Hyperguides
Bones, joints, movement and musculoskeletal care.
Plain radiographs may reveal posterior spurs and calcification in the distal extent of the tendon and bony overgrowth or cystic changes in the calcaneus consistent with chronic inflammation. Although we do not use MRI…
Plain radiographs may reveal posterior spurs and calcification in the distal extent of the tendon and bony overgrowth or cystic changes in the calcaneus consistent with chronic inflammation. Although we do not use MRI…
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 to the Achilles tendon occur due…
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 posterior fibula, the…
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 open repair occur in…
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 precipitated by a…
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 prescribed physical therapy program…
Achondroplasia is the most common form of skeletal dysplasia, with a prevalence of approximately 1 in 40,000 persons. Although it is transmitted as an autosomal dominant condition, at least 80% of patients with…
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 prone to injury. Most of…
Acromioclavicular joint injuries are among the most common shoulder injuries in contact sports. Fortunately, most sports-related acromioclavicular joint injuries are mild, requiring only symptomatic treatment. As the…
Avulsion fractures of the dorsal lip of the navicular account for about 50% of navicular fractures. The mechanism of injury is acute foot plantar flexion in which the talonavicular ligament and joint capsule pull off…
Avulsion fractures of the dorsal lip of the navicular account for about 50% of navicular fractures. The mechanism of injury is acute foot plantar flexion in which the talonavicular ligament and joint capsule pull off…
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 Clinic Series, the most…
Tutorial 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 frozen shoulder.…
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 occur. Delayed union is…
Introduction 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 lumbar spine has a…
The ball and socket configuration of the hip joint is inherently stable and allows excellent range of motion in all directions. The acetabulum lies between the anterior and posterior columns of the pelvis, and is…
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…
The radial nerve and profunda brachii artery follow the winding course marked by the radial groove. The medial border is defined by the lesser tuberosity to the medial supracondylar ridge while the lateral border…
segments also define the proximal path of the biceps tendon through the intertubercular or bicipital groove, a common site of shoulder pathology. Finally, the proximal humeral shaft provides insertions for deltoid,…
The bony anatomy of the ankle consists of articulations between the tibia and talus and between the fibula and talus. Although motion exists between the tibia and fibula at the ankle, no articular cartilage is present…
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 disease is an enthesopathy. The enthesis…
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 flexion) and posterolateral bundle (tight…
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 of total hip…
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 that are classified under the term…
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 debridement to…
Articular Cartilage Characteristics Hypocellular Avascular Alymphatic Structure and Function Three zones - Chondrocyte density is highest in the superficial zone Superficial or tangential zone Chondrocytes are flattened…
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 an improved ability to diagnose…
Non-traumatic 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 many as 20% of trisomy…
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 like Legg-Calv-Perthes…
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 lymphatic and venous…
Back pain is the fifth most common cause for a medical visitation. Back pain is benign in most patients; only a select group of patients require further work-up and treatment. Annually, back pain is accountable for more…
Structure Osteoblasts are never found individually; they form clusters of cells on the bone surface. Osteoblasts are active cells with an eccentric nucleus that is on the opposite side of the bone surface. A prominent…
More than 90% of hand and wrist masses are benign soft tissue tumors.1 Tumor size, location, mobility, color, and texture provide clues to diagnosis. Biopsy is the only means for a definitive diagnosis.
The association between secondary osteoarthritis of the hip and residual acetabular dysplasia in early adulthood has been reported previously.1 The main cause of osteoarthritis is believed to be increased joint contact…
Biceps Tendinitis and Rupture 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…
The sagittal T2-weighted magnetic resonance image (MRI) in Figure 1 shows complete disruption of the distal biceps tendon with 3.5- cm retraction proximal to the radial tuberosity attachment. A small high T2-signal…
After reviewing the tutorial, the surgeon should be able to understand the following concepts related to the topic of biomaterials in orthopedic surgery.
The structural strength of bone is related to its mass and distribution of that mass including the bone diameter power relationship with torsional/bending strength. Bone mass is related to axial strength and…
Blood management in orthopedic surgery today consists of allogenic transfusions, autologous blood, intra- and postoperative blood salvage, and erythropoietin alpha.1 In my experience, intraoperative salvage is never…
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 decreases when children…
Cartilaginous tumors are the second most common class of primary bone tumor,1 and the most common primary bone tumor of the upper extremity.1,2 Histologically, cartilaginous tumors contain some form of hyaline…
Bone augmentation is an attempt to solve the problem of bone stock deficiency. This deficiency can be the result of trauma, tumor, infection, non-union.
Autologous bone is the gold standard grafting material for spinal fusion.1 Despite its success, however, autologous bone is associated with defined morbidities. Alternatives/adjuncts, such as bone marrow aspirates, have…
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 orthopedic surgeon to have a…
Tutorial 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 finger where the PIP…
Tutorial 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 finger where the PIP…
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 roots, neuroma-in-continuity, or a combination…
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, blue towels are used to…
Treatment options for fractures of the os calcis include ice and elevation, followed by early range of motion. Non-weightbearing is maintained until the fracture is healed. This treatment is recommended for nondisplaced…
Etiology 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 commonly occurs in the…
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 prerequisite when…
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 prerequisite when…
Carpal tunnel syndrome (CTS) is a median neuropathy emanating at the wrist level. In the 1950s, George S. Phalen, MD, categorized the clinical signs and symptoms of CTS1,2 — which has become the most commonly diagnosed…
Following review of the material below, the orthopedic surgeon should have an understanding of the normal response of cartilage to injury, and the range of techniques in use or under investigation for the treatment of…
Cavus foot presents as a neuromuscular disorder in 2/3 of patients; 1/2 have Charcot-Marie-Tooth-Disease.
Cemented femoral component and cement removal in revision total hip arthroplasty occupies a substantial portion of surgical time, even for a well-prepared surgeon. A variety of tools and techniques are available to…
Approximately three-quarters of patients who undergo THA are revised due to aseptic loosening caused by the release of submicron particulate debris from the bearing surfaces and subsequent host reactions within the…
Debris-associated osteolysis is the most common cause for revision total hip arthroplasty (THA) when polyethylene is used. Cross-linked polyethylenes show some promise but raise more questions. New polyethylenes are…
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 element of rotation.…
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 supine, the neck will…
A fracture of the odontoid process is the most common injury to the second cervical vertebrae. It constitutes 10% to 15% of all cervical spine fractures. It is usually precipitated by a blow to the vertex of the skull.1…
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 performed in Minnesota…
The diagnosis of CMT is made by physical exam, family history, and ancillary tests. The tests include electromyography (EMG), nerve conduction velocity (NCV), and muscle and peripheral nerve biopsy. The patient may…
Sacrococcygeal chordoma is a rare neoplasm that arises from notochordal rests. The notochordal remnants are present in the midline of the spinal column so the malignant neoplasm is always based in the center of the…
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 subcompartments. Exercise-induced…
The precise definition of biceps tendinitis remains elusive. Biceps tendinitis can be further delineated on the macroscopic level into tendinitis and tenosynovitis. Tendinitis represents an alteration in the structure…
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 instability can take the form of…
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 instability can take the form of…
Clavicle fractures are not difficult to diagnose. Patient history and physical examination are supported by plain radiographs.
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. Only after multiple…
Kenneth D. Brandt, MD Clinical Professor of Medicine University of Kansas Medical Center Kansas City, Kansas The patient, a 68 year old housewife and avid gardener who has been married for 38 years to a malpractice…
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 are common. No other…
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 of anatomical…
Clubfoot is a common and controversial foot deformity. Clubfoot is classified as congenital depending upon neuromuscular aspects, hereditary factors and arrested fetal development. Teratologic classification is the…
By definition, a compartment syndrome occurs when there is severe swelling in a closed compartment such that the tissue pressure within the compartment rises to a level that impairs the perfusion of both muscle and…
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, oftentimes associated with…
Congenital Kyphosis (CK) is uncommon. It is frequently severe and can produce deformity, reduced pulmonary function and paraplegia. Unfortunately, few physicians are aware of its devastating potential. Early treatment…
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 pseudarthrosis is typically on the…
Congenital synostosis of the proximal radius and ulna represents a failure of longitudinal segmentation during intrauterine development. Present at birth, the deformity becomes obvious in early adolescence as the…
The term biomaterials is generally used to refer to synthetic materials used temporarily or permanently to augment or replace tissues and their functions. However, the most important biomaterials are the body's natural…
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 prerequisite when…
An adult-acquired flatfoot deformity is associated with rupture of the posterior tibial tendon (Slide 1). Occasionally, exacerbation of a preexisting and longstanding flatfoot deformity may be present or a rupture of…
Developmental coxa vara is characterized by an ossification defect in the inferior portion of the femoral neck adjacent to the subcapital growth plate. There is an associated decrease in the angle between the…
Eversmann. Entrapment and Compression Neuropathies: Operative Hand Surgery. 3rd ed.; Green DP, (ed.); New York, NY:Churchill Livingstone 1993.
Eversmann. Entrapment and Compression Neuropathies: Operative Hand Surgery. 3rd ed.; Green DP, (ed.); New York, NY:Churchill Livingstone 1993.
When choosing a treatment method for patients with ankle arthritis, physicians must obtain a thorough knowledge of patients' activity level, interests, athletic activities, occupation, and physical needs. These factors…
De Quervain disease is a stenosing hypertrophy of the retinaculum over the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons in the first dorsal compartment of the wrist.
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 prognosis. Dedifferentiated…
The posterior cruciate ligament (PCL) is saved approximately 60% of the time and substituted 40% of the time. When substituting, a more conforming, deep-dish polyethylene can be used.
Many physicians believe that degenerative disk disease is the most common cause of chronic, disabling low back pain (also know as diskogenic pain or internal disk disruption).1,2 In patients with degenerative disk…
Adult scoliosis can be loosely divided into two categories - either an extension of a preexisting scoliosis, such as adolescent idiopathic scoliosis, or a de novo scoliosis, also known as senescent scoliosis or adult…
The term spondylolisthesis comes from the concatenation of two Greek words - spondylo (vertebra) and olisthesis (slipping). In the lumbar spine, spondylolisthesis is classified into several types according to the system…
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 prerequisite when…
Intermediate to long-term reports of posterior stabilized total knee replacement (TKR) have demonstrated durable results with excellent function at 10- to 15-year follow-up.1,2 In addition, fluoroscopic kinematic…
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 vertical orientation than…
A neuroma of the foot, often referred to as a Morton's neuroma, is a condition that is more commonly found in women than in men and in patients with mild hypermobile pes planus. Patients with increased stress on the…
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, spine, joints, and feet of…
Distal biceps tendon tears are uncommon injuries that typically occur in active, middle-aged men. The tears are most often traumatic in etiology and result from forced extension or pronation of a flexed and supinated…
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 fractures). This article…
Introduction Dupuytren contracture is a progressive fibromatosis of subcutaneous palmar connective tissue leading to the development of flexion contractures of the hand. The structures involved in this disease are the…
Introduction Dupuytren contracture is a progressive fibromatosis of subcutaneous palmar connective tissue leading to the development of flexion contractures of the hand. The structures involved in this disease are the…
Dupuytren's disease is a condition of the hand that is characterized by tissue neogenesis in the form of nodules and cords. The disease tissue is comparable to the tissue found in benign neoplastic fibromatosis, but it…
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, is hyperelasticity of the skin.…
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 accidents (transport-related…
Introduction The elbow is made up of three articulations in one common synovial cavity: the ulnohumeral (ulnotrochlear) joint, the radiohumeral (radiocapitellar) joint and the proximal radioulnar joint. The ulnohumeral…
Incidence and Epidemiology Arthrodesis of the elbow is a rare procedure. Hallock in 1932 was one of the first surgeons to report on a technique for elbow fusion. Historically, most of the reported cases have been done…
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 mechanism: hyperextension of the elbow…
Incidence and Epidemiology Dislocations of the elbow usually result from a fall onto the outstretched extended elbow. Simple elbow dislocations have no associated fracture and are classified according to the direction…
Infections of the upper extremity are common in children (Slide 10). These problems are challenging to diagnose. The history is often unreliable and physical examination is sometimes difficult to interpret, especially…
Chondromas are benign hyaline cartilage tumors. When a chondroma is within the medullary cavity, the lesion is called an enchondroma. If a chondroma occurs on the surface of the bone, it is called a periosteal…
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 the bone, it is called a periosteal…
Review of this tutorial material should allow the orthopaedic surgeon to have an understanding of the structure and function of the epiphyseal growth plate, its regulation, and the biochemistry of the overall process 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 encase the scapula and provide dynamic…
Tutorial The elbow joint is a trochoginglymoid joint providing both flexion and extension through an ulnohumeral hinge and axial rotation through a radiohumeral and proximal radioulnar pivoting motion (trochoid). Normal…
The thoracic spine consists of 12 vertebrae, and represents the largest segment of the spine. As surgical approaches and internal fixation techniques in the spine continue to evolve, a thorough knowledge of the…
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 knowledge of the…
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 discusses the evaluation…
In the 1980s, excellent 10-year results were reported from numerous centers that used the so-called "second-generation cement technique." This consisted of using a canal plug, a doughy high-strength cement, a cement gun…
Ewing tumor is a primitive, small blue cell tumor that most commonly affects young patients. The exact cell of origin is not known. James Ewing believed that the tumor arose from endothelium within the osseous system.…
External fixation has been used to treat fractures for more than 130 years. External fixation was first reported in 1853 by Malgaigne, who described using an external claw device to treat patellar fractures. In the 21st…
Distal femurs come in a spectrum of sizes and shapes. Inventory management demands a finite number of proportional sizes to be available. Most systems have at least six full sizes and a variable number of half sizes.…
Femoral neck stress fractures must be diagnosed early for patients to have a successful outcome. Diagnosis is based upon history, physical examination, and imaging modalities.
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 the shape of the…
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 are common lesions in children. These lesions are usually asymptomatic and discovered as incidental findings. Some studies have shown an incidence rate as high as…
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 terminal deficiency if the foot is…
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 plate, overlies the nail bed, which…
Introduction 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 and disabling…
Introduction 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 and disabling…
Most fractures of the tibial diaphysis can be managed with functional bracing. Many fractures, however, require operative stabilization. Grade III open fractures are unstable and require fixation. Closed fractures and…
Flatfoot, or calcaneovalgus deformity, is the most common neonatal foot deformity. The foot is positional and flexible, but has limited plantarflexion secondary to contracted dorsiflexors. Most treatments for flatfoot…
The bony anatomy of the foot can be divided into the hindfoot, midfoot, and forefoot. The hindfoot consists of the talus and calcaneus, which articulate at three facets, the posterior being the largest. The…
Anatomy and Biomechanics 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…
The majority of injuries involving the scapula are due to high-energy trauma, most often motor vehicle accidents.1-8 Examples of specific injuries include scapulothoracic dissociation,1,2,6,7 scapular fractures,3,4,8-12…
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 or functionally…
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 articular surface of the…
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 as associated thoracic rib…
Frostbite, by definition, is freezing and crystalizing of fluids in cells and tissues due to prolonged exposure to freezing temperatures (-10° C).
A new era of orthopedic surgery has been marked by gene therapy, an approach that provides options for treating patients with orthopedic conditions. Orthopedic surgeons must understand the terminology, fundamental…
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 may also be used to…
There are two main types of biopsy: needle and open. Needle biopsy is performed with either a fine needle or a core biopsy needle. The goal of fine needle aspiration is to obtain enough cells to allow a diagnosis. The…
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 tumor, as both benign…
(Note: In patients with rheumatoid arthritis, the erosions are beside the joint, the joint space is narrowed, and osteopenia is present. The clinical presentation of rheumatoid arthritis is the exact opposite of that of…
Hallux rigidus is a common clinical condition associated with pain in the hallux metatarsophalangeal (MP) joint and limited range of motion, particularly dorsiflexion.
For mild deformity, (i.e., HV with an intermetatarsal angle of equal to or less than 13 degrees and HV angle less than 30°), a distal metatarsal osteotomy with or without a distal lateral soft tissue release may be…
For mild deformity, (i.e., HV with an intermetatarsal angle of equal to or less than 13 degrees and HV angle less than 30°), a distal metatarsal osteotomy with or without a distal lateral soft tissue release may be…
A study of juvenile hallux valgus¹ found the foot deformity of 9 out of 10 females (average age 11.8 years; 40% < 10 years old). Maternal transmission was noted in 75% of the cases. One-half of the population had an…
Either a fusion or resection arthroplasty should be performed in patients who have arthritis at the MP joint. If a patient has a fixed deformity of the hallux IP joint, then the only possible correction of the IP joint…
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 head of the biceps…
A mechanism contributing to the growth and development of the hand is that pluripotent mesenchymal cells differentiate. The cell population size increases by mitosis and the intracellular structural protein is…
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 intratendinous or intraosseous.…
Animal bites are one of the most common sources of infection in the child's hand. These wounds are treated by a combination of antibiotic therapy, irrigation, debridement and open-wound management. Pasteurella multocida…
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 with hemophilias A and B…
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 Barr in 1934 showed that herniated…
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 many different types…
Hip fusion remains an important but often overlooked option for selected patients with unilateral hip disease. This article considers the indications for hip fusion and current reconstructive practice and describes the…
Homocystinuria is an inborn error of metabolism in which the enzyme cystathionine -synthase is deficient.1,2 As in the majority of enzyme deficiencies, homocystinuria is an autosomal recessive disorder because even half…
Hyperparathyroidism is a condition which is caused by excessive amounts of parathyroid hormone (PTH). The primary etiologies of hyperparathyroidism are, in decreasing order, adenoma, hyperplasia and cancer. Secondary…
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 using a Cobb angle of 20° or greater is 0.3%. There is an…
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, infectious organisms likely to infect…
Internal impingement, or posterosuperior glenoid impingement, is the contact that occurs between the greater tuberosity and the posterosuperior aspect of the glenoid rim during abduction, external rotation, and…
Osteoarthritis of the Knee1,2 Randomized trials have shown a significant benefit of corticosteroid injection over placebo at 1 to 3 weeks (in various studies). Using pain as an outcome measure, the benefit is not…
Osteobiologics is the study of bone formation and turnover. Clearly, this has direct relevance to orthopedics in general. Spinal applications are becoming better understood.
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 upon the manifestations of the…
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 examined medical records of 1240…
The mechanical properties of an external fixation frame, used to treat any bone defect, determine the biomechanical environment in the healing bone gap.1-11 Mechanical properties of various external fixators have been…
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 this condition has been…
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 this condition has been…
Also known as congenital cervical synostosis, Klippel-Feil syndrome is a rare syndrome characterized by cervical fusion and multiple congenital malformations. One of the major clinically apparent deformities of this…
The knee joint is the largest joint in the human body. It has a single cavity with three articulations:
The stability of the knee is imparted by ligaments, bony anatomy and menisci, and dynamic structures crossing the knee. The major ligaments include the anterior cruciate ligament (ACL), posterior cruciate ligament…
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 plateau is convex. It is…
The lateral ligamentous complex is composed of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). The ATFL consists of two bands and blends with…
Tutorial Overloading conditions can adversely effect a tendon structure via chronic microtrauma. These conditions often manifest histologically as the degeneration of collagen fibers (tendinosis) and often exist without…
Lateral epicondylitis is commonly referred to as tennis elbow, although the condition is caused by a variety of sports- and work-related activities and more frequently affects non-athletes.1 Lateral epicondylitis was…
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 involving the origin of the common…
Lateral condyle fractures are some of the more problematic fractures seen in children. This may be because the lateral condyle is mostly cartilaginous and the innocuous initial appearance of the injury may lead to late…
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 posterior talocalcaneal…
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 posterior talocalcaneal…
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 and coxa plana.…
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 metatarsal bases, yielding…
Anatomy and Biomechanics Repetitive forces applied to the growing elbow may adversely affect the normal development of the elbow joint at multiple sites medially, laterally or posteriorly. The primary factor in the…
Locking plates are a popular method of internal fixation. Locking plates are most often used as a bridging plate in fractures with bone loss and short articular fragments.
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 than a patient with…
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 sciatica). This pathologic…
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 until the 1950s when it…
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 herniated intervertebral disk and…
Plain radiographs, myelography, computed tomography (CT) and magnetic resonance imaging (MRI) are the core imaging modalities used in the evaluation of the lumbosacral spine. Despite the increased sophistication and…
Plain radiographs, myelography, computed tomography (CT) and magnetic resonance imaging (MRI) are the core imaging modalities used in the evaluation of the lumbosacral spine. Despite the increased sophistication and…
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 characterized by five robust…
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, although an exact correlation…
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 herniated intervertebral disk and…
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 of the body as well…
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 of the body as well…
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 degeneration,…
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 characterized by five robust…
Spinal infections may involve the vertebral body (vertebral osteomyelitis), the intervertebral disc (infectious discitis), or the spinal canal and its contents (spinal epidural abscess). Vertebral osteomyelitis is…
Spinal infections may involve the vertebral body (vertebral osteomyelitis), the intervertebral disc (infectious discitis), or the spinal canal and its contents (spinal epidural abscess). Vertebral osteomyelitis is…
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 spirochete Borrelia burgdorferi. The…
Lymphoma of bone is a common malignancy that may affect people of all ages - young children, adolescents, young and old adults. The presentation of lymphoma may be insidious and nonspecific. The radiographic changes in…
Macrodactyly, which is a rare anomaly of the upper extremity, has also been referred to as megalodactyly, overgrowth, gigantism, localized hypertrophy, or macrodactylia fibrolipomatosis (Slide 1).
Tutorial 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 wrist and…
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:
Weiss SW, Goldblum JR. Malignant fibrohistiocytic tumors. In: Enzinger & Weiss’s Soft Tissue Tumors. 4th ed. Chicago, Ill: Mosby; 2001:535-570.
Malignant tumors comprise 1% to 2% of all hand tumors and are most common in middle-aged and elderly patients.1,2 A multidisciplinary approach involving an orthopedic surgeon, radiologist, pathologist, and radiation…
The term mallet finger describes a spectrum of injuries that are related to loss of continuity of the conjoined lateral bands at the distal joint of the finger, leading to the characteristic deformity where the distal…
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 history and examination must be…
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 necessary to have a…
Extensor mechanism disruption is among the most feared and devastating complications of total knee arthroplasty (TKA). In the past, generally poor treatment results of this complication have led to the conclusion that…
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 some of the manifestations of…
A 59-year-old woman with a 36-year history of leprosy was referred to the clinic by the community physician because of a spreading ulcer on the right foot that failed to heal despite medical treatment (Slide 1, Slide 2,…
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 portion, the posterior…
Introduction The medial epicondyle is the last secondary ossification center to fuse with the distal humerus. This fusion occurs at approximately 15 years of age.1 The epicondyle is posteromedially placed on the distal…
Tutorial Patients complaining of medial epicondylitis describe aching pain in the flexor musculature arising from the medial epicondyle. Often wrist flexion or pronation against resistance can elicit symptoms. The…
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 epicondylitis is a pathological…
Since the work of Zuppinger1 and the treatise published by Strasser,2 orthopedists and engineers who designed total knee prostheses believed human knee motion was guided by the cruciate ligaments acting in a crossed…
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 result of a twisting injury to the…
The importance of the meniscus has changed over time. It has been looked upon as a vestigial remnant of no functional importance, but now is known to be a vital contributor to the long-term maintenance of knee function.…
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 into fractures of the…
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 than it is dorsally…
Metasul (Sulzer Orthopedics Ltd, Baar, Switzerland) has been used for 13 years in Europe. Presently, more than 150,000 Metasul articulation surfaces are implanted worldwide. With changes that have occurred in…
Metastatic bone disease is a common problem that virtually every 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 metastatic bone…
Pain is followed by weakness of the lower extremities, sensory loss and bladder and bowel changes. Complete paraplegia may be the final sequence of thoracic metastatic disease. In patients whose paraplegia develops…
Pain is followed by weakness of the lower extremities, sensory loss and bladder and bowel changes. Complete paraplegia may be the final sequence of thoracic metastatic disease. In patients whose paraplegia develops…
Jaffe estimated that more than 70% of patients who die from cancer have skeletal metastases that often involve the spine.1 The spine is the most common site for metastases within the skeletal system. Management requires…
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 associated with…
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 metatarsal. The main…
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 anterior cruciate ligament (ACL) in skeletally…
Knee joint replacement is one of the most successful operations in orthopedic surgery. Over 95% of patients have excellent relief of pain, good mobility, and the ability to return to most of their normal activities of…
Although surgeons' understanding and techniques have improved significantly over the past 30 years, flexor tendon repair continues to be challenging and unpredictable outcomes often ensue. For many years, surgeons…
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 dislocates in the direction…
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, or insensate digit that…
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 been stimulated by a…
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-navicular coalitions are…
Compression neuropathy of the radial nerve is much less common than in the ulna or median nerves. Five distinct clinical syndromes have been described.
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 chromosome 22 and occurs in…
Non-traumatic disorders of the sternoclavicular (SC) are numerous and include non-traumatic subluxation, arthritis, and infection. Spontaneous, congenital, or developmental dislocation have all been reported and are…
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 of weight loss,…
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., head trauma or alcohol intoxication) or…
Introduction Fractures of the olecranon process are uncommon in children. When they do occur, it is usually the result of a fall. Olecranon fractures occur at a slightly older age than supracondylar fractures (9 years)…
Other benign cartilage tumors, besides those mentioned in this section, are Ollier disease and Maffucci syndrome.
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, osteoblastoma is…
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-inversion injuries. They are usually…
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 avascular. The overlying…
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 aberrant foci of…
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. Manifestations depend on the…
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.
Rickets (youth) and osteomalacia (adult) result from the failure to mineralize epiphyseal cartilage, which increases the hypertrophic zone, and bone, which decreases the mineralization rate and increases unmineralized…
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 septic infarction of bone…
Osteoporosis is the most common metabolic bone disease and is characterized by low bone mass and microarchitectural deterioration of the bone tissue. A normal mineral:collagen ratio is present in osteoporosis, whereas…
Cortical bone has high volume and low surface area. Trabecular bone has low volume and high surface area.. External modeling occurs when the increase in periosteal diameter and the endosteal diameter is greater than the…
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 bone formation resulting…
Lytic phase The lytic phase is the initial phase of Paget's disease and is characterized by intense osteoclastic bone resorption. Radiographs show purely lytic involvement of the bone. There is often expansion with…
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.1 The infection rate is…
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:
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), which is in the second layer, is the major…
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, "jumper's knee," which is generally felt…
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 adequate spontaneous respirations. With…
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…
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…
The anterior compartment of the lower leg (Slide 1) 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…
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:
Unlike central nervous system nerves, peripheral nerves are capable of regeneration, given the appropriate environment.
Both muscles arise from the posterior fibula proximally and course down the lateral aspect of the leg contained by common synovial sheath to enter a fibro-osseous tunnel on the posterior aspect of the distal fibula. The…
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 can be treated with…
Fractures of the phalanges are very common. When first evaluating a patient, it is important to note age, hand dominance, occupation, other associated medical problems, and the mechanism of injury. A thorough physical…
Distal humeral physeal fractures are most common when the epiphysis is largely cartilaginous. Therefore they occur most often in the very young child but may be seen in children up to 6 years of age. Physeal fractures…
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 operative management to limit the…
The mechanical functions of bone are to provide stability and mobility to the musculoskeletal system and protection to the vital organs. The mechanical properties of bone depend on the structure and composition of the…
Pigmented villonodular synovitis (PVNS) is a reactive lesion that is a proliferation of the synovial lining of a joint. The synovial membrane hypertrophies and patients present with recurrent atraumatic effusions. The…
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. Most injuries are related…
The evolution and selection of femoral fixation in primary total hip arthroplasty (THA) has moved toward biological fixation with immediate stability and ingrowth of the implant. Concerns with the use of cementless…
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…
Early in the development of modern, surface total knee replacement (TKR) the prostheses were intended to function with either retention of the posterior cruciate ligament (PCL) or after removing the PCL. With the…
With the patient sitting, palpation of the posteromedial aspect of the ankle may identify edema and tenderness along the PTT. Manual testing of tendon strength is performed by asking the patient to simultaneously…
The posterolateral corner of the knee is composed of the iliotibial band, biceps, lateral collateral ligament (LCL), popliteus, fabellofibular ligament, popliteofibular ligament (PFL), arcuate ligament, coronary…
Preoperative planning is important in revision total knee replacement (TKR). Revision TKR can be a challenging experience for all involved. Multiple implant options include cemented and cementless primary and revision…
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 deficiency in the majority of…
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 than 90% occurred in people older…
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 and generally heal with…
While most fractures of the proximal humerus are minimally displaced and can be treated nonoperatively,1-6 severely displaced fractures and fracture-dislocations require operative treatment. Early surgical options…
Introduction The median nerve is formed by the anterior divisions of the lateral and medial cords. It travels down the arm adjacent to the brachial artery just anterior to the medial intermuscular septum and posterior…
Introduction The median nerve is formed by the anterior divisions of the lateral and medial cords. It travels down the arm adjacent to the brachial artery just anterior to the medial intermuscular septum and posterior…
Spinal cord compromise can result from direct compression of epidural abscess, granulation tissue, or destroyed disk fragments, and caused by collapsed vertebral body. Ischemia may aggravate spinal cord damage as a…
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 hematogenous spread of bacteria from…
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 deep portion of muscle…
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 post-axial. Radial club hand is…
Compression neuropathy of the radial nerve is much less common than in the ulna or median nerves. Five distinct clinical syndromes have been described.
The radial nerve is a continuation of the posterior cord of the brachial plexus as the axillary nerve branches off. The radial nerve receives contributions from the C5-C8 posterior divisions. In the axilla, the radial…
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 centers appear thereafter in a…
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 excellent union rates with…
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 rarely occurs after skin…
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 forces such as muscular…
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 involvement of the other rotator cuff…
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 from macrotrauma,…
Hip fractures that fail to heal typically cause marked pain and profound disability. Effective strategies to salvage these difficult problems are important. Treatment of failed hip fractures is divided by fracture…
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 annual incidence of 35,000…
Patients with scaphoid fractures are commonly affected by scaphoid nonunion fractures. Treating patients with scaphoid nonunion fractures can be challenging for physicians. Many patients with scaphoid fractures have…
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 incidence in males and a…
Written by William F. Harvey, MD, MSc, FACR A 58-year-old man with ongoing joint pain and swelling The patient is a white man aged 58 years who is newly referred to a rheumatology practice for ongoing management of his…
A Segond fracture is an avulsion injury of the lateral proximal tibia that was first described by the French surgeon Paul Segond in cadaveric experiments in the late 19th century.1-5 The avulsion fracture occurs caudal…
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 delayed. Timely diagnosis by…
Anatomy and Biomechanics Development The shoulder joint 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 joint. The…
In 1982, Charles Neer II, MD introduced the concept of “limited goals” when treating patients with glenohumeral arthritis and a deficient rotator cuff.1 This concept illustrates the therapeutic challenge represented by…
Slipped upper femoral epiphysis (SUFE) is the posterior displacement of the femoral capital epiphysis on the femoral neck through sudden or gradual deformation of the subcapital growth plate. Body habitus and structural…
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 is not necessarily expected as a result of…
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, slowly growing mass.…
Frassica FJ, McCarthy EF. Orthopaedic pathology. In: Miller MD, ed. Review of Orthopaedics. Philadelphia, Pa: W.B. Saunders; 1996:292.
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 decreased incidence of…
Heary RF, Vaynman AY. Spinal cord injury and paralysis. In: Orthopaedic Surgery Essentials Spine. Bono CM, Garfin SR, eds. Philadelphia, Pa: Lippincott Williams and Wilkings; 2004:58-62.
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 younger than 30 years…
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 illness within a few years…
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 whose spine is compromised due to…
Core knowledge1 The normal range of degrees of thoracic kyphosis is 20° to 50°. The mean in normal adults is 35°. The normal range of degrees of lumbar lordosis is 40° to 80°. The mean in normal adults is approximately…
Spondyloepiphyseal dysplasia congenita has a prevalence of approximately 3 to 4 per 1 million. Its central features include significant spinal and epiphyseal involvement without metaphyseal enlargement. Although…
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. Separation of a spondylolysis leads to subluxation of the…
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 radiographic features - from a minimal…
The diagnosis and treatment of sports-related injuries and damages are increasing in significance for clinicians. This is due to the considerable increase in the number of individuals playing sports and the resulting…
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 of the scapula…
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 repetitive and prolonged gripping…
Sternoclavicular joint injuries are rare occurrences in both the athletic and general population. The stability of the sternoclavicular joint relative to other joints of the shoulder girdle contributes to the rarity of…
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 midface hypoplasia, hearing loss, retinal…
Tutorial The elbow is prone to develop stiffness as a result of its high degree of joint congruity. The surrounding tissues also play a role in elbow stiffness. Both the close continuity of the capsule to the overlying…
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 mechanical phenomenon resulted in…
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 results in lateral…
Labrum 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 and hyaline cartilage of the…
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 incidence in children 5 to…
Supramalleolar osteotomy is traditionally used to correct distal tibial deformity secondary to injury, growth disturbances after physeal injury, and paralytic conditions, primarily in children. Recently, however, distal…
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. It then courses beneath the…
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 related sports such as…
The evaluation of a patient with a cavus or cavovarus foot begins with reviewing the patient’s history. Frequently, patients are unaware of a cavus foot and may present for a manifestation of a hereditary sensory motor…
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 either intramedullary or…
The answers to these questions will help a surgeon determine the best operative approach. Surgeons should never sacrifice a part of or the entire peroneal tendon in athletes (i.e., gymnasts and ballet dancers) who use…
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. Initially, this is a flexible…
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. Initially, this is a flexible…
Syndactyly, derived from the Greek syn meaning together and dactylos meaning digit, defines a deficiency of the interdigital web space. Syndactyly may be either complete, in which the interdigital web extends the entire…
Synovial chondromatosis results when metaplasia of the subsynovial fibroblasts produces nodules of cartilage in the synovial membrane.
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 humerus are the most…
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 originally described, in airplane…
Tarsal coalition presents as painful hindfoot, with limited motion, usually in valgus position, and often with protective peroneal spasm. Differential diagnosis includes: tarsal coalition, inflammation (osteochondroses,…
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 misdiagnosed. The mechanism of the…
Tears of the subscapularis tendon are less common than other types of rotator cuff tears. Tears of the subscapularis tendon occur secondary to traumatic insults in patients who are younger than 50 years old, whereas…
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 precipitated by a…
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 stride lengths. .
Diabetes mellitus is the most common metabolic disorder in the Western hemisphere. Diabetes mellitus affects approximately 5% to 8% of Caucasians. It is estimated that for every known patient there is another patient…
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 (flexion balance) is a…
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 primary function of the PCL…
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 as 60%.1 A number ofstudies…
Historically, there has been limited treatment options available for diseases that affect the cartilage, bone, or synovium in the hip joint. Nonoperative treatment may result in persistent symptoms whereas open…
Performing subtalar arthrodeses was advocated primarily for treating foot deformities and secondarily for treating injuries and paralysis (poliomyelitis). In 1943, Leavitt performed subtalar arthrodeses on patients with…
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, especially at the upper and…
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, fulminant…
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 compressive neurovascular disorder…
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 detailed below.1,2 Perhaps…
Differences in the presentation and treatment of spinal fractures exist among thoracic, thoracolumbar, and lumbar spine regions because of the differing biomechanical properties and neuroanatomy of the areas.…
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 flexion-extension at the MP…
For partial TH, such as type 2, it may be possible to fuse the proximal tibia and fibula and perform a Syme's amputation for an unstable foot and ankle.
Degenerative arthritis of the ankle joint, whether idiopathic, traumatic, or from a systemic process, presents a significant orthopedic problem. One of the most important clinical issues today is surgical…
Tutorial Implant arthroplasties of the elbow are designated as constrained, semi-constrained, and unconstrained. The differentiation is based on the rigidity of the fixation of the humeral component to the ulnar…
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 need to be ruled out:…
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 joint cartilage, and the…
The treatment of hallux valgus is determined by specific principles that include the age and activity level of a patient, the extent of the deformity, the presence of arthritis in the hallux metatarsal phalangeal joint,…
Periprosthetic fractures about total knee arthoplasty (TKA) are relatively rare (0.5% to 3%). The most common periprosthetic fracture about TKA is the supracondylar fracture. It is an infrequent injury; however, the…
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 pre-axial. Ulnar club hand is a…
Sensory loss extends distally to the underneath of the little finger and to the ulnar-volar aspect of the ring finger. There is also sensory loss proximally in the ulnar-dorsal aspect of the palm and the back of the…
Sensory loss extends distally to the underneath of the little finger and to the ulnar-volar aspect of the ring finger. There is also sensory loss proximally in the ulnar-dorsal aspect of the palm and the back of the…
Fracture healing1 Primary (osteonal) fracture healing occurs with rigid plate fixation. Osteoclasts cut a path across the osteosynthesis site and blood vessels and osteoblasts fill in the gap with new bone. Occurs with…
Avascular necrosis (AVN) of the femoral head is a progressive, crippling syndrome for which no widely accepted treatment is available. Avascular necrosis is associated with a variety of both traumatic and nontraumatic…
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 neural compromise has occurred.…
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 incision, understanding…
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