Chapter 40

Orthopedic surgery has evolved substantially during the last decade. Improvements in implant design and materials have been responsible for significant advances in our ability to treat patients with complex orthopedic problems. Like all medical fields, orthopedic surgery has become a group of subspecialized fields in recent years. This chapter reflects this trend, divided into the following sections: Orthopedic Trauma: Fractures & Joint Injuries, Pediatric Orthopedics, Sports Medicine, Joints, Orthopedic Spine, Orthopedic Oncology, and Foot & Ankle.

Varus and valgus are frequently used to describe angular musculoskeletal deformities. They refer to the direction of the apex of the deformity in relation to the midline of the body. When the apex points away from the midline, the deformity is termed varus; when the apex points toward the midline, the deformity is termed valgus. Knock-knees is an example of a valgus deformity: The apex is defined by the patient’s knees pointing toward the body’s midline. Conversely, bow-leggedness is a varus deformity. These terms can also be applied to fractures such that the apex of the deformity is the fracture itself. Comminution describes a fracture that is significantly fragmented. A fracture is displaced when the main bony fragments are translated or separated from each other. Displacement can further be subcategorized into minimally, moderately, or completely displaced.

Open fractures define fractures with overlying wounds such that the fracture is exposed to the external environment. Open fractures can be obvious in significant trauma with substantial degloving of the soft tissues, or they can be more subtle with only a small poke hole visible when draining fracture hematoma. As a result, when patients are transferred from other hospitals or urgent care facilities, all splints should be removed, and the skin overlying all fractures must be carefully inspected for open injury. Open fractures are orthopedic emergencies and must be addressed with prompt surgical debridement and irrigation to minimize the subsequent development of infection and associated fracture nonunions.

Joint dislocations also warrant immediate treatment. Reduction is the maneuver used to restore proper alignment of a joint or fracture. Vascular structures spanning the joint or fracture may be damaged at the time of injury. Alternatively, these structures may be compressed or kinked due to the resulting deformity. Arterial pulses should always be assessed distal to a musculoskeletal injury and carefully documented. Often, absent pulses are restored with reduction of a joint or fracture. If reduction does not successfully return pulses, the vessels are likely torn; early repair and reconstruction is often required to restore distal circulation to the limb. Vascular injuries repaired prior to fracture or joint reduction and stabilization may be in danger of subsequent failure due to bony instability. Orthopedists can quickly stabilize fractures and dislocations using external fixation, providing a stable scaffold onto which necessary vascular repairs can be made.

Joint or fracture reduction may be treated by open or closed techniques. A ...

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