Tarascon Pocket Orthopaedica

Fourth Edition From the publishers of the Tarascon Pocket Pharmacopoeia®

Damian M. Rispoli World Headquarters Jones & Bartlett Learning 5 Wall Street Burlington, MA 01803 978-443-5000 [email protected] www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online book- sellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com.

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Treatments and side effects described in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect that is not described herein. Drugs and medical devices are discussed that may have limited availability controlled by the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice, and government regulations often change the accepted standard in this field. When consideration is being given to use of any drug in the clinical setting, the health care provider or reader is responsible for determining FDA status of the drug, reading the package insert, and reviewing prescribing information for the most up-to-date recommendations on dose, precautions, and contraindications, and determining the appropriate usage for the product. This is especially important in the case of drugs that are new or seldom used. Production Credits Director of Product Management: Amanda Martin Cover Design: Kristin E. Parker Product Manager: Teresa Reilly Rights & Media Specialist: John Rusk Product Assistant: Anna-Maria Forger Media Development Editor: Troy Liston Production Editor: Daniel Stone Cover Image (Title Page, Part Opener, Marketing Manager: Lindsay White Chapter Opener): © Library of Congress Manufacturing and Inventory Control Supervisor: Printing and Binding: Cenveo Amy Bacus Cover Printing: Cenveo Composition: S4Carlisle Publishing Services ISBN: 978-1-284-05034-9 6048 Printed in the United States of America 22 21 20 19 18 10 9 8 7 6 5 4 3 2 1 Tarascon Pocket Orthopaedica Fourth Edition Trauma Protocols 1 Suggested Antibiotic Prophylaxis Initial Approach to Trauma If Urologic Criteria Are Met 76 Assessment and Management 1 Suggested Antibiotic Prophylaxis Trauma Radiographs 2 for GI Procedures 76 Tension Pneumothorax 2 Anticoagulation Therapy 76 Chest Tube 2 Blood Transfusion 77 IV Maintenance Therapy 3 Viral 77 Cardiac Tamponade 3 Systemic Reactions 77 Foley Catheter 3 Ca++/Phosphate 78 Major Differences in Pediatric Regulation of Calcium and Versus Adult Polytrauma 5 Phosphate Metabolism 78 Anatomy 7 Laboratory 78 Muscle Tables 7 Joint Fluid Analysis 78 Approaches 17 Gross Examination 79 Cross Sections 21 Differential (% Neutrophils) 79 Arteries 26 Culture 79 Ligaments 30 Polarized Microscopy 79 Nerve Plexi 36 Tests For Infection 80 Peripheral Nerves (Motor) 39 Gram Stain 80 Peripheral Nerves (Sensory) 46 Tissue Frozen Section 80 Nerves 47 Metabolic Bone Disease 80 Dermatomes 49 Clinical and Radiologic Overview Antimicrobials 51 of Metabolic Bone Disease 80 Arthritis—Septic 51 Nerves, EMG/NCV 81 Total Joint Arthroplasty—Criteria EMG Findings/Meaning 81 for Infection 53 Electrodiagnostic Findings in Antibiotics for Surgical Prophylaxis 63 Various Peripheral Nerve Disorders 82 Emergency Procedures 65 Nerve Injury Classification 83 Compartment Syndrome 65 Obesity 83 Acute Stabilization of the Pelvis Obesity Standards [World Health Methods 72 Organization] 83 GENERAL ORTHOPAEDICS 75 Osteonecrosis 84 Antibiotic Prophylaxis 75 Etiologies 84 Potentially Increased Risk 75 MRI 84 Suggested Antibiotic Prophylaxis If Surgeon Chooses Dental Prophylaxis 75 iv Tarascon Pocket Orthopaedica Natural History 84 Reflexes 96 Treatment Options 84 Characteristics of Myelodysplasia Staging System for Osteonecrosis Levels 97 of the Hip 84 Growth Centers 97 Osteoporosis 85 Growth Plates 97 Osteoporosis 85 Foot 99 DEXA Osteoporosis Criteria 85 Angles and Characteristics 100 Osteoporosis Risk Factors 85 Normal Talo-Calcaneal Angle Is Calcium Recommendations 86 20–40 Degrees 100 Vitamin D 86 Clubfoot Treatment—Ponseti Prophylactic Reccomendations 86 Technique 100 Pain Management, Degenerative Brachial Plexus 100 Arthritis 86 Brachial Plexus Birth Injuries 100 1st Line of Treatment 86 Osteochondroses (Osteonecrosis at 2nd Line of Treatment 87 Apophysis/Physis) 101 Perioperative Management 87 General 101 Perioperative Management in the Arthroscopic Classification of Patient With Rheumatologic Osteochondritis Dissecans (Guhl) 101 Disorders 87 Night Pains 101 Nonsteroidal Anti-Inflammatory Back Pain in Children 102 Drug Half-Life 88 Mucopolysaccharidosis 102 Supplemental Hydrocortisone for Dysplastic Conditions 103 Surgical Stress 89 Disproportionate Dwarfism 103 Tetanus 89 Proportionate Dwarfism 104 Wound Classification for Tetanus Salter-Harris Classification 105 Prophylaxis 89 Salter-Harris Classification Tetanus Immunization Schedule 89 of Physeal Injuries 105 Tobacco Abuse 90 Slipped Capital Femoral Epiphysis 106 Tobacco’s Effects 90 Slipped Capital Femoral Epiphysis 106 Tourniquet 90 Classification 106 Tourniquet Use 90 Radiographic Evaluation 106 Venous Thromboembolic Disease 91 Physical Exam 106 Commonly Used Prophylaxis Grading 106 Options 92 Treatment 106 Guidelines for Duration of Therapy 92 Limp 107 Wound Healing 93 Evaluation 107 PEDIATRIC ORTHOPAEDICS 95 Radiographs 107 Medications 95 Ultrasound 107 Analgesics 95 MRI 107 Antihistamines 95 Transient Synovitis vs. Septic Milestones and Angles 95 Arthritis 108 Gait 95 Five Predictors of Septic Hip Rotational Profile 96 Arthritis 108 Development of Cervical Spine 96 Osteomyelitis in Children 109 Limp—Differential Diagnosis 110 Tarascon Pocket Orthopaedica v Vertebral Infection 110 Concussion 164 Discitis 110 Concussion: Major Features 164 Genu Varum 110 Neuropsychological Testing 164 Scoliosis 111 Concussions in Athletes 164 Neuromuscular Scoliosis 111 Stages of Concussive Injury 165 Infantile Idiopathic Scoliosis 111 Spinal Evaluation 165 Early Onset Idiopathic Scoliosis 111 Steroids in Emergent Cord Injury 165 Adolescent Idiopathic Scoliosis 111 Autonomic Dysreflexia 166 Treatment Guidelines 112 Spondylolysis and Progression Risk Factors 112 Spondylolisthesis 166 Lenke Classification of Adolescent Listhesis Grades 166 Idiopathic Scoliosis 114 Muscle Strength Testing 166 Congenital Spinal Deformities 114 Reflexes 166 Child Abuse 117 Lumbar Spinal Stenosis 167 Skeletal Survey in Child Abuse 117 Spondylolysis 167 Differential Diagnosis in Child Frankel Grade 167 Abuse 117 Low Back Pain Treatment 168 Specificity of Musculoskeletal Acute Low Back Pain (≤ 6 wk) 168 Findings in Child Abuse 117 Chronic LBP (> 6 wk), Worsening Legg-Calves-Perthes 118 Radiculopathy 168 Legg-Calvé-Perthes Stages 118 Spinal Cord Injury Syndromes 169 Herring Classification 118 Spinal Cord Injury Treatment Risks 118 by Functional Level 169 Physical signs 118 Traction 171 Key to prognosis 118 Traction Setups 171 DDH 119 Traction Pin Placement 171 Developmental Dysplasia Distal Femoral Pin 172 of the Hip 119 Proximal Tibial Traction Pin 172 Risk With History 119 Traction Types 173 Distribution 119 Trauma—Adult 177 Algorithm for Evaluation and Hand 177 Treatment of DDH 120 Small Joint Fusion 179 Physical Exam and Injections 121 Fingers 179 Physical Exam: Hand 121 Thumb 179 Wrist Injection 128 Hand 179 Wrist Block 128 Wrist 182 Physical Exam: Elbow 129 Radius/Ulnar Shaft 183 Physical Exam: Shoulder 132 Elbow 184 Physical Exam: Spine 136 Shoulder 189 Physical Exam: Hip 138 Shoulder Girdle 194 Physical Exam: Knee 138 Cervical Spine 196 Physical Exam: Ankle/Foot 140 Thoracic and Lumbar Spine 200 Radiologic Views 143 Fracture Types and Columnar Radiologic Views: Spine 143 Involvement 201 Radiologic Views: Upper Extremity 149 Stress Fractures 201 MRI Signal Characteristics 151 Pelvis Fractures 202 Radiologic Views: Hip/Pelvis 154 Pelvic Fractures With Hemodynamic Radiologic Views: Lower Extremity 158 Instability 203 Radiologic Views: Foot/Ankle 159 vi Tarascon Pocket Orthopaedica Periprosthetic Femur Fracture Pelvic and Acetabulum Fractures 235 Classification and Treatment 207 Femoral Shaft Fractures 237 Hip Fractures 207 Knee Fractures and Dislocations 238 Hip Dislocations 209 Tibia and Fibula Fracture 240 Femoral Shaft Fractures 211 Ankle Fractures 241 Knee Fractures 211 Foot Fractures 243 Knee Dislocation/Soft Tissue Injury 212 Trauma Scores/Classifications 245 Tibia/Fibular Fractures 213 Gustillo Classification 245 Classification of Acute Lateral Ankle Open Hand Injuries 246 Sprains 214 Management of Severe Extremity Leg/Ankle Fractures/Dislocations 215 Soft Tissue Trauma 247 Foot Fractures and Dislocations 216 Tumor 248 Trauma—Pediatric 221 Staging System for Musculoskeletal Pediatric Trauma—Wrist and Lesions (Enneking) 248 Hand Fractures 221 Scoring System to Predict Wrist and Hand Fractures 222 Pathologic Fracture 249 Radius/Ulnar Shaft Osteoblastic Metastasis 249 (Fracture/Dislocation) 223 Skeletal Fixation of Metastatic Elbow 226 Carcinoma 249 Shoulder 231 Lodwick’s Classification Spine Fractures 233 (Radiographs of Bone Lesions) 250 Hip Fractures and Dislocations 234 Malignant Lesions 251 Apophyseal Avulsion Fractures 234 Intra-Articular Tumors 251 Apophyseal Avulsion Fractures Musculoskeletal Tumor Society Around the Pelvis 235 (MSTS) Stages of Disease 251 Editorial Board Damian Rispoli, MD Chief, Shoulder and Elbow Surgery Weirton Medical Center, Weirton, WV

David Carmack, MD Tracy Popey, MD Chief, Orthopedic Surgery Department Orthopedic Surgeon Medical Director, Orthopedic Trauma Service Chief of Anesthesia, Chief of Surgery Eastern Maine Medical Center, Bangor, ME Highlands Hospital, Connellsville, PA Marc Deschaine, MPAS, PA-C Eric Ritchie, MD Faculty Specialist Orthopaedics Owner / Pediatric Orthopaedic Surgeon Deputy Medical Director - MARC Clinic Trinity Adult and Pediatric Orthopaedic Department of Orthopaedics Specialists The University of Texas Health Science Center at San Antonio, San Antonio, TX Evan Jones, MD Flight Commander Orthopaedic Surgery Chief of Hand Service Joint Base Elmendorf-Richardson, AK *Affiliations are given for information purposes only, and no affiliation sponsorship is claimed. Damian M. Rispoli authored this book in his private capacity. The views expressed in the book do not necessarily represent the views of either the United States Air Force or the United States government. A NOTE FROM THE AUTHOR The Tarascon Pocket Orthopaedica is intended as a quick reference for orthopedic practice. It represents a compilation of facts and data that I have had the occasion to need at times—the basic information that was passed on to me from many talented individuals. If you find an error or wish to make a suggestion, please let us know (e-mail: [email protected]). A special thanks to my partner Vicki Rispoli, who makes everything better! Thanks and appreciation to Josh, Zach, Beth, Ben, and Erika, who never stop teaching their parents.

Trauma Protocols 1 TRAUMA PROTOCOLS Initial Approach to Trauma Assessment and Management PRIMARY SURVEY A • If poor or no air movement, perform jaw thrust or insert Assess Airway (immobilize oral or nasal airway. cervical spine) • Intubate if Glasgow Coma Scale ≤ 8, poor response to above, severe shock, flail chest, or need to hyperventilate. • Cricothyroidotomy or laryngeal mask airway if needed. B • Examine neck and thorax to detect deviated trachea, Assess Breathing flail chest, sucking chest wound, and breath sounds. • Administer O2, apply pulse oximeter, measure ETCO2. • Needle chest for tension pneumothorax, apply occlusive dressing to 3 sides of sucking chest wound, reposition ET tube, or insert chest tubes (36–38 Fr) if needed. C • Apply pressure to external bleeding sites, establish two Assess Circulation large peripheral IV lines, obtain blood for basic labs and type and crossmatch, and administer 2 L NS IV prn. • Check pulses, listen for heart sounds, observe neck veins, assess cardiac rhythm, and treat cardiac tamponade. • Apply cardiac monitor, and obtain BP and HR (pulse quality). D Measure Glasgow Coma Scale or assess if: Assess Disability AVPU (Alert, responds to Verbal stimuli, Painful, (Neurologic Status) U nresponsive to pain) • Pupil assessment—size and reactivity E Exposure • Completely undress patient (but keep warm) and examine all surfaces. RESUSCITATION (Perform simultaneously during primary survey) Reassess ABCDEs • Reassess ABCDEs if patient deteriorates. Address abnormality as identified; place chest tube if needed. • Emergent thoracotomy if > 1.2–1.5 L of blood from initial chest tube, > 100–200 mL/h after 1st h, or persistent ↓BP. • Administer 2nd 2-L NS bolus, then blood prn. • Place NG tube and Foley catheter (unless contraindicated). Reproduced with permission from Tarascon Adult Emergency Pocketbook, 3rd ed. Lompoc, CA: Tarascon Publishing, 2005. 2 Tarascon Pocket Orthopaedica SECONDARY SURVEY History • Obtain AMPLE history (see below). Physical Exam • Perform head-to-toe examination (including rectal/back). X-rays • Obtain cervical spine, chest, pelvic films, CT scans, etc. Address Injuries • Reduce/splint fractures, call consultants as soon as needed; administer analgesics, tetanus, and antibiotics prn. Disposition • Initiate transfer, admit, or ready OR. Document all findings, X-rays, labs, consultants, and talk to family. Reproduced with permission from Tarascon Adult Emergency Pocketbook, 3rd ed. Lompoc, CA: Tarascon Publishing, 2005.

Trauma Radiographs • Chest and AP pelvis • Chest and pelvis radiograph may aid in resuscitative effort.

TRAUMA HISTORY A Allergies M Medications currently using (legal, illicit, and herbal) P Past illness/pregnancy L Last meal E Events/environment related to the injury Chest and pelvis radiograph may aid in resuscitative effort. Abnormal C-spine film can identify pathology. Negative or inadequate films do not rule out pathology.

Tension Pneumothorax • Chest pain, air hunger, respiratory distress, tachycardia, hypotension, hyper-resonant percussion, tracheal deviation, unilateral absent breath sounds, jugular venous distention (JVD), and cyanosis. • Emergent treatment: Large-bore needle into the 2nd intercostal space in the mid- clavicular line. Definitive treatment requires a chest tube. Chest Tube • Transverse incision at nipple level (usually 5th rib) in the midaxillary line. Tunnel to rib midaxillary line, place curved clamp into chest over the top of the rib (pro- tects neuro-vascular bundle on inferior surface). Spread with clamp, insert finger into chest to clear area. Insert chest tube, secure in place, attach to Pleur-evac or Heimlich valve. Trauma Protocols 3 IMPORTANT TRAUMA NUMBERS Blood Volume Estimation of Systolic BP 70 kg man ~ 5 L BP ~ 60 mm Hg carotid pulse Child 80–90 mL/kg BP ~ 70 mm Hg femoral pulse BP ~ 80 mm Hg radial pulse Initial Fluid Management Warm All IV fluids! 1–2 L in adult; 20 mL/kg in child 1 unit of packed red blood cells should ↑ hemoglobin by 1.0 g/dL or hematocrit by 3.0%.

NORMAL ACID–BASE VALUES

pH PCO2 HCO3 Arterial 7.37–7.43 37–43 22–26 Venous 7.32–7.38 42–50 23–27 Shock = inadequate tissue perfusion.

IV Maintenance Therapy 0–10 kg = 4 cc/kg/h 10–20 kg = 40 cc/h + 2 cc/kg/h > 20 kg = 60 cc/h + 1 cc/kg/h Cardiac Tamponade Beck’s Triad: [1] Venous pressure elevation, [2] decreased arterial pressure, [3] muffled heart tones. • Echocardiogram or ultrasound may aid in diagnosis. • Monitor ECG during pericardiocentesis, 6-inch, 16- to 18-gauge needle, enter left and 1 cm inferior to xiphoid process, 45 degrees to the skin, advance while aiming at left scapular tip, aspirate as you advance. Foley Catheter • Assess prostate, scrotum, and perineum for signs of trauma. Consider retrograde urethrogram (RUG) with pelvic fracture. Mandatory with exam abnormality (blood at meatus, high-riding prostate, severe pelvic trauma).

AMERICAN COLLEGE OF SURGEONS ESTIMATED FLUID AND BLOOD LOSSES (ADULT) Class I Class II Class III Class IV Blood loss (mL) ≤ 750 750–1500 1500–2000 > 2000 Blood loss (%) < 15 15–30 30–40 > 40 Pulse rate (bpm) < 100 100–120 120–140 > 130 Blood pressure Normal Normal Decreased Decreased Pulse pressure Normal or ↑ Decreased Decreased Decreased (continues) 4 Tarascon Pocket Orthopaedica AMERICAN COLLEGE OF SURGEONS ESTIMATED FLUID AND BLOOD LOSSES (ADULT) Continued Class I Class II Class III Class IV Respiratory rate 14–20 20–30 30–40 > 35 Urine output > 30 20–30 5–15 Negligible (mL/h) Mental status Slightly Mildly Anxious, Confused, anxious anxious confused lethargic Fluid replacement Crystalloid Crystalloid Crystalloid, Crystalloid, (3:1 rule) blood blood Reproduced with permission from Krantz BE (ed.). Advanced Trauma Life Support for Doctors, Student Course Manual, 6th ed. Chicago, IL: American College of Surgeons, 1997.

SYSTEMIC RESPONSES TO BLOOD LOSS (MILD, MODERATE, AND SEVERE) System < 30% Loss 30–40% Loss > 45% Loss Cardiac Weak and thready Marked ↑ heart rate, low Hypotension, pulse, increased normal pressure, ↓ pulse tachycardia, then heart rate pressure, absent peripheral bradycardia with weak and thready central pulses CNS Anxious, irritable, ↓ Level of consciousness Comatose confused and pain response Skin Cool, clammy, Cyanosis, markedly Pale, cold mottled skin, prolonged cap refill prolonged cap refill Kidneys Increased specific Minimal urine output No urine output gravity, decreased urine output

AMERICAN COLLEGE OF SURGEONS PEDIATRIC VITAL SIGNS Blood Heart Rate Pressure Respiratory Urine Output Age (years) Wt. (kg) (bpm) (mm Hg) (/min) (mL/kg/h) 0–1 0–10 < 160 > 60 < 60 2.0 1–3 10–14 < 150 > 70 < 40 1.5 3–5 14–18 < 140 > 75 < 35 1.0 6–12 18–36 < 120 > 80 < 30 1.0 > 12 36–70 < 100 > 90 < 30 0.5 Data from Krantz BE (ed.). Advanced Trauma Life Support for Doctors, Student Course Manual, 7th ed. Chicago, IL: American College of Surgeons, 2004. Trauma Protocols 5 Major Differences in Pediatric Versus Adult Polytrauma Pediatric patients (JAAOS 2013;21(3):170-179): • Develop hypotension at greater loss of blood volume (maintain equilibrium longer). • Organ failure occurs acutely and simultaneously. • Lower risk of lung injury but a greater risk of organ versus bony injury. • Higher local and lower systemic inflammatory response. • Low risk of death with pelvic injury but greater morbidity associated with organ injuries. • High rate of recovery from neurologic injuries.

GLASGOW COMA SCALE Eye Opening (Score) Best Verbal (Score) Best Motor (Score) Spontaneous (4) Oriented, converses (5) Obeys commands (6) To verbal command (3) Disoriented, converses (4) Localizes pain (5) To pain (2) Inappropriate words (3) Flexion, withdrawal (4) None (1) Incomprehensible (2) Flexion (abnormal) decorticate (3) None (1) Extension, decerebrate (2) None (1) The total of the scores from all three categories represents the Glasgow Coma Scale finding. A completely nonresponsive individual would have the lowest score of 3; a completely alert and functioning individual would have the highest possible score of 15.

PEDIATRIC VERBAL SCORE V-Score Verbal Response 5 Appropriate words or social smile, fixes, and follows 4 Cries, consolable 3 Persistently irritable 2 Restless, agitated 1 None Data from Krantz BE (ed.). Advanced Trauma Life Support for Doctors, Student Course Manual, 6th ed. Chicago, IL: American College of Surgeons, 1997: 304. 6 Tarascon Pocket Orthopaedica of burn + 2 in 1st 24h, with ½ 2 Formul a Parklan d subsequent 16 hours. injury not time of arrival) CARVAJAL’S FORMULA over the 1st 8 hours and ½ Lactated ringers 4 ml/kg/% burn bod y 16 hours. (Hours calculated from time of Carvajal’s solution 5,000 mI/m FLUID RESUSCITATION IN BURN VICTIM S surface area in 1st 24 hours + maintenance fluid, with ½ over 1st 8 hours, & next maintenance 2000 mI/m Used with Permission from Tarascon Adult Emergenc y ESTIMATION OF TOTAL BODY SURFACE AREA BURNED Pocketbook , 3rd ed. Tarascon Publishing, Lompoc, CA: 2005. 9% 18% 9% 1% 18% 18% Bac k Front 18% 9% Anatomy—Muscle Tables 7 ANATOMY—MUSCLE TABLES Spinal Segment CNXI, C2, 3, 4 C6, 7, 8 (posterior division) C5 (root) C5 (root) C5 (root) C5, 6, 7, 8 T1 (lateral/ medial cord) C7, 8 T1 (medial cord) C5, 6 (superior trunk) C5, 6, 7 (roots) C5, 6 (posterior cord) C5, 6, 7 (posterior cord) C5, 6 (posterior cord) C5, 6, 7 (posterior cord) C(4), 5, 6 (superior trunk) C(4), 5, 6 (superior trunk) - Insertion Clavicle, scapular spine, acromion Humerus, intertubercular groove Scapula, medial border Scapula, medial spine Scapula, superior medial Humerus, lateral intertuber cular groove Scapula, coracoid Clavicle, inferior Scapula, ventral medial Humerus, deltoid tubercle Humerus, medial intertubercular groove Humerus, greater tuberosity Humerus, lesser tuberosity Humerus, greater tuberosity Humerus, greater tuberosity Origin Spinous process C7–T12 Spinous process T6–S5, ilium Spinous process T2–5 Spinous process C7–T1 process C1–4 Transverse Sternum, ribs, clavicle Ribs 3–5 Rib 1 Ribs 1–9 Lateral 1/3 clavicle, acromion, lateral 1/3 scapula Scapula, inferolateral Scapula, dorsolateral scapula Ventral Supraspinatus fossa Infraspinatus fossa Nerve Spinal accessory Thoracodorsal Dorsal scapular Dorsal scapular Dorsal scapular Lateral/medial pectoral Medial pectoral Nerve to subclavius Long thoracic Axillary Lower subscapular Axillary Upper and lower subscapular Suprascapular Suprascapular Muscle Trapezius Latissimus dorsi Rhomboid major Rhomboid minor Levator scapulae Pectoralis major Pectoralis minor Subclavius Serratus anterior Deltoid major Teres minor Teres Subscapularis Supraspinatus Infraspinatus Shoulder Girdle 8 Tarascon Pocket Orthopaedica Spinal Segment C6, 7 (lateral cord) C5, 6 (lateral cord) C6, 7, 8 (T1) (posterior cord) C5, 6 (lateral posterior cord) C6, 7 (medial and lateral cords) C6, 7, (8) (medial and lateral cords) C7, 8 T1 (medial and lateral cords) C7, 8 T1 (medial and lateral cords) C7, 8 (medial cord)

Insertion Humerus, mid/medial Radius (radial tuberosity) Ulna, olecranon Ulna, coronoid process Radius, mid lateral 2nd–3rd metacarpal bases Palmar aponeurosis Middle phalangeal bases Pisiform, hamate, 5th metacarpal base

Origin Coracoid Coracoid—short head Supraglenoid tubercle—long head Long head—infraglenoid tubercle Lateral head and medial head— posterior humerus Anterior humerus Humerus, medial epicondyle, coronoid Humerus, medial epicondyle Humerus, medial epicondyle Humerus, medial epicondyle, anterior radius Humerus, medial epicondyle, dorsal ulnar border

Nerve Musculocutaneous Musculocutaneous Radial Musculocutaneous— medial Radial—lateral Median Median Median Median Ulnar

Muscle Coracobrachialis Biceps Triceps Brachialis Pronator teres Flexor carpi radialis Palmaris longus Flexor digitorum superficialis Flexor carpi ulnaris Arm Region Forearm Region—Superficial Flexors Anatomy—Muscle Tables 9

Spinal Segment C7, 8 T1 (medial and lateral cords) C8 T1 (medial and lateral cords) C7, 8 T1 (medial and lateral cords) C5, 6 (posterior cord) C(5), 6, 7, (8) (posterior cord) C(5), 6, 7, (8) (posterior cord) C7, 8 (posterior cord) C6, 7, 8 (posterior cord) C6, 7, 8 (posterior cord) C6, 7, 8 (posterior cord)

Insertion Distal phalangeal bases Thumb distal phalangeal base distal radius Volar Radius, distal lateral 3rd metacarpal base 2nd metacarpal base Ulna, proximal dorsal Extensor aponeurosis Small finger extensor apparatus 5th metacarpal base

Origin Ulna, anterior and medial Radius, anterior and lateral Distal ulna Humerus, lateral supracondylar ridge Humerus, lateral supracondylar ridge Humerus, lateral epicondyle Humerus, lateral epicondyle Humerus, lateral epicondyle Common extensor tendon Humerus, lateral epicondyle

Nerve Median (anterior interosseous)-index/ long, Ulnar-ring/small Median (anterior interosseous) Median (anterior interosseous) Radial (Radial) Posterior interosseous Radial Radial Radial (posterior interosseous) Radial (posterior interosseous) Radial (posterior interosseous)

Muscle Flexor digitorum profundus Flexor pollicis longus Pronator quadratus Brachioradialis Extensor carpi radialis brevis Extensor carpi radialis longus Anconeus Extensor digitorum communis Extensor digiti minimi Extensor carpi ulnaris Forearm Region—Deep Flexors Forearm Region—Superficial Extensors 10 Tarascon Pocket Orthopaedica C8 T1 (medial and lateral cord) C8 T1 (medial and lateral cord) C8 T1 (medial cord) C8 T1 (medial and lateral cord) C8 T1 (medial cord) Spinal Segment C5, 6, 7 (posterior cord) C6, 7, 8 (posterior cord) C6, 7, 8 (posterior cord) C6, 7, 8 (posterior cord) C6, 7, 8 (posterior cord)

Proximal phalangeal base, radial Thumb metacarpal Proximal phalangeal base, ulnar Proximal phalangeal base, ulnar Insertion Radius, dorsolateral 1st metacarpal base Thumb proximal phalangeal base Thumb dorsal phalangeal base Index finger extensor aponeurosis (ulnar)

Scaphoid, trapezoid Trapezium Capitate, 2nd–3rd metacarpal Flexor retinaculum, trapezium Origin Humerus, lateral epicondyle, ulna Radius, dorsal ulna Radius, dorsal Ulna, dorsolateral Ulna, dorsolateral

Median Median Ulnar Median Ulnar Nerve Radial (posterior interosseous) Radial (posterior interosseous) Radial (posterior interosseous) Radial (posterior interosseous) Radial (posterior interosseous) Superficial head Deep head Muscle Supinator Abductor pollicis longus Extensor pollicis brevis Extensor pollicis longus Extensor indicis proprius Abductor pollicis brevis Opponens pollicis Adductor pollicis Flexor pollicis brevis • • Forearm Region—Deep Extensors Hand/Wrist—Thenar Muscles Anatomy—Muscle Tables 11 L2, 3, 4 (posterior) L(1), 2, 3, 4 (posterior) L2, 3, 4 (posterior) L2, 3, 4 (posterior) Spinal Segment C8 T1 (medial cord) C8 T1 (medial cord) C8 T1 (medial cord) C8 T1 (medial cord) C7, 8 T1 (medial & lateral cords) C8 T1 (medial cord) C8 T1 (medial cord) C8 T1 (medial cord) Insertion Ulnar palm (fascial) Proximal phalangeal base, ulnar Proximal phalangeal base, ulnar Small finger metacarpal Radial aspect of lateral bands Proximal phalangeal base, extensor apparatus Proximal phalangeal base, extensor apparatus Lesser trochanter Lesser trochanter tubercle (quadriceps Tibial mechanism) part of pes anserinus Tibia, Flexor digitorum profundus (radially) Metacarpal shaft Metacarpal shaft Iliac fossa process L1–L5 Transverse Direct: Ilium, anterior inferior spine Indirect: acetabulum, superior rim Anterior superior iliac spine Origin carpal ligament, palmar aponeurosis Transverse Pisiform Hamate, transverse carpal ligament Hamate, transverse carpal ligament Nerve Ulnar Ulnar Ulnar Ulnar Femoral Femoral Femoral Femoral Median (index and middle) Ulnar (ring and small) Ulnar Ulnar Muscle Palmaris brevis Abductor digiti minimi Flexor digiti minimi brevis Opponens digiti minimi Lumbrical Dorsal interossei interossei Volar Iliacus Psoas Rectus femoris (direct and indirect heads) Sartorius Hand/Wrist—Hypothenar Muscles Hand/Wrist—Intrinsic Muscles Hip Flexors 12 Tarascon Pocket Orthopaedica L5–S2 (posterior) S1, 2 (posterior) L2, 3, 4 (anterior) L5–S3 (anterior) L5–S3 (anterior) L4–S1 (anterior) L4–S1 (anterior) Spinal Segment L2, 3, 4 (anterior) L4, 5 (anterior) L2, 3, 4 (anterior) L2, 3, 4 (anterior) L2, 3, 4 (anterior) adductor pectineal line Insertion linea aspera, and Femur, tubercle linea aspera/ Femur, linea aspera Femur, part of pes anserinus Tibia, Posterior femur (gluteal sling), iliotibial band proximal greater Femur, trochanter (piriformis fossa) trochlear fossa Femur, medial greater trochanter Femur, medial greater trochanter Femur, medial greater trochanter Femur, quadrate line Femur,

Origin Inferior pubic rami, ischial tuberosity Inferior pubic rami Pubic rami, anterior Inferior symphysis pubic arch Ilium, posterior-to-posterior gluteal line Sacrum, anterior sciatic notch Ischiopubic rami, obturator membrane Ischiopubic rami, obturator membrane Outer ischial spine Ischial tuberosity Ischial tuberosity Inferior gluteal Nerve to piriformis Obturator Nerve to obturator internus Nerve to obturator internus Nerve to quadratus femoris Nerve to quadratus femoris Nerve Obturator (posterior) Sciatic (tibial) [predominant] Obturator (posterior) Obturator (anterior) Obturator (anterior) Muscle Adductor magnus Adductor brevis Adductor longus Gracilis Gluteus maximus Piriformis Obturator externus Obturator internus Superior gemellus Inferior gemellus Quadratus femoris Hip Adductors Hip External Rotators Anatomy—Muscle Tables 13 L5, S1 (anterior) L5, S1, 2 (anterior) L4, 5, S1 (anterior) L5, S1, 2 (anterior) L2, 3, 4 (posterior) L2, 3, 4 (posterior) L2, 3, 4 (posterior) L2, 5, 4 (posterior) Spinal Segment L4–S1 (posterior) L4–S1 (posterior) L4–S1 (posterior) posterior Insertion greater trochanter Femur, anterior border of greater Femur, trochanter (base) tubercle via Gerdy’s Tibia, iliotibial band Lateral patella (quadriceps mechanism) Medial patella (quadriceps mechanism) Patella (quadriceps mechanism) Patella (quadriceps mechall) Fibular head, lateral tibia lateral condyle Tibia, anterior crest Tibia, Oblique popliteal ligament, capsule, posterior medial tibia, popliteus, medial meniscus inferior Origin Ilium, between posterior and anterior gluteal lines Ilium, between anterior and gluteal lines Ilium, anterior iliac crest Ischial tuberosity, medial Ischial tuberosity, Lateral linea aspera, lateral intramuscular septum distal–medial Ischial tuberosity, proximal/lateral Ischial tuberosity, Iliotibial line, greater trochanter, Iliotibial line, greater trochanter, lateral linea aspera Iliotibial line, medial linea aspera, supracondylar line anterior proximal shaft Femur, Anterior inferior iliac spine Nerve Superior gluteal Superior gluteal Superior gluteal Femoral Femoral Femoral Fermoral Sciatic (tibial) Sciatic (peroneal) Sciatic (tibial) Peroneal Muscle Gluteus medius Gluteus minimus fascia lata Tensor lateralis Vastus medialis Vastus intermedius Vastus Rectus femoris Biceps, long head Biceps, short head Semimembranosus Semitendinosus Hip Abductors Anterior Thigh Posterior Thigh 14 Tarascon Pocket Orthopaedica Spinal Segment L4, 5, S1 (posterior) L4, 5, S1 (posterior) L4, 5, S1 (posterior) L4, 5, S1 (posterior) L4, 5, S1 (posterior) L4, 5, S1 (posterior) L5, S1, 2 (anterior) L5, S1, 2 (anterior) L5, S1 (anterior) Insertion Medial cuneiform, 1st metatarsal Great toe, distal phalanx Lesser toes, mid and distal phalanx 5th metatarsal Medial cuneiform, 1st metatarsal 5th metatarsal tuberosity Calcaneus (Achilles tendon) Calcaneus (Achilles tendon) Calcaneus Origin Lateral tibia Mid fibula, interosseous membrane condyle, fibula Tibial Fibula, extensor digitorum longus tendon Proximal fibula Distal fibula posterior Distal femur, medial and lateral femoral condyles Fibula, tibia lateral femoral Femur, condyle Superficial peroneal Superficial peroneal Tibial Tibial Tibial Nerve Deep peroneal Deep peroneal Deep peroneal Deep peroneal Muscle anterior Tibialis Extensor hallucis longus Extensor digitorum longus Peroneus tertius Peroneus longus Peroneus brevis Gastrocnemius Soleus Plantaris Leg Muscles—Anterior Compartment Leg Muscles—Lateral Compartment Leg Muscles—Superficial Posterior Compartment Anatomy—Muscle Tables 15 Spinal Segment L5, S1 (anterior) L5, S1 (anterior) L5, S1 (anterior) L5, S1 (anterior) L4, 5, S1 (posterior) L4, 5, S1 (anterior) L4, 5, S1 (anterior) S1, 2 (anterior) Insertion Proximal tibia Great toe, distal phalanx Lesser toes, distal phalanx medial cuneiform Navicular, Lesser toes, proximal phalangeal base Great toe—proximal phalangeal base Lesser toes, distal phalanx Base of 5th toe Origin lateral femoral Femur, condyle Fibula, head Fibula Tibia interosseous Tibia/fibula, membrane Superolateral calcaneus Calcaneal tuberosity Calcaneal tuberosity Calcaneal tuberosity Nerve Tibial Tibial Tibial Tibial Deep peroneal Medial plantar Medial plantar Lateral plantar Muscle Popliteus Flexor hallucis longus Flexor digitorum longus posterior Tibialis Extensor digitorum brevis Abductor hallucis Flexor digitorum brevis Abductor digiti minimi Leg Muscles—Deep Posterior Compartment Ankle/Foot Muscles—Dorsal Layer First Plantar Layer (Three Muscles) 16 Tarascon Pocket Orthopaedica Spinal Segment S1, 2 (anterior) L4, 5, S1, 2 (anterior) L5, S1 (anterior) L5, S1, 2 (anterior) S1, 2 (anterior) S1, 2 (anterior) S1, 2 (anterior) Insertion Flexor digitorum longus tendon Extensor digitorum longus tendon Great toe—proximal phalanx Fibular sesamoid Small toe, proximal phalanx Base of proximal phalanx Proximal phalanx medially Origin Medial and lateral calcaneus Flexor digitorum longus tendon Cuboid lateral cuneiform Oblique head—2nd–4th metatarsal base, transverse head—plantar metatarso-phalangeal ligament; toes 2–4 Base of 5th metatarsal head Metatarsal shafts 3–5 metatarsal shafts Nerve Lateral plantar Medial and lateral plantar Medial plantar Lateral plantar Lateral plantar Lateral plantar Lateral plantar Muscle Quadratus plantae Lumbrical (This layer also includes the tendons of flexor digitorum longus and hallucis longus.) Flexor hallucis brevis Adductor hallucis Flexor digitorum minimi brevis Dorsal interossei Plantar interossei (This layer also includes the tendons of peroneus longus and tibialis posterior.) Second Plantar Layer (Two Muscles and Two Tendons) Muscles and Two Second Plantar Layer (Two Third Plantar Layer (Three Muscles) Tendons) Muscles and Two Fourth Plantar Layer (Two Anatomy—Approaches 17 ANATOMY—APPROACHES

Approach / Eponym Shoulder Interval—Muscle (nerve) Deltopectoral—Henry Deltoid (axillary) and pectoralis major (medial/lateral pectoral) Lateral Deltoid splitting no internervous plane (~ 5 cm limit) Posterior Infraspinatus (suprascapular) and teres minor (axillary)

Proximal Humerus Anterior Deltoid (axillary) and pectoralis major (medial/lateral pectoral) Medial brachialis (musculocutaneous) and lateral brachialis (radial) Anterolateral No true internervous interval Brachialis (radial) and brachioradialis (radial) Posterior No true internervous interval; long and lateral head of triceps superficial, medial head splitting deep (radial) Lateral No true internervous interval; Triceps (radial) and brachioradialis (radial)

Elbow Posterior No internervous plane Medial Proximal—Brachialis (musculocutaneous) and triceps (radial) Distal—Brachialis (musculocutaneous) and pronator teres (median) Anterolateral Proximal—Brachialis (musculocutaneous) and brachioradialis (radial) Distal—Pronator teres (median) and brachioradialis (radial) Anterior Proximal—Brachialis (musculocutaneous) and brachioradialis (radial) Distal—Pronator teres (median) and brachioradialis (radial) Posterolateral— Anconeus (radial) & extensor carpi ulnaris (posterior Kocher interosseous)

Forearm Anterior—Henry Proximal—Pronator teres (median) and brachioradialis (radial) Distal—Brachioradialis (radial) and flexor carpi radialis (median) Dorsal—Thompson Proximal—Extensor carpi radialis brevis (radial) and extensor digitorum communis (posterior interosseous) Distal—Extensor carpi radialis brevis (radial) and extensor pollicis longus (posterior interosseous) Ulnar Extensor carpi ulnaris (posterior interosseous) and flexor carpi ulnaris (ulnar) 18 Tarascon Pocket Orthopaedica Wrist Shoulder Interval—Muscle (nerve) Dorsal No internervous plane; between 3rd and 4th dorsal compartments Scaphoid—volar No internervous plane; between 3rd and 4th dorsal compartments Scaphoid—dorsolateral No internervous plane; between flexor carpi radialis (median) and radial artery No internervous plane; between extensor pollicis longus and extensor pollicis brevis (posterior interosseous)

Pelvis Ilioinguinal No true internervous plane (along pelvic crest) Extended iliofemoral Superficial—Sartorius (femoral) and tensor fascia lata (superior gluteal) Deep—Rectus femoris (femoral) and gluteus medius (superior gluteal)

Hip Anterior—Smith-Peterson Superficial—Sartorius (femoral) and tensor fascia lata (superior gluteal) Deep—Rectus femoris (femoral) and gluteus medius (superior gluteal) Anterior—Modified Stoppa No true internervous plane Superficial—Splits rectus abdominus muscle (thoracoabdominal nerves) Deep—Releases rectus abdominus from posterior pubic rami Anterolateral—Watson-Jones No true internervous plane; tensor fascia lata (superior gluteal) and gluteus medius (superior gluteal) Lateral—Hardinge No true internervous plane Deep—Splits gluteus medius proximally (superior gluteal) —Splits vastus lateralis distally (femoral) Posterior—Kocher/Lagenbach No true internervous plane Splits gluteus maximus (inferior gluteal) Medial—Ludloff Superficial—No true internervous plane; adductor longus and gracilis (anterior division obturator) Deep—Adductor brevis (anterior division obturator) and adductor magnus (sciatic [tibial]) and posterior division of obturator) Anatomy—Approaches 19 Femur Shoulder Interval—Muscle (nerve) Lateral No internervous plane; splits vastus lateralis (femoral) Anteromedial No true internervous plane Rectus femoris (femoral) and vastus medialis (femoral) Posterolateral Vastus lateralis (femoral) and hamstrings (sciatic) Posterior distal femur Biceps femoris (sciatic) and vastus lateralis (femoral)

Knee Medial parapatellar No true internervous plane Vastus medialis (femoral) and rectus femoris (femoral) Medial No true internervous plane Vastus medialis (femoral) and sartorius (femoral) Lateral Iliotibial band (superior gluteal) and biceps femoris (sciatic) Posterior Semimembranosus/medial gastrocnemius (tibial) and biceps femoris/lateral gastrocnemius (tibial)

Leg Anterior No internervous plane; tibialis anterior (peroneal) and tibial periosteum Anterolateral Superficial—Peroneus brevis (superficial peroneal) and extensor digitorum longus (deep peroneal) Deep—Tibialis posterior (tibial) and extensor muscles (deep peroneal) Posterolateral Gastrocnemius, soleus, flexor hallucis longus (tibial) and peroneus brevis and longus (superficial peroneal) Fibula Peroneal muscles (superficial peroneal) and flexor muscles (tibial)

Ankle Anterior or Dorsal No internervous plane; extensor hallucis longus (deep peroneal) and extensor digitorum longus (deep peroneal) To Medial Malleolus No internervous plane; direct approach To Lateral Malleolus Peroneus tertius (deep peroneal) and peroneus brevis (superficial peroneal) Posteromedial No internervous plane; tibialis posterior or flexor digitorum longus (tibial) and flexor digitorum longus or flexor hallucis longus (tibial) Posterolateral Peroneus brevis (superficial peroneal) and flexor hallucis longus (tibial) 20 Tarascon Pocket Orthopaedica POPSIQ Mnemonic Pudendal nerve and artery Nerve to Obturator internus Posterior femoral cutaneous nerve Sciatic nerve Inferior gluteal nerve and artery

Contents of the Sciatic Notch (Greater Sciatic Notch) Above the Piriformis Superior gluteal nerve Superior gluteal artery Below the Piriformis Damian Rispoli 2009 Inferior gluteal nerve Inferior gluteal artery Pudendal nerve Internal Pudendal nerve Nerve to the Obturator internus Sciatic nerve Posterior femoral cutaneous nerve Nerve to Quadratus femoris Lesser Sciatic Notch Greater Sciatic Notch Anatomy—Cross Sections 21 ANATOMY—CROSS SECTIONS

Proximal Arm Cross Section

Cephalic v. Short head, biceps Pectoralis major Coracobrachialis Long head, biceps Median antebrachial cutaneous n. Musculocutaneous n. Basilic v. Median n. Humerus Ulnar n. Lateral head, triceps Brachial a. and v.’s Deltoid Medial brachial cutaneous n. Long head, triceps Radial n.

Teres major Latissimus dorsi tendon Damian Rispoli 2009

Mid Arm Cross Section Lateral antebrachial cutaneous n. Cephalic v. Humerus Medial intermuscular septum Brachialis Biceps brachii Posterior antebrachial cutaneous n. Median n. Medial antebrachial Radial collateral a. cutaneous n. Lateral IM Medial brachial septum cutaneous n. Radial n. Basilic v. Middle collateral a. Lateral head, triceps Brachial a. and v.’s

Medial head, triceps Ulnar n. Superior ulnar collateral a. Long head, triceps Damian Rispoli 2009 22 Tarascon Pocket Orthopaedica

Distal Arm Cross Section

Biceps Brachial fascia Cephalic v. Brachialis Lateral antebrachial Median n. cutaneous n. Medial antebrachial Brachioradialis cutaneous n.

Radial n. Brachial a. & v. Extensor carpi radialis longus Ulnar n.

Medium IM septum Posterior antebrachial cutaneous n. Triceps Lateral IM septum Humerus

Damian Rispoli 2009 Triceps tendon

Proximal Forearm Cross Section (volar=top, right=ulnar) Superficial branch radial n. Radius Radial a. Medial antebrachial v. Brachioradialis Pronator teres Cephalic v. Medial antebrachial cutaneous n. Lateral Palmaris longus antebrachial Flexor carpi radialis cutaneous n. Flexor digitorum superficialis Extensor carpi radialis longus Ulnar n. Extensor carpi Flexor carpi ulnaris radialis brevis Flexor digitorum Radial n. profundus Extensor digitorum Median n., Ulnar a. & communis Anconeus Common Interosseous a. (volar to dorsal) Extensor digiti quinti minimi FP longus Ulna Posterior antebrachial cutaneous n. Supinator Extensor carpi ulnaris Damian Rispoli 2009 Anatomy—Cross Sections 23 24 Tarascon Pocket Orthopaedica

Proximal Thigh Cross Section (anterior=top, right=medial)

Lateral femoral Sartorius cutaneous n. Femoral and Deep femoral a. & v. Rectus femoris Femoral n. Tensor fascia lata Adductor longus Saphenous n. Vastus mediaIis Pectineus Iliopsoas Obturator n. (ant.) Adductor brevis Vastus intermedius Obturator n. (post.) Femur Gracilis

Vastus lateralis Adductor magnus Semimembranosus Gluteus maximus Semitendinosus Sciatic n. Biceps femoris Posterior femoral cutaneous n. Damian Rispoli 2009

Mid Thigh Cross Section (anterior=top, right=medial)

Vastus medialis Femoral a. & v. Rectus femoris Saphenous n & n. to v. medius Vastus intermedius Sartorius Adductor longus Vastus lateralis Adductor brevis

Femur Gracilis Great saphenous v. Iliotibial tract Adductor magnus Biceps femoris, short head Deep femoral a. & v. Sciatic n. Biceps femoris, long head Semimembranosus

Semitendinosus Damian Rispoli 2009 Anatomy—Cross Sections 25

Distal Thigh Cross Section (anterior=top, right=medial)

Q femoris tendon Vastus intermedius Vastus medialis Articularis genu Femur Iliotibial tract Adductor magnus tendon Saphenous n. Vastus lateralis Descending genicular a. Popliteal a. Sartorius Tibial n.

Common peroneal n. Great saphenous v.

Biceps femoris Gracilis Semitendinosus Popliteal v. Semimembranosus

Damian Rispoli 2009

Mid Leg Cross Section (anterior=top, right=medial)

(A)Anterior tibial a. & v. Deep peroneal n. Tibialis anterior(A) (A) Extensor hallucis longus Tibia (A)Extensor digitorum longus Tibialis posterior(DP) (L)Superficial peroneal n. Great saphenous v. (L)Peroneus longus Saphenous n. Flexor digitorum (L)Peroneus brevis longus(DP) Fibula Posterior tibial a. & v. (DP)Flexor hallucis longus Tibial n.(DP) Lateral sural cutaneous n. Soleus(SP) (SP)Lateral gastrocnemius Plantaris(SP) Medial gastrocnemius(SP) Personeal communicating branch of lateral saphenous n. Medial sural cutaneous n.(SP) Lesser saphenous v. Compartments: Anterior(A), Lateral(L), Deep Posterior(DP), Superficial Posterior(SP) Damian Rispoli 2009 26 Tarascon Pocket Orthopaedica ANATOMY—ARTERIES artery trun k artery Damian Rispoli 200 9 Thyrocervica l Supreme thoracic Lateral thoracic Thoracodorsal artery mino r Transverse cervical arter y Pectorali s Circumflex scapular artery Subscapular arter y Arteries about the Shoulde r Suprascapular artery circumflex Axillary artery circumflex Anterior humeral Thoracoacromial trun k Posterior humeral Deltoacromial branch Anatomy—Arteries 27

Shoulder Spaces and Intervals (posterior view of shoulder)

Supraspinatus Teres minor Infraspinatus Axillary n. Triangular space Posterior humeral circumflex a. Circumflex Quadrangular space scapular a. Triceps, lateral head Teres major Radial n. Profunda brachii a. Triangular interval Triceps, long head Damian Rispoli 2009

Arteries about the Elbow

Superior ulnar collateral a.

Middle collateral a. Inferior ulnar collateral a.

Radial collateral a. Anterior ulnar recurrent a.

Posterior ulnar recurrent a. Brachial a.

Ulnar recurrent a.

Radial recurrent a. Ulnar a.

Radial a. Common interosseous a. Interosseous recurrent a. Anterior interosseous a. Posterior interosseous a.

Damian Rispoli 2009 28 Tarascon Pocket Orthopaedica

Structures at the elbow (Radial to Ulnar) Tendon – Artery – Nerve

Arteries of the Forearm

Brachial a.

Anterior ulnar recurrent a. Radial recurrent a. Posterior ulnar recurrent a. Interosseous Common recurrent a. interosseous a. Posterior interosseous a. Ulnar a. (behind IO membrane)

Anterior interosseous a. Radial a. Palmar branch Anterior Dorsal carpal interosseous a. branch

Superficial palmar Palmar carpal branch branch Damian Rispoli 2009 Anatomy—Arteries 29 Nerves Frame the Wrist (Radial to Ulnar) Superficial branch of the radial nerve → radial artery → median nerve → ulnar artery → ulnar nerve

Pelvic Arteries

Iliolumbar a. Aorta External iliac a. Common iliac a. Lateral sacral a. & branches Internal iliac a. Middle rectal a. (hypogastric a.) Internal pudendal a. Superior gluteal a. Superior vesicular a. Obturator a.

Damian Rispoli 2009

Vasculature of the knee

Descending branch of Descending genicular a. deep femoral a. Hunter’s Canal Popliteal a. Femoral a. Medial superior Saphenous a. Articular a. genicular a. Lateral superior Lateral superior genicular a. genicular a. Middle Lateral inferior genicular a. genicular a. Lateral inferior Anterior tibial genicular a. recurrent a. Anterior tibial a. Medial inferior genicular a. Posterior tibial a. Damian Rispoli 2009 Peroneal a. Behind the Knee-Medial to Lateral Artery -Vein-Nerve 30 Tarascon Pocket Orthopaedica ANATOMY—LIGAMENTS

Glenohumeral Ligaments (lateral disarticulated view) Coracoacromial ligament

Acromion Superior glenohumeral ligament

Biceps tendon Coracoid (long head) Subscapularis

Infraspinatus Middle glenohumeral ligament Axillary Anterior inferior pouch glenohumeral ligament Teres minor Posterior inferior glenohumeral ligament Damian Rispoli 2009

Shoulder (Posteriorly) Triangular space—Circumflex scapular artery Quadrangular space—Posterior humeral circumflex artery, axillary nerve Triangular interval—Profunda brachii artery, radial nerve Axillary artery (divided into three parts by the pectoralis minor muscle) 1. Supreme thoracic artery (before muscle, one branch) 2. Thoracoacromial and lateral thoracic arteries (under muscle, two branches) 3. Subscapular, anterior, and posterior humeral circumflex arteries (after muscle, three branches) Medial Layers of the Knee (JBJS 61A:56-62, 1979) I. Sartorius and fascia II. Superficial medial collateral ligament, posterior oblique ligament, semimembranosus III. Deep medial collateral ligament, capsule Lateral Layers of the Knee (JBJS 64A:536-541, 1982) I. Iliotibial tract, biceps (peroneal nerve deep to layer I) II. Patellar retinaculum, patellofemoral ligament, popliteofibular ligament III. Arcuate ligament, fabella-fibular ligament, capsule, lateral collateral ligament Anatomy—Ligaments 31

Elbow Ligaments

Annular Ligament Radial Collateral Ligament Lateral Lateral ulnar collateral Ligament

Anterior Bundle Posterior Bundle

Medial Transverse Bundle

Most important to stability Damian Rispoli 2009

Volar Wrist Ligaments

Triquetrocapitate Deltoid ligament (V) ligament

Space of “Poirier” Radial collateral ligament Lunotriquetral ligament

Radioscaphocapitate Ulnolunate ligament ligament Short radiolunate Radioscapholunate ligament ligament Radiolunate ligament

(long radiolunate) Damian Rispoli 2009 32 Tarascon Pocket Orthopaedica

Finger Extensor Apparatus

A H

B I C D D K C E E L F G G F

A. Terminal tendon B. Triangular ligament C. Transverse retinacular ligament D. Conjoined lateral band E. Oblique & transverse fibers of the intrinsic apparatus F. Lumbrical muscle (originating on the radial side of the flexor digitorum profundus tendon) G. Interossei muscle H. Flexor digitorum profundus insertion I. Flexor digitorum profundus tendon J. Extensor digitorum communis tendon K. Flexor digitorum superficialis tendon L. Sagittal bands

Damian Rispoli 2009 Anatomy—Ligaments 33

Finger Pulley System

C1 C2 C3

A1 A2 A3 A4 MC P1 P2 P3

Damian Rispoli 2009

A2 & A4 most important (prevents tendon bowstringing) A1 released in surgical treatment of a trigger digit

Damian Rispoli 2017 34 Tarascon Pocket Orthopaedica

Pelvic Ligaments Iliolumbar Ligaments Anterior Sacral Ligaments

Sacrum Sacrospinous Ligament Sacrotuberous Ischial Spine Ligament Arcuate Line Pubic rami (Pelvic Brim) Damian Rispoli 2009

Knee Ligaments Meniscofemoral ligaments Humphreys - Patellar tendon Anterior to PCL Wrisberg - Transverse (intermeniscal Posterior to PCL ligament)

Anterior cruciate Lateral Meniscus ligament

Medial Meniscus Popliteus

Semimembranosus tendon Posterior cruciate ligament Damian Rispoli 2009 Lateral Meniscus more mobile (1-1.5cm/3x> medial) Medial Meniscus tethered by medial collateral ligament Anatomy—Ligaments 35

Posterior Knee Ligaments/Tendons (medial=right, lateral=left)

Plantaris Medial gastrocnemius Lateral gastrocnemius Lateral collateral ligament Adductor tubercle

Popliteus tendon Semimembranosus Five Insertions of the Oblique popliteal ligament Semimembranosus Fabellofibular ligament 1. Oblique Popliteal ligament Arcuate ligament 2. Posterior capsule Popliteus 3. Posteromedial tibia (main) 4. Popliteus 5. Medial meniscus Damian Rispoli 2009

Ankle Ligaments Posterior Anterior Anterior inferior Posterior inferior tibiofibular tibiofibular ligament ligament Anterior Superficial talofibular deltoid Deltoid ligament ligament (ATFL) Deep deltoid Calcaneofibular (more Posterior talofibular ligament (CFL) horizontal) ligament (PTFL) Ligaments of the syndesmosis Anterior inferior tibiofibular ligament Posterior inferior tibiofibular ligament Transverse tibiofibular ligament Interosseous ligament Interosseous membrane Damian Rispoli 2009 36 Tarascon Pocket Orthopaedica ANATOMY—NERVE PLEXI

Brachial Plexus

Roots Trunks Divisions Cords Branches Trunks = upper, middle, lower Divisions = anterior and posterior Cords = lateral, posterior, medial Dorsal scapular n. N. to Subclavius Suprascapular n.

Long thoracic n. Musculocutaneous n. Axillary n. Lateral pectoral n. Medial pectoral n. Radial n. Upper subscapular n. Median n. Thoracodorsal n. Ulnar n. Lower subscapular n. Medial brachial & antebrachial cutaneous n.

Plexus Mnemonic - Robert Taylor Drinks Cold Beer Roots, Trunks, Divisions, Cords, Branches Posterior Branches Mnemonic -STAR (medial to lateral) Subscapular (upper and lower surround thoracodorsal n.) Thoracodorsal Axillary Radial Damian Rispoli 2009 Anatomy—Nerve Plexi 37

Lumbar Plexus

T12 Subcostal n. Anterior & L1 Iliohypogastric n. Posterior Anterior Divisions Ilioinguinal n. Divisions L2

L3 Posterior Lateral femoral Divisions L4 cutaneous n. (L2,3)

Femoral n. (L2,3,4) Lumbosacral trunk Accessory obturator n. (L3,4) Obturator n. (L2,3,4) Damian Rispoli 2009

Sacral Plexus (Posterior Division)

L4 L5

S2 Anterior Division S3 Superior gluteal n. (L4,5,S1) Inferior gluteal n. (L5,S1,2) Perforating cutaneous n. N. to piriformis Posterior femoral cutaneous n. Common peroneal (L4,5,S1,2) (S1,2 & Anterior S2,3) Damian Rispoli 2009 38 Tarascon Pocket Orthopaedica

Sacral Plexus (Anterior Division) L4

Pudendal n. (S2,3,4) Tibial n. (L4,5,S1,2,3) Posterior femoral cutaneous n. (S2,3, & posterior S1,2)

To obturator internus To quadratus femoris & superior gemellus & inferior gemellus

Damian Rispoli 2009 Anatomy—Peripheral Nerves (Motor) 39 ANATOMY—PERIPHERAL NERVES (MOTOR)

Axillary (C5,6) and Musculocutaneous (C(4),5,6,7)

Lateral cord Posterior cord Deltoid Medial cord Lateral Brachial cutaneous n. Coracobrachialis

Biceps, short head Brachialis (medial 1/2) Biceps, long head

Lateral antebrachial cutaneous n.

Damian Rispoli 2009 anterior & posterior branches 40 Tarascon Pocket Orthopaedica

Median (C(5),6,7,8,T1)

Anterior Interosseous n. Lateral cord Median innervated -Flexor pollicis longus Posterior cord hand muscles -Flexor digitorum profundus Medial cord LOAF (index/long) Lumbricals -Pronator quadratus Opponens pollicis Abductor pollicis brevis Flexor pollicis brevis Median n. Flexor digitorum profundus (to index/middle) Pronator teres Abductor pollicis Palmaris longus Opponens pollicis brevis Flexor carpi radialis Flexor digitorum superficialis Flexor pollicis brevis Flexor pollicis longus Lumbricals Pronator quadratus

Damian Rispoli 2009 Anatomy—Peripheral Nerves (Motor) 41 42 Tarascon Pocket Orthopaedica Anatomy—Peripheral Nerves (Motor) 43

Femoral (L2,3,4(posterior)) & Obturator (L2,3,4(anterior))

Psoas major

Iliacus

Rectus femoris Sartorius Vastus lateralis Vastus medialis Vastus intermedius Obturator externus Articularis genu Pectineus Adductor brevis Adductor longus Gracilis

Damian Rispoli 2009 Adductor magnus

Superior gluteal n. (L4,5,S1) - Gluteus medius, Gluteus minimus, Tensor fascia lata Inferior gluteal n. (L5,S1,2) - Gluteus maximus 44 Tarascon Pocket Orthopaedica

Sciatic - Tibial Division (L4,5,S1,2,3)

L4 L5 S1 S2 S3

Biceps femoris, Adductor magnus long head Semitendinosus Semimembranosus

Gastrocnemius Popliteus Soleus Gastrocnemius Tibialis posterior Flexor digitorum Flexor hallucis longus longus

Abductor digiti minimi Abductor Flexor digitorum Hallucis brevis Lumbricals Quadratus plantae Medial plantar n. Flexor digiti Flexor hallucis minimi brevis Lateral plantar n. & interossei brevis Adductor hallucis Damian Rispoli 2009 Lumbricals Anatomy—Peripheral Nerves (Motor) 45

Sciatic - Common Peroneal (L4,5,S1,2)

L4 L5 S1 S2

Biceps femoris, Extensor hallucis longus short head Peroneus longus Tibialis anterior Peroneus brevis Extensor hallucis brevis Extensor digitorum longus Peroneus tertius Extensor digitorum brevis

Damian Rispoli 2009 46 Tarascon Pocket Orthopaedica ANATOMY—PERIPHERAL NERVES (SENSORY)

Upper Extremity Peripheral Nerve Sensory Innervation Anterior Posterior Anterior Supraclavicular n. pectoral n. Axillary n. Radial n. Lateral Inferior lateral cutaneous n. brachial Medial cutaneous n. Radial n. - antebrachial Lateral cutaneous n. Posterior brachial antebrachial cutaneous n. - cutaneous n. Ulnar n.- Superficial branch Radial n. Palmar radial n. Posterior cutaneous br. antebrachial Median n. cutaneous n. Palmar Ulnar n. cutaneous br. Ulnar n. Median n. Damian Rispoli 2009

Upper Extremity Dermatome Anterior Posterior C4

Damian Rispoli 2009 Anatomy—Nerves 47 ANATOMY—NERVES

Lower Extremity Peripheral Sensory Innervation

Anterior Posterior Femoral- Genitofemoral n.

Obturator n. Lateral femoral cutaneous n.

Posterior femoral cutaneous n. Saphenous n. Tibial n. Lateral sural cutaneous n. Sural n. Lateral calcaneal n. Superficial Medial peroneal n. calcaneal n. Medial Deep plantar n. peroneal n. Lateral plantar n. Damian Rispoli 2009 48 Tarascon Pocket Orthopaedica

Lower Extremity Dermatome

Anterior Posterior L2 L1 S3 L3 S4 L4 S5 L2 C1 L5 S2 S1 L1 L3 L2

L4 L5

Damian Rispoli 2009 Anatomy—Dermatomes 49 ANATOMY—DERMATOMES

C2 C2 C3 C3 C4 C5 C6 C4 C7 C8 C5 T1 T1 T2 T3 T2 T4 C T3 T5 T T4 T6 5 C8 T8 T7 1 T5 T9 T6 C8 T10 T7 T11 T12 L1 T8 L2 T9 L3 L4 T10 L5 T11 S1 C6 S2 L1 T12 C6 C7 C7 C8 C8 L2 S2 S1 L3 S2 L4

S1 L5 S2

S1 L S1 5 L4

REFERENCES FOR ANATOMY SECTION Hollingshead WH. Anatomy for Surgeons, Vol. 3, 2nd ed. New York, NY: Harper and Row, 1969. Hoppenfeld S, DeBoer P. Surgical Exposures in Orthopaedics: The Anatomic Approach, 3rd ed. Philadelphia, PA: JB Lippincott, 2004. Miller MD (Ed.). Review of Orthopaedics, 4th ed. Philadelphia, PA: WB Saunders, 2004. Netter FH. The CIBA Collection of Medical Illustrations, Vol. 8. Summit, NJ: CIBA-Geigy, 1991. Pansky B. Review of Gross Anatomy, 5th ed. New York, NY: Macmillan, 1984.

ANTIMICROBIALS

7 d if × (continues) biopsy). Duration cefotaxime or ceftizoxime cefotaxime until culture 2001;83A(12):1878–1890.]

or and cefotaxime. and doxycycline 100 mg po bid cefotaxime. or and J Bone Joint Surg. 2009;48:1201) cefazolin, or may not require operative irrigation and debridement. 1 Jun 2016] decreased since widespread vaccination in use. 10-d Clin Infect Dis. accounts for 50–80%. Cultures usually blood negative, joint

Int J Mol Sci N. gonorrhoeae sp. and GNR) [Mader JT, sp. and GNR) [Mader JT, H. influenzae S. aureus : Also consider contiguous osteomyelitis (occurs in 2/3 of patients), : : : Culture urethra, cervix, anal canal, throat, blood, and joint if suspect (MRSA unlikely, prevalence low): Cefazolin (MRSA unlikely, : MRSA possible, vancomycin : Gram-positive cocci in clusters; vancomycin 15–20 mg/kg IV q8–12h : MRSA not likely, nafcillin : MRSA not likely, high prevalence): Vancomycin (MRSA likely, : Gram stain negative; ceftriaxone 1 g IV q24h Treatment/Notes 1st 2nd Note especially in femoral head, proximal humerus, and radial head (up to 60% have bony involvement). 1st results available, then tailor 2nd Note therapy as good 30-d if clinical response and C-reactive protein levels normalize. ( 1st 1 g IV q8h 2nd Note positive. Note gonococcus. Add azithromycin 1 g po gonococcus suspected or proven. , 10%) Vancomycin 10–15 mg/kg/d q4–6h. 10%) Vancomycin Arthritis—Septic Staphylococcus >

3%,

Streptococcus

) and 3 wk ( and , unknown 36%) H. influenzae S. aureus, S. pyogenes N. gonorrhoeae (more common and most 14%, , N. gonorrhoeae N. meningitidis 27 %, , Enterobacteriaceae, group B sp., (local clindamycin resistance

or Common Microbes S. aureus Streptococcus (Blood cultures often positive.) S. aureus S. pneumoniae gram-negative bacilli 6%, other 14% (gonococci, N. gonorrhoeae commonly missed), rare aerobic gram-negative bacilli 10%, PICU, immunocompromised) Streptococcus > , years (sexually H. influenzae + Age/Condition Birth–3 months 3 months–14 years MRSA (prevalence Clindamycin 30–40 mg/kg/d [Update on the management of pediatric acute osteomyelitis and septic arthritis, 15 active) Typically requires operative drainage and antibiotics. Empiric therapy is initiated following cultures (blood, synovial fluid, and/or Typically 2 wk ( Acute Single Joint

51 52 Tarascon Pocket Orthopaedica

ceftriaxone meropenem with or lipid-based amphotericin B or

: Cefepime 2 g q8h IV : Vancomycin 15–20 mg/kg IV q8–12h. : Vancomycin : Vancomycin 15–20 mg/kg IV q8–12h : Vancomycin cefepime 2 g q8h IV. or : Consider CPPD and gout (see joint fluid analysis section). : After an intra-articular aspiration the treatment is surgical with anti : Fluconazole 400 mg (6 mg/kg) IV q24h 3 wk or infection within 30 days of implantation). Treatment/Notes Gram-positive cocci on Gram stain Gram-negative bacilli on Gram stain 1 g q8h IV. Negative Gram stain 1 g IV q24h Note Note microbial treatment based on culture results. 1st Treat for at least 3–5 mg/kg IV q24h for several wk then oral fluconazole. 6 wk/indefinitely with retained hardware. Surgical debridement required. Best option is not clearly defined at present. Most favor 1- or 2-stage exchange if the infection is not acute (symptoms < Antibiotic therapy is based on cultures and should involve an infectious disease specialist. -

Entero . spp. N Engl spp S. aureus

albicans Strep , gram-negative 30–43%, and non- Staph 2004;35(16):1645–1654] spp. 3–7%, anaerobes 2–4%, culture

Common Microbes S. aureus, Streptococcus bacilli Candida albicans Coag. negative 12–23%, mixed 10–11%, 9–10%, gram-negative rods 3–6%, coccus negative, oral bacteremia 6–13%. [ J Med. Continued

years (not : Empiric therapy Debride and retain 1-stage exchange 2-stage exchange + Age/Condition 15 sexually active) Adult—Candidiasis joint Total Note is NOT recommended. Options: 1. 2. 3. Acute Single Joint Antimicrobials 53 Total Joint Arthroplasty—Criteria for Infection Major Criteria (1 of 2 needed) 1. There is a sinus tract communicating with the prosthesis. 2. A pathogen is isolated by culture from at least two separate tissue or fluid samples obtained from the affected prosthetic joint. Minor Criteria (4 of 6 needed) 3. Elevated serum erythrocyte sedimentation rate (ESR >30 mm/h) and serum C-reactive protein (CRP > 10 mg/L) concentration 4. Elevated synovial leukocyte count (1100–4000 cells/mcL) 5. Elevated synovial neutrophil percentage (PMN%: 64–69%) 6. Presence of purulence in the affected joint 7. Isolation of a microorganism in one culture of periprosthetic tissue or fluid 8. Greater than five neutrophils per high-power field in five high-power fields observed from histologic analysis of periprosthetic tissue at ×400 magnification Data from Parvizi J. New Definition for Periprosthetic Joint Infection: From the Workgroup of the Musculoskeletal Infection Society. CORR 2011 Nov;469(11):2992-2994.

INCREASED PROSTHETIC JOINT INFECTION RISK • Obesity • Psychiatric pathology • Steroid injection < 3 months from surgery • Low nutritional parameters 1. Albumin 2. Protein 3. Vitamin D 4. Iron 5. Transferrin 6. Zinc

CULTURE GUIDELINES PreOp 1. Consider repeat aspiration if first is negative and high clinical suspicion. 2. Delay aspiration until off antibiotics for 2 wk. IntraOp 1. Obtain biopsies before irrigation. 2. Deep culture samples. 3. Avoid electrocautery in obtaining biopsies. 4. Best sites: intramedullary, prosthesis/bone interface. 5. Biopsy direct to bottle/media; avoid glove/drape contact. 54 Tarascon Pocket Orthopaedica J Am Acad fluoroquinolone (adults) or and /d × : 5% of dog bites get infected; consider treating if severe or co- : Soft tissue rest, consider surgical drainage; hand is a common site. : Antibiotics for prophylaxis. Barbs may need to be excised. : Clindamycin 300 mg po 4 : Cefuroxime 500 mg po q12h or doxycycline 100 bid (no cephalexin) : Amoxicillin/clavulanate (po) 875/125 mg bid or 1000/62.5 mg, 2 tabs : Amoxicillin/clavulanate (po) 875/125 mg bid or 1000/62.5 mg, 2 tabs : Amoxicillin/clavulanate (po) 875/125 mg bid or 1000/62.5 mg, 2 tabs Treatment/Notes 1st : Ceftriaxone 1 g IV qd Gram stain not usually helpful! if Remember to screen for sexually transmitted disease. Consider Lyme indicated, polyarticular gout, autoimmune disease. Treatment/Notes 1st 2nd trimethoprim/sulfamethoxazole (children) Note morbidities. Consider rabies. 30–50% get infected. 1st 2nd Note Beware puncture of teeth into tendon sheaths/joints and to bone. 1st Note Beware tendon sheath and joint penetration. , S. aureus

sp., , streptococci,

S. aureus (75%), streptococci, s (50%), Common Microbes cani P. Bacteroides, Fusobacterium Capnocytophaga canimorsus multocida P. Neisseria, Moraxella Toxins Common Microbes acute N. gonorrhoeae, B. burgdorferi (Lyme), hepatitis B, parvovirus B19 rheumatic fever, rubella vaccine, staph and strep may also be causes. ) ♂

2015;23(1):47–57] ) ♀ adult/child adult ↑ N Engl J Med. ↑ N Engl J Med. ACUTE MULTIPLE JOINTS ACUTE MULTIPLE Age/Condition Adult Age/Condition Dog 80% of all bites ( [ 1999;340:85–92] Cat 5–15% of all bites ( [ 1999;340:138] Catfish barb Bites **No pharmacological treatment substitutes for an adequate irrigation and, if indicated, a debridement of devitalized tissue. [ Orthop Surg. Antimicrobials 55 - 5 d; Otherwise: × ticarcillin/clavulanate or 14–28 days. lower extremities × = 2002;84A(19)1624–1629). Adult

cefoxitin 2 g IV q8h or J Bone Joint Surg. trimethoprim/sulfamethoxazole or surgical drainage. Be sure to check location of wound in all piperacillin/tazobactam 3.375 g IV q6h; PCN allergy: clindamycin or = : Antivenom is treatment. Give until symptoms resolve. Rarely need initially for 30 d. Increase to 60 d if incomplete response. : Treat : Consider rabies immune globulin and vaccine if animal not available for : Fight bites: Unreliable history from intoxicated patient. Joint : Ceftriaxone 2 g IV qd or PCN G 20–24 mU/d : Doxycycline 100 mg po bid (pig), 3rd-generation cephalosporin, ticarcil : Antibiotics as necessary prophylaxis with ceftriaxone : Amoxicillin/clavulanate (po) 875/125 mg bid or 1000/62.5 mg, 2 tabs : Prophylaxis: amoxicillin/clavulanate (po) 875/125 mg bid 1st Note fasciotomy. Think tetanus! Follow for compartment syndrome (2–8% require fasciotomy). Crotalidae is responsible for 99% of snakebites in the United States. 2nd Note Antivenin rather than surgery is the treatment of choice in severe rattlesnake envenomation in children ( snake bites 80% upper extremities. Children upper 1st 2nd lin/clavulanate, ampicillin/sulbactam, imipenem Note testing or tests positive. The most common source in the US are bats with racoons, skunks, & foxes also sources. 1st ampicillin/sulbactam 1.5 g IV q6h 3.1 g IV q6h and ciprofloxacin Note penetration degrees of joint range motion. People punch with closed fists and sustain layered penetration! 67% penetration and injury to articular cartilage.

26% (rat) 15%, 41%, Staph epidermidis Staphylococcus, Peptostreptococcus E. corrodens Enterobacter, S. epidermidis, Enterobacter, and , 82%, sp. 29%, Corynebacterium Pseudomonas Clostridium Streptococcus Streptobacillus moniliformis Viridans strep 100%, 53%, S. aureus Bacteroides ♀

& ♂ ♂ ♂ J Am Acad Snake (pit viper) 70–80% [ Orthop Surg. 2015;18(12):749–59] Miscellaneous—bat, raccoon, skunk, rat, pig Human 2–3% of all bites Fight Occlusive 56 Tarascon Pocket Orthopaedica

or vancomycin vancomycin metronidazole

doxycycline

or and or and clindamycin (MSSA, or aztreonam or cephalexin 500 mg po 4×/d,

linezolid for vancomycin. or or meropenem 70.

-lactam/lactamase inhibitor moxifloxacin or > β or imipenem Bactrim DS 1–2 tab po bid (MRSA)

or levofloxacin or or ) 300–450 mg po tid. : Based on susceptibilities plus : Vancomycin Strep -lactam/lactamase inhibitor doripenem : May substitute daptomycin : Dicloxacillin 500 mg po 4×/d, : Same as above β Treatment/Notes Local wound measures. No antimicrobial therapy. Oral amoxicillin/clavulanate (unless MRSA) 875/125 mg po bid 100 mg po bid MRSA, Oral IV therapy Ampicillin-sulbactam, piperacillin-tazobactam, ertapenem (till r/o MRSA) IV therapy plus Note Ciprofloxacin for 2006;117(7, suppl):2125): (group B strep) HIV, HBV, HCV, herpes simplex HCV, HBV, HIV, Rhabdoviridae (rabies) Hantavirus, rhabdoviridae (rabies) Simian B (usually MRSA) , able to probe bone, radiographic abnormalities, ESR 2 2 cm Common Microbes Skin flora, colonization S. aureus S. agalactiae S. pyogenes Same as above plus the possibility of coliforms. Add anaerobes to the above mix. Plast Reconstr Surg. > 2006;339B:4905; BMJ Glucose control. Relieve pressure in area of ulceration. Poor concordance with swab. Needle aspiration inferior. Obtain a culture/bone biopsy. Osteomyelitis risks—Ulcer Always evaluate and treat vascular insufficiency. Human Dog, Bat, Racoon, Skunk Rodents Monkeys Age/Condition Simple ulceration without inflammation Ulceration with inflammation/ erythema (mild infection) Ulceration with significant inflammation/erythema (moderate infection) With systemic symptoms Viral Infections Associated With Bite Injuries Diabetic Foot General ( 1. 2. 3. 4. 5. Antimicrobials 57 cefazolin 2g IV q8h or oxacillin 2g IV q4h or : Gram stain and culture negative. May be confused for a felon! : Vancomycin 15–20 mg/kg IV q8–12h or linezolid 600 mg po bid. : Vancomycin : Nafcillin 2g IV q4h : Avoid hand immersion : Avoid : Consider MRSA coverage if risk factors are present or in an area of : Trimethoprim/sulfamethoxazole 160/800 mg po bid pending culture : Trimethoprim/sulfamethoxazole : Irrigation/debride, obtain cultures : Famciclovir or valacyclovir clotrimazole : Topical Treatment/Notes 1st 2nd results 1st Notes 1st Note Treatment/Notes MSSA MRSA Note high prevalence. Splint/soft tissue rest. 2–3 wk of antibiotics. Bursectomy uncommon. and 80%, rare > , MRSA possible species Common Microbes S. aureus Herpes simplex Candida Common Microbes S. aureus Mycobacterium tuberculosis marinum Age/Condition Nail biting Herpetic whitlow immersion Water Age/Condition Adult Hand/Paronychia Bursitis (May need wound debridement) 58 Tarascon Pocket Orthopaedica

67%). > ceftriaxone and and levofloxacin 750 mg

treatment.

or levofloxacin 750 mg po q24h

linezolid 600 mg po q8h

detected. May use piperacillin- or or resistance to fluoroquinolones, add or another gram-negative. MRI to evaluate and cefepime 2 g po q8h

or Salmonella Pseudomonas Pseudomonas cefepime 2 g po q8h

or : Look for local signs/symptoms. Blood culture often positive ( for PCN allergic. : Vancomycin : No ceftriaxone if : Onset within 30 d of spinal implant treat for 3 months, after : Due to increased : MRSA not likely—Nafcillin or oxacillin and ceftazidime cefepime : MRSA not likely—Nafcillin or oxacillin : Daptomycin 6 mg/kg IV q24h : Levofloxacin : MRSA possible—Vancomycin and ceftazidime or cefepime : MRSA possible—Vancomycin : MRSA possible—Vancomycin 15–20 mg/kg IV q8–12h (trough µg/mL) : Vancomycin : Ciprofloxacin Treatment/Notes 1st 2nd Note 1st 2nd Note to culture results. Tailor Add ceftazidime or cefepime if Gram stain positive for gram-negative bacilli. Alternatives: Clindamycin, trimethoprim-sulfamethoxazole, linezolid (lacks FDA approval) 1st ceftriaxone 2g po q24h po q24h 2nd 2g po q24h Note tazobactam for r/o epidural abscess. Note remove implant, culture, and treat. 1st 2nd Note a 3rd-generation cephalosporin until susceptibility results offer more guidance. , , K. Streptococcus Streptococcus , gram-negative bacilli, , group A , group A , various other etiologies most common, consider Streptococcus, K. kingae Common Microbes S. aureus group B S. aureus rare gram-negative bacilli, kingae S. aureus rare gram-negative bacilli, S. aureus can occur S. aureus Salmonella 4 months > 21 years 21 Vertebral osteo 21 Vertebral > > /– epidural abscess) + Age/Condition 0–4 months Children Adult Adult ( Sickle cell anemia Osteomyelitis A specific microbe diagnosis essential via blood and tissue cultures. The following represents the initial empiric Antimicrobials 59 - ceftazi

and lipid-based amphotericin B or

: Sternoclavicular joints, ribs, spine, and long bones : Think of in delayed union and nonunion. : Look for foreign body and debride if necessary (1–2% in children), : Surgery for exposed bone or osteomyelitis : Vancomycin and ciprofloxacin : Vancomycin and ciprofloxacin : Vancomycin : Linezolid 600 mg IV/po bid (not FDA approved) and ceftazidime 2 g q8h IV : Ceftazidime 2 g q8h IV or cefepime q12h : Penicillinase-resistant PCN and ciprofloxacin : Penicillinase-resistant PCN and ciprofloxacin 15–20 mg/kg IV q8–12h (trough µg/mL) : Vancomycin : Ciprofloxacin 750 mg po bid or levofloxacin qd : Fluconazole 400 mg (6 mg/kg) IV q24h 1st 2nd Note 1st 2nd 1st dime 2 g q8h IV or cefepime q12h 2nd or cefepime 2 g q12h IV Note 1st 2nd Note administer tetanus or booster. Base treatment on bone biopsy results; no acute unless systemic illness Note Based on results of deep culture. No empiric treatment. 1st Treat for 3–5 mg/kg IV q24h for several wk then oral fluconazole. 6–12 months. Surgical debridement often required with removal of hardware/implants if possible. and non- , Enterobacteriaceae Pseudomonas Pseudomonas , , gram-negative bacilli, , sp. S. aureus S. aureus, Pseudomonas S. aureus Pseudomonas aeruginosa Pseudomonas aeruginosa Polymicrobial Most often in diabetics S. aureus aeruginosa Candida albicans albicans Intravenous drug user Dialysis After open reduction internal fixation (ORIF) Sneaker puncture insufficiency Vascular Chronic osteomyelitis Adult—Candidiasis 60 Tarascon Pocket Orthopaedica Recommended Antibiotic Choices for Pediatric Osteomyelitis (J Am Acad Orthop Surg. 2001;9(3):166–175)

IV Antibiotics PO Antibiotics (Divided 4/d) Neonate Nafcillin 150–200 mg/kg/d and Dicloxacillin 75–100 mg/kg/d or Gentamicin 5–7.5 mg/kg/d or Cephalexin 100–150 mg/kg/d or Cefotaxime 150 mg/kg/d Clindamycin 30 mg/kg/d < 3 years (Not Hib Nafcillin 150 mg/kg/d and Dicloxacillin 75–100 mg/kg/d or immunized) Cefotaxime 150 mg/kg/d or Cephalexin 100–150 mg/kg/d or single therapy with cefuroxime Clindamycin 30 mg/kg/d 150–200 mg/kg/d > 3 years (Hib Cefazolin 100–150 mg/kg/d or Dicloxacillin 75–100 mg/kg/d or Immunized) Nafcillin 150–200 mg/kg/d or Cephalexin 100–150 mg/kg/d or Clindamycin 30–40 mg/kg/d Clindamycin 30 mg/kg/d MRSA (prevalence >10%, PICU, immunocompromised) Clindamycin 30–40 mg/kg/d or (local clindamycin resistance >10%) vancomycin 10–15 mg/kg/d q4–6h. [Update on the management of pediatric acute osteomyelitis and septic arthritis, Int J Mol Sci., 1 Jun 2016]

Cierny-Mader Staging System (Contemp Orthop. 1985;10:17–37) Description Systemic or Local Factors (Affecting Immune Surveillance, Metabolism, Vascularity) Anatomic Type Systemic (Bs) Local BI Stage 1 Medullary Malnutrition Chronic lymphedema osteomyelitis Stage 2 Superficial Renal, hepatic Venous stasis osteomyelitis failure Stage 3 Localized Diabetes mellitus Major vessel osteomyelitis compromise Stage 4 Diffuse osteomyelitis Chronic hypoxia Arteritis Physiologic Class Immune disease Extensive scarring A Host Normal Malignancy Radiation fibrosis B Host Extremes of age Small vessel disease Bs Systemic Immunosuppression/ Neuropathy compromise deficiency Bl Local compromise Asplenic Bls Systemic and local HIV/AIDS compromise C Host Treatment worse Ethanol/tobacco than the disease abuse Antimicrobials 61

(continues)

ceftaroline

or ceftaroline or azithromycin 500 mg po vancomycin — clindamycin 300–450 mg ciprofloxacin 400 mg IV or levofloxacin 750 mg IV q24h. Also add or ) : Irrigation and debridement of Also add PCN allergic

Note -lactam/lactamase inhibitor. daptomycin 6 mg/kg IV q24h β ertapenem. or /d 10d; or × daptomycin 6 mg/kg IV q24h or linezolid 600 mg po bid. With sepsis consider or 4 d. × Pseudomonas aeruginosa for + telavancin 10 mg/kg IV q24h. telavancin 10 mg/kg IV q24h. doripenem (non-FDA) or or or gram-negative bacilli add: : Vancomycin 15 mg/kg IV q12h. : Vancomycin = : Penicillin VK 500 mg po 4 : Penicillin G 1–2 million units IV q6h or cefazolin 1 g q8h, change to 1 d then 250 mg po qd : Tetanus! Surgical debridement if needed; splint for soft tissue rest. Tailor Surgical debridement if needed; splint for soft tissue rest. Tailor : Tetanus! : Early irrigation and debridement as indicated : Trimethoprim/sulfamethoxazole 160/800 mg po bid : Trimethoprim/sulfamethoxazole : Minocycline 100 mg po bid : Clindamycin 300–450 mg po tid. With sepsis consider piperacillin/tazobactam : Clindamycin 300–450 mg po tid × meropenem : Vancomycin 15–20 mg/kg IV q8–12h : Vancomycin

Treatment/Notes Outpatient qd Inpatient outpatient oral regimen when afebrile (10d total treatment). PCN allergic to include ruling out abscess. abscess if present. Workup 1st or 15–20 mg/kg q8–12h. 2nd vancomycin 15–20 mg/kg q8–12h 600 mg IV q12h q12h (q8h if culture Note antibiotic to cultured bug. 1st Gram stain Note Needs culture and sensitivity irrigation/debridement. Oral po tid. IV 600 mg IV q12h Splint and Elevation and Splint -

- (MSSA, Pseudomo

, occa S. aureus tetani, (water exposure), Enterobacter, C. Enterobacter, S. aureus , possible MRSA and , group A, B, C, or G — Streptococcus Streptococcus, Aeromonas , Common Microbes Group A sional group B/C/G, (MRSA) Group A S. aureus Polymicrobial: MRSA), group A and anaerobic Streptococcus perfringens nas Acinetobacter S. aureus Streptococcus S. aureus Age/Condition Cellulitis, outpatient Cellulitis, inpatient Infection—wound, severe Post-op infection without sepsis Post-op infection with gram-positive cocci on Gram stain Skin Infections 62 Tarascon Pocket Orthopaedica ceftaroline

or 24 h increases > ciprofloxacin 400 mg IV q12h 24 h); maintain a low threshold < levofloxacin 750 mg IV q24h. Also add or ) Surgical delay daptomycin 6 mg/kg IV q24h or ) Pseudomonas aeruginosa telavancin 10 mg/kg IV q24h. for or + rapidly progressive! : Early irrigation and debridement as indicated : IV antibiotics and observation if caught early ( : Nafcillin 1–2 g IV q4–6h, vancomycin 1 q12h and gentamicin or imipenem : Vancomycin 15–20 mg/kg IV q8–12h : Vancomycin : Cefazolin 1 g IV q8h Treatment/Notes 1st 600 mg IV q12h (q8h if culture Note 1st 2nd 0.5–1 g IV q6h Note for irrigation and debridement. Need Gram stain/culture to determine pathogen. Initial therapy: Penicillin G if strep or clostridia. Imipenem meropenem polymicrobial. Add vancomycin or daptomycin if MRSA suspected. Definitive therapy based on intraoperative Gram stain and culture. Note: Wide immediate surgical debridement! mortality rate. Remove all necrotic fascia and fat. Skin excision back to healthy bleeding tissue. 2nd look at 24–48 h, then as needed. - , gram- sp. Streptococcus , group A, B, C, or G , sp., group A, C, and G. Strep Clostridia K. pneumoniae Common Microbes S. aureus Streptococcus S. aureus negative rods 5 types: 1. 2. 3. Polymicrobial; aerobic & aerobic. 4. Community assoc. MRSA 5. Rare; 500–1500 cases/year (US) Involves fascia, subcutane ous tissue, and thrombosis of microcirculation Soft tissue crepitance (gas in the SQ tissue) may be only early sign. : Presents with exquisite pain, swelling, and fever ( . Continued

(late): Hemorrhagic bullae, skin necrosis, fluctuance, crepitance, gas (inconsistent sign ~ 17% in one series). Am Acad Surgical J Emergency! J Bone Joint Surg Age/Condition Post-op infection with sepsis Flexor tenosynovitis Necrotizing fasciitis [ 2003;84A:1454– 1459; Orthop Surg. 2009;17(3): 174–182] Necrotizing fasciitis Hard signs Skin Infections Antimicrobials 63 Infection Imitators • Gout/pseudogout (polarized light microscopy) • Calcific tendonitis (normal labs, intratendinous mineralization) • Pyoderma gangrenosum • Childhood leukemia masquerading as a septic joint Key Atypical Infections Organism Systemic Therapy Sporothrix schenckii Ketoconazole, supersaturated solution of potassium iodide, amphotericin, surgical debridement Mycobacterium marinum Rifampin, tetracycline, minocycline, amikacin Mycobacterium tuberculosis Isoniazid, rifampin, ethambutol, pyrazinamide Mycobacterium avium Azithromycin, clarithromycin, ethambutol, rifabutin Common Antibiotics—Mechanisms of Action Inhibits Antibiotics Cell wall synthesis Carbenicillin, cephalosporin, methicillin, nafcillin, oxacillin, penicillin, piperacillin, ticarcillin Cell membrane function Amphotericin, nystatin, polymyxin Protein synthesis Aminoglycosides, chloramphenicol, clindamycin, erythromycin, tetracycline Nucleic acid synthesis Sulfonamides DNA gyrase Quinolones Bacterial RNA synthesis Rifampin

Antibiotics for Surgical Prophylaxis (J Am Acad Orthop Surg. 2008;16:283–293) Timing • Begin within 60 min of incision (cephalosporin, clindamycin) 120 min (vancomycin) • Complete infusion > 10 min prior to tourniquet inflation Dosing • Single preoperative dose recommended • Redose during a prolonged procedure and/or increased blood loss • Discontinue antibiotics 24 h after surgery • Dosage: Cefazolin 2 g (weight < 120 kg), 3 g (weight > 120 kg), Pediatric 30 mg/kg. Redosing interval 4 h. Cefuroxime 1.5 g (Pediatric 50 mg/kg) Redosing interval 4 h. Ceftriaxone 2 g (Pediatric 50–75 mg/kg) Redosing interval N/A Vancomycin 15 mg/kg (Adult & Pediatrics) Redosing interval 4–8h Clindamycin 900 mg (Pediatric 10 mg/kg) Redosing interval 6 h. 64 Tarascon Pocket Orthopaedica Antibiotic Choice • 1st choice: Cephalosporin (cefazolin, cefuroxime) • β-lactam allergic: Clindamycin, vancomycin • History of MRSA (infection or colonization): Vancomycin • Consider no antibiotic prophylaxis in clean, simple hand surgery cases < 2 h. • Consider no antibiotic prophylaxis for hand, knee, and foot cases not involving the implantation of foreign materials. Antibiotic References • Gilbert DN, et al. The Sanford Guide to Antimicrobial Therapy 2017. Sperryville, VA: Antimicrobial Therapy Inc.; 2017. • Abrams RA, Botte MJ. Hand infections: Treatment recommendations for specific types. J Am Acad Orthop Surg. 1996;4(4):219–230. • Rizvi M, et al. The role of prophylactic antibiotics in elective hand surgery. J Hand Surg. 2008;33A:413–420. • Bratzler DW, et al. Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery. Am J Health Syst Pharm. 2013;70(3):195–283. Common Oral Antimicrobial Doses and Mixtures Antimicrobial Formulations Dose (Frequency)1 Amoxicillin (Amoxil ) Susp: 125, 250 mg/5 mL 30–50 mg/kg/d (bid–tid) Caps: 125, 250 mg Max dose 500 mg Amoxicillin/clavulanate Susp: 200, 400, [600] mg/5 mL 45 mg/kg/d (bid) (Augmentin) [ES] Tabs: 125, 250, 500 mg Max dose 500 mg Ampicillin (Polycillin) Susp: 125, 250 mg/5 mL 50–100 mg/kg/d (4×/d) Caps: 250, 500 mg Max dose 500 mg Azithromycin (Zithromax) Susp: 100, 200, 1000 mg/5 mL 10 mg/kg qd 1st day, Caps: 250 mg (max 500 mg) then 5 mg/kg qd ×4 d

Cefaclor (Ceclor ) Susp: 125, 250 mg/5 mL 20–40 mg/kg/d (tid) 2nd-generation Caps: 250, 500 mg Max dose 500 mg Cefadroxil (Duricef ) Susp: 125, 250, 500 mg/5 mL 30 mg/kg/d (bid) 1st-generation Caps: 500, Tab: 1000 mg Max dose 1000 mg Cefdinir (Omnicef ) Susp: 125 mg/5 mL 14 mg/kg/d (qd–bid) 3rd-generation Caps: 300 mg Max daily dose 600 mg Cefixime Suprax( ) Syrup: 100 mg/5 mL 8 mg/kg/d (qd/bid) 3rd-generation Tabs: 200, 400 mg Max dose 400 mg Cefpodoxime (Vantin) Susp: 50, 100 mg/5 mL 10 mg/kg/d (bid) 3rd-generation Tabs: 100, 200 mg Max dose 400 mg Emergency Procedures 65 Antimicrobial Formulations Dose (Frequency)1 Cefprozil (Cefzil ) Susp: 125, 250 mg/5 mL 15 mg/kg/d (bid) 3rd-generation Tabs: 250 mg/5 mL Max dose 500 mg Ceftibuten (Cedax ) Susp: 90, 180 mg/5 mL 9 mg/kg/d (qd) 3rd-generation Caps: 400 mg Max dose 400 mg Cefuroxime (Ceftin ) Susp: 125 mg/5 mL 15–30 mg/kg/d (bid) 2nd-generation Tabs: 125, 250, 500 mg Max dose 500 mg Cephalexin (Keflex ) Susp: 125, 250 mg/5 mL 25–50 mg/kg/d (4×/d) 1st-generation Caps: 250, 500 mg Max dose 500 mg Clarithromycin (Biaxin ) Susp: 125, 250 mg/5 mL 15 mg/kg/d (bid) Tabs: 250, 500 mg Max dose 500 mg Clindamycin (Cleocin ) Solution: 75 mg/5 mL 10–30 mg/kg/d (tid/bid) Caps: 75, 150 mg (max 600 mg) (30–40 mg/kg/d if DRSP)2 Dicloxacillin (Dynapen ) Susp: 62.5 mg/5 mL 25–100 mg/kg/d (4×/d) Caps: 125, 250, 500 Max dose 500 mg Doxycycline (> 8 years) Tabs/Caps: 50,100 mg Susp: 2–4 mg/kg/d (bid) (Vibramycin) 25 mg/5 mL, Syrup: 50 mg/5 Max dose 200 mg/d mL, Erythromycin (ERYC, EES, Susp: 200, 400 mg/5 mL 20–50 mg/kg/d (4×/d) E-mycin) Tabs: 200 (chew), 250, 400, 500 Max dose 500 mg Erythromycin/sulfisoxazole Susp: 200 mg and 50 mg EM/kg/d (4×/d) (Pediazole ) 600 mg/5 mL Max EM dose 500 mg Penicillin (Pen-Vee K) Susp: 125, 250 per 5 mL 25–50 mg/kg/d (4×/d) Tabs: 125, 250, 500 mg Max dose 500 mg Trimethoprim/ Susp: 40 mg and 200 mg/5 mL 6–12 mg/kg/d TMP bid sulfamethoxazole Tabs: 80/400, 160/800 Max dose 160 TMP (Bactrim, Septra) Vancomycin (Vancocin ) Caps: 125, 250 40 mg/kg/d ×7 d Max dose 2000 mg/d 1Max dose = maximum individual oral dose. 2DRSP = drug-resistant S. pneumoniae. Modified with permission fromTarascon Pediatric Emergency Pocketbook, 5th ed. Lompoc, CA: Tarascon; 2007.

EMERGENCY PROCEDURES Compartment Syndrome (J Am Acad Orthop Surg. 1996;4:209–218) • Increased pressure within a confined space interferes with proper tissue perfusion within the space. • Pressure increase may be intrinsic Bleeding, edema, fluid • Or extrinsic Pneumatic antishock trousers, cast, tight dressing, over distraction external fixator 66 Tarascon Pocket Orthopaedica • Findings: Pain out of proportion to physical findings (pain is the most reliable and earli- est symptom) Increasing analgesic requirements in children or noncommunicative patients (may be equivalent to pain out of proportion) Pain with passive ROM (cardinal sign) Pain on palpation of the swollen compartment, tensely swollen compartment, tight shiny skin, hypesthesia, paresthesia, anesthesia (late finding), weakness, paresis (late finding). Late findings occur after irreversible damage has occurred! Compartment Pressure Values

Compartment syndrome is felt to be present Within 30 mm Hg of diastolic pressure if compartment pressures are: OR Above 30 mm Hg—absolute pressure

Needle manometer measurements are generally allowed to be slightly higher. Most surgeons prefer to use the measurement of compartment pressure relative to diastolic pressure. A “zone of peak pressure” occurs within several centimeters of the fracture site; values can vary significantly at greater distances causing an underestimation of the compartment pressure. (J Bone Joint Surg. 1996;78B:99–104, J Bone Joint Surg. 1980;62A:286–291)

Traditional Compartment Measurement Set-Up

Three-way stopcock - open, saline meniscus in proximal tube, insert needle, increase pressure in syringe until meniscus moves, read pressure

Meniscus Mercury Manometer Manometer and limb must be at the same level

Damian Rispoli 2009

Measuring Techniques (Multiple) • Needle manometer (Clin Orthop. 1975;113:43) • Wick catheter (J Bone Joint Surg. 1976;58A:1016) • Slit catheter (J Trauma 1981;21:446–449) • STIC catheter Emergency Procedures 67 The simplest technique utilizes the STIC catheter. It is a handheld device that is easy to use and usually readily available at larger institutions. Another simple technique is to use an arterial line setup. This can be connected to a standard pressure monitor at the bedside or in the OR. Additionally, the arterial line setup comes in a sterile package and can then be used intraoperatively with the help of the OR nurse or anesthetist. Ensure the setup is “zeroed” at the level of the limb being tested. Compartment Release (Fasciotomy) Techniques Finger Usually done on the ulnar side of the index, long, and ring fingers and the radial side of the thumb and small finger. Special attention and alteration of this should be based on the patient’s vocation and avocation. The incision is a standard mid- axial incision as shown. The line for the mid axial incision is drawn off points that correspond to the dorsal extent of the flexion creases in maximal flexion. The volar neurovascular bundles are left volar, and the line of dissection is between them and the flexor tendon sheath (Green DP, ed.Operative Hand Surgery. New York, NY: Churchill Livingstone; 1993). 68 Tarascon Pocket Orthopaedica

Dorsal incisions 2nd and 4th metacarpal

Incision for release of Damian Rispoli 2009 thenar compartment

Hand The volar incision lies in the crease between the thenar and hypothenar eminences. From it one can release the carpal tunnel and Guyon’s canal. The incision is curved over the wrist flexion crease to prevent contractures. The dorsal incisions are made in line with the second and fourth metacarpals as shown. The incisions split the dorsal interossei fascia and then course around the muscle to release the palmar interossei. The thenar and hypothenar compartments are released through incisions over the respective metacarpals. Forearm (Clin Orthop. 1978;134:225–229; 1981;161:252–261) Two incisions, one dorsal and one volar, are used to decompress the forearm. The volar incision includes the carpal tunnel release. Taking the incision ulnar after the carpal tunnel release leaves tissue to cover the median nerve as it exits from under the flexor digitorum superficialis. The dorsal incision should be used to decompress the dorsal and mobile wad compartments. Intraoperative pressure measurements can aid in making the decision to proceed with the dorsal release. Often the volar release is sufficient to lower the pressure dorsally to subcritical levels. Arm The volar incision can be carried up past the elbow and into an anterior lateral approach to the arm to release brachial compartments if necessary. Anterior and posterior compartments may then be released through the anterolateral incision. Emergency Procedures 69

Thigh Fasciotomy (JBJS 68A:1439,1986) Anterior

Lateral

Damian Rispoli 2009

Thigh (J Bone Joint Surg. 1986;68A:1439) Thigh compartment syndromes are being more commonly reported. The incisions are anterolateral and if needed straight medial. The hamstring compartment is released via the anterolateral incision. Always consider extension to the gluteal compartment as clinically indicated. 70 Tarascon Pocket Orthopaedica Leg (J Bone Joint Surg. 1977;59A:184–187) Three common techniques for fasciotomy of the leg exist: fibulectomy, perifibular fasciotomy, and the double-incision technique. The most commonly advocated is the double-incision technique. The two vertical incisions must be separated by at least an 8-cm skin bridge. Both incisions span from knee to ankle. The medial incision is at least 2 cm posterior to the posteromedial border of the tibia (avoids bone exposure and damage to the saphenous nerve and vein). The fascia overlying the gastrocnemius is split to release the superficial compartment. The deep compartment fascia is split over the flexor digitorum longus, and proximally the soleal attachment to the tibia is released to access the proximal portion of the deep posterior compartment (tibialis posterior). The lateral incision is made midway between the posterolateral tibial border and the anterolateral border of the fibula. The fascia is split 1 cm anterior and 1 cm posterior to the intramuscular septum. The superficial peroneal nerve must be protected.

Leg Fasciotomy (JBJS 59A:184–187, 1977)

Medial

Damian Rispoli 2009

Ankle (J Bone Joint Surg. 2002;84B(1):11–14) Consider extensor retinaculum syndrome (severe pain and swelling of the ankle, hy- poesthesia or anesthesia in the web space of the great toe, weakness of extensor hallucis longus and extensor digitorum communis, and pain on passive flexion of the toes, especially the great toe). Prompt recognition and decompression can potentially avoid negative long-term sequelae. Emergency Procedures 71 Foot (J Orthop Trauma 1992;223–228, Orthopedics 1990;13:711–717) A foot compartment syndrome is difficult to detect. Clinical suspicion and pressure measurement are necessary to identify those requiring release. Two techniques are shown. The main compartments are medial, central, lateral, interosseous, and calcaneal. All involved compartments should be released if indicated.

Important to note! (J Trauma 1996;40(3):342–344) There is universal agreement that acute compartment syndromes should be treated surgically. However, the treatment of compartment syndromes presenting late with evidence of compartment damage is less clear. The damage done in a compartment is a function of many variables including compartment pressure magnitude, time of pressure elevation, diastolic pressure, concomitant crush injury, and time since onset, among others. It has been shown that late release of compartments is associated with an unacceptable complication rate. Hard and fast rules regarding the treatment of compartment syndromes do not exist. The guidelines given along with heightened clinical suspicion and an educated response are most appropriate. Ensure you check serum CKs and place a Foley catheter to monitor urine color. If positive for myoglobinuria, treat with aggressive hydration and alkalization with sodium bicarbonate. NOTE: A urine dipstick positive for blood in the absence of RBCs on microscopic analysis is indicative of myoglobinuria.

Foot Fasciotomy (J Orthop Trauma 223-228, 1992; Orthopedics 13:711-717, 1990)

Dorsal Incision

Medial Incision Damian Rispoli 2009 72 Tarascon Pocket Orthopaedica Acute Stabilization of the Pelvis Methods Pelvic Binder *Centered on greater trochanters*

Sheet wrapped around the pelvis and Skeletal traction clamped snugly Internal rotation of the legs and wrapping Anterior external fixation frame both together

• Persistent hemodynamic instability after binder placement: • Rule out intra-abdominal bleeding • Patient fully warm and resuscitated • Consider: Pelvic angiography (rule out arterial injury) • May rarely consider pelvic external fixation if in OR for exploratory laparotomy • Some (rarely) advocate for retroperitoneal packing to control venous bleeding. Pelvic External Fixation Iliac Crest Pins (Traditional) Use 5-mm pins with the threads placed in the anterior half of the iliac crest. Pins must be at least 1 cm apart. Use 2–3 pins per side. Incisions, 2–3 cm, are made along the crest and angled toward the umbilicus. The crest is identified, and the walls may be palpated, and/or the proper angle of the crest identified with a guidewire. The crest is perforated with a drill; the pin is then inserted and allowed to find its way between the inner and outer table. The pins should be directed toward the strong bone in the supra-acetabular region. All threads should be buried in the crest bone. Supra-Acetabular Pins Placed into the strong pillar of bone from the anterior inferior iliac spine posteriorly. The hip capsule reflection is usually 16 mm above the joint but may extend to 20 mm. The lateral femoral cutaneous nerve is at risk (usually 10 mm but at times as close as 2 mm). The anterior inferior iliac spine (AIIS) is identified (4–6 cm inferior to the anterior superior iliac spine and 3–4 cm medial). It may be identified percutaneously using fluoroscopy or by palpation via a small incision. The fluoroscopic image best utilized is the obturator oblique view. Positioning is then confirmed on the iliac oblique inlet view. The pin is confirmed to be proximal to the joint capsule and headed toward the sciatic buttress proximal to the greater sciatic notch. Lastly, the obturator oblique inlet view is used to demonstrate and advance the pin between the inner and outer tables. • Frame construction should take into consideration possible need for abdominal exploration, interventional venous thrombosis, and concomitant injuries (including potential need for acetabular/pelvic fixation). • Double frame can be helpful to allow access to belly without loss of fixation. Emergency Procedures 73

General Orthopaedics—Antibiotic Prophylaxis 75 GENERAL ORTHOPAEDICS—ANTIBIOTIC PROPHYLAXIS Joint arthroplasty antibiotic prophylaxis and dental and urologic procedure recommendations (2002) Potentially Increased Risk

Immunocompromised/Suppressed Patients With Comorbidities Inflammatory arthropathies Previous prosthetic joint infection (rheumatoid arthritis, systemic 1st 2 years post arthroplasty lupus erythematosus) Hemophilia Disease-induced immunosuppression Insulin-dependent diabetes Drug-induced immunosuppression Malnourishment XRT-induced immunosuppression Malignancy HIV infection American Academy of Orthopaedic Surgeons. Antibiotic Prophylaxis for Urologic Patients with Total Joint Replacements. Document 1023. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2002. American Academy of Orthopaedic Surgeons. Antibiotic Prophylaxis for Dental Patients with Total Joint Replacements. Document 1014. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2002. Whall CW, J Am Dental Assoc. 1997;128(7):1004–1008.

2012 Recommendations for prevention of orthopaedic implant infection in patients undergoing dental procedures 1. Surgeons may consider discontinuing this practice. (Limited recommendation AND only related to hip and knee arthroplasty) 2. The AAOS committee recommends neither for or against prophylactic antibiotics. (Inconclusive recommendation) 3. Joint arthroplasty patients should maintain good oral health. (Consensus recommendation) The AAOS recommends relying on the overall patient’s condition, mutual communication with patient and other professionals, and basing any decision on the available evidence. (J Am Acad Orthop Surg. 2013;21(3):180–189.)

Suggested Antibiotic Prophylaxis if Surgeon Chooses Dental Prophylaxis

PCN tolerant Amoxicillin, cephalexin, cephradine—2 g po 1 h prior PCN allergic Clindamycin—600 mg po 1 h prior Can’t take po, PCN tolerant Ampicillin—2 g IV/IM 1 h prior or cefazolin—1 g IV/IM 1 h prior Can’t take po, PCN allergic Clindamycin—600 mg IV/IM 1 h prior 76 Tarascon Pocket Orthopaedica Suggested Antibiotic Prophylaxis if Urologic Criteria Are Met

PCN Tolerant (choice of quinolone or amp/gent) Preprocedural Dosing Ciprofloxacin 500 mg po 1–2 h prior Levofloxacin 500 mg po 1–2 h prior Ofloxacin 400 mg po 1–2 h prior Ampicillin and 2 g IV and Gentamicin 1.5 mg/kg IV 30–60 min prior

PCN Allergic Preprocedural Dosing Vancomycin and 1 g IV over 1–2 h and gentamicin 1.5 mg/kg IV 30–60 min prior

Suggested Antibiotic Prophylaxis for GI Procedures

PCN Tolerant Preprocedure Postprocedure Ampicillin and gentamicin 2 g IV and 1.5 mg/kg (80 mg) IV 30 min prior Amoxicillin 1.5 g po 6 h post

PCN Allergic Preprocedure Postprocedure Vancomycin and 1 g IV and 1.5 mg/kg IV Repeat 8 h post gentamicin (~80) 1 h prior

GENERAL ORTHOPAEDICS—ANTICOAGULATION THERAPY *See Commonly Used Prophylaxis Options Page 92 Management of anticoagulation or antiplatelet therapy is best performed by coordinating with the primary care provider in the setting of elective surgery. Factors to consider are the reason for anticoagulation, estimated thromboembolic risk, bleeding risk, and the need for a bridge. • Antiplatelet therapy irreversibly inhibits platelet function, which will recover in 7–10 d. • The half-lives of the antiplatelet drugs are short enough that after 24 h, they would have minimal anti-platelet effect on any transfusion. Efficacy of platelet transfusion to effect hemostasis is unclear. • Most authors note no significant adverse effect if anti-platelet therapy is required to continue concordant with an emergent or non-delayable orthopedic surgery. • Anticoagulant therapy has a variably reversible effect on blood clotting (see Anticoagulant Therapy Considerations). General Orthopaedics—Blood Transfusion 77 Anticoagulant therapy considerations (assuming high/moderate bleeding risk) Drug Half-Life Hold (elective) Reversal Agent Restart Warfarin 36–72h 5 d (INR <1.3)* Vitamin K 1 d FFP or PCC Dabigatran 12–17h 2–3 d Idarucizumab Rapid onset 2–3 d Rivaroxaban 5–9h 2–3 d PCC Rapid onset 2–3 d Apixaban 8–12h 2–3 d PCC Rapid onset 2–3 d Edoxaban 10–14h 2–3 d PCC Rapid onset 2–3 d LMWH 3–5h bid: no evening dose Protamine 48–72h qd: ½ dose in AM, (partially no evening dose effective) Hold time should be increased in the setting of renal insufficiency. *controversial Abbreviations: FFP, fresh frozen plasma; LMWH, low molecular weight heparin; PCC, prothrombin complex concentrate.

GENERAL ORTHOPAEDICS—BLOOD TRANSFUSION Estimated risk of allogeneic blood transfusion Viral

HIV 1:1 million Hepatitis B virus 1:100,000 Hepatitis C virus 1:500–5000 Human T-cell lymphotropic virus 1:2 million Cytomegalovirus Varies ~ 1:2500 Bacterial contamination Varies ~ 1:2500

Systemic Reactions

Fatal hemolytic Less than 1:6 million Nonfatal hemolytic 1:6000 Fever 1:100 Urticaria Allergic Graft vs. host disease Rare Alloimmunization Common Keating AM, Meding JB. Perioperative blood management practices in elective orthopaedic surgery. J Am Acad Orthop Surg. 2002;10(6):393–400. 78 Tarascon Pocket Orthopaedica GENERAL ORTHOPAEDICS—CA++/PHOSPHATE Regulation of Calcium and Phosphate Metabolism (J Bone Joint Surg. 1995;77A:459–469)

Stimulus for Effect on Serum Stimulus for Decreased Calcium and Increased Excretion Excretion Phosphorus Parathyroid ↓ Serum calcium ↑ Serum calcium ↑ Serum calcium hormone (PTH) ↑ 1,25-(OH)2 D ↓ Serum phosphorus (parathyroid chief cells)

1,25-(OH)2 vitamin D ↑ PTH ↓ PTH ↑ Serum calcium (kidney proximal ↓ Serum calcium ↑ Serum calcium ↑ Serum phosphorus tubules) ↓ Serum phosphorus ↑ Serum phosphorus Calcitonin ↑ Serum calcium ↓ Serum calcium Transient ↓ serum (thyroid parafollicu- calcium lar cells)

End-Organ Effects

1,25-(OH)2 Parathyroid Hormone Vitamin D Calcitonin Bone ↑ Osteoclastic activity ↑↑↑ Osteoclastic ↓ Osteoclastic ↑ Osteoclast precursors activity activity Intestine Acts indirectly on gut by ↑↑↑ Intestinal ↑ 1,25-(OH)2 in kidney uptake of calcium and phosphorus

Kidney ↑ 25-(OH) D to 1,25-(OH)2 D in proximal tubules ↑ Resorption of filtered calcium ↑ Urinary loss of phosphorus

GENERAL ORTHOPAEDICS—LABORATORY Joint Fluid Analysis (JAMA 1990;264:1009–1014.) Types I. Noninflammatory II. Inflammatory III. Septic IV. Hemorrhagic General Orthopaedics—Laboratory 79 Gross Examination Blood (hemarthrosis); fat (violation of subchondral bone/fracture) The more inflammatory the joint fluid is, the more opaque it becomes.

Total WBC count < 2000 mm3—Noninflammatory May be seen in systemic lupus erythematosus, systemic sclerosis, and crystalline arthropathy. Osteoarthrosis typically has a WBC count < 1000 mm3.

2000–100,000 mm3—Intermediate range Some joint sepsis can be in the 50K–100K range, especially Gonococcus, TB, immune- compromised host, and partially treated infection. Likewise, crystalline arthropathies, rheumatoid arthritis, and Reiter’s can also be in the 50K–100K range.

> 100,000 mm3—Septic joint until proven otherwise The presence of crystals does not rule out infection with this presentation.

Total Joint Arthroplasty 1100–4000 Minor criteria for a prosthetic joint infection (see page 53 in ANTIMICROBIALS)

Differential (% Neutrophils) < 50% Noninflammatory < 90% RA > 90% Infectious 64–69% Minor criteria for a prosthetic joint infection Culture Cultures are indispensable in directing antibiotic therapy. Sterile prep and handling are imperative! Blood culture vials could increase sensitivity. Gram stain 50–75% sensitive (do it yourself if necessary) Culture > 90% sensitive Polarized Microscopy • Monosodium urate crystals (gout): Needle-shaped or long with blunt ends, strongly negative birefringent (brilliantly bright against a dark background) • Calcium pyrophosphate crystals (CPPD or pseudogout): Rod-shaped/rhomboidal, weak positive birefringent Note: Intra-articular betamethasone can mimic gout crystals. Using polarized light microscopy • Gout—yellow when parallel, blue when perpendicular • CPPD—opposite 80 Tarascon Pocket Orthopaedica TESTS FOR INFECTION Gram Stain 1. Heat fix slide until dry 2. Grams violet × 1 min, rinse 3. Grams iodine × 1 min, rinse 4. Decolorizer 30 s 5. Safranin × 1 min, rinse 6. Air dry Tissue Frozen Section • Tissue biopsy: Target the most inflammatory looking tissue. • 0 Polymorphonuclear cells/high-power field is evidence of the lack of infection. • 5–10 Polymorphonuclear cells/high-power field is evidence of a probable infection (Clin Orthop. 1982;170:175–183). • 10 Polymorphonuclear cells/high-power field increases specificity to 99% (J Bone Joint Surg. 1996;78A:1553–1558.)

GENERAL ORTHOPAEDICS—METABOLIC BONE DISEASE Clinical and Radiologic Overview of Metabolic Bone Disease

Radiographic Disease Etiology Clinical Findings Findings Hypercalcemia Hyperparathyroidism ↑ PTH—adenoma Kidney stones, Osteopenia, focal hyperreflexia lytic areas Familial syndromes PTH—MEN/Renal Endocrine/renal Osteopenia dysfunction Hypocalcemia Hypoparathyroidism PTH—idiopathic Neuromuscular Calcified basal irritability ganglia PHP/Albright’s PTH receptor Short metacarpal/ Brachydactyly, dysfunction tarsal exostosis Obesity Renal osteodystrophy CRF—phosphate Renal abnormalities “Rugger jersey” excretion spine Rickets (osteomalacia) Vitamin D deficient Diet vitamin D, Osteomalacia, Rachitic rosary, malabsorption hypotonia, muscle bowed long bones, weakness, tetany growth plates General Orthopaedics—Nerves, EMG/NCV 81 Radiographic Disease Etiology Clinical Findings Findings Vitamin D dependent I enzyme defect, II Similar but (I) to (II) Poor mineralization (types I and II) receptor defect severity to vitamin D dependent, alopecia Vitamin D resistant Phosphate Hypophosphatemia, Poor mineralization (hypophosphatemic) resorption lower limb deformi- (tubular) ties, stunted growth Hypophosphatasia Alkaline Osteomalacia, early Poor mineralization phosphatase tooth loss Osteoporosis ↓ Estrogen/ Kyphosis, fracture Insufficiency testosterone- fractures ↓ bone mass Scurvy ↓ Diet vitamin C Fatigue, bleeding, Thin cortices, corner effusions sign Osteosclerosis or Increased Osseous Density Paget’s (5th decade) Defunct osteo- Deformity, pain, Coarse thick clasts, disordered congestive heart trabeculae, picture bone turnover failure, fractures frame vertebrae, enlarged bone Osteopetrosis Osteo/chondro- Hepatosplenomegaly, Bone within bone clastic activity anemia (thymus) Abbreviations: CRF, chronic renal failure; MEN, multiple endocrine neoplasia; PHP, pseudo-hypoparathyroidism; PTH, parathyroid hormone. Adapted from Miller MD (Ed.). Review of Orthopaedics, 3rd ed. Philadelphia, PA: W.B. Saunders; 2000:25.

GENERAL ORTHOPAEDICS—NERVES, EMG/NCV EMG Findings/Meaning

Finding Significance Silence at rest, bi- and triphasic potentials Normal Fibrillation potential at rest, positive sharp Partial denervation waves Polyphasic motor units Chronic denervation New motor units Nerve regeneration No action potential Complete lesion 82 Tarascon Pocket Orthopaedica ↓ ↓ /– /– /– /– (diffuse) (diffuse) Demyelinating Polyneuropathy + + ↑ ↑ + + (diffuse) (diffuse) Axonal Polyneuropathy ↓ ↓ Normal Normal + + 2000;8:195. ↓ ↓ /– /– /– (severe) /– (severe) (focal) (focal) Focal Entrapment + + ↑ ↓ + + J Am Acad Orthop Surg. (acute) (chronic) (focal) (focal) Plexus Lesion ↓ ↓ Normal Normal + + Electrodiagnostic Findings in Various Peripheral Nerve Disorders ↓ /– (acute) (chronic) Root Lesion + Normal Normal Normal + + Finding Motor nerve amplitude Sensory nerve amplitude Distal latency Conduction velocity Fibrillations Large polyphasic MUAPs Adapted from Robinson LR. Role of neurophysiologic evaluation in diagnosis. General Orthopaedics—Obesity 83 Nerve Injury Classification Seddon Sunderland Pathologic Findings Neurapraxia 1 Localized myelin damage (compression) Axonotmesis 2 Loss of axonal continuity; endo-, peri-, and epineurium intact 3 Axonal and endoneurial continuity lost 4 Axonal, endoneurial, perineurial continuity lost Neurotmesis 5 Complete nerve lesion Sunderland S. Nerve Injuries and Their Repair: A Critical Appraisal. New York, NY: Churchill Livingstone; 1991. Seddon HJ. Surgical Disorders of the Peripheral Nerves. Baltimore, MD: Williams and Wilkins; 1972:68–88.

GENERAL ORTHOPAEDICS—OBESITY Obesity is an independent risk factor for: • VTE disease • Pulmonary embolism Surgically at risk for: • Passive ulceration • Position-related scalp alopecia • Leg/thigh compartment syndromes • Nerve palsies Obesity Standards [World Health Organization] Class BMI Normal 19.5–24.9 Overweight 25–29.9 Obese ≥ 30 Morbid Obesity ≥ 40 Super Obese ≥ 50 J Am Acad Orthop Surg. 22(11):683–90, 2014 J Bone Joint Surg. 94A(11):1045–52, 2012

BMI > 35: • Difficulty with intubation • Increased mortality in the obese in injury due to high-velocity trauma 84 Tarascon Pocket Orthopaedica GENERAL ORTHOPAEDICS—OSTEONECROSIS Etiologies

Alcoholism Antiphospholipid antibody syndrome Dysbaric disorders Endotoxic reactions/systemic bacterial infections Gaucher’s disease Hyperlipidemia (types II and IV) Hemoglobinopathies (HbS) Inflammatory (lupus, inflammatory bowel disease) Hypercoagulable states Trauma (dislocation, neck fracture) Irradiation Pregnancy Viral etiologies (hepatitis, HIV, CMV, Hypersensitivity states (anaphylaxis, allograft rubella, rubeola, varicella rejection) Malignancy (metastatic carcinoma, Hypercortisolism (endogenous [Cushing’s] and acute promyelocytic and lymphoid exogenous) leukemia)

MRI Single best study to detect osteonecrosis: 98% specificity. Natural History • Necrotic sector small (< 15%)—May resolve, prognosis usually good • Necrotic sector large (> 50%)—Collapse and arthrosis 85%, usually needs a total hip replacement Treatment Options • Observation (crutches, unload joint) • Core decompression +/– curettage and grafting • Rotational osteotomy (rarely done) • Hip arthrodesis (rarely done) • Hip arthroplasty • Other Stages are graded on the quantity of the femoral head involvement. Involvement is calculated by finding the product of the % involvement of the coronal AP and the % involvement of the sagittal lateral. Staging System for Osteonecrosis of the Hip Steinberg Modification of the Ficat/Arlet Classification (J Bone Joint Surg. 1995;77B:34) Stage Criteria O Normal radiographs, bone scan, and MRI I Normal radiographs, positive bone scan, and/or MRI II Abnormal radiographs—cystic or sclerotic changes in femoral head III Abnormal radiographs—subchondral collapse/crescent sign IV Abnormal radiographs—femoral head flattening V Abnormal radiographs—loss of joint space +/– acetabular changes VI Abnormal radiographs—degenerative changes (advanced) General Orthopaedics—Osteoporosis 85 Stage Grading Criteria II A < 20% head involvement on radiographs or MRI B 20–40% C > 40% III A Crescent (subchondral collapse) < 15%, no flattening B 15–30% crescent, no flattening C > 30% crescent, no flattening IV A < 15% collapse and < 2-mm depression B 15–30% or 2–4 mm C > 30% or > 4 mm V A Mild (IV and includes estimate of acetabular involvement) B Moderate (IV and includes estimate of acetabular involvement) C Severe (IV and includes estimate of acetabular involvement) GENERAL ORTHOPAEDICS—OSTEOPOROSIS Osteoporosis Type I (postmenopausal) Type II Age-related (> 75 years old) • Affects 45% of women > 50 years old • Lifetime risk of 40% for fractures • Treatment may reduce risk by 50% (J Bone Joint Surg. 2008;90:1362–1374. J Am Acad Orthop Surg. 2004;12(2):67–71. J Am Acad Orthop Surg. 1999;7:19–31. J Bone Joint Surg. 2000;82A:1063–1070.) DEXA Osteoporosis Criteria • Based on 25-year-old control. Plain films reveal osteopenia> 30% • DEXA study is the most accurate. • DEXA has the least radiation. • T-score –2.0 SD without risk factors –1.5 SD with risk factors Osteoporosis Risk Factors • Sedentary • Thin • Caucasian N. European • Smoker Bone density has the strongest • Alcohol relation with fracture, but • Phenytoin fracture may occur even with • Low calcium normal bone density. • Low vitamin D • Breastfeeding • Any adult fracture 86 Tarascon Pocket Orthopaedica Calcium Recommendations

Age Range RDA (mg/day) Infants Birth–6 months 200 7–12 months 260 Children 1–3 years 700 4–8 years 1000 9–18 years 1300 14–18 years 1300 pregnant/lactating Adolescents/adult 19–50 years 1000 19–50 years 1000 pregnant/lactating 51–70 years 1000♂, 1200♀ 71+ years 200 National Institutes of Health. Calcium: Fact Sheet for Professionals. https://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/

Vitamin D • 200 IU daily < 50 years • 400 IU 51–70 years • 600 IU > 71 years • Vitamin D3 the preferred form Prophylactic Reccomendations Men and premenopausal women: Physiologic calcium, vitamin D (400–800 U/ day), adequate nutrition, fall prevention, balance and exercise programs GENERAL ORTHOPAEDICS—PAIN MANAGEMENT, DEGENERATIVE ARTHRITIS 1st Line of Treatment Tylenol • Safest medication, no gastrointestinal irritation; however, has no anti-inflammatory properties • Maximum dose 4000 mg/day • Must be cautious of concomitant liver disease especially with alcohol abuse. General Orthopaedics—Perioperative Management 87 2nd Line of Treatment NSAIDs (Aspirin and Cyclo-Oxygenase 1 Inhibitors) NSAIDs are the most common pharmacologic agent used to treat osteoarthrosis. • Decreased platelet function, renal toxicity, hepatic toxicity (rare), gastrointestinal irritation • Absolute risk of gastrointestinal irritation constant over time; cumulative risk increases with time • 100,000 hospitalizations annually for gastrointestinal side effects • 16,500 deaths annually • 2.5–5.5 times more likely to be hospitalized than without NSAIDs • Utilization with misoprostol, omeprazole, lansoprazole decreases gastrointestinal risk NSAIDs • Decrease the antihypertensive properties of the thiazide diuretics and angiotensin- converting enzyme inhibitors • Increase circulating warfarin levels • Increase circulating lithium levels Cyclo-Oxygenase 2 Inhibitors • No platelet inhibition • Lower gastrointestinal risk • Possible increased cardiovascular risk • Some studies suggest an opioid-sparing effect postoperatively • Cyclo-oxygenase 2 has been shown to be important in bone healing, but early studies don’t show a clinical effect (rabbit model) J Bone Joint Surg. 2002;84A(10):1763–1768.

Several prostaglandins, notably E2, are implicated in new bone formation.

Don’t use celecoxib in sulfonamide allergic patients.

J Am Acad Orthop Surg. 2004;12(3):139–143.

GENERAL ORTHOPAEDICS—PERIOPERATIVE MANAGEMENT Perioperative Management in the Patient With Rheumatologic Disorders (58% will undergo an orthopedic procedure; 24% undergo large joint replacement)

Important Drug Medication Interactions Perioperative Management Aspirin (non-reversible Stop 7–10 days prior COX inhibitor) Restart immediately after NSAIDs Antihypertensive Stop 5 half-lives before surgery medications (COX) Restart 7–14 days after Warfarin [COX-2—may not need to stop] 88 Tarascon Pocket Orthopaedica Important Drug Medication Interactions Perioperative Management Corticosteroids Increased risk of tendon May need stress dose management. (popular treat- rupture if used with Tailor to specific patient. ment—60% overall, fluoroquinolones Overall: ↑infection, weaken bones, 80% undergoing joint Antifungal; clarithro- ↓wound healing, repl.) mycin may potentiate steroid effects Methotrexate (DMARD) Possible neutropenia if Minor procedures—continue used with PCN IV Moderate or major procedures consider holding in patients with ↑infection risk or vascular insufficiency. Leflunomide May elevate levels of Minor procedures—continue warfarin or rifampin Moderate or major procedures (controversial) consider holding 1 wk before, add cholestyramine Sulfasalazine May potentiate warfarin’s Continue effects Hydroxychloroquine Continue Tumor necrosis factor Avoid live vaccines Minor procedures—continue antagonists Moderate or major procedures consider holding etanercept 2 wk, adalimumab 3 wk, and infliximab 6 wk. Restart after wound healing. Interleukin antagonists Minor procedures—continue Moderate or major procedures consider holding 1 week before, restart after wound healing.

Nonsteroidal Anti-Inflammatory Drug Half-Life Drug Half-Life (h) Celecoxib 11 Diclofenac 1.2–2 Etodolac 6–7 Ibuprofen 1.6–1.9 Indomethacin 4.5 Nabumetone 24–29 Naproxen sodium 12–15 Piroxicam 30 Overall: ↓immunity, cardiovascular disease (60% increased risk of death), interstitial lung disease, cervical spine disease (need to clear C-spine), and rheumatoid nodules. Multiple DMARDs increase the risk of infection. Sendhu K, et al. Perioperative management of rheumatoid medications in orthopaedic surgery. Orthopaedics, 2017;40;5:282–286. General Orthopaedics—Tetanus 89 Supplemental Hydrocortisone for Surgical Stress Surgical Stress Procedure Recommended Supplemental Dose Minor Hand or foot surgery 25 mg hydrocortisone (5 mg prednisone) Arthroscopy day of surgery Moderate Joint replacement 50–75 mg hydrocortisone (prednisone arthroplasty 10–15 mg) day of procedure tapering over Ligament reconstruction 1–2 days to preoperative dose Major Poly trauma 100–150 mg hydrocortisone (prednisone Bilateral or revision 20–30 mg) day of procedure tapering over arthroplasty 1–2 days to preoperative dose Multilevel spine fusion Modified from Howe CR, et al. Perioperative medication management for the patient with rheumatoid arthritis. J Am Acad Orthop Surg. 2006;14:544–551.

GENERAL ORTHOPAEDICS—TETANUS Wound Classification for Tetanus Prophylaxis

Clinical Features Tetanus Prone Nontetanus Prone Age of wound > 6 h ≤ 6 h Configuration Stellate, avulsion Linear Depth > 1 cm ≤ 1 cm Mechanism Missile, crush, burn, frostbite Sharp surface (glass, knife) Devitalized tissue Present Absent Contaminants (dirt, saliva) Present Absent

Tetanus Immunization Schedulea Tetanus Prone Nontetanus Prone Tetanus Product Tdb TIG Td TIG Unknown, < 3 doses Yes Yes Yes No 3 or more doses Noc No Nod No a Data from Morbid Mortal Wkly Rep. 1990;39:37. b Yes, if wound > 24 h old. For children < 7 yr, DPT (DT if pertussis vaccine contraindicated). For persons ≥ 7 yr, Td preferred to tetanus toxoid alone. c Yes, if > 5 yr since last booster. d Yes, if > 10 yr since last booster. 90 Tarascon Pocket Orthopaedica GENERAL ORTHOPAEDICS—TOBACCO ABUSE Tobacco’s Effects

Decreased Increased Bone mineral density Mitogens WBC function, leukocytosis Autoantibodies (RF) Serum immunoglobins Perioperative complications Antibody response • Nonunion, delayed union T-cell response • Infection Mass & cellularity of lymphoid tissue • Soft tissue/wound healing complications Low back pain & degenerative disc disease Risk of fracture and tendon rupture J Bone Joint Surg. 2013;95A(9):850–859.

• 20% of our patients continue to smoke • Former smokers have better outcomes than current smokers! [MMWR 2010; 59(35):1135–40] • Perioperative cessation may mitigate risk

Function Time Needed to Improve Risk Immune function 2–6 wk Wound healing 3–4 wk Pulmonary function 6–8 wk Fracture risk Up to 10 yr

GENERAL ORTHOPAEDICS—TOURNIQUET Tourniquet Use Definitive data are lacking.

Duration Inflation time< 2 h safe, may extend to 2.5 safely. If anticipated OR time ≥ 2.5 h: Deflate tourniquet at 2 h (reperfusion interval) for 10 min the repeat q1h. Inflation pressure Upper extremity ≤ 250 mm Hg Lower extremity ≤ 300 mm Hg A more specific number can be obtained by noting the pressure at which the Doppler pulse signal ceases (limb occlusion pressure) then choosing that number + a safety margin (25–50 mm Hg). General Orthopaedics—Venous Thromboembolic Disease 91 GENERAL ORTHOPAEDICS—VENOUS THROMBOEMBOLIC DISEASE [J Am Acad Orthop Surg. 2017;25(12):789–798] Patient factors that increase DVT/PE risk: • Hypercoagulable states, previous documented VTE • Obesity, advanced age • Immobilization • Estrogen therapy • Cancer • Thrombophilia (antithrombin III deficiency, protein C & S abnormalities), molecular risk factors (Factor V Leiden, prothrombin 20210A) • Chronic obstructive pulmonary disease • Atrial fibrillation • Anemia • Depression • Elevated Charlson comorbidity index Patient factors that increase the risk for major bleeding • History of bleeding disorder • History of recent GI bleed • History of recent hemorrhagic stroke Decreases thromboembolic risk: • Epidural and spinal anesthetic, hypotensive anesthesia • Autologous transfusions, decreased blood loss (J Bone Joint Surg. 2000;82A:252–270) Due to improvements in operative and anesthetic technique that affords accelerated rehabilitation, the pulmonary embolism rate (including the rate for fatal pulmonary embolism) for total hip and knee arthroplasty has decreased independent of routine thromboembolic prophylaxis. A North American consensus to prophylaxis postoperatively exists for both total hip and knee arthroplasty.

Most thrombosis in elective surgery occurs in the 1st postoperative week with the peak occurring at 4 days.

Efficacy and safety: • Aspirin (low risk for postoperative bleeding complications) • Warfarin (lowest risk for proximal deep venous thrombosis and symptomatic pulmonary embolism) • Sequential compression devices (lowest risk for postoperative bleeding complication) • Low molecular weight heparins (lowest total deep venous thrombosis risk; increased risk of postoperative bleeding) • Low-dose heparin (increased risk of major and minor postoperative bleeding complications)

Low molecular weight heparin (reports cite enoxaparin) with indwelling catheters contraindicated due to increased bleeding risk (occurrence of epidural hematomas with concomitant use) 92 Tarascon Pocket Orthopaedica Commonly Used Prophylaxis Options

Option Mechanism Drawbacks Low Molecular Weight Factor IIa inhibitor Require subcutaneous Heparin: (less than unfractionated injections Enoxaparin, dalteparin heparin), Factor Xa inhibitor Rate of bleeding complications Indirect Factor Xa Indirect Factor Xa inhibitor Require subcutaneous Inhibitors: injections fondaparinux Rate of bleeding complications Aspirin Cyclo-oxygenase inhibitor Randomized controlled trials against newer agents pending. Warfarin Vitamin K antagonist Drug & food interactions Bleeding risk Dose adjustments/ monitoring requirements. Direct Factor Xa inhibitors: Direct Factor Xa inhibitor Rate of bleeding Apixaban, rivaroxaban complications. Consider delayed administration 18–24h postoperative. No commercially available reversal agent. Intermittent pneumatic Suspected decrease Patient compliance compression in stasis and possible Randomized controlled activation of anticlotting trials lacking factors.

Guidelines for Duration of Therapy 10–14 d up to 35 d [Chest 2012;141(suppl 2):e278S–e325S] No recommendation due to lack of definitive data (AAOS)

Warfarin, sequential compression devices, and low molecular weight heparin all individually decreased the risk of pulmonary embolism. No difference in the rate of fatal pulmonary embolism among the agents You would need a cohort of 100,000 patients to see a change in the incidence of fatal pulmonary embolism rate. Deep venous thrombosis may not lead to fatal pulmonary embolism in a predictable manner. General Orthopaedics—Wound Healing 93 GENERAL ORTHOPAEDICS—WOUND HEALING

Normal Wound Healing Indices Malnutrition/Poor Wound Healing Serum albumin > 3.5 g/dL Total lymphocyte count < 1500/mm3 Absolute lymphocyte count > 1500/mm3 Serum albumin < 3.5 g/dL Absolute Doppler pressure 70 mm Hg Serum transferrin level < 226 mg/dL Differential pressure index (ABI) > 0.5 TCPO2 30 mm Hg

Pediatric Orthopaedic—Milestones and Angles 95 PEDIATRIC ORTHOPAEDIC—MEDICATIONS Analgesics Medication Product Dosage* Route Maximum Acetaminophen 80 mg/0.8 mL 10–15 mg/kg po 5 dose/day drops q4–6h (≤ 4000 mg/d) Acetaminophen 160 mg/5 mL 10–15 mg/kg po 5 dose/day elixir q4–6h (≤ 4000 mg/d) Acetaminophen 80 mg 10–15 mg/kg po 5 dose/day chew q4–6h (≤ 4000 mg/d) Acetaminophen 325 mg 10–15 mg/kg po 5 dose/day tabs q4–6h (≤ 4000 mg/d) Aspirin 81 mg 10–15 mg/kg po q4–6h Ibuprofen 100 mg/5 mL 5–10 mg/kg po 40 mg/kg/d q6–8h Diazepam 0.12–.08 mg/kg/d po/pr 0.6/8h divided tid–4×/d IV/IM 0.04–0.2 q2–4h Meperidine 1–1.8 mg/kg IV/SC/po slow IV Morphine 0.1–0.2 mg/kg IV/IM/ 15 mg q4h 0.1–0.2 mg/kg SC po * All doses mg/kg unless otherwise noted

Antihistamines Medication Product Dosage* Route Maximum Hydroxyzine 10 mg/5 mL 0.5 4×/d po Diphenhydramine 12.5 mg/5 mL 5 mg/kg/d po/IV/IM 300 mg/day 25, 50 mg Divided 4×/d

PEDIATRIC ORTHOPAEDIC—MILESTONES AND ANGLES Gait Milestone Approximate Time Frame Sitting 6 months Cruises 12 months (variable) Independent walking 15 months Runs 18 months Mature gait kinematics 3–7 yr Time/distance parameters (step length and velocity) continue to increase until growth complete. 96 Tarascon Pocket Orthopaedica Rotational Profile Foot progression angle: 5–20 degrees Maximum varus ~ Birth external rotation Genu rectus ~ 18 months Hip: Internal rotation: 30–60 degrees Maximum valgus ~ 3 yr (< 20 degrees femoral anteversion) Hip: External rotation: 20–60 degrees Femoral anteversion: (> 70 degrees femoral anteversion) 1 yr—31 degrees Thigh foot angle: 0–20 degrees external 8 yr—24 degrees rotation (< negative 10 degrees tibial 15 yr—15 degrees torsion) (Improves 15 degrees up to 15 yr old)

Development of Cervical Spine Age Feature < 6 mo C1 body invisible and all synchondroses are open, vertebrate are normally wedged anteriorly, and there is often no lordosis to the noninjured spine. 1 yr Body of C1 becomes visible radiographically. 3 yr Posteriorly located spinous process synchondroses fuse. Dens becomes ossified (visible radiographically). 3–6 yr Neurocentral (body) and C2-odontoid synchondroses fuse. Summit ossification center appears at the apex (top) of the odontoid. Anterior wedging of the vertebral bodies resolve (and is not normal if seen). 8 yr Pseudosubluxation and predental widening resolve; lordosis is normal now. 12–14 yr Secondary ossification centers appear at spinous process tips; summit ossification center of odontoid fuses (if it does not os odontoideum occurs); superior/inferior epiphyseal rings appear on body. 25 yr Secondary ossification centers at tips of spinous processes fuse. Superior/inferior epiphyseal rings fuse to vertebral body. Used with permission from Tarascon Pediatric Emergency Pocketbook, 5th ed. Lompoc, CA: Tarascon; 2007.

Reflexes Reflex Disappears Hand grasping 2–4 months Plantar grasping 1 year Moro 4–6 months Stepping 1–2 months Crossed extension 1 month Withdrawal Should always be present Positive support response 4 months Extensor thrust 2 months Symmetric tonic neck Present by 6 months, no absolute time for disappearance Parachute Present by 6 months, persists through life Pediatric Orthopaedic—Growth Centers 97 Characteristics of Myelodysplasia Levels Level Hip Knee Feet Orthosis Ambulation L1 External — Equinovarus HKAFO Non rotation/ flexion L2* Adduction/ Flexed Equinovarus HKAFO Non flexion L3* Adduction/ Recurvatum Equinovarus KAFO Household flexion L4* Adduction/ Extension Cavovarus AFO Household + flexion L5 flexion Limited Calcaneovalgus AFO Community flexion S1 Shoes Near normal *Increased risk of hip dislocation in these groups. Abbreviations: AFO, ankle foot orthosis; HKAFO, hip knee ankle foot orthosis; KAFO: knee ankle foot orthosis.

PEDIATRIC ORTHOPAEDIC—GROWTH CENTERS Growth Plates

Growth Plate Appearance Closure* Clavicular body 6th fetal week Medial clavicle 17 18–24 Acromion 15–18 18–19 Coracoid 1 18–21 Scapular body 1st fetal week 20–21 Glenoid 18 19 Humeral body 6th–8th fetal week 19 Humeral head ♂: 6 mo–2 yr Head/tuberosities 4–6 (80% of humeral growth) ♀: 3 mo–18 mo Fuse with shaft ♂: 19–21, ♀: 18–20 Greater tuberosity ♂: 1/2–1, ♀: 1/4–1.5 “ Lesser tuberosity 3–5 “ Lateral epicondyle ♂: 12, ♀: 11 ♂: 17, ♀: 14” Trochlea ♂5 mo, ♀4 mo “ Capitellum ♂: 5 mo, ♀: 4 mo “ (6 wk–8 mo) Medial epicondyle ♂: 5–7, ♀: 3–6 (3–7) ♂: 18, ♀: 15 Olecranon ♂: 10, ♀: 8 ♂: 15–17, ♀: 14–15 (continues) 98 Tarascon Pocket Orthopaedica Growth Plates Continued Growth Plate Appearance Closure* Radius body 6–12th fetal week Radial head ♂: 5, ♀: 4 (3–6) ♂: 15–17, ♀: 14–15 Radial tuberosity 10–12 14–18 Distal radius 3 mo–1.5 ♂: 19, ♀: 17

LEG GROWTH Femur 15% proximal, 38% distal; Tibia 27% proximal, 15% distal

Growth Plate Appearance Closure* Ulna body 6th–8th fetal week Distal ulna ♂: 6, ♀: 5 (4–9) ♂: 19, ♀: 17 Scaphoid ♂: 5.5, ♀: 4.5 (2.5–9) Variable Lunate 4 (6 mo–9.5) Variable Triquetrum ♂: 2.25, ♀:1.75 (1/2–4) Variable Pisiform ♂: 11, ♀: 9 Variable Trapezium ♂: 5, ♀: 4 (1.5–10) Variable Trapezoid ♂: 6, ♀: 4 (2.5–9) Variable Hamate 6 mo (0–1.5) Variable Capitate 6 mo (0–1) Variable Thumb metacarpal ♂: 2.5, ♀: 1.66 (1–3.5) 14–21 Proximal thumb P1 5 mo–2.5 14–21 Proximal thumb P2 ♂: 1.5, ♀: 1 14–21 Distal I/M/R/S metacarpal 1–1.5 14–21 Phalanges PI, II, and III 5 mo–2.5 14–21 Iliac crest Puberty 16–18 Iliac tubercle ischial spine 13–15 Fuse at puberty Pubic tubercle 18–20 Fuse at puberty Acetabulum 10–13 Fuse at puberty Ischial spine 13–15 Fuse at puberty Femoral body 6th–12th fetal week Femoral head 4 mo ♂: 17–18, ♀: 16–17 Greater trochanter 3 16–17 Pediatric Orthopaedics—Foot 99 Growth Plate Appearance Closure* Lesser trochanter ♂: 12, ♀: 11 16–17 Distal femur 36th fetal week ♂: 18–19, ♀: 17 Patella ♂: 4–5, ♀: 3 Fuse at puberty Proximal tibia 40th fetal week ♂: 18–19, ♀: 16–17 Tibial tuberosity 7–15 19 Proximal fibula ♂: 4, ♀: 3 ♂: 18–20, ♀: 16–18 Distal tibia 6 mo 17–18 (med. mal. 16–18) Distal fibula ♂: 1, ♀: 9 mo 17–18 Calcaneus 24th–26th fetal week 12–22 Calcaneal apophysis 5–12 12–22 Talus 26th–28th fetal week Variable Cuboid 40th fetal week Variable Navicular ♂: 3, ♀: 2 Variable Cuneiforms 3 mo–2 Variable Metatarsal 8–12th fetal week 18 Phalanges 6 mo–4 yr 11–22 *Range = age in yr except as noted.

PEDIATRIC ORTHOPAEDICS—FOOT 100 Tarascon Pocket Orthopaedica Angles and Characteristics Metatarsus Adductus Talipes Equinovarus Talo-calcaneal angle 20–40 degrees < 20 degrees Characteristics Adducted forefoot Talus and calcaneus parallel

Normal Talo-Calcaneal Angle Is 20–40 degrees Calcaneovalgus Metatarsus varus Clubfoot + Dorsiflexion Yes Yes No Shape of sole Deviates laterally Deviates medially Deviates medially “Banana” “Kidney” “Kidney” Heel position Valgus Valgus Varus

Clubfoot Treatment—Ponseti Technique (J Bone Joint Surg. 1992;74a(3): 448–454) • Long leg cast, changed weekly • Usually requires Achilles tenotomy at 6 wk to correct equines • Dennis-Brown bar and boots full-time for 3 months; nap and nighttime until 3 yr • Correct in this order: Cavus Adductus Varus Equinus (“CAVE”)

PEDIATRICS—BRACHIAL PLEXUS Brachial Plexus Birth Injuries Name Roots Loss Prognosis Erb-Duchenne C5/6 Deltoid, elbow flexors, dorsiflexion at hand/ Best wrist, “waiter’s tip deformity” Klumpke C8/T1 Hand intrinsics, wrist flexors Poor Total plexus C5–T1 Flaccid arm, sensory and motor loss Worst

• 2 per 1000 births • Clavicle and proximal humerus fractures may mimic with pseudo-paralysis. • Treat by maintaining passive ROM. Return may be up to 18 months. • No biceps function at 3 months is an ominous sign. Pediatric Orthopaedics—General 101 Osteochondroses (Osteonecrosis at Apophysis/physis) Location Eponym Elbow (capitellum) Panner’s Phalanges (hand) Thiemann’s Spine Scheuermann’s Ischiopubic synchondrosis Van Neck’s Femoral head Legg-Calvé-Perthes Inferior patella Sinding-Larsen-Johansson Proximal tibial epiphysis Blount’s Tibial tuberosity Osgood-Schlatter’s Calcaneus Sever’s Tarsal navicular Köhler’s Metatarsal head Freiberg’s Scaphoid Preiser’s Lunate Kienböck’s

PEDIATRIC ORTHOPAEDICS—GENERAL Arthroscopic Classification of Osteochondritis Dissecans (Guhl)

Classification Stage Treatment Intact I Drilling (K-wire retrograde) Early-separated lesion II In situ pinning Partially detached lesion III Debride base, reduce, pinning Salvageable loose body IV Debride base, reduce, pinning Unsalvageable loose body Removal and debridement NOTE: Attempt casting if physis is open in stages I & II.

Night Pains Awakens child at night; less or potentially gone during the daytime.

Localized pain (short differential) Osteoid osteoma Leukemia Acute osteomyelitis Generalized pain (long differential) Spinal dysraphism or tether Knee—osteochondritis Skeletal tumor Feet—deformity Fibrous dysplasia Perthes disease of the hips Muscle—hemangioma Joints—arthritis Subacute osteomyelitis Köhler’s disease 102 Tarascon Pocket Orthopaedica Back Pain in Children Diagnostic Workup According to Symptom Severity Clinical Situation Recommended Workup No systemic signs (fever) Often none Negative physical exam Close follow-up Pain < 3 months +/– radiographs No systemic signs (fever) Radiographs Pain > 3 months Negative exam CBC, ESR Normal X-rays Bone scan with SPECT* Positive bone scan Add CT (rule out bony tumor, spondylolysis) Negative X-rays Positive ESR Add antinuclear antibodies and HLA-B27 Positive neurologic findings MRI Symptoms worsened at follow-up *SPECT, single-photon emission computed tomography. Bhatia NN, et al. Diagnostic modalities for the evaluation of pediatric back pain. J Pediatr Orthop. 2008;28(2):230–233.

Mucopolysaccharidosis Syndrome Inheritance Intelligence Cornea Urinary Excretion MPS I: Hurler’s Autosomal Mental Cloudy Dermatan/heparin (most severe) recessive retardation sulphate MPS II: Hunter’s X-linked Mental Clear Dermatan/heparan recessive retardation sulphate MPS III: Autosomal Mental Clear Heparan sulphate Sanfilippo’s recessive retardation MPS IV: Morquio’s Autosomal Normal Cloudy Keratan sulphate (most common) recessive Pediatric Orthopaedics—Dysplastic Conditions 103 (continues) Radiologic Features Lumbar stenosis, bow legs. At risk for atlantoaxial instability and spinal stenosis Metaphyseal flaring, delayed epiphyseal ossification, hypoplastic dens delayed epiphysis Platyspondyly, dysplastic dens Platyspondyly, Stippled epiphysis Dumbbell femurs, osteopenia/ hypoplasia Flared metaphysis, wide irregular physes, bowed legs Flared metaphysis, wide irregular physes, bowed legs Clinical Findings Abnormal facies and spine inhibition of endochondral ossification Normal facies, short limbed, ligamentous laxity, atlantoaxial instability, scoliosis, early OA Flattened facies Kyphosis, hip pain Flat facies Detached retina, scoliosis, cleft palate Coxa vara, wide eyes, bow legs, waddling gait Severe limb shortening, prominent forehead, micrognathia Zone E E E E P P M M Disproportionate Dwarfism Mode AD/SM AD AD/SM XR AD AR (fatal) AD AD AD PEDIATRIC ORTHOPAEDICS—DYSPLASTIC CONDITIONS ORTHOPAEDICS—DYSPLASTIC PEDIATRIC Error Fibroblast growth factor receptor-3 Cartilage oligomeric protein (COMP) II collagen Type II collagen Type X collagen Type PTH-related peptide receptor Dysplasia Achondroplasia (most common form) Pseudoachondroplasia SED (congenital) SED (tarda) Chondrodysplasia punctata Kniest syndrome Schmid metaphyseal chondrodysplasia Jansen metaphyseal chondrodysplasia 104 Tarascon Pocket Orthopaedica ; XR, X-linked recessive. ; XR, X-linked recessive. Radiologic Features Irregular epiphyseal ossification Hemienlarged epiphysis Symmetric cortical thickening Radiologic Features Thick bone, bullet-shaped metacarpals Kyphoscoliosis, odontoid hypoplasia Delayed physeal closure - 1996;78A(10):1583–1598. 1996;78A(10):1583–1598.

. Continued J Bone Joint Surg. J Bone Joint Surg Clinical Findings Mild dwarfing, delayed ambulation—waddling gait Bow legs Delayed walking Clinical Findings Corneal changes, urinary sugars, atlantoaxial instability Short limbs and stature, kyphoscoliosis, cleft palate, cauliflower ears, hitchhiker thumb, rigid clubfoot Absent clavicles, wide cra nial sutures Zone E M D Zone P P M Proportionate Dwarfism Mode AD — AD Disproportionate Dwarfism Inheritance AR/XR AR AD Error I- COMP II-type IX collagen Error Sulfate transporter Dysplasia Multiple epiphyseal dysplasia Dysplasia epiphysealis hemimelica (Trevor’s) Progressive diaphyseal dysplasia Dysplasia Mucopolysaccharidosis Diastrophic dysplasia Cleidocranial dysplasia Abbreviations: AD, autosomal dominant; AR, recessive; OA, osteoarthrosis; SED, spondyloepiphyseal dysplasia; SM, spontaneous mutation physeal. Zones: D, diaphyseal; E, epiphyseal; M, metaphyseal; P, Dietz FR, Matthews KD. Update of the genetic basis disorders with orthopaedic manifestations. Abbreviations: AD, autosomal dominant; AR, recessive; OA, osteoarthrosis; SED, spondyloepiphyseal dysplasia; SM, spontaneous mutation physeal. Zones: D, diaphyseal; E, epiphyseal; M, metaphyseal; P, Dietz FR, Matthews KD. Update of the genetic basis disorders with orthopaedic manifestations. Pediatric Orthopaedics—Salter-Harris Classification 105 PEDIATRIC ORTHOPAEDICS—SALTER-HARRIS CLASSIFICATION Salter-Harris Classification of Physeal Injuries

Type Description Characteristics I Transverse through growth plate Younger age II Same as I with a metaphyseal fragment Older age (> 10) (Thurston-Holland fragment) III Through growth plate with extension Intra-articular through epiphysis into joint IV Through epiphysis and metaphysis Growth arrest V Crush injury to the growth plate Late growth arrest VI Damage to the perichondral ring of Physeal bridge/asymmetric growth Lacroix irregularity (angular deformity) J Bone Joint Surg. 45A:587–622, 1963.

I II Thurston- Holland Fragment

III IV S - Sliding A - Above L - Lower T - Through E - Everything R - Periosteal Ring V VI

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Salter-Harris Classification (JBJS 45A:587-622;1963) 106 Tarascon Pocket Orthopaedica PEDIATRIC ORTHOPAEDICS—SLIPPED CAPITAL FEMORAL EPIPHYSIS Slipped Capital Femoral Epiphysis • Prevalence 0.2/100,000 (Japan) to 10.08/100,000 (Northeastern US) • 60% male • Mean age = 13.5 in boys, 12 in girls 50% • > 95th percentile for weight • Bilaterality as high as 63% (J Bone Joint Surg. 2000;82A:1185) Classification Preslip Acute (10–15%) Chronic (85%) Acute on chronic

Stable: Walk without crutches (nearly 0% avascular necrosis) Unstable: Can’t walk without crutches (up to 50% avascular necrosis) Radiographic Evaluation • Radiographs show a superior and anterior slip of the proximal femoral metaphysis with respect to the capital femoral epiphysis. In a gradual slip, you may see superior and anterior remodeling on the femoral metaphysis and periosteal new bone formation. • Ultrasound to look for effusion and periosteal bone formation (unstable). • MRI and bone scans may also be used. Physical Exam Flexed and externally rotated position may mimic fracture in pain and presentation. (Represents a Salter-Harris I of the proximal femoral physis.) Grading Slips < 30 degrees mild, 30–50 degrees moderate, > 50 degrees severe (AVN risk increases with severity). Good results with in situ pinning with mild and moderate slips. Treatment In situ pinning favored—single pin under fluoroscopic guidance (still controversies especially with respect to traction, reduction). Treatments ranging from hip spica casting to osteotomies have been proposed. Prophylactic pinning of the contralateral side is controversial: • Incidence of bilateral slip ~20% • Should be strongly considered for age < 10 yr, endocrinopathy, renal failure, patients with predicted unreliable follow-up (J Bone Joint Surg Am. 2004;86A(12):2658–2665.) Pediatric Orthopaedics—Limp 107

Femoral Head Femoral Head below Kline’s line above Kline’s line Blurring No Blurring

Slip Kline’s line should No Slip Metaphyseal intersect a part of Blanch the lateral aspect of Damian Rispoli 2009 the femoral capital epiphysis Kline’s Line and Metaphyseal Blurring

PEDIATRIC ORTHOPAEDICS—LIMP Evaluation C-reactive protein more useful than ESR to follow trend and returns more quickly to normal. Radiographs • Obtain spine, pelvis, and extremity • Periosteal reaction ~ 2 wk • Medial joint space increased > 2 mm in hip is significant • Endosteal erosion, disc space mineralization in discitis Ultrasound Less invasive, easy to get, operator dependent MRI Good for soft tissue and differential between dead and living bone. Early Perthes: evaluate spinal cord and disc 108 Tarascon Pocket Orthopaedica Transient Synovitis vs. Septic Arthritis Diagnosis Sequelae Transient synovitis Self-limited Septic arthritis Osteonecrosis Growth arrest Sepsis Joint destruction Differential diagnoses: Slipped capital femoral epiphysis Fracture Legg-Calvé-Perthes disease Rheumatoid arthritis Osteomyelitis Psoas abscess Pyogenic sacroiliitis Lyme disease

Five Predictors of Septic Hip Arthritis 1. ESR > 40 2. C-reactive protein > 2.0 mg/dL 3. WBC > 12,000 4. Nonweight bearing 5. Temperature > 38.5°C (101.5°F) C-reactive protein and fever are strongest independent risk factors. (Caird MS, et al. J Bone Joint Surg. 2006;88A:1251–1257)

Number of Predictors Present Percent Chance of a Septic Arthritis No predictors 16.9% 1 predictors 36.7% 2 predictors 62.4% 3 predictors 82.6% 4 predictors 93.1% 5 predictors 97.5% Caird MS, et al. Factors distinguishing septic arthritis from transient synovitis of the hip in children. J Bone Joint Surg. 2006;88A:1251–1257.

~ 10–16% of septic arthritis from contiguous bacterial osteomyelitis (hip, shoulder, ankle). Song KM, Sloboda JF. Acute hematogenous osteomyelitis in children. J Am Acad Orthop Surg. 2001;9(3):166–175. Pediatric Orthopaedics—Limp 109 Osteomyelitis in Children See antibiotic section (p. 60) for choice of antibiotics and common pathogens. Usu- ally via a blood-borne route. Rarely crosses the physis (subacute osteomyelitis can) and usually resides in the metaphysis or epiphysis due to vascular anatomy. Physical exam may show pain, loss of function, erythema, warmth, and occasionally abscess.

Osteomyelitis Algorithm

Possible Osteomyelitis

Negative Radiographs Positive

Bone scan

Consider Negative Aspiration Positive

Antibiotics Negative MRI, Antibiotics CT, US

No clinical improvement for 48 hours Positive Positive Negative

MRI, CT, US, Biopsy and Antibiotics reassess surgical diagnosis debridement

Antibiotics Biopsy and surgical debridement

Song KM, Sloboda JF. Acute hematogenous osteomyelitis in children. J Am Acad Orthop Surg. 2001;9(3):166–175. 110 Tarascon Pocket Orthopaedica Limp—Differential Diagnosis A hip radiograph is invaluable for any child with a limp and without an obvious etiology. Toddlers 4–10 yr 11–16 yr Developmental hip dysplasia Perthes Slipped capital femoral Mild cerebral palsy Osteomyelitis epiphysis Toddlers fracture Septic hip/joint Toxic synovitis Juvenile RA Leg length difference DDH (untreated) Discitis > 1–2 inches Tumor Tarsal coalition Vertebral Infection

> 5 yr: Low-grade fever, nonweight bearing, flexed spinal posture,+ /– abdominal pain < 5 yr: Usually toxic appearing Discitis Refusal to walk or sit, decreased ROM of spine, MRI is diagnostic early Radiographs may show late disc space narrowing Treat: Bed rest (no traction), immobilization, +/– antibiotics Genu Varum Disorder of the posterior medial physis Blount’s disease = Drennan’s angle > 11° Metaphyseal beaking African-American, obese common

Metaphyseal- Diaphyseal Angle

Drennan’s Angle

(JBJS 64:1158 –1163,1982)

Damian Rispoli 2009 Pediatric Orthopaedics—Scoliosis 111 Treatment Based on Age and Langenskiöld Stages Age Stage Treatment < 18 months I–II None 18–24 months I–II Night bracing 2–3 yr I–II Daytime brace 3–8 yr III–V Osteotomy VI (bony bridge) Resection of bony bridge

PEDIATRIC ORTHOPAEDICS—SCOLIOSIS Neuromuscular Scoliosis Common in neuromuscular conditions; may progress rapidly; may progress after maturation; often associated with pelvic obliquity, bony deformities, and involvement of the cervical spine. Infantile Idiopathic Scoliosis 2 months–3 yr Other associated defects Left-sided thoracic Most common in United Kingdom Male predominance Curve < 20 degrees, rib vertebral angle difference < 20 Skull flattening degrees resolve MRI severe curves

Early Onset Idiopathic Scoliosis

3–10 yr 70% need treatment High risk for progression 50% surgery 50% bracing

Adolescent Idiopathic Scoliosis Scoliometer threshold = 7 degrees; progression = increased Cobb angle > 5 degrees (curve apex < T8 use Boston bucket, > T7 use Boston + Milwaukee) Hard or difficult to brace hypokyphosis/thoracic lordosis in a brace. Progression vs. Magnitude/Skeletal Maturity (expressed in percentage of progression) Risser Sign 5–19 degrees 20–29 degrees 1–2 22% 68% 2–4 1.6% 23% Lonstein JE, Carlson JM. The prediction of curve progression in untreated idiopathic scoliosis during growth. J Bone Joint Surg. 1984;66:1067. 112 Tarascon Pocket Orthopaedica Treatment Guidelines Curve Progression Risser stage Therapy 0–25 degrees — 0–4 Serial observation 25–30 degrees 5–10 degrees 0–1 Brace (halt or slow progression) 30–40 degrees — 0–1 Brace (halt or slow progression) > 45 degrees — 0–4 Surgery* > 50 degrees — 5 Surgery (young adults) *Posterior spinal fusion

Progression Risk Factors • Curve > 20 degrees • < 12 yr • Risser 0–1 at presentation.

MRI Criteria: Rapid Progression (Tumor, Tethered Cord, Syringomyelia) Structural abnormality in plain films Pain Excessive kyphosis Left thoracic curve and focal neuro finding Juvenile onset (< 11) Radiographic abnormality Abnormal neurologic exam Associated syndromes

King Curves (Patterns of Idiopathic Scoliosis) (J Bone Joint Surg. 1983;83A:1302–1313) Type Definition Flexibility I S-shaped thoracolumbar curve, crosses midline Lumbar > thoracic II S-shaped thoracolumbar curve, crosses midline Lumbar < thoracic III Right thoracic curve, T4 does not tilt into the curve Lumbar vertebrae highly flexible IV Long thoracic curve, T4 tilts into the curve L4 tilts to thoracic curve V Double thoracic curve T1 tilts to upper curve Pediatric Orthopaedics—Scoliosis 113 Damian Rispoli 2009 34 Risser Stages (5 = Fusion of Iliac Apophysis ) 12 114 Tarascon Pocket Orthopaedica Lenke Classification of Adolescent Idiopathic Scoliosis Proximal Main Thoracolumbar/ Type Curve Type Thoracic Thoracic Lumbar 1 Main thoracic (MT) Nonstructural Structural Nonstructural (major) 2 Double thoracic (DT) Structural Structural Nonstructural (major) 3 Double major (DM) Nonstructural Structural Structural (major) 4 Triple major (TM) Structural Structural Structural (major) 5 Thoracolumbar/ Nonstructural Nonstructural Structural (major*) lumbar (TL/L) 6 Thoracolumbar/ Nonstructural Structural Structural (major*) lumbar-main thoracic (TL/L-MT) Note: *Major = largest Cobb measurement, always structural. Minor = all other curves with structural criteria. (J Bone Joint Surg. 83A(8):1169–1181, 2001)

Congenital Spinal Deformities Associated with genitourinary abnormalities (25%), cardiac (10%), and dysraphism (25%; commonly diastematomyelia)

Risk of Progression Curve Progression Unilateral unsegmented bar and contralateral Rapid and relentless hemivertebrae Unilateral unsegmented bar Rapid Fully segmented hemivertebrae Steady Partially segmented hemivertebrae Less rapid, <40 degrees at maturity Incarcerated hemivertebrae None or slow Nonsegmented hemivertebrae Little Note: Top three usually need surgery. Bottom three can be observed—partially segmented hemivertebrae will sometimes need excision. Pediatric Orthopaedics—Scoliosis 115 y 2001 thoraco- ertical Line V y JBJS 83A:1169-1181, and/or lumbar apex bod Apical Lumbar Modifier C lumba r, above or below the apical disc CSVL does not touch the apical May have a thoracic, Harms J. vertebral body or bodies immediatel disc Apical CSV L- Central Sacral Betz RR, l minimal Lenke LG, pe B les, Ty Lumbar Modifier B If in doubt choose to moderate L-spine rotation CSVL touches apical vertebra body/bodies or pedic Must have a thoracic apex les up to stable no or minimal scoliosi s Lumbar Modifier A Damian Rispoli 2009 and rotation of L-spine vertebrae, CSVL between pedic 116 Tarascon Pocket Orthopaedica Structural Criteria Location of Apex (Minor Curves) (Scoliosis Research Society definition) Proximal thoracic Side-bending Cobb ≥ 25 Curve Apex degrees Thoracic T2–T11-12 Disc Main thoracic T2–T5 Kyphosis ≥ +20 Thoracolumbar T12–L1 degrees Lumbar L1–2 disc, L4 Thoracolumbar/ Side-bending Cobb ≥ 25 lumbar degrees T10–L2 Kyphosis ≥ +20 degrees Side-bending Cobb ≥ 25 degrees T10–L2 Kyphosis ≥ +20 degrees

Modifiers (See Lumbar Modifiers) Thoracic Sagittal Modifier Thoracic Sagittal Profile T5–T12 – [Negative] hypokyphotic < 10 degrees N [Normal] 10–40 degrees + [Positive] hyperkyphotic > 40 degrees

Classification Notation Curve type (1–6) + lumbar spine modifier (A, B, or C)+ thoracic sagittal modifier (–, N, or+ )

Scheuermann’s Kyphosis (Thoracic) • Kyphosis > 45 degrees, 5 degrees or more anterior wedging at three consecutive vertebrae. • Other radiographic findings= disc narrowing, end-plate changes, spondylolysis (30–50%), scoliosis (33%), and Schmorl’s nodes. • More common: adolescents with poor posture and occasionally aching pain. • Hyperkyphosis that does not improve with hyperextension (if hyperkyphosis improves with hyperextension diagnosis = postural kyphosis, tight hamstrings. • Brace progressive curves (Risser 1–3), > 1 year, may improve curve. • Risser 5, > 75 degrees, consider fusion. Lumbar Scheuermann’s: Athletes/manual laborers, less common, end-plate changes, Schmorl’s nodes, ↓ disc height, lacks wedging, mechanical back pain Usually self-limited Lowe TG. Scheuermann disease. J Bone Joint Surg. 1990;72A:940–945. Pediatric Orthopaedics—Child Abuse 117 PEDIATRIC ORTHOPAEDICS—CHILD ABUSE Skeletal Survey in Child Abuse • AP bilateral hands, forearms, arms, thighs, legs, and feet • AP/lateral axial skeleton and trunk • AP/lateral skull Differential Diagnosis in Child Abuse Diagnosis Factors and/or characteristics Accident Age, mechanism of injury, assoc. injuries, no delay in seeking care Birth trauma Obstetric history, callus within 2 wk of birth, humeral or clavicle fracture, distal humeral physeal separation Osteogenesis imperfecta Family history, osteopenia, blue sclera, dental abnormalities, wormian bones, skin-test abnormalities Caffey’s disease Family history, diffuse periosteal elevation, mandibular involvement, irritability, inflammation, swelling, stiffness Rickets Physeal widening, metabolic abnormalities, deformity, osteopenia, Looser’s lines, laboratory abnormalities Congenital syphilis Metaphyseal erosions, periosteal bone formation, positive serological tests, pseudoparalysis Congenital insensitivity to Infection, joint destruction, neurologic abnormalities, family pain, Riley-Day syndrome history

Coagulation disorders Bruising, coagulopathy, laboratory abnormalities Leukemia Metaphyseal lucencies, systemic symptoms, hematologic abnormalities, + bone marrow biopsy Normal radiographic Angulation of ossifying metaphysis, cortical irregularities, variants spurring, juxtaphyseal variants Adapted from Kocher MS, Kasser JR. Orthopedic aspects of child abuse. J Am Acad Orthop Surg. 2000;8:10–20.

Specificity of Musculoskeletal Findings in Child Abuse High specificity Metaphyseal corner lesions, posterior rib, scapular, spinous process, or sternal fractures Moderate specificity Multiple fractures, fractures of different ages, epiphyseal separations, vertebral body, digital, or complex skull fractures Low specificity Clavicular, long-bone shaft, or linear skull fractures (but common in child abuse) 118 Tarascon Pocket Orthopaedica PEDIATRIC ORTHOPAEDICS—LEGG-CALVES-PERTHES Osteonecrosis of the proximal femoral epiphysis • Boys 4–8 yr • Delayed skeletal maturation Legg-Calvé-Perthes Stages Stage Characteristics Initial Physeal irregularity, metaphyseal blurring, radiolucencies Fragmentation Radiolucencies and radiodensities Reossification Normal density returns Healed Residual deformity

Herring Classification A = normal pillar height, B = > 50% height, C = < 50% (J Pediatr Orthoped. 12:143–150, 1992) Herring’s Modified Lateral Pillar Classification and Surgical Indications Chronological Age Skeletal Age Herring Group Surgical Treatment ≤ 8 ≤ 6 A, B, B/C border No benefit from surgical treatment (tend to do well) > 8 > 6 B, B/C border Innominate osteotomy or varus femoral osteotomy Any Any C No benefit from surgical treatment (tend to do well) J Bone Joint Surg. 2004;86A:2121–2134.

Risks • Positive family history • Low birth weight • Abnormal birth presentation Physical signs • Trendelenburg gait • Hip or knee pain • Decreased range of motion (especially abduction and internal rotation) Key to prognosis Age > 6 yr = worse Bilateral 12–15% Pediatric Orthopaedics—DDH 119 PEDIATRIC ORTHOPAEDICS—DDH Developmental Dysplasia of the Hip Developmental dysplasia of the hip (DDH) (Risk = 1:1000) Associated conditions: metatarsus adductus, clubfoot, calcaneovalgus, torticollis Increased in Native Americans and Laplanders Rare in individuals of African descent Risk With History 6% risk with normal parents and 1 affected sibling 12% risk with 1 affected parent 36% risk with 1 affected parent and sibling Distribution

80% Female Left 60%, right 20%, both 20% Increased risk with breech or firstborn Twice as common in subsequent siblings Radiographs may be confirmatory, but do not rule out the diagnosis of DDH. If subluxation suspected, dynamic ultrasound may be helpful. 120 Tarascon Pocket Orthopaedica Algorithm for Evaluation and Treatment of DDH (J Am Acad Orthop Surg. 1999;8:232–242)

Abnormal hip at birth

Subluxated Dislocated or dislocatable

Observe at Nonreducible Reducible three weeks

Neuromuscular Stable Subluxation Pavlik harness* examination

No Pavlik Operative Reduced Not treatment harness treatment reduced at 2 weeks Stable/no dysplasia Subluxation Full-time wean Reevaluate Wean from Neuromuscular harness examination No Dysplasia dysplasia The surgeon places Pavlik initially Weekly follow-ups till full ROM End Closed or If not reduced/stable by 3 weeks,consider harness open other treatment options reduction 2-week follow-ups till clinically and Abduction brace radiographically stable AP pelvis out of brace; wean out of brace If residual acetabular dysplasia persists, *6 weeks plus 2 times the age the harness may be worn 12 hours/day (weeks) at application until radiographs show no dysplasia Physical Exam and Injections 121 PHYSICAL EXAM AND INJECTIONS Physical Exam: Hand Test Description Positive Findings Allen’s Compress radial and ulnar arteries Arterial patency in (J Trauma 1981;21: at wrist, make fist, relax fist, release the hand 471–479) arteries one at a time, shows ulnar and radial artery patency (can be performed on fingers). Carpal tunnel Direct pressure over the carpal Reproduces median compression tunnel just distal to distal wrist nerve symptoms flexion crease, 30–60 sec. Crossed finger test Cross long and index finger Intact ulnar nerve (J Hand Surg. (tests 1st volar and 2nd dorsal 1980;5:560–565) interosseous muscle). Elbow flexion Hyperflexion elbow ~ 30–60 sec, Ulnar nerve reproduces ulnar nerve symptoms. compression Elson test Flex finger at proximal interpha- Central slip intact (J Bone Joint Surg. langeal joint over table edge, have (Br) 1986;68: patient extend the joint against 229–231) resistance. Distal joint should remain supple. Finkelstein Thumb in palm, ulnar flex wrist, DeQuervain’s clenching fist can give a false tenosynovitis positive result. Reproduces pain in 1st dorsal compartment. Flexor digitorum Hyperextend MCPJ, lock PIPJ in Tendon continuity profundus extension, have patient flex DIPJ. Flexor digitorum Isolate finger by extending all others, Tendon continuity superficialis have patient flex finger. Flex finger with metacarpophalangeal joint extended; otherwise, hand intrinsics contribute. Froment’s Have patient pinch a piece of paper. Ulnar neuropathy Weak pinch and flexion of DIPJ of thumb signify ulnar neuropathy (weak adductor pollicis and flexor pollicis brevis). Passive test of Flex wrist, grasp forearm just proxi- Tendon continuity continuity mal to wrist flexion crease, squeezing here will flex fingers. Phalen’s Volar flex wrist ~ 30–60s (reproduces Median nerve (J Bone Joint Surg. median nerve findings) compression 1966;48:211–228) (continues) 122 Tarascon Pocket Orthopaedica Physical Exam: Hand Continued Test Description Positive Findings Quadriga effect The four flexor digitorum profundus Limits full flexion of tendons share a common muscle uninvolved digits belly. Shortening of one tendon causes the muscle tendon units of the remaining three tendons to functionally lengthen. Regan test Shucking ulnar wrist while stabilizing Lunotriquetral ligament the lunate. Spurling’s Axial load skull with the neck in Nerve root compres- extension and deviation to the sion, radicular pain symptomatic side worsens nerve root compression. Tenodesis effect Flex wrist, fingers extend. Extend Tendon continuity wrist, fingers flex (resting tone— intact tendons). Tinel’s Tap directly over peripheral nerve, Nerve irritation, symptoms in distribution of nerve. neuroma Watson test Thumb over volar distal pole of Scapholunate interos- (J Hand Surg. 1980;13: scaphoid, radial deviation of wrist seous ligament tear 657–660) flexes scaphoid, with torn scapholunate ligament the proximal pole of the scaphoid slips over the dorsal lip of the radius.

Flexor Digitorum Profundus Flexor Digitorum Superficialis (You must isolate and test each finger separately) Damian Rispoli 2009 Physical Exam and Injections 123

Quick Neurologic Assessment of the Hand

Anterior Interosseous Nerve Ulnar Nerve Posterior Interosseous Nerve -Tests the flexor digitorum profundus -Active finger abduction -Tests the extensor indicis (index) and flexor pollicis longus -See crossed finger test proprius and digiti quinti minimi

Damian Rispoli 2009

Flexor and Extensor Tendon Zones

Flexor Zones I. Distal to flexor digitorum I superficialis insertion I I II. Within finger flexor retinaculum (“No man’s land”) III. The palm I IV. Carpal tunnel V. Wrist and forearm TI. Distal to flexor pollicis II longus insertion TII. Thumb flexor retinaculum TI TIII. Thenar eminence Extensor Zones III TII I. Distal interphalangeal joint II. Middle phalanx (PII) III. Proximal interphalangeal joint TIII IV IV. Proximal phalanx (PI) V. Metacarpal VI. Dorsal wrist V VII. Distal forearm VIII. Mid/proximal forearm Damian Rispoli 2009 124 Tarascon Pocket Orthopaedica

Flexor Sheaths, Radial, and Ulnar Bursa

Tendon Sheaths

Ulnar Bursa

Radial Bursa

Flexor Tendons

Damian Rispoli 2009 Physical Exam and Injections 125

Tenodesis Effect

Manual compression proximal to wrist causes passive finger flexion

Damian Rispoli 2009

Mallet Finger

Loss of continuity of the terminal tendon of the extensor apparatus Patient lacks the ability to actively extend terminal phalanx

Damian Rispoli 2009 126 Tarascon Pocket Orthopaedica

Swan Neck Deformity

Lax or disrupted volar plate Dorsal subluxation of the sagittal bands Flexion of the distal phalanx Hyperextension of the proximal interphalangeal joint

Damian Rispoli 2009

Judgement of the Rotational Alignment in the Fingers and Hand

Rotational alignment of the fingers is estimated by the fact that as the fingers are flexed into a first they will point to the tubercle of the scaphoid. Additionally, at resting flexion the nail beds of the fingers will be roughly parallel.

Damian Rispoli 2009 Physical Exam and Injections 127

Finger Block - Flexor Tendon Sheath Block

Direct volar injection midline and down to bone over the A2 pulley. Slowly withdraw while injecting. Inject when you feel a loss of resistance to avoid injecting the substance of the tendons. You can feel the fluid flow into the flexor sheath.

Damian Rispoli 2009

Digital nerve block may also be performed by blocking the volar and dorsal sensory branches at the level of the metacarpophalangeal joint. 128 Tarascon Pocket Orthopaedica Wrist Injection Inject dorsally through the fourth dorsal compartment 1 cm distal to Lister’s tubercle aiming for the capitolunate (mid-carpal interval or 3-4 portal) interval. Palpate/ visualize the fluid entering the wrist joint.

Wrist Block • Ulnar nerve—Inject radial and dorsal to the flexor carpi ulnaris (FCU) at the proximal wrist flexion crease. Beware the ulnar artery just radial to the nerve. Raise a wheal ulnar to the FCU tendon to get the dorsal branch. • Median nerve—Inject ulnar to the palmaris longus tendon at the distal wrist flexion crease. Angle needle 30 degrees to the skin, aiming distally. Stop needle or injection for any median nerve symptoms. • Radial nerve—Inject radial to the radial artery at the level of the radial styloid. Raise a wheal around dorsally and radially to get all the branches at this level.

Wrist Block

Sensory Branch of the Radial nerve

Ulnar Nerve Median Nerve

Damian Rispoli 2009 Physical Exam and Injections 129 Physical Exam: Elbow

Test Description Positive Findings Lateral pivot shift Patient supine, elbow flexed; Apprehension = lateral hold wrist in supination and collateral ligament apply valgus load; other insufficiency hand holds forearm and adds an axial load. Milking maneuver Grasp thumb of supinated Medial collateral ligament hand and pull lateral while laxity applying counterforce to lateral elbow. Pain and instability occur in midrange from flexion to extension. PIN compression Resisted supination with Posterior interosseous nerve the elbow flexed reproduces compression pain over PIN at the proximal volar forearm. Tennis elbow Pain just distal to the lateral Lateral epicondylitis epicondyle with resisted wrist extension (elbow extended). Valgus instability Valgus load applied to the Medial collateral ligament extended elbow with the insufficiency wrist in supination. Posterolateral rotatory Stabilize the humerus, elbow Posterolateral rotatory drawer extended; grasp the proximal instability (J Bone Joint Surg. forearm with the thumb un- 1991;73:440–446) der the radial head, supinate the forearm, slowly flex the elbow; subluxation reaches maximum at 40 degrees flexion. Moving valgus stress Constant moderate valgus Medial elbow pain at 120–70 (Am J Sports Med. force is applied to the fully degrees, medial collateral 2005;33(2):231–239) flexed elbow; quickly extend ligament tear (total/partial) the elbow. Radiocapitellar plica Full extension of the elbow in Click at terminal flexion or (Arthroscopy 2001;17(5): supination Full flexion of the ext. reproduces pain with a 491–495) elbow in pronation symptomatic plica 130 Tarascon Pocket Orthopaedica

Posterolateral Rotatory Drawer

Damian Rispoli 2009

Patient supine Shoulder flexed to 90° and stable Posterior and lateral force on the proximal radius External rotation force ~40° of flexion

Moving Valgus Stress Test (AJSM 33(2):231–9, 2005)

Support Elbow Quickly Extend Valgus Stress Pain=MCL injury (usually 120−170)

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Lateral Pivot Shift Test

Valgus Force Axial Compression Maximal Supination

Damian Rispoli 2009

From Flexion to Extension (radiocapitellar joint subluxed to reduced)

Elbow Joint Injection/Aspiration

Damian Rispoli 2009

Inject in the center of a triangle formed by the radial head, lateral epicondyle, and the olecranon. Alternately you can inject directly into the olecranon fossa from the posterolateral edge of the olecranon. 132 Tarascon Pocket Orthopaedica

Carrying Angle

The angle formed by the arm and the forearm. Important to observe when treating elbow fractures.

Normally a variable valgus angulation

Damian Rispoli 2009

Physical Exam: Shoulder Test Description Positive Findings Apprehension 90 degrees of abduction and Anterior capsular (J Bone Joint Surg. external rotation; apprehension of instability 1984;66B:551–556) dislocation. Belly press Hands flat on stomach, have pa- Intact subscapularis (J Bone Joint Surg. tient actively keep elbows anterior 1996;78A:1015–1023) to frontal plane of body. Cross arm Bring arm from 90 degrees for- Acromioclavicular arthrosis ward flexion to across the chest, causing pain at acromioclavicular joint. Drop arm Slowly lower arm from 90 degrees Rotator cuff tear abduction to the side; drop arm is positive. Drop sign 90-degree elevation, near full Drop wrist = infraspina- (J Shoulder Elbow Surg. external rotation, elbow flexed tus tear 1996;5:307–313) to 90 degrees; support elbow, release wrist. Physical Exam and Injections 133 Physical Exam: Shoulder Test Description Positive Findings External rotation Elbow passive flexed at 90 de- Can’t hold position = lag sign grees, 20 degrees elevation, near superior or posterior (J Shoulder Elbow Surg. max external rotation cuff tear 1996;5:307–313) Hawkins test Impingement with internal rota- Pain = impingement (Am J Sports Med. tion at 90 degrees forward flexion 1980;8:151–158) (labral and AC joint pathology → false +) Horn blower’s Lifts arm up to 90 degrees Posterior rotator cuff tear external rotation and 90 degrees abduction, weak 5 abnormal Jobe test Shoulder at 90 degrees abduction, Weakness = supraspina- (Clin Orthop. 30 degrees forward flexion, inter- tus tear 1983;173:117–124 nal rotation (thumb pointed down) and Clin Sp Med. 1983;2:281–289) Lag sign Maximum internal rotation at Subscapularis pathology (J Bone Joint Surg. shoulder. Unable to maintain lift 1996;78A:1015–1023) off position is + Liftoff Patient lifts flat hand off back: Subscapularis pathology (J Bone Joint Surg. ability to lift off = intact sub- 1991;73B:389–394) scapularis (test negative). Load shift Axially applied force to humerus Posterior capsular instability while bringing the arm from straight lateral abduction to 90 degrees of forward flexion Causes apprehension or posterior shift Neer impingement sign No pain with test after subacro- Pain relief = impingement mial injection. Neer impingement test Passive forward flexion> 90 Pain = impingement (Clin Orthop. 1983;173: degrees, scapula stabilized by 70–77) examiner (arthrosis, stiffness, Ca11 tendonitis, and bony lesions → false +) O’Brien 1. Shoulder 90 degrees forward 1. Pain/click suggests (Am J Sports Med. flexion, 30 degrees ad- SLAP lesion 1998;26(5):610–614) duction, resisted forward 2. Ant/superior pain flexion with thumb pointed suggests AC pathology to ground 2. Rotate to full supination and resisted forward flexion again. (continues) 134 Tarascon Pocket Orthopaedica Physical Exam: Shoulder Continued Test Description Positive Findings Posterior drawer Patient supine, posterior directed Posterior subluxation = (J Bone Joint Surg. force with shoulder at 80–120 posterior instability 1966;66B:557–560) degrees abduction and 30 degrees forward flexion Relocation Supine apprehension; apprehen- Anterior capsular sion resolves with a posterior instability directed force on humerus. Speed’s Flex shoulder against resis- Pain = bicipital (J Bone Joint Surg. tance, elbow extended, forearm tendonitis, SLAP 1966;48:1496–1502) supinated. Pain in the bicipital groove = +. Sulcus sign Downward axial load to Ligamentous laxity humerus subluxates humeral (test symmetry) head inferiorly Yergason Resisted supination, elbow Pain = bicipital tendonitis at 90 degrees, forearm in pronation. Abbreviations: AC, acromioclavicular joint; SLAP, superior labrum anterior-posterior. Physical Exam and Injections 135 136 Tarascon Pocket Orthopaedica Physical Exam: Spine Test Description Positive Findings Adson’s test Patient seated, arm dependent, neck ↓ pulse = thoracic outlet (Ann Surg. 1927; toward side being tested and extended, syndrome 85:839–857) deep breath. ↓ pulse is positive Babinski Stroking the bottom of the foot causes Upper motor neuron lesion reflex toe extension. Myelopathic sign (myelopathy, stroke, multiple sclerosis) Bowstring Hip flexed to 90 degrees, knee flexed to Reproduces radicular pain reduce radicular symptoms, pressure placed on tibial nerve in popliteal area. Crossed straight Passive lifting of contralateral straight 98% specific for HNP (lower leg raise leg, flex hip with straight knee. lumbar radiculopathy) Femoral nerve Place the patient laterally on the Reproduces radicular traction test unaffected side, examiner passively pain (upper lumbar extends the hip and flexes the knee of radiculopathy) the affected side. Clonus Forced dorsiflexion of the foot Reflex rhythmic plantar flexion response> 4 beats Upper motor neuron lesion Myelopathic sign (myelopathy, stroke, multiple sclerosis) Hoffmann’s Flicking DIPJ of middle finger causes Upper motor neuron lesion involuntary flexion of DIPJ of index and Myelopathic sign (my- IPJ of thumb. elopathy, stroke, multiple sclerosis) Lhermitte’s Forward flexion of neck causes Stenotic sign causing lancinating pain down spinal cord to myelopathy arms/legs. Nonorganic 1. Pain (out of proportion) to superfi- May indicate heavy signs (Waddell’s cial touch (superficial tenderness) psychosocial overlay signs) (Spine 2. Pain with axial rotation of the pelvis (three or more of five signs 1980;5:117–125) and with axial loading on the top of present) the skull (simulation) 3. Sitting straight leg raise < lying SLR (distraction) 4. Nonanatomic weakness or sensory changes 5. Overreaction Straight leg raise Passive lifting of straight leg, flex hip Reproduces radicular with straight knee, ± dorsiflexion of symptoms; dorsiflexion foot (Lasègue maneuver). should reproduce symptoms at less hip flexion (lower lumbar radiculopathy) Physical Exam and Injections 137

Femoroacetabular disease patterns

No Impingement

Pincer Cam Impingement Normal Clearance Impingement

Combined Impingement Over-coverage of Femoral Reduced Femoral Head Head by the Acetabulum and Neck Offset

Combination of Cam and Pincer

Modified from Lavigne M. Parvizi J. Beck M. Siebenrock KA. Ganz R. Leunig M. Anterior femoroacetabular Impingement Part I. Clin Orthop Rel Res 2004, 18:61–66.

Developmental Hip Dysplasia

Hold thigh gently (like holding a tomato), don’t press Barlow too hard on the thigh

Relaxation (the baby) is imperative, sleeping is perfect.

Damian Rispoli 2009 OrtolanI (Out to In) 138 Tarascon Pocket Orthopaedica Physical Exam: Hip Test Description Positive Findings Anteroposterior Patient supine with the hip in 90 de- Pain is indicative of femo- impingement grees of flexion. roacetabular impingement Internal rotation and adduction recreates the symptoms. Barlow Infant relaxed, hips flexed; gently Subluxable or dislocat- adduct, hip may sublux or dislocate. able DDH FABER Flexion, abduction, and external rota- Sacroiliac joint, hip joint, tion may cause pain in sacroiliac joint, tendonitis hip joint, or iliopsoas insertion. Galeazzi Infant relaxed and supine, feet DDH, dislocated hip flat, knees flexed. Asymmetric knee height = DDH Ober Lateral position, contralateral side Contracture in the iliotibial down, hip and knee at 90 degrees. band or tensor fascia lata Examiner abducts and extends hip prevents adduction past (ipsilateral knee at 90 degrees); adduct midline hip toward the contralateral leg. Ortolani Infant relaxed hips flexed; gently ab- Developmental hip dyspla- duct, hip should relocate. sia (DDH) Posteroinferior Supine position, patient slides buttocks Pain is indicative of femo- impingement to the end of the table and extends the roacetabular impingement hip, externally rotate the hip. Resisted straight Active straight leg raise against resist- Hip irritability or arthrosis leg raise ance reproduces groin or low posterior buttock pain (also known as the Stinchfield test).

Physical Exam: Knee Test Description Positive Findings Anterior drawer Pull tibia forward with knee at 90 Laxity = ACL injury (test degrees. symmetry) Asymmetric external Patient prone, knees flexed at 90 PLC or PLC/PCL injury rotation degrees, externally rotate both feet at 30 degrees and 90 degrees. Asymmetric external rotation > 10–15 degrees = posterolateral corner injury; if asymmetric at both 30 degrees and 90 degrees, then PLC and PCL. Physical Exam and Injections 139 Physical Exam: Knee Test Description Positive Findings Dial test Supine with hip flexed to 90 degrees Asymmetry at: 30 de- (Clin Orthop Rel Res. or prone with the hip at 0 degrees. grees = posterolateral 1991;264:235–238) Test with knee at 30 degrees and corner, 90 degrees = pos- 90 degrees. Grasp both feet and terior cruciate ligament maximally externally rotate. Compare sides. External rotation Pick up leg by great toe, knee goes Combined posterior recurvatum into varus and recurvatum and tibial lateral and ACL or PCL external rotation. Posterolateral tibial injury subluxation. Lachman’s Pull tibia forward with respect to fe- Laxity = ACL injury (test mur with knee flexed to 30 degrees. symmetry) McMurray’s Supine, knee and hip flexed to 90 de- Pain at medial joint (J Bone Joint grees. Valgus load and tibial internal line and click = medial Surg (Br). and external rotation. meniscal tear 1942:29:407–414) Patellar Laterally push patella with the knee in Apprehension = patellar apprehension 20–30 degrees of flexion. dislocation or subluxation Pivot shift Take extended and internally rotated ACL injury (test symmetry) knee and flex with a valgus force, relocation = ACL injury. Posterior drawer Knee flexed at 90 degrees, foot flat PCL injury or insufficiency and fixed, posterior force on tibia. Subluxation of condyles toward or anterior to the anterior tibial margin = PCL laxity/deficiency. Varus/valgus at 0 Flex knee 0 degrees off exam table MCL/LCL and PCL or ACL degrees edge, stress varus and valgus. Varus/valgus at 30 Flex knee 30 degrees off exam table Valgus laxity = MCL degrees edge, stress varus and valgus. Varus laxity = LCL 140 Tarascon Pocket Orthopaedica

Knee Injection/Aspiration

Reliability of Intra-articular delivery: Lateral mid patellar 93%, Anteromedial 75%, Anterolateral 71% (JBJS 84A 1522-1527, 2003.)

Tilt patella away from needle. Insert needle under the patella and into the knee joint. May go either medial or lateral. This can also be done with the knee flexed at 90° using standard Damian Rispoli 2009 inferior arthroscopy portal landmarks.

Physical Exam: Ankle/Foot

Test Description Positive Findings Ankle squeeze test Squeeze calf above syndesmosis, pain High ankle sprain, syndes- at syndesmosis or below = injury. mosis injury Ant. drawer Knee flexed, quad relaxed, cup heel, Asymmetric excursion = stabilize tibia, pull forward on heel ankle instability Asymmetric anterior excursion = ankle instability (anterior tibiofibular ligament injury). Coleman block test Place a block under the lateral Fixed hindfoot deformity hindfoot; supple hindfoot deformities accommodate for the block, fixed do not accommodate. Silfverskiöld Test dorsiflexion of the ankle with Dorsiflexion > with knee the knee extended and then flexed flexion= isolated gastroso- at 90 degrees. leus contracture Physical Exam and Injections 141 Physical Exam: Ankle/Foot Test Description Positive Findings Single leg heel Patient standing, lift one foot off Posterior tibial tendon raise ground, raise heel of contralateral dysfunction side. Lack of ability to perform or weakness with lack of hindfoot inversion is positive. Talar tilt Inversion at ankle causes tilting and Asymmetry = ankle (J Am Acad Orthop lifting of the talus from the mortise. instability > 5 degrees Surg. 1998;6: comparison, > 10 degrees 368–377) absolute Thompson’s Patient prone, knee flexed, squeez- Absence of plantar ing calf should cause ankle plantar flexion = Achilles rupture flexion. Too many toes sign Patient standing, examine from Too many toes = posterior behind looking for number of toes tibial tendon dysfunction laterally. Asymmetric examine is positive.

Ankle Joint Aspiration/Injection

Palpate the joint line, direct the needle at the medial or lateral corner and under the tibial plafond. Avoid saphenous vein medially, the superficial peroneal nerve laterally, and the dorsalis pedis artery centrally.

Damian Rispoli 2009 142 Tarascon Pocket Orthopaedica

Ankle Block

Posterior View (medial left, lateral right)

Saphenous n.

Tibial n. Deep peroneal n. Sural n.

Achilles tendon

Superficial peroneal n.

Extensor retinaculum

Anterior View Damian Rispoli 2009 (lateral left, medial right)

Tibial nerve block—Inject behind the medial malleolus, halfway between the malleolus and the calcaneus. Deep peroneal nerve block—Inject lateral to the extensor hallucis longus and anterior tibial artery level with the inferior extensor retinaculum. Superficial peroneal nerve block—Inject subcutaneously anterior to the extensor tendons. Saphenous nerve—Inject subcutaneously anterior to the medial malleolus. Sural nerve—Inject midway between the posterior border of the lateral malleolus and the calcaneus. Radiologic Views 143 RADIOLOGIC VIEWS Radiologic Views: Spine Line/Angle Normal Description Significance Atlanto dens 3 mm: adults Distance from the anterior In trauma: 3–5 mm: interval (ADI) 4 mm: children odontoid to posterior border rupture of transverse of the anterior arch of C1 ligament 5–10 mm: alar ligament stretched 10–12 mm: rupture of all ligaments ADI increased with atlantoaxial instability (Down’s, Morquio’s, Larsen’s, achondroplasia, SED, rheumatoid arthritis, trauma) Anterior spinal Within 1–2 mm Longitudinal projection from Posterior spinal canal laminar line at each level the opisthion and the anterior alignment cortex of the posterior arch of C1 (atlas) and the C2/3 laminae. Basion-dens < 12 mm Distance from the basion to Craniocervical joint Interval upper odontoid tip. alignment Basion-axis 4–12 mm Distance between a line Craniocervical joint interval projecting cranially from the alignment posterior cortex of C2 body to the basion. Cobb angle 0 degrees Cobb method is the method chosen by the Scoliosis Research Society for measuring and following scoliotic curves. Can also be used to measure kyphosis and lordosis. (continues)

Cervical Radiographic Lines

Anterior Posterior Skull Wackenheim’s Skull Base Base McCrae’s

Chamberlain’s McGregor’s

Hard C1 Palate C2

ADI SAC Damian Rispoli 2009 144 Tarascon Pocket Orthopaedica

Cobb Angle Choose the “end vertebra,” the most tilted from the horizontal above the apex and below the apex of the curve. Draw a horizontal line across the upper end plate of the upper vertebrae and the lower end plate of the lower vertebrae. Draw lines perpendicular to these tangents until they intersect each other. The angle of the intersection is the Cobb angle.

Damian Rispoli 2009

Radiologic Views: Spine Continued Line/Angle Normal Description Significance Chamberlain’s Odontoid tip Straight line from the pos- Intrusion of odontoid line < 3 mm above terior edge of the foramen into foramen magnum this line magnum to the upper corner Basilar invagination. of the most posterior aspect Seen in rheumatoid of the hard palate. arthritis, congenital conditions. Harris line 4–12 mm The distance between a line Occipitocervical injury drawn from tip of dens to basion and second line drawn parallel to the posterior border of the dens. Lateral < 2 mm of Distance between the lateral Atlantoaxial alignment atlanto-dens asymmetry aspect of the dens and the interval medial aspect of the lateral mass of C1. Lateral mass > 7 mm Combined horizontal distance Transverse atlantal distance for the lateral border of C1 ligament rupture and (overhang) to that of C2 (open mouth atlanto-axial instability odontoid radiographs or CT images). (continues) Radiologic Views 145

C1 Lateral Mass

C2 Vertebrae

a b

a + b = lateral mass displacement

Power’s Ratio - AB/CD, Normal <1.0

Skull Base

Anterior C1

Damian Rispoli 2009 Anterior C2 146 Tarascon Pocket Orthopaedica Radiologic Views: Spine Continued

Line/Angle Normal Description Significance McCrae’s line Odontoid tip Lateral C-spine: Diameter Any existing compres- should be below line drawn in the plane of the sion will likely be this line foramen magnum opening. asymptomatic if the tip is below this line McGregor’s Odontoid tip Upper corner of the most Landmarks identifiable line not > 4.5 mm posterior aspect of the hard in all age groups above this line palate to the lowest border of the occipital skull. Pavlov’s ratio > 0.8 Distance from the posterior < 0.8 is consistent margin of the vertebral body with cervical stenosis to the anterior margin of the spinous process divided by the distance from the anterior to the posterior margin of the vertebral body. Prevertebral < 7 mm at AP thickness of soft tissue Increased swelling in soft tissue C2/3 stripe anterior to C2/3 verte- this space can indicate swelling bral cortex. upper C-spine injury. Power’s ratio < 0.9 normal Ratio of lines drawn from ba- > 1 Anterior atlanto- sion to C1 posterior arch and occipital dissociation. opisthion to C1 anterior arch. Does not identify posterior dislocation or distraction injuries. Sacral Normal < 30 Angle formed by a line drawn Risk for progression inclination degrees parallel to the posterior of slip sacrum at S1 and one perpendicular to the floor. Scotty dog No collar Oblique view of the lumbar Defect in the pars spine. interarticularis (spondylolysis) Space avail- 13–14 mm at Distance from posterior as- Smaller distances able for the craniocervical pect of odontoid (craniocervi- indicative of cord cord (SAC) junction; 12 cal junction) or vertebral body compression/stenosis mm below C2 (below C2) to the nearest posterior structure. Slip angle < 10 degrees Angle formed by a line Risk for progression of perpendicular to the sacrum slip if > 10 degrees at S1 and the inferior end plate of L5. Wackenheim Lines up within Straight projection from the Craniocervical joint Line 1–2 mm of the caudal posterior projection of dissociation of odontoid tip the clivus toward the upper dislocation C-spine. Radiologic Views 147

Lumbar Oblique Radiographs

Spondylolysis 80% seen on lateral view, additional 15% seen on oblique view.

Collar

Damian Rispoli 2009

Measurements in Spondylolisthesis

Slip Angle Sacral Inclination

Listhesis is also graded on the percentage of displacement of the superior vertebrae on the inferior vertebrae. I. 0–25% II. 25–50% Damian Rispoli 2009 III. 50–75% IV. > 75% 148 Tarascon Pocket Orthopaedica

Damian Rispoli 2009

Scapholunate AngleCapitolunate Angle Normal 30–60 degrees Normal < 30 degrees

Anterior and Posterior Fat Pad Sign

Damian Rispoli 2009

Hemarthrosis lifts the capsule and pericapsular fat out of the coronoid and olecranon fossae. Posterior sign is highly significant; anterior may be present without injury/trauma. Radiologic Views 149

Both lines should bisect the central 1/3 of the capitellum

Radiocapitellar Line

Anterior Humeral Line

Damian Rispoli 2009

Radiologic Views: Upper Extremity Line/Angle Normal Description Significance Anterior hu- Line passes Line carried straight down Asymmetric, anterior, meral line through mid-third from the anterior cortex of or posterior to the of the lateral the humeral diaphysis middle third of the condylar ossific capitellum indicative nucleus of fracture Capitolunate 0–15 degrees Intersection of the capitate > 20 degrees sug- angle axis and lunate axis on the gests carpal instability lateral wrist view Carrying 10–15 degrees Angle formed by the longi- Carrying angle is usu- angle 15–20 degrees tudinal axis of the humerus ally symmetric and can 15 degrees in and the longitudinal axis of be used as an indica- children the ulna measured in the tor of malalignment frontal plane with the elbow in extension. Radial 22 degrees The angle formed by the in- Useful in estimating inclination (24 ± 2.5 degrees) tersection of a line between the degree of defor- the most distal points on the mity of distal radius lateral and ulnar edges of fractures the distal radius with a line perpendicular to the longitudinal axis of the radius on a PA view of the wrist (continues) 150 Tarascon Pocket Orthopaedica Radiologic Views: Upper Extremity Continued Line/Angle Normal Description Significance Radiocapi- Line passes Line drawn down the longi- Dislocation/sublux- tellar line thru mid 1/3 of tudinal axis of the radius ation of radial head capitellum (Monteggia fracture) Radiolunate 0 degrees Longitudinal axis of the > 15 degrees flex- angle radius with the axis of the ion = VISI (lunate tilt) lunate > 10 degrees extension = DISI Radial volar 11 degrees volar On lateral view, angle In fractures: > 5 mm tilt (11 degrees ± 2 formed by line drawn be- of radial shortening degrees) tween the most distal volar on the PA or > 20 and dorsal tips of the distal degrees of dorsal an- radius and a line drawn gulation on the lateral perpendicular to the longitu- is associated with a dinal axis of the radius poor outcome. Scapholu- 30–60 degrees Angle formed by the scaph- > 70 degrees = DISI. nate angle oid axis and the lunate axis < 30 degrees = VISI. ORIF scaphoid if > 60 degrees and displaced > 1 mm Scapholu- < 3 mm Gap between scaphoid and Gap > 3 mm suggests nate interval lunate on PA clenched fist scapholunate liga- view (consider comparison ment tear view or dynamic study) Ulnar 0 degrees mm On PA of wrist, draw one line 0 mm = ulnar neutral, variance perpendicular to the longitu- stress distribution dinal axis of the radius and 80% thru proximal tangential to the articular radius and 20% thru pole of the distal ulna and proximal ulna. + 4 mm one line perpendicular to ulnar positive vari- the longitudinal axis of ance. The ratio is 40% the radius and tangential radius, 60% ulna. With to the lunate fossa of the negative ulnar vari- distal radius. Measure the ance, stress is 96% distance between the lines. radius, 4% ulna. Ulnar tangent distal to the radial tangent = positive ulnar variance. Wrist arcs Collinear On lateral wrist, in neutral Asynchronous angula- position, radial, lunate, and tion indicative of capitate axes are colinear. carpal instability Seen on the PA radiograph of the wrist. Abbreviations: DISI, dorsal intercalated segmental instability; VISI, volar intercalated segmental instability. Radiologic Views 151

Damian Rispoli 2009

Volar Tilt ~ 11 Degrees

Osteoarthrosis Rheumatoid Arthritis Osteophytes No osteophytes Sclerosis Osteopenia Asymmetric Symmetric Subchondral cysts Periarticular erosions DIPJs PIPJs and MCPJs Burnt-out rheumatoid arthritis may look like or mimic osteoarthrosis.

MRI Signal Characteristics • Bright on T1: Fat, gadolinium, methemoglobin, proteinaceous fluid, melanin • Bright on T2: Fluid • Bright with gadolinium: Vascular tissue • STIR (poor resolution): Fluid (profoundly suppresses fat signal) • Gradient echo: Cartilage, “blooming” artifact in ferrous laden tissue (pigmented villonodular synovitis) 152 Tarascon Pocket Orthopaedica

Metacarpals

Thumb Metacarpal

Hook of Hamate Hamate Trapezium Triquetrum Trapezoid Pisiform

Capitate

Scaphoid Ulna Lunate

Sigmoid Notch Radius

Damian Rispoli 2009

Wrist Radiographic Lines

Damian Rispoli 2009

Radial Inclination ~ 21 Degrees Radiologic Views 153

Metacarpals

Thumb Metacarpal

Capitate Trapezoid Trapezium

Lunate Scaphoid

Radius Ulna

Damian Rispoli 2009 Lateral Wrist Radiograph

DDH Lines and Radiographic Assessment

DDH side Normal side

Acetabular HiIgenreiner’s Line Index

Shenton’s Lines Perkin’s Lines Damian Rispoli 2009 Note: Break in Shenton’s line and absence of ossific nucleus on DDH side (ossific nucleus normally present at 4–6 months is delayed and small in DDH) 154 Tarascon Pocket Orthopaedica

Acetabular roof

llioischial line

Posterior lschial spine acetabular lip lliopectineal line

Anterior Teardrop acetabular lip

Damian Rispoli 2009

Pelvic Radiographic Lines

Radiologic Views: Hip/Pelvis Line/Angle Normal Description Significance Acetabular Birth < 30 degrees Angle formed a line drawn Indicates degree of ac- index 1 yr < 25 degrees along the roof of the acetabu- etabular dysplasia 3 yr < 20 degrees lum and Hilgenreiner’s line 6 yr < 15 degrees 10 yr < 10 degrees Anterior Normal ≥ 17 On a false profile view, center degrees the angle between a line edge drawn from the center of angle the femoral head and one from the center of the hip to the foremost aspect of the acetabulum Epiphyseal < 25 degrees Angle formed by a line tangent 40–70 degrees = coxa angle to proximal femoral epiphysis vara and Hilgenreiner’s line Hilgen- Ossific nucleus A horizontal reference line In a dislocated hip, reiner’s inferior to this line drawn through the triradiate the femoral head is line cartilage in the upper outer quadrant. Radiologic Views 155 Radiologic Views: Hip/Pelvis Line/Angle Normal Description Significance Ilioischial No cortical AP view of pelvis: The serpigi- Cortical disruption line disruption nous line that runs from the indicates a fracture of most distal juncture of the sa- the posterior column. crum to the ischium, along the Teardrop may be V or U border of the ischium to the shaped in the presence ischial tuberosity, and down of acetabular dysplasia. to the distal juncture of the medial border of the posterior column of the acetabulum. Iliopectin- No cortical AP view: The most medial Cortical disruption eal line disruption border of the pelvic ring. indicates a fracture of Oblique (obturator) view: the the anterior column pelvic brim line, the anteromedial border of the anterior column. Klein’s line Symmetric Line drawn tangent to the Can be suggestive of a left–right superior femoral neck on the SCFE (warning: bilateral AP pelvis slips!) Neck shaft 124 degrees ± 7 Angle formed by a line drawn < 110 degrees = sig- angle degrees through the femoral neck nificant coxa vara. Coxa and a line drawn through the valga significance is femoral shaft variable, depends on acetabular coverage. Usually ↑ the valgus ↓ the coverage. Perkins Ossific nucleus A reference line that runs Four quadrants are cre- vertical medial to this line vertically through the lateral ated by the intersection line aspect of the bony acetabulum of Hilgenreiner’s and and is perpendicular to Hil- Perkins lines. In a sub- genreiner’s line luxated hip, the femoral head will be in the lower, outer quadrant. Shenton’s Smooth curve Traces the arc between top of Smooth curve broken in line without a break obturator foramen and medial hip dysplasia, some frac- (curve) femoral neck tures, and hip dislocation Teardrop Teardrop shape; AP hip/pelvis, teardrop-shaped Disruption suggests 5–8 mm medial to line medial to the head of the fracture or penetration head > 5–8 mm femur (quadrilateral plate) through the acetabulum suggests lateral into the pelvis displacement Wiberg 20–35 degrees Angle formed by a line drawn Decreased in dysplasia center Abnormal = from center of the femoral of the acetabulum as edge < 20 degrees head to the lateral edge of seen in hip dysplasia angle (CE the acetabular roof and line angle) through the center of the femoral head and perpendicular to Hilgenreiner’s line 156 Tarascon Pocket Orthopaedica

Inlet 25 degrees cephalad to caudal

Outlet 60 degrees caudal to cephalad

Damian Rispoli 2018 Inlet and Outlet Pelvic Views

Iliac View Obturator View

45 degree obliques

Damian Rispoli 2018 Inlet and Outlet Pelvic Views Obturator and Lliac Views Radiologic Views 157

Anterior Center Edge Angle (Lequesne Rev Rheum 28:643-52, 1961)

Vertical line through the center of the Line from the center femoral head of the femoral head to the lateral aspect of the acetabulum

False-profile radiograph (65 degree oblique with the foot rotated parallel to the x-ray cassette) Damian Rispoli 2009

Discoid Meniscus Pelligrini-Steida (squaring, widening, Lesion cupping) (Chronic MCL)

Lateral Capsular Sign Fairbank’s Changes (Segond fracture — -post menisectomy- associated with (squaring, ridging, narrowing) anterior cruciate [sclerosis is often added, ligament tear) but not stated in the original article]

Damian Rispoli 2009 AP Knee Radiograph 158 Tarascon Pocket Orthopaedica

Blumensaat’s Line (roof of the intercondylar notch)

Notch in lateral condyle

Tibial Spines

Medial Plateau (concave) Damian Rispoli 2009

Knee Radiographic Lines

Radiologic Views: Lower Extremity

Line/Angle Normal Description Significance Blumensaat’s NA A line drawn along the The lower pole of the line superior aspect of the inter- patella should reach condylar notch on a lateral this line. In patella knee view alta, the lower pole is above this line. Congruence –6 degrees Angle formed by a line Increased in patients angle –10 degrees from apex of sulcus angle with recurrent patella through lowest point of ar- dislocations ticular ridge of patella and line bisecting sulcus angle Insall ratio 1:1 ratio Measure on the lateral knee 20% variation repre- (0.8–1.2) view flexed to 30 degrees, sents patella alta (> ratio of patella length to 1.2) or patella baja length of patellar tendon (< 0.6). Lateral patel- Opens laterally Angle formed by a line Lines may be parallel lofemoral angle drawn parallel to the lateral or open medially (Laurin) surface of the patella and a in patients with line drawn from the medial recurrent patella to lateral femoral condyles subluxation Radiologic Views 159 Radiologic Views: Lower Extremity Line/Angle Normal Description Significance Proximal tibial < 11 degrees Angle formed by a line In varus, an angle > metaphyseal- perpendicular to axis of 11 degrees suggests diaphyseal angle the tibia and a line going Blount’s disease. through the medial and Many feel > 14 de- lateral lips of the proximal grees = Blount’s. tibial metaphysis Q angle < 15 degrees Not a radiographic angle. Increased Q angle as- Measured clinically from sociated with laterally the angle derived by a line subluxated patella from the ASIS to the center (from the increased of the patella, with a line lateral force of the from the center of the pa- quadriceps) tella down the tibial spine. Sulcus angle 126–150 de- Angle formed by a line Larger angles are grees (average drawn from the lowest point associated with sub- 138 degrees) of intercondylar sulcus luxation or dislocation to highest points on the of the patella. medial and lateral femoral condyles (knee flexed 45 degrees, X-ray beam angled 30 degrees from horizontal)

Kellgren and Lawrence Grading System for Knee Osteoarthritis 0 No osteophytes, no osteoarthritis 1 Doubtful osteophytes 2 Minimal osteophytes, can have narrowing, cystic changes, and sclerosis 3 Moderate or definite osteophytes with moderate loss of joint space 4 Severe with large osteophytes and definite joint space narrowing Kohn MD, Clin Orthop Rel Res. 2016;474(8):1886.

Radiologic Views: Foot/Ankle Line/Angle Normal Description Significance Anteroposterior 25–45 degrees An angle formed by In clubfoot and hind- talocalcaneal the longitudinal axis foot varus the angle is angle (Kite’s of the calcaneus and decreased. Approaches angle) the longitudinal axis of “parallelism.” the talus (continues) 160 Tarascon Pocket Orthopaedica Radiologic Views: Foot/Ankle Continued Line/Angle Normal Description Significance Bohler’s angle 25–40 degrees Measures the posterior Angle may be in- facet height; shows creased, decreased, degree of deformity and or reversed depending compression in calca- on the severity of the neal fractures calcaneal fracture. Fleck sign Fleck at the base of the Avulsion of the Lisfranc 2nd metatarsal seen on ligament of the base of AP or 30-degree oblique the 2nd metatarsal weight-bearing or stress view First metatar- < 15 degrees Angle formed by a line Increased in hallux sophalangeal through the longitudinal valgus (bunions) angle axis of the 1st metatarsal with that drawn through the longitudinal axis of the proximal phalanx Gissane angle 120–145 degrees Angle that runs from the May be altered in calcaneo-cuboid joint to calcaneal fracture. It the posterior margin of indicates the anterior, the posterior facet middle, and posterior facet relationships. Intermetatarsal < 9 degrees Angle formed by lines An angle of > 15 angle through the longitudinal degrees merits consid- axis of the 1st and 2nd eration of a proximal metatarsals osteotomy to correct deformity Lateral talocalca- 35–50 degrees Angle formed by a line Decreased in clubfoot neal angle drawn through the (talipes equinovarus) longitudinal axis of the talus and a line drawn along the plantar surface of the calcaneus Meary’s angle 0 degrees Lateral foot X-ray: An > 4 degrees convex angle formed by the upward = pes cavus. longitudinal axis of the > 4 degrees convex talus and the longitu- down = pes planus. dinal axis of the first Can also be used to metatarsal grade deformity (mild < 15 degrees, moderate 15–30 degrees, severe > 30 degrees). Radiologic Views 161 162 Tarascon Pocket Orthopaedica Bohler’s Angle Normal 25-40 degrees

Gissane’s Angle Normal 120-145 degrees

Damian Rispoli 2018

Bunion Angles

Hallux Valgus Angle (Normal <15 degrees)

Intermetatarsal Angle (Normal <9 degrees)

Damian Rispoli 2009 Radiologic Views 163

Radiographic Assessment of Tarso-Metatarsal Joint Injuries

Obtain Weight Bearing AP, Lateral, and 30° Oblique views If weight bearing is not possible take stress views (forefoot abduction stress) AP View – 1st/2nd Metatarsal base distance ≤ 3 mm (any doubt obtain comparison views) Medial border of the 2nd metatarsal is in line with the medial border of the middle cuneiform. 1st metatarsal aligns with the medial/lateral borders of the medial cuneiform 1st/2nd interspace continuous with the medial/middle cuneiform interspace 30° Oblique – Medial border of the 4th metatarsal is in line with the medial border of the medial border of the cuboid The lateral border of the 3rd metatarsal is in line with the lateral border of the lateral cuneiform 3rd/4th interspace continuous with lateral cuneiform/cuboid

Damian Rispoli 2009 30 Degree Oblique AP View 164 Tarascon Pocket Orthopaedica CONCUSSION Defined as a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces. Concussion: Major Features • Direct blow to an individual with an “impulsive” force transmitted to the head • Rapid onset short-lived impairment of neurologic function with spontaneous resolution • While it may result in structural changes more commonly the acute clinical manifestations reflect a functional disturbance. • Results in a graded set of clinical symptoms with/without loss of consciousness. Resolution usually occurs in a typical and sequential course, however, it may rarely result in prolonged post-concussive symptoms. • Results in no abnormalities on standard structural neuroimaging studies. (Clin J Sports Med. 2009;19:185–200)

NOTE Any athlete who is symptomatic after a concussion requires serial evaluation. If at any point the exam reveals deterioration in mental status or loss of consciousness after a concussion, immediate transportation to an emergency facility is indicated.

Neuropsychological testing • A very useful management tool • Protocols not clearly validated (e.g., Lovell MR. Neuropsychological assessment of the professional athlete. In: Echemendia RJ, ed., Sports Neuropsychology: As- sessment and Management of Traumatic Brain Injury. New York: Guilford Press; 2006:176–189). • Preseason testing • 72h post-concussion • Repeat in 5–7 d if deficit present • Repeat q1–2 wk follow-up until patient returns to baseline. Concussions in Athletes Observe and evaluate for at least 15 min (Am J Sports Med. 1999;27:5 676–685). Grade Symptoms Duration Recommended Return 1 Confusion, no amnesia Minutes When symptoms resolve. Most now recommend against same-day return. 2 Retrograde amnesia Hours to days 1 week* 3 Amnesia after impact Days 1 month* *Second episode—out for the entire season. Spinal Evaluation 165 Stages of Concussive Injury Most athletes experiencing a concussion have resolution of physical symptoms in 2 wk and a return of neuropsychological testing to baseline in 7–10 d. Acute Concussion: Symptoms usually lasting 2 wk Physical: Headache, dizziness, hearing loss, balance difficulties, insomnia, nausea+ /– emesis, decreased athletic performance Cognitive Deficits: Loss of short-term memory, difficulty concentrating, diminished attention, diminished work/school performance Emotional: Irritability, anger, fear, mood swings Sleep: Difficulty initiating sleep, hypersomnolence, drowsiness Diffuse Axonal Injury Defined by LOC> 6 h—consider avoidance of all future contact sports. Persistent Concussion: Symptoms lasting 1–6 wk postinjury Prolonged Concussion Syndrome: Symptoms lasting > 6 months Lowered concussion threshold, diminished athletic and work or school performance Chronic Traumatic Encephalopathy Emotional: Irritability, anger, fear, with/without mood swings. Personality disturbances, depression, alcohol and/or other substance abuse disorders. Suicidality/suicide. J Bone Joint Surg. 2012;94A(17):1618–1627

SPINAL EVALUATION Steroids in Emergent Cord Injury (Global Spine Journal 2017;7(3S):84S–94S; J Orthop Trauma 2016;33:S7-S13) Contraindications: • Age < 13 (controversial) • Nerve root or cauda equina • Gunshot wounds or other penetrating injury • Pregnancy • Already on steroids • Other life-threatening injury Therapy (methylprednisolone sodium succinate) initiated: Within 8 h after injury: After 8 h after injury: 30 mg/kg IV for the 1st hour Not recommended 5.4 mg/kg/h IV for the next 23 h Not recommended Remember to protect gastric mucosa with H2 blocker 166 Tarascon Pocket Orthopaedica Autonomic Dysreflexia Catastrophic hypertensive event caused by impacted feces or an obstructed urinary catheter and occurs with complete spinal cord injury above T8–T10. Spondylolysis and Spondylolisthesis

Class Type Age Pathology/Other I Congenital Child Dysplastic S1 superior facet II Isthmic 5–50 Elongation/fracture of L5 S1 pars III Degenerative Older Subluxation due to facet (L4, L5) arthrosis IV Traumatic Young Acute fracture (not pars) V Pathologic Any Bony elements destroyed/incompetent VI Postsurgical Adult Over-resected arches/facets

Listhesis Grades I. 0–25% II. 25–50% III. 50–75% IV. 75–100% V. > 100% Muscle Strength Testing Score Exam 0 No movement 1 Visible contraction 2 Movement without gravity 3 Movement with gravity 4 Less than full strength 5 Full strength

Reflexes Root Level Reflex C5 Biceps C6 Brachioradialis C7 Triceps L4 Knee jerk S1 Ankle jerk Spinal Evaluation 167 Lumbar Spinal Stenosis Canal ≤ 12 mm; stenosis ≤ 10 mm AP diameter; lateral recess stenosis < 2 mm

Spondylolysis • Defect in the pars interarticularis • Most common cause of low back pain in children • Fatigue fracture (gymnastics, football linemen) • 80% visible on plain films, 15% on obliques (Scottie dog) • Treatment is symptomatic, avoid extension • Casting for more severe or symptomatic cases

Frankel Grade Grade Function A Complete paralysis B Sensory function only below level of injury C Incomplete motor function (grade 1–2/5) below injury level D Fair to good motor function (grade 3–4/5) below injury level E Normal function (5/5)

Upper vs. Lower Motor Lesions Findings UMN LMN Strength ↓ ↓ Tone ↑ ↓ Deep tendon reflex ↑ ↓ Superficial tendon reflex ↓ ↓ Babinski + − Clonus + − Fasciculations − + Atrophy − + Simon SR. Orthopedic Basic Science, 2nd ed. Rosemont, IL: AAOS; 1994:354. 168 Tarascon Pocket Orthopaedica

Spinal Cross Section Dorsal Columns (Sensory–deep touch, proprioception, vibratory) Lateral Corticospinal Tract (Motor)

Arm/Leg/Trunk Lateral (Medial to Lateral) Spinothalamic Tracts (Sensory– Damian Rispoli 2009 pain/temperature) Ventral Ventral Corticospinal Spinothalamic Tract (Motor – Tracts (Sensory – voluntary) light touch)

LOW BACK PAIN TREATMENT Acute Low Back Pain (≤ 6 wk) • 70% better in 2 wk, 90% better in 4–6 wk • NSAIDs or acetaminophen • Opioids/muscle relaxants of no additional benefit • Minimize bed rest < 48 hr (encourage modified light activity) • Radiographs or MRI in the presence of red flags Chronic LBP (> 6 wk), Worsening Radiculopathy • Rule out cauda equina syndrome—surgical emergency • Radiographs, MRI as indicated • Enlist the aid of pain clinic, mental health, etc. • Workmen’s compensation and pending litigation have worse long-term prognoses. Spinal Cord Injury Syndromes 169 SPINAL CORD INJURY SYNDROMES Mechanism of Injury/ Pathology Characteristics Prognosis Brown- Penetrating trauma Loss of ipsilateral motor, Best Sequard contralateral pain and temperature Root Foraminal compression/ Based on level Good herniated disc Central Age > 50, extension injury, Upper > lower extremities, Fair possible vascular etiology motor and sensory loss Anterior Flexion-compression Incomplete motor, some Poor sensory loss Complete Burst fracture, canal No function below level Poor compromise of injury

Spinal Cord Injury Treatment by Functional Level Level Working Not Working Treatment/Mobility < C4 — Diaphragm, upper Respirator dependent extremities C4 Diaphragm/trapezius Upper extremities Wheelchair chin/puff C5 Elbow flexors Below elbow Electric wheelchair, ratchet C6 Wrist extensors Elbow extensors Wheelchair, flexor hinge C7 Elbow extensors Grasp Wheelchair, independent T1 Intrinsics Abdominals, lower Wheelchair, independent extremities T2–12 Upper extremities, Lower extremities Wheelchair, HKAFO (nonfunc- abdominals tional ambulation) L1 Upper extremities, Lower extremities KAFO, minimal ambulation abdominals, quads L2 Iliopsoas Knee/ankle KAFO, household ambulation L3 Quadriceps Ankle AFO, community ambulation L4 Tibialis anterior Toe dorsiflexion, plantar AFO, community ambulation flexors L5 Extensor hallucis and Plantar flexors AFO, independent digitorum longus S1 Gastrocnemius, soleus Bowel/bladder 6 metatarsal bar NOTE: Level = functional level (functional level is the most distal intact motor level (fair motor grade). HKAFO, hip knee ankle foot orthosis; KAFO, knee ankle foot orthosis; AFO, ankle foot orthosis. Data from Miller MD, ed. Review of Orthopaedics, 3rd ed. Philadelphia, PA: WB Saunders; 2000:458

Traction 171 TRACTION Traction Setups Zimmer Traction Handbook: A Complete Reference Guide to the Basics of Traction. Warsaw, IN: Zimmer; 1992. General Principles • Skin traction should not be used over an open wound. • Skin traction should not be used when it would impede or affect the neurovascular status of the limb. • Ensure no history of allergies to skin adhesives. • Do not reuse traction cord. • Pad all bony prominences. • All weights must hang free and must not lie above the patient. • Knots must be free from pulleys, especially in dynamic traction. Likewise, the moving parts of the traction setup should be free from interference from bed, bed sheets, etc. • You must communicate and explain the basic principles and dangers to the support staff. • Patient transport should be done under physician supervision, or the traction setup rechecked upon arrival at any new location. • Skin care and neurovascular status need to be monitored regularly. Traction Pin Placement Calcaneal Traction Pin The pin is placed on the bone via an incision through the skin and blunt dissection down to the calcaneus. It is placed from medial to lateral. The pin is positioned at a point 2.5 cm inferior and 2.5 cm posterior to the tip of the lateral malleolus on the medial aspect of the calcaneus. The pin is then drilled through the calcaneus and de- livered via a stab incision laterally. Care is taken to protect the medial neurovascular structures and the subtalar joint. 172 Tarascon Pocket Orthopaedica

Lower Extremity Traction Pin Placement

Distal Femoral Traction Pin

Proximal Tibial Traction Pin

Damian Rispoli 2009

Distal Femoral Pin • With knee flexed at 90 degrees if planning 90–90 position to prevent iliotibial band interference with traction • Parallel to the joint surface • 90 degrees to the shaft • 5/64- or 3/32-threaded Steinmann pin; when the pin tents the lateral skin, an incision is used to deliver it through the skin. • Pin level is 1 fingerbreadth above patella with the knee extended or just above the distal femoral flare. • If intramedullary fixation is planned, the pin must be placed anterior or posterior to the center to allow for rod passage. • Pin is passed medial to lateral to protect neurovascular structures through Hunt- er’s canal (adductor hiatus). Proximal Tibial Traction Pin • At the level of the tibial tubercle • 1–2 cm posterior to anterior tibial crest • Passed lateral to medial to protect common peroneal nerve • Not favored in children due to potential interference with growth plates • Consider knee stability prior to placement. Traction 173 TRACTION IS NOT BENIGN! Traction Types Pediatric Traction In general, skeletal traction is not recommended as a method of treatment for children over 12 years old (increased incidence of shortening and angulation). Indications include unstable femur fracture < 6 years old, > 3 cm shortening; fracture < 6 years old, unstable in hip spica; associated other injuries in a child able to cooperate with bed rest. Skin complications can occur with > 5 lb skin traction. Bryant’s Traction • Rarely used, neurovascular complications. • Hips at 90 degrees, knees at 0 degrees, chest restraint, Bradford frame, weight adjusted to just lift the sacrum off the Bradford frame. • Do not use in > 2 years, > 25 lb, beware of serious neurovascular compromise. Modified Bryant’s Traction • Decreases incidence of neurovascular compromise. • May use in older patients with contraindications to a femoral traction pin. Russell Skin Traction/Split Russell Traction (adults and children) • Peroneal nerve neurapraxia possible. • Posterior bowing at fracture site possible. Buck’s Traction • Elevate the foot of the bed; closely monitor skin! 174 Tarascon Pocket Orthopaedica

Application of Skin Traction

Damian Rispoli 2009

Benzoin to lateral and medial leg Horseshoe of adhesive backed felt Wrap loosely with an Ace wrap Include metal traction bar in felt loop

90–90 Skeletal Traction Hip and knee at 90 degrees Beware of overdistraction

**The distal femoral traction pin is placed with the knee flexed so the iliotibial band does not drag over the pin. Damian Rispoli 2009 Traction 175

Russell’s Skin Traction

Skin traction to leg Pillow or traction setup supporting femur Sling may also be placed on leg with pillow supporting the thigh

Damian Rispoli 2009

Balanced Suspension (with or without skeletal traction)

–Elevate foot of bed

Damian Rispoli 2009 176 Tarascon Pocket Orthopaedica Halo Placement • Halo is placed just below the area of greatest circumference, just above the eye- brows, 1 cm above ear tips, and below the skull equator. • Pins placed with local anesthetic; positions as shown. • Eyes closed tightly. Areas shaved. • Pins subsequently tightened circumferentially in a diagonal, opposite manner. Adults: 2 lb-in., 4 lb-in., and finally 6–8 lb-in. Child < 5 yr: 4–6 lb-in., 2 lb-in., or finger tight in infants/toddlers. • Children need multiple pins (up to 8). • Retighten at 24–48 h.

Supraorbital nerve Supratrochlear Frontal Sinus nerve

Frontal SA Sinus AV SA SA SA

SA=Safe Areas, AV=Avoid Area Damian Rispoli 2009 Halo Placement

Gardner-Wells Tongs

Damian Rispoli 2009 -Pins positioned below the temporal ridges, 2 cm above the external auditory canal and temporalis muscle -Tongs are secure when pressure pin extrudes 1 mm Trauma—Adult 177 TRAUMA—ADULT Hand

Injury/Eponym Classification/Limits Treatment Distal phalanx Longitudinal, transverse, Splint 3–4 wk (PIPJ free), fracture comminuted Nail broken/avulsed—fix nail bed Nail intact—trephination alone (J Hand Surg. 1999;24A:1166) Extensor digitorum Stretched Splint distal interphalangeal avulsion (terminal Torn joint in extension. tendon) Bony avulsion Full time for 6 wk Mallet finger Then only at night for 6 wk Can alternate volar and dorsal splint to protect skin. If any break in treatment start back at 0 wk. Flexor digitorum Leddy/Packer (J Hand Surg. profundus tendon 1979;2:66–69) avulsion I: Tendon retracts to palm Fix within 7–10 d. II: Tendon retracts to PIPJ Fix within 2 wk (may repair late up to 3 months). Rugger jersey finger III: Bony fragment retracts to ORIF (early) A4 pulley IIIA (IV): Bony fragment and ORIF and reattach tendon (early) avulsed tendon Metacarpal and Indications for operative Goal—Full and rapid restora- phalangeal fracture treatment: tion of function! • Malrotation (spiral, oblique) Surgeon’s choice (avoid • Intra-articular, open fracture > 4 wk immobilization): (relative) • ORIF (associated with • Subcapital phalangeal stiffness) fracture • Open reduction, • Bone loss, polytrauma, and percutaneous pinning hand fracture • Closed reduction, • Multiple hand/wrist percutaneous pinning fractures • Traction (used uncommonly— • Fracture with soft tissue PIPJ fracture/dislocations) injury • ORIF (composite wiring, • Reconstruction, shortening intramedullary fixation, • (< 1 cm) external fixation) Central slip disruption Soft tissue Acute (< 1 month): extension Boutonniere Bony fragment splint × 6 wk Chronic: Regain passive range of motion, then Fowler tenotomy or central slip reconstruction Extensor tendon < 50% laceration Primary closure, rehabilitation laceration > 50% laceration Repair tendon, rehabilitation 178 Tarascon Pocket Orthopaedica

Boutonniere Deformity

Damian Rispoli 2009

Note: Central slip disruption, volar subluxation of lateral bands, characteristic deformity. Tenderness over the PIPJ may be the only obvious acute clinical finding.

Thumb Metacarpal Fractures

Bennett’s Rolando’s Transverse Oblique Salter-Harris II

Damian Rispoli 2009

Acceptable limits on phalangeal fractures: • < 10-degree rotation (some argue no rotational deformity) • < 1–2 mm of articular step off (goal is anatomic reduction of the joint) • 5 degrees in the sagittal/10 degrees coronal plane (shaft) • 20 degrees in the sagittal plane (metaphyseal) • < 25- to 30-degree apex volar (↑ risk of pseudoclawing) Acceptable limits on metacarpal fractures: • Minimal to no rotational deformity • 1–2 mm of step off (goal is anatomic reduction) Small Joint Fusion 179 • < 10 degrees in the coronal plane • Sagittal deformity < 10 degrees index/long < 20 degrees ring < 30 degrees small • No pseudoclawing (limit apex volar malreduction) SMALL JOINT FUSION Fingers • MCPJ: Index 25 degrees and add 5 degrees each additional digit • PIPJ: Index 40 degrees and add 5 degrees each additional digit • DIPJ: 0 degrees ± 5–10 degrees of supination Thumb • IPJ 0–15 degrees • MCPJ 5–15 degrees with 10 degrees pronation • CMCJ 40 degrees palmar abduction 20 degrees radial adduction aim for pulp-to-pulp contact with fingers Data from Green DP, Hotchkiss RN, Pederson WC, Wolfe SW. Green’s Operative Hand Surgery, 5th ed. Philadelphia: Elsevier; 2005. Hand

Injury/Eponym Classification/Limits Treatment Flexor tendon Zone specific classification > 60% repair laceration (J Bone Joint Surg. 2002;84A(9):1684–1706) Tendon repair may delay up to 2–3 wk, atraumatic technique, strict supervised rehabilitation postoperatively 4th/5th 20–45 degrees angulation acceptable Closed reduction cast/ metacarpal neck Check rotation! splint × 3–4 wk Boxer’s fracture 2nd/3rd metacar- 15 degrees is acceptable Percutaneous pinning to pal neck adjacent metacarpal or ORIF Transverse Accept 30 degrees 5th, 20 degrees 4th, Closed reduction/cast ver- metacarpal 10 degrees 2nd and 3rd sus percutaneous pinning or ORIF Oblique < 5 mm short Closed reduction or open metacarpal reduction, percutaneous pinning > 5 mm or malrotation Percutaneous pinning or ORIF (continues) 180 Tarascon Pocket Orthopaedica Hand Continued Injury/Eponym Classification/Limits Treatment Thumb Closed reduction, percu- metacarpal taneous pinning, ORIF if Bennett’s→ Intra-articular volar lip necessary Rolando’s→ Intra-articular Y ORIF (if noncomminuted) External fixation/traction (if comminuted) Transverse Closed reduction spica cast × 4 wk Oblique Closed reduction spica cast × 4 wk 5th metacarpal Intra-articular base fracture Most stable (if not) base Closed reduction, Baby Bennett percutaneous pinning DIPJ dislocation Dorsal Closed reduction, splint × 2 wk With collateral sprain Buddy tape 3–6 wk With collateral tear Fix radial collateral ligament (index, ring, and middle) Fix ulnar collateral ligament (small finger, dominant hand) Volar PIPJ Volar (central slip torn) ORIF irreducible or dislocation incongruous Rotatory Attempted closed reduction, open if fails closed reduction Dorsal PIPJ Dorsal (volar plate torn) Closed reduction (open if not dislocation I: Hyperextension reducible) then: Buddy tape or extension block splint II: Major ligament injury Extension block splint III: Proximal dislocation Extension splint × 4–6 wk, consider OR for > 4 mm residual displacement Dorsal PIPJ Located Extension block fracture- Subluxated (V sign dorsally—Light) Volar plate arthroplasty, dislocation ORIF, traction splint, force couple pinning MCPJ dislocation Collateral ligament injury Splint MCP 50 degrees × 3 wk, ORIF > 2–3 mm or > 20% joint surface Small Joint Fusion 181 Injury/Eponym Classification/Limits Treatment Dorsal Closed reduction Simple (translation without traction), splint × 7–10 d Dorsal Open reduction Complex (volar plate interposition) Volar Open reduction (sesamoid in ↑ joint space, palmar skin puckered, less deformity seen) CMCJ dislocation Small finger CMCJ dislocation Closed reduction, percutaneous pinning Multiple CMCJ dislocation Open reduction, percutaneous pinning Thumb MCPJ Sprain (< 35 degrees on stress views) Thumb spica cast × 6 wk ulnar collateral Tear (> 35 degrees or 15 degrees > Open repair ligament injury than noninjured on stress views) (Stener lesion = adductor Gamekeeper/ *Test in full extension and 30 degrees aponeurosis interposition Skier’s of flexion between torn ends of ulnar collateral ligament) Thumb Sprain/tear Splint × 4 wk followed by MCPJ radial col- removable splint × 4 wk lateral ligament Thumb MCPJ dor- Simple Reduce, cast × 3 wk sal dislocation Complex Single reduction attempt (volar plate ± flexor pollicis longus interposition) Thumb Hyperpronation and CMCJ dislocation percutaneous pinning Cast 6–10 wk Hamate meta- Cain Reduce/stable: cast, reduce/ carpal fracture/ IA: Ligament injury unstable: percutaneous dislocation pinning IB: Dorsal hamate fracture Reduce/stable: cast, reduce/ unstable: ORIF II: Comminuted dorsal hamate fracture ORIF: restore dorsal buttress III: Coronal hamate fracture ORIF: restore joint surface (Goal: < 2 mm step off, < 5 mm short) 182 Tarascon Pocket Orthopaedica Wrist

Injury/Eponym Classification/Limits Treatment Distal radius AO • Closed reduction+cast Colles’ (dorsal) A: Extra-articular or closed reduction, pin- Smith’s (volar) B: Intra-articular with part ning, +/– cast or ORIF of metaphysis intact C: complex intra-articular (See box on pg. 184 for limits.) Distal radius dorsal rim Reduce, pronation Dorsal Barton’s ORIF if necessary Radial styloid Reduce, percutaneous Chauffeur’s pinning or cannulated screw, cast in ulnar deviation Volar rim ORIF Volar Barton’s

Note: Late osteoarthritis increases following distal radius fractures with residual dorsal tilt > 10 degrees or 1-mm articular step voff.

Damian Rispoli 2009

Dorsal Barton’s Fracture

Damian Rispoli 2009 Damian Rispoli 2009 Radial Styloid Fracture

Volar Barton’s Fracture Small Joint Fusion 183 Wrist Injury/Eponym Classification Treatment Distal radio- Dorsal Reduce, long arm cast in ulnar joint supination × 6 wk dislocation Volar Reduce, long arm cast in pronation × 6 wk Open reduction ± internal fixation or percutaneous pinning if irreducible Scaphoid Can be classified based on time or ana- Stable/nondisplaced- (78% of tomic configuration long arm cast up to 3+ all carpal Evaluate scapholunate interval with months or closed reduction fractures) clenched fist views or intraoperative vs. ORIF [blood supply stress view Displaced [1 mm, dorsal and Consider splint × 1–3 wk and repeat X-rays scapholunate > 60 distal] if not radiographically apparent fracture degrees, lunatocapitate > MRI if acutely or if pain persists 15 degrees]: ORIF Dorsal chip Commonly triquetrum Short arm cast × 6 wk Hook of CT to evaluate Acute: Short arm cast × 6 wk Hamate Chronic: Excise for persistent pain Perilunate Mayfield (stage II= I + II, Early (6–8 wk) dislocation III = II + III, etc.) Open reduction, ligament ± scaphoid I: Scapholunate dissociation repair, percutaneous fracture II: Lunocapitate dissociation pinning, ORIF scaphoid III: Lunotriquetral disruption fracture if present IV: Lunate dislocation

Radius/Ulnar Shaft Injury/Eponym Classification Treatment Radius and ulna Nondisplaced or displaced ORIF (selective nonoperative in Both bone nondisplaced) Ulna fracture Nondisplaced Long arm cast or fracture brace (accept 10 degrees and 50% displacement) Nightstick Displaced ORIF: Beware wrist/elbow injury Proximal ulna Bado (Clin Orthop. 1967; ORIF, closed reduction of radial head fracture/radial 50:71–86) (open if nonreducible) head dislocation I: Radial head anterior (PIN most commonly injured nerve) Monteggia II: Head posterior III: Head lateral IV: Head anterior and both bone fracture Proximal radius Nondisplaced Long arm cast in supination, close follow-up Displaced ORIF Distal radius frac- Eponyms: Galeazzi, Pied- ORIF ture and radioul- mont, reverse Monteggia, nar dissociation fracture of necessity, etc. 184 Tarascon Pocket Orthopaedica Elbow Supracondylar Extension: Nondisplaced Long arm cast Malgaigne Displaced ORIF (double plating) Transcondylar (very uncommon fracture) Reduce (closed treatment diffi- Kocher Intra articular-posterior fragment cult, ankylosis common), percuta- Posadas Intra articular-anterior fragment neous pinning, ORIF if necessary (no consensus in the literature) Condylar I: Lateral trochlear ridge intact Nondisplaced: Long arm cast Milch (lateral > (Salter-Harris IV) in supination (lateral), long arm medial) II: Fracture through lateral troch- cast in pronation (medial), some lear ridge (Salter-Harris II) need ORIF Displaced: ORIF Monteggia Fracture

Proximal Ulna Fracture Dislocation of the Radial Head

Damian Rispoli 2009

Distal radius fracture limitations Disrupted (consider ORIF): DRUJ • ≥ 2 cm loss of radial height • Change in radial inclination ≥ 10 degrees • Loss of volar tilt ≥ 10 degrees Radius • Loss of reduction of the distal radio- Fracture ulnar joint 1–2 mm step off

External fixation note: > 2-mm capitolunate gap = potential overdistraction and can result in stiffness.

Distal radioulnar joint is disrupted in distal radius fractures if dorsal tilt Damian Rispoli 2009 > 25–30 degrees and ulnar styloid Galeazzi Fracture > 3 mm displaced. Small Joint Fusion 185 Elbow Continued Injury/Eponym Classification/Limits Treatment Bicolumnar AO (see illustration) Generally, these fractures are treated A: Extra-articular operatively. Restoration of the joint sur- B: Partial articular face is paramount. Rigid fixation with C: Complete articular early motion (immobilize < 2 wk) helps to avoid fibrosis/ankylosis that occurs with prolonged immobilization. Total elbow replacement may be considered in the elderly with osteoporotic bone where fixation may be difficult or impossible to attain. Olecranon Colton (Inj 1973;5:121–129) I: Nondisplaced Cast/splint, 3 wk or less II: Displaced ORIF (tension band, lag screw, plate) A: Avulsion B: Oblique/transverse Oblique: Screw, plate Transverse: Tension band, plate C: Comminuted Attempt reduction and fixation if not possible to excise (coronoid and anterior structures must be intact for stability, advance/reattach triceps to bone). May also consider nonoperative treatment in the elderly/osteoporotic if joint is congruous. D: Fracture/dislocation ORIF (no excision) Coronoid Regan/Morrey (J Bone Joint Surg. 1989;71A:1348–1354) I: Tip avulsion Early motion II: < 50% Early motion III: > 50% ORIF Capitellar I: Large trochlear piece Nondisplaced: Splint Hahn-Steinthall Displaced: ORIF Kocher-Lorenz II: Minimal subchondral Nondisplaced: Splint bone (Kocher-Lorenz) Displaced: ORIF vs. excise III: Comminuted (rare) ORIF vs. excision Trochlea Very rare Nondisplaced: Splint Laugier Displaced: ORIF Epicondylar Medial (Granger) more com- Manipulation/reduction, posterior mon than lateral splint with the elbow and wrist flexed × 10–14 d, then active motion is begun, symptomatic fragments can be excised late (continues) 186 Tarascon Pocket Orthopaedica

Coronal Shear Fractures

Hahn- Kocher- Steinthall Lorenz

Damian Rispoli 2009

AO Classification of Distal Humerus Fractures

A1 A2 A3

B1 B2 B3

C1 C2 C3

Damian Rispoli 2009 Small Joint Fusion 187 Elbow Continued Injury/Eponym Classification/Limits Treatment Radial head Mason I: Nondisplaced Early motion, ± aspiration II: Moderate displacement Treat like type I for no mechanical block, ORIF for mechanical block, or consider ORIF if > 1/3 of joint, > 30 degrees angulation, > 3 mm step off II: Comminuted ORIF versus excision + replacement for instability (elbow or DRUJ) IV: With dislocation Reduce dislocation, ORIF, replacement Hotchkiss (J Am Acad Orthop Surg. 1997;5:1–10) I: Non/minimally displaced, no Early motion, ± aspiration mechanical block, < 2 mm displaced or marginal lip II: Displaced head > 2 mm ORIF (can excise radial head fragments or angulated neck, ± block < 25%) or incongruity, without severe comminution (reconstructible) III: Severe comminution, Excision with replacement for instability not reconstructible (radio- of elbow or DRUJ graphic or intraoperative determination) Elbow General principles: Stable: Closed reduction, < 7 d, dislocation • Ensure adequate immobilize anesthesia/relaxation. Unstable: Open repair • Supinate forearm to rotate coronoid into trochlear groove. • Axial traction on forearm. • Flex elbow with direct anterior force on olecranon tip. • Palpable clunk signifies reduction. • Test for stability throughout ROM. Humeral shaft Location/pattern Coaptation splint, cast brace, or hanging [spiral fracture and radial arm cast. nerve injury = Holstein-Lewis] ORIF: Floating elbow, segmental, pathologic, obesity, ipsilateral chest wall injury, polytrauma, bilateral fractures, spinal cord injury, need to weight bear, brachial artery or plexus injury, unacceptable alignment in splint (> 15 degrees varus/ valgus, > 20 degrees anterior/posterior, > 3 cm short, > 15-degree malrotation) or radial nerve palsy post reduction. 188 Tarascon Pocket Orthopaedica

Essex-Lopresti

Radial Head Fracture

Disrupted Interosseous Membrane

Disrupted Distal Radioulnar Joint

Damian Rispoli 2009

Proximal Humerus Anatomic Neck Head Greater Tuberosity Lesser Tuberosity Surgical Neck

Damian Rispoli 2009 Small Joint Fusion 189 3.5 months without recovery > 2004;13(4):427–433.) J Shoulder Elbow Surg. Shoulder Treatment Closed treatment lesser tuberosity to defect. Restore with bone graft. Transfer Prosthesis vs. osteotomy Early motion with nonoperative treatment affected most amenable to nonoperative treatment Valgus ORIF vs. closed reduction, percutaneous pinning/screw fixation Consider nonoperative treatment with close radiographic follow-up. Many fractures do well without surgery. Hemiarthroplasty or reverse shoulder (older patients) for completely displaced humeral head segments with high likelihood of avascular necrosis (Hertel R, et al. Predictors of humeral head ischemia after intracapsular fracture the proximal humerus. 20%) < 50%) > Classification/Limits Stable ( Unstable (20–50%) ( Neer classification: 1 part 2 part 3 part 4 part 1 cm > 45 degrees > 5% of the total. < Radial nerve exploration: Open fracture, penetrating trauma with radial nerve dysfunction, palsy following manipulation, Injury/Eponym Impression Hill-Sachs Proximal humerus (A part is defined as displaced or angulated.) 3rd most common fracture (5%) but 3 & 4 part consist of 190 Tarascon Pocket Orthopaedica

AO Classification of Proximal Humeral Fractures

A: Unifocal Extra-articular 2-part fracture

Intact Blood Supply B: Bifocal Extra-articular

Possible injury to blood supply C: Articular fracture involving the anatomic neck High likelihood of necrosis Damian Rispoli 2009 Small Joint Fusion 191 - - trapezius palsy, scapulothoracic dissociation. trapezius palsy, + 2 cm short (somewhat controversial), open fracture, dis 2007;89A(1):1–10) ≥ Continued Absolute: patho placed with skin compromise, vascular injuries needing repair, logic fracture bilateral neurologic disorder, Relative: 2 cm displaced, floating shoulder, injuries, multiple trauma, ipsilateral upper extremity fracture, prolonged intolerance to immobilization. need for recumbency, Consider ORIF for Groups I and II: • • J Bone Joint Surg. Shoulder Treatment 5-mm displacement after reduction: ORIF Closed reduction, ORIF if 3-part Prosthesis, selective ORIF in young patient with reconstructible fracture (controversial) Group I: Majority will heal with nonoperative treatment Completely displaced fractures best treated with ORIF ( Conservative Groups I, II, and IV: Selective ORIF in patients with high demands IIA and IIB V: III: Closed, late acromioclavicular excision for arthrosis Group III: Nonoperative - A: Ligaments intact and with distal fragment B: Conoid torn, trapezoid with intact distal fragment Classification/Limits Anterior (greater tuberosity displaced) May need CT to appreciate Group I: Middle 1/3 (85%) Group II: (see page 191) Distal 1/3 (Neer) (10%) I: Minimal displacement II: Medial to coraco-clavicular ligament III: Involving acromioclavicu lar joint Periosteal sleeve IV: Comminuted V: Group III: Medial 1/3 (5%) Injury/Eponym Proximal humerus fracture/ dislocation Posterior (lesser tuberosity displaced) Head-splitting fracture Clavicle 192 Tarascon Pocket Orthopaedica Damian Rispoli 2009 s on si

Le of

hor (AJSM 23(1:93-98,1995) c P) rface on an su s LA 5mm r la = (S

cep

extensi cu bi al or r < or ri rm de e arti te No th un os -P or ri te I. Fraying of the biceps anchor II. Tear of the biceps anchor/labrum anterior & posterior to midline A. Tear anterior to midline B. Tear posterior to midline Ill. Bucket handle–type tear with an intact biceps tendon IV. Tear extends from biceps anchor/labrum up into tendon (Arthroscopy 6:274–279,1990) V. Anterior-inferior Bankart lesion extends into biceps anchor VI. Unstable labral flap tear with a of the biceps anchor VII. Tear of the biceps anchor extends inferior to middle glenohumeral ligament An

IV. abrum L IIB. or Posterior ri Supe III. IIA. Anterio r II. I. Combined Small Joint Fusion 193 (continues) 25% glenoid involved or greater than 5 mm than 5 or greater involved 25% glenoid > Treatment Closed treatment Selective ORIF large displaced fragment (associated injury common) Selective ORIF large displaced fragment ORIF if of step off and humeral head subluxated Up to 20% of the glenoid can be excised with labrum repaired back to the rim. Closed reduction, massive internal trauma, vascular and brachial plexus injuries

other side 1974; × . 1.5 Orthop >

Acta Shoulder Girdle Classification/Limits Zdravkovich and Damholt ( 45:60–65) I: Body II: Coracoid and acromion III: Neck and tubercle Ideberg I: Anterior avulsion fracture inferior glenoid free II: Transverse/oblique III: Upper 1/3 glenoid and coracoid Horizontal glenoid thru body IV: Combination II–IV V: Internal forequarter amputation AP CXR-medial scapular border

3–10 mm Surg. = Orthop

Acad J Am Injury/Eponym Scapula Relative indications: Articular step off 20–30% glenoid involvement 10–20 mm glenoid medialize Glenopolar angle 20–22 degrees Angulation 30–45 degrees [ 2012;20(3):13041] Glenoid Scapulothoracic dissociation 194 Tarascon Pocket Orthopaedica Treatment Reduce: Stimson: Prone, arm hanging with weight at wrist Milch: External rotation, abduction, posteriorly directed force on the anterior of shoulder Stabilize chest, distal/ Traction/countertraction: abduction traction on forearm, add gentle rotation Confirm reduction (X-rays), immobilize (classically comfortable adduction/internal rotation) Lateral upper arm traction, distal lower and gentle rotation Reduce/immobilize Rehabilitation, debride if fails conservative treatment Rehabilitation, surgical repair in athletes or failed conservative treatment Continued Shoulder Girdle subglenoid > Classification/Limits Subcoracoid Seizure, electrical shock Luxatio erecta Partial Complete Injury/Eponym Anterior dislocation Posterior dislocation Inferior dislocation Rotator cuff tear Small Joint Fusion 195 Treatment Sling/range of motion Sling/range of motion Selective ORIF (controversy persists) Reduce/repair (controversy persists) Increased risk of type II SLAP in III & IV Reduce/repair (controversy persists) Increased risk of type II SLAP in III & IV Reduce/repair Closed reduction with traction Closed reduction with towel clip, open if closed reduction fails (beware great vessels, have thoracic surgeon readily available or present) Nonoperative Surgical repair (nonoperative in selected cases: ~30% loss of flexion/supination strength) Rehabilitation versus tenodesis in young or active (cosmetic “Popeye” deformity will bother some people) Classification/Limits I: Acromioclavicular ligament (AC) sprain [0%] coracoclavicular (CC) sprain [0–25%] II: AC tear, III: AC, CC [25–100%] Clavicular subluxated posterior into trapezius IV: III with large displacement [100–300%] Type V: VI: Clavicle subcoracoid Anterior Posterior Atraumatic Distal Proximal Injury/Eponym Acromioclavicular injury (percent displaced in [ ]) Sternoclavicular injury Biceps tendon 196 Tarascon Pocket Orthopaedica 3 wk then halo vest versus C1 ≥ Treatment Cervical collar (minimal collapse) Halo vest (significant collapse) Cervical collar (minimal collapse) Halo vest (significant collapse) Stable injury Cervical collar for comfort Rigid posterior segmental stabilization, instrument from occiput to C2 (minimum) Rigid posterior segmental stabilization, instrument from occiput to C2 (minimum) Soft or rigid cervical collar consider craniocervical dissociation Rigid collar, Rigid collar versus halo vest Posterior C1/C2 fusion versus traction followed by halo vest Halo vest versus posterior C1/C2 fusion Recumbent traction for ring ORIF - 2 mm

> 2 mm with 2 mm with Cervical Spine ≤ > 7 mm) 7 mm) < ≥ (osseous and ligamentous injury (osseous and ligamentous injury + + Classification/Limits Anderson/Montesano (Spine 13(7): 731–736,1988) I: Impaction (stable) II: Plus skull fracture (shear injury) fracture, avulsed alar ligament III: Transverse I: MRI at craniocervical junction), traction test. II: MRI at craniocervical junction), traction test. III: Craniocervical malalignnment on static radiography Stable: Posterior arch fracture Anterior arch avulsion fracture C1 ring fracture (LMD C1 ring fracture (LMD Unstable: Anterior arch fracture with poste rior displacement (relative to dens) Unilateral sagittal split fracture of lateral mass

combined 2014;22(11):718–729] = Surg. axial load) Orthop

= Acad Jefferson Injury/Eponym Occipital condyle fracture NOTE: Consider craniocervical dissociation Craniocervical dissociation test: Controlled application Traction of weight in OR under fluoroscopy. C1 (Atlas) fracture ( Lateral mass distance distance of the overhang lateral aspect of C1 on C2. (See radiology section.) J Am [ Small Joint Fusion 197 - 65 > (continues) 5 mm, poste > craniocervical dissociation) = Treatment Closed reduction/immobilization Beware/evaluate for associated fractures Mid-substance tears: C1/C2 fusion Bony avulsion: Posterior C1/C2 fusion versus recumbent traction followed by halo vest C1/C2 fusion, include occiput if craniocervical junction ( occiput/C1 involved Cervical orthosis (beware associated injury) Posterior occiput: C2 fusion for instability (Controversial) IIA: Halo vest or non-rigid orthosis IIB: Anterior screw fixation if favorable body habitus. IIC: Posterior atlantoaxial spinal fusion. Risk for nonunion: Fracture pattern, displaced rior displacement, quality of reduction, smoking, age Halo immobilization vs. cervical orthosis Cervical orthosis verus halo vest Halo vest versus ORIF (displaced/spinal cord injury) posterior C1/3 or C2/3 fusion) C2/3 ACDF, Reduction/halo with some extension Careful not to overdistract

2 mm) < . 2005;5(2): Spine J J Bone Joint Surg. ( 1 mm displacement < vertebral foramen—common) + Modification

Classification/Limits A: Rotation centered on the dens, transverse atlantal ligament intact between C1 & C2, transverse B: Translation atlantal ligament disrupted C: Distraction indicating craniocervical dissociation Anderson/D’Alonzo ( 1974;56A(8):1663–1674) Grauer 123–129) I: Oblique apical/avulsion II: Base fracture without involvement of the C2 superior articular facet IIA: transverse, IIB: oblique (ant. sup. to post. inf.) IIC: oblique (ant. inf. to post. sup.) III: Fracture into body with involvement of the C2 superior articular facet. Levine I: Nondisplaced (no angulation, IA: Atypical (unilateral arch, contralateral vertebrae, II: Significant angulation and translation

Surg. Surg. Orthop Orthop

Acad Acad J Am J Am Injury/Eponym Atlantoaxial dislocation Odontoid fracture [ 2010;18(7):383–394] (high nonunion rate ~ 26–85%) Odontoid fracture [ 2010;18(7):383–394] (high nonunion rate ~ 26–85%) spondylolisthesis of C2 Traumatic Hangman’s 198 Tarascon Pocket Orthopaedica = /– posterior + halo immobilization; = 5 lb/level), open reduction/posterior fusion + fusion = 3.5 mm: fusion 11 degrees: fusion 25% compression with intact posterior wall Treatment Reduction/halo versus fixation (posterior approach) posterior C1/3 or C2/3 fusion Consider posterior C2/3 ACDF, Open reduction and posterior C1/3 or C2/3 fusion (10 lb Traction failed closed reduction, consider MRI rule out disc herniation > > < nonoperative; stable unstable Symptomatic fusion, Neuro deficit: Corpectomy, instrumentation collar vs. halo based on instability, Neuro intact: Treat anterior fusion Continued vertebral vertebral Cervical Spine 25% displacement of C2/3 facet dislocation) < axial load with anterior column + + Classification/Limits IIA: C2/3 disc torn, anterior longitudinal ligament intact, slight or no translation but severe angulation III: Fracture/dislocation (C2 arch Unilateral ( body) Bilateral (25–50% displacement of body) Translation Angular displacement Canal compression Clay shovelers Flexion injury and often posteriorly displaced vertebral body Injury/Eponym C3-C7 facet dislocation C3-C7 fracture C3-C7 burst C3-7 spinous process fracture C3-7 teardrop fracture Small Joint Fusion 199 Clinical instability in the lower cervical spine (Spine 1976;1:15) • 2 points each: Anterior elements destroyed or functionless Posterior elements destroyed or functionless Sagittal plane translation > 3.5 mm Relative sagittal plane rotation > 11 degrees Positive stretch test Spinal cord damage • 1 point each: Nerve root damage Abnormal disc narrowing Dangerous loading anticipated • > 5 is unstable

Thoracolumbar Injury Classification and Severity Score Injury Characteristic Qualifier Points Injury morphology Compression ---- 1 Burst 2 Rotation/translation ---- 3 Distraction ---- 4 Neurologic Status ---- Intact ---- 0 Nerve root ---- 2 Spinal cord, conus Incomplete 3 medullaris Complete 2 Cauda equina ---- 3 Thoracolumbar Injury Clas- Posterior ligamentous ---- sification System and Severity complex integrity Score Treatment Guide Intact ---- 0 Management Points Suspected/indeterminate ---- 2 Nonsurgical < 4 Disrupted ---- 3 Either 4 Spine 2005;30:2325–2333. Surgical > 4 200 Tarascon Pocket Orthopaedica Thoracic and Lumbar Spine Injury/Eponym Classification/Limits Treatment Thoracolumbar Injury Compression = loss of height See Chart Classification and of the vertebral body or disruption Severity Score through the vertebral end plate. [Spine 2005;30: Rotation/translation = horizontal 2325–2333] displacement of one thoracolumbar vertebral body with respect to another. Distraction = anatomic dissociation in the vertical axis. Burst fracture A: Axial load Stable = hyperextension B: Axial and flexion cast/brace C: Axial and flexion Unstable = early operative D: Axial and rotation stabilization E: Axial and lateral flexion Height < 50% Angulation > 20 degrees Canal compromise > 50% Scoliosis > 10 degrees Neurologic injury Flexion/ distraction Beware of intra-abdominal/seat Bony = hyperextension Chance belt injuries cast/brace Soft tissue = ORIF Fracture-dislocation Flexion-rotation ORIF: Early mobilization Shear Sacral fracture Zone Observation: Stable/ I: Sacral ala (neurologic injury rare) impacted, < 1 cm displacement II: Sacral foramina (28% neural Iliosacral fixation (ORIF vs. injury) percutaneous) III: Medial to foramina (> 50% Unstable neural injury) Stress Fractures 201 Fracture Types and Columnar Involvement Type Anterior Middle Posterior Compression Compression None None or distraction Burst Compression Compression None or distraction Seat belt None or compression Distraction Distraction Fracture/dislocation Compression ± Distraction ± Distraction ± rotation/shear rotation/shear rotation/shear [Data from Spine 1983; Nov-Dec;8(8):817-31]

Stable spine fracture criteria: • No transient or persistent neurologic injury • Acceptable alignment • At least one column intact • No significant ligamentous disruption Gunshot wounds to the spine (remove bullet/fragment, decompress): • Progressive neurologic deficit due to neural compression (bullet, fragment, hematoma) • Persistent cerebrospinous fluid leak • Spinal instability • Consider decompression for cauda equina level injuries Define projectile path for broad-spectrum IV antibiotic coverage • Posterior entrance: 48–72 h • AP wound (transabdominal, no colon injury): minimum 5–7 d • AP wound (transcolonic): 7–14 d HIGH RATE OF INFECTION

STRESS FRACTURES Low Risk: Upper extremity, ribs, pars interarticularis, pelvis (sacrum, pubic rami), femoral shaft, tibial shaft, fibula, calcaneus, and metatarsal shaft High Risk: Femoral neck, patella, anterior cortex of the tibia, medial malleolus, talus, tarsal navicular, 5th metatarsal, 2nd metatarsal base, and great toe sesamoids 202 Tarascon Pocket Orthopaedica Pelvis Fractures See algorithm, page 203.

Injury/Eponym Classification/Limits Treatment Pelvis (see page 204) Young and Burgess. (Skeletal Weight-bearing status de- LC = lateral compression Radiol. 1986;15:103–109) pends on stability of pelvic Stress exam under anes- Lateral compression (LC) ring component, selected thesia if posterior sacral I: Sacral compression, stabilization for unstable fracture is complete transverse anterior ring complete sacral fractures injury (fracture vs. symphysis injury) LC II: Sacral/Iliac wing frac- External fixation. ORIF vs. ture, anterior ring fracture closed reduction percutane- (sacrospinous (SS) and ous fixation sacrotuberous (ST) ligament intact) LC III: LCII + SS and ST liga- External fixation vs. ORIF vs. ment torn and contralateral closed reduction percutane- sacroiliac (SI) disruption ous fixation APC = anterior posterior Anterior posterior compres- Symptomatic treatment compression sion (APC) I: < 2.5 cm sym- Stress exam under anes- physis pubis, ± sacroiliac thesia if anterior ring opens (SI) joint widening > 2.5 cm APC II: Disrupted symphysis Anterior fixation if unstable or anterior ring, SS and Add posterior fixation if ST torn unstable posteriorly. Selective nonoperative if poor surgical candidate APC III: APC II and post- Same as APC II SI ligament (internal hemipelvectomy) VS = vertical shear Vertical shear: APC III and Same as APC II vertical displacement CMI: Combination mecha- Same as APC II nism injury Stress Fractures 203 Pelvic Fractures With Hemodynamic Instability le ation ential x er y stab e fi cumf initiv wrap ation x s onsider cir C Hemodynamicall e fi Ye or & Plan or & Plan def initiv Monit Monit y def

leed . y with y to y leeding om ot oneal b ial b it ing Injur r y te vic r l No lapar vic angiograph l Pe Mechanical Instabilit eat ar le tr Pe No intraper stab s Ye ential oducts le le r Hemodynamicall ting pr cum fe y unstab y unstab r wice), cir king) to xa le

y nal fi y to r ee d Hemodynamicall Hemodynamicall oneal pac om te it , consider PRBC/Clot leeding y unstab oper IV Fluid bolus (T ial b vic ex wrap oneal bl r it etr te ing lapa rt y pel vic angiograph l equir eat ar r Appl Intraper tr Pe (consider r Hemodynamicall 204 Tarascon Pocket Orthopaedica II II Vertical Shear II Young and Burgess Classification of Pelvic Fractures Damian Rispoli 2009 Lateral Compressio n Anterio r Posterio r Compressio n Stress Fractures 205 Pelvis Fractures Continued Injury/Eponym Classification/Limits Treatment Acetabular fracture Letournel Nonoperative: (see page 206) Five simple fracture Roof arc angle > 45 degrees as patterns measured off the AP, iliac oblique, and Posterior wall obturator oblique Posterior column < 50% posterior wall with stable re- Anterior wall duction* < 2–3 mm displacement Anterior column Severe osteoporosis Simple transverse Medical contraindication Five complex/associated Relative nonoperative indications: fracture patterns Secondary congruence of the ac- T-shaped etabulum with associated both column Posterior wall and fracture column ORIF-Unstable joint, incongruous joint Transverse and poste- Note: Consider exam under anesthesia rior wall using fluoroscopy to aid in determina- Anterior with posterior tion of instablity. hemitransverse Note: Temporary skeletal traction Associated both columns

Damian Rispoli 2009

Proximal Femoral Neck Shaft Angle 124 +/– 7 degrees 206 Tarascon Pocket Orthopaedica

Head

Neck

Intertrochanteric

Subtrochanteric Damian Rispoli 2009

Hip Fractures

Letournel Classification of Acetabular Fractures (JBJS 46A:1615-1647, 1964)

Simple Acetabular Fractures (5 types)

Posterior Posterior Anterior Anterior Transverse Wall Column Wall Column Complex/ Associated Acetabular Fractures (5 types)

T-shaped Posterior Transverse Anterior Both Column & Posterior with Posterior Columns Damian Rispoli 2009 & Wall Wall Hemitransverse Stress Fractures 207 Periprosthetic Femur Fracture Classification and Treatment Type Fracture Location Recommended Treatment I Trochanteric region Nonoperative II Proximal metaphysis/diaphysis not Nonoperative or cerclage fixation involving stem tip IIIA Diaphyseal fracture at stem tip Long-stem ingrowth revision or ORIF: Plate Disruption of prosthetic interface with screws ± cerclage (< 5%) ORIF: Cortical struts with cerclage cables IIIB Diaphyseal fracture at stem tip Cemented stem: Long-stem ingrowth Disruption of prosthetic interface revision (> 25%) Ingrowth stem: Long-stem ingrowth revision or ORIF: Plate with screws ± cerclage ORIF: Cortical struts with cerclage cables IIIC Supracondylar fracture at tip of a Nonoperative if stable or ORIF: Plate with long-stem prosthesis screws ± cerclage IV Supracondylar fracture distant to Nonoperative if stable or ORIF: Plate with the stem tip screws (must extend proximal to stem tip) ORIF: Supracondylar intramedullary nail Long-stem ingrowth revision Data from Miller MD, ed. Review of Orthopaedics, 3rd ed. Philadelphia, PA: WB Saunders; 2000:252.

Hip Fractures Injury/Eponym Classification/Limits Treatment Femoral neck fracture Garden (J Bone Joint Surg. Closed reduction internal fixa- Avascular necrosis: 1971;53B:183–196) tion (three screws) vs. hip screw Nondisplaced I: Incomplete, valgus impacted ± derotational screw 8–18%, Displaced II: Complete, nondisplaced Hemiarthroplasty: Elderly, sick, 15–33% III: Complete, partial displaced pathologic fracture, rheumatoid Nonunion: IV: Complete fracture and arthritis, patient with a seizure Nondisplaced <5%, displacement disorder, Parkinson’s disease, Displaced 10–30% Garden types III and IV, total hip arthroplasty for patient with preexisting osteoarthrosis Blickenstaff/Morris (stress Non-weight bearing with assis- fractures) tive devices I: Callus Compression (inferior-medial II: Nondisplaced neck) with fatigue line <50% III: Displaced neck width ORIF/CRIF (cannulated screws): Tension side (superior-lateral neck) Compression (inferior-medial neck) with fatigue line > 50% neck width (continues) 208 Tarascon Pocket Orthopaedica Hip Fractures Continued Injury/Eponym Classification/Limits Treatment Intertrochanteric Evans (J Bone Joint Surg. Closed reduction internal fixa- 1949;31B:190–203) tion with sliding compression I: Nondisplaced screw vs. cephalomedullary nail II: Displaced with trochanteric entry point III: Reverse obliquity Unstable = type III or postero- IV: Subtrochanteric spike medial comminution Stable/unstable No sliding hip screw with type III (reverse obliquity: fixed-angle device) Osteopenia/pathologic fracture: Consider calcar replacing hemiarthroplasty Nonoperative treatment is always an option; higher morbidity and mortality Greater trochanter Nondisplaced Activity modification Displaced > 1 cm ORIF Lesser trochanter Nondisplaced Activity modification Displaced (beware pathologic > 2 cm ORIF fracture) Subtrochanteric Seinsheimer (J Bone Joint Surg. 1978;60A:300–306) I: Non/minimally displaced Intramedullary nail-locked (cephalomedullary nail trochanteric entry) II: 2 part Intramedullary nail-locked III: 3 part Reconstruction nail or condylar plate/screw IV: Comminuted Reconstruction nail or condylar plate/screw V: Subtrochanteric- Sliding compression screw + intertrochanteric long side plate (older), condylar blade (young) Stress Fractures 209 Hip Dislocations Injury/Eponym Classification/Limits Treatment Anterior Epstein Emergent closed reduction, open if I: Superior irreducible A: No fracture ORIF if irreducible unstable, or intra-articular B: Head fracture bodies C: Acetabular fracture Methods: II: Inferior Stimson-Prone, leg hanging off table, immo- A: No fracture bilize pelvis, knee/ankle at 90 degrees, distal B: Head fracture traction, and gentle rotation C: Acetabular fracture Allis-Supine, stabilize pelvis, lateral traction to inner thigh, long traction to femur, slight hip flexion, and rotation Reverse Bigelow-Supine, hip partial flexion and abduction, distal jerk, no reduction, then add internal rotation and extend Posterior Thompson/Epstein Emergent closed reduction, open if necessary I: No or minimal fracture ORIF if irreducible unstable, or intra- II: Posterior acetabu- articular bodies lar rim Methods: III: Comminuted rim Stimson-Prone, leg hanging off table, immo- IV: Acetabular floor bilize pelvis, knee/hip at 90 degrees, distal V: Femoral head traction, and gentle rotation (J Bone Joint Surg. Allis-Supine, stabilize pelvis, traction inline 1951;73A:746–778) with deformity, hip flexion to 90 degrees, and rotation Bigelow-Supine, stabilize pelvis, hand holds ankle; forearm behind knee to apply long traction, hip flexed to 90 degrees or more, abduction, external rotation, extension to lever head into acetabulum Posterior with Pipkin femoral head (see page 210) (type V I: Head caudad All: Emergent closed reduction Thomas- Excise loose fragment if blocks motion or Epstein) displaced; ORIF if large fragment II: Head cephalad ORIF if large fragment or part of weight- bearing dome III: Femoral head and ORIF (young), selective arthroplasty (older) neck IV: Associated acetabu- ORIF (young), selective arthroplasty (older) lar fracture 210 Tarascon Pocket Orthopaedica

Pipkin Classification (JBJS 39A:1027-1042, 1957)

III

III IV Damian Rispoli 2009

Shatzker Classification (ClinOrthop 138:94-104, 1979) I II III

IV V VI

Damian Rispoli 2009 Stress Fractures 211 Femoral Shaft Fractures

Femur (2 cm from Winquist (Orthop Clin N Am. Locked intramedullary nail lesser trochanter to 1980;11:633–647) (external fixator, ORIF, traction) 8 cm above joint) I: Transverse, < 25% butterfly II: Transverse, 25–50% butterfly III: > 50% butterfly, no comminution IV: Comminuted, no cortical contact V: Segmental limits: < 15-degree malrotation, < 1- to 1.5-cm shortening Femoral neck Closed reduction percutaneous and shaft pinning vs. ORIF of neck (first). Intramedullary rod or plate for shaft vs. cephalomedullary nail Femoral shaft/tibial “Floating knee” Intramedullary rod femur and shaft tibia; consider external fixator for tibia or femur (based on extent of soft tissue injury) Can use external fixator for a temporary solution

Knee Fractures Injury/Eponym Classification/Limits Treatment Supracondylar AO > 6–8 cm proximal-intramedullary nail anterograde < 6–8 cm condylar blade plate/screw, retrograde nail, distal femoral lock- ing plate (required ORIF of displaced articular fragments) Patella Nondisplaced, transverse, Nondisplaced = cylinder cast, knee im- lower pole, upper pole, mobilizer if extensor mechanism intact comminuted, vertical ORIF: no active extension, < 2 mm separation, incongruent joint, consider excising comminuted fragment and reattaching tendon Tibial plateau Shatzker (see page 210) (treatment based I: Split lateral plateau Closed treatment if nondisplaced; on joint stability, closed reduction percutaneous fixation displacement and if no incarcerated meniscus by scope or articular congruity) MRI; ORIF if incarcerated meniscus II: Split/depression lateral Closed treatment if nondisplaced; ORIF plateau with elevation of the depressed joint surface for > 3 mm displacement (some accept as much as 4–10 mm) or instability (continues) 212 Tarascon Pocket Orthopaedica Knee Fractures Continued Injury/Eponym Classification/Limits Treatment III: Isolated depression Closed treatment, ORIF (similar criteria as type II) IV: Medial split/ Closed treatment (only for selected depression nondisplaced), otherwise ORIF V: Bicondylar ORIF versus external fixation VI: Type V and metaphy- ORIF versus external fixation seal extension Tibial spine Meyer/McKeever (J Bone Joint Surg. 1959;41A:209–222) I: Anterior elevation Long leg cast 15–20 degrees of flexion × 4–6 wk II: Anterior 1/3–1/2 Long leg cast 15–20 degrees of elevated flexion × 4–6 wk, unstable = MRI and treat like III IIIA: Displaced MRI, arthroscopic fixation versus ORIF IIIB: Displaced and rotated MRI, arthroscopic fixation versus ORIF Tibial tubercle ORIF

Knee Dislocation/Soft Tissue Injury Injury/Eponym Classification/Limits Treatment Quadriceps rupture Surgical repair Patellar tendon rupture Surgical repair Patellar dislocation Conservative treatment. Rule out osteochondral injury. Evaluate medial patella-femoral ligament, consider repair Proximal tibia-fibula Ogden Treat subluxation conservatively. dislocation • Subluxation Dislocations: closed reduction • Posteromedial (knee 90 degrees) ± anesthesia • Anterolateral Limited immobilization • Superior Selective ORIF for unstable injuries Knee dislocation Descriptive of tibia in See algorithm page 213 relation to femur

ABI % 0.9 No risk of major arterial injury. Delayed thrombus still a risk (vascular exams q4–6h × 24 h. ABI , 0.9 Ultrasound versus CT angiogram Stress Fractures 213 Knee Dislocation Algorithm

Multiple ligament injured knee

History/exam/radiographs

Emergent closed Dislocated Located reduction Vascular/neurologic status

Dislocated + Pulses? Doppler? −

Vascular Surgical reduction consult arteriogram Located Consider external +/- Vascular repair fixation to +/- External fixation maintain reduction Ankle—brachial index If > 0.9 low likelihood of Observation period significant arterial injury Neurovascular status Skin—MRI Consider arteriogram Beware of intimal tears presenting with late vascular Ligament surgery involvement

Tibia/Fibular Fractures

Tibia Johner/Wruhs Closed reduction and cast = low energy, A: Simple minimal displaced, isolated 1: Spiral All others-intramedullary nail, external 2: Oblique fixator, plate 3: Transverse **Maintain a high index of suspicion for B: Butterfly compartment syndrome 1: By torsion Acceptable reduction limits 5 degrees varus 2: One (bend) and valgus, 10 degrees anterior and posterior, 3: Multiple (bend) 10 degrees rotation, and 1 cm shortening C: Comminuted (Data from Rockwood CR, Green DP. Fractures 1: Torsion in Adults. 4th ed. Baltimore, MD: Lippincott- 2: Segmental Raven; 1996:2139) 3: Crush 214 Tarascon Pocket Orthopaedica

Maissenouve Fracture

Weber Proximal Classification Fibula Fracture C: Above the Joint Line Injury to IO Membrane B: At the Joint Line

Distal Syndesmosis A: Injury Below the Joint Line

Damian Rispoli 2009 Damian Rispoli 2009

Classification of Acute Lateral Ankle Sprains Grade Description I ATFL stretching without complete tear II Partial to complete ATFL tear with a partial tear of the CFL III ATFL and CFL tear, possible capsular disruption and PTFL tear Abbreviations: ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; PTFL, posterior talofibular ligament. (J Am Acad Orthop Surg. 2008;16:608–615) Stress Fractures 215 Leg/Ankle Fractures/Dislocations Injury/Eponym Classification/Limits Treatment Ankle fractures Lauge-Hansen (Arch Surg. Bimalleolar fracture or AITFL = anterior inferior 1950;60:957–985) equivalent ORIF talofibular ligament Supination: Adduction Selected nonoperative PITFL = posterior inferior 1: Lateral malleolus or lateral treatment for nondisplaced talofibular ligament collateral ligament fractures without syndes- 2: Medial malleolus (shear) motic injury Supination: External rotation Syndesmotic stabilization 1: AITFL (screw, suture button with 2: Lateral malleolus (spiral) braided suture, etc.) for 3: Posterior malleolus or PITFL widened mortise 4: Medial malleolus or deltoid In general: ligament A = Closed Pronation: Abduction B and C = ORIF ± 1: Medial malleolus or deltoid syndesmotic screw 2: AITFL/PITFL or posterior malleolus 3: Lateral malleolus Pronation: External rotation 1: Medial malleolus or deltoid 2: AITFL or bony avulsion 3: High fibular 4: Posterior malleolus or PITFL Danis/Weber A: Fibular fracture below the syndesmosis B: At the syndesmosis C: Above the syndesmosis Tibial stress fracture Activity modification Fibular shaft Cast for pain control

Syndesmotic Fixation • Tibiofibular diastasis> 1 mm 2 mm lateral talar shift • Tibiofibular clear space> 6 mm • Medial clear space> 4 mm on external rotation stress X-ray • < 10 mm tibia/fibula overlap on AP X-ray • < 1 mm tibia/fibula overlap on mortise X-ray Leg/Ankle Fractures/Dislocations Injury/Eponym Classification/Limits Treatment Tibial plafond Ruedi/Allgower Nonoperative stable/nondisplaced fractures I: Minimally displaced II and III: ORIF vs. external fixation if dis- II: Incongruous placed (min. invasive). Soft tissues are the III: Comminuted key. You can always bridge and wait. Achilles tendon Casting (higher rerupture) vs. surgical repair rupture (skin necrosis) 216 Tarascon Pocket Orthopaedica Foot Fractures and Dislocations Stress fracture, 2nd metatarsal, calcaneus Activity modification and short leg cast March Posterior talar Short-leg cast or excision of fragments process Shepard’s Lateral talar Short-leg cast, excision of fragments, process or ORIF Talar head Nondisplaced Nonoperative Displaced ORIF or fragment excision Talar body ORIF for displaced fractures Talar neck Hawkins/Canale Short-leg Hawkins Sign I: Nondisplaced (< 1 mm), nonwalking vertical cast Relative osteopo Aviator’s Astralgus II: Displaced + subtalar ORIF: rosis of the talar subluxation dislocation Anatomic dome at 6–8 wk reduction signifies anintact vascular supply. III: Displaced and talar ORIF: ( body dislocation Anatomic J Bone Joint Surg. reduction 1970;52A:991–1002). IV: With talar head ORIF (lateral screw first to prevent dislocation varus): Anatomic reduction Subtalar Calcaneus: Medial (85%) Closed reduction/cast, open reduction dislocation Calcaneus: Lateral (15%) if irreducible Basketball foot Blocks to reduction: Lateral: posterior tibial tendon, flexor digitorum longus Medial: extensor digitorum brevis, talonavicular joint Stress Fractures 217

Calcaneus Fractures OTA Group A: Avulsion, Process, or Tuberosity Group B: Nonarticular Body

Anterior Process

Non-Comminuted Comminuted Medial Sustentaculum Group C: Articular Fractures Involving Posterior Facet

Tuberosity

Non-Comminuted Comminuted Nondisplaced 2-Part 3-Part 4 or More Parts

Damian Rispoli 2009

Foot Fractures and Dislocations Continued Injury/Eponym Classification/Limits Treatment Calcaneal fractures A: Avulsion, process, Short-leg non-walking cast vs. ORIF tuberosity CT scan beneficial, selective ORIF for B: Nonarticular articular displacement and calcaneal C: Articular involving the body widening posterior facet The overall goal is to restore congruous joint surface and the overall morphology of the calcaneus. Midtarsal injury Medial stress Closed reduction percutaneous fixa- Longitudinal stress tion vs. ORIF/percutaneous fixation Lateral stress The goal is restoration of the ana- Plantar stress tomic relationships Crush Navicular (be vigilant Cortical avulsion Reduce/pin large fragment for midtarsal injury) Tuberosity fracture ORIF (screw/washer) Body fracture ORIF displaced Stress fracture Short-leg non-walking cast Cuboid, nutcracker ORIF and bone graft or external fixator (restore lateral column) (continues) 218 Tarascon Pocket Orthopaedica Foot Fractures and Dislocations Continued Injury/Eponym Classification/Limits Treatment Tarso-metatarsal Homolateral isolated Closed reduction percutaneous fracture/dislocation divergent fixation vs. ORIF (usual; reliably Lisfranc reduces joints) Lisfranc ligament: Base of the 2nd metatarsal to the medial cuneiform Can consider primary fusion for pre- dominantly ligamentous injuries (J Bone Joint Surg. 2006;88A(3): 514–520) Metatarsal Shaft Closed reduction/selective fixation displaced 1st metatarsal 2nd through 4th nonoperative unless it alters weight-bearing dynamics Head Closed reduction ± cast/pinning Pseudo-Jones→ 5th metatarsal Symptomatic care in Ace wrap, hard (Orthop Clin N Am. sole shoe, or short leg walking cast 1995;26:353–361) Zone I (tuberosity avulsion)

5th Metatarsal Fractures

Peroneus Tertius Peroneus Brevis

Lateral Band of Zone III Plantar Fascia (Implicated in Zone II Damian Rispoli 2009 Zone I Fractures) Zone I Stress Fractures 219 Injury/Eponym Classification/Limits Treatment Jones → Zone II Short-leg non-weight-bearing cast × 6 wk, ORIF (late or athlete) J Bone Joint Surg. Zone III (diaphyseal Short-leg non-weight-bearing 2002;84A:209–214→ stress fracture) cast × 6+ wk Type I (acute) Prolonged short-leg non-weight-bearing Type II (delayed) cast (sedentary); otherwise ORIF with/ Type III (nonunion) without bone grafting ORIF if symptomatic or high- performance athlete, may consider pulsed electromagnetic field J( Am Acad Orthop Surg. 2000;8(5):332–8) Metatarsophalangeal Reduce/buddy tape ± pinning joint dislocation (unstable) Phalanges Buddy tape ± cast or cast shoe Selective ORIF versus percutaneous pinning intra-articular displaced fracture

Trauma—Pediatric 221

20 degrees, age > 1 wk). < 1.5 mm) > 50% or significant volar sag may need > 10 yr), ORIF if needed > percutaneous pinning (angulation ± 25% of joint surface, displacement 10 yr; 10–15 degrees, age > Treatment Closed reduction/splinting: stable Pinning: unstable Extension splinting × 6 wk (rarely operative) B with large dorsal fragment Type operative intervention. C and D need operative intervention to restore joint surface extensor Types continuity. retraction proximal to the A4 pulley likely means E requires tendon repair, Type disruption of the vincular system—repair acutely ( Closed reduction/splint, percutaneous pinning if unstable, ORIF joint incongruity ( Closed reduction < Closed reduction/splint, percutaneous pinning (often), ORIF if needed ORIF (usually necessary) if displaced or incongruous TRAUMA—PEDIATRIC

Pediatric Trauma—Wrist and Hand Fractures Pediatric Trauma—Wrist Avulsed extensor and Avulsed Salter-Harris fracture Salter-Harris –Extra-articular Salter-Harris II –Extra-articular Salter-Harris –Intra-articular III/IV Classification/Limits Extraphyseal A: Transverse B: Longitudinal split C: Comminuted Physeal (Mallet finger) I or II A: Salter-Harris III or IV B: Salter-Harris C: A and dislocation D: E: Volar A: Physeal B: Shaft C: Phalangeal neck D: Articular/condylar ) open fracture NOTE: Displaced physeal fractures > 1 week old are at increased risk of damage during any reduction maneuver. Injury/Eponym Distal phalanx fractures Seymour fracture (any distal phalanx fracture with a nail bed injury, Jersey or reverse mallet (physeal E) Proximal and middle phalanx 222 Tarascon Pocket Orthopaedica

Treatment Buddy tape Reduction under local anesthesia Without collateral or volar plate instability: buddy tape × 3 wk Collateral instability: immobilize at 20–30 degrees flexion × 3 wk, then buddy tape plate laxity: dorsal splint at 45 degrees or extension block splinting × 3 wk Volar Irrigation and debridement, reduction then treat as closed Closed, unstable: percutaneous pinning, displaced head splitting need ORIF Closed, unstable: percutaneous pinning Closed, unstable: percutaneous pinning, ORIF rare Closed reduction percutaneous pinning, ORIF if irreducible Closed reduction usually unsuccessful; operative as needed All: Closed reduction vs. open for failed closed, cast × 3 wk ( collaterals intact) (Collaterals torn, and volar plate torn not in joint) (Collaterals torn and volar plate interposed in joint) Wrist and Hand Fractures Classification/Limits Jammed finger Dislocation Open injuries A: Epiphyseal and physeal B: Neck fracture C: Shaft fracture D: Metacarpal base fracture Dorsal (index finger most common) Farabeuf Incomplete dislocation Complete simple Complete complex Injury/Eponym Proximal interphalangeal joint dislocation (PIPJ) Metacarpal fractures Finger metacarpal dislocation Thumb metacarpal dislocation Trauma—Pediatric 223 -

(continues) 20 degrees (treat like finger metacarpal fractures) 1-mm displacement) or additional carpal injury consider percutaneous pinning for instability < > ± 10 degrees and Closed reduction (treat like finger metacarpal fractures) Accept angulation Closed reduction, external fixation (severe open fractures), traction Displaced type D fracture: ORIF, (complex injuries) fractures need ORIF Displaced Salter-Harris Closed reduction percutaneous pinning Cast immobilization (long arm thumb spica cast) Significantly displaced (considered based on skeletal age and angulation > open reduction percutaneous pinning vs. internal fixation Treatment Closed reduction/cast associated proximal ipsilateral fracture, Operative indications: Soft tissue injury, failed closed reduction, open, comminuted intraphyseal, carpal tunnel symp toms, compartment syndrome Closed reduction/cast Open reduction for failed closed Radius/Ulnar Shaft (Fracture/Dislocation) Salter-Harris II, fragment Salter-Harris radial 1: Extra-articular, 1: Extra-articular, 2: Intra-articular Head Shaft Metacarpal base A: Distal to physis II, fragment ulnar B: Salter-Harris C: III or IV D: Salter-Harris Extremely rare A: Distal pole B: Midwaist C: Proximal pole Classification classification Salter-Harris A: Transphyseal B: Intraphyseal (styloid) Thumb metacarpal fractures CMCJ dislocation Scaphoid Injury/Eponym Distal radius Distal ulna 224 Tarascon Pocket Orthopaedica : 1 cm bayonet Continued : 15 degrees angulation, 45 malrotation, 100% ≤ ♂ 10–16 yr: 10 degrees angulation, 30 malrotation, > 1 cm bayonet

♂ ≤ 10 yr ≤ & ♀ 8–14 yr & 8 yr >

Treatment Majority closed reduction/cast Closed reduction percutaneous intramedullary pinning indications: Severe swelling, ipsilateral fracture, re-reduction (external fixation, open reduction uncommon) Limits of Acceptable Alignment ≤ displacement, ♀ 100% displacement, Data from JAAOS 24(11):780-8, 2106. : 15 degrees angulation, 45 malrotation 10–16 yr: 10 degrees angulation, 30 malrotation ♂ > Acceptable angulation, distal metaphysis

♂ 10 yr Radius/Ulnar Shaft (Fracture/Dislocation) ≤ & ♀ 8–14 yr & 8 yr >

Classification Greenstick Compression Complete ≤ ♀ Data from JAAOS 24(11):780-8, 2016. Injury/Eponym Radius and ulna Both bone Acceptable angulation (see definitions that follow) Trauma—Pediatric 225

12-yr-old and 12-yr-old > ORIF ± ORIF ± Treatment Reduce (traction/flexion), long arm cast, flexion/supination [most common ~ 70%] Reduce (traction/extension), long arm cast, some extension Reduce (extension/pressure), long arm cast, 90 degrees flexion/supination Reduce (supination), Flexion, supination, pressure over radial head Reduce (supination/pressure), long arm cast, 100 degrees flexion, supination Reduce Reduce (traction/supination), long arm cast, 90 degrees flexion/supination Closed reduction percutaneous pinning if unstable failed closed reduction: ORIF - - (see page 230) Classification Bado I: Anterior dislocation of the radial head with a fracture of the ulnar diaphysis II: Posterior dislocation of the radial head with an ulnar diaphy seal or metaphyseal fracture with posterior angulation III: Lateral or anterolateral dislo cation of the radial head with a fracture of the ulnar metaphysis Anterior dislocation of the IV: radial head, fracture of the middle 1/3 of the radius, and an ulna fracture at the same or more proximal level Nursemaid’s Minimally displaced head Displaced head Galeazzi Injury/Eponym Ulnar fracture/radial head dislocation Monteggia Radial head subluxation Radial head dislocation Ulnar fracture/radial neck fracture Radius fracture/distal radioulnar joint dislocation 226 Tarascon Pocket Orthopaedica

. 2012;20(2):69–77. J Am Acad Orthop Surg Management of Supracondylar Factors Used to Determine Emergent Humerus Fractures in Pediatric Patients 1999;8(10):1429–1433] Open fracture Dysvascular limb Skin puckering Floating elbow Median nerve palsy Evolving compartment syndrome age Young Cognitive disability Data from Azbug JM, Herman MJ. Management of supracondylar humerus fractures in children: current concepts. J Bone Joint Surg. Elbow Treatment

11% (most common, Extension: AIN, Flexion: ulnar nerve) . 2010;30(3):253 –263. (Dysvascular) > Pulseless and White Closed Reduce/Pin Observe in OR (~20 min) Adequate perfusion: Admit Observe closely Arm in a splint at 45 degrees Inadequate perfusion: Explore/repair artery Observe closely Consider fasciotomy Classification Evaluate with quality AP and lateral X-rays 3% of all pediatric fractures (98% extension) most common, 5- to 7-yr-old Posterior fat pad: 76% occult fracture [ Nerve injuries J Pediatr Orthop Fracture With a Pulseless Hand Type III or IV Supracondylar Humerus Type Pulseless and Pink Closed Reduce/Pin Observe in OR Admit Observe closely Arm in a splint at 45 degrees Data from JAAOS 20(2):69-77, 2012. Injury/Eponym Supracondylar Trauma—Pediatric 227 - (continues) 90 degrees. > 2 mm after reduction) < 90 degrees, 3–4 wk > 2 mm displaced on all radiographic views: Long arm cast and weekly radio 2 mm: Closed reduction percutaneous pinning ( Long arm cast: 90 degrees flexion, forearm neutral, 3–4 wk IIA: Closed reduction, long arm cast IIB: Closed reduction/percutaneous pinning (some authors prefer this for all type IIs) Closed reduction/percutaneous pinning (Multiple lateral pins favored by some over medial/lateral configuration due to 10% risk of ulnar nerve injury with medial pin) Long arm cast vs. posterior splint Closed reduction, long arm cast vs. percutaneous pinning Closed vs. open reduction percutaneous pinning Be careful of neurovascular status with casting in flexion Closed reduction and cast Closed reduction percutaneous pinning Closed reduction percutaneous pinning < graphs for 3 wk, immobilize 6 wk. > versus open or arthroscopic reduction and percutaneous pinning. 12 mo, Salter-Harris I 12 mo, Salter-Harris < I: Nondisplaced II: Displaced, posterior cortex intact IIA: No rotation/translation IIB: Rotation/translation III: No cortical contact (posterior medial and posterior lateral) No intact hinge (unstable IV: flexion & ext.) I: Nondisplaced II: Displaced with contact III: No contact DeLee A: I Salter-Harris B: 1–3 yr, II Salter-Harris C: 3–12 yr, Jakob I: Intact articular surface II: Articular surface disrupted III: Rotated fragment Milch fracture IV, I: Salter-Harris through capitella–trochlear groove II, fracture II: Salter-Harris through trochlea , 1984.] .

Surg Gynecol Obstet J Bone Joint Surg. Extension Gartland [ 1959;109(2):145–154] Wilkins (IIA & IIB) [Rockwood et al., Fractures in Children Leitch (IV) [ 2006;88(5):980–985] Supracondylar flexion Distal humeral physeal separation Lateral condyle fractures Common 6 yr old 228 Tarascon Pocket Orthopaedica 9 yr old: general anesthesia, closed reduction > Continued Irreducible or unstable dislocation, incarcerated fragment, open fracture Ulnar nerve dysfunction, high demand Treatment Closed reduction/cast vs. ORIF Excise vs. ORIF Splint vs. cast Closed reduction/cast vs. percutaneous pinning Closed or open reduction/percutaneous pinning vs. internal fixation Nonoperative: non/minimally displaced, displaced low demand Operative indications Absolute: Relative: Closed reduction percutaneous pinning vs. traction ORIF Limited open reduction and traction Sedation, closed reduction Young: Older Aftercare: active elbow flexion at 5 d, sling 10 d Elbow Elbow dislocated Elbow located Elbow dislocated Elbow located Classification Hahn-Steinthall Kocher-Lorenz Kilfoyle I: Fracture to physis II: Complete, nondisplaced III: Displaced Acute injuries Non/minimally displaced Displaced Incarcerated fragment Chronic tension Toniolo/Wilkins I: Nondisplaced II: Displaced, no metaphyseal comminution III: Metaphyseal comminution Proximal radioulnar joint intact and A: Posterior (posterior-medial posterior-lateral) B: Anterior C: Medial D: Lateral Injury/Eponym Capitellum fracture Medial condyle fracture Medial epicondylar apophysis Little Leaguer elbow T-Condylar Elbow dislocation Trauma—Pediatric 229 - internal ± 10–14 d × 60 degrees pronation/supination, 3 mm transla < 10–14 d × 30 degrees, no angulation: Long arm cast vs. posterior splint, and early 30 degrees: Closed reduction (general anesthesia) using flexion-pronation, 45 degrees: Closed reduction (general anesthesia) using flexion-pronation, Immobilization, incarceration: Operative intervention Nondisplaced: Splint/cast in extension Displaced: ORIF vs. percutaneous pinning Nondisplaced: Cast in extension Significantly displaced: ORIF < range of motion > long arm cast > Ace wrap, or percutaneous pins, then long arm cast Fixed 40 degrees angulation, tion, head completely displaced: Wire reduction, open reduction fixation neck + A: Salter-Harris I/II A: Salter-Harris IV B: Salter-Harris C: Metaphyseal fracture D: Reduction injury E: Dislocation injury A: Pure apophyseal B: Apophysis and metaphysis fracture 1: Valgus 2: With elbow dislocation 1: Angular 2: Torsional 1: Osteochondritis dissecans 2: Physeal injury angulation Proximal radioulnar joint dislocation A: Divergent (anterior-posterior and medial-lateral B: Radioulnar translocation I: Apophysitis II: Incomplete stress III: Complete fracture A: Flexion 2: Varus) B: Extension (1: Valgus, C: Shear Group I: Head Group II: Neck Group III: Stress Lateral epicondylar apophysis Olecranon apophysis Olecranon metaphysis Radial head and neck 230 Tarascon Pocket Orthopaedica

Milch Fracture Classification

Milch I Milch II (Salter-Harris IV) (Salter-Harris II)

Damian Rispoli 2009

Nursemaid’s Elbow

Nursemaid’s Elbow -Refusal to move arm -Pain at elbow 2. Flex Elbow -May give characteristic history (longitudinal pull)

Treatment -Supinate forearm -Flex elbow with pressure over radial head -Radial head should relocate 3. Gentle pressure -Success is walking away to on radial head return later and see the child using the arm 1. Supinate Forearm Damian Rispoli 2009 Trauma—Pediatric 231 - - J

(continues) 10%. J Child Orthop. < 13 yr old. Group III limited remodel > . 2012;86;68:570–573 and Beringer et al. . 1998;18:31–37] J Bone Joint Surg Br 10 yr old, II 10–13 III percutaneous pinning ± < : Biceps tendon interposition blocking reduction in Shoulder Treatment Splint Collar and cuff Velpeau Sugar tong splint Minimally displaced: splint vs. hanging arm cast Unstable Soft tissue interposition or open fracture: ORIF studies support nonoperative treatment even in the face of severe displace Two ment or angulation [Baxter et al. Pediatr Orthop Age criteria based on a systematic review [Pahlavan et al. 2011;5(3):187–194] Groups I Criteria for angulation II and IV. ing due to age consider surgery for N-H Type still controversial. Note Supportive Figure-of-8, sling Sling Sling Closed vs. open reduction

1965; 2/3 shaft 1/3 shaft 5 mm displaced ≤ ≤ 12 yr 2 yr old ≤ Clin Orthop Relat Res. Classification Birth injury 0–3 yr 3–12 yr > Salter-Harris Neer-Horowitz [ 41:24–31] I: II: III: Complete shaft IV: 0–2 yr old > I and II Salter-Harris Anterior Posterior Injury/Eponym Humeral shaft Proximal humerus Peak 5–11 yr old Midshaft clavicle Medial clavicle Sternoclavicular joint 232 Tarascon Pocket Orthopaedica reconstruction/repair ± Continued Treatment Closed reduction, rehabilitation, Similar to adults Sling, figure-of-8, consider ORIF for certain type IIs I–III: Closed treatment Closed reduction vs. open reduction/repair reconstruction Open reduction, repair, Closed reduction vs. open ABCs, reconstruction/repair Shoulder 100% contralateral side) > Classification Traumatic Anterior and posterior Anatomic I: Nondisplaced, intact ligaments IIA: Fracture medial to coracoclavicular ligaments IIB: Conoid ligament tear III: Fracture into acromioclavicular joint I: Sprain II: Partial tear dorsal periosteum III: Large tear dorsal periosteum Posterior displacement IV: Significant superior displaced V: ( VI: Inferior displaced (subcoracoid rare) Injury/Eponym type II fractures. Medial clavicular physis is the last to close (~ 25 yr old). Sternoclavicular dislocations usually represent Salter-Harris Glenohumeral dislocation Scapular fracture Lateral clavicle Acromioclavicular joint Scapulothoracic dissociation Trauma—Pediatric 233

: The spinal cord ends at L3 in newborns and migrates to L1 or L2 by 1 wk: Soft collar, NSAIDs 1 wk: Soft collar, 1 month: Relax, traction, collar/brace 4–6 wk 3 month: C1–C2 fusion Treatment High index of suspicion, CT and MRI Occiput: C3 fusion Minerva vs. HALO vest C1–C2 fusion < < 1–3 month: HALO > Minerva cast vs. HALO immobilization Usually nonoperative Unstable: fuse Usually nonoperative Operative fixation: Unstable, open wound, progressive neurologic deficit, slipped vertebral apophysis Note adolescence. - Spine Fractures - Chance/Seat 5 mm 5 mm > < ) With compression Without compression Classification Spinal Cord Injury Without Radio graphic Abnormality High mortality Ligament disruption Rotatory subluxation I: No anterior shift II: Anterior III: Anterior Posterior shift IV: Posterior ligament injuries fracture Wedge/compression Distraction/shear fracture Fracture: dislocation Facet dislocation/listhesis Flexion Flexion-distraction ( belt injury Shear Consider using the Thoracolum bar Injury Classification and Severity Score (see Adult Thoracic Spine)

J Am Acad Orthop Surg. Injury/Eponym SCIWORA Occiput-C1 dislocation C1: Atlas fracture C1–C2 injuries C2 fracture Hangman’s C2–C7 fracture Thoracic and lumbar fractures [ 2013;21(12):707–16] 234 Tarascon Pocket Orthopaedica Treatment Closed reduction and spica cast vs. open percutaneous pinning (open treatment more common with head dislocation) increases with Closed reduction vs. open percutaneous pinning (AVN displacement) Closed reduction vs. open percutaneous pinning/compression screw Abduction spica cast, close F/U, ORIF indicated for displacement in cast then casting vs. closed reduction and compression screw Traction Percutaneous pinning Nonweight bearing Closed reduction, open reduction (irreducible), CT scan (intra-articular bodies) Apophyseal Avulsion Fractures Apophyseal Avulsion Hip Fractures and Dislocations Classification (with and I: Transepiphyseal without dislocation) (45–50%) II: Transcervical III: Cervicotrochanteric Displaced Nondisplaced Intertrochanteric IV: Devas Tension Compression Anterior Posterior 32(1):42,2009. Orthopaedics 2 cm displacement 2 cm displacement Description Nondisplaced ≤ ≥ Symptomatic nonunion Painful heterotopic bone growth Injury/Eponym Hip fracture Delbet Stress fracture Hip dislocation Type I II III IV Data from McKinney et al. Trauma—Pediatric 235 (continues) 2 cm (most treat nonoperative) 2 cm (most treat nonoperative) 3cm > > > 15 cm displacement > Treatment Consider surgery for Consider surgery for displacement Chronic pain Consider surgery for displacement Chronic pain or femoral acetabular impingement Nonsurgical management Consider surgery for displacement Nonsurgical Consider surgery for symptomatic non-union Treatment Restore joint congruity and hip stability advance Short period of rest, relax muscles associated with spine/tuberosity, partial weight bearing as tolerated Short bedrest, advance partial weight bearing as tolerated Short bedrest, advance partial weight bearing as tolerated Short bedrest, advance partial weight bearing as tolerated Short bedrest, advance partial weight bearing as tolerated Pelvic and Acetabulum Fractures Apophyseal Avulsion Fractures Around the Pelvis Apophyseal Avulsion A: Avulsion fracture A: Avulsion (ASIS, AIIS, ischial tuberosity) B: Pubis/ischium C: Iliac wing D: Sacrum/coccyx A: 2 ipsilateral rami Classification See above See above See above See above See above See above Classification Key and Conwell I: No ring break II: Single break → Duverney Injury/Eponym Ischial tuberosity Anterior superior iliac spine Anterior inferior iliac spine Most common Pubic symphysis Iliac crest Greater and lesser trochanter Injury/Eponym Pelvic fracture 236 Tarascon Pocket Orthopaedica 3 cm > Continued 6 wk, advance partial weight bearing as tolerated 6 wk, advance partial weight bearing as tolerated × × Treatment Short bedrest, advance weight bearing as tolerated Short bedrest, advance weight bearing as tolerated Bedrest Bedrest Bedrest, traction, ORIF as pelvic fracture Treat Restore congruity ORIF ORIF -

+ Pelvic and Acetabulum Fractures symphysis iliac joint dislocation fracture dislocation B: Fracture/subluxation C: Fracture/subluxation sacro A: 2 anterior fracture/dislocation B: 2 vertical fracture/dislocation C: Severe multiple fractures A: Small fragment, nondisplaced pelvic B: Linear, unstable joint C: Linear, D: Due to central fracture/ Classification III: Double break Acetabular fracture IV: → → Straddle Malgaigne Injury/Eponym Trauma—Pediatric 237 , 4th ed. Philadelphia, PA: , 4th ed. Philadelphia, PA: Fractures in Children 2 cm in spica traction: Delayed > 3 cm shortening: Immediate spica 3 cm initial, 10 mm short 11 yr: 5 degrees varus/valgus, 10 anterior/posterior, 12 yr–Adult Stable: Pavlik Unstable: Immediate spica or traction and delayed < > Stable: Immediate spica flexible intramedullary nail delayed spica, external fixator, Unstable: Traction, Flexible/rigid intramedullary nail based on maturity and fracture configuration Limits of acceptable angulation: 15 mm short 0–2 yr: 30 degrees varus/valgus, anterior/posterior, 20 mm short 2–5 yr: 15 degrees varus/valgus, 20 anterior/posterior, 15 mm short 6–10 yr: 10 degrees varus/valgus, 15 anterior/posterior, > [Rockwood CA, et al. Lippincott-Williams and Wilkins; 1997:1201.] Treatment 0–6 mo: 6 mo–5 yr: flexible intramedullary nails Polytrauma: External fixator, 6–11 yr: ≥ and cast vs. brace Traction Stable: Cast Unstable: Closed vs. open reduction internal fixation/percutaneous pinning

Femoral Shaft Fractures

averages 0.9 cm J Bone Joint Surg. ( 2–10 yr old: Overgrowth 2002;84A(12):2288–2300) Classification Anatomic/descriptive is very variable Treatment between centers! Subtrochanteric Supracondylar Injury/Eponym Femur fracture Subtrochanteric/Supracondylar 238 Tarascon Pocket Orthopaedica - 2 mm residual displacement) percutaneous pin < 2 mm residual displacement), long leg cast. < Severe head trauma with posturing Skeletal maturity Severe soft tissue injury Irreducible closed I, II: Closed reduction ( Unstable: 2 smooth percutaneous crossed pins. Closed reduction percutaneous pinning or screw fixation III, IV: Treatment Fix one, usually the tibia Fix femur if: Nondisplaced: Long leg cast and close follow-up Displaced Nondisplaced: Long leg cast, 30 degrees flexion Displaced: Closed reduction ( ning I & II, ORIF III IV (re-establish joint congruity) Beware vascular injury. Neuro and vascular injuries: 14%, Consider ligament injuries (exam post fixation). Nondisplaced, minimally displaced with active extension to 0 degrees: Long leg cast Displaced: ORIF

Knee Fractures and Dislocations J Bone Joint Surg. 1980;62A:205–215) Classification Letts/Vincent A: Diaphyseal/closed B: Metaphyseal/diaphyseal closed C: Epiphyseal/diaphyseal D: One fracture open E: Both open Salter-Harris Salter-Harris Ogden ( I: Tubercle through the tibial II: Tubercle apophysis and exiting anteriorly through the tibial III: Tubercle apophysis and anterior epiphysis and exiting though the articular surface through the Tubercle IV: apophysis exiting the posterior metaphysis Injury/Eponym Floating knee Distal femoral physeal fracture Proximal tibial physeal fracture tubercle avulsion Tibial Trauma—Pediatric 239 3–6 mo (arthroscopy) 6–12 wk. × × immobilization unless unstable or detached ± 1 cm consider open curettage, reduction, and fixation ≥ activity ↓ tension band ± 1 cm excise and drill; Treat as I if reduced. Open versus arthroscopic fixation for unreducible II, III, Treat and IV. I: Long leg cast/brace in (neutral-20 degrees) II: Closed reduction. Initially treat with Operative treatment for failure on nonoperative < Long leg cast ORIF (tension band) ORIF Similar to adults except children may be primarily repaired; isolated ligament injuries may be treated nonoperatively Closed reduction, cylinder cast Intra-articular osteochondral fracture may need excision vs. ORIF Closed reduction, rest vs. cast - , 5–15 yr ♂ < J Bone Joint

♀ 1970;52A:1677–1684) (beware vascular injury) Myers/McKeever ( Surg. I: Incomplete, nondisplaced II: Hinged (posterior) III: Supinated/rotated Comminuted IV: 33% bilateral, Nondisplaced Displaced (2–3 mm step off or 3 mm) Periosteal sleeve (usually 8–12 yr) Anterior: 40%: hyperextension Posterior: 30%: dashboard, fall on flexed knee Lateral: 18%: varus Medial: 4%: valgus Rotatory: 4%: twisting (postero lateral most common of this type, may be unreducible) Subluxation Anterior/lateral Posterior/medial Superior Intercondylar eminence fracture 8–14 yr old Osteochondral fractures (knee) Patella fracture Knee dislocation Patellar dislocation joint dislocation Tibiofibular 240 Tarascon Pocket Orthopaedica Treatment Nondisplaced: Long leg cast 10 degrees flexion Displaced: Closed vs. open reduction, long leg cast Nondisplaced: Long leg cast Displaced: Closed reduction, long leg cast Nondisplaced: Long leg cast Displaced: Closed vs. open reduction, long leg cast, internal or external fixation (plate/screws, flexible nails) Long leg cast Soft tissue reconstruction/stabilization Based on pathologic condition and fracture ** Be sure to counsel for overgrowth and correction based on age deformity: Spontaneous correction to 3 yr postinjury Valgus Tibia and Fibula Fracture Tibia 1 cm short 10 degrees angulation (varus, valgus, or recurvatum) ***GOAL < < fracture fracture both tibial, isolated fibular, Classification I: Proximal tibial metaphyseal II: Distal tibial metaphyseal III: Diaphyseal fracture isolated Special IV: Toddler’s Bicycle spoke Pathologic Injury/Eponym and fibular fracture Tibia Data from Rockwood CR, Green DP. Fractures in Adults. 4th ed. Baltimore, MD: Lippincott-Raven; 1996:2139. Data from Rockwood CR, Green DP. Trauma—Pediatric 241 1 mm. > 15 degrees plantar flex 10 valgus 2 mm or translation < < No varus > 2 yr growth 2 yr growth 5 degrees all planes Acceptable - ≥ < < percutaneous pinning or screw fixation

± 2 mm step off: ORIF > 2012;94A(13):1234–1244 3 mm initial or 2 residual articular step-off: ORIF > 2 mm displacement and 3 mm physeal widening can indicate interposed periosteum Treatment Closed vs. open reduction, cast **Restore ankle mortise/joint surface Triplane Based on CT scan. ORIF displacement Tillaux: Generally: > > Follow fractures for at least 1 yr post injury J Bone Joint Surg. Ankle Fractures 23:733-739, 2003) JPedOrthop (Data from Transverse fibula, shear Transverse medial malleolus Pronation/eversion external rotation High fibula, medial malleolar transverse physeal Supination-plantar flexion posterior Transphyseal Supination-external rotation oblique tibial Oblique fibular, Classification Dias/Tachdjian Supination-inversion • • • • • • • Axial compression (Salter- Harris V) III (Salter-Harris Juvenile Tillaux lateral tibial physis) III tibia (Salter-Harris Triplane IV anterior lateral, Salter-Harris posterior medial) CT scan SH I and II post reduction due to higher incidence of malreduction Injury/Eponym Ankle fracture 242 Tarascon Pocket Orthopaedica

Anterior Lateral Axial Section

Damian Rispoli 2009 Juvenile Tillaux

Tri-Plane Fracture

AP Lateral Damian Rispoli 2009 Radiographic Representation Trauma—Pediatric 243 (continues) graft ± Treatment Cast Cast vs. closed reduction percutaneous pinning Closed reduction percutaneous pinning 6 wk non-weight-bearing 6 wk non-weight-bearing Arthroscopy: Excision, microfracture, bone graft Arthroscopy: Excision, microfracture, bone graft Nonoperative Nondisplaced: Cast Displaced: Closed reduction percutaneous pinning vs. open percutaneous pinning vs. internal fixation Nonoperative Unstable: Closed reduction percutaneous pinning Short leg nonwalking cast, ORIF Short leg cast vs. postoperative shoe Foot Fractures A: Complete incongruity B: Partial instability C: Divergent or total instability Classification Neck I: Nondisplaced I: Minimally displaced II: Displaced Berndt/Harty I: Subchondral trabecular injury II: Incomplete separation II: Complete, nondisplaced Displaced V: Anatomic Hardcastle Jones Pseudo-Jones Injury/Eponym fracture Talus Osteochondral fracture Lesser tarsal fracture Tarsometatarsal injuries Metatarsals Base 5th metatarsal 244 Tarascon Pocket Orthopaedica pinning . 2007;27(8):856–862] J Pediatr Orthop Continued Treatment Activity modification Nonoperative Historically treated nonoperatively Good results with operative treatment [ Older age and joint incongruity may need closed reduction percutaneous vs. ORIF and the literature Long leg cast versus surgical treatment. This is a rare injury, is unclear as to the best treatment. - Foot Fractures supe ± Anterior inferior lateral process A: Tuberosity/apophysis B: Sustentaculum tali C: Anterior process D: E: Body avulsion posteriorly Tuberosity rior involvement no subtalar involvement Body, Subtalar involvement, Nondisplaced Subtalar involvement, displaced A: Tongue B: Joint depression Nonclassifiable Classification Essex-Lopresti 1 Type 2 Type 3 Type 4 Type 5 Type 6 Type See classification for apophyseal injuries around the hip. Injury/Eponym Stress fracture Phalangeal fracture Calcaneus Calcaneal apophyseal avulsion Trauma Scores/Classifications 245 TRAUMA SCORES/CLASSIFICATIONS Gustillo Classification [J Trauma 1984;24:742–746]

Grade Description Antibiotic Choice I* I Wound usually < 1 cm, clean, 1st-generation cephalosporin such 3L minimal muscle contusion, as cefazolin (Ancef) 1 gm IV q8h low energy fracture (usually for 3 d (post wound closure) inside-out type wound) II Wound usually > 1 cm, significant 1st-generation cephalosporin such 6L soft tissue injury (flaps, avulsed as cefazolin (Ancef) 1 gm IV q8h skin, nerve injury extensive muscle for 3 d (post wound closure) contusions), minimal to moderate crush component, moderate energy fractures, minimal comminution III** Wound usually > 10 cm, extensive Cefazolin for 5 d plus gentamicin 9L soft tissue damage, high energy 2 mg/kg and adjusted for serum fractures, crush/shear injuries levels or tobramycin, add 4 million units IV PCN G q6h for farmyard, highly contaminated, vascular injuries, or extensive crush injuries IIIA Soft tissue adequate for local 9L coverage, gunshot wound (GSW), segmental fracture IIIB Periosteal stripping, exposed Consider antibiotic bead pouch*** 9L bone, extensive soft tissue injury, contamination, requires soft tissue reconstructive surgery IIIC Type III with vascular injury requiring Consider antibiotic bead pouch*** 9L repair for limb survival Data from Chapman MW, Olson SA. Open fractures. In Rockwood CA, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults. 4th ed. Philadelphia: Lippincott-Raven Publishers; 1996: 305–352. Anglen JA, Wound Irrigation in Musculoskeletal Injury, JAAOS. 2001 9(4):219–226. *Irrigation: Additives (antiseptics, antibiotics, and surfactants) not universally recommended **Automatic type IIIs: Segmental fractures, farmyard injuries, fractures occurring in highly contaminated environments, shotgun wounds, high-velocity gunshot wounds ***Antibiotic beads: Tobramycin, gentamicin, vancomycin, or cephalosporin (0.5–1 g per 40 g cement). Topical antibiotics in the irrigant are controversial but favored by some. Consider culture. [Clin Orthop. 1986;212:227] Thorough and adequate debridement and irrigation are imperative and the keystone in the treatment of all open injuries. 246 Tarascon Pocket Orthopaedica Open Hand Injuries Consider: 1. The patient as a whole 2. Other injuries; resuscitation 3. History 4. Physical exam 5. Restoration of blood flow 6. Debridement (repeat debridement) 7. Skeletal stability 8. Repair of damaged structures 9. Appropriate timing of closure and coverage (when in doubt, don’t close) 10. Proper dressings and elevation 11. Tetanus prophylaxis and antibiotics (antibiotics as useful “adjuncts.” Antibiotics never substitute for adequate debridement. Cover severe wounds with oxacillin or 1st-generation cephalosporin.) 12. Secondary reconstruction 13. Rehabilitation (as early as possible) 14. Tetanus prophylaxis [Brown PW. Open injuries of the hand. In: Green’s Operative Hand Surgery, 3rd ed. Philadelphia, PA: Churchill Livingstone; 1993:1607–1630.] Trauma Scores/Classifications 247

y, s, talit es age uting ation, v ascular x le ib es age e mor v ocedur nal fi ageab uction ladder er ation, v v T contr x ocedur y consultation, pr sal Ext Limb sal ther limb sal immediat ischemia < 6 hour ger r constr nal fi (clinical decision ) rd staged pr consultation, plastic rm Fu er sur ools: s Re limb NO t int owa Wa Ye t e inition) ailur e f oad def Mangled limb y/lat (Br l Ear Management of Severe Extremity Soft Tissue Trauma Management of Severe Extremity Soft Tissue ,

e, s ty s, Ye tali ocedur uting e mor le (clinical ib close) ving pr ’t ageab decision) v eser don immediat ischemia > 6 hour limb contr rd rm not sal owa Wa Amputation (consider open t length-pr 248 Tarascon Pocket Orthopaedica TUMOR

Age Distribution of Various Common Bone Lesions Age Malignant Benign Birth to 5 yr Leukemia Osteomyelitis Metastatic neuroblastoma Osteofibrous dysplasia Metastatic rhabdomyosarcoma Osteochondroma (after 5 yr) Wilms’ tumor Chondroblastoma (after 5 yr) 10–25 yr Osteosarcoma Eosinophilic granuloma Ewing’s sarcoma Osteomyelitis Leukemia Enchondroma Adamantinoma Fibrous dysplasia Aneurysmal bone cyst Giant cell tumor Simple bone cyst 40–80 yr Metastatic bone disease Hyperparathyroidism Myeloma Paget’s disease Lymphoma Mastocytosis Paget’s sarcoma Post radiation sarcoma Malignant fibrous histiocytoma

Staging System for Musculoskeletal Lesions (Enneking) Stage GTM Description IA G1T1M0 Low grade, intracompartmental, no metastasis IB G1T2M0 Low grade, extracompartmental, no metastasis IIA G2T1M0 High grade, intracompartmental, no metastasis IIB G2T2M0 High grade, extracompartmental, no metastasis IIIA G1 or 2 T1M1 Any grade, intracompartmental, metastasis IIIB G1 or 2 T2M1 Any grade, extracompartmental, metastasis

Grade: G1: low-grade, less common, metastasis < 25% G2: high-grade, metastasis > 25% Tumor site: T1 intracompartmental T2 extracompartmental Metastasis: M0: no metastasis (regional or systemic) M1: metastasis (regional or systemic) Skip lesions place the patient into a stage III category. Tumor 249 General Guidelines for Prophylactic Fixation in Metastatic Disease Pattern of bone destruction Purely lytic: High risk Purely blastic: Lower risk Size < 25–35% cortical destruction: Low risk > 50–75% cortical destruction: High risk Location High-risk regions: Femur neck, subtrochanteric, diaphysis Pain Risk increased with activity-related pain (mechanical pain) Post irradiation Fixation to improve pain and increase mechanical strength (Beware of wound-healing complications post radiation.) Prognosis Survival < 4 wk: Nonoperative treatment Data from Frassica FJ, et al. Metastatic bone disease: Evaluation, clinicopathologic features, biopsy, fracture risk, nonsurgical treatment, and supportive management. AAOS Instructional Course Lectures. 2000;49:453–459.

Scoring System to Predict Pathologic Fracture

Parameter Score 1 2 3 Pain None Moderate Activity related Location Upper extremity Lower extremity Peritrochanteric Bone destruction Blastic Mixed Lytic Size < 1/3 1/3–2/3 > 2/3 Fracture group: median 10, range 7–12 Nonfracture group: median 7, range 4–9 Scores 9 or higher: fixation recommended Data from Mirels H. Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop. 1989;249:256–264.

Osteoblastic Metastasis “LBP”: Lung/breast/prostate 30–60–90% of respective lesions are blastic on radiographic evaluation. Skeletal Fixation of Metastatic Carcinoma • Goal is to maximize function and minimize pain. • The goal is not to effect a cure in metastatic disease. • Skeletal fixation or radiation therapy can meet goals (should generally radiate following skeletal fixation). 250 Tarascon Pocket Orthopaedica Laboratory Studies in Evaluation of a New Tumor Patient 5–40 yr 40–80 yr Complete blood count with differential Complete blood count with differential Erythrocyte sedimentation rate Erythrocyte sedimentation rate Peripheral blood smear Chemistry group, calcium and phosphate Serum or urine electrophoresis Urinalysis PSA CBC: Myeloma, infection, any marrow-packing disorder ESR: Infection Peripheral blood smear: Lymphoma, leukemia, infection Chemistry, calcium, phosphate: Metabolic disease, diabetes, metastasis, osteosarcoma Serum or urine electrophoresis: Myeloma Urinalysis: Renal cell

Round Cell Lesions by Age Lesion Age Neuroblastoma 2–3 Subchondral bone lesions Eosinophilic granuloma 4–20 Giant cell tumor Ewing’s sarcoma 10–25 Chondroblastoma Lymphoma 30–60 Clear cell chondrosarcoma Myeloma 50+ Metastasis 50+ Infection Any

Five lesions that can look like anything (radiographically): • Fibrous dysplasia • Metastatic lesions • Chondroid lesions • Infection • Eosinophilic granuloma Lodwick’s Classification (Radiographs of Bone Lesions) IA: Well circumscribed, sclerotic IB: Circumscribed, minimally sclerotic IC: Poorly circumscribed II: Moth eaten (geographic) III: Permeative (diffuse) Tumor 251 Malignant Lesions

Bone Soft Tissue Osteosarcoma1 Soft tissue sarcoma Chondrosarcoma2 Fibrosarcoma Ewing’s sarcoma3 Liposarcoma4 Metastatic lesions Leiomyosarcoma Lymphoma Malignant spindle cell sarcoma (NOS) Myeloma Malignant schwannoma/neurofibrosarcoma Chordoma Rhabdomyosarcoma5 Adamantinoma Synovial sarcoma6 1,2,31st, 2nd, and 3rd most common primary bone sarcomas. 4Most common soft tissue sarcoma in adults. 5Most common soft tissue sarcoma < 15 yr old. 6Most common soft tissue sarcoma of the lower extremities.

Intra-Articular Tumors • Pigmented villonodular synovitis (nodular or diffuse) • Synovial chondromatosis • Synovial cell sarcoma (rare) • Synovial chondrosarcoma • Lipoma arborescens Musculoskeletal Tumor Society (MSTS) Stages of Disease Benign Disease Malignant Disease 1 Benign, inactive (latent) I Low grade 2 Benign, active II High grade 3 Benign, aggressive III With regional or distant metastasis 252 Tarascon Pocket Orthopaedica i i y s s i a p h t D y s s e a p h M Epiphysis Damian Rispoli 200 9 Non-ossifying Fibroma Osteochondroma Giant-Cell Tumor— Child Giant-Cell Tumor (adult extends to end of bone ) Round Cell Lesions -Ewing’s Sarcoma (equally as common in the metaphysis ) -Reticulum Cell Sarcoma -Myelom a Fibrosarcoma Adamantinoma Enchondroma Osteoblastoma Osteosarcoma Osteoid Osteoma Fibrous Dysplasia Chondrosarcoma Chondroblastoma Fibrous Cortical Defec t Simple Bone Cyst Chondromyxoid Fibroma Modified from Madewell JE, Ragsdal e BD, Sweet DE. Radiologic and Pathologic analysis of solitary bone lesions, Part I. Internal Margins. Radiol Clin North Am 1981;19(4):784-814 Appendix A: Steroid Preparations 253 APPENDIX A: STEROID PREPARATIONS Steroid Preparations Equivalent Solubility Generic Name Trade Name Dose (mg)* Most soluble Betamethasone sodium Celestone 0.6 phosphate Soluble Dexamethasone sodium Decadron 0.75 phosphate Hydeltrasol Prednisolone sodium 5 phosphate Slightly Prednisolone tebutate Prednisol TBA 5 soluble Triamcinolone triacetate Aristospan Forte 4 Methylprednisone acetate Depo-Medrol 4 Relatively Dexamethasone acetate Decadron-LA 0.75 insoluble Hydrocortisone acetate Hydro-acetone 20 Prednisolone acetate Predalone 5 Triamcinolone acetonide Kenalog 4 Combination Triamcinolone hexacetonide Aristospan 4 Betamethasone sodium Celestone Soluspan 0.6 phosphate Betamethasone acetate1 *For example, 0.6 mg of betamethasone sodium phosphate is equivalent to 0.75 mg of dexamethasone sodium phosphate, which is equivalent to 5 mg of prednisolone. 1Betamethasone acetate is slightly soluble Fadale PD, Wiggins ME. Corticosteroid injections: Their use and abuse. J Am Acad Orthop Surg. 1994;2(3):133–139.

Concerns

Three Main Concerns: Postinjection flare Long-term joint damage Serious infection Other Concerns: Crystal-induced synovitis Local cutaneous atrophy Steroid arthropathy

Intra-articular steroid injections have been shown to be: • Good for short-term pain relief in osteoarthrosis flares • Good short-term relief ~1–3 weeks (placebo-controlled studies) • Recommended no more than four injections per year in a single joint [AAOS IMCA Osteoarthritis of the Knee, 2002]

**Recent literature identified an increased risk of infection with steroid injections given within 3 months of total joint arthroplasty (hip, knee, and shoulder)** 254 Tarascon Pocket Orthopaedica APPENDIX B: INTERNET RESOURCES Journals American Journal of Sports Medicine: www.ajsm.org Arthroscopy: www.arthroscopyjournal.org Clinical Orthopaedic and Related Research: www.clinorthop.org Journal of Arthroplasty: www.arthroplastyjournal.org Journal of Bone and Joint Surgery: www.jbjs.org Journal of Foot and Ankle Surgery: www.jfas.org Journal of Hand Surgery: http://www.sciencedirect.com/science/journal/03635023 Journal of Orthopaedic Trauma: www.journals.lww.com/jorthotrauma Journal of Shoulder and Elbow Arthroplasty: www.jshoulderelbow.org Journal of the American Academy of Orthopaedic Surgeons: www.jaaos.org Journal of Trauma: www.jtrauma.com Orthopaedic Blue Journal (Healio): www.healio.com/orthopedics/journals/ortho Orthopedics Today: www.healio.com/orthopedics Physician and Sports Medicine: www.physsportsmed.com Spine: www.spinejournal.com Companies Acumed: www.acumed.net Arthrex: www.arthrex.com DePuy/J&J: www.depuysynthes.com Exactech: www.exac.com Jones and Bartlett Learning: www.jblearning.com Orthofix: www.orthofix.com Skeletal Dynamics: www.skeletaldynamics.com Stryker: www.stryker.com Smith & Nephew: www.global.smith-nephew.com Tarascon Publishing: www.tarascon.com Wolters-Kluwer: www.lww.com Wright Medical Group/Tornier: www.wright.com Zimmer/Biomet: www.zimmerbiomet.com Orthopedic Web Sites AAOS Appropriate Use Criteria: www.aaos.org/auc American Academy of Orthopedic Surgery: www.aaos.org Orthogate: www.orthogate.org Orthoinfo (AAOS): www.orthoinfo.aaos.org Orthoillustrated (Arthrex): www.orthoillustrated.com Wheeless Online: www.wheelessonline.com Bone tumor information site: www.bonetumor.org General Web Sites U.S. Centers for Disease Control and Prevention: www.cdc.gov U.S. National Library of Medicine: www.nlm.nih.gov National Institutes of Health (NIH): www.nih.gov NIH Library: www.ncrr.nih.gov Index 255 INDEX Note: Page number followed by “p” indicates that the entry is a pediatric reference

A anterior drawer arthritis, degenerative, ABCDEs mnemonic, 1 ankle, 140 86–87 acetabular fractures, knee, 138 arthroplasty, total joint, 53 205, 206 anterior humeral line, 149 arthroscopic classification, of acetabular index (DDH), anterior interosseous nerve osteochondritis dissecans, 153, 154 quick neurologic test, 123 101p acid–base values, 3 schematic, 40 asymmetric external rotation acromioclavicular joint anterior spinal laminar test, 138 injection/aspiration, 134 line, 143 atlanto dens interval acute concussion, 165 anteroposterior (ADI), 144 acute lateral ankle sprains, impingement, 138 atypical infections, 63 classification of, 214 anteroposterior talocalcaneal autonomic dysreflexia, 166 adolescent idiopathic angle, 159 axillary nerve schematic, 39 scoliosis, 111–114 antibiotic doses, 64–65p Lenke classification of, 114 antibiotic mechanisms, 63 B Adson’s test, 136 antibiotic prophylaxis, Babinski sign (spine), 136 adult trauma 75–76 Baby Bennett’s fracture, 180 ankle, 214–215 for dental procedures, 75 back pain, in children, 102p elbow, 184–188 for GI procedures, 76 Bado classification, femur, 211 for urologic procedures, 76 184, 225p foot, 216–219 anticoagulation therapy, balanced suspension, forearm, 183 76–77 with/without skeletal hand, 177–181 antihistamines, 95p traction, 175 hip, 207–210 antimicrobial Barlow (DDH), 137, 138p knee, 211–213 antivenin, 55 Barton’s fracture, 182 leg, 215 bites, 54–55 basion-axis interval, 143 pelvis, 201–205 bursitis, 57 basion-dens interval, 143 periprosthetic, 207 diabetic foot, 56 basketball foot, 216 shoulder, 189–195 flexor tenosynovitis, 62 bat bite, 55 spine, 196–201 hand, 57 belly press, 132 wrist, 182–183 necrotizing fasciitis, 62 Bennett’s fracture, 178, 180 Allen’s test, 121 osteomyelitis, 58–60, 109p Berndt/Harty classification, allogeneic blood transfusion septic arthritis, 51–54 243p risk, 77 skin infections, 61–62 bites (traumatic), 54–55 analgesics, 95p apprehension test viral infections associated angles, 95–97p (shoulder), 132 with, 56 ankle arm blanch sign (SCFE), 107p approaches, 19 cross section, 21–23 Blickenstaff/Morris class block, 142 fasciotomy, 68–69 (femoral neck), 207 fasciotomy, 70 muscles, 8 blood joint injection/aspiration, trauma (fracture), 183 estimated loss, 3–4 141 arteries pressure estimation, 3 ligaments, 35 axillary, 30 systemic response, 4 muscles, 15–16 elbow, 27–28 transfusion risk, 77 radiologic views, 159–160 forearm, 28 volume, 3 tests, 140–141 knee, 29 Blount’s disease, 101, 110 trauma (fracture), pelvis, 29 Blumensaat’s line, 158 214–215, 241p shoulder, 26–27 Bohler’s angle, 160, 162 256 Index bone lesions, radiographs chronic traumatic DEXA osteoporosis criteria, 85 of, 250 encephalopathy, 165 diabetic foot infection, 56 both bone fracture, 183, Cierny-Mader staging dial test (knee), 139 224p system, 60 Dias/Tachdjian Boutonniere deformity, clonus (spine), 136 classification, 241 177, 178 clubfoot, 100p diffuse axonal injury, 165 bowstring (spine), 136 Cobb angle, 143, 144 discitis, 110p Boxer’s fracture, 179 Coleman block test, 140 discoid meniscus, 157 brachial plexus, 36, Colles’ fracture, 182 dislocation 100–101p Colton classification, 185 carpus/perilunate, 183 Brown-Sequard common peroneal nerve, 45 elbow, 187, 228–229p syndrome, 169 compartment syndrome, facet, 198 Bryant’s traction, 173 65–67 glenohumeral, 232p Buck’s traction, 173 complete cord syndrome, 169 hand, 180–181, burns, 6 concussion, 164–165 221–223p bursitis, 57 in athletes, 164 hip, 209, 234p neuropsychological knee, 212–213, 239p C testing, 164 patella, 212, 239p Cain classification, 181 stages of injury, 165 radial head, 225p calcaneal fractures, 217 congenital spine deformities, scapulothoracic, 194, 232p calcaneal traction pin, 171 114p shoulder, 194–195, calcaneovalgus, 100p congruence angle, 158 231–232p calcium metabolism, 78 coxa vara tibia-fibula, 240p calcium pyrophosphate epiphyseal angle, 154 distal femoral traction crystals (CPPD), 79 neck shaft angle, 155, 205 pin, 172 calcium recommendations, 86 cross arm test, 132 distal phalanx fracture, Capitolunate angle, 148, 149 cross section 177, 221 cardiac tamponade, 3 arm, 21–22 dog bite, 54 carpal tunnel tests, 121 forearm, 22–23 Drennan’s angle, 110 carrying angle (elbow), 149 leg, 25 drop arm test, 132 Carvajal’s formula, for fluid spinal cord, 168 drop sign, 132 resuscitation in burns, 6 thigh, 24–25 Duverney fracture, 235p cat bite, 54 wrist, 23 dysplastic conditions, catfish barb, 54 crossed finger test, 121 103–104p central cord syndrome, 169 crossed straight leg raise, 136 cervical spine cyclo-oxygenase 2 E development, 96p inhibitors, 87 early onset idiopathic cervical spine radiographic scoliosis, 111p lines D elbow atlanto dens interval, 144 Danis/Weber classification, approaches, 17 Chamberlain’s line, 144 215 fat pad (x-ray), 148 McCrae’s line, 146 deep peroneal nerve flexion test, 121 McGregor’s line, 146 block, 142 injection, 131 Pavlov’s ratio, 146 degenerative arthritis, ligaments, 31 Power’s ratio, 145, 146 86–87 radiographic views, 132 space available for the cord Delbet class, 234p radiologic views, 149–150 (SAC), 146 DeLee classification, 227p tests, 129–132 cervical spine trauma, dermatomes, 49 trauma (fracture), 196–201 peripheral, 46, 48 184–188, 226–230p Chamberlain’s line, 144 developmental dysplasia of Elson test, 121 chance fracture, 200 the hip (DDH), 119 EMG/NCV test, 81–82 Chauffeur’s fracture, 182 evaluation and treatment, epiphyseal angle, 154 chest tube, 2 algorithm for, 120 Epstein classification, 209 child abuse, 117p lines/angles, 154–155 Erb-Duchenne palsy, 100p Index 257 Essex-Lopresti fracture, 188 Foley catheter, 3 gout, 79 classification, 244p foot Gram stain, 80 extensor digitorum avulsion, deformities, 99–100p growth centers, 97–99p 177 fasciotomy, 71 Guhl classification, of extensor tendon zones, 123 muscles, 15–16 osteochondritis dissecans, external rotation lag radiologic views, 159–160 101p sign, 133 trauma (fracture), gunshot wounds (spine), 201 external rotation recurvatum 216–219, 243–244p Gustillo classification, 245 (knee), 139 forearm approaches, 17 H F arteries, 28 Hahn-Steinthall class, 185, FABER test, 138 cross section, 22–23 186, 228p Fairbank’s changes, 157 fasciotomy, 68–69 halo placement, 176 fasciotomy muscles, 8–10 hand ankle, 70 trauma (fracture), 183, fasciotomy, 67–68 arm, 68–69 223–225p infections, 57 finger, 67 fractures injuries, 246 foot, 71 acetabular, 205, 206 muscles, 10–11 forearm, 68–69 ankle, 215, 241p rotational alignment, 126 hand, 67–68 arm, 183, 223–225p tests, 121–127 leg, 70 carpal bones, 183, 222p trauma (fracture), thigh, 69 elbow, 184–188, 226–230p 177–181, 221–223p femoral nerve femur, 211, 237p Hangman’s fracture, 197 schematic, 43 foot, 216–219, 243–244p Hardcastle classification, 243p traction test, 136 forearm, 183, 223–225p Hardinge approach, 18 femur trauma (fracture), hand, 177–181, 221–223p Harris line, 144 211, 237p hip, 207–208, 234p Hawkins sign/test, 133, 216 finger knee, 211–212, 238–239p Hawkins/Canale fasciotomy, 67 pelvic, 201–205, 235p classification, 216 mallet finger, 125 periprosthetic, 207 hematoma block, 127 finger block, 127 Salter-Harris, 105p Henry approach, 17 finger extensor apparatus, 32 shoulder, 189–195, herpetic whitlow, 57 finger puller system, 33 231–232p Herring classification, 118p Finkelstein test, 121 spine, 196–201, 200, 233p Hilgenreiner’s line, 153, 154 first metatarsophalangeal tibia/fibula, 212, 213, 240p Hill-Sachs lesion, 189 angle (bunions), 160, 162 wrist, 182–183, 221–223p hip fleck sign, 160 Frankel grading, 167 approaches, 18 flexor digitorum profundus Froment’s sign, 121 muscles, 11–13 tendon avulsion, 177 frozen section, 80 radiographic lines, flexor digitorum profundus 154–155 test, 121, 122 G tests, 138 flexor digitorum superficialis Galeazzi fracture, 183, trauma (fracture), test, 121, 122 184, 225p 207–210, 234p flexor tendon Galeazzi test, 138 Hoffmann’s sign (spine), 136 block, 127 Gamekeeper’s thumb, 181 Holstein-Lewis fracture, 187 laceration, 179 Garden classification, 207 Horn blower’s test, 133 sheaths, 124 Gardner-Wells tongs, 176 Hotchkiss classification, 187 test for continuity, 121 genu varum, 110p human bite, 55 zones, 123 Gissane’s angle, 160, 162 Hunter’s syndrome, 102p flexor tenosynovitis, 62 Glasgow coma scale, 5 Hurler’s syndrome, 102p floating knee, 211, 238p glenohumeral dislocation, hydrocortisone, fluid loss estimate, 3–4 232p supplemental, 89 fluid management, 3 glenohumeral injection, 135 hypercalcemia, 80 fluid resuscitation in burns, 6 glenohumeral ligaments, 30 hypocalcemia, 80–81 258 Index I Kocher approach, 17, 18 lower versus upper motor Ideberg classification, 194 Kocher-Lorenz fracture, 185, neuron lesions, 167 iliac crest pins, 72 186, 228p Ludloff approach, 18 ilioischial line, 154, 155 Kocher’s fracture, 184 lumbar iliopectineal line, 154, 155 kyphosis, 116 plexus, 37 impingement sign/test, 133 stenosis, 167 infantile idiopathic scoliosis, L trauma (fracture), 200 111p Lachman’s test, 139 lunate tilt, 150 infection imitators, 63 lag sign, 133 infection, laboratory tests Lagenbach approach, 18 M for, 80 lateral atlanto-dens Maissenouve fracture, 214 inferior gluteal nerve, 43 interval, 144 Malgaigne fracture, 184, Insall ratio (patella), 158 lateral capsular sign, 157 236p intermetatarsal angle, lateral mass distance, 144 malignant lesions, 251 160, 162 lateral patellofemoral angle mallet finger, 125, 177, 221p intra-articular tumors, 251 (Laurin), 158 March fracture, 216 IV, initial fluid, 3 lateral pivot shift test, Mason classification, 187 IV maintenance therapy, 3 129, 131 Mayfield’s stages, 183 lateral talocalcaneal McCrae’s line, 146 J angle, 160 McGregor’s line, 146 Jakob classification, 227p Lauge-Hansen, 215 McMurray’s test, 139 Jefferson fracture, 196 Laugier fracture, 185 Meary’s angle, 160 Jersey fracture, 221p Laurin angle (patella), 158 median nerve Johner/Wruhs leg innervated hand muscles classification, 213 approaches, 19 (LOAF), 40 joint fluid analysis, 78–79 cross section, 25 schematic, 40 Jones fracture, 219, 243p fasciotomy, 70 meniscofemoral ligaments, 34 muscles, 14–15 metabolic bone disease, K trauma (fracture), 80–81 Kellgren and Lawrence 215, 240p metacarpal fracture, grading system, for knee Legg-Calves-Perthes, 118p 177–179 osteoarthritis, 159 Lenke classification, metaphyseal blanch sign, Key/Conwell class, 235p scoliosis, 114 107p Kilfoyle classification, 227p Letournel classification, of metaphyseal-diaphyseal King curves, 112p pelvic fractures, 205, 206 angle, 110p, 159p Kite’s angle, 159 Letts/Vincent class, 238p metastatic carcinoma, Klein’s line, 155 Lhermitte’s sign (spine), 136 skeletal fixation of, 249 Kline’s line, 107p liftoff test, 133 metatarsal fracture, 218 knee ligaments metatarsophalangeal joint approaches, 19 ankle, 35 dislocation, 219 arteries, 29 elbow, 31 metatarsus varus, 100p diaphyseal angle, 110p knee, 34–35 Meyer/McKeever injection/aspiration, 140 pelvic, 34 classification, 212 lateral and medial shoulder, 30 midtarsal injury, 217 layers, 30 syndesmosis, 35 Milch classification, radiographic lines, wrist, 31 227p, 230p 157–158 limp, in children, 107–111p Milch fracture, 184 tests, 138–140 Lisfranc injury, 218 milestones, 95–97p trauma (fracture), Listhesis grades, 166 milking maneuver test, 129 211–213, 238–239p little leaguer elbow, 228p modified Bryant’s knee osteoarthritis, Kellgren load shift test, 133 traction, 173 and Lawrence grading Lodwick’s classification, 250 monosodium urate system for, 159 low back pain, 168 crystals, 79 Index 259 Monteggia fracture, 183, nightstick fracture, 183 limp, 107–111p 184, 225p 90–90 skeletal traction, 174 medications, 95p Morquio’s syndrome, 102p nonsteroidal anti- milestones and angles, motor innervation inflammatory drug 95–97p axillary/MC, 39 (NSAIDs), 87, 88 myelodysplasia levels, 97p common peroneal, 45 Nursemaid’s elbow, 225p, night pains, 101p femoral/obturator, 43 230p osteomyelitis, 58–60 inferior gluteal, 43 nutcracker fracture, 217 reflexes, 96p median, 40 rotational profile, 96p obturator, 43 O septic arthritis, 51, 108 radial, 41 obesity, 83 traction, 173p sciatic, 44 O’Brien’s test, 133 verbal score, 5p superior gluteal, 43 obturator nerve, 43 vital signs, 4p tibial, 44 Ogden classification, 212, pediatric trauma ulnar, 42 238p ankle, 241p moving valgus stress test, Olecranon fracture, 185 elbow, 226–230p 129, 130 open hand injuries, 246 femur, 237p MRI signal characteristics, oral antibiotic doses, 64–65p foot, 243–244p 151 orthopaedic oncology. See forearm, 223–225p mucopolysaccharidosis, 102p tumor hand/wrist, 221–223p muscle strength testing, 166 Ortolani test, 137, 138p hip, 234p muscles osteoarthrosis (radiographic knee, 238–239p arm, 8 arthritis), 151 leg, 240p foot/ankle, 15–16 osteoblastic metastasis, 249 pelvis, 235–236p forearm, 8–10 osteochondral fracture, 243p shoulder, 231–232p hand/wrist, 10–11 osteochondritis dissecans, spine, 233p hip, 11–13 Guhl classification, 101p Pelligrini-Steida lesion, 157 leg, 14–15 osteochondroses, 101 pelvic arteries, 29 shoulder, 7 osteomyelitis, 58–60p, 109p pelvic external fixation, 72 thigh, 13 osteonecrosis, 84–85 pelvic ligaments, 34 musculocutaneous nerve, 39 osteoporosis, 85–86 pelvic radiographic lines, 154 musculoskeletal lesions, risk factors, 85 pelvic stabilization, acute, 72 staging system for, 248 osteosclerosis, 81 pelvis Musculoskeletal Tumor approaches, 18 Society (MSTS) stages of P radiologic views, 154–155 disease, 251 pain management, 86–87 trauma (fracture), myelodysplasia levels, 97 Parkland formula, for fluid 201–205, 235–236p Myers/McKeever resuscitation in burns, 6 perioperative management, classification, 239p paronychia, 57 87–89 passive test of continuity, 121 peripheral dermatomes N patellar apprehension, 139 lower extremity, 48 navicular fracture, 217 pathologic fracture, scoring upper extremity, 46 neck-shaft angle, 155, 205 system to predict, 249 peripheral nerve disorders, necrotizing fasciitis, 62 Pavlov’s ratio, 146 electrodiagnostic findings needle manometer, 66 pediatric in, 82 Neer classification, 189 back pain, 102p peripheral sensory Neer impingement test/ calcium recommendation, innervation sign, 133 86p lower extremity, 47 nerve injury, classification child abuse, 117p upper extremity, 46 of, 83 foot deformities, 99–100p periprosthetic fractures, 207 neuromuscular scoliosis, genu varum, 110p Perkins vertical line, 111p growth plates/centers, 153, 155 night pains in children, 101p 97–99p persistent concussion, 165 260 Index phalangeal fracture, 177, pseudo-Jones fracture, S 178, 219 218, 243 sacral inclination, 146 Phalen’s test, 121 pseudogout, 79 sacral plexus, 37–38 phosphate metabolism, 78 sacral spine trauma, 200 physical exam/injections Q Salter-Harris classification, elbow, 129–132 Q angle (knee), 159 105p, 223p, 238p foot/ankle, 140–141 quadrangular space, 30 Salter-Harris type II hand, 121–127 Quadriga effect, 122 fracture, 178 hip, 138 Sanfilippo’s syndrome, 102p knee, 138–140 R saphenous nerve block, 142 shoulder, 132–135 raccoon bite, 55 scaphoid fracture, 223p spine, 136–137 radial bursa, 124 scapholunate wrist, 128 radial head dislocation, 225p angle, 148, 150 Piedmont fracture, 183 radial inclination, 149 interval, 150 pig bite, 55 radial nerve exploration, 189 scapulothoracic dislocation, Pipkin classification, radial nerve, schematic, 41 194, 232p 209, 210 radial volar tilt, 150 Scheuermann’s kyphosis, 116 pivot shift (knee), 139 radiocapitellar line, 149 sciatic nerve, 44–45 plexus radiocapitellar plica, 129 sciatic notch, contents, 20 brachial, 36 radiologic views scoliometer, 111p lumbar, 37 foot/ankle, 159–160 scoliosis, 111p sacral (posterior), 37 hip/pelvis, 154–155 Cobb angle, 143, 144 sacral (anterior), 38 lower extremity, 158–159 King curves, 112p pneumothorax (tension), 2 spine, 143–144, 146 progression risk polarized microscopy, 79 upper extremity, 149–150 factors, 112 Ponseti technique, 100 radiolunate angle, 150 Risser stages, 112p, 113p POPSIQ mnemonic, 20 rat bite, 55 treatment guidelines, 112 Posadas fracture, 184 reflexes, 96p, 166 Scotty dog, 146 post menisectomy Regan test, 122 secondary survey, 2 radiographic changes, 157 Regan/Morrey classification, Seddon classification, 83 posterior drawer 185 segond fracture, 157 knee, 139 relocation sign, 134 Seinsheimer shoulder, 134 resisted straight leg classification, 208 posterior interosseous raise, 138 semimembranosus five nerve schematic, 41 resuscitation, 1 insertions, 35 PIN compression, 129 reverse mallet finger, 221p septic arthritis, 51–54, 108 quick neurologic test, 123 reverse Monteggia severe extremity soft tissue posteroinferior fracture, 183 trauma, management impingement, 138 rheumatoid arthritis of, 247 posterolateral rotatory (osteoarthrosis), 151 Seymour fracture, 221p instability (elbow), rheumatologic disorders, Shatzker classification, 129, 130 perioperative management, 210, 211 Power’s ratio, 145, 146 87–88 Shenton’s line, 153, 155 prevertebral soft tissue Risser stages, 112p, 113p shoulder swelling, 146 Rolando’s fracture, 178, 180 approaches, 17 primary survey, 1 rotational profile, 96p arteries, 26–27 prolonged concussion round cell lesions, by ligaments, 30 syndrome, 165 age, 250 muscles, 7 proximal humerus, 17 Ruedi/Allgower spaces, 27, 30 proximal tibial metaphyseal- classification, 215 tests, 132–135 diaphyseal angle, 159p Rugger jersey finger, 177 trauma (fracture), proximal tibial traction Russell’s skin traction, 189–195, 231–232p pin, 172 173, 175 Silfverskiöld test, 140 single leg heel raise test, 141 Index 261 skeletal survey, in child supra-acetabular tissue frozen section, 80 abuse, 117p pins, 72–73 tobacco abuse, 90 Skier’s thumb, 181 sural nerve block, 142 Toniolo/Wilkins skin infections, 61–62 surgical stress, classification, 228p skin traction, 174 hydrocortisone for, 89 too many toes sign, 141 skunk bite, 55 Swan neck deformity, 126 total joint arthroplasty, 53 slip angle syndesmosis, ligaments tourniquet, 90 (spondylolisthesis), 146 of, 35 traction, 171–176 slipped capital femoral systemic responses to blood types of, 173 epiphysis, 106–107p loss, 4 traction pins, placement of, Klein’s line, 155 systolic blood pressure, 171–172 small joint fusion, 179–181 estimated, 3 transient synovitis versus Smith-Peterson approach, 18 septic arthritis, 108 Smith’s fracture, 182 T trauma. See adult trauma; snake bite, 55 T-Condylar fracture, 228p pediatric trauma space available for the cord talar tilt test, 141 trauma radiographs, 2 (SAC), 146 talipes equinovarus, 100p tri-plane fracture, 242p Speed’s test, 134 talo-calcaneal angle, 100p triangular interval, 30 spinal cord injury, 165–169 tamponade (cardiac), 3 triangular space, 30 syndromes, 169 tarso-metatarsal fracture/ tumor, 248–252 treatment by functional dislocation, 218 intra-articular, 251 level, 169 tarso-metatarsal injuries new patient, evaluation spine (x-ray), 163 of, 250 gunshot wounds, 201 teardrop, 154, 155 Tylenol, 86 radiology, 143–144, 146 tendon laceration, 179 stable fracture criteria, 201 tennis elbow test, 129 U stenosis criteria, 167 tenodesis effect, ulnar bursa, 124 tests, 136–137 122, 125 ulnar nerve trauma (fracture), tension pneumothorax, 2 quick neurologic 196–201, 233p tetanus, 89 test, 123 split Russell’s traction, 173 immunization, 89 schematic, 42 spondylolisthesis, wound classification, 89 ulnar variance, 150 147, 166 thigh upper versus lower motor sacral inclination, 146 approaches, 19 nerve lesions, 167 slip angle, 146 cross section, 24–25 spondylolysis, 166 fasciotomy, 69 V Scotty dog, 146 muscles, 13 V-sign of Light, 180 Spurling’s test, 122 trauma (fracture), 211 valgus elbow test, 129 steroids in cord injury, 165 Thompson approach, 17 varus/valgus (knee), 139 straddle fracture, 236p Thompson/Epstein vasculature straight leg raise, 136 classification, 209 elbow, 27–28 stress fracture risk, 201 Thompson’s test, 141 forearm, 28 subacromial injection, 135 thoracic spine trauma, 200 knee, 29 subchondral bone Thurston-Holland fragment, pelvis, 29 lesions, 250 105p shoulder, 26–27 sulcus angle (patella), 159 tibial nerve venous thromboembolic sulcus sign, 134 block, 142 disease (VTE), 91–92 Sunderland classification, 83 schematic, 44 verbal score, pediatric, 5p superficial peroneal nerve tibial traction pin, vertebral infection, 110p block (ankle), 142 proximal, 172 vital signs, pediatric, 4p superior gluteal nerve, 43 Tillaux fracture, 242p vitamin D recommendation, 86 superior labrum anterior- Tinel’s test, 122 volar approach, 18 posterior (SLAP) lesions, 192 tissue biopsy, 80 volar wrist ligaments, 31 262 Index W wound healing indices, 93 wrist injection, 128 Wackenheim line, 146 wrist wrist radiographic lines/ Waddell’s signs, 136 approaches, 18 angles, 152 Watson-Jones approach, 18 cross section, 23 capitolunate, 148 Watson test, 122 ligaments, 31 scapholunate, 148 Weber classification, 214 muscles, 10–11 white blood cell (WBC) nerves framing, 29 Y count, 79 trauma (fracture), Yergason’s test, 134 Wiberg center edge 182–183, 221–223p Young/Burgess classification, angle, 155 wrist arcs, 150 of pelvic fractures, Winquist classification, 211 wrist block, 128 202, 204