Chapter 40: Orthopedic Surgery

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.

TERMINOLOGY

Varus and valgus are descriptive terms frequently used for the characterization of 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, such that the apex is defined by the patient’s knees pointing toward the body’s midline. Conversely, “bow-legged” is an example of 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 where only a small poke hole is visible with 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 refers to 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 on to which necessary vascular repairs can be made.

Joint or fracture reduction may be treated by open or closed techniques. A dislocation or fracture is described as unstable if there is a high likelihood of subsequent deformation after reduction is performed. Following reduction, unstable fractures or dislocations may be stabilized by closed or open means. Closed treatment may involve traction, casts, splints, or braces; open techniques involve surgical exposure of the fracture or joint and reduction followed by maintenance of the reduction with internal or external fixation devices. The surgical treatment of an unstable fracture or dislocation is therefore described as “Open reduction with internal or external fixation.”

SPLINTING AND CASTING

Splinting and casting are noninvasive ways of stabilizing fractures and maintaining reductions. Splints are typically made of plaster and are not circumferential, while casts are ­circumferential and can be made of either plaster or fiber-glass. Splints are best used for a short period of time (days up to one or two weeks) in acute scenarios shortly after injury or after an operation when swelling is a concern to avoid compartment syndrome. Casts are sturdier, used to maintain bones in appropriate alignment for extended periods of time (weeks to a few months). For example, a distal radius fracture may be reduced and placed in a sugar-tong splint with follow-up in clinic. At clinic follow-up, if the reduction is adequate and swelling has subsided, the splint can be overwrapped in a cast or transitioned to a new cast for continued closed treatment. After ankle fractures are surgically fixed with open reduction and internal fixation, they are often placed in a short-leg splint with stirrups postoperatively, followed by transitioning to short-leg cast for 4-6 weeks to protect the operative repair. There are many types of splints and casts depending on the type of injury being treated. Examples of splints include the volar forearm, sugar-tong, long-arm posterior, double sugar-tong, coaptation, short leg posterior with or without stirrups, and long-leg posterior. Splints can be augmented with a thumb spica or foot plate depending on the injury. Examples of casts include short-arm, long-arm, with or without thumb spica, as well as short-leg, long-leg, spicas.

ORTHOPEDIC HISTORY TAKING AND PHYSICAL EXAMINATION

Key elements of the history taking include the demographics of the patient (age, sex, and race), comorbidities, hand dominance (if there is an upper extremity injury), mechanism of injury, allergies to medication, and smoking or drinking history.

Examination begins with visualization of the injured extremity noting deformity, swelling, and or bruising. Careful skin examination is crucial to rule out wounds and the presence of open fracture. Neurovascular examination should be performed documenting motor and sensory function as well as strength of pulses (palpable, 1+, 2+, or identifiable by Doppler). Finally, careful secondary exam should be performed on all other joints and extremities testing for tenderness to palpation as well as range of motion. Distracting pain from the primary injury can often prevent a patient from realizing they have an injury elsewhere. Secondary examinations should be performed multiple times during the treatment course of the patient. As the pain from the primary injury subsides, patients may begin to appreciate additional injuries.

ORTHOPEDIC EMERGENCIES

The following is list of conditions that require immediate orthopedic evaluation and treatment: compartment syndrome, open fractures, septic arthritis, and acute dislocations. Additionally, there are other injuries such as femoral neck fractures, that depending on the age of the patient and choice of treatment that require intervention as soon as ­possible. Each of these conditions will be elaborated on in the upcoming chapters.

Compartment Syndrome

Compartment syndrome is caused by increased pressure in a closed fascial space that initially leads to compromised perfusion followed by severe tissue damage. Nerves and muscles in the affected area can be significantly compromised in a matter of hours. Severe ischemia for 6-8 hours leads to muscle and nerve death leading to chronic debilitating dysfunction of the affected extremity. As a result, compartment syndrome is an orthopedic emergency requiring immediate evaluation and treatment. Compartment syndrome can occur after fracture, limb compression or crush, vigorous exercise, or burns.

Although, it most commonly occurs in the forearm and leg, it can occur in the foot, thigh, and arm. Compartment syndrome typically presents as a painful, swollen, tense extremity. Pain with passive range of motion of the digits and pain out of proportion are considered to be the most reliable early indicators of compartment syndrome. Clinical signs of compartment syndrome include the 5 Ps: pain, poikilothermia, pallor, paresthesias, and finally pulselessness. A change in pulses is a very late sign occurring after significant damage has already occurred. Of note, compartment syndrome can occur at intracompartmental pressures well below arterial pressure. Therefore, compartment syndrome can occur in a pink limb with normal pulses.

Compartment syndrome is a clinical diagnosis; many authors advocate that if compartment syndrome is suspected immediate fasciotomy should be carried out. In scenarios where patients are obtunded, intubated, or otherwise unable to express having pain, compartment pressure can be evaluated using a commercially available self-contained pressure monitor. If a commercial pressure monitor is not available, large bore catheter can be inserted in the compartment under sterile technique. The catheter is connected to a pressure monitor via intravenous tubing filled with sterile saline solution. Absolute pressure more than 30 mm Hg in any compartment, or a pressure within 30 mm Hg of the diastolic blood pressure in hypotensive patients are indications for surgical compartment release.

Fasciotomy should be carried out with complete release of the skin and fascia of the involved compartments. Adjacent compartments in the same limb are typically released as well. Compartment pressures are rechecked after release to ensure adequate decompression. The wounds are left open and covered with sterile dressings or a vacuum-assisted closure (VAC), and are subsequently treated with delayed primary closure or skin grafting days later.

Open Fractures

An open fracture is a defined as an osseous disruption with a break in the overlying skin and soft tissues resulting in communication between the fracture, its hematoma, and the external environment. Any wound occurring on the same limb as a fracture must be carefully inspected to prove that it is not an open fracture. Open fractures have important soft tissue consequences: (1) contamination of the wound and fracture by the external environment, (2) crushing, stripping, and devascularization that results in soft tissue devitilization and subsequent increased infection susceptibility, (3) disruption of the soft tissue envelope may affect the type of fracture immobilization as well as adversely affect fracture healing due to the loss of osteoprogenitor cell contribution from overlying soft tissues, and finally (4) loss of function from damaged muscle, tendon, nerve, vascular, and ligamentous structures.

Open fractures are typically high energy injuries. One-third of patients with open fractures have multiple injuries. As a result, initial evaluation of the patient with an open fracture follows the ABCDEs: airway, breathing, circulation, disability, and exposure. Initial resuscitation is performed along with immediate treatment for any-potential life-threatening injuries. The head, chest, abdomen, pelvis, and spine are individually evaluated for injury. Injuries to the other extremities should be identified. Neurovascular exam for the injured limb should be carefully documented; the skin and soft tissues should be assessed as well. Wound hemorrhage should be managed with direct pressure rather than limb tourniquets or clamping which may disrupt perfusion to the rest of the limb. Exploration of the wound in the emergency department setting is not indicated if operative intervention is planned due to risk of further contamination and precipitation of additional hemorrhage. If surgical delay is anticipated, gentle irrigation with sterile normal saline may be undertaken. Only obvious foreign fragments that are easily accessible should be removed. Bone fragments should not be removed and disregarded, regardless of apparent nonviability. Sterile injection of joints can be performed to determine if there is communication with a nearby wound. The wound should be covered with a sterile normal saline soaked piece of gauze (iodine has fallen out of favor due to reports of tissue toxicity). Provisional reduction and splinting should be performed, follow by subsequent neurovascular examination to confirm no additional damage. Standard trauma survey includes radiographic evaluation of the spine, chest, abdomen, and pelvis. The injured extremity including the joint above and below, along with any other extremities suspected of injury should be evaluated with x-rays in anticipation of operative intervention.

Angiogram should be performed if vascular injury is suspected in the following scenarios: knee dislocation, cool, pale hand, or foot with poor distal capillary refill, high energy injury in an area of susceptible vessels (eg, Popliteal fossa), and documented ABI less than 0.9 in an extremity with an associated injury. Of note, evaluation of the contralateral limb may reveal underlying vascular disease as the cause of decreased ABI rather than acute injury.

Open fractures can be characterized using the Gustilo and Anderson classification: Grade I: clean skin opening is less than 1 cm, Grade II: Laceration is less than 1 cm but is less than 10 cm, soft tissue damage without significant fracture comminution or crush component; Grade IIIA: extensive soft tissue damage, Grade IIIB: extensive soft tissue injury with periosteal stripping or bone exposures requiring flap coverage, and Grade IIIC: concomitant vascular injury requiring repair.

Antibiotic treatment and tetanus prophylaxis should be addressed as soon as possible in the emergency department setting. Grade I and II fractures require treatment with a first-generation cephalosporin. Previously, grade III fractures mandated the addition of an aminoglycoside to cephalosporin; however, the most recent recommendations entail treatment with ceftriaxone. For farm injuries with gross contamination, add a penicillin in addition to ceftriaxone.

Operative intervention should be carried out for open fractures as soon as possible. Intervention less than 8 hours after injury has been reported to result in a lower incidence of infection and subsequent osteomyelitis. In the operating room, the wound should be extended proximally and distally to examine the zone of injury. Meticulous debridement of the soft tissues, including the skin, subcutaneous fat, and surrounding muscle should be carried out. Large skin flaps should be avoided as their development risks further devitilization. The fracture surfaces should be exposed and debrided. Fractures can be stabilized provisionally or definitively with external or internal fixation depending on the scenario and surgeon expertise. Pulsatile lavage irrigation should be carried out, followed by meticulous hemostasis. Fasciotomy should be considered as treatment for or prophylaxis against impending compartment syndrome. Historically, only the surgically extended portions of the wound were closed, followed by dressing the open wound with saline soaked gauze or VAC. Serial debridements should be performed every 24-48 hours until there is no evidence of remaining necrotic soft tissue and bone. Bone grafting and wound coverage using delayed primary closure, skin graft, rotational, or free muscle flaps can be performed at this time.

FRACTURES & JOINT INJURIES

1. Fractures & Dislocations of the Spine

Demographics

There are more than 10,000 new spinal cord injuries each year. The ratio of male to female patients sustaining vertebral fractures is 4:1. For patients with spinal cord injury the overall mortality rate is 17% during the initial hospital stay. Unfortunately, delayed diagnosis happens frequently due to loss of consciousness secondary to trauma or intoxication with alcohol or drugs. As a result, suspicion for spinal cord injury should remain high in trauma patients who are unable to provide an accurate history.

Anatomy

The spinal cord occupies between 35% and 50% of the spinal canal depending on the vertebral level. The remainder of the canal is filled with cerebrospinal fluid, dura mater, and epidural fat. The caudal termination of the spinal cord, located dorsal to the L1 vertebral body and L1-L2 intervertebral disk, is called the conus modularis. The conus modularis gives off motor and sensory nerve rootlets, also known as the “cauda equina” or horse’s tail.

The spinal column consists of four major components that contribute to its stability: (1) the vertebral bodies, (2) the posterior elements (pedicles, laminae, spinous process, and interlocking paired facets at each level), (3) the intervertebral disk; and (4) and attached ligamentous tissues (interspinous ligaments, facet capsules, and ligamentum flavum).

The atlas is the first cervical vertebra (C1). Although it does not have a vertebral body, it has two large lateral masses which serve as weight-bearing articulations between the skull and the vertebral column. The tectorial membrane and the alar ligaments are key contributors to normal craniocervical stability. The axis is the second cervical vertebra, whose body is the largest in the cervical spine. The transverse atlantal (aka cruciform) ligament is the primary stabilizer of the atlantoaxial joint, with the alar ligaments providing secondary stability. There are five additional cervical vertebra (C3-C7).

The thoracolumbar spine consists of 12 thoracic vertebrae and 5 lumbar vertebrae. The thoracic region is naturally kyphotic (apex of bow is posterior), while the lumbar region is lordotic (apex of bow is anterior). The thoracic spine is much stiffer than the lumbar spine in flexion-extension and lateral bending, due to the additional stability provided by the rib cage as well as thinner intervertebral disks. As a result, due to its transition zone status, the thoracolumbar junction (T11-L1) is more susceptible to injury.

The spinal column can also be conceptualized as three columns with regards to its stability: (1) the anterior column (the anterior half of the vertebral body, anterior half of the intervertebral disk, and anterior longitudinal ligament), (2) the middle column (the posterior half of the vertebral body, posterior half of the intervertebral disk, and posterior longitudinal ligament), and (3) the posterior column (the facet joints, lateral masses, intraspinous ligaments, supraspinous ligaments, and spinous processes). In general, a one-column injury is relatively stable, while a three-column injury is significantly unstable, with increased risk of injury to the spinal cord.

The spinal cord roots exit the spinal canal through the intervertebral foramina. In the cervical spine, the C1 root exits above the C1 vertebral body; the C2 root exits below the C1 vertebral body. This pattern continues for the other cervical nerve roots ending with the C8 root exiting below the C7 body. In the thoracic and lumbar spine, each root exits under the pedicle with the same number. For example, the L4 nerve root exits under the L4 pedicle.

Clinical Evaluation

Clinical evaluation of the spine injury patient begins with the ABCDEs. All victims of trauma are suspected of having a spinal column injury until it proven otherwise. Initially, patients are placed in a c-collar and on a backboard until the patient’s spine can be assessed. A special backboard with head cutout should be used for children (6 years old or less) to prevent unintended neck flexion due to their proportionally larger head size and resulting prominent occiput.

The head-tilt-chin-lift maneuver should be avoided due to possible further disruption of the cervical spine. Airway and breathing are ensured by intubation and mechanical ventilation. Nasotracheal intubation is the safest method of airway control in the acute setting because it leads to less cervical spine motion compared with direct oral intubation.

Neurogenic shock with hypotension and bradycardia can occur in the setting of spinal cord injury. Initial resuscitation of the patient entails administration of isotonic fluids, as well as evaluating injuries to the head, chest, abdomen, pelvis, and extremities. The diastolic pressure should be kept above 70 mm Hg to maximize spinal cord blood flow. However, once the diagnosis of neurogenic shock is established, the blood pressure should be managed with vasopressors to prevent fluid overload.

If within 8 hours of injury, administer Methylprednisolone for complete or incomplete spinal cord injuries. An initial bolus of 30 mg/kg is administered over the first 15 minutes followed by 5.4 mg/kg/h over the following 24 hours (if steroids were started within 3 hours after injury) or 48 hours (if steroids were started within 3-8 hours after injury). Treatment with methylprednisolone has been shown to improve long-term motor recovery.

Sensory deficits caused by either cord or root level injuries can result in the rapid development of decubitus ulcers over insensate skin over high-pressure areas of the body (eg, the heels and ischium). As a result, timely assessment and removal of the patient from the spine board and onto an appropriate bed is critical.

Evaluating the spine includes logrolling the patient for visual inspection, palpation of the spinous processes for tenderness or diastasis, and performance of a rectal exam assessing resting tone, perianal sensation, and the bulbocavernosus reflex (squeeze of the glans penis or pull on urethral catheter results in contraction of the anal sphincter). Neurologic examination should also be performed assessing motor strength and dermatomal sensation. The motor strength testing and motor nerve roots match up as follows: shoulder abduction (C5), elbow flexion and wrist extension (C6), elbow extension and wrist flexion (C7), wrist extension and finger flexion (C8), finger abduction (T1), hip flexion (L2), knee extension L3, ankle dorsiflexion (L4), long toe extensors (L5), and ankle plantar flexors (S1). Careful evaluation and documentation of the patient’s neurologic status will allow the physician to determine the appropriate treatment plan and estimate the prognosis for functional recovery.

The cervical spine can be cleared clinically in patients if the following criteria are met: (1) no posterior midline tenderness, (2) full pain-free range of motion, (3) no focal neurologic deficit, (4) normal level of alertness, (5) no evidence of intoxication, and (6) no distracting injury. Radiographic evaluation is not required. The process of the clearing the thoracolumbar spine is similar; however, anteroposterior and lateral radiographs of the TLS spine should be routinely obtained for evaluation. If any of the above criteria are not met for clearing the cervical spine, due to its increased sensitivity compared to radiographs, CT scan with sagittal reconstructions of the cervical spine to rule-out injury has become the standard of care.

In addition to spinal trauma, other injuries should be assessed since they may influence the treatment of the patient. Suspicion of associated injuries is dependent on the mechanism and location of injury. Cervical Spine injuries can be associated with injuries to the vertebral artery. Flexion-distraction injuries (seat-belt injuries) of the thoracolumbar spine are associated with intra-abdominal injuries. Axial loading injury mechanisms that often result in burst fractures of the lumbar spine are also responsible for axial loading injury patterns in the lower lumbar spine and lower extremities. These include fractures of the pars interarticularis of the L5 vertebra, the tibial plafond, and the calcaneus.

It is important to note that any injury associated with progressive neurologic deficit warrants surgical intervention.

Neurologic injury can be described as complete (no sensation/motor caudal to the level of the spinal cord pathology) or incomplete (some neurologic function persists caudal to the level of injury). Four major patterns of incomplete spinal cord injury can occur: (1) Brown-Séquard Syndrome (hemicord injury with ipsilateral muscle paralysis, loss of proprioception, and light touch sensation, (2) Central Cord Syndrome (flaccid paralysis of the upper extremities and spastic paralysis of the lower extremities with sacral sparing, (3) Anterior Cord Syndrome (motor and pain/temperature loss controlled by the corticospinal and spinothalamic tracts with preserved light touch and proprioception controlled by the dorsal columns), (4) Posterior Cord Syndrome (rare, involves loss of deep pressure, deep pain, and proprioception with full voluntary power, pain, and temperature sensation), and (5) Conus Modularis Syndrome (T12-L1 injuries resulting in loss of voluntary bowel and bladder control with preserved lumbar root function).

Nerve root lesions can occur at any level accompanying spinal cord injury. These lesions may be partial or complete, resulting in radicular pain, sensory dysfunction, weakness, hyporeflexia, or areflexia.

Cauda Equina syndrome is caused by multilevel lumbosacral root compression within the lumbar spinal canal. Clinical presentation can include saddle anesthesia, bilateral radicular pain, numbness, weakness, hyporeflexia or areflexia, and loss of voluntary bladder or bowel function.

Classification of Neurologic Injury

The motor and sensory examination outlined by the American Spinal Injury Association (ASIA) is one system to assess the impact on the patient of spinal cord injury. This grading system allows the patient to be assessed through scales of impairment and functional independence, evaluating remaining sensory and motor function. A thorough neurologic examination should be performed and documented when the patient is initially seen and at frequent intervals thereafter both to ensure that there is no further neurologic deterioration and to document the resolution of spinal shock.

Spinal shock is defined as spinal cord dysfunction due to physiologic disruption, resulting in hypotonia, areflexia, and paralysis distal to the level of injury. Resolution usually occurs within 24 hours with the return of reflex arcs caudal to the level of injury; the bulbocavernosus reflex is usually the first one to come back.

If a patient has a complete neurologic deficit after spinal shock has resolved, the chance for recovery of neurologic function below the level of injury is extremely poor. In contrast, patients with root level injuries (at or below the cauda equina) will recover from functionally complete injuries if they have not been transected and if initial compression by bone fragments, malalignment, or disk material has been relieved.

Determination of Sensory Levels

The sensory level is determined by the patient’s ability to perceive pinprick (using a disposable needle or safety pin) and light touch (using a cotton ball). Testing of a key point in each of the 28 dermatomes on the right and left sides of the body as well as evaluation of perianal sensation is necessary. The variability in sensation for each individual stimulus is graded on a 3-point scale:

• 0 = Absent

• 1 = Impaired

• 2 = Normal

• NT = Not testable

In the cervical spine, the C3 and C4 nerve roots supply sensation to the entire upper neck and chest in a cape-like distribution from the tip of the acromion to just above the nipple line. The next adjacent sensory level is the T2 dermatome. The brachial plexus (C5-T1) supplies the upper extremities.

ASIA also recommends testing of pain and deep pressure sensation in the same dermatomes as well as evaluation of proprioception by testing the position sense of the both index fingers and both great toes.

Determination of Motor Levels

The motor level is determined by manual testing of a key muscle in the ten paired myotomes from cephalad to caudal. The strength of each muscle is graded on a six-point scale:

• 0 = Complete paralysis

• 1 = Palpable or visible contraction

• 2 = Full range of motion of the joint powered by the muscle with gravity eliminated

• 3 = Full range of motion of the joint powered by the muscle against gravity

• 4 = Active movement with full range of motion against moderate resistance

• 5 = Normal strength

• NT = Not testable

ASIA Impairment Scale

The grading system is as follows: (1) Grade A (complete impairment; no motor or sensory function is preserved below the neurologic injury level), (2) Grade B (incomplete; sensory but not motor function is preserved below the neurologic level and extends through the sacral segment S4-S5), (3) Grade C (incomplete; motor function is preserved below the neurologic level with key muscles having a muscle grade < 3), (4) Grade D (incomplete; motor function is preserved below the neurologic level of injury; most key muscles below the neurologic level have a muscle grade > 3), and (5) Grade E (normal: motor and sensory function is normal).

Imaging Studies

A. Cervical Spine

Plain radiographs can be used as the first imaging modality for the cervical spine, although CT scan of the cervical spine is becoming the initial test of choice due to its increased sensitivity and consistent ability to visualize the occipitocervical and cervicothoracic junctions. The standard series of radiographs includes an anteroposterior, lateral, and an open-mouth “odontoid” view. Eighty-five percent of all significant injuries to the cervical spine will be detected on the lateral view of the cervical spine. Radiographic markers of cervical spine instability include the following: compression fractures with more than 25% loss of height, angular displacement more than 11 degrees between adjacent vertebrae, translation more than 3.5 mm, and intervertebral disk space separation more than 1.7 mm. If the standard lateral view does not adequately visualize the C7-T1 junction, further studies such as a swimmer’s view, oblique views, or CT of this area are necessary. Flexion-extension views of the cervical spine can be performed if instability is still suspected in a patient with otherwise normal radiographic findings. Performance of these radiographs should be delayed in a patient with neck pain, as muscle spasm can mask instability.

B. Thoracolumbar Spine

All patients with significant injury and pain in the spinal area require anteroposterior and lateral x-rays of symptomatic regions of the thoracic and lumbar spine. CT can be used to evaluate canal compromise, and for preoperative planning MRI is useful for assessing the degree of neural injury and prognosis.

Complications

Patients with cervical spine injury may have impaired pulmonary function secondary to intercostal nerve paralysis. Mobilization of secretions by chest physical therapy and frequent suctioning are critical for preventing atelectasis and pulmonary infections. All patients with sensory deficits and paralysis are at high risk of developing pressure ulcers. Padding and suspension of high-risk pressure points (heels), frequent turning, and vigilant nursing care are necessary.

Patients with thoracolumbar spine fractures with or without spinal cord injury may have paralytic ileus secondary to sympathetic chain dysfunction. Oral intake should be limited to clear fluids initially, and gastric suction may be necessary if the degree or duration of ileus is significant.

The stress caused by the injury itself—in combination with systemic corticosteroid therapy—can increase the incidence of gastrointestinal ulceration and bleeding. High-dose corticosteroids can also contribute to the development of pancreatitis and infections.

Venous thromboembolic disease remains a significant problem in the management of patients with spinal injury. Pulmonary embolism is the most common cause of preventable death in hospitalized patients. Heparin can be used for DVT prophylaxis, until the patient’s mobility improves.

CERVICAL SPINE INJURIES

Injuries to the Occiput-C1-C2 Complex

A. Occipital Condyle Fractures

Occipital condyle fractures can be classified as follows: (1) type I (impaction of condyle, stable), (2) type II (shear injury associated with basilar or skull fractures; potentially unstable), (3) type III (condylar avulsion fracture, unstable). Treatment involves rigid cervical collar immobilization for 8 weeks for stable injuries and halo immobilization or surgical stabilization for unstable injuries.

B. Occipitoatlantal Dislocation

Also known as craniovertebral dislocation, this is almost always fatal. Postmortem studies show this injury to be the leading cause of death in motor vehicle accidents. Rare survivors usually have severe neurologic deficits. Immediate treatment includes halo vest application with strict avoidance of traction. Long-term stabilization is done surgically with occipitocervical fusion.

C. Atlas Fractures

Atlas fractures are rarely associated with neurologic injury. Instability due to transverse alar ligament insufficiency should be suspected with identification of bony avulsion or widening of the lateral masses on radiographic evaluation. These injuries can be classified as follows: (1) isolated bony apophysis fracture, (2) isolated posterior arch fracture, (3) isolated anterior arch fracture, (4) comminuted lateral mass fracture, and (5) burst fracture (fractures of the anterior and posterior ring). Stable fractures (posterior arch or nondisplaced fractures) may be treated with rigid cervical orthosis; unstable fractures require prolonged halo immobilization. Chronic instability or pain may be treated with C1-C2 fusion.

D. Transverse Ligament Rupture

This injury is rare, but usually fatal when it occurs. This injury is diagnosed by visualizing the avulsed lateral mass fragment, an atlantodens interval (ADI) more than 3 mm in adults, atlantoaxial offset more than 6.9 mm on an odontoid radiograph, or direct visualization of the rupture on MRI. Survivors are treated with halo or C1-C2 fusion.

E. Fractures of the Odontoid Process (Dens)

There is a significant association with other cervical spine fractures and a 5%-10% incidence of neurologic injury. The vascular supply to the odontoid arrives through the apex and the base of this bone with a watershed area in the neck. Odontoid fractures are classified as follows: (1) type I (oblique avulsion fracture of the apex), (2) type II (fracture at the junction of the body and the neck; high nonunion rate, which can lead to myelopathy), (3) type IIa (highly unstable comminuted injury extending from the waist of the odontoid to the vertebral body), and (4) type III (fracture extending in the cancellous body of C2 and possibly involving the lateral facets). Treatment entails cervical orthosis for type I fractures and halo immobilization for type III fractures. Treatment of type II fractures is controversial due to the high incidence of nonunion related to poor vascularity; halo or surgical intervention is advocated depending on patient factors.

F. C2 Lateral Mass Fractures

These injuries are usually diagnosed via CT scan. Treatment varies from collar immobilization to late fusion for chronic pain.

G. Traumatic Spondilisthesis of C2

Also known as the Hangman’s fracture, this injury may be associated with cranial nerve, vertebral artery or craniofacial injuries. Type I injuries are nondisplaced fractures without angulation, less than 3 mm of translation, and the C2-C3 disk is intact. Type II injuries are displaced fractures of the pars. Type IIa is a displaced pars fracture with disruption of the C2-C3 disk. Type III is a dislocation of the C2-C3 facet joints in addition to the pars fracture. Type I injuries are treated with rigid cervical orthosis, type II injuries are treated with halo immobilization, type III injuries are usually treated initially with halo immobilization followed by surgical stabilization.

Injuries to C3-C7

Injuries for the remaining vertebrae from C3-C7 include teardrop fractures of the anterior portion of the vertebral body due to compression flexion, vertical compression (burst fractures), anterior dislocations due to distractive flexion, vertebral arch and lamina fractures due to compressive extension, distractive extension injuries resulting in posterior dislocations, and lateral flexion injuries resulting in translational dislocations.

“Clay shoveler’s fracture” is an avulsion fracture of the spinous processes of the lower cervical and upper thoracic vertebra.

“Sentinel fracture” is a fracture through the lamina on either side of the spinous process.

Treatment for each of these fractures includes the use of cervical orthoses, halo immobilization, traction, and surgery. Soft cervical orthosis does not provide any significant immobilization. It is used as needed for the patient’s comfort. Rigid cervical orthoses do not provide complete immobilization; this treatment mainly limits range of motion in the ­flexion-extension plane. Cervicothoracic orthoses are effective in flexion-extension and rotational control, but do not limit lateral bending very effectively. Halo immobilization offers rigid immobilization in all planes as does surgical treatment. Traction can be used to reduce unilateral or bilateral facet dislocations with neurologic deficits or to stabilize and indirectly compress the canal in patients with neural deficits from burst-type fractures. Traction is contraindicated in type IIa spondolisthesis injuries of C2 and distractive cervical spine injuries.

Choice of treatment depends on the type of injury and individual patient characteristics. In general, stable fractures can be managed with bracing, while unstable fractures require more rigid stabilization via halo application or surgical treatment.

Halo Application

The halo apparatus includes the metal ring and halo vest. The halo ring should be applied approximately 1 cm above the ears. Anterior pin sites should be placed above the supraorbital ridge, anterior to the temporalis muscle over the lateral 2/3 of the eyebrow to avoid the supraorbital nerve. Posterior sites are variable and are placed to maintain the horizontal orientation of the halo. Pin pressure should be 6-8 lbs in the adult. Pin care is essential. The halo vest relies on a tight fit that should be carefully maintained.

Thoracolumbar Spinous Injuries

Anteroposterior and lateral radiographs of the Thoracolumbosacral spine are the standard initial evaluation. Abnormal interpedicular distance, height loss, and canal compromise should all be noted. Minor spine injuries include articular process fractures, transverse process fractures, spinous process fractures, and pars interarticularis fractures. Generally, these injures can simply be observed. Six significant injury patterns requiring treatment are described: (1) wedge compression fracture, (2) stable burst fracture, (3) unstable burst fracture, (4) chance fracture, (5) Flexion-distraction injury, and (6) translational injuries.

A. Compression Fractures

Based off of the three column theory of instability, compression fractures are fractures that only affect the anterior column. Compression fractures can be anterior or lateral. In general these fractures are stable injuries and are rarely associated with neurologic injury. Fractures are considered unstable if there is more than 50% loss of vertebral body height, angulation more than 20-30 degrees, or multiple adjacent compression fractures. Four subtypes are described based off of endplate involvement: type A (fracture of both endplates), type B (fracture of superior endplate), type C (fracture of inferior endplate), and type D (both endplates are intact). Stable fractures are treated with Jewett brace or thoracolumbar spinal orthosis (TLSO). Unstable fractures can be treated with hyperextension casting or with surgery.

B. Burst Fractures

Burst fractures are fractures that involve the anterior and middle columns of the spinal cord. Radiographs may show loss of posterior vertebral body height and splaying of the pedicles on the anteroposterior view. It is important to note that no direct relationship exists between the amount of canal compromise and the degree of neurologic injury. Treatment can entail tho TLSO bracing or hyperextension in casting for stable fracture patterns without neurologic compromise. If the TLSO fails to restore appropriate alignment on radiographs, surgery should be considered. Early surgical intervention restoring sagittal and coronal alignment should also be considered for fractures with loss of vertebral height more than 50%, angulation more than 20-30 degrees, scoliosis more than 10 degrees, and concomitant neurologic deficit. Surgical treatment options include decompression via a posterior or anterior approach with or without instrumentation.

C. Flexion-Distraction Injuries

Also known as Chance fractures, involve all three columns of the spinal cord. These fractures are also known as “seat-belt type injuries” due to the most common mechanism by which they occur and often are associated with abdominal injuries. Radiographically, one may appreciate increased interspinous distance on the AP and lateral views. Four types of Chance fractures are recognized: (1) type A (one-level bony injury), (2) type B (one-level ligamentous injury), (3) type C (two-level injury through the bony middle column, (4) type D (two-level through the ligamentous middle column). Treatment for type A fractures may entail TLSO; however, one should consider surgical stabilization for the other three fractures given their innate lack of stability.

D. Fracture-Dislocations

Fracture-dislocations involve injury to all three columns with translational deformity. These injuries are often associated with neurologic injury and require surgical stabilization due to their unstable nature. There are three types of fracture-dislocations: (1) Flexion-rotation, (2) Shear, and (3) Flexion-distraction. Patients without neurologic injury do not require emergent surgery; however, patients whose fractures are stabilized within 72 hours of injury have a lower incidence of complications such as pneumonia and undergo a shorter hospital stay when compared to patients whose fractures are stabilized outside this time-frame.

E. Gunshot Wounds

Generally, fractures associated with low-velocity gunshot wounds are usually stable when a handgun is the weapon. These injuries are typically associated with a low infection rate and can be prophylactically treated with broad-spectrum antibiotics for 48 hours.

Any present neural injury, is usually secondary to “blast effect,” in which the energy of the bullet is absorbed and transferred to the soft tissues. As a result, decompression is usually not indicated. An exception to this rule is if the bullet fragment is found in the spinal canal between levels T12 and L5. Steroids after gunshot wounds to the spine are not recommended.

F. Spine Fractures or Dislocations With Neurologic Deficit

1. Incomplete neurologic deficit

If there is a neurologic deficit, surgical decompression is indicated. This can be done either through an anterior approach with bone graft and internal fixation, a posterior costotransversectomy approach, or a combined anterior and posterior approach. The operative plan is individualized to the particular patient. Patients with incomplete neurologic deficits and unstable fractures or fracture-dislocations have the same stability requirements as patients without neurologic deficits. They are best managed with open reduction, instrumentation, and spinal fusion. Neural canal compromise should be managed as in the preceding paragraph.

2. Complete neurologic deficit

No operative procedure has been devised that will achieve recovery in cases of complete neurologic deficit that has persisted beyond the stage of spinal shock. However, surgical stabilization is often necessary (1) because spinal instability may interfere with early mobilization and rehabilitation training and (2) because it may result in loss of function at a higher level by causing mechanical injury on the root or cord segment just above the level of injury.

FRACTURES & DISLOCATIONS OF THE PELVIS

Pelvic fractures are among the most serious injuries and account for 3% of all fractures. The mechanism is often high energy in nature; 60% result from vehicular trauma (eg, automobile, motorcycle, bicycle), 30% from falls, and 10% from crush injuries, athletic injuries, or penetrating trauma. Pelvic fractures are the third most commonly seen injury in fatalities due to motor vehicle accidents.

Life-threatening hemorrhage, deformity, neurologic injury, and genitourinary injury are all potential complications that must be identified and treated early in the setting of a pelvic fracture. Pelvic fractures pose a formidable clinical challenge. Hemodynamically unstable patients who present to the emergency department with pelvic fracture have a mortality rate of 40%-50%.

Anatomy

An understanding of pelvic anatomy is essential for identifying fracture patterns and complications. The pelvis is made up of three bones: two innominate bones joined anteriorly at the symphysis and posteriorly at the paired sacroiliac joints. The innominate bones are further subdivided into the ilium, ischium, and pubis.

The acetabulum is the portion of the pelvic bone that articulates with the femoral head to form the hip joint. It results from closure of the triradiate cartilage and is covered with hyaline cartilage. The innominate bone support of the acetabulum can be thought of as an inverted Y formed by two columns. The anterior column (iliopubic component) extends from the iliac crest to the pubic symphysis including the anterior wall of the acetabulum. The posterior column (ilioischeal component) extends from the superior gluteal notch to the ischial tuberosity including the posterior wall. The acetabular dome is the superior weight-bearing portion of the acetabulum at the junction of the anterior and posterior columns, including contributions from both.

The stability of the pelvis is dependent on its ligamentous attachments. A thick fibrocartilaginous disk joins the anterior aspects of the innominate bones to form the pubic symphysis. This joint acts as a supporting strut for the pelvis because the stability of the ring depends mostly upon the sacroiliac joints.

The posterior ligamentous structures supporting the sacroiliac joints can be divided into anterior and posterior complexes. The anterior sacroiliac joint ligaments are broad and flat and connect the iliac wing and the sacral ala. These ligaments primarily resist external rotation and torsional forces. The sacro-iliac ligaments provide most of the stability. Composed of the interosseous sacroiliac ligaments within the joint and the posterior sacroiliac ligaments spanning the sacrum between the posterior iliac spines, the posterior complex is considered to be the strongest ligament in the human body. The posterior sacroiliac complex resists shear forces between the sacrum and the ilium, clinically preventing displacement of the ilium onto the sacrum.

The pelvic floor contains two additional strong ligaments, the sacrospinous and the sacrotuberous ligaments. The sacrospinous ligament maintains rotational control while the sacrotuberous ligament is especially important in maintaining vertical stability of the pelvis. Additional stability is conferred by ligamentous attachments between the spine and the pelvis. The iliolumbar ligaments originate from L4 and L5 transverse processes and insert on to the posterior iliac crest. The lumbosacral ligaments originate from the transverse process of L5 and insert to the sacrum ala.

Stability

Pelvic stability can be defined as the ability of the pelvic ring to withstand physiologic forces without abnormal deformation. Pathologically, the pelvic ring fails under one or more of three basic modes. External rotation strains the pubic symphysis and the sacrotuberous, sacrospinous, and anterior sacroiliac joint ligaments. After roughly 2.5 cm of diastasis, the pelvic floor ligaments and the anterior sacroiliac ligaments begin to fail, giving rise to gross rotatory instability. Because the posterior ligament complex is largely intact, superior or posterior displacement of the involved hemipelvis does not occur. Combined external and shear forces are necessary to completely disrupt pelvic stability. Conversely, internal rotation places the pubic rami under compression and the posterior ligament complexes under tension. The rami often fail in their midportions with transverse fractures and sacral alar impaction. The pelvic floor ligaments remain intact, and gross posterior stability is maintained. Therefore, fractures involving torsional forces on the pelvis often have partial instability in the rotatory plane only, with maintenance of stability to other displacement.

Complete instability, however, occurs with disruption of both the anterior and the posterior ligamentous restraints. These injuries often present with widely displaced sacroiliac joints and multiaxial instability of the involved hemipelvis. Such fractures have components of superior and posterior displacement relative to the sacrum in addition to rotational displacement in the sagittal and horizontal planes.

Clinical Evaluation

Physical examination includes palpation of the pelvic bony landmarks, compression maneuvers to assess stability, rectovaginal examination looking for bony spikes protruding through the mucosa representing an open fracture, and looking for blood at the urethral meatus, or a high-riding prostate on rectal exam which may indicate genitourinary injury. If bladder or urethral injury is suspected, retrograde urethrogram should be considered. The mortality rate of open pelvic fractures is as high as 50%—compared with 8%-15% for closed fractures. A secondary musculoskeletal survey examining each of the other four limbs including distal vascular status and a thorough neurologic examination should be performed as well.

Radiographic Examination

The anteroposterior radiograph required in all patients with blunt trauma rapidly identifies the major pelvic injury. The AP pelvis radiograph can be looked at in a systematic way: the pubic rami, pubic symphysis (looking for widening >2.5 cm), the iliopectineal lines (represents limit of the anterior column of the acetabulum) ilioischial lines (represents limit of the posterior column of the acetabulum), the anterior lip of the acetabulum, the posterior lip of the acetabulum, the radiographic roof of the acetabulum, the pelvic wings, the sacro-iliac joints, femoral head position (rule-out concomitant hip dislocation), associated fracture of the femoral head or femoral neck, and finally the lumbar spine. Disruption of the iliopectineal line, ilioischial line, the anterior lip, posterior lip, or the radiographic roof may be indicative of acetabular fracture. Suspected acetabular fractures should be further evaluated with Judet’s views (iliac oblique and obturator oblique). The iliac oblique (45-degree external rotation view) view better delineates the anterior column and posterior wall of the acetabulum, while the obturator oblique (45-degree internal rotation view) characterizes the posterior column and anterior wall of the acetabulum in greater detail. Inlet and outlet radiographs are often required to supplement the anteroposterior film. The inlet view (patient supine, the tube directed 60 degrees caudal) can be used to evaluate for any anterior-posterior instability, while the outlet view (patient supine, tube directed 45 degrees cephalad) will best show any vertical displacement. CT scan is recommended for any suspected pelvis fracture; this modality is especially good for evaluation of the acetabulum and posterior pelvis, including the sacrum and sacro-iliac joints.

Acute Management

Immediate care of the polytrauma patient with a pelvic fracture must address associated retroperitoneal hemorrhage, pelvic ring instability, and injuries to the genitourinary system and rectum as well as fractures open to the peritoneum. Cessation of blood loss, minimization of septic sequelae, and stabilization of the fracture, allowing early and safe patient mobilization, are the immediate treatment goals. Hemorrhage is the leading cause of death in patients with pelvic fracture, accounting for 60% of the deaths. Most of the blood loss is from the fracture site or injured retroperitoneal veins; only 20% of the deaths are associated with major arterial injury. An average blood replacement of 5.9 units has been reported.

General resuscitative principles are applied to stabilize the patient and provide adequate tissue perfusion. Once other sites of hemorrhage have been ruled out, active bleeding from a pelvic fracture may be controlled by wrapping a pelvic binder or sheet circumferentially around the pelvis. The sheet should enclose the bilateral anterior superior iliac spines and greater trochanters, and can be fixed in placed by clipping the two ends with a hemostat. Wrapping the pelvis in this way stabilizes major fracture fragments and closes down the volume of the pelvis, dramatically reducing active blood loss. If this fails to control hemorrhage, angiography or arterial embolization is indicated. Definitive internal fixation is usually required after hemorrhage has been controlled and the patient has been stabilized.

Fracture-dislocations of the pelvis should be treated with immediate closed reduction of the hip. Stability should be assessed by ranging the hip through a full arc of motion. Unstable hips should be rereduced and placed in skeletal traction. An Irreducible hip or new-onset sciatic nerve palsy after closed hip reduction requires immediate operative treatment.

Classification & Treatment

Fractures of the pelvis may be classified according to the Young and Burgess system based off of mechanism of injury. AP compression (APC) injuries result from anteriorly applied force. APC-I characterizes less than 2.5 cm of symphyseal diastasis; vertical fractures of one or both pubic rami occur, however, the sacroiliac ligaments are intact imparting rotational and vertical stability. In an APC-II injury disruption of the anterior sacro-iliac ligaments results in greater than 2.5 cm of symphyseal diastasis that is rotationally unstable, but vertically stable due to intact posterior sacroiliac ligaments. APC-III injury occurs with complete disruption of the symphysis, sacrotuberous, sacrospinous, anterior, and posterior sacroiliac ligaments resulting in a pelvis that is rotationally and vertically unstable. Lateral compression (LC) injury results from a laterally applied force to the pelvis that leads to shortening of the anterior sacroiliac, sacrospinous, and sacrotuberous ligaments with resulting transverse or oblique fractures of the pubic rami. LC-I injury describes transverse fractures of the pubic rami with sacral compression on the side of injury without rotational or vertical instability. LC-II injuries describe the addition of a crescent iliac wing fracture on the side of impact with variable disruption of the posterior ligamentous structures resulting in rotational instability. LC-III describes an LC-I or LC-II injury on the side of impact with continuation of the force producing an external rotation or open book (APC) type injury on the contralateral side. Vertical shear (VS) injury due vertical or longitudinal forces caused by falls onto an extended lower extremity, impacts from above, or motor vehicle accidents with a lower extremity impacted against the dashboard or floorboard, typically results in complete ligamentous disruption, rotational and vertical instability, with a high incidence of neurovascular injury, and hemorrhage. Combined mechanical (CM) describes a combination of injuries often due to crush mechanism.

Pelvic fractures may also be classified according to instability using the Tile classification: type A (rotationally and vertically stable), type B (rotationally unstable and vertically stable, or type C (rotationally and vertically unstable). Common radiographic signs of pelvic instability include (1) displacement of the posterior sacroiliac complex more than 5 mm in any plane; (2) the presence of a posterior fracture gap rather than an impaction; and (3) the presence of an avulsion fracture of the transverse process of the fifth lumbar vertebra or the sacro-ischial end of the sacrospinous ligaments.

Type A fractures involve the pelvic ring in only one location and are considered stable. Type A1 fractures are avulsion fractures that usually occur at muscle origins such as the anterosuperior iliac spine, anteroinferior iliac spine, and ischial apophysis. These fractures most often occur in adolescents, and conservative treatment is usually sufficient. Rarely, symptomatic nonunions develop and can be best treated surgically.

Type A2 fractures are isolated fractures of the iliac wing without involvement of the hip or sacroiliac joints and are usually a result of direct trauma. Even with significant displacement, bony healing is expected and treatment is therefore symptomatic. Healing may be accompanied by ossification of the hematoma with exuberant new bone formation. Finally, type A3 fractures are isolated fractures of the obturator foramen and usually involve minimal displacement of the pubic or ischial rami. The posterior sacroiliac complex is intact, and the pelvis remains stable. Treatment is symptomatic, with early ambulation and weight bearing as tolerated.

Type B fractures involve breaks in the pelvic ring in two or more sites. This creates a pelvic fracture that is rotationally unstable but vertically stable. Type B1 fractures are open book fractures that occur from anteroposterior compression. Unless the anterior separation of the pubic symphysis is severe (> 6 cm), the posterior sacroiliac complex is usually intact and the pelvis is relatively stable to vertical forces. Significant associated injuries to the perineal and urogenital structures are often present and should always be looked for. For minimally displaced symphysial injuries (< 2.5 cm), only symptomatic treatment is needed. However, if conservative treatment is pursued, serial radiographs are required after mobilization is begun to monitor for subsequent increased displacement that may require surgery. For more displaced fracture-dislocations, reduction is done by LC using the intact posterior sacroiliac complex as the hinge on which the “book is closed.” Reduction can be maintained with the use of an external fixator; however, internal fixation with a symphyseal plate is currently favored. “Closing the book” decreases the space available for hemorrhage, increases patient comfort.

Type B2 and B3 fractures involve a lateral force applied to the pelvis, causing inward displacement of the hemipelvis through the sacroiliac complex and ipsilateral (B2) or, more often, contralateral (B3) pubic rami fractures. The degree of involvement of the posterior sacroiliac ligament complex will determine the degree of instability. The hemipelvis is infolded, with overlapping of the pubic symphysis. Reduction can be accomplished with external fixation, with internal fixation, or with both. External fixation facilitates nursing care but is not strong enough for ambulation. Definitive care usually is accomplished with internal fixation of both the anterior and posterior aspects of the pelvic ring. Major hemorrhage is associated with these fracture types.

Type C fractures are both rotationally and vertically unstable. They often result from a VS injury such as a fall from a height. Anteriorly, the pubic symphysis or pubic rami may be disrupted. Posteriorly, the sacroiliac joint may be disrupted and dislocated, or there may be a fracture through the sacrum or adjacent iliac wing. The hemipelvis is completely unstable, and there may be associated massive hemorrhage and injury to the lumbosacral pelvis. External fixation is insufficient to maintain reduction, but it may help to control hemorrhage and ease nursing care in the acute stage. Internal fixation is usually required as definitive treatment.

SACRAL FRACTURES

Fractures of the sacrum can be described using the Denis classification according to the location of the fracture in relation to the sacral foramen: Denis I: lateral to the foramen, Denis II: through the foramen, and Denis III: medial to the foramen. The incidence of neurologic injury increases with higher classification.

FRACTURES OF THE ACETABULUM

Fractures of the acetabulum (Figure 40–1) occur through direct trauma on the trochanteric region or indirect axial loading through the lower limb. The position of the limb at the time of impact (rotation, flexion, abduction, or adduction) will determine the pattern of injury. Comminution is common.

Classification

Letournel has classified acetabular fractures into ten different types: five simple patterns (one fracture line)-posterior wall, posterior column, anterior wall, anterior column, transverse and five complex patterns (the association of two or more simple patterns)-T-shaped, posterior column and posterior wall, transverse and posterior wall, anterior column/posterior hemi-transverse, and both column. This is the most widely used classification system as it allows the surgeon to choose the most appropriate surgical approach.

Treatment

The goal of treatment is to achieve a spherical congruency between the femoral head and the weight-bearing acetabular dome and to maintain it until the bones are healed. As with other pelvic fractures, acetabular fractures are frequently associated with abdominal, urogenital, and neurologic injuries, which should be systematically sought and treated. Significant bleeding is often present and should be stopped as soon as possible.

The stabilized patient with protrusion (the femoral head is impacted through the fracture of the acetabulum into the pelvis) or unstable fracture-dislocation should be put in longitudinal skeletal traction through a distal femoral or proximal tibial pin pulling axially in neutral position. Postreduction x-rays are obtained. Operative indications for acetabular fractures include displacement (> 2-3 mm), large posterior wall fragments, interposed intra-articular loose fragment, femoral head fractures, unstable reductions, and an irreducible fracture dislocation by closed methods. The choice of approach is of primary importance, and more than one approach will sometimes prove necessary. Acetabular surgery uses extensile approaches and sophisticated reduction and fixation techniques and is best performed by pelvic surgeons.

Complications

Complications inherent to the injury include posttraumatic degenerative joint disease, heterotopic ossification, femoral head osteonecrosis, deep vein thrombosis, and other complications related to conservative treatment. Surgery is performed to prevent or delay osteoarthritis (OA), but it increases the possibility of complications such as infection, iatrogenic neurovascular injury, and increased heterotopic ossification. When the reduction is stable and fixation is solid, the patient can be mobilized after a few days with non–weight-bearing ambulation, and weight bearing may begin as early as 6 weeks. Prophylactic anticoagulation and aggressive pulmonary toilet are key elements of postoperative care.

SHOULDER INJURIES

1. Clavicular Fractures

Epidemiology, Mechanism, Anatomy, and Clinical Evaluation

Clavicle fractures are relatively common accounting for between 2% and 12% of all fractures. Clavicle fractures are characterized by location: medial, lateral, and middle third of the clavicle which is the most common type (80%). The most common mechanism of injury is fall on to the ipsilateral shoulder (87%); direct impact (7%) and falls onto an outstretched hand cause the rest. The clavicle is an S-shaped bone that serves as a strut bracing the shoulder in relation to the trunk, allowing the shoulder to function at maximum strength. The clavicle is stabilized by the acromioclavicular and coracoclavicular ligaments. The acromioclavicular ligaments prevent horizontal displacement while the coracoclavicular ligaments provide vertical stability. The middle one-third of the clavicle protects the brachial plexus, superior lung, subclavian and axillary arteries. As a result, it is critical to document a thorough neurovascular examination, and rule-out concomitant injuries such as brachial plexus palsy, vascular injury, and pneumothorax. It is also important to note the appearance of the skin as tenting may be an indication for surgery. Clavicle fractures are most often incidentally seen on the AP radiograph of the chest. Proximal third clavicle fractures can be further evaluated with computed tomography to differentiate between sternoclavicular dislocations from epiphyseal injury.

Classification

Clavicle fractures are classified into three groups: Group I: middle third fracture, Group II: distal third, Group III: proximal third. Group II fractures are subclassified into three types according to the location of the coracoclavicular ligaments relative to the fracture. Type I fractures are interligamentous, either in between the conoid and trapezoid ligaments or between the coracoclavicular and acromioclavicular ligaments, with the ligaments still intact. Because ligaments are attached to both the proximal and distal fracture segments, the fracture is typically nondisplaced or minimally displaced. Group II, type II fractures occur medial to the coracoclavicular ligaments or in between the conoid and trapezoid ligaments with the conoid ligament torn, such that the proximal fracture segment is predisposed to significant displacement. Group II, type III is a distal-third fracture of the articular surface of the AC joint without ligamentous injury.

Treatment

Clavicle fractures are typically treated conservatively with a sling or figure of eight brace for 4-6 weeks until healing is appreciated radiographically and clinically (area no longer tender with palpation). Sling is typically preferred due to lower incidence of skin problems and increased patient comfort. Some degree of shortening and deformity is expected with closed treatment. However, shoulder dysfunction is rare and there is no scar. Strict indications for surgery include open clavicle fractures, associated neurovascular injury, and skin tenting concerning for impending open fracture. Some authors advocate fixing significantly displaced (> 1-2 cm) middle-third clavicle fractures and Group II, type II distal clavicle fractures, due to predisposition to nonunion which may result in cosmetic deformity and shoulder dysfunction.

2. Acromioclavicular Dislocation

The AC joint is diarthroidal with fibrocartilage-covered articular surfaces between the medial acromion and the lateral end of the clavicle. The AC ligaments blend with fibers from the deltoid and trapezius to provide strength to the joint. As described previously, the AC ligaments provide horizontal stability while the coracoclavicular ligaments provide vertical stability. The mechanism for dislocation of the acromioclavicular joint is most commonly direct impact caused by a fall on the tip of the shoulder. Thorough neurovascular examination along with standard trauma series of the shoulder (AP, scapular-Y, and axillary views) completes the standard workup. Stress radiographs in which 10-15 lb weights are strapped to the wrists and an AP radiograph is taken of both shoulders comparing coracoclavicular distances, to differentiate between partial grade I to II injuries and grade III AC separations.

Classification and Treatment

Type I is a strain of the acromioclavicular ligament. Type II injury involves rupture of the acromioclavicular ligament and strain of the coracoclavicular ligament complex, with slight superior displacement of the superior clavicle type III injury involves rupture of both the acromioclavicular and the coracoclavicular ligaments, which causes marked superior migration of the lateral end of the clavicle types IV, V, and VI injuries involve detachment of the deltoid and trapezius from the distal clavicle in addition to disruption of the AC and CC ligaments with marked posterior, superior, and inferior displacement of the clavicle, respectively.

Treatment

Type I, II, and III AC joint injuries are typically managed nonoperatively with a sling for approximately 4 weeks ­followed by gradual return to full activity. Most patients do not have significant dysfunction or any need to modify their activities. Surgical reconstruction may be indicated for types IV, V, and VI AC joint injuries. Type III injuries in young athletes or laborers who perform a lot of overhead work may be treated surgically.

3. Sternoclavicular Joint Dislocation

Dislocation of the sternoclavicular joint is rare. The mechanism of injury is usually a motor vehicle accident or sporting injury. Physical examination and anteroposterior and anteroposterior-cephalic tilt x-rays may demonstrate asymmetry. However, computed tomography is diagnostic test of choice as it can distinguish fractures of the medial clavicle from SC dislocation and can show minor subluxation. Anterior dislocation is more common, but posterior dislocation can cause injury to the esophagus, trachea, great vessels, subclavian artery, carotid artery, and pneumothorax. Dislocations of the sternoclavicular joint in children are often associated with physical fractures.

Treatment

Most injuries to the sternoclavicular joint may be treated with a ice for the first 24 hours and immobilization with a sling, sling and swathe, or figure-of-eight bandage. Posterior dislocations may require emergent reduction if there is associated vascular compression or injury to the trachea, esophagus, or lungs. Closed reduction of posterior dislocations has been described using shoulder retraction and a towel clip. Rarely, open reduction may be necessary.

4. Scapular Fracture

Scapular fractures are classified by anatomic location: scapula body, neck, spine, acromion, coracoid, or glenoid. Scapular body fractures are often associated with other injuries such as subclavian vessel injury, aortic rupture, pneumothorax, rib fractures, brachial plexus injuries, and other soft tissue injuries associated with high-energy trauma. Fractures of the acromion and coracoid are rare. Glenoid fractures must be carefully evaluated for articular surface step-off and associated glenohumeral instability. These fractures may be caused by a blow on the shoulder or by a fall on the outstretched arm. Diagnosis with anteroposterior x-ray in the plane of the scapula and axillary x-ray may be supplemented by an axial view of the scapular body and transscapular {ss}Y{end}-view. CT scan may also be helpful if surgery is being considered.

Treatment

Most scapular fractures are treated nonoperatively in a sling for 4-6 weeks. Associated injuries may need to be treated emergently and should not be overlooked. Surgical indications are controversial, but may include displaced intra-articular fractures involving more than 25% of the articular surface, scapular neck fractures more than 40 degree angulation or 1 cm of medial translation, scapula neck fractures with an associated displaced clavicle fracture, acromion fractures that cause subacromial impingement, and coracoid fractures that cause functional AC separation.

5. Dislocation of the Shoulder Joint

The shoulder (glenohumeral) joint is the most commonly dislocated joint in the body due to its freedom of motion and mobility in multiple planes. Diagnosis and management of this is presented in detail in the Sports Medicine section of this chapter.

6. Proximal Humerus Fracture

Fractures of the proximal humerus occur most commonly in elderly individuals with osteoporosis, after a fall initial assessment should seek to determine the cause of any related fall as well as the fracture pattern. Prodromal symptoms related to a syncopal episode, myocardial infarction, stroke, transient ischemic attack, or seizure are possible etiologies that should be investigated. Associated injuries include neurovascular injuries, dislocation, and rotator cuff tears. Axillary nerve function should be assessed testing sensation over lateral aspect of shoulder, overlying deltoid (motor testing is usually not possible, due to pain).

Diagnosis is established by standard shoulder trauma series (AP, lateral scapular Y, and axillary views). The axillary view is the best view for evaluating glenoid articular fractures and dislocations. If axillary view cannot be obtained due to pain, a Velpeau axillary view where the patient is left in a sling leaned obliquely backward 45 degrees over the cassette with the beam directed caudally is another option. Computed tomography can be used to further evaluate articular involvement, fracture displacement, impression fractures, and glenoid rim fractures.

Classification and Treatment

Proximal humerus fractures can be classified according to the system developed by NEER. There are four major parts of the proximal humerus: humeral head, humeral shaft, greater, and lesser tuberosities. A part is defined as displaced if there is more than 1 cm of fracture displacement, or more than 45 degrees of angulation. Most proximal humerus fractures are minimally displaced (< 1 cm and < 45 degrees of angulation) and can be treated in a sling with early gentle range of motion exercises. Displaced fractures usually require surgery. Surgical options include closed reduction and percutaneous fixation, open reduction and internal ­fixation, and prosthetic arthroplasty (Figures 40–2 and 40–3). Other indications for surgery include superior displacement of the greater tuberosity fragment of 5 mm or more which can lead to subacromial impingement, lesser tuberosity fractures that block internal rotation. Patients often lose some range of motion, but excellent pain relief and function can be attained. Long-term complications include shoulder stiffness and avascular necrosis of the humeral head (due to disruption of the arcuate branch off of the anterior circumflex humeral artery).

FRACTURES OF THE SHAFT OF THE HUMERUS

Most fractures of the shaft of the humerus result from direct trauma; indirect mechanism from fall on an outstretched arm is also a possibility. A careful neurovascular exam is required (radial nerve injury is most common). AP and lateral radiographs of the humerus, as well as shoulder and elbow series are mandatory to rule out the possibility of fracture or dislocation involving adjacent joints. Humerus fractures can be described descriptively: open versus closed, location (proximal, middle, and distal third), nondisplaced versus displaced, transverse, oblique, spiral, segmental or comminuted fracture, intrinsic condition of bone (osteopenic or not), and if there is any articular extension.

Treatment

Most midshaft humeral fractures can be treated nonoperatively in a cast, splint, or brace. Alignment should be verified using AP and lateral x-rays with the patient standing. Twenty degrees of anterior angulation, 30 degrees of varus angulation, and up to 3 cm of bayonet apposition are acceptable for continued closed treatment. Other surgical ­indications include open fractures, concomitant vascular injury, pathologic fracture, “floating elbow” (concomitant fracture of the forearm bones), segmental fracture, intra-articular extension, and bilateral humeral fractures. Radial nerve injury most commonly occurs with middle third fractures. Most radial nerve injuries are the result of stretching or contusion; function usually returns in 3-4 months. Delayed surgical exploration is warranted if there is no evidence of recovery on EMG or nerve conduction velocity studies at this time.

FRACTURES & DISLOCATIONS ABOUT THE ELBOW

Anatomy & Biomechanics

The elbow is a modified hinge joint consisting of three separate articulations: ulnohumeral, radiohumeral, and proximal radioulnar. The elbow joint is intrinsically stable with bony and soft tissue contributions. The trochlea-olecranon fossa, coronoid fossa, radiocapitellar joint, biceps, triceps, and brachioradialis provide anterior-posterior stability during flexion and extension. On the medial side of the elbow the anterior bundle of the medial collateral ligament (MCL) is the primary stabilizer to valgus stress, while the lateral ulnar collateral ligament is the primary stabilizer on the opposite side of the elbow preventing posterolateral instability. Normal elbow range of motion entails 0-150 degrees of flexion, 85 degrees of supination, and 80 degrees of pronation. Functional range of motion requires 30-130 degrees of flexion, 50 degrees of pronation, and supination. Elbow injury mandates careful examination of the entire upper extremity including shoulder and wrist, with thorough neurovascular examination. AP, lateral, and oblique radiographs are required to adequate visualize the elbow joint.

Distal Humerus Fractures

The distal humerus can be conceptualized as medial and lateral columns, each roughly triangular in shape and composed of a condyle articulating with the bones of the forearm and an epicondyle (distal part of the humerus that flares just above the elbow joint at the level of the supracondylar ridge) connecting to the shaft of the humerus. These fractures can be classified descriptively: intercondylar (most common), supracondylar fractures (extension or flexion type), transcondylar, condylar, capitellum, trochlea, lateral epicondyle, medial epicondyle, or fractures of the supracondylar process. These fractures can also be classified using the AO system based on the concept of column integrity and articular involvement. Type A fractures are extra-articular (epicondylar, supracondylar, transcondylar) fractures. Type B fractures only involve a portion of the articular surface (unicondylar or intercondylar). Type C fractures involve the entire distal articular surface.

Radiographic Evaluation

Standard AP, lateral, and oblique radiographs should be obtained. Traction radiographs or computed tomography may provide better fracture pattern visualization for preoperative planning. On the lateral radiograph, the anterior or posterior “fat pad sign” representing displacement of the adipose layer over the joint capsule may be the only indication of a nondisplaced distal humerus fracture. The AP radiograph should be carefully scrutinized for an intercondylar split. If an intercondylar split is present, the amount of rotation, in addition to displacement and fracture comminution should be noted.

Management

The patient can be initially managed with a posterior long-arm splint with the elbow flexed at 90 degrees and the forearm neutral. Nonoperative treatment is indicated for nondisplaced or minimally displaced fractures. Surgery is indicated for displaced fractures, vascular injury, or open fracture.

SPECIFIC FRACTURE TYPES

Supracondylar Fractures of the Humerus

Supracondylar fractures are much more common in children. There are two types: extension (distal fragment is displaced posteriorly) and flexion (distal fragment is ­displaced anteriorly). Nondisplaced, minimally displaced, and severely comminuted fractures in the elderly with limited functional needs may be treated nonoperatively. Posterior splint immobilization is continued for 1-2 weeks after which gentle range of motion exercises are begun. The splint may be discontinued and weight bearing advanced after six weeks if signs of radiographic healing are appreciated. Surgical options include open reduction internal fixation with plates and screws. Total elbow replacement may be considered in elderly patients who were otherwise active with good preinjury function with severely comminuted fractures not amenable to ORIF.

Transcondylar Fractures

Nonoperative treatment is indicated for nondisplaced or minimally displaced fractures or for debilitated elderly patients with poor function preinjury. Range of motion exercises should be initiated as soon as the patient is able to tolerate therapy. Surgical options include ORIF or total elbow arthroplasty.

Intercondylar Fractures

Intercondylar fractures are the most common type of distal humerus fracture in adults. Fracture fragments are often displaced due to opposing muscle forces on the medial (flexor mass) and lateral (extensor mass) epicondyles, causing rotation of the articular surfaces (Figure 40–4). Fractures can be classified as type I (nondisplaced), type II (slight displacement with no rotation between the condylar fragments), type III (displacement with rotation), and type IV (comminution of the articular surface). Nonoperative treatment with two weeks of immobilization followed by range of motion exercises is indicated for nondisplaced fractures. Type IV fractures in the elderly with osteopenic bone can be treated with the “bag of bones” technique which entails very short-term immobilization with early range of motion. Open reduction internal fixation with dual plates is the preferred surgical treatment. Early range of motion is critical to prevent stiffness, unless fixation is tenuous. TEA is another option.

Condylar Fractures

Medial or lateral condyle fractures are rare in adults (Figure 40–5). Type I (Milch classification) fractures do not traverse the lateral trochlear ridge. Involvement of the lateral trochlear ridge (type II) leads to medial-lateral instability. Nonoperative treatment, entailing a posterior splint with elbow flexed to 90 degrees and the forearm supinated for lateral condyle fractures or pronated for medial epicondyle fractures, may be pursued for nondisplaced or minimally displaced fractures. Open or displaced fractures can be treated surgically with screw fixation with or without collateral ligament repair as needed.

Capitellum Fractures

Capitellum fractures are rare, representing less than 1% of all elbow fractures. Due to lack of significant soft tissue attachments, these fractures may result in a free articular fragment that may displace anteriorly into the coronoid or radial fossa causing a block to elbow flexion. These fractures typically result from a fall on an outstretched arm with the force transmitted through the radial head to the capitellum. Occasionally, radial head fracture may also be present. Capitellum fractures can be classified as follows (Figure 40–6): type I “Hahn-Steinthal” large osseous fragment with or without trochlear involvement, type II “Kocher-Lorenz” fragment articular cartilage with minimal subchondral bone attached, and type III (significant comminution). Nonoperative treatment, reserved for nondisplaced fractures, consists of immobilization in a posterior splint followed by elbow range of motion exercises. Surgical treatment entails ORIF with screws or excision for type II fractures, severely comminuted type I fractures or chronic missed fractures with limited range of motion.

Trochlea Fractures

These fractures are extremely rare and associated with elbow dislocation. Nondisplaced fractures can be treated with posterior splint for three weeks, followed by elbow range of motion exercises. Displaced fractures are treated with ORIF; fragments not amenable to internal fixation can be excised.

Epicondylar Fractures

Lateral epicondyle fractures can be treated with symptomatic immobilization with early range of motion. Nondisplaced or minimally displaced medial epicondyle fractures can be treated with immobilization in posterior splint with the forearm pronated, wrist and elbow flexed for 10-14 days. ORIF is indicated for displaced fractures, especially in the presence of ulnar nerve symptoms, valgus stress instability, wrist flexor weakness, and symptomatic nonunion.

Supracondylar Process Fractures

The supracondylar process is osseous or cartilaginous projection arising from the anteromedial surface of the humerus. The ligament of Struthers which connects the supracondylar process to the medial epicondyle is a fibrous arch through which the median nerve and brachial artery passes. Most of these fractures are amenable to closed treatment with symptomatic posterior splint immobilization followed by early range of motion. Median nerve or brachial artery compression are indications for surgical exploration and release.

Elbow Dislocation

Elbow dislocation most commonly results from a fall on an outstretched hand. A careful neurovascular ­examination along with AP and lateral radiographs of the elbow are required. Simple elbow dislocation (no associated fracture) are classified according to the direction of displacement of the ulna relative to the humerus: posterior (most common type), posterolateral, posteromedial, lateral, medial, and anterior (Figure 40–7). Acute elbow dislocations should undergo closed reduction with patient under sedation and adequate anesthesia as soon as possible. For posterior dislocation, the reduction maneuver entails longitudinal traction with elbow flexion. Postreduction range of motion exam, neurovascular exam, and radiographs should be performed, followed by placement in a posterior splint with 90 degrees of flexion. A block to full range of motion may indicate an incarcerated fracture fragment or inadequate reduction. If reduction does not restore arterial flow, angiography, and immediate operative intervention are warranted. Postreduction films should be carefully evaluated for concentric reduction and associated fractures (medial or lateral epicondyle, radial head, coronoid process). Elbow dislocation with radial head and coronoid process fractures is known as the “terrible triad”, due to associated instability. Surgical intervention is indicated when the elbow cannot be held concentrically reduced position, redislocates, or if the dislocation is deemed unstable (if the elbow dislocates prior to reaching 30 degrees of flexion from a fully flexed position). Recovery of motion and strength may take 3-6 months. The most common complication is stiffness, associated with prolonged immobilization. Recently, the trend has been to immobilize elbows for one week postinjury, and then start range of motion exercises. If symptomatic heterotopic ossification is present, excision can be pursued 6 months or longer after injury.

FRACTURES OF THE PROXIMAL ULNA

Olecranon Fractures

The olecranon is the most proximal palpable portion of the ulna. The subcutaneous position of the olecranon causes it to be especially susceptible to direct trauma. Posteriorly, the triceps tendon envelops the articular capsule before it inserts on to the olecranon. As a result, displaced fractures of the olecranon represent a functional disruption of the triceps mechanism, resulting in loss of active elbow extension. Anteriorly, the olecranon forms the greater sigmoid (semilunar) notch of the ulna, which articulates with the trochlea. The most proximal anterior portion of the ulna is the coronoid process, which lends stability to the elbow joint.

Olecranon fractures may result from a direct blow (fall on to the tip of the elbow) resulting in a comminuted olecranon fracture, or fall onto an outstretched arm accompanied by a strong, sudden triceps contraction resulting in a transverse or oblique fracture. Careful neurovascular exam followed by AP and lateral radiographs should be part of the initial evaluation. A true lateral radiograph should be carefully scrutinized for the extent of the fracture, any displacement of the radial head (the radial head should point toward the capitellum in all views; if this is not the case subluxation or dislocation is present), degree of comminution and articular surface involvement. Olecranon fractures are classified based on fracture pattern (transverse, transverse-impacted, oblique, comminuted, oblique-distal, or fracture dislocation) or according to the Mayo classification: type I (nondisplaced or minimally displaced), type II (displacement without elbow instability), type III (fracture with features of elbow instability). The goals of treatment are to restore articular congruity, restoration, and preservation of the elbow extensor mechanism and range of motion.

Nondisplaced fractures or displaced fractures in the elderly with poor preinjury function can be managed with closed treatment in a long-arm splint or cast with the elbow flexed from 45-90 degrees. Careful follow-up with radiographs should be done at weekly intervals for at least 2 weeks. In general, there is sufficient stability at 3 weeks to allow early motion from full extension to 90 degrees of flexion, with progression of flexion at 6 weeks. Of note some authors are advocating earlier range of motion at one week out from injury to prevent stiffness.

Indications for surgery include any disruption of the extensor mechanism (any displaced fracture) or articular incongruity. Multiple surgical options are available, including intramedullary fixation, tension band wiring, plate and screws, and excision. Postoperatively the patient should be placed in a posterior splint with early range of motion.

The most frequent complication of these fractures is prominent implants that subsequently require removal after healing has occurred. Elbow stiffness and loss of fixation have also been reported.

Coronoid Fractures

The coronoid process is the anterior beak-shaped portion of the ulna, forming the buttress anteriorly of the greater sigmoid notch. The anterior portion of the MCL attaches here, as well as a portion of the anterior capsule, contributing to elbow stability.

Isolated fractures of the coronoid are uncommon and are more frequently associated with posterior elbow dislocations or other fractures about the elbow. The mechanism of injury is usually forced posterior displacement of the proximal ulna as with a dislocation or hyperextension force of the elbow. Oblique radiographs may aid evaluation of these fractures as they are sometimes difficult to see on lateral and anteroposterior views.

These fractures have been classified by Regan and Morrey based on the size of the fracture fragment (Figure 40–8): type I (coronoid process tip avulsion), type II (single or comminuted fragment involving 50% or less of the coronoid process), type III (a single or comminuted fragment involving > 50% of the process). Type I fractures can be treated with immobilization in flexion for 3 weeks (or less if the fragment and elbow are stable). Associated fractures should be treated as appropriate in each case with the goal of fracture stability for early range of motion. Isolated coronoid fractures without elbow instability can be treated in the same way as type I fractures. Unstable type II fractures and type III fractures usually require operative intervention.

FRACTURES OF THE PROXIMAL RADIUS

Radial Head Fractures

Radial head fractures typically result from a fall on an outstretched arm causing an axial load collision between the radial head and capitellum. Patients typically present with limited elbow and forearm motion, along with pain with passive range of motion of the forearm. The forearm and wrist should be examined for any tenderness which may indicate the presence of an Essex-Lopresti type injury (radial head-fracture dislocation with associated ­interosseous ­ligament and distal radioulnar joint disruption). After documentation of neurovascular status, anteroposterior, lateral, and radial head view radiographs should be evaluated for fracture. Nondisplaced fractures should be suspected if a fat pad sign is present without obvious fracture. If Essex-Lopresti injury is suspected, additional radiographs of the forearm and wrist are indicated as well.

The Mason classification system is used to describe these fractures (Figure 40–9): type I (nondisplaced fractures), type II (marginal fractures with displacement), type III (comminuted fractures involving the entire radial head), and type IV (fracture associated with elbow dislocation).

Assessment of range of motion and stability to valgus stress is critical and can be performed after aspiration of the hemarthrosis and injection of lidocaine. This can be done through direct lateral needle insertion at the “soft spot” between the olecranon, radial head, and capitellum. Any mechanical block to motion should be carefully documented, as this can affect treatment decision-making.

Most isolated radial head fractures are treated with a brief period of immobilization in a sling followed by early range of motion 24-48 hours after the injury. Surgery is indicated for mechanical block to range of motion and type three fractures. A relative indication for surgery is displacement of a large fragment (> 2 mm); however, this is controversial. Surgical treatment options include ORIF, fragment excision with or without prosthetic replacement. Type IV injuries should be treated with closed reduction, followed by additional treatment based off of the above outlined criteria.

FRACTURES OF THE FOREARM

Forearm fractures are more common in men than women, secondary to a higher incidence of motor vehicle collisions, athletic injury, altercations, and falls from height experienced by men. The forearm acts as a ring: a fracture that significantly shortens the radius or ulna will cause disruption of the proximal radio-ulnar joint or distal radio-ulnar joint. The ulna acts as an axis around which the laterally bowed radius rotates during supination and pronation. The interosseous membrane occupies the space between the radius and ulna; it provides a significant contribution to forearm stability.

Clinical assessment includes careful neurovascular exam (median, radial, and ulnar nerves) and assessment of any open wounds (even superficial wounds) can expose an ulna fracture to the outside world due to its subcutaneous position. Practitioners should have a high index of suspicion for compartment syndrome, if pain out of proportion, tense compartments, or pain on passive stretch is present. Both-bone forearm fractures or fracture of one bone with concomitant injury to the elbow or wrist joint are more common than a fracture to either bone in isolation. As a result, it is crucial to obtain anteroposterior and lateral radiographs of the forearm that include both the wrist and elbow joints. The radial head must be aligned with the capitellum on all views to rule-out subluxation or dislocation.

Forearm fractures can be classified from a descriptive standpoint (closed vs. open, location, comminuted, segmental, multifragmented, displacement, angulated, and rotational alignment).

FRACTURES OF THE SHAFT OF THE RADIUS

Isolated Radial Shaft Fractures

Radial shaft fractures can result from direct trauma or indirect trauma such as a fall on an outstretched hand. Although, isolated fractures of the proximal two-thirds of the radius are possible, a fracture of the distal one-third should raise high suspicion for concomitant injury to the distal radial-ulna joint (DRUJ). Nondisplaced fractures can be managed closed in a long-arm cast. Any displacement, loss of radial bow, or concomitant injury to the DRUJ is surgical indications. Fractures of the radius are typically fixed with open reduction internal fixation with 3.5 mm DCP plates.

This is a fracture of the shaft of the radius (most commonly the distal third) in conjunction with a distal radioulnar joint injury. Wrist pain on physical examination should arouse suspicion. The diagnosis should be confirmed radiographically. DRUJ disruption is suggested by the following radiographic findings: fracture at the base of the ulnar styloid, widening of the distal radioulnar joint space on the anteroposterior radiograph, subluxation of the ulna, and radial shortening greater than 5 mm relative to the distal ulna.

In adults, these injuries should always be treated surgically with open reduction and internal fixation, along with intraoperative evaluation of the DRUJ. After fixing the radius, if the joint is stable through full pronation and supination, only short-term immobilization in a splint is required to protect the incision. If the joint can be reduced but is unstable with rotation, additional surgical treatment is necessary. If there is a repairable ulnar styloid fracture, then open reduction with internal fixation of this piece will result in a stable DRUJ. If there is no ulnar styloid fracture but the distal radioulnar joint is reducible but unstable with rotation, then two 0.0625-inch Kirschner wires are used to pin the distal ulna to the radius in a reduced position (usually supination). With both open reduction with internal fixation of the ulnar styloid and the use of transfixing pins, the forearm should be immobilized in full supination in an above-elbow cast or brace for 4-6 weeks. The transfixing pins are removed prior to allowing forearm range of motion. Rarely, the distal radioulnar joint cannot be reduced. In this instance, a dorsal approach to the joint is used to extract interposed tissues (extensor carpi ulnaris is most common) blocking reduction.

FRACTURES OF THE SHAFT OF THE ULNA

Isolated Ulnar Shaft Fractures (Nightstick Fractures)

Ulna night stick fractures usually results from a direct blow to the ulna along its subcutaneous border. Careful neurovascular examination and radiographs of the forearm including the wrist and elbow are essential. Radiographs should be carefully scrutinized for elbow dislocation; the radial head should point to the capitellum in all views or a Monteggia variant may be present. Nondisplaced or minimally displaced fractures may be treated acutely in a sugar tong splint. When swelling has subsided (after 7-10 days), the patient’s arm can be transitioned to a long-arm cast or functional brace. Displaced fractures (> 10 degrees of angulation or > 50% displacement of the shaft) are best treated surgically with open reduction internal fixation.

Monteggia’s Fracture

Monteggia’s fracture is a fracture of the proximal ulna with a radial head dislocation. Thorough neurovascular exam is necessary; injuries to the radial nerve or posterior interosseous nerve have been described. The Bado classification is based of the direction of the radial head dislocation: type I (anterior), type II (posterior), type III (lateral or anterolateral), and type IV (anterior dislocation with a fracture of the radius and ulna) (Figure 40–10).

Closed reduction and casting of Monteggia fractures should only be attempted in children. These injuries are typically treated with open reduction internal fixation with plates and screws. Of note failure of the ulna to reduce may indicate annular ligament interposition. If open reduction of the radial head is necessary, consideration should be given toward repairing the annular ligament. Postoperatively, if the repair is considered stable, the patient can be placed in a posterior splint for 7-10 days, followed by beginning range of motion exercises.

Both-Bone Forearm Fractures

Fractures of both radius and ulna are usually the result of high energy mechanisms (motor vehicle accidents or fall from a height). The fractures are most often displaced. Careful examination to rule out neurovascular injury and compartment syndrome should be performed. Radiographs of the entire forearm including the elbow and wrist are necessary.

Treatment for both-bone forearm fractures in adults consists of open reduction and internal fixation with compression plating using 3.5-mm dynamic plates. The goal of plate fixation is to restore: the normal ulnar and radial length, rotational alignment, and radial bow (which have been shown to be essential for rotation of the arm). With solid fixation, active range of motion of the forearm and elbow can be started at 10-14 days. Open fractures can also be treated successfully with these methods. However, if there is excessive soft tissue damage or wound contamination, the use of an external fixator may be a preferable option.

Complications of this fracture include nonunion, malunion, infection, neurovascular injury, compartment syndrome, synostosis, and loss of motion.

INJURIES OF THE WRIST REGION

Anatomy

The distal radius has three articulations: the sigmoid notch which articulates with the ulna, and facets for the scaphoid and lunate bones. The base of the ulna styloid serves as an insertion point for the triangular fibrocartilage ­complex (TFCC) which is the primary stabilizer of the DRUJ. Normally, 80% of the axial load is supported by the distal radius and 20% by the ulna and TFCC. There are six dorsal compartments of the wrist that contain wrist and digital extensor tendons. On the volar surface, the pronator quadratus lies across the distal radius and ulna. Just anterior to the pronator quadratus are the contents of the carpal canal, containing nine digital flexor tendons and the median nerve. Anterior to the transverse carpal ligament lie the flexor carpi radialis, flexor carpi ulnaris, and palmaris longus muscles. Guyon’s canal contains the ulnar nerve and artery. It is bounded by the volar retinacular ligament and flexor retinacular ligament, the hook of the hamate radially, and the pisiform ulnarly.

Extrinsic ligaments connect the radius to the carpus and the carpus to the metacarpals. The proximal row of carpal bones consisting of the scaphoid, lunate, triquetrum, and pisiform bones, are attached to the distal radius via two sets of radiocarpal ligaments (volar and distal). The volar radiocarpal ligaments (radioscaphocapitate, ­radioschapolunate, radiolunate, and radiolunotriquetral) are stronger and confer more stability to the radiocarpal articulation when compared to the dorsal radiocarpal ligaments. The radiocarpal joint is the primary joint for wrist motion (70 degrees of flexion/extension, 20 and 40 degrees of radial and ulnar deviation, respectively).

Intrinsic ligaments connect carpal bone to carpal bone (eg, scapholunate, etc). The distal carpal row, consisting of the trapezium, trapezoid, capitate, and hamate, is connected to each other and the base of the metacarpals with strong extrinsic ligaments. As a result, the distal carpal row is relatively immobile. The lunate is the key to carpal stability; injury to the scapholunate or lunotriquetral ligaments leads to unstable motion of the lunate and generalized carpal instability. Disruption of the scapholunate ligament or scaphoid fracture can lead to excessive dorsiflexion of the lunate and triquetrum (dorsal intercalated segmental instability). Injury to the lunotriquetral ligament leads to volar flexion of the lunate (volar intercalated segmental instability). The space of Poirer (ligament-free area between the capitate and lunate) is a potential area of weakness.

Normal anatomic relationships include radial inclination of 23 degrees, 11 mm of radial length, 11-12 degrees of palmar tilt, a 0 degree capitolunate angle (straight line drawn from the shaft of the third metacarpal, through the capitate and lunate with the wrist in a neutral position), a 47 degree scapholunate angle, and less than 2 mm of scapholunate space.

The vascular supply to the wrist consists of the radial, ulnar, and anterior interosseous arteries intertwining to form a network of arterial arches on the volar and dorsal surfaces of the carpal bones. The radial artery gives off branches that supply the scaphoid volarly (supplies distal scaphoid) and dorsally (supplies proximal scaphoid). The lunate typically receives blood supply from dorsal and volar surface branches.

1. Distal Radius Fracture

Epidemiology

More than 450,000 distal radius fractures occur annually in the United States, representing one-sixth of all fractures treated in emergency departments. The incidence of distal radius fractures increases with old age and osteopenia.

Mechanism

The most common mechanism for a distal radius fracture is fall on to an outstretched dorsiflexed hand. High-energy mechanisms such as motor vehicle collisions and falls from height can result in highly displaced or significantly comminuted fractures in younger patients.

Clinical Evaluation

Patients typically present with a swollen, ecchymotic, tender wrist. Deformity of the wrist is variable with dorsal displacement of the distal segment (Colles fracture) being more common than volar (Smith-type fracture). The ipsilateral elbow and shoulder should be carefully evaluated for concomitant injury. Careful neurovascular examination is paramount including the motor and sensory median, ulnar, and radial nerve distributions (Motor: a-ok, finger spread, and thumbs up signs; Sensory: volar aspect of the thumb, index, middle fingers, volar aspect of the small finger, and dorsal aspect of the thumb). Particular attention should be given to median nerve function as carpal tunnel syndrome is a relatively common complication (13%-23%) due to traction injury, fracture fragment trauma, hematoma, or increased compartment pressure.

Radiographic Evaluation

Posteroanterior and lateral views of the wrist should be obtained. Elbow and shoulder symptoms should also be evaluated radiographically. Contralateral wrist views may be used for comparison ulnar variance and the DRUJ. Computed tomography scan can be useful for further characterization of intra-articular involvement and preoperative planning. Normal radiographic relationships include the following averages: 23 degrees of radial inclination, 11 mm of radial length, and 11 degrees of palmar or volar tilt.

Classification

Distal radius fractures can be characterized descriptively—open versus closed, displacement, angulation, comminution, and loss of radial length. The Frykman classification organizes these fractures based on the degree of articular involvement as well concomitant fracture of the distal ulna (Figure 40–11). Higher classification fractures have worse prognoses.

Treatment

Emergent operative management is indicated for open fractures. Acute surgical intervention should be considered for distal radius fractures complicated by carpal tunnel syndrome that is not relieved with closed reduction.

Nonoperative Treatment

All distal radius fractures should undergo closed reduction, even if surgical intervention is expected. The benefits of fracture reduction include limiting postinjury swelling, pain relief, and median nerve decompression. Although casting may be considered for nondisplaced or minimally displaced fractures with minimal swelling, a sugar-tong splint is generally preferred encompassing the dorsal and volar aspects of the wrist, limiting subsequent forearm rotation and possible fracture displacement. One week post injury the patient may be transitioned to a long-arm cast. If closed treatment is planned, radiographic evaluation should be done on a weekly basis for the first two to three weeks to monitor for displacement. Acceptable radiographic parameters for continued closed treatment include: radial length within 2-3 mm of the contralateral wrist, neutral palmar tilt (0 degrees), intra-articular step off less than 2 mm, and radial inclination less than 5-degree loss. Surgery is indicated if reduction with respect to the above stated parameters cannot be achieved or maintained.

Closed Reduction Technique

Hematoma block, Bier block, or conscious sedation can be used to provide analgesia. Hematoma block offers the benefit of speed and does not require that the patient have been without oral intake for a significant amount of time. Conscious sedation offers the benefit of muscle relaxation facilitating reduction. Initially manual or fingertrap-assisted traction is applied facilitating reduction via ligamentotaxis. For dorsally tilted fractures, volar directed pressure is applied to the distal fracture segment. C-arm if available can be used to assess fracture reduction. Once reduction is adequate a well-molded long-arm (“sugar tong”) splint can be applied with the wrist in neutral and the metacarpaphalangeal joints free.

Techniques of Surgical Management

Many surgical options are available. Choice of operation is determined by several factors, including the fracture pattern, bone quality, and surgeon preference.

Closed Reduction Percutaneous Pinning

Reduction is achieved via closed means, followed by fixation typically with 0.0625-inch Kirschner wires. Interfragmentary technique entails wires used to stabilize a fracture and prevent collapse after reduction is achieved. With intrafocal technique where these wires are driven into the fracture site, used to lever the pieces achieving reduction, and then driven through the opposite cortex to maintain reduction. Postoperatively patients are placed in a splint or cast. The wires are typically removed after 6 weeks once bone healing is appreciated radiographically.

External Fixation

This technique uses ligamentotaxis to restore radial length and radial inclination, but it rarely restores palmar tilt. It is especially useful for treating very comminuted or intra-articular fractures where there are several small pieces. External fixation is also useful for treating open fractures with severe tissue compromise or as a temporizing measure when a patient has other critical medical issues that need immediate attention.

Open Reduction and Internal Fixation

In recent years, volar plating has become much more popular compared to dorsal plating due to its advantages when treating distal radius fractures with significant dorsal comminution, as well as the extensor tendon complications associated with dorsal plating of the distal radius.

Complications

Stiffness of the wrist and digits is common. Patients should be instructed to begin range of motion exercises for the digits immediately after the fracture is initially treated. Include median nerve dysfunction, malunion, nonunion, stiffness, posttraumatic arthritis, tendon rupture, finger, wrist, and elbow stiffness. Articular congruity post surgical fixation is critical for avoiding the development of posttraumatic arthritis.

Isolated Radial Styloid Fracture

Also called a “chauffeur’s fracture,” “backfire fracture,” or “Hutchinson fracture” this is an avulsion fracture with ­extrinsic ligaments remaining attached to the styloid fragment. This injury is often associated with intercarpal ligamentous injuries such as scapholunate dislocation or perilunate dislocation. This injury often requires open reduction with internal fixation.

FRACTURES OF THE ULNAR STYLOID

Fractures of the ulnar styloid are commonly seen in conjunction with distal radius fractures and can also be seen in isolation. Fractures of the tip of the ulnar styloid are often too small to fix. However, large fragments (the entire styloid from its base) may be indicative of a TFCC disruption that can lead to DRUJ instability. As a result, these displaced fractures should be treated with open reduction and internal fixation.

DISTAL RADIOULNAR JOINT DISLOCATION

DRUJ dislocation is discussed earlier in the section describing the Galeazzi fracture. DRUJ dislocation can also occur with a simple distal radius fracture. Careful examination of radiographs and the distal radioulnar joint will keep the clinician from missing this injury in the face of a distal radius fracture.

FRACTURES & DISLOCATIONS OF THE CARPUS

Most carpal bone fractures occur in the proximal carpal row, with the scaphoid being the carpal bone most commonly fractured. Carpal bone fractures usually occur in younger people, often from high energy falls on an outstretched hand Wrist radiographs can be difficult to interpret, and careful scrutiny is necessary so as not to miss these injuries. In addition to the standard anteroposterior, lateral, and oblique views of the wrist, special radiographic views such as a scaphoid view (anteroposterior radiograph with the wrist supinated 30 degrees and in ulnar deviation), clenched fist view (to evaluate for carpal instability), or carpal tunnel view can often be helpful. Computed tomography is also useful to identify fractures if radiographs are inconclusive; MRI is sensitive for detecting occult fractures, osteonecrosis of carpal bones, and soft injuries including disruption of the scapholunate ligament or TFCC.

1. Fracture of the Scaphoid

The scaphoid is the carpal bone most commonly fractured. Anatomically, the scaphoid is divided into proximal and distal poles, a tubercle, and a waist. The blood supply for the scaphoid comes largely from branches of the radial artery traveling from a distal to proximal location. As a result, fractures of the scaphoid at the waist or more proximal are particularly prone to nonunion or avascular necrosis.

Fractures of the scaphoid most commonly occur as a result of a fall on an outstretched hand. Patients typically present with pain on the radial side of their wrist and tenderness to palpation over the anatomic snuffbox. Physical examination maneuvers include the scaphoid lift test (reproduction of pain with dorsal-volar shifting of the scaphoid) and the Watson test (painful dorsal scaphoid displacement as the wrist is moved from ulnar to radial deviation with compression of the tuberosity). Radiographic evaluation includes a “scaphoid view,” in addition to the standard wrist series. Initial radiographs are nondiagnostic in up to 25% of cases. As a result, if clinical exam suggests a scaphoid fracture, it is appropriate to employ a trial of immobilization with repeat radiographs in 1-2 weeks. Additionally, technetium bone scan, MRI, or CT scan can be used to diagnose occult scaphoid fractures that continue to not be visualized on radiograph, despite persistent pain. Scaphoid fractures can be classified based on the pattern (horizontal oblique, transverse, vertical oblique), displacement (nondisplaced fractures with no step-off are considered stable, displaced fractures > 1 mm, scapholunate angulation > 60 degrees, radiolunate angulation > 15 degrees), and location (tuberosity, distal pole, waist, and proximal pole). Nondisplaced fractures should be treated in a long-arm thumb spica cast for 6 weeks. After 6 weeks, the patient’s wrist can be placed in a short-arm spica cast until the fracture is united. Expected time to union for distal third fractures is 6-8 weeks, 8-12 weeks for middle third fractures, and 12-24 weeks for proximal third fractures. Surgical indications include fracture displacement more than 1 mm, radiolunate angle more than 15 degrees, scapholunate angle more than 60 degrees, humpback deformity, or nonunion. Complications of scaphoid fractures include fracture nonunion or avascular necrosis (Figure 40–12). Patients with long-standing scaphoid nonunions go on to develop early arthritis of the radioscaphoid joint secondary to altered mechanics of the wrist.

2. Fracture of the Lunate

The lunate is the carpal bone most likely to dislocate, but fractures are rare. Fractures usually result from a fall on an outstretched hand. Patients typically present with tenderness to palpation over the volar wrist overlying the distal radius and lunate with painful range of motion. Radiographs are usually not helpful due to overlapping densities of multiple bones; CT, MRI, or bone scan are usually required to make the diagnosis. Nondisplaced fractures can be treated in a short- or long-arm cast. Displaced or angulated fractures require surgical treatment. Osteonecrosis (Keinbock’s disease), can complicate this injury leading to advanced collapse and radiocarpal degeneration. Several surgical treatments are available for this sequella.

3. Fracture of the Hamate

This fracture generally occurs from a direct blow to the area such as occurs when swinging a baseball bat or golf club that suddenly comes to an abrupt stop as it encounters a firm surface. Patients present with ulnar-sided hand pain over the hamate. Fracture will often not be seen on routine wrist and hand radiographs. A carpal tunnel view (20 degree supination oblique view of the wrist) should be obtained if this fracture is suspected. If the diagnosis is suspected clinically but the radiographs show no fracture, a CT scan may be helpful. Nondisplaced fractures may be treated in a short-arm cast for six weeks. Displaced fractures of the body can be treated with open reduction internal fixation with screws or wires.

4. Other Carpal Bone Fractures

Fractures can occur in any of the other carpal bones as well, but much less commonly. Triquetral avulsion or dorsal impaction fractures can occur from falls on the outstretched hand. Isolated fractures of the remaining carpal bones are rare and generally occur with high-energy trauma and other injuries.

5. Traumatic Carpal Instability

Severe injury to the wrist causing damage to the complex ligamentous structures may lead to carpal bone dissociation, carpal dislocations, and fracture dislocations. The lunate is often called the “carpal keystone”; its ligamentous attachments to the radius and other carpal bones make a significant contribution to radiocarpal stability. A sequence of progressive perilunate instability starts with scapholunate disruption (stage I), then midcarpal or capitolunate disruption (stage II), lunotriquetral disruption (stage III), ending in disruption of the radiolunate joint leading to volar lunate dislocation (stage IV).

Scapholunate dissociation secondary to disruption of the scapholunate and the radioscapholunate ligament leads to altered kinematics of the wrist and early degenerative arthritis. Clinical findings include volar wrist tenderness/bruising, positive Watson test, pain with grasping, and decreased grip strength. Radiographically, widening of the scapholunate space more than 3 mm (“Terry Thomas” sign), or scapholunate angle more than 70 degrees on the lateral are indicative of scapholunate disruption. Closed reduction with an audible, palpable click followed by thumb spica immobilization for 8 weeks is the first line of treatment. Inability to obtain or maintain reduction is surgical indications.

Lunotriquetral dissociation occurs as a result of disruption of the radiolunotriquetral ligament. Patients typically present with swelling over the peritriquetral area and tenderness dorsally, typically 1-2 cm distal to the ulnar head. Radiographs may show disruption of the normal proximal carpal row contour; frank gapping of the lunotriquetral space is rarely seen. Treatment with a short arm cast for 6-8 weeks or closed reduction with pinning of the lunate to the triquetrum is warranted.

Carpal dislocations represent a continuum of perilunate ligamentous injury with frank lunate dislocation being the final stage. Patients present with severe wrist pain and swelling after trauma. Most dislocations can be diagnosed with adequate AP and lateral views of the wrist. With a perilunate dislocation, the lunate remains in its normal position, articulating with the distal radius, but is angled in a volar direction, and the rest of the carpus is dislocated. With lunate dislocation, on the lateral radiograph the lunate will be volar to the rest of the carpus and not in alignment with the distal radius. Treatment of carpal dislocations is accomplished with closed reduction of the midcarpal joint via traction combined with direct manual pressure over the capitate and lunate. Irreducible dislocations or unstable injuries should be treated surgically with open reduction internal fixation.

Ulnocarpal dissociation may result from disruption of the TFCC, where the lunate and triquetrum assume a supinated and palmar flexed position, while the distal ulna subluxes dorsally. Radiographs may show ulnar styloid avulsion or dorsal displacement of the ulna; MRI may demonstrate TFCC tear. Treatment requires operative repair of the TFCC and/or ORIF of large displaced ulnar styloid fragments.

Even with the best care, carpal bone and ligament injuries can be devastating, with long-term sequelae of pain, stiffness, and early arthritis.

FRACTURES & DISLOCATIONS ABOUT THE HAND

Metacarpal and phalangeal fractures are relatively common comprising a significant portion of emergency department visits. The significant variation in mechanism of injury accounts for the large number of different types of fracture patterns seen in hand injuries. Axial load or “jamming” injuries often result in shearing articular fractures or metaphyseal compression fractures, sometimes with concomitant injury to the carpus, forearm, elbow, and shoulder due to force transmission. Injury mechanisms with a bending component result in diaphyseal fractures or joint dislocations. Individual digits or joints caught in clothing or equipment can result in spiral fractures or complex dislocations. Industrial settings with heavy objects predispose to crushing mechanisms of injury. The direction of fracture angulation depends on the deforming forces caused by attached muscle. The palmar and dorsal interosseous muscles arise from the metacarpal shafts, usually flexing the fracture causing apex-dorsal angulation. Proximal phalynx fractures typically angulate in the opposite direction, apex-volar. Middle phalynx fractures angulate variably, while distal phalynx fractures are usually comminuted tuft fractures resulting from crush injuries. Clinical evaluation includes documentation of the patient’s age, hand dominance, occupation, mechanism of injury, time of injury, exposure to contamination, and financial issues (workman’s compensation). Physical examination should document neurovascular status, and pay particular attention range of motion, angulation, and malrotation (best evaluated when the intervening joint is flexed to 90 degrees). Radiographic evaluation includes AP, lateral, and oblique radiographs of the hand and the specific injured digit. Fractures can be classified descriptively: open versus closed, location, fracture pattern (comminuted, transverse, spiral, vertical split, extra-articular versus intra-articular, stable versus unstable, and angulational or rotational deformity. Fractures of the small bones of the hand heal more rapidly than fractures of larger bones, and prolonged immobilization can cause stiffness and loss of motion that can be difficult or impossible to regain. As a result, fractures of the metacarpals and phalanges should not be immobilized for more than 3 weeks except under rare circumstances, due to subsequent development of stiffness. The safe position for splinting or casting of the hand is with slight wrist extension, the MP joints flexed 60-90 degrees, and the PIP and DIP joints extended. This “intrinsic plus” position, puts the ligaments of the hand on maximum stretch, avoiding posttreatment stiffness.

1. Open Fractures, Fight Bite, and Animal Bites

These types of fractures require special consideration. Open fractures of phalanges or metacarpals can be classified according to the Swanson, Stabo and Anderson classification: type I (clean wound without significant contamination or delay in treatment), type II (contamination with gross dirt/debris, human or animal bite, lake/river injury, barnyard injury or in patients with significant systemic illness such as diabetes, hypertension, rheumatoid arthritis [RA], hepatitis, or asthma). Type I injuries can be treated with primary internal fixation and immediate wound closure. Although type II injuries can be treated with primary internal fixation (no increase in infection rate); these injuries should not be closed primarily. Delayed closure is preferred to decrease infection risk.

Any laceration overlying a joint in the hand, particularly the metacarpal-phalangeal (MCP) joint must be suspected as being caused by a human tooth. Also known as a “fight bite,” these injuries should be assumed to have been contaminated with oral flora and treated aggressively with broad spectrum antibiotics including anaerobic coverage. Animal bites require antibiotic treatment that covers Pasteurella and Eikenella.

2. Metacarpal Fractures

Metacarpal Head Fractures

Fractures of the metacarpal can be subclassified as follows: epiphyseal fractures, collateral ligament avulsion fractures, oblique, vertical, and horizontal head fractures, comminuted fractures, and fractures with joint loss. Most of these fractures require anatomic reduction to reestablish joint congruity and avoid posttraumatic arthritis. Stable reductions of fractures may be splinted in the intrinsic plus position. If unstable, percutaneous pinning, ORIF, or external fixation are options.

Metacarpal Neck Fractures

Metacarpal neck fractures are typically caused by direct trauma with volar comminution and dorsal apex angulation. The most common metacarpal neck fracture is the “boxer’s fracture” of the fifth metacarpal, usually caused by the fist striking a stationary object. These fractures can typically be closed reduced successfully. The degree of acceptable ­deformity varies according to the metacarpal injured: less than 10 degrees for the second and third metacarpal, less than 30-40 degrees for the fourth and fifth metacarpals. Unstable fractures require surgical intervention with percutaneous pinning or open reduction internal fixation.

Metacarpal Shaft Fractures

Nondisplaced or minimally displaced metacarpal shaft fractures can be reduced and splinted. Surgical indications include rotational deformity (all fingers should point toward the scaphoid when flexed), dorsal angulation more than 10 degrees for second and third metacarpals, and more than 40 degrees for fourth and fifth metacarpals.

Metacarpal Base

Fractures of the base of the second, third, and fourth metacarpals are typically minimally displaced and treated with splinting and early range of motion. A reverse Bennett fracture is a fracture dislocation of the fifth metacarpal and hamate bones. This injury often requires ORIF.

Fractures of the thumb metacarpal base can be extra-articular or intra-articular. Extra-articular fractures are usually transverse or oblique, and amenable to closed reduction and casting. Unstable fractures may require percutaneous pinning. Intra-articular fractures come in two types: type I or Benett’s Fracture where a single fracture line separates the majority of the metacarpal from the volar lip fragment and type II also known as Rolondo’s fracture which is a comminuted intra-articular fracture usually with a “Y” or “T” pattern including dorsal and palmar fragments. Both type I and type II fractures are treated with closed reduction and percutaneous pinning or ORIF.

3. Proximal and Middle Phalanx Fractures

Intra-articular fractures can be classified as condylar fractures or fracture-dislocations. There are three types of condylar fractures: unicondylar, bicondylar, or osteochondral. Each of these fractures require anatomic reduction; ORIF should be performed for more than 1 mm displacement. Comminuted intra-articular fractures not amenable to surgical treatment, can be treated closed with early protected mobilization.

Fracture dislocations come in two varieties: volar lip fracture or dorsal lip fracture. Volar lip fracture (dorsal fracture-dislocation) treatment is controversial; if less than 35% of the articular surface is involved the injury may be treated with buddy taping, however, for more than 35% some recommend ORIF or volar plate arthroplasty if the fracture is comminuted while others recommend extension block splint if the joint is not subluxed. Dorsal lip fracture (volar fracture-dislocation) with less than 1 mm of displacement may be treated closed with splinting while more than 1 mm displacement requires operative intervention.

Extra-articular fractures of the phalanges should be initially treated with closed reduction with finger-trap traction and splinting. Unstable fractures should be treated surgically.

Distal phalynx fractures

Intra-articular dorsal lip fractures may be complicated by an extensor tendon disruption resulting in a “mallet finger.” “Mallet finger” may also result from purely tendinous disruption, without fracture. For either scenario, treatment is controversial. Some recommend full-time extension splinting for 6-8 weeks, while others recommend surgical intervention. For professionals who work extensively with their hands, such as surgeons, full-time extension splinting is not practical. Closed reduction with percutaneous pinning is a good option.

Intra-articular volar lip fractures can be associated with a flexor digitorum profundus rupture resulting in a “jersey finger” often seen in football or rugby players, most commonly involving the ring finger. Treatment is typically surgical, especially if large displaced bony fragments are present.

Extra-articular fractures can be transverse, longitudinal, or comminuted (nail matrix injury very common). These fractures are usually treated with closed reduction and splinting that traverses the DIP joint, leaving the PIP joint free. Surgery is indicated for fractures with wide irreducible displacement, due to the increased risk of nonunion.

Nailbed Injuries

Nailbed injuries are easily missed in the context of distal phalynx fractures. When untreated, these injuries result in nail growth disturbances. Subungual hematomas are often indicative of nail bed injury. The nail plate should be removed and the hematoma drained. Nailbed disruptions should be carefully sutured with 6-0 chromic catgut under magnification. The nailplate should be replaced to keep the nail fold open; alternatively a piece of aluminum foil or xeroform gauze can be used.

4. Dislocations of the Digits

Carpometacarpal dislocations are usually high energy injuries. Careful neurovascular examination is essential. These injuries usually require surgical intervention for maintenance of a stable reduction.

MCP joint dislocations are usually dorsal in direction, presenting with a hyperextended posture. Simple dislocations can be reduced by flexion of the joint without traction. Wrist flexion, causing the flexor tendons to relax, can be used to facilitate the reduction maneuver. Complex MCP dislocations with the volar plate interposed in the joint are irreducible. The pathognomonic radiograph finding is the appearance of the sesamoid in the joint space. Complex dislocations require surgery. Traction during reduction of simple dislocations should be avoided as simple dislocations can be converted into complex ones. Volar dislocations are rare; however, because they are particularly unstable, they often require surgical intervention.

Thumb MCPs are unique due to the multiplanar motion of the thumb MCP joint. With a one-sided collateral ligament injury, the phalynx tends to sublux volarly rotating around the opposite intact ligament. The ulnar collateral ligament of the thumb MP joint is the most commonly injured ligament in the digits. If the injury is acute, it is called a “skier’s thumb,” whereas chronic injury from repetitive trauma is known as a “gamekeeper’s thumb.” Nonoperative treatment with reduction and thumb spica splinting or casting is usually sufficient. A “Stener” lesion occurs when the ulnar collateral ligament avulses, and comes to rest dorsal to the adductor aponeurosis. The ulnar collateral ligament is not able to return to its normal insertion, preventing healing. As a result, Stener lesions and irreducible MCP dislocations require surgical intervention.

Proximal interphalangeal (PIP) joint dislocations include dorsal dislocation, pure volar dislocation, and rotatory volar dislocation. Once reduced, rotatory volar dislocations, collateral ligament ruptures, and dorsal dislocations congruent in full extension on the lateral radiographs can all begin active range of motion exercises immediately with adjacent digit strapping. Dorsal dislocations that continue to sublux on lateral radiograph, can be treated with a few weeks of extension block splinting. Volar dislocations with central slip disruptions are treated with 4-6 weeks of PIP extension splinting, followed by an additional 2 weeks of night-time splinting. Irreducible dislocations or unstable reductions may require surgical intervention.

Distal interphalangeal (DIP) dislocations and thumb IP joint dislocations can present late. Injuries are considered chronic after 3 weeks. Acute reduced dislocations may begin immediate active range of motion. Unstable dislocations should be immobilized in 30 degrees of flexion for 3 weeks. Complete collateral ligament injury should be protected from lateral stress for at least 4 weeks. Recurrent stability can be treated with Kirschner wire fixation. Chronic dislocation may be treated with open reduction to resect scar tissue, allowing for a tension free reduction. Transverse open wounds in the volar skin crease are not infrequent. Open dislocations require debridement to prevent infection.

INJURIES OF THE HIP REGION

1. Hip Dislocations

Epidemiology

Hip dislocations of the native hip are relatively rare, usually due to high energy injury such as a motor vehicle accident. Posterior hip dislocations (85%-90%) are more common than anterior (remaining 10%-15%). Ten to twenty percent of posterior hip dislocations can be complicated by sciatic nerve injury. Anterior hip dislocations are associated with a greater incidence of femoral head injury. Up to 50% of patients with a hip dislocation will sustain a concomitant fracture elsewhere (most commonly of the ipsilateral femur or pelvis).

Anatomy

The hip articulation is a ball-and-socket joint, formed by the femoral head and acetabulum. Forty percent of the femoral head is covered by the acetabulum. The labrum surrounding the acetabulum has the effect of deepening the hip joint, increasing its stability. The medial and lateral circumflex femoral arteries from the profunda femoral artery form an extracapsular vascular ring at the base of the femoral neck; ascending branches provide the primary blood supply to the femoral neck and head, along with a minor contribution from the ligamentum teres off of the obturator artery. The contribution of the medial and lateral circumflex arteries is often disrupted with hip dislocation, leading to long-term complications including avascular necrosis. The sciatic nerve exits the pelvis at the greater sciatic notch, traveling deep to the piriformis muscle, down the posterior aspect of the thigh.

Clinical Evaluation

A full trauma survey is essential due to the high energy nature of this injury. Patients typically present with severe discomfort and inability to move the injured extremity. The classic appearance of a posterior hip dislocation is shortened extremity with the hip flexed, internally rotated and adducted (Figure 40–13). Patients with an anterior ­dislocation hold their hip with marked external rotation, mild flexion, and abduction. Careful neurovascular examination is key. If the sciatic nerve is injured often the tibial nerve is preserved with the peroneal portion of the nerve showing the effects of injury. Radiographic evaluation includes an AP view of the pelvis as well as radiographs of the entire ipsilateral femur. Evaluate the femoral neck and acetabulum to rule-out concomitant fractures.

Treatment

The hip should be reduced emergently due to the risk of osteonecrosis from associated vascular disruption. Regardless of the direction of the dislocation, the hip can be reduced with in-line longitudinal traction with the patient supine. The key to successful reduction is relaxation of the patient’s muscles which is accomplished with adequate sedation (ideally via general anesthesia, or iv sedation if general anesthesia is not available) and fatiguing of the patient’s muscles that occurs with time. Following closed reduction, the hip should be examined for stability by flexing the hip to 90 degrees in neutral position and applying a posteriorly directed force. If any subluxation is detected, the hip is deemed unstable, and will require surgery or traction. Postreduction radiographs should be obtained to confirm reduction. Careful comparison should be made with the contralateral side, to determine of the reduction is concentric. Even slight asymmetry or subluxation may indicate the presence of a concomitant fracture or incarcerated piece of bone in the joint. Additionally, postreduction CT should be performed to investigate the presence of other fractures or an incarcerated bony fragment. If closed reduction is unsuccessful, open reduction should be performed as soon as possible.

Fractures of the Femoral Head

Fractures of the femoral head are extremely rare. Most are secondary to motor vehicle accidents and are associated with hip dislocations. Clinical evaluation included careful neurovascular exam, AP view of the pelvis as well as AP and lateral radiographs of the injured hip. Femoral head fractures can be classified according to the Pipkin classification: type I (hip dislocation with fracture of the femoral head inferior to the vovea capitis femoris), type II (hip dislocation with fracture of the femoral head superior to the fovea capitis femoris), type III (type I or type II injury with femoral neck fracture), and type IV (type I or type II injury with associated fracture of the acetabular rim). Type I fractures involve the non–weight-bearing surface of the femoral head. As a result, closed treatment can be pursued if reduction is adequate (<1 mm step-off). Type II fractures involve the weight-bearing surface. Thus, if the reduction is not anatomic as seen on CT, surgical treatment should be pursued. Type III and type IV injuries usually require surgical treatment. Complications include osteonecrosis and posttraumatic arthritis.

The Femoral Neck

Approximately 350,000 fractures of the femoral neck occur each year. This number is expected to double by the year 2050 due to the aging demographics of the American population. Fractures of the femoral neck occur most often in elderly patients with osteopenic bone after a fall. Femoral neck fractures in patients less than 50 years old are rare, usually due high energy trauma. Patients with displaced fractures usually present with inability to walk, severe pain, and an externally rotated and shortened extremity. Patients with nondisplaced fractures may present with mild, persistent hip pain (for several days or couple of weeks); these patients often will have been walking, as a result index of suspicion should be high. A careful secondary survey should be performed, as 10% of elderly patients have associated upper extremity injuries. Radiographic evaluation includes AP pelvis radiograph, AP and lateral radiographs of the hip; and internal rotation or traction view can further delineate the fracture pattern. If no fractures are detected in an elderly patient with persistent hip pain, one should consider MRI or bone scan to look for a nondisplaced or incomplete fracture.

Fractures of the femoral neck may be classified according to location (subcapital, transcervical, and basicervical), or based on stability of the fracture pattern. The Pauwel’s classification describes increasing instability of the increasing fracture angle from the horizontal: type I (30 degrees), type II (50 degrees), and type III (70 degrees). The garden classification describes four patterns: type I (incomplete fracture/valgus impacted), type II (complete fracture, nondisplaced), type III (complete fracture, with partial displacement, the trabecular bone pattern of the femoral head does not line up with the acetabulum), and type IV (completely displaced fracture, the trabecular bone pattern of the head does line up with the acetabulum).

Some authors advocate nonoperative treatment with limited weight-bearing for type I or valgus impacted fractures. Others advocate internal fixation with multiple screws to prevent fracture displacement. Type II (nondisplaced) fractures are treated with internal fixation, regardless of the patient’s age. Treatment of type III and type IV (displaced) fractures is more controversial. For patients less than 60 years old, with good bone quality and little fracture comminution open-reduction internal fixation is the usual choice. For patients more than 60 years old, with osteopenic bone and comminuted fractures arthroplasty is the treatment of choice. Unipolar hemi-arthroplasty is most commonly used. If the patient has evidence of preexisting acetabular arthritis, total hip-arthroplasty may be offered. Recent studies have suggested that in the elderly, previously active patient with intact mental status, total hip arthroplasty may be the best treatment option for displaced femoral neck fracture. Although, bipolar arthroplasty theoretically reduces the risk of prosthetic arthritis compared with unipolar hemiarthroplasty; this has not been borne out in the literature. As a result, given the higher cost, most authors do not advocate the use of bipolar hemiarthroplasty.

2. Trochanteric Fractures

Fracture of the Lesser Trochanter

Isolated fractures of the lesser trochanter are quite rare. This fracture occurs most commonly in the adolescent patient secondary to forceful iliopsoas contracture. In the elderly patient, this fracture may be secondary to metastatic disease.

Fracture of the Greater Trochanter

Like isolated fractures of the lesser trochanter, isolated fracture of the greater trochanter is rare. The typical mechanism is direct blow due to fall in an elderly patient. Treatment is typically nonoperative. In a young, active patient with a widely displaced greater trochanter, surgery may be ­considered.

Intertrochanteric Fractures

Intertrochanteric fractures describe fractures that occur in the region between the greater and lesser trochanters of the proximal femur. These fractures are extracapsular, occurring in cancellous bone with abundant blood supply. Unlike displaced femoral neck fractures, these fractures are not predisposed to nonunion and osteonecrosis. These fractures are relatively common, accounting for nearly 50% of all fractures of the proximal femur (Figure 40–14). The typical presentation occurs in an elderly individual after a fall. Clinical evaluation includes neurovascular check, secondary survey, and appropriate x-rays (AP pelvis, AP, and lateral of injured hip). One may consider an internal rotation or traction view for improved delineation of the fracture. Consider MRI or Technetium bone scan in a patient with persistent hip pain despite negative radiographs; these two studies may be useful for delineating nondisplaced or incomplete fractures.

It is important to evaluate the location of fracture line (proximal to distal), obliquity of the fracture line, the degree of comminution (paying specific attention to the posteromedial cortex which determines stability) and magnitude of displacement. Basicervical neck fractures are located just proximal to or along the intertrochanteric line. These fractures are usually extracapsular; however, the proximity to the blood supply of the femoral neck can result in a higher incidence of osteonecrosis. Typically, intertrochanteric fractures have an oblique fracture line that extends from the lateral cortex proximally to the medial cortex distally; this “standard obliquity” fracture pattern is considered stable, amenable to standard surgical treatment. “Reverse obliquity” intertrochanteric fractures (oblique fracture line extending from the medial cortex proximally to the lateral cortex distally), are considered unstable. Significant posteromedial comminution indicates an unstable fracture. Finally, subtrochanteric extension of the fracture should be noted, as it may affect treatment choice.

Nonoperative treatment is associated with a higher mortality rate when compared to operative treatment. As a result, it may be considered only for patients who carry high surgical risk or demented/nonambulatory patients with mild hip pain. Early bed to chair immobilization is crucial to avoid the risks and complications of prolonged recumbence (atelectasis, deep venous thrombosis, and ulcers).

Treatment is usually surgical, with the goal being early ambulation with full weight-bearing status. Dynamic hip screw (large screw and side plate) is the typical surgical implant of choice. Intramedullary hip screws are used for “unstable” fracture patterns including: reverse obliquity IT fractures, fractures with significant posteromedial comminution, and fractures with subtrochanteric extension. Finally, arthroplasty may be chosen in patients for whom previous ORIF has failed or as primary treatment for comminuted, unstable fractures.

Subtrochanteric Fracture

The Subtrochanteric femur fracture is located between the lesser trochanter and a point 5-cm distal to the lesser trochanter. This stretch of bone is subjected high biomechanical stresses. The medial and posteromedial cortices are sites of high compressive forces, while the lateral cortex experiences high tensile forces. Additionally, this area of bone is composed mainly of cortical bone. Due to less vascularity when compared to cancellous bone, the potential for healing is diminished.

The mechanism of injury may be low energy such as a fall in an elderly person or high energy in patients involved in motor vehicle accidents, falls from heights, or gunshot wounds. Additionally, fractures in this region may be pathologic in nature due to bone metastases.

Clinical evaluation includes standard trauma evaluation for patients involved in high-energy injury mechanisms. Field-dressings or splints should be completely removed to examine for soft-tissue injury and rule-out open fracture. Neuro-vascular status should be documented. Secondary survey should be performed. Blood loss can be significant in the thigh compartments, representing a potential source for hypovolemia. Traction pin should be considered until definitive fixation can be performed, to limit further soft tissue damage and bleeding. Radiographic evaluation includes the AP pelvis, AP and Lateral views of the hip and femur down to the knee.

The fracture may be classified according to its distance from the lesser trochanter, fracture line characterization, number of bone fragments, and involvement of the piriformis fossa.

Open fractures should be treated with immediate surgical debridement and fracture stabilization. Surgical treatment can involve the use of an intramedullary nail or fixed-angle plates depending on the fracture pattern (Figure 40–15).

The fracture is typically healed by 3-4 months postoperatively months, but delayed union and nonunion are not uncommon. Hardware failure can occur in these cases, requiring repeat internal fixation and bone grafting.

FRACTURE OF THE SHAFT OF THE FEMUR

A femoral shaft fracture is a fracture of the femoral diaphysis that occurs between 5 cm distal to the lesser trochanter and 5 cm proximal to the adductor tubercle. Femoral shaft fractures typically occur in young men after high-energy trauma, such as motor vehicle accidents. This injury can occur in the elderly after a fall, although less common. Fractures that are inconsistent with the level of trauma should be suspected for pathologic fracture.

The vascular supply to the femoral shaft is derived mainly from the profunda femoral artery. Due to the large volume of the three fascial compartments of the thigh (anterior, medial, and posterior), significant blood loss and hemodynamic instability can occur. In one series, blood loss was greater than 1200 mL, with 40% of patients ultimately requiring blood transfusion.

Clinical evaluation includes careful neurovascular exam and secondary survey looking for concomitant injury to other joints and extremities. Specific attention should be paid to the ipsilateral hip and knee joints. Knee ligament injuries are common and easily missed. Radiographic evaluation should include AP and lateral views of the femur as well as the ipsilateral hip and knee. AP pelvis should also be obtained. Ipsilateral femoral neck and intertrochanteric fractures have been reported in up 10% of patients with femur fractures.

Femoral shaft fractures can be classified descriptively: open versus closed, location (proximal, middle, and distal one-third), pattern (spiral, oblique, and transverse), degree of comminution, angulation, rotational deformity, displacement, and amount of shortening. Winquist and Hansen described a classification based off amount of comminution: type I (minimal or no comminution), type II (cortices of both fragments at least 50% contact), type III 50%-100% cortical comminution, and type IV (circumferential comminution with no cortical contact).

In the acute setting, femoral shaft fractures can be stabilized with skeletal traction. Traction provides pain relief, and can help minimize soft tissue injury and blood loss. Ideally surgical stabilization should occur within 24 hours of injury (Figure 40–16). If surgery is delayed due to an unstable patient, traction has the added benefit of pulling the fracture fragments out to length, making subsequent fracture reduction and operative treatment more manageable.

Open fractures constitute a surgical emergency. Fractures should be debrided and stabilized as soon as possible. The most frequently used surgical treatment for femoral shaft fractures is intramedullary (IM) nailing. Compared with plate fixation, IM nailing offers the following benefits: lower infection rate, less extensive exposure/dissection of the fracture promoting healing, less quadriceps scarring, and lower tensile and shear stresses on the implant. Other advantages include early functional use of the extremity (the surgeon may allow immediate weight-bearing depending on strength of surgical management), restoration of length and alignment, rapid and high union rate, and low refracture rates.

IM nailing can be performed in an antegrade or retrograde fashion. Indications for retrograde nailing include ipsilateral injuries (fracture of the femoral neck, pertrochanteric, patella, acetabulum, or tibia), bilateral femoral shaft fractures, morbidly obese patient, pregnant woman, ipsilateral knee amputation, or when speed of surgical treatment is essential (unstable patient). Contraindications to retrograde nailing include restricted knee motion (< 60 degrees), patella baja, presence of associated open traumatic wound increasing the risk of intra-articular knee sepsis. One major disadvantage to retrograde nailing is the postoperative incidence of anterior knee pain.

Other surgical options include plating and external fixation. External fixation may be used acutely as a temporary bridge in the severely injured, unstable patient. Plating may be indicated in patients whose femoral canals are not amenable to IM nailing (medullary canal too narrow, medullary canal obliterated due to infection, previous closed fracture management, etc).

Postoperatively early patient mobilization and knee range of motion is recommended. Weight-bearing status is dependent on multiple factors, including the strength of operative fixation, patient’s other injuries, soft tissue status, and location of fracture. Later complications are those of prolonged recumbence, joint stiffness, malunion, nonunion, leg-length discrepancy, and infection.

INJURIES OF THE KNEE REGION

1. Fractures of the Distal Femur

Distal Femur fractures account for about 7% of all femur fractures. Incidence follows a bimodal age distribution with the first peak occurring in young adults as a result of high-energy trauma and the second peak occurring in the elderly after a fall. Distal femur fractures can be subclassified as supracondylar or condylar fractures.

The supracondylar region of the femur is the area between the femoral condyles and the junction of the metaphysic with the femoral shaft. The distal femur widens from the cylindrical shaft to form two curved condyles separated by an intercondylar groove. The medial condyle extends more distally and is more convex than the lateral condyle, producing the normal valgus position of the distal femur. The proximal fracture fragment is typically pulled superiorly by the quadriceps and hamstrings, the distal fragment is typically displaced and angulated posteriorly due to the pull of the gastrocnemius muscle.

Neurovascular examination is key as the distal fragment may impinge on the popliteal fossa, causing a loss or marked decrease of pedal pulses. Immediate reduction is indicated. If reduction of the fracture fragment fails to restore pulses, immediate arteriogram, and vascular operative intervention is indicated. Secondary survey should be performed, with concomitant injury to the ipsilateral hip, knee, leg, and ankle ruled-out. If a distal femoral fracture is associated with an overlying laceration or wound, the ipsilateral knee should be injected with 50 mL of sterile normal saline to rule-out continuity with the wound.

Radiographic evaluation includes anteroposterior, lateral, and oblique radiographs of the distal femur as well as the entire length of the femur (Figure 40–17). Traction views and computed tomography may be helpful for preoperative planning. MRI may be used to evaluate injuries to the meniscus and ligaments of the knee. Arteriography should be considered in the setting of knee dislocation (up to 40% associated vascular disruption reported in the literature).

Distal femur fractures may be classified descriptively: open versus closed, location (supracondylar, intercondylar, and condylar), fracture pattern (spiral, oblique, and transverse), intra-articular versus extra-articular, degree of comminution, angulation, rotational deformity, displacement, and amount of shortening.

Nonoperative treatment may be pursued for stable nondisplaced fractures. Treatment involves immobilization of the extremity in a hinged knee brace with partial weight-bearing.

Displaced distal femur fractures are best treated surgically. If operative treatment is delayed more than 8 hours, a tibial traction pin should be considered. Plates and screws are the typical choice of implant. A variety of plates are available including the 95-degree condylar blade plate, nonlocking periarticular plates, and locking periarticular plates. Due to the advantage of increased stability, locking periarticular plates are becoming more popular.

Dislocation of the Knee Joint

Traumatic knee dislocation is extremely rare. However, this injury can be limb threatening due to disruption of the vasculature. The knee is a “hinge” joint consisting of three articulations: patellofemoral, tibiofemoral, and tibiofibular. Normal range of motion of the knee is from 10 degrees of extension to 140 degrees of flexion. Significant soft tissue injury including disruption of three out of four major ligaments of the knee (anterior cruciate, posterior cruciate, medial collateral, and lateral collateral ligaments) is necessary for knee dislocation to occur. During knee dislocation the popliteal vascular bundle may be injured or tethered. Associated fractures of the tibial eminence, tibial tubercle, fibular head or neck, and capsular avulsions should be ruled-out. The mechanism is typically high energy.

If the knee remains dislocated at presentation, immediate reduction should be performed without waiting for radiographs. Postreduction neurovascular status should be carefully documented. Isolated ligament examination may be difficult to perform due to patient discomfort. Standard ligament examination includes Lachman’s testing for the ACL, posterior drawer for the PCL, and varus and valgus stress to assess the LCL and MCL, respectively. Due to the incidence of delayed ischemia resulting from vasospasm or thrombosis occurring hours or even days after reduction, serial neurovascular exams should continue to be performed.

If a limb remains ischemic (absent pulses) after reduction, emergent surgical exploration is indicated; do not wait for an arteriogram. If the limb continues to display abnormal vascular status (diminished pulses, decreased capillary refill or ABI < 0.9) then arteriogram is indicated. Normal vascular status should be followed closely with serial exams.

Radiographic evaluation includes AP, lateral, notch views of the knee as well as “sunrise” view of the patella. Arteriography is indicated as described above. MRI is used to evaluate the ligaments and menisci of the knee, as well as articular cartilage lesions.

Knee dislocations can be classified according to the displacement of the proximal tibia in relation to the distal femur (anterior, posterior, lateral, medial, and rotational).

Immediate closed reduction is achieved with axial traction followed by placement of a splint with the knee in 20-30 degrees of flexion. Of note, posterolateral dislocation usually requires open reduction. Surgery is indicated for unsuccessful closed reduction, residual soft tissue interposition, open injuries, and vascular injuries. External fixation may be necessary for grossly unstable knees and dislocations that required vascular repair. Prophylactic fasciotomy of the leg compartments should be considered at the time of vascular repair to eliminate the compartment syndrome caused by postischemic edema. Ligamentous repair is controversial; timing of surgery is dependent on the status of both the patient and the limb.

2. Fracture of the Patella

Patella fractures only represent 1% of all skeletal injuries, occurring most commonly in the 20- to 50-year-old age group. The patella is the largest sesamoid bone in the body, with the quadriceps tendon inserting at its superior pole and the patellar ligament originating from the inferior pole. The patella has seven articular facets; the lateral facet is the largest (accounting for 50% of the articular surface). The medial and lateral extensor retinacula are strong longitudinal expansions of the quadriceps that envelop the patella and insert on the tibia. If the retinacula are intact, active extension will be preserved despite patella fracture.

The function of the patella is to increase the lever arm and mechanical advantage of the quadriceps tendon. The blood supply originates from the geniculate arteries which form anastomoses circumferentially around the outer border of the patella. Fractures of the patella may result from direct trauma or more commonly from forceful quadriceps contraction while the knee is semi-flexed during a stumble or fall.

Open lacerations associated with patella fracture should be investigated with 50 mL of sterile saline solution instilled into the knee joint to rule-out communication and open fracture. Active knee extension should be assessed; decompression of hemarthrosis and intra-articular lidocaine injection may facilitate testing.

Radiographic examination anteroposterior, lateral, and sunrise views of the knee. Of note bipartite patella (8% of the population) may be confused with fracture. Bipartite patella usually occurs in the superolateral portion of the patella and has smooth margins. Interestingly, it is bilateral in 50% of patients; thus contralateral knee x-rays may facilitate diagnosis.

Patella fractures may be classified descriptively: open versus closed, degree of displacement, fracture pattern (stellate, comminuted, transverse, vertical, polar, or osteochondral).

Nondisplaced or minimally displaced (2 mm) with minimal articular disruption (1 mm or less) can be treated nonoperatively in a knee immobilizer for 4-6 weeks if the extensor mechanism remains intact.

Surgical treatment for displaced fractures includes tension band wires, cerclage wiring, screws, or combination thereof. Retinacular disruption should also be repaired at the time of surgery. Postoperatively, the patient should be placed in a splint to protect the skin; knee motion should be instituted early 3-6 days postoperatively with progression to full weight bearing by 6 weeks. Severely comminuted or marginally repaired fractures may be immobilized longer. Partial patellectomy may be performed in the setting of large salvageable fragment with a smaller, comminuted polar fragment not amenable to stable surgical fixation. Total patellectomy is rarely indicated, reserved for extensive patella fractures with severe comminution.

Dislocation of the Patella

Patella dislocation is more common in women as well as patients with connective tissue disorders (Ehlers-Danlos or Marfan’s) due to increased soft tissue laxity. Dislocation of the patella can be acute (traumatic) or chronic (recurrent).

Patients with an unreduced patella dislocation will present with inability to flex the knee, hemarthrosis, and palpably displaced patella. Patients with reduced or chronic patella dislocation may demonstrate a positive “apprehension test,” where laterally directed force applied to the patella with the knee in extension reproduces pain and sensation of impending patella dislocation.

Radiographic evaluation includes anteroposterior and lateral views of the knee along with sunrise views of bilateral patellae for comparison. Assessment of patella alta (high-­riding patella) or patella baja should also be performed using the Insall-Salvati ratio (the ratio of the patellar ligament length compared to the length of the patella, normal = 1.0; a ratio of 1.2 indicates patella alta, while 0.8 indicates patella baja).

Patella fractures may be classified descriptively: reduced versus unreduced, congenital versus acquired, acute (traumatic) versus chronic (recurrent), as well as direction of dislocation (lateral, medial, intra-articular, superior; note: lateral is most common).

These injuries are typically treated closed with reduction and casting or bracing with the knee in extension. Operative intervention is generally reserved for recurrent dislocation.

Tear of the Quadriceps Tendon

Quadriceps tendon tears occur most commonly in patients more than 40 years old. The tendon usually ruptures within 2 cm of the superior pole of the patella. Location of rupture is associated with the patient’s age: for patients more than 40 years old, the tear usually occurs at the bone-tendon junction, however, for patients less than 40 years old, the tear is often midsubstance. Risk factors for quadriceps tendon rupture include anabolic steroid use, local steroid injection, diabetes mellitus, inflammatory arthropathy, and chronic renal failure. Typically patients present with a history of a sudden “pop” while stressing the extensor mechanism. Patients have pain at the site of injury, difficulty with weight-bearing, knee joint effusion, tenderness at the upper pole of the patella, and a palpable defect proximal to the superior pole of the patella. Complete tears result in loss of active knee extension, partial tears can still have knee extension.

Radiographic examination includes anteroposterior, lateral, and sunrise views of the knee. Nonoperative treatment includes immobilization with the knee in extension for 4-6 weeks followed by progressive physical therapy. Complete ruptures should be surgically repaired. Choice of surgical technique varies depending on location of the tear: complete ruptures near bone require reapproximation of the tendon to bone using nonabsorbable sutures passed through bone tunnels. Midsubstance tears may undergo end-to-end repair.

Tear of the Patellar Ligament

Patella tendon ruptures are less common than quadriceps tendon ruptures. This injury typically occurs in patients less than 40 years old. Rupture commonly occurs at the inferior pole of the patella; risk factors include RA, lupus, diabetes, renal failure, systemic corticosteroid treatment, local steroid injection, and chronic patella tendonitis. Patients typically provide a history of an “audible” pop after forceful quadriceps contraction. Physical examination may show a palpable defect, hemarthrosis, painful passive range of motion, and partial or complete loss of active extension. Radiographic examination includes AP and lateral x-rays of the knee. Nonoperative treatment is reserved for partial tears, with intact extensor mechanism. Early repair (within 2 weeks of surgery) is preferred to delayed repair (> 6 weeks from injury), which is technically more demanding due quadriceps contraction and patellar migration, as well as adhesions.

FRACTURES OF THE PROXIMAL TIBIA

1. Fractures of the Tibial Plateau

Tibial plateau fractures account for 1% of all fractures. Isolated lateral tibial plateau fractures are most common; although isolated fractures of the medial tibial plateau and bicondylar fractures happen as well.

Anatomy

The tibia is the primary weight-bearing bone in the leg, supporting 85% of the transmitted load. The tibial plateau consists of the articular surfaces of the medial and lateral tibial plateaus. The medial plateau is larger and concave in shape, while the lateral plateau extends higher and is convex in shape. Normally, the plateau has a 10-degree posteroinferior slope. The two plateaus are separated by the intercondylar eminence, which serves as the tibial attachment for the anterior and posterior cruciate ligaments. There are three bony prominences 2- to 3-cm distal to the tibial plateau that serve as important insertion sites for tendinous structures: the tibial tubercle is located anteriorly and serves as the insertion for the patellar ligament, pes ansirinus is located medially and serves as attachment for semi-tendinosus, sartorius, and gracilis muscles, and Gerdy’s tubercle which is the insertion sight for the iliotibial band is located laterally. The peroneal nerve travels around the neck of the fibular head splitting into the superficial peroneal nerve which travels down the lateral aspect of the leg anterior to the fibula and the deep peroneal nerve which dives deep and travels down through the anterior compartment. The trifurcation of the popliteal artery is located posteriorly between the adductor hiatus proximally and the soleus complex distally. These structures are all at risk with a tibial plateau fracture.

Mechanism of Injury

Tibial plateau fractures are usually the result of axial loading coupled with varus or valgus force. There is a bimodal distribution where young people experience these fractures after motor vehicle collisions, while the elderly can after a simple fall.

Clinical Evaluation

Neurovascular examination is necessary to documenting the function of the deep peroneal, superficial peroneal, medial, and lateral plantar nerves distally is crucial. Additionally, the documentation of the popliteal artery, dorsalis pedis, and posterior tibial artery is required as well. Associated injuries include meniscal tears as well as injuries to the collateral and cruciate ligaments. Although, initial swelling and pain may prevent examination of these ligaments. When the swelling has reduced, ligamentous testing should be carried out. Consider intra-articular injection of the knee in the acute setting, in order to carry out a ligamentous exam.

The skin should be carefully examined for any breaks to rule-out open fracture. Intra-articular injection of 50 mL of sterile normal saline can be performed to rule-out communication of the fracture and overlying skin lacerations.

Radiographic Examination

AP and lateral x-rays of the knee are part of the standard evaluation (Figure 40–18). Additionally, 40 degree internal or external rotation oblique views can be used to better assess the lateral and medial tibial plateaus respectively. A 5-10 degree caudally tilted plateau view can be used to evaluate articular step-off. CT scan is best for assessing the articular surface and is often used for preoperative planning. Associated ligamentous injury may be indicated by avulsion of the fibular head (LCL injury) and Segond sign (lateral capsular avulsion off of the lateral tibial plateau, indicating ACL disruption). MRI should be considered if ligamentous injury is suspected. Arteriography should be performed if vascular injury is suspected.

Classification

Tibial plateau fractures are most commonly classified according to the Schatzer classification: type I (lateral plateau, split fracture), type II (lateral plateau, split depression fracture), type III (lateral plateau, depression fracture), type IV (medial plateau fracture), type V (bicondylar plateau fracture), and type VI (plateau fracture with extension into the metaphysis. Of note, types IV-VI are higher energy fractures. Type I split fractures usually occur in younger individuals and are often associated with injury to the MCL. Type III depression fractures usually occur in older individuals with osteoporotic bone.

Treatment

Initial treatment for lower energy fractures usually entails placement in a knee immobilizer locked in full-extension, non–weight-bearing status with crutches. For higher energy fractures with significant displacement, placement in a posterior splint or external fixation should be considered.

Nondisplaced or minimally displaced fractures can be treated with protected weight-bearing and early knee range of motion in a hinged brace. Radiographs should be taken at regular intervals to ensure no further displacement. Progression to full weight bearing can occur at 8-12 weeks from injury, if no further displacement occurs and fracture healing is appreciated radiographically.

Surgical indications include displacement of the articular surface, open fractures, compartment syndrome, or associated vascular injury. A variety of operative methods are used including external fixation, and open reduction internal fixation with plates or screws depending on fracture type and surgeon preference.

The postoperative course usually entails non–weight-bearing with continuous passive motion and progressive active range of motion. Progression to full weight-bearing is usually allowed by 8-12 weeks after surgery.

FRACTURE OF THE SHAFTS OF THE TIBIA & FIBULA

Fractures of the tibia and fibula are the most common long bone fractures. Mechanism of injury can be low-energy due to twisting/rotation or high energy related to motor vehicle accidents. Isolated fractures of the tibia and/or fibula are rare; these fractures most often occur together.

Anatomy

The tibia is a tubular bone with a triangular cross-section. The tibia has a subcutaneous anteromedial border and is otherwise enveloped by four tight fascial compartments (anterior, lateral, posterior, and deep posterior). The fibula is responsible for 10%-15% of the weight-bearing load. The common peroneal nerve is located subcutaneously, traveling around the fibular neck, making it particularly vulnerable to direct blows or traction injuries at this level.

Clinical Evaluation

Neurovascular status, including the deep peroneal, superficial peroneal, medial, and lateral plantar nerves, as well as the posterior tibial artery and dorsalis pedis artery should be documented carefully. Thorough skin examination should be performed to rule-out open fracture. Additionally, the examiner should have a high suspicion for compartment syndrome in the acute setting. Pain out of proportion, pain with passive stretch, tense compartments, numbness, tingling, and cool toes are all signs of compartment syndrome. For obtunded or intubated patients who cannot relate an accurate history or their symptoms (pain level, presence of numbness/tingling), a monitor can be used to measure pressures in each of the four compartments. Greater than 30 mm Hg or pressure within 30 mm Hg of the diastolic pressure, are accepted indications for fasciotomy.

Radiographic Evaluation

Radiographic investigation begins with AP and lateral x-rays of the tibia and fibula (Figure 40–19). Additionally, x-rays of the joint above and below should also be performed to rule-out other injury. Radiographs should be examined carefully to determine the location and morphology of the fracture, the presence of any secondary fracture lines that could displace during operative management. CT scan and MRI are rarely necessary. Technetium bone scans and MRI can be used in patients with persistent pain to diagnose stress fractures in tibial shafts that were not visible on radiographs.

Classification

Fractures of the tibia shaft can be classified descriptively: open versus closed, anatomic location (proximal, middle, or distal third), fragment number and position (comminution, butterfly fragments), configuration (transverse, spiral, oblique), angulation (varus/valgus, anterior/posterior), shortening, displacement (percentage of cortical contact), rotation, and associated injuries.

Open fractures are classified according to the Gustilo and Anderson classification, described at the beginning of this chapter.

Treatment

Fracture reduction and closed treatment in a long-leg cast with the knee in 0-5 degrees of flexion may be attempted for isolated, closed, low-energy fractures with minimal displacement and comminution. Protected weight-bearing with crutches with advancement to full weight bearing after 2-4 weeks is usually tolerated. After 4-6 weeks the long-leg cast may be exchanged for a short-leg cast or fracture brace. Regular radiographic follow-up is crucial to ensure no further displacement of the fracture. Acceptable parameters for continued closed treatment include: less than 5 degrees of varus/valgus angulation, less than 10 degrees of anterior/posterior angulation, less than 10 degrees of rotational deformity (external rotation is tolerated better than internal rotation), less than 1cm shortening, and more than 50% cortical contact.

Fractures with significant displacement or comminution that requires operative intervention, can be treated acutely with a posterior long-leg splint or external fixation if significant shortening is noted. Definitive surgical treatment includes several options: intramedullary nailing, external fixation, plates, and screws. Intramedullary nailing is by far the most popular technique as it preserves the periosteal blood supply, optimizing conditions for fracture healing. Compartment syndrome should be treated emergently with four-compartment fasciotomies. Concomitant fractures of the fibula do not require surgical treatment once the tibia has been stabilized.

1. Fracture of the Shaft of the Fibula

Isolated fracture of the shaft of the fibula is uncommon though it can occur with a direct blow to the side of the lower leg. Particular attention should be given to clinical and radiographic examination of the ankle and knee to rule out ligamentous or other subtle bony injuries. If no other injury is present, immobilization is for comfort only. Three weeks or a month in a walking cast or removable cast boot is usually sufficient, and complete healing can be expected.

INJURIES OF THE ANKLE REGION

1. Ankle Fracture

The incidence of ankle fractures has increased significantly since the 1960s. Most ankle fractures are isolated malleolar fractures; however, bimalleolar and trimalleolar fractures make up approximately one-third of the total. Open fractures are rare.

Anatomy

The ankle is a hinge joint composed of the fibula, tibia, and talus articulations along with several important ligaments. Specifically, the distal tibial articular surface is often referred to the “plafond,” which combined with the medial and lateral malleoli, forms the mortise which is a constrained articulation with the talar dome.

The talar dome is trapezoidal in shape and almost entirely covered with articular cartilage. The anterior portion of the talus is wider than the posterior portion. The tibial plafond is also wider anteriorly in order to accommodate the shape of the talus, conferring intrinsic stability to the ankle joint.

The medial malleolus, which articulates with the medial facet of the talus, can be divided into the anterior colliculus and posterior colliculus which serve as attachments for the superficial and deep deltoid ligaments, respectively. The deltoid ligament provides ligamentous support to the medial aspect of the ankle. The superficial portion of the deltoid is composed of three ligaments: tibionavicular ligament (prevents inward displacement of the talar head), tibiocalcaneal ligament (prevents valgus displacement), and the superficial tibiotalar ligament.

The lateral malleolus is the distal portion of the fibula, articulating with the lateral aspect of the talus. The distal fibula is attached to the distal tibia via soft-tissue constraint known as the syndesmosis. The syndesmosis, which is made up of four ligaments (anterior inferior tibiofibular, posterior inferior tibiofibular, transverse tibiofibular, and interosseous ligaments), resists axial, rotational, and translational forces, making it critical for ankle stability. The fibular collateral ligament, composed of the anterior talo-fibular ligament (ATFL), posterior talo-fibular ligament, and calcaneofibular ligament provides additional stability to the lateral aspect of the ankle.

Clinical Evaluation

Neurovascular status (deep peroneal, superficial peroneal, medial and lateral plantar nerves, posterior tibial artery, and dorsalis pedis artery) should all be documented. The skin should be examined for open injury and blistering. The entire length of the fibula, including the proximal portion (head and neck) should be palpated, to rule-out additional fractures. The “squeeze test” performed approximately 5 cm to the intermalleolar axis can be used to assess for syndesmotic disruption.

Radiographic Evaluation

Initial workup includes AP, Lateral and mortise (15-20 degrees of internal rotation) x-rays of the ankle. Radiographs of the full tibia and fibula including the knee joint should be obtained to identify additional injuries. The dome of the talus should be centered under the tibia in all three views. Tibiofibula overlap less than 10 mm, tibiofibula clear space more than 5 mm, and medial clear space between the medial malleolus and talus all indicate syndesmotic disruption. If initial mortise views do not indicate medial clear space widening, an external rotation or gravity stress can be applied to the ankle. If widening more than 4 mm is noted with this stress, then significant syndesmotic injury is likely. Additionally, talar shift is indicative of ligamentous disruption. CT scan, MRI, and bone scan can be used to further investigate ankle injuries.

Classification

Ankle fractures can be classified according to the Lauge–Hansen system which focuses on four patterns of ankle injury that are the result of different mechanisms. The Supination-adduction (SA) fracture patent usually results in medial displacement of the talus and a transverse or avulsion-type fracture of the fibula distal to the joint and/or a vertical medial malleolus fracture. The supination-external rotation (SER) injury is the most common, producing variable disruption of the ATFL, spiral fracture of the distal fibula, posterior malleolus fracture, and fracture of the medial malleolus or deltoid ligament disruption. The pronation-abduction (PA) or pronation-external rotation (PER) injuries result in variable injury or fracture to the medial malleolus, deltoid ligament, syndesmotic ligament, and distal fibula fractures.

Ankle fractures can also be classified according to the Weber classification based off of the level of fibula injury: Weber A (fracture of the fibula below the tibia plafond), Weber B (oblique or spiral fracture of the fibula occurring at or near the level of the syndesmosis), and Weber C (fracture of the fibula above the level of the syndesmosis). The two classification systems correlate as follows: Weber A (SA injury pattern), Weber B (SER), and Weber C (PA or PER).

Other fracture variants include: Maisonneuve fracture (ankle injury with fracture of the fibula proximal third) and various avulsion fractures due to disrupted ligaments.

Treatment

The goal of treatment is anatomic restoration of the ankle joint with preservation of fibular length and rotation. Initial treatment, includes closed reduction and placement in a well-padded posterior splint with stirrups. Postreduction radiographs should be obtained to ensure correct position of the talus under the tibia. The injured limb should be elevated to the level of the heart at all times.

Nondisplaced, stable fracture patterns (isolated malleolus fractures) without disruption of the syndesmosis can be treated closed–transitioned from the splint to a long-leg cast for 4-6 weeks with serial radiographic examination to ensure no subsequent displacement. After this time, the patient can be transferred to a short-leg cast. Weight-bearing is restricted until fracture healing is demonstrated.

Surgical treatment is indicated for displaced medial malleolus fractures, and lateral malleolar fractures with displacement more than 2 mm or any loss of fibular length. Isolated lateral malleolus fractures with minimal displacement and no loss of length should be investigated for syndesmotic injury. Medial sided tenderness or medial clear-space widening noted radiographically is indicative of additional injury resulting in what is likely an unstable ankle fracture; as a result, surgery is usually recommended.

Surgical treatment includes plates and/or screws. For bimalleolar and trimalleolar fractures, the fibula is initially fixed with a plate and screws. The medial malleolus fracture remains unreduced, it should be stabilized with screws or tension band construct. Indications for surgical fixation of the posterior malleolus fracture include: involvement of more than 25% of the articular surface, persistent more than 2-mm displacement, or persistent posterior subluxation of the talus. Bimalleolar equivalent fractures (fibula fractures with medial ligament injury or syndesmotic disruption) may require syndesmotic screws. Proximal fibula fractures with syndesmotic disruption can be stabilized with syndesmotic screws once correct fibula length and rotation are achieved via reduction maneuvers.

Postoperative course usually entails non–weight-bearing in a splint/cast/removable boot for 4-6 weeks until fracture healing is appreciated radiographically. Ankle range of motion exercises should be started early to prevent postoperative stiffness.

2. Ankle Sprain

Ankle sprain is common, usually the result of forced inversion or eversion of the foot. Pain is usually maximal over the anterolateral aspect or medial aspects of the joint depending on the mechanism of injury. Ankle sprain is a diagnosis of exclusion. If no fractures, dislocations, or widening (> 4 mm) is appreciated between either malleolus or the talus then ankle sprain is a reasonable diagnosis.

Ankle sprains are usually treated with “RICE” (rest, ice, compression with elastic ace wrap, and elevation), NSAIDs, and non–weight-bearing or protected weight-bearing with crutches for 3-5 days. Splinting or use of an air cast is optional. Continued pain and/or swelling that have not improved require further workup.

3. Syndesmosis Injuries

Introduction

Syndesmotic injuries account for approximately 1% of all ankle ligament injuries. Many of these injuries go on undiagnosed and can lead to chronic ankle pain and instability if not treated appropriately.

Clinical Evaluation and Diagnosis

Patients often present late, several hours or even days after a twisting injury to ankle, with persistent swelling/pain/difficulty weight-bearing. The fibula should be palpated along its entire length, proximally and distally. Two clinical tests have been used to evaluate for isolated syndesmotic injury: (1) the squeeze test—if squeezing the fibula midcalf reproduces distal tibiofibular pain or (2) external rotation test—pt is seated with knee flexed to 90 degrees, examiner stabilizes the patient’s leg and externally rotates the foot; if pain is reproduced at the syndesmosis than injury is likely.

Radiographic Evaluation

Radiographic evaluation starts with anteroposterior, lateral, and mortise views of the ankle looking for widening of the medial clear space between the medial malleolus and the medial border of the talus or widening of the tibiofibular clear space (interval between the medial border of the fibula and the lateral border of the posterior tibial malleolus). If no injury is appreciated, external rotation stress view (mortise view with an external rotation stress applied to the foot with the leg stabilized) should be performed.

Classification

Syndesmotic injuries can be organized according to the Edwards and DeLee classification: type 1 (diastasis involving lateral subluxation without fracture), type 2 (lateral subluxation with plastic deformation of the fibula), type 3 (posterior subluxation/dislocation of the fibula), and type 4 (superior subluxation/dislocation of the talus).

Treatment

Patients can be initially immobilized in a non–weight-bearing cast for 2-3 weeks, followed by use of an ankle-foot orthosis that eliminates external rotation of the foot for and additional 3 weeks. Operative intervention with syndesmotic screws from the fibula to the tibia is considered for patients with and irreducible diastasis. These patients are often kept non-weight bearing for 6 weeks with screw removal at 12-16 weeks.

4. Pilon Fractures

Epidemiology

Tibial Plafond or “Pilon” fractures are fractures that involve the weight bearing surface of the distal tibia that articulates with the talus (Figure 40–20). Pilon fractures account for 7%-10% of all tibia fractures. Most occur in men aged 30-40 years old from high energy mechanisms such as motor vehicle collisions or falls from significant height. As a result, extra care should be taken to rule out concomitant injuries. Specifically, tibial plateau, calcaneus, pelvis, and vertebral fractures should be ruled-out.

Mechanism of Injury

A fall from significant height results in an axial compression force directed through the talus into the tibial plafond, causing impaction and comminution of the articular surface. Shear injuries, such as can occur in a skiing accident, will result in a fracture with two or more large fragments and minimal comminution. Combined compression and shear result in fracture pattern that is somewhere in between.

Clinical Evaluation

Examination of the patient includes documentation of a neurovascular exam and secondary survey to rule-out other injuries. Careful skin examination should be performed to exclude open fracture. Swelling is often rapid and considerable, potentially resulting in skin necrosis and blistering depending on fracture displacement. As a result, these fractures should be reduced provisionally and placed in a splint as soon as possible. The amount of swelling should be noted; some authors advocate waiting 7-10 days before taking patients to surgery for swelling to subside or until “skin wrinkling” is appreciated to avoid postoperative wound complications.

Radiographic Evaluation

Initial radiographic evaluation includes anteroposterior, lateral, and mortise views of the ankle joint. CT with thin cuts, coronal, and sagittal reconstructions is useful for preoperative evaluation of the fracture pattern and articular surface. One should also consider radiographs of the contralateral side, which can be used for preoperative templating.

Classification

The Ruedi and Algower classification is most commonly used: type 1 (nondisplaced fracture), type 2 (displaced fracture with minimal impaction and comminution), and type 3 (displaced fracture with significant comminution and/or metaphyseal impaction).

Treatment

Choice of treatment is based off of multiple factors including the fracture pattern, as well as patient characteristics: age of patient, functional status, severity of injury to soft tissues, bone, cartilage, degree of comminution and/or osteoporosis, other injuries to the patient, and comfort level of the surgeon.

Nonoperative treatment, which involves long-leg cast for 6 weeks followed by bracing and range of motion exercises with progressive weight-bearing, is reserved for the non-displaced fracture or severely debilitated patients.

Displaced fractures are usually treated surgically. Surgery may be delayed for 7-14 days to allow the soft tissues to calm down in an effort to avoid postoperative wound complications. “Skin wrinkling” may indicate that enough swelling has subsided for operative intervention to occur. Spanning external fixation should be considered initially to provide stabilization, partial fracture reduction, and restoration of length while waiting for final surgical management. Associated fibula fractures may undergo open reduction internal fixation at the time of fixator application.

The goals of operative fixation of pilon fractures include restoration of fibula length and stability, restoration of the tibial articular surface, buttressing of the distal tibia, and bone grafting metaphyseal defects as needed. Definitive surgical management may involve plates and screws, external fixation, or a combination thereof.

5. Achilles Tendon Rupture

Epidemiology

Achilles tendon problems are often related to overuse injury. In the setting of trauma, acute rupture can occur. Delayed or missed diagnosis is common, caregivers should therefore have a high index of suspicion for this injury.

Anatomy

The Achilles tendon is the largest tendon in the body. It has a paratenon with visceral and parietal layers, instead of a true synovial sheath, allowing approximately 1.5 cm of tendon glide. There are three sources for the tendon’s blood supply: (1) musculotendinous junction, (2) osseous insertion, (3) and multiple mesosternal vessels on the tendon’s anterior surface.

Clinical Evaluation

Complete rupture often results in a palpable defect in the tendon that is not present with an incomplete injury. In the setting of complete rupture the Thompson test (plantar flexion with calf squeeze) is positive (no plantar flexion occurs) and the patient is unable to perform a single heel-raise.

Treatment

Surgical treatment compared with non-operative management results in lower recurrent rupture rates, improved strength, and a higher percentage of patients returning to sports activities. However, there are significant complication rates associated with surgery including, wound infection, skin necrosis, and nerve injuries. As a result, surgery is usually reserved for the young, athletic patient looking to return to playing sports.

Nonoperative treatment usually entails 2 week immobilization in a plantar-flexed splint, followed by 6-8 weeks of cast immobilization with progressive dorsiflexion to neutral and slow advancement of weight bearing. Cast removal is followed by the use of a heel-lift with eventual transition back to normal shoes. Progressive resistive exercises are started at 8-10 weeks from injury, with return to sports at 4-6 months. Maximal recovery can take up to one year; some residual weakness is often present.

Operative treatment can be done percutaneously or through a medial longitudinal approach. Postoperative management is similar to that which is used for closed treatment.

6. Peroneal Tendon Subluxation

Subluxation or frank dislocation of the peroneal tendon is rare, usually resulting from injury sustained during sports activities such as skiing. Clinical evaluation reveals lateral ankle swelling and tenderness posterior to the lateral malleolus. Radiographs may show a small fleck of bone off of the posterior aspect of the lateral malleolus indicating avulsion injury. MRI can be used for evaluation if diagnosis remains unclear. Treatment involves reduction of the tendon and placement in a well-molded cast with foot in slight plantar flexion and mild inversion. If dislocation of the tendon continues, operative intervention may be considered.

INJURIES OF THE FOOT

1. The Talus

Anatomy

Sixty percent of the talus is covered by articular cartilage including the superior surface which is the weight-bearing portion. The cartilage extends medially and laterally in a plantar direction allowing articulation with the medial and lateral malleoli. The inferior surface of the talar body articulates with the calcaneus. The anterior aspect of the talus is wider than the posterior aspect, conferring inherent stability to the ankle joint. The neck of the talus extends from the body proximally and posteriorly, deviates medially, to join the talar head anteriorly and distally. The talar neck is most vulnerable to fracture. The head of the talus meets with the navicular bone anteriorly, the spring ligament inferiorly, the sustentaculum tali posteroinferiorly, and the deltoid ligament medially. The lateral process of the talus meets the posterior calcaneal facet inferiorly and the lateral malleolus superolaterally. The posterior process of the talus has a medial and lateral tubercle separated by a groove for the flexor hallucis longus tendon. An os trigonum, which can be mistaken for fracture, is present just posterior to the lateral tubercle in up to 50% of normal feet. The blood supply to the talus is composed of arteries to the sinus tarsi (originating from the peroneal and dorsalis pedis artery), an artery of the tarsal canal (posterior tibial artery), and the deltoid artery (posterior tibial artery). The vascular supply reaches the talus through various fascial structures; when these structures are disrupted, for example, with dislocation, avascular necrosis of the talus can result.

Fractures of the Talus

A. Epidemiology and Mechanism of Injury

Fractures of the talus represent approximately 2% of all lower extremity injuries. These injuries most commonly occur from high-energy mechanisms such as falls from significant height or motor vehicle accidents resulting in hyperdorsiflexion causing the talar neck to impact the anterior portion of the tibia.

B. Clinical Presentation and Radiographic Examination

Patients typically present with foot pain and diffuse swelling of the hindfoot. Associated fractures of the ankle and foot are common.

Initial radiographs include anteroposterior, lateral, and mortise views of the ankle as well as anteroposterior, lateral, and oblique views of the foot. A Canale view with the ankle in maximum equines (plantar-flexion), pronated 15 degrees and the radiograph machine directed 15 degrees from the vertical, provides optimal visualization of the talar neck. Additionally, a CT scan should be considered for better fracture characterization and to assess for any articular involvement. Bone scan and/or MRI should be considered for patients with persistent hindfoot pain despite negative radiographs to look for occult fractures of the talar neck.

C. Classification

Fractures of the talus are classified initially based off their anatomic location: talar neck fractures, talar body fractures, talar head fractures, lateral process fractures, and posterior process fractures.

Fractures of the talar neck are further subclassified based off of the Hawkins classification: I (nondisplaced), II (with associated subtalar dislocation), III (with associated subtalar and tibiotalar dislocation), and IV (associated subtalar, tibiotalar, and talonavicular dislocations).

D. Treatment

Truly nondisplaced fractures with no signs of articular comminution on CT scan can be treated nonoperatively initially in a short-leg cast, non–weight-bearing for at least 6 weeks until radiographic signs of healing are noted, followed by progressive weight-bearing.

Displaced fractures should be treated with closed reduction and splint placement. Open or irreducible fractures require immediate operative treatment. Surgery entails open reduction and internal fixation with plates and screws.

Other Fractures of the Talus

Lateral process fractures of the talus are commonly seen in snow-boarders. These fractures are often misdiagnosed as ankle sprains upon initial presentation. If the fracture is displaced less than 2 mm, then it can be treated closed with a short-leg cast. Greater than 2 mm of displacement requires operative intervention.

Posterior process fractures of the talus can be difficult to diagnose due to the presence of the os trigonum. Nondisplaced or minimally displaced fractures of the posterior process can be treated with a non–weight-bearing short-leg cast. Displaced fractures require surgical treatment with open reduction and internal fixation.

Talar head fractures may be associated with fractures of the navicular bone or talonavicular disruption. Nondisplaced or minimally displaced fractures can be treated for six weeks in a partial weight bearing short-leg cast molded to preserve the longitudinal arch. After discontinuation of the cast, an arch support should be worn in the shoe to reduce stress on the talonavicular articulation for an additional 4-6 months. Displaced fractures are treated with ORIF and/or primary excision of small fragments.

Complications

The most common complication is posttraumatic arthritis. Avascular necrosis occurs as well and correlates with initial fracture displacement: Hawkins I (0%-15%), Hawkins II (20%-50%), Hawkins III (20%-100%), and Hawkins IV (100%). Other complications include delayed union or nonunion, malunion, and wound complications.

Subtalar Dislocation

Subtalar dislocation is defined by the simultaneous dislocation of the distal articulations of the talocalcaneal and talonavicular joints. Inversion of the foot results in medial subtalar dislocation, while eversion causes lateral subtalar dislocation. The large majority of these dislocations are medial (approximately 85%). All subtalar dislocations should be reduced as soon as possible with knee flexion, accentuation of the deformity to unlock the calcaneus and longitudinal traction. Subtalar dislocations are often stable once closed reduction is achieved. CT scan should be performed postreduction to assess for other associated fractures or continued subluxation. Failed closed reduction may be due to interposed extensor digitorum brevis muscle in the case of a medial dislocation or posterior tibial tendon for lateral dislocation. Unsuccessful closed reduction requires operative intervention.

Total Dislocation of the Talus

Total dislocation of the talus is rare and usually an open injury. In general, open reduction with internal fixation is required. Complications including infection, osteonecrosis, and posttraumatic arthritis are common.

2. The Calcaneus

Fracture of the Calcaneus

A. Epidemiology

The calcaneus is the most frequently fractured tarsal bone, constituting approximately 2% of all fractures. The large majority of calcaneus fractures occur in men aged 21-45 years old.

B. Mechanism

Most intra-articular calcaneus fractures are the result of axial loading where the talus is driven into the calcaneus during a fall from significant height or motor vehicle accident. Extra-articular calcaneus fractures may be the result of twisting injuries. For diabetic patients there is an increased incidence of calcaneus tuberosity fractures resulting from Achilles avulsion injuries.

C. Clinical Presentation

Patients often present with significant heel pain, swelling, and ecchymosis. When open fractures occur, they most often occur on the medial side of the foot. Compartment syndrome should be carefully ruled out. Associated injuries to rule out include lumbar spine injuries and other lower extremity fractures. Of note bilateral calcaneus fractures occur approximately 10% of the time.

D. Radiographic Evaluation

Initial radiographs include a lateral radiograph of the hindfoot, AP of the foot, a Harris axial view, and standard ankle series. The lateral radiograph should be examined to determine the Bohler tuber joint angle (intersection of the line drawn from the anterior process to the highest point of the posterior facet and the line drawn from the superior aspect of the calcaneal tuberosity to the highest point of the posterior facet). The Bohler angle is usually 20-40 degrees. A decrease in this angle indicates significant depression of the weight bearing posterior facet. The AP radiograph should be examined for extension of the fracture into the calcaneocuboid joint. A Harris axial view can be taken with the foot maximally dorsiflexed and the radiograph beam directed 45 degrees cephalad to better visualize the articular surface. However, dorsiflexion may be difficult due to patient discomfort. CT scan with 3-5 mm cuts offers the best ­characterization of the articular surface and as a result is most useful for preoperative planning (Figure 40–21).

E. Classification

Extra-articular fractures of the calcaneus include fractures of the anterior process, calcaneal tuberosity, medial process, sustentaculum tali, and body fractures outside of the articular surface. Anterior process and calcaneal tuberosity fractures are best seen on lateral radiographs. Fractures of the medial process, sustentacular, or body fractures are best investigated on axial views or CT scan. Intra-articular fractures can be classified according to the Sanders classification which is based off of the coronal cuts of CT scans showing the number and location of articular fracture fragments. The posterior facet of the calcaneus is divided into three fractures lines (A, B, and C) moving from lateral to medial. There can be a total of four pieces: lateral, central, medial, and sustentaculum tali. The classification is as follows: type I (all nondisplaced fractures regardless of number of fracture lines), type II (two-part fracture, with further subclassification based on the location of the fracture line IIA, IIB, IIC), type III (three-part fractures, subtypes IIIAB, IIIAC, IIIBC), and type IV (four part articular fractures).

F. Treatment

Treatment remains controversial—even with adequate reduction fractures of the calcaneus often result in chronic pain and functional disability. Nonoperative indications include nondisplaced or minimally displaced extra-articular fractures, nondisplaced intra-articular fractures, anterior process fractures with less than 25% involvement of the calcaneocuboid articulation, fractures in patients with severe peripheral vascular occlusive disease or diabetes (due to frequent wound complications associated with surgery), fractures in patients with other severe medical comorbidities, and fractures associated with significant soft tissue compromise. Initial treatment involves placement in a bulky-Jones splint or dressing with avoidance of pressure on the heel. The splint is converted to a prefabricated boot locked in neutral to prevent equines contracture with elastic compression stocking to prevent dependent edema. Early subtalar and ankle joint range of motion is started; non–weight-bearing is instituted for approximately 10-12 weeks until radiographic healing is appreciated.

Operative indications included displaced intra-articular fractures, fractures of the anterior process with more than 25% involvement of the calcaneocuboid joint, displaced calcaneal tuberosity fractures, fracture-dislocations of the calcaneus, open fractures of the calcaneus, tuberosity fractures that are displaced resulting in prominence through the skin, incompetence of the gastrocnemius-soleus complex, and/or extend into the articular surface. Surgery should only be attempted 7-14 days after the injury allowing enough time for swelling to subside. Fracture fixation depends on the type of fracture. Anterior process fractures are typically fixed with small or minifragment screws. Calcaneal tuberosity fractures usually require lag screw fixation with or without cerclage wire. Intra-articular posterior facet fractures may be fixed with lag screws into the sustentaculum tali and a thin lateral plate providing a lateral buttress. Postoperatively the patient is kept non–weight-bearing for 8-12 weeks with early subtalar range of motion exercises.

3. Fractures of the Midfoot

Epidemiology, Mechanism of Injury, and Anatomy

Fractures of the midfoot are relatively rare, most often resulting from direct impact during a motor vehicle accident or a combination of axial loading and torsion during fall from a significant height. The midfoot consists of five bones: navicular, cuboid, medial, middle, and lateral cuneiforms. The midtarsal joint consists of the calcaneocuboid and talonavicular articulations which act together with the subtalar joint during eversion and inversion of the foot. The cuboid extends distal to the three naviculocuneioform joints minimizing motion at this level.

Clinical and Radiographic Evaluation

Patient presentation is variable ranging from a limp with mild swelling and dorsal foot tenderness to a grossly swollen, painful midfoot resulting in nonambulatory status. Initial radiographs include AP, lateral, and oblique x-rays of the foot. Stress views and weight-bearing x-rays can provide additional detail including detection of any ligamentous instability. CT scan is best for characterizing fracture-dislocations or discovering injuries that are otherwise undetected on x-ray. MRI may be used to evaluate ligamentous injury.

Navicular Bone

The navicular is the keystone bone of the foot’s medial longitudinal arch, transmitting motion from the subtalar joint to the forefoot. The talonavicular articular surface is concave and has a significant arc of motion. The distal articular surface has three separate facets for the three cuneiforms. Not much motion occurs at these joints. The navicular tuberosity is the medial prominence located on the inferior aspect of the navicular bone provides an attachment point for the posterior tibial tendon. Anatomic variants include the shape of the tuberosity and the presence of an accessory navicular bone (up to 15% of the time and bilateral 70-90% of the time).

Patients typically present with painful foot and dorsomedial swelling and tenderness. Radiographic Evaluation can include medial and lateral oblique x-rays of the midfoot in addition to the standard foot series, to assess the lateral pole of the navicular as well as the medial tuberosity.

Classification

There are three basic types of navicular fractures with a subclassification of the body type fractures. Avulsion-type fractures can involve the talonavicular or naviculocuneioform ligaments. Tuberosity fractures usually involved disruption of the tibialis posterior tendon insertion without damage to the joint surface. Type I body fractures divide the navicular into dorsal and plantar pieces. Type II body fractures split the navicular into medial and lateral pieces. Type III body fractures are comminuted and often have significant displacement of the medial and lateral poles.

Treatment

Nondisplaced fractures without instability may be treated closed in a cast or boot non–weight-bearing for 6-8 weeks. Disruption of the articular surface more than 2 mm requires operative intervention. Small fragments may be excised if symptomatic. Larger fragments (> 25% of the articular surface) require ORIF with lag screw fixation. If more than 40% of the talonavicular joint cannot be reconstructed, acute talonavicular fusion should be considered. Isolated dislocation or subluxation of the navicular bone without fracture requires surgical stabilization.

Cuboid Bone

The Cuboid Bone is part of the “lateral column” of the foot articulating with the calcaneus proximally, the navicular and lateral cuneiform medially, and the fourth and fifth metatarsal distally. The peroneus longus travels through a groove on the plantar surface of the cuboid on its way to its insertion at the base of the first metatarsal. Injury to the cuboid bone is usually seen in conjunction with injury to the talonavicular or Lisfranc joints. Patients typically present with dorsolateral foot pain and swelling. In addition to foot series, stress radiographs, and CT scan should be considered. MRI can be used to evaluate for stress fractures that are otherwise not seen on radiograph. Cuboid fractures without articular disruption or any loss of length can be treated closed, non–weight-bearing in a boot for 6-8 weeks. If more than 2 mm disruption of the articular surface is appreciated or the cuboid is compressed, then ORIF should be pursued. Calcaneocuboid fusion should be considered for fractures with residual articular displacement.

Tarsometatarsal (LisFranc) Joint

Injury to the LisFranc Joint is relatively rare. However, given that up to 20% of the time this injury goes undiagnosed initially, suspicion should remain high especially in the poly-trauma patient with foot swelling or pain.

In the AP plane the base of the second metatarsal is recessed between the medial and lateral cuneioforms, limiting translation. In the coronal plane, the middle three metatarsal bones have trapezoidal shaped bases that form a transverse arch preventing displacement in the plantar direction. The second metatarsal base is “keystone” responsible for the inherent stability of the transmetatarsal joint. The Lisfranc ligament travels from the medial cuneiform to the base of the second metatarsal bone providing additional stability. Of note the dorsalis pedis artery travels in between the first and second metatarsal bones at the LisFranc joint; as a result it is vulnerable to injury with disruption or manipulation of this joint.

There are three common mechanisms of injury: (1) twisting (forced abduction of the forefoot) such as is seen in equestrians who fall from a horse with their foot caught in the stirrup, (2) axial load, and (3) crush injury.

Clinical evaluation includes careful neurovascular documentation given the proximity of the dorsalis pedis artery to this joint. Additionally, compartment syndrome of the foot should be ruled out. Stress testing applying gentle forefoot abduction or pronation with the hindfoot stabilized may be performed.

Radiographic evaluation includes anteroposterior, lateral, and oblique views of the foot. Normally, the medial border of the second metatarsal should be collinear with the medial border of the middle cuneiform on the AP view; additionally the medial border of the fourth metatarsal should line up with the medial border of the cuboid bone. Dorsal displacement of the metatarsals on the lateral view is also indicative of ligamentous injury. Weight-bearing views should be performed as well looking for any displacement. CT scan can provide greater detail. Associated injuries to the cuneioforms, cuboid, and/or metatarsals are common and should be ruled out.

If no instability (displacement) is appreciated on standard and stress radiographs a diagnosis of midfoot sprain may be considered with initial non–weight-bearing treatment and progressive weight-bearing as comfort allows. Repeat x-rays should be obtained once swelling has subsided. For any displacement of the tarsometatarsal joint more than 2 mm, surgery should be pursued with screws and k-wires.

Fractures of the Forefoot

Fractures of the first metatarsal are rare due its larger size and increased strength compared to the other metatarsals. Isolated fractures of the first metatarsal without instability may be treated with weight bearing as tolerated in a short-leg cast or removable boot for 4-6 weeks. If displacement is detected of the first metatarsal through the joint or fracture site, operative intervention is required.

Fractures of the second, third, or fourth metatarsals are much more common. Most isolated fractures can be treated closed with hard-soled shoes and progressive weight-bearing. Operative indications include fractures with more than 10 degrees of deviation in a dorsal or plantar direction or 3-4 mm of translation in any plane.

Fifth metatarsal fractures usually result from direct trauma and are divided into two groups: proximal base fractures and distal spiral fractures. The proximal fifth metatarsal fractures are further sub-divided: Zone I (cancellous tuberosity, which is the insertion of the peroneal brevis), Zone II (distal to the tuberosity), and Zone III (distal to the proximal ligaments, without extension past the proximal 1.5 cm of the diaphyseal shaft). Zone I injuries are treated symptomatically with hard-soled shoe. The treatment of Zone II injuries, aka Jones fractures, is controversial due to healing difficulty. Some authors advocate weight-bearing as tolerated, others recommend non–weight-bearing in a short leg cast or surgical intervention. Zone 3 injuries may be treated non–weight-bearing in a cast or with surgery. Fractures distal to the proximal 1.5 cm of the diaphyseal shaft, are called “Dancer’s fractures” and are treated symptomatically with a hard-soled shoe.

4. Metatarsophalangeal Joint

Injuries to the first MTP joint are relatively common especially in persons who participate in athletic activities such as ballet, football, or soccer. The MTP joint is composed of a cam-shaped metatarsal head articulating with the concave proximally articular surface of the proximal phalynx. The stability of the joint is provided by ligamentous constraints which include the medial and lateral collateral ligaments as well as the dorsal capsule and plantar plate which are ­reinforced by the extensor hallucis longus and flexor hallucis longus tendons respectively. “Turf toe” which is a hyperextension injury of the first MTP joint, resulting in stretching of the plantar capsule and plate, may be treated with RICE, nonsteroidal anti-inflammatory drugs (NSAIDS), and protective taping with gradual return to activity. MTP dislocations are treated with closed reduction and short-leg cast with toe extension for 3-4 weeks. Dislocations with displaced avulsion fractures require surgical intervention with lag screws or tension-band technique.

Injuries to the lesser MTP joints are common as well. Simple dislocations or nondisplaced fractures are managed with gentle reduction and buddy taping. Intra-articular fractures may be treated with excision for small fragments or ORIF with Kirshner wires or screws.

5. Fractures & Dislocations of the Phalanges of the Toes

Phalangeal fractures are the most common injury to the forefoot. The proximal phalynx of the fifth toe is the most common phalynx injured. Like the fifth digit, the first digit is also particularly vulnerable to injury due their border positions in the foot. Mechanisms of injury usually entails direct blow such as from a dropped heavy object or axial load resulting from a stubbing injury. Fractures and/or dislocations are diagnosed with foot series radiographs (AP, lateral, oblique). MRI or bone scan may aid in the diagnosis of stress fractures that are not visible on x-ray. Nondisplaced fractures are treated with stiff-soled shoe and protected weight-bearing with advancement as tolerated. Buddy taping may be used as well. Fractures with clinical deformity require reduction. Operative intervention is only performed for those rare fractures with gross instability or persistent intra-articular deformity. Dislocated IP joints without fracture are usually amenable to closed reduction and buddy taping with progressive advancement of activity.

6. Fracture of the Sesamoids of the Great Toe

Fractures of the sesamoid bones is rare, occurring with hyperextension injuries in ballet dancers and runners. The medial sesamoid is more frequently fractured than the lateral sesamoid due to increased weight-bearing on the medial side of the foot. Fractures of the sesamoids must be distinguished from bipartite sesamoids which are relatively common, up to 30% of the general population (bilateral in 85% of cases). These fractures are initially treated closed with soft padding and short-leg walking cast for 4 weeks followed by shoe with metatarsal pad for additional 4-8 weeks. Sesamoidectomy is reserved for cases of failed conservative treatment.

CHILDREN’S FRACTURES & DISLOCATIONS

Children’s skeletal injuries differ from those of adults in several significant ways. An important difference is the presence of the growth plate or physis, giving immature bone is its potential for longitudinal growth. Bones increase in diameter by appositional growth from the periosteum. Injuries to the physis may disrupt skeletal growth. Children’s bones heal rapidly, and nonunion is exceedingly rare. The periosteum is thick and strong, surrounding the long bone like a sleeve and helps to minimize fracture displacement and promote healing.

When injury occurs in a young child, especially one under 3 years of age, a careful social history should be taken (see Chapter 45). State law in all jurisdictions requires that suspected cases of abuse be reported to local authorities.

Closed treatment is usually sufficient for children’s fractures. Manipulation also known as closed reduction under sedation may be required for significant displaced fractures. Open fractures, fractures with articular surface displacement, and less commonly fractures that cannot be reduced by closed means require operative treatment.

Although children’s fractures do heal rapidly and immobilization rarely causes joint stiffness in children, so casts can be left on until union is achieved.

The bone in growing children is mechanically different from that in adults; immature bone is more porous and fails in compression as well as in tension. An example is the so-called buckle or torus fracture that occurs at the metaphysis of the distal radius. This stable injury should be protected in plaster for 3 weeks to control symptoms and prevent further trauma to the weakened bone.

Immature bone is less brittle than that of adults, and children’s bones may therefore bend but not fracture. This plastic deformation may produce significant deformity that requires manipulation to restore alignment.

Greenstick fractures are also a result of the plasticity of children’s bones. Incomplete disruption of a long bone occurs such that the bone fractures on the tension side but the opposite cortex remains in continuity. The periosteum remains intact on the concave side and typically the intact cortex resists any significant angulation at the fracture site.

1. Growth Plate Fractures

About 15% of children’s fractures involve a growth plate—most commonly the distal radius, distal tibia or fibula (or both), and distal humerus.

Classification

Classification of physeal injuries helps to distinguish patterns that may disturb growth and also provides some guidance for treatment. It should be recognized that even “benign” injuries to the growth plate of the distal femoral and tibia can have clinically significant consequences.

Physeal injuries are classified according to the Salter and Harris system (Figure 40–22).

A. Type I

Type I injuries have fracture lines that follow the growth plate, separating the epiphysis from metaphysis. Without displacement, radiographs may appear normal. This is often a clinical diagnosis with tenderness localized over the physis confirming that a growth plate injury has occurred. Healing occurs rapidly, usually within 2–3 weeks.

B. Type II

In type II injuries, the fracture line traverses the epiphysis and exits in the metaphysic. The metaphyseal fragment is often referred to as the Thurston–Holland sign and is diagnostic of a growth plate injury. Type II injuries are the most common physeal fractures. Satisfactory alignment can often be achieved with gentle closed reduction and casting. If pin fixation is required, smooth pins can be safely used across the physis. The risk of growth disturbance is highest for distal femoral and distal tibial fractures.

C. Type III

Type III physeal injuries are those in which the fracture line exits through the epiphysis at the articular surface. Any displacement at the articular surface requires operative intervention.

D. Type IV

Salter–Harris-type IV fractures cross both the metaphysic and the epiphysis. Because it involves the articular surface, anatomic reduction is essential to minimize the complications of type IV growth plate fractures, including growth disturbance, malunion, and articular incongruity. Even with perfect reduction, growth may be affected, and the prognosis is guarded.

E. Type V

Type V growth plate injuries are due to severe axial loading. Some or all of the physis is so severely compressed that growth potential is destroyed. Initial radiographs may appear normal like with SH 1 injuries. A history of a significant mechanism with swelling and tenderness over the physis should suggest the possibility of such an injury. Subsequent follow-up radiographs are critical to watch for premature closure of the physis, and/or progressive angular deformity due to asymmetric injury to the growth plate.

Treatment

A. Conservative Treatment

Most fractures involving the physis may be managed nonoperatively. Nondisplaced fractures are protected in a cast until healed. Typically 3–6 weeks is usually sufficient depending upon the child’s age and the site of injury. Displaced type I and type II injuries should be treated with a single attempt at closed reduction followed by immobilization as above. Because of the significant remodeling potential, acceptance of some deformity is better than repeated vigorous attempts at reduction which causes additional damage to the physis. Attempts at reduction should be avoided if more than seven days have passed since the injury.

B. Operative Treatment

Displaced type III and type IV injuries usually require open reduction and internal fixation. Fixation is ideally place within the metaphysic or epiphysis. If it is necessary to cross the physis, only smooth pin fixation is recommended. Cast immobilization may be required to supplement fixation.

Prognosis

All injuries that involve physes should be followed at least 12-18 months to confirm that growth has not been disrupted. The parents should be warned at the time of the injury of the possibility of altered growth. Physeal arrest may result in angular deformity and/or limb length inequality. When a physeal bar is suspected, CT scan or MRI can be used to localize the area, and estimate its size. If the bony bar is less than 50% of the physis and the child has at least two years of growth remaining, resection of the bar can be considered. Alternatively, the portion of the physis that remains open can be intentionally closed down to limit angular deformity. Limb length inequalities will occur if there is a complete physeal arrest. If the difference is less than 2 cm, no treatment is typically required. Differences of 2-5 cm are most frequently managed with an epiphysiodesis on the contralateral limb. Limb lengthening techniques can be considered with limb length inequalities exceed 5 cm.

2. Upper Extremity Fractures & Dislocations

Proximal Humeral Fractures

Separation of the unossified proximal humeral epiphysis has been described following difficult delivery of an infant. The child is unable to use the arm raising the concern for brachial plexus palsy. This “pseudoparalysis” resolves on the order of 7-10 days and radiographs demonstrate abundant callus, confirming the fracture. Older children most commonly sustain SH II fractures. Significant displacement and angulation is well tolerated and the child can be treated in a sling for 3 weeks. In the adolescent approaching maturity displaced fractures are treated with closed reduction and pin fixation. There is so much potential for remodeling in the proximal humerus that the best obtainable closed reduction is preferable to open surgery. Residual deformity, loss of motion, and functional problems are exceedingly rare following sustain proximal humerus fractures.

Supracondylar Fractures of the Humerus

Supracondylar fractures are among the most common injury in children ages 4-8 years. The typical mechanism is a hyperextension injury to the elbow. Type 1 of undisplaced supracondylar fractures present with elbow pain, swelling, and tenderness at the site. Radiographs usually show a positive fat pad sign, indicating elbow hemarthrosis and a nondisplaced fracture of the distal humerus anteriorly. The fracture line may be subtle so comparison radiographs of the uninjured elbow may be helpful. Cast immobilization for 3-4 weeks is recommended. Type II fractures are those in which there is posterior angulation of the distal fragment, with an intact periosteal hinge. The anterior humeral line no longer bisects the capitellum on the lateral radiograph. Closed reduction and pinning is advised to restore this relationship. Type III fractures are completely displaced. These are serious injuries that threaten the neurovascular structures. The radial pulse and the function of the radial, ulnar, and median (including anterior interosseous) nerves should be checked immediately. If ischemia is present initially, prompt reduction of deformity is the next step toward restoration of normal perfusion. If pulses cannot be restored with ­reduction then an angiogram and vascular consultation is urgent. When the loss of pulses occurs following attempts at reduction, vascular entrapment should be suspected and prompt surgical exploration of the brachial artery may be required.

Fracture reduction is secured with percutaneous pin fixation and splint immobilization for 4-6 weeks. Long-term problems include elbow stiffness, malunion, and growth arrest. Nerve injuries typically represent neuropraxias that resolve with observation over the subsequent 3-6 months.

Flexion type supracondylar fractures are rare, but when they do occur are typically managed with open reduction and pin fixation. The ulnar nerve is most at risk with these injuries.

Subluxation of the Radial Head (Nursemaid’s Elbow)

This common minor injury occurs in children under 4 years of age. It is caused by a sudden pull on the extended pronated arm, usually by an adult tugging on a reluctant toddler. The pronated radial head slips partially under the annular ligament and displaces into the radiocapitellar joint. The child suddenly stops using the arm, holding it in a flexed and pronated position. Radiographs show no abnormalities since positioning for elbow films will often reduce the subluxation. Reduction is achieved by firmly supinating the forearm and flexing the elbow while pressing down on the radial head. Often a “click” is felt when reduction is achieved. Soon after reduction the child becomes less apprehensive and gradually resumes use of the arm.

Other Fractures & Dislocations of the Elbow

There are a few injuries unique to the pediatric elbow which warrant mention. Fractures of the distal humerus including displaced lateral condyle fractures and displaced medial epicondyle fractures require surgery to restore articular congruity. Radial neck fractures with angulation that inhibits forearm rotation require reduction and fixation. Displaced olecranon fractures, if not reduced by elbow extension, will also require internal fixation. Monteggia and monteggia variant fractures represent a spectrum of injuries which include forearm fracture with radial head dislocation. Radiographs of the elbow are essential following any ulnar or radial shaft fractures to look for this injury.

Forearm Fractures

Fractures of the shafts of both the radius and the ulna occur frequently in children. The most common problem is malunion with angular or rotational deformity which limits supination-pronation. Initial treatment is closed reduction. Because of the remodeling potential in the growing child, anatomic reduction is not essential. Side-by-side or “bayonet” apposition is acceptable but angulation should be minimized. Radiographs are repeated weekly for 3 weeks to permit early remanipulation should the fracture displace. If displacement occurs repeat reduction and possibly internal fixation with intramedullary nails or plates maybe required.

Galeazzi fracture combines dislocation of the distal radioulnar joint with fracture of the radial shaft. To avoid missing this injury radiographs of the wrist and the elbow are obtained to confirm that normal bony relationships are present.

3. Lower Extremity Fractures & Dislocations

Traumatic Hip Dislocation

In children, traumatic dislocation is more common than fracture of the hip and has fewer complications. Prompt closed reduction under general anesthesia with good muscle relaxation is usually successful. Interposed soft tissue or bone fragments may necessitate open reduction. Following reduction, the hip should be protected for 4-6 weeks until soft tissue healing has occurred. With prompt reduction, avascular necrosis is rare but radiographs should be followed for 18 months.

Fractures of the Proximal Femur

Proximal femur fractures are rare in children. This is fortunate, as displacement and injury to the growth plate and blood supply predispose to complications including avascular necrosis, physeal arrest, and nonunion. Fractures involving the proximal femur are typically the result of high energy trauma.

In children, most hip fractures involve the femoral neck. If there is no displacement, spica cast immobilization maintains alignment during healing, but close radiographic monitoring is required for prompt identification of any displacement. Displaced fractures of the femoral neck should be treated with anatomic reduction and screw fixation preferably placed short of the physis. Satisfactory results are achieved in half or less of cases, with avascular necrosis, varus malunion, and physeal arrest among the most common complications. Intertrochanteric and subtrochanteric fractures can generally be managed with open reduction and internal fixation. Late problems (eg, angular deformity and unequal limb lengths) are rare but do occur.

Femoral Shaft Fractures

Femoral shaft fractures are fairly common childhood injuries. They often result from significant trauma, so that other injuries may also be present. Radiographs of the hip are required to ensure that fracture or dislocation is not present. The knee should also be x-rayed. Infants are treated with pavlik harness. Children ages 1-6 are most commonly treated with closed reduction and spica casting for 4-6 weeks. Titanium elastic nails have become the mainstay of treatment for the older child. Standard antegrade femoral nails are reserved only for skeletally mature adolescents because of the risk of avascular necrosis when the physes remain open.

Fractures of the Tibia & Fibula

Fractures of the tibia and fibula are not unusual in childhood. An occult undisplaced spiral fracture may cause the toddler to refuse to weight bear (“toddler’s fracture”). These fracture heal rapidly in a long-leg cast. Nerve and vessel damage may be present, especially with displaced fractures of the proximal metaphysis. Fractures of the tibial spine and tibial tubercle are unique to children. If displaced, these fractures require open reduction and fixation. Stiffness about the knee is common and fracture healing must be balanced with restoration of joint motion to avoid long-term problems.

Fractures of the Distal Fibula Physis and Transitional Fractures

Fractures of the distal fibular occur frequently in children. This injury is the equivalent of an ankle sprain in the skeletally mature individual. Physical examination localizes tenderness to the distal fibular growth plate, and radiographs will typically be interpreted as normal. Treatment is symptomatic, with resolution of symptoms expected in 3-4 weeks.

Children are at risk for so called transitional fractures of the distal tibia. These occur most commonly in kids ages 10-14 when a portion of the growth plate is closed, but some portion still remains open. A Tillaux fracture is a fracture involving the anterolateral distal tibial epiphysis. Any displacement warrants open reduction and screw fixation. Triplane fractures of the distal tibia are identified as SH III injuries on the AP radiograph and SH II injuries on the lateral radiograph. Again, anatomic reduction and fixation is critical.

GAIT DISORDERS & LIMB DEFORMITY

Abnormalities of the lower extremities in children may be noticed by parents as the child learns to walk. The two most common areas of concern include rotational malalignment and angular deformity at the knees.

1. Intoeing

A normal foot progression angle with walking is 10 degrees external rotation. There are three common causes of the “foot turning in” in children. Metatarsus adductus represents adduction of the forefoot. This deformity is typically present at birth and passively correctable. Mild cases will resolve with stretching. If it persists beyond early childhood, surgical correction is an option.

Tibial torsion is an internal rotation deformity of the tibia. On physical exam the ankle axis (a line connecting the tips of the medial and lateral malleoli) is internally rotated relative to the tibial tubercle. This developmental variant is common in children 1-3 years of age and almost always corrects spontaneously with growth. Special shoes and orthotic devices have not been shown to change the natural history and are no longer recommended. Rarely spontaneous correction does not occur (by age 6) and tibial derotational osteotomy can be considered.

Femoral anteversion is another common finding in children who walk with their feet turned in. Parents will report that the child is a “W” sitter. Observation reveals that the whole limb is internally rotated, so that the patella as well as the foot points medially. On clinical determination internal rotation at the hip approaches 90 degrees. Femoral anteversion can correct spontaneously up until the age of 12. If functional limitations are noted, a femoral derotational osteotomy can be considered.

2. Angular Deformity of the Lower Extremities (Knock-Knees & Bowlegs)

Varus or “bow legs” denotes deviation of the knees away from midline. Valgus or “knock knees” denotes deviation of the knees toward midline. Children may develop bowlegs from about 12-18 months to 3 years. The majority of children will show spontaneous resolution and occasionally progression to slight valgus between ages 3 and 4 years. In young children, angular deformity of the knees requires radiographs evaluation after the age of 2 years if it is asymmetric, associated with abnormally short stature or progressing. The differential diagnosis included infantile blounts and rickets. If metabolic bone disease is suspected, serum calcium, phosphate, and alkaline phosphatase should be measured. Operative treatment may be considered in if deformity persists after the age of 3.

Pathologic Genu Varum

It is important to distinguish physiologic tibia vara from pathologic conditions associated with varus including rickets, Blount’s disease and skeletal dysplasias. Blount’s disease (tibia vara) has both infantile and adolescent forms. Radiographs in infantile blounts typically show metaphyseal beaking and changes in the medial proximal tibial physis. The metaphysial-diaphysial angle (> 11 degrees) of the tibia helps to differentiate between physiologic bowing and infantile tibia vara. Progressive tibia vara should be treated with corrective osteotomy of the proximal tibia and fibula. Overcorrection into valgus alignment is recommended because recurrence is common. Adolescents blounts is most common in obese patients. Excessive stress on the medial tibial physis is thought to inhibit normal growth leading to bowing. When the growth plates remain open, growth can be modulated using staples or plates to temporarily tether the lateral growth plate and allow for gradual correction. After skeletal maturity, proximal tibial osteotomy is recommended to restore normal mechanical alignment.

SYSTEMIC DISORDERS AFFECTING BONES & JOINTS IN CHILDREN

1. Juvenile Rheumatoid Arthritis

RA is an autoimmune disorder whose exact cause remains elusive. There are three basic clinical forms of juvenile rheumatoid arthritis (JRA). Pauciarticular arthritis generally involves a single joint, most commonly the knee or the ankle but occasionally the hip or an upper extremity (mainly the elbow or the wrist). Clinical symptoms include the insidious onset of swelling and loss of motion at the affected joint. Systemic manifestations are absent. Iridocyclitis, or inflammation of the iris and ciliary body, is most common in this form and JRA and an ophthalmology evaluation is necessary.

Polyarthritis is characterized by multiple joint involvement and minimal evidence of systemic disease. Fingers and toes, the neck, and the temporomandibular joints are more likely to be involved. The course is persistent, with periods of exacerbation.

Systemic rheumatoid disease (Still’s disease) usually presents with multiple (more than five) involved joints, fever, lymphadenopathy, hepatosplenomegaly, rash, subcutaneous nodules, and pericarditis. The course may be remitting or relentless, causing severe permanent disability. Inflamed joints develop synovial hypertrophy and pannus, which destroy articular cartilage. The associated hyperemia can stimulate the adjacent physes, with resulting overgrowth, or physeal arrest. Damage to underlying bone and ligament can produce severe deformity and joint subluxation. Musculoskeletal involvement may include the cervical spine, with spontaneous fusion of the apophysial joints and result in C1-2 instability.

When a single joint is inflamed, it is necessary to exclude lyme disease in endemic areas, septic arthritis, and reactive synovitis. Polyarticular JRA must be differentiated from rheumatic fever and leukemia.

Medical management is the first line of treatment; anti-inflammatory agents and range of motion exercises as synovitis resolves and appropriate bracing to minimize stiffness and allow function. Synovial biopsy can be done percutaneously with arthroscopy to help confirm the diagnosis. Synovectomy is controversial but some believe that is may slow the progression of arthritis.

2. Brachial Plexus Palsy

Brachial plexus palsy has three general patterns of involvement: (1) Erb’s palsy, involving C5 and C6 (upper trunk); (2) Klumpke’s paralysis, involving C8 and T1 (lower trunk); and (3) whole plexus. The first step in treatment is recognition. Physical therapy to maintain range of motion is started immediately and continued as the child is followed for recovery of function. Recovery of the biceps (elbow flexion and forearm supination) by 3-6 months is generally a good prognostic sign. If no spontaneous improvement is seen, neurosurgical evaluation/intervention is recommended. If muscle imbalance persists at the shoulder, transfer of the latissimus dorsi and teres major muscles, so that they become external rotators, is an option. Humeral osteotomy is typically reserved for the older child with residual internal rotation contracture.

SCOLIOSIS & SPINAL DEFORMITY

The spine is in balance when the head is aligned with the pelvis in the coronal and sagittal planes. Scoliosis is spinal curvature of more than 10 degrees in the coronal or frontal plane. Scoliosis is a three-dimensional deformity with concurrent rotational component that creates a rib and/or lumbar prominence. Deformity may also exist in the sagittal plane. Normal kyphosis ranges from 20-40 degrees. Scheurmann’s kyphosis is defined as vertebral body wedging at three consecutive levels and greater than 40 degrees of kyphosis in the sagittal plane.

The etiology of spinal deformity in children may be congenital, neuromuscular, traumatic, or idiopathic (of unknown cause). The cause of deformity is an important determinant of the natural history, treatment options, and the goals of management. Any family history of scoliosis should be elicited.

Clinical Findings

Spinal deformity may be recognized in the perinatal period or during infancy in children with congenital anomalies of the spine. Most commonly, deformity of the spine is detected during the preadolescent growth spurt, when the spine is growing most rapidly. Spinal deformity is most commonly detected by family members, sports physicals, and primary care physicians. Routine school screening using the Adams forward bending test has improved recognition. Scoliometer measurements of greater than 7 degrees are an indication for orthopedic evaluation.

Physical examination of the patient with spinal deformity includes both examination of the spine and a comprehensive examination. The location of the curve, deviation of the trunk from the midline (trunk shift), shoulder asymmetry, pelvic obliquity, and flexibility of the spine should be recorded. Clinical findings suggestive of intraspinal pathology, such as tethered cord or a syrinx include asymmetric abdominal reflexes, clonus, muscle weakness or contractures, and foot deformities. Patients with congenital scoliosis may have associated chest wall deformity and sacral dimples. Scoliosis due to connective tissue pathology may present with joint hypermobility.

Imaging Studies

Spinal deformity occurs in three dimensions, and most imaging studies are limited by providing only a two-dimensional representation. Plain radiographs are useful for the detection of deformity and monitoring progression of deformity. The Cobb angle is used to measure deformity in the coronal and sagittal planes. An angular measurement is made between the end-vertebrae that are most tilted from the horizontal at either end of the curve (Figure 40–23). Other radiographic measures may include trunk shift relative to the pelvis and overall sagittal and coronal balance of the spine measuring a plumb-line between C7 and the sacrum.

MRI examination of the entire spine is an important imaging tool because of the association between intraspinal anomalies with certain types of spinal deformity. Congenital scoliosis may be associated with intraspinal abnormalities, including tethering of the cord, ­syringomyelia, ­diastematomyelia, diplomyelia, lipoma, teratoma, and neuroenteric cysts. MRI of the entire spine is indicated for patients with congenital scoliosis, patients with abnormal neurologic findings on physical examination, atypical curve patterns including left thoracic curves, as well as infantile and juvenile idiopathic scoliosis.

1. Idiopathic Scoliosis

Idiopathic scoliosis is the most common cause of spinal deformity in children and adolescents. The prevalence of adolescent idiopathic scoliosis is estimated at 2%-3% by age 16. Curves larger than 20 degrees are present in 0.3%-0.5% of adolescents. The ratio of affected males to females is equal in curves less than 15 degrees. However, for curves larger than 20 degrees, females are seven times more likely to be affected than males.

Nonoperative management of adolescent idiopathic scoliosis is intended to prevent progression of deformity during the growing years. Bracing is the only nonoperative treatment that has demonstrated efficacy in the management of progressive idiopathic scoliosis. Bracing is recommended for curves over 25-30 degrees in a child who remains skeletally immature. The efficacy of bracing is less predictable in larger curves.

Treatment Options

Surgical management of adolescent idiopathic scoliosis is intended to prevent additional progression of deformity. Spinal fusion may be considered for curves greater than 45-50 degrees in patients when significant growth remains. The natural history studies of untreated idiopathic scoliosis suggest that curve size is a risk factor for curve progression once skeletally mature. Curves under 30 degrees at maturity are not thought to progress, curves 30-40 degrees progress 0.5 degrees/year and curves over 40 degrees progress 1 degree/year on average.

2. Neuromuscular Scoliosis

Neuromuscular scoliosis presumably develops from a lack of trunk control. The term encompasses a spectrum of disorders all of which result in some compromise of the patient’s ability to control posture and trunk position. The severity of deformity is related to the severity of weakness or spasticity, the patient’s age at presentation of neuromuscular pathology, and the rostral or caudal level of involvement within the spinal cord. A child with known neuromuscular disorder is monitored for progression of spinal deformity in concert with management of associated deformities involving the hips, feet, and upper extremities.

Neuromuscular scoliosis may present in patients with disorders involving upper motor neurons, lower motor neurons, or primary myopathies. Upper motor neuron disorders may include cerebral palsy, spinocerebellar degeneration (Friedreich’s ataxia, Charcot–Marie–Tooth disease, and Roussy–Levy disease), syringomyelia, spinal cord tumor, and spinal cord trauma. Lower motor neuron disorders include poliomyelitis, spinomuscular atrophy, myelodysplasia, dysautonomia, and trauma. Primary myopathies that may lead to neuromuscular deformity of the spine include muscular dystrophy, arthrogryposis, and congenital hypotonia.

Neuromuscular scoliosis characteristically presents with long, sweeping curves involving the thoracolumbar spine. This may result in imbalance of the trunk relative to the pelvis. Pelvic obliquity is common in neuromuscular scoliosis, resulting in poor sitting balance and skin breakdown. Pulmonary compromise may be an important feature of neuromuscular curves due to the combination of thoracic deformity with intercostal and accessory muscle weakness. The child with neuromuscular scoliosis often has comorbidities and functional considerations that are distinct from the patient with idiopathic or congenital scoliosis.

Treatment Options

In the neuromuscular patient goals of treatment include sitting balance, prevention of sacral and ischial skin breakdown, and facilitating caregivers ability to assist with patient transfers and mobility.

Orthotics—including molded body jackets and thoracolumbar orthoses—may be useful in preserving sitting balance and preventing or delaying surgical stabilization. Indications for surgery include curve progression, poor sitting balance, and respiratory compromise. In the patient who is nonambulatory, fusion of the spinal column to the pelvis can be performed to correct pelvic obliquity.

3. Congenital Scoliosis

Congenital anomalies of the spine are caused by defects in the embryologic formation and segmentation of spinal elements. The formation of the spine begins during the third week of embryonic development. Abnormalities of either the notochord or the neural arch may lead to congenital anomalies of the spine. Congenital anomalies may include unilateral failure of formation (hemivertebrae and wedge vertebrae), failure of segmentation, rib fusions, and mixed or complex anomalies. These anomalies of the spine appear to be sporadic events and not hereditary. Because the cardiac and renal systems are developing simultaneously, these organ systems may also be affected. Routine cardiac evaluation and ultrasound of the renal system is recommended in patients with congenital scoliosis.

Progression of deformity in congenital scoliosis is dependent upon the type of vertebral anomaly, the position of the vertebral anomaly within the spine, and the growth potential for that segment of the spine.

Treatment Options

Bracing has not been effective for congenital scoliosis and is not recommended. If progression of deformity is noted, surgical intervention is recommended. The goal of surgery in young patients is to prevent the development of a severe rigid deformity.

SEPTIC ARTHRITIS

General Considerations

Infection is usually hematogenous and more frequent in infants exposed to invasive measures likely to cause bacteremia. The joint can be primarily involved, or secondary involvement may occur by spread of osteomyelitis from the proximal femur. Hip sepsis has also followed penetration of the joint during attempted blood aspiration from the femoral vein.

Staphylococcus aureus and Streptococcus pyogenes are the most common causative organisms.

Clinical Findings

A. Symptoms and Signs

Refusal to bear weight, and pain with hip motion are early signs. Fever is unlikely in very young children, but sepsis may be suggested by generalized irritability and failure to thrive. Another focus of infection should increase suspicion. The hip is typically held flexed in slight abduction and external rotation. Attempts to move the hip are resisted and especially painful.

B. Laboratory Findings

The sedimentation rate and CRP are commonly elevated, but the white blood count may be normal. Leukocytes are abundant in the joint fluid and Gram-stained smears of fluid show microorganisms as well.

C. Imaging Studies

The early radiographic signs are subtle, with obliteration of soft tissue planes and a suggestion of capsular distention (Figure 40–24). Ultrasound imaging provides an early indication of a joint effusion and aspiration can be done under ultrasound guidance. Bone scan may initially be negative, especially in children under 6 months of age, but usually shows increased uptake around the involved joint before radiographic changes become evident. MRI may help identify associated osteomyelitis.

Differential Diagnosis

Alternative diagnoses include fractures of the femur, acute osteomyelitis of the proximal femur, and iliopsoas abscess. Congenital hip dislocation is not painful and limited ­abduction with limb length inequality is noted. Transient synovitis typically presents with less severe symptoms, low-grade fevers, and responds to anti-inflammatory agents.

Complications

Structural sequelae include pathologic dislocation and irreversible destruction of the femoral head and neck. Chronic persisting infection may also result.

Treatment

Emergent surgical drainage is required. Side effects from a negative arthrotomy are so few that an aspiration is warranted if the diagnosis is uncertain. Gram-stained smears of intra-articular fluid guide the initial choice of parenteral antibiotic, which is modified if necessary according to the results of culture and sensitivity tests. Intravenous antibiotics are given until clinical improvement followed by oral antibiotics for 4 weeks.

Course & Prognosis

If the diagnosis is made and surgical drainage performed in a timely fashion the long-term results are good. Delay and nonoperative treatment are predictably followed by the complications mentioned earlier in the chapter.

TRANSIENT SYNOVITIS OF THE HIP (TOXIC SYNOVITIS)

Transient synovitis is a common cause of a painful hip in young children. A respiratory illness often precedes the complaints of pain, which may be localized to the knee, thigh, or hip. The short duration of symptoms, absence of diagnostic radiographic signs, and nearly normal laboratory studies suggest a benign process. Children of any age may be affected, with the average age is 6 years. Perhaps the most important aspect of transient synovitis is recognition.

Clinical Findings

A. Symptoms and Signs

When first evaluated, the child has rarely been symptomatic for more than a week. Pain in the lower extremity with activity (or even with rest) is the most common complaint. Limp and refusal to weight bear are also common. Passive range of motion of the hip must be checked and compared carefully with the opposite side. Normally, the child should be able to relax and motion should be free and easy without “guarding,” which is especially noticeable with rotation or at extremes of flexion or extension. Low-grade fever may be present, but the child does not appear ill.

B. Laboratory Findings

Although the white blood cell count and erythrocyte sedimentation rate may be somewhat elevated, they are usually normal. Hip aspiration, if performed to help clarify a confusing case, reveals clear synovial fluid with a low white cell count, no organisms on Gram-stained smears, and negative cultures for all types of organisms.

C. Imaging Studies

Radiographs are essential to rule out other diagnoses. X-rays are usually normal with transient synovitis of the hip. Hip ultrasound will show little or no effusion.

Differential Diagnosis

Septic arthritis is the primary concern. Legg–Perthes disease (avascular necrosis), slipped capital femoral epiphysis, and, rarely, other forms of inflammatory joint disease such as RA or rheumatic fever must be considered.

Treatment

Hospitalization for observation and serial clinical exams is often advised to ensure that an infection is not missed. The hip is placed at rest and anti-inflammatory agents are initiated. This almost always relieves symptoms promptly and also helps confirm the diagnosis. The child should then be reexamined to make certain that normal hip motion and comfort have been achieved. Anteroposterior and lateral x-rays are repeated in 2-3 months to ensure that avascular necrosis has not developed. Occasionally, signs of systemic reaction are more pronounced or the child continues to guard the hip longer than usual. In such cases, needle aspiration confirmed by arthrogram should be performed to rule out infection.

Prognosis

Recurrent symptoms may develop after release from the hospital and resumption of activity but usually resolve with more rest.

DEVELOPMENTAL DYSPLASIA/DISLOCATION OF THE HIP

General Considerations

Developmental hip dysplasia (DDH) may be detected at birth or develop early in life. The incidence of dislocation is 1 in 1000 infants. Both hips may be involved. DDH is more common in first born, females and with breech positioning. It is rarely painful or disabling to the child but results in significant symptoms in adults if left untreated. The hip may be dislocated by reducible, reduced but dislocatable or dislocated and not reducible.

Clinical Findings

A. Symptoms and Signs

The physical signs of DDH are the key to diagnosis. They may be subtle, however, and can be missed by the most experienced examiner. This emphasizes the need for repeated evaluation of the hips during routine “well baby” checks.

1. Dislocatable hip (Barlow positive)

The examiner attempts to displace the infant’s femoral head posterolaterally from the acetabulum by means of a provocation test (Figure 40–25). In a positive test, the femoral head is felt to displace out of the acetabulum. Mechanical instability—not a “click”—is the essential finding.

2. Dislocated but reducible hip (Ortolani positive)

Ortolani described relocation of a dislocated femoral head when the examiner abducts the flexed hip and lifts the greater trochanter anteriorly. The soft tissues surrounding the joint may not be lax enough to permit reduction. A fixed hip dislocation will result in limited abduction, apparent shortening of the affected side, and asymmetric thigh creases (if the dislocation is unilateral). As the child begins to walk, an abnormal gait becomes apparent. If dislocation is bilateral, the diagnosis is more challenging; the gait is “waddling,” and lumbar lordosis is prominent.

B. Imaging Studies

Until the cartilaginous acetabulum and femoral head become substantially ossified, x-rays may fail to indicate the true condition of the hip joint. Obvious abnormalities must be considered significant, but apparently normal radiographs do not exclude hip dysplasia until a well-ossified femoral head is adequately contained by the acetabulum. Femoral head ossification is usually present by 6 months of age but is may be delayed in DDH. Figure 40–26 shows several of the many radiographic relationships that are important for evaluation of the hip joint in infants. In older children, the femoral head should be adjacent to the radiolucent triradiate cartilage that forms the medial wall of the acetabulum. Displacement of the femoral head confirms dislocation. A shallow acetabulum that poorly covers the femoral head is termed dysplastic. Ultrasonography is the best technique for assessing the infant’s hip prior to ossification of the femoral head.

Differential Diagnosis

Proximal femoral focal deficiency and congenital coxa vara are rare conditions that produce shortening or instability in the hip region. Pathologic dislocation can occur rapidly in infected hips; the femoral head is displaced from a radiographically normal acetabulum. Hip dislocation may be caused by muscle imbalance in children with cerebral palsy or myelomeningocele.

Complications

Complications include inability to gain or maintain a stable reduction, avascular necrosis of the femoral head following operative or nonoperative treatment, and limitation of motion.

Treatment

A. Dislocatable hip

Neonates with confirmed dislocatable and reducible hips should be treated by means of abduction splinting (Pavlik harness) until stability is confirmed. It is important to flex the hips and abduct them no more than 60 degrees to avoid interfering with the blood supply and injury to the femoral nerve.

B. Dislocated hip

1. Birth to 18 months

In this age group, closed reduction is usually possible. Reduction can be maintained with a spica cast. If closed reduction is not possible or cannot be maintained, open reduction is required. Arthrography and computed tomography are used to confirm reduction.

2. Eighteen months to 4 years

Open reduction is more likely to be required in this group. If adequate reduction is obtained, satisfactory results are more likely. Acetabular remodeling is best until age 4.

3. Older children and adults

Treatment of newly diagnosed congenital hip dysplasia in this age group is difficult. Acetabular remodeling through growth is minimal. Achievement of a concentric reduction does not ensure a stable pain-free hip. Salvage osteotomies of the innominate bone have been described for improving acetabular coverage of the femoral head. Pain and limitation of motion will eventually necessitate total hip arthroplasty for many of these individuals.

SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)

During the period of rapid skeletal growth in early adolescence, the normal relationship of the femoral head with the femoral neck may become disturbed by a shearing displacement through the growth plate—known as slipped capital femoral epiphysis. The head remains within the acetabulum, while the femoral neck shifts anteriorly and laterally. This displacement may occur in response to minor trauma, or it can be gradual, as indicated by reactive bone formation and remodeling of the femoral neck adjacent to the growth plate. An acute SCFE may be superimposed upon a gradual “chronic” one. Involvement is bilateral in at least 25% of cases. SCFE are considered stable if the child can bear weight, and unstable if weight bearing is not tolerated. The risk of avascular necrosis is reported to be near 50% for unstable SCFE. This condition can lead to severe deformity and may cause early degenerative joint disease.

Clinical Findings

A. Symptoms and Signs

The patient typically reports pain in the knee or thigh and limps. Hip motion is limited especially flexion and internal rotation, with obligatory external rotation found on exam.

B. Imaging Studies

Radiographs are diagnostic in all but the most minimal slips (Figure 40–27). The epiphysis is not centered on the neck but rather relatively displaced posterior and medial. Since posterior displacement is often more marked, the displacement is more evident on the lateral view. Bony callus, or widening of the metaphysis adjacent to the growth plate, indicates a chronic slip. A significant SCFE produces a bony prominence on the anterolateral femoral neck, restricting hip motion.

Treatment

Surgical stabilization of the proximal femoral epiphysis is advised. In situ pinning of the epiphysis without reduction is then performed. The surgeon should make sure that screw does not enter the joint space. Gradual mobilization with protected weight bearing follows. The goal of in site pinning is to prevent further slip and gain closure of the physis. The opposite side must be watched until the physis closes as well. If severe deformity prevents hip motion, a subtrochanteric osteotomy or excision of the bony prominence on the femoral neck may be considered.

PERTHES (LEGG–CALVE–PERTHES) DISEASE

Perthes disease is an uncommon hip affliction that occurs in about one in 2000 children, generally between the ages of 4 and 10. Boys are affected five times as often as girls, but girls tend to have more severe involvement. About 10%-15% of patients have bilateral disease. The etiology is unknown but the hallmark is avascular necrosis of the proximal femoral epiphysis. Few patients achieve normal hip development. Others acquire permanent deformity of the femoral head, with limited motion and degenerative joint disease becoming symptomatic in middle age.

Determinants of Final Outcome

A. Stages of Illness

The disease involves four stages: sclerosis, fragmentation, reossification, and remodeling. The earliest clinical signs are pain in the thigh and limping. Radiographs show an apparent increase in density of the capital epiphysis. Later a ­subchondral crescent-shaped radiolucent fracture may occur, and the metaphysis may widen. The epiphysis becomes irregular and flattened during fragmentation. Gradually, reossification occurs and symptoms subside. The ultimate shape will depend upon the remolding of the proximal femur with growth. A spherical head correlates well with good long-term results.

B. Age of Patient

Younger patients have a better prognosis. Boys generally have less sever involvement than girls.

C. Severity of Involvement

The lateral pillar classification divides patients with Legg–Perthes disease into three groups—according to the extent of involvement of the lateral pillar of the epiphysis relative to the central portion of the head; group A has minimal involvement the epiphysis involved, group B with 50% decrease in height of the lateral pillar, and group C, with involvement of the entire head.

D. The “Head at Risk”

Catterall proposed certain clinical and radiographic criteria for determining whether the femoral head might deform in the course of the disease. The clinical criteria are (1) obesity, (2) decreasing range of motion of the involved hip, and (3) adduction contracture. The radiographic criteria are (1) lateral subluxation of the femoral head, (2) Gage’s sign (widening of the lateral part of the growth plate, so that the superior portion of the femoral neck appears convex), (3) calcification lateral to the epiphysis in the cartilaginous femoral head, (4) diffuse metaphysial reaction, and (5) a horizontal growth plate.

Clinical Findings

A. Symptoms and Signs

Insidious development of limp and sometimes pain in the groin, anterior thigh, or knee eventually bring the patient to a physician. An occasional case presents as acute synovitis. Examination shows antalgic gait, decreased hip motion (especially abduction and internal rotation), and sometimes flexion-adduction contracture. Passive motion is guarded rather than free.

B. Laboratory Findings

Bone scan may help with early diagnosis and assessment of the extent of head involvement.

C. Imaging Studies

Well-exposed radiographs in both anteroposterior and frog-leg lateral views are essential. Findings will depend upon the stage and severity of disease, as discussed above, but initial films usually show increased density and deformity of the femoral head epiphysis, which may be flattened or fragmented (Figure 40–28).

Differential Diagnosis

The early inflammatory stage of Legg–Perthes disease can be confused with toxic synovitis and septic arthritis. The epiphysial abnormalities are similar to those seen in epiphysial dysplasias, hypothyroidism, and avascular necrosis from other causes, notably sickle cell anemia, Gaucher’s disease, and chronic use of corticosteroid drugs.

Treatment

Treatment requires categorization according to the stage of disease, the extent of head involvement, and the condition of the hip joint at the time of presentation. The mobility of the involved joint must be determined and then followed as an important indicator of need for intervention and prognosis.

A. Observation

Children under the age of 6 without “at risk” signs typically do well with symptomatic treatment including activity restriction, stretching, and anti-inflammatory agents. In older children, if the femoral head remains contained in the acetabulum and motion is maintained observation is recommended.

Surgical Treatment

On occasion surgery is necessary to reorient the acetabulum or the proximal femur to achieve containment. Both innominate osteotomy and varus proximal femoral osteotomy have been successful.

Prognosis

Prolonged follow-up is necessary to determine the outcome. Long-term results are best correlated with the shape of the femoral head at the completion of skeletal growth.

FOOT DEFORMITIES IN CHILDREN

Positional deformities of the foot are described with the following specific terms. Equinus refers to plantar flexion. Calcaneus is the opposite position, or dorsiflexion. The forefoot alone may be in adduction, known as metatarsus adductus. The hindfoot deformity may be varus or valgus.

The goal of treatment of any foot deformity is a pain-free, flexible, plantigrade foot during normal gait.

1. Clubfoot

Talipes equinovarus, or clubfoot, is the most common foot deformity affecting approximately one in 1000 children. It occurs twice as often in boys and is bilateral half the time. There is a familial tendency, with a 5% chance that a sibling will also be affected. It can be idiopathic, or associated with an underlying syndrome.

Clinical Findings

A. Symptoms and Signs

In clubfoot, there is varus of the hindfoot, adduction of the forefoot, and equinovarus deformity. The exact etiology remains uncertain. The joints principally involved are both the subtalar and talonavicular joints. The adjacent ankle and midtarsal joints are affected to a lesser degree. The overlying soft tissues are contracted. Successful treatment requires serial casting with correction of the deformities, cavus-adduction-varus-equinus, in that order as described by Ponseti. Surgical intervention is rarely required for clubfeet if treated early with casting.

Treatment

Initial treatment is always nonoperative and should be started as soon as possible, preferably the day the infant is born.

A. Manipulation

Gentle manipulation into a corrected position should be done in order to stretch the contracted soft tissues—specifically, to align the calcaneus and navicular relative to the talus. Gentleness is required to avoid tissue trauma and to prevent overcorrection of the forefoot relative to persisting tarsal deformity.

B. Casting

After manipulation, a plaster cast is applied and molded to maintain the corrected position. Manipulation and cast application are repeated weekly, typically for 6 weeks. Often a percutaneous tendoachilles lengthening is needed for residual equinus.

Casting is followed by application of Denis Browne bar with reverse last shoes worn at first full time and then at night and during nap times for two years. During this time, routine follow-up is required to monitor for recurrence.

C. Surgical Treatment

The traditional surgery involved a posteromedial release of the ankle and subtalar joints with realignment of the talonavicular and talocalcaneal joints. Surgery is rarely recommended for clubfoot.

2. Metatarsus Adductus

Metatarsus adductus is a common forefoot deformity that is often quite flexible. If passively correctable, there is an 85% chance of spontaneous correction by age 3 years. Easy passive correction also suggests that treatment is unnecessary. If the forefoot cannot readily be returned to a normal position, manipulation, and casting can be recommended. Only a very rare severe deformity will require surgical release or osteotomy and fusion of the tarsometatarsal joints.

3. Flatfoot

The normal newborn foot appears flat because subcutaneous fat fills the longitudinal arch. This fat deposit recedes over the first 4 years of life to reveal the typical adult appearance of a medial arch under the midfoot, which does not touch the floor with weight bearing. An inadequate bony arch, which permits the medial portion of the midfoot to bear weight, is the essential feature of true flatfoot. This deformity is further classified as rigid or flexible.

Rigid flatfoot is identified by the absence of normal mobility of the hindfoot. Rigid flatfoot presenting later in childhood is usually due to coalition of the tarsal bones. Associated episodic foot pain and spasm of the peroneal muscles are typical. Depending on the child’s age and symptoms and the site of coalition, resection may be advisable or nonoperative treatment may suffice.

In flexible flatfoot, weight bearing obliterates the medial arch and also produces obvious valgus alignment of the calcaneus. Standing on tiptoes or sitting with the feet hanging free will restore the arch. Some patients with flexible flatfoot develop foot pain with weight bearing.

Treatment of asymptomatic flexible flatfoot in children is controversial. Parents distressed by the foot’s appearance or by abnormal shoe wear often request treatment, but there is little evidence that treatment prevents future symptoms, and the majority of children with flexible flatfoot have no symptoms in adulthood.

The child with painful flexible flatfoot deformity deserves treatment. Exercises to stretch tight gastro-soleus muscle groups or to strengthen intrinsic plantar muscles are usually advised, and external support for the mediolongitudinal arch can be provided if necessary. If nonoperative treatment fails to control symptoms or if deformity precludes use of normal footwear, surgery may be considered.

PAIN SYNDROMES OF THE SHOULDER

1. Rotator Cuff Tendinitis and Subacromial Bursitis

General Considerations

Inflammation within the glenohumeral joint is the most frequent cause of shoulder pain and limitation of motion. The patient is typically middle-aged. Repetitive overhead activity from occupation or sports is a common cause. The most common site of inflammation at onset is the insertion of the rotator cuff tendons, particularly the supraspinatus tendon. The location of the supraspinatus tendon between the greater tuberosity of the humeral head and the overhanging acromion process renders it particularly vulnerable to mechanical compression. The subacromial space is another common site of inflammation with subdeltoid soreness frequently radiating along the lateral humerus to the deltoid insertion.

Clinical Findings

Night pain is common. Active abduction becomes especially painful when the inflamed rotator cuff and overlying bursa are compressed beneath the acromion. The range of active abduction may be extended if the patient is instructed to rotate the arms so that the palms face upward. This rotates the greater tuberosity posteriorly, so that the attached rotator cuff tendons pass behind the acromion, resulting in diminished pain with continued abduction.

Treatment

The initial treatment of rotator cuff tendinitis and subacromial bursitis is with anti-inflammatory agents (naproxen, ibuprofen), and physical therapy to preserve motion. Slings and shoulder immobilization should not be used for more than a few days, since capsular adhesions and prolonged stiffness may result. Gentle passive range-of-motion exercises should be started as soon as tolerated, followed by active pendulum exercises. Active exercise is gradually increased while passive range of motion is continued.

If pain does not respond to oral anti-inflammatory agents, relief may be obtained by injection into the subacromial bursa.

2. Biceps Tendinitis

General Considerations

A common inflammatory process producing shoulder pain involves the biceps tendon in the bicipital groove. Biceps tendonitis usually affects individuals whose occupation involves repetitive biceps flexion against resistance or whose recreational activities include forceful throwing of a ball. Pain is prominent over the anterior aspect of the arm and is aggravated by shoulder motion. Symptoms are worse at night and improve with rest. Deltoid muscle spasm may be present and may limit both active and passive motion.

Clinical Findings

Biceps tendinitis can be distinguished from rotator cuff tendinitis by localization of tenderness to the bicipital groove. Forearm supination against resistance with the elbow flexed at the patient’s side elicits extreme tenderness in the region of the bicipital groove when the tendon is palpated near the shoulder. Instability of the tendon in the groove is occasionally manifested by a snapping sensation as the arm is abducted and externally rotated. Subluxation of the tendons can be provoked by Yergason’s maneuver, in which the patient actively flexes the elbow against resistance while the physician rotates the humerus externally. An unstable tendon will “pop” out of the groove.

Treatment

Treatment of bicipital tendinitis includes cessation of offending activities and short-term immobilization of the shoulder in a sling and a trial of nonsteroidal anti-inflammatory agents. Surgery is occasionally required to stabilize a subluxating tendon. When discomfort has subsided, progressive mobilization is begun with exercises similar to those described in the section on rotator cuff tendinitis.

3. Adhesive Capsulitis (Frozen Shoulder)

General Considerations

A common cause of shoulder pain in middle-aged and elderly patients is adhesive capsulitis, or the so-called frozen shoulder. This disorder may complicate other inflammatory shoulder ailments, particularly in individuals immobilized for prolonged periods. It may also occur without any identifiable inciting trauma and has been associated with cardiovascular disease, diabetes, RA, and degenerative cervical spine disease. Though the exact pathogenesis is unknown, the end result is a chronically inflamed, contracted capsule densely adherent to the humeral head, the acromion, and the underlying biceps and rotator cuff tendons. Normal bursae are obliterated by scarring.

Clinical Findings

A. Symptoms and Signs

The onset of symptoms is usually gradual and heralded by complaints of diffuse tenderness with disproportionately severe restriction of active and passive motion. Motion is not improved by lidocaine or corticosteroid injection.

B. Imaging Studies

Arthrography reveals a contracted joint capsule and no bursal filling. X-rays may reveal osteopenia of the humeral head.

Treatment

The natural history of adhesive capsulitis is occasionally spontaneous resolution. Subsidence of pain and return of nearly full motion can be obtained, though the process may persist for 6 months to several years. Efforts to speed return of function have included intensive physical therapy and anti-inflammatory agents. Rarely, surgical intervention is required to release the capsule, and this can be done arthroscopically. Clearly, the best treatment of this condition is prevention. Prolonged disuse or immobilization of a painful shoulder must be avoided. Early mobilization is stressed, with initiation of gentle range of motion exercises and guidance by the physician and the physical therapist.

4. Dislocation of the Shoulder Joint

The shoulder (glenohumeral) joint is the most commonly dislocated joint in the body because it is less constrained than other joints and motion is possible in multiple planes. The constraints that prevent instability include the labrum, negative pressure of the joint, and glenohumeral ligaments. The rotator cuff also provides dynamic stability by compressing the humeral head against the glenoid. These static and dynamic stabilizers create a delicate balance between motion and stability.

Dislocations are usually related to overhead trauma when the arm is in abduction, extension, and external rotation. Most traumatic dislocations are anterior, but posterior dislocations can occur. Shoulder instability is classified by several factors including traumatic versus atraumatic, initial versus recurrent, acute versus chronic, the direction of dislocation, and voluntary versus involuntary.

Anterior Dislocations of the Shoulder Joint

Anterior dislocations can be diagnosed by history and physical examination. The arm is held in a position of slight abduction and external rotation. The anterior shoulder area appears full, and there is a vacant sulcus in the posterior shoulder area. Anteroposterior x-ray in the plane of the scapula and axillary x-ray are necessary to determine the direction of the dislocation and the presence of fracture. Humeral head impression fractures (Hill Sachs lesion) and glenoid rim fractures are easily missed if the radiographs are inadequate. Dislocation may also be complicated by injury to the brachial plexus (most commonly the axillary nerve) and rotator cuff tear. The examiner should check for sensory changes over the deltoid to assess the axillary nerve.

Posterior Dislocation of the Shoulder Joint

Posterior dislocation is characterized by fullness beneath the spine of the scapula, flattening of the anterior shoulder, prominence of the coracoid, and restriction of motion in external rotation. The reported incidence of missed diagnosis is as high as 60%. The injury occurs either from direct or indirect force to the anterior shoulder, so that the humeral head is pushed out posteriorly. Common causes of posterior dislocation of the shoulder are seizures or electrical shock. Anteroposterior x-rays of the chest may look deceptively normal with posterior dislocation, but an axillary view and an anteroposterior x-ray in the scapular plane will show the true position of the head in relation to the glenoid. This dislocation may also be reduced by longitudinal and gentle transverse traction. The reduction may be held in a sling for 3-4 weeks with some external rotation if necessary.

Multidirectional Instability

Patients with congenital or acquired laxity may develop symptomatic shoulder instability in multiple directions. These patients should be initially treated with of rehabilitation and strengthening monitored by a physical therapist. Most of these patients recover stability with muscular strengthening of the rotator cuff and scapular stabilizing muscles.

Voluntary Dislocators

Patients who voluntarily dislocate their shoulders have a high recurrence rate after surgical procedures. Therefore, surgery is usually avoided in this population.

Treatment

The treatment of shoulder dislocations consists of closed reduction after careful examination and documentation of neurovascular status and good quality x-rays. Many methods of closed reduction have been described, including gentle traction in the prone position and traction-countertraction with a sheet. All methods of reduction rely on adequate analgesia and relaxation. Forceful reductions should be avoided because they may cause brachial plexus injury, vascular injury, or fracture. Postreduction x-rays document a concentric reduction and rule out any associated fracture. Once reduced, the arm is placed in a sling for 3-4 weeks before protected motion exercises are initiated.

Surgical reconstruction is indicated for anterior traumatic instability that is recurrent. The incidence of recurrent instability approaches 80%-90% for active young athletes. Therefore, the indication for surgery depends on age and activity level as well as the number of traumatic dislocations and associated fracture or soft tissue injury. After operative repair, the shoulder is usually immobilized in a shoulder immobilizer for 3-6 weeks before active motion is begun. Open and arthroscopic surgical repairs of the labrum for anterior dislocation are successful in preventing further episodes of dislocation in most patients.

5. Rotator Cuff Tears

Rotator cuff tears and rotator cuff impingement are common sources of shoulder pain. Four rotator cuff muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) function to move the arm and stabilize the shoulder joint. There is a full spectrum of injury ranging from tendonitis to impingement and rotator cuff tears. The most severe condition is a massive, chronic rotator cuff tear that subsequently leads to proximal migration of the humeral head and arthritic changes of the humeral head known as rotator cuff arthropathy.

Patients with “rotator cuff syndrome” usually present with pain and weakness related to attempted overhead activities and active movements with the arm away from the body. Physical examination demonstrates impingement pain with certain overhead movements and rotator cuff weakness. Diagnosis is made by history and physical examination. Ultrasound and MRI are useful tests to evaluate rotator cuff tears and associated intra-articular pathology (Figure 40–29).

Treatment

The treatment of shoulder pain related to rotator cuff pathology (inflammation, degeneration, and tear) depends on other patient variables such as age, activity level, hand ­dominance as well as the chronicity and level of pain and dysfunction. Tears may result from single event trauma (a fall on the outstretched hand), repetitive trauma (baseball pitchers), or degeneration of the rotator cuff in older patients.

Most cases of shoulder pain related to the rotator cuff tendonitis are initially treated nonoperatively. Activity modification, NSAIDs, and physical therapy can be beneficial. Some patients require a subacromial injection to control inflammation and pain. Rotator cuff tears can be treated with surgical repair. Acute traumatic rotator cuff tears should be repaired acutely in order to prevent rotator cuff atrophy and retraction. Acromioplasty and distal clavicle excision are performed at the same time if coracoacromial arch impingement contributes to the rotator cuff tear.

6. Glenohumeral Arthritis

Arthritis of the glenohumeral joint may be caused by OA, inflammatory disease, previous trauma, previous surgery, or arthritis of recurrent instability. Patients have pain with activities as in arthritis in other joints. They may also complain of stiffness, which is usually progressive over time. Physical examination discloses limited motion. Examination by proper shoulder x-rays shows the characteristic joint space narrowing and humeral head osteophytes.

Before operative treatment is elected, a thorough course of conservative measures is indicated. Surgery becomes an option for patients with significant pain and limitation of activity because of their arthritis. Shoulder arthroplasty (hemiarthroplasty, total shoulder replacement) can provide pain relief; however, motion is rarely restored to normal. Contraindications to total arthroplasty are active or latent septic arthritis, paralysis of the shoulder musculature, and neuropathic joints.

PAIN SYNDROMES OF THE ELBOW

1. Tennis Elbow (Humeral Epicondylitis)

General Considerations

Though far more common in nonathletes, humeral epicondylitis is commonly termed tennis elbow. This overuse syndrome is uncommon before age 18 years and most frequent in the fourth and fifth decades. Tennis elbow is commonly seen in nonathletes performing activities that require frequent rotary motion of the forearm, such as gardening, use of screwdrivers or wrenches, turning of doorknobs, and even operation of vehicles without power-assisted steering.

Clinical Findings

Tennis elbow is characterized by tenderness and pain at the humeral epicondyle provoked by extension of the wrist. The origin of the inflamed common extensor muscle is the source of discomfort. The pain is readily reproduced with resisted extension of the wrist with the elbow extended.

Though the pathogenesis of tennis elbow is unknown, symptoms are usually attributed to inflammation of the origin of the common extensor muscle and, in some cases, to a tear in the origin of the extensor carpi radialis brevis. The tears are thought to be the result of repeated stress on degenerated tendon fibers. Elbow motion remains normal.

Differential Diagnosis

Differential diagnosis includes radial nerve irritation at the elbow, which may often be delineated by electromyography (EMG).

Treatment

A. Medical Treatment

Most patients with tennis elbow respond favorably to a brief period of rest and anti-inflammatory agents followed by a program of exercises to strengthen the forearm muscles. Subtendinous injection of soluble corticosteroids with lidocaine may be required in more severe cases. Repeated injections may further weaken tendons and should be avoided.

A nonelastic forearm band may be prescribed and worn near the elbow during occupational or recreational activities that aggravate the condition. The band is thought to be effective either because it limits full contraction of the tender muscles or because it slightly alters the position of the extensor tendons.

B. Surgical Treatment

Rarely, patients with severe or refractory symptoms may require operative treatment. Most surgeons repair the origin of the torn wrist extensor tendon after excision of granulation tissue and any rough subjacent bone. Lengthening of the short wrist extensor results in loss of strength.

2. Olecranon Bursitis

General Considerations

Olecranon bursitis is a common cause of periarticular elbow pain. Like epicondylitis, this condition is often related to occupational activities, in this case prolonged periods of leaning on the elbow.

Clinical Findings

A. Symptoms and Signs

The subcutaneous olecranon bursa becomes distended, sometimes to dramatic proportions. The skin of the extensor surface of the forearm may be edematous and pitted. Traumatic bursitis is often only mildly painful despite marked swelling.

Treatment

Treatment of idiopathic or traumatic olecranon bursitis consists of protecting the bursa from further pressure or irritation. Compression dressings may be necessary if symptoms are prolonged. Recurrence is not uncommon. Excision of the bursa may be required for rare persistent cases. The bursa must be totally excised and the overlying skin sutured to the olecranon periosteum to ensure obliteration of the space.

INJURIES TO THE LIGAMENTS, MENISCI, & CARTILAGE OF THE KNEE JOINT

Internal derangement of the knee joint mechanism is usually caused by trauma but can also result from overuse. Injuries to the ligaments, cartilage, and meniscus commonly occur as combined lesions.

X-rays are often normal in suspected ligament or cartilage injury. MRI is valuable imaging modality. MRI assists with preoperative confirmation of a clinical diagnosis.

Once a diagnosis is obtained, arthroscopy is a valuable diagnostic and therapeutic tool for the knee joint. The arthroscope is introduced into the knee joint through a small stab incision allows examination of structures inside. Meniscus tears, ligament reconstruction and chondral injury can all be addressed arthroscopically.

Injury to the Menisci

Injury to the medial meniscus is the most frequent internal derangement of the knee joint. Clinical findings include swelling, pain, and varying degrees of restriction of flexion or extension. True locking (inability to fully extend the knee) is highly suggestive of meniscal tear. A marginal tear permits displacement of the medial fragment into the intercondylar region (bucket handle tear) and prevents either complete extension or complete flexion. Motion may cause pain over the anteromedial or posteromedial joint line. Tenderness can often be elicited at the joint line. Weakness and atrophy of the quadriceps femoris may be present. Injury to the lateral meniscus is less common. Pain and tenderness may be present over the lateral joint line.

Initial treatment may be conservative. Swelling and pain can be relieved by aspiration. Isometric quadriceps exercises should be performed frequently throughout the day with the knee in maximum extension, and the emphasis should be placed on restoring range of motion. Physical therapy and nonsteroidal anti-inflammatory drugs are helpful.

Arthroscopy with either meniscal debridement for central tears or meniscus repair for peripheral tears is recommended. Isometric quadriceps exercises and range of motion exercises are resumed and are gradually increased. As soon as the patient is able to perform these exercises comfortably, graded resistance maneuvers should be started. Exercises should be continued until motion and strength is equal to the other healthy knee.

Injury to the Ligaments

Ligaments in general prevent displacement or angulation beyond its normal arc of motion.

A. Medial Collateral Ligament

The MCL is the primary restraint to valgus. Forced abduction of the leg at the knee causes injury varying from strain to complete rupture. The MCL is attached to the medial meniscus at the joint line.

A history of a twisting injury or direct blow at the knee with valgus strain can usually be obtained. Pain is present over the medial aspect of the knee joint. In severe injury, joint effusion may be present. Tenderness can be elicited at the site of the lesion. When only an isolated ligamentous tear is present, x-ray examination may not be helpful unless it is made while valgus stress is applied.

Treatment of an incomplete tear consists of protection from further injury while healing progresses in a brace that allows motion but protects the knee from valgus injury. It may be helpful to bend the brace into varus to take load off of the ligament.

Tear of the MCL is frequently associated with other lesions, such as tear of the medial meniscus and rupture of the anterior cruciate ligament.

B. Lateral Collateral Ligament

Tear of the lateral collateral ligament is often associated with injury to surrounding structures including the popliteus muscle tendon or the iliotibial band. Avulsion of the apex of the fibular head may occur, and the peroneal nerve may be injured.

Pain and tenderness are present over the lateral aspect of the knee joint, and hemarthrosis may be present. X-rays may show bone avulsion from the fibular head.

The treatment of partial tear is similar to that described for partial tear of the MCL. If complete tear is detected healing is rare without surgical intervention, and exploration and reconstruction is required.

C. Anterior Cruciate Ligament

The function of the anterior cruciate ligament is prevention of anterior displacement of the tibia relative to the femur. Injury to the anterior cruciate ligament is often associated with injury to the menisci or the MCL. The cruciate ligament may be avulsed with part of the tibial tubercle in children (Figure 40–30), but it usually ruptures within the substance of its fibers in adults.

The characteristic clinical sign of tear of the anterior cruciate ligament is a positive lachman: the knee is flexed to 30 degrees and pulled forward, and excessive anterior excursion of the proximal tibia (in comparison with the opposite normal knee) is noted. MRI is helpful for identifying associated meniscal or chondral injury. Reconstruction is usually required for young active patients who wish to participate in sports that call for sudden cutting or twisting movements. Reconstruction is delayed until full range of motion is obtained. With avulsion, displaced tibial bone is present, and attachment of the fragment in anatomic position by arthroscopy is necessary.

D. Posterior Cruciate Ligament

Tear of the posterior ligament may occur within its substance or by avulsion of a fragment of bone at its tibial attachment. Tear of the posterior cruciate ligament can be diagnosed by the posterior “drawer” sign: The knee is flexed at a right angle, and the upper tibia is pushed backward; if excessive posterior excursion of the proximal tibia can be noted, tear of the posterior ligament is likely. MRI is very accurate for diagnosis of these injuries.

Bony avulsion of the PCL should be addressed surgically with reattachment. Isolated PCL tears can be treated nonoperatively. Treatment is directed primarily at the associated injuries and maintenance of competency of the quadriceps strength.

Cartilage Injury

Damage to the cartilage is common with trauma to the knee and should be differentiated from OA. Developments in cartilage transplantation, including autograft and allograft reconstruction, have improved the prognosis for these injuries. Arthroscopy and MRI are required for accurate diagnosis (Figure 40–31). Cartilage can also be biopsied from the knee, cultured, and then emplaned at a later date.

Ligamentous Reconstruction of the Knee

Knee joint instability may be (1) single plane (medial, lateral, posterior, or anterior), (2) rotatory, or (3) a combinations of the two.

Reconstructive procedures to replace the function of the anterior and posterior cruciate ligament include use of a portion of autograft or allograft tendon to recreate the native ligament. Indications for major reconstruction of knee ligaments depend on the patient’s age and activity level and the status of the articular cartilage within the knee.

PAIN SYNDROMES OF THE HIP

1. Bursitis & Tendonitis of the Hip

Bursitis and tendonitis are frequent causes of pain around the hip area. These conditions most commonly affect ­middle-aged and elderly patients. Patients with a history of prior hip surgery, such as hip replacement or fixation of a hip fracture, may be especially prone to these conditions.

Clinical Findings

A. Symptoms and Signs

A common complaint is the inability to sleep or rest on the affected side. The painful area is localized over the prominence of the greater trochanter, and the pain is reproduced by firm palpation. Hip bursitis may be associated with tendonitis of the hip abductors that insert onto the greater trochanter. Pain due to tendonitis may be reproduced with active hip abduction against resistance.

It is important to differentiate extra-articular sources of hip pain such as bursitis and tendonitis from intra-articular sources such as OA. Intra-articular pathology is suggested by pain localized to the groin, limited internal rotation, and reproduction of the patient’s pain at the extremes of ­rotation.

B. Imaging Studies

Plain radiographs are extremely useful in the evaluation of hip joint disorders.

Treatment

Trochanteric bursitis often responds to rest, oral anti-inflammatory medications, and stretching. Corticosteroid injection is highly effective in refractory cases. Rapid relief of symptoms confirms injection of the proper area.

2. The Snapping Hip

The painful snapping hip is most commonly caused by the iliotibial band snapping over the prominence of the greater trochanter. Less commonly, the iliopsoas tendon may be the cause of pain as it snaps over the hip joint capsule.

Snapping due to the iliotibial band can be reproduced with passive flexion of the hip starting from an adducted position. Snapping of the iliopsoas tendon may be reproduced with passive extension and internal rotation of the hip starting from a flexed and externally rotated position. Fluoroscopy after injection of the iliopsoas bursa with contrast can help to confirm this diagnosis.

Treatment usually consists of stretching and strengthening exercises. In rare circumstances, surgical release may be indicated for refractory cases.

ARTHRITIS

General Considerations

Arthritis is an umbrella term for different inflammatory and noninflammatory disorders affecting synovial joints. Patients with advanced arthritis will experience pain, loss of motion, and joint deformity resulting in significant disability. Three major types of arthritis will be discussed in the following chapter: rheumatoid arthritis, spondyloarthritis, and osteoarthritis.

1. Rheumatoid Arthritis

General Considerations

RA is a chronic inflammatory, autoimmune disease that attacks the synovial joints, causing a symmetric, erosive, deforming polyarthritis. RA is more common in women than in men affecting approximately 75 out of every 100,000 people. RA in many cases results in partial or total disability and is associated with a shortened life expectancy.

Clinical Evaluation

Patients typically complain of joint pain, swelling, tenderness, and early morning stiffness that last greater than 1 hour and improve with activity. The joints most commonly involved include the MCP, PIP, and metatarsophalangeal (MTP). The cervical spine is often involved as well. In later stages of RA, tendon subluxation, tendon rupture, and joint destruction occur.

Currently, the most specific laboratory finding for RA is the presence of anticyclic citrullinated peptide antibodies. Approximately, two-thirds of RA patients will display these antibodies. Rheumatoid factor is a more sensitive but less specific laboratory finding, present in approximately ninety percent of patients with RA. Other common laboratory findings include presence of antinuclear antibody with homogenous pattern, elevated erythrocyte sedimentation rate (ESR), elevated C-reactive protein (CRP), decreased hematocrit, and increased platelet count.

Radiographs typically show bony erosions and osteopenia. Joint space narrowing, bone resorption, deformity, dislocation, and fragmentation occur as the disease process progresses. “Protrusio acetabuli” (medial migration of the femoral head through the acetabulum into the pelvis is sometimes seen on x-ray.

Etiology

Currently, tumor necrosis factor alpha (TNF-alpha) and interleukin-1b (IL-1b) are considered to be the major proinflammatory cytokines responsible for the pathogenesis of RA. When these two cytokines are secreted, they stimulate synovial cells to proliferate and produce collagenase which leads to cartilage degradation, bone resorption and inhibition of proteoglycan synthesis. Additionally, these two cytokines induce other inflammatory cytokines and matrix metalloproteinases which further contribute to and sustain the inflammatory cascade.

Treatment

In the past, treatment of RA was purely for symptom relief, consisting of splinting and rest of inflamed joints with oral NSAIDS. However, with the advent of disease-modifying antirheumatic drugs (DMARDS) and anticytokine medications the actual progression of the disease has been curtailed in patients.

Currently, three TNF-alpha antagonists are approved for the treatment of RA in the United States: infliximab, etanercept, and adalimumab. When one of these three drugs are used in combination with methotrexate, patients experience better functional outcomes and less joint structural damage over the course of time when compared to patients who are treated with only one medication. Due to the increased risk of serious infection, especially tuberculosis reactivation, patients should be screened for TB prior to starting one of the TNF-alpha antagonists. Additionally, patients with demyelinating disease should not take one of these agents.

Glucocorticoids have also been used to treat active RA for several years. The immediate anti-inflammatory effects of glucocorticoids are well-known. However, glucocorticoids have severe long-term side effects that make their continued use undesirable. At this time, treatment with low-dose prednisolone for the first six months of treatment in combination with a DMARD (eg, methotrexate) is an acceptable management plan. However, after six months, the prednisolone should be discontinued in favor of other therapy.

Other treatment medications for RA include anakinra (IL-1 receptor antagonist), abatacept (T-cell modulator), rituximab (B-cell modulator), doxycycline (matrix metalloproteinase modulator), and statins (anti-inflammatory). These medications may be considered when therapy with TNF-alpha antagonists is contraindicated.

For patients with severe arthritic change, joint-­replacement surgery can provide excellent pain relief and improved function. Joints that can be replaced include the hip, knee, shoulder, elbow, and metacarpophalangeal joints. Additionally, fusion may be considered for diseased joints of the hand and wrist which are not amenable to replacement.

2. Seronegative Spondyloarthritis

General Considerations

Spondyloarthritis encompasses a group of inflammatory arthritides characterized by spinal and peripheral joint oligoarthritis and enthesitis (fibrosis and calcification at the point of attachment between muscle and bone). This family of diseases includes ankylosing spondylitis (AS), psoriatic arthritis, enteropathic arthritis (associated with inflammatory bowel disease), reactive arthritis, and undifferentiated spondyloarthropathy.

3. Ankylosing Spondylitis

AS is a chronic inflammatory disease of the axial skeleton characterized by back pain, prolonged morning stiffness, and progressive loss of motion of the axial spine. There can also be sacroiliac involvement, arthritis of the hips, and peripheral arthritis. This disease typically affects young adults, with peak onset usually between 20 and 30 years of age. Males are more commonly affected than females. Over time, there is increased flexion of the neck, increased thoracic kyphosis, and loss of lumbar lordosis leading to a stooped posture. Radiographs will show squaring of the vertebral bodies early on. With disease progression, bridging syndesmophytes, ankylosis of the facet joints, calcification of the anterior longitudinal ligament, and atlantoaxial (C1-C2) subluxation may be noted.

Laboratory values have little role in the diagnosis of AS. ESR and CRP are often elevated. HLA-B27 is the only genetic locus definitively linked to AS; however, it is not specific.

Treatment with NSAIDS is very effective with significant improvement in back pain. Recently, TNF-alpha antagonists (infliximab, etanercept, and adalimumab) have been effective in the treatment of AS in clinical trials. As in patients with RA, tuberculosis screening should take place prior to the initiation of TNF-alpha treatment.

4. Psoriatic Arthritis

Psoriatic arthritis is chronic inflammatory disease characterized by skin lesions and arthritis of the peripheral joints. One-third of patients have arthritis of the spine as well. Patients may experience nail pitting and onycholysis (painless separation of the nail from the nail bed).

Psoriatic arthritis is commonly treated with NSAIDS. DMARDS such as methotrexate are also used with success. Like RA and AS, recent success has been demonstrated with the use of anti-TNF alpha agents.

5. Enteropathic Arthritis, Reactive Arthritis, and Undifferentiated Spondylarthropathy

Enteropathic arthritis is the spondyloarthropathy associated with ulcerative colitis and/or Crohn’s disease. Typically, the spondyloarthropathy in these patients progresses independently of the bowel pathology. Patients with reactive arthritis develop axial disease after exposure to an infectious agent such as Salmonella, Shigella, or Chlamydia. Undifferentiated spondyloarthropathy characterizes spinal disease without an adequate number of symptoms or signs to designate a specific type of arthritis. Treatment for these types of arthritides includes TNF-alpha inhibitors and NSAIDS.

6. Osteoarthritis

OA is a common age-related pathology characterized by damage to hyaline articular cartilage, synovitis, thickening of the joint capsule and bony remodeling. In contrast to RA, patients with OA will complain of joint pain worse with activity and short-acting stiffness after inactivity. Female sex, prior joint injuries, family history, and obesity are additional risk factors for the development of OA. Radiographs will often show joint space narrowing, sclerosis, and osteophytes.

Initial treatment includes NSAIDS or acetaminophen for pain relief and physical therapy to strengthen and improve the flexibility of muscles around the pathologic joint. A significant drawback to chronic NSAID treatment is the development of gastrointestinal toxicity including ulceration. Cox-2 inhibitors, such as celebrex, were introduced as anti-inflammatory alternatives without the same gastrointestinal side effects. However, due to concerns over possible increase in serious cardiovascular events, some Cox-2 inhibitors (rofecoxib and valdecoxib) were withdrawn from the market. At this time, there are Cox-2 inhibitors (celecoxib, etoricoxib, and lumircoxib), that have been shown to have similar efficacy for treatment of OA compared to nonspecific NSAIDS with fewer gastrointestinal side effects and without significant increase in the rate of serious cardiac events.

Exercise and weight loss are two additional interventions that are critical for the management of OA. Obesity is strongly associated with the development of OA. For the average person, their knees feel 3-6 times their body weight during activities such as walking and running. Moderate weight loss will reduce the pain and inflammation associated with OA, as well as slow the progression of this disease. Also improving the strength and flexibility of muscles around joints through exercise will lead to better functional outcome and pain ratings.

Other treatment options include intra-articular injection of glucocorticoids and hyaluronans. These injections appear to improve pain in the short term, without many significant side effects. However, these treatments do not provide significant long-term relief for most patients, nor do they alter disease progression.

Glucosamine and chondroitin sulfate result in improved pain and function for some patients and no effect for other patients. Given that side effects are minimal, treatment with these two products is reasonable for those who have an improvement in their symptoms.

For severe cases of OA, surgery including total joint replacement may be considered depending on the state of the disease and patient characteristics.

7. Hip Disorders and Reconstruction

General Considerations