patients ages 45-65 years
o pleomorphic lipoma
common in middle aged patients
may be confused with liposarcomas
o angiolipoma
unique in that it is painful when palpated
often present with small nodules in the upper extremity
o intramuscular lipoma
often symptomatic and require marginal resection
o hibernoma
tumor of brown fat
affects younger patients (20-40 years old)
Symptoms
Symptoms
o usually a painless mass that has been present for a long time
exception is the angiolipoma, which is painful when palpated
Physical exam
o palpable, mobile, painless lesion
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Imaging
Radiographs
o may show a radiolucent lesion in the soft tissues
o may see mineralization, which should raise concern for synovial cell sarcoma
may see calcifications or presence of bone within the lesion
CT scan
o well demarcated lesion
o lesion looks akin to subcutaneous fat
MRI
o well demarcated lesion
o homogenous, signal intensity matches adipose tissue on all image
sequencing
o shows well demarcated lesion with same characteristics as mature fat III:8 T1
high signal intensity on T1 weighted images
high signal intensity on T2 weighted images, entirely suppressed by
STIR or fat saturated sequences
low signal intensity on STIR image
Histology
Biopsy often not necessary as diagnosis can be made by imaging (MRI)
Gross appearance
III:9 STIR
o Lipomas are soft, lobular, may be encapsulated and whitish/yellowish in color
o Hibernoma are reddish brown because of rich vascular supply in addition to high numbers of
mitochondria
Histology in general shows bland acellular stroma with neoplastic cells that lack cellular atypia
Histology varies by variant
o spindle cell lipoma
mixture of mature fat cells and spindle cells
mucoid matrix with varying number of birefringent collagen fibers
o pleomorphic lipoma
lipocytes, spindle cells, and scattered atypical giant cells
o angiolipoma
mature fat cells with nests of small arborizing vessels
o intramuscular lipoma
pathology shows lipoblasts and muscle infiltration
Treatment
Nonoperative
o observation only
indications
lesion is painless and MRI is determinate for a benign fatty lesion
Operative
o marginal resection (may be intralesional)
indications
symptomatic lesions
mass is rapidly growing
tumors located deep to the fascia or in the retroperitoneum
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deep or retroperitoneal lipomas show a higher likelyhood to be/become atypical
lipomatous tumors
in the retroperitoneum, referred to as well-differentiated liposarcoma
in the extremities, referred to as atypical lipomas
spindle cell/pleomorphic lipomas are treated by marginal resection
Complications
Local recurrence
o uncommon (< 5%)
2. Liposarcoma
Introduction
Liposarcomas are a heterogenous class of sarcomas with differentiation towards adipose tissue
o the lipoblast (signet ring-type cell) is a hallmark of liposarcomas
Epidemiology
o liposarcomas are the second most common form of soft tissue sarcomas in adults
o lipomas do not predispose a patient to a liposarcoma
Age and location
o occur in older individuals (50-80yrs)
o affect more males than females
o tend to occur deep to fascia
o more common in lower extremity than upper extremity
o common in retroperitoneum
Genetics
o myxoid liposarcoma - translocation (12;16)
Malignant potential
o metastasis risk correlates with grade/sub-type of liposarcoma
low grade (well-differentiated) has a metastasis rate of < 1%
intermediate grade (myxoid) has a metastasis rate of 10-30%
high grade has a metastasis rate of > 50%
Prognosis
o well-differentiated liposarcomas exhibit < 10% local recurrence rates and <1% chance of
metastasis and almost complete survival
o with appropriate treatment, intermediate and high grade liposarcomas show ~ 20% risk of local
recurrence but they exhibit 5 year survival between 25 - 50%
Classification & Grade
Histologic types
o liposarcoma types are related to the developmental stage of the lipoblasts from which they form
all are from primitive mesenchymal cells
o types include
well-differentiated
same entity as atypical lipomatous tumor
myxoid
most common ~ 50% of all liposarcomas
round cell
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pleomorphic
dedifferentiated
Imaging
Plain Radiographs
o may show soft tissue calcification or ossification in well-differentiated liposarcomas
MRI
o well-differentiated liposarcomas look similar to lipomas on MRI
bright on T1, dark on T2
may show differences in rate of growth, stranding, size
o high-grade liposarcomas look similiar to other sarcomas on MRI
dark on T1, bright on T2
although high grade liposarcomas appear fibrogenic, they may have 10% fat composition,
so they appear dark on T1 and bright on T2 unlike a lipoma which images iso-intense to
sub-cutaneous fat on all sequences
CT Chest/Abd/Pelvis
o myxoid liposarcomas have a tendency for abnormal metastasis outside of the lungs, such as
spread to the retroperitoneum
therefore, histologic diagnosis of myxoid liposarcoma should be evaluated with CT
Chest/Abd/Pelvis
T1 T2 T1 T2
well-differentiated liposarcomas high-grade liposarcomas
Histology
Characteristic histology
o immature lipoblasts (signet ring-type cells)
o mature adipocytes
Well-differentiated liposarcoma (central/retroperitoneal)
o also known as atypical lipomatous tumor (extremities)
o low grade
o atypical lipoblasts, minimally cellular
o fatty stroma background
o stain for MDM2/CDK4
o have ring chromosome 12
Myxoid liposarcoma
o low to intermediate grade
o proliferating lipoblasts upon a myxoid stroma matrix
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OrthoBullets2017 Soft Tissue Tumors | Lipogenic Tumors
o signet ring lipoblasts may occur
Round cell liposarcoma
o poorly differentiated liposarcoma with characteristic small round blue cells
Pleomorphic liposarcoma
o high-grade pleomorphic tumor
o giant lipoblasts with bizarre nuclei
Dedifferentiated liposarcoma
o high-grade sarcoma adjacent to well-differentiated lipomatous lesion
Treatment
Operative
o marginal resection without radiotherapy
indications
well-differentiated liposarcoma
outcomes
low risk of local recurrence, metastasis extremely rare
dedifferentiation risk of 2% in extremities and 20% in retroperitoneal lesions
o wide surgical resection with adjuvant radiotherapy
indications
intermediate grade liposarcomas
high grade liposarcomas
outcomes
radiation decreases local recurrence
chemotherapy may be beneficial in selected patients
myxoid liposarcomas with >10% round cells have high likelihood of metastasis
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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By Dr, AbdulRahman AbdulNasser Soft Tissue Tumors | Vascular Tissue
G. Vascular Tissue
Presentation
Symptoms
o pain of variable intensity depending on activity level
o symptoms of vascular engorgement if hemangioma is large
aching
heaviness
swelling
Physical exam
o examine patient in both supine and standing position
lower extremity lesions will fill up after several minutes of standing
o inspection
mass of variable size depending on activity level
Imaging
Radiograph
o may show small phleboliths (calcifications) inside the lesion
o erosion into adjacent bone
MRI with gadolinium
o differentiates these benign lesions from arteriovenous malformations and angiosarcomas
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OrthoBullets2017 Soft Tissue Tumors | Vascular Tissue
o increased signal on T1- and T2- weighted images
o focal areas of low-signal are a sign of blood flow or calcifications
o heterogeneous lesion with numerous small blood vessels and fatty infiltration (bag of worms)
Studies
Histology
o gross
varies depending on whether it is capillary type or cavernous type
color spectrum varies from red to tan to yellow
o micro
no malignant cells noted by cellular pleomorphism noted
many vascular dilations with large nuclei filled with erythrocytes
vascular lumens infiltrated with muscle fibers (intramuscular type)
cavernous shows large vessels with lots of fatty tissue
Differential
Other vascular malformations
o arteriovenous malformations
o cavernous hemangiomas
o angiomatosis
o vascular ectasia
Sarcoma
o important to distinguish from sarcoma
Treatment
Nonoperative
o observation, NSAIDS, vascular stockings, and activity modification
indications
first line of treatment
childhood lesions
o sclerotherapy or embolization
performed by interventional radiology (IR)
indications
large, painful lesions that fail NSAID and vascular stockings therapy
Operative
o marginal excision
indications
small lesions of the hand
o wide surgical resection
indications
lesions resistant to nonoperative management
outcomes
high incidence of local recurrence
Complications
Kasabach-Merritt syndrome
o rare complications caused by entrapped platelets leading to a possbly fatal coagulopathy
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By Dr, AbdulRahman AbdulNasser Soft Tissue Tumors | Vascular Tissue
2. Angiosarcoma
Introduction
Rare malignant and very aggressive tumor that derives from endothelium of blood vessels
Epidemiology
o demographics
male>female
elderly
o location
osseous involvement in <10%
60% long bone with osseous involvement
o risk factors
chronic vascular stasis
trauma
Prognosis
o poor
o high local failure rate and amputation is often required
o propensity for lymphatic spread
o metastases to lung is common
Symptoms
Symptoms
o pain
o symptoms often insidious
Physical exam
o hallmarked with
overlying skin changes
Imaging
Radiograph : may see invasion of bone
MRI : study of choice to evaluate soft tissue mass
Studies
Histology
o vascular channels
o variable degree of anaplasia
o malignant cells associated with vascular structures
Treatment
Operative
o wide surgical resection
indications
treatment of choice
relatively insensitive to chemotherapy and radiation
o amputation : indications
to achieve local control of disease
very aggressive tumor
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OrthoBullets2017 Soft Tissue Tumors | Dermatologic
H. Dermatologic
Presentation
Symptoms
o pain
Imaging
Radiographs
o recommended views
AP and lateral of affected area
o findings
lytic lesion
Treatment
Operative
o wide surgical resection +/-skin graft +/- radiation
indications
standard traditional treatment
adjunctive radiation
indications
lesions >2cm wide
4mm deep
perineural invasion
lymph node metastases
o Mohs microsurgery
indications
becoming more popular
smaller lesions
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By Dr, AbdulRahman AbdulNasser Soft Tissue Tumors | Dermatologic
highest cure rate
technique
lymph node biopsy may be necessary
2. Glomus Tumor
Introduction
Rare benign tumor of the glomus body, often occurring in the subungual region
o may involve either the soft tissue and/or bone
o frequently associated with a delay in diagnosis
o glomus tumor may also be called a paraganglioma
Epidemiology
o demographics
occurs in patients 20 to 40 years of age
o location
75% occur in hand
50% are subungual
50% have erosions of distal phalanx (primary involvement of bone being very rare)
less common locations: palm, wrist, forearm, foot
Anatomy
Glomus body
o the glomus body is a perivascular temperature regulating structure frequently located at the tip of
a digit or beneath the nail
Presentation
Symptoms (classic triad)
o paroxysmal pain
o exquisite tenderness to touch
o cold intolerance
Physical exam
o small bluish nodule
o often difficult to see, especially in the subungual location
o nail ridging or discoloration is common
o Love test
pressure to the area with a pinhead elicits exquisite pain
100% sensitive, 78% accurate
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OrthoBullets2017 Soft Tissue Tumors | Dermatologic
o Hildreth test
tourniquet inflation reduces pain/tenderness and abolishes tenderness to the Love test
92% sensitive, 91% specific
Imaging
Radiographs
o glomus tumors can produce a pressure erosion of the underlying bone and an
associated deformity of the bone cortex
MRI
o helpful to establish diagnosis
o present as a low T1 signal and high T2 signal
Studies
Histology
o well-defined lesion lacking cellular atypia or mitotic activity
small round cells with dark nuclei
associated small vessels in a hyaline/myxoid stroma
o can show gland-like or nest structures, separated by stromal elements
Treatment
Operative
o marginal excision is curative
indications
symptoms affecting quality of life
outcomes
due to the benign nature of this disease, recurrence is uncommon
several cases of malignant glomus tumors have been reported in the literature
o reconstruction of nail bed contour with autologous fat graft
indications
for large defects after resection
Complications
Recurrence
o 20%
3. Actinic Keratosis
Introduction
Keratotic, pre-malignant lesions
Epidemiology
o common in fair-skinned individuals
o common in elderly patients
o results from significant lifetime sun exposure
keratinocyte damage
Associated conditions
o may lead to squamous cell carcinoma
Prognosis
o typically slow-growing and persistent if untreated
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By Dr, AbdulRahman AbdulNasser Soft Tissue Tumors | Dermatologic
Presentation
Symptoms
o typically asymptomatic
o occasionally tender
Physical exam
o thin, adherent transparent or yellow scale that progressively increases in thickness
o often with telangiectasias
o can progress to cutaneous horn
difficult to distinguish from squamous cell carcinoma at this point
o rough, ―sand-paper‖ texture
often easier to detect by palpation rather than observation
o frequently on sun-exposed areas
face, head, neck, dorsal hands, ears
Evaluation
Skin biopsy
o dysplastic epidermis with keratinocyte atypia
hyperkeratotic cell with lower epithelial cells showing loss of polarity and hyperchromatic
nuclei
no invasion into dermis
Differential
Squamous cell carcinoma
Actinic cheilitis
Lentigo maligna
Treatment
Prevention
o Annual follow-up for skin cancer monitoring
o avoid sun exposure
o use sunscreen
Lifestyle modification
o avoid sun exposure
o use sunscreen
Surgical
o liquid nitrogen (cryotherapy) = most common treatment
o electrodesiccation and curettage
Pharmacological
o topical 5-fluorouracil
typically reserved for those with widespread actinic keratoses
Complications
Prognosis
o typically slow-growing and persistent if untreated
Prevention
o avoid sun exposure
o use sunscreen
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OrthoBullets2017 Soft Tissue Tumors | Dermatologic
Complications
o risk of progression to squamous cell carcinoma
Presentation
Symptoms
o typically asymptomatic, but may be tender if ulcerated
o slow-growing
Physical exam
o pink, pearly-white, almost translucent dome-shaped nodule or papule
o overlying telangiectasias
o commonly develop raised or rolled border
o commonly ulcerate, bleed, and crust in the center (a non-healing ulcer)
o frequently on sun-exposed areas
Evaluation
Diagnosis by skin biopsy
o basophilic palisading cells on histology
o nests of basaloid cells in dermis
Differential
Squamous cell carcinoma
Actinic keratosis
Treatment
Prevention
o use sunscreen
o avoid sun exposure
Surgical
o electrodesiccation and curettage
indications
typically for non-facial tumors that are small or superficial – not used for aggressive
tumors
best technique determined by
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By Dr, AbdulRahman AbdulNasser Soft Tissue Tumors | Dermatologic
size
location
histology
cosmetic considerations
outcomes
cure rate up to 92%
o Mohs micrographic surgery
indications
especially if on face or if recurrence
outcomes
cure rate up to 99%
o wide local surgical excision
outcomes
cure rate up to 90%
5. Melanoma
Introduction
An aggresive skin malignancy of melanocytic origin
o types include
acral lentiginous melanoma
subungual melanoma is a subtype of ALM
Epidemiology
o demographics
slightly more common in men (male:female ratio = 1.2:1)
age bracket is 50-70yrs
o location
thumb > great toe > index finger
sun exposed areas
o risk factors
sun exposure
UV radiation suppresses skin immunity, induces melanocyte cell division, produces free
radicals, damages melanocyte DNA
family history
skin characteristics
blue eyes, fair hair and complexion, freckling
xeroderma pigmentosa
familial atypical mole or melanoma (FAMM) syndrome
multiple benign and dysplastic nevi
dysplastic nevi are a precursor
immunesuppression
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OrthoBullets2017 Soft Tissue Tumors | Dermatologic
Pathophysiology
o progresses through phases of growth
Prognosis
o depth is the most important prognostic factor
< 0.7 mm - survival is 96%
> 4.0 mm - survival is 47%
o poor prognostic factors for melanoma
deep lesion
male sex
lesion on neck or scalp
positive lymph nodes and metastases
ulceration
o subungual melanoma has poor prognosis overall with 5yr survival 40-60%
Anatomy
Melanocytes
o derived from neural crest cells
o found in deepest layer of epidermis, separated from dermis by basement membrane
o dermis is divided into papillary dermis and reticular dermis
o subcutaneous tissue is deep to reticular dermis
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By Dr, AbdulRahman AbdulNasser Soft Tissue Tumors | Dermatologic
Classification
Breslow classification
o thickness =< 0.75mm
o thickness 0.76 - 1.5mm
o thickness 1.51 - 4mm
o thickness >4mm
Clark classification
o Level I - involves epidermis (in situ melanoma), no invasion
o Level II - invades papillary dermis
o Level III - invades papillary dermis up to papillary-reticular interface
o Level IV - invades reticular dermis
o Level V - invades subcutaneous tissue
Presentation
History
o pigmented lesion with recent change in shape or size
o nail trauma
subungual melanoma renders the nail dystrophic and vulnerable to trauma
Symptoms
o itching or bleeding
Physical exam
o brown-black pigmented lesion, may ulcerate
o extension of brown-black pigment of the nail bed or nail plate to the cuticle and nail folds
(Hutchinson sign)
o characterized by (ABCDEs)
Asymmetry
Border irregularity
Color variation
Diameter (<6mm benign)
Elevation
Enlargement
Imaging
CXR
o indications
lungs are often first site of metastases
Ultrasound
o indications
diagnose lymph node involvement
PET or CT
o indications
detect metastases
Studies
Labs
o CBC
o AST and ALT
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OrthoBullets2017 Soft Tissue Tumors | Other Soft Tissue Tumors
liver metastases
o LDH : predictive for poor prognosis
Histolology
o melanocytes with
marked cellular atypia
invasion into the dermis
vacuolated cytoplasm
hyperchromatic nuclei with prominant nucleoli
Differential
Differentials for melanoma
o nevi
o seborrheic keratosis
o basal cell carcinoma
Subungual melanoma is mistaken for
o trauma
o subungual hematoma
o onychomycosis
Treatment
Operative
o local resection with a 1cm margin
indications
lesion is < 1mm thick
o local resection with 1-2cm margin, sentinel node biopsy
indications
lesion is 1-2mm thick
technique
if sentinel node biopsy positive perform radical node dissection
o local resection, lymph node dissection, chemotherapy
indications
evidence of metastasis
o amputation
indications
subungual melanoma
outcomes
distal amputation with sufficient margins has similar recurrence rates and survival to
proximal (carpometacarpal/tarsometacarpal) amputations
may include lymph node dissection and isolated limb perfusion
Prevention
o prevent melanoma with sunscreen and avoiding sun exposure
Complications
Recurrence
o usually regional lymph nodes
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By Dr, AbdulRahman AbdulNasser Soft Tissue Tumors | Other Soft Tissue Tumors
1. Epithelioid Sarcoma
Introduction
A rare malignant slow-growing, nodular, soft tissue tumor
o often mistaken for a benign granulomatous process.
Age & location
o occurs in adolescents and young adults (ages 10-35 years)
o 2:1 male to female ratio
o most common soft tissue sarcoma of the hand and wrist
also occurs in forearm, buttock/thigh, knee, and foot
o mass is deep or superficial
may ulcerate and mimic skin carcinoma, rheumatoid nodule, or granuloma when superficial
may be attached to tendons, tendon sheaths, or fascia when deep
Genetics
o unknown
Malignancy
o regional lymph node metastases common
o systemic metastasis to lungs can occur
Prognosis : extremely poor
Symptoms
Symptoms
o small, firm, painless, slow growing mass commonly occurring in the upper extremity
Physical exam
o 3-6 cm firm, painless mass
may have skin ulceration
Imaging
Radiographs
o calcification occurs within the lesion in 10-20%
o erosion of adjacent bone is sometimes found
MRI
o indeterminate in appearance
dark on T1
bright on T2
o tendon sheath nodule may be visualized
Histology
Characteristics
o nodular pattern with central necrosis within granulomatous areas
o epithelial appearance with ovoid or polygonal cells with eosinophilic cytoplasm
o dense, hyalinized collagen deposits intercellularly
o cellular pleomorphism is rare
o keratin-positive staining
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OrthoBullets2017 Soft Tissue Tumors | Other Soft Tissue Tumors
Treatment
Operative
o wide excision with adjuvant radiotherapy
indication
all operable tumors
technique
perform sentinel node biopsy to evaluate for regional lymph node metastasis
outcomes
high rate of multiple recurrences if mistaken for a benign lesion and inadequately excised
o amputation
indications
may be necessary to prevent spread of disease in cases of multiple recurrences
2. Intramuscular Myxomas
Introduction
Benign soft tissue tumor that presents as a slow growing deeply seated mass confined within the
skeletal muscle (intramuscular)
o myxo from greek means mucus
o likely develop from premature mesenchymal stem cells which differentiate into benign
fibroblasts which loose their capacity to secrete collagen
Epidemiology
o demographics
occur in 40 to 60 year olds
slight female predilection
o associated conditions
commonly located in the thigh, shoulder, buttock, or upper arm
Associated conditions
o Mazabraud's syndrome
a syndrome characterized by multiple intramuscular myxomas associated with monostotic or
polyostotic fibrous dysplasia
o myxoid liposarcomas
important to differentiate from a myxoid liposarcomas, which occurs in
an intermuscular location
Prognosis
o local recurrence and metastasis uncommon
Presentation
Symptoms
o slowly growing mass
o may or may not be painful
pain in soft tissue sarcomas is often based on compression of surrounding tissues like vessels
or nerves
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By Dr, AbdulRahman AbdulNasser Soft Tissue Tumors | Other Soft Tissue Tumors
Imaging
MRI
o homogeneous appearance
o bright T2 signal
o dark T1 signal
o intramuscular location
intramuscular location of myxomas is important to differentiate from myxoid liposarcoma,
which occurs in an intermuscular location
Studies
Histology
o characterized by bland and hypo-cellular myxoid stroma
o no cellular atypia
o low nuclear to cytoplasmic ratio
o no atypical mitosis
Treatment
Nonoperative
o observation
indications
for asymptomatic lesions
Operative
o marginal surgical excision
indications
symptomatic benign low-grade tumors
neoadjuvant chemo-radiotherapy is not needed
local recurrence and metastasis uncommon
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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9
ORTHO BULLETS
Volume
Nine
Basic Science
2017
Collected By : Dr AbdulRahman AbdulNasser
[email protected]
OrthoBullets 2017
OrthoBullets 2017
Preface
Orthobullets.com is an educational resource for
orthopaedic surgeons designed to improve
training through the communal efforts of those
who use it as a learning resource. It is a simple but
powerful concept. All of our topics, technique
guides, cases, and user-generated videos are
free, and will stay that way.
Table of Contents
I. Musculoskeletal biology ..................................................................................................... 0
A. Bone Basic Science ....................................................................................................... 1
1. Types of Bone ................................................................................................................. 1
2. Bone Cells ...................................................................................................................... 3
3. Bone Matrix .................................................................................................................... 8
4. Bone Marrow .................................................................................................................. 9
5. Bone Circulation ........................................................................................................... 10
6. Bone Signaling & RANKL .............................................................................................. 12
7. Normal Bone Metabolism .............................................................................................. 14
B. Bone Formation & Healing ........................................................................................... 19
1. Embryology .................................................................................................................. 19
2. Endochondral Bone Formation ..................................................................................... 25
3. Intramembranous Bone Formation ............................................................................... 28
4. Bone Remodeling ......................................................................................................... 29
5. Fracture Healing .......................................................................................................... 30
6. Nonunion ...................................................................................................................... 34
7. Bone Growth Factors.................................................................................................... 36
8. Bone Grafting ............................................................................................................... 39
9. PTH & Vit D Physiology ................................................................................................. 44
C. Biologic Tissues .......................................................................................................... 46
1. Muscle Biology & Physiology ........................................................................................ 46
2. Ligaments..................................................................................................................... 49
3. Tendons ....................................................................................................................... 53
4. Articular Cartilage ........................................................................................................ 56
5. Cartilage ...................................................................................................................... 61
6. Synovium & Synovial Fluid ............................................................................................ 63
7. Collagen ....................................................................................................................... 65
D. Molecular Biology ........................................................................................................ 68
1. Molecular Biology Basics.............................................................................................. 68
2. Immunology .................................................................................................................. 70
3. Inheritance Patterns of Orthopaedic Syndromes .......................................................... 72
4. Genetic Pearls .............................................................................................................. 74
OrthoBullets 2017
3. Pustulosis palmoplantaris............................................................................................166
4. Acute Rheumatic Fever ...............................................................................................168
F. Metabolic Disease ......................................................................................................169
1. Hypercalcemia ............................................................................................................169
2. Hypocalcemia..............................................................................................................170
3. Hypoparathyroidism ....................................................................................................172
4. Hyperparathyroidism...................................................................................................173
5. Hypophosphatasia .......................................................................................................175
6. Pseudohypoparathyroidism .........................................................................................177
7. Scurvy .........................................................................................................................179
III. Medications & Toxicity ...................................................................................................182
A. Medications ................................................................................................................183
1. Bisphosphonates .........................................................................................................183
2. Prophylaxis Antibiotics ................................................................................................185
3. Antibiotic Classification & Mechanism .........................................................................187
4. Anti-inflammatory Medications ....................................................................................194
5. Analgesic Medications.................................................................................................196
6. Anesthesia ..................................................................................................................200
7. Platelet-Rich Plasma ....................................................................................................208
B. Toxicology ..................................................................................................................209
1. Lead Toxicity ...............................................................................................................209
IV. Clinical Science .............................................................................................................210
A. Clinical Studies ...........................................................................................................211
1. Statistic Definitions .....................................................................................................211
2. Level of Evidence ........................................................................................................218
3. Clinical Trial Design .....................................................................................................220
4. Outcome Measure Tools ..............................................................................................223
B. Healthcare Worplace ..................................................................................................228
1. Occupational Health ....................................................................................................228
2. Legal and Ethics ..........................................................................................................229
OrthoBullets2017 | Bone Basic Science
ORTHO BULLETS
I.Musculoskeletal biology
- 0 -
By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Basic Science
1. Types of Bone
Introduction
Bone can be classified based on both anatomy and structure
o anatomic
long bones
flat bones
o structure
macroscopic level
cortical
cancellous
microscopic level
lamellar
woven bone
Anatomic classification
Long bones
o e.g. femur, humerus, tibia, forearm bones
o three anatomic regions in long bones
diaphysis
thick cortical bone surrounding a central canal of cancellous bone
outer region covered by periosteum
metaphysis
thin cortical bone surrounding loose trabecular bone
epiphysis
end of bone that forms the articular surface
contains the physis and the subchondral region under the articular cartilage
Flat bones
o e.g. skull, pelvis, scapula
o varied structure of either purely cortical bone or cortical bone with a thin central trabecular
region
Macroscopic structural classification
Cortical
o 80% of skeleton
o metabolism
characterized by slow turnover rate and high Young's modulus
o structure
made of packed osteons or Haversian systems
osteons
I:1 In this image we see mature,
outer border defined by cement lines lamellar cortical bone. 1 - A new
vascular canals Haversian system or osteon 2 -
Haversian canal 3 - Interstitial region
contain arterioles, venules, capillaries, and nerves between osteons
if oriented along long axis of bone: Haversian canals
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OrthoBullets2017 Musculoskeletal biology | Bone Basic Science
if oriented transversely to long axis of bone: Volkmann canals
interstitial lamellae
the region between osteons
Cancellous bone (spongy or trabecular bone)
o metabolism
lower Young's modulus and more elastic
high turnover to remodel according to stress across the bone
o structure
boney struts organized into a loose network
each strut is approximately 200 micrometers in diameter
I:2 Cancellous bone is a trabecular
30-90% of bone is porous and contains bone marrow framework of bone which is highly
increased porosity in osteoporosis porous. The porous region of the bone
contains bone marrow. Metaphyseal
Microscopic structural classification regions have larger amounts of cancellous
bone and subsequently better healing
Woven bone potential than diaphyseal regions.
o immature or pathologic bone that is woven and random and is not stress oriented
o compared to lamellar bone, woven bone has:
more osteocytes per unit of volume
higher rate of turnover
o weaker and more flexible than lamellar bone
Lamellar bone
o secondary bone created by remodeling woven bone
o organized and stress oriented
o stronger and less flexible than woven bone
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Basic Science
2. Bone Cells
Osteoblasts
Origin
o derived from undifferentiated mesenchymal cells
o mesenchymal cells then differentiate into osteoprogenitor cells
Structure
o contain increased amounts of endoplasmic reticulum, Golgi apparatus, and mitochondria than
other cells
o allows for synthesis and secretion of bone matrix
Function
o form bone by producing non-mineralized matrix
alkaline phosphatase
type I collagen
osteonectin
osteocalcin
stimulated by 1,25 dihydroxyvitamin D
o regulate osteoclast function
Signaling
o osteoblastic differentiation
BMP stimulates mesenchymal cells to become osteoprogenitor cells
core binding factor alpha-1 (cbf alpha -1: RUNX2)
stable beta-catenin plays a major role in inducing cells to form osteoblasts with resulting
intramembranous bone formation
platelet derived growth factor (PDGF) induces osteoblast differentiation
insulin derived growth factor (IDGF) induces osteoblast differentiation
o osteoblast bone production
PTH receptor
stimulates alkaline phosphatase and type I collagen production
1,25 dihydroxyvitamin D receptor
stimulates matrix and alkaline phosphatase synthesis
production of bone specific proteins (osteocalcin)
estrogen inhibits bone resorption and stimulates bone production by inhibiting adenylyl
cyclase
glucocorticoids inhibit collagen and bone matrix production
prostaglandins stimulate bone resorption by activating adenylyl cyclase
o osteoclast signaling
interconnected signaling allows coupling of bone resorption and formation
osteoclast activation
PTH receptors on osteoblast bind to PTH which when leads to expression of RANKL
RANKL binds to RANK receptor on osteoclast and bone resorption
osteoclast inhibition
osteoblasts can secrete OPG (osteoprotegrin)
OPG binds to RANKL on the osteoblast, preventing RANK activation
inhibits osteoclast activity
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OrthoBullets2017 Musculoskeletal biology | Bone Basic Science
Location
o more metabolically active cells at the bone surface
o less active cells in more central bone
activated by disruption of the more peripheral osteoblasts
Osteoclasts
Function
o reabsorb bone
osteoblasts regulate osteoclast bone reabsorbtion (see above)
steps in resorption cycle
migration to resorption site
bone attachment
polarization (formation of membrane domains)
dissolution of hydroxyapatite
degradation of organic matrix
removal of degradation products from resorption lacuna
apoptosis of the osteoclasts or return to the non-resorbing stage.
Origin
o originate from hematopoietic cells from macrophage cell lineage
o monocyte progenitors fuse together to form mature multinuclear cells
Cellular biology
o cellular anatomy
multinucleated giant cells
o cellular physiology
bone reabsorbtion occurs at ruffled border
Howship's lacunae
are site of bone resorption where ruffled border meets bone surface
tartrate resistant acid phosphate
secreted by osteoclasts to lowers the Ph (utilizing carbonic anhydrase) and increases
the solubility of hydroxyapatite crystals
deficiency of carbonic anhydrase prevents bone resorption
proteolytic digestion
the organic matrix is then removed by proteolytic digestion
cathepsin K
is one major proteolytic enzyme that degests organic matrix at ruffled border
bisphosphonates mechanism
prevents osteoclasts from forming ruffled border and producing acid hydrolases
Molecular biology
o osteoclast-bone attachment
osteoclast attaches to bone matrix at sealing zone
attach to bone surfaces via integrins on osteoclast surface
integrins include αVβ3, αVβ5, α2β1, αVβ1
αVβ3 (on osteoclast) is a receptor for vitronectin (on bone surface)
Arg-Gly-Asp (RGD) sequence of extracellular bone proteins directly allows binding
to integrins
antibodies to αVβ3 and RGD inhibit bone resorption
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Basic Science
- 5 -
OrthoBullets2017 Musculoskeletal biology | Bone Basic Science
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Basic Science
o osteoclast polarization
contain specialized membrane domains
ruffled border (RB)
functional secretory domain (FSD)
basolateral membrane (BL)
o mineralized bone matrix degradation
hydroxyapatite crystals dissolved by HCl secreted through ruffled border into resorption
lacuna (RL)
RL is an extracelllular space between RB and bone matrix, sealed from ECF by sealing
zone
uses ATP-consuming proton pumps in RB and in intracellular vacuoles
H+ come from carbonic anhydrase II
RB has high number of chloride channels (maintain electroneutrality)
o organic bone matrix degradation
lysosomal cysteine proteinases
matrix metaloproteinases (MMPs), esp MMP-9
cathepsin K : mutation in cathepsin K gene leads to pycnodysostosis
o removal of degradation products
by transcystosis to FSD, where they are secreted into ECF
tartrate-resistant acid phosphatase (TRAP) is localized in transcytotic vesicles, generates
reactive O2 species that destroys collagen
o osteoclast-osteoblast signaling
osteoblasts upregulate and downregulate osteoclast activity
osteoclast activation
RANKL (NF-kB ligand)
expressed by osteoblasts and tumor cells to activate osteoclasts
IL-1
found adjacent to loose total joint implants and known to activate osteoclasts
osteoclast inhibition
calcitonin
IL-10
Osteocytes
Origin
o are former osteoblasts trapped in the matrix they produced
o account for 90% of cells in the mature skeleton
Structure
o high nucleus to cytoplasm ratio
o have long cellular processes which communicate with other cells via canalculi in the bone
Function
o maintain bone and cellular matrix
o important in regulation of calcium and phosphorous concentrations in bone
o do not express alkaline phosphatase
Signaling
o stimulated by calcitonin
o inhibited by PTH
o communicate with adjacent osteocytes via gap junctions in canaliculi
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OrthoBullets2017 Musculoskeletal biology | Bone Basic Science
Osteoprogenitor Cells
Origin
o originate from mesenchymal stem cells
o environment will determine their function
Function
o become osteoblasts under low strain and high oxygen tension
o become cartilage under intermediate strain and low oxygen tension
o become fibrous tissue under high strain
3. Bone Matrix
Introduction
Bone is made up of
o organic component
40% of dry weight
o inorganic component
60% of dry weight
Organic component
Components include
o collagen
90% of organic component
primarily type I collagen
provides tensile strength
it is a triple helix composed of one alpha-2 and two alpha-1 chains
o proteoglycans
responsible for compressive strength
inhibit mineralization
composed of glycosaminoglycan-protein complexes
o matrix proteins
includes noncollagenous proteins
function to promote mineralization and bone formation
three main types of proteins involved in bone matrix
osteocalcin
most abundant non-collagenous protein in the matrix (10%-20% of total)
produced by mature osteoblasts
function
promotes mineralization and formation of bone
directly involved in regulation of bone density
attracts osteoclasts
signaling
stimulated by 1,25 dihydroxyvitamin D3
inhibited by PTH
clinical application
marker of bone turnover
can be measured in urine or serum
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Basic Science
osteonectin
secreted by platelets and osteoblasts
function
believed to have a role in regulating calcium or organizing mineral in matrix
osteopontin
function : cell-binding protein
o cytokine and growth factors
small amounts present in matrix
aid in bone cell differentiation, activation, growth, and turnover
include
IL-1, IL-6, IGF, TGF-beta, BMPs
Inorganic component
Components include
o calcium hydroxyapatite (Ca10(PO4)6(OH)2
provides compressive strength
o osteocalcium phosphate (brushite)
4. Bone Marrow
Introduction
Gelatinous tissue found in the inner spaces of bone that contains progenitor cells and stromal cells
Types of bone marrow
o red marrow
hematopoietic tissue
composition
40% water
40% fat
20% protein
o yellow marrow
fatty tissue
composition
15% water
80% fat
5% protein
Function
o primary function of hematopoiesis
o controls the inner diameter of bone
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OrthoBullets2017 Musculoskeletal biology | Bone Basic Science
Yellow Bone Marrow
Location
o most commonly found in diaphysis or shaft of long bones
femur, humerus, tibia
Function
o contains mostly fat cells
o may revert to red bone marrow if there is an increased demand for red blood cells (e.g. trauma)
5. Bone Circulation
Introduction
Bone receives 5-10% of cardiac output
Bones that receive tenuous blood supply
o scaphoid
o talus
o femoral head
o odontoid
Blood supply to long bone comes from three sources
o nutrient artery system
o metaphyseal-epiphyseal system
o periosteal system
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Basic Science
o then branch into ascending and descending branches
then branch into arterioles and supply the inner 2/3 of mature bone via the haversion system
Metaphyseal epiphyseal system
Arteries arise from periarticular vascular plexus
o e.g. geniculate arteries
Periosteal System
Low pressure system that supplies the outer 1/3 of bone
o connected by
Volkman's artery (perpendicular to long axis)
Haversion system (parallel to long axis)
Intracortical Vascularization
Intracortical vessels travel within canals
o Primary Haversian canals
o Secondary Volkmann canals
Growth Plate
Perichondrial artery is the major source of nutrition of the growth plate
Pathoanatomy
Fractures
o patterns of blood flow following fracture
immediate phase
initial decrease in blood flow after fracture
flow is centripetal (outside to inside)
because high pressure nutrient artery system is disrupted
low pressure periosteal system predominates
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o hours to days
increase in blood flow (regional acceleratory phenomenon)
peaks at 2 weeks and returns to normal in 3-5 months
Intramedullary nails
o unreamed intramedullary nails preserve endosteal blood supply
o reaming devascularizes inner 50-80% of the cortex and delays revascularization of endosteal
blood supply
o loose fitting nails spare cortical perfusion and allow more rapid reperfusion
o tight fitting nails compromise cortical perfusion and reperfusion is slow
Osteoclast Activation
Osteoclast activation stimulates bone resorption
Molecules that stimulate bone resorption
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Basic Science
o RANKL
RANKL (ligand) is secreted by osteoblasts and binds to the RANK receptor on osteoclast
precursor and mature osteoclast cells
o PTH (secreted by many cancer cells)
activation of its receptor stimulates adenylyl cyclase
binds to cell-surface receptors on osteoblasts to stimulate production of RANKL and M-CSF
o interleukin 1 (IL-1)
stimulates osteoclast differentiation and thus bone resorption
o 1,25 dihydroxy vitamin D
stimulates RANKL expression
o prostaglandin E2
activates adenylyl cyclase and stimulates resorption
o IL-6 (myeloma)
o MIP-1A (myeloma)
Osteoclast Inhibition
Osteoclast Inhibition decreases bone resorption
Molecules that inhibit bone resorption
o osteoprotegerin (OPG)
decoy receptor produced by osteoblasts and stromal cells that binds to and sequesters
RANKL
inhibits osteoclast differentiation, fusion, and activation
o calcitonin
interacts directly with the osteoclast via cell-surface receptors
o estrogen (via decrease in RANKL)
stimulates bone production (anabolic) and prevents resorption
inhibits activation of adenylyl cyclase
o transforming growth factor beta (via increase in OPG)
o interleukin 10 (IL-10) : suppresses osteoclasts
Clinical Implications
Osteopetrosis
o condition caused by a genetic defect resulting in absence of osteoclastic bone resorption
o a mouse RANKL knockout model creates a osteopetrosis-like condition
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Osteoyltic bone metastasis
o found to be mediated by the RANK and RANKL pathway
o RANKL is produced directly by the cancer cells
o blocking of RANKL by OPG results in decreased skeletal metastasis in animal models
o bisphosphonates decrease skeletal events in cancer metastasis
Calcium
Location
o bone (99%)
o blood and extracellular fluid (0.1%)
o intracellular (1%)
Function
o calcium has a wide range of function including
muscle cell contraction
nerve conduction
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Basic Science
clotting mechanisms
Forms of calcium
o bone
majority is hydroxyapatite
o serum
Ca++ bound to protein (45%)
free-ionized Ca++ (45%)
bound to various anions, eg. citrate, bicarbonate (10%)
Regulation
o absorption from the digestive tract
o resorption from bone
o resorption in the kidneys
Dietary requirements
o 2000 mg/day for lactating women
o 1500 mg/day for pregnant women, postmenopausal woman, and patients with a healing bone
fracture
o 1300 mg/day for adolescents and young adults
o 750 mg/day for adults
o 600 mg/day for children
Dysfunction
o hypercalcemia
o hypocalcemia
Phosphate
Location
o bone (86%)
o blood and extracelluar fluid (0.08%)
o intracellular (14%)
Function
o key component of bone mineral
o important in enzyme systems and molecular interactions
Forms of phosphate
o bone
majority is hydroxyapatite
o serum
mostly inorganic phosphate (H2PO4-)
Regulation
o plasma phosphate is mostly unbound and reabsorbed by the kidney
o may be excreted in urine
o elevated serum phosphate can lead to increased release of PTH and bone resorption
Dietary intake
o 1000-1500 mg/day
PTH
Structure
o 84 amino acid peptide
Origin
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o synthesized and secreted from chief cells in the four parathyroid glands
Net effect
o increases serum calcium
o decreases serum phosphate
Mechanism
o bone
PTH stimulates osteoblasts to secrete IL-1, IL-6 and other cytokines to activate osteoclasts
and increase resorption of bone
Increases osteoblast production of M-CSF (macrophage colony-stimulating factor) and
RANKL, which increases number of osteoclasts.
Paradoxically, osteoclasts do not express receptor for PTH
o kidney
stimulates enzymatic conversion of 25-(OH)-vitamin D3 converted to 1,25-(OH)2-vitamin
D3 (active hormone form) which:
increases resorption of Ca++ in kidney (increasing serum Ca++)
increases excretion of PO4- from kidney (decreasing serum phosphate)
o intestine
no direct action
indirectly increase Ca++ absorption by activating 1,25-(OH)2-vitamin D3
Dysfunction
o PTH-related protein and its receptor have been implicated in metaphyseal dysplasia
Parathyroid hormone-related protein (PTHrP) has related effects to PTH as it binds to the same
receptors on osteoblasts and renal cells to increase serum calcium
Calcitonin
Structure
o 32 amino-acid peptide hormone
Origin
o produced by clear cells in the parafollicles of the thyroid gland (C cells)
Net effect
o limited role in calcium homeostasis
o inhibit number and activity of osteoclasts
Function
o bone
inhibits osteoclastic bone resorption by decreasing number and activity of osteoclasts
osteoclast have receptor for calcitonin
Inc. serum Ca > secretion of calcitonin > inhibition of osteoclasts > dec. Ca (transiently)
Dysfunction
o secreted by medullary thyroid tumors and mulitple endocrine neoplasia type II tumors
o Recombinant calcitonin used to treat Paget disease, osteoporosis, and hypercalcemia in
malignancy
Vitamin D
Structure
o fat soluble secosteroid (steroid with a 'broken ring')
Origin
o produced by skin when exposed to sunlight (UV B-generated Vitamin D)
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Basic Science
o dietary intake (lipid-soluble vitamin D3)
o active metabolite 1,25-(OH)2-vitamin D3 formed by two hydroxylations in the liver and kidney,
respectively
Net effect
o maintains normal serum calcium levels by activating osteoclasts for bone resorption and
increasing intestinal absorption of calcium (increase serum Ca++)
o promotes the mineralization of osteoid matrix
Function
o liver
activated-vitamin D3 converted to 25-(OH)-vitamin D3
o kidney
25-(OH)-vitamin D3 converted to 1,25-(OH)2-vitamin D3 (active hormone form)
activated by
increased levels of PTH
decreased levels of serum Ca++, P
1,25-(OH)2-vitamin D3 (active hormone form)can be inactivated to 24,25-(OH)2-vitamin D3
inactivity occurs with:
decreased levels of PTH
increased levels of serum Ca++, P
vitamin D parallels that of PTH by increasing reabsorption of Ca in the kidneys
o bone
1,25-(OH)2-vitamin D3 stimulates terminal differentiation of osteoclasts
when osteoclasts mature they do not respond to 1,25-(OH)2-vitamin D3 and respond mostly
to cytokines released by osteoblasts
1,25-(OH)2-vitamin D3 promotes the mineralization of osteoid matrix produced by
osteoblasts
Dysfunction
o Vitamin D deficiency causes osteomalacia and rickets
o phenytoin (dilantin) causes impaired metabolism of vitamin D
Estrogen
Structure
o D ring steroid hormone
Origin
o predominantly in the ovaries
o synthetic forms available
Net effect
o prevents bone loss by decreasing the frequency of bone resorption and remodeling
Function
o alone, because bone formation and resorption are coupled, it also indirectly decreases bone
formation
o leads to an increase in bone density of the femoral neck and reduces the risk of hip fracture
o most important sex-steroid for peak bone mass attainment in both men and women
Therapeutic estrogen
o outcomes
decreases bone loss if started within 5-10 years after onset of menopause
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significant side effects so risk/benefit ratio must be evaluated
gains in bone mass usually limited to an annual increase of 2-4% for the first 2 years of
therapy
o secondary effects
increases risk of
heart disease
breast cancer
decreases risk of
hip fracture
endometrial cancer (if combined with cyclic progestin)
o laboratory
will see a decreases in
urinary pyridoline
serum alkaline phosphatase
Thyroid Hormone
Function
o regulates skeletal growth at the physis by stimulating
chondrocyte growth
type X collagen synthesis
alkaline phosphatase activity
o thyroid hormones increase bone resorption and can lead to osteoporosis
large doses of therapeutic thyroxine can mimic this process and cause osteoporosis
Growth Hormone
Function
o increases serum calcium by
increased absorption in intestine
decreasing urinary excretion
o function is interdependent with insulin, somatomedins, and growth factors (TGF-B, PDGF,
mono/lyphokines)
Gigantism
o oversecretion or increased response to growth hormone effecting the proliferative zone of the
growth plate
Steroids
Function
o increase bone loss by
decreasing Ca++ absorption in intestine through a decrease in binding proteins
decreasing bone formation (cancellous more so than cortical bone) by
decreasing collagen synthesis
inhibiting osteoblast activity
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Formation & Healing
1. Embryology
Limb Development
Overview
o the appendicular system forms between the 4-8 weeks of gestation
o limb bud development
appears to be under the control of fibroblast growth factors (FGF)
enlargement of the limb bud is due to the interaction between the apical ectodermal ridge
(AER) and the mesodermal cells in the progress zone.
Steps of limb development
o notochord expresses Shh
o Shh regulates limb bud formation
limb bud is combination of lateral plate mesoderm and somatic mesoderm
growing outwards into ectoderm (called apical ectodermal ridge)
limb bud formed at embryonic stage 12 (26 days after fertilization)
o mesenchyme condenses into preskeletal blastemal at core of limb bud
o chondrification occurs where mesenchyme differentiates into chondrocytes
All upper limb bones are endochondral except distal parts of distal phalanges (membranous)
From proximal (humerus, 36 days after fertilization) to distal (distal phalanges, 50 days)
Factors required for chondrification
transcription factors – Sox-5, Sox-6, Sox-9
transforming growth factor superfamily – TGF-b, BMP-2
FGF family
receptor mutation leads to acrocephalosyndactyly (Apert syndrome)
patients with severe craniofacial features have mild hand syndactyly (gain of function
in FGFR2c affinity for FGF2 expressed in craniofacial area )
patients with mild craniofacial features have severe hand syndactyly (loss of function
in FGFR2c specificity for FGF2, and is now able to bind FGF10, more expressed in
hands)
retinoids
hedgehog gene products
PTHrP
cadherins
WNT5a and WNT7a
o Formation of joints requires repression of chondrogenesis at sites of future joints
proteins involved – WNT4, WNT14, growth and differentiation factor 5 (also known as
cartilage-derived morphogenetic protein 1)
shoulder interzone appears at 36 days, hand interzones appear at 47 days
o Finger separation
digital rays are evident within hand paddle at stage 17 (41 days)
interdigital mesenchyme cells undergo programmed cell death (stage 19 to 22)( days 47-54)
transcription factor Msx2 is expressed in interdigital mesenchyme, regulates BMP4-mediated
programmed cell death pathway
transcription factor Hox-7 also expressed in interdigital zones
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OrthoBullets2017 Musculoskeletal biology | Bone Formation & Healing
Limb patterning
o Proximodistal
first signaling center to appear is AER
controls proximal to distal growth
forms under FGF10 stimulation
removal /defect in AER results in proximal limb truncation
example is central deficiency (cleft hand)
another example is radial clubhand (radial dysplasia, absence of radius)
FGFs expressed in AER include FGF4, FGF8, FGF9, and FGF 17
FGF8 expressed earliest and is obligatory for normal limb development
FGF4, 9 and 17 are redundant
disrupted FGF signalling leads to arrested limb development
o Anteroposterior (radioulnar) limb growth (nomenclature: ulnar=posterior, radius=anterior)
second signaling center to appear is ZPA (zone of polarizing activity), along posterior limb
bud
grafting ZPA on anterior limb margin leads to mirror-image digit duplication (ulnar
dimelia, or mirror hand)
signaling molecule is Shh compound (dose dependent)
normal
high concentration of Shh on posterior (ulnar) side for small finger development
low concentration of Shh on anterior (radial) side for thumb development
posterior/ulnar side abnormalities
abnormal upregulation of Shh in the ZPA results in polydactly on the ulnar (posterior)
side
extent of duplication is dose dependent (higher dose = more replication)
downregulation of Shh (on the posterior/ulnar side) leads to loss of ulnar digits
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Formation & Healing
anterior/radial side abnormalities
abnormal upregulation of Shh in the anterior aspect of the limb bud (where Shh
concentration is supposed to be low) leads to loss of thumb
timing
posterior elements (little finger/ulna) are formed EARLY prior to anterior elements
which are formed LATE (radius/thumb)
disruption of AP patterning will result in loss of later forming elements
(radius/thumb)
o Dorsoventral axis
third signaling center is non-AER limb ectoderm /Wnt signalling center (progress zone, PZ)
dorsal limb ectoderm expresses WNT7a
activates Lmx1b (LIM-homeodomain factor) to regulate dorsal patterning
WNT7a is responsible for all dorsal features (including nails)
ventral ectoderm expresses en-1 (engrailed-1 protein, antagonistic to WNT7a)
inhibits WNT7a (and restricts it to dorsal ectoderm)
allows ventral limb development
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OrthoBullets2017 Musculoskeletal biology | Bone Formation & Healing
Key Genes
o Sonic Hedgehog (Shh) genes
secreted by ZPA
involved with HOX gene expression
anterior-posterior (radioulnar) growth
anterior (radial) mesoderm expresses ALX4
posterior (ulnar) mesoderm expresses Hox8
concentration gradient dictates formation of digits
little finger develops where there is highest Shh concentration
thumb develops where there is lowest Shh concentration
activates Gremlin
Gremlin inhibits BMPs that would otherwise block FGF expression in the AER
o Hox genes
anterior-posterior (radioulnar) patterning
together with Shh
regulate somatization of the axial skeleton, essentially patterning digit formation
o Wnt genes (Wnt7a)
expressed in dorsal (non-AER) ectoderm (Wnt signalling center)
dorsal-ventral growth
Mutations
o removal of AER
truncated limb
o duplication of ZPA
mirror-image duplication of the limb
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Formation & Healing
Key Genes/Regions
Gene/Region Expresses Regulates
Apical ectodermal ridge (AER) FGF8 is dominant (also FGF 4, Proximal to distal growth and
9, 17, which are redundant) interdigital necrosis
Zone of polarizing activity (ZPA) Shh Anterior-posterior (radio-ulnar)
growth
Non-AER limb ectoderm (dorsal) Dorsal ectoderm expresses Dorso-ventral growth
WNT7a, that activates Lmx1b
(regulates dorsal patterning)
Non-AER limb ectoderm (ventral) Ventral ectoderm expresses en- Dorso-ventral growth
1, antagonistic to WNT7a
(regulates ventral patterning)
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OrthoBullets2017 Musculoskeletal biology | Bone Formation & Healing
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Formation & Healing
Anatomy
Blood supply
o perichondrial artery
You have not been
heard from for a while.
major source of
nutrition to physis
Longitudinal Physeal Growth
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OrthoBullets2017 Musculoskeletal biology | Bone Formation & Healing
Physeal Growth Plate
(letters on left correspond to histology in top right)
Cells store lipids, glycogen, and proteoglycan Gaucher's
Reserve Zone aggregates for later growth and matrix diastrophic dysplasia
production Kneist*
Low oxygen tension Pseudoachondroplasia*
Proliferative Proliferation of chondrocytes with longitudinal Achondroplasia
growth and stacking of chondrocytes. Gigantism
Zone Highest rate of extracellular matrix production MHE
Increased oxygen tension in surroundings
inhibits calcification
Hypertrophic Zone of chondrocyte maturation, chondrocyte SCFE (not renal)
hypertrophy, and chondrocyte calcification. Rickets (provisional calcification zone)
Zone Three phases occur in the hypertrophic zone Enchondromas
o Maturation zone: preparation of matrix Mucopolysarcharide disease
for calcification, chondrocyte growth acromegaly
o Degenerative zone: further preparation SED
of matrix for calcification, further MED
chondrocyte growth in size (5x) Schmids
o Provisional calcification zone: Kneist*
chondrocyte death allows calcium Pseudoachondroplasia*
release, allowing calcification of matrix Fractures most commonly occur
Chondrocyte maturation regulated by local through the zone of provisional
growth factors (parathyroid related peptides, calcification, specifically Salter-Harris I
expession regulated by Indian hedgehog fractures
gene)
Type X collagen produced by hypertrophic
chondrocytes important for mineralization
Primary Spongiosa Vascular invasion and resportion of Metaphyseal "corner fracture" in child
transverse septa. abuse
(metaphysis) Osteoblasts align on cartilage bars produced Scurvy
by physeal expansion.
Primary spongiosa mineralized to form woven
bone and then remodels to become
secondary spongiosa (below)
Secondary spongiosa Internal remodeling (removal of cartilage Renal SCFE
(metaphysis) bars, replacement of fiber bone with lamellar
bone)
External remodeling (funnelization)
Physis Periphery
Groove of Ranvier During the first year of life, the zone spreads Osteochondroma
over the adjacent metaphysis to form a
fibrous circumferential ring bridging from the
epiphysis to the diaphysis.
This ring increases the mechanical strength
of the physis and is responsible for
appositional bone growths
o supplies chondrocytes to periphery
Perichondrial Dense fibrous tissue that is the primary
fibrous ring of La limiting membrane that anchors and supports
Croix the physis through peripheral stability
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Formation & Healing
I:9 Illustration of relationship of the perichondrial ring of La Croix providing peripheral stability.
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OrthoBullets2017 Musculoskeletal biology | Bone Formation & Healing
Embryonic Long Bone Formation
Overview
o allows growth in width and length
o formed from mesenchymal anlage around 6th week in utero.
Steps of formation include
o vascularization
vascular buds invade the mesenchymal model
o primary ossification centers form
(at ~ 8 weeks) osteoprogenitor cells migrate through vascular buds and differentiate into
osteoblasts forming the primary ossification centers
o cartilage model forms
grows through appositional (width) and interstitial (length) growth
o marrow forms
marrow is formed by resorption of central portion of the cartilage anlage by myeloid
precursor cells that migrate in through the vascular buds
o secondary ossification centers form
develop at bone ends and lead to epiphyseal ossification center (growth plate)
4. Bone Remodeling
Introduction
Wolff's Law
o bone remodels in response to mechanical stress
Piezoelectic charges
o bone remodels is response to electric charges
o compression side is electronegative and stimulates osteoblast formation
o tension side is electropostive and stimulates osteoclasts
Hueter-Volkmann Law
o theory that bone remodels in small packets of cells known as
Basic Multicellular Units (BMUs)
o theory suggest that mechanical forces influence longitudinal
growth
o compressive forces inhibit growth
o may play role in scoliosis
Remodeling Mechanism
Cortical bone
o remodels by osteoclastic tunneling (cutting cone)
osteoclastic resorption > layering of osteoblasts > layering of lamellae > cement line laid
down
osteoclast make up head of cutting cone, followed by capillaries and then osteoblasts which
lay down the osteoid to fill the cutting cone
sclerostin inhibits osteoblastogenenesis to decrease bone formation
o cortical bone continues to change over time
cortical area decreases as age increases
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linked to increase fracture risk
medullary canal volume increases as age increases
Cancellous bone remodels by
o osteoclastic resorption
o osteoblastic deposition of layers of lamellae
5. Fracture Healing
Introduction
Fracture healing involves a complex and sequential set of events to restore injured bone to pre-
fracture condition
o stem cells are crucial to the fracture repair process
the periosteum and endosteum are the two major sources
Fracture stability dictates the type of healing that will occur
o the mechanical stability governs the mechanical strain
o when the strain is below 2%, primary bone healing will occur
o when the strain is between 2% and 10%, secondary bone healing will occur
Modes of bone healing
o primary bone healing (strain is < 2%)
intramembranous healing
occurs via Haversian remodeling
occurs with absolute stability constructs
o secondary bone healing (strain is between 2%-10%)
involves responses in the periosteum and external soft tissues.
enchondral healing
occurs with non-rigid fixation, as fracture braces, external fixation, bridge plating,
intramedullary nailing, etc.
o bone healing may occur as a combination of the above two process depending on the stability
throughout the construct
Inflammation Hematoma forms and provides source of hemopoieitic cells capable of secreting growth factors.
Macrophages, neutrophils and platelets release several cytokines
o this includes PDGF, TNF-Alpha, TGF-Beta, IL-1,6, 10,12
o they may be detected as early as 24 hours post injury
o lack of TNF-Alpha (ie. HIV) results in delay of both enchondral/intramembranous
ossification
Fibroblasts and mesenchymal cells migrate to fracture site and granulation tissue forms around
fracture ends
o during fracture healing granulation tissue tolerates the greatest strain before failure
Osteoblasts and fibroblasts proliferate
o inhibition of COX-2 (ie NSAIDs) causes repression of runx-2/osterix, which are critical for
differentiation of osteoblastic cells
Repair Primary callus forms within two weeks. If the bone ends are not touching, then bridging soft
callus forms.
o the mechanical environment drives differentiation of either osteoblastic (stable enviroment)
or chondryocytic (unstable environment) lineages of cells
Enchondral ossification converts soft callus to hard callus (woven bone). Medullary callus also
supplements the bridging soft callus
o cytokines drive chondocytic differentiation.
o cartilage production provides provisional stabilization
Type II collagen (cartilage) is produced early in fracture healing and then followed by type I
collagen (bone) expression
Amount of callus is inversely proportional to extent of immobilization
o primary cortical healing occurs with rigid immobilization (ie. compression plating)
o enchondral healing with periosteal bridging occurs with closed treatment
Remodeling Begins in middle of repair phase and continues long after clinical union
o chondrocytes undergo terminal differentiation
complex interplay of signaling pathways including, indian hedgehog (Ihh), parathyroid
hormone related peptide (PTHrP), FGF and BMP
these molecules are also involved in terminal differentiation of the appendicular
skeleton
o type X collagen types is expressed by hypertrophic chondrocytes as the extraarticular
matrix undergoes calcification
o proteases degrade the extracellular matrix
o cartilaginous calcification takes place at the junction between the maturing chondrocytes
and newly forming bone
multiple factors are expressed as bone is formed including BMPs, TGF-Betas, IGFs,
osteocalcin, collagen I, V and XI
o subsequently, chondrocytes become apoptotic and VEGF production leads to new vessel
invasion
o newly formed bone (woven bone) is remodeling via organized osteoblastic/osteoclastic
activity
Shaped through
o Wolff's law: bone remodels in response to mechanical stress
o piezoelectic charges : bone remodels is response to electric charges: compression side is
electronegative and stimulates osteoblast formation, tension side is electropostive and
simulates osteoclasts
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Variables that Influence Fracture Healing
Internal variables
o blood supply (most important)
initially the blood flow decreases with vascular disruption
after few hours to days, the blood flow increases
this peaks at 2 weeks and normalizes at 3-5 months
un-reamed nails maintain the endosteal blood supply
reaming compromises of the inner 50-80% of the cortex
looser fitting nails allow more quick reperfusion of the endosteal blood supply versus
canal filling nails
o head injury may increase osteogenic response
o mechanical factors
bony soft tissue attachments
mechanical stability/strain
location of injury
degree of bone loss
pattern (segmental or fractures with butterfly fragments)
increased risk of nonunion likely secondary to compromise of the blood supply to the
intercalary segement
External variables
o Low Intensity Pulsed Ultrasound (LIPUS)
exact mechanism for enhancement of fracture healing is not clear
alteration of protein expression
elevation of vascularity
development of mechanical strain gradient
accelerates fracture healing and increases mechanical strength of callus (including torque and
stiffness)
the beneficial ultrasound signal is 30 mW/cm2 pulsed-wave
healing rates for delayed unions/nonunions has been reported to be close to 80%
o bone stimulators
four main delivery modes of electrical stimulation
direct current
decrease osteoclast activity and increase osteoblast activity by reducing oxygen
concentration and increasing local tissue pH
capacitively coupled electrical fields (alternating current, AC)
affect synthesis of cAMP, collagen and calcification of carilage
pulsed electromagnetic fields
cause calcification of fibrocartilage
combined magnetic fields
they lead to elevated concentrations of TGF-Beta and BMP
o COX-2
promotes fracture healing by causing mesenchymal stem cells to differentiate into osteoblasts
o radiation (high dose)
long term changes within the remodeling systems
cellularity is diminished
Patient factors
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Formation & Healing
o diet
nutritional deficiencies
vitamin D and calcium
as high as 84% of patients with nonunion were found to have metabolic issues
greater than 66% of these patients had vitamin D deficiencies
in a rat fracture model
protein malnourishment decreases fracture callus strength
amino acid supplementation increases muscle protein content and fracture callus
mineralization
gastric bypass patients
calcium absorption is affected because of duodenal bypass with Roux-en-Y procedure
leads to decreased Ca/Vit D levels, hyperparathyroidism (secondary) & increased Ca
resportion from bone
treat these patients with Ca/Vit D supplementation
gastric banding does not lead to these abnormalities because the duodenum is not
bypassed
o diabetes mellitus
affects the repair and remodeling of bone
decreased cellularity of the fracture callus
delayed enchondral ossification
diminished strength of the fracture callus
fracture healing takes 1.6 times longer in diabetic patients versus non-diabetic patients
o nicotine
decreases rate of fracture healing
inhibits growth of new blood vessels as bone is remodeled
increase risk of nonunion (increases risk of pseudoarthrosis in spine fusion by 500%)
decreased strength of fracture callus
smokers can take ~70% longer to heal open tibial shaft fractures versus non-smokers
o HIV
higher prevalence of fragility fractures with associated delayed healing
contributing factors
anti-retroviral medication
poor intraosseous circulation
TNF-Alpha deficiency
poor nutritional intake
o medications affecting healing
bisphosphonates are recognized as a cause of osteoporotic fractures with long term usage
recent studies demonstrated longer healing times for surgically treated wrist fractures in
patients on bisphosphonates
long term usage may be associated with atypical subtrochanteric/femoral shaft fractures
systemic corticosteroids
studies have shown a 6.5% higher rate of intertrochanteric fracture non unions
NSAIDs
prolonged healing time becaue of COX enzyme inhbition
quinolones
toxic to chondrocytes and diminishes fracture repair
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6. Nonunion
Introduction
A nonunion is an arrest in the fracture repair process
o progressive evidence of non healing of a fracture of a bone
o a delayed union is generally defined as a failure to reach bony union by 6 months post-injury
this also includes fractures that are taking longer than expected to heal (ie. distal radial
fractures)
o large segmental defects
should be considered functional non-unions
Pathophysiology
o multifactorial
most commonly, inadequate fracture stabilization and poor blood supply lead to nonunion
infection
eradication needs to occur along with the achieving fracture union
location
scaphoid, distal tibia, base of the 5th metatarsal are at higher risk for nonunion because
blood supply in these areas
pattern
segmental fractures and those with butterfly fragments
increased risk of nonunion like because of compromise of the blood supply to the
intercalary segment
Classification
Types of nonunion
o septic nonunion
o pseudoarthrosis
o hypertrophic nonunion
caused by inadequate immobilization with adequate blood supply
type 2 collagen is elevated
typically heal once mechanical stability is improved
o atrophic nonunion
caused by inadequate immobilization and inadequate blood supply
o oligotrophic nonunion
produced by inadequate reduction with fracture fragment displacement
Presentation
Symptoms
o important to discern injury mechanisms, non operative interventions, baseline metabolic,
nutritional or immunologic statuses and use of NSAIDs and/or nicotine containing products
o assess pain levels with axial loading of involved extremity
Physical exam
o important to complete a thorough neurovascular exam, including the status of the soft tissue
envelope
o assess mobility of the nonunion
o assess extremity for the presence of deformity
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Formation & Healing
Imaging
Radiographs
o plain radiographs are the cornerstone for evaluation of fracture healing; four views should be
included
o full length weight bearing films should obtained if a limb length discrepancy is present
CT
o if the status of union is in question, a CT scan should be obtained; hardware artifact may limit
utility of the CT scan
Treatment
Nonoperative
o fracture brace immobilization
o bone stimulators
contraindications include synovial pseudoarthroses, nonunions
that move and greater than 1 cm between fracture ends
Operative
o infected nonunion
often associated with pseudoarthrosis
chance of fracture healing is low if infection isn't eradicated
staged approach often important
modalities
need to remove all infected/devitalized soft tissue
use antibiotic beads, VAC dressings to manage the wound
with significant bone loss, bone transport may be an option
muscle flaps can be critical in wound management with soft tissue loss
o pseudoarthrosis
may be found in association with infection
joint capsule may be encountered with operative exposure
modalities
removal of atrophic, non-viable bone ends
internal fixation with mechanical stability
maintenance of viable soft tissue envelope
o hypertrophic nonunions
often have biologically viable bone ends
issue with fixation, not the biology
modalities
internal fixation with application of appropriate mechanical stability
o oligotrophic nonunions
often have biologically viable bone ends
may require biological stimulation
modalities
internal fixation
o atrophic nonunions
often have dysvascular bone ends
mobile
modalities
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need to ensure biologically viable bony ends are apposed
fixation needs to be mechanically stable
bone grafting
autologous iliac crest (osteoinductive) is gold standard
BMPs
osteoconductive agents (ie. crushed cancellous chips, DBM)
establishment of healthy soft tissue flap/envelope
Techniques
Bone stimulators
o four main delivery modes of electrical stimulation
direct current
decrease osteoclast activity and increase osteoblast activity by reducing oxygen
concentration and increasing local tissue pH
capacitively coupled electrical fields (alternating current, AC)
affect synthesis of cAMP, collagen and calcification of carilage
pulsed electromagnetic fields
cause calcification of fibrocartilage
combined magnetic fields
o bone simulators work through induction coupling, which stimulates bone growth through the
following direct effects
increasing expression of BMP7
increasing expression of BMP7
increasing expression of BMP2
increasing expression of TGF-beta1
increasing expression of osteoblasts proliferation
increasing expression of BMP2
increasing expression of TGF-beta1
increasing expression of osteoblasts proliferation
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Formation & Healing
Bone Morphogenetic Protein (BMP) & SMADs
Overview
o BMPs belong to the TGF-B superfamily
o BMP 2,4,6, and 7 all exhibit osteoinductive activity
o BMP 3 does not exhibit osteoinductive activity
o Mutations in BMP-4 are associated with Fibrodysplasia ossificans progressiva
Mechanism
o osteoinductive
leads to bone formation
activates mesenchymal cells to transform into osteoblasts and produce bone
Signaling Pathways and Cellular Targets
o BMP targets undifferentiated perivascular mesenchymal cells
o activates a transmembrane serine/threonine kinase receptor that leads to the activation of
intracellular signaling molecules called SMADs
SMADS are primary intracellular signaling mediators
currently eight known SMADs, and the activation of different SMADs within a cell leads to
different cellular responses.
Clinical applications
o FDA-approved uses
rhBMP-2
single-level ALIF from L2 to S1 levels in degenerative disc disease together with the
lumbar tapered fusion device (LT Cage; Medtronic)
open tibial shaft fractures stabilized with an IM nail and treated within 14 days of the
initial injury
rhBMP-7
as an alternative to autograft in recalcitrant long bone nonunions where use of autograft is
unfeasible and alternative treatments have failed
as an alternative to autograft in compromised patients (with osteoporosis, smoking or
diabetes) requiring revision posterolateral/intertransverse lumbar fusion for whom
autologous bone and bone marrow harvest are not feasible or are not expected to promote
fusion
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o contraindications
pregnancy
allergy to bovine type I collagen or recombinant human rhBMP-2
infection
tumor
skeletal immaturity
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Formation & Healing
Fibroblast Growth Factor (FGF)
Overview
o FGF-1 and FGF-2 are most abundant
o promote growth and differentiation of a variety of cells
epithelial cells
myocytes
osteoblasts
chondrocytes
Mechanism
o binds to membrane spanning tyrosine kinase
o associated with angiogenesis and chondrocyte and osteoblast activation
o involved in early stages of fracture healing
8. Bone Grafting
Introduction
A material with either osteoconductive, osteoinductive, and/or osteogenic properties
o autografts
o allografts
o demineralized bone matrix (DBM)
o synthetics
o bone morphogenetic protein (BMP)
o stem cells
Epidemiology
o incidence
almost 1 million bone grafting procedures performed in US each year, with a growth of
almost 13% per year
Indications
o assist in healing of fractures, delayed unions, or nonunions
o assist in arthrodeses and spinal fusions
o replace bone defects from trauma or tumor
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Resorption rates
o relative resorption rates of bone graft substitutes
fastest to slowest
calcium sulfate > tricalcium phosphate > hydroxyapatite
Outcomes
o allograft retrieval
retrieval studies are helpful in understanding the body's response to allografts
5 years after implantation, allograft articular cartilage is completely acellular - no donor or
recipient chondrocytes will be present
Properties
Bone graft has aspects of one or more of these three properties
o osteoconductive
material acts as a structural framework for bone growth
demineralized bone matrices (DBMs)
the various three-dimensional makeups of the material dictate the conductive properties
o osteoinductive
material contains factors that stimulate bone growth and induction of stem cells down a bone-
forming lineage
bone morphogenetic protein (BMP) is most common from the transforming growth factor
beta (TGF-B) superfamily
o osteogenic
material directly provides cells that will produce bone including primitive mesenchymal stem
cells, osteoblasts, and osteocytes
mesenchymal stem cells can potentially differentiate down any cell line
osteoprogenitor cells differentiate to osteoblasts and then osteocytes
cancellous bone has a greater ability than cortical bone to form new bone due to its larger
surface area
autologous bone graft (fresh autograft and bone marrow aspirate) is the only bone graft
material that contains live mensenchymal precursor cells
Antigenicity
Allograft is a composite material and therefore has many potential antigens (cell surface
glycoproteins)
o Class I and Class II antigens on graft are recognized by host T lymphocytes and elicit an immune
response
o immunogenic cells are marrow-based, endothelium, and retinacular-activating cells
bone marrow cells elicit the greatest immune response
extracellular matrix also acts as an antigen
type I collagen stimulates both humoral and cell-mediated responses
noncollagenous matrix (proteoglycans, osteocalcin)
o hydroxyapatite has not been shown to elicit an immune response
primary rejection is cell-mediated related to the major histocompatibility complex (MHC)
incompatibility
Overview
See table next page
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Formation & Healing
Types of Bone Graft
Autograft
Cancellous - Less structural support
- Greater osteoconduction
- Rapid incorporation via creeping substitution
Cortical - Slower incorporation due to need to remodel existing Haversion canals
- Interstitial lamellae preserved
- Provides more structural support
- 25% of massive grafts sustain insufficiency fractures
Vascularized bone - Technically challenging with quicker union and cell preservation
graft - Examples include: free fibula strut graft (peroneal artery), free iliac crest (deep
circumflex iliac arteries), distal radius used for scaphoid fx (1-2 intercompartmental
superretinacular artery branch of radial artery)
Allograft
Fresh
- Highest risk of disease transmission and immunogenicity
- BMP preserved and therefore osteoinductive
Fresh frozen - Less immunogenicity than fresh
- BMP preserved and therefore osteoinductive
Freeze dried - Least immunogenic
(croutons) - Least structural integrity
- BMP depleted (purely osteoconductive)
- Lowest likelihood of viral transmission
Demineralized Bone Matrix
Grafton DBM - Osteoinductive and osteoconductive
- Contains: collagen, bone morphogenetic proteins, transforming growth factor-
beta, residual calcium
- Does NOT contain mesenchymal precursor cells
Synthetics
Silicate based
grafts
Aluminum oxide Alumina ceramic bonds bind to bone in response to stress and strain
Calcium - Osteoconduction and osteointegration
phosphate grafts - Biodegrade very slowly
- Highest compressive strength
- Many prepared as ceramics (heated to fuse into crystals)
- Examples include: tricalcium phosphate, Norian (Synthes), hydroxyapatitie (tradename
Collagraft by Zimmer)
Calcium sulfate - Osteoconductive
- Quick resorption
- Examples include: OsteoSet (Wright medical)
Coralline - Calcium carbonate skeleton is converted to calcium phosphate via a thermoexchange
hydroxyapatine process (Interpore)
Calcium carbonate - Chemically unaltered marine coral
- Osteoconductive
- Examples include: Biocora (Inoteb, france)
Bone Growth Factors
BMP see Rank-L and Bone Growth Factors
TGF-B
IGF-II
PDGF
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OrthoBullets2017 Musculoskeletal biology | Bone Formation & Healing
Autograft
Bone graft transferred from one body site to another in the same patient
Indications
o gold standard
Properties
o osteogenic, osteoinductive, and osteoconductive
o least immunogenic
o cortical, cancellous, or corticocancellous
o vascular or nonvascular
Donor sites
o bone marrow aspirate
source of osteogenic mesenchymal precursor cells
iliac crest and vertebral body most common sites
variable number of cells depending on patient age
o iliac crest is the most common site for autograft
provides both cancellous and cortical graft
higher complication rate with anterior versus posterior harvesting
2% to 36% complication rate
blood loss and hematoma
injury to lateral femoral cutaneous or cluneal nerves
hernia formation
infection
fracture
cosmetic defect
chronic pain
o fibula and ribs are most common sources of vascularized autografts
o tibial metaphysis
Allograft
Bone graft obtained from a cadaver and inserted after processing
Most commonly used bone substitute
Properties
o osteoconductive only due to lack of viable cells
the degree of osteoconduction available depends on the processing method (fresh, frozen, or
freeze-dried) and type of graft (cortical or cancellous)
o cortical, cancellous, corticocancellous, and osteoarticular (tumor surgery)
Osteoarticular allograft
o immunogenic
o preserved with glycerol or dimethyl sulfoxide (DMSO)
o cryogenically preserved (few viable chondrocytes remain)
o tissue-matched (syngeneic) grafts decrease immunogenicity
Processing methods
o debridement of soft tissue, wash with ethanol (remove live cells), gamma irradiation
(sterilization)
dose-dependent higher doses of irradiation kills bacteria and viruses but may impair
biomechanical properties
o fresh allograft
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Formation & Healing
cleansing and processing removes cells and decreases the immune response improving
incorporation
indications
rarely used due to disease transmission and immune response of recipient
o frozen or freeze-dried
reduces immunogenicity while maintaining osteoconductive properties
reduces osteoinductive capabilities
shelf life
one year for fresh frozen stored at -20 degrees C
five years for fresh frozen stored at -70 degrees C
indefinite for freeze-dried
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OrthoBullets2017 Musculoskeletal biology | Bone Formation & Healing
Graft Healing
Vitamin D Physiology
Overview
o Vitamin D and PTH play an important role in calcium homeostasis
skin, liver, parathyroid gland, kidney, bone, and small intestine all play a role
Increased PTH and Vitamin D leads to increase serum calcium levels
Synthesis
o 7-Dehydrocholesterol
precursor to calcitriol is stored in the skin where UV exposure converts it to previtamin D3.
o cholecalciferol (Vitamin D3)
Previtamin D3 is then bound to vitamin-D binding protein (DBP) where it is carried to the
liver and metabolized to 25-hydroxyvitamin D3
o 25-hyrdoxyvitamin D3
when calcium is low, parathyroid hormone (PTH) levels become elevated which activates 1-
alpha-hydroxylase in the kidney
1-alpha-hydroxylase converts 25-hydroxyvitamin D to the active Vitamin D (calcitriol)
laboratory study of choice to determine Vitamin D deficiency
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Bone Formation & Healing
o 1,25-dihydroxyvitamin D3 (Vitamin D, calcitriol)
active form that controls calcium homeostasis in body by targeting intestines and bones (see
function below)
Function
2+
o ↑ serum Ca and phosphate via
↑ absorption of calcium and phosphate from the intestine
2+
↑ bone resorption of Ca and phosphate
2+
o recall PTH functions to ↑ serum Ca but ↓ serum phosphate
Regulation
o PTH stimulates 1,25-(OH)2 vitamin D production
o hypocalcemia/hypophoshatemia stimulates 1,25-(OH)2 vitamin D production
o 1,25-(OH)2 vitamin D feedback negatively on itself
PTH Physiology
Synthesis
o secreted by the chief cells of parathyroid
Function
2+
o ↑ serum Ca and ↓ serum phosphate in response to hypocalcemia/hypomagnesemia via
↑ bone resorption of calcium and phosphate (bone is destroyed)
PTH receptor is on the osteoblasts which secretes IL-1 to activated osteoclasts
↑ kidney resorption of calcium in distal convoluted tubule
↓ kidney resorption of phosphate
↑ 1,25-(OH)2 vitamin D production
Clinical Conditions
Conditions related to PTH
o hypoparathyrodism
o pseudohypoparathyroidism
o renal osteodystrophy
Conditions related to Vitamin D
o Rickets
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OrthoBullets2017 Musculoskeletal biology | Biologic Tissues
C. Biologic Tissues
Gross Anatomy
Myotendinous junction
o weak link in muscle and often site of tears (especially with eccentric contraction)
o involution of muscles cells maximized surface area for attachment
Noncontractile elements
o Epimysium surrounds muscle bundles
o Perimysium surrounds muscle fascicles
o Endomysium surrounds individual fibers
Muscle Contraction
Contractile elements
o derived from myoblasts
o the muscles fiber (an elongated cell) is the basic unit of contraction
o a myofibril is a collection of sarcomeres
Sarcomere composition
o filaments
thick myosin filaments
thin actin filaments
o bands
H band is myosin only
I band is actin only
A band is both actin and myosin
Z line flanks each sarcomere and acts as site of attachment for actin filament
during muscle contraction
A band stays the same length
I band reduces in length
H zone reduces in length
Action stimulation
o nerve cell body delivers electrical signal to motor endplate (junction between muscle and nerve)
nerve action potentials are started with passage of sodium ions through voltage gated
channels
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Biologic Tissues
o Ach is released and diffuses across synaptic cleft to bind to Ach receptor
myasthenia gravis patient has shortage of Ach receptors
botox blocks release of Ach from end plate
o Ach binding triggers depolarization of sarcoplasmic reticulum and release of calcium into
muscles cytoplasm
o excitation-contraction coupling
in low calcium environment
tropomyosin blocks myosin-binding sites on actin
in high calcium environment
calcium binds to troponin (on thin filaments) leading to a configuration change of
tropomyosin (on thin filaments)
exposing myosin-binding sites on actin filament
actin forms cross-bridges to myosin, and the ATP breakdown, the two fibers contract past
one another
Types of muscle contraction
o isometric
muscle contracts with constant length (e.g. pushing against an immovable object)
o isokinetic
muscle contracts with constant speed (requires specific equipment like cybex machines)
o plyometric
rapid lengthening followed by contraction of muscle groups (e.g. jumping up and down on
boxes)
o isotonic - muscle contract with constant tension
concentric
muscle shortens during contraction (e.g. biceps curl)
eccentric
muscle lengthens during contraction (e.g. "negative" of a biceps curl)
Force generation
o force generated is most dependent on muscle cross-sectional area
o muscle fiber size increases with strength conditioning
Contraction speed
o duration and speed of contraction is most dependent on fiber type
Muscle Types
Type I muscle Type II muscle
(slow twich - ST) (fast twitch - FT)
"slow red ox muscles"
Metabolism • aerobic / oxidative • anaerobic / glycolytic
Energy • Aerobic system (oxidative • ATP-CP system
source phosphorolation via Krebs cycle)
Exercise • endurance (distance running) • high strength of contraction
duration • low strength of contraction • high speed of contraction (large force
• low speed of contraction generation per cross sectional area)
• first to atrophy with deconditoning • fatigue rapidly
• sprinting is example
Note • high yield ATP • high yield ATP (increased ATPase)
• requires O2 and thus more vascular • low intramuscular triglycerine stores
• increase mitochondria in cells
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Metabolic Systems
Three systems are used to generate energy for muscles
o ATP-CP anaerobic system
(adenosine triphosphate-creatinine phosphate system, "phosphagen system")
basis for creatine phosphate supplementation (main side effect: muscle cramping)
used for intense metabolic exercise lasting less than 20 seconds (e.g., 100 meter sprint)
converts carbohydrates stored within muscle into energy
anaerobic (does not use oxygen and does not produce lactate)
formulas
ATP –» ADP + P + energy
ADP –» AMP + P + energy
o lactic anaerobic system (lactic acid metabolims)
intense muscle activity lasting 20 to 120 seconds (e.g., 400 meter sprint)
involves hydrolysis of one glucose molecule
formula
glucose –» lactic acid + energy
o aerobic system
used in longer duration and lower intensity exercises
Krebs cycle generates ATP from glucose and fatty acids through oxidative phosphorylation
Muscle Injury
Muscles soreness
o caused by edema and inflammation in the connective tissue
neutrophils are the most abundant cells early on after acute injury
generates free radicals that possibly increase muscle damage
o worse with unaccustomed eccentric exercise
o peaks at 24-48 hours
o elevated CK levels seen in serum
Muscles strain
o occur at myotendinous junction (off during eccentric contraction which produces highest forces
in skeletal muscle)
o pathoanatomy in inflammation followed by fibrosis
Muscle atrophy
o caused by disuse or nerve injury
o leads to fatty infiltration and increased fatigability
o muscles crossing a single joint atrophy faster
o loss of cross-sectional area leads to decreased force generation
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Biologic Tissues
2. Ligaments
Introduction
Ligaments function to
o restrict joint motion
o stabilize joint
o have mechanoreceptors and free nerve endings that help with joint proprioception
Composition
Extracellular components consist of
o water
o Type I collagen (70% of dry weight)
o elastin
higher elastin content than tendons
o lipids
o proteoglycans
o epiligament coat
present in some ligaments, not all
analogous to epitenon of tendons
Cellular component
o the main cell type in both tendons and ligaments is the fibroblast
o both tendons and ligaments have low vascularity and cellularity
Ligaments vs. tendons
o composition
compared to tendons, ligaments have
lower percentage of collagen
higher percentage of proteoglycans and water
less organized collagen fibers
rounder fibroblasts
Bone insertion
Two types of ligament bone insertion
o indirect (fibrous insertion)
most common form of bone insertion
superficial fibers insert into the periosteum
deep fibers insert directly into bone via perforating collagen fibers called Sharpey fibers
at insertion, endotenon becomes continuous with periosteum
examples
MCL inserting into proximal tibia
o direct (fibrocartilaginous insertion)
has both deep and superficial fiber insertion
deep fibers
have four transitional zones of increasing stiffness that allow for force dissipation and
reduce stress concentration
Zone 1 (tendon or ligament proper)
consists of well aligned type I collagen fibers with small amounts of proteoglycan
decorin
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Zone 2 (fibrocartilage)
consists of types II and III collagen, with small amoutns of type I, IX and X
collagen, and proteoglycans aggrecan and decorin
Zone 3 (mineralized fibrocartilage)
consists of type II collagen, with significant amounts of type X collagen and
aggrecan
Zone 4 (bone)
is made up of type I collagen, with high mineral content
examples : supraspinatus insertion
Blood Supply
Origin
o receives blood supply at insertion site (different from tendons)
ACL (and PCL) receives blood supply from middle geniculate artery
o have uniform microvascularity within ligament
Biomechanical Properties
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Biologic Tissues
Ligament vs. tendons
o stress-strain differences between tendons and ligaments
tendons carry higher loads, recruit fibers quickly
smaller toe region
ligaments recruit fibers gradually
elongated toe region
Ligament Failure
Mechanism
o rupture of sequential series of collagen fibers
o ligaments do not plastically deform
Failure site
o usually midsubstance in adults
o usally at bony insertion in children
ligament avulsion
occurs at junction of mineralized and unmineralized fibrocartilage layers
Classification
o ligament injuries are classified into 3 grades
Grade I
corresponds to mild sprain
Grade II
corresponds to moderate sprain/partial tear
Grade III
corresponds to complete tear
Ligament Healing
Phases
o inflammatory phase
occurs at 1-7days
influx of neutrophyils and macrophages
production of type III collagen
growth factors involved
TGF-β1
IGF
PDGF
BMPs -12 and -13
bFGF
o proliferation phase
occurs at 7-21 days
gradually replaced by type I collagen
tendons and ligaments are weakest at day 5-21
o remodeling phase
occurs at >14 days
o maturation phase
up to 18 months
Factors that impair ligament healing
o intra-articular
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OrthoBullets2017 Musculoskeletal biology | Biologic Tissues
extra-articular ligaments (e.g. knee MCL) have a greater capacity to heal compared with
intra-articular ligaments (e.g. knee ACL)
o increasing age
o immobilization
reduces strength of both intact and repaired ligament
o smoking
o NSAIDS
including indocin, celcoxib, parecoxib
o diabetes
o alcohol intake
o decreased growth factors
bFGF, NGF, and IGF-1
o decreased expression of genes involved with tendon and ligament healing
examples include
procollagen I
cartilage oligomeric matrix protein (COMP)
tenascin-C
tenomodulin
scleraxis
Factors that improve ligament healing (experimental)
o extra-articular
extra-articular ligaments (e.g. knee MCL) have a greater capacity to heal compared with
intra-articular ligaments (e.g. knee ACL)
o compromised immune response
CD44 (receptor for lymphocyte activation) knockout mice have faster patellar tendon healing
Interleukin 10 (anti-inflammatory cytokine) improves patellar tendon healing in mice
Interleukin 1 (inflammatory mediator) receptor antagonist inhibits loss of mechanial
properties in patellar tendons in rabbits
depletion of macrophages (source of TGF-β1 that stimulates fibrosis) improves ACL graft
healing in mice (less scar, more fibrocartilage)
o mesenchymal stem cells
improved healing of tendon graft in bone tunnel in rabbits and rats
promote healing of partial tears of digital flexor tendons in horses
insufficient for rat rotator cuff repair (shear stresses too high)
o growth factors
PDGF-BB
increases cellular proliferation and limits adhesions in dog flexor tendon repairs, but
provides no improvement in tensile strength
GCSF
improves tendon incorporation into bone tunnels in ACL reconstruction in dogs
BMP-2 and -12
improves healing in animal rotator cuff models
o scaffolds to help primary ligament healing (instead of reconstruction)
collagen-platelet-rich plasma hydrogel helps primary ACL repair
but still inferior to native ACL strength
o neuropeptides
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Biologic Tissues
denervation degrades tendons and ligaments
calcitonin gene-related peptide improves MCL healing in rabbits
Scarring
o tendons and ligaments heal with scar tissue that
reduces ultimate strength
causes adhesions
3. Tendons
Introduction
Function
o transfer forces from muscle to bone to produce joint motion
o tendons orient themselves along stress
Types
o paratenon covered tendons
e.g., patellar, achilles tendons
have rich vascular supply and thus heal better
often injured due to trauma and most often fail at the
musculotendinous junction
tendon-bone junction
o sheathed tendons
e.g., hand flexor tendons
less vascularized and have avascular areas that receive nutrition by diffusion
often injured due to laceration and at risk for adhesions
Anatomy
Composition
o groups of collagen bundles (fascicles) separated by endotenon and surrounded by epitenon
o composed of
water
tendons primarily composed of water
collagen
Type I collagen makes up 85% of dry weight of tendons
Type III collagen make up 0-5% of dry weight of tendons
proteoglycans
make up 0-5% of dry weight of tendons
decorin
is the most predominant proteoglycan in tendon
regulates collagen fiber diameter (length of 300nm, diameter of 1.5nm)
forms cross-links between collagen fibers and transfers loads between collagen fibers
aggrecan
is proteoglycan found in areas of tendon compression
Structure
o has a highly ordered hierarchical structure
o microfibrils<subfibrils<fibrils<fascicles<tendon unit
o insert into bone via 4 transitional tissues of increasing modulus)
tendon
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type I and III collagen, elastin, proteoglycans, tendon fibroblasts
uncalcified fibrocartilage
aggrecan, types I, II and III collagen, fibrochondrocytes
tidemark - straight, basophilic line separating uncalcified and calcified fibrocartilage, a
mechanical boundary between soft-hard tissue
calcified fibrocartilage (separated from fibrocartilage by tidemark)
type II collagen, aggrecan, types I and X collagen, fibrochondrocytes
irregular boundary, with interlocking of calcified fibrocartilage zone with bone
bone
osteocytes, osteoclasts, osteoblasts, type I collagen, apatite
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Biologic Tissues
Fibrocartilaginous Enthesis (Direct
Fibrous Enthesis (Indirect Attachment)
Attachment)
Attachment Metaphysis and diaphysis of long bones Epiphysis and apophysis
4 distinct zones (tendon, fibrocartilage,
Composition Perforating mineralized collagen fibers
calcified fibrocartilage, and bone)
Insertion angle changes slightly during Insertion angle changes greatly during
Angle of Insertion
motion motion (thus prone to overuse injury)
Deltoid-humerus attachment, adductor
Example magnus-linea aspera attachment, pronator Rotator cuff, Achilles tendon
teres attachment
Material Properties
Characteristics
o tendons contain more collagen and are less viscoelastic than ligaments
o viscoelastic behavior with nonlinear elasticity
the rate at which tendon sees force can influence the mechanical property
o biomechanical effects
exercise has positive effect
immobilization has detrimental effect
age dependent
increase in strength from birth to maturity
decrease in strength after maturity
laser/heat causes tendons to shrink
vary with exposure to hydration, temperature, pH
tendons should be tested under physiologic relevant conditions I:12 Load-elongation or stress-
strain curve
Advantages
o strong in tension (can withstand 5-10% as opposed to 1-4% in bone)
Disadvantages
o buckle in compression
o demonstrate creep and stress relaxation
Load-elongation or stress-strain curve
o toe region
initial nonlinear segment of curve during low loads due to tendons being "crimped"
o linear region
intermediate loads
o failure region : high loads
Tendon Healing
Stages of tendon healing
Stages of Soft Tissue Healing (including tendons)
Hemostasis Platelets initiate coagulation cascade 5-15 minutes
Fibrin clot and fibronectin interaction leading to
chemotaxis to stabilize torn tendon edges
Inflammation Fibroblasts produce type III collagen 1-7 days
macrophages help initiate healing and remodeling
Organogenesis Tissue modeling via large amounts of disorganized 7-21 days
collagen and angiogenesis
Remodeling Tissue remodeling replacing type III collagen to type I up to 18 mos.
collagen
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Tendon Surgical Repair
Strength following repair
o tendon repairs are weakest at 7-10 days
o most of strength by 21-28 days
o maximum strength at 6 months
final strength only reaches 2/3 of normal even years after repair
Early mobilization
o allows earlier ROM but decreased tendon repair strength
o beneficial for flexor tendon healing to prevent adhesion formation
4. Articular Cartilage
Introduction
Articular cartilage is one of five forms of cartilage
o hyaline or articular cartilage
o fibroelastic cartilage (meniscus)
o fibrocartilage (at tendon and ligament insertion into bone)
o elastic cartilage (trachea)
o physeal cartilage (growth plate)
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Biologic Tissues
5. Cartilage
Introduction
Main types of cartilage include
o articular (hyaline) cartilage
o fibrocartilage (tendon/ligament junction with bone) and fibroelastic cartilage (menisci)
o elastic cartilage (trachea)
o epiphyseal cartilage (growth plates)
Cartilage contents (avascular, aneural, and alymphatic)
o cells
chondrocytes
o extracellular matrix
water
collagen
proteoglycans
noncollagenous proteins
Cell differentiation
o cartilage is formed from mesenchymal stem cells designated towards the cartilagenous lineage
multi-step process involving activation and migration of cells to necessary sites
SOX-9 is a key transcription factor involved in the differentiation of cells towards the
cartilage lineage
Metabolism
o regulated through mechanical stimulation
o pH of cartilage is 7.4
disruption in pH can lead to an abnormal cartilage structure
Nutrition
o oxygen and other nutrients supplied to cartilage from synovial fluid diffusion
Loading
o physiologic loading is chondroprotective
o underloading leads to cartilage thinning, tissue softening, and reduced proteoglycan content,
leading to cartilage fibrillation, ulceration and erosion
o overloading leads to cartilage damage (in vitro only)
has not been shown in clinical setting
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Function
o decreases friction and distributes loads
o cartilage exhibits stress-shielding of the solid matrix components due to its high water content,
the incompressibility of water, and the structural organization of the proteoglycan and collagen
molecules
Fibrocartilage
Location
o tendon/ligament junction with bone
o pubic symphysis
o annulus fibrosis of the intervertebral disc
o menisci
Composition
o fibrous cartilage
Type I collagen (predominantly)
extracellular matrix
proteoglycans I:13 Fibrocartilage
chondrocytes
water
o fibroelastic cartilage
fewer proteoglycans and glycoproteins compared to
hyaline cartilage
Function
o healing response to injury of articular cartilage including
chondroplasty microfracture
drilling
abrasion arthroplasty
o compressive strength
I:14 Elastic cartilage
Elastic Cartilage
Location
o auricle of external ear
o epiglottis
o auditory tube
Composition
o chondrocytes surrounded by a thin collagenous network
Type II collagen (predominantly)
elastin fiber network
extracellular matrix
proteoglycans and glycoproteins
chondrocytes
water
Function
o highly elastic
o designed to tolerate repetitive deformation
I:15 Epiphyseal cartilage
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Biologic Tissues
Epiphyseal cartilage
Location
o also known as the epiphyseal plate or epiphyseal ossification center
o between the epiphysis and metaphysis at each end of long bones
Composition
o stacked chondrocytes are divided into different zones of maturation
o proteoglycans and growth factor (e.g.BMP-2) are found in the extracellular matrix between
chondrocytes
o progressive chondrocyte maturation and calcification of the extracellular matirix
o infiltration of osteoprogenitor cells to produce osteoblasts and osteoid
Histology of Epiphyseal cartilage
o Reserve zone
o Proliferative zone
o Hypertrophic zone
o Primary spongiosa
o Secondary spongiosa
Function
o linear growth via endochondral ossification
o can allow extensive bone deformity remodeling potential
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Synovial Fluid
Function
o lubricates articular cartilage and provides nourishment through diffusion
Origin
o made from a ultrafiltrate of blood plasma
regulated by synovium
healthy knee contains ~2mL of synovial fluid
Consists of
o hyaluronin
uridine diphosphoglucose dehydrogenase enzyme critical for its synthesis
o lubricin
a key lubricating glycoprotein
o proteinase
o collagenases
o prostaglandins
Biomechanics
o synovial fluid exhibits non-Newtonian flow characteristics
the viscosity coefficient is not a constant
the fluid is not linearly viscous
viscosity increases as the shear rate decreases
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Biologic Tissues
7. Collagen
Overview
Collagen is a naturally occurring family of proteins
o over 25 types of collagen have been described
Makes up the most abundant type of protein found in humans
o ~25% of the whole-body protein content is composed of some type of collagen
o found in multiple tissues like cartilage, tendon, bone, ligament, skin (see table below)
o multiple different forms of collagen exist, each with different biomechanical properties suited to
the environment in which that form is expressed
Collagen is made of elongated fibrils formed by fibroblast cells
o synthesis of collagen is unique in that it occurs both inside and outside the cell
Biochemisty
Composition
o collagen is composed of a triple helix of
two alpha1 chains
one alpha2 chain
o several common amino acid sequences are found in collagen including
Glycine-X-Hydroxyproline
Glycine-Proline-X
Formation of collagen fibers
o alpha chains
three alpha chains (two alpha1 and one alpha 2) are formed
o procollagen
two alpha1 and one alpha2 combine to form procollagen
o tropocollagen
procollagen is processed by extracellular protein modification into a tropocollagen molecule
after being expressed from the golgi apparatus
o collagen fibril
aldehyde formation on tropocollagen lysine and hydroxylysine allow for covalent bonding
between tropocollagen molecules forming the collagen fibril
o collagen fiber
multiple collagen fibrils aggregate to form a collagen fiber
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Types of Collagen
Type
Location I II III IV V VI VII VIII IX X XI
Bone o
Ligament o
Tendon o
Meniscus o
Disc - Annulus o
Disc - Pulposus o
Cartilage - Articular o o o o
Cartilage - Basement Membrane o
Cartilage - Deep calcified layer o o
Cartilage - Reparative(fibrocartilage) o o
Skin o o
Blood Vessels o
Epithelial Basement Membrane o o
Collagen lattice o
Type I Collagen
o accounts for more than 90% of the total collagen content in the body
o found in
bone
ligament
tendon
meniscus
annulus of intervertebral disks
skin
healed cartilage
scar tissue
nerves
o related clinical conditions
osteogenesis imperfecta
Ehlers-Danlos syndrome
Type II Collagen
o is found
articular (hyaline) cartilage
nucleus pulposus of intervertebral disks
o type II collagen has a very long half life
Type III Collagen
o found in skin and blood vessels
o related clinical conditions
Ehlers-Danlos syndrome
Dupuytren's contracture
Type IV Collagen
o found in basement membranes
o related clinical conditions
renal diseases like Goodpasture's and Alport syndromes
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Molecular Biology
Type V, VI, IX Collagen
o occur in small amounts in articular cartilage
o type IX collagen gene deletion linked to development of OA in women and in knockout mice
o mutations in COL9A1, COL9A2, COL9A3 linked to multiple epiphyseal dysplasia (MED)
however 70% of MED is associated with COMP
fragmented ossific centers
coxa vara hips
genu valgum
shortened, stunted metacarpals
Type VII and VIII Collagen
o basement membrane (epithelial)
Type X Collagen
o is found in the deep calcified layer of cartilage
o produced only by hypertrophic chondrocytes during enchondral ossification (growth plate,
fracture callus, heterotopic ossification)
associated with calcification of cartilage in the deep zone of articular cartilage
o increased in early arthritis
o related clinical conditions
Schmid metaphyseal chondrodysplasia
Type XI Collagen
o an adhesive with the function of holding the collagen lattice together in cartilage
D. Molecular Biology
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Molecular Biology
Genetic Terms
Nucleotides
o thymine, adenine, guanine, and cytosine
Codon
o sequence of three nucleotides
o each codon correlates to one of the 20 amino acids
o linking of the amino acids create a protein
Gene promotor
o regulatory portion of DNA that controls initiation of transcription
Gene enhancers
o site on DNA that transcription factors bind to
o regulate transcription
Transcription
o DNA => mRNA
Translation
o mRNA => protein
Haploid
o Haploid is the amount of DNA in a human egg or sperm cell (half the amount of DNA in a
normal cell)
Cell Cycle
Phases
o G0
represents a "stable" phase
cells are diploid (2N) in the G0 and G1 phases
o G1
initial growth phase
cells are diploid (2N) in the G0 and G1 phases
oS
DNA replication/synthesis phase
cells become tetraploid (4N) at the end of S and
for the entire G2 phases
o G2
gap phase
cells become tetraploid (4N) at the end of S and for the entire G2 phases
oM
mitosis phase
Apoptosis
Defined as programmed cell death
Requires a series of intracellular signaling events
Different from cell lysis - where a cell releases its contents into the surrounding area
One hallmark of cancer is the cell's loss of apoptosis
Research techniques
Agarose gel electrophoresis
o separates DNA based on size
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o DNA is negatively charged
o gel exposed to electric field
o smaller pieces moves through gel faster
Southern blotting
o restriction enzymes cut up DNA
o separate on agarose gel
o identifies DNA sequence
Northern blotting
o restriction enzymes cut up RNA
o separate on agarose gel
o identifies RNA sequence
Western blotting
o SDS-PAGE gel
o identifies protein
DNA ligation
o combining different DNA fragments not found together naturally to create recombinant DNA
Plasmid vector
o an extrachromosomal element, often circular, that can replicate and be transferred independently
of the host chromosome
o one example of the function of a plasmid is antibiotic resistance
o can be introduced into bacteria in the process of transformation
Polymerase chain reaction (PCR)
o DNA => DNA
o a molecular biology tool used to generate many copies of a DNA sequence
o uses "primers" specific to a segment of DNA
o requires temperature-mediated enzyme DNA polymerase
Reverse transcription polymerase chain reaction (RT-PCR)
o RNA => DNA
o variant of polymerase chain reaction (PCR) used in molecular biology to generate many copies
of a DNA sequence from fragments of RNA
o RNA strand is first reverse transcribed into its DNA complement
o amplification of the resulting DNA proceeds using polymerase chain reaction
2. Immunology
Introduction
Types of Immune Responses
o innate response
not specific to a type of immunological challenge
represents the immune response which does not have memory
e.g., anatomic barriers (skin), inflammation, complement cascade
recognizes structures common to multiple microbes
found in nearly all forms of life
cells include
natural killer cells
mast cells
eosinophils
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Molecular Biology
basophils
phagocytic cells (macrophages, neutrophils, and dendritic cells)
o acquired response
portion of immune response which has memory
occurs in a pathogen and antigen specific mechanism
requires antigen processing and presentation
performed by antigen presentation cells (APC)
B cells and dendritic cells are two examples of APCs
the APC breaks down the protein antigen in a multitude of enzymatic reactions and
presents key peptide sequences via the major histocompatibility complex (MHC)
receptors
once presented on the surface of the APC, the T-cell receptor recognizes the
MHC/antigen complex prior to T-cell activation
cells include
CD8+ T lymphocytes
T helper cells
delta gamma T cells
B cells and plasma cells
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Immunologic Variations
Benign Ethnic Neutropenia
o Most common neutropenia in the world
o Approximately 25%-50% of people of African descent and some sub-groups in the Middle East
found to have low ANC without increased infection risk
o ANC < 1.5 x 10(9) cells/L considered "abnormally low" without clear clinical relevance.
4.5% African Americans, 0.79% white Americans, 0.38% Mexican-Americans below this
ANC
o Also more common in males vs females, athlete vs non-athlete, and children under age 5
Pedigree Analysis
A pedigree chart displays a family tree and the members of the family affected by a genetic trait
Use
o a pedigree chart can be used to determine the mode of transmission
o dominance
whether the trait is dominant or recessive
o linkage : whether the trait is X-linked or autosomal
Key
o shapes
circles represent females
squares represent males
o color
a black circle/square represents an individual affected by the genetic trait
a white circle/square represents an individual that is not affected by the trait
o lines
horizontal
a male and female connected by a horizontal line have mated and have children
vertical
vertical lines connect parents to their children
Autosomal Dominant
Description
o only need to get the abnormal gene from one parent in order for you to inherit the disease.
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Molecular Biology
Examples
o Syndactyly
o Polydactyly
o Marfan's syndrome
o Cleidocranial Dysostosis
o Hereditary Multiple Exostosis
o Achondroplasia
o MED |( Multiple Epiphyseal Dysplasia)
o Metaphyseal chondrodysplasia (Schmid and Jansen types)
o Kniest dysplasia
o Malignant hyperthermia
o Ehlers-Danlos syndrome
o Osteogenesis imperfecta (types I and IV)
o Osteochondromatosis/Multiple Hereditary Exostosis
o Osteopetrosis (tarda, mild form)
Autosomal Recessive
Description
o an autosomal recessive disorder means two copies of an abnormal gene must be present in order
for the disease or trait to develop.
Examples
o Diastrophic Dysplasia
o Friedreich's Ataxia
o Gaucher disease
o Spinal muscular atrophy
o Sickle cell anemia
o Osteogenesis imperfecta (II and III)
o Hypophosphatasia
o Osteopetrosis (infantile, malignant form)
Sex-linked Dominant
Examples
o Hypophosphatemic rickets
o Leri-Weill dyschondrosteosis (bilateral Madelung's deformity)
4. Genetic Pearls
Pediatric Dwarfisms
Genetic Pearls of Skeletal Dysplasia
Autosomal Dominant
Achondroplasia FGFR-3 Inhibition of chondrocytes proliferation
Apert Syndrome FGFR-2 Inhibition of chondrocytes proliferation
CMT (80-90%) * PMP22 Nerve demyelination
Pseudoachondroplasia COMP Abnormal cartilage formation
SED congenital ** COL2A1 / Type II collagen Defect in cartilage matrix formation
Kniest's Syndrome Type II collagen Type II collagen
MED - Type I *** COMP Type II collagen
MED - Type II *** Type IX collagen
Jansen's metaphyseal PTHrP Functional defect in parathyroid hormone
chondrodysplasia
Schmid's metaphyseal Type X Collagen Defect in cartilage matrix formation
chondrodysplasia
Cleidocranial dysplasia CBFA-1 Impaired intramembranous ossification
Osteogenesis Imperfecta COL1A1/COL1A2 Type I collagen
(Type I, IV)
Autosomal Recessive
Diastophic dysplasia DTD (Sulfate Transport Protein) Defect in sulfaction of proteoglycan
Friedreich's Ataxia Frataxin
Osteo. Imperfecta COL1A1/COL1A2 Type I collagen
(Type II, III)
McKusick metaphyseal Unknown
X Linked Recessive
SED tarda ** COL2A1 Type II collagen
CMT (10-20%) * connexin gene Nerve demyelination
* CMT = Charcot-Marie-Tooth Disease (peroneal muscular atrophy) See these topics in Pediatrics.
** SED congenita = Spondyloepiphyseal Dysplasia ***MED = Multiple Epiphyseal Dysplasia
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Molecular Biology
Epigenetics
Overview
o epigenetic changes include inheritable genetic alteration (developmental or environmental cues)
that do NOT involve DNA mutation
o DNA methylation, histone modification, nucleosome location, or noncoding RNA are
components of epigenetics
o osteoarthritis is thought to have epigenetic mechanisms that influence the disease process
Translocations
Overview
o translocations allow expression of genes (oncogenes) that are usually not active.
o cytogenetic analysis allows for the detection of gene translocations by evaluating the size and
number of chromosomes isolated from the cell nucleus.
Examples
o present in up to 95% of sarcomas.
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Oncogenes
Definition
o induce uncontrolled growth
o normal function causes leads to uncontrolled cell
Examples
o FAK
focal adhesion kinase)
o Erb-2
epidermal growth factor variant
Tumor Antigens
Definition
o tumor antigens are used in the diagnosis, monitoring of treatment response, and are being
researched for treatment options as anti-cancer vaccines
Examples
o carcinoembryonic antigen (CEA)
colorectal carcinoma
o carbohydrate antigen 19-9 (CA-19-9)
pancreatic cancer
o carbohydrate antigen 125 (CA-125)
ovarian cancer
o cancer antigen 15-3 (CA-15-3)
breast cancer
o alpha fetoprotein (AFP)
can be seen in many cancers, but is most commonly seen in hepatocellular carcinomas
Assays
Western blot
o detects protein
Southern blot
o detects DNA
Northern blot
o detects RNA
Southwestern blot
o detects DNA binding proteins
RT-PCR
o reverse transcription PCR
o highly sensitive, detects low copy number of RNA
o reversed transcribed into complimentary DNA (cDNA)
o may be used together with Northern blot
siRNA
o blocks translation of mRNA
o useful for loss-of-function experiment designs
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Material Science
E. Material Science
1. Material Properties
Introduction
Biomaterials encompasses all synthetic and natural materials used during orthopaedic procedures
Basic definitions
o load : a force that acts on a body
o stress
definition : intensity of an internal force
calculation : force / area
units : Pascal's (Pa) or N/m2
o strain
definition : relative measure of the deformation of an
object
calculation : change in length / original length
units : none
Mechanical property definitions
o elastic deformation
reversible changes in shape to a material due to a load
material returns to original shape when load is removed
o plastic deformation
irreversible changes in shape to a material due to a load
material DOES NOT return to original shape when load is removed
o toughness
definition : amount of energy per volume a material can absorb before failure (fracture)
calculation : area under the stress/strain curve
units : joules per meter cubed, J/m3
o creep : increased load deformation with time under constant load
o load relaxation : decrease in applied stress under conditions of constant strain
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o hysteresis (energy dissipation)
characteristic of viseoelastic materials where the loading curve does not follow the unloading
curve
the difference between the two curves is the energy that is dissipated
o finite element analysis
breaking up a complex shape into triangular or quadrilateral forms and balancing the forces
and moments of each form to match it with its neighbor
Material Strength: Stress vs Strain Curve
Derived from axially loading an object and plotting the stress verses strain curve
Elastic zone
o the zone where a material will return to its original shape
for a given amount of stress
o "toe region" see graph below
applies to a ligaments stress/strain curve
represents straightening of the crimped ligament
fibrils
Yield point
o the transition point between elastic and plastic
deformation
Yield strength
o the amount of stress necessary to produce a specific amount of permanent deformation
Plastic zone
o the zone where a material will not return to its orginal shape for a given amount of stress
Breaking point
o the object fails and breaks
Ultimate (Tensile) strength
o defined as the load to failure
Hooke's law
o when a material is loaded in the elastic zone, the stress is proportional to the strain
Young's modulus of elasticity
o measure of the stiffness (ability to resist deformation) of a material in the elastic zone
o calculated by measuring the slope of the stress/strain curve in the elastic zone
o a higher modulus of elasticity indicates a stiffer material
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Material Science
Young's Modulus of Metals and Biologics
Relative values of Young's modulus of elasticity (numbers correspond to numbers on illustration to
right)
o Ceramic (Al2O3)
o Alloy (Co-Cr-Mo)
o Stainless steel
o Titanium
o Cortical bone
o Matrix polymers
o PMMA
o Polyethylene
o Cancellous bone
o Tendon / ligament
o Cartilage
Material Descriptions
Brittle material
o a material that exhibits linear stress stain relationship up until the point of failure
o undergoes elastic deformation only, and little to no plastic deformation
o examples
PMMA
ceramics
Ductile Material
o undergoes large amount of plastic deformation before
failure
o example
metal
Viscoelastic material
o a material that exhibits a stress-strain relationship that is
dependent on duration of applied load and the rate by
which the load is applied (strain rate)
a function of the internal friction of a material
examples
ligaments
bone
Isotropic materials
o possess the same mechanical properties in all directions
example
golf ball
Anisotropic materials
o possess different mechanical properties depending on the direction of the applied load
o examples
ligaments
bone
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Metal Characteristics
Fatigue failure
o failure at a point below the ultimate tensile strength secondary to repetitive loading
depends on magnitude of stress and number of cycles
Endurance limit
o defined as the maximal stress under which an object is immune to fatigue failure regardless of
the number of cycles
Creep
o phenomenon of progressive deformation of metal in response to a constant force over an
extended period of time
Corrosion
o refers to the chemical dissolving of metal. Types include
galvanic corrosion
dissimilar metals leads to electrochemical destruction
mixing metals 316L stainless steel and cobalt chromium (Co-Cr) has highest risk of
galvanic corrosion
can be reduced by using similar metal
crevice corrosion
occurs in fatigue cracks due to differences in oxygen tension
316L stainless steel most prone to crevice corrosion
fretting corrosion
description
a mode of destruction at the contact site from the relative micromotion of two
materials or two components
clinical significance
common at the head-neck junction in hip arthroplasty
most common cause of mid-stem failure in modular revision type stems
arthroplasty involving modular implants are at risk for fretting corrosion and
failure between the components of the final implant
increased risk with the increased number of interfaces between the various
components
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Material Science
Specific Metals
Titanium
o uses
fracture plates
screws
intramedullary nails
some femoral stems
o advantages
very biocompatable
forms adherent oxide coating through self passivation
corrosion resistant
low modulus of elasticity makes it more similar to biologic materials as cortical bone
o disadvantages
poor resistance to wear (notch sensitivity) (do not use as a femoral head prosthesis)
generates more metal debris than cobalt chrome
Stainless Steel (316L)
o components
primarily iron-carbon alloy with lesser elements of
chromium
molybdenum
manganese
nickel
o advantages
very stiff
fracture resistant
o disadvantages
susceptible to corrosion
stress shielding of bone due to superior stiffness
Cobalt alloy
o components
cobalt
chromium
molybdenum
o advantages
very strong
better resistance to corrosion than stainless steel
Specific Non-Metals
Ultra-high-molecular-weight polyethylene
o advantages
tough
ductile
resilient
resistant to wear
o disadvantages
susceptible to abrasion
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wear usually caused by third body inclusions
thermoplastic (may be altered by extreme temperatures)
weaker than bone in tension
o other
gamma irradiation
increases polymer chain cross-linking which improves wear characteristics
decreases fatigue and fracture resistance
Polymethylmethacrylate (PMMA, bone cement)
o functions
used for fixation and load distribution in conjunction with orthopaedic implants
functions by interlocking with bone
may be used to fill tumor defects and minimize local recurrence
o properties
2 component material
powder
polymer
benzoyl peroxide (initiator)
barium sulfate (radio-opacifier)
coloring agent (green chlorophyll or blue cobalt)
liquid
monomer
DMPT (N,N-Dimethyl para-toluidine, accelerator)
hydroquinone (stabilizer)
o advantages
reaches ultimate strength at 24 hours
strongest in compression
Young's modulus between cortical and cancellous bone
o disadvantages
poor tensile and shear strength
insertion can lead to dangerous drop in blood pressure
failure often caused by microfracture and fragmentation
Silicones
o polymers that are often used for replacement in non-weight bearing joints
o disadvantages
poor strength and wear capability responsible for frequent synovitis
Ceramics
o advantages
best wear characteristics with PE
high compressive strength
o disadvantages
typically brittle, low fracture toughness
high Young's modulus
low tensile strength
poor crack resistance characteristics
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Material Science
Bone
Bone composition
o composed of collagen and hydroxyapatite
o collagen
low Young's modulus
good tensile strength
poor compressive strength
o hydroxyapatite
stiff and brittle
good compressive strength
Mechanical properties
o advantages
strongest in compression
a dynamic structure
remodels geometry to increase inner and outer cortex to alter the moment of inertia and
minimize bending stresses
o disadvantages
weakest in shear
Failure (fracture)
o tension
usually leads to transverse fracture secondary to muscle pull
o compression
due to axial loading
leading to a crush type fracture
bone is strongest in resisting compression
o bending
leads to butterfly fragment
o torsion
leads to spiral fracture
the longer the bone the greater the stresses on the outer cortex under torsion
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2. Structural Properties
Introduction
Charateristics of orthopaedic implants depend
o structural properties (this topic)
o material properties
Structural characteristic differs from strength characteristic
o not only depends on the material, but also the structural
configuation of the object (cylinder, rectangle)
o the stuctural properties can also be demonstrated in a stress
vs. strain curve
Bending Rigidity (stiffness)
Definitions
o defined as the slope of the curve in the elastic range on a structure stress-strain curve
o stress shielding of proximal bone in THA is related to implant stem stiffness
Solid Cylinder
o proportional to the radius to 4th power for a solid cylinder
o cylinder A has great rigidity than cyliner B on illustration above (and thus has greater radius)
Hollow Cylinder
o proportional to the radius to the 3rd power for a hollow cylinder
Rectangular Object
o proportional to the (base x height) to the 3rd power
Deflection
Proportional to: (applied force/elastic modulus)(area moment of inertia)
3. Orthopaedic Implants
Introduction
Characteristics of orthopaedic implants depends on
o material properties
o structural properties
Screws
Definitions
o pitch : distance between threads
o lead : distance advanced with one revolution
o screw working distance (length) Cancellous screw Cortical screw
defined as the length of bone traversed by the screw
o outer diameter
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Material Science
o root (inner) diameter
o bending strength is proportionate to inner (minor) diameter^3
o pullout strength is proportionate to outer (major) diameter^2
maximized by
large outer diameter difference
fine pitch Locking screw
pedicle screw pullout most affected by quality of bone (degree of osteoporosis)
Types of screws
o cortical screws
o cancellous screws
o locking screws
Plate Properties
Overview & definitions
o a load-bearing devic
o e that is most effective when placed on the tension side
o plate working distance
the length between the 2 screws closest to the fracture on each end of the fracture.
decreasing the working distance increases the stiffness of the fixation construct
Structural properties
o bending rigidity proportional to thickness to the 3rd power
o titanium has Young's modulus of elasticity that most closely approximates cortical bone
Biomechanics
o absolute stability
constructs heal with primary (Haversian) healing
must eliminate micromotion with lag screw fixation
must be low strain at fracture site with high fixation stiffness
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o relative stability
constructs heal with enchondral healing
strain rates must be <10%, or fibrous union will predominate
Plate Variations
Concave plates
o placing a concave bend on a plate is useful in transverse fractures to ensure compressive forces
occur on both the far and near cortices of the fracture
Compression plates
o compression plates work by placing a cortical screw eccentrically into an oval hole in the plate
Locking plates
o advantages of locking plates
locked plate/screw constructs compared to non-locked plate/screw constructs result in less
angulation in comminuted metaphyseal fractures
o indications for locking plate technology
indirect fracture reduction
diaphyseal/metaphyseal fractures in osteoporotic bone
bridging severely comminuted fractures
plating of fractures where anatomical constraints prevent plating on
the tension side of the bone (e.g. short segment fixation).
o locking plate screw biomechanics
bicortical locking screws have significantly more resistance to all
applied forces, with resistance to torsion increased the most (versus
unicortical)
unicortical locking screws have less torsion fixation strength than
non-locking bicortical constructs
o percutaneous locking plates
application has less soft-tissue stripping but higher chance malunion
o hybrid locked plates
utilize locking and nonlocking screws in order to assist with fracture
reduction (nonlocking screws) as well as provide a fixed angle
construct (locking screws). I:16 Radiograph: Example
o locking plate construct stability increases with: of compression plating of a
bicortical locking screws midshaft humerus fracture
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Material Science
Illustration: Example of a hybrid AP Radiograph: Example of distal AP and lateral views AP Radiograph: Bending
plate. Locking hole is threaded femoral locking plate. This fixed after plate fixation of rigidity of hollowed femoral
and left empty, while this screw is angle construct was utilized for both bone forearm nail proportional to 3rd
placed in the eccentrically bridging across the fracture site. fractures. Bridge plate power, while torsional
located compression slot hole. fixation of radius was rigidity proportional to 4th
utilized due to amount power.
of comminution
Intramedullary nails
Overview
o a load-sharing device
Structural Properties
o stiffness
torsional rigidity
defined as amount of torque needed to produce torsional (rotational) deformation
proportional to the radius to the 4th power
depends on
shear modulus
polar moment of inertia
increased by reaming
decreased by slotting of nail
bending rigidity
proportional to the radius to the 4th power for a solid nail
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OrthoBullets2017 Musculoskeletal biology | Material Science
Radius of curvature
o intramedullary nail radius of curvature is greater
(straighter) than the radius of curvature of the femur
Interlocking options
o dynamic locking-->axially and rotationally stable fractures
o static locking-->axially and rotationally unstable fractures
o secondary dynamization for nonunion I:17 Larger radius of curvature of nail in
remove proximal interlocking screw or move proximal comparison to femur bone can cause anterior
perforation at anterior distal femur.
interlocking screw from the static to dynamic slot
External fixators
Factors that increase stability of conventional external fixators
o contact of ends of fracture
o larger diameter pins (most important)
o additional pins
o decreased bone to rod distance
o pins in different planes
o increasing size or stacking rods
o rods in different planes
o increased spacing between pins
Factors that increase stability of circular (Ilizarov) external fixators
o larger diameter wires I:18 External Fixator
o decreased ring diameter
o olive wires
o extra wires
o wires cross perpendicular to each other
o increased wire tension
o placement of two central rings close to fracture
o increased number of rings
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Material Science
4. Bioabsorbable Materials
Introduction
Bioabsorbable materials were invented to address issues with synthetic implants including
o migration
o growth disturbance
o rigidity
o radioopacity
o infection
o need for implant removal operations
Indications include but are not limited to
o pediatric orthopaedics
transphyseal SR PLGA 80/20 screws only cause temporary growth arrest in rabbits (unlike
nonbioabsorbable implants)
o osteomyelitis
antibiotic eluting PLA
o carriers for growth factors
rhBMP2 and rhBMP7
o augmentation of bone healing at iliac crest bone harvest site
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OrthoBullets2017 Musculoskeletal biology | Material Science
less crystallic and more rapidly degraded than PLLA alone
example is P(L/D)LA 70/30 in oral-maxillofacial surgery
simple and self-reinforced forms
o PLGA copolymers
combination of PLA and PGA
low crystallinity
used in oral-maxillofacial surgery
simple and self-reinforced forms
Self reinforcing (SR)
o composite structure made from partially crystalline/amorphous material made of orientated
fibers/fibrils and binding matrix
o better biomechanical properties
improved rigidity and strength along longitudinal axis
malleable at room temperature
no need for heating-cooling
can withstand 4 times bending
minimal "memory" (tendency to return to previous shape after bending)
can be sterilized by gamma irradiation
gamma irradiation cannot be used with non-reinforced materials
will reduce its molecular weight and adversely affect the mechanical properties of the
implant
Biodegradation
Primary mechanisms of biodegradation
o poly-hydroxy-acid degradation
breakdown is by random hydrolysis of ester bonds, which leads to
reduction of molecular weight
loss of mechanical properties
final products are CO2, H2O, and products of TCA (tricarboxylic acid, Krebs) cycle
o kidney excretion
PDS and PGA products can be excreted by the kidney
o enzyme breakdown
enzymes are involved with PLA and PGA degradation
o lowered pH
polymer breakage produces products that lower pH
accelerating the breakdown
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Material Science
o material crystallinity
determines hydrophobicity and degradation speed
amorphous and hydrophillic materials degrade faster
more contact with water molecules
crystalline and hydrophobic
materials degrade slower
less contact with water molecules
Additional variable that affect degradation
o chemical composition and molecular weight
o fiber orientation (SR or simple)
o monomer concentration (in polymers)
o stereoisomerism and conformation
o pores and surface area/volume ratio
o pores and surface area/volume ratio
o sterilization method (gamma irradiation vs others)Degradation method (enzymatic vs hydrolysis)
Histopathology
Granulomatous inflammation
o cellular reactions around bioabsorbale implants are characterized by
T lymphocytes (CD4>CD8)
plasma cells
endothelial cells
birefringent polymer debris
thin macrophage layer
multinucleated giant cells
Capsule formation
o a capsule forms around implants that consists of
internal cell layer
2-3 cells thick
type III collagen predominance
external fibrous layer
few spindle shaped cells
type I collagen predominance
Stages
o begins with infiltration of neutrophils
tissue reaction to trauma
o followed by CD4 T lymphocytes infiltration
o macrophages infiltration is last
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symptoms appear late in materials with low degradation rate
e.g. PLLA at 5 years postop
o physical exam
synovitis
discharging sinus
Labs
o fluid cultures are sterile
unless there is secondary bacterial infection after bursting
Radiography
o osteolysis is seen in up to 60% of cases
Treatment
o nonoperative
observation
healing without active treatment
o operative
aspiration and/or surgical debridement
implant removal
indicated if there is sterile implant failure
or if there is secondary bacterial infection
arthrodesis
if there is severe osteoarthritis
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Wheelchair propulsion
o 9% increase in energy expenditure compared to ambulation in normal subjects
Ambulation assistive devices
o cane
o axillary crutch
2 axillary crutches are required for proper gait if lower extremity is non-weightbearing or toe-
touch weightbearing
Patient specific factors need to be considered when identifying the correct prosthesis for a patient
Low demand patients may not require a prosthesis for activities of daily living
Pearls for prosthetic gait abnormalities
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OrthoBullets2017 Musculoskeletal biology | Material Science
wrist disarticulation or long transradial amputation with sufficient pronation,
supination, and elbow flexion and extension
o shoulder units
due to increased energy expenditure and weight of prosthesis many choose to use a purely
cosmetic prosthesis
indications
forequarter or shoulder level amputation
Knee Prosthesis
Knee prostheses provide controlled knee motion
Indications
o transfemoral and knee disarticulation amputations
Technique
o the prosthesis needs to be in line with the weightbearing axis of the patient's knee
o errors in technique
slightly posterior knee center of rotation allows better control of stance phase with more
difficult flexion
slightly anterior knee center of rotation flexion is easier with less control
Socket
o the connection between the stump and the prosthesis
o protects the stump and transmits forces
o preparatory socket may need to be adjusted several time as edema resolves
o patellar tendon-bearing prosthesis is most common
Suspension systems
o attaches prosthesis to residual limb using belts, wedges, straps, and suction
o suction suspension
standard suction
form-fitting rigid or semi-rigid socket which fits onto residual limb
silicon suction
silicon-based sock fits over the stump and is then inserted into the socket
silicon provides an airtight seal between prosthesis and amputated stump
Knee joint
o polycentric (four-bar linkage) knee
indications
transfemoral amputation
knee disarticulations
bilateral amputations
techniques
variable knee center of rotation
controlled flexion
ability to walk at a moderately fast pace
supports increased weight compared to constant friction
I:24 Polycentric knee
knee
o stance-phase control (weight-activated) knee
indications
older patients with proximal amputations
patients walking on uneven terrain
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Material Science
techniques
acts like a constant-friction knee in swing phase
weightbearing through the prosthesis locks up through the high-friction housing
o fluid-control (hydraulic and pneumatic) knee
indications
active patients willing to sacrifice a heavier prosthesis for more utility and variability
techniques
allows for variable cadence via a piston mechanism
prevents excess flexion
extends earlier in the gait cycle
o constant friction (single axis) knee
indications
general use
patients walking on uneven terrain
most common pediatric prosthesis I:25 Constant friction knee
not recommended for older or weaker patients
technique
hinge that uses a screw or rubber pad to apply friction to the knee to decrease knee swing
only allows a single speed of walking
relies on alignment for stance phase stability
o variable-friction (cadence control)
technique
multiple friction pads increase knee flexion resistance as the knee extends
variable walking speeds are allowed
not very durable
o manual locking knee
technique
constant friction knee hinge with an extension lock
extension lock can be unlocked to allow knee to act like a constant-friction knee
Pylon
o simple tube or shell that attaches the socket to the terminal device
o newer styles allow axial rotation and absorb, store, and release energy
o exoskeleton
soft foam contoured to match other limb with hard outer shell
o endoskeleton
internal metal frame with cosmetic soft covering
Terminal device
o Most commonly a foot, but may take other forms
Foot Prosthesis
Single axis foot
o ankle hinge allows dorsiflexion and plantar flexion
o disadvantages
poor durability
I:26 SACH foot
poor cosmesis
SACH (solid ankle cushioned heel) foot
o indications
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OrthoBullets2017 Musculoskeletal biology | Material Science
general use in patients with low activity levels
use is being phased out
o disadvantages
overloads the nonamputated foot
Dynamic response (energy-storing) foot
o indications
general use for most normal activities
patients who regularly ambulate over uneven surfaces likely benefit from multi-axial
articulated protheses
o articulating and non-articulating dynamic-response foot prostheses are available
articulating
allows inversion, eversion, and rotation of the
foot I:27 Dynamic response foot
indications
patients walking on uneven surfaces
advantages
allows inversion, eversion, and foot
rotation
absorbs loads and decreases shear forces
flexible keels
acts as a spring to decrease
contralateral loading, allow dorsiflexion, and provide a spring-like push-off
posterior projection from keel gives a smooth transition from heel-strike
sagittal split allows for inversion and eversion
non-articulating
have short or long keels
shorter keels are not as responsive and are indicated for moderate-activitiy patients
longer keels are indicated for high-demand patients
different feet for running and lower-demand activities available
Prosthetic Complications
General issues
o choke syndrome
caused by obstructed venous outflow due to a socket that is too snug
acute phase
red, indurated skin with orange-peel appearance
chronic phase
hemosiderin deposits and venous stasis ulcers
o skin problems
contact dermatitis
most commonly caused by liner, socks, and suspension mechanism
treatment
remove the offending item with symptomatic treatment
cysts and excess sweating
signs of excess shear forces and improperly fitted components
scar
massage and lubricate the scar for a well-healed incision
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By Dr, AbdulRahman AbdulNasser Musculoskeletal biology | Material Science
o painful residual limb
possible causes include heterotopic ossification, bony prominences, poorly fitting prostheses,
neuroma formation, and insufficient soft tissue coverage
Transtibial prostheses
o swing-phase pistoning
ineffective suspension system
o stance-phase pistoning
poor socket fit
stump volume changes (stump sock may need to be changed)
o foot alignment abnormalities
inset foot
varus strain, circumduction and pain
outset foot
valgus strain, broad-based gait and pain
anterior foot placement
stable increased knee extension with patellar pain
posterior foot placement
unstable increased knee flexion
dorsiflexed foot
increased patellar pressure
plantar-flexed foot
drop-off and increased patellar pressure
o pain or redness related to pressure
o prosthetic foot abnormalities
heel is too soft
leads to excessive knee extension
heel is too hard
leads to excessive knee flexion and lateral rotation of toes
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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OrthoBullets2017 Systemic Disease | Material Science
ORTHO BULLETS
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Metabolic Bone Disease
Prognosis
o prior fragility fracture is the strongest predictor of a future fracture from low energy trauma
o vertebral fractures
associated with 15% increase in 5-year mortality
associated with increased morbidity
back pain
loss of height
poor balance
respiratory compromise
restrictive lung disease
pneumonia
history of 1 vertebral fracture results in 5 fold increased risk of 2nd vertebral fracture and 5
fold increased risk of hip fracture
history of 2 vertebral fractures is the strongest indicated for further compression fractures in
postmenopausal women
o hip fractures
associated with 20% increase in mortality
men have higher mortality rates following hip fractures than women
associated with increased morbidity
reduced quality of life
only one third of patients with hip fractures return to their previous level of function
history of 1 hip fracture results in up to 10 fold increased risk of 2nd hip fracture
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Metabolic Bone Disease
o FRAX score
WHO fracture risk assessment tool that calculates the 10-year risk of hip fracture and 10-year
risk of major osteoporosis-related fracture
factors include age, sex, personal history of fracture, low BMI, oral steroid use, secondary
osteoporosis, parental history of hip fracture, smoking status and alcohol intake.
Classification
Type I (Post menopausal) Type II (Senile)
Post menopausal (highest incidence in 50-70 years
Age group >70 years old
old)
Bone affected Almost exclusively trabecular Trabecular > cortical
Bones fractured Distal radius and vertebral Hip and pelvis
Net negative change in calcium levels because of
Effect on calcium decreased intestinal absorption and increased urinary Poor calcium absorption
excretion of calcium.
Reduced circulating levels of total (but not free) 1,25
Effect on Vit D
dihydroxyvitamin D.
Labs
25 hydroxyvitamin D level
o low 25 hydroxy cholecalciferol levels (25 hydroxy vit D) in patients sustaining low energy
fractures
Imaging
Radiographs
o indications
suspicion of fracture
loss of height
pain in thoracic or lumbar spine
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o recommended views
lateral spine radiograph
AP pelvis or hip
o findings
thinned cortices
loss of trabecular bone
kyphosis
codfish vertebra
o sensitivity and specificity
usually not helpful unless > 30% bone loss
Dexa Scan (Dual Energy Xray Absorptiometry)
o usually performed in
lumbar spine: measures BMD from L2 to L4 and compiles scores
hip: measure BMD from femoral neck, trochanter, and intertrochanter region and compiles
scores
o sensitivity and specificity
most accurate with the least radiation exposure
The blue areas on the graph show the usual bone mass for DEXA Scan: This graph plots Bone Mineral Density
women of different ages. As illustrated, the bone mass is lower (BMD), going up the left edge against age along the
among elderly women. A 70-year-old woman's bone mass is bottom. The blue band across the graph shows the
indicated by a cross in the figure. It is estimated that 95 per cent range of normal BMD across the span of a lifetime. You
of the population belong within the blue areas. Those in the dark can see that bone density is highest between ages 20 to
blue area have a bone mass above average in relation to age, 45, then decreases. The little white square stands for the
while people belonging to the light blue area are below average patient's estimated BMD (1.036) at her current age (55).
in relation to their age. The curve for men is similar but is higher The DEXA scanner puts the box at the lower end of the
placed on the chart and shows a smaller decline with age. In normal blue zone for her age.
this example I believe we are looking at the graph for the Neck
region of the hip only. The dexa scan of her neck shows a BMD
is 0.543 as demonstrated by the cross on the graph. This gives
her a T score of -3.52 for the femoral neck. Based on the fact
that she falls in the blue, I believe her BMD is normal in the
neck. However, the diagnosis of osteoporosis is based on the
Central Dexa Scan, which includes the total hip which includes
the neck, troch, and intertroch region. Her total score is 0.664.
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Metabolic Bone Disease
DEXA Scan Report: The Z Score: This DEXA scan report says that this patient's lumbar spine density compared to women
her age is 0.7 standard deviations below average. The T-Score: This number compares this patient's bone density with a
twenty-year old female and shows that she is 1.4 standard deviations below mean. Impression: The patient is 2.6 times as
likely as other women her age to suffer a compression fracture of a vertebral body.
Term Definition
BMD absolute, patient-specific score determined from certain anatomic areas
T score BMD relative to normal young matched controls (30-year-old women)
Z score BMD relative to similar aged patients
L2-4 lumbar density of 1 to 2.5 standard of deviations (T score -1 to -2.5) below
Osteopenia
the peak bone mass of a 25 year old individual
L2-4 lumbar density > 2.5 standard of deviations (T score <-2.5) below the peak
Osteoporosis
bone mass of a 25 year old individual
Studies
Biopsy
o after tetracycline labeling
o indications
may be helpful to rule out osteomalacia
Histology
o thinned trabeculae
o decreased osteon size
o enlarged haversian and marrow spaces
o osteoclast ruffled border
Increases osteoclast ruffled border seen with
PTH I I:1 Slide demonstrating loss of interconnected trabecular
bone (stained with Masson's trichrome)
1,25 dihydroxy Vit D3
Prostaglandin E
flattened ruffled border seen with
Bisphosphonates
Calcitonin
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OrthoBullets2017 Systemic Disease | Metabolic Bone Disease
Differential
Osteoporosis Osteomalacia
Reduced bone mass, normal
Definition Bone mass variable, reduced mineralization
mineralization
Post menopausal (Type I)
Age Any age
or elderly (Type II)
Vit D deficiency or abnormal vit D pathway,
Endocrine abnormality, age, idiopathic,
Etiology hypophosphatemia, hypophosphatasia, renal
inactivity, alcohol, calcium deficiency
tubular acidosis
Symptoms
Pain and tenderness at fracture site Generalized bone pain and tenderness
and signs
Appendicular fracture predominance, symmetric,
Xray Axial fracture predominance
includes pseudofractures (Looser zones)
Serum Ca Normal Low or normal
Serum PO4 Normal Low or normal
ALP Normal Elevated (except hypophosphatasia)
Urinary Ca High or normal Normal or low (high in hypophosphatasia)
Bone biopsy Tetracycline labeling normal Tetracycline labeling abnormal
Treatment
Nonoperative
o lifestyle modification & vitamins
indications
calcium and Vitamin D
o pharmacologic treatment
indications
2008 National Osteoporosis Foundation Guidelines for Pharmacologic Treatment of
Osteoporosis suggests that pharmacologic treatment be considered for
postmenopausal women and men >= 50yrs old with:
hip/vertebral fracture
T score between -1.0 and -2.5 at the femoral neck/spine and
10-year risk of hip fracture ≥ 3% or
10-year risk of major osteoporosis-related fracture ≥ 20% by FRAX calculation
T score -2.5 or less at the femoral neck/spine.
pharmacologic agents
calcium and Vitamin D
bisphosphonates
Conjugated Estrogen-progestin hormone replacement (HRT)
Estrogen-only replacement (ERT)
Salmon calcitonin (Fortical or Miacalcin)
Raloxifene (Evista)
Teriparatide (Forteo)
Operative
o osteoporotic vertebral compression fracture
o femoral neck fracture
o distal radius fracture
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Metabolic Bone Disease
Pharmacologic Agents
Bisphosphonates
o 1st line therapy
o indications for pharmacologic treatment
hip or vertebral fracture
T-score <2.5 at the femoral neck or spine (after exclusion of secondary causes)
low bone mass (T-score between -1.0 and -2.5) and
10-year probability of a hip fracture ≥ 3% or greater or
10-year probability of a major osteoporosis-related fracture ≥ 20% based on WHO
algorithm
o mechanism
accumulate at sites of bone remodeling and are incorporated into bone matrix
are released into acid environment once bone is resorbed, and are then taken up by
osteoclasts
decrease osteoclastic bone resorption, flattening of osteoclast ruffled border and increased
osteoclast apoptosis
renal excretion without undergoing metabolism
exact mechanism depends on presence of nitrogen on alkyl chain (see table below)
o technique
improved rates of treatment when coordinated by treating orthopedic surgeon and referral to
osteoporosis clinic is made
DEXA scan and referral to endocrinologist
o outcomes
alendronate reduces the rate of hip, spine and wrist fractures by 50%
risedronate reduces vertebral and nonvertebral fractures by 40% (each) over 3 years
IV zolendronic acid reduces the rate of spine fractures by 70% and hip fractures by 40% over
3 years
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Contraindications/
Drug Indications Mechanism Effects Characteristics
Adverse Effects
Calcium reduces
fracture risk by
34%.
daily calcium and
Vit D Vitamin D
supplementation requirements are as
reduces hip follows:
fracture risk by Age 1-3yrs -
10% and 500mg/d
prophylactic in all
nonvertebral Age 4-8yrs -
Calcium & Vit D patients, best for
fracture risk by 800mg/d
Type II (senile)
7%. Age 9-18yrs - 1000
to 1500mg/d
High dose vitamin
Age >50 yrs- 1200
D (median,
to 1500 mg/d calcium
800IU/d) reduces
800-1,000 IUs Vit.
hip fractures by
D
24% and
nonvertebral
fractures by 30%.
Esophagitis,
dysphagia, gastric
T score <-2.5SD,
Non-nitrogen ulcers, osteonecrosis
fragility fracture of Produce toxic ATP etidronate, clodronate,
containing of the jaw (ONJ),
the hip, in both men analog, tiludronate
Bisphosphonates atypical
and women
subtrochanteric
fractures
Alendronate
reduces vertebral
fractures by 48%
and nonvertebral
fractures by 47%.
Risedronate
pamidronate,
Inhibit farnesyl reduces vertebral Esophagitis,
T score <-2.5SD, alendronate
Nitrogen pyrophosphate fractures by 65% dysphagia, gastric
fragility fracture of (Fosamax), risedronate
containing synthase and nonvertebral ulcers, ONJ, atypical
the hip, in both men (Actonel),
bisphosphonates (mevalonate fractures by 39%. subtrochanteric
and women zolendronate (Reclast),
pathway) fractures
ibandronate (Boniva)
Ibrandronate
reduces
vetebralfracture
risk by 77%, hip
fractures by 41%
and nonvertebral
fractures by 15%.
Decreased the risk of
hip fracture, but it also
Conjugated led to small increases
Estrogen-progestin in women with in a woman's risk
hormone Type I (within 6 of breast cancer, CAD
replacement years of menopause) and heart
(HRT) attack, stroke, PE,
DVT, and Alzheimer's
disease
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Metabolic Bone Disease
Contraindications/
Drug Indications Mechanism Effects Characteristics
Adverse Effects
Taking unconjugated
indicated for women estrogen
Estrogen receptors are
Estrogen-only with prior (alone) increases the
present on osteoblasts
replacement (ERT) hysterectomy risk of endometrial
and osteoclasts
hyperplasia / uterine
cancer)
Men with low levels Not yet approved by
Testosterone
of testosterone FDA for osteoporosis
Women >5y
Intranasal - Transient
postmenopause,
Binds membrane rhinitis. Injectable -
Salmon calcitonin decreases pain in Injection or nasal
receptors on nausea, vomiting,
(Fortical or acute vertebral spray (destroyed by
osteoclasts to flushing,
Miacalcin) compression gastric acid)
inhibit resorption hypersensitivity
fractures (acts as
reactions
neurotransmitter)
Selective estrogen
Agonist on estrogen receptor modulator
receptors in bone (SERM), slows bone
(reduce osteoclast resorption and mild Hot flashes, leg
Raloxifene resorption). increase in bone cramps.
Women
(Evista) Antagonizes thickness. Reduces Contraindicated in
estrogen receptor in risk of vertebral patients with VTE
breast, reducing fractures only (not
breast cancer risk. non-vertebral
fractures).
Transient
Receptors on
1-34 amino terminal hypercalcemia,
osteoblasts
residues of parathyroid dizziness, nausea,
(activates
Severe hormone (1-84) ; given headache.
Teriparatide osteoblasts) and
osteoporosis/high by daily subcutaneous
(Forteo) renal tubule cells,
fracture risk injections (continuous Contraindicated in
also stimulates
infusion leads to bone Paget's disease due to
intestinal absorption
resorption) potential
Ca and PO4
osteosarcoma risk
Monoclonal Ig2 Arthralgia,
Reduced vertebral
against RANKL nasopharyngitis,
Postmenopausal fractures by 68%,
Denosumab (inhibits binding of SC injection to arm, back pain.
women at high risk hip fractures by
(Prolia) RANKL to RANK, thigh, abdomen
of fracture 40%, nonvertebral
like Contraindicated in
fractures by 20%.
osteoprotegerin) severe hypocalcemia
Complications
Osteonecrosis of the jaw (ONJ) is associated with IV bisphosphonates (but not oral bisphosphonates)
o incidence : rare
o treatment : stop bisphosphonates
Atypical subtrochanteric transverse stress fractures (in patients on long-term bisphosphonates)
o incidence : rare
o mechanism
extremely low bone turnover rates
shown by reduced markers of bone resorption (e.g. urinary collagen type 1 cross-linked N-
telopeptide, NTx)
o treatment : operative fixation with intramedullary nail and stop bisphosphonates
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2. Renal Osteodystrophy
Introduction
Definition
o a spectrum of disease seen in patients with chronic renal disease.
o characterized by bone mineralization deficiency due to electrolyte and endocrine abnormalities
o common cause of hypocalcemia
Pathophysiology
o hypocalcemia
due to the inability of the damaged kidney to convert vitamin D3 to calcitrol (the active form)
because of phosphate retention (hyperphosphatemia)
o hyperparathyroidism and secondary hyperphosphatemia
caused by hypocalcemia and lack of phosphate excretion by damaged kidney
o uremia related phosphate retention
is a key pathological step
Associated conditions
o orthopaedic manifestations
osteomalacia (adults) and growth retardation (children)
AVN
tendinitis and tendon rupture
carpal tunnel syndrome
deposition of amyloid (β2 microglobulin)
pathologic fracture
from brown tumors (hyperparathyroidism) or amyloid deposits
osteomyelitis and septic arthritis II:2 Pathologic fracture
Classification
High-turnover renal bone disease (high PTH disease)
o chronically elevated phosphate leads to secondary hyperparathyroidism
hyperphosphatemia lowers serum Ca, stimulating PTH
phosphorus impairs renal 1α-hydroxylase, reducing 1,25(OH)2 vitamin D3 production
phosphorus retention directly stimultes PTH production
hyperplasia of chief cells of parathyroid gland
o associated lab values
decreased calcium, increased serum phosphate, increased alkaline phosphate, increased
parathyroid hormone
Low turnover renal bone disease (normal PTH disease)
o characterized by lack of secondary hyperparathyroidism
o normal levels of PTH with characteristic bone lesions marked by low levels of bone formation
o excess deposition of aluminium into bone affects bone mineralization
impairs differentiation of precursors into osteoblasts, and osteoblast proliferation
impairs PTH release from parathyroid gland
disrupts mineralization
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Metabolic Bone Disease
Presentation
Symptom
o weakness
o bone pain
o pathological fracture
commonest complication
o skeletal deformity
o symptoms of hypocalcemia
abdominal pain
muscle cramps
dyspnea
convulsions/seizures
mental status changes
Physical exam
o provocative tests for tetany
Trousseau's Sign
carpalpedal spasm after blood pressure readings
Chvostek's Sign
facial muscle contractions after tapping on the facial nerve
Imaging
Radiographs
o findings
Looser's zones
brown tumor
osteosclerosis
from mineralization of osteomalacic bone
rugger jersey spine
widened growth plate and zone of provisional calcification (children)
varus deformity of the femurs (children)
fracture
soft-tissue calcification
osteopenia
CT
o osseous resorption
Looser zone in the femoral Looser zone in the distal brown tumor
neck of an adult fibula of a child
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Treatment
Nonoperative
o treat underlying renal condition or relieve urologic obstruction
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Metabolic Bone Disease
3. Rickets
Introduction
A defect in mineralization of osteoid matrix caused by inadequate calcium and phosphate
o prior to closure of physis known as rickets
o after physeal closure called osteomalacia
Pathophysiology
o disruption of calcium/phosphate homeostasis
o poor calcification of cartilage matrix of growing long bones
o occurs at zone of provisional calcification
o leads to increased physeal width and cortical thinning and bowing
o Vitamin D and PTH play an important role in calcium homeostasis
Associated conditions
o orthopaedic manifestations include
brittle bones with physeal cupping/widening
bowing of long bones
ligamentous laxity
flattening of skull
enlargement of costal cartilage (rachitic rosary)
kyphosis (cat back)
Classification
Types include
o familial hypophosphatemic (vitamin D-resistant) (see below)
o vitamin D-deficient (Nutritional)
o vitamin D-dependent (type I & type II)
o renal osteodystrophy
o hypophosphatasia
Imaging
Radiographs
o recommended views
AP and lateral of affected bone
o findings
physeal widening
metaphyseal cupping
Looser's zones (pseudofracture on the compression side of bone)
decreased bone density
prominence of rib heads at the osteochondral junction (rachitic rosary)
bowing (often genu varum)
Studies
Laboratory studies
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Histology
o zone of proliferation is disordered and elongated in growthplate
o widened osteoid seams
o swiss cheese trabeculae
o poorly defined zone of provisional calcification
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Metabolic Bone Disease
Physiology
o low Vitamin D levels lead to decreased intestinal absorption of calcium
o low calcium levels leads to a compensatory increase in PTH and bone resorption
o bone resorption leads to increased alkaline phosphatase levels
Clinical findings
o rachitic rosary (enlargement of costochondral junction)
o bowing of knees
o codfish vertebrae
o retarded bone growth (widened osteoid seams, physeal cupping)
o muscle hypotonia
o dental disease
o pathologic fractures
o waddling gate
Laboratory values
o low to normal serum calcium
o low serum phosphate
o elevated alkaline phosphatase
o elevated parathyroid hormone
o low vitamin D
Treatment
o Vitamin D (5000 IU daily)
indications
resolves most deformities
Hereditary Vitamin D-Dependent Rickets (Type I and II) II:4 Codfish vertebrae
Rare disorder
Clinical features similar to Vitamin D-Deficient Rickets but more severe
Clinical characteristics
o Type I
joint pain/deformity, hypotonia, muscle weakness, growth failure, and hypocalcemic seizures
or fractures in early infancy
o Type II
bone pain, muscle weakness, hypotonia, hypocalcemic convulsions, growth retardation,
severe dental caries or teeth hypoplasia
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Pathophysiology
o Type I
caused by defect in renal 25-(OH)-vitamin D1 alpha-hydroxylase
prevents conversion of inactive form of vitamin D to active form
responsible gene 12q14
o Type II
caused by a defect in intracellular receptor for 1,25-(OH)2-vitamin D
Genetics
o type II
autosomal recessive
Laboratory values
o type II is distinguished from type I by markedly elevated levels of 1,25-(OH)2-Vitamin D
Treatment
o physiologic doses (1-2 micrograms/day) of 1,25-(OH)2-Vit D
indications
type I
o daily high dose Vitamin D + elemental calcium
indications
type II
4. Osteomalacia
Introduction
A metabolic bone disease where defective mineralization results in a large amount or unmineralized
osteoid
o qualitative defect as opposed to a quanitative defect like osteoporosis
o rickets and osteomalacia are manifestations of the same pathologic process
Epidemiology
o incidence
rare in the US (approximately 1 in 1000)
much less common than osteoporosis
because of adequate exposure to sunlight and dairy products fortified with vitamin D
o demographics
rickets is found in children (open physis)
osteomalacia is found in adults (closed physis)
o risk factors
the following conditions predispose a patient to osteomalacia
vitamin-D deficient diets
malabsorption e.g. celiac disease
renal osteodystrophy
hypophosphatemia
chronic alcoholism
tumors (tumor-induced osteomalacia)
drugs
drugs associated with vitamin D deficiency
phenytoin
phenobarbital
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Metabolic Bone Disease
rifampin
cholestyramine
cadmium
glucocorticoids
drugs affecting phosphate homeostasis
aluminium-containing phosphate-binding antacid
ifosfamide
drugs affecting bone mineralization
aluminium
etidronate
fluoride
1,25-(OH) Urinary
Serum Ca Serum P Alk phos PTH 25-(OH)vit D
vit D Ca
Osteomalacia low low high high low low low
Osteoporosis normal normal variable normal normal normal normal
Tumor induced
low very low low low low low low
osteomalacia
Osteopetrosis normal normal high normal normal normal normal
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Histology
o requires transiliac biopsy for definitive diagnosis
o Histology
Characteristic histology includes
o technique
requires transiliac biopsy for definitive diagnosis
o findings
widely separated osteoid seams
greater amounts of unmineralized osteoid than normal
o Treatment
Nonoperative
o large doses of oral vitamin D (1000IU/day), treat underlying cause
indications
most patients
o technique
specific subgroups of patients
on long-term anticonvulsant therapy
supplement with 400-800IU/day of vitamin D
with hepatobiliary disease
supplement with 25(OH)-vit D
with renal disease
supplement with 1,25(OH)2 vit D
5. Oncogenic Osteomalacia
Introduction
Definition
o paraneoplastic syndrome of renal phosphate wasting
o caused by bone tumor or soft tissue tumor
Epidemiology
o demographics
age bracket
age of onset is late childhood to early adulthood
Pathophysiology
o the tumor secretes a humoral factor ("phosphatonin") that affects the proximal renal tubules
o reduces calcitriol production in the kidney and inhibits phosphate transport
o leads to increased renal phosphate excretion, hypophosphatemia and osteomalacia
o types of tumors that cause oncologic osteomalacia (known as phosphaturic mesenchymal tumor)
benign tumors (more common)
phosphaturic mesenchymal tumors (mixed connective tissue variant) e.g.
hemangiopericytoma (commonest cause)
osteoblastoma-like tumors
ossifying fibrous tumors
nonossifying fibrous tumors
malignant causes (rare)
osteosarcoma
fibrosarcoma
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Metabolic Bone Disease
Genetics
o mutations
phosphatonin gene is FGF23
Associated conditions
o orthopaedic manifestations
pathological fractures of long bones and vertebrae
Presentation
Symptoms
o generalized bone and muscle pain
o fractures of long bones, ribs and vertebrae
o proximal muscle weakness II:8 Bilateral superior and inferior pubic ramus
Looser's zones (also note right transcervical fracture
o fatigue and diffuse osteopenia)
Imaging
Radiographs
o findings
diffuse osteopenia
Looser's zones (pseudofractures)
Octrotide scans (radiolabeled somatostatin analog)
o gallium-68 DOTA-octreotate PET scan
o indium-111 pentetreotide SPECT/CT
o indications
to identify primary tumors when TIO is suspected
will only identify tumors expressing somatostatin receptors
Studies
25-(OH)vit 1,25- Urinary
Serum Ca Serum P Alk phos PTH
D (OH)vit D Ca
Osteomalacia low low high high low low low
Osteoporosis normal normal variable normal normal normal normal
Tumor induced
low very low low low low low low
osteomalacia
normal
Osteopetrosis normal normal high normal normal normal
Treatment
Nonoperative
o phosphate supplementation with 1,25-dihydroxyvitamin D
Operative
o tumor removal
outcomes
resolution of hypophosphatemia and low vitamin D levels within hours of resection
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B. Joint Diseases
1. Gout
Introduction
A monosodium urate crystal deposition disorder
o primary gout
an idiopathic disorder of nucleic acid metabolism that leads to hyperuricemia and deposition
of monosodium urate crystals in joints (a purine breakdown product)
o secondary gout
is associated with a disease with high metabolic turnover (psoriasis, hemolytic anemia,
leukemia, chemotherapy)
Epidemiology
o demographics
recurrent attacks seen in men from ages 40-60 years
o location
usually seen in lower limb
podagra (arthritis attacks of great toe)
crystal deposition as tophi
ear helix, eyelid olecranon, Achilles tendon
o risk factors
chemotherapy
Pathophysiology
o dysfunctional nucleic acid metabolism causing hyperuricemia
o deposition of monosodium urate crystals in synovium of joint
o crystals lead to an inflammatory response activating
proteases
prostaglandins
leukotriene B4
free oxygen radicals
Associated conditions
o renal stones
o septic arthritis
the presence of uric acid crystals does not exclude septic arthritis
Presentation
Symptoms
o pain in joint
o can resemble septic arthritis
o symptoms of renal stones
Physical exam
o may have decreased range of motion due to pain
o white toothpaste-like appearance of tophus aspirate
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Imaging
Radiographs
o recommended views
AP and lateral of affected joint
o findings
may see punched out periarticular erosion with sclerotic overhanging borders
may see soft tissue crystal deposition (tophi)
Studies
Labs
o serum uric acid
elevated uric acid is not diagnostic (80% of people with an elevated uric acid will never have
a gout attack)
Crystal analysis
o diagnosis made by joint aspiration and crystal analysis
o monosodium urate (MSU) crystals are
thin, tapered, needle-shaped intracellular crystals
yellow when aligned parallel to red compensator
blue when aligned across the direction of polarization
strongly negatively birefringent
Treatment
Acute gout
o indomethacin vs. colchicine
indications
first line of treatment
medications
indomethacin (indocin) 50mg tid
NSAID
inhibits phagocytosis
colchicine
indicated in acute attacks if patient has a history of peptic ulcers
inhibits inflammatory mediators
can be given intravenously
o oral, intraarticular or IV glucocorticoid
indication
patient unable to take NSAID or colchicine
Chronic gout
o allopurinol
indications
first line of treatment for chronic gout attack
medications
allopurinol is an xanthine oxidase inhibitor
o colchicine
indications
for prophylaxis after recurrent attacks
up to 85% effective
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2. Pseudogout (CPPD)
Introduction
A metabolic disease resulting in deposition of calcium pyrophosphate dihydrate (CPPD) crystals
within the joint space
o characterized by recurrent monoarticular arthritis
Epidemiology
o commonly affects the elderly
o rarely affects younger patients, unless occurring in conjunction with other disease
Associated conditions
o hemochromatosis
o hyperparathyroidism
o SLE
o gout
o RA
o Wilson's disease
o hemophilia
o long term hemodialysis can cause a pyrophosphate like deposition disorder
o chondrocalcinosis is present in 7% of patients
Mimics gout except
o affects older patients > 60 years old
o affects more proximal joints
o positively-birefringent crystal
Presentation
Symptoms
o acute, onset joint tenderness
o warm, erythematous joint
o commonly on knee and wrist joints
Physical exam
o erythematous, monoarticular arthritis
o joints tender to palpation
o may observe superficial mineral deposits under the skin at affected joints
Imaging
Radiographs
o may see calcification of fibrocartilage structures
(chondrocalcinosis)
TFCC in wrist
meniscus in the knee
Evaluation
Joint aspiration crystal analysis
o weakly positively birefringent rhomboid-shaped crystals
Treatment
Acute pseudogout
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o nonoperative
NSAIDS
splint
intra-articular steroids
splints for comfort
Chronic pseudogout
o nonoperative
intraarticular yttrium-90 injections
colchicine ( 0.6 mg PO bid for recurrent cases)
prophylactic colchine can help to prevent recurrence
Complications
Can result in permanent damage to the joints and renal disease
3. Hemochromatosis
Introduction
A chronic and often silent disorder that results from inappropriate levels of iron in the blood and
tissue
Epidemiology
o prevalence
1 in 200 people of northern European extraction
o demographics
usually presents in 4th-5th decade of life
women usually present later than men due to the protective effect of iron loss during menses
and pregnancy
o location
multi-system disease
hypogonadism
diabetes
liver cirrhosis
cardiomyopathy
arthritis
may be unilateral or bilateral
may affect one or multiple joints
Pathophysiology
o increased dietary iron absorption and/or increased iron release from cell
o leading to inappropriate levels of iron into organs and tissues
Genetics
o inheritance
autosomal recessive
o mutations
C282Y allele is most common
Prognosis
o produces arthritis and chondrocalcinosis in > 50% of patients
o treatment returns life expectancy to normal if patient non cirrhotic and no diabetic
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Presentation
Symptoms
o classically presents with non-specific symptoms
fatigue
lethargy
joint or muscle pain
o may present with systemic symptoms
impotence
diabetes
skin hyperpigmentation
Examination
o arthropathy
most often in PIPJ, MCPJ of index and middle finger
larger joints may also be affected
highly suspicious with bilateral ankle OA
Imaging
Radiographs
o may identify arthritis of the joints
o chonrocalcinosis presents in >50% of patients
Studies
Labs
o serum ferritin levels
o serum iron levels (>30 µmol/L)
o total iron-binding capacity
o TSH
o lipid profile
Liver Biopsy (gold standard)
o hemosiderin in parenchymal cells
Treatment
Nonoperative
o decrease iron intake
indications
standard of treatment to reduce iron overload
methods
reduced consumption of red meat
avoid raw shellfish
limit supplemental vitamin C
avoid excessive alcohol (secondary liver damage)
o phlebotomy regime
indications
weekly blood letting sessions to reduce serum ferritin levels
contraindications
severe anemia
congestive heart failure
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Joint Diseases
Operative
o total joint arthroplasty
indications
large joint involvement
Orthopaedic Manifestations
Bilateral ankle arthritis
o hemochromatosis should be suspected when symmetrical ankle arthropathy occurs in young men
Classification
Eichenholtz Classification
Stage 0 • Joint edema
• Radiographs are negative
• Bone scan may be positive in all stages
Stage 1 • Joint edema
• Radiographs show osseous fragmentation with joint dislocation
Stage 2 • Decreased local edema
• Radiographs show coalescence of fragments and absorption of fine bone debris
Stage 3 • No local edema
• Radiographs show consolidation and remodeling of fracture fragments
Stage 0 - hot foot, normal Stage 1 - fragmentation, Stage 2 - coalescence, Stage 3 - Remodelling
x-rays; MR shows bone bone resorption, sclerosis, fracture healing,
edema and fractures dislocations, fractures debris resorption
Presentation
Symptoms
o swollen shoulder or elbow
o 50% have pain, 50% are painless
o loss of function
Physical exam
o inspection
swollen, warm, erythematous joint
mimics infection
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o motion
joint may be mechanically unstable
loss of active motion, but passive motion is maintained
o neurovascular
a neurologic evaluation is essential
Imaging
Radiographs
o recommended views
standard views of affected joint
AP and scapula Y of the shoulder
AP and lateral of the elbow II:9 Neuropathic shoulder joint due to
o findings syringomyelia. Characteristic radiographic
findings include obliteration of joint space,
early changes fragmentation of both articular surfaces of a
degenerative changes may mimic osteoarthritis joint leading to subluxation or dislocation.
and surrounding soft tissue edema.
late changes
obliteration of joint space
fragmentation of both articular surfaces of a joint leading
to subluxation or dislocation
scattered "chunks" of bone in fibrous tissue
joint distention by fluid
surrounding soft tissue edema
heterotopic ossification
fracture
MRI
o indications
MRI of cervical spine to rule out syrinx when neuropathic
shoulder arthropathy is present II:10 A sagittal MRI of the
Bone scan cervical spine reveals a syrinx
or fluid-filled cavity within
o technetium bone scan the spinal cord.
findings
may be positive (hot) for neuropathic joints and osteomyelitis
o indium WBC scan
findings
will be negative (cold) for neuropathic joints and positive (hot) for osteomyelitis
useful to differentiate from osteomyelitis
Differential
Osteomyelitis/septic joint
o difficult to distinguish from osteomyelitis based on radiographs and physical exam
common findings in both conditions
swelling, warmth
elevated WBC and ESR
technetium bone scan is "hot"
unique to Charcot joint disease
indium leukocyte scan will be "cold" (negative)
will be "hot" (positive) for osteomyelitis
Treatment
Nonoperative
o rest, elevation, protected immobilization with a sling, and restriction of activity
indications : neuropathic shoulder joint
o functional bracing
indications : neuropathic elbow joint
technique : should allow flexion-extension, but neutralizes varus-valgus stresses
Operative
o arthrodesis
do not attempt during acute inflammatory stage (Eichenholtz 0-2) because of continued bone
erosion
only perform during quiescent stage (Eichenholtz 3)
requires long periods of immobilization
o total joint replacement
indications
Charcot joint is a contraindication to total joint replacement
due to poor bone stock, prosthetic loosening, instability, and soft-tissue compromise
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5. Ochronosis
Introduction
Degenerative arthritis that results from alkaptonuria
Pathophysiology
o excess homogentistic acid is deposited in the joints
o acid polymerizes in joint and leads to early joint arthritis
Genetics
o rare inborn defect in homogentisic acid oxidase enzyme system
Associated conditions
o orthopaedic manifestations
ochronotic spondylitis
commonly occurs in fourth decade
progressive degenerative changes in spine
calcification
narrowing of disc spaces
Presentation
Symptoms
o may complain of black urine
caused by polymerization of homogentistic acid
Imaging
Radiographs
o spine
findings
irregular calcification
narrowing of intervertebral discs
Treatment
Nonoperative
o no current medical treatment available
6. Reiter's
Introduction
A seronegative spondyloarthropathy characterized by:
o urethritis
o conjunctivitis or uveitis
o arthritis
Epidemiology
o incidence
rare
o demographics
occurs most commonly in young man (<40 years of age)
rarely occurs in children, but sometimes appears in adolescents
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o location
arthritis
may be unilateral or bilateral
may affect one or multiple joints
Pathophysiology
o associated infections
mycoplasma
yersinia
salmonella
shigella
chlamydia
campylobacter
Genetics
o may be genetic component making certain individuals more susceptible
Prognosis
o most cases resolve within weeks, but can last up to months
o recurrence occurs in up to half of cases over period of several years
Presentation
Symptoms
o urinary discomfort or pain
usually appears within days or weeks of infection
o inflammation or dryness of the eye
o joint pain
may develop within weeks of initial infection and urinary symptoms
o other non-specific pain symptoms including
heel pain (Achilles tendon pain)
low back pain
Physical exam
o nongonococcal urethritis
o conjunctivitis or uveitis
o arthritis
o skin lesions on palms/soles
may resemble psoriasis
genital skin lesions
o low-grade fever
Imaging
Radiographs : may identify arthritis of the joints
Studies
Diagnosis is based primarily on symptoms and presentation
Labs
o HLA-B27 positive in 75% of cases
o CRP elevated
o ESR elevated
Urinalysis : may identify signs of active infection
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Treatment
Nonoperative
o antibiotics, symptomatic treatment, observation
indications : standard of treatment in most cases
medications
direct antibiotics at underlying infection
azithromycin and doxycycline indicated for Chlamydia
NSAIDs for pain and inflammation
o systemic steroids
indications : severe or recalcitrant cases
Complications
Aortic insufficiency
Arrhythmia
7. Psoriatic Arthritis
Introduction
A seronegative spondyloarthropathy that presents with the following orthopaedic manifestations
o 5 patterns of arthritis
asymmetric oligo/monoarticular arthritis affecting DIPJ, PIPJ, MCPJ
DIP-predominant arthritis
arthritis mutilans
symmetric, RF-negative polyarthritis
psoriatic spondyloarthropathy
Epidemiology
o incidence : affect up to 5-20% of patients with psoriasis
o demographics : equally affects men and women
Genetics
o HLAB27 found in 50%
Presentation
Symptoms
o arthritic symptoms in hands
Physical exam
o rash with silvery plaques over extensor surfaces (elbows, knees)
typically precede joint involvement by several years (80-85% of time)
o hands
dactylitis (sausage digit)
onychodystrophy (nail pitting)
onycholysis (lifting of nail plate starting distally)
arthritis mutilans
opera glass hands (la main en lorgnette)
excess skin from the shortening of the phalanx bones becomes folded transversely, as
if retracted into one another like opera glasses
o chronic uveitis
o entheses such as achilles tendonitis, posterior tibial tendonitis, and plantar fasciitis
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II:11 Rash with silvery plaques II:12 Sausage digit II:13 Nail pitting
Imaging
Radiographs
o hands
distal phalanx acrolysis
DIP arthritis
classic finding is "pencil-in-cup" deformity
simultaneous destruction of the head of the middle
phalanx and expansion of the base of the distal
phalanx
different than DJD by presence of centripetal erosions
which cause joint space widening)
small joint erosions or fusions (PIP, MCP, and wrist
commonly involved)
fluffy periostitis (caused by periosteal ossification)
acroosteolysis (resorption of the distal phalanx tuft)
flail digits
o spine in axial disease
sacroiliitis
syndesmophytes
paravertebral ossification
destructive discovertebral lesions
DIP joint erosion and acrolysis in a patient with psoriatic arthritis pencil-in-cup deformity
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Joint Diseases
Studies
HLAB27 found in 50%
RA and ANA tests are usually negative
Treatment
Nonoperative
o NSAIDS, methotrexate, sulfasalazine, cyclosporine,TNF-alpha inhibitors
indications : mainstay of treatment , similar to RA
Operative
o digit fusion vs resection arthroplasty
indications : advanced joint diseas
8. Hemophilic Arthropathy
Introduction
A condition characterized by repetitive hemarthroses and ultimately joint deformation in patients
with bleeding disorders
Epidemiology
o incidence
has decreased significantly due to home factor treatment
o demographics
young males
affects patients between 3-15 years old
o location
knee is most commonly affected
elbow, ankle, shoulder and spine are also involved
Pathophysiology
o mechanism of injury
persistent minor trauma
o root bleeding disorder may be
hemophilia A
X-linked recessive
decrease factor VIII
hemophilia B - Christmas disease
X-linked recessive
decreased factor IX
von Willebrand's disease
rare cause of joint bleeds
more commonly mucosal bleeding
autosomal dominant
abnormal factor VIII with platelet dysfunction
o pathoanatomy
synovitis -> cartilage destruction (enzyme based) -> joint deformity
Associated conditions
o orthopaedic manifestations
hemarthrosis
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intramuscular hematoma (pseudotumor)
may lead to nerve compression
femoral nerve palsy may be caused by iliacus hematomas
leg length discrepancy
due to epiphyseal overgrowth
fractures
due to generalized osteopenia
normal healing chronology
o medical conditions and comorbidities
HIV
prevalence up to 90% in hemophiliacs
Prognosis
o prognostic variables
degree of factor deficiency
determines severity of disease
mild: 5-25%
moderate: 1-5%
severe: 0-1%
presence of factor VIII inhibitors (including IgG antibodies)
IgG antibody inhibits response of therapeutic factor treatment (monocolonal recombinant
factor VIII)
found in 5-25% of hemophiliac patients
is a relative contraindication for surgical interventions
should be screened for preoperatively
Classification
Arnold-Hilgartner Staging
Stage 1 • Shows swelling of the soft tissues
Stage 2 • Shows osteoporotic changes
Stage 3 • Shows development of subchondral cysts
• Joint is grossly intact
Stage 4 • Shows cartilage loss with narrowing of the joint
Stage 5 • Demonstrates severe arthritis of affected joint
Imaging
Radiographs
o knee
squaring of patella and femoral condyles (Jordan's sign)
ballooning of distal femur
widening of intercondylar notch
joint space narrowing
patella appear long and thin on
lateral
o ankle
joint arthritis
o elbow
joint arthritis
o epiphyseal overgrowth
o generalized osteopenia
o fractures
MRI
o can be used to identify early
degeneratve joint disease II:15 widening of the intercondylar notch I I:14 Coronal MRI of a patient
Ultrasound and ballooning of the distal femur with hemophilic arthropathy of the
ankle. Note the cartilaginous
o often helpful to follow intramuscular destruction of the talus.
hematomas
Studies
Labs
o screening for factor VIII inhibitors (including IgG antibodies)
indicated prior to surgery as presence will negate effects of factor treatment
Histology
o hypertrophy and hyperplastic changes to the synovium
Differential
Septic arthritis : concomitant infection should be ruled out by physical exam and joint aspiration
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Treatment
Nonoperative
o compressive dressings, analgesics, short term immobilization followed by rehabilitation
indications : joint pain
modalities
steroids for to help reduce inflammation
splints and braces
physical therapy to prevent contracture development
o factor administration
indications
vigorous physical therapy
increase factor VIII to 20%
acute hematomas (including intramuscular hematomas)
increase factor VIII to 30%
acute hemarthrosis and soft tissue surgery
increase factor VIII to 40-50%
skeletal surgery
increase factor VIII to 100% for first week following surgery then maintain at > 50%
for second week following surgery
modalities
home transfusion therapy
has reduced the severity of arthropathies
o desmopressin
indications : mild or moderate hemophillia A
Operative
o synovectomy
indications : recurrent hemarthroses recalcitrant to medical management
techniques : increase factor VIII to 40-50%
outcomes
decreases incidence of recurrent hemarthroses
limits pain and swelling
o synoviorthesis
indications : chronic hemophiliac synovitis that is recalcitrant to medical management
technique
destruction of synovial tissue with intra-articular injection of radioactive agent
colloidal phosphorus-32 chromic phosphate
o total joint arthroplasties
indications : end stage arthropathy
perioperative care
increase factor VIII to 100% for first week postoperatively then maintain at > 50% for
second week postoperatively
o arthrodesis
indications : arthropathy of the ankle
perioperative care
increase factor VIII to 100% for first week postoperatively then maintain at > 50% for
second week postoperatively
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Blood Conditions
C. Blood Conditions
Diagnosis Criteria
Major (1)
o hypoxemia (PaO2 < 60)
o CNS depression (changes in mental status)
o petechial rash
o pulmonary edema
Minor (4)
o tachycardia
o pyrexia
o retinal emboli
o fat in urine or sputum
o thrombocytopenia
o decreased HCT
Additional
o PCO2 > 55
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o pH < 7.3
o RR > 35
o dyspnea
o anxiety
Presentation
History
o symptoms usually present within 24 hours of inciting event
Symptoms
o patient complains of feeling "short of breath"
o patient appears confused
Physical exam
o tachycardia
o tachypnea
o petechiae
axillary region
conjunctivae
oral mucosa
Studies
ABG
o hypoxemia (PaO2 < 60 mmHg)
Treatment
Nonoperative
o mechanical ventilation with high levels of PEEP (positive end expiratory pressure)
indications : acute fat emboli syndrome
Prevention
o early fracture stabilization
indications
early fracture stabilization (within 24 hours) of long bone fracture is most important
factor in prevention of FES
techniques to reduce the risk of fat emboli
overreaming of the femoral canal during a TKA
use of reamers with decreased shaft width reduces the risk during femoral reaming for
intramedullary fixation
use of external fixation for definitive fixation of long bone fractures in medically unstable
patients decreases the risk
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Blood Conditions
Risk factors for thromboembolism
o Virchow's triad
venous stasis
hypercoagulable state
intimal injury
o primary hypercoagulopathies (inherited)
MTHFR/C677T/TT gene mutation carries highest risk
factor V Leiden mutation
antithrombin III deficiency
protein C deficiency
protein S deficiency
activated protein C resistance
o secondary factors (acquired)
malignancy
recently been associated with up to 20% of all new diagnoses of VTE
elevated hormone conditions
recombinant erythropoeitin
hormone replacement
oral contraceptive therapy
late pregnancy
elevated antiphospholipid antibody conditions
lupus anticoagulant
anticardiolipin antibody
history of thromboembolism
obesity
aging
CHF
varicose veins
smoking
general anesthetics (vs. epidural and spinal)
immobilization
increased blood viscosity
Pathophysiology
Mechanism of clot formation
o stasis
o fibrin formation
thromboplastin (aka Tissue Factor (TF), platelet tissue factor, factor III, or CD142) is
released during dissection which leads to activation of the extrinsic pathway and fibrin
formation
o clot retraction
o propagation
Prophylaxis
Overview
o prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE) is most important
factor in decreasing morbidity and mortality
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o prophylaxis treatment should be determined by weighing risk of bleeding vs risk of pulmonary
embolus
AAOS risk factors for major bleeding
bleeding disorders
history of a recent gastrointestinal bleed
history of a recent hemorrhagic stroke
AAOS risk factors for pulmonary embolus
hypercoagulable state
previous documented pulmonary embolism
Prophylaxis in hip & knee replacement
o mechanical prophylaxis
compressive stockings recommended
pneumatic compression devices are recommended by the AAOS across all risk (low to high
risk of either bleeding or pulmonary embolism) groups undergoing total hip or total knee
arthroplasty
increase venous return and endothelial-derived fibrinolysis
decrease venous compliance and venous stasis
o medical treatment
see anticoagulation section below
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Blood Conditions
o vena cava filter placement
indications
preoperative identification of DVT in a patient with lower extremity or pelvic trauma who
is high risk for DVT development
see anticoagulation
Pulmonary Embolism
Introduction
o 700,000 asymptomatic PE/yr in USA
of these 200,000 are fatal
o procedures associated with pulmonary embolism
hip fracture
elective total hip arthroplasty
the greatest risk of activation of the clotting cascade during total hip arthroplasty occurs
during insertion of the femoral component
elective total knee arthroplasty
spine fracture with paralysis
o early diagnosis and treatment is most important factor for survival
Presentation
o PE should be suspected in postoperative patients with
acute onset pleuritic pain and dyspnea
tachypnea
tachycardia
Evaluation
o EKG
o ABG
Imaging
o CXR
o nuclear medicine ventilation-perfusion scan (V/Q)
o pulmonary angiography
is gold standard
o helical chest CT
widely considered first line imaging modality
Treatment
o continuous IV heparin infusion followed by warfarin therapy
indications
in most cases as first line treatment
technique
continuous IV heparin infusion typically given for 7-10 days
warfarin therapy typically given for 3 months
monitor heparin therapy with PTT (partial thromboplastin time)
monitor coumadin therapy with INR (international normalized ratio)
o thrombolytics
indications
in specific cases
technique
see anticoagulation
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3. Anticoagulation
Introduction
The coagulation cascade comprises a series of reactions that lead to formation of fibrin, which leads
to platelet activiation and clot formation
o an imbalance of the coagulation cascade can cause thromboembolism and DVT
Virchow's triad describes risk factors for thromboembolism and DVT and includes
o venous stasis
o endothelial damage
o hypercoagulable state
Orthopaedic surgery predisposes high risk of thromboembolism and certain procedures may require
anticoagulation
o there are many choices of anticoagulants, each has advantages and disadvantages
Compression Stocking
Mechanism
o increases fibrinolytic system
o decreases venous stasis
Evidence : literature supports efficacy in TKA
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Blood Conditions
ASA (acetylsalicylic acid)
Introduction
o thromboxane function
under normal conditions thromboxane is responsible for the aggregation of platelets that
form blood clots
o prostaglandins function
prostaglandins are local hormones produced in the body and have diverse effects including
the transmission of pain information to the brain
modulation of the hypothalamic thermostat
inflammation
Mechanism of ASA
o inhibits the production of prostaglandins and thromboxanes through irreversible inactivation of
the cyclooxygenase enzyme
acts as an acetylating agent where an acetyl group is covalently and irreversibly attached to
a serine residue in the active site of the cyclooxygenase enzyme.
this differentiates aspirin different from other NSAIDs which are reversible inhibitors
Metabolism
o renal
Fondaparinux
Overview
o trade name: Arixtra
o has advantage of not requiring lab value monitoring
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Mechanism
o indirect factor Xa inhibitor (acts through antithrombin III)
Metabolism
o renal
Evidence
o studies show decreased incidence of DVT when compared to enoxaparin in hip fx and TKA
patients
Risk
o highest bleeding complications
not to be used in conjunction with epidurals
Warfarin
Mechanism of anticoagulation
o inhibits vitamin K 2,3-epoxide reductase
prevents reduction of vitamin K epoxide back to active vitamin K
o vitamin K is needed for gamma-carboxylation of glutamic acid for factors
II (prothrombin), VII (first affected), IX, X
protein C, protein S
Monitoring
o target level of INR (international normalized ratio) is 2-3 for orthopaedic patients
o not achieved for 3 days after initiation
Reversal
o vitamin K (takes up to 3 days)
o fresh frozen plasma (acts immediately)
Risk
o difficult to dose requires the frequent need for INR lab monitoring
o can have adverse reaction with other drugs including
rifampin
phenobarbital
diuretics
cholestyramine
Rivaroxaban (Xarelto)
Overview
o others in the same class include apixaban (Eliquis) and edoxaban (Savaysa or Lixiana)
o Mechanism of action of these drugs can be deduced from the name.
Rivaro(Identifier)-xa(FactorXa)-ban(inhibitor)
Mechanism
o direct Xa inhibitor
Metabolism
o liver
Antidote
o no current antidote
o andexanet alpha being investigated
Risk
o Bleeding
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Neurologic Diseases
Dabigatran (Pradaxa)
Mechanism
o reversible direct thrombin (factor IIa) inhibitor
Metabolism : renal
Antidote : idarucizumab (FDA approved Oct 2015)
Risk
o GI upset
o bleeding
Herbal Supplements
Increased bleeding
o gingko, ginsing, and garlic have been found to increase the rate of bleeding
o related to effect on platelets
o proper history taking can avoid complications
Increased warfarin effect (increase INR)
o omega-3 fish oil
affects platelet aggregation and vitamin K dependent coagulation factors
Reduced warfarin effect (reduces INR)
o coenzyme Q10
o green tea
direct warfarin antagonist (reduces INR)
o St John's wort
increases catabolism of warfarin (reduces INR)
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OrthoBullets2017 Systemic Disease | Neurologic Diseases
D. Neurologic Diseases
1. Stroke
Introduction
Acute onset of focal neurologic deficits resulting from
o diminished blood flow (ischemic stroke)
o hemorrhage (hemorrhagic stroke)
Epidemiology
o incidence
o risk factors include
diabetes
smoking
atrial fibrillation
cocaine
Pathophysiology
o etiology include
35% - atherosclerosis of the extracranial vessels (carotid atheroma)
30% -cardiac and fat emboli, endocarditis
15% - lacunar
occur in areas supplied by small perforating vessels and result from
atherosclerosis
hypertension
diabetes
10% - parenchymal hemorrhage
10% - subarachnoid hemorrhage
Watershed occurs at areas at border of two arterial supplies
o often follow prolonged hypotension
TIA is charcaterized by transient neurologic deficits for less than 24 hours (usually less than 1 hr.)
Presentation
Edema occurs 2-4 days post-infarct.
Watch for symptoms
o decorticate (cortical lesion): flexion of arms
o decerebrate (midbrain or lower lesion): extension of arms
hemiparesis.
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Neurologic Diseases
Other stroke syndromes
o lateral medullary infarct (Wallenburg syndrome)
loss of pain and temp on ipsilateral face and contralateral body, vestibulocerebellar
impairment, Horner's syndrome
Imaging
CT without contrast
o indicated for acute presentation
o important to diagnose as ischemic or hemorrhagic
MRI
o indicated for subacute
o vascular studies of intra and extracranial vessels
Studies
Labs
o should include coagulation studies
o lumbar puncture to r/o encephalitis
Echo
o to check for mural thrombus, rule out endocarditis
EEG to rule out seizure
Differential
Brain tumor, epi / subdural bleeds, brain abscess, endocarditis, multiple sclerosis, metabolic
(hypoglycemia), neurosyphillis
Treatment
Nonoperative
o thrombolytics
indications : for occlusive disease
modalities
give IV tPA if within 3-4.5 hours
can consider intra-arterial thrombolysis in select patients (major MCA occlusion) up to 6
hours after onset of symptoms
o warfarin/aspirin therapy
indications
for embolic disease and hypercoagulable states give warfarin / aspirin once the
hemorrhagic stroke has been ruled out
o anti-hypertensive medications
Do not overtreat hypertension. Allow BP to rise to 200/100 to maintain perfusion
Operative
o thrombectomy
indications
Within 6 hours in an ischemic stroke with a proximal cerebral arterial occlusion,
compared to alteplase alone, improved reperfusion, early neurological recovery, and
functional outcome.
o endarterectomy
indications
if corotid > 70% occluded
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Prognosis, Prevention, and Complications
Less than 1/3 achieve full recovery
For embolic disease give warfarin / aspirin for prophylaxis
Carotid endarterectomy if stenosis is > 70%. Contraindicated if vessel is 100% occluded.
Manage hypertension
2. Multiple Sclerosis
Introduction
A chronic inflammatory disease that causes demyelination and widespread axonal injury in the
central nervous system, leading to motor and sensory dysfunction
Epidemiology
o incidence
5 per 100,000 people in the US
o demographics
20-40 years old
women>men
northern latitude
o risk factors
genetic
not considered a hereditary disease
environment
stress
smoking
decreased sunlight/low vitamin D exposure
Pathophysiology
o pathophysiology
believed to be caused by a combination of genetic, environmental and infectious factors
recent research suggests a T-cell mediated autoimmune mechanism
Associated conditions
o orthopaedic
increased fracture risk
relating to increased risk of falling and decreased bone mineral density
osteoporosis
relating to physical inactivity, vitamin D deficiency, immunomodulatory medication
gait abnormalities
muscle paralysis causing foot drop, etc
muscle and joint spasticity
Prognosis
o patterns of disease progression
remitting-relapsing (most common)
primary progressive
secondary progressive
progressive relapsing
o life expectancy
5 to 10 years lower than that of unaffected people
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Neurologic Diseases
Presentation
History
o clinically defined by two or more episodes of neurological dysfunction (brain, spinal cord or
optic nerves) that are separated in time and space
Symptoms
o symptoms of disease are based on the systems involved
psych
fatigue, depression, mood disorders
central nervous system
optic neuritis, diplopia, nystagmus
ENT
dysarthria, dysphagia
MSK
weakness, loss of balance and coordination, spasms, ataxia, falls
neuro
parasthesis, hypoesthesia, peculiar sensory phenomena's (e.g. sensation of wetness)
GI
incontinence, diarrhea, constipation
urology
incontinence, frequency, retention
Physical exam
o inspection
assess for gait abnormalities (e.g. wide-based gait, limb ataxia, slapping foot)
joint or muscle contractures
o neurological examination
muscle spasticity
increased deep tendon reflexes
muscle weakness
Babinski positive
o special tests
fundoscopy
MLF syndrome (Internuclear Ophthalmoplegia)
Lhermitte's sign
Evaluation
Laboratory studies
o CBC, lytes, TSH, comprehensive metabolic panel
used to exclude concomitant illnesses
usually normal
o CSF analysis
Mononucleur pleocytosis (25%)
elevated CSF IgG (80%)
oligoclonal bands on electrophoresis
Imaging studies
o MRI
indications : obtain MRI with gadolinium of brain and spinal cord
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findings
multiple focal demyelination scattered in brain and spinal cord
asymmetric periventricular plaques
Differential
Cervical myelopathy, CNS mass lesion, vitamin B12 deficiency, sarcoidosis, CNS infections
Treatment
Nonoperative
o immunomodulators
indications
treatment attempt to return function after an attack, prevent new attacks, and prevent
disability
modalities
corticosteroids
indicated for acute exacerbations
prophylactic immunosuppresants (interferon beta)
may decrease the number and severity of relapses
has been shown to decrease the progression of relapsing remitting multiple sclerosis
o antispasticity agents
indications
increased muscle tone with spasms
modalities
oral agents
baclofen, gabapentin, clonazapem
botox injections
o physiotherapy
indications
improve gait and balance
modalities
gentle stretching exercises for spasticity
progressive resistant-training
o osteoporosis management
Complications
Increased fracture risk
o relating to increased risk of falling and decreased bone mineral density
Osteoporosis
o relating to physical inactivity, vitamin D deficiency, immunomodulatory medication
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Neurologic Diseases
Presentation
Symptoms
o painless weakness in one extremity that extends to the other extremities
o fasciculations
o impaired speech or swallowing
o reduced head control
o breathing difficulty
o muscle cramping
o urinary frequency or incontinence (late findings)
o sensory remains normal
Physical exam
o neck ptosis (neck drop) due to neck extensor weakness
o manual muscle testing elicits muscle cramping
o upper motor neuron (UMN) signs
spasticity
hyperreflexia
(+) Hoffman's
(+) Babinski's
spastic dysarthria
o lower motor neuron (LMN) signs
muscular atrophy
weakness
clinical fasciculations
clumsiness
Evaluation
Diagnosis
o dependent on demonstration of both UMN and LMN involvement
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o combination of UMN and LMN in the same extremity, in the absence of pain or sensory
symptoms, and cranial nerve findings is highly indicative of ALS
o often misdiagnosed as cervical myelopathy or radiculopathy
Laboratory diagnosis
o there are currently no laboratory tests that confirm the diagnosis
EMG / NCS - shows denervation + reinnervation
o widespread decreased amplitude of CMAP and slowed motor conduction velocity
o denervation (fibrillations and positive waves) + decreased recruitment in ≥ 3 extremities
o reinnervation
o abnormal spontaneous fibrillation & fasciculation potentials
o normal sensory studies (SNAP, sensory nerve action potentials)
Differentials
Peripheral compressive neuropathy
o hyperreflexia and other UMN signs (Babinski, Hoffman) are present in ALS (which can present
in a single extremity mimicking cubital/carpal tunnel syndrome), but absent in peripheral
neuropathy
o ALS has normal sensory studies on EMG/NCS
Treatment
Nonoperative
o currently no cure or effective treatment
goals of treatment
provide supportive care
prevent progression
maintain independent patient function and comfort
o riluzole
indications
modest benefits only
prolongs life by 2-3 months
mechanism
blocks tetrodotoxin-sensitive sodium channels associated with damaged neurons
delays onset of ventilator-dependence and may prolong survival
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Neurologic Diseases
Prevention
o vitamin C 500 mg daily x 50 days in distal radius fractures treated conservatively
200mg daily x 50 days if impaired renal function
o vitamin C also has been shown to decrease the incidence of CRPS (type I) following foot and
ankle surgery
o avoid tight dressings and prolonged immobilization
Prognosis
o responds poorly to conservative and surgical treatments
Classification
Presentation
Cardinal signs
o exaggerated pain
o swelling
o stiffness
o skin discoloration
Physical exam
o vasomotor disturbance
o trophic skin changes
o hyperhidrosis
o "flamingo gait" if the knee is involved
Imaging
Radiographs
o patella osteopenia if the knee is involved
Three-phase bone scan
o indications
to rule out CRPS type I (has high negative predictive value)
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o findings
RSD shows positive phase III that does not correlate with positive phase I and phase II
phase background
phase I (2 minutes) : shows an extremity arteriogram
phase II (5-10 minutes) : shows cellulitis and synovial inflammation
phase III (2-3 hours) : shows bone images
phase IV (24 hours) : can differentiate osteomyelitis from adjacent cellulitis
Thermography
o questionable utility
EMG/NCV
o may show slowing in known nerve distribution e.g. slowing of median nerve conduction for
CRPS type II in forearm
Studies
Diagnosis
o diagnosis is clinical, but can be confirmed by pain relief with sympathetic block
o early diagnosis is critical for a successful outcome
Treatment
Nonoperative
o physical therapy and pharmacologic treatment
indications : indicated as first line of treatment
modalities
gentle physiotherapy
tactile discrimination training
graded motor imagery
medications
NSAIDs
alpha blocking agents (phenoxybenzamine)
antidepressants
anticonvulsants
calcium channel blockers
GABA agonists
o nerve stimulation
indications : symptoms present mainly in the distribution of one major peripheral nerve
programmable stimulators placed on affected nerves
o chemical sympathectomy
indications
acts as another option when physical therapy and less aggressive nonoperative
management fails
Operative
o surgical sympathectomy
indications : failed nonoperative management, including chemical block
o surgical decompression
indications : CRPS type II with known nerve involvement e.g. carpal tunnel release if median
nerve involved
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Systemic Diseases
E. Systemic Diseases
1. Rheumatoid Arthritis
Introduction
A chronic systemic autoimmune disease with a genetic predisposition
Epidemiology
o incidence : most common form of inflammatory arthritis
o demographics : affects 3% of women and 1% of men
Pathophysiology
o immunology
cell-mediated (T cell-MHC type II) immune response against soft tissues (early), cartilage
(later), and bone (later)
rheumatoid factor
an IgM antibody against native IgG antibodies
immune complex is then deposited in end tissues like the kidney as part of the
pathophysiology
mononuclear cells
are the primary cellular mediator of tissue destruction in RA
IL-1, TNF-alpha
are part of cascade that leads to joint damage
immune response thought be related to
infectious etiology or
HLA locus
o pathoanatomy
cascade of events includes
antigen-antibody and antibody-antibody reactions >
microvascular proliferation and obstruction >
synovial pannus formation (histology shows prominent intimal hyperplasia) >
joint subluxation, chondrocyte death/joint destruction, and deformity >
tendon tenosynovitis and rupture
Genetics
o associated with specific HLA loci (HLA-DR4 & HLA DW4)
o ~15% rate of concordance amongst monozygotic twins
Associated conditions
o orthopaedic manifestations
see below
o medical conditions & comorbidities
rheumatoid vasculitis
pericarditis
pulmonary disease
Felty's syndrome (RA with splenomegaly and leukopenia)
Still's disease (acute onset RA with fever, rash and splenomegaly)
Sjogren's syndrome (autoimmune condition affecting exocrine glands)
Decreased secretions from salivary and tear duct glands
Lymphoid tissue proliferation
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Prognosis
o significant advances in pharmacologic management have led to a decrease in surgical
intervention
Presentation
Symptoms
o insidious onset of morning stiffness and polyarthropathy
o usually affects hands and feet
DIP joint of hand is usually spared
may also affect knees, cervical spine, elbows, ankle and shoulder
Physical exam
o subcutaneous nodules in 20% (strong association with positive serum RF)
o ulnar deviation with metacarpophalangeal (MCP) subluxation, swan neck deformity
o hallux valgus, claw toes, metatarsophlanageal (MTP) subluxation
o joints become affected at later stage in disease process
Imaging
Radiographs
o periarticular erosions and osteopenia
o protrusio acetabuli
medial migration of femoral head past the radiographic teardrop
Also seen in Marfan's syndrome, Paget's disease, Otto's pelvis and other metabolic bone
conditions
o joint space narrowing
o central glenoid erosion
Studies
Labs
o anti-CCP (cyclic citrullinated peptide, most sensitive and specific test)
o anti-MCV (mutated citrullinated vimentin)
o elevated ESR
o elevated CRP
o positive RF titer (most commonly IgM)
targets the Fc portion of IgG
elevated in 75-80% of patients with RA
o joint fluid testing
decreased complement
may have elevated RF levels
Pharmacologic Management of RA
1st Line:
Low dose steroids
Corticosteroids
2nd Line:
Disease modifying anti-rheumatic drugs (DMARDs)
Methotrexate a folate analogue with anti-inflammatory properties linked to inhibition of
neovascularization
therapeutic effects increased when combined with tetracyclines due to anti-
collagenase properties
Leflunomide an inhibitor of pyrimidine synthesis
Sulfasalazine exact mechanism unknown, but associated with a decrease in ESR and CRP
blocks the activation of toll-like receptors (TLR), which decreases the activity of
Hydroxychloroquine
dendritic cells, thus mitigating the inflammatory process
Others D-penicillamine
3rd Line:
DMARDS / Biologic Agents / TNF antagonists
Etanercept (Enbrel) TNF-alpha receptor fusion protein (TNF type II receptor fused to IgG1: Fc portion)
that binds to TNF-alpha
Infliximab (Remicade)
human mouse chimeric anti-TNF-alpha monoclonal antibody
Adalimumab (Humira) human anti-TNF-alpha monoclonal antibody
Golimumab (Simponi) human anti-TNF-alpha monoclonal antibody
Certolizumab (Cimzia) pegylated human anti-TNF-alpha monoclonal antibody
4th Line:
DMARDS / Biologic Agents / IL-1 antagonists
Anakinra (Kineret) recombinant IL1 receptor antogonist
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Biologic Agents: Other
Rituximab (Rituxan) monoclonal antibody to CD20 antigen (inhibits B cells)
Abatacept (Orencia) selective costimulation modulator that binds to CD80 and CD86 (inhibits T cells)
IL6 receptor inhibitor (2nd line treatment for poor response to TNF-antagonist
Tocilizumab (Actemra)
therapy)
TNF antagonists (etanercept, Continue for minor procedures. Stop etanercept 1wk before for
major procedures. Plan surgery at the end of dosing interval for
infliximab, adalimumab)
adalimumab and infliximab. Restart all 10-14days after.
Continue for minor procedures. Stop 1-2 days before for major
IL-1 antagonist (anakinra)
procedures. Restart 10 days after.
Cervical Spondylitis
Cervical spondylitis includes
o atlantoaxial subluxation
o basilar invagination
o subaxial subluxation
Finger Conditions
Rheumatoid nodules
o epidemiology
most common extra-articular manifestation of RA
seen in 25% of patients with RA and associated with aggressive disease
an extraarticular process found over IP joints, over olecranon, and over ulnar border of the
forearm
o prognosis
erosion through skin may lead to formation of sinus tract
o presentation
patients complain of pain and cosmetic concerns
o treatment
non operative
steroid injection
operative
surgical excision
indications
cosmetic concerns, pain relief, diagnostic biopsy
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Systemic Diseases
Arthritis Mutilans
o seen in patients with RA or psoriatic arthritis
o digits develop gross instability with bone loss (pencil in cup deformity, wind chime fingers)
o treated with interposition bone grafting and fusion
Ulnar drift at MCP joint
o introduction
volar subluxation associated with ulnar drifting of digits
pathoanatomy
joint synovitits >
radial hood sagittal fiber stretching >
concomitant volar plate stretching
extrinsic extensor tendons subluxate ulnarly >
lax collateral ligaments allow ulnar deviation deformity >
ulnar intrinsics contract further worsening the deformity >
wrist radial deviation further worsens >
flexor tendon eventually drifts ulnar
o presentation
extensor lag at level of MCP joint
o treatment
operative
synovectomy, extensor tendon centralization,
and intrinsic release
indications
early disease
MCP arthroplasty
silicone MCP arthroplasty is most common
indications
late disease
thumb MCP involvement + thumb IP involvment
techniques
important to correct wrist deformity at same time if it is radially deviated
synovectomy, volar capsular resection, ulnar collateral ligament release, radial
collateral ligament repair/reconstruction, extensor tendon realignment, intrinsic
tendon release
outcomes
ultimate function is less predictable
overall patient satisfaction of 70%
1 year followup shows improved ulnar drift and extensor lag
complications
infection
implant failure
deformity recurrence
MCP fusion
indications
thumb MCP involvement without IP involvement
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Boutonniere deformity
o pathoanatomy
synovitis of PIP leads to central slip and dorsal capsule attenuation
increasing PIP flexion
lateral bands subluxate volar to axis of rotation of PIP
oblique retinacular ligament contracture causes extension contracture of DIP
o treatment
splinting
for flexible PIP
extensor reconstruction (central slip imbrication or
Fowler distal tenotomy)
for moderate deformity
PIP arthrodesis or arthroplasty
for rigid contractures
Swan neck deformity
o pathoanatomy
terminal tendon rupture from DIP synovitis leads to DIP flexion/PIP hyperextension
FDS, volar plate and collateral ligament attenuation from synovitis leads to decreased volar
support of PIP, and hyperextension deformity
lateral band subluxate dorsal to PIP axis of rotation
contracture of triangular ligament, attenuation of transverse retinacular ligament
o treatment
splinting
for flexible PIP (prevent hyperextension)
FDS tenodesis or proximal Fowler tenotomy
for flexible PIP and failed splinting
dorsal capsule release, lateral band mobilization, collateral ligament and intrinsic
release, extensor tenolysis
for rigid deformities
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Systemic Diseases
Thumb Conditions
Wrist Conditions
Caput-ulna syndrome
o pathoanatomy
synovitis in the DRUJ > ECU subsheath stretching > ECU subluxation > supination of the
carpal bones away from the head of the ulna > volar carpal subluxation > increased pressure
over the extensor compartments > tendon rupture
distinguish from extensor lag caused by PIN compression neuropathy (seen in RA due to
elbow synovitis)
o treatment
Darrach distal ulna resection
must also relocate ECU dorsally with a retinacular flap or perform ECU stabilization of
ulna
ulnar hemiresection
Sauvé-Kapandji (ulnar pseudoarthrosis)
has advantage of preserving the TFCC
good option for younger patients
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Systemic Diseases
Radiocarpal Destruction
o pathoanatomy
synovitis and capsular distension leads to supination, radial deviation (angulation) of carpus
ulnar and volar translocation of the carpus on the radius
with scaphoid flexion, radiolunate widening, lunate translocation (ulnarwards)
secondary radioscaphoid arthrosis
ulnar deviation of the fingers at the MP joints creating the classic zigzag deformity
o treatment
synovectomy
indications
early disease
technique
transfer of ECRL to ECU to diminish deforming forces (Clayton's procedure)
radiolunate fusion (Chamay) or radioscapholunate fusion
indications
intermediate disease with preserved midcarpal joint
wrist fusion
indications
advanced disease, poor bone stock
remains gold standard
often combined with Darrach
total wrist arthroplasty
indications
sedentary patients with good bone stock
advantages over fusion is motion and best in patients with reasonable motion preop
Elbow Conditions
Rheumatoid elbow
o nonoperative
rheumatoid elbow is mainly managed with medical management and cortisone injections
o operative
synovectomy and radial head excision
indications
focus of degeneration is in radiohumeral joint
posterior interosseous nerve compression secondary to radial head synovitis
technique
performed through lateral approach to elbow
interposition arthroplasy
indications
young active patients who are not candidates of TEA
technique
resection and contouring of humeral surface
cover humeral surface with cutis autograft, Achilles tendon, fascia, or dermal allograft
some use distraction external fixator to unload membrane and enhance its bonding to
bone and improve motion
results less predictable than TEA, but avoids prosthetic complications
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total elbow arthoplasty
indications
pain
loss of motion
instability
technique
semiconstrained device has best results
outcomes
reliable procedure for advanced RA of elbow
5 lb single arm weight lifting restriction
Shoulder Conditions
Introduction
o RA is most prevalent form of inflammatory process affecting the shoulder with >90% developing
shoulder symptoms
o commonly associated with rotator cuff tears
Evaluation
o classic radiographic findings include
central glenoid wear
periarticular osteopenia
cysts
Hip Conditions
Protrusio acetabuli
Knee Conditions
Operative II:16 Protrusio acetabuli
o synovectomy of knee
decreases pain and swelling but does not alter prevent radiographic progression and does not
prevent the need for TKA in the future
normal synovium reforms, but degenerates to rheumatoid synovium over time
range of motion is not improved
o total knee arthroplasty
rheumatoid arthritis is considered an indication for resurfacing of the patella during total knee
arthroplasty
Foot & Toe Conditions
Introduction
o usually bilateral and symmetric
o forefoot joints are the first to be affected
o human leukocyte antigen (HLA)-DR4 positive
Toe hyperextension deformity
o the earliest manifestation of rheumatoid arthritis of the forefoot is synovitis of the MTP joints
with eventual hyperextension deformity of the MTP joints including distal migration of the
forefoot pad, painful plantar callosities and skin ulcerations over bony prominences.
o treatment
arthrodesis of the 1st MTP joint and lesser MTP joint resections
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Talonavicular arthritis
o common to have degenerative changes
o treat with fusion
Cervical Conditions
Present in 90% of patients with RA
o diagnosis often missed
Cervical rheumatoid spondylitis includes three main patterns of instability
o atlantoaxial subluxation
most common form of instability
o basilar invagination
o subaxial subluxation
Complications
Postoperative infection
o history of prior surgical site infection (SSI)
is the most significant risk factor for development of another SSI
o immunosuppressive therapy
the literature is controversial whether RA patients on immunosuppressive therapy have
significantly increased infection rates for orthopaedic procedures
pharmacologic therapy may need to be changed prior to surgical interventions
surgery should be performed when immunosuppressive agents are at their lowest levels
etanercept should be discontinued 3 days prior to surgical procedures
adalimumab should be discontinued 10 days prior to surgery
the lowest level of infliximab is found 2 weeks prior to the next scheduled infusion
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Presentation
Symptoms
o fever
o pain in multiple joints : hip pain (osteonecrosis)
Physical exam
o butterfly malar rash
o large joint swelling and synovitis
o hand and wrist manifestation are common (90%)
swelling and synovitis of PIPs, MCPs, and carpus
ligamentous laxity
Raynaud's phenomenon
dorsal subluxation of ulna at DRUJ
Imaging Studies
Radiographs
o usually no evidence of joint destruction
o osteonecrosis of hips is common
Labs
Usually positive for
o ANA (95%)
o anti-DNA antibodies
o HLA-DR3
o few are RF positive
Treatment
Nonoperative
o NSAIDS, methotrexate, sulfasalazine, cyclosporine, antimalarials, DMARDs
treatment is similar to RA
Operative
o digit fusion vs resection arthroplasty for hand
indicated in advanced joint disease
soft tissue procedures have high failure rates
arthrodesis is treatment of choice for PIP or DIP deformities
3. Pustulosis palmoplantaris
Introduction
Crops of sterile pustules that occur on one or both hands and feet, also known as pustular psoriasis
Introduction
o demographics : more common in middle-aged men than in women
rare in children
o risk factors
the majority of patients are smokers (65–90%)
increased stress
infection (i.e acute or chronic tonsillitis)
drugs (i.e.TNF-alpha inhibitors)
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Pathophysiology
o unknown
therories
activated nicotine receptors in the sweat glands cause an inflammatory process
Associated conditions
o orthopaedic conditions
chronic recurrent multifocal osteomyelitis
synovitis–acne–pustulosis–hyperostosis–osteomyelitis (SAPHO) syndrome
rare presentations of arthropathy
o medical conditions & comorbidities
autoimmune diseases
gluten sensitive enteropathy (celiac disease)
thyroid disease
type 1 diabetes
Prognosis
o not contagious
o varies in severity and can persist for many years
o little effect on general health
Presentation
Symptoms
o pruritis, bruning sensation and occasionally pain
o worsend by pressure, rubbing and friction
o may have discomfort walking
o significant psychologic effect
Physical exam
o inspection
1 to 10 mm sterile pustules on palms +/- soles of feet
surrounding erythema and fissures
usually bilateral
o motion
joint pain suggestive of SAPHO
Studies
Labs
o no serological tests are specific for disease
o laboratory tests for bacterial infection are negative
Biopsy and diagnositc injections
o skin biopsy may be helpful but is rarely necessary
Treatment
Non-operative
o general measures
smoking cessation
skin moiturization
avoidance of irritants
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o topical corticosteroids, oral retinoid, photochemotherapy
indications
first-line therapy
outcomes
low-risk for adverse effects with topical corticosteriod therapy
Presentation
Symptoms
o extremely painful joints; usually knees and ankles
Physical exam
o red and tender joints with effusions
F. Metabolic Disease
1. Hypercalcemia
Introduction
Causes of hypercalcemia include
o malignancy
o hypercalcemia in malignancy caused by parathyroid-related hormone protein (PTHrP)
o characterized by:
hypercalcemia, hypophosphatemia, low PTH
examples of malignancies:
Paget's Disease
Multiple Myeloma
Squamous cell cancer of the lung
ectopic production of PTH
Multiple endocrine neoplasia (type I and II)
Pituitary adenoma
o medical conditions
primary hyperparathyroidism
sarcoidosis
Familial hypocalciuric hypercalcemia
hyperthyroidism
Addison's disease
Zollinger-Ellison syndrome
o drugs
thiazide diuretics
o dietary
calcium ingestion (milk-alkali syndrome)
hypervitaminosis D
hypervitaminosis A
Presentation
Symptoms
o CNS
confusion
stupor
weakness
o gastrointestinal
constipation
anorexia
nausea
vomiting
o kidney
polyuria
kidney stones
polydipsia
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Treatment
Hydration
o saline diuresis
Drug therapies
o loop diuretics
o bisphosphonates
o mithramycin
o calcitonin
o galium nitrate
Dialysis (severe)
2. Hypocalcemia
Introduction
Causes of hypocalcemia include
o decreased PTH that can be caused by
hypoparathyrodism
pseudohypoparathyroidism
renal osteodystrophy
o decreased vitamin D3
Presentation
Symptom
o symptoms of hypocalcemia
paresthesia
fingertip, toes, perioral
abdominal pain, biliary colic
muscle cramps, tetany
dyspnea (laryngospasm, bronchospasm)
convulsions
mental status changes
anxiety, fatigue, mood swings
Physical exam
o findings of tetany
Trousseau's Sign
carpopedal spasm after blood pressure readings
inflate BP cuff 20mmHg above systolic BP x 3-5min
hand adopts a MCP flexed, DIP and PIP extended position
more sensitive than Chvostek's sign
Chvostek's Sign
facial muscle contractions after tapping on the facial nerve
o dermatologic
fungal nail infections
hair loss
blotchy skin
pigment loss, vitiligo
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Radiographs
Basal ganglia calcification
o comprises striatum, globus pallidus, substantia nigra, subthalamic nucleus
Evaluation
Serum calcium, phosphate, vit D, PTH
Serum albumin
o low serum albumin (low protein) leads to low total calcium
but ionized calcium levels will be normal
pH
o alkalosis increases albumin binding to ionized calcium
leads to hypocalcemia
EKG
o prolonged QT interval
Serum Serum
PTH Common Cause
Ca Phos
Hyperparathyroidism ↑ ↓ ↑ adenoma
Hypoparathyroidism ↓ ↑ ↓ parathyroidectomy
Ectopic PTH ↑ ↓ ↓ malignancy
celiac disease, other GI
Vit D malabsorption ↓ ↓ ↑
isease
Hypo vit D with no phosphate excretion renal failure, pseudo
↓ ↑ ↑
from the kidney. hypoparathyroidism
Treatment
Nonoperative
o calcium gluconate infusion
with cardiac monitoring to prevent hypercalcemia)
o activated vitamin D (calcitriol)
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3. Hypoparathyroidism
Introduction
Decreased production of parathyroid hormone (PTH) by chief cells of the parathyroid gland
resulting in
o decreased plasma calcium levels
o increased plasma phosphate levels
o decreased 1,25(OH)2 Vitamin D levels
Etiology
o Iatrogenic : thyroidectomy most common cause
Pathophysiology
o decreased PTH levels cause
decreased urinary excretion of phosphate at kidneys
serum phosphate levels increase
decreased conversion of inactive form of vitamin D to active form
1,25(OH)2-vitamin levels decrease
Prognosis
o no current hormone replacement therapy available
o treatment is aimed at supplementing vitamin D and calcium levels
Presentation
Symptoms
o hypocalcemia
more common in hypoparathyroidism
neuromuscular irritability
Chvostek's sign
seizures
tetany
cataracts
fungal infections of the nail
hair loss
skin changes
vitiligo
blotchiness of skin
Imaging
Radiographs
o skull
basal ganglia calcification
Evaluation
Labs
o decreased
PTH
calcium
1,25-Vit D
urinary calcium
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o increased
serum phosphate
o normal
alkaline phosphatase
pH
o alkalosis increases albumin binding to ionized calcium
leads to hypocalcemia
EKG
o prolonged QT interval
Serum Serum
PTH Common Cause
Ca Phos
Hyperparathyroidism ↑ ↓ ↑ adenoma
thyroidectomy (including
Hypoparathyroidism ↓ ↑ ↓
parathyroid)
Ectopic PTH ↑ ↓ ↓ malignancy
Vit D malabsorption ↓ ↓ ↑ celiac disease, other GI disease
hypo vit D with no phosphate excretion from renal failure, pseudo
↓ ↑ ↑
the kidney hypoparathyroidism
Treatment
Nonoperative
o calcium and vitamin D supplementation
indications
decreased serum calcium level
decreased levels of vitamin D
outcomes
must monitor labs on a regular basis
4. Hyperparathyroidism
Introduction
Increased parathyroid hormone (PTH) production that may be of primary, secondary or tertiary
causes
Epidemiology
o incidence
occurs in 0.1% of the population
90% result form a single adenoma
remaining 10% from parathyroid hyperplasia
o demographics
more common in women
hyperparathyroidism and maligncacy make up the majority of patients with hypercalcemia
Pathophysiology
o PTH indirectly stimulates osteoclasts by binding to its receptor on osteoblasts, inducing RANK-
L and M-CSF synthesis
o Excessive PTH leads to over-stimulation of bone resorption
cortical bone affected more than cancellous
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Associated conditions
o Brown tumor
Resembles a giant cell tumor of bone relating to focal demineralization of bone in the setting
of hyperparathyroidism.
Classification
Primary
o typically the result of hypersecretion of PTH by a parathyroid adenoma/hyperplasia
o may result in osteitis fibrosa cystica
breakdown of bone, predominently subperiosteal bone
commonly involves the jaw
Secondary
o secondary parathyroid hyperplasia as compensation from hypocalcemia or hyperphosphatemia
2+
↓ gut Ca absorption
↑ phosphorous
o associated conditions
chronic renal disease
renal disease causes hypovitaminosis D
2+
leads to ↓ Ca absorption
renal osteodystrophy
bone leisons due to secondary hyperparathyroidism
Tertiary
o parathyroid glands become dysregulated after secondary hyperparathyroidism
2+
secrete PTH regardless of Ca level
Presentation
Symptoms
o often asymptomatic
o weakness
o kidney stones ("stones")
o bone pain ("bones")
o constipations ("groans")
o uncommon cause of secondary hypertension
Evaluation
Serology
o primary
hypercalcemia
↑ PTH
o secondary
hypocalcemia/normocalcemia
↑ PTH
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o malignancy
↓ PTH
o ↑ alkaline phosphatase
o normal anion gap metabolic acidosis
↓ renal reclamation of bicarbonate
Urinalysis
o primary
hypercalciuria (renal stones)
↑ cAMP
Radiograph
o cystic bone spaces ("salt and pepper")
often in the skull
o loss of phalange bone mass
↑ concavity (see key image of this topic)
EKG
o shortened QT
Treatment
Acute hypercalcemia
o IV fluids
o Loop diuretics
Symptomatic hypercalcemia is treated surgically
o treat with parathyroidectoy
o complications include post-op hypocalcemia
o manifests as numbness, tingling, and muscle cramps
o should be treated with IV calcium gluconate
Complications
Peptic ulcer disease
2+
o ↑ gastrin production stimulated by ↑ Ca
Acute pancreatitis
2+
o ↑ lipase activity stimulated by ↑ Ca
CNS dysfunction
o anxiety, confusion, coma
o result of metastatic calcification of the brain
Osteoporsis
o Bone loss occurs as result of bone resorption due to excess PTH
5. Hypophosphatasia
Introduction
Metabolic bone disease characterized by a generalized impairment of bone mineralization
Incidence
o estimated to be 1 in 100,000
Pathophysiology
o low levels of alkaline phosphate result in decreased synthesis of inorganic phosphate necessary
for bone matrix formation
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o osteoid that forms in the hypertrophic zone of the growth plate fails to mineralize
o the zone of provisional calcification never forms and growth is inhibited
Genetics
o inheritance pattern
autosomal recessive
o caused by a mutation in the tissue-nonspecific isoenzyme of alkaline phosphatase (TNSALP)
Associated conditions
o orthopaedic manifestations
similar to rickets
bow legs
short stature
o non-orthopaedic manifestations
abnormal tooth formation
loss of teeth
Presentation
Clinical findings
o presentation similar to rickets
genu varum
short stature
o abnormal dentition
Imaging
Radiographs
o recommended : AP and lateral of affected bone
o findings
abnormal bone formation
"deossification of bone" adjacent to growth plate
physeal widening
Evaluation
Labs
o serum
decreased serum alkaline phosphatase
o urine
phosphoethanolamine in the urine diagnostic for hypophosphatasia
Treatment
Nonoperative
o no approved therapies
phosphate therapy under investigation but not utilized at this time
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6. Pseudohypoparathyroidism
Introduction
Rare genetic disorder
Mechanism
o PTH resistance
decreased target cell response to PTH
Classification
Type 1a - Albright hereditary osteodystrophy
o defect in GNAS1 (Gsα protein)
defective gene from mother
upstream defect
proximal to formation of cAMP
o skeletal defects
short 4th, and 5th metacarpals and metatarsals or short 4th metacarpal only
"knuckle, knuckle, dimple, dimple" sign on closed fist
differentials
Turner syndrome
short 4th metacarpal only
"knuckle, knuckle, dimple, knuckle"
Down syndrome
short middle phalanx
brachydactyly
exostoses
o round facies
o obesity
o short stature
o diminished intelligence
Type 1b
o defect in GNAS1 (Gsα protein)
o normal appearance
Type 2
o unknown gene defect
o downstream defect
distal to formation of cAMP
o normal appearance
Presentation
Symptom
o symptoms of hypocalcemia
paresthesia : fingertip, toes, perioral
abdominal pain, biliary coli
muscle cramps, tetany
dyspnea (laryngospasm, bronchospasm)
convulsions
mental status changes : anxiety, fatigue, mood swings
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Physical exam
o findings of tetany
Trousseau's Sign
carpopedal spasm after blood pressure readings
inflate BP cuff 20mmHg above systolic BP x 3-5min
hand adopts a MCP flexed, DIP and PIP extended position
more sensitive than Chvostek's sign
Chvostek's Sign
facial muscle contractions after tapping on the facial nerve
o dermatologic
fungal nail infections
hair loss
blotchy skin : pigment loss, vitiligo
Evaluation
Laboratory
o high PTH
o low calcium
o high phosphate
o low vit D
Ellsworth-Howard test
o method to differentiate type 1 and type 2 by administering exogenous PTH
Type 1
will show no increase in urinary cAMP and phosphate
Type 2
will show increased excretion of urinary cAMP and phosphate
Differential
Causes of hypocalcemia
o renal osteodystrophy (low Ca, high PTH, high phosphate, high ALP)
o hypoparathyrodism (low Ca, low PTH, high phosphate)
o pseudopseuodohypoparathyroidism
mechanism
no PTH resistance
normal target cell response to PTH
genetics
defect in GNAS1 (Gsα protein)
defective gene from father
skeletal defects
also has short 4th metacarpal and metatarsal
metastatic calcification
laboratory
normal PTH
normal calcium
normal phosphate
normal vit D
o decreased vitamin D3
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By Dr, AbdulRahman AbdulNasser Systemic Disease | Metabolic Disease
Response to
Type Appearance PTH Calcium Phos Vit D PTH Genetics
administration
Hypoparathyroidism Normal ↓ ↓ ↑ ↓ - -
no increase in
Pseudohypoparathyroidism Type Skeletal GNAS1 (maternal
↑ ↓ ↑ ↓ urinary cAMP
1a defects defect, upstream)
or phosphate
Pseudohypoparathyroidism Type GNAS1 and
Normal ↑ ↓ ↑ ↓
1b STX16
increased
GNAS1
Pseudohypoparathyroidism Type 2 Normal ↑ ↓ ↑ ↓ urinary cAMP
(downstream)
and phosphate
Skeletal GNAS1 (paternal
Pseudopseudohypoparathyroidism N N N N
defects defect)
Treatment
Nonoperative
o oral calcium and 1alpha-hydroxylated vitamin D metabolites
indications
all patient with pseudohypoparathyroidism
o IV calcium replacement
indications : patients with severe symptoms of hypocalcemia
7. Scurvy
Introduction
Definition
o Vitamin C (ascorbic acid) deficiency
Epidemiology
o incidence
8% of men and 6% of women in the US have vitamin C deficiency
o demographics
male: female ratio is 4:3
o bimodal age bracket
infants 5-10months
uncommon in infants <7mths who are being breast fed as breast milk has vitamin C
men >60 years
o location
wrists, knees, sternal ends of ribs
areas of rapid growth in children
o risk factors
elderly, especially men who live alone
chronic malnutrition
overcooking destroys vitamin C
alcoholic
smokers
malabsorptive conditions (Whipple's disease, inflammatory bowel disease, cancer
chemotherapy)
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Pathophysiology
o humans are unable to synthesize L-ascorbic acid because the enzyme L-gluconolactone oxidase
is nonfunctional
o Vitamin C deficiency leads to decrease in chondroitin sulfate and collagen synthesis and repair
o impaired intracellular hydroxylation of collagen peptides
o net effect is altered bone formatin with the greatest effect occuring in the metaphysis
o defect in spongiosa of the metaphysis at the growth plate
o because the demand for type I collagen is greatest during new bone formation
Prognosis : excellent prognosis if treated early
Presentation
History
o infant diet consisting of evaporated or
condensed milk
o "tea and toast" diet in elderly
Symptoms
o malaise and fatigue
o pain
bone pain
myalgia, because of reduced carnitine production
o bleeding
gum bleeding and loosening of teeth
hematuria
hematemesis
hemorrhage
iron deficiency
Physical exam
o petechiae and ecchymosis
o joint effusions
o swelling over long bones because of subperiosteal hemorrhage
o scorbutic rosary (costochondral separation)
angular step-off deformity in children
differentiated from rachitic rosary, which is rounded and nodular
Imaging
Radiographs
o recommended views
wrist radiographs
knee
sternal ends of ribs
o findings
the white line of Frankel
widened zone of provisional calcification
between epiphysis and metaphysis
Trummerfeld zone
transvese radiolucent band in the metaphysis adjacent to the Frankel line
also known as the scurvy line
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Wimberger ring
ring of increased density surrounding epiphysis
Pelkin spur and fracture
metaphyseal spurs and fractures
corner sign of Park
metaphyseal clefts
thin cortices ("pencil-point" cortex)
decreased trabeculae with ground-glass osteopenia
subperiosteal elevation
epiphyseal separation
fractures and dislocations
Studies
The diagnosis is usually made based on history, clinical and radiological picture, and resolution of
symptoms following vitamin C administration. Lab tests are usually not helpful.
Labs
o fasting serum ascorbic acid level is low
Histology
o replacement of primary trabeculae with granulation tissue
o areas of hemorhage
o widening zone of provisional calcification of the physis
Treatment
Nonoperative
o vitamin C replacement
o indications
signs and symptoms of scurvy
chronic malnutrition
o techniques II:17 Pencil-point cortices characteristic of
oral vitamin C at 250mg qid x 1 week in adults scurvy, Ground glass osteopenia
characteristic of scurvy.
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ORTHO BULLETS
III.Medications &
Toxicity
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By Dr, AbdulRahman AbdulNasser Medications & Toxicity | Medications
A. Medications
1. Bisphosphonates
Introduction
Overview
o class of drugs that prevent bone mass loss by inhibiting osteoclast resorption
prevent formation of osteoclast ruffled borders microtubules, causing apoptosis
inhibition of osteoclasts also infereres with normal bone healing and remodeling
o there are two types of bisphosphonates
non-nitrogen containing
tiludronate
clodronate
etidronate
nitrogen containing
alendronate
risedronate
pamidronate
zolendronate
zoledronic acid - relatively new and appealing to patients, due to IV adminstration
every 12 months
Indications
o osteoporosis
o metastatic bone disease
o multiple myeloma
o paget's disease
o polyostotic fibrous dysplasia
o total joint arthroplasty to prevent osteolysis
o early stage avascular necrosis
o osteogenesis imperfecta
o metastatic hypercalcemia
Contraindications
o severe renal disease
primary mode of excretion is renal
o following lumbar fusion
decreased spinal fusion rates in lab animal models (increased fusion mass size, but decreases
the actual fusion rate)
Mechanism
Delivery
o bisphophonates accumulate in high concentration in bone due to binding affinity to calcium
o bisphosphonates are ingested by osteoclasts and work by two different methods depending on
presence of nitrogen atom on the alkyl chain
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Nitrogen containing bisphosphonates mechanism
o inhibits osteoclast farnesyl pyrophosphate synthase enzyme, required in mevalonate (cholesterol
pathway)
inhibits GTPase formation
Non-nitrogen containing bisphosphonates (simple) mechanism
o induce osteoclasts to undergo premature death and apoptosis
does so by forming a toxic adenosine triphosphate (ATP) analogue
Treatment
Vertebral Compression Fractures
o indications
vertebral compression fracture in osteoporotic patient
bone mineral density 2.5 or more standard deviations below that of young healthy adults
(T score < 2.5 SD)
o outcomes
1 year of treatment with a pharmacologic antiosteoporotic medication, the risk of vertebral
fracture decreases by 50-60%
Non-vertebral Fragility fractures
o indications
fragility fracture in osteoporotic patient
o outcomes
effective in reducing the risk of multiple fractures
Osteogenesis imperfecta
o cyclical IV pamidronate administration
reduces bone pain and fracture incidence III:1 Complications: Jaw osteonecrosis
increases level of ambulation and bone density
Multiple myeloma
o indications
diagnosis of multiple myeloma
o outcomes
reduced incidence of skeletal events in multiple myeloma
Avascular necrosis
o indications
early, precollapse AVN
o outcomes III:2 Complicatios : Atypical
still considered investigational subtrochanteric and femoral stress
fractures
randomized clinical trial showed that bisphosphonate
treatment was more effective at preventing head collapse than placebo at 2 years
(bisphosphonate collapse 6.9% vs placebo collapse 76%)
Side Effects & Complications
Jaw osteonecrosis
Atypical subtrochanteric and femoral stress fractures
Radiographic changes consistent with osteopetrosis
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2. Prophylaxis Antibiotics
Perioperative Abx Overview
Includes preoperative and postoperative antibiotics
o 25-50% of all antibiotics used are for prophylaxis
Indications
o routine adminstration of prophylactic antibiotics is accepted in
patients who will have a foreign body implanted
bone grafting procedures
large dissection resulting in significant dead space or hematoma
expecting significant blood loss
o orthopaedics procedures that do not require prophylactic antibiotics
carpal tunnel surgery
diagnostic arthroscopy is more controversial
Most likely pathogens to cause infection in orthopaedic procedures includes
o S aureus
o S epidermidis
o aerobic streptococci
o anaerobic cocci
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Dental Procedure Abx Prophylaxis in TJR Patients (AAOS & ADA)
Indications
o TJA patients at increased risk of hematogenous seeding should be given prophylactic antibiotics
prior to dental procedures. This includes
all patients for the first two years after TJA
immunocompromised patients
drug induced immunosuppression
radiation induced immunosuppression
inflammatory arthropathies including SLE and RA
comorbidities including
previous prosthetic joint infection
Type I (insulin-dependent) diabetes
malnourishment
hemophilia
HIV
malignancy
o evidence to support recommendations
AAOS and ADA recognizes there is limited or inconclusive evidence to support the
recommendations above and practitioners should use clinical judgment
Administration
o antibiotics is given 1 hour before dental procedure
o patients NOT allergic to penicillin should be given
amoxicillin or cephalexin 2 grams orally
if unable to take oral medications than 1 gram cefazolin or 2 gram ampicillin IV or IM
o if allergic to penicillin
clindamycin 600 mg orally
if unable to take oral medications than clindamycin 600 mg IV
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By Dr, AbdulRahman AbdulNasser Medications & Toxicity | Medications
Penicillinase Second
Resistant Generation
Methicillin Cefacor
Nafcillin Cefotetan (Cefotan)
Oxacillin other
other
Aminopenicillins Third Generation
Ampicillin Ceftriaxone
(Rocephin)
other
Fourth Generation
Cefpirome
Cefepime
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Antibiotic Classification & Indications
Inhibits Cell Wall Synthesis
Penicillins
(bactericidal: blocks cross linking via competitive inhibition of the transpeptidase enzyme)
Class/Mechanism Drugs Indications (**Drug of Toxicity
Choice)
Penicillin Penicillin G Strep. pyogenes (Grp.A)** Hypersensitivity reaction
Aqueous penicillin G Step. agalactiae (Grp.B)** Hemolytic anemia
Procaine penicillin G C. perfringens(Bacilli)**
Benzathine penicillin G
Penicillin V
Aminopenicillins Ampicillin Above + Above
Amoxicillin ↑ Gram-negative:
E. faecalis**
E. Coli**
Penicillinase-resistant- Methicillin Above + Above +
penicillins Nafcillin PCNase-producingStaph. Interstitial nephritis
Oxacillin aureus
Cloxacillin
Dicloxacillin
Antipseudomonal Carbenicillin Above + Above
penicillins Ticarcillin Pseudomonas
Piperacillin aeruginosa**
Cephalosporins
(bactericidal: inhibits bacterial cell wall synthesis via competitive inhibition of the transpeptidase enzyme)
1st generation Cefazolin Staph. aureus** Allergic reaction
Cephalexin Staph. epidermidis** Coombs-positive
Some Gram-negatives: anemia (3%)
E. Coli
Klebsiella
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By Dr, AbdulRahman AbdulNasser Medications & Toxicity | Medications
Aztreonam Aztreonam Gram-negative rods
Aerobes
Hospital-acquired infections
Polymyxins Polymyxin B Topical Gram-negative
Polymyxin E infections
Bacitracin Bacitracin Topical Gram-positive
infections
Protein Synthesis Inhibition
Anti-30S ribosomal subunit
Aminoglycosides Gentamicin Aerobic Gram-negatives Nephrotoxicity
(bactericidal: irreversible Neomycin Enterobacteriaceae Ototoxicity
binding to 30S) Amikacin Pseudomonas
Tobramycin
Streptomycin
Tetracyclines Tetracycline Rickettsia Hepatotoxicity
(bacteriostatic: blocks tRNA) Doxycycline Mycoplasma Tooth discoloration
Minocycline Spirochetes (Lyme's Impaired growth
disease)
Demeclocycline Avoid in children < 12
years of age
Anti-50S ribosomal subunit
Macrolides Erythromycin Streptococcus Coumadin Interaction
(bacteriostatic: reversibly Azithromycin H. influenzae (cytochrome P450)
binds 50S) Clarithromycin Mycoplamsa pneumonia
Chloramphenicol Chloramphenicol H influenzae Aplastic Anemia
(bacteriostatic) Bacterial Meningitis Gray Baby Syndrome
Brain absces
Lincosamide Clindamycin Bacteroides fragilis Pseudomembranous
(bacteriostatic: inhibits S aureus colitis
peptidyl transferase by Coagulase-negative Hypersensitivity
Staph & Strep Reaction
interfering with amino acyl-
Excellent Bone Penetration
tRNA complex)
Linezolid Linezolid Resistant Gram-positives
(variable)
Streptogramins Quinupristin VRE
Dalfopristin GAS and S. aureus skin
infections
DNA Synthesis Inhibitors
Fluoroquinolones
(bactericidal: inhibit DNA gyrase enzyme, inhibiting DNA synthesis)
1st generation Nalidixic acid Steptococcus Phototoxicity
Mycoplasma Achilles tendon rupture
Aerobic Gram + Impaired fracture
healing
2nd generation Ciprofloxacin As Above +Pseudomonas as above
Norfloxacin
Enoxacin
Ofloxacin
Levofloxacin
3rd generation Gatifloxacin As above + Gram-positives as above
4th generation Moxifloxacin As above + Gram-positives + as above
Gemifloxacin anaerobes
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Other DNA Inhibitors
Metronidazole Metronidazole (Flagyl) Anaerobics Seizures
(bacteridical: metabolic Crebelar dysfunction
biproducts disrupt DNA) ETOH disulfram
reaction
RNA Synthesis Inhibitors
Rifampin Rifampin Staphylococcus Body fluid discoloration
(bactericidal: inhibits RNA Mycobacterium (TB) Hepatoxicity (with INH)
transcription by inhibiting
RNA polymerase)
Mycolic Acids Synthesis Inhibitors
Isoniazid Isoniazidz TB
Latent TB
Folic acid Synthesis Inhibitors
Trimethoprim/Sulfonamides Trimethoprim/Sulfamethoxazole UTI organisms Thrombocytopenia
(bacteriostatic: inhibition with (SMX) Proteus Avoid in third trimester
PABA) Sulfisoxazole Enterobacter of pregnancy
Sulfadiazine
Pyrimethamine Pyrimethamine Malaria
T. gondii
Bacteria Overview
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Antibiotic Resistance Mechanisms
Bacteria develop ability to hydrolyze these drugs using β lactamase
o confers resistance to penicillin
o e.g. E. coli, Staph epidermidis, Pseudomonas aeruginosa, Klebsiella pneumoniae
o add β lactamase inhibitor e.g. clavulanic acid in amoxicillin-clavulanate (Augmentin)
Genetic mutation of mecA
o carried by Staphylococcal cassette chromosome (SCCmec) mobile genetic unit
o a bacterial gene encoding a penicillin-binding protein (PBP2a).
PBP2a has reduced affinity for antibiotics
confers resistance to methicillin, oxacillin, nafcillin
e.g. MRSA
SCCmec type IV has less genetic elements and is specific to CA-MRSA, making CA-
MRSA less multi-drug resistant
Altered cell wall permeability
o confers resistance to tetracyclines, quinolones, trimethoprim and β lactam antibiotics
Creation of biofilm barrier
o provides an environment where offending bacteria can multiply safe from the hoste immune
system
Salmonella
Staph epidermidis
Active efflux pumps
o confers resistance to erythromycin and tetracycline
o e.g. msrA gene in Staph
Altered peptidoglycan subunit (altered D-alanyl-D-alanine
of NAM/NAG-peptide)
o confers resistance to vancomycin
o e.g. vancomycin resistant enterococcus (VRE) III:3 D zone test
Ribosome alteration
o erm gene confer inducible resistance to MLS (macrolide lincosamide streptogranin) agents via
methylation of 23s rRNA
o demonstrate using D zone test
for inducible clindamycin resistance in Staph and beta hemolytic Strep
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Penicillins
Mechanism
o interfer with bacterial cell wall synthesis
Subclassification and tested examples
o natural
penicillin G
o penicillinase-resistant
methicillin (Staphcillin)
o aminopenicillins
ampicillin (Omnipen, Polycillin)
Cephalosporins
Overview
o bactericidal
Mechanism
o disrupts the synthesis of the peptidoglycan layer of bacterial cell walls
does so through competitive inhibition on PCB (penicllin binding proteins)
peptidoglycan layer is important for cell wall structural integrity.
o same mechanicsm of action as beta-lactam antibiotics (such as penicillins)
Subclassification and tested examples
o first generation
cefazolin (Ancef, Kefzol)
o second generation
cefaclor (Ceclor)
o third generation
cefriazone (Rocephin)
o fourth generation
cefepime (Maxipime)
Fluoroquinolones
Mechanism
o blocks DNA replication via inhibition of DNA gyrase
Side effects
o inhibit early fracture healing through toxic effects on chondrocytes
o Increased rates of tendinitis, with special predilection for the Achilles tendon.
Tenocytes in the Achilles tendon have exhibited degenerative changes when viewed
microscopically after fluoroquinolone administration.
Recent clinical studies have shown an increased relative risk of Achilles tendon rupture of
3.7.
Subclassification and tested examples
o ciprofloxacin (Cipro)
o levofloxacin (Levaquin)
Aminoglycosides
Mechanism
o bactericidal
o inhibition of bacterial protein synthesis
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work by binding to the 30s ribosome subunit, leading to the misreading of mRNA. This
misreading results in the synthesis of abnormal peptides that accumulate intracellularly and
eventually lead to cell death. These antibiotics arebactericidal.
Subclassification and tested examples : gentamicin (Garamycin)
Vancomycin
Coverage : gram-positive bacteria
Mechanism
o bactericidal
o an inhibitor of cell wall synthesis
Resistance
o increasing emergence of vancomycin-resistant enterococci has resulted in the development of
guidelines for use by the (CDC)
o indications for vancomycin
serious allergies to penicillins or beta-lactam antimicrobials
serious infections caused by susceptible organisms resistant to penicillins (MRSA, MRSE)
surgical prophylaxis for major procedures involving implantation of prostheses in institutions
with a high rate of MRSA or MRSE
Rifampin
Most effective against intracellular phagocytized Staphylococcus aureus in macrophages
Linezolid
Linezolid binds to the 23S portion of the 50S subunit and acts by preventing the formation of
the initiation complex between the the 30S and 50S subunits of the ribosome.
Splenectomy
Splenectomy patients or patients with functional hyposplenism require the following vaccines and/or
antibiotics
o Pneumococcal immunization
o Haemophilus influenza type B vaccine
o Meningococcal group C conjugate vaccine
o Influenza immunization
o Lifelong prophylactic antibiotics (oral phenoxymethylpenicillin or erythromycin)
4. Anti-inflammatory Medications
Introduction
Non-steroidal anti-inflammatory drugs (NSAIDS) have the following effects
o anti-inflammatory
o antipyretic
o analgesic
o antiplatelet
Mechanism
o inhibit the COX (cyclooxygenase) enzymes ultimately inhibiting the synthesis and release of
prostaglandins
COX enzymes catalyze the formation of prostaglandins and thromboxane from arachidonic
acid
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COX Inhibitors
NSAIDS inhibit both COX-1 and COX-2
o Aspirin (ASA)
salicylate that irreversibly binds a serine COX enzyme residue
half life >1 week
binds to COX and blocks active site
inhibits thromboxane A2 blocking platelet aggregation
o ibuprofen
reversible competitive COX inhibitor
o indomethacin
acts on the lipoxygenase side of the arachidonic metabolic pathway
inhibibits leukotriene inflammatory mediators
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Benefits
o selective inhibition of COX-2 results in anti-inflammatory action without disrupting the
beneficial effects of COX-1 (maintaining gastric mucosa, regulating renal blood flow,
influencing platelet aggregation)
o can be used in the perioperative period because they do not affect platelet function
o no more efficacious in treating osteoarthritis than non-specific COX inhibitors
Side effects : cardiac toxicity
Side Effects
Renal dysfunction
Gastrointestinal side effects
o pain and dyspepsia
o peptic ulcer perforation, bleeding, or obstruction
2% to 4% occurence in chronic users
o risk factors
concurrent anticoagulant use (most important)
age >60 years
history of previous gastrointestinal disorder
Delayed fracture healing
o animal fracture models have shown decreased endochondral ossification in the absence of a
COX-2 enzyme
Platelet dysfunction
Cardiac Toxicity
Corticosteroids (Systemic)
Steroid Dose Pack
o efficacy
o side effects
Corticosteroid Intra-articular-Injections
Efficacy
Side Effects
o Local flare
o Fat atrophy
o Skin pigmentation changes
o Facial flushing
5. Analgesic Medications
Introduction
Definitions
o acute pain
implies presence of tissue damage
o chronic pain (3-6 months)
no implication of tissue damage necessary
o pathologic pain
pain from abnormal nervous system functioning (neuropathic)
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Pathophysiology
o afferent pain pathways
nociceptors
transduce signal through various substances
Substance P
a sensory neurotransmitter that plays an important role in pain
depletion of substance P increases the threshold to painful stimuli
Capsaicin is thought to function by decreasing Substance P
peripheral nerves
nociceptors transmit pain to type A and C peripheral nerve fibers
spinal cord
peripheral nerves transmit the pain signal via the dorsal column and spinothalamic tract
brainstem
spinal cord transmits the pain signal to the thalamus
site of pain modulation with endogenous opiates
Agents (details below)
o Acetaminophen
o NSAIDS
o Opiates
o Gaba synthesis agents
o Adjunctive agents
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Acetaminophen
Mechanism
o not fully understood
o inhibits prostaglandin synthesis
o minimal antinflammatory effects
As effective for pain control as aspirin
Toxicity
o overdose leads to hepatic disfunction
o contraindicated in the setting of pre-existing hepatic dysfunction
NSAIDs
Mechanism : decrease transduction of pain
See anti-inflammatory medications
Local anesthetics
Mechanism
o decrease transduction of pain
o interfere with nerve conduction to provide a reversible loss of sensation in a specific location
affects the depolarization phase of action potentials (cells fail to depolarize enough to fire
after excitation leading to a blocked action potential)
Examples
o amide family
lidocaine (Xylocaine)
bupivacaine (Marcaine)
o esters of p-aminobenzoic acid
procaine (Novocain)
butethamine (Monocaine)
o esters of meta-aminobenzoic acid
cyclomethycaine (Surfacaine)
metabutoxycaine (Primacaine)
o esters of benzoic acid
cocaine
ethyl aminobenzoate (Benzocaine)
Adverse effects
o FDA warning on the administration of continuous intra-articular infusion of local anesthetics for
pain control
Some patients have been noted to have chondrolysis following infusion
Opiates
Overview
o useful in chronic nociceptive pain
Mechanism
o perispinal method affects modulation of pain
o systemic opiates change the perception and modulation of pain
Administration
o oral, IV, intraspinal
o oral administration preferred (more convenient and less costly)
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bony procedures require more analgesia than soft tissue procedures
o patient compliance can improve with long-acting preparations that providue more uniform serum
drug levels
o implantable systems are available for intrathecal administration
Prescription dosing guide for upper extremity surgery
o no narcotics
trigger finger release, nonop Dupuytren's release, small lumps/bumps
o 10 narcotic tablets
mucous cyst, carpal tunnel, deQuervain‟s, Dupuytren‟s releases and small joint fusion
o 20 narcotic tablets
wrist ganglion cysts, hand fracture ORIF, LRTI and tendon transfers
o 40 narcotic tablets
large trauma, wrist fusion, open carpal surgery and DRUJ reconstruction
Chronic use
o addiction occurs in a minority of patients
o chronic opiates should be prescribed by pain management specialists
o written contracts should be obtained
o prescriptions should always be refilled in person
Methadone
Synthetic diphenylheptaine-derivative opioid receptor agonist
High bioavailability (three times as much as morphine), effective, and inexpensive
Metabolism
o cytochrome P450 system
Rapid distribution phase (2-3 hours) and prolonged elimination phase (15-60 hours)
Caution
o can accumulate to high levels with repeated dosing
o rates of elimination vary considerably
o risk of respiratory depression, cardiac toxicity (torsades de pointes)
o consult with a qualified pain specialist when prescribing for the first-time
GABA agents
Agents
o Pregabalin (Lyrica)
o Gabapentin (Neurontin)
Mechanism
o decrease transduction of pain
Reduce hyper-excitability of voltage dependent Ca2+ channels in activated neurons.
Gabapentin is an anticonvulsant also used to treat neuropathic pain
o binds presynaptic calcium channels to inhibit release of neurotransmitters
Efficacy
o evidence of effectiveness primarily for postherpetic neuralgia, diabetic nueropathy, and
fibromyalgia
o little evidence for other uses, though often prescribed for other forms of chronic neuropathic pain
(such as complex regional pain syndrome, CRPS)
o gabapentin has been shown to be as effective and less expensive than pregabalin
Discontinuation requires a tapering dose
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Muscle relaxants
Overview : Useful to treat pain secondary to muscle spasms
Agents
o Cyclobenzaprine (Flexeril)
mechnism of action not fully understood
centrally acting
potentiates norepinephrine and binds serotonin receptors
Use
o may decrease pain during first two weeks after an injury
o no proven benefit after first two weeks
o may be effective for fibromyalgia
o not effective to reduce spasticity secondary to neuromuscular disorders
Toxicity
o overdose rare
o may interact with other substances
MAOIs
alcohol
Adjuvant agents
Heterogeneous class of medications the provide additive analgesic effect to traditional NSAIDs and
opioids
o anticonvulsants
o antidepressants
o antihistamines
o psychostimulants
o anti-spasmodics
6. Anesthesia
Anesthesia
Components of anesthesia
o amnesia
o anxiolysis
o analgesia
o akinesia
o attenuation of autonomic repsonses to noxious stimuli
General Anesthesia
Pharmacologically induced, reversible loss of conciousness, irrespective of airway management
o inhalational anesthesia
by volatile liquids vaporized in a carrier gas including
isoflurane
sevoflurane
desflurane
nitrous oxide
associated with increased gaseous abdominal distension
leads to increased difficulty with fluoroscopic identification during pelvic and spinal
procedures
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o intravenous anesthesia
non-opioids
propofol
etomidate
benzodiazepines
dexmedetomidine
ketamine
opioids
fentanyl, alfentanil, sufentanil, remifentanil
morphine
hydromorphone
neuromuscular blocking agents
depolarizing agents
bind to, depolarize, and transiently block ACh receptor
short-acting: succinylcholine
no intermediate or long-acting agents
non-depolarizing agetns
bind to and transiently block ACh receptor, but do not depolarize
no short-acting agents
intermediate-acting: rocuronium, vecuronium, atracurium, cisatracurium
long-acting: pancuronium
III:5 Location of an infraclavicular block, which is used for operations involving the arm and forearm,
from the lower humerus down to the hand
Axillary block
o indications
postoperative analgesia for surgery to the elbow, forearm, wrist and hand
Bier block
o indications
short (< 60 mins) operative procedures (i.e., carpal tunnel release) in the hand and forearm
o technique
Esmarch exsanguination and tourniquet inflation
inject lidocaine through a small, distal (hand) intravenous catheter on the surgical side
deflate tourniquet after a minimum of 30 minutes to avoid venous release of local anesthetic
and potential local anesthetic systemtic toxicity (LAST)
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Local Anesthesia - Spinal
Spinal
o indications
often used for knee and hip arthroplasty
o technique
a single injection with a small 24 or 27-gauge needle
combination of morphine and bupivacain is often used
o complications
spinal headache (decreased with small gauge needle), hematoma and opioid side effects
(nausea, vomiting, purities, respiratory depression)
Epidural
o indication
often used for knee and hip arthroplasty
o technique
similar to spinal anesthesia, except an indwelling catheter is placed
combination of opioid and local anesthetic
o complications
postoperative hypotension and motor impairment
spinal headache, hematoma and opioid side effects (nausea, vomiting, pruritus, respiratory
depression)
Combined spinal epidural
o indications
often used for knee and hip arthroplasty
o technique
an epidural needle is placed into the epidural space and spinal anesthesia is administered
through a spinal needle followed by placing an epidural catheter
o complications
postoperative hypotension and motor impairment
spinal headache, hematoma and opioid side effects (nausea, vomiting, purities, respiratory
depression)
Local Anesthesia - Lower Extremity
Lumbar plexus/ psoas compartment nerve block
o indications
surgeries involving the hip, anterior thigh and knee
a sciatic block can be given concomitantly to provide pain relief to the entire lower extremity
o technique
targets the lumbar plexus (L1 to L4 spinal nerves) which form the obturator nerve, lateral
femoral cutaneous nerve, and femoral nerve
the injection is usually placed 3-5 cm lateral to the spinous process of L4 and is often guided
by ultrasound and nerve stimulators
o complications
nerve damage and intravascular injection
epidural diffusion, retroperitoneal hematomas, intrathecal injections and an increased risk of
falls
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Femoral nerve block
o indications
surgeries around the knee
concomitant sciatic nerve block can be done to increase analgesia around the knee
o technique
targets the femoral nerve (L2-L4)
the injection occurs just lateral to the femoral artery and on a line connecting the anterior
superior iliac spine to the pubic symphysis
o complications
nerve damage and intravascular injection
increased risk of falls, prolonged quadriceps weakness and infections
Sciatic nerve block
o indications
surgeries involving the leg, ankle and foot
can be combined with the femoral or lumbar plexus block to provide analgesia to the entire
lower extremity
o technique
targets the sciatic nerve providing analgesia to the common peroneal and tibial nerves
multiple techniques have been described
lines are drawn between the greater trochanter and the posterior superior iliac spine
(PSIS), and the greater trochanter and the sacral hiatus
halfway between the greater trochanter and the PSIS a perpendicular line is drawn, and
the injection is placed where the perpendicular line crosses the line between the greater
trochanter and the sacral hiatus
complications
nerve damage and intravascular injection
vascular injury, heel ulcers and a delay in diagnosis of nerve injuries after surgery
Obturator nerve block
o indications
adductor muscle spasm, severe hip pain from osteoarthritis
adjuvant pain management for knee surgeries
o technique
targets the anterior and posterior branch of the obturator nerve
blocking the anterior branch leads to decreased sensation at the hip joint and inner thigh,
where blocking the posterior branch decreases sensation around the knee
injection site is usually 2 cm inferior
and 2 cm lateral to the pubic tubercle
o complications
nerve injury and intravascular
injection
damage to structures in the pelvic
cavity
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Popliteal nerve block
o indications
used for surgery around the foot and ankle
often used in conjunction with the saphenous nerve block
o technique
targets the sciatic nerve prior to its bifurcation
injection site is often 10 cm proximal to the popliteal crease
o complications
nerve injury and intravascular injection
hematoma, persistent foot drop and pressure sores
Saphenous nerve block
o indications
procedures around the medial aspect of the knee, leg and ankle
o technique
targets the saphenous nerve
multiple different techniques, but it is often blocked behind the sartorius muscle
o complications
nerve injury and intravascular injection
hematoma and infection
Blood Management
Risks of transfusion
o transfusion errors
o allergic reaction
o infection
o down-modulation of immune system
Ways to reduce postop anemia and need for allogeneic transfusion
o surgical
hemostasis
meticulous dissection
o transfusion triggers
example of strict transfusion triggers based on hemoglobin levels
average patient, 8.1g/dl
young (<60yr) patients without co-morbidity, 6.5g/dl
compromised patients, 9.7g/dl
o subcutaneous epoetin injections
used preop for patients with low Hb (10-13g/dl)
able to bring up Hb by 1.9d/dl
administer with supplementary PO iron
dosing
long interval to surgery
600IU/kg once weekly x 3wk before surgery
short interval to surgery
300IU/KG daily x 2wk
o autologous blood donation (ABD) and acute normovolemic hemodilution (ANH)
ABD
donate 1-2 units preoperatively
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ANH
collect 2-3 units at 1 hour preoperatively
receive crystalloid/colloid intraoperatively
re-infuse ABD blood postoperatively
o COX2 inhibitors analgesia (instead of COX1 NSAIDS)
Avoids antiplatelet effects of
o anti-coagulation management
stop anticoagulation a few days preoperatively
restart just before surgery
o platelet rich plasma (PRP), fibrin sealants, anti-fibrinolytics
PRP
apply PRP to wounds might reduce capsule/subcutaneous bleeding
fibrin sealants
very low risk of infection from microbial/viral contamination during processing
antifibrinolytics
aprotinin
tranexamic acid (TXA)
topical
IV
o hypotensive epidural anesthesia (HEA)
epidural dermatomal block from T2 distal
blocks cardio-accelerator fibers of sympathetic chain
causes bradycardia which is treated with low-dose epinephrine
lowers MAP to 50mmHg
keeps normal heart rate, CVP, stroke volume, cardiac output
can be used in high risk patients with
hypertension
poor cardiac function
chronic kidney disease
o cell saver
expensive
intraoperative
washed vs unwashed (filtered)
indications
revision surgery
high EBL
contraindications
infection
malignancy
EBL <500ml
postoperative
filtering of shed blood (trap clots and debris)
within 6h of end of surgery to avoid bacterial contamination, febrile reaction
after 6h, converted to vacuum drain (not retransfused)
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Complications
Malignant hyperthemia
o rare (1:15,000 to 1:50,000) life-threatening condition
o autosomal dominant transmission
abnormalities in the ryanodine receptor (RYR1) gene
o triggers
volatile inhalational anesthetic agents
succinylcholine
o symptoms
hypermetabolic state
increased skeletal muscle contraction and metabolism
rigidity
masseter spasm
rapid oxygen depletion
increased carbon dioxide concentration (EtCO2) and body temperature
o outcome
if untreated, leads to circulatory collapse and death
o treatment
provide antidote
active cooling
o antidote
dantrolene (calcium blocker)
Local anesthetic systemic toxicity (LAST)
o intravascular bupivicaine
effect
CNS
seizures, coma, respiratory arrest
CVS
asystole, ventricular fibrillation, cardiac arrest
antidote
intravenous 20% lipid emulsion
Bone cement implanation syndrome
o associated with use of bone cement during joint arthroplasty procedures
o symptoms
hypotension
hypoxemia
o treatment
intravenous fluids
vasopressors
100% inspired oxygen
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7. Platelet-Rich Plasma
Introduction
Platelet rich plasma (PRP) consists of plasma sample from one's own blood enriched with
autologous platelets
o indications
controversially used in orthopaedics for possible stimulation of bone and soft tissue healing
o preparation technique
PRP is created by centrifugation of blood to separate platelet rich plasma layer from a sample
of whole blood
calcium chloride used to initiate platelet activation in the prepared sample of PRP
o optimal concentration
3-5x that of whole blood
>5x inhibits healing
Platelet function
o plays an important role in the inflammatory cascade response after injury
o growth factors released from platelets include
PDGF
TGF-B
VEGF
IGF-1
EGF (epidermal growth factor)
CTGF (connective tissue growth factor)
FGF-2
Proposed function of PRP
o increase ECM deposition
o reduce pro-apoptotic signals
o minimize joint inflammation
Clinical Application
PRP efficacy is controversial due to small amount of high level studies in literature
o soft tissue injury healing
no consensus for acute ligamentous, tendon and muscle injuries or chronic tendonopathies
o osteoarthritis
no consensus in evidence, lack of studies with long term followup
o fracture healing / fusion
limited evidence for bone formation (some studies show detrimental effects)
o ACL reconstruction
literature does NOT support PRP for ligamentization/graft maturation, patient reported
outcomes
direct application to patellar and tibial plug donor sites (BPTB) linked to improved patient-
reported outcomes of knee function and decreased patellar tendon gap
o meniscal repair
no clear evidence to support use in meniscal repair
o rotator cuff repair
no benefit in augmenting RC repair (possible detrimental effects)
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o tendon healing
lateral epicondylar tendinosis (tennis elbow)
potential benefit (improved patient reported outcomes and pain scores)
midsubstance/insertional Achilles tendinopathy
current literature does NOT support
Summary
Potential benefits for BPTB donor sites and tennis elbow
B. Toxicology
1. Lead Toxicity
Lead Toxicity
Lead toxicity inhibits parathyroid hormone-related peptide (PTHrP) and may affect bone mineral
density
Imaging
o radiographs can reveal radiodense metaphyseal bands
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In June 2017
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ORTHO BULLETS
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By Dr, AbdulRahman AbdulNasser Clinical Science | Clinical Studies
A. Clinical Studies
1. Statistic Definitions
Introduction
This topic covers the following statistical principles
o Measures of Central Tendency
o Sensitivity
o Specificity
o False Positive Rate
o False Negative Rate
o Positive Predictive Value
o Negative Predictive Value
o Likelihood Ratio
o Incidence
o Prevalence
o Relative Risk
o Odds Ratio
o Number Needed to Treat
o Post-test Odds of Disease
o Power
o Effect Size
o Variance
o Type II (beta) Error
o Type I (alpha) Error
o Confidence Interval
o Statistical Inference
o Funnel plot
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Mean
o defined as arithmetic average
o the most frequently used measure of central tendency
o uses all values of data
o highly sensitive to extreme values (especially skewed distributions)
Sensitivity
Definition
o probability that test results will be positive in patients with disease
Equation
o sensitivity = a / (a + c) or
o sensitivity = TP / (TP + FN)
Relevance
o sensitive tests are useful for screening since they are unlikely to miss a patient with disease
Example
o a new test is developed to quickly diagnose HIV. There are 10 patients in the study group with
the disease. Upon testing of all 10 patients, only 6 results return positive. What is the sensitivity
of the new test?
o solution
sensitivity = a / (a + c)
sensitivity = 6 / 10
sensitivity = 60%
disease pos disease neg
true positive false positive
test pos
a (6) b
false negative true negative
test neg
c (4) d
TOTAL 10 b+d
Specificity
Definition
o probability test result will be negative in patients without disease
Equation
o specificity= d / (b + d) or
o specificity = TN / (FP + TN)
Relevance
o specific tests are useful for confirmation as they don't result in treatment of an unaffected
individual
Example
o in a population of 90 patients who are disease free, a test incorrectly diagnoses 5 patients with
disease. What is the specificity of this test?
o solution
specificity = d / (b + d)
specificity = 85 / 90
specificity = 94.4%
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disease pos disease neg
true positive false positive
test pos
a b (5)
false negative true negative
test neg
c d (85)
TOTAL a+c b + d (90)
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disease pos disease neg
true positive false positive
test pos
a (9) b (4.5)
false negative true negative
test neg
c (1) d (85.5)
TOTAL a+c (10) b+d (90)
PPV = a / (a + b)
PPV = 9 / (9 + 4.5)
PPV = 67%
Likelihood Ratio
Definition
o likelihood that a given test result would be expected in a patient with the target disorder
compared to the likelihood that that same result would be expected in a patient without the target
disorder
Classification
o positive likelihood ratio
definition
describe how the likelihood of a disease is changed by a positive test result
equation : positive likelihood ratio = sensitivity / (1 - specificity)
o negative likelihood ratio
definition
describe how the likelihood of a disease is changed by a negative test result
equation : negative likelihood ratio = (1 - sensitivity) / specificity
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By Dr, AbdulRahman AbdulNasser Clinical Science | Clinical Studies
Incidence
Number of newly reported cases of a disease in specific time period per unit measurement of
population
Prevalence
The total number of cases of a disease present in a location at any time point
Relative Risk
Definition
o risk of developing disease for people with known exposure compared to risk of developing
disease without exposure
obtained from cohort studies
when RR > 1, the incidence of the outcome is greater in the exposed/treated group
Equation
o incidence risk of YES = a / (a + b)
o incidence risk of NO =c / (c + d)
o relative risk = [(a / a + b)] / [(c / c + d)]
Disease Status
Risk Present Absent
Yes a b
No c d
Example
o a study is performed concerning the relationship between blood transfusions and the risk of
developing hepatitis C. A group of patients is studied for three years.
Disease Status
Transfused Hepatitis C Healthy
Yes 75 595
No 16 712
solution
o disease incidence in transfused
"YES" = 75 / (75 + 595) = .112
o disease incidence in patients not transfued
"NO" = 16 / (16 + 712) = .022
o relative risk (RR) = 0.112 / 0.022 = 5.09
Odds Ratio
Definition
o probability of having a risk factor if one has a disease
obtained from case control studies (retrospective)
Equation
o OR = (odds of developing disease in exposed patients) / (odds of developing disease in
unexposed patients)
Number Needed to Treat
Definition
o number of patients that must be treated in order to achieve one additional favorable outcome
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OrthoBullets2017 Clinical Science | Clinical Studies
Equation
o number needed to treat = (1 / absolute risk reduction)
Example
o you learn the number-needed-to-screen with FOBT is nearly 1000 to prevent colon cancer. What
is the absolute risk reduction associated with FOBT?
o solution
absolute risk reduction (ARR) = 1 / number needed to treat
ARR = 1 / 1000
ARR = .1%
Power
Definition
o an estimate of the probability a study will be able to detect a true effect of the intervention
Equation
o power = 1 - (probability of a type-II, or beta error)
Effect size
Definition
o magnitude of the difference in the means of the control and experimental groups in a study with
respect to the pooled standard deviation
Variance
Definition
o an estimate of the variability of each individual data point from the mean
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By Dr, AbdulRahman AbdulNasser Clinical Science | Clinical Studies
o bydefinition, alpha-error rate is set to .05, meaning there is a 1/20 chance a type-I error has
occurred
Related principle
o Bonferroni correction
post-hoc statistical correction made to P values when several dependent or independent
statistical tests are being performed simultaneously on a single data set
Confidence Interval
Definition
o the interval that will include a specific parameter of interest, if the experiment is repeated
Statistical Inference
Definition
o used to test specific hypotheses about associations or differences among groups of
subjects/sample data
Classification
o parametric inferential statistics
continuous data that is normally distributed
o nonparametric inferential statistics
categorical data that is not normally distributed
Study types
o when comparing two means
student t-test
used for parametric data
mann-whitney or wilcoxon sum rank test
used for non-parametric data and
o when comparing proportions or categorical data
chi-square test
used for two or more groups of categorical data
fisher exact test
used when sample sizes are small or
number of occurrences in a group is low
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OrthoBullets2017 Clinical Science | Clinical Studies
2. Level of Evidence
Introduction
A method utilized in evidenced based medicine to determine the clinical value of a study
See details of Clinical Design Trials
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By Dr, AbdulRahman AbdulNasser Clinical Science | Clinical Studies
JBJS LOE
AAOS Recommendations
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OrthoBullets2017 Clinical Science | Clinical Studies
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By Dr, AbdulRahman AbdulNasser Clinical Science | Clinical Studies
Randomized controlled trial
Definition
o a study in which patients are randomly assigned to the treatment or control group and are
followed prospectively
o provides the most compelling evidence that the study treatment causes the expected effect on
human health
o randomization minimizes study bias
Crossover design
o administration of two or more therapies, one after the other, in a random order
o susceptible to bias if washout period is inadequate
o single blinded study vs. double blinded study
Analysis
o intent-to-treat analysis
outcomes based on the group into which they were randomized, regardless of whether the
patient actually received the planned intervention
minimizes non-responder bias
o per protocol
excludes patients who were not compliant with the protocol guidelines
Example
o you want to determine whether your new toothpaste prevents cavities better than your old
toothpaste. You randomly assign a large number of patients to either an intervention group,
which uses the new toothpaste, or to a control group, which uses the old toothpaste. You would
then measure the amount of cavities between the groups over time.
Orthopaedic Literature Examples
o Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes
Research Trial (SPORT): a randomized trial. JAMA. 2006.
o Should insertion of intramedullary nails for tibial fractures be with or without reaming? A
prospective, randomized study with 3.8 years' follow-up. J Orthop Trauma. 2004.
o Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures.
A multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007.
Cohort study
Definition
o a study in which patient groups are separated non-randomly by exposure or treatment, with
exposure occurring after (prospective), or before (retrospective), the initiation of the study
Evidence
o Level II or III evidence
Analysis
o results usually reported as relative-risk
Example
o you want to determine if smoking is a risk factor for the development of lung cancer. You
identify a group of smokers and a group of non-smokers, and follow them over time measuring
the desired outcome, in this case, lung cancer.
Orthopaedic Literature Examples
o A prospective cohort study of the effects of lower extremity orthopaedic surgery on outcome
measures in ambulatory children with cerebral palsy. J Pediatr Orthop. 2009.
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OrthoBullets2017 Clinical Science | Clinical Studies
o Functional outcomes following displaced talar neck fractures. J Orthop Trauma. 2004.
o Risk of revision for fixed versus mobile-bearing primary total knee replacements. J Bone Joint
Surg Am. 2012.
Case-control study
Definition
o a study in which patient groups are separated by the current presence (cases) or absence
(controls) of disease and examined for the prior exposure of interest
Evidence
o Most are Level III evidence
Analysis
o usually reported as odds-ratio
Example
o you want to determine if smoking is a risk factor for the development of lung cancer. You
compare the smoking history of individuals with lung cancer (cases) and those without
(controls).
Orthopaedic Literature Examples
o Fluoride in drinking water and risk of hip fracture in the UK: a case-control study. Lancet. 2000.
o Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003.
o Risk factors and short-term mortality of venous thromboembolism diagnosed in the primary care
setting in the United Kingdom. Arch Intern Med. 2007.
Meta-analysis
Definition
o a systematic review that summarizes results of other studies
Evidence
o may be used in increase the statistical power of several under-powered studies
Example
o you want to determine if wearing sunscreen results in fewer cases of melanoma. You pool the
results of 9 randomized controlled studies and statistically analyze the data to determine the
effect of the relationship.
Orthopaedic Literature Examples
o Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-
analysis. J Bone Joint Surg Am. 2003.
o Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies. Spine (Phila Pa
1976). 2006.
o Influence of osteoporosis on fracture fixation--a systematic literature review. Osteoporos Int.
2008.
Cross-sectional Study
Definition
o study group is analyzed at a given time ("snapshot") with no follow-up
Example
o you want to determine the prevalence of baseball injuries during the 2003 little-league season
Orthopaedic Literature Examples
o Variability in the definition and perceived causes of delayed unions and nonunions: a cross-
sectional, multinational survey of orthopaedic surgeons. J Bone Joint Surg Am. 2012.
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By Dr, AbdulRahman AbdulNasser Clinical Science | Clinical Studies
o Hypovitaminosis D in patients scheduled to undergo orthopaedic surgery: a single-center
analysis. J Bone Joint Surg Am. 2010.
o Treatment preferences for displaced three- and four-part proximal humerus fractures. J Orthop
Trauma. 2010.
Case Series
Definition
o a retrospective account of multiple patients with the same injury or treatment with no control or
comparison group
useful for generating hypotheses for additional studies
Evidence
o level IV evidence
Example
o you have found that several of your patients who have used a new lipid lowering medication
have developed hemorrhagic cysts. You want to alert other members of the community of this
possible association.
Orthopaedic Literature Examples
o Familial bilateral osteochondritis dissecans of the femoral head. J Bone Joint Surg Am. 2009.
o Familial osteofibrous dysplasia. A case series. J Bone Joint Surg Am. 2005.
o Treatment of posterior cruciate ligament tibial avulsion fractures through a modified open
posterior approach: operative technique and 12- to 48-month outcomes. J Orthop Trauma. 2008.
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OrthoBullets2017 Clinical Science | Clinical Studies
Harris Hip Score
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By Dr, AbdulRahman AbdulNasser Clinical Science | Clinical Studies
Achilles tendinosis
plantar fasciitis
Consists of 5 subscales:
o pain
o other symptoms
o function in daily living (ADL)
o function in sport and recreation
o foot and ankle-related Quality of Life (QOL)
Scoring
o last week is taken into consideration when answering the questionnaire
o each question gets a score from 0 to 4
normalized score (100 indicating no symptoms and 0 indicating extreme symptoms) is
calculated for each subscale.
the result can be plotted as an outcome profile
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OrthoBullets2017 Clinical Science | Clinical Studies
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By Dr, AbdulRahman AbdulNasser Clinical Science | Clinical Studies
o if all 10 sections are completed the score is calculated as follows:
Example: 16 (total scored), 50 (total possible score) x 100 = 32%
o if one section is missed or not applicable the score is calculated:
16 (total scored) 45 (total possible score) x 100 = 35.5%
o interpretation of scores
Survivorship Analysis
Overview
o often used to measure success of joint replacements
o analyzes data from patients with different lengths of follow-up
for analysis, it is assumed that all patients had their operation simultaneously
o chance of implant surviving for a particular length of time is calculated as the survival rate
calculation method is either life table or product limit method
LIfe table method
o number ofjoints being
followed and the number of failures are determined for
each year after operation (number of joints being followed and the number of failures
are determined foreach year after operation each year of follow-up, failure rate is
calculated from the number of failures and the „number at risk‟
o annual success rate, determined from the failure rate, is cumulated to give a survival rate for each
successive year, this can change only once per year
Product limit method
o same as life table method, but the survival rate is recalculated each time a failure occurs
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OrthoBullets2017 Clinical Science | Healthcare Worplace
B. Healthcare Worplace
1. Occupational Health
Risk of Transmission
Risk of HIV transmission
o needlestick
seroconversion from a contaminated needlestick is ~ 0.3%
exposure to large quantities of blood increases risk
seroconversion from exposure to HIV contaminated mucous membranes is ~0.09%
o frozen bone allograft
risk of transmission is <1 per million
donor screening is the most important factor in prevention
no reported cases of transmission from frozen bone allograft since 2001
o blood transfusion
risk of transmission from blood transfusion is 1/500,000 per unit transfused
seronegative blood may still transmit virus due to delay between HIV infection and antibody
development
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By Dr, AbdulRahman AbdulNasser Clinical Science | Healthcare Worplace
Risk of Hepatitis B transmission
o needlestick
37% to 62% eventually seroconvert following needlestick
22 to 31% develop clinical Hepatitis B infection following needlestick
Risk of Hepatitis C transmission
o needlestick
0.5 to 1.8% risk of transmission
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OrthoBullets2017 Clinical Science | Healthcare Worplace
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By Dr, AbdulRahman AbdulNasser Clinical Science | Healthcare Worplace
o "improper performance" makes up 45% of lawsuits
o the most commonly associated procedures
1. operative procedures of joint structures (not including spinal fusion)
2. open reduction of dislocation
3. closed reduction of fractures
4. operative procedures on bones
5. operative procedures on cranial and peripheral nerves
Most common clinical diagnosis associated with orthopaedic lawsuits (as of 2008)
1. osteoarthritis (21%)
2. disorder of joint, not including arthritis
3. fracture of femur
Legislation
Patient Protection and Affordable Care Act - 2010
Physician Payments Sunshine Act - 2010
o Requires collection and reporting of financial relationships between physicians / teaching
hospitals and businesses (manufacturers of drugs, devices, medical supplies)
o All payments beyond $10 must be reported to Centers for Medicare and Medicaid Services
Physician Impairment
Impairment of a healthcare professional is the inability or impending inability to practice according
to accepted standards as a result of substance use, abuse, or dependency (addiction).
A surgeon (resident, fellow or attending) who discovers chemical impairment, dependence, or
incompetence in a colleague or supervisor has the responsibility to ensure that the problem is
identified and treated.
Medical Negligence
Negligence is the failure to provide the standard of health care resulting in medical injuries
A second-opinion physician has an ethical obligation, but not legal obligation, to disclose if the
standard of care has been breached by a treating physician.
A successful patient-plaintiff lawsuit for medical negligence against a physician requires that the
following FOUR elements be alleged and proven in a court of law
o duty
the duty of the physician is to provide care equal to the same standard of care ordinarily
executed by surgeons in the same medical specialty.
o breach of duty
breach of duty occurs when action or failure to act deviates from the standard of care.
o causation
causation is present when it is demonstrated that failure to meet the standard of care was the
direct cause of the patient‟s injuries.
o damages
damages are monies awarded as compensation for injuries sustained as the result of medical
negligence
Workers Compensation
A Workers' Compensation patient is determined to reach maximum medical improvement
when further restoration of function is no longer anticipated and can then settle his/her claim.
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OrthoBullets2017 Clinical Science | Healthcare Worplace
Ability for worker's compensation patients to choose their own physician varies by the statutes of
each state.
Legal definitions
o impairment
loss of function resulting from an anatomic or physiologic derangement.
o disability
limitation of an individual‟s capacity to meet certain personal social or occupational
demands.
Relations with Industry and Hospitals
Acceptable Standards of professionalism
o practicing orthopaedic surgeons may accept tuition, travel, and modest hospitality (including
meals and receptions) to attend an industry sponsored non-CME course given at a local
convention center
o must disclose relationships with industry to patients, colleagues, and their institution
o can only receive gifts with a market value under $100
Medical Innovation
Royalties
o if an implant is used by which the surgeon is receiving royalties, this information must be
disclosed to the patient
Patient Transfer
EMTALA
o all patients must be appropriately screened in the original emergency room/hospital
o risk of patient transfer must be less than the risk of keeping patient
o accepting hospital/center must know of, and accept patient
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By Dr, AbdulRahman AbdulNasser Clinical Science | Healthcare Worplace
Physician Advertising
Advertising by physicians becoming more commonplace
o AMA and AAOS can't prevent physicians from advertising services
o FTC, AAOS, state medical boards can sanction for false advertising
o things to avoid
using terms such as "cure" if no cure truly exists
using terms such as "painless" or "bloodless" to describe surgery
overstating credentials such as "board certified in joint replacement" if no such qualification
exists
using terms such as "world renowned"
Diversity
Important to understand cultural differences
o patient-physician relationships are enhanced
o disparities in health care are eliminated
o access to orthopaedic care is optimized
Important to understand your own implicit biases
o Implicit bias is present when your unconscious prejudices or stereotypes influence the care
delivered to the patient.
o Implicit bias is a determinant of health disparities.
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10
ORTHO BULLETS
Volume Ten
Anatomy
&
Approaches
2017
Collected By : Dr AbdulRahman AbdulNasser
[email protected]
OrthoBullets 2017
OrthoBullets 2017
Preface
Orthobullets.com is an educational resource for
orthopaedic surgeons designed to improve
training through the communal efforts of those
who use it as a learning resource. It is a simple but
powerful concept. All of our topics, technique
guides, cases, and user-generated videos are
free, and will stay that way.
1. Femur Lateral Approach ........... 121 2. Tarsus and Ankle Kocher (Lateral)
2. Femur Posterolateral Approach 122 Approach ...................................... 152
Anatomy
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Shoulder Muscles
ORTHO BULLETS
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OrthoBullets2017 Upper Limb Anatomy | Shoulder Muscles
A. Shoulder Muscles
Serratus
Origin Superolateral surfaces of upper 8 or 9 ribs at the
side of chest
Insertion Vertebral border of scapula
Draws scapula forward and upward; abducts
Action scapula and rotates it; stabilizes vertebral border of
scapula
Innervation Long thoracic nerve (C5, C6, C7) >>
Arterial Supply Circumflex scapular artery
Clinical
Scapular Winging
Conditions
Levator scapulae
Origin Posterior tubercles of transverse processes of C1 -
C4 vertebrae
Insertion Superior part of medial border of scapula
Elevates scapula and tilts its glenoid cavity inferiorly
Action
by rotating scapula
Dorsal scapula (C5) and cervical (C3 and C4)
Innervation
nerves (C3, C4, C5)
Arterial Supply Dorsal scapular artery
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Shoulder Muscles
Rhomboid Minor and Major
Origin Minor: nuchal ligament and spinous processes of C7
and T1 vertebrae; Major: spinous processes of T2 - T5
vertebrae
Medial border of scapula from level of spine to inferior
Insertion
angle
Retract scapula and rotate it to depress glenoid cavity;
Action
fix scapula to thoracic wall
Innervation Dorsal scapular nerve ( C4 and C5) (C4, C5)
Arterial Supply Dorsal scapular artery
Scalene
Origin Transverse process of C2 to C7
Anterior and medial scalene insert on first rib. Posterior
Insertion
scalene inserts on second rib.
Anterior and medial scalene elevate first rib and flexes
Action neck to same side. Posterior scalene elevates second
rib and flexes neck to same side.
Innervation Brachial plexus
Ascending cervical a., a branch of the thyrocervical
Arterial Supply
trunk
Pectoralis Minor
Origin 3rd to 5th ribs near their costal cartilages
Medial border and superior surface of coracoid process
Insertion
of scapula
Stabilizes scapula by drawing it inferiorly and anteriorly
Action
against thoracic wall
Innervation Medial pectoral nerves; (C8 and T1)
Arterial Supply Pectoral branch of the thoracoacromial trunk
2. Arm Adductors
Pectoralis Major
Origin Clavicular head: anterior surface of medial half of
clavicle; Sternocostal head: anterior surface of sternum,
superior six costal cartilages, and aponeurosis of external
oblique muscle
Insertion Lateral lip of intertubercular groove of humerus
Adducts and medially rotates humerus; draws scapula
Action anteriorly and inferiorly; Acting alone: clavicular head
flexes humerus and sternocostal head extends it
Lateral and medial pectoral nerves; clavicular head (C5
Innervation and C6, sternocostal head (C7, C8, and T1) (C5, C6, C7,
C8, T1)
Arterial Supply pectoral branch of the thoracoacromial trunk
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OrthoBullets2017 Upper Limb Anatomy | Shoulder Muscles
Teres Major
Origin Dorsal surface of inferior angle of scapula
Insertion Medial lip of intertubercular groove of humerus
Action Adducts and medially rotates arm
Lower subscapular nerve (C6 and C7) (C6,
Innervation
C7)
Arterial Supply Subscapular and circumflex scapular arteries
Latissimus Dorsi
Origin Spinous processes of inferior 6 thoracic
vertebrae, thoracolumbar fascia, iliac crest,
and inferior 3 or 4 ribs
Insertion Floor of intertubercular groove of humerus
Extends, adducts, and medially rotates
Action humerus; raises body toward arms during
climbing
Thoracodorsal nerve (C6, C7, and C8) (C6,
Innervation
C7, C8)
Arterial Supply Thoracodorsal artery
Coracobrachialis
Origin Tip of coracoid process of scapula
Insertion Middle third of medial surface of humerus
Action Helps to flex and adduct arm
Musculocutaneous nerve (C5, C6 and C7)
Innervation
(C5, C6, C7)
Arterial Supply Muscular branches of brachial artery
3. Arm Abductors
Deltoid
Origin Lateral third of clavicle, acromion, and spine of
scapula
Insertion Deltoid tuberosity of humerus
Anterior part: flexes and medially rotates arm;
Action Middle part: abducts arm; Posterior part:
extends and laterally rotates arm
Innervation Axillary nerve (C5 and C6) (C5, C6)
Arterial Supply Deltoid branch of thoracoacromial artery
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Shoulder Muscles
Infraspinatus
Origin Infraspinous fossa of scapula
Insertion Middle facet on greater tuberosity of humeruss
Laterally rotate arm; helps to hold humeral
Action
head in glenoid cavity of scapula
Innervation Suprascapular nerve (C5 and C6) (C5, C6)
Suprascapular and circumflex scapular
Arterial Supply
arteries
Teres Minor
Origin Superior part of lateral border of scapula
Insertion Inferior facet on greater tuberosity of humerus
Laterally rotate arm; helps to hold humeral
Action
head in glenoid cavity of scapula
Innervation Axillary nerve (C5 and C6) (C5, C6)
Arterial Supply Subscapular and circumflex scapular arteries
Subscapularis
Origin Subscapular fossa of scapula
Insertion Lesser tuberosity of humerus
Medially rotates arm and adducts it; helps to
Action
hold humeral head in glenoid cavity of scapula
Upper and lower subscapular nerves (C5, C6
Innervation
and C7) (C5, C6, C7)
Arterial Supply Subscapular artery
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OrthoBullets2017 Upper Limb Anatomy | Arm Muscles
B. Arm Muscles
1. Elbow Flexors
Biceps Brachii
Origin Short head: tip of coracoid process of scapula; Long
head: supraglenoid tubercle of scapula
Tuberosity of radius and fascia of forearm via bicipital
Insertion
aponeurosis
Supinates forearm and, when it is supine, flexes
Action
forearm
Innervation Musculocutaneous nerve (C5,C6 )
Arterial Supply Muscular branches of brachial artery
Brachialis
Origin Distal half of anterior surface of humerus
Insertion Coronoid process and tuberosity of ulna
Major flexor of forearm -- flexes forearm in all
Action
positions
Innervation Musculocutaneous nerve (C5,C6) & Radial nerve
Muscular branches of brachial artery, recurrent radial
Arterial Supply
artery
Brachioradialis
Origin Proximal 2/3 of lateral supracondyle ridge of humerus
Insertion Lateral surface of distal end of radius
Action Flexes forearm
Innervation Radial nerve (C5, C6, C7)
Arterial Supply Radial recurrent artery
2. Elbow Extensors
Triceps Brachii
Origin Long head: infraglenoid tubercle of scapula; Lateral
head: posterior surface of humerus, superior to radial
groove; Medial head: posterior surface of humerus,
inferior to radial groove
Proximal end of olecranon process of ulna and fascia
Insertion
of forearm
Chief extensor of forearm; long head steadies head
Action
of abducted humerus
Innervation Radial nerve (C6, C7 and C8) (C6, C7, C8)
Arterial Supply Branches of deep brachial artery
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Arm Muscles
3. Common Flexors
Pronator Teres
Origin Medial epicondyle of humerus and coronoid process of ulna
Insertion Middle of lateral surface of radius
Action Pronates and flexes forearm (at elbow)
Innervation Median nerve (C6, C7)
Arterial Supply Ulnar artery, anterior recurrent ulnar artery
Palmaris Longus
Origin Medial epicondyle of humerus
Insertion Distal half of flexor retinaculum and palmar aponeurosis
Action Flexes hand (at wrist) and tightens palmar aponeurosis
Innervation Median nerve (C7 and C8) (C7, C8)
Arterial Supply Ulnar artery
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OrthoBullets2017 Upper Limb Anatomy | Arm Muscles
4. Deep Flexors
Flexor Digitorum Profundus
Origin Proximal 3/4 of medial and anterior surfaces of ulna and
interosseous membrane
Insertion Base of the distal phalanx of digits 2 - 5
Flexes distal phalanges at distal interphalangeal joints of
Action
medial four digits; assists with flexion of hand
Medial part: ulnar nerve (C8 and T1); Lateral part: anterior
Innervation
interosseous branch of median nerve (C8 and T1) (C8, T1)
Arterial Supply Ulnar and anterior interosseous arteries
Pronator quadrates
Origin Distal 1/4 of anterior surface of ulna
Insertion Distal 1/4 of anterior surface of radius
Pronates forearm; deep fibers bind radius and ulna
Action
together
Anterior interosseous nerve from median nerve (C8 and
Innervation
T1) (C8, T1)
Arterial Supply Anterior interosseous artery
5. Common Extensors
Anconeus
Origin Lateral epicondyle of humerus
Lateral surface of olecranon and superior part of posterior
Insertion
surface of ulna
Assists triceps in extending forearm (terminal 15° of
Action extension and supination); stabilizes elbow joint; abducts
ulna during pronation
Innervation Radial nerve (C7, C8 and T1) (C7, C8, T1)
Medial collateral artery; recurrent posterior interosseous
Arterial Supply
artery, posterior branch of radial collateral artery
- 8 -
By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Arm Muscles
Extensor Carpi Radialis Longus
Origin Lateral supracondyle ridge of humerus
Insertion Base of 2nd metacarpal
Wrist extension and wrist abduction (radial
Action
deviation)
Innervation Radial nerve (C6, C7)
Arterial Supply Radial artery
Extensor Digitorum
Origin Lateral epicondyle of humerus
Insertion Extensor expansions of medial four digits
Extends medial four digits at
Action metacarpophalangeal joints; Extends hand at
wrist joint
Posterior interosseous nerve (C7 and C8), the
Innervation continuation of the deep branch of the radial
nerve (C7, C8)
Interosseous recurrent and posterior
Arterial Supply
interosseous arteries
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OrthoBullets2017 Upper Limb Anatomy | Arm Muscles
Extensor Carpi Ulnaris
Origin Lateral epicondyle of humerus and
posterior border of ulna
Insertion Base of 5th metacarpal
Wrist extension and wrist adduction
Action
6. Deep Extensors
Supinator
Origin Lateral epicondyle of humerus, radial
collateral and annular ligaments, supinator
fossa and crest of ulna
Lateral, posterior and anterior surfaces of
Insertion
proximal 1/3 of radius
Supinates forearm (i.e., rotates radius to
Action
turn palm anteriorly)
Deep branch of radial nerve (C5 and C6)
Innervation
(C5, C6)
Arterial Supply Recurrent interosseous artery
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Arm Muscles
Extensor Pollicis Brevis
Origin Posterior surfaces of radius and interosseous
membrane
Insertion Base of proximal phalanx of thumb
Extends proximal phalanx of thumb at
Action
metacarpophalangeal joint
Posterior interosseous nerve (C7 and C8), the
Innervation continuation of the deep branch of the radial nerve
(C7, C8)
Arterial Supply Posterior interosseous artery
Clinical
De Quervain's Tenosynovitis
Relevance
Extensor Indicis
Origin Posterior surface of ulna and interosseous
membrane
Insertion Extensor expansion of 2nd digit
Action Extends 2nd digit and helps to extend hand
Posterior interosseous nerve (C7 and C8), the
Innervation continuation of the deep branch of the radial nerve
(C7, C8)
Arterial Supply Posterior interosseous artery
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OrthoBullets2017 Upper Limb Anatomy | Hand Muscles
C. Hand Muscles
1. Thenars
Opponens Pollicis
Origin Flexor retinaculum and tubercles of scaphoid and
trapezium
Insertion Lateral side of 1st metacarpal
Draws 1st metacarpal laterally to oppose thumb
Action
toward center of palm and rotates it medially
Recurrent branch of median nerve (C8 and T1) (C8,
Innervation
T1)
Arterial Supply Superficial palmar branch of the radial artery
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Hand Muscles
Adductor Pollicis
Origin Oblique head: bases of 2nd and 3rd metacarpals,
capitate, and adjacent carpals; Transverse head:
anterior surface of body of 3rd metacarpal
Insertion Medial side of base of proximal phalanx of thumb
Draws 1st metacarpal laterally to oppose thumb
Action
toward center of palm and rotates it medially
Innervation Deep branch of ulnar nerve (C8 and T1) (C8, T1)
Arterial Supply Deep palmar arterial arch
2. Hypothenars
Palmaris brevis
Origin Transverse carpal ligament, palmar apnurosis
Insertion Ulnar palm
Action Wrinkles the skin of medial palm
Innervation Ulnar nerve
Arterial Supply Ulnar artery
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OrthoBullets2017 Upper Limb Anatomy | Hand Muscles
3. Intrinsics
Dorsal interossei
Origin Dorsal 1 - 4: Adjacent sides of two metacarpals
(bipennate muscles)
Dorsal 1 - 4: Extensor expansions and bases of
Insertion
proximal phalanges of digits 2 - 4
Dorsal 1 - 4: Abduct digits from axial line and act with
Action lumbricals to flex metacarpophalangeal joints and
extend interphalangeal joints
Innervation Deep branch of ulnar nerve (C8 and T1) (C8, T1)
Arterial Supply Dorsal 1 - 4: Dorsal and palmar metacarpal arteries
Palmar interossei
Origin Palmar 1 - 3: Palmar surfaces of 2nd, 4th and 5th
metacarpals (unipennate muscles)
Palmar 1 - 3: Extensor expansions of digits and bases
Insertion
of proximal phalanges of digits 2, 4 and 5
Palmar 1 - 3: Adduct digits toward axial line and assist
Action lumbricals in flexing metacarpophalangeal joints and
extending interphalangeal joints
Innervation Deep branch of ulnar nerve (C8 and T1) (C8, T1)
Arterial Supply Palmar 1 - 3: Palmar metacarpal arteries
Lumbrical Muscles
Origin FDP tendon
Insertion Radial lateral band of the extensor expansion (tendon)
Action Extends PIP and DIP joint.
1nd & 2nd lumbricals innervated by median nerve.
Innervation
3rd & 4th lumbicals innervated by ulnar nerve
Arterial Supply Palmar 1 - 3: Palmar metacarpal arteries
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In July 2017
- 14 -
By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Nerves of Upper Limb
1. Brachial Plexus
Introduction
Standard: C5, C6, C7, C8, T1 – 77% of patients
Prefixed: Prefixed (contributions from C3, C4) – 22%
Postfixed (roots caudal to T1) – 1%
Anatomy
Remember: Robert Turner Drinks Cold Beer
Roots (5): ventral rami of C5-T1, superior and posterior to subclavian
o dorsal scapular nerve (C5): through levator scapula to supply levator scapula, rhomboid major &
minor
o long thoracic nerve (C5, 6, 7): posterior to plexus onto thoracic wall to supply serratus anterior
Trunks (3): emerge from triangle formed by anterior scalene, middle scalene, first rib
o superior (C5,6 roots)
suprascapular nerve (C5, 6): through suprascapular notch to supraspinatus, infraspinatus, AC
and glenohumeral joints
nerve to subclavius (C5, 6)
o middle (C7)
o inferior (C8, T1)
Divisions (6): 3 anterior, 3 posterior (each trunk gives 1 anterior and 1 posterior division)
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OrthoBullets2017 Upper Limb Anatomy | Nerves of Upper Limb
Cords (3):
o Posterior Cord: formed from 3 posterior division
upper subscapular nerve (C5, 6): subscapularis
lower subscapular nerve (C5,6): subscapularis, teres major
thoracodorsal nerve (C6, 7, 8): latissmus dorsi
o Lateral Cord: ant divisions of superior & middle trunks (C5, 6, 7)
lateral pectoral nerve (C5, 6, 7): pectoralis major, communication with medial pectoral nerve
o Medial Cord: anterior division of inferior trunk (C8, T1)
medial pectoral nerve (C8, T1): pierces pec minor; supplies pec minor and major
medial brachial cutaneous nerve (T1)
medial antebrachial cutaneous nerve (C8, T1)
Branches (6) – 2 terminal branches from each cord
Posterior cord:
axillary nerve (C5, 6): through quadrilateral space to teres minor, deltoid, major nerve
supply to glenohumeral joint, superior lateral brachial cutaneous nerve
radial nerve (C5 – T1): runs with long head of triceps (triangular interval) into radial
groove on posterior humerus; supplies elbow & forearm extensors, supinator; posterior
brachial cutaneous, inferior lateral brachial cutaneous, posterior antebrachial cutaneous,
superficial radial (post. radial hand)
Lateral cord:
lateral cord of median nerve (C5 – C7): joins medial cord anterior to axillary artery then
travels with artery: wrist flexors (except FCU, ulnar ½ FDP), pronators, radial two
lumbricals, OP, APB, superficial head FPB); sensory distribution in hand
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Nerves of Upper Limb
3. Musculocutaneous Nerve
Innervation
Motor
o coracobrachialis
o biceps
o medial brachialis
Sensory
o lateral antebrachial cutaneous nerve
forearm sensory
Origin
C5,6,7
o superior trunk
lateral cord
musculocutaneous nerve
branch to coracobrachialis
branch to biceps
branch to brachialis
lateral antebrachial cutaneous nerve (terminal branch)
Course
Pierces Coracobrachialis
o pierces coracobrachialis 3-8 cm distal to coracoid
o gives branch to coracobrachialis
4. Radial nerve
Innervation
Motor
o radial nerve proper
o triceps
anconeus
ECRL
ECRB
brachioradialis
o PIN
ED
supinator
EDM
ECU
APL
EPL
EPB
EIP
Sensory
o posterior cutaneous nerve arm I :1 Reinnervation sequence depends on nerve
o posterior cutaneous nerve - forearm length. Based on the shortest mean nerve and
branch length, the order of reinnervation is
o superficial branch radial nerve BR (brachioradialis), ECRL, supinator,
o dorsal digital branch ECRB, EDC, ECU, EDQ, APL, EPL, EPB,
EIP.
Origin
Radial nerve originates from the posterior cord of the brachial plexus (C5-T1)
o behind axillary artery
Course
Posterior wall axilla
o courses on the posterior wall of the axilla (on subscapularis, latissimus dorsi, teres major)
o 3 Branches in axilla
posterior cutaneous nerve of the arm
branch to long head of triceps
branch to medial head of triceps
Triangular interval
o it then runs through the triangular interval with profunda brachii artery in posterior compartment
between long head of triceps and humerus
Spiral groove
o next it courses through the spiral groove between lateral and medial heads of triceps
bottom line = Safe zone posteriorly of 10 cm distal to the lateral acromion and 10 cm
proximal to lateral epicondyle
o branches in spiral groove
inferior lateral cutaneous nerve of the arm
posterior cutaneous nerve of the forearm
branch to lateral head of triceps
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OrthoBullets2017 Upper Limb Anatomy | Nerves of Upper Limb
branch to medial head of triceps and anconeus
Lateral intermuscular septa
o Next it passes through the lateral intermuscular septa never less than 7.5 cm above the distal
articular surface.
o runs between brachialis and brachioradialis (anterior to lateral epicondyle)
gives branches to supply: lateral brachialis, brachioradialis, ECRL, ECRB
Terminal branches
o level of radiohumeral joint line, divides into terminal branches
superficial sensory branch
Deep branch/PIN
ECRB branch
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Nerves of Upper Limb
Motor Innervation
Motor
o common extensors
ECRB (often from radial nerve proper, but can be from PIN)
Extensor digitorum communis (EDC)
Extensor digiti minimi (EDM)
Extensor carpi ulnaris (ECU)
o deep extensors
Supinator
Abductor pollicis longus (APL)
Extensor pollicus brevis (EPB)
Extensor pollicus longus (EPL)
Extensor indicis proprius (EIP)
Senory Innervation
Sensory
o sensory fibers to dorsal wrist capusle
provided by terminal branch which is located on the floor of the 4th extensor compartment
o no cutaneous innervation
Clinical
PIN compression Syndrome
o in PIN palsy, the last muscle to recover is the extensor indicis proprius
Dorsal Approach to Radius (Thompson)
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OrthoBullets2017 Upper Limb Anatomy | Nerves of Upper Limb
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Nerves of Upper Limb
Origin
Originates from the radial nerve proper at the level of the radiocapitellar joint.
Course
Underneath the brachioradialis
o runs distally in the forearm underneath the brachioradialis, lateral to the radial artery.
Forearm deep fascia
o It pierces the deep fascia of the forearm approximately 7 cm proximal to the radiocarpal joint
(9 cm proximal to radial styloid)
o runs over snuff box to supply dorsal radial surface of hand
Terminal branches
o It then divides into two branches: medial and lateral.
7. Axillary Nerve
Innervation
Motor
o deltoid
o teres minor
Sensory
o superficial lateral cutaneous nerve of arm
lateral shoulder sensation
Origin
Originates from the brachial plexus
o middle trunk, posterior division, posterior cord
Carries fibers from C5 and C6
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OrthoBullets2017 Upper Limb Anatomy | Nerves of Upper Limb
Course
Comes off posterior cord behind the axillary artery, anterior to the subscapularis muscle
Travels through the quadrangular space
o runs here with the posterior circumflex humeral artery and vein
Gives off an anterior, posterior, and articular terminal branch
Terminal branches
o anterior branch
wraps around the surgical neck of the humerus on the undersurface of the deltoid
supplies the anterior deltoid muscle
traditional "safe zone" from lateral acromion is 5 cm
anterior branch has been shown to run 3-5 cm from the acromion in 20% of patients
arm abduction to 90° REDUCES distance between acromion and nerve by 30%
damage to nerve with a muscle split here will denervate the anterior deltoid
terminates in small cutaneous branches for the anterior/anterolateral skin
o posterior branch
supplies the teres minor and posterior deltoid muscles
branch to the teres minor is closest to glenoir labrum and most susceptible during
arthroscopy
pierces the deep fascia and terminates as the superior lateral cutaneous nerve of the arm
o articular branch
enters the shoulder joint inferior to the subscapularis
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Nerves of Upper Limb
8. Median nerve
Innervation
Motor
o superficial volar forearm group
o Pronator teres
Flexor carpi radialis
Palmaris longus
o intermediate group
Flexor digitorum superficialis
o deep group
Flexor digitorum profundus (lateral)
Flexor pollicis longus
Pronator quadratus
o hand
1st and 2nd lumbricals
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
Origin
Brachial plexus
o C5-T1 roots
medial and lateral cords
Course
Anterior compartment of arm
o anterior compartment (anteromedial to humerus)
o runs with brachial artery (lateral in upper arm / medial at elbow)
o no branches in the arm
Forearm
o enters the forearm between the pronator teres and biceps tendon
o travels between flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP)
o then emerges between the FDS and flexor pollicis longus (FPL)
Hand
o the nerve then enters the hand via the carpal tunnel, along with the tendons of the FDS, FDP and
FPL
Terminal branches
o anterior interosseous branch (AIN)
innervates the deep volar compartment of forearm except the ulnar half of the FDP
o palmar cutaneous branch
supplies sensory innervation to lateral palm
o recurrent branch (to thenar compartment)
o digital cutaneous branches
supply the radial 3 1/2 digits (palmar)
can also supply the index, long, and ring fingers dorsally
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OrthoBullets2017 Upper Limb Anatomy | Nerves of Upper Limb
Clinical Conditions
Carpal Tunnel Syndrome
AIN Neuropathy
Pronator Syndrome
Motor Innervation
Motor
o deep forearm muscles
flexor digitorum profundus - radial half
flexor pollicis longus
pronator quadratus
Sensory Innervation
Sensory
o sensory fibers to volar wrist joint capsule
o no cutaneous innervation
Clinical Conditions
AIN compressive neuropathy
Pediatric supracondylar fractures
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Nerves of Upper Limb
Course
Arm
o lies posteromedial to brachial artery in anterior compartment of
upper 1/2 arm
o pierces medial IM septum at the arcade of Struthers ~ 8cm from
medial epicondyle and lies medial to the triceps
the arcade of Struthers is an aponeurotic band extending from
the medial IM septum to the medial head of the triceps
Elbow
o runs behind medial epicondyle with superior ulnar collateral artery
o Cubital tunnel
roof - Osbourne’s ligament proximally (extension of deep forearm fascia between heads of
FCU) and FCU aponeurosis distally
floor - posterior and transverse bands of MCL and elbow joint capsule
o sends small sensory branch to elbow that can be sacrificed
Forearm
o enters forearm between 2 heads (humeral and ulnar heads) of FCU
o runs between FCU and FDP
Wrist
o the ulnar nerve and artery pass superficial to the transverse carpal ligament
o bifurcates into sensory and deep motor branches in Guyon's canal
roof - volar carpal ligament
floor - transverse carpal ligament, hypothenar muscles
ulnar border - pisiform and pisohamate ligament, abductor
digiti minimi muscle belly
radial border – hook
of hamate
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OrthoBullets2017 Upper Limb Anatomy | Nerves of Upper Limb
I:6 Ulnar nerve at the wrist lying superficial to the transverse carpal ligament
I:7 The ulnar nerve bifurcates into sensory and deep motor branches in Guyon's canal
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Nerves of Upper Limb
Innervation
Motor Innervation
o forearm
FCU
FDP ring and small
o thenar
adductor pollicis
deep head of flexor pollicis brevis (FPB)
o fingers
interossei (dorsal & palmar)
3rd & 4th lumbricals
o hypothenar muscles I:8 Demonstrating deep flexor-pronator mass - the most distal possible
abductor digiti minimi site of compression of the ulnar nerve
opponens digiti minimi
flexor digiti minimi
Sensory Innervation
o sensory branches of ulnar nerve
dorsal cutaneous branch
palmar cutaneous branch
superficial terminal branches
Clinical Conditions
Cubital Tunnel Syndrome
o sites of compression (proximal to distal)
medial intermuscular septum
most proximal site, 8cm proximal to medial
epicondyle
Arcade of Struthers
medial epicondyle (osteophytes)
cubital tunnel retinaculum (Osborne's ligament) I:9 Reduced cubital tunnel volume during
anconeus epitrochlearis muscle replaces Osborne's elbow flexion
ligament in 11% of population, causing static
compression
aponeurosis of the two heads of the FCU (arcuate ligament)
often continuous with Osbourne's ligament
deep flexor/pronator aponeurosis
most distal site, 4 cm distal to medial epicondyle
o elbow flexion reduce cubital tunnel volume because
FCU aponeurosis tenses
Osborne's ligament becomes taught
MCL bulges into cubital tunnel
o the internal anatomy of the ulnar nerve explains the predominance of hand symptoms in cubital
tunnel syndrome
fibers to FCU and FDP are central and hand intrinsic fibers are peripheral
Ulnar tunnel syndrome
o compression in Guyon’s Canal
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OrthoBullets2017 Upper Limb Anatomy | Nerves of Upper Limb
no involvement of dorsal cutaneous nerve since it branches before canal
no involvement of FDP of 4th & 5th and FCU
causes
ganglia most common cause (from triquetrohamate joint, 30-50%)
other causes include mass, trauma (fracture of distal radius or ulna, hook of hamate),
muscle anomaly, ulnar artery aneurysm or thrombosis
compression sites
Zone 1: proximal to bifurcation, both motor & sensory symptoms
caused by hook of hamate fracture and ganglia
Zone 2: deep motor branch, motor symptoms only
caused by hook of hamate fracture and ganglia
Zone 3: superficial sensory branch, sensory symptoms only
caused by ulnar artery aneurysm or thrombosis
- 30 -
By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Nerves of Upper Limb
- 31 -
OrthoBullets2017 Upper Limb Anatomy | Nerves of Upper Limb
Origin
C5,6,7
o superior trunk
lateral cord
musculocutaneous nerve
lateral antebrachial cutaneous nerve
Terminal Branches
Volar
o runs distally along radial border of forearm, supplying lateral volar forearm skin sensation
o small branches innervate the radial aspect of radiocarpal joint
o ends in communicating branches to
superficial branch of the radial nerve (dorsal radial thumb innervation)
palmar cutaneous branch of median nerve (volar thumb innervation)
Dorsal
o runs distally along dorsal radial forearm, supplying dorsal-lateral cutaneous innervation
o ends in communicating branches
superficial radial nerve
dorsal antebrachial cutaneous branch of radial nerve
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In July 2017
- 32 -
By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Nerves of Upper Limb
Brachial Plexus
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OrthoBullets2017 Upper Limb Anatomy | Blood Supply of the Upper Limb
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Anatomic Regions of The Upper Limb
Quadrangular Space
Borders
o medial: long head of triceps
o lateral: humeral shaft
o superior: teres minor
o inferior: teres major
Contents
o axillary nerve
passes through the quadrilateral space on
its path to innervate the teres minor and
deltoid and provide sensation to the lateral
arm
o posterior humeral circumflex artery
Triangular Space
Borders
o inferior: teres major
o lateral: long head of triceps
o superior: lower border of teres minor
Contents
o scapular circumflex artery
Triangular Interval
Borders
o superior: teres major
o lateral: lateral head of the triceps or the humerus
o medial: long head of the triceps
Contents
o profunda brachii artery
o radial nerve
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In July 2017
- 35 -
OrthoBullets2017 Lower Limb Anatomy | Anatomic Regions of The Upper Limb
ORTHO BULLETS
- 36 -
By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Hip / Thigh Muscles
Psoas
Origin Anterior surfaces and lower borders of transverse
processes of L1 - L5 and bodies and discs of T12 - L5
Insertion Lesser trochanter
Action Flex the torso and thigh with respect to each other
Innervation Direct fibers of L1 - L3 of lumbar plexus (L1, L2, L3)
Arterial Supply Lumbar branch of iliopsoas branch of internal iliac artery
Sartorius
Origin Anterior superior iliac spine
Superior aspect of the medial surface of the tibial shaft
Insertion near the tibial tuberosity (joins gracilis and
semitendinosus at the pes anserinus)
Flexes and laterally rotates the hip joint and flexes the
Action
knee
Innervation Femoral nerve (L2, L3, L4)
Arterial Supply Muscular branches of the femoral artery
Relevant Conditions : Anterior Superior Iliac Spine (ASIS) Avulsion
Pectineus
Origin Pecten pubis and pectineal surface of the pubis
Insertion Pectineal line of femur
Action Adducts the thigh and flexes the hip joint
Femoral nerve usually, although it may sometimes
Innervation receive additional innervation from the obturator nerve as
well (L2, L3, L4)
Medial circumflex femoral branch of femoral artery and
Arterial Supply
obturator artery
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OrthoBullets2017 Lower Limb Anatomy | Hip / Thigh Muscles
Vastus lateralis
Origin Superior portion of intertrochanteric line, anterior and
inferior borders of greater trochanter, superior portion of
lateral lip of linea aspera, and lateral portion of gluteal
tuberosity of femur
Lateral base and border of patella; also forms the lateral
Insertion patellar retinaculum and lateral side of quadriceps femoris
tendon
Action Extends the knee
Innervation Muscular branches of femoral nerve (L2, L3, L4)
Rectus femoris
Arterial Supply Lateral circumflex femoral artery
Vastus intermedius
Origin Superior 2/3 of anterior and lateral surfaces of femur; also
from lateral intermuscular septum of thigh
Lateral border of patella; also forms the deep portion of the
Insertion
quadriceps tendon
Action Extends the knee
Innervation Muscular branches of femoral nerve (L2, L3, L4)
Arterial Supply Lateral circumflex femoral artery
Vastus medialis
Origin Inferior portion of intertrochanteric line, spiral line, medial
lip of linea aspera, superior part of medial supracondylar
ridge of femur, and medial intermuscular septum
Medial base and border of patella; also forms the medial
Insertion patellar retinaculum and medial side of quadriceps femoris
tendon
Action Extends the knee
Innervation Muscular branches of femoral nerve (L2, L3, L4)
Femoral artery, profunda femoris artery, and superior
Arterial Supply
medial genicular branch of popliteal artery The three vasti
- 38 -
By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Hip / Thigh Muscles
Gluteus medius
Origin Dorsal ilium inferior to iliac crest
Insertion Lateral and superior surfaces of greater trochanter
Major abductor of thigh; anterior fibers help to rotate hip
Action
medially; posterior fibers help to rotate hip laterally
Innervation Superior gluteal nerve (L4, L5, S1) (L4, L5, S1)
Arterial Supply Superior gluteal artery
Relevant Approaches : Lateral Approach to Hip
Clinical conditions : Trendelenberg Gait
Physical exam : Trendelenberg Sign
Gluteus minimus
Origin Dorsal ilium between inferior and anterior gluteal lines; also
from edge of greater sciatic notch
Insertion Anterior surface of greater trochanter
Action Abducts and medially rotates the hip joint
Innervation Superior gluteal nerve (L4, L5, S1) (L4, L5, S1)
Arterial Supply Superior gluteal artery
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OrthoBullets2017 Lower Limb Anatomy | Hip / Thigh Muscles
Adductor brevis
Origin Anterior surface of inferior pubic ramus, inferior to
origin of adductor longus
Pectineal line and superior part of medial lip of linea
Insertion
aspera
Adducts and flexes the thigh, and helps to laterally
Action
rotate the thigh
Anterior or posterior division of obturator nerve (L4,
Innervation
L2, L3)
Arterial Supply Obturator artery and medial circumflex femoral artery
Adductor magnus
Origin Inferior pubic ramus, ischial ramus, and inferolateral
area of ischial tuberosity
Gluteal tuberosity of femur, medial lip of linea aspera,
Insertion
medial supracondylar ridge, and adductor tubercle
Powerful thigh adductor; superior horizontal fibers also
Action help flex the thigh, while vertical fibers help extend the
thigh
Posterior division of obturator nerve innervates most of
Innervation the adductor magnus; vertical or hamstring portion
innervated by tibial nerve (L2, L3, L4)
Medial circumflex femoral artery, inferior gluteal artery,
Arterial Supply 1st - 4th perforating arteries, obturator artery, and
some superior muscular branches of popliteal artery
- 40 -
By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Hip / Thigh Muscles
Gracilis
Origin Inferior margin of pubic symphysis, inferior ramus of
pubis, and adjacent ramus of ischium
Insertion Medial surface of tibial shaft, just posterior to sartorius
Flexes the knee, adducts the thigh, and helps to
Action
medially rotate the tibia on the femur
Innervation Anterior division of obturator nerve (L2, L3)
Obturator artery, medial circumflex femoral artery, and
Arterial Supply
muscular branches of profunda femoris artery
Semitendinosus
Origin From common tendon with long head of biceps
femoris from superior medial quadrant of the
posterior portion of the ischial tuberosity
Insertion Superior aspect of medial portion of tibial shaft
Extends the thigh and flexes the knee, and also
Action rotates the tibia medially, especially when the knee is
flexed
Innervation Tibial nerve (L5, S1, S2)
Perforating branches of profunda femoris artery,
Arterial Supply inferior gluteal artery, and the superior muscular
branches of popliteal artery
Semimembranosus
Origin Superior lateral quadrant of the ischial tuberosity
Insertion Posterior surface of the medial tibial condyle
Extends the thigh, flexes the knee, and also rotates
Action
the tibia medially, especially when the knee is flexed
Innervation Tibial nerve (L5, S1, S2)
Perforating branches of profunda femoris artery,
Arterial Supply inferior gluteal artery, and the superior muscular
branches of popliteal artery
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OrthoBullets2017 Lower Limb Anatomy | Hip / Thigh Muscles
Biceps femors long head
Origin Common tendon with semitendinosus from superior
medial quadrant of the posterior portion of the ischial
tuberosity
Primarily on fibular head; also on lateral collateral
Insertion
ligament and lateral tibial condyle
Flexes the knee, and also rotates the tibia laterally;
Action
long head also extends the hip joint
Innervation Tibial nerve (L5, S1, S2)
Perforating branches of profunda femoris artery,
Arterial Supply inferior gluteal artery, and the superior muscular
branches of popliteal artery
Piriformis
Origin Anterior surface of lateral process of sacrum and
gluteal surface of ilium at the margin of the greater
sciatic notch
Insertion Superior border of greater trochanter
Lateral rotator of the hip joint; also helps abduct the
Action
hip if it is flexed
Innervation Piriformis nerve (L5, S1, S2) (L5, S1, S2)
Superior and inferior gluteal and internal pudendal
Arterial Supply
arteries
- 42 -
By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Hip / Thigh Muscles
Obturator externus
Origin External surface of obturator membrane and anterior
bony margins of obturator foramen
Trochanteric fossa on the medial surface of the
Insertion
greater trochanter
Action Rotates the thigh laterally; also helps adduct thigh
Posterior division of obturator nerve innervates most
Innervation
of the obturator externus; (L3, L4)
Arterial Supply Obturator and medial circumflex femoral arteries
Obturator internus
Origin Internal surface of obturator membrane and posterior
bony margins of obturator foramen
Medial surface of greater trochanter of femur, in
Insertion
common with superior and inferior gemelli
Rotates the thigh laterally; also helps abduct the
Action
thigh when it is flexed
Nerve to the obturator internus and superior gemellus
Innervation
-- a branch of the sacral plexus (L5, S1) (L5, S1)
Internal pudendal and superior and inferior gluteal
Arterial Supply
arteries
Superior gamellus
Origin Ischial spine
Medial surface of greater trochanter of femur, in
Insertion
common with obturator internus
Rotates the thigh laterally; also helps abduct the
Action
flexed thigh
Nerve to the obturator internus and superior gemellus
Innervation
-- a branch of the sacral plexus (L5, S1) (L5, S1)
Arterial Supply Inferior gluteal artery
Inferior Gemellus
Origin Posterior portions of ischial tuberosity and lateral
obturator ring
Medial surface of greater trochanter of femur, in
Insertion
common with obturator internus
Rotates the thigh laterally; also helps abduct the
Action
flexed thigh
Innervation Nerve to the quadratus femoris and inferior gemellus
Arterial Supply Inferior gluteal artery
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OrthoBullets2017 Lower Limb Anatomy | Leg Muscles
Quadratus femoris
Origin Lateral margin of obturator ring above ischial
tuberosity
Quadrate tubercle and adjacent bone of
Insertion
intertrochanteric crest of proximal posterior femur
Action Rotates the hip laterally; also helps adduct the hip
Quadratus femoris branch of nerve to the quadratus
Innervation
femoris and inferior gemellus (L5, S1) (L5, S1)
Medial circumflex femoral artery, inferior gluteal
artery, 1st - 4th perforating arteries, obturator artery,
Arterial Supply
and some superior muscular branches of popliteal
artery
Relevant Posterior (Southern) approach to hip
Approaches Posterior (Kocher-Langenbach) approach to acetabulum
B. Leg Muscles
Peroneus tertius
Origin Arises with the extensor digitorum longus from the
medial fibular shaft surface and the anterior
intermuscular septum (between the extensor
digitorum longus and the tibialis anterior)
Insertion Dorsal surface of the base of the fifth metatarsal
Works with the extensor digitorum longus to dorsiflex,
Action
evert and abduct the foot
Innervation Deep peroneal nerve (L5, S1)
Arterial Supply Anterior tibial artery
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OrthoBullets2017 Lower Limb Anatomy | Leg Muscles
Soleus (S1)
Origin Posterior aspect of fibular head, upper 1/4 - 1/3 of
posterior surface of fibula, middle 1/3 of medial border
of tibial shaft, and from posterior surface of a tendinous
arch spanning the two sites of bone origin
Eventually unites with the gastrocnemius aponeurosis
Insertion to form the Achilles tendon, inserting on the middle 1/3
of the posterior calcaneal surface
Action Powerful plantar flexor of ankle
Innervation Tibial nerve (S1, S2) (S1, S2)
Arterial Supply Posterior tibial, peroneal, and sural arteries
Plantaris (S1)
Origin Inferior aspect of lateral supracondylar line of distal
femur
Middle 1/3 of the posterior calcaneal surface, just
Insertion
medial to Achilles tendon
Action Plantar flexor of ankle; also flexes knee
Innervation Tibial nerve (L5, S1, S2) (L5, S1, S2)
Arterial Supply Sural arteries
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Leg Muscles
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OrthoBullets2017 Lower Limb Anatomy | Foot Muscles
Flexor Hallucis Longus (FHL)
Origin Inferior 2/3 of posterior surface of fibula, lower part of
interosseous membrane
Insertion Plantar surface of base of distal phalanx of great toe
Flexes great toe, helps to supinate ankle, and is a very
Action
weak plantar flexor of ankle
Innervation Tibial nerve (S2, S3) (S2, S3)
Arterial Supply Muscular branch of peroneal and posterior tibial artery
C. Foot Muscles
1. Dorsal Layer
Extensor Digitorum & Hallucis Brevis
Origin Dosal surface of calcaneus
Insertion Base of PP of 2nd, 3rd, 4th toes
Action Extends toes
Innervation Deep peroneal nerve (L5)
Arterial Supply Dorsalis pedis artery
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Foot Muscles
Abductor digiti minimi (LPN)
Origin Calcaneal tuberosity
Insertion Base of fifth toes
Action Abduct small toe
Innervation Lateral plantar nerve
Arterial Supply
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OrthoBullets2017 Lower Limb Anatomy | Foot Muscles
Adductor hallucis (LPN)
Origin Oblique: second to fourth metatarsal
Insertion Proximal phalanx of great toe (lateral side)
Action Adduct great toe
Innervation Lateral plantar nerve
Arterial Supply
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Nerves of the Lower Limb
1. Lumbosacral Plexus
Anatomy
ventral rami from T12-S3
found on the anterior surface of the quadratus lumborum and lies posterior to the psoas muscle
sciatic nerve composed of L4-S3
o peroneal division more lateral than the tibial division
NAVAL: Within the triangle, from a lateral to medial direction, are the femoral Nerve, Artery, and
Vein and the Lymphatic vessels
POP'S IQ: nerves exiting below piriformis are : Pudendal, Obturator internus, Postfemoral
cutaneous, Sciatic, Inferior gluteal, Quadratus femoris
L5 nerve root endangered during percutaneous iliosacral screw placement
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OrthoBullets2017 Lower Limb Anatomy | Nerves of the Lower Limb
Superior gluteal L4-S1 Gluteus medius and minimus/tensor fascia lata
Quadratus femoris L4-S1 Quadratus femoris/inferior gemellus
Peroneal L4-S2
Semimembranosus/semitendinosus/biceps (long
head)/adductor
Tibia L4-S3
magnus/gastrocnemius/soleus/plantaris/popliteus/tibialis
posterior/flexor digitorum longus/flexor hallucis longus
Obturator internus L5-S2 Obturatorius internus/superior gemellus
Inferior gluteal L5-S2 Gluteus maximus
Posterior femoral
S1-S3 Sensory: posterior thigh
cutaneous
- 52 -
By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Nerves of the Lower Limb
2. Femoral nerve
Innervation
Motor
o anterior division branches
sartorius
pectineus
o posterior division branches
rectus femoris
vastus medialis
vastus lateralis
vastus intermedius
Sensory
o anterior division branches provides sensation to
anteromedial asepct of the thigh, consists of
2 branches:
medial cutaneous nerve of thigh
intermediate cutaneous nerve
o posterior division
saphenous nerve
provides sensation to anteromedial aspect of lower leg
infrapatellar branches to knee
piereces the sartorius and fasica lata medial to the knee, and provides cutaneous
innervation to the skin anteriorly over the patella
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OrthoBullets2017 Lower Limb Anatomy | Nerves of the Lower Limb
Origin
L2 to L4 nerve roots
o lumbosacral plexus
femoral nerve
anterior division branches
posterior division branches
Course
Through psoas
o courses through the psoas major muscle
o emerges from lateral border of psoas; then passes downward between psoas and iliacus
Deep to inguinal ligament
o Runs deep to the inguinal ligament to enter the thigh
o branches 4 cm inferior to the inguinal ligament (anterior and posterior branches)
Terminal Branches
o anterior division branches
medial cutaneous nerve of thigh
intermediate cutaneous nerve
motor branch to sartorius
motor branch to pectineus
o posterior division branches
saphenous nerve
motor branches to
rectus femoris
vastus medialis
vastus lateralis
vastus intermedius
articular branches to knee
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Nerves of the Lower Limb
3. Obturator nerve
Innervation
Sensory
o medial aspect of the thigh
o articular branches to hip and knee joints
Motor
o obturator externus
o adductor longus
o adductor magnus
o adductor brevis
o gracilis
Relevent Approaches
Hip Medial Approach
Modified Stoppa Approach
Clinical Conditions
Obturator nerve injury
o can be an iatrogenic injury from retraction during the modified Stoppa approach
Origin
II:1 SG N.A.V: Superior Gluteal
Lumbo-sacro plexus nerve, artery and vein
o nerve roots L4-S1
IG N.A.V: Inferior Gluteal nerve,
artery and vein
Course
Greater sciatic notch
o leaves pelvis through the greater sciatic notch
o contents of greater sciatic notch include
superior gluteal nerve
superior gluteal artery and vein
o runs over the piriformis between the gluteus medius and minimus
do not split gluteus medius more than 5 cm proximal to greater trochanter due to risk of
denervating the muscle
at risk during the lateral (Hardinge) approach to the hip
Terminal brances
o branch to gluteus medius
o branch to gluteus minimus
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Nerves of the Lower Limb
o branch to tensor fascia lata
Nerve Injury & Clinical Conditions
Gluteus Medius Nerve Injury
o Trendelenburg Gait
the tilted pelvis and shifted center of gravity are compensated through shifts in the upper
body over the affected hip during the period of single-leg stance.
the combination of sagging pelvis and upper body shifts results in a classic waddling gait.
Origin
Originates from the sacral plexus
o carries fibers from L5, S1, and S2
Course of Nerve
Arises from the ventral divisions of L5, S1 and S2
Leaves the pelvis through the greater sciatic foramen
Runs underneath the piriformis
Divides into muscular branches to supply the gluteus maximus
6. Sciatic nerve
Innervation
Tibial division
o motor
semitendinous
semimembranous
long head biceps femoris
gastrocnemius
o sensory innervation
none
Peroneal division
o motor
popliteus
soleus
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OrthoBullets2017 Lower Limb Anatomy | Nerves of the Lower Limb
tibialis posterior
flexor digitorum longus
flexor hallucis longus
abductor hallucis
flexor digitorum brevis
flexor hallucis brevis
foot lumbricals
quadratus plantae
flexor digiti minimi
adductor hallucis
foot interossei
abductor digiti minimi
o sensory
articular branch to knee joint
sural nerve branch
runs distal with the small saphenous vein
anastomoses with a branch from the peroneal nerve
continues distal on lateral aspect of the Achilles tendon
terminates as the lateral dorsal cutaneous nerve of the foot
common peroneal nerve
o motor
short head of biceps femoris
o deep peroneal nerve
motor
leg
tibialis anterior
extensor digitorum longus
peroneus tertius
extensor hallucis longus
foot
extensor digitorum brevis (lateral terminal branch)
extensor hallucis brevis (lateral terminal branch)
sensory
articular branch to the ankle joint
medial terminal branch: 1st dorsal webspace
o superficial peroneal nerve
motor
lateral compartment of leg
peroneus longus
peroneus brevis
sensory
majority of skin on the dorsum of foot, excluding webspace between hallux and second
digit (deep peroneal nerve)
anterolateral distal 1/3 of leg
Origin
The sciatic nerve originates from lumbosacral plexus L4-S3
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Nerves of the Lower Limb
o tibialdivision
orginates from anterior preaxial branches of L4,L5,S1,S2,S3
o peroneal division
originates from from postaxial branches of L4,L5,S1,S2
Course
Exits sciatic notch
o runs anterior or deep to piriformis
o runs posterior or superficial to short external rotators (superior gemellus, inferior gemellus,
obturator internus)
Posterior leg
o It then runs down the posterior leg where it breaks into its three main divisions at the level of the
mid thigh
Terminal branches
o common peroneal nerve
o tibial nerve
7. Tibial nerve
Overview
Motor
o gastrocnemius
o popliteus
o soleus
o tibialis posterior
o flexor digitorum longus
o flexor hallucis longus
o abductor hallucis
o flexor digitorum brevis
o flexor hallucis brevis
o foot lumbricals
o quadratus plantae
o flexor digiti minimi
o adductor hallucis
o foot interossei
o abductor digiti minimi
Sensory
o articular branch to knee joint
o sural nerve branch
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OrthoBullets2017 Lower Limb Anatomy | Nerves of the Lower Limb
runs distal with the small saphenous vein
anastomoses with a branch from the peroneal nerve
continues distal on lateral aspect of the Achilles tendon
terminates as the lateral dorsal cutaneous nerve of the foot
Reflexes
o none
Origin
L4-S3 roots
o lumbosacral plexus
sciatic nerve
tibial nerve
medial plantar nerve
lateral plantar nerve
Terminal Branches
Medial plantar nerve
o runs under the abductor hallucis and superficial to the flexor digitorum brevis
o gives motor branches to:
abductor hallucis
flexor digitorum brevis
flexor hallucis brevis
1st lumbrical
o gives sensory branches to:
plantar medial 3 1/2 digits
medial 3 1/2 dorsal nailbeds
Lateral plantar nerve
o runs between the flexor digitorum brevis and quadratus plantae
o gives motor branches to:
quadratus plantae
flexor digiti minimi
adductor hallucis
interossei
three lateral lumbricals
abductor digiti minimi
o gives sensory branches to:
lateral plantar surface
lateral 1 1/2 toes
lateral 1 1/2 dorsal nailbeds
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Nerves of the Lower Limb
Nerve Injury & Clinical Conditions
Tibial Nerve Injury
o can result from direct trauma or peripheral neuropathy (less common)
o leads to:
loss of ankle and toe plantarflexion
weakened foot inversion
sensory loss to the plantar aspect of the foot
Origin
CNS origin
o is derived from the common peroneal (fibular) nerve, which
is made of the dorsal branches of L4 and L5
Course
Bifurcation of the common peroneal nerve
o between the fibula and upper part of the peroneus longus
Interosseous membrane
o passes deep to extensor digitorum longus along anterior surface of
interosseous membrane
Crosses anterior tibial artery
o runs initially lateral to the anterior tibial artery, but crosses over to
run on the medial side by the time it reaches the ankle joint
Anterior tarsal tunnel
o deep peroneal nerve passes through the anterior tarsal tunnel
Terminal branches
o lateral terminal branch
o medial terminal branch
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OrthoBullets2017 Lower Limb Anatomy | Nerves of the Lower Limb
Injury & Clinical Conditions
Damage to this nerve results in foot drop
o most common isolated mononeuropathy of the lower extremity
o systemic causes of injury
lower motor neuron disease
diabetes
ischemia
inflammatory conditions
o iatragenic injuries
TKA
surgical approach
Origin
CNS origin
o terminal branch of the common peroneal nerve
o nerve roots: L4-S1
Course
Bifurcation of the common peroneal nerve
o begins at the bifurcation of the common peroneal nerve
Proximal neck of fibula
o passes between peroneal muscles and lateral side of extensor
digitorum longus
o gives off motor branches to peroneus longus and brevis
Anterolateral distal leg
o descends and supplies only sensory innervation
Deep crural fascia
o superficial peroneal nerve pierces deep crural
Terminal branches
o medial dorsal cutaneous nerve
o intermedial dorsal cutaneous nerve
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Nerves of the Lower Limb
Injury & Clinical Conditions
Superficial peroneal nerve entrapment
o mechanism
ankle sprains and ankle twisting causing stretching of superficial peroneal nerve
compression where the nerve exits the deep fascia of the leg
o presentation
pain and paresthesias over dorsum of foot
Direct damage
o mechanism
fractures of the proximal fibula
perforating injury to lateral leg
o presentation
loss of eversion
motor to peroneus longus and brevis injured
loss of sensation over most of dorsal foot and anterolateral aspect of distal leg
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OrthoBullets2017 Lower Limb Anatomy | Blood Supply of the Lower Limb
Overview
Aorta
o common iliac a.
internal iliac a.
external iliac a.
femoral a.
medial femoral circumflex a.
lateral femoral circumflex a.
femoral profunda a. (deep artery of thigh)
1st perforating branch a.
2nd perforating branch a.
3rd perforating branc a.
superfical femoral a.
popliteal a.
anterior tibial a.
posterior tibial a.
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Anatomic Regions of the Lower Limb
1. Compartments of leg
Compartments
The leg is divided into four osseofascial compartments by
o interosseous membrane of the leg
o transverse intermuscular septum
o anterior intermuscular (crural) septum
Compartment Contents
Anterior compartment
o muscular
tibialis anterior
extensor hallucis longus
extensor digitorum longus
peroneus tertius
o neurovascular
deep peroneal nerve
anterior tibial vessels
Lateral compartment
o muscular
peroneus longus
peroneus brevis
o neurovascular
superficial peroneal nerve
Superficial posterior compartment
o muscular
gastrocnemius
plantaris
soleus
o neurovascular
sural nerve
Deep posterior compartment
o muscular
tibialis posterior
flexor hallucis longus
flexor digitorum longus
popliteus
o neurovascular
tibial nerve Collected By : Dr AbdulRahman
posterior tibial vessels AbdulNasser
[email protected]
In July 2017
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OrthoBullets2017 Lower Limb Anatomy | Anatomic Regions of the Lower Limb
Approaches
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Anatomic Regions of the Lower Limb
ORTHO BULLETS
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OrthoBullets2017 Upper Limb Approaches | Shoulder Approaches
A. Shoulder Approaches
Internervous plane
Internervous plane
o deltoid muscle (axillary nerve.)
o pectoralis major (medial and lateral pectoral nerve)
Position
Approach
Incision
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Shoulder Approaches
The musculocutaneous nerve enters the biceps 5-8cm distal to the
coracoid process; retraction of the conjoint tendon must be done
with care.
o the fascia on the lateral side of the conjoint tendon is incised to reveal
the subscapularis
External rotation puts the subscapularis fibers on stretch
o the subscapularis may be released from its insertion on the lesser
tuberosity through the tendon or via an osteotomy
o the capsule is then incised (as needed) to enter the joint
Dangers
Musculocutaneous nerve
o renters medial side of biceps muscle 5-8 cm distal to coracoid (stay
lateral)
o can have neurapraxia if retraction is too vigorous
Cephalic vein
o should be preserved if possible; if injured, can ligate
Axillary nerve
o at risk with release of subscapularis tendon (runs distal to) or with
incision of teres major tendon or latissimus dorsi tendon (runs proximal
to)
Anterior circumflex humeral artery
o runs anteriorly around the proximal humerus cephalad to pectoralis
major tendon
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OrthoBullets2017 Upper Limb Approaches | Shoulder Approaches
Internervous plane & Applied Anatomy
Internervous plane
o None (deltoid split proximally to the axillary nerve)
Applied anatomy
o The deltoid is difficult to repair back to the acromion; limited
detachment is recommended.
Preparation
Anesthesia
o general
o brachial plexus block (interscalene)
Position
o beach chair
Tourniquet
o None
Approach
Incision
o An incision is made along the anterolateral edge of the shoulder,
generally starting at the coracoid.
Superficial dissection
o The superficial fascia is encountered and incised
o Superficial vessels are numerous; attention must be paid to these to
facilitate visualization
o The deltoid is then sharply released from the acromion or clavicle,
depending on area of surgical need
This should be limited, as deltoid repair is often difficult
o The acromial branch of the thoracoacromial artery must be ligated
when encountered deep to the deltoid, near the acromioclavicular
joint
Deep dissection
o The coracoacromial ligament is then released from the acromion
The ligament can be excised by releasing it from the coracoid as
well
o The subacromial bursa is now seen and can be excised to reveal
rotator cuff pathology
Dangers
Axillary nerve
o This nerve runs transversely across the surface of the deltoid muscle
approximately 7 cm distal to the acromion
Acromial branch of the thoracoacromial artery
o Runs directly under the deltoid muscle
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Shoulder Approaches
Anesthesia
General
Regional
Internervous plane
Internervous plane
o no true internervous plane (deltoid is split in line with its fibers)
Approach
Incision
o 5 cm incision is made from the tip of the acromion distally in line with the arm
this is generally made at the posterior edge of the clavicle, but can be adjusted according to
pathology
Superficial dissection
o deltoid is split in line with its fibers no more than 5 cm distal to the lateral edge of acromion (to
protect the axillary nerve)
o a stay suture is placed at the inferior apex of the split to prevent propogation of the split
Deep dissection
o subacromial bursa lies directly deep to the deltoid muscle and can be excised to reveal the
underlying rotator cuff insertion and proximal humerus
Extension
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OrthoBullets2017 Upper Limb Approaches | Shoulder Approaches
o distal extension is only possible by performing a second, separate deltoid split distal to the
axillary nerve
o the approach can be extended proximally parallel to the spine of the scapula to expose the entire
supraspinatus
this requires division of the overlying trapezius muscle parallel to the spine of the scapula
and division of the acromion in line with the incision, both of which require repair
Dangers
Axillary nerve
o leaves posterior aspect of axilla by traversing quadrilateral space (teres minor, teres major, long
head of triceps, medial border of humerus)
o it travels around the humerus coursing anteriorly and laterally to enter and innervate the deltoid
via its deep surface
o at this point, it runs transversely 5-7 cm distal to the edge of the acromion from posterior to
anterior
o cannot extend split further due to risk to denervation of anterior deltoid
o need to make a second incision distally in order to provide a safe "second window" if distal
extension is needed (generally for fractures)
4. Posterior to Shoulder
Introduction
Overview
o this approach is infrequently used
o this approach offers access to the posterior and inferior aspects
of the shoulder
Indications
o proximal humerus fracture-dislocations
o glenoid fractures/osteotomy
o removal loose bodies
o irrigation and debridement of septic joint
o scapular neck fractures
Internervous plane
Internervous plane
o teres minor (axillary n.)
o infraspinatus (suprascapular n.)
Preparation
Anesthesia
o general anesthetic
Table
o radiolucent flat-top table
Patient Position
o prone is most common
o lateral
o beach-chair
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Shoulder Approaches
Approach
Incision
o the patient is positioned in the lateral decubitus position with the ipsilateral arm draped free
o the incision is made along the scapular spine, extending to the lateral acromial border
Superficial dissection
o attention must be paid to superficial skin vessels, as these can bleed significantly
o the origin of the deltoid is released from the scapular spine
o the plane between the deltoid and infraspinatus is encountered and bluntly developed
this is typically easiest to find at the lateral aspect of the incision
o the deltoid is retracted distally/laterally
Deep dissection
o the interval between the infraspinatus (suprascapular nerve) and teres minor (axillary nerve) is
bluntly developed
this is often difficult to find, but should be done carefully
o retract the infraspinatus superiorly and the teres minor inferiorly to expose the posterior glenoid
and scapular neck
Dangers
Suprascapular nerve
o passes around the base of the scapular spine (do not retract infraspinatus too vigorously)
Axillary nerve
o runs through the quadrangular space beneath the teres minor (stay superior to the teres minor)
o this is accompanied by the posterior circumflex humeral artery
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OrthoBullets2017 Upper Limb Approaches | Shoulder Approaches
Internervous plane
Internervous plane between
o suprascapular nerve (infraspinatus) and
o axillary nerve (teres minor)
Approach
Positioning
o standard positioning
prone
o alternative positioning
beach chair
lateral decubitus
Incision
o classic incision
curved incision
starting from posterolateral lip of the acromion,
extending medial along the spine of the scapula,
right angle turn at the medial border of the scapula
o modified incision
straight incision
starting from posterolateral lip of the acromion, I:1 curved incision straight incision
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Shoulder Approaches
avoid injury to posterior branch of axillary nerve
retract infraspinatus superiorly
avoid injury to suprascapular nerve and artery
o deep dissection
lateral
identify underlying posterior glenoid capsule deep to musculature
incise posterior capsule in line with muscular interval
allows access to the posterior aspect of glenohumeral joint
medial
dissecting the infraspinatus along off the medial border of scapula
retract infraspinatus muscle belly superior and lateral, as this will maintain its
suprascapular neurvascular pedicle
allows access to the inferior aspect of scapular body
o improve exposure
lateral
the infraspinatus tendon insertion can be tagged and cut approx. 1-2 cm lateral to its
insertion on greater tuberosity
retract medially
medial
dissection of infraspinatus off the medial border of scapula is extended superiorly to the
scapular spine
Dangers
Suprascapular nerve
o anatomy
passes around the base of the spine of the scapula as it runs from the supraspinous fossa to
the infraspinous fossa
o risk of injury
forceful medial and superior retraction of infraspinatus muscle
Axillary nerve
o anatomy
passes through the
quadrangular space beneath the
teres minor
o risk of injury
dissection carried out inferior to
the teres minor
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OrthoBullets2017 Upper Limb Approaches | Shoulder Approaches
Positioning
Beach chair
o advantage of ability to also do deltopectoral
approach to shoulder
o reduces venous pressure and bleeding
Lateral decubitus
o advantage of joint distraction
can be associated with neuropraxias from
I:2 Beach chair Lateral decubitus
traction
Primary Portals
Posterior portal
o function
primary viewing portal used for diagnostic arthroscopy
o location and technique
located 2 cm inferior and 1 cm medial to posterolateral corner of acromion
portal may pass between infraspinatus (suprascapular nerve) and teres minor (axillary nerve)
or pass through the substance of infraspinatus
this is usually the first portal placed
direct anteriorly towards tip of coracoid
Anterior portal
o function
viewing and subacromial decompression
o location & technique
lateral to coracoid process and anterior to AC joint
portal passes between pectoralis major (medial and lateral pectoral nerves) and deltoid
(axillary nerve)
o this portal is usually placed under direct supervision from the posterior portal with aid of spinal
needle
Lateral portal
o function
subacromial decompression
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Shoulder Approaches
o location & technique
located 1-2 cm distal to lateral edge of acromium
portal passes through deltoid (axillary nerve)
Secondary Portals
Anteroinferior (5 o'clock) portal
o function
placement of anchors in anterior labral repair
o location & technique
located slightly inferior to coracoid
this portal is usually placed under direct supervision from the posterior portal with aid of
spinal needle
Posteroinferior (7 o'clock) portal
o function
placement of anchors for posterior labral repair
o location & technique
this portal is usually placed under direct supervision from the posterior portal with aid of
spinal needle
Nevasier (supraspinatus) portal
o function
anterior glenoid visualization and SLAP repairs
o location & technique
located just medial to lateral acromion
goes through supraspinatus muscle (suprascapular nerve)
Port of Wilmington (anterolateral) portal
o function
Used to evaluate/repair posterior SLAP and RTC lesions
o location & technique
just anterior to posterolateral corner of acromium
this portal is usually placed under direct supervision from the posterior portal with aid of
spinal needle
Diagnostic Scope
Performed with 30° scope through the posterior portal to identify
1. Biceps tendon
2. Supraspinatus
3. Infraspinatus and teres minor.
4. Rotator interval (formed by biceps tendon, superior edge of subscapularis, and glenoid)
5. Anterior ligamentous complex (MGHL, IGHL)
6. Subscapularis recess (loose bodies)
7. Anterior labrum
8. Glenoid
9. Humeral head
Anatomic variations
o region of anterosuperior labrum and MGHL has wide anatomic variability
attached labrum with broad MGHL is most common
sublabral hole with cordlike MGHL
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OrthoBullets2017 Upper Limb Approaches | Shoulder Approaches
Buford complex
has absent labrum and cordlike MGHL
o bare areas of cartilage are normal on
central glenoid
posterior humeral head
Dangers
Posterior portal
o axillary nerve
leaves axilla through quadrangular space and winds around humerus on deep surface of the
deltoid muscle and passes ~ 7 cm below tip of acromoium
at risk if the posterior portal is made too inferior
o suprascapular nerve
runs through supraspinatus fossa and infraspinatus fossa before innervating both of these
muscles.
at risk if the posterior portal is made too medial
Anterior portal
o cephalic vein
runs in deltopectoral groove & at risk if portal is too lateral
o musculocutaneous nerve
enters muscles 2-8 cm distal to tip of coracoid
at risk if anterior portal is made too inferior
Anesthesia
o phrenic nerve
with intrascalence block (anesthesia)
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In July 2017
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Humerus Approaches
B. Humerus Approaches
Surgical Plane
Internervous plane
o proximal
Deltoid muscle (axillary nerve) and pectoralis major (medial
and lateral pectoral nerves)
o distal
Medial brachialis (musculocutaneous nerve) and lateral
brachialis (radial nerve)
Preparation
Postion
o Supine with arm on arm board, abducted 60 degrees
Approach
Incision
o Make a curved incision from the tip of the coracoid process
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OrthoBullets2017 Upper Limb Approaches | Humerus Approaches
o Distally, the fibers of the brachialis are split longitudinally
along the midline to expose the periosteum and humeral
shaft
Extension
o Proximal extension can be obtained by developing the
anterior approach to the shoulder with full deltopectoral
dissection
o Distal extension cannot be obtained with this approach
Dangers
Anterior circumflex humeral artery
o At risk proximally between the pectoralis major and deltoid muscle
Axillary nerve
o Can be injured with vigorous retraction of the deltoid
Radial nerve
o must be identified before any incision is made into the brachialis muscle or before periosteal
elevation of the brachialis off the humerus occurs
o also at risk on the middle 1/3 of the humerus where it lays in the spiral groove on the posterior
humerus
Plane
Internervous plane (none)
Approach
Incision
o make a curved incision over the lateral border of the biceps
centered over the fracture site
Superficial dissection
o identify the lateral border of the biceps muscle and retract
medially
o Ensure that the lateral antebrachial cutaneous nerve is retracted
with the biceps
o This reveals the brachialis and brachioradialis muscles lying
underneath
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Humerus Approaches
Deep dissection
o Incise the fascia overlying these muscles and develop
the intermuscular plane
o The radial nerve lies between the brachialis and
brachioradialis muscles
The nerve is generally easiest to find in the distal
arm, just proximal to the elbow
This must be traced proximally until it pierces the
lateral intermuscular septum and be carefully
protected
o The brachialis and biceps are retracted medially and
the brachioradialis laterally
o Subperiosteal elevation of the brachialis reveals the
humeral shaft underneath
Extension
o Proximal extension can be obtained by developing the
interval between the brachialis medially and the
lateral head of the triceps posterolaterally.
o Distal extension can be obtained by extending into an
anterior approach to the elbow
This distal interval lies between the brachioradialis
(radial n.) and pronator teres (median n.)
Care must be taken to avoid iatrogenic injury to the
lateral antebrachial cutaneous nerve in this extensile
approach
Dangers
Lateral cutaneous nerve of the forearm
o This terminal branch of the musculocutaneous nerve is
injured at the distal end of the incision as it exits the biceps laterally
Radial nerve
o Must be identified before any incision is made into the brachialis muscle or before periosteal
elevation of the brachialis off the humerus occurs
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OrthoBullets2017 Upper Limb Approaches | Humerus Approaches
Preparation
Anesthesia
o general
o local
Position
o prone with arm on arm board, abducted 45-60 degrees
o lateral with arm over the top of the body
Tourniquet
Intraoperative Imaging
Approach
Incision
o incision from 8 cm distal to the acromion to the olecranon fossa
Superficial dissection
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Humerus Approaches
Anatomic Plans
Internervous plane (none)
o Between the triceps (radial n.) and brachioradialis (radial n.)
Positioning
Anesthesia
Position
o supine with arm lying across chest
Turniquet
Approach
Incision
o make a curved or straight incision over the lateral supracondylar ridge
Superficial dissection
o incise the deep fascia in line with the skin incision
o identify the plane between the brachioradialis and triceps
Cut in between these two muscles down to bone
Reflect the triceps posteriorly and the brachioradialis anteriorly
Deep dissection
o rhe common extensor origin can be released off the lateral humerus and
the triceps can be similarly elevated posteriorly
Extension
o proximal extension cannot be obtained due to the radial nerve crossing
proximally in line with the incision
o distal extension can be obtained by extending into the interval between
the anconeus (radial n.) and extensor carpi ulnaris (posterior
interosseous n)
this extension can only be carried to the radial head to avoid
potential injury to the posterior interosseous nerve
Dangers
Radial nerve
o This nerve is at risk with proximal extension, as the nerve pierces the
lateral septum in the distal third of the arm
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OrthoBullets2017 Upper Limb Approaches | Elbow Approaches
C. Elbow Approaches
Internervous plane
None
o the extensor mechanism is either split or detached
o the radial nerve innervates the triceps muscle more proximally
Preparation
Anesthesia
o general
o supraclavicular or infraclaviclar nerve block
Position
o prone or lateral decubitus
with elbow flexed and arm hanging from side of table
Tourniquet
o can be applied if needed as sterile tourniquet to upper arm
Approach
Incision
o begin 5cm proximal to the olecranon in the midline of the
posterior distal humerus
o curve laterally proximal to the tip of the of the olecranon along
the lateral aspect of the olecranon process
o then curve medially over the middle of the posterior aspect of
the subcutaneous ulna
Superficial dissection
o first, palpate the ulnar nerve and fully dissect it out
is helpful to pass tape or penrose for identification at all times
o incise deep posterior fascia in the midline
o can either split triceps fascia, or continue with olecranon osteotomy
o if performing olecranon osteotomy, drill and tap olecranon prior to osteotomy
o score the olecranon with an osteotome to allow perfect reduction when the osteotomy is repaired
o V-shaped osteotomy of the olecranon 2 cm from the tip using an oscillating saw
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Elbow Approaches
Deep dissection
o strip soft tissue from the edges of the osteotomy site and retract
the olecranon fragment proximally
o subperiosteal dissection of the medial and lateral borders of the
humerus allows exposure of entire distal fourth of the humerus
Dangers
Ulnar nerve
o should initially be indentified and protected during the approach
o can usually be palpated 2cm proximal to medial epicondyle
o transposition of the ulnar nerve has shown no benefit to reducing
the incidence of ulnar neuritis
Median nerve
o strict subperiosteal dissection off the anterior surface of the
humerus protects the nerve
o flexion of the elbow relaxes the anterior structures.
Radial nerve
o in danger proximally as it travels from the posterior to anterior
brachial compartments through lateral intermuscular septum
o can usually be found at the lateral border of the humerus near distal 1/3 junction
Brachial artery
o runs with the median nerve (see above)
Internervous plane
Proximally between
o brachialis (musculocutaneous nerve)
o triceps (radial nerve)
Distally between
o brachialis (musculocutaneous nerve)
o pronator teres (median nerve)
Preparation
Anesthesia
o general
o supraclavicular or infraclaviclar nerve block
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OrthoBullets2017 Upper Limb Approaches | Elbow Approaches
Position
o supine
with arm flexed and supported by arm board over the patient
Tourniquet
o applied to upper arm
Approach
Incision
o curved incision 8 to 10 cm long on the medial aspect of the elbow
centered over the medial epicondyle
Superficial dissection
o incise the fascia over the ulnar nerve starting proximally
isolate nerve along the entire length of the incision
o expose the common flexor origin on the medial epicondyle
o develop brachialis and PT interval
o avoid the median nerve which enters PT near the midline
o if necessary can perform osteotomy of the medial epicondyle
osteotomy is reflected distally
ensure retained MCL ligament into osteotomy fragment
o develop brachialis and triceps interval
Deep dissection
o incise capsule and medial collateral ligament
Extension
o local
abduction of forearm opens medial aspect of joint
can dislocate laterally by dissecting off joint capsule and periosteum
o proximal
anterior surface of distal fourth of humerus can be exposed by
developing plane between brachialis and triceps
o distal
limited by the branches of the median nerve
Dangers
Ulnar nerve
o is at risk during approach
o must be dissected out to ensure protection
Median nerve
o aggressive traction on the osteotomy fragment can cause a traction injury
to the median and anterior interosseous nerves
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Elbow Approaches
Intermuscular plane
Proximal between
o brachialis (musculocutaneous nerve) and
o brachioradialis (radial nerve)
Distally between
o brachioradialis (radial nerve) and
o pronator teres (median nerve)
Preparation
Patient is supine on table with arm on radiolucent arm board
Consider use of sterile tourniquet if dissection may proceed
proximally
Ensure fluoroscopic imaging can be obtained
Approach
Incision
o Make curved incision starting 5 cm proximal to flexion
crease along the lateral border of the biceps
o Continue distally by following medial border of the
brachioradialis
Superficial dissection
o Identify lateral antebrachial cutaneous nerve (sensory branch of
the musculocutaneous nerve which becomes superficial 2 inches
proximal to the elbow crease, lateral to the biceps tendon)
o Incise the deep fascia along the medial border of the
brachioradialis
o Identify radial nerve proximally at level of the elbow joint
(between brachialis and brachioradialis)
o Follow the radial nerve distally until it divides into its three main branches:
PIN (enters the supinator)
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OrthoBullets2017 Upper Limb Approaches | Elbow Approaches
sensory branch (travels deep to brachioradialis)
motor branch to ECRB
o Develop brachiaradialis and PT interval distal to the division
of the radial nerve.
o Ligate recurrent branches of the radial artery and muscular
branches that enter the brachialis just below the elbow to
allow better retraction
Deep dissection
o Joint capsule
incise the joint capsule between the radial nerve laterally
and the brachialis muscle medially
o Proximal radius
expose proximal radius by supinating the forearm to bring the supinator muscle anteriorly.
Incise the muscle origin down to bone, lateral to the insertion of the biceps tendon
Extension
o Proximal
extends into the anterolateral approach to the arm developing the plane between
the brachialis and the triceps muscles
o Distal
extends to the anterior approach to the radius between the planes of the brachioradialis and
pronator teres muscles proximally, and the brachioradialis and flexor carpi radialis (median
nerve) muscles distally.
Dangers
Lateral antebrachial cutaneous nerve of the forearm
o must incise skin and subcutaneous tissues carefully
Radial nerve
PIN
o vulnerable as it winds around the neck of the radius within the substance of the supinator muscle.
Incise the supinator muscle at its origin with forearm supinated to protect the nerve.
Recurrent branch of the radial artery
o must be ligated to mobilize the brachioradialis
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Elbow Approaches
Plane
Intermuscular plane between
o anconeus (radial n.)
o extensor carpi ulnaris (posterior interosseous n.)
Preparation
Anesthesia
o general
advantageous for immediate post-operative neurologic
examination or intra-operative airway control in patients with
difficult airway
o brachial plexus nerve blocks
advantageous for post-operative pain control
Position
o supine
with upper extremity supported on a hand table or on patient's trunk
o lateral decubitus
with arm supported over a bolster
o forearm pronated in both positions
Tourniquet applied to arm
o sterile tourniquet
greater elbow access with sterile tourniquet
exsanguinate limb with Esmarch or elevation
Approach
Incision
o landmarks
lateral humeral epicondyle
radial head
2.5 cm distal to lateral epicondyle, head (or crepitus in fractured)
palpable with pronation/supination
olecranon
o incision
make a ~5cm longitudinal or gently curved incision based off the
lateral epicondyle and extending distally over the radial head
approximately
incision angle can be varied based on need to address associated
pathology
Superficial dissection
o incise deep fascia in line with incision
o identify plane between ECU and anconeus distally
Deep dissection
o maintain arm in pronation to move PIN away from field
o split proximal fibers of supinator, staying on the posterior cortex of the
radius away from PIN
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OrthoBullets2017 Upper Limb Approaches | Forearm & Wrist Approaches
o ifLCL intact, stay 1 cm anterior to crista supinatoris to avoid damage
in cases of elbow dislocation, LCL frequently not intact
o incise capsule longitudinally
avoid dissecting distally or anteriorly (PIN)
maintain dissection in mid radiocapitallar plane to avoid damaging
LCL
Extension
o proximal
Approach
Incision
o longitudinal incision
begin just lateral to biceps tendon on flexor crease of
elbow
end at radial styloid process
Superficial dissection
o incise the deep fascia in line with skin incision
o develop a plane between BR and FCR distally
o move proximal to develop plane between PT and BR
o identify the superficial radial nerve beneath BR
o ligate the branches of the radial artery to aid lateral
retraction of BR
Deep dissection - proximal third
o follow the biceps tendon to its insertion on the bicipital
tuberosity
o radial to the insertion of biceps tendon incise the bursa to
gain access to the proximal part of radius (radial artery
which runs along the ulnar side of the biceps tendon)
o fully supinate the forearm to displace the PIN radially and
bring the origin of the supinator muscle into the anterior
aspect of the radius
o incise the supinator muscle along the line of its broad
insertion and continue subperiosteal dissection laterally
Deep dissection - middle third
o pronate the forearm to bring the insertion of the pronator
teres, along the radial aspect of the radius, into view
o detach the pronator insertion from bone and retract medially
Deep dissection - distal third
o partially supinate the forearm
o dissect the periosteum off the lateral aspect of the distal
third of the radius, lateral to the pronator quadratus and
flexor pollicis longus
Dangers
Posterior interosseous nerve
o enters the supinator muscle beneath a fibrous arch known
as the arcade of Frohse
the arch is formed by the thickened edge of the superficial head of the supinator muscle
compression of the nerve at this point produces paralysis or dysfunction of the extensors
known as posterior interosseous nerve entrapment syndrome
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OrthoBullets2017 Upper Limb Approaches | Forearm & Wrist Approaches
Plane
Internervous plane between
o flexor carpi radialis (median nerve)
o flexor pollicis longus (AIN)
Position
Anesthesia
o General anesthesia
o Bier block
Position
o place supine on table
o supinate arm and place on armboard
Tourniquet
o exsanguinate arm (if using tourniquet)
Approach
Incision
o make incision along palpable flexor carpi radialis (FCR) tendon
sheath
make ulnar or radial curve so you don't cross perpendicular to
flexion crease
Superficial dissection
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Forearm & Wrist Approaches
o incise skin flaps and subcutaneous fat
o section fibers of volar FCR tendon sheath in line with tendon
o retract FCR tendon ulnarly and incise through the dorsal
aspect of the FCR sheath
can retract FCR radially if carpal tunnel access is
necessary
Deep dissection and access to volar wrist joint
o underneath the FCR sheath is the flexor pollicis longus (FPL)
- this must be retracted ulnarly
o after the FPL is bluntly retracted, the pronator quadratus (PQ)
is seen
o incise the radial and distal borders of the PQ, elevating the
muscle off the volar radius
Proximal Extension
o indications
to further expose median nerve or radius
o dissection
extend incision up middle of forearm
incise deep fascia between PL and FCR
retract PL and FCR to expose FDS
median nerve is immediately under the deep surface of
FDS
Distal Extension
o indications
to further expose the scaphoid
o dissection
extend incision obliquely in a radial direction across
the flexor crease
continue this in line with the thumb ray
elevate the thenar musculature off the volar wrist
capsule
open capsule if necessary
Dangers
Palmar cutaneous branch of median nerve
o arises 5 cm proximal to wrist joint
o runs ulnar to FCR
Radial artery
o cannot ligate if Allen's test reveals no/poor ulnar artery contribution to hand
o care must be taken when retracting during procedure
Volar wrist capsule ligaments
o do not remove from volar distal radius unless access to wrist joint is needed
o errant release will lead to radiocarpal instability
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OrthoBullets2017 Upper Limb Approaches | Forearm & Wrist Approaches
Internervous Plane
Proximally between
o ECRB (radial nerve)
o EDC (pin nerve)
Distally between
o ECRB (radial nerve)
o EPL (pin nerve)
Preparation
Position
o place patient supine
if arm is abducted to the side on an arm board, the forearm
should be pronated
if arm is adducted across the chest, the forearm should be
supinated
Approach
Landmarks
o Proximal
lateral epicondyle of the humerus
o Distal
dorsoradial tubercle (Lister's tubercle)
Incision
o starting point is anterior and distal to the lateral
epicondyle of the humerus
o straight or gently curved incision along the dorsolateral
aspect of the forearm
o be aware of superficial radial nerve and cephalic vein
distally
o end incision just distal and ulnar to Lister's tubercle
Superficial dissection
o proximal third
incise fascia in line with skin incision using interval between ECRB and the EDC to reveal
supinator
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Forearm & Wrist Approaches
o middle third
identify the abductor pollicis longus (APL) and extensor
pollicis brevis (EPB) emerging between ECRB and EDC
o distal third
undermine the APL and EPB tendons medially to identify
plane between EPL and ECRB
Deep dissection
o proximal third
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OrthoBullets2017 Upper Limb Approaches | Forearm & Wrist Approaches
Internervous Plane
No true intermuscular plane
o dissection carried out between the third and fourth extensor
compartments
Relevant anatomy
o radial styloid
o ulnar styloid
o Lister's tubercle
o extensor tendon compartments
Preparation
Anesthesia
o regional blocks
o general sedation
Position
o place supine on table
o pronate arm and place on armboard
Turnoquite
o exsanguinate arm
Approach
Incision
o make ~ 8 cm incision midline (halfway between radial and
ulnar styloid)
can extend proximally or distally as needed
Superficial dissection
o incise subcutaneous fat inline with skin incision
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Forearm & Wrist Approaches
o expose extensor retinaculum
Deep dissection
o incise extensor retinaculum over the extensor digitorum
communis and extensor indicis proprius (fourth compartment)
o mobilize tendons radially and ulnarly to expose the underlying
radius and joint capsule
o incise the joint capsule longitudinally on the dorsal radius and
carpus
o continue dissection below the capsule (dorsal radiocarpal
ligament) toward the radial and ulnar sides of the radius to
expose the entire distal radius and carpal bones
Dangers
Radial nerve (superficial radial nerve)
o emerges from beneath brachioradialis tendon just above the
wrist joint before traveling to dorsum of the hand
o distal extent of approach at base of 3rd metacarpal
Dorsal cutaneous branches
o supplied by both radial and ulnar nerves
o lie in subcutaneous fat
o injury may lead to painful neuromas
Radial artery
o crosses wrist joint laterally
o avoid by maintaining dissection below the periosteum
Interosseous ligaments
o can destabilize carpus
o avoid by raising flaps
Scaphoid devascularization
o avoid by not detaching capsular attachment on dorsal ridge
of scaphoid
Internervous Plane
Between
o ECU (PIN nerve)
o FCU (ulnar nerve)
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OrthoBullets2017 Upper Limb Approaches | Forearm & Wrist Approaches
Preparation
Anesthesia
o general
o supraclavicular/ infraclaviclar or axillary nerve block
Position
o patient supine with arm placed across chest
o or elbow flexed while surgical assistant holds forearm vertically
Tourniquet
o applied to upper arm
Approach
Incision
o palpate subcutaneous ulnar border of ulna
o make linear longitudinal incision over subcutaneous border
of ulna
length based on procedure
Superficial dissection
o incise deep fascia in distal incision in line with skin
incision
o divide plane between ECU and FCU
o dissect down to subcutaneous border of ulna
at middle 1/3 of ulna must divide fibers of ECU to
reach bone
Deep dissection
o incise periosteum over ulna
perform subperiosteal dissection
o In the proximal fifth of the ulna, part of triceps insertion
must be detached to gain access to the bone
Dangers
Ulnar nerve
o proximally passes through two heads of FCU
o travels down forearm under FCU and on top of FDP
o protect by dissecting FCU subperiosteally
Ulnar artery
o travels down forearm with ulnar nerve
ulnar artery is radial to ulnar nerve
o protect by dissecting FCU subperiosteally
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Hand Approaches
E. Hand Approaches
Preparation
Anesthesia
o local (most common)
o regional
Position
o patient supine on table
o supinate operative arm and place on armboard with palm facing
up
Tourniquet
o exsanguinate arm
Internervous Plane
Distal
o no internervous plane
o no muscles are transected
APB and palmaris brevis fibers that cross the midline can
occassionally be dissected
o true anatomic dissection
major nerves identified, dissected out and preserved
plane of dissection between median nerve and FCR
Approach
Incision
o landmark
thenar crease
o make incision just ulnar to the thenar crease in hand and
ulnar to palmaris longus in wrist
begin 4cm distal to flexion crease
make ulnar curve so you dont cross perpendicular to
flexion crease
also helps protect palmar cutaneous branch
end 3 cm proximal to flexion crease
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OrthoBullets2017 Upper Limb Approaches | Hand Approaches
Superficial dissection
o incise skin flaps
o incise fat
o section fibers of superficial palmar fascia in line with
incision
o retract curved flaps medially to expose insertion of PL
into flexor retinaculum
o retract PL tendon toward ulna to expose median nerve
between PL and FCR
o pass a blunt object between median nerve and flexor
retinaculum.
o incise entire length of retinaculum/transverse carpal
ligament on ulnar side of nerve
Deep dissection
o identify motor branch of median nerve (anterolateral side
of median nerve as it emerges from carpal tunnel)
o if require access to volar aspect of wrist joint
mobilize median nerve and retract radially (so you
dont stretch motor branch)
mobilize and retract flexor tendons
incise base of carpal tunnel longitudinally
Extension
o Indications
to further expose median nerve
o Proximal
extend incision up middle of arm
incise deep fascia between PL and FCR
retract PL (ulnarly) and FCR (radially) to expose FDS
median nerve adheres to deep surface of FDS
Dangers
Palmar cutaneous branch of median nerve
o arises 5 cm proximal to wrist joint
o runs ulnar to FCR before crossing flexor retinaculum
o greatest threat when you do not curve your incision ulnar
Motor branch of median nerve
o significant anatomic variation
o risk to nerve minimized if incision through retinaculum
made ulnar to median nerve
Superficial palmar arch
o crosses palm at level of distal end of outstretched thumb
o in danger if flexor retinaculum blindly cut (can go too far
distally)
o avoid injury if retinaculum cut under direct observation
for its entire length
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Hand Approaches
ORTHO BULLETS
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OrthoBullets2017 Pelvis Approaches | Acetabulum Approaches
A. Acetabulum Approaches
Approach
Incision
o a transverse incision is made approximately 2 cm above the
symphysis
this is carried short of each external inguinal ring
o for the "lateral window", an incision is made along the iliac crest, starting ~2 cm posterior to the
ASIS, following the iliac crest posteriorly
Superficial dissection
o subcutaneous tissue and rectus fascia are incised transversely
o the pyrimidalis muscle is released and tagged for later repair
o the rectus abdominus fascia is split along the linea alba
o the transversalis fascia is opened superior to the pubic symphysis
this opens the potential space of Retzius (space behind the symphysis and anterior to the
bladder)
o for the "lateral window", the insertion of the external oblique is released, permitting dissection
into the internal iliac crest fossa (requires elevation of the iliacus muscle)
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Acetabulum Approaches
Deep dissection
o the origin of the rectus abdominus muscle is released off the posterior pubic rami but maintained
anteriorly
a Hohmann retractor is used to retract the rectus anteriorly
o the iliopectineal fascia is released to enter the true pelvis
o anastamoses between the external iliac and obturator vessels (corona mortis) should be identified
along the superior pubic ramus and ligated
o the iliopsoas can now be subperiosteally elevated, and a retractor is used to retract the iliopsoas
and external iliac vessels
the entire pelvic brim should be visualized at this time
o the obturator neurovascular bundle is exposed and protected as the quadrilateral surface and
posterior column are dissected
Dangers & Complications
Obturator nerve and vessels
o retracted carefully during exposure of the quadrilateral plate and posterior column
Corona mortis
o these anastamoses must be ligated as they appear on the lateral 1/3 of the superior pubic ramus
o they are nearly universally present but vary significantly in size
External iliac vessels
o exposed and retracted early in the exposure; must be mobilized to expose the iliac fossa and false
pelvis
Bladder
o Foley catheter limits injury; placement of a malleable retractor anterior to bladder also helps
protect
Intermuscular plane
No internervous plane
o gluteus maximus innervated by inferior gluteal nerve
o nerve branches of upper 1/3 of muscle cross intended interval of dissection halfway between
level of greater trochanter and PSIS
muscle split is stopped when first nerve branch to upper part of muscle is encountered
Vascular plane
o upper 1/3 of muscle
supplied by superior gluteal artery
o lower 2/3 of muscles
supplied by inferior gluteal artery
o line of fat on surface marks interval
Preparation
Anesthesia
o patient must be relaxed
Position
o lateral position
posterior wall and lip fxs (can use skeletal traction when using lateral position)
allows for femoral head dislocation
position of choice for joint arthroplasty
allows buttock tissue to "fall away" from the field
o prone position
for transverse fx (flex the knee to prevent stretching of sciatic nerve)
femoral head is maintained in reduced position throughout procedure
improves quadrilateral surface access
improved access to cranial and anterior aspect of posterior wall fractures
Imaging
o ensure appropriate imaging can be obtained prior to formal prepping and draping
Approach
Incision
o longitudinal incision centered over greater trochanter
start just below iliac crest, lateral to PSIS
mini-incision approach shows no longterm benefits to hip function
extend to 10 cm below tip of greater trochanter
Superficial dissection
o through subcutaneous fat
o incise fascia lata in lower half of incision
o extend proximally along anterior border of gluteus maximus
split gluteus maximus muscle along avascular plane
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Acetabulum Approaches
release portion of gluteal sling to aide in anterior retraction of muscle belly
o detach short external rotators after tagging
the piriformis should be tagged and released approximately 1.5cm from the tip of the greater
trochanter to avoid damaging the blood supply to the femoral head
the piriformis will provide a landmark leading to the greater sciatic notch
the contents of the greater sciatic notch include:
piriformis
superior and inferior gluteal vessels and nerves
sciatic and posterior femoral cutaneous nerves
internal pudendal vessels
nerves to the obturator internus and quadratus femoris
the obturator internus should be tagged 1.5 cm from the greater trochanter and blunt
dissection should be used to follow its origin to the lesser sciatic notch
posterior retraction will protect the sciatic nerve
o clear abductors and soft tissue to visualize posterior capsule and posterior wall region
Deep dissection
o no further dissection is needed in setting of isolated posterior wall fracture
o palpable exposure of quadrilateral plate to assess reduction of posterior column accomplished by
elevation of obturator internus elevation
access can be enlarged by release of sacrospinous ligament
o hip joint exposure
perform marginal capsulotomy
capsular attachments to posterior wall fragments need to be kept intact to prevent
devascularization
femoral traction can allow visualization of intra-articular surface of hip joint
o osteotomy of greater trochanter
extends access along external surface of anterior column
Dangers
Sciatic nerve
o initially located along posterior surface of quadratus femoris muscle
quadratus femorus anatomy is constant; rarely damaged in setting of fracture
o extend hip and flex knee to prevent injury
o minimize chance of injury by using proper gentle retraction and releasing your short external
rotators (obturator internus) posteriorly to protect the sciatic nerve from traction
o treat injury with observation and use of ankle-foot orthosis
prognosis for recovery of tibial division is good despite severe initial damage
prognosis for recovery of peroneal division is dependant on severity of initial injury
Inferior gluteal artery
o leaves pelvis beneath piriformis
o if it is cut and retracts into the pelvis, then treat by flipping patient, open abdomen, and tie off
internal iliac artery
First perforating branch of profunda femoris
o at risk of injury with release of gluteus maximus insertion
Femoral vessels
o at risk with failure to protect anterior aspect of the acetabulum, or with placement of retractors
anterior to the iliopsoas muscle
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Superior gluteal artery and nerve
o leaves the pelvis above the piriformis and enters the deep surface of the gluteus medius.
o this tethering limits upward retraction of gluteus medius and blocks you from reaching the iliac
crest
o injury can cause excessive bleeding
Quadratus femoris
o excessive retraction and injury must be avoided to prevent damage to medial circumflex artery
Heterotopic Ossification
o debride necrotic gluteus minimus muscle to decrease incidence of HO
Positioning
Anesthesia
o patient must be paralyzed throughout case
Position
o supine with greater troch on side of fracture at edge of table
o place bump under ipsilateral buttock
o flex affected leg to relax iliopsoas and neurovascular structures
Imaging
o ensure clear fluoroscopic images can be obtained prior to draping
Catheter
o insert catheter to empty bladder (will obscure vision)
Incision
Incision
o incision begins at midline 3-4cm proximal to symphysis pubis
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Acetabulum Approaches
o proceeds laterally to ASIS, then along anterior 2/3's of iliac crest
o extend incision beyond most convex portion of ilium
Superficial Dissection
o dissect through subcutaneous fat
o start laterally, incise periosteum along iliac crest
o release abdominal and iliacus muscle insertions from ilium
o superiosteally elevate iliacus from internal iliac fossa to SI joint and pelvic brim
o pack internal iliac fossa for hemostasis
o through lower portion of incision expose aponeurosis of external oblique and rectus abdominus
o divide exposed aponeurosis in line with skin incision one cm proximal to external inguinal ring
will often have to sacrifice lateral cutaneous nerve of the thigh
o thus unroofs inguinal canal, and exposes inguinal ligament
identify and protect ilioinguinal nerve
o isolate spermatic cord/round ligament and place penrose around structures to retract
o sharply incise inguinal ligament, leaving 1-2mm cuff of ligament still attached to divided origin
of internal oblique, transversus abdominus, and transversalis fascia
o may need to divide conjoint tendon at its insertion on pubis as well as anterior rectus sheath
Deep Dissection
o bluntly dissect a plane between the symphysis pubis and the bladder (space of Retzius), pack
with sponges
o expose anterior aspect of femoral vessels and surrounding lymphatics in midportion of
incision (lacuna vasorum)
lacuna musculorum is lateral and contains iliopsoas, femoral nerve, and lateral femoral
cutaneous nerve
o identify iliopectineal fascia, which seperates the lacuna vasorum and lacuna musculorum
o dissect vessels and lymphatics from medial aspect of fascia, free iliopsoas and femoral nerve
from lateral aspcet of fascia
o sharply divide iliopectineal fascia down to pectineal eminence, then detach from pelvic brim;
allows access to true pelvis, quadrilateral plate, and posterior column
o place second penrose drain around iliopsoas, femoral nerve, and lateral femoral cutaneous nerve
o place thrid penrose drain around femoral vessels and lymphatics
o identify and ligate corona mortise before retracting vessels
o subperiosteal dissection is used to expose pelvic brim, rami, and quadrilateral surface
Preparation
Position
o lateral decubitus positioning is utilized in this approach.
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Acetabulum Approaches
Approach
Incision
o the incision is carried along the iliac crest
starting from the PSIS and running anteriorly to the ASIS
it is then continued down from the ASIS in line with the
posterior femur
Superficial dissection
o separate the abdominal musculature from the gluteal musculature
at the iliac crest.
o develop the interval between the sartorius and tensor fasciae latae.
o retract the tensor laterally and dissect through the fascia lata distal
to the muscle (longitudinally).
o elevate the tensor fasciae latae from the ASIS.
Deep dissection
o dissect gluteal muscles off iliac crest
o subperiosteally dissect the gluteal muscles off the iliac crest from
anterior to posterior and cephalad to caudad.
o continue the elevation until the PSIS and greater sciatic notch are
encountered.
o the lateral branches of the anterior femoral circumflex vessels must
be ligated to further retract the tensor and fascia lata laterally.
o elevate the direct head of the rectus femoris from the pelvis as well
as the gluteus minimus (off the proximal femur).
o sequentially tag and resect the insertions of the
gluteus medius/minimus
piriformis
conjoint tendon (superior and inferior gemelli/obturator
internus)
Take care to protect the superior gluteal artery and nerve as
well as the sciatic nerve.
o release hip capsule, if not injured.
o access to the internal iliac fossa may be obtained inferiorly by
releasing the indirect head of the rectus femorus and superiorly by
releasing the abdominal musculature off the iliac wing and
elevating the iliacus from the internal fossa.
elevating the abdominal musculature from the iliac crest and
iliacus from the internal fossa in this approach will completely
devitalize the wing. This aspect of the approach should be used
on a very limited basis.
Wound closure
o 3 drains are placed before closure, one along the posterior column,
another in the distal portion of the incision, and a third in the internal
iliac fossa
o order of wound closure/repair:
hip capsule, external rotators
gluteus medius, must be fixed anatomically and with strong sutures
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gluteus minimus
rectus femoris origin with transosseous sutures, knee extension facilitates this repair
sartorius and abdominal muscles if taken down
fascia, subcutaneous layers, and skin
B. Hip Approaches
Planes
Internervous plane-Superficial
o sartorius (femoral n.)
o tensor fasciae latae (superior gluteal n.)
Internervous plane-Deep
o rectus femoris (femoral n.)
o gluteus medius (superior gluteal n.)
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Hip Approaches
o supine
Approach
Incision
o make incision from anterior half of iliac crest to ASIS
o from ASIS curve inferiorly in the direction of the lateral patella for
8-10 cm
Superficial dissection
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o should remain protected as long as you stay lateral to sartorius
muscle
Ascending branch of lateral femoral circumflex artery
o found proximally in the internervous plane between the tensor
fascia latae and sartorius
o be sure to ligate to prevent excessive bleeding
Intermuscular plane
Between
o tensor fasciae latae (superior gluteal nerve)
o gluteus medius (superior gluteal nerve)
Preparation
Anesthesia
o general or spinal/epidural is appropriate
Position
o generally performed in the lateral decubitus position
o patient's buttock close to the edge of the table to let fat fall away
from incision
Landmarks
o ASIS
o greater trochanter
o shaft of the femur
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Hip Approaches
Approach
Incision
o make incision starting 2.5 cm posterior and distal to ASIS
o as it runs distal, it becomes centered over the tip of the greater
trochanter
crosses posterior 1/3 of trochanter before running down the shaft
of the femur
Superficial dissection
o incise fat in line with incision and clear fascia lata
o incise fascia
incise in direction of fibers, this will be more anterior as your
dissect proximal
incise at the posterior border of the greater trochanter
o develop interval between tensor fasciae latae and gluteus medius
there will be a small series of vessels in this interval
o externally rotate the hip to put the capsule on stretch
o identify origin of vastus lateralis
Deep dissection
o detach abductor mechanism by one of two mechanisms
trochanteric osteotomy (shown in this illustration)
distal osteotomy site is just proximal to vastus lateralis ridge
partial detachment of abductor mechanism
place stay suture to prevent muscle split and damage to
superior gluteal nerve
nerve is 5cm proximal to the acetabular rim
o expose anterior joint capsule
o detach reflected head of rectus femoris from the joint capsule to
expose the anterior rim of the acetabulum
easier with leg flexed slightly
o elevate part of the psoas tendon from the capsule
o perform anterior capsulotomy
o dislocate hip with external rotation
Extension
o proximal
incise more fasciae latae proximally to allow increased
adduction and external rotation of the leg
o distal
incise down the deep fascia of the leg
allows access to the vastus lateralis which can be elevated to
allow direct access to the entire femur
Dangers
Femoral nerve
o most common problem is compression neuropraxia caused by
medial retraction
o direct injury can occur from placing retractor into the psoas muscle
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Femoral artery and vein
o can be damaged by retractors that penetrate the psoas
o confirm that anterior retractor is directly on bone
Abductor limp
o caused by trochanteric osteotomy and/or disruption of abductor mechanism
o caused by denervation of the tensor fasciae by aggressive muscle split
Femoral shaft fractures
o usually occurs during dislocation (be sure to perform and adequate capsulotomy)
Plane
Superficial
o no superficial internervous plane as both the adductor longus and
gracilis are innervated by the anterior division of the obturator nerve
Deep
o internervous plane between adductor brevis and adductor magnus
adductor brevis supplied by the anterior division of the obturator
nerve
adductor magnus has dual innervation
adductor portion is supplied by the posterior division of the
obturator nerve
ischial portion by the tibial portion of the sciatic nerve
Preparation
Position
o patient is supine with the affected hip in a flexed, abducted, and
externally rotated position
Approach
Incision
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Hip Approaches
o longitudinal incision over the adductor longus
o begin incision 3 cm below the pubic tubercle
o length of incision is determined by the amount of femur that needs to be
exposed
Superficial dissection
o develop plane between gracilis and adductor longus muscles
Deep dissection
Plane
Internervous plane
o no true internervous plane
Intermuscular plane
o splits gluteus medius distal to innervation (superior gluteal nerve)
o vastus lateralis is also split lateral to innervation (femoral nerve)
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Preparation
Anesthesia
o options
general
spinal
Position
o lateral
o supine
Approach
Incision
o begin 5cm proximal to tip of greater trochanter
o longitudinal incision centered over tip of greater trochanter and
extends down the line of the femur about 8cm
Superficial dissection
o split fascia lata and retract anteriorly to expose tendon of
gluteus medius
o detach fibers of gluteus medius that attach to fascia lata using
sharp dissection
Deep dissection
o split fibers of gluteus medius longitudinally starting at
middle of greater trochanter
do not extend more than 3-5 cm above greater trochanter
to prevent injury to superior gluteal nerve
o extend incison inferior through the fibers of vastus lateralis
o develop anterior flap
anterior aspect of gluteus medius from anterior greater
trochanter with its underlying gluteus minimus
anterior part of vastus lateralis
requires sharp dissection of muscles off bone or lifting
small fleck of bone
o expose anterior joint capsule
follow dissection anteriorly along greater trochanter and
onto femoral neck which leads to capsule
gluteus minimus needs to be released from anterior greater
trochanter
Structures at Risk
Superior gluteal nerve
o runs between gluteus medius and minimus 3-5 cm above
greater trochanter
o protect by
limiting proximal incision of gluteus medius
putting a stay suture at the apex of gluteal split
Femoral nerve
o most lateral structure in neurovascular bundle of anterior thigh
o keep retractors on bone with no soft tissue under to prevent iatrogenic injury
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Hip Approaches
Planes
Internervous plane
o no internervous plane
Intermuscular plane
o gluteus maximus
innervated by inferior gluteal nerve
muscle split is stopped when first nerve branch to upper part of
muscle is encountered
Vascular plane
o superior gluteal artsupplies proximal 1/3 of muscle
o inferior gluteal artery
supplies distal 2/3 of muscle
o line of fat on surface of gluteus maximus marks interval
Preparation
Anesthesia : general most common
Position
o lateral position
indications
hip arthroplasty
position of choice
posterior wall and lip fractures
skeletal traction may be used in lateral position
advantages
allows for femoral head dislocation
allows buttock tissue to "fall away" from the field
o prone position
indications
transverse fractures of acetabulum
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Approach
Incision
o make 10 to 15 cm curved incision one inch posterior to posterior edge of
greater trochanter (GT)
begin 7 cm above and posterior to GT
curve posterior to the GT and continue down shaft of femur
o mini-incision approach shows no long-term benefits to hip function
Superficial dissection
o incise fascia lata to uncover vastus lateralis distally
o lengthen fascial incision in line with skin incision
o split fibers of gluteus maximus in proximal incision
cauterize vessels during split to avoid excessive blood loss
Deep dissection
o internally rotate the hip to place the short external rotators on stretch
o place stay suture in piriformis and obturator internus tendon (short
external rotators)
evidence shows decreased dislocation rate when short external
rotators repaired during closure
o detach piriformis and obturator internus close to femoral insertion
reflect backwards to protect sciatic nerve
o incise capsule with longitudinal or T-shaped incision
o dislocate hip with internal rotation after capsulotomy
Proximal extension
o may extend proximal incision towards iliac crest for exposure of ilium
Distal extension
o extend incision distally down line of femur down to level of knee
o vastus lateralis may either be split or elevated from lateral
intermuscular septum
Dangers
Sciatic nerve
o location
initially located along posterior surface of quadratus femoris
muscle
quadratus femorus anatomy is constant; rarely damaged in
setting of fracture
o prevention
extend hip and flex knee to prevent injury
use proper gentle retraction and release short external rotators (obturator internus) posteriorly
to protect the sciatic nerve from traction
o treatment of injury
treat injury with observation and use of ankle-foot orthosis
o prognosis
recovery of tibial division is good despite severe initial damage
recovery of peroneal division is dependent on severity of initial injury
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Hip Approaches
Inferior gluteal artery
o location
leaves pelvis below piriformis
o treatment of injury
if cut and retracts into pelvis, flip patient, open abdomen, and tie off internal iliac artery
First perforating branch of profunda femoris
o at risk
during release of gluteus maximus insertion
Femoral vessels
o at risk
with failure to protect anterior aspect of the acetabulum
with placement of retractors anterior to the iliopsoas muscle
Superior gluteal artery and nerve
o location
leaves pelvis through the greater sciatic notch
contents of greater sciatic notch include
superior gluteal nerve
superior gluteal artery and vein
runs over the piriformis between the gluteus medius and minimus
enters the deep surface of the gluteus medius.
do not split gluteus medius more than 5 cm proximal to greater trochanter due to risk of
denervating the muscle
also at risk during the lateral (Hardinge) approach to the hip
Quadratus femoris
o excessive retraction and injury must be avoided to prevent damage to medial circumflex artery
Heterotopic ossification (HO)
o debride necrotic gluteus minimus muscle to decrease incidence of HO
Collected By : Dr AbdulRahman
AbdulNasser
[email protected]
In July 2017
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ORTHO BULLETS
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Femur Approaches
A. Femur Approaches
Intramuscular plane
No internervous or intermuscular plane
Intramuscular plane
o split the tensor fascia lata (superior gluteal nerve)
o split vastus lateralis (femoral nerve)
Blood Supply of thigh
Preparation
Anesthesia
o general
o spinal, epidural, and/or femoral blocks
Position
o supine
with sandbag below buttock to internally rotate operative leg
o lateraldecubitus
best for shaft of femur
Tourniquet
o can be applied for distal femur surgery
Approach
Incision
o landmark
palpate tip of greater trochanter
o make incision longitudinal
beginning over the midline of greater trochanter
extending down the lateral side of the thigh in line with the
lateral aspect of the femur
Superficial dissection
o incise tensor fascia lata
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Deep dissection
o incise the fascia over the vastus lateralis
o split vastus lateralis
can also lift vastus lateralis off intermuscular septum
watch for perforators
can retract into the posterior compartment of
the thigh
o expose desired area of femur with subperiosteal dissection
continued distally as necessary
helpful to place homan retractors over anterior and
posterior aspects of femur
Dangers
Perforating branches of the profunda femoris artery
o at risk within vastus lateralis dissection
o should be ligated to prevent hematoma
o femoral osteotomies
o treatment of chronic or acute osteomyelitis
o biopsy and treatment of bone tumors
Internervous plane
Between
o vastus lateralis (femoral nerve)
o lateral intermuscular septum covering the hamstring
muscles (sciatic nerve)
Blood Supply of thigh
Preparation
Anesthesia
o general
o spinal, epidural, and/or femoral blocks
Position
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Femur Approaches
o supine
with sandbag below buttock
o lateral decubitus
Tourniquet
o can be applied for distal femur surgery
Approach
Incision
o landmarks
palpate lateral femoral epicondyle for distal landmark
o make incision longitudinal on the posterolateral aspect of
the thigh
o continue proximally along the posterior part of the shaft
Superficial dissection
o through tensor fascia lata
Deep dissection
o reflect vastus lateralis anteriorly and dissect between it and
lateral intermuscular septum
easier to identify plan distally
o can continue vastus lateralis elevation until linea aspera is
seen
o incise the periosteum and continue dissection on top of
femur
helpful to place homan retractors over anterior and
posterior aspects of femur
Dangers
Perforating branches of profunda femoris artery
o at risk as they pierce lateral intermuscular septum
o should be ligated to prevent hematoma
Superior lateral geniculate vessels
o at risk distally near femoral condyles
o should be ligated to prevent hematoma
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Preparation
Anesthesia
o as dictated by the type of procedure
o most cases involving the anteromedial approach will require
a general anesthetic
Position
III:2 This intraoperative fluoroscopic
o supine on radiolucent table for fracture fixation image demonstrates stabilization of the
o prepare and drape the affected extremity so that it can be moved prior partial articular fracture with a
buttress plate and lag screws. The lateral
freely Hoffa component has been stabilized with
o consider bump under contralateral hip to facilitate access to the anterior to posterior lag screws
medial femur
Tourniquet
o elevate if needed for visualization
o use sterile tourniquet so as not to limit proximal extension of draping or exposure
Approach
Incision
o 10- to 15-cm longitudinal incision
centered over the interval between rectus femoris and vastus medialis
vastus may be atrophied in patients with knee pathology making identification difficult
extend distally along medial aspect of patella if exposure of the knee joint is required
Superficial dissection
o incise deep fascia
incise in line with skin incision
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Femur Approaches
Deep dissection
o open knee joint capsule
begin distally by opening the knee joint capsule via the medial retinaculum
o split the quadriceps tendon proximally
leave a cuff of tendon attached to the vastus to allow for later repair
o develop the interval between vastus medialis and rectus femoris
o identify and split vastus intermedius proximally
split vastus intermedius in line to expose femur
o incise the periosteum longitudinally and elevate as needed for exposure
Dangers
Medial superior genicular artery
o crosses field just above knee joint
Vastus medialis
o distal fibers insert directly on medial border of patella
o disrupted during exposure
o meticulous closure to prevent lateral patella subluxation
Intermuscular plane
Between
o lateral intermuscular septum which covers vastus lateralis (femoral nerve)
o biceps femoris (sciatic nerve)
Approach
Position
o prone
Incision
o Longitudinal (20 cm) down the midline of the posterior aspect of the thigh
Superficial dissection
o Deep fascia of the thigh
o avoid posterior femoral cutaneous nerve
Deep dissection
o Begin proximally; retract the long head of biceps femoris medially and lateral intermuscular
septum laterally
o In the distal half, retract the long head of the biceps laterally to expose the sciatic nerve; retract
the sciatic nerve laterally
o excise periosteum longitudinally
o expose desired area of femur with subperiosteal dissection
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Dangers
Posterior femoral cutaneous nerve
Sciatic nerve
Nerve to biceps femoris
B. Knee Approaches
1. Knee Arthroscopy
Indications
Arthroscopy is a surgical technique that can be applied to perform the following types of procedures:
o Diagnostic surgery
o Meniscal repair or resection
o Removal of loose bodies
o ACL and PCL reconstruction
o Synovial biopsy or synovectomy
o Chondral defect repair, including microfracture
o Osteochondritis dissecans treatment
o Knee debridement for osteoarthritis
controversial whether or not it provides symptomatic relief
Primary Portals
Anterolateral
o function
standard portal
used as the primary viewing portal
o location & technique
make with knee in flexion, adjacent to patellar tendon over soft spot on joint line
Anteromedial
o function
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Knee Approaches
standard portal
used as the primary instrumentation portal
o location & technique
make with knee in flexion, adjacent to patellar tendon over soft spot on joint line
Superomedial
o function
accessory portal
most commonly used for water in/out flow
o location & technique
make with knee in extension
Superolateral
o function
accessory portal
most commonly used for water in/out flow
o location & technique
make with knee in extension
most common site for aspiration or injection
Secondary Portals
Posteromedial portal
o function
helps visualize posterior horn and PCL
o location & technique
1 cm above joint line behind the MCL
Posterolateral portal
o function
helps visualize posterior horn and PCL
o location & technique
1 cm above joint line between LCL and biceps tendon
Transpatellar portal
o function
used for central viewing or grabbing
o location & technique
1 cm distal to patella and splits the patellar tendon
do not use if performing a bone-patella-bone graft harvest
Proximal superomedial portal
o function
used for anterior compartment visualization
o location & technique
4 cm proximal to patella
Far medial and far lateral portals
o function
used for accessory instrument placement
often helpful for loose body removal
o location & technique
place where can be best utilized for need
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Diagnostic Scope
Should systematically check the following locations and structures
o with knee fully extended start in suprapatellar pouch
loose bodies
o patellofemoral joint
patellofemoral cartilage
patellofemoral tracking
o trochlear groove III:3 patellofemoral joint
o lateral gutter
insertion of popliteus
o lateral compartment
anterior horn of lateral meniscus
o medial gutter
o with knee flexed to 90 move to medial compartment
medial meniscus
medial femoral condyle cartilage III:4 popliteus tendon in lateral gutter
medial tibial plateau cartilage
o intercondylar notch
ACL
PCL
posteromedial corner
best seen with 70 degree scope placed through notch (Modified
Gillquist view)
o with knee in figure-four position finish in lateral compartment
III:5 medial compartment shows
lateral meniscus
an intact medial meniscus.
popliteal hiatus
lateral femoral condyle cartilage
lateral tibial plateau cartilage
Complications
Iatrogenic articular cartilage damage
o is most common complication
Hemarthrosis
Neurovascular injury III:7 intercondylar notch shows III:6 lateral compartment shows
o posteromedial portal intact ACL. intact lateral meniscus.
saphenous nerve
o posterolateral portal
common peroneal nerve
Intermuscular Plane
Intermuscular plane III:9 An intermuscular plane is utilized
between rectus femoris (femoral nerve) and
o incise between rectus femoris (femoral nerve) and the vastus medialis (femoral nerve).
o vastus medialis (femoral nerve)
Approach
Incision
o landmark
palpate midline of patella in line to tibial tubercle III:10 The incision is started beginning 5 cm
above superior pole of the patella extending
o make midline longitudinal incision to the level of the tibial tubercle.
begin 5 cm above superior pole of the patella
extending to the level of the tibial tubercle
curved or straight incision can be used
and can be done with knee flexed
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Superficial Dissection
o divide subcutaneous tissues below skin incision
o deepen dissection between the vastus medialis and quadriceps
tendon
o develop medial skin flap to expose the quadriceps tendon,
medial border of the patella, and medial border of the patellar
tendon
o perform medial parapatellar arthrotomy
take care not to damage the anterior insertion of the medial
meniscus (irrelevant for TKA)
o retract or excise the infrapatellar fat pad
Deep dissection III:11 The superficial Dissection divides
o dislocate patella and flip laterally the subcutaneous tissues below the skin
incision deepening the dissection between
protect insertion of patellar tendon on tibia the vastus medialis and quadriceps tendon
if difficult to flip patella then extend incision between rectus to develop a medial skin flap and expose
the quadriceps tendon, medial border of
femoris and vastus medialis proximally the patella,
if contractures continue to prevent dislocation of the patella
then can detach tibial tuberosity bone block and reattach
afterwards with a screw
o flex knee to 90 degrees to gain exposure to entire knee joint
Extension
o proximal
may extend to distal two thirds of femur
incise between rectus femoris and vastus medialis
split underlying vastus intermedius to expose femur
Variations
o midvastus approach
proximal portion of the arthrotomy extends into the muscle
belly of the vastus medialis III:12 Perform the medial parapatellar
patella can be difficult to evert and is subluxated laterally arthrotomy and retract or excise the
infrapatellar fat pad out of the dissection.
instead
o subvastus (Southern) parapatellar approach
muscle belly of the vastus medialis is lifted off the
intermuscular septum
patella can be difficult to evert and is subluxated laterally
instead
benefits include
preserving the blood supply to the patella
preserving the anatomy of the quadriceps tendon
(maintains stability of knee)
Dangers
Superior lateral genicular artery III:13 Dislocate patella and flip it laterally.
o at risk during lateral retinacular release Take care to protect the insertion of
patellar tendon on the tibial tubercle.
o may be last remaining blood supply after medial parapatellar
approach and fat pad excision
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Knee Approaches
Infrapatellar branch of saphenous nerves
o saphenous nerve becomes subcutaneous on medial aspect of knee
after piercing the fascia between the sartorius and gracilis
o saphenous nerve then gives of infrapatellar branch that provides
sensory to the anteromedial aspect of the knee
o injury can lead to postoperative neuroma
if cut during surgery, resect and bury end to decrease chance of
painful neurom
Skin Necrosis
o cutaneous blood supply may be tenuous in cases of previous surgery
(revision TKA) or poor host (rheumatoid etc.)
skin is supplied by perforating arteries which run in the muscular
fascia so any medial or lateral skin flaps (if needed) should be just III:14 Incision landmarks are from
below (deep to) the fascia to avoid skin necrosis the midline of the patella in line to
the tibial tubercle.
old incisions should, as best as possible, be crossed at 90 degrees.
parellel longitudinal incisions are problematic so maximizing
the skin bridge is important (5-6cm recommended clinically)
Anatomy
There are three anatomic layers to the medial knee
o layer 1
sartorius
deep fascia
o Zone between Layer 1 & 2
gracilis
semitendinosus
o layer 2
superficial MCL
posterior oblique ligament
o layer 3
deep MCL
capsule
coronary ligaments
Intermuscular Plan
No internervous or intermuscular plane
Preparation
Anesthesia
o general
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o sciatic or femoral nerve block
Position
o supine
Tourniquet
o applied to thigh
Approach
Incision
o landmark
palpate adductor tubercle along medial aspect of knee
o make long, curved incision 2 cm proximal to the adductor tubercle
start midline
end 6 cm below the joint line with slight anterior curve
Superficial dissection
o raise skin flaps exposing fascia
o sacrifice the infrapatellar branch of the saphenous nerve
nerve crosses field transversely
o save the saphenous nerve itself
nerve is located between sartorius and gracilis
Deep dissection
o can either be exposed anterior or posterior to superficial medial
collateral ligament
anterior to the superficial medial collateral ligament
provides access to anterior medial side of joint
incise the fascia along the anterior border of sartorius
flex the knee to allow sartorius to retract posteriorly
knee flexion uncovers the semitendinosis and
gracilis
retract all three pes muscles posteriorly to expose the
tibial insertion of the superficial medial ligament
make a longitudinal medial parapatellar incision to
access joint
posterior to the superficial medial collateral ligament
provides access to posterior medial side of joint
incise the fascia along the anterior border of sartorius
retract it posteriorly, together with semitendinosis and
gracilis
if the capsule is intact, expose the posteromedial corner
of the joint by separating the medial head of
gastrocnemius from semimembranosus
separate the medial head of gastrocnemius from the
posterior capsule
Dangers
Infrapatellar branch of the saphenous nerve
o crosses transversely across operative field
o usually sacrificed
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o should be buried in fat to prevent neuroma
Saphenous vein
o is located between sartorius and gracilis
Medial inferior genicular artery
o may be damaged as medial head of gastrocnemius is lifted off tibia
Popliteal artery
o lies along midline posterior joint capsule
o adjacent to medial head of gastrocnemius
Anatomy
There are three anatomic layers to the lateral knee
o layer 1
ITB
biceps
fascia
o layer 2
patellar retinaculum
patellofemoral ligament
o layer 3
LCL
arcuate ligament
fabellofibular ligament
capsule
Internervous between
o iliotibial band (ITB) (superior gluteal nerve) anteriorly
biceps femoris tendon (sciatic nerve) posteriorly
Preparation
Anesthesia
o general
o sciatic or femoral nerve block
Position
o supine
can place bump under hip
Tourniquet
applied to thigh
Approach
Incision
o landmarks
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palpate lateral border of patella over lateral joint
palpate Gerdy's tubercle
marking insertion of IT band
o knee should be flexed during approach
o make long, curved incision at lateral border of center of patella
begin 3 cm lateral to edge of patella
end 4-5 cm distal to joint centered over Gerdy's tubercle
Superficial dissection
o mobilize skin flaps widely
o incise fascia between ITB and biceps femoris
avoid common peroneal nerve on posterior border of biceps femoris
retract ITB anteriorly and biceps posteriorly
exposes superficial lateral collateral ligament (LCL)
o retract lateral head of gastrocnemius posteriorly
Deep dissection
o can enter knee joint anterior or posterior to LCL
anterior arthrotomy
exposes entire lateral meniscus
posterior arthrotomy
exposes posterior horn of lateral meniscus and posterolateral corner
Dangers
Common peroneal nerve
o at risk on posterior border of biceps femoris
Popliteal artery
o at risk posterior to posterior horn of lateral meniscus
Popliteus tendon
o runs within joint adjacent to lateral meniscus
o attaches to posterior aspect of meniscus and femur
o at risk if performing a posterior arthrotomy
Lateral superior genicular artery
o at risk between femur and vastus lateralis
Lateral inferior genicular artery
o at risk between lateral head of gastrocnemius and posterolateral corner
o should be ligated
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Knee Approaches
Plane
No true internervous or intermuscular plane
Dissection is maintained underneath the gastrocnemius muscle belly
Preparation
Anesthesia
o general anesthesia with endotracheal tube
Preparation
o radiolucent table
o C-arm fluoroscopy
Position
o prone positioning is necessary
slightly flex knee via a bump under the ankle
Approach
Incision
o inverted L-shaped incision is made
horizontal limb is in Langer's lines in the popliteal space
vertical limb begins at the medial corner of the popliteal fossa
and extends distally
o S-curve incision
above incision can be extended proximally on the lateral side
for more extensile exposure
Superficial Dissection
o full thickness fasciocutaneous flaps are created
o sural nerve and short saphenous vein should be protected
Deep Dissection
o tendon of the gastrocnemius is seen and the muscle is retracted
laterally
the posterior aspect of the knee capsule is then seen
o popliteus and soleus are subperiosteally elevated off the
posterior tibia
this exposes almost all of the posterior tibia
Approach extension
o if additional medial access is necessary, the medial head of
the gastrocnemius can be released
posterolateral extension should be limited due to risk of common
peroneal nerve injury
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Structures at Risk
Popliteal artery
o risk is minimized with maintenance of access under the
gastrocnemius
o origin before knee
a continuation of the superficial femoral artery
transition is at hiatus of adductor magnus muscle
anchored by insertion of adductor magnus as enters region of
posterior knee
o course in posterior knee
relation to anatomy structures of knee
lies posterior to the posterior horn of the lateral horn of the
lateral meniscus
lies directly behind posterior capsule
o branches within knee
at supracondylar ridge gives branches the provide blood supply
to the knee
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Leg Approaches
C. Leg Approaches
Internervous Plane
None
dissection carried epi-periosteal between tibialis
anterior and tibia
Preparation
Anesthesia
o general
o sciatic or saphenous nerve blocks
Position
o supine I II:17 Superficial
Tourniquet III:18 Make a longitudinal dissection elevates skin
flaps to expose the medial
incision 1 cm lateral to the
exsanguinate limb (subcutaneous) border of
anterior border of tibia.
the tibia.
Approach
Incision
o make a longitudinal incision 1 cm lateral to the anterior border of tibia
o length of incision depends on procedure, but the tibia may be exposed
along its entire length
Superficial dissection
o elevate skin flaps to expose the medial (subcutaneous) border of the
tibia
o be sure to protect the long saphenous vein when retracting the skin
flaps
Deep dissection
o medial subcutaneous surface
essential to minimize subperiosteal stripping III:19 Deep dissection allows exposure to
incise periosteum longitudinally along the middle of the both the medial subcutaneous surface,
and the lateral extensor surface of the
tibia.
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medial border
reflect the periosteum anteriorly and posteriorly
o lateral extensor surface
incise periosteum over anterior border of the tibia
subperiostally dissect the tibialis anterior and neurovascular bundle and retract laterally
Structures at Risk
Long Saphenous Vein
is on medial side of calf and should be protected when raising a medial skin flap
Internervous Plane
Interval between
o peroneus brevis (superficial peroneal nerve) - lateral compartment
o extensor digitorum longus (deep peroneal nerve) - anterior compartment
Approach
Position
o lateral decubitus or semi-lateral
o exsanguinate limb if desired
Incision
o make a longitudinal incision over the anterior edge of the fibula (center it over the pathology in
the tibia)
Superficial dissection
o Incise tissue and fascia in line with the skin incision, careful not to injure the short saphenous
vein that runs along the posterior border of the fibula
o develop plane between peroneus brevis and extensor digitorum longus
o dissect down to anterolateral border of the fibula
o protect the superficial peroneal nerve that lies on the peroneus brevis muscle
Deep surgical dissection
o gently detach the extensor musculature form the anterior aspect of the interosseous membrane
using blunt instruments or cautery
o follow the anterior surface of the interosseous membrane to the lateral border of the tibia
(failure to stay on the surface of the interosseous membrane may lead to injury to the
neurovascular bundle in the anterior compartment
o expose the anterolateral border of the tibia
perform subperiosteal dissection (elevating tibialis anterior) of the lateral surface of tibia
moving anteriorly
o expose desired region of the lateral surface of the tibia
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Leg Approaches
Dangers
Short saphenous vein
Superficial peroneal nerve (gives off all motor branches in upper third of leg - therefore only sensory
branches at the level of this incision)
o injury to the nerve at this level leads to numbness on the dorsum of the foot
Anterior tibial artery and deep peroneal nerve
o protected as long as you stay on the anterior surface of the interosseous membrane
Plane
Internervous plan between
o tibial nerve (posterior compartment)
gastrocnemius
soleus
FHL
o superficial peroneal nerve (lateral compartment)
peroneus bevis
peroneus longus
Preparation
Anesthesia
o options include
general
spinal
peripheral nerve block
Position
o prone or in lateral position
Tourniquet
o exsanguinate limb using elevation or Esmarch
Approach
Incision
o longitudinal incision on lateral border of the gastrocnemius : make of desired length
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Superficial dissection
o reflect skin flaps
take care not to damage the short saphenous vein
o incise fascia
incise in line with the incision
o develop intermuscular plane
develop plan between the gastrocnemius and soleus (posterior group) and peroneal muscles
(lateral group)
muscular branches of peroneal artery lie with peroneus brevis proximally and may need to
ligated
o retract the soleus and gastrocnemius posteromedially
once done identify the origin of FHL and soleus on the posterior border of the fibula
Deep dissection
o detach the FHL and soleus
detach from the posterior border of the fibula and retract posteromedially
may expose entire length of fibula)
o detach posterior tibialis
remove off the posterior surface of the interosseous membrane
the posterior tibial artery and nerve will be posterior to posterior tibialis and FHL
o follow IOM to tibia
follow the posterior surface of the interosseous membrane to the lateral border of the tibia
o release posterior tibialis and FDL of tibia
dissect the posterior tibialis and flexor digitorum longus off the posterior surface of the
Structures at Risk
Short saphenous vein
Peroneal artery and branches
o avoid injury by staying on the posterior surface of the interosseous membrane
o branches may be ligated and coagulated
Posterior tibial artery and nerve
o avoid injury by staying on the posterior surface of the interosseous membrane
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Leg Approaches
Internervous plane
Between
o peroneal muscles (superficial peroneal nerve)
o muscles of the posterior compartment (tibial nerve)
Approach
Position
o may be done supine with bump under affected limb or in lateral position
Incision
o Make linear longitudinal incision along the posterior border of the fibula (length depends on
desired exposure)
o may extend proximally to a point 5cm proximal to the fibular head
proximally follow in line with the biceps femoris tendon
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Superficial dissection
o begin proximally and incise the fascia taking great care not to damage the common peroneal
nerve
o identify the posterior border of the biceps femoris tendon and its insertion into the head of the
fibula
o about 10-12 cm above the tip of the lateral malleolus, the superficial peroneal nerve pierces the
fascia
o identify and isolate the common peroneal nerve as it courses behind the biceps femoris tendon
o mobilize the common peroneal nerve by cutting the fibers of the peroneus longus
Deep dissection
o develop plane between peroneal muscles and soleus down to bone
o make a longitudinal incision in the periosteum of the fibula
o strip the muscles that originate on the fibula to expose your desired segment of fibula
Extensile measure
o distal - may be extended distally to become continuous with
Approach to the lateral malleolus
Ollier's lateral approach to the tarsus
Kocher lateral approach to the ankle and tarsus
Lateral approach to the calcaneus
Dangers
Common peroneal nerve
o avoid injury by isolating proximally
Superficial peroneal nerve
o susceptible to injury at junction of middle and distal third of leg
o if injured will cause numbness on the dorsum of the foot
D. Ankle Approaches
Intermuscular plane
Intermuscular plane
o extensor hallucis longus (deep peroneal nerve)
extensor digitorum longus (deep peroneal nerve)
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Ankle Approaches
Preparation
Anesthesia
o general
o spinal
Position
o supine
Tourniquet
o can elect for partial exsanguination (can allow better
visualization of neurovascular bundle)
Approach
Incision
o make15 cm incision over anterior ankle
begin 10 cm proximal to joint
cross joint midway between malleoli
stay superficial to avoid injury to superficial peroneal
nerve branches
Superficial dissection
o incise deep fascia of leg in line with skin incision
o incise extensor retinaculum
o find plane between EDL and EHL a few cm above joint
o identify neurovascular bundle
mobilizing tibialis anterior artery and deep peroneal
nerve
o retract EHL and neurovascular bundle medially
o retract EDL laterally
o remaining joint capsule tissue cleared to expose anterior ankle joint
Deep dissection
o incise capsule of ankle joint in line with incision
o expose full width of ankle joint by subperiosteal and subcapsular dissection of the tibia and talus
Medial variation
o can make 15cm incision anterior to medial malleolus
o incise deep fascia to medial side of tibialis anterior tendon
retract tibialis anterior laterally to expose ankle joint
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Dangers
Superficial peroneal nerve cutaneous branches
o at greatest danger during skin incision
Neurovascular bundle (deep peroneal nerve and anterior
tibial artery)
o above joint runs between EDL and EHL
o crosses behind EHL at level of the joint
Internervous plane
Internervous plane
o flexor hallucis longus (tibial nerve)
o peroneal muscles (superficial peroneal nerve)
Preparation
Anesthesia
o general
o spinal
Position
o prone
o lateral
o supine
large bump needed under ipsilateral hip to allow for
access
Tourniquet
o if used, exsanguinate leg prior to tourniquet elevation
Approach
Incision
o incision made along posterior border of fibula
typically centered about fibula fracture (if present)
need to extend almost to tip of fibula to allow
deeper access
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Ankle Approaches
Superficial dissection
o disect down to fibula
access to fibula is done with superficial dissection down to
lateral or posterolateral fibula (subcutaneous)
with proximal dissection, care must be taken to minimize
risk to the superficial peroneal nerve
Deep dissection
o access fibula
access to fibula is obtained with posterior retraction of the
peroneus longus and brevis muscles/tendons
o access the posterior malleolus
access to posterior malleolus is obtained with anterior
retraction of peroneus longus and brevis muscles/tendons
identify interval between FHL and peroneal tendons and
bluntly split areolar tissue
elevate the FHL off the distal posterior tibia
retract the FHL medially to allow access to the posterior
malleolus
care must be taken not to release the PITFL off the
fragment
devitalizes posterior malleolar fragment
can lead to post-fixation syndesmotic instability
Dangers
Superficial peroneal nerve
o at risk with superficial dissection proximally
Posterior tibial vessels
o should remain protected behind FHL
Tibial nerve
o should remain protected behind FHL
Sural nerve
o at risk with further dissection distally
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III:21 This shows the superficial dissection of III:22 Deeper dissection, revealing the peroneal III:23 Posterior malleolus revealed with anterior
this approach, with the fibula (and fracture) tendons and the interval for this approach, just retraction of the peroneal tendons and
easily visualized. Injury-related soft tissue behind them. The retractors are in place, about medial/posterior retraction of the FHL.
stripping tends to allow for easy access to the to reveal the posterior malleolus.
fibula fracture.
Approach
Position : supine with bump under buttock
Incision
o make longitudinal incision along the posterior margin of the fibula (center incision over fracture
site)
o extend 2 cm distal to the tip of the lateral malleolus (if needed)
Superficial dissection
o elevate skin flaps taking care not to damage the short saphenous vein and sural nerve that runs
posterior to the fibula
o look for the superficial peroneal nerve crossing from the lateral to anterior compartments (~10
cm proximal to tip of fibula)
Deep dissection
o longitudinally incise the periosteum of the subcutaneous surface of the fibula
o strip off just enough periosteum to expose the fracture site and achieve a reduction
o as you extend the incision proximally take care not to damage the superficial peroneal nerve
Extensile measure
o proximal - may be developed proximally to become continous with the Lateral approach to the
fibula
o distal - may be extended distally to become continous with
Ollier's lateral approach to the tarsus
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Ankle Approaches
Kocher lateral approach to the ankle and tarsus
Lateral approach to the calcaneus
o posterior
can access posterolateral tibia for fixation
interval is the peroneal muscles/tendons and flexor hallucis longus
Dangers
Sural nerve
o cutting may lead to formation of a painful neuroma and numbness along the lateral skin of the
foot
Short Saphenous vein
Terminal branches of peroneal artery
o lie deep to medial surface of distal fibula
o can be damaged if dissection does not stay subperiosteal
o may form hematoma after removal or tourniquet
Superficial peroneal nerve
o crosses from posterior to anterior over the fibular shaft at the proximal end of the incision
Planes
No internervous plane
Preparation
Anesthesia
o options include
block vs. general
Preparation
o c-arm, mini vs. full-size to confirm fracture reduction
Position
o supine
o place foot in slight external rotation to allow better visualization of medial malleolus
if a bump is utilized, it can be removed to allow extremity to externally rotate
Tourniquet : optional - can be used on the thigh or leg
Approach
Incision
o Make 10cm longitudinal, curved incision on medial ankle
begin 5cm proximal to medial malleolus over subcutaneous tibia
continue incision across anterior third of medial mallelous
this can be curved apex anteriorly for improved visualization of the ankle joint
finish 5cm distal and 5cm anterior to tip of medial malleolus
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Superficial dissection
o mobilize skin flaps
o identify and protect long saphenous vein just anterior to medial malleolus
o identify and protect long saphenous nerve, if possible, next to vein
o clear remaining tissues down to periosteum
Deep dissection
o expose fracture site for medial malleolus fracture
o make small incision in anterior joint capsule to visualize joint and dome of talus
o split fibers of deltoid ligament to allow hardware to seat directly on bone
o posterior tibial tendon should be visualized to ensure that it remains intact
Dangers
Saphenous nerve
o prevent injury by protecting and preserving the long saphenous vein
o often too small for direct visualization
o damage to nerve may cause
formation of painful neuroma
numbness over medial foot
Long Saphenous vein
o prevent injury by mobilizing anterior skin flaps with caution
o preservation is ideal so it can be utilized as a vein graft in future
Intermuscular interval
plane exists between
o tibialis posterior tendon (tibial nerve)
o flexor digitorum (tibial nerve)
Approach
Position
o supine
o exsanguinate limb
Incision
o Make 10 cm longitudinal curved incision with concavity of incision pointing anterior
begin 5 cm above the medial maleollus on the posterior border of the tibia
curve incision distally following the posterior border of the medial malleolus
end incision 5cm distal to medial malleolus
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Ankle Approaches
Superficial dissection
o Mobilize skin flaps
should be safetly posterior to long saphenous vein and saphenous nerve
o Incise retinaculum behind medial malleolus in a way that it can be repaired
Deep dissection
o retract tibialis posterior anteriorly
o retract remaining structure posteriorly (neurovascular bundle, FHL, FDL)
o perform subperiosteal dissection to expose posterior border of the tibia
stay on bone to avoid injury to posterior structures
Dangers
Tibialis posterior muscle
Flexor digitorum longus tendon
Flexor hallucis longus tendon
Posterior tibial artery and vein
Tibial nerve
Plane
Internervous plane between
o Peroneus tertius (deep peroneal n.)
o peroneus brevis (superficial peroneal n.)
Preparation
Anesthesia
o general
o spinal / epidural
Position
o place supine on table
o bump under ipsilateral hip
Tourniquet
o exsanguinate leg (if using tourniquet)
Approach
Incision
o proximally centered between tibia and fibula
o distal extension across the ankle, centered on 4th ray
Superficial dissection
o full thickness flaps utilized
o care must be taken to protect superficial peroneal nerve
located in the subcutaneous tissue, immediately under the skin
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Deep dissection
o fascia incised proximally and extensor retinaculum incised over ankle
o anterior compartment tendons elevated and retracted medially
o minimal arthrotomy performed
large arthrotomies lead to devascularization of the anterior distal tibia
and should be avoided
Proximal extension
o indications
for proximal plate placement
o dissection is limited proximally by anterior compartment muscle
attachments to anterior fibula
Distal extension
o indications
to access talar fractures or talonavicular injuries
to allow placement of pins for distraction
o dissection
can extend incision to talonavicular joint if needed
extensor digitorum brevis must be elevated
Dangers
Superficial peroneal nerve
Deep peroneal nerve
Anterior tibial artery
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Tarsal Joint Approaches
Approach
Position
o supine with bump under buttock
o exsanguinate leg
Incision
o begin incision 12 cm proximal to tip of lateral malleolus
o extend distally along posterior margin of fibula
o curve anterior following course of peroneal tendons
o end 2cm below and 2 cm anterior to tip of lateral malleolus
Superficial dissection
o subperiostally expose the fibula
o incise sheaths of peroneal tendons and displace tendons anteriorly
Deep dissection
o if fibula is not fractured perform osteotomy 10 cm proximal to tip
o divide interosseous membrane, and anterior and posterior tibiofibular ligaments
careful to preserve calcaneofibular and talofibular ligaments
o rotate distal fibula to expose lateral and posterior aspects of the distal tibia
if performing in children be careful not to damage the distal fibular physis
o Repair fibula with syndosmosis screw from proximal part of the lateral malleolus through the
tibiofibular syndesmosis
overdrill fibula to close down syndesmosis
Approach
Position
o supine
o can exanguinate leg if using tourniquet
Incision
o begin incision anteromedial to fibula 5 cm proximal to ankle joint
o carry incision over ankle joint to base of fourth metatarsal
may be extended both proximally and distally
Superficial dissection
o incise fascia, superior and inferior extensor retinacula down to periosteum of distal tibia and
ankle joint capsule
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o identify and retract intermediate dorsal cutaneous branches of superficial peroneal nerve
o retract extensor tendons, deep peroneal nerve, and dorsalis pedis artery medially
o divide extensor digitorum brevis in direction of its fibers (or may detach proximal origin and
reflect distally)
Deep dissection
o expose ankle joint capsule
o expose talonavicular joint and calcaneocuboid joint (same plane)
o expose subtalar joint (must first remove lateral fat pad)
o if needed: extend dissection distally to expose joint between cuboid and 4th and 5th metatarsals
o if needed: extend dissection distally to expose joint between cuboid and third cuneiform
Dangers
Avoids most important vessels and nerves
Approach
Position
o supine with bump under buttock
o partial exsanguination (allows better visualization of neurovascular bundle)
Incision
o begin just lateral to distal head of talus
o curve posteriorly to point 2.5 cm below tip of lateral malleolus
o curve proximally and run parallel to fibula and 2.5 cm posterior to it
o end 5-10 cm proximal to the lateral malleolus
Superficial dissection
o incise fascia down to peroneal tendons and retract them posteriorly
may divide peroneal tendons with Z-plasty for larger operative field and repair at end of case
o Avoid lesser saphenous vein and sural nerve which lay posterior to incision
Deep dissection
o Divide calcaneofibular ligament and expose subtalar joint
o If desired may expose calcaneocuboid joint through distal end of incision
o If desired may divide talofibular ligaments and dislocate talus by medial traction to expose
articular surface of the tibia
Dangers
Lesser saphenous vein
Sural nerve
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Calcaneus Approaches
Internervous Plane
Between
o peroneus tertius (deep peroneal n.)
o peroneus brevis (superficial peroneal n.)
Approach
Position
o supine with bump under buttock
o partial exsanguination
Incision
o make a 8-10 cm curved incision
begin incision over dorsal-lateral talonavicular joint
extend posteriorly over the sinus tarsi (soft tissue depression just anterior to lateral malleolus)
incise obliquely to point 2.5 cm below tip of lateral malleolus
Superficial dissection
o incise fascia and divide inferior extensor retinaculum in line with incision
o ligate veins crossing operative field
o mobilize small flaps (large flaps may necrose)
o incise deep fascia and extensor retinaculum in line with incision
careful not to damage peroneus tertius and extensor digitotum longus
o in the superior (distal) part of the incision expose peroneus tertius and EDL and retract medially
o in inferior part of incision expose peroneal tendons and retract inferior
Deep dissection
o Partially resect fat pad over sinus tarsi with sharp dissection (leave attached to skin flap)
o Identify and detach origin of extensor digitorum brevis under fat pad
o Reflect extensor digitorum brevis distally
o Identify and incise dorsal capsule of talocalcaneonavicular joint
o Identify and incise capsule of calcaneocuboid joint
o Incise peroneal retinacula and reflect peroneal tendons anteriorly
o Identify and incise capsule of posterior talocalcaneal joint
Dangers
Skin flap necrosis
o keep skin small and thick
o avoid sharp curves
Extensor digitorum longus tendon
Peroneus brevis tendon
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OrthoBullets2017 Lower Limb Approaches | Calcaneus Approaches
F. Calcaneus Approaches
Incision
Begin 2.5 anterior and 4cm distal to medial malleolus
o carry the incision posteriorly along the medial surface of the foot
to visualize the sustentaculum, the inicision should be 5 cm long following the neurovascular
structures
identify the posterior tibial tendon, the neurovascular bundle and the flexor hallucis tendon
Develop the interval between the neurovascular bundle and the flexor hallucis tendon
Incise the retinaculum
o feel for the bump of the sustentaculum
this is immediately above the flexor hallucis tendon
Deep Dissection
Divide the fat and fascia to define the inferior margin of abductor hallucis
Define the inferior margin of the abductor hallucis
Mobilize the muscle belly
o retract it dorsally
this exposes the medial and inferomedial aspects of the body of the calcaneus
Continue the dissection distally by dividing the plantar aponeurosis and the muscles attaching to the
calcaneus
Subperiostally strip muscle and plantar aponeurosis off the medial and inferior calcaneus
Dangers
Medial calcaneal nerve
Nerve to abductor digiti minimi
Intermuscular Plane
No internervous plane
Peroneal longus and brevis both supplied by superficial peroneal nerve
Approach
Position
o place supine on table
o bump under buttock on affected side
o tilt table 20 degrees away from surgeon to improve visualization
o exsanguinate limb
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Calcaneus Approaches
Incision
o begin 2-4 cm proximal to lateral malleoulus on the posterior border of the fibula
o extend incision down posterior fibula and bend around lateral maleolus over the peroneal
tubercle
o curve distally to a point 4 cm inferior and 2.5 cm anterior to lateral malleolus (follow the course
of the peroneal tendons)
Superficial dissection
o Mobilize skin flaps
careful to avoid sural nerve and short saphenous vein that run posterior to the lateral
malleolus
o Incise the deep fascia to uncover the peroneal tendons
o Incise the inferior peroneal retinaculum over peroneus brevis
must repair at end of case to prevent dislocation
o Incise sheath of peroneus longus
o Mobilize peroneal tendons and retract them anteriorly over the lateral malleolus
Deep dissection
o identify calcaneofibular ligament and incise
o locate the posterior talocalcaneal joint capsule and incise it transversly
inverting the foot will expose the articular surface
o to expose lateral surface of calcaneus perform subperiosteal dissection inferiorly
Deep Dissection
Divide superficial and deep fascia
Isolate peroneal tendons
o if necessary and there is no infection may divide tendons by Z-plasty and repair at end of case
Incise and elevate the periosteum below the tendons
Subperiostally elevate tissues (including tendons) superiorly and inferiorly off the lateral surface of
the calcaneus
3. U Approach to Calcaneus
Indications
Calcaneus fracture
Positioning
Place patient prone
Support leg on sandbag
Incision
Make lateral incision as described in lateral approach to calcaneus
Make medial incision as described in medial approach to calcaneus
Connect medial and lateral incisions with a transverse posterior incision inferior to the insertion of
Achilles tendon
This forms a U-shaped incision around the posterior four-fifths of bone
Deep Dissection
Divide superficial and deep fascia
Incise periosteum transversely in line with the incision
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OrthoBullets2017 Lower Limb Approaches | Calcaneus Approaches
Dissect subperiosteally to create U-shaped flap consisting of skin, fatty heel pad, plantar aponeurosis
and muscles
Elevate plantar aponeurosis and muscles off the calcaneus to expose the bone
Cincinnatti Incision
Indications
Clubfoot release
o tendo Achilles lengthening or advancement
o one-stage posteromedial release (Turco procedure)
Correction of congenital vertical talus
Subtalar stabilization
Talectomy
Excision of accessory navicular
Excision of calcaneonavicular bar
Treatment of insertional Achilles tendinopathy
Incision
Begin anteromedially, at the navicular-cuneiform joint
Carry the incision posteriorly, beneath the medial malleolus
Posteriorly, ascend slightly to pass transversely over the tendo Achilles, at the level of the tibiotalar
joint
o this incision differs from the calcaneus U-approach slightly because the upward deflection
improves exposure of the tendo Achilles and tibiotalar joint
Laterally, curve gently over the lateral malleolus
End the incision anterolaterally just distal to the sinus tarsi
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Calcaneus Approaches
III:25 Exposure afforded by the III:26 Slide lengthening of the III:27 Talonavicular fixation with
Cincinnatti incision allows
visualization of (A) medial
tendo Achilles a K wire III:28 Detachment of
tendinopathic tendon from the
neurovascular structures
calcaneus following debridement
(retracted with penrose drain),
(B) Achilles tendon, (C) tibia and
(D) fibula. The tibiotalar joint is
also clearly visible
Dangers
Sural nerve (lateral)
o lies 18.8mm from the lateral border of the Achilles tendon at its insertion
o crosses over the lateral edge of the Achilles tendon 9.8cm above the insertion
Medial calcaneal nerve (medial)
Nerve to abductor digiti minimi (medial)
Planes
No true internervous or intermuscular plane
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OrthoBullets2017 Lower Limb Approaches | Calcaneus Approaches
Approach
Incision
Superficial dissection
o place the posterior arm of the incision midway between the
fibula and the Achilles tendon
o place the horizontal arm in line with the base of the fifth
metatarsal
o proximal and distal ends of the incision are bluntly spread
through until sural nerve is identified
o full thickness fasciocutaneous flaps are sharply created over calcaneus
o must not bevel the full-thickness aspect of the incision
o the vascular supply to the flap is a watershed area.
Deep dissection
o at the corner of the incision, make the incision directly to the bone to ensure that a full thickness
flap is created.
avoid any undermining of the edges
o a thick subperiosteal flap is sharply raised off of the lateral wall of the calcaneus until the sinus
tarsi, neck, and posterior facet are visualized
o 1.6mm K-wires can be placed into the talus, fibula, and cuboid
the wires are then bent, allowing a "hands-free" retraction technique
o calcaneofibular ligament is sharply released from the calcaneus, exposing the peroneal tendon
sheath
o the peroneal tendons are subperiosteally elevated and reflected in anterior flap
Approach extension
o can extend proximally to a lateral approach to ankle/fibula if needed
o distal extension limited by sural nerve
Dangers
Peroneal tendons
o risk is minimized with maintenance of access under the
anterior flap
o must evaluate upon closure for instability or laceration(s)
Sural nerve
o risk is minimized with maintenance of access under the
anterior flap
o must dissect out proximal aspect of vertical limb and
anterior aspect of horizontal limb to minimize iatrogenic
injury
Wound dehiscence
o most common complication of this approach
o lateral calcaneal artery is responsible for corner of flap
o careful attention to skin handling and closure with Allgower-Donati suture technique minimizes
soft tissue complications
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Forefoot Approaches
G. Forefoot Approaches
Deep Dissection
Disect through subcutaneous tissues and fascia
Laterally retract medial branch of first dorsal metatarsal artery and medial branch of dorsomedial
nerve (branch of superficial peroneal nerve)
Disect fascia down to bursa over medial aspect of metatarsal head
Make racquet-shaped flap/incision through fascia and into joint
o base of the flap should attach at base of proximal phalanx
Internervous Plane
None
o the bone is subcutaneous
Preparation
Anesthesia
o general
o block
Positioning
o supine with bump under ipsilateral hip
Tourniquet
o placed on middle of thigh or calf
o exsanguinate limb by elevation for 3-5 minutes
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OrthoBullets2017 Lower Limb Approaches | Forefoot Approaches
Technique
Incision
o 5-6 cm incision medial and parallel to tendon of extensor
hallucis longus (EHL)
o start 2-3 cm proximal to MTP joint
o extend distally to the proximal interphalangeal joint
Superficial dissection
o incise deep fascia in line with incision
o retract EHL laterally
o retract dorsal digital branch of the medial cutaneous nerve
laterally
Deep dissection
o make a U-shaped incision through joint capsule
base of the flap should attach at base of proximal phalanx
Dangers
Tendons
o extensor hallucis longus
lies in lateral edge of wound
retract laterally
o flexor hallucis longus
lies in groove on the plantar surface of the proximal phalanx
may be injured during subperiosteal stripping
Nerves
o dorsal digital branch of the medial cutaneous nerve
Positioning
Supine on operating table with a bolster under the thigh to flex the knee and keep the foot
plantigrade on the table
Incision
Make 2-3cm dorsolateral incision parallel to corresponding extensor tendons
If 2 adjacent joints need to be exposed, make the incision between them
Superficial Dissection
Incise the deep facia in line with the incision
Retract the extensor tendon to reveal the MTP joint
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Forefoot Approaches
Deep Dissection
Perform transverse or longitudinal arthrotomy
Retract the joint capsule to expose the MTP joint
Deep Dissection
Disect through subcutaneous tissues and fascia to joint capsule.
Reflect dorsal digital nerves and arteries dorsally and plantar digital artery and nerve plantarward.
Open capsule transversely or longitudinally
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OrthoBullets2017 Spine Approaches | Forefoot Approaches
ORTHO BULLETS
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Thoracic Spine
A. Thoracic Spine
Intermuscular plane
Between 2 paraspinal muscles
o each has segmental supply from posterior rami of lumbar nerves
Approach
Position
o prone (most common)
o abdomen free with bolsters
reduces venous plexus filling
o avoid pressure points at hip, chest
Incision
o midline incision
o tip of superior spinous process to spinous process of affected level
Position
o lateral decubitus, affected side upwards & over break
o hip flexed
o opens interspinous spaces
Incision
o from tip of superior spinous process to spinous process of caudal affected level
o midline incision
Landmarks
o tip of iliac crest: L4/5 interspace
o posterior superior iliac spince: S2
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OrthoBullets2017 Spine Approaches | Thoracic Spine
Superficial dissection
o skin
o subcutaneous fat
o fascial layer (lumbodorsal)
o spinous processes
cartilagious tip in pediatric patients
o paraspinal muscles stripped off lamina (subperiosteal)
superficial (erector spinae)
course: transverse & spinous process of inferior vertebrae to spinous processes of
superior vertebrae
function: extend and stabilize back
deep: transversospinalis (multifidis & rotators)
o facet joint
dissection laterally to tip of mamillary process
o lateral dissection taken to transverse process
transverse process of lower vertebra is at level of facet joint
Deep dissection
o ligamentum flavum
travels from superior aspect of inferior lamina to midway point of superior lamina
o removed with kerrison from leading edge of lower lamina
o epidural fat
o dural covering (seen as blue-white covering)
dissection is kept lateral to protect dura & visualize roots
Extension
o proximal
continue midline with incision as above
can be taken to C1
o distal:
continue with midline incision as above
can be taken to sacrum
Dangers
vascular area between transverse processes
venous plexus surrounding nerves
nerve roots
exiting nerve root exits foramen below the same level pedicle and above the disc
posterior rami
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Thoracic Spine
o infection in the thoracic spine
o osteotomies
o biopsy
Planes
No true internervous or intermuscular plane
Dissection is intramuscular through
o latissimus dorsi
o serratus anterior
Approach
Incision
o make an incision starting halfway up the medial border of the scapula halfway between the
scapula and thoracic spine
o curve incision down to a point two fingerbreadths below the tip of scapula
o finish the incision by curving upwards towards the inframammary crease
Superficial dissection
o divide latissimus dorsi in the direction of the incision
o divide the serratus anterior along the same line to the ribs
o enter the chest via intercostal space or rib resection
ribs resection approach
offers greater exposure and bone for autograft
intercostal approach
considerations
use 5th intercostal space for pathology from upper thoracic spine to T10
from T10 and lower, use 6th intercostal space
technique
cut the periosteum on upper border of rib
entering on upper border of rib protects intercostal nerve and vessels
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OrthoBullets2017 Spine Approaches | Lumbar Spine
enter the pleura
resect posterior three fourths of the rib for added exposure
insert rib spreader
Deep dissection
o deflate lung
o retract lung anteriorly with moist lap sponge
o incise pleura over lateral esophagus to allow for retraction of esophagus
o retract esophagus anteriorly
o tie off as few intercostal vessels as possible
o reflect periosteum over spine with elevators to expose involved vertebrae
Dangers
Intercostal vessels
o vulnerable during
rib resection when running along undersurface of rib, and
exposure of vertebrae within chest
o avoid injury by entering pleura from above the ribs
Lungs
o avoid injury by using sharp instruments wisely when within chest
o expand lungs every 30 minutes to prevent microatelectasis
Esophagus
o avoid injury through adequate retraction of esophagus while working on spine
Artery of Adamkiewicz
o travels on left side between T9-L2 in 60% of patients
o must preserve to prevent spinal cord ischemia
B. Lumbar Spine
Internervous Plane
Between two paraspinal muscles (erector spinae)
o each innervated by segmental nerves coming from posterior primary rami of lumbar nerves
o damaging posterior primary rami does not denervate paraspinal muscles due to segmental
innervation
Preparation
Anesthesia : general to protect airway in prone position
Position
o prone
o lateral flexion position
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Lumbar Spine
Approach
Incision
o landmarks
can palpate spinous process (midline)
highest point on iliac crest marks L4-5 interspace
o make midline incision
Superficial dissection
o incise fat and lumbodorsal fascia to spinous process
preserve interspinous ligament
o detach paraspinal muscles (erector spinae)
subperiostally
o dissect down spinous process and lamina to facet joint
o move medial to lateral taking down or sparing the facet
capsule
o continue anterior to transverse process if necessary
Deep dissection
o remove ligamentum flavum by cutting attachment to
edge of lamina
ligamentum flavum attaches to the lamina halfway up the undersurface
o idenitfy epidural fat and dura
o using blunt dissection stay lateral to dura and continue to floor of spinal canal
Closure
o fascia is closed with watertight closure
o closed wound suction drain placed deep to the lumbodorsal fascia if drain is required
Dangers
Segmental vessels
o between facet and transverse process
o supply paraspinal muscles
o vigorously cauterize as they are encountered
Nerve roots
o each nerve root must be identified and protected
Venous plexus
o surrounds nerve roots
o may bleed during blunt dissection
o stop with Gelfoam or bipolar cautery
Iliac vessels
o can be damaged during discectomy if you pass instruments too far anterior through the annulus
Dura
o dura exposed after entering ligamentum flavum
o thin spatula tool can be used to gently retract dura away from area of focus
o epidural veins may bleed and make visualization difficult so hemostasis is of utmost importance
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OrthoBullets2017 Spine Approaches | Lumbar Spine
Internervous Plane
Intermuscular plane between
o multifidus
o longissimus
Approach
Incision
o incision make 3 cm from midline
Superficial dissection
o find plane between multifidus and longissimus and develop with blunt dissection
Deep dissection
o manually palpate transverse process
o place clamp on transverse process and confirm level with radiograph
o dissect transverse process above and below
o identify pars medially
Dangers
Dorsal root ganglion
Postion
Place in semilateral position (45 degrees to horizontal)
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By Dr, AbdulRahman AbdulNasser Upper Limb Anatomy | Lumbar Spine
o use sandbags or bean bag to hold patient at angle
o or place patient supine and tilt table
Place left side up
o aorta is more resistent to injury than vena cava
Incision
Make incision from
o posterior half of 12th rib to
o lateral border of rectus abdominis (midway
between umbilicus and pubic symphysis)
Approach
Approach to spine
o incise subcutaneous fat
o expose aponeurosis of external oblique muscle
o divide external oblique in line with fibers
o divide internal oblique in line with incision and perpendicular to muscle fibers
o divide transverus abdominis in line with skin incision
o bluntly disect plane between retroperitoneal
fat and psoas fascia
o retract peritoneal cavity medially
bring ureter with peritoneal cavity
o follow surface of psoas muscle to vertebral bodies
o tie off segmental lumbar arteries of aorta in the field
of dissection
L4/5 disc space
o mobilize aorta to the contralateral side
o place needle in disc and take lateral xray to identify
level
L5/S1 disc space
o work between the bifurcation of aorta
o place needle in disc and take lateral xray to identify
level
Dangers
Sympathetic chain
o lateral aspect of vertebral body
Genitofemoral nerve
o anterior surface of psoas muscle attached to fascia
Segmental arteries
o segmental lumbar arteries and veins
Collected By : Dr AbdulRahman
o aorta
AbdulNasser
Ureter
[email protected]
o lies between psoas fascia and peritoneum
In July 2017
attached more firmly to peritoneum
stroke to produce peristalsis to confirm
Superior hypogastric plexus : injury leads to retrograde ejaculation
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