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The hip is the most structurally stable joint in the body. Acetabular stability is enhanced by three thickenings in the hip capsule, the iliofemoral, ischial-femoral and pubo-femoral ligaments. The ...

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Essential anatomic and biomechanical features

The hip is the most structurally stable joint in the body. Acetabular stability is enhanced by three thickenings in the hip capsule, the iliofemoral, ischial-femoral and pubo-femoral ligaments. The iliofemoral ligament is one of the strongest fibrous capsular restraints in the body. Anatomically, it resembles an inverted Y and is, therefore, referred to as the "Y ligament of Bigelow." It is found in the anterior aspect of the hip and resists hyperextension. The ischial-femoral ligament is the thinnest of the three capsular ligaments. The superior portion resists forced internal rotation of the hip. The inferior portion resists flexion. The pubo-femoral ligament passes directly in front of the lower aspect of the femoral head and attaches to the distal aspect of the femoral neck. It resists abduction of the hip.

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Vascular Anatomy of the Proximal Femur

The blood supply to the proximal femur is complex and changes as the child ages. The vessels of the ligamentum teres provide a small amount of the overall blood delivered to the capital femoral epiphysis. Metaphyseal vessels transverse the femoral neck into the capital femoral epiphysis at birth (Slide 1). These arteries regress as the physis develops, forming an avascular barrier to vessel penetration. The metaphyseal blood circulation to the epiphysis is completely gone by 4 years old. As the metaphyseal vessels regress, the lateral epiphyseal vessels become more prominent. The lateral epiphyseal vessels consist of two branches, the posterior superior and the posterior inferior systems. Both arise from the medial femoral circumflex artery (Slide 2). The retinacular arterial system penetrates the hip capsule and travels in a proximal direction covered by retinacular folds along the neck of the femur (occurring between 3 and 4 years old). The lateral posterior superior vessels predominate, supplying blood to the anterior lateral portion of the femoral head. The posterior inferior and posterior superior arteries persist throughout life and supply the femoral head.

SLIDE 1		SLIDE 2

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Muscles around the Hip

Twenty-one muscles span the hip joint. Thirteen cross a single joint (ileum to femur). Six muscles cross both the hip and the knee joints. One muscle arises from the lumbar spine and attaches to the femur.

The hip flexors include the sartorius muscle, rectus femoris muscle, iliopsoas muscle and pectineal muscle. These muscles are innervated by the femoral nerve. The pectineus is also innervated by the obturator nerve.

The adductor compartment of the thigh contains the adductor magnus, gracilis and obturator externus. This group of muscles is innervated by the obturator nerve. The adductor magnus also has some innervation from the sciatic nerve.

The hip extensors include the gluteus maximus and the hamstring muscles. The gluteus maximus is innervated by the inferior gluteal nerve. The hamstring muscles are innervated by the tibial portion of the sciatic nerve, with the exception of the short head of the biceps which is innervated by the common perineal division of the sciatic nerve.

The abductor muscles of the hip include the gluteus medius, the gluteus minimis and the tensor fascia lata. These muscles are innervated by the superior gluteal nerve.

The final group of muscles that cross the hip joint are the short external rotators (piriformis, obturator internus, gemellus superior and quadratus femoris).

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Femur

The angle created by the femoral shaft and the neck of the femur in the coronal plane varies from 125° to 135°. The average adult has approximately 14° of anteversion in the proximal femur. There is also a slight anterior bow to the diaphysis of the femur.

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Knee Joint

The knee joint consists of three articulations (medial tibial-femoral, lateral tibial-femoral and patella-femoral). The knee functions as a modified hinge which allows for flexion, extension and some rotation. The knee can support the body's weight standing without muscular activity because of its unique bony structure. The flat tibial-femoral articulation allows for maximum mobility. Stability is imparted from the surrounding muscles, ligaments and cartilage.

The lateral femoral condyle is wider than the medial femoral condyle; the medial femoral condyle is longer and more curved posteriorly than the lateral. The tibia slopes distally from anterior to posterior by approximately 10°.

The patella is a triangular bone with a central articular ridge that divides it into a medial and a lateral facet. The lateral facet is always in contact with the lateral condyle of the femur. The medial facet is only in contact with the femur in maximum flexion. The line joined by the central articular ridge and the lateral aspect of the patella should diverge from a line formed by the center of the femoral sulcus and the lateral femoral condyle.

There are four major interarticular structures in the knee. The medial and lateral menisci serve as shock absorbers in addition to deepening the tibial plateau for the articulation of the femoral condyles. The fibrocartilaginous menisci are crescent-shaped fibrocartilaginous structures. The medial meniscus is semi-circular in shape. The lateral meniscus is almost circular and covers a larger surface area on the tibial plateau than does the medial meniscus. The anterior cruciate ligament is attached to the femur on the medial aspect of the lateral condyle. It runs in an oblique direction, attaching to the anterior tibia. The posterior cruciate ligament is attached to the posterior aspect of the lateral surface of the medial femoral condyle. It runs in a vertical direction, attaching to the posterior proximal surface of the tibia in the mid-line.

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Extra-Articular Knee Ligaments

The capsule and the collateral ligaments are the primary extra-articular stabilizing structures of the knee. The menisci attach peripherally to the capsule. The popliteus tendon runs through the popliteal hiatus to insert on the femoral condyle from its origin on the tibia. The course of the popliteus tendon necessitates a less firm attachment of the lateral meniscus to the tibia and capsule than that of the medial meniscus. The medial collateral ligament is one of the three medial structures (fascia beneath skin, superficial medial collateral ligament, medial capsule of knee) that provide stability against a valgus force. The lateral extra-articular stabilizing structures also form three layers. The superficial layer consists of the lateral retinaculum and the ileotibial band. The fibular collateral ligament, fabello-fibular ligament and the arcuate ligaments make up the middle layer. The lateral capsule of the knee is the deep layer.

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Vascular Anatomy of the Knee

The superficial femoral artery enters the posterior aspect of the knee through the adductor hiatus to become the popliteal artery. The popliteal artery is closely approximated to the posterior aspect of the femur and tibia by the genicular arteries. The popliteal artery divides into the posterior tibial and anterior tibial arteries at the distal border of the popliteal muscle. The anterior tibial artery is situated between the two heads of the posterior tibial muscle, above the inner-osseous membrane, into the anterior compartment of the leg (between the fibula and the tibia). The largest division from the posterior tibial artery is the perineal branch, which divides from the posterior tibial artery several centimeters distal to the bifurcation of the popliteal artery into the posterior tibial and anterior tibial arteries.

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Nerves

The sciatic nerve, which supplies the posterior muscles in the thigh, is composed of two branches: the tibial and the common peroneal nerves. The tibial nerve arises from the sciatic nerve in the middle aspect of the thigh and courses distally through the popliteal fossa. It is the most superficial major neurovascular structure in the popliteal fossa, running between the two heads of the gastrocnemius as it crosses the popliteal vessels from lateral to medial. The common perineal nerve passes superficial to the tendon of the lateral head of the gastrocnemius coursing behind the fibular head. It pierces the perineus longus and divides into the superficial and deep branches.

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Compartments of the Lower Leg

The anterior compartment of the lower leg (Slide 3) contains the tibialis anterior, the extensor hallucis longus and the perineus tertius muscles. These muscles are innervated by the deep perineal branch of the sciatic nerve and are supplied by the anterior tibial artery.

Slide 3

The lateral compartment contains the peroneus longus and the peroneus brevis muscles. These are innervated by the superficial peroneal nerve. In some patients, the peroneus longus is also innervated from the deep perineal nerve. The blood supply to the lateral compartment of the lower leg is from perforating branches of the peroneal artery.

The superficial posterior compartment of the lower leg contains the gastrocnemius, soleus and plantaris muscles. These muscles are innervated by the tibial nerve.

The deep posterior compartment contains the popliteus, the flexor digitorum longus, the posterior tibialis and the flexor hallucis longus muscles. The tibial nerve provides innervation to the muscles in this compartment.

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Ankle Joint

The ankle connects two unequal lever arms (lower leg and foot). The longer lever is made up of the tibia and the fibula. The fibula is the lateral buttress to the ankle. It supports approximately one-sixth of the body's weight. The tibia is the medial buttress of the ankle and supports the balance of the body's weight. The talus articulates with the fibula and tibia. It is wider anteriorly than posteriorly. This provides enhanced stability when the ankle is dorsiflexed.

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Developmental Anatomy

The legs of a newborn have a different angular and rotational profile than those of an adult. Most newborn hips have an outward rotation of 90° and no significant internal rotation. Infants also have physiological genu varum. Eighty-five percent of newborns with have an internal tibial rotation. Fifteen percent of newborns will have neutral or external tibial rotation. Children with internal tibial torsion may also have distal tibial varus from intrauterine molding. The tibial-femoral axis changes with age and growth and from approximately 15° of varus at birth to 0° between 1 and 2 years old. Most children will develop 12° of genu valgum at approximately 3 years old. This slowly corrects to 5° to 6° of genu valgum by approximately 7 years old (Slide 4).

Slide 4

The increased outward rotation at the hip present at birth decreases as the child ages. The rotation should reach its adult value of approximately 55° of outward rotation and 45° of inward rotation by 3 years old (Slide 5). Some children develop excessive inward rotation of the hip (femoral anteversion). This spontaneously corrects in 95% of affected children by the age 8 years old.

Slide 5

The average foot progression angle changes little from walking age to late adulthood (Slide 6). The transmalleolar axis measures the rotation of the tibia (Slide 7). The thigh-foot angle measures the overall rotation of the tibia and the foot with the ankle (Slide 8). These change as the child ages.

SLIDE 6		SLIDE 7		SLIDE 8

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Physeal Growth

The capital femoral epiphysis ossifies at approximately 6 months old. The greater trochanteric epiphysis is the next to appear (at 4 years old). This is followed by the lesser trochanter at 8 years old. The physis adjacent to the three proximal femoral epiphyses close in the opposite order of appearance of the epiphysis. All growing centers are normally closed by 15 years old in a female and 17 years old in a male.

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Knee

The distal femoral epiphysis is present birth. The physis closes at approximately 14 years old in a girl and 16 years old in a boy. The proximal tibial epiphysis appears at approximately 2 months old. The physis closes between 12 and 14 years old. Closure progresses from posterior to anterior. The epiphysis of the fibula is present between 1 and 3 years old. Its physis is the last in the knee to close (by approximately 18 years old).

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Ankle

With a radial neck fracture, the tenderness is usually localized to the lateral elbow. It may be referred distally in some patients. The pain is usually greater with pronation and supination of the forearm than with elbow flexion and extension. There have also been occasional reports of compartment syndrome occurring with this fracture.²

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Bibliography

Frost HM. Biomechanical control of knee alignment: Some insights from a new paradigm. Clin Orthop. 1997; 335:335-342.

Hollister AM, Jatana S, Singh AK, Sullivan WW, Lupichuk AG. The axes of rotation of the knee. Clin Orthop. 1993; 290:259-269.

MacEwen GD, Kasser JR, Heinrich SD, eds. Pediatric Fractures: A Practical Approach to Assessment and Treatment. Baltimore, Md: Williams & Wilkins; 1993.

Reckling FW, Reckling JAB, Mohn MP. Orthopaedic Anatomy and Surgical Applications. St. Louis, Mo: Mosby Yearbook; 1990.

Salenius P, Vankka E. The development of the tibiofemoral angle in children. J Bone Joint Surg Am. 1975; 57:259-261.

Staheli LT, Corbett M, Wyss C, King H. Lower-extremity rotational problems in children. Normal values to guide management. J Bone Joint Surg Am. 1985; 67:39-47.

Wheelwright EF, Minns RA, Law HT, Elton RA. Temporal and spatial parameters of gait in children. Normal control data. Dev Med Child Neurol. 1993; 35:102-113.

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Outline

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References

1. Dobas DC, Silvers MD. The frequency of partite sesamoids of the first metatarsophalangeal joint. J Am Podiatry Assoc. 1977:  67;880–882.
2. Hobart MH. Fracture of sesamoid bones of the foot: With report of a case. J Bone Joint Surg. 1929: 11;298-302.
3. Waizy H, Jäger M, Abbara-Czardybon M, Schmidt TG, Frank D. Surgical treatment of AVN of the fibular (lateral) sesamoid. Foot Ankle Int. 2008: 29;231-236.
    

Which of the below patient factors has been associated with...

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This tutorial is a summary of a recent meta-analysis.1 The authors are from the University of Western Australia. ...

Stance phase: 62% (Heel strike to toe-off)RememberFirst double limb stanceIntermediateSecond double limb supportSwing phase: 38% (Toe-of ...

The syndesmosis between the tibia and fibula at the ankle consists of five defined structures

Subtalar dislocations most commonly occur with the foot dislocated medially with respect to the ankle. Less commonly, lateral dislocation occurs. Inversion causes medial dislocation, while eversion ...

Stress fractures of the tarsal navicular are seen in young athletes who run and jump frequently. Patients experience dorsomedial foot pain that worsens with activity. Cavus feet and calcaneal-navic ...

The lateral talar process is a wedged-shaped prominence that compromises the most lateral aspect of the talar body. Superiorly, it articulates with the talofibular joint, and inferiorly, with the p ...

Several classification systems have been introduced for calcaneus fractures. Letournel’s1 classification describes the most common types of fractures effectively, although it does not provide ...

Acute navicular fractures can be divided into avulsion and axial compression fractures. ...

Achilles tendon rupture can be a debilitating injury that results in significant loss of function if left untreated. Ruptures are generally associated with a gradual degeneration of the tendon prec ...

Great toe extra-articular fractures usually occur from striking the unprotected toe against an object or from dropping an object onto the toe. Most of these fractures have minimal displacement and ...

Calcaneus fractures are often caused by high-energy injuries, such as falls from heights and motor vehicle accidents. When a patient presents with a calcaneus fracture, a thorough patient ...

Ruptures of the Achilles tendon are common, and treatment options have evolved over the past two decades. The treatment of acute Achilles rupture is operative, followed by a carefully pre ...

The consequences of unrecognized compartment syndrome of the foot can be devastating. A patient with compartment syndrome of the foot has a markedly dysfunctional, painful, and stiff foot ...

Major fractures and dislocations of the tarsometatarsal joint are easy to diagnose, but minor sprains, particularly those associated with athletic and low-energy injuries, are often misdi ...

The diagnosis of an osteochondral defect is often missed as patients are initially treated for an ankle sprain. Any patient with persistent intra-articular symptoms after treatment of an ...

The lateral talar process is a wedged-shaped prominence that compromises the most lateral aspect of the talar body. Superiorly, it articulates with the talofibular joint, and inferiorly, ...

Acute navicular fractures can be divided into avulsion and axial compression fractures. ...

May be difficult to diagnose, especially with crush injuries and calcaneus fracturesHard to differentiate pain from the fracture or crush from compartment syndro ...

The anterior tibial tendon is the primary dorsiflexor of the ankle. It has two main functions during the gait cycle. It contracts concentrically during the swing phase of gait to help clear the flo ...

Anatomy of the peroneus brevis tendon The peroneus brevis tendon is located between the peroneus longus and the fibula. Subluxation of the perone ...

Function of the peroneus longus Supports the arch Plantarflexes the first metatarsal Weak evertor of the subtalar joint We ...

Vascular Supply A single nutrient artery enters the junction between the proximal and middle third of bone The nutrient artery bifurcates pro ...

An acute Achilles tendon rupture is commonly visible and palpable on examination (Slide 1). Patients experience an acute tearing sensation in the posterior leg, as if an object struck the ...

Talar neck fractures constitute 50% of talus fractures. The mechanism of injury is acute dorsiflexion of the forefoot, and usually occurs in motor vehicle accidents, falls, or as original ...

Osteochondral defects of the talus occur on both medial and lateral sides of the talar dome. Lateral lesions are more closely associated with trauma, and are caused by dorsiflexion-invers ...

Stress fractures of the tarsal navicular are seen in young athletes who run and jump frequently. Patients experience dorsomedial foot pain that worsens with activity. Cavus feet and calca ...

The lateral talar process is a wedged-shaped prominence that compromises the most lateral aspect of the talar body. Superiorly, it articulates with the talofibular joint, and inferiorly, ...

Acute navicular fractures can be divided into avulsion and axial compression fractures. ...

Wrist denervation procedures are performed for treatment of chronic wrist pain more commonly in Europe than the United States. However, articles by Dellon and Berger have continued to attract int ...

Radial polydactyly is a relatively common congenital anomaly that frequently presents as thumb duplication. Clinical cases vary in the extent of duplication. Presentations range from the ...

Macrodactyly, which is a rare anomaly of the upper extremity, has also been referred to as megalodactyly, overgrowth, gigantism, localized hypertrophy, or macrodactylia fibrolipomatosis ( ...

Ulnar club hand is classified as a post-axial longitudinal deficiency. The axis of the forearm lies along the middle finger; the ulnar side is considered post-axial and the radial side is ...

Radial club hand is classified as a pre-axial longitudinal deficiency. The axis of the forearm lies along the middle finger; the radial side is considered pre-axial and the ulnar side is ...

Thumb hypoplasia is a congenital hand anomaly, which ranges in severity from the presence of a small and weak thumb to complete absence of the thumb. The International Federation of Societies for S ...

Ganglions are benign, mucin-filled, cystic lesions that account for the majority of all hand masses. They arise from joint capsules, tendons, and tendon sheaths, but ganglions may also be ...

Swan-neck deformity describes a posture of the finger in which the proximal interphalangeal joint (PIP) is in hyperextension and the distal interphalangeal (DIP) joint is in flexion. Init ...

Stenosing tenosynovitis, commonly referred to as trigger finger, most commonly occurs in otherwise healthy middle-aged women. It is also seen in younger patients whose vocations involve r ...

Since its description by Robert Kienböck over 85 years ago, the disease bearing his name has remained a mystery to orthopedic surgeons. Neither the causes nor a universally accepted treatment for t ...

Boutonniere deformity is not synonymous with a proximal interphalangel joint (PIP) flexion contracture (i.e., post fracture, osteoarthritis or flexor tendon etiology). The position of a f ...

The carpometcarpal (CMC) joint of the thumb is formed by the articular surfaces of the distal trapezium and the proximal thumb metacarpal. Osteoarthritis (OA) of the CMC joint is a common ...

Growth and development of the hand occurs as pluripotent mesenchymal cells differentiate. The cell population size increases by mitosis and the intracellular structural protein is synthesized. Intr ...

As the ulnar nerve emerges from the medial cord of the brachial plexus and travels down the upper extremity, 5 potential compression sites have been identified: the arcade of Struthers, medial intermuscular septum, medial epicondyle, cubital tunnel, and the flexor carpi ulnaris (FCU) aponeurosis...

Polydactyly is the second most common congenital hand anomaly, with an incidence of 1 per every 3000 live births¹...

Brachial plexus trunk injury comprises 20% of all peripheral nerves injuries, and the trend is increasing. Brachial plexus injuries result from car accidents, particularly motorcycle acci ...

Radial nerve palsy can be produced by a variety of disorders or injuries occurring anywhere between the brachial plexus and the wrist... 

Nicholas A. Bontempo, MD
Resident
New England Musculoskeletal Institute
University of Connecticut Health Center
Farmington, CT

Jennifer Moriatis Wolf, MD
Associate Professor
New England Musculoskeletal Institute
Department of Orthopedic Surgery
University of Connecticut Health Center
Farmington, CT

Introduction
The proximal interphalangeal (PIP) joint is the articulation between the proximal phalanx and the middle phalanx of the ulnar four digits. The PIP joint is a hinge joint contributing to 85% of the motion required to grab an object.¹ Stability of the joint relies upon the bony architecture of the proximal and middle phalanges. The proximal phalangeal head has two condyles similar to the distal femur. The base of the middle phalanx has two saddle-shaped concavities that articulate with these condyles. Soft tissue stability is due to the collateral ligaments, volar plate, joint capsule, lateral bands of the extensor hood, and the flexor and extensor tendons.² 

The PIP joint can dislocate in one of three directions: volar, dorsal, or lateral (Figure 1, Figure 2 and Figure 3).³ The direction of dislocation refers to the location of the middle phalanx in relation to the proximal phalanx. Dislocations involving fractures of either the proximal or middle phalanx at the joint often represent a greater severity of injury. This tutorial focuses on simple dislocations at the PIP joint.







Dorsal Dislocations
Dorsal dislocations are usually a result of hyperextension, along with some form of axial loading.⁴ This mechanism of injury is commonly seen in ball-handling sports such as basketball or volley ball. Dorsal dislocations can be further subclassified into three types: type I injury is a hyperextension injury; type II injury represents a true dorsal dislocation; and type III injury is a fracture dislocation of the PIP joint. Type I and II injuries rarely require surgical intervention, but type III injuries often require more invasive methods of treatment.

Type I hyperextension injuries are painful but are relatively benign. They are characterized by partial or complete avulsion of the volar plate from the base of the middle phalanx. Patients may experience swelling and stiffness of the PIP joint for up to 6 months.  Because these injuries are inherently stable, the current recommendation for treatment is immobilization of the PIP joint for comfort for less than 1 week. ³

Type II dislocations, once reduced, are stable to active and passive testing. These injuries represent avulsion of the volar plate along with a major bilateral split in the collateral ligaments.  The joint should not be immobilized for more than 2 to 3 weeks. During immobilization, a dorsal splint should immobilize only the PIP joint in approximately 20° to 30° of flexion. A flexion contracture can develop if the joint is splinted in more than 30° of flexion. Following the initial 2 to 3 weeks of immobilization, the finger should be buddy-taped to the adjacent finger, and active use and range of motion exercises should be implemented. Patients suffering from this type of injury can have a stiff and swollen PIP joint for at least 6 months.⁵

Type III dislocations usually result in a fracture off the base of the middle phalanx, and they can be stable or unstable. When the fracture fragment is less than 40% of the articular surface, the joint can be classified as stable because the fracture does not disrupt the insertion of the collateral ligaments. When the fracture fragment is larger than 40% of the articular surface, the joint is typically unstable due to disruption of the collateral ligaments.^{3, 6} Stable fracture dislocations of the PIP joint can generally be treated nonoperatively with 3 weeks of dorsal block splinting followed by range of motion exercises. Unstable fracture dislocations usually require surgical intervention for reduction and stabilization of the fracture fragment. 

Lateral Dislocations
When the PIP joint dislocates laterally, one of the collateral ligaments ruptures along with a partial avulsion of the volar plate from its insertion on the middle phalanx.⁷  To assess stability of the joint after reduction, the collateral ligaments and volar plate should be tested with the joint in extension. If, on varus and valgus stress testing of the PIP joint, there is more than 20° of angulation, it can be assumed that there is complete disruption of the associated collateral ligament and at least one of the secondary stabilizers of the PIP joint (ie, volar plate, articular contour). As long as the joint is reduced on X-ray, the affected digit can be buddy-taped to the digit adjacent to the injured collateral ligament.⁷

Volar Dislocations
Volar PIP joint dislocations are rare injuries that are usually the result of axial compression in a semiflexed digit. When a volar dislocation occurs, the physician must assume that the central slip has been ruptured.³ The central slip is the terminal part of the extensor tendon that inserts on the dorsal base of the middle phalanx. If the PIP joint is volarly dislocated and cannot be reduced, then one must assume that there is soft tissue interposed that is preventing reduction (ie, central slip, collateral ligament, fracture fragment).⁸ With an injury to the central slip, a boutonniere deformity can develop where there is flexion at the PIP joint and hyperextension at the distal interphalangeal joint.⁹ Treatment includes reduction and immobilization of the PIP joint in full extension for 4 to 6 weeks while the ruptured central slip heals.⁴

In addition to a pure volar dislocation, volar rotatory subluxation can occur, described as unilateral disruption of the collateral ligament and partial volar plate avulsion. The involved condyle buttonholes between the central slip and the ipsilateral lateral band, and this interposition makes reduction difficult.³ Intuitively it would make sense to pull traction and rotate the digit in order to reduce it. Pulling traction, however, leads to tightening of the capsule and surrounding soft tissue structures, making reduction more difficult.

The proper way to reduce a PIP joint that has suffered volar rotatory subluxation is to apply gentle traction and to hold the metacarpophalangeal (MCP) and PIP joints at 90° of flexion, which relaxes the volarly displaced lateral bands. With the MCP and PIP joints flexed, a gentle rotatory motion will help disengage the intraarticular portion of the lateral band. If it is still difficult to achieve reduction, the wrist can be held in some extension to relax the extensor tendons and the extensor mechanism. Once the joint is reduced, the patient’s active range of motion should be tested. The patient may have full active extension due to an intact contralateral lateral band and portion of the central slip. If the patient has incomplete active extension, then the PIP joint should be splinted in full extension for 6 weeks.¹⁰ If the joint cannot be reduced in a closed fashion, operative open reduction may be necessary.

Conclusion
Dislocations about the PIP joint are common injuries of the hand. It is important to understand the type of dislocation to understand the structures that have been violated. Although dorsal PIP joint dislocations are the most common and often require a brief period of immobilization, volar PIP joint dislocations require much different management because of the involvement of the central slip. Injury radiographs of the dislocated joint will help confirm the type of dislocation so that, once reduced, the proper treatment course can be taken. Unstable fracture dislocations of the PIP joint often require surgical intervention, and understanding the type of dislocation will help determine the surgical treatment that is needed.

References:

1. Leibovic SJ, Bowers WH. Anatomy of the proximal interphalangeal joint. Hand Clin. 1994;10(2):169-178.
2. Kuczynski K. The proximal interphalangeal joint. Anatomy and causes of stiffness in the fingers. J Bone Joint Surg Br. 1968;50(3):656-663.
3. Glickel SZ, Barron OA, Catalano LW III.  Dislocations and ligament injuries in the digits.  In: Green DP, Hotchkiss RN, Pederson WC, Wolfe SW, eds. Green’s Operative Hand Surgery. 5th ed. Philadelphia, Pa.: Elsevier; 2005:342-388.
4. Bindra RR, Foster BJ. Management of proximal interphalangeal joint dislocations in athletes. Hand Clin. 2009;25(3):423-435.
5. Blazar PE, Steinberg DR. Fractures of the proximal interphalangeal joint. J Am Acad Orthop Surg. 2000;8(6):383-390.
6. Kiefhaber TR, Stern PJ. Fracture dislocations of the proximal interphalangeal joint. J Hand Surg Am. 1998;23(3):368-380.
7. Freiberg A, Pollard BA, Macdonald MR, Duncan MJ. Management of proximal interphalangeal joint injuries. Hand Clin. 2006;22(3):235-242.
8. Johnson FG, Greene MH. Another cause of irreducible dislocation of the proximal interphalangeal joint of a finger. J Bone Joint Surg Am.1966;48(3):542-544.
9. Aiache A, Barsky AJ, Weiner DL. Prevention of the boutonniere deformity. Plast Reconstr Surg.1970;46(2):164-167.
10. Bindra R. Dislocations and fracture dislocations of the metacarpophalangeal and proximal interphalangeal joints. In: Ring DC, Cohen MS, eds. Fractures of the Hand and Wrist. New York: Informa Healthcare; 2007:41-74.

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Infections of the hand may occur secondary to injury or as a complication of elective surgery. Effective management of hand infections requires knowledge of the anatomy of the hand, infec ...

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Cubital Tunnel Syndrome occurs with ulnar nerve entrapment as it crosses the elbow. Careful examination is required to differentiate this condition from nerve entrapment at the wrist - ul ...

The thoracic outlet is comprised of the musculoskeletal structures traversed by the nerves and blood vessels to the upper extremity as they enter the arm. Thoracic outlet syndrome is a co ...

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Median nerve entrapment at the carpal tunnel is the most frequently encountered entrapment neuropathy. Marie and Foix, in 1913, are credited with describing the relationship between median nerve en ...

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Dupuytren's contracture is a progressive thickening of the palmar fascia, wherein nodules and cords of tissue form and cause contracture of the metacarpophalangeal and proximal interphalangeal joi ...

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Since its introduction by Chen in 1979, wrist arthroscopy has evolved into an effective method of evaluating, diagnosing, and treating intra-articular pathology of the wrist. This surgi ...

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Amputation in hand fractures is an extreme measure. While digits should not be wantonly amputated, it is a hollow victory to save a stiff, malaligned, painful, dysvascular, cold-sensitive ...

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The term perionychium describes the region on the dorsal aspect of the distal phalanx that includes the nail bed and surrounding soft tissues. The "hard nail," referred to as the nail pla ...

Traction is the most common mechanism of injury in brachial plexus palsies that are birth-related or traumatic in nature.1 Rupture of peripheral nerves, avulsion of nerve root ...

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Frostbite, by definition, is freezing and crystalizing of fluids in cells and tissues due to prolonged exposure to freezing temperatures (-10° C). ...

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Fractures of the distal radius are among the most common traumatic injuries, representing nearly 20% of all fractures seen in emergency departments and occurring in a bimodal age distribu ...

The Galeazzi fracture pattern was first described by Sir Astley Cooper in 1822.1 However, the fracture bears the name of the Milanese surgeon, Ricardo Galeazzi, who in 1934 reported on 1 ...

The boxer's fracture is a fracture of the neck of the fifth metacarpal. Among the most common traumatic injuries of the hand, this fracture accounts for approximately 10% to 20% of all hand fractu ...

The Bennett's fracture of the thumb metacarpal (MC) base was first described by E.H. Bennett in 1882.1 Although this fracture is not common, it is notorious for causing the fractured th ...

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Osteotomies Around the Knee
Costas G. Papakostidis, MD

Popliteal tendinitis is one of the many causes of lateral knee pain in runners. It is seen much less frequently than iliotibial band syndrome. Only rarely is the tendon traumatically affected ...

Patellar tendinitis is a syndrome of overuse characterized by anterior knee pain brought on by running, jumping, and kicking activities. Blazina's original paper in 1973 coined the term, "ju ...

Reprinted with permission from Scott WN, Clarke HD. A fencepost solution. Orthopedics. 2002; 25:959-960.Early in the development of modern, surface total knee replacement (TKR ...

Wound healing is critical for the success of any total knee arthroplasty (TKA). Delays in wound healing risk infection and failure. Wound problems are minimized by selecting the proper skin incisio ...

Stiffness after total knee replacement (TKR) can be one of the more frustrating complications of this usually successful procedure. This article reviews potential causes of this complication and di ...

Reprinted with permission from Gustke K. Preoperative planning in revision total knee replacement. Orthopedics. 2002; 25:975.Preoperative planning is important in revision total k ...

Reprinted with permission from Hofmann AA. A double deep-dish geometry. Orthopedics. 2002; 25:961.The posterior cruciate ligament (PCL) is saved approximately 60% of the time and ...

Reprinted with permission from Laskin RS. Common misconceptions in total knee replacement. Orthopedics. 2002; 25:953-954.Knee joint replacement is one of the most successful opera ...

Total knee arthroplasty (TKA) has been a major advance for the treatment of the arthritic knee, predictably achieving excellent results at 10- to 15-year follow-up in more than 95% of patients.

A successful total knee arthroplasty (TKA) is a function of proper implant selection, proper alignment, and especially achieving proper soft-tissue balance. Establishing posterior stability (flexio ...

Reprinted with permission from Scott RD. Femoral component sizing: Betwixt & between. Orthopedics. 2002; 25:955.Distal femurs come in a spectrum of sizes and shapes. Inventory ...

Restoration of function in revision total knee replacement (TKR) often depends on careful documentation of bone loss prior to and at revision TKR. To obtain durable results in revision TKR, it is n ...

Treatment results have been variable but success rates have averaged approximately 80% (Table1). In the largest series to date, Nazarian and Booth5 reported a 78% success rate at 3.6-yea ...

Total knee replacements (TKR) fail due to reasons common to all procedures regardless of experience, case volume, technical expertise, or type of prosthesis. These failure modes comprise the genera ...

Minimizing postoperative blood loss is every surgeon's goal. The logistical problems of pre-donation, the cost of marrow stimulating medications, and the vagaries of using nonautologous blood have ...

When conservative measures offer no permanent solution for pain caused by medial or lateral knee arthritis, surgeons should consider a corrective tibial head osteotomy, unicompartmental knee prosth ...

Tibia fractures are the most common long bone fractures that result in nonunions and malunions. The tibia is subcutaneous, its blood supply is precarious, and complications of operative treatment ...

Stress fractures can occur if normal bone is exposed to repeated abnormal stress (fatigue fractures) or if normal stress is placed on bones with compromised elastic resistance (insufficiency fractu ...

The knee joint is a hinged joint that permits flexion and extension. The proximal tibia is composed of both a medial and lateral tibial plateau. The medial plateau is concave and the lateral plat ...

The structures of the medial side of the knee have been well described.1-4 One study described three medial soft tissue layers.4 The medial patellofemoral ligament (MPFL), whi ...

The posterior cruciate ligament (PCL) is the strongest of the cruciate ligaments. Reported injuries to the PCL are much less frequent than those of the anterior cruciate ligament (ACL). The ...

Osteochondritis dissecans (OCD), first described by Konig1 in 1988, is an avascular necrosis involving a bone at the osteochondral junction in the epiphysis. The subchondral bone becomes ...

The stability of the knee is imparted by ligaments, bony anatomy and menisci, and dynamic structures crossing the knee. The majorligaments include the anterior cruciate ligament (ACL), posterior cr ...

Nonoperative therapies are appropriate for management of patients with osteoarthritis of the knee. This article focuses on several such measures including exercise as a therapeutic modality, effect ...

Although total joint arthroplasty is a highly successful surgical procedure, development of osteolysis and aseptic loosening remains an important problem leading to arthroplasty failure...

Treatment options for large articular cartilage defects include abrasion arthroplasty, microfracture, autologous chondrocyte implantation, mosaicplasty, osteotomy, arthroplasty, and fresh allograft tissue transplantation.
 

Three methods are used to administer electrical stimulation to bone: direct current, capacitive coupling, and inductive coupling...

Endogenous parathyroid hormone (PTH) is the primary regulator of calcium and phosphate metabolism in the bone and kidneys...

The incorporation of cortical bone grafts differs from that of cancellous bone grafts in three specific ways...

Although autogenous cancellous bone grafts may be ideal for many situations, their use is complicated by limited available volume and donor site morbidity¹...

David J. Hak, MD, MBA
Denver Health
University of Colorado
Denver, CO

Numerous studies in animals and humans have shown that low-intensity pulsed ultrasound accelerates fracture healing. The characteristics of the commercially available low intensity pulsed ultrasound device to aid fracture healing (Exogen, Smith and Nephew. Memphis, TN) are a frequency of 1.5 MHz, a signal burst width of 200 microns, a signal repetition frequency of 1 kHz, and an intensity of 30 mW/cm2. 

Mechanism of Action

Although the exact mechanism of action has been debated, it is theorized that ultrasound pressure waves influence biologic activity either directly by deformation of the cell membrane or extracellular matrix, or indirectly through an electrical effect caused by cell deformation. Low-intensity pulsed ultrasound has been shown in vivo to accelerate all stages of the fracture repair process – inflammation, soft callus formation, hard callus formation. Ultrasound treatment also has been shown to accelerate mineralization in vitro with increases in osteocalcin, alkaline phosphatase, VEGF and MMP-13 expression.¹

Human clinical studies

Among the clinical trials of low-intensity pulsed ultrasound on fracture healing conducted in humans are several small prospective randomized studies. Heckman et al performed a prospective, randomized, double blind, placebo-controlled study of 67 closed or type I open tibial fractures.² Patients were randomly assigned either an active ultrasound device or a placebo device. The device was applied for 20 minutes per day for 20 weeks or until the investigator felt the fracture had healed. All patients were treated by closed reduction and cast immobilization. The acceleration of fracture healing seen in patients treated with the active ultrasound device was statistically significant when measured by both clinical and radiographic criteria. The overall time to healing, including both clinical and radiographic criteria, was 96 days (standard deviation ± 4.9 days) in the patients treated with the active ultrasound device compared with 154 days (SD ± 13.7 days) in the patients treated with the placebo device (P=.0001).

Kristiansen et al performed a multicenter, prospective, randomized, double blind, placebo-controlled study of 61 patients with distal radius fractures treated by closed reduction and short arm cast.³ Patients were again randomly assigned either an active ultrasound device or a placebo device. The device was applied for 20 minutes per day for 10 weeks. Time to healing in the fractures treated with the active ultrasound device was significantly shorter than those treated with the placebo device. The mean time to healing in the ultrasound treatment group was 61 days (SD ± 3 days) compared with 98 days (SD ± 5 days) in the patients treated with the placebo device (P<.0001). In addition, there was a significant decrease in volar angulation reduction loss in patients treated with ultrasound (P<.01).

Because smoking has been shown to slow fracture healing, Cook et al performed a subgroup analysis of these two studies, comparing the results of patients who were smokers with those that were nonsmokers.⁴ The researchers reported that the use of low-intensity ultrasound accelerated both tibial and distal radius fracture healing in patients who smoke. Tibial fracture healing time was decreased by 41% in smokers and by 36% in nonsmokers compared with the placebo group. In patients with distal radius fractures, treatment with ultrasound reduced the healing time by 51% in smokers and by 34% in nonsmokers. 

Emami et al performed a prospective, randomized, double blind, placebo-controlled study of 30 patients with tibial shaft fractures treated with a reamed intramedullary nail.⁵ Patients were randomly assigned either an active ultrasound device or placebo. The investigators found that ultrasound had essentially no effect on fracture healing. In fact, the results of this study have lead some surgeons to speculate that the presence of an intramedullary nail attenuates the ultrasound waves, diminishing any beneficial effects.  One criticism of this study is the small number of patients, which may have reduced the power and increased the risk that their nonsignificant result may be due to a statistical Type II error.

A current ongoing clinical study, Trial to Evaluate Ultrasound in the Treatment of Tibial Fractures (TRUST), is being conducted to evaluate the safety and efficacy of low-intensity pulsed ultrasound applied to tibial fractures treated with intramedullary nailing.⁶ This is a randomized, placebo-controlled clinical trial that plans to enroll 500 patients.  The primary outcome measure is radiographic fracture healing, and the secondary outcome measure is the rate of tibial nonunion formation.
   
Ultrasound has also been evaluated in the treatment of scaphoid fractures, clavicle, fibula, delayed unions, and nonunions.^7-13 Although many of these studies have shown fracture healing acceleration, some have shown no effect.^5,8,9 For cases of delayed union and nonunion the reported overall success rate of ultrasound treatment in the various studies is approximately 67% in the humerus, 82% in the femur, and 87% in the tibia.¹⁴

Summary

Low-intensity pulsed ultrasound has been shown to accelerate fracture healing in several small prospective randomized studies. However, further investigation with larger scale well-designed prospective randomized clinical studies is warranted to better determine the effectiveness and optimal indication for the use of ultrasound in patients with fractures.

References

1. Pounder NM, Harrison AJ. Low intensity pulsed ultrasound for fracture healing: a review of the clinical evidence and the associated biological mechanism of action. Ultrasonics. 2008;48:330-338.
2. Heckman JD, Ryaby JP, McCabe J, Frey JJ, Kilcoyne RF. Acceleration of tibial fracture-healing by non-invasive, low-intensity pulsed ultrasound. J Bone Joint Surg Am. 1994;76:26-34.
3. Kristiansen TK, Ryaby JP, McCabe J, Frey JJ, Roe LR. Accelerated healing of distal radial fractures with the use of specific, low-intensity ultrasound. A multicenter, prospective, randomized, double-blind, placebo-controlled study. J Bone Joint Surg Am. 1997;79:961-973.
4. Cook SD, Ryaby JP, McCabe J, Frey JJ, Heckman JD, Kristiansen TK.  Acceleration of tibia and distal radius fracture healing in patients who smoke. Clin Orthop Relat Res. 1997;337:198-207.
5. Emami A, Petrén-Mallmin M, Larsson S. No effect of low-intensity ultrasound on healing time of intramedullary fixed tibial fractures. J Orthop Trauma. 1999;13:252-257.
6. ClinicalTrails.gov. Trial to evaluate ultrasound in the treatment of tibial fractures (TRUST). http://clinicaltrials.gov/ct2/show/NCT00667849?term=TRUST&rank=6. Access June 7, 2011.
7. Mayr E, Rudzki MM, Rudski M, Borchardt B, Hausser H, Ruter A. Does low does intensity, pulsed ultrasound speed healing of scaphoid fractures? Handchir Mikrochir Plast Chir. 2000;32:115–122.
8. Lubbert PH, van der Rijt RH, Hoorntje LE, van der Werken C. Low-intensity pulsed ultrasound (LIPUS) in fresh clavicle fractures: a multi-centre double blind randomised controlled trial. Injury. 2008;39:1444-1452.
9. Handolin L, Kiljunen V, Arnala I, Pajarinen J, Partio EK, Rokkanen P. The effect of low intensity ultrasound and bioabsorbable self-reinforced poly-L-lactide screw fixation on bone in lateral malleolar fractures. Arch Orthop Trauma Surg. 2005;125:317–321.
10. Jingushi S, Mizuno K, Matsushita T, Itoman M. Low-intensity pulsed ultrasound treatment for postoperative delayed union or nonunion of long bone fractures.  J Orthop Sci. 2007 Jan;12(1):35-41.
11. Schofer MD, Block JE, Aigner J, Schmelz A. Improved healing response in delayed unions of the tibia with low-intensity pulsed ultrasound: results of a randomized sham-controlled trial. BMC Musculoskelet Disord. 2010;11:229.
12. Nolte PA, van der Krans A, Patka P, Janssen IM, Ryaby JP, Albers GH. Low-intensity pulsed ultrasound in the treatment of nonunions. J Trauma. 2001;51:693–702.
13. Pigozzi F, Moneta MR, Giombini A, et al. Low-intensity pulsed ultrasound in the conservative treatment of pseudoarthrosis. J Sports Med Phys Fitness. 2004;44:173–178.
14. Watanabe Y, Matsushita T, Bhandari M, Zdero R, Schemitsch EH. Ultrasound for fracture healing: current evidence. J Orthop Trauma. 2010;24 Suppl 1:S56-61.

The Use of Extracorporeal Shock Wave Therapy to Improve Fracture Healing

David J. Hak, MD, MBA
Denver Health
University of Colorado
Denver, CO

Introduction
Extracorporeal shock wave therapy (ESWT) is commonly used in the treatment of urolithiasis (kidney stones). Extracorporeal shock waves are single, high-amplitude sound waves generated by either electrohydraulic, electromagnetic, or piezoelectric methods that propagate in tissue, leading to a sudden rise of ambient pressure and maximum pressure at the wave front, followed by lower tensile amplitude.¹ Initial animal experiments in the early 1990’s examined the effect of shock wave energy on bone and fracture healing. Positive basic science findings have lead to subsequent human clinical trials.

Mechanism of Action
Two major mechanisms, membrane hyperpolarization, and the formation of oxygen free radicals, have been proposed to explain how the mechanical shock wave energy is translated into its biological effects.

In a rabbit fracture model, ESWT treatment has been shown to increase vascular endothelial growth factor (VEGF), endothelial nitric oxide synthase, proliferating cell nuclear antigen, and bone morphogenetic protein 2 (BMP-2).² Other animal fracture studies have shown that ESWT treatment produces increased callus formation, decreased healing time, and increased mechanical strength of the healed fractures.^3,4

Human clinical studies
Zelle et al reported a review of 10 studies investigating shock wave therapy in the treatment of fractures and delayed unions and/or nonunions.¹ The overall union rate was 76% in the 924 patients reviewed (95% confidence interval 73%–79%). The union rate was significantly higher in hypertrophic nonunions than in atrophic nonunions.
Wang et al performed a prospective, randomized  study of 56 patients with 59 acute high-energy fractures.⁵ All patients underwent open reduction and internal fixation (ORIF) with intermedullary (IM) nailing and plate fixation; patients in the active arm of the study received additional shockwave therapy following surgery while patients in the control group did not. There were 40 femur fractures (19 in the shock wave group and 21 in the control group) and 19 tibia fractures (9 in the shock wave group and 10 in the control group). Patients were evaluated at 3, 6 and, 12 months with clinical assessments of pain score, weight bearing status, and radiographs. The primary endpoint was the rate of nonunion at 12 months and the secondary end point was the rate of fracture healing at 3, 6 and, 12 months.

At 12 months, the rate of nonunion was 11% in the group treated with shock wave compared with 20% in the control group (P < 0.001). Also, the rate of fracture healing was significantly better in the shock wave treatment group compared with the control group at 3, 6, and 12 months (P < 0.001).

Cacchio et al reported on a prospective, randomized, multicenter study of 126 patients with long-bone nonunions.⁶ The study included patients with hypertrophic nonunions (n = 92) and atrophic nonunions (n = 34). Patients were randomized to one of three groups. Groups 1 and 2 both received four shock wave treatments; group 1 receiving an energy flux density of 0.40 mJ/mm² and group 2 received an energy flux density of 0.70 mJ/mm2. The four shock wave treatments were administered at weekly intervals and performed under regional anesthesia. The third group of patients was randomized to surgical treatment. The location of nonunions included in this study were femurs (n = 34), tibias (n = 67), humerus (n = 15), and radius/ulna (n = 10).

The authors reported that extracorporeal shock wave therapy was as effective as surgery in stimulating union in long bone hypertrophic nonunions. At 6 months the percentage of patients that had healed in each group was 70% in group 1 and 71% in group 2, compared with 73% in the surgically treated patients in group 3. Early clinical outcomes at 3 and 6 months were better in the shock wave treated groups, but at 12 and 24 months there were no differences in the clinical outcomes, except for the DASH scores.

Summary
Extracorporeal shock wave therapy appears to be a promising adjunct in the management of patients with nonunions. The current level of evidence is rated as poor because of the absence of high quality prospective randomized studies. Further investigation with large- scale, well-designed, prospective, randomized clinical studies is warranted to better determine the effectiveness and optimal indication for the use of extracorporeal shock wave therapy in patients with nonunions and acute fractures.

References

1. Zelle BA, Gollwitzer H, Zlowodzki M, Bühren V. Extracorporeal shock wave therapy: current evidence. J Orthop Trauma;24 Suppl 1:S66-S70.
2. Wang CJ, Wang FS, Yang KD. Biological effects of extracorporeal shock wave in bone healing: a study in rabbits. Arch Orthop Trauma Surg. 2008;128(8):879–884.
3. Wang CJ, Huang HY, Chen HH, Pai CH, Yang KD. Effect of shock wave therapy on acute fractures of the tibia: a study in a dog model. Clin Orthop Relat Res. 2001;387:112–118.
4. Wang CJ, Yang KD, Wang FS, Hsu CC, Chen HH. Shock wave treatment shows dosedependent enhancement of bone mass and bone strength after fracture of the femur. Bone. 2004;34(1):225–230.
5. Wang CJ, Liu HC, Fu TH. The effects of extracorporeal shock wave on acute high-energy long bone fractures of the lower extremity. Arch Orthop Trauma Surg. 2007;127(2):137-142.
6. Cacchio A, Giordano L, Colafarina O, Rompe JD, Tavernese E, et al. Extracorporeal shock-wave therapy compared with surgery for hypertrophic long-bone nonunions. J Bone Joint Surg Am. 2009;91:2589-2597.

Excessive bleeding can complicate many Orthopaedic surgical procedures...

Intra-articular injection of hyaluronic acid, so called viscosupplementation, is commonly used in the management of patients with knee osteoarthritis. It has been used in various forms since...

The commercial availability of recombinant human bone morphogenetic proteins (rhBMP) has introduced a new health care expense. The relatively high cost of this product has raised economic concerns ...

Bone repair following fracture has been divided into three main phases: the inflammatory phase, the reparative phase, and the remodeling phase. During the inflammatory phase prostaglandin ...

In the United States, bone graft substitutes may be regulated and approved in different manners depending on specific characteristics of the product. Varying levels of safety and efficacy ...

Platelet-derived growth factor (PDGF) is a 35,000 kd polypeptide growth factor that is synthesized by numerous cell types including platelets, macrophages, and endothelial cells...

The commercial availability of recombinant human bone morphogenetic protein (rhBMP) has provided surgeons with a powerful tool to accelerate and improve bone healing. rhBMP-2, which is indicated for use in open tibial shaft fractures treated with an intramedullary nail ...

Three important terms are used when describing bone grafts and bone graft substitutes. An understanding of these three terms (osteogenesis, osteoconduction, and osteoinduction) is an esse ...

Three important terms are used when describing bone grafts and bone graft substitutes. An understanding of these three terms (osteogenesis, osteoconduction, and osteoinduction) is an esse ...

Three important terms are used when describing bone grafts and bone graft substitutes. An understanding of these three terms (osteogenesis, osteoconduction, and osteoinduction) is an esse ...

Three important terms are used when describing bone grafts and bone graft substitutes. An understanding of these three terms (osteogenesis, osteoconduction, and osteoinduction) is an essential prer ...

Bone grafting is a common surgical procedure used to facilitate bone healing. For bone grafting, autograft is the gold standard in grafting material. Autograft provides osteoconductive, o ...

The mainstay of postoperative analgesia for moderate or severe orthopedic procedures is oral or intravenous opioids. However, although opioids provide potent analgesia, they also cause side effects ...

Three important terms are used when describing bone grafts and bone graft substitutes. An understanding of these three terms (osteogenesis, osteoconduction, and osteoinduction) is an esse ...

Three important terms are used when describing bone grafts and bone graft substitutes. An understanding of these three terms (osteogenesis, osteoconduction, and osteoinduction) is an esse ...

Despite the lack of Food and Drug Administration (FDA) approval, the use of antibiotic-impregnated polymethylmethacrylate spacers has become an important step in treating chronic, deep infections o ...

Pain management may be considered by some clinicians to be more of an art than a science. Due to the relative subjectivity and inter-patient variation of pain assessment, standardizing the treatmen ...

Three important terms are used when describing bone grafts and bone graft substitutes. An understanding of these three terms (osteogenesis, osteoconduction, and osteoinduction) is an esse ...

Gene therapy involves the transfer of genes to individuals for therapeutic purposes. Apart from the use of gene therapy in genetic diseases to compensate for abnormal or deficient gene products, it ...

Stem cells have three important distinguishing characteristics: Stem cells are undifferentiated cells. Stem cells are capable of self-replicating for indefinite periods in cult ...

The four phases of fracture healing include the inflammatory phase, the early post fracture phase, the soft callus phase, and the hard callus phase.The order of the appearance of growth fact ...

Endogenous parathyroid hormone (PTH) is the primary regulator of calcium and phosphate metabolism in bone and kidney. Its main function is to maintain the concentration of calcium in the extracellu ...

With an estimated incidence rate of 240 per 100,000 person-years, knee osteoarthritis (OA) is a major public health problem in the U.S. and often results in pain, loss of function, and disability.¹ As no disease-modifying medical interventions exist for knee...

Viscosupplementation (VIS) is a common treatment modality for osteoarthritis (OA) of the knee. It has been used internationally for over 20 years...

Intra-articular injection of hyaluronic acid, so called viscosupplementation, is commonly used in the management of patients with knee osteoarthritis. It has been used in various forms since...

The commercial availability of recombinant human bone morphogenetic protein (rhBMP) has provided surgeons with a powerful tool to accelerate and improve bone healing. rhBMP-2, which is indicated for use in open tibial shaft fractures treated with an intramedullary nail ...

Osteoarthritis of the knee may affect >6% of the adult population, with overall prevalence rates of 27% in adults aged <70 years and 44% in those aged >80 years...

Platelet-derived growth factor (PDGF) is a 35,000 kd polypeptide growth factor that is synthesized by numerous cell types including platelets, macrophages, and endothelial cells...

The commercial availability of recombinant human bone morphogenetic proteins (rhBMP) has introduced a new health care expense. The relatively high cost of this product has raised economic concerns ...

Bone repair following fracture has been divided into three main phases: the inflammatory phase, the reparative phase, and the remodeling phase. During the inflammatory phase prostaglandin ...

In the United States, bone graft substitutes may be regulated and approved in different manners depending on specific characteristics of the product. Varying levels of safety and efficacy ...

The management of unicompartmental knee osteoarthritis particularly in a relatively young population represents a unique challenge for orthopedic surgeons

Nonsteroidal antiinflammatory drugs (NSAIDs) are among the most common medications used to treat the signs and symptoms of arthritis through inhibition of prostaglandin biosynthesis

The patient is a white man aged 58 years who is newly referred to a rheumatology practice for ongoing management of his osteoarthritis. He has a history of joint pain lasting more than 15 years. 

A 66-year-old Caucasian female with history of hypertension, hyperlipidemia and gastroesophageal reflux disease (GERD) presented at the office with complaints of 

Osteoarthritis (OA) is a worldwide public health problem and often causes pain, loss of function, and disability...

It is currently accepted that morphologic alterations of the hip increase the risk of future osteoarthritis (OA)...

Since the American College of Chest Physicians (ACCP) issued a clinical guideline in 2004¹ that addressed venous thromboembolism (VTE) prophylaxis following hip (THR) and knee replacement (TKR) and strongly advocated the universal use of potent pharmacologic agents, there has been growing resistance among orthopedic surgeons to adopt this recommendation in routine practice...

One in four people, regardless of sex, race, education, injury history, or body mass index, will develop symptomatic hip osteoarthritis (OA) by age 85.¹...

The differential diagnosis of a painful joint following total joint arthroplasty is substantial and includes prosthetic loosening, metal hypersensitivity, periprosthetic fracture, and periprosthetic joint infection (PJI), among others...

Osteoarthritis (OA) is one of the most common conditions treated in the primary care setting, with patients commonly referred to rheumatology or orthopedic specialists...

A 70-year-old retired teacher who remains physically active complained of right medial knee pain that began 6 weeks prior to his initial visit...

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Nonoperative therapies are appropriate for management of patients with osteoarthritis of the knee. This article focuses on several such measures including exercise as a therapeutic modality, effect ...

Osteotomies Around the Knee
Costas G. Papakostidis, MD

Arthritis of the wrist is estimated to affect 5.3% of the U.S. population, based on radiographic assessments of 4,000 wrists.1 After having rheumatoid arthritis (RA) for 10 yea ...

When choosing a treatment method for patients with ankle arthritis, physicians must obtain a thorough knowledge of patients' activity level, interests, athletic activities, occupation, a ...

Blood management in orthopedic surgery today consists of allogenic transfusions, autologous blood, intra- and postoperative blood salvage, and erythropoietin alpha.1 In my experience, in ...

Following review of the material below, the orthopedic surgeonshould have an understanding of the normal response of cartilage to injury, andthe range of techniques in use or under investigation fo ...

Gout is caused by the deposition of monosodium urate crystals in tissues.1 Neutrophils ingest the crystals and then release potent lysosomal enzymes. < ...

Hypocellular Avascular Alymphatic ...

Osteoarthritis and inflammatory arthritis Meniscal tears Tendinitis Tenosynovitis < ...

Hemophilic arthropathy is a process in which patients with clotting disorders have recurrent bleeding into their joints, resulting in joint destruction of the knees, elbows, and ankles. Patients wi ...

Gastrointestinal (GI) hemorrhage is associated not only with use of prescription NSAIDs, but also with OTC products.¹

 

Osteoarthritis (OA) is a common age-related disease that causes severe morbidity in the adult population...

Osteoarthritis (OA) is a chronic, debilitating disease with no effective treatments...

It has long been reported that aging is a physiological event in any organ or tissue, and it is no different in the musculoskeletal system. Although the prevalence of osteoarthritis (OA) increases with age, not all joints in...

 Osteoarthritis, a debilitating degenerative joint disease predominantly found in elderly individuals, is typified by joint pain and stiffness...

Osteoarthritis is a common, chronic, and debilitating disease. There are few effective treatments, with joint replacement a primary exception...

Osteoarthritis (OA) is the most common form of arthritis.¹ The lifetime risk of symptomatic knee OA is approximately 40% in men and 47% in women.²

Osteoarthritis is not a part of normal aging.¹ It results from biomechanical abnormalities in the context of genetic susceptibility...

 

Hyaluronan is an integral component of healthy cartilage and synovial fluid in diarthrodial joints. It serves numerous functions within the joint and has been identified as an important molecule in the pathogenesis of...

As the most common arthritis and a leading cause of chronic disability worldwide, osteoarthritis (OA) is associated with progressive destruction of articular cartilage...

Interleukin-1 (IL-1) is a 17 kDa protein produced by many types of cells, including those present in human joints with osteoarthritis (OA).1 The two isoforms of IL-1 are α and β; IL-1α is intracellular, whereas IL-1β is secreted and mediates local autocrine and paracrine responses. To initiate cellular responses, IL-1 binds to type I IL-1 receptors...

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Derek D. Ulvila, BE
University of Miami
Miller School of Medicine
Miami, Florida

Seth R. Thaller, MD, DMD, FAAP, FACS
Chief, Division of Plastic and Reconstructive Surgery
University of Miami
Miller School of Medicine
Miami, Florida

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Every operating room contains the necessary elements to ignite a fire. Approximately 100 surgical fires occur out of the more than 23 million inpatient and 27 million outpatient surgeries performed annually in the United States.¹ Although a rare occurrence, an operating room fire can be disastrous for all involved resulting in up to 20 serious injuries and 1 or 2 deaths each year.¹ This tutorial will analyze the fire triangle, which is the foundation for the ignition of operating room fires, and ways to prevent operating room fires. Many potential sources of fire within the operating room will be identified. Lastly, this tutorial will outline the surgeon’s role and the proper steps to take if a surgical fire occurs.

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The fire triangle consists of the 3 elements that are necessary for the creation of any fire or explosion^2,3:

• Ignition source
• Fuel source
• Oxidizer

The removal of any element of the fire triangle minimizes the potential formation of fire.⁴ Each member of the operating room team must recognize the various items within their immediate environment that may contribute to the formation of a fire.

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In general, ignition sources supply intense heat and energy in a concentrated area. Based on the Emergency Care Research Institute’s (ECRI) review of case reports, investigators found that electrosurgical units (ESUs) were involved in 68% of operating room fires, making them the most common source of ignition.¹ The tip of the electrode of the ESU can produce intense heat and energy and can ignite many items located within the operating room. ESUs can also produce electrical arcs (ie, sparks) concentrating the electrical current onto specific points, thereby initiating combustion. Lasers are the second most common source of ignition, accounting for 13% of operating room fires.¹ The amount of time required for a laser to ignite is affected by the power output, duration of pulse, distance from fuel, oxygen concentration, and the presence of liquid, blood, or tissue residue.^5-7 Additionally, lasers are particularly dangerous because reflected laser beams can cause fires in unexpected locations.⁵ Heat from the tip of a fiberoptic light source and hot tissue embers have also been implicated in igniting fires.^4,5 Other sources include sparks from burrs, drills, defibrillators, and faulty equipment.⁴

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Numerous fuel sources are found within the operating room. Alcohol is a potent fuel source and can be found in a variety of operating room items such as alcohol swabs, iodophor, and chlorhexidine digluconate.^4,8,9 Tinctures, which by definition are suspended in alcohol, include benzoin, mastisol, collodion, and merthiolate.^2,4,5,8,10 Even catgut sutures are stored in an alcohol solution.^4,8,9 Not only can alcohol in liquid form be flammable but the associated vapors can also be combustible. Petroleum-based ointments such as petroleum jelly, acetone, ether degreasers, aerosols, paraffin, and wax are all flammable.^4,8,10

Along with ointments and solutions, equipment used in the surgical field can act as the source of fuel. These include cloth or paper drapes, towels, gowns, sponges, laps, ray-techs, throat or nasal packing, sutures, mesh, and latex gloves.^2,4,5,8-10 Drape fabric will absorb oxygen, greatly enhancing the potential to ignite and intensify the heat with which it burns.⁴ Plastic equipment such as tegaderm, nasogastric tubes, endotracheal tubes, nasal cannula and oxygen lines, suction tubes, or blood pressure cuffs can catch fire as well.^2,4,5,8-10 The patient’s head, facial, and body hair (which includes lanugo), hairspray, gastrointestinal gases, and bladder gases are also important considerations.^2,4,5,8-10

In the past, many fires and explosions resulted from the use of flammable or explosive anesthetic agents. However, the likelihood of fires or explosions resulting from the use of anesthetic agents is now small. Explosive anesthetic agents are rarely used and precautions and safety measures have advanced over time.³

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An oxidizer, which acts as a source of oxygen, is necessary to support combustion. The most common oxidizer in the surgical setting is oxygen. The concentration of oxygen in the surgical field is an extremely important issue of which the surgeon should be acutely aware. According to the ECRI’s review of case reports, an oxygen-enriched environment (defined as any oxygen concentration greater than 21%) was a contributing factor in 74% of operating room fires.¹ Fires involving oxygen-enriched environments ignite faster, burn hotter, spread more rapidly, and are harder to extinguish.^2,10 As the oxygen concentration increases above that of room air, less heat and energy are required to ignite materials.^5,10 Therefore, many materials that will not burn or sustain a flame in normal air (= 21% oxygen) will readily do so in an oxygen-enriched environment.^2,10

Nitrous oxide, which contains an oxygen molecule, is also an oxidizing agent that can support combustion.^2-5,10 Nitrous oxide may be a more reactive oxidant than oxygen³ due to its unstable structure.³ Therefore, fires involving nitrous oxide can be even more severe than those in 100% oxygen. Note that anesthesia using oxygen and nitrous oxide increases the concentration of both gases within the bowels of the patient, which poses additional risk for explosion.⁹

Recently, monitored anesthesia care (MAC) has been administered for an increasing number of operating room procedures.⁸ Commonly, MAC utilizes conscious sedation with supplemental oxygen via the nasal cannula. One concern of performing procedures under MAC is the possibility for the development of oxygen-enriched environments. Exposure to ambient air prevents the accumulation of oxygen. However, increased oxygen concentrations may still be present immediately adjacent to the nasal cannula.⁸ Oxygen is heavier than room air and it will settle in low areas. Tenting is a possible significant complication of using open delivery of supplemental oxygen (ie, via the nasal cannula). This phenomenon results in the accumulation of pockets of concentrated oxygen below the drapes due to interrupted airflow. Commonly, towels or drapes block exposure to ambient air and thus pose an additional risk for tenting. The danger of tenting is that these oxygen-enriched pockets can unexpectedly escape onto the surgical field and, if combined with an ignition source and fuel source, can lead to an operating room fire.

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Ignition sources

Fire prevention begins preoperatively by making sure that electrical equipment undergoes regularly scheduled maintenance.⁵ In the operating room, all electrical cords must be inspected for fraying before plugging them into the outlet. If a defibrillator is to be used in the operating room, prevent arcing by using gel and maintaining close contact between the skin and the defibrillator pads.¹¹ Additionally, turn off oxygen prior to defibrillation or cardioversion.¹² Fiberoptic scopes and headlights should never be rested on flammable materials such as drapes.² To avoid the end of an active fiberoptic light cable from inadvertently laying on a drape, ensure that the light cable is connected to the scope or headlight before turning on the light source.⁵ For the same reason, when finished, turn off the light source before disconnecting the fiberoptic cable.

When using an ESU, a few simple practices can help reduce the risk of fire. When the ESU is not in use, place the electrode in a non-conductive holster. If it is set aside on the drapes, it may inadvertently ignite a fire or directly burn the patient.² If the ESU is not in the holster, then it may fall off of the surgical field. If this occurs, do not leave the electrode dangling against the drapes. Remove the electrode immediately to prevent the ESU from being accidentally activated and igniting a fire.¹⁰ Only use ESUs with an audible activation tone and be able to readily recognize the sound of the tone.¹⁰ Activate the ESU only when the tip of the electrode is in direct view.⁵ This is especially important when using a microscope. Similarly, deactivate the ESU before removing the electrode from the surgical field.⁵ If using open delivery of supplemental oxygen during head and neck procedures, instruct the anesthesiologist to stop the supplemental oxygen at least 1 minute prior to the use of the ESU,^2,4,5,10 allowing time for the oxygen to dissipate. Always use the lowest effective power setting.⁴ Avoid long continuous durations of use. Minimize arcing by keeping the tip of the electrode clean. Buildup on the tip tends to cause accumulation of heat and can even ignite, especially in an oxygen-enriched environment.⁴ An alternative way to decrease arcing and heat buildup is to use bipolar cautery.⁴ Bipolar cautery is recommended whenever possible during procedures involving open delivery of oxygen.¹⁰ Bipolar electrodes confine current propagation to a few millimeters.¹³ Always remove unneeded footswitches after placing the device in “standby” mode to prevent accidental activation.¹⁰ Lastly, never use the ESU to incise the trachea. Such contact between the ESU and endotracheal tube or cuff can result in a severe airway fire.^2,4,10

Lasers should only be activated when the tip is in the direct view of the surgeon.¹⁰ If using an endoscope or the patient is intubated, ensure that the laser beam will be clear of the endoscope and/or endotracheal tube before activating the laser.¹⁰ Laser output should be set to the lowest possible power density and pulse duration.² Never clamp the laser fibers to the surgical drapes because clamping can break the fibers and allow part of the laser’s energy to escape at the point of breakage, causing ignition of the laser fiber sheath.² Metal instruments should have a flat finish to minimize reflection of the laser beam.¹² Use metal corneal protectors rather than plastic to prevent thermal injury to the cornea.² For laser facial skin resurfacing, use a combination of intravenous sedation and localized nerve blocks. Avoid the use of supplemental oxygen to minimize fire risk.² If open delivery of supplemental oxygen is to be used during head and neck procedures, stop the supplemental oxygen at least 1 minute prior to the use of the laser,⁵ allowing adequate time for the oxygen to dissipate. Laser-resistant endotracheal tubes should be used with general anesthesia or airway surgery. Manufacturer’s recommendations for the use of endotracheal tubes should be closely followed.¹⁰ Endotracheal cuffs should be filled with saline that is colored with methylene blue to visually assist in the detection of damage to the cuff by the laser.⁵ If damage to the cuff does occur, the dyed saline can also act as an extinguisher.⁵ Access to the endotracheal tube should always be maintained to allow an immediate response to airway fires. Lasers should be placed in standby mode whenever they are not in active use.² As with ESUs, remove unneeded footswitches after placing the device in standby mode to prevent accidental activation.^2,10

Robert A. Rubin, MD, MPH
Department of Anesthesia
Southern California Kaiser Permanente
West Los Angeles Medical Center

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Providing safe anesthesia in developing nations is challenging, especially for pediatric patients. Safety is essential in any situation where anesthesia must be provided in an unfamiliar and foreign environment.

Anesthesia providers pride themselves in being prepared. This is especially important in an unfamiliar environment. On international surgical missions, the surgical team will often be faced with unfamiliar languages, patient populations, hospital layouts, and team members. Uncertain oxygen supplies and limited resources also contribute to environmental stress for anesthesiologists.

Providing a safe, secure perioperative experience during a surgical mission requires a number of considerations.

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Personnel
It is important to have the best possible team and personnel available. They should be experienced in the types of surgery contemplated, be flexible team players, and have an Advanced Cardiac Life Support (ACLS) certification and a Pediatric Advanced Life Support (PALS) certification if the team will be operating on children. A biomedical technician experienced in anesthesia and surgical equipment must be present. Team leaders (surgical, anesthesia, nursing) need to be identified and their responsibilities must be as clear as possible, as do the objectives of the mission.

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Equipment
Proper equipment is the cornerstone of providing a safe and effective anesthetic. The author considers the following to be necessities:

• Portable Anesthesia Machine with appropriate vaporizers for inhalational agent to be used; it is best if unit is pneumatic driven
• Pulse oximeters
• CO₂ monitors
• Electrocardiograph
• Defibrillator with adult and pediatric paddles
• Portable suction device
• Emergency airway kits and adjuncts
• Laryngoscope with blades
• Temperature monitoring device
• Crash box with emergency pharmaceuticals

Much of the above equipment can be found in portable units such as the Datascope Passport 2 monitor (Datascope Corp., Paramus, NJ). Equipment should have battery capabilities. Other equipment, like a laryngeal mask airway, portable ventilator, or portable sterilizer, should be considered. If onsite equipment will be used it must be inspected by a trained biomed technician. The surgical team should know beforehand exactly what equipment will be used and have the chance to become familiar with it.

Surgical resources are in short supply in developing countries. Sutures and anesthesia supplies are the most difficult resources to obtain. The author considers the following to be necessities:

• Endotracheal tubes in the appropriate sizes and quantity for the planned surgeries
• Suction catheters
• Catheters, tubing, and other supplies needed for intravenous therapy; appropriate fluid usually can be obtained at the host institution
• Syringes and tape sufficient for the planned surgeries
• Anesthesia circuits
• Anesthesia pharmaceuticals such as propofol, ketamine, succinylcholine, atropine, epinephrine, and dexamethasone; if the surgical team is considering paralyzation, then appropriate non-depolarizing muscle relaxants and a reversal agent like neostigmine are needed
• Local anesthetics premixed with epinephrine to avoid mixing mistakes on site
• Analgesics such as acetaminophen, ibuprofen, and ketorolac

Most narcotics can be obtained in-country. It is not advisable to travel with them in checked luggage; doing so may find you in trouble with the local authorities. Overuse of narcotics on missions can cause unwanted complications like unrecognized respiratory depression. Only team members most experienced with their actions and adverse effects should administer narcotics.

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Policy and Procedures
All members of the surgical team must have a thorough understanding of the procedures and polices that will be in effect during the mission. A clear and concise policies/procedures manual should be produced and distributed to all team members prior to departure. Patient selection criteria, responsibilities during an emergency situation (eg, respiratory/cardiac arrest), pain control, discharge criteria, and other topics should be covered in this manual.

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Language
There will often be multinational members of the surgical team during an international mission. Proper communication among all members of the surgical team, the patients, and the host country’s hospital personnel, is an essential aspect of operating room safety. Language barriers must be overcome, and it may be beneficial to include team members who are fluent in the native language. Communication is essential for a team’s ability to provide safe medical care. It is often helpful to have signs and placards in the operating room that express useful information and phrases.

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On-Site Considerations
Once the surgical team arrives on site, it is important to evaluate and understand the surroundings to ensure a safe mission. All members of the surgical team should understand the hospital layout and anticipated patient flow. Consider how patients will be transported from the patient wards to preoperative area and operating rooms and then to recovery. Evaluate the physical distance between these locations and how and by whom patients will be transported. Identify important hospital departments, such as the intensive care unit (ICU), laboratory, and blood bank and their capabilities. It is important to know the local medical professionals and administrators who run each of these departments. Their help and knowledge is essential. Identify the oxygen source and electrical capacity for the operating rooms and post anesthesia care unit. Plans for oxygen disruption must be understood by all members of the surgical team. Backup oxygen tanks and a backup electrical generator are recommended. A biomedical technician should certify any electrical equipment before use. Trial runs of all emergency procedures should be conducted before the first day of operating. All members of the surgical team must understand who is in charge and the location of emergency medical equipment

Identify proper patients and conduct an adequate evaluation system. Doing so is paramount for a successful and safe surgical experience. Perioperative evaluation is well-understood by most experienced medical volunteers. If contemplating operating on pediatric patients, then special care and attention should be given to the following:

Age
Age parameters must be clear before the mission. ICU capability, medical staff, and ventilator availability will impact these parameters.

Physical examination
The surgical team must identify any concomitant congenital anomalies (eg, heart, lung, neurological, airway) or ongoing medical conditions (eg, malaria, parasites, AIDS) that might complicate the administration of anesthesia. The patient should have normal heart sounds, good preoperative oxygen saturation, a normal pulse, and normal lung function without wheezing, rales, or rhonchi. The nutritional status of each patient is also important.

History
Allergies, any family history of anesthesia complications, and surgical history should be evaluated. Any previous experience with malaria, parasites, AIDS, seizures, or other conditions may also be relevant.

Laboratory

Preoperative hemoglobin/hematocrit should be conducted if blood loss is anticipated. Assess what blood is available at the hospital.

If operating on children, the surgical team must be aware that children in developing countries do not have the same nutritional status, potential for healing, and postoperative care as children in the developed world. Conservative selection is essential to ensure safety.

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Immediate Preoperative Preparation
Reexamine the patient on the day of surgery to ensure that no problems have surfaced such as wheezing or vomiting that might complicate anesthesia. Nothing by mouth (NPO) status is very important as dehydration can be a severe problem. Most anesthesia practitioners follow these guidelines for NPO status in pediatric patients:

• NPO clear liquids (including breast milk) 2 to 3 hours preoperatively
• NPO solids 6 to 8 hours preoperatively
• Comorbidities or signs/history of reflux require NPO status of 6 to 8 hours preoperatively for any form of intake

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Intraoperative Management
Intraoperative anesthetic management is essential during surgery. Positive surgical results will not be possible if anesthetic management leads to a disastrous outcome. Being in a foreign land, in an unfamiliar operating room and hospital may require changes in practice. The author recommends the following for pediatric patients:

Induction

• Two anesthesia providers for each induction
• Perform inhalation induction, then begin intravenous therapy, then secure the airway
• Succinylcholine chloride should not be given to pediatric patients
• Do not use paralyzation unless necessary for the surgical case

Monitoring

• Patient must be monitored 100% of the time
• Use a precordial stethoscope
• Monitor O₂ saturation, CO₂, temperature, blood pressure, and electrocardiogram readings

Pain (intraoperative)
Local anesthetic may be used
Acetaminophen suppositories may be used
Fentanyl may be used

Other recommendations

• Dexamethasone (.3 mg/kg) should be administered for swelling of the airway and the surgical site
• Use a tongue stitch for cleft palate surgeries to prevent postsurgical partial airway obstruction
• Document throat pack information
• Extubate while the patient is awake
• A complete and legible anesthesia record with a timeline should be created before the surgery

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Conclusion
Safe administration of anesthesia is essential during all surgical missions. A surgical mission, regardless of the specialty, provides an opportunity to exchange information with in-country medical hosts. The author finds foreign colleagues to be knowledgeable, well-read, and motivated. Many are less experienced with the newer anesthesia agents, equipment, and techniques. There are differences on certain aspects of how anesthesia is approached. For example, constant monitoring of the patient may not be practiced at the host hospital. However, patients must be monitored for the duration of the surgery in any mission setting. Many techniques used by foreign surgical teams are preformed due of lack of equipment and/or supplies. However, the author finds that most are attempting to provide the best care with the resources available.

Note: The above tutorial is based on the author’s 14 years of experience with surgical missions and as the Chief Medical Officer of Operation Smile.

Derek D. Ulvila, BE
University of Miami
Miller School of Medicine
Miami, Florida

Seth R. Thaller, MD, DMD
Chief, Division of Plastic and Reconstructive Surgery
University of Miami
Miller School of Medicine
Miami, Florida

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Venous thromboembolism (VTE) refers to the clinical entity consisting of deep venous thrombosis (DVT) and pulmonary embolism (PE). VTE is a serious complication in surgical patients and may result in significant morbidity and mortality. Plastic surgeons must be aware of the risk of VTE and use prophylactic measures to maximize and ensure patient safety. Certain VTE risk factors and a risk assessment model for VTE are available for plastic surgeons. Mechanical and pharmacological options available for VTE prophylaxis exist. 

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VTE is a well-documented risk encountered in surgical patients. Table 1 lists the incidence of VTE for procedures that are specific to plastic surgery. VTE is responsible for up to 15% of all in-hospital deaths and 5% of all perioperative deaths.^1,2 The overall incidence of DVT in the United States is between 84 and 150 cases per 100,000.2 The overall annual incidence of PE is between 23 and 69 cases per 100,000.¹ Acute PE has an average case fatality rate within 2 weeks of diagnosis of approximately 11%.¹

Virchow’s triad consists of venous stasis, hypercoagulability, and endothelial injury.³ Formation of a venous thromboembolus can be attributed to factors relating to one of these 3 components.³ However, it is important to consider all surgical patients at some risk for the development of VTE.⁴ Other known risk factors include: previous VTE, general anesthesia, immobilization, malignancy, advanced age, obesity, trauma, heart failure, hormone replacement therapy or oral contraceptive use, pregnancy, severe infection, history of radiation therapy (especially pelvic), and genetic or acquired thrombophilias (Table 3).^2,4-6

Davison and researchers¹ developed a VTE prophylaxis risk assessment model designed for plastic surgery patients. This model stratifies plastic surgery patients into 4 categories of VTE risk: low risk, moderate risk, high risk, and highest risk. A patient’s risk factors are divided into exposing risk factors that are associated with the clinical setting and predisposing risk factors that are associated with the patient. The slides below display the risk assessment model. Slide 1 identifies and calculates the patient’s total number of exposing risk factors. Slide 2 identifies and calculates the patient’s total number of predisposing risk factors. Slide 3 adds the total number of exposing risk factors to the total number of predisposing risk factors to find the patient’s combined number of VTE factors. Slide 4 assigns the patient to a risk category for VTE based on their combined number of VTE factors. Note that some risk factors are more significant than others. Therefore, certain risk factors are considered to be greater than 1 risk factor. For example, if a patient has had a previous myocardial infarction, this is the equivalent of 3 factors.

Table 1. Incidence of VTE.

Procedure # of patients Incidence of DVT Incidence of PE Incidence of VTE Source Abdominoplasty 10,490 1.1% 0.8% 1.9% Grazer et al23 Belt lipectomy 32 0% 9.4% 9.4% Aly et al24 Body contouring 138     2.9% Shermak et al6 Body contouring 360     5.28% Hatef et al8 Rhytidectomy 9,937 0.34% 0.14% 0.49% Reinisch et al25 TRAM flap breast reconstruction 679     1.03% Liao et al9

Table 2. Risk factors for VTE^4-6

Surgery Heart or respiratory failure General anesthesia > spinal/epidural anesthesia Paralysis or spinal cord injury Previous DVT or PE Malignancy Immobilization (such as from surgery or a fracture) Inflammatory bowel disease Increasing age Nephrotic syndrome Obesity (body mass index > 30) Myeloproliferative disorders Trauma Paroxysmal nocturnal hemoglobinuria Hormone replacement therapy or oral contraceptive use Central venous catheterization History of spontaneous miscarriages Antiphospholipid antibody syndrome Pregnancy and postpartum period Homocystinemia Severe infection Heparin-induced thrombocytopenia Smoking history of radiation therapy (especially pelvic) Other hypercoagulable states (Factor V Leiden, prothrombin 20210A, protein C or S deficiency or dysfunction, antithrombin deficiency) Varicose veins   Myocardial infarction or cerebrovascular accident

Table 3. Summary of VTE prophylaxis recommendations

Low Risk Early ambulation and proper positioning Moderate Risk Early ambulation and proper positioning IPCD with GCS High Risk Early ambulation and proper positioning Consider LMWH or fondaparinux IPCD with GCS/TD> Highest Risk Early ambulation and proper positioning IPCD with GCS LMWH or fondaparinux

Slide 1. Step 1: Exposing risk factors

1 Factor Minor surgery       2 Factors Major surgery* Immobilizing plaster cast Patients confined to bed for > 72 hrs Central venous access 3 Factors Previous myocardial infarction Congestive heart failure Severe sepsis Free flap 5 Factors Hip, pelvis, or leg fractures Stroke Multiple trauma Acute spinal cord injury

*Major surgery is defined by the use of general anesthesia or any procedure lasting longer than 1 hour.

Total Number of Exposing Factors = _______

Slide 2. Step 2: Predisposing risk factors

Clinical Setting 1 Factor Age 40 to 60 Pregnancy or < 1 month postpartum Obesity > 20% ideal body weight Oral contraceptive / Hormone replacement therapy Clinical Setting 2 Factors Age > 60 Malignancy     Clinical Setting 3 Factors History of DVT or PE       Inherited 3 Factors Any genetic hypercoaguable disorder       Acquired 3 Factors Lupus anticoagulant Anti-phospholipid antibodies Hyper-viscosity   Acquired 3 Factors Heparin-induced thrombo-cytopenia Myelo-proliferative disorders Homo-cystinemia

Total Number of Predisposing Factors = _______

Slide 3. Step 3: Combined risk factors

Combined Number of VTE Factors (Exposing + Predisposing) = _______

1 Factor Low risk 2 Factors Moderate risk 3-4 Factors High risk > 4 Factors Highest risk

Slide 4. Step 4: Risk Assignment

The following example demonstrates assessing a patient’s risk of VTE using the risk assessment model created by Davison and researchers.⁵

Example: A 36-year-old woman without any significant past medical history who uses oral contraceptives presents for an abdominoplasty.

Step 1: Exposing risk factors = 2 factors (major surgery = 2 factors)
Step 2: Predisposing risk factors = 1 factor (oral contraceptive use)
Step 3: Exposing + Predisposing = 3 factors
Step 4: VTE Risk Category = High risk for VTE

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VTE prophylaxis should be directed toward minimizing the 3 components of Virchow’s triad. Recommendations from the most recent American College of Chest Physicians (ACCP) Evidence-Based Clinical Practice Guidelines for the Prevention of Venous Thromboembolism are referenced throughout the following section. It is important to note that plastic surgery patients have not been included in the studies leading to the recommendations by the ACCP. Therefore, the following recommendations for VTE prophylaxis in plastic surgery patients are based on current plastic surgery literature^2,4-10 and inferential conclusions drawn from the ACCP. These recommendations must be individualized according to clinical needs.

Early ambulation and proper positioning
The goal of these recommendations is to reduce the venous stasis component of Virchow’s triad. Early ambulation and proper positioning of the patient on the operating room table are recommended for patients in all risk categories.⁵ Patients should begin ambulation as soon as possible and walk at least 3 times per day. Operating room positioning should involve the knees being flexed to 5 degrees (accomplished by placing a pillow) to maximize blood flow through the popliteal veins.^2,5 Extremity constriction and external pressure on the patient must be avoided because they can further impede venous return.^4,5

Graduated compression stockings

Graduated compression stockings (GCSs) increase venous return by applying continuous circumferential pressure to the lower extremities. GCSs are a form of mechanical prophylaxis and minimize the risk of VTE by targeting the venous stasis component of Virchow’s triad. GCSs reduce the incidence of DVT.11 Better outcomes have been achieved when GCSs are combined with other modalities. GCSs combined with low-dose unfractionated heparin (LDUH) provide better prophylaxis against VTE than either option used alone.⁵ The combination of GCSs and intermittent pneumatic compression stockings may have a beneficial effect on the prevention of VTE.⁵ As with all forms of mechanical prophylaxis, GCSs are well suited for use in patients at high risk of bleeding.12 The main limitation of GCSs is compliance. GCSs must only be removed for a short period of time each day (eg, while bathing) to be effective.¹² Contraindications for the use of GCSs include peripheral arterial disease and peripheral neuropathy.^3,13 GCSs are recommended for use in moderate, high, and highest risk patients.⁵

Intermittent pneumatic compression devices

Intermittent pneumatic compression devices (IPCDs) prevent VTE with 2 mechanisms. IPCDs increase venous return through the deep veins of the legs by applying periodic pressure to the lower extremities. IPCDs increase fibrinolytic activity by reducing levels of plasminogen activator-1.5 Therefore, IPCDs reduce VTE risk by targeting both the venous stasis and hypercoagulability components of Virchow’s triad. Like other forms of mechanical prophylaxis, IPCDs are well suited for use in patients at high risk of bleeding.¹² IPCDs must be applied prior to surgery and the induction of anesthesia for maximum effectiveness.⁵ Use should be continued postoperatively until the patient is able to fully ambulate.5 Combination of GCSs and IPCDs may have a beneficial effect on the prevention of VTE.⁵ Furthermore, a Cochrane Database Systematic Review found that use of IPCDs combined with an anticoagulant (unfractionated heparin or low-molecular-weight heparin [LMWH]) significantly reduced the incidence of both symptomatic PE and deep vein thrombosis compared to IPCD use alone.¹⁴ As with GCSs, IPCDs are limited by compliance. IPCDs should only be removed for short periods of time each day (eg, while walking or bathing) to be clinically effective.¹² Contraindications to IPCDs include acute thrombophlebitis, suspected DVT, congestive heart failure, pulmonary edema, and peripheral arterial disease.¹⁵ IPCDs are recommended for use in moderate, high, and highest risk categories of patients.⁵

Aspirin

Aspirin decreases the incidence of VTE in general surgery and orthopedic surgery patients.⁵ However, it is reported to be less effective than other modalities.⁵ Aspirin use is associated with an increased risk of major bleeding, especially if combined with other antithrombotic agents.¹² Therefore, aspirin is not recommended for VTE prophylaxis in patients who undergo surgery.⁵

Heparins

Unfractionated heparin and LMWH are anticoagulants that work by enhancing antithrombin III activity.¹⁶ When unfractionated heparin binds to antithrombin III, it causes the neutralization of activated coagulation factors, including thrombin (IIa) and factors XIIa, XIa, IXa, and Xa.16 In the presence of heparin, antithrombin III activity is increased by a factor of several thousand.¹⁷ However, unfractionated heparin also binds to other cells and plasma proteins,¹⁸ leading to unpredictable pharmacokinetic and pharmacodynamic properties and non-hemorrhagic complications (ie, heparin-induced thrombocytopenia and osteoporosis).¹⁸ Like unfractionated heparin, LMWH binds to antithrombin III. However, the result is a predominant inhibition of activated factor X (Xa) and less inhibition of other coagulation factors.¹⁸ LMWH also has less binding of other cells and plasma proteins¹⁸ resulting in LMWH’s predictable pharmacokinetic and pharmacodynamic properties, long half-life, and low risk of non-hemorrhagic complications.¹⁸ Unfractionated heparin and LMWH are forms of pharmacologic prophylaxis that minimize VTE risk by targeting the hypercoagulability component of Virchow’s triad.
 

LDUH and LMWH reduce the risk of asymptomatic DVT and symptomatic VTE by at least 60% in general surgery patients compared to no VTE prophylaxis.¹² In plastic surgery patients, one study by Seruya and colleagues⁷ demonstrated a significantly lower rate of VTE in patients on mechanical prophylaxis plus subcutaneous heparin (unfractionated or LMWH), as compared to patients on mechanical prophylaxis alone. According to the ACCP, when LDUH and LMWH were directly compared in general surgery patients, no single study has shown a significant difference in the rates of symptomatic VTE.¹² However, low doses of LMWH (less than or equal to 3,400 anti-Xa units/day) are associated with fewer bleeding complications than 5,000 units every 8 or 12 hours of LDUH.^5,12 In contrast, use of higher doses of LMWH (greater than 3,400 anti-Xa units/day) resulted in more bleeding complications than LDUH.5,12 LMWH has additional advantages over LDUH that can be demonstrated by understanding the mechanisms of these anticoagulants. Due to a longer half-life, LMWH is only administered once daily as compared to either every 8 or every 12 hours with LDUH. LMWH’s reduced binding of other plasma proteins yields a more predictable anticoagulant response. Therefore, LMWH does not need routine coagulation monitoring. In fact, the ACCP recommends against routine coagulation monitoring in patients treated with LMWH.¹⁸ Similarly, this decreased binding of other plasma proteins results in LMWH’s significantly lower risk of heparin-induced thrombocytopenia compared to LDUH.⁵ Although, in patients with heparin-induced thrombocytopenia antibodies, there is cross-reactivity with LMWH.18 Unlike with LDUH, if clinical bleeding occurs, there is no proven method for neutralizing LMWH.18 In vitro studies and animal studies with LMWH have shown that protamine sulfate is able to neutralize LMWH’s anti-IIa effect, but cannot completely neutralize the anti-Xa effect.¹⁸ Therefore, although neutralizing the anti-IIa effect of LMWH will normalize the activated partial thromboplastin time and thrombin time laboratory values, no human studies convincingly demonstrate or refute a beneficial effect of protamine sulfate on bleeding associated with the use of LMWH.¹⁸

Studies related to the optimal timing of the first dose of pharmacological VTE prophylaxis come from orthopedic surgery.^19,20 The North American Fragmin Trial found no significant difference in the rates of total and proximal DVT between LMWH started preoperatively and LMWH started postoperatively.¹⁹ Although not considered to be significant, there was a trend toward increased bleeding in the group started preoperatively.¹⁹ For patients undergoing major orthopedic surgery, the ACCP recommends starting LMWH preoperatively or postoperatively for VTE prophylaxis.¹² For patients at high risk for bleeding, the ACCP recommends that the initial dose of LMWH should be delayed 12 to 24 hours after surgery, and until primary hemostasis has been demonstrated by examination of the surgical site.¹² In a subgroup of plastic surgery patients, Seruya and colleagues⁷ compared mechanical prophylaxis with mechanical prophylaxis combined with enoxaparin (a LMWH) administered at 40 mg subcutaneously and initiated at 12 hours postoperatively. Mechanical prophylaxis in combination with enoxaparin significantly lowered the rate of VTE. However, rates of hematoma/bleeding remained comparable between the 2 groups. Therefore, initiation of LMWH at 12 hours postoperatively may be beneficial for plastic surgery patients. At this point, optimal timing for initiation of VTE prophylaxis should be determined by the surgeon based on individual patient needs.
 

Given the decreased risk for bleeding complications, heparin-induced thrombocytopenia, and ease of administration and monitoring, LMWH appears to be a better choice for VTE prophylaxis in plastic surgery patients.⁵ Therefore, in high risk category patients, VTE prophylaxis with LMWH should be considered.⁵ For the highest risk category of patients, VTE prophylaxis with LMWH is recommended.^5,7

Fondaparinux

Fondaparinux, like LDUH and LMWH, aims to reduce VTE risk by targeting the hypercoagulability component of Virchow’s triad. Fondaparinux is a synthetic pentasaccharide anticoagulant that works by binding to antithrombin III, causing specific inhibition of activated factor X (Xa).¹⁸ Fondaparinux’s specific anti-Xa activity is greater than LMWH (700 units/mg and 100 units/mg, respectively) and like LMWH has a predictable anticoagulant response.¹⁸ Fondaparinux also has a longer half-life than LMWH.¹⁸ Therefore, it can similarly be administered once daily.¹⁸ For these reasons, fondaparinux, like LMWH, can be administered without routine laboratory monitoring.¹⁸ When postoperative fondaparinux plus IPCD use was compared to postoperative IPCD use alone for patients undergoing major abdominal surgery, rates of VTE were significantly lower with fondaparinux plus IPCD use than IPCD use alone.²¹ Although, rates of major bleeding were increased with fondaparinux plus IPCD than IPCD use alone.²¹ However, another study of thromboprophylaxis with 2.5 mg subcutaneously daily of fondaparinux started postoperatively was compared with dalteparin (a LMWH) at 5,000 units subcutaneously daily started preoperatively.²² These results showed no significant differences between the 2 groups in rates of VTE, major bleeding, or death.²²

Timing of initiation of thromboprophylaxis appears important. One study on patients undergoing major orthopedic surgery found the incidence of major bleeding was significantly higher in patients who received a first dose of fondaparinux within 6 hours of skin closure as compared to those who received a first dose after 6 hours.²⁰ Therefore, in patients undergoing major orthopedic surgery, the ACCP recommends starting fondaparinux 6 to 8 hours after surgery or the next day.¹² As with LMWH, for patients at high risk for bleeding, the ACCP also recommends that the initial dose of fondaparinux should be delayed 12 to 24 hours after surgery, and until primary hemostasis has been demonstrated by examination of the surgical site.¹²

Fondaparinux does not bind to protamine sulfate, which is the antidote for heparin.¹⁸ If a bleeding complication occurs with fondaparinux, recombinant factor VIIa may be effective at neutralizing the effects of fondaparinux.¹⁸ One important difference between fondaparinux and LDUH and LMWH is that fondaparinux does not cross-react with heparin-induced thrombocytopenia antibodies.¹⁸ No reports of heparin-induced thrombocytopenia with fondaparinux use can be cited. Furthermore, this agent has been used successfully to treat patients with heparin-induced thrombocytopenia.¹⁸ ACCP recommends the use of fondaparinux for the same indications as the use of LDUH and LMWH for VTE prophylaxis in general surgery patients.¹² Therefore, just like LMWH use in plastic surgery patients, fondaparinux should be considered for VTE prophylaxis in high-risk category patients. For the highest risk category patient, VTE prophylaxis with fondaparinux is recommended.

Summary of recommendations

Table 2 provides a summary of VTE prophylaxis recommendations for each category of risk.

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Plastic surgeons should be aware of the risk of VTE and be able to identify the various risk factors. Patients should be categorized as low, moderate, high, and highest risk based on their risk factors for VTE. Appropriate prophylactic measures must be used based on the patient’s risk category for VTE to maximize patient safety.

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1. Konstantinides S. Acute PE. N Engl J Med. 2008; 359:2804-2813.
2. Most D, Kozlow J, Heller J, Shermak MA. Thromboembolism in plastic surgery. Plast Reconstr Surg. 2005; 115:20e-30e.
3. Agu O, Hamilton G, Baker D. Graduated compression stockings in the prevention of venous thromboembolism. Br J Surg. 1999; 86:992-1004.
4. McDevitt NB. Deep vein thrombosis prophylaxis. American Society of Plastic and Reconstructive Surgeons. Plast Reconstr Surg. 1999; 104:1923-1928.
5. Davison SP, Venturi ML, Attinger CE, Baker SB, Spear SL. Prevention of venous thromboembolism in the plastic surgery patient. Plast Reconstr Surg. 2004; 114:43e-51e.
6. Shermak MA, Chang DC, Heller J. Factors impacting thromboembolism after bariatric body contouring surgery. Plast Reconstr Surg. 2007; 119:1590-1596.
7. Seruya M, Venturi ML, Iorio ML, Davison SP. Efficacy and safety of venous thromboembolism prophylaxis in highest risk plastic surgery patients. Plast Reconstr Surg. 2008; 122:1701-1708.
8. Hatef DA, Kenkel JM, Nguyen MQ, et al. Thromboembolic risk assessment and the efficacy of enoxaparin prophylaxis in excisional body contouring surgery. Plast Reconstr Surg. 2008; 122:269-279.
9. Liao EC, Taghinia AH, Nguyen LP, Yuch JH, May JW, Orgill DP. Incidence of hematoma complication with heparin venous thrombosis prophylaxis after TRAM flap breast reconstruction. Plast Reconstr Surg. 2008; 121:1101-1107.
10. Kim EK, Eom JS, Ahn SH, Son BH, Lee TJ. The efficacy of prophylactic low-molecular-weight heparin to prevent pulmonary thromboembolism in immediate breast reconstruction using the TRAM flap. Plast Reconstr Surg. 2009; 123:9-12.
11. Wells PS, Lensing AW, Hirsh J. Graduated compression stockings in the prevention of postoperative venous thromboembolism. A meta-analysis. Arch Intern Med. 1994; 154:67-72.
12. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practices Guidelines (8th Edition). Chest. 2008; 133:381S-453S.
13. Gillies TE, Ruckley CV, Nixon SJ. Still missing the boat with fatal PE. Br J Surg. 1996; 83:1394-1395.
14. Kakkos SK, Caprini JA, Geroulakos G, Nicolaides AN, Stansby GP, Reddy DJ. Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients. Cochrane Database Syst Rev. 2008; 4:CD005258.
15. Lachmann EA, Rook JL, Tunkel R, Nagler W. Complications associated with intermittent pneumatic compression. Arch Phys Med Rehabil. 1992; 73:482-485.
16. Goljan EF. Rapid Review: Pathology. 2nd ed. Philadelphia, PA: Mosby Elsevier; 2007
17. Konkel BA. Bleeding and thrombosis. In: Fauci AS, Braunwald E, Kasper DL, et al. eds. Harrison’s Principles of Internal Medicine. 17th ed. New York, NY: McGraw-Hill; 2008. Available at: http://www.accessmedicine.com.medlib.med.miami.edu:2048/resourceTOC.aspx?resourceID=4. Accessed July 5, 2009.
18. Hirsh J, Bauer KA, Donati MB, et al. Parenteral anticoagulants: American College of Chest Physicians Evidence-Based Clinical Practices Guidelines (8th Edition). Chest. 2008; 133: 141S-159S.
19. Hull RD, Pineo GF, Francis C, et al. Low-molecular-weight heparin prophylaxis using dalteparin in close proximity to surgery vs warfarin in hip arthroplasty patients: A double-blind, randomized comparison. Arch Intern Med. 2000; 160:2199-2207.
20. Turpie A, Bauer K, Eriksson B, Lassen M. Efficacy and safety of fondaparinux in major orthopedic surgery according to the timing of its administration. Thromb Haemost. 2003; 90:364-366.
21. Turpie AG, Bauer KA, Caprini JA, Comp PC, Gent M, Muntz JE. Fondaparinux combined with intermittent pneumatic compression versus intermittent pneumatic compression alone for prevention of venous thromboembolism after abdominal surgery: A randomized, double-blind comparison. J Thromb Haemost. 2007; 5:1854-1861.
22. Agnelli G, Bergqvist D, Cohen AT, Gallus AS, Gent M, PEGASUS investigators. Randomized clinical trial of postoperative fondaparinux versus perioperative dalteparin for prevention of venous thromboembolism in high-risk abdominal surgery. Br J Surg. 2005; 92:1212-1220.
23. Grazer FM, Goldwyn RM. Abdominoplasty assessed by survey, with emphasis on complications. Plast Reconstr Surg. 1977; 59:513.
24. Aly AS, Cram AE, Chao M, Pang J, Mckeon M. Belt lipectomy for circumferential truncal excess: The University of Iowa experience. Plast Reconstr Surg. 2003; 111:398-413.
25. Reinisch JF, Bresnick SD, Walker JW, Rosso RF. DVT and pulmonary embolus after face lift: A study of incidence and prophylaxis. Plast Reconstr Surg. 2001; 107:1570-1577.

Yash Avashia, BS
University of Miami Miller School of Medicine
Miami, Florida

Seth R. Thaller, MD, DMD
Chief, Division of Plastic and Reconstructive Surgery
University of Miami Miller School of Medicine
Miami, Florida

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Complementary and alternative medicine (CAM) is composed of a wide category of therapeutic practices and is defined as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.”¹ Today, a rapidly growing area of CAM is herbal medicine (phytomedicine), which is a group of drugs whose pharmacologic activity is derived from various plant extracts and components to treat a wide range of diseases and symptoms. Patients may have a variety of reasons to take these over-the-counter, herbal medicines. These medicines are not subjected to conventional oversight by the U.S. Food and Drug Administration (FDA) and are not required to pass a screening for efficacy and safety prior to actual marketing. With only a partial workup on these medicines, their support is predominantly contingent upon a general understanding of the benefits reinforced by anecdotal experiences. A growing percentage of surgical patients are using or have used herbal remedies. Recent studies indicate anywhere from 22% to 60% of preoperative patients using some sort of herbal remedy on a daily basis.^2-4 Unfortunately, the public lacks awareness regarding the adverse effects of these medicines during the perioperative period. Relatively few physicians inquire about patients’ use of herbal medicines. Up to 70% of patients do not disclose the use of them.⁵ Low cost, ease of availability, and marketing all play a factor in reasons why patients do not consider herbal medications medicinal products.^6,7 Herbal medicines have a potential to adversely interact with prescribed medications and anesthetics administered during surgical procedures. Adverse reactions may cause perioperative bleeding, skin reactions, and cardiovascular instability.⁵ Specifically, these reactions include effects on blood pressure, bleeding time, coagulation, skin pigmentation, skin hypersensitivity, sedation, electrolytes, and diuresis.⁸

 

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Bleeding

Among the various available medicinal plants, those containing coumarin and salicylate are associated with an increased risk of perioperative bleeding. Another subset of herbal medicines derived from plants specifically inhibit platelet function. This category includes garlic, ginkgo, ginger, feverfew, and ginseng use. Previous reports have demonstrated an adverse effect on either platelet activation or coagulation.⁶⁵ Herbal medicines not known to cause bleeding may be manipulated directly or pharmacokinetically by interacting with synthetic agents known to increase the risk of bleeding during surgical procedures.⁵

Garlic (Allium sativum) has been used to treat a wide range of symptoms. These include cough, cold, flu, chronic bronchitis, whooping cough, ringworm, asthma, intestinal worms, fever, digestive, gallbladder, and liver disorders.⁵ It has also been reported to have a functional role in treating infections, cancer, diabetes, hypertension, and hyperlipidemia.⁹ The German Commission E and the European Scientific Cooperative on Phytotherapy have passed garlic as a primary preventative of atherosclerosis and as an adjunct treatment for hyperlipidemia.¹⁰ Several studies indicate garlic as a moderator of hypertension and hyperlipidemia.^6,7

From these studies, the active chemicals involved in the molecular process to curb hypertension and hyperlipidemia have been shown to be 3-hydroxy-3-methyglutaryl coenzyme A reductase and 14-alpha-demethylase inhibitors.^11,12 A recent clinical study reported a 6.1% mean reduction in cholesterol and 5.5% mean reduction in systolic blood pressure.66 Despite its beneficial effects, garlic has adverse side effects; namely, prolonged PT/PTT along with spontaneous hemorrhage and perioperative bleeding.^13-15 Platelet adhesion to fibrinogen may be reduced by garlic extracts by as much as 30%.¹⁶

Ginkgo (Ginkgo biloba) is a commonly used treatment for dementia, cerebral complications, and peripheral arterial disease. In addition, ginkgo extracts have shown to improve memory and cognition.¹⁰ Gingko (GBE) is commonly found in geriatric vitamin supplements. Previous reports show ginkgo to be a probable cause of spontaneous hyphema, bilateral subdural hematomas, and fatal intercerebral mass bleeding.^17-19 A recent report described spontaneous postoperative bleeding from a laparoscopic cholecystectomy.⁶⁸ A likely scenario is ginkgo’s interaction with prescribed anticoagulants and antiplatelet agents.^17,18,20-22 The lack of data to understand the possible effects of synergism between herbal medicines, such as ginkgo, and other prescribed medicines should caution patients. Animal studies indicate that combining ticlopidine and GBE leads to a 150% marked increase in bleeding time and an antagonistic effect on platelet aggregation.²³ Another study showed a GBE extract to inhibit platelet activating factor induced platelet aggregation in healthy volunteers.²⁴

Ginseng (Panax ginseng) is the herb of choice for promoting vitality and longevity in patients with physical or mental fatigue. Ginseng demonstrates an irreversible antiplatelet effect.²⁵ Panaxynoland ginsenosides were the primary chemical components to mediate the inhibition of platelet aggregation, release reaction, and thromboxane formation.²⁵ With these findings, ginseng should not be used with warfarin, heparin, aspirin, and NSAIDs.
 

Ginger (Zingiber officinale) is a spice and herbal medicine used with a digestive aid or a remedy for common digestive symptoms such as indigestion, bloating, and cramping. A previous study showed ginger to be an inhibitor of thromboxane synthetase.26 Continued heavy use of ginger may potentially prolong bleeding times. Despite this theory, there have not been any published cases reporting bleeding problems associated with ginger. On the contrary, ginger has shown to improve postoperative vomiting.^27,28

Feverfew (Tanacetum parthenium) is an herbal medicine used for migraine prevention. Similar to ginger, there are no reported cases associated with bleeding problems. Its parthenolide constituent has been shown to be associated with platelet activity and aggregation.^29,30 Feverfew may induce withdrawal symptoms. Proper methods to taper patients off of feverfew prior to surgery must be taken into account. Withdrawal syndrome is characterized by nervousness, tension, headaches, insomnia, stiffness, joint pain, and tiredness.³¹

Table 1. Common Herbal Extracts and its Pharmacological Effect and Perioperative Concern Herbal Extract Pharmacological Effect Perioperative Concern Garlic Inhibition of platelet aggregation, increase fibrinolysis, equivocal BP lowering Risk of bleeding, combined with other medications that inhibit platelet aggregation Ginkgo Inhibition of platelet activating factor Risk of bleeding, combined with other medications that inhibit platelet aggregation Ginseng Lowers blood glucose, inhibition of platelet aggregation, increases PT-PTT in animals Hypoglycemia, potential risk of bleeding; potential decrease anticoagulation effects of warfarin. Ginger Digestive aid Affect platelet aggregation and prolong bleeding times Feverfew Inhibits platelet activity and platelet aggregation Risk of bleeding Ephedra Increase HR and BP through direct and indirect sympathomimetic effects Risk of MI and stroke from tachycardia and HTN; ventricular arrhythmias with halothane; long term use depletes catecholamines and causes intraoperative hemodynamic instability; life threatening interaction with MAOIs Kava Sedation, anxiolysis Increases sedative effects of anesthetics, potential for addiction, tolerance, and withdrawal after abstinence unstudied. Valerian Sleep aid Increases sedative effects of anesthetics, withdrawal, may increase anesthesia requirements St. John Wort Inhibition of NT reuptake, MAO inhibition unlikely P450 enzymes (CYP 3A4) affecting cyclosporine, warfarin, steroids, protease inhibitors, and calcium channel blockers, and many other drugs; decrease serum digoxin levels Echinacea Activation of cell mediated immunity Allergic reactions decreased effectiveness of immunosuppressants; potential for

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Skin Reactions

Herbal medicines can also affect the skin. They can potentiate adverse effects after certain skin improving procedures or adversely react with other medications that have photosensitizing effects. Plastic surgeons commonly perform skin resurfacing procedures to improve skin quality. Kava (Piper methysticum), a herbal ingredient found in many herbal drinks, is an alternative to synthetic anxiolytics and tranquilizers.³² Dermatopathy associated with kava includes scaly skin eruptions, reddened eyes, and a yellowish discoloration of skin, hair, and nails.³³ Two yellow pigments found in kava seem to cause skin discoloration.³⁴ St. John’s wort (Hypericum perforatum) is another commonly used herbal medicine for its effects on mild depressive states, anxiety, nervous unrest, and sleep disorders.³⁵ It does pose a risk for photosensitivity due to the active constituent, hypericin.³⁶ There is also a potential risk of using St. John’s wort with other photosensitizing components causing severe adverse effects on the skin. Such drug regimens should be avoided. Numerous plant species contain an estradiol-like functioning component, called phytoestrogens.³⁷ Because it can either potentiate or antagonize estrogen effects, patients who have recently undergone skin resurfacing procedures may find changes in skin pigmentation if they are on phytoestrogens. In addition to the discoloration, the combination of both estrogen and phytoestrogens may result in unwanted symptoms such as nausea, hypotension, bloating, and edema. Dong quai (Angelica sinesis), red clover (Trifolium pratense), and alfalfa (Medicago sativa) are 3 predominantly used phytoestrogens.^38,39

Plant extracts have had a long history of being used to enhance wound healing treatments. Through either administration in topical preparations of high water content (moist compresses, hydrogels, and tinctures) or of high fat content (lipophilic creams and ointments), these active herbal ingredients present their anti-inflammatory, anti-bacterial, anti-fungal, or wound healing properties.⁴⁰ Examples of such herbal extracts are chamomile, witch hazel, podohyllin, calendula flowers, bittersweet, purple acne flower, St. John’s wort oil, arnica, and comfrey.⁴¹ The last 2 extracts are useful in treating discomfort associated posttraumatic or postoperative situations.42,43 There are a few disclaimers. Arnica’s active component, helanalin, provides its anti-inflammatory and anti-microbial effects. When administered in safe concentrations it reduces ecchymosis, inflammation, and edema, but when administered in an undiluted mixture, it poses toxic effects.^40,44 Comfrey’s active constituent, pyrrolixidine alkaloid, has shown to be hepatotoxic, carginogenic, and mutagenic in rats.^45-47 Botanical remedies such as tea tree oil, peppermint oil, and various conifer derived oils, have anti-microbial and anesthetic effects.⁴⁰ Terpinen-4-ol48 is the active ingredient of tea tree oil and has been proven to work as an arsenal against numerous bacteria and fungi. These include methicillin sodium-resistant Staphylococcus aureus.⁴⁹ In addition, studies have shown that a 5% tea tree oil water based gel can reduce the average number of acne lesions with fewer side effects when compared to 5% benzoyl peroxide lotions.⁵⁰ Skin irritation and contact dermatitis are side effects for sensitive skin.⁵¹

Aloe vera is obtained from the inner tissue of aloe vera plant leaves. It is a commonly used for its wound healing properties.⁴⁰ Aloe vera induces the growth and adhesion of normal human cells and enhances the healing of wounded monolayers of cells.⁵² Its pharmacologically active ingredients are carboxypeptidase, salicylates, and other substances that inhibit the local vasoconstricting effects of thromboxanes.⁵³ Compared to many cosmetic lotions that claim to have aloe vera but in insignificant concentrations, 95% aloe vera gel has proven to accelerate wound healing and preserve skin circulation following frostbite injuries.⁵⁴ This is not confirmed for low concentration non-prescribed lotions. When used with topical steroids such as hydrocortisone acetate, the anti-inflammatory effects are potentiated.⁵⁵ In addition, aloe vera has shown to increase collagen activity and enhance the wound contraction from excisional wounds.⁵⁶

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Cardiovascular Effects

Along with bleeding and skin manifestations, herbal medicines have been shown to have direct cardiovascular effects.⁵⁷ Ephedra, an extract from the plant Ephedra sinica, or ma huang, was banned by the FDA in 2004 for sale as a separate supplement in response to growing evidence of adverse effects.⁵⁸ Today, this ingredient is commonly mixed in many herbal medicines to promote secondary benefits such as weight loss, increased energy, and to treat bronchitis and asthma. Common alkaloids derived from ephedra include pseudoephedrine, norephedrine, and norpseudoephedrine. These sympathomimetic amines’ principle mode of activity is through adrenergic receptor stimulation. Ephedra has been shown to induce a dose-dependant increase in many sympathetic responses: specifically, blood pressure and heart rate. Ephedra use combined with many perioperative drugs, such as vasopressors, create a synergistic hyper-sympathomimetic response: hypertension, palpitations, tachycardia, seizures, and stroke.⁵⁹ When combined with monoamine oxidase inhibitors, myocarditis, hyperpyrexia, hyertension, and coma may ensue.^60,61 The use of ephedra, or any herbal remedies with ephedra as an active constituent, should be avoided before surgery. Patients using it should consult their physicians about the possible long-term adverse effects of ephedra. Besides ephedra, other herbal medicines such as garlic and black cohosh have the potential to reduce blood pressure.^62,63 Herbal stimulant laxatives and herbal diuretics may induce hypokalemia and should be used with caution during the perioperative period.⁶⁴

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Conclusion

The use of herbal medicines is growing exponentially. Today, there is a discrepancy between the perceived safety and actual safety of herbal medicines. This may be attributed to drug marketing and to the lack of comprehensive oversight by the FDA. With the wide range of benefits presented with these herbal remedies is an equally wide range of potential risk factors. Perioperative bleeding, skin reactions, and cardiovascular effects are some of the primary concerns associated with herbal medicines. Unfortunately, many surgical patients do not report use of these remedies because they are not considered medications. It is imperative that patients discontinue the use of herbal medicines at least 7 days prior to surgery to avoid perioperative complications. Surgeons should be aware of the adverse reactions associated with herbal medicines as well. Patients being administered these medicines after surgery for wound healing purposes should be informed of the potential side effects. Herbal medicine is a vast new avenue for disease and symptom treatment. While it may seem completely beneficial and harmless, there are actual risk factors and adverse effects that should be made known to the patient populations.

 

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References

 

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59. Haller CA, Benowitz NL.Adverse cardiovascular and central nervous system events associated with dietary supplements containing ephedra alkaloids. N Engl J Med. 2000;343:1833-1838.
60. Zaacks SM, Klein L, Tan CD, Rodriguez ER, Leikin JB. Hypersensitivity myocarditis associated with ephedra use. J Toxicol Clin Toxicol. 1999;37:485-489.
61. Ang-Lee MK, Moss J, Yuan C-S. Herbal medicines and perioperative care. JAMA. 2001;286:208-216.
62. Kaye AD, De Witt BJ, Anwar M, et al. Analysis of responses of garlic derivatives in the pulmonary valscular bed of the rat. J Appl Physiol. 2000;89:353-358.
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The epiphyseal growth plates account for the majority of long bone growth in children, and provide a prototypical example of the process of endochondral ossification, or bone formation vi ...

In the early walking phase of normal gait development, the child has a wide base with flexion at the hips and knees. Children in this stage are flatfooted and walk with a drop foot gait in short st ...

In the early walking phase of normal gait development, the child has a wide base with flexion at the hips and knees. Children in this stage are flatfooted and walk with a drop foot gait in short st ...

The hip is the most structurally stable joint in the body. Acetabular stability is enhanced by three thickenings in the hip capsule, the iliofemoral, ischial-femoral and pubo-femoral ligaments. The ...

The radial head articulates with the capitellum. Both surfaces are covered by articular cartilage, but the diameter of the radial head is always greater than that of the capitellum. The radial head ...

Development The shoulder forms as a single cartilaginous anlage at 5 weeks gestation. Between 6 and 7 weeks of gestation, a cleft forms in the anlage creating the glenohumeral jo ...

The occipitocervical junction consists of the articulations from the occiput to the atlas and from the atlas to the axis. This highly mobile area of the spine contributes 50% of cervical flexion be ...

The first cases of Charcot-Marie-Tooth disease (CMT) were reported in 1855 by Aran and Virchow. They described patients with lower extremity weakness followed by upper extremity involvement. In 188 ...

Cervical alignment varies with positioning of the patient. This is especially important in young children. The head has been shown to be disproportionately large in children, so if they are placed ...

Nontraumatic subluxation at the C1-C2 junction is rare, but most commonly seen in children with Down syndrome, skeletal dysplasia, or after a pharyngeal inflammation. It has been reported that as m ...

The first cases of Charcot-Marie-Tooth Disease (CMT) were reported in 1855 by Aran and Virchow. They described patients with lower extremity weakness followed by upper extremity involvement. In 188 ...

Clubfoot is a common, controversial congenital foot deformity.There is an increased incidence of  hereditary factors and arrested fetal development. Teratologic classification is the result of ...

Tarsal coalition presents as painful hindfoot, with limited motion, usually in valgus position, and often with protective peroneal spasm. Differential diagnosis includes: tarsal coalition, inflamma ...

Flatfoot, or calcaneovalgus deformity, is the most common childhood foot deformity. The foot is positional and flexible, but has limited plantarflexion secondary to contracted dorsiflexors. Most tr ...

Hallux valgus can occur at any age.1 Patients with onset of the condition before the age of 10 are referred to as juvenile hallux valgus, and those with an onset between the ages of 10 a ...

In 1914, Henken was the first surgeon to describe congenital vertical talus (CVT).1 Since then, numerous terms have been proposed to define this pathology. Some of those historical terms ...

In 1912, James Warren Sever, MD, described an inflammatory injury to the calcaneal apophysis associated with muscle strain in the immature skeleton.1 ...

Cavus foot deformity was first described by Andrey in 1743.1 Cavus foot deformity results in a variety of shapes, each with an abnormally high longitudinal arch, or cavus, with or withou ...

Bowing of the lower extremities is a normal stage in the musculoskeletal development of infants. Physiologic bowing may occur in infants <2 years of age. As a result of growth, bowing naturally ...

Congenital absence of the fibula is the most common deficiency of long bones; it is often sporadic and can be described as complete or incomplete. The condition is referred to as a termin ...

Tibial hemimelia (TH) is a deficiency of the tibia that is due to an unknown cause. However, TH has been seen in some autosomal dominant syndromes, in which case it is often bilateral.

Proximal femoral focal deficiency (PFFD) is a congenital absence of the proximal femur. The absence of the proximal femur is evident both clinically and radiographically. The cause of the ...

As a generic term, developmental dysplasia of the hip (DDH) includes varying degrees of subluxation and dislocation. Acetabular dysplasia indicates a shallow socket that tends to have a more vertic ...

Growth and development of the hand occurs as pluripotent mesenchymal cells differentiate. The cell population size increases by mitosis and the intracellular structural protein is synthesized. Intr ...

Madelung deformity is a skeletal abnormality of the forearm and wrist characterized by prominence of the distal ulna, shortening and lateral bowing of the forearm, and volar and ulnar tilt of the w ...

The scapula develops as a mesenchymal condensation at the level of the fourth cervical somite and migrates to the upper thoracic spine by the 12th fetal week. The failure of normal caudal migration ...

Congenital pseudarthrosis of the clavicle is a rare condition in which part of the middle portion of the clavicle has a discontinuity. Signs or symptoms of fracture are absent.1 The pseu ...

Estimates of the incidence of Scheuermann disease in the general population range from 0.5% to nearly 10%, and are dependent on the diagnostic criterion used. Most studies have reported a higher in ...

Congenital kyphosis (CK) is uncommon. It is frequently severe and can produce deformity and paraplegia. Unfortunately, few physicians are aware of its devastating potential. Early treatment is cruc ...

Nontraumatic subluxation at the C1-C2 junction is rare, but most commonly seen in children with Down syndrome, skeletal dysplasia, or after a pharyngeal inflammation. It has been reported that as m ...

Also known as congenital cervical synostosis, Klippel-Feilsyndrome is a rare syndrome characterized by cervical fusion and multiplecongenital malformations. One of the major clinically apparent def ...

Spondyloepiphyseal dysplasia congenita has a prevalence of approximately 3 to 4 per 1 million. Its central features include significant spinal and epiphyseal involvement without metaphyse ...

Fibrous dysplasia (also known as osteitis fibrosa cystica) results from a somatic mutation that produces a mosaic distribution of lesions in one, several, or many bones. The normal medull ...

Cleidocranial dysplasia affects the growth of many parts of the skeleton, primarily bones of membranous origin. Classic features of cleidocranial dysplasia include widening of the cranium ...

Diastrophic dysplasia has more numerous and severe skeletal abnormalities than other dysplasias. The word diastrophic comes from Greek and means distorted, which aptly describes the ears, ...

Orthopedic surgeons must be familiar with multiple epiphyseal dysplasia because this disorder is often subtle, variable, and unrecognized initially. Multiple epiphyseal dysplasia affects ...

Pseudoachondroplasia was one of the first rhizomelic short stature conditions distinguished from achondroplasia. Pseudoachondroplasia involves the metaphyses, the spine, and the epiphyses ...

Larsen's syndrome is a variable disorder known to geneticists and orthopedic surgeons, but not to many other specialists. Patients with Larsen's syndrome have hypertelorism and multiple ...

Arthrogryposis multiplex congenita is a nonprogressive disease that consists of two or more different joint contractures present at birth. There are more than 150 different conditions tha ...

Marfan syndrome is a well-defined clinical disorder with extensive phenotypic variability. Marfan syndrome affects approximately 1 in 5,000-10,000 persons. In addition, many persons show ...

Stickler syndrome was first described by Gunnar Stickler and colleagues at the Mayo Clinic in 1965.1 They reported a unique autosomal dominant condition in a family with midfac ...

Osteogenesis imperfecta (OI) is a disorder of type I collagen, a structural protein that comprises bones, dentin, cornea, sclera, dermis, tendons, fascia, meninges, and organ capsules. Ma ...

Ehlers-Danlos syndrome (EDS) is a family of disorders caused by a variety of defects in collagen metabolism (Slide 1). The cardinal feature, common through all subtypes of this syndrome, ...

Constriction band syndrome is also known as amniotic band syndrome or Streeter's dysplasia. The details of etiology are unknown but relate to in utero bands or strands of tissue that may encircle ...

Dysplasia epiphysealis hemimelica, also known eponymically as Trevor's disease, is a localized osteochondral overgrowth involving single or multiple epiphyses or ossification centers. (Slide) The ...

Bladder exstrophy is part of a spectrum of anomalies that may involve the bladder, pelvis, intestinal tract, and external genitalia. The most common form of bladder exstrophy is classic exstrophy, ...

Spondylolysis refers to a defect of the pars interarticularis of the lumbar vertebrae. It is usually bilateral, although unilateral cases occur in 20% of cases. The presence of defects in the pars ...

Early-onset scoliosis (EOS) is defined as a spinal deformity of any etiology that presents under the age of 5 years.¹...

Metatarsus adductus is a forefoot adduction with a normal mid and hindfoot. It occurs in 1 in every 1000 live births and is bilateral in 50% of the cases. There is a low incidence of hip dysplasia ...

Incidence Talocalcaneal coalitions are equal in frequency to calcaneonavicular coalitions. Combined, talocalcaneal and calcaneonavicular coalitio ...

Surgeons often assume that revision surgery does not have as many complications for children as it does for adults. In planning surgery and informing parents, it is sometimes overlooked...

Hip pain, either in the form of localized pain or referred pain, may be the principal manifestation of a variety of diseases in the pediatric population. In a prospective epidemiological study, researchers discovered...

The word “syndrome” is from the Greek, meaning “to run together”. In most cases, use of the term “syndrome” implies that a condition is defined by its evident features and not by a known underlying etiology. Syndromes are often characterized...

Brachial plexus trunk injury comprises 20% of all peripheral nerves injuries, and the trend is increasing. Brachial plexus injuries result from car accidents, particularly motorcycle acci ...

Lipomas are the most common benign soft tissue tumor, but are rare during the first two decades of life. Lipomas frequently occur around the shoulder area and usually present as an asymptomatic, sl ...

Bone and soft tissue tumors are uncommon in the general population and are even more uncommon in the upper extremity in children. Although not often seen, it is helpful for the practicing orthopedi ...

Most patients with hereditary multiple osteocartilaginous exostoses present with bony prominences. However, patients with multiple osteocartilaginous exostoses have a generalized disturbance of ske ...

Hemihypertrophy/hemihypotrophy refers to asymmetries between sides of the body. These asymmetries may involve limbs, trunk, or organs. Side-to-side differences up to 1 cm after infancy are normal b ...

Surgical site infection is estimated to affect over 200,000 procedures in the US each year.¹ The purpose of this tutorial is to review the factors contributing to surgical site infections...

Hematogenous bacterial osteomyelitis occurs in the metaphysis of the long bones. The humerus is most commonly involved in the upper extremity. Bacterial precipitation in the metaphysis leads to sep ...

Hematogenous bacterial infection of the hip joint in children is an emergency because proteolytic enzymes in the purulent exudate will destroy articular cartilage if appropriate treatment is delaye ...

A proper diagnosis is essential to deliver precise treatment to children with elbow injuries. The distal humerus is largely cartilaginous in the first 2 years of life, but ossification ce ...

Lyme disease is a tick-borne spirochetal infection that is most prevalent in the northeastern part of the United States, as well as Wisconsin and California. It is caused by the spirochet ...

In the United States the reported incidence of juvenile rheumatoid arthritis (JRA) ranges from 9.2 to 13.9 per 100,000 people.¹ A more recent follow-up study by Peterson et al.² ...

Popliteal cysts, also referred to as Baker cysts, are the most common masses found in the popliteal fossa. Popliteal cysts are characterized as simple, synovial-lined ganglion cysts and arise from ...

Temporary hip joint distension with attendant pain, limp, and limitation of motion characterize transient synovitis of the hip in children. Other, more serious conditions with similar presentation ...

Acute rheumatic fever is an autoimmune process that occurs a few weeks following streptococcal pharyngitis. It complicates approximately 1%-5% of streptococcal throat infections, and it r ...

Juvenile rheumatoid arthritis (JRA) is a disease of variable onset and course. The primary diagnostic criterion is swelling in one or more joints that persists for at least 6 weeks. Based ...

Congenital muscular torticollis is a presumed in utero deformation resulting in sternocleidomastoid muscle contracture causing tilt of the ear toward the affected side and chin rotation to the cont ...

In contrast to the adult population, lumbar intervertebral disk herniation is a relatively rare cause of low-back complaints in the pediatric population. Twelve years after Mixter and Bar ...

Neurofibromatosis exists in two forms that are both characterized by disordered growth of nervous tissue. The central form, NF2, is transmitted autosomal dominantly from defects on chromo ...

Scoliosis is defined empirically as a lateral trunk rotation of over 10°, and has a prevalence of 2% to 3%. The incidence of idiopathic scoliosis associated with a Cobb angle of 20&de ...

Many options exist for the treatment of a limb-length discrepancy. Although the etiology of the discrepancy is important, focusing on its magnitude at maturity reveals which treatment option is m ...

A limb-length discrepancy (LLD) is a common occurrence, which results in various physiologic adaptations. Approximately 70% of the general population has LLD of up to 1 cm. A signific ...

Osteochondritis dissecans (OCD), first described by Konig1 in 1988, is an avascular necrosis involving a bone at the osteochondral junction in the epiphysis. The subchondral bone becomes ...

The proximal radial epiphysis is the second ossification center to appear about the elbow. It ossifies as a small wafer-like structure beginning at approximately 4 years of age. Normally, the artic ...

Clubfoot is a common, controversial congenital foot deformity. There is an increased incidence of  hereditary factors and arrested fetal development. Teratologic classification is the result o ...

Performing subtalar arthrodeses was advocated primarily for treating foot deformities and secondarily for treating injuries and paralysis (poliomyelitis). In 1943, Leavitt performed subtalar arthro ...

Legg-Calvé-Perthes disease begins with idiopathic ischemia of part or all of the femoral capital epiphysis. Osteonecrosis leads to multiple overriding fractures of trabeculae within the epiphysis a ...

Spondylolysis refers to a defect of the pars interarticularis of the lumbar vertebrae. It is usually bilateral, although unilateral cases occur in 20% of cases. The presence of defects in the pars ...

Conscious sedation is a controlled lessening of a patient's awareness of the environment and pain perception while maintaining stable vital signs, an independent airway, and ade ...

Chronological age in the pediatric patient is only a crude indicator of growth and development, not telling the whole story to the orthopedic surgeon. Children mature and undergo growth spurts at ...

From the orthopedic point of view, a child cannot be thought of as merely a little adult. Despite similarities in anatomy, there are underlying differences in motor function depending on the age of ...

A chondromyxoid fibroma is a benign, localized lesion of bone with distinct differentiated connective tissue consisting of chondroid, fibrous, and myxoid elements. ...

Bone cysts are benign, expansive, destructive tumor-like reactive processes. They are classified as aneurysmal or simple, although many bone cysts have features of both. Simple bone cysts have also ...

Homocystinuria is an inborn error of metabolism in which the enzyme cystathionine β-synthase is deficient.1,2 As in the majority of enzyme ...

Proximal tibial metaphyseal fractures commonly occur in young children and are often undisplaced and quickly heal. However, despite their innocuous appearance, greenstick and comp ...

The distal femoral physis is susceptible to fracture from various forces to the knee as it usually fails before the medial collateral ligament. As with other physeal injuries, the Salter-Harris (SH ...

Traditional medicine teaches that infants and children with a diaphyseal femur fracture do well when treated with "basic principles" of conservative care. Postfracture joint stiffness does not occu ...

The hip is the most structurally stable joint in the body. Acetabular stability is enhanced by three thickenings in the hip capsule, the iliofemoral, ischial-femoral, and pubo-femoral ligaments. Th ...

Fracture of the olecranon process is uncommon in children. When it does occur, it is usually the result of a fall. Olecranon fractures occur at a slightly older age than supracondylar fractures (9 ...

The Monteggia fracture-dislocation is a great "fooler" in orthopedic surgery. A Monteggia fracture consists of a radial head dislocation in conjunction with an ulnar fracture. The radial head dislo ...

As children pass the typical age for supracondylar fracture of the elbow, which is the first decade of life, fractures of the elbow become less common. T- or Y-condylar fractures of the distal hume ...

Fractures of the supracondylar portion of the distal humerus are among the most common elbow injuries seen in children. The fractures mainly occur within the first decade of life, have a peak incid ...

Injuries to the upper end of the humerus usually heal andremodel well with observation because of the great amount of growth andremodeling potential. Deformity in this region is much less evident o ...

Elbow dislocations occur most commonly in children >6 years of age. They are not nearly as common in children as supracondylar fractures of the humerus, which occur by the same m ...

Anterior knee pain can result from many pathological conditions involving not only the knee, but also the hip. Most are related to overuse injuries. The exception is referred pain from a condition ...

A discoid meniscus is a common congenital abnormality, affecting approximately 1% of all lateral menisci in the U.S. population. The medial meniscus is involved less frequently, representing only ...

Growth from the distal femoral physis is approximately 10 mm to 11 mm per year. The knee joint capsule and collateral ligaments originate just distal to the distal femoral physis, concentrating any ...

The most common mechanisms of tibial spine avulsions are sports and trauma. Because of the decreased resistance to tensile stress of the bone and cartilage of the juvenile tibial spine compared to ...

Diaphysis fractures of the femur and tibia constitute approximately 18% of all fractures in adolescents. These fractures result from high-energy injuries - the most common are motor vehicle acciden ...

The proximal tibial epiphysis is continuous with the tubercle and forms an "L," as seen from a lateral perspective. The tibial tubercle begins to ossify in children aged 8 to 9 years old; the epiph ...

Pediatric femoral shaft fractures occur with two peaks of incidence, ages 2 to 3 years and 12 to 13 years, because cortical thickness increases dramatically throughout childhood. Therefore, infants ...

Proximal tibial physis growth occurs at an average of 6 mm to 7 mm per year. Injuries to the proximal tibial physis are less than half as common as those of the distal femur. The proximal tibial ep ...

Subtrochanteric femur fractures in children are defined as fractures below the lesser trochanter, within a distance equal to 10% of the length of the entire femur. Such fractures tend to affect you ...

In contrast to the adult population, lumbar intervertebral disk herniation is a relatively rare cause of low-back complaints in the pediatric population. Twelve years after Mixter and Bar ...

Traumatic hip dislocations occur with less force in young children than skeletally mature individuals, presumably due to the unossified acetabular cartilage and capsular laxity. The most common mec ...

Hip fractures in children, although rare, are noteworthy because of the high energy needed for fracture and risk of associated injury. Equally important is the rate of serious complications such as ...

Because of the elasticity of a child's pelvis, acetabular fractures in children are rare and usually follow major trauma. Acetabular fractures often involve the triradiate cartilage. Fractures of ...

Pediatric pelvic fractures occur most often when child pedestrians are struck by a motor vehicle or when they are passengers in motor vehicles. Fracture patterns in pediatric patients differ from t ...

The proximal radial epiphysis is the second ossification center to appear about the elbow. It ossifies as a small wafer-like structure beginning at approximately 4 years of age. Normally, the artic ...

Fracture of the olecranon process is uncommon in children. When it does occur, it is usually the result of a fall. Olecranon fractures occur at a slightly older age than supracondylar fractures (9 ...

The Monteggia fracture-dislocation is a great "fooler" in orthopedic surgery. A Monteggia fracture consists of a radial head dislocation in conjunction with an ulnar fracture. The radial head dislo ...

Supracondylar humeral fractures are among the most frequent skeletal injuries in children. Treatment is often challenging, particularly with completely displaced fractures. Surgeons must be aware o ...

In 1930, Grisel described a syndrome in which rotatory displacement of C1 on C2 resulted from inflammation of adjacent neck tissues after acute upper respiratory infection. He proposed that lymphat ...

The concept of spinal cord injury without radiographic abnormality (SCIWORA) was introduced by Pang and Wilberger in 1982. Spinal cord injury without radiographic abnormality is a syndrome describi ...

Generally, adolescent soccer is considered to be less injury-intensive than other sports. In fact, it is a relatively safe sport.1 In this sense, damage to the locomotor system ...

Anterior cruciate ligament (ACL) injuries occur less commonly in children than in adults. In adults, the ACL inserts directly into the bone by means of Sharpey fibers, which are tendon fibers that ...

Fractures involving the physes are common in the pediatric population. Most of these injuries can adequately be treated with closed reduction and immobilization. Some, however, require op ...

When performing shoulder arthroplasty, proper exposure sets the stage for correct prosthetic component placement and soft tissue reconstruction. A clear appreciation of the anatomic basis for the ...

The proximal humerus can be conceptualized into four parts, each corresponding to an original center of ossification. The large head segment includes the articular surface which conforms to the gle ...

The humeral diaphysis is defined by the upper border of the pectoralis major muscle insertion to the flare of the supracondylar ridges. Proximally, its shape is cylindrical. Distally, it flattens i ...

The articular relationship of the glenohumeral joint is often described as a golf ball resting on a tee. Given the relative lack of bony conformity, when compared to other ball-and-socket joint suc ...

Three main reasons exist why sports medicine physicians who care for overhead throwers should have a rudimentary knowledge of pitching mechanics: Sports medicine physicians take care of ...

The scapula is a bone with complex geometry which overlies the second through seventh ribs and is tilted forward 30° with respect to the coronal plane. Seventeen muscles completely en ...

This entity is most commonly a component of rotator cuff disease caused by impingement. Attrition due to chronic inflammation may lead to frank rupture. Glenohumeral arthritis with osteop ...

Rotator cuff disease comprises a spectrum of pathology from inflammation of the sub-acromial bursa and supraspinatus tendon to full thickness tears of the supraspinatus tendon to involvem ...

The etiology of calcific tendinitis is unknown. It may be caused by ischemic changes in association with inflammation and calcium salt deposition. Microtrauma may also play a role. It com ...

Development The shoulder forms as a single cartilaginous anlage at 5 weeks gestation. Between 6 and 7 weeks of gestation, a cleft forms in the anlage creating the glenohumeral jo ...

The acromioclavicular (AC) ligament has superior, inferior, anterior, and posterior divisions. The AC ligaments provide stability in all planes when exposed to small forces. However, with larger forces...

Tears of the subscapularis tendon are less common than other types of rotator cuff tears. Tears of the subscapularis tendonoccur secondary to traumatic insults in patients who are younger than 50 y ...

The precise definition of biceps tendinitis remains elusive. Biceps tendinitis can be further delineated on the macroscopic levelinto tendinitis and tenosynovitis. Tendinitis represents an alterati ...

The shoulder is the most commonly dislocated major joint in the body. The incidence of traumatic anterior shoulder dislocation is approximately 2%.1 Traumatic recurrent anterior shoulder ...

Lesions of the rotator cuff affect athletes who play sports that involve overuse of the shoulder including baseball, tennis, team handball, and volleyball. Rotator cuff injuries in athletes arise f ...

For carefully selected patients with primary anterior shoulder instability after traumatic dislocation, Bankart repair, open or arthroscopic, has been shown to have a high success rate. In a recent ...

One of the known complications of instability surgery is the development of glenohumeral arthritis.^1-8 Shoulder arthroplasty for the treatment of instability associated arthritis has numerous challenges, including...

Proximal humerus nonunions present a significant challenge for the surgeon. Many patients with proximal humerus nonunions present with significant scarring, failed instrumentation from prior surgery, as well as...

One of the most devastating complications for the patient, as well as the surgeon, is a nerve injury after shoulder arthroplasty. These injuries present with profound and severe short-term, as well as potentially long-term, consequences. Minimal information is available for...

One of the most devastating complications after shoulder arthroplasty is the development of instability. Once this complication develops, it is a challenging problem to solve. A careful history, thorough examination, and appropriate imaging studies will ...

While there has been a significant trend toward performing rotator cuff repair in an arthroscopic manner, knowledge of an open repair is also helpful in certain circumstances. In revision rotator cuff surgery, on occasion, a large number of suture anchors may have been previously placed leaving minimal available space for ...

All of the above, with the exception of diabetes, are causes of secondary frozen shoulder. A healing surgical neck or tuberosity fracture can scar the capsuloligamentous structures leading to froze ...

Neer introduced the concept of impingement of the coracoacromial arch on the rotator cuff as the etiology of rotator cuff tendinopathy and rotator cuff tears.1 Neer contended that this m ...

Non-traumatic disorders of the sternoclavicular (SC) are numerous and include non-traumatic subluxation, arthritis, and infection. Spontaneous, congenital, or developmental dislocation ha ...

Originating from spinal roots C5 and C6, the suprascapular nerve courses laterally across the posterior triangle of the neck deep to the trapezius muscle to reach the suprascapular notch. ...

The management of a periprosthetic humeral fracture after shoulder arthroplasty presents a significant challenge for orthopedic surgeons. The reported incidence ranges between 1.6% and 2.3%.1, ...

The management of shoulder arthritis in patients with rheumatoid arthritis (RA) presents a distinctive challenge for surgeons. In addition to the typical cartilage and bone wear found in patients w ...

Ideal management of partial thickness and massive rotator cuff tears continues to challenge the orthopedic surgeon. With recent advances in technique, surgical options have evolved from simple open ...

One of the known complications of instability surgery is the development of glenohumeral arthritis.1-8 Shoulder arthroplasty for the treatment of instability associated arthritis has n ...

Shoulder arthroplasty presents a reliable option for improving pain relief and restoring function in patients with glenohumeral arthritis. However, complications may occur following surgery. One ...

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Gover ...

Proximal humerus malunions present a unique challenge to the orthopedic surgeon. In addition to the apparent distortion of bony anatomy, significant soft tissue contractures frequently create a c ...

Posterior glenohumeral instability represents both a diagnostic and therapeutic challenge. Posterior glenohumeral instability is rare with less than 5% of all glenohumeral dislocations occurring in ...

The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. ...

Bicipital tendonitis, or inflammation of the long head of the biceps (LHB) tendon, is a well-documented entity and is associated with shoulder pain, decreased throwing velocity, and disability. It ...

The goal of rotator cuff repair is to decrease pain, improve function, and restore strength through restoration of a stable bone-tendon construct. Factors involved in optimal tendon-to-bone healing ...

In 1982, Charles Neer II, MD introduced theconcept of “limited goals” when treating patients with glenohumeral arthritisand a deficient rotator cuff.1 This concept illustrates thetherape ...

One of the most devastating complications for the patient, as well as the surgeon, is a nerve injury after shoulder arthroplasty. These injuries present with profound and severe short-term, as we ...

Reprinted with permission from Pell RF, Whipple RR. Fracture-dislocation of the scapula. Orthopedics. 2001; 24:595-597.   The majority of injur ...

Fractures of the scapula are produced as a result of violent high energy trauma to the upper extremity. These fractures are often overlooked due to other life-threatening injuries, such a ...

Acromioclavicular joint injuries are among the most common shoulder injuries in contact sports. Fortunately, most sports-related acromioclavicular joint injuries are mild, requiring only symptomati ...

Sternoclavicular joint injuries are rare occurrences in both the athletic and generalpopulation. The stability of the sternoclavicular joint relative to other joints of theshoulder girdle contribut ...

Clavicle fractures are divided into three types based on their location:Type I clavicle fractures are in the middle one third and constitute 80% to 85% of all clavicle fractures (Slide) ...

LabrumThe glenoid labrum is a gasket-like structure made up of fibrocartilage attached to the rim of the bony glenoid. The labrum lies in a transition zone between the joint capsule and ...

Injuries to the upper end of the humerus usually heal and remodel well with observation because of the great amount of growth and remodeling potential. Deformity in this region is much less evident ...

Injury to the acromioclavicular (AC) joint is one of the more common injuries to the shoulder girdle. The subcutaneous position of the joint and relative paucity of surrounding muscle make it ...

When preparing a patient for brachial plexus exploration, the shoulder is elevated, usually by a folded sheet, and the patient’s head is rotated away from the side to be exposed. On this cadaver, b ...

For examinations, one should know the normal range of degrees of: Thoracic kyphosis Lumbar lordosis Sagittal alignment Important blood vessels

Schmorl's nodes (intraosseous vertebral lesions) are herniations of the intervertebral disk through weak areas in the adjacent vertebral end plates and into the vertebral body.1 Some of ...

The thoracic spine consists of 12 vertebraes, and represents the largest segment of the spine. As surgical approaches and internal fixation techniques in the spine continue to evolve, a thorough kn ...

The spinal column consists of 33 vertebrae that form a firm, but flexible, shaft that supports the trunk and appendages and provides protection for the spinal cord. The lumbar spine is ch ...

The thoracic spine consists of 12 vertebrae, and representsthe largest segment of the spine. As surgical approaches and internal fixationtechniques in the spine continue to evolve, a thorough knowl ...

Also known as congenital cervical synostosis, Klippel-Feilsyndrome is a rare syndrome characterized by cervical fusion and multiplecongenital malformations. One of the major clinically apparent def ...

Kyphosis represents an anterior concave curvature of the spine, which is normally seen in the thoracic and sacral spine. Lordosis represents a posterior concave curvature of the spine, which is nor ...

Spina bifida is a defect in neural tube formation and closure that occurs for unknown reasons. Supplementation of dietary folate at the time of conception has been strongly linked to a decre ...

Cervical alignment varies with positioning of the patient. This is especially important in young children. The head has been shown to be disproportionately large in children, so if they are placed ...

Radiculopathy is defined as pain or neurological deficit secondary to nerve root or spinal nerve injury or compression.1 Typical symptoms include sensory and motor loss involving the aff ...

Metastasis to the skeletal system is a common occurrence, particularly in the spine. Spinal metastasis may manifest from a variety of primary cancers, with lung, breast, prostate, and renal cell be ...

The sciatic nerve is the largest peripheral nerve in the body. Along with its divisions, it is responsible for innervating the muscles of the posterior thigh, leg, and foot. Injury to the sciatic n ...

Lower back pain is one of the most common conditions involving the musculoskeletal system. The term lower back pain refers to many sites of pain (or pain generators), including the intervertebral d ...

The term spondylolisthesis was termed by Kilian in 18541 who theorized that the gradual subluxation of the lumbosacral facets were responsible for this pathology. Today, it ...

Imaging of the spine is a valuable tool in diagnosis of pathological processes involved with the neural or bony elements of the spinal column. These diagnostic tests should be used as tools to conf ...

Disability due to low back pain is among the most costly health problems facing industrialized societies. It is estimated that low back pain afflicts up to ...

The prevalence of symptomatic lumbosacral disk herniation is relatively small. It is important to differentiate between the reasonably well-defined entity of sciatica resulting from a her ...

Spinal stenosis represents a narrowing of the spinal canal or neural foramina producing root ischemia and neurogenic claudication. Degenerative lumbar spinal stenosis is the result of chronic disc ...

Adult scoliosis can be loosely divided into two categories: Extension of a preexisting scoliosis, such as adolescent idiopathic scoliosis De novo scoliosis, also know ...

The term spondylolisthesis comes from the concatenation of two Greek words - spondylo (vertebra) and olisthesis (slipping). In the lumbar spine, spondylolisthesis is classified into sever ...

Degeneration of the intervertebral disk is a universal, age-related process; therefore, radiculopathy secondary to cervical spondylosis is a relatively common phenomenon. A population-based survey ...

Neck pain is a common ailment in adults. Non-traumatic neck pain in adults is often due to arthritis and degenerative disk disease. In children and young adults, non-traumatic neck pain is less com ...

The consequences of normal aging of the spine include progressive disk dehydration, chemical alterations and subsequent mechanical "incompetence," which may be manifested in low back pain ...

The prevalence of symptomatic lumbosacral disk herniation is relatively small. It is important to differentiate between the reasonably well-defined entity of sciatica resulting from a herniat ...

Spinal stenosis represents a narrowing of the spinal canal or neural foramina producing root ischemia and neurogenic claudication. Degenerative lumbar spinal stenosis is the result of chr ...

Thoracic disk herniation is extremely uncommon as compared toincidence in the cervical and lumbar region. The variable and nonspecificpresentations make correct diagnosis more difficult, especially ...

The term spondylolisthesis is used to describe the displacement of one vertebral segment on another. Most commonly, it relates to pathology associated with the lumbosacral spine. The lumb ...

In contrast to the adult population, lumbar intervertebral disk herniation is a relatively rare cause of low-back complaints in the pediatric population. Twelve years after Mixter and Bar ...

The posterior approach to the spine allows easy access to multiple levels for decompression, instrumentation, and fusion. This approach ...

Anterior lumbar interbody fusion (ALIF) is often used for patients who have discogenic low back pain, for patients who require anterior column support after a posterior procedure, or ...

Ossification of the cervical posterior longitudinal ligament (OPLL) represents a spectrum of disease. This condition begins with hypertrophy of the posterior longitudinal ligament (PLL) and is followed by...

The spinal column consists of 33 vertebrae that form a firm yet flexible structure that supports the trunk and appendages as well as provides protection for the spinal cord. The vertebrae are divid ...

The spine is the third most common site for skeletal metastases following the lung and liver, respectively. The spinal metastases most frequently originate from carcinoma of the breast, lung, prost ...

Spine infections are usually a result of a hematogenous spread from other body sources. Diskitis is most common among children 1 to 9 years of age. Due to the widespread, early use of antibiotics, ...

The spine is the most common site of skeletal metastasis, with the lumbar vertebrae being the most frequently affected. Metastatic disease to the spine may occur with almost any of the so ...

The reported incidence of metastatic disease in the thoracic spine ranges approximately from 30% to 46% of all metastatic lesions of the spine, and most metastatic lesions are seen in the ...

Vertebral osteomyelitis is the most common extradural infectious process affecting the spine.1 However, the diagnosis is frequently missed or delayed until major vertebral destruction or ...

Diskitis, or spondylodiskitis, is an inflammation of the intervertebral disk space that is often overlooked upon initial examination.1 It is generally caused by a bacterial infection or ...

Pyogenic vertebral osteomyelitis in the thoracic spine is not rare, and is associated with a significant morbidity and mortality. Infection of the thoracic spine mostly results from hemat ...

Spinal infections may involve the vertebral body (vertebral osteomyelitis), the intervertebral disc (infectious discitis), or the spinal canal and its contents (spinal epidural abscess). ...

Pyogenic osteomyelitis is commonly seen in the lumbar andthoracic spine. The incidence of the thoracic pyogenic osteomyelitis reportedfrom several studies ranges from 40% to 50% of all cases of spi ...

Ankylosing spondylitis is a systemic rheumatic disease that involves chronic inflammation of the spine and the sacroiliac joints. It is more common in men than in women, with age predominance in th ...

Cervical spine disorders are commonly seen in clinical practice. Conditions of the cervical spine can be classified into different categories based on etiology. Those secondary to trauma and dege ...

Torticollis is a disorder that results in limited motion of the cervical spine, causing the head to remain in a tilted position. Torticollis is caused by muscular, skeletal, or neurologic abnormali ...

Ankylosing spondylitis (AS) is a painful and progressive arthritis of the sacroiliac joints and spine that typically presents in patients between 20 and 40 years of age.1,2 The ...

Ninety-five percent of herniated disks are located in the lumbar spine.1 Lumbar herniated disks present as back pain or radicular leg pain or weakness (which is commonly referred to as s ...

Lumbar stenosis is a narrowing of the space available for the neural elements in the lumbar spine. Although the concept of lumbar stenosis was introduced by Protal in 1803, it was not popularized u ...

Thoracic disk herniation is extremely uncommon as compared to incidence in the cervical and lumbar region. The variable and nonspecific presentations make correct diagnosis more difficult, especial ...

Cervical radiculopathy is a peripheral neurological condition that involves mechanical or chemical injury of spinal nerve roots C1-C8. Degenerative disease is a common cause of cervical radiculopat ...

The function of spinal orthoses is to restrict spinal motion, realign spinal segments, prevent/correct deformity, and prevent further neurological/mechanical instability in a patient whos ...

Spondylolisthesis is characterized by the slipping of one vertebral body over another. Spondylolisthesis can have different etiologies and often shows a variety of clinical and radiograph ...

Minimally invasive lumbar interbody fusion techniques have evolved in recent years in an effort to decrease the operative morbidity associated with traditional anterior and posterior open approache ...

Lumbar pedicle screw fixation is widely used by spine surgeons alone or in conjunction with interbody fusion. Common indications for pedicle screw fixation include rigid stabilization for patients ...

Scoliosis is defined empirically as a lateral trunk rotation of over 10°, and has a prevalence of 2% to 3%. The incidence of idiopathic scoliosis associated with a Cobb angle of 20&de ...

The cervical spine consists of seven cervical vertebrae with eight cervical nerve roots. Each cervical vertebra consists of a spinous process, two lateral masses, and an anterior vertebral body, ex ...

Lumbar spinal fusions are performed to eliminate the motion between two vertebral bodies, often with contemporaneous correction of deformity or decompression of neural elements. This may decrease t ...

An estimated 700,000 vertebral body compression fractures occur each year in the United States.1 Historically, vertebral body compression fractures are rarely treated surgically. The med ...

Injuries of the subaxial cervical spine (C3-C7) are among the most common and potentially most devastating injuries involving the axial skeleton. Injuries occur more commonly at the cervi ...

Operative stabilization of the C1-C2 complex has received increasing attention. Due to poor outcomes in patients, particularly the elderly, treated nonoperatively for axis fractures, open reduction ...

Causes of occipitocervical instability include rheumatoid arthritis, trauma, congenital deformity, infectious disease, and basilar invagination or cranial settling. Symptoms may include ...

Autologous bone is the gold standard grafting material for spinal fusion.1 Despite its success, however, autologous bone is associated with defined morbidities. Alternatives/ad ...

Spinal fusion remains an important treatment option for numerous pathologies. However, achieving a successful fusion is challenging, and rates of pseudarthrosis have been reported as high ...

Osteobiologics is the study of bone formation and turnover. Clearly, this has direct relevance to orthopedics in general. Spinal applications are becoming better understood. ...

Spinal cord tumors represent between 4% and 15% of all central nervous system (CNS) tumors.1 The majority of tumors are located inside the dural compartment and are further described as ...

Neoplasms of the spine can be broadly categorized into: Metastatic tumors Primary tumors Primary spinal tumors are rare

Neoplasms of the spine can be broadly categorized into: Metastatic tumors Primary tumors Primary spinal tumors are rare:

Langerhans cell histiocytosis (LCH), or eosinophilic granuloma, commonly involves the spine. Patients may have one or multiple sites of involvement and generally feel pain over the affected area(s) ...

Myeloma of bone is the most common primary malignant bone tumor. Plasma cells are normally present in inflammatory conditions. Plasma cells normally function by producing antibodies after having be ...

The spine is the most common site of skeletal metastasis, with the lumbar vertebrae being the most frequently affected. Metastatic disease to the spine may occur with almost any of the solid tumors ...

Traction is the most common mechanism of injury in brachial plexus palsies that are birth-related or traumatic in nature.1 Rupture of peripheral nerves, avulsion of nerve root ...

Spinal cord injuries represent one of the most survivable, yet disabling injuries known to man. An estimated 10,000 North American people are injured in the spinal cord each year, most of whom are ...

Advances in intensive medical care and rehabilitative care have changed the paradigm on spinal cord injuries. Early in the 20th century, a spinal cord injury was considered a universally fatal illn ...

Central cord syndrome is the most common incomplete spinal cord lesion. Central cord syndrome is usually seen in patients with preexisting cervical spondylosis who then sust ...

Reprinted with permission from Vaccaro AR, Madigan L, Ehrler DM. Contemporary management of adult cervical odontoid fractures. Orthopedics. 2000; 10:1109-1113. A fractur ...

Gunshot injuries have become increasingly common in the civilian population, particularly in urban areas.1 Operative treatment is based on the need to decompress the neural elements.

Incomplete traumatic spinal cord injury often is the result of acute central cord injuries, a disorder sometimes characterized as being limited to the elderly. Central cord syndrome (CCS) occur in ...

Traumatic injuries of the thoracolumbar spine make up approximately 40% of all spine injuries. Up to 60% of spinal injuries occur between the T11 and L1 segments due to anatomic considerations deta ...

Because spinal anatomy is complex, classifying thoracolumbar fractures can be challenging. Advances in imaging techniques have improved fracture identification and have helped clinicians understand ...

In 1930, Grisel described a syndrome in which rotatory displacement of C1 on C2 resulted from inflammation of adjacent neck tissues after acute upper respiratory infection. He proposed that lymphat ...

Fractures of the odontoid process make up 7% to 14% of all cervical spine fractures.1 Odontoid fractures are frequently missed due to an altered mental status of a patient (e.g ...

Facet dislocations or fracture-dislocations are relatively common injuries in the subaxial cervical spine. Facet dislocations are often caused by flexion and distractive forces, with or without an ...

Burners and stingers are acute traction injuries of the brachial plexus that are characterized by a burning and stinging pain running from the shoulder to the hand.1-7 Injuries of this t ...

Two components of the anterior cruciate ligament (ACL) were described as early as 1938 when Palmer described an anteromedial and posterolateral component of the ACL.1 This anatomy was la ...

The trochanteric bursa is lateral to the greater trochanter, lying between the greater trochanter and the iliotibial band. The iliotibial band is a tract of fascia that originates from the confluen ...

Lateral epicondylitis is commonly referred to as tennis elbow, although many patients with this condition are not tennis players. Lateral epicondylitis is a pathological condition involvi ...

Medial epicondylitis occurs less frequently than its lateral counterpart and is commonly referred to as golfer's elbow, although many patients with this condition are not golfers. Medial epicondyl ...

Although there are many factors that affect outcomes after rotator cuff repair, functional outcome largely depends upon tendon healing of the repaired rotator cuff and the prevention of postoperative stiffness that limits shoulder function....

A devastating condition, chondrolysis is characterized by the disappearance of the joint’s articular cartilage....

Burners and stingers are acute traction injuries of the brachial plexus that are characterized by a burning and stinging pain running from the shoulder to the hand.1-7 Injuries of this t ...

Generally, adolescent soccer is considered to be less injury-intensive than other sports. In fact, it is a relatively safe sport.1 In this sense, damage to the locomotor system ...

The posterior cruciate ligament (PCL) is the strongest of the cruciate ligaments. Reported injuries to the PCL are much less frequent than those of the anterior cruciate ligament (ACL). The ...

The most common mechanisms of tibial spine avulsions are sports and trauma. Because of the decreased resistance to tensile stress of the bone and cartilage of the juvenile tibial spine compared to ...

Generally, adolescent soccer is considered to be less injury-intensive than other sports. In fact, it is a relatively safe sport.1 In this sense, damage to the locomotor system ...

Achilles tendinitis, which is either insertional or noninsertional, can occur following trauma, secondary to overuse, or it may by part of a systemic enthesopathy. Tendinitis which is noninsertiona ...

Peroneal tendon subluxation/dislocation is an uncommon but significant injury that is often misdiagnosed as a simple ankle sprain. The etiology is usually traumatic, most often described ...

The Achilles tendon is the strongest tendon in the body. During ambulation the Achilles tendon is subjected to high tensile loads that commonly result in its injury. Pathological changes ...

Ankle injuries are the most common injuries sustained in sporting activities. The most commonly injured structures in the ankle are the lateral ligaments, accounting for up to 45% of bas ...

Although an ankle sprain is one of the most common injuries in young, active patients, the incidence of ankle sprains is probably underestimated because many patients with injuries do not seek medi ...

Ruptures of the Achilles tendon are common, and treatment options have evolved over the past two decades. The treatment of acute Achilles rupture is operative, followed by a carefully pre ...

When examining patients for ankle instability, it is important to answer the following questions: Is the patient a high-performance athlete? Does the pa ...

The diagnosis of an osteochondral defect is often missed as patients are initially treated for an ankle sprain. Any patient with persistent intra-articular symptoms after treatment of an ...

Stress fractures of the tarsal navicular are seen in young athletes who run and jump frequently. Patients experience dorsomedial foot pain that worsens with activity. Cavus feet and c ...

This tutorial is a summary of a recent meta-analysis.1 The authors are from the University of Western Australia. ...

Anatomy of the peroneus brevis tendon The peroneus brevis tendon is located between the peroneus longus and the fibula. Subluxation of the perone ...

Function of the peroneus longus Supports the arch Plantarflexes the first metatarsal Weak evertor of the subtalar joint We ...

Vascular Supply A single nutrient artery enters the junction between the proximal and middle third of bone The nutrient artery bifurcates pro ...

Achilles tendinitis, which is either insertional or noninsertional, can occur following trauma, secondary to overuse, or it may by part of a systemic enthesopathy. Tendinitis which is noninsertiona ...

An acute Achilles tendon rupture is commonly visible and palpable on examination (Slide 1). Patients experience an acute tearing sensation in the posterior leg, as if an object struck the ...

Osteochondral defects of the talus occur on both medial and lateral sides of the talar dome. Lateral lesions are more closely associated with trauma, and are caused by dorsiflexion-invers ...

Stress fractures of the tarsal navicular are seen in young athletes who run and jump frequently. Patients experience dorsomedial foot pain that worsens with activity. Cavus feet and calca ...

K. Mathew Warnock, MD
Houston, Texas

The glenoid labrum is a gasket-like structure made up of fibrocartilage attached to the rim of the bony glenoid. The labrum lies in a transition zone between the joint capsule

Christopher B. Dewing, MD
San Diego, California

The articular relationship of the glenohumeral joint is often described as a golf ball resting on a tee. Given the relative lack of bony conformity

T. Bradley Edwards, MD
Houston, Texas

Posterior glenohumeral instability represents both a diagnostic and therapeutic challenge. Posterior glenohumeral instability is rare with less than 5% of all glenohumeral dislocations occurring in a posterior direction

Sameh A. Labib, MD
Atlanta and Decatur, Georgia

John S. Gould, MD
Birmingham, Alabama

Peroneal tendon subluxation/dislocation is an uncommon but significant injury that is often misdiagnosed as a simple ankle sprain

Daniel J. Solomon, MD
San Diego, California

The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

The arthroscope has revolutionized the way orthopedic surgeons approach rotator cuff tears...

T. Bradley Edwards, MD
Houston, Texas

Neer introduced the concept of impingement of the coracoacromial arch on the rotator cuff as the etiology of rotator cuff tendinopathy and rotator cuff tears

Sourav Poddar, MD
Denver, Colorado

Reed Bartz, MD
Denver, Colorado

A concussion, or mild traumatic brain injury (MTBI), is defined as a complex pathophysiological process affecting the brain due to significant biomechanical forces.

Reed L. Bartz, MD
Denver, Colorado

Three main reasons exist why sports medicine physicians who care for overhead throwers should have a rudimentary knowledge of pitching mechanics

William M. Hart, MD
Denver, Colorado

Sourav K. Poddar, MD
Denver, Colorado

Reed L. Bartz, MD
Denver, Colorado

The use of nutritional and ergogenic supplements in sports is a common occurrence that is growing in prevalence.

Hip arthroscopy has been performed since the 1990s, but the surgical technique and instrumentation has evolved dramatically over the past few years...

The anterior cruciate ligament (ACL) has garnered a lot of attention in orthopedic literature...

The use of allogeneic musculoskeletal tissue in orthopedic surgery has doubled in the last decade due to increased availability...

Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures in orthopedic surgery, with more than 100,000 surgeries performed annually. Follow-up data suggest 85% to 90% long-term stability with the use of patellar tendon or hamstring autograft.^1,2 Recent reports suggest similar results with...

The ideal graft material for anterior cruciate ligament (ACL) reconstruction should have structural properties similar to the native ACL, permit secure fixation, demonstrate rapid biologic incorporation, be readily available, and minimize...

The acromioclavicular (AC) ligament has superior, inferior, anterior, and posterior divisions. The AC ligaments provide stability in all planes when exposed to small forces. However, with larger forces...

Stability of the patellofemoral joint is reliant on an interplay between osseous anatomy, soft tissue competency, limb alignment, and dynamic muscle activity.¹ Patellar instability, ranging from subluxation to frank dislocation, is a common problem presenting in adolescent and young adult patients and is...

Osteochondral lesion of the talus (OLT) should be suspected in patients with continued ankle pain without a clear etiology. These lesions are caused by a fragment of cartilage that has detached from the talar dome and...

Degenerative conditions that affect the glenohumeral joint are not uncommon and may cause symptoms in up to 20% of patients.¹ While focal chondral defects can be a pain generator, it is important to ...

Medial tibial stress syndrome (MTSS) is defined as posteromedial tibia pain in athletes induced by exercise. This syndrome has been poorly defined and has previously been referred to as shin splint ...

The gastrocnemius muscle consists of two heads (lateral and medial) that originate from the respective femoral condyles (Slide 1). The soleus muscle originates from the proximal one-third of the po ...

During the acceleration phase of a baseball pitch, excessive valgus force applied to the medial elbow causes forceful wedging of the olecranon into the olecranon fossa.1-6 This repetitiv ...

During the acceleration and follow-through phases of a baseball pitch, forceful elbow extension leads to extreme loads on the triceps insertion to the olecranon. Acute or chronic overload of the tr ...

The posterolateral corner of the knee is composed of the iliotibial band, biceps, lateral collateral ligament (LCL), popliteus, fabellofibular ligament, popliteofibular ligament (PFL), ar ...

Normal daily loads on the anterior cruciate ligament (ACL) account for only 20% of the failure capacity.1 The ACL is composed of two bundles - the anteromedial bundle (tight in ...

Hyaline joint cartilage is approximately 3 mm to 5 mm thick and is devoid of blood vessels as well as nerves; lymphatic drainage does not occur. Chondrocytes comprise only 5% to 10% of hyaline join ...

Meniscal tears, which affect medial menisci more frequently than lateral menisci, are the most common indication for knee surgery.1 In young patients, meniscal tears are usually the resu ...

Articular cartilage damage is a common finding in traumatic knee injuries sustained by athletes. A chondral injury can lead to progressive, irreversible degenerative changes in the knee.Tech ...

The use of bioabsorbable implants for fixation of anterior cruciate ligament (ACL) grafts has increased dramatically over the past decade. Advantages of the use of bioabsorbable fixation include le ...

Adherence to a well-designed rehabilitation protocol is important for a successful and timely recovery following anterior cruciate ligament (ACL) reconstruction. In the 1980s, common postoperative ...

Bipartite patella is an accessory ossification center of the patella that does not fuse to the primary patella. The incidence of bipartite patella has been reported to be 2%, with 50% of cases occu ...

The anterior cruciate ligament (ACL) is the most common totally disrupted ligament of the knee.1 It has been estimated that more than 80,000 ACL tears occur in the United States each yea ...

Traditionally, the leg is described as having four anatomic compartments, but recent literature suggests that the deep posterior compartment may be subdivided into two or three separate s ...

Several authors have classified fractures of the base of the fifth metatarsal. Avulsion fractures of the tuberosity that enter the cuboid fifth metatarsal articulation result in minimal morbidity a ...

Studies have shown that operative treatment of patients with freshly ruptured Achilles tendons is generally considered to be more appropriate than nonoperative treatment. However, complications in ...

Chronic groin pain ends the careers of many high-level athletes, particularly professional soccer, hockey, and American football players.1 A better understanding of athletic pubalgia and ...

Tears of the subscapularis tendon are less common than other types of rotator cuff tears. Tears of the subscapularis tendonoccur secondary to traumatic insults in patients who are younger than 50 y ...

The precise definition of biceps tendinitis remains elusive. Biceps tendinitis can be further delineated on the macroscopic levelinto tendinitis and tenosynovitis. Tendinitis represents an alterati ...

Internal impingement, or posterosuperior glenoid impingement, is the contact that occurs between the greater tuberosity andthe posterosuperior aspect of the glenoid rim during abduction, external r ...

For carefully selected patients with primary anterior shoulder instability after traumatic dislocation, Bankart repair, open or arthroscopic, has been shown to have a high success rate. In a recent ...

The knee is the most commonly injured joint in childhood sports.1 With the increasing participation of children in competitive athletics, midsubstance disruption of the a ...

Stress fractures can occur if normal bone is exposed to repeated abnormal stress (fatigue fractures) or if normal stress is placed on bones with compromised elastic resistance (insufficiency fractu ...

The structures of the medial side of the knee have been well described.1-4 One study described three medial soft tissue layers.4 The medial patellofemoral ligament (MPFL), whi ...

Osteochondritis dissecans (OCD), first described by Konig1 in 1988, is an avascular necrosis involving a bone at the osteochondral junction in the epiphysis. The subchondral bone becomes ...

The hamstring muscle group is made up of the semitendinosus, semimembranosus, and biceps femoris. These muscles flex the knee and adduct and extend the thigh. The superficial muscles are the long h ...

External blows that cause tissue damage and vascular disruption lead to muscle contusions. An external blow creates a compression wave that travels through soft tissues and causes damage to the dee ...

The proximal end of the second metatarsal is recessed between the medial and lateral cuneiform. This mortise configuration locks the tarsometatarsal complex. No ligament binds the first and second ...

Rib fractures in athletes are rare and can be divided into two types. The first type involves direct trauma and usually affects the lower ribs. The second type involves fracture from indirect force ...

The main stabilizer to valgus stresses applied to the elbow is the medial (or ulnar) collateral ligament. The medial collateral ligament is composed of three parts including the anterior oblique po ...

The shoulder is the most commonly dislocated major joint in the body. The incidence of traumatic anterior shoulder dislocation is approximately 2%.1 Traumatic recurrent anterior shoulder ...

Lesions of the rotator cuff affect athletes who play sports that involve overuse of the shoulder including baseball, tennis, team handball, and volleyball. Rotator cuff injuries in athletes arise f ...

The diagnosis and treatment of sports-related injuries and damages are increasing insignificance for clinicians. This is due to the considerable increase in the number ofindividuals playing sports ...

Innovations in water sports have produced variations to traditional surfing. Surfing, a sport in which people stand on a board and allow surf and breakers to carry them to shore, has given rise to ...

Introduction
Acetabular fractures usually occur as the result of a high-energy impact, either directly above the hip, transmitted through the femoral head after impact to the lower extremity, or a fall from height. The treatment of these fractures is challenging for a number of reasons. The fractures are intra-articular for most; the joint is deeply seated with important neuro-vascular structures in its vicinity; anatomical reduction can be difficult; and finally patients often present with associated orthopedic and non-orthopedic injuries.

In this tutorial, we look at acetabular fractures and discuss patients’ acute management, classifications of fractures treatment indication as well as surgical techniques.

Evaluation
Initial evaluation of a patient with suspected acetabular injury should follow the Advanced Trauma Life Support (ATLS) protocol. Priority is given to airways, cervical spine immobilization, breathing and circulation. When the patient has been stabilized, radiologic imaging is appropriate. If a pelvic fracture is associated with a displaced acetabular fracture, fixation of the pelvic fracture takes priority so that a reconstruction of the acetabulum can occur on a solid base. However, if the acetabular fracture is nondisplaced, it should be fixed prior to the pelvic fracture so that it does not become displaced during the effort to secure the pelvis. Other associated injuries should be ruled out, and distal neurovascular status – a complication seen in 12% to 25% of cases – should be assessed and documented.^1,2

Radiography
Obtaining plain films of the pelvis is the initial step in diagnosing injury to the acetabulum. Views should include an AP pelvis and Judet views (iliac and obturator oblique views). When examining an AP pelvis radiograph, 6 lines should be inspected closely for possible disruption (figure 1). These lines are:

1. Iliopectineal line
   • Disruption indicates an anterior column fracture.
2. Ilioischial line
   • Disruption indicates a posterior column fracture.
3. Teardrop – at the junction of the anterior two-thirds and posterior one-third of the acetabulum. It is made up of the cotyloid fossa and medial quadrilateral plate.
   • Position change with respect to the anterior column demonstrates a vertical fracture in the anterior two-thirds of the acetabulum.
   • Position change with respect to the posterior column demonstrates a vertical fracture in the posterior one-third of the acetabulum.
4. Acetabular dome
5. Anterior acetabular wall
   • Disruption indicates an anterior wall fracture.
6. Posterior acetabular wall
   • Disruption indicates a posterior wall fracture.

Judet views include iliac and obturator oblique films. The iliac oblique (with the unaffected side tilted up 45°) shows the best view of the ilioischial line (ie, posterior column) and anterior wall. Conversely, the obturator oblique (with the affected side tilted up 45°) is best for examining the posterior wall and anterior column.

The acetabular dome is analyzed in these 3 views using measurements such as the roof arc angles described in the 1980s by Dr. Joel M. Matta. On each film, a line is drawn from the center of the acetabular dome to the center of the femoral head. A second line extends from the center of the femoral head to the center of the fracture line. The arc angle subtended by these two lines — called the roof arc angle — can be used to assess the need for surgery. If any of the 3 views shows a roof arc angle less than 45°, consider surgical intervention. Note that roof arc angle measurements are only valid if there is no subluxation of the hip. If the fracture does not enter the joint on any of the 3 views, the joint is intact.

CT imaging evaluates the fracture for both articular surface involvement and marginal impaction. Using 1.5-mm slices, the CT subchondral arc — correlated with roof arc angle — is measured. If there is no fracture within 10 mm of the dome (7 slices of 1.5-mm thickness or 5 slices of 2-mm thickness), the dome is intact (equivalent to 45° roof arc). Three dimensional reconstruction of the pelvis is also very useful for preoperative planning.

Classification
Dr. Emile Letournel classified acetabular fractures into 5 elemental and 5 complex (associated) types:

Elemental

• Anterior wall
• Anterior column
• Posterior wall
• Posterior column
• Transverse

Complex (Associated)

• Posterior column + posterior wall
• Transverse + posterior wall
• T-shaped
• Anterior column + posterior hemitransverse
• Both columns

A simplified algorithm for classifying acetabular fractures using x-ray imaging was proposed by Ly et al in a paper published in 2011.³ One wall fractures are either anterior or posterior. One column fractures are anterior column, posterior column, or posterior column plus posterior wall (ie, if there is a posterior column fracture, look for an associated posterior wall fracture as well).

If 2 columns are disrupted, explore whether there is acetabulum left on the pelvis. If not, this is a both column fracture. The spur sign is present in 80% of such fractures, but if the posterior wall is involved, it will be absent.

If any portion of the acetabulum remains attached to the pelvis, explore is the obturator foramen is involved. If it is, the pattern is either T-shaped or anterior column plus posterior hemi-transverse. Distinguish between the 2 by looking at the fracture lines. If the anterior column fracture line exists high, or if the angle between the 2 fracture lines within the acetabulum is large, this is an anterior column plus posterior hemitransverse fracture. In T-shaped fractures, the 2 fracture lines should be relatively straight.

If the obturator foramen is not involved, the fracture pattern is transverse or transverse plus posterior wall. The involvement of the posterior wall distinguishes between the 2 types.

Determinants of Outcome
Many factors influence outcome following acetabular fracture. Fracture location is key; Matta showed that patients with malunions within the weight-bearing dome, roof arcs less than 45° or broken subchondral arcs experienced early osteoarthritis (OA) and poor results. Similarly, incongruity greater than 2 mm results in OA in 50% of patients. Stability of the fracture plays a role as well. In the posterior wall, a fracture in the inferior half of up to 50% may be acceptable; in the superior half of the posterior wall, however, an examination under anesthesia (EUA) should be performed to assess for instability and residual incongruity.

Other factors include associated neurologic injury (usually the peroneal distribution of the sciatic nerve) and/or cartilage injury. If the sciatic nerve is damaged, functional recovery is seen in 65% of patients. Cartilage damage is associated with an increased risk for osteonecrosis at 5 years after the injury (1.7%); the risk is even greater for patients experiencing posterior dislocation (7%). Letournel and Judet’s published series reported 120 fractures in patients older than 60 years, of which 103 were treated with open reduction internal fixation (ORIF).² When results were stratified by age, the best outcomes were noted in younger patients, with the poorest results occurring in patients older than 50 years.

After surgery to reduce acetabular fractures, a reduction of fracture displacement to less than 1 mm signifies better outcomes.^4,5 A surgeon’s ability to reduce fractures is affected by surgical experience, the timing of the procedure (within 15 days for elemental and 10 days for associated fracture patterns),⁶ and the fracture pattern and associated comminution.

Considerations
Risks of surgical treatment include injury to the sciatic nerve, occurring in approximately 2% of surgical procedures. Other associated neurovascular injuries include damage to the superior gluteal artery and nerve (located in the posterior upper one-third of the greater sciatic notch) or to the obturator nerve (in any fracture pattern involving the obturator foramen). Heterotopic ossification (HO) is associated with an extensile approach, injury to the femoral head, and a T-shaped fracture pattern. Indomethacin and/or low-dose radiation have been shown to reduce heterotopic ossifications and may be considered, especially if elevating superior to the acetabulum. There is a 2% to 5% risk for infection, which is increased in Morel-Lavallée lesions. Finally, arthritis is present radiographically in 15% to 45% of patients 5 years after ORIF.⁷

Non-Operative Indications
Indications for non-operative treatment include non-displaced fractures or displaced fractures with low transverse or low column patterns. In both-column fractures, the entire articular surface is separated from the ilium, so the hip may simply medialize and achieve secondary congruency. These may have better outcomes with non-operative treatment.

Operative Indications
Indications for surgical treatment include incongruency (defined as greater than 2-mm displacement in the upper 10 mm to 12 mm of the acetabulum), intra-articular fragments, marginal impaction, and instability. Fractures involving less then 25% of the acetabulum are typically stable and may not require surgery. If the fracture extends through 25% to 50% of the acetabulum, the outcomes are more unpredictable. Gross instability is always an indication for surgery. Patients younger than 60 year with minimal comorbidities and no previous osteoarthritis should also be considered for surgery. Ultimately, the surgeon must decide if the fracture pattern can be improved with ORIF.

Considerations for acute total hip arthroplasty (THA) include intra-articular comminution, full thickness cartilage loss, impaction injury to the femoral head, and impaction of the acetabulum representing more than 40% of the weight-bearing area. Mears and colleagues demonstrated 79% outcomes rated good or excellent for THA after acetabular fracture.⁸ In most cases, the cups settled 3 mm medial and 2 mm vertical and then stabilized. Only 11% of patients developed HO; 11% developed excess medialization; and 16% developed noticeable wear.

Surgical Approaches: Selection
The Kocher-Langenbeck approach is best for access to the posterior column. If visualization is required superior to the acetabulum, perform a partial tenotomy of the posterior gluteus medius, leaving a cuff for tendon repair, or a trochanteric osteotomy.

To access the anterior column and inner table, use an ilioinguinal approach. An extended iliofemoral approach offers access to both columns simultaneously, but it does not expose the anterior column as well as the ilioinguinal. Additionally, recovery is longest with this approach, and the risk for HO is highest.

A triradiate approach provides similar exposure to the iliofemoral, but exposure to the posterior ilium and SI joint is not as good. This approach is useful during a Kocher-Langenbeck if the anterior column is irreducible or access to the anterior joint is necessary. The anterior limb is accessible from the greater trochanter (GT) to the anterior superior iliac spine (ASIS) through a Smith-Peterson approach, and the surgeon may elevate the tensor fascia lata and gluteus medius/minimus to the iliac tubercle. If greater exposure is required, perform a GT osteotomy. If additional exposure to the anterior column or medial hip is necessary, the surgeon may elevate the anterior hip capsule, rectus femoris, sartorius, and inguinal ligament attachments of the ASIS and anterior inferior iliac spine to allow access to the iliac fossa.

A modified triradiate approach results in reduced soft tissue stripping, but because the rectus femoris is left intact, the surgeon cannot visualize the anterior articular surface. Thus, if the fracture involves significant damage to the anterior column, use an extended iliofemoral approach. In general, if additional anterior exposure becomes necessary during an Kocher-Langenbeck (ie, an anterior column plus posterior hemi-transverse fracture with more displacement than expected), a modified triradiate approach is useful. Access to the posterior limb is the same as a Kocher-Langenbeck. For access to the anterior limb, leave the tensor fascia lata and gluteus medius and minimus attached to the iliac crest and release the medial one-third of the direct rectus only. If further visualization is required, perform a GT osteotomy but do not elevate the abductors.


Table: Summary of Fracture Patterns and Recommended Approaches


Reduction Techniques
Anterior wall
Use an ilioinguinal approach. Plate the fractures along the pelvic brim, but beware, screws may be easily placed into the acetabulum. Thus, place the screws parallel to the quadrilateral plate.

Anterior column
Use an ilioinguinal approach. If the fracture is not complete, it must be completed in order to facilitate reduction. Assess reduction along the iliac fossa and quadrilateral plate. Use lag screws and a plate on the pelvic brim to fixate the fracture.

Posterior wall
Use a Kocher-Langenbeck approach. Pay attention for marginal impaction, which is a depression of the articular surface where the femoral head has forced its way through the fracture. If this is not reduced, it results in incongruity and instability. Elevate the articular cartilage (ie, reduce it to the femoral head), and buttress it with a cancellous graft (often taken from the greater trochanter).

Use 2 lag screws if possible and a reconstruction plate, also known as a “recon” plate or “Loch-Ness monster.” Fashion a spring plate by flattening a one-third-tubular plate, cutting the distal hole, and bending the plate to 90°. Note that this plate should be slightly under-contoured, such that it applies a spring-like force when tightened into place.

Posterior column
These fractures are usually reduced with a Kocher-Langenbeck approach. The surgeon must correct the rotation of the fragments; use a Schanz screw as a joystick. Compress the fracture with lag screws, and plate the column.

Transverse
These fractures are also usually reduced through a Kocher-Langenbeck approach. Again, use a Schanz screw as a joystick for rotational reduction, and fixate the fracture with lag screws and a plate. For the rare fracture that is high anteriorly and low posteriorly, consider using an ilioinguinal approach.

Posterior column + posterior wall
Using a Kocher-Langenbeck approach, reduce the posterior column first with a plate located close to the sciatic notch. Use a second plate for the posterior wall.

Transverse + posterior wall
Use a Kocher-Langenbeck approach, and reduce the transverse fracture first with a lag screw and/or a plate. Like the posterior column plus posterior wall pattern, the plate should be located close to the sciatic notch to accommodate a second plate that will be required for the posterior wall.

T-Shaped
Begin with a Kocher-Langenbeck approach, and try reducing the anterior column first. Use a lag screw from posterior to anterior. Assess the reduction with fluoroscopy and palpate along the quadrilateral plate. If the anterior column is unable to be reduced, fixate the posterior column and move to an iliofemoral approach to reduce the anterior column.

Anterior column + posterior hemitransverse
An ilioinguinal approach is normally used for access to these fractures. Reduce and stabilize the anterior column first, then assess the reduction of the posterior hemitransverse fracture through the second window along the quadrilateral plate. The fracture is usually reduced and can be fixated with lag screws.


Both column
Most both column fractures are reduced via an ilioinguinal approach. Reduce the anterior column first, and fixate it with a plate on the pelvic brim. Use a minimal number of screws to make the posterior reduction easier. Access the posterior column through the second window, and reduce it; assess the reduction by palpating the quadrilateral plate and greater sciatic notch. Fixate the fracture with lag screws from the pelvic brim into the posterior column. Note that approximately one-third of these fractures require an extended iliofemoral approach; these generally involve fracture lines crossing the SI joint, significant intraarticular impaction or comminution, or complex posterior column fractures.

References

1. Wright R, Barrett K, Christie MJ, Johnson KD. Acetabular fractures: long-term follow-up of open reduction and internal fixation. J Orthop Trauma. 1994;8(5):397-403.
2. Letournel É, Judet R, Elson R. Fractures of the acetabulum. 2nd ed. Berlin; New York: Springer-Verlag, 1993:xxiii, 733 p.
3. Ly TV, Stover MD, Sims SH, Reilly MC. The use of an algorithm for classifying acetabular fractures: a role for resident education? Clin Orthop Relat Res. 2011;469(8):2371-2376.
4. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am. 1996;78(11):1632-1645.
5. Briffa N, Pearce R, Hill AM, Bircher M. Outcomes of acetabular fracture fixation with ten years' follow-up. J Bone Joint Surg Br. 2011;93(2):229-236.
6. Madhu R, Kotnis R, Al-Mousawi A, et al. Outcome of surgery for reconstruction of fractures of the acetabulum. The time dependent effect of delay. J Bone Joint Surg Br. 2006;88(9):1197-1203.
7. Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum. A meta-analysis. J Bone Joint Surg Br. 2005;87(1):2-9.
8. Mears DC, Velyvis JH. Acute total hip arthroplasty for selected displaced acetabular fractures: two to twelve-year results. J Bone Joint Surg Am. 2002;84-A(1):1-9.

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Bone graft is often used in orthopedic trauma to fill critical size defects in bone that otherwise would not heal adequately with mechanical stabilisation alone.

Distal tibia fractures that do not extend to the joint are difficult to treat...
 

Central cord syndrome is the most common incomplete spinal cord lesion. Central cord syndrome is usually seen in patients with preexisting cervical spondylosis who then sust ...

Reprinted with permission from Vaccaro AR, Madigan L, Ehrler DM. Contemporary management of adult cervical odontoid fractures. Orthopedics. 2000; 10:1109-1113. A fractur ...

Gunshot injuries have become increasingly common in the civilian population, particularly in urban areas.1 Operative treatment is based on the need to decompress the neural elements.

Incomplete traumatic spinal cord injury often is the result of acute central cord injuries, a disorder sometimes characterized as being limited to the elderly. Central cord syndrome (CCS) occur in ...

Because spinal anatomy is complex, classifying thoracolumbar fractures can be challenging. Advances in imaging techniques have improved fracture identification and have helped clinicians understand ...

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Fractures of the odontoid process make up 7% to 14% of all cervical spine fractures.1 Odontoid fractures are frequently missed due to an altered mental status of a patient (e.g ...

Facet dislocations or fracture-dislocations are relatively common injuries in the subaxial cervical spine. Facet dislocations are often caused by flexion and distractive forces, with or without an ...

Proximal tibial metaphyseal fractures commonly occur in young children and are often undisplaced and quickly heal. However, despite their innocuous appearance, greenstick and comp ...

The distal femoral physis is susceptible to fracture from various forces to the knee as it usually fails before the medial collateral ligament. As with other physeal injuries, the Salter-Harris (SH ...

Traditional medicine teaches that infants and children with a diaphyseal femur fracture do well when treated with "basic principles" of conservative care. Postfracture joint stiffness does not occu ...

The hip is the most structurally stable joint in the body. Acetabular stability is enhanced by three thickenings in the hip capsule, the iliofemoral, ischial-femoral, and pubo-femoral ligaments. Th ...

Fracture of the olecranon process is uncommon in children. When it does occur, it is usually the result of a fall. Olecranon fractures occur at a slightly older age than supracondylar fractures (9 ...

The Monteggia fracture-dislocation is a great "fooler" in orthopedic surgery. A Monteggia fracture consists of a radial head dislocation in conjunction with an ulnar fracture. The radial head dislo ...

As children pass the typical age for supracondylar fracture of the elbow, which is the first decade of life, fractures of the elbow become less common. T- or Y-condylar fractures of the distal hume ...

Fractures of the supracondylar portion of the distal humerus are among the most common elbow injuries seen in children. The fractures mainly occur within the first decade of life, have a peak incid ...

Injuries to the upper end of the humerus usually heal andremodel well with observation because of the great amount of growth andremodeling potential. Deformity in this region is much less evident o ...

Elbow dislocations occur most commonly in children >6 years of age. They are not nearly as common in children as supracondylar fractures of the humerus, which occur by the same m ...

Anterior knee pain can result from many pathological conditions involving not only the knee, but also the hip. Most are related to overuse injuries. The exception is referred pain from a condition ...

A discoid meniscus is a common congenital abnormality, affecting approximately 1% of all lateral menisci in the U.S. population. The medial meniscus is involved less frequently, representing only ...

Growth from the distal femoral physis is approximately 10 mm to 11 mm per year. The knee joint capsule and collateral ligaments originate just distal to the distal femoral physis, concentrating any ...

Diaphysis fractures of the femur and tibia constitute approximately 18% of all fractures in adolescents. These fractures result from high-energy injuries - the most common are motor vehicle acciden ...

The proximal tibial epiphysis is continuous with the tubercle and forms an "L," as seen from a lateral perspective. The tibial tubercle begins to ossify in children aged 8 to 9 years old; the epiph ...

Pediatric femoral shaft fractures occur with two peaks of incidence, ages 2 to 3 years and 12 to 13 years, because cortical thickness increases dramatically throughout childhood. Therefore, infants ...

Proximal tibial physis growth occurs at an average of 6 mm to 7 mm per year. Injuries to the proximal tibial physis are less than half as common as those of the distal femur. The proximal tibial ep ...

In contrast to the adult population, lumbar intervertebral disk herniation is a relatively rare cause of low-back complaints in the pediatric population. Twelve years after Mixter and Bar ...

Traumatic hip dislocations occur with less force in young children than skeletally mature individuals, presumably due to the unossified acetabular cartilage and capsular laxity. The most common mec ...

Hip fractures in children, although rare, are noteworthy because of the high energy needed for fracture and risk of associated injury. Equally important is the rate of serious complications such as ...

Because of the elasticity of a child's pelvis, acetabular fractures in children are rare and usually follow major trauma. Acetabular fractures often involve the triradiate cartilage. Fractures of ...

Because of the elasticity of a child's pelvis, acetabular fractures in children are rare and usually follow major trauma. Acetabular fractures often involve the triradiate cartilage. Fractures of ...

Pediatric pelvic fractures occur most often when child pedestrians are struck by a motor vehicle or when they are passengers in motor vehicles. Fracture patterns in pediatric patients differ from t ...

The proximal radial epiphysis is the second ossification center to appear about the elbow. It ossifies as a small wafer-like structure beginning at approximately 4 years of age. Normally, the artic ...

Fracture of the olecranon process is uncommon in children. When it does occur, it is usually the result of a fall. Olecranon fractures occur at a slightly older age than supracondylar fractures (9 ...

The Monteggia fracture-dislocation is a great "fooler" in orthopedic surgery. A Monteggia fracture consists of a radial head dislocation in conjunction with an ulnar fracture. The radial head dislo ...

Supracondylar humeral fractures are among the most frequent skeletal injuries in children. Treatment is often challenging, particularly with completely displaced fractures. Surgeons must be aware o ...

In 1930, Grisel described a syndrome in which rotatory displacement of C1 on C2 resulted from inflammation of adjacent neck tissues after acute upper respiratory infection. He proposed that lymphat ...

The concept of spinal cord injury without radiographic abnormality (SCIWORA) was introduced by Pang and Wilberger in 1982. Spinal cord injury without radiographic abnormality is a syndrome describi ...

Anterior cruciate ligament (ACL) injuries occur less commonly in children than in adults. In adults, the ACL inserts directly into the bone by means of Sharpey fibers, which are tendon fibers that ...

Fractures involving the physes are common in the pediatric population. Most of these injuries can adequately be treated with closed reduction and immobilization. Some, however, require op ...

Subtrochanteric femur fractures in children are defined as fractures below the lesser trochanter, within a distance equal to 10% of the length of the entire femur. Such fractures tend to affect you ...

The most common mechanisms of tibial spine avulsions are sports and trauma. Because of the decreased resistance to tensile stress of the bone and cartilage of the juvenile tibial spine compared to ...

Subtrochanteric femur fractures in children are defined as fractures below the lesser trochanter, within a distance equal to 10% of the length of the entire femur. Such fractures tend to affect you ...

Endogenous parathyroid hormone (PTH) is the primary regulator of calcium and phosphate metabolism in bone and kidney. Its main function is to maintain the concentration of calcium in the extracellu ...

The lateral talar process is a wedged-shaped prominence that compromises the most lateral aspect of the talar body. Superiorly, it articulates with the talofibular joint, and inferiorly, with the p ...

Several classification systems have been introduced for calcaneus fractures. Letournel’s1 classification describes the most common types of fractures effectively, although it does not provide ...

Acute navicular fractures can be divided into avulsion and axial compression fractures. ...

Great toe extra-articular fractures usually occur from striking the unprotected toe against an object or from dropping an object onto the toe. Most of these fractures have minimal displacement and ...

Calcaneus fractures are often caused by high-energy injuries, such as falls from heights and motor vehicle accidents. When a patient presents with a calcaneus fracture, a thorough patient ...

The consequences of unrecognized compartment syndrome of the foot can be devastating. A patient with compartment syndrome of the foot has a markedly dysfunctional, painful, and stiff foot ...

Major fractures and dislocations of the tarsometatarsal joint are easy to diagnose, but minor sprains, particularly those associated with athletic and low-energy injuries, are often misdi ...

The lateral talar process is a wedged-shaped prominence that compromises the most lateral aspect of the talar body. Superiorly, it articulates with the talofibular joint, and inferiorly, ...

Acute navicular fractures can be divided into avulsion and axial compression fractures. ...

Vascular Supply A single nutrient artery enters the junction between the proximal and middle third of bone The nutrient artery bifurcates pro ...

Talar neck fractures constitute 50% of talus fractures. The mechanism of injury is acute dorsiflexion of the forefoot, and usually occurs in motor vehicle accidents, falls, or as original ...

The lateral talar process is a wedged-shaped prominence that compromises the most lateral aspect of the talar body. Superiorly, it articulates with the talofibular joint, and inferiorly, ...

Acute navicular fractures can be divided into avulsion and axial compression fractures. ...

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Olecranon fractures can range from simple nondisplaced fractures to complex fracture-dislocations of the elbow. They are intraarticular injuries requiring anatomic restoration of the articular surface. Rigid internal fixation to permit

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Fractures of the distal tibial metaphysis are often the result of high-energy trauma, as this anatomic region is very strong, particularly in young individuals. Fractures are either completely extra-articular or they may have...

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Marjolin's ulcer, which was first described more than 1.5 centuries ago, involves a rare malignant transformation of chronic scar tissue or ulcer.1 Marjolin's ulcers are rare ...

This tutorial is a summary of a recent meta-analysis.1 The authors are from the University of Western Australia. ...

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Although ipsilateral fractures of the femoral neck and shaft are uncommon, it is critical to recognize a femoral neck fracture that may occur in conjunction with a femoral shaft fracture. The com ...

Radial nerve palsy associated with radialshaft fracture is a common occurrence. Approximately one in ten patients with ahumeral shaft fractures will also have associated radial nerve palsy. In anep ...

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The mechanical properties of an external fixation frame,used to treat any bone defect, determine the biomechanical environment in thehealing bone gap.1-11 Mechanical properties of variou ...

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It is essential to understand the bony anatomy of Lisfranc's joint to avoid missing subtle injuries to the midfoot. The second metatarsal base is recessed with respect to the first and third metat ...

Statically locked antegrade reamed intramedullary nailing inserted with a closed technique is an effective treatment for femoral shaft fractures. Multiple large clinical studies have reported exc ...

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Buehler and colleagues4 reported on the use of a more lateral and proximal entrance site to achieve reduction of proximal tibial shaft fractures. They also used a medially plac ...

Osteofibrous Dysplasia is an uncommon condition that occurs only in the cortex of the tibia. The condition is sometimes referred to as ossifying fibroma or Jaffe-Campanacci disease. ...

Eye opening Spontaneous: 4 To voice: 3 To pain: 2 None: 1 Verbal response...

Reprinted with permission from Pell RF, Whipple RR. Fracture-dislocation of the scapula. Orthopedics. 2001; 24:595-597.   The majority of injur ...

Fractures of the scapula are produced as a result of violent high energy trauma to the upper extremity. These fractures are often overlooked due to other life-threatening injuries, such a ...

Clavicle fractures are divided into three types based on their location:Type I clavicle fractures are in the middle one third and constitute 80% to 85% of all clavicle fractures (Slide) ...

Tibia fractures are the most common long bone fractures that result in nonunions and malunions. The tibia is subcutaneous, its blood supply is precarious, and complications of operative treatment ...

Stress fractures can occur if normal bone is exposed to repeated abnormal stress (fatigue fractures) or if normal stress is placed on bones with compromised elastic resistance (insufficiency fractu ...

The knee joint is a hinged joint that permits flexion and extension. The proximal tibia is composed of both a medial and lateral tibial plateau. The medial plateau is concave and the lateral plat ...

Osteochondritis dissecans (OCD), first described by Konig1 in 1988, is an avascular necrosis involving a bone at the osteochondral junction in the epiphysis. The subchondral bone becomes ...

The stability of the knee is imparted by ligaments, bony anatomy and menisci, and dynamic structures crossing the knee. The majorligaments include the anterior cruciate ligament (ACL), posterior cr ...

The term perionychium describes the region on the dorsal aspect of the distal phalanx that includes the nail bed and surrounding soft tissues. The "hard nail," referred to as the nail pla ...

The Bennett's fracture of the thumb metacarpal (MC) base was first described by E.H. Bennett in 1882.1 Although this fracture is not common, it is notorious for causing the fractured th ...

In 1984, an estimated 238,000 hip fractures occurred in the United States.1 By 1993, more than 307,000 hospitalizations for hip fractures were recorded in the United States, and more t ...

A patient presented with electric combustion of both hands. The combustion resulted in spread and deep skin damage, and defect of other structures. Tendons and nerves on the left hand were involv ...

Slipped Capital Femoral Epiphysis: (SCFE) is the posterior displacement of the femoral capital epiphysis on the femoral neck through sudden or gradual deformation of the subcapital growth plate. Bo ...

The scaphoid, or carpal navicular, is the most commonly fractured carpal bone, compromising up to 75% of all carpal fractures. More than 90% of these fractures heal, but there is still an ...

Metacarpal fractures are common and account for 30% of all hand fractures. The ulnar aspect of the hand is more commonly affected than the radial aspect. These fractures can be subdivided ...

The finger metacarpophalangeal (MCP) joint is a condyloid-type joint, which allows motion in extension, flexion, adduction, and some circumduction. The metacarpal head is wider on the palmar aspect ...

Traction is the most common mechanism of injury in brachial plexus palsies that are birth-related or traumatic in nature.1 Rupture of peripheral nerves, avulsion of nerve root ...

The thumb metacarpophalangeal (MP) joint in combination with the first carpometacarpal joint provides the hand with tremendous functionality. In addition to the primary arc of motion of f ...

Although surgeons' understanding and techniques have improved significantly over the past 30 years, flexor tendon repair continues to be challenging and unpredictable outcomes often ensu ...

Patients with scaphoid fractures are commonly affected by scaphoid nonunion fractures. Treating patients with scaphoid nonunion fractures can be challenging fo ...

Fractures of the distal radius are among the most common traumatic injuries, representing nearly 20% of all fractures seen in emergency departments and occurring in a bimodal age distribu ...

The Galeazzi fracture pattern was first described by Sir Astley Cooper in 1822.1 However, the fracture bears the name of the Milanese surgeon, Ricardo Galeazzi, who in 1934 reported on 1 ...

The boxer's fracture is a fracture of the neck of the fifth metacarpal. Among the most common traumatic injuries of the hand, this fracture accounts for approximately 10% to 20% of all hand fractu ...

Metacarpal fractures represent 30% to 50% of hand fractures.1 Deformation of the metacarpals due to fracture may significantly impair the function of the hand. The consequences of a poor ...

The term jersey finger describes an injury that occurs when the flexor digitorum profundus (FDP) tendon is avulsed from its insertion on the base of the distal phalanx. This is an uncommon injury, ...

Subtalar dislocations most commonly occur with the foot dislocated medially with respect to the ankle. Less commonly, lateral dislocation occurs. Inversion causes medial dislocation, while eversion ...

Achilles tendon rupture can be a debilitating injury that results in significant loss of function if left untreated. Ruptures are generally associated with a gradual degeneration of the tendon prec ...

Ruptures of the Achilles tendon are common, and treatment options have evolved over the past two decades. The treatment of acute Achilles rupture is operative, followed by a carefully pre ...

The diagnosis of an osteochondral defect is often missed as patients are initially treated for an ankle sprain. Any patient with persistent intra-articular symptoms after treatment of an ...

The anterior tibial tendon is the primary dorsiflexor of the ankle. It has two main functions during the gait cycle. It contracts concentrically during the swing phase of gait to help clear the flo ...

Function of the peroneus longus Supports the arch Plantarflexes the first metatarsal Weak evertor of the subtalar joint We ...

An acute Achilles tendon rupture is commonly visible and palpable on examination (Slide 1). Patients experience an acute tearing sensation in the posterior leg, as if an object struck the ...

Stress fractures of the tarsal navicular are seen in young athletes who run and jump frequently. Patients experience dorsomedial foot pain that worsens with activity. Cavus feet and calca ...

The syndesmosis between the tibia and fibula at the ankle consists of five defined structures

Amputation in hand fractures is an extreme measure. While digits should not be wantonly amputated, it is a hollow victory to save a stiff, malaligned, painful, dysvascular, cold-sensitive ...

Upper extremity trauma accounts for 30% to 40% of all trauma to the locomotor system.1 Hand trauma comprises 28% of all upper extremity injuries. In the majority of cases, peripheral ner ...

May be difficult to diagnose, especially with crush injuries and calcaneus fracturesHard to differentiate pain from the fracture or crush from compartment syndro ...

Understanding the anatomy of the femur is important for successful management of femoral shaft fractures and related injuries of the thigh. The anatomy of the femoral diaphysis can be defined by ...

May be variable bone involvementMultiple bone (polyostotic disease)McCune-Albright syndromeMultiple bone lesions (Slide 1 and Slide 2) ...

Myxoma is an uncommon tumor of soft tissue...

Lipomas are benign fatty tumors, and are the most common soft-tissue tumor in adults...

First described in 1942,1 chondroblastoma represents approximately 1% of all benign bone lesions...

Tumor staging uses parameters such as histologic grade, anatomic location and size, and presence or absence of nodal or metastatic disease, to help categorize tumors...

Traumatic injuries of the thoracolumbar spine make up approximately 40% of all spine injuries. Up to 60% of spinal injuries occur between the T11 and L1 segments due to anatomic considerations deta ...

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Gaucher's disease is caused by an accumulation of glucocerebrosides (glucosylceramide) in macrophages. The specific enzyme deficiency is glucocerebrosidase (acid beta-glucosidase, lysosomal enzyme ...

Pain is common following lower extremity amputations. Approximate frequencies are...

Prescribing an above knee prosthesis is difficult. One concept is a “stance control decision tree.”...

Ambulation with a prosthesis following an amputation requires greater energy than the patient without an amputation...

The causes of upper extremity amputations (mechanism of original injury) varies from a region of the world to another. In Western Europe, common causes are...

Melorheostosis is a rare sclerosing dysplasia characterized by tissue contractures and hyperostosis in a linear pattern. The Greek root of the name means flowing wax. The etiology is unknown, but h ...

Fractures Tibia Femur Supracondylar humerus Both bone forearm ...

Paget disease of bone was defined in 1876 as a localized disorder of bone remodeling of unknown etiology. It is characterized by increased osteoclastic bone resorption and compensatory increased bo ...

Hemicorporectomy (translumbar amputation) is the removal of the bony pelvis, pelvic contents, lower extremities, and external genitalia by disarticulation of the lumbar spine due to diseases inoper ...

Remodeling disease caused by excessive osteoclastic activity Rarely diagnosed in patients younger than 40 years of age; most patients diagnosed after age 50

Schwannomas are benign nerve sheath tumors that arise from the Schwann cell and grow as eccentric masses on the nerve. These tumors can present as either small or large soft tissue masses. ...

Although back pain commonly occurs in adults, the incidence of back pain is less in children and adolescents. Children with scoliosis may develop back pain secondary to their spinal curve. Generally...

Chemotherapy drugs can be classified into three broad classes1: Directly damage DNA Alkylating agents, platinum compounds, anthracyclines Epipodop ...

External beam irradiation creates free radicals (oxygenation of water molecules). The free radicals damage the DNA. When the DNA cannot be repaired, cell death occurs.The dose of irradiation ...

Giant cell tumor (GCT) is a common benign tumor of poorly differentiated mononuclear cells. The cell of origin of this tumor is unknown. There can be confusion over the histologic picture of this t ...

Pigmented villonodular synovitis (PVNS) is a reactive lesionthat is a proliferation of the synovial lining of a joint. The synovialmembrane hypertrophies and patients present with recurrent atrauma ...

Sacral lesions include a spectrum of conditions. Two sets of differentials exist, one for patients younger than 40 years of age and the other for patients 40-80 years of age.

Synovial tumors and tumor-like lesions represent a distinct entity within soft tissue tumors. Joints, bursae, and tendon sheaths have the same type of synovial membrane. Therefore, tumors can devel ...

Neoplasms:AdamantinomaOsteofibrous dypslasi ...

Ewing's tumor is a primitive, small blue cell tumor that most commonly affects young patients. The exact cell of origin is not known. James Ewings believed that the tumor arose from endothelium wi ...

Sacrococcygeal chordoma is a rare neoplasm that arises from notochordal rests. The notochordal remnants are present in this midline of the spinal column so the malignant neoplasm is always based in ...

Adamantinoma is a rare tumor that has a predilection for the tibia. This lesion occurs primarily in young people (age 15 to 35 years) and affects males and females almost equally. In the Mayo Clini ...

Malignant fibrous lesions of bone are much less common than other malignant bone tumors, such as osteosarcoma and chondrosarcoma. There are three malignant fibrous lesions of bone: ...

Malignant fibrous lesions of bone are much less common than other malignant bone tumors, such as osteosarcoma and chondrosarcoma. There are three malignant fibrous lesions of bone: ...

Fibrous cortical defects and nonossifying fibromas arecommon lesions in children. These lesions are usually asymptomatic anddiscovered as incidental findings. Some studies have shown an incidence r ...

Clear cell chondrosarcomas are very rare. They are characterized by swollen, glycogene-rich clear cells, occurring usually in the femur, tibia, vertebrae, or pubis of adults. It is a slow-growing. ...

Dedifferentiated chondrosarcoma is a distinct type of chondrosarcoma that has a characteristic bimorphic histologic appearance. They are very high-grade malignant tumors with an unfavorable prognos ...

Chondrosarcomas are slow growing tumors and patients may note a long duration of symptoms (even up to years). The pain of a low grade chondrosarcoma is usually a dull ache which has less intensity ...

Refers to a group of soft tissue tumors with a storiform or cartwheel growth patternMost common adult soft tissue sarcomaMore common in men than wo ...

Other benign cartilage tumors, besides those mentioned in this section, are Ollier disease and Maffucci syndrome. Characteristics of Ollier disease include multiple enchondromatosis, us ...

Osteochondromas are benign cartilage tumors that arise from the surface of either a flat or long bone. Ostochondromas and enchondromas are the most common of all bone tumors. The tumor arises from ...

Chondromas are benign hyaline cartilage tumors. (Slide 1) When a chondroma is within the medullary cavity, the lesion is called an enchondroma. If a chondroma occurs on the surface of ...

Superficial (fascial) Plantar fibromatosis (Ledderhose disease) Palmar fibromatosis (Dupuytren's disease)

Synovial chondromatosis results when metaplasia of the subsynovial fibroblasts produces nodules of cartilage in the synovial membrane. ...

Malignant Malignant fibrous histiocytoma (MFH) Fibrosarcoma (FS) Liposarcoma Synovial sarcoma Epithelioid sarcoma ...

Location: Upper and lower extremities - 60% Thigh is most common location Specific tumors and site predilection ...

The common translocations that occur in bone and soft tissue sarcomas are presented below: Bone sarcomas Translocation ...

There are three different types of osteosarcoma that may occur on the surface of a bone rather then in the intramedullary cavity. The three tumors each have different names and clinical features:

There are three different types of osteosarcoma that may occur on the surface of a bone rather then in the intramedullary cavity. The three tumors each have different names and clinical features:

Osteosarcoma is the most common primary malignant mesenchymal bone tumor. Metastatic bone disease, myeloma of bone, and lymphoma are more common, but they are not mesenchymal bone tumors. There are ...

Malignant fibrous histiocytoma (MFH) is a pleomorphic sarcoma composed of a mixture of fibroblast-like myofibroblasts and histiocyte-like cells with no malignant osteoid.

Unlike osteoid osteoma, osteoblastoma does not have a limited growth potential. In the past osteoblastoma was called "giant osteoid osteoma." In contrast to osteoid osteoma which is very common, os ...

Osteoid osteoma is a distinctive small neoplasm that has a self-limited growth pattern. The tumor itself is a small nidus of osteoblasts and osteoid that are arranged in a haphazard fashion. ...

Multiple myeloma is a malignant plasma dyscrasia characterized by monoclonal gammopathy and a constellation of bone lesions, renal failure, anemia, and hypercalcemia. ...

Lymphoma of bone is a common malignancy that may affectpeople of all ages - young children, adolescents, young and old adults. Thepresentation of lymphoma may be insidious and nonspecific. The radi ...

The spine is the third most common site for skeletal metastases following the lung and liver, respectively. The spinal metastases most frequently originate from carcinoma of the breast, lung, prostate ...

Metastatic bone disease is a common problem that virtuallyevery physician must be aware. When a patient between the ages of 40 and 85 years presents with bone pain without an etiology, one must have ...

A 70-year-old man has a destructive lesion in his femur. While he is walking in the supermarket, he falls to the ground. He is brought to the emergency department in intense pain. His radiographs s ...

The RB (retinoblastoma gene) controls the checkpoint in regard to cells passing from the G1 (or G0 resting phase) into S or synthesis phase.One should remember that the RB gene is phosphoryl ...