Free Orthopedics Review | Dr Hutaif General Orthopedics -...

Open debridement is the treatment of choice if an early deep wound infection is confirmed after spinal fusion. The instrumentation is left in place to stabilize the wound and promote fusion. The wound is closed as long as it can be cleaned up adequately during surgery, and muscle has a healthy appearance. If this cannot be achieved or if several debridements fail, the wound may be left open.

Idiopathic adolescent scoliosis is likely to progress in adulthood if it exceeds 50°. The rate of progression in adults is slower than during adolescence; about 1° per year. Nevertheless, it is likely to have some effect on pulmonary function later during adulthood. The effect is one of restrictive rather than obstructive lung disease. There is an increase in the risk of back pain, although it is rarely disabling. Patients with idiopathic scoliosis as a group have a more negative body image, although it is not a serious life impairment. In all of these parameters, there are individual exceptions.

Idiopathic scoliosis in skeletally immature patients should be braced if it is greater than 30° and significant growth remains (estimated by a Risser sign of 0, 1, or 2). Studies have shown that patients with idiopathic scoliosis without atypical findings do not need magnetic resonance imaging. Physical therapy and electrical stimulation have been shown not to have any effect on the progression of idiopathic scoliosis.

A lower chance of curve control with brace treatment has been shown with curves greater than 40°, correction of less than 50% in brace, brace worn fewer than 16 hours per day, or male gender. Positive family history has not been shown to be related to curve progression or chance of control.

Halo-gravity traction is a safe and effective means of gradually correcting large curves. It allows balanced force application and continuous neurological monitoring. C ranial and peripheral nerves should be monitored. The weight can be increased gradually up to 35% to 45% of body weight, as documented in published series.

The tibial metaphyseal-diaphyseal (M-D) angle, no matter what threshold is set, has a significant number of false-positives or false-negatives. Using the ratio of femoral to tibial M-D angle improves diagnostic accuracy significantly. The Langenskjold rating, tibiofemoral angle, and intercondylar distances, although conceptually important, have low diagnostic accuracy for an individual patient.

The Dega osteotomy, originally described in Poland in 1964, is an incomplete transiliac osteotomy. The medial pelvic cortex is largely preserved, and the osteotomy hinges upon this point. Both osteotomies are best performed in young children, before triradiate cartilage closure. The Salter osteotomy is stabilized by pins, so the Dega needs no internal fixation. The Salter osteotomy lengthens the limb because it is a complete osteotomy.

After the age of 15 in boys (13 in girls), most of the growth (4.5 cm on average) occurs in the spine.

The most accurate way to monitor the motor tracts of the spinal cord is to stimulate the motor cortex. Stimulation at the level of the spinal cord conducts mainly antidromically through sensory pathways. Stimulation of the tibial and peroneal nerve is performed for monitoring sensory pathways only; these are an important indicator of spinal cord integrity but do not monitor the motor pathways per se. Stimulation of the gastrocnemius does not have any value for monitoring.

There are no radiographic findings diagnostic of Sever disease. Sclerosis and irregularity are normal findings, although they are often mistakenly called evidence of disease. The diagnosis of Sever disease is made by tenderness over the calcaneal apophysis.

Distal radial physeal fractures are common injuries. Reduction should be done gently and not repeated multiple times. Fractures presenting late like this one are difficult to manipulate atraumatically, but have good remodeling potential. Therefore, a cast should be applied to limit any further displacement, but no manipulation or operation is recommended.

Stretching produces good results in more than 90% of infants. Presence of a palpable mass in the sternomastoid predicts a lower success rate than absence of such a mass. The other factors are either positive or neutral.

Avascular necrosis is a risk of traumatic hip dislocation. The risk is closest to 10%.

The Lenke system is more comprehensive than the King system, for the latter considers the entire range or thoracolumbar and lumbar curve possibilities, as well as the sagittal plane. The Lenke system also appears to have a higher interobserver reliability.

X-linked dominant inheritance would explain the preponderance of girls with this condition, because they have twice as great a chance of having an affected x-chromosome. One affected x-chromosome is sufficient to convey the disease in a dominant condition. The imprinting phenomenon refers to a condition that varies depending upon whether the mother or the father passed it on (as in Angelman versus Prader-Willi syndromes).

A recent long-term study has shown that open reduction of displaced medial epicondyle fractures does not yield superior results to closed treatment. This applies even when the elbow is initially dislocated. Excision of the epicondyle with suture of the ligament yields the highest incidence of late problems, such as flexion contractures and degenerative changes.

Anesthesia and surgery can be detrimental to a fetus, especially during the first trimester. Patient self-report is not accurate in many cases. Immunospot testing of the first morning urine for human chorionic gonadotropin is 99.4% sensitive and specific, rapid, and inexpensive. Serum HC G testing is less rapid and more expensive; therefore, not appropriate for surgical screening. The other tests are not used to ascertain pregnancy status.

Bae and Waters have shown that adolescents with significant posttraumatic elbow flexion contractures can gain an average of 54Â
° of motion with surgical release. They believe postoperative physical therapy and continuous passive motion are considered critical to success of surgical release. Lengthening of the biceps or triceps is not recommended. Measures to prevent postoperative heterotopic ossification did not influence the outcome.

Pediatric atlanto-occipital dislocation is increasing in frequency due to improved emergency care. Although the injuries are sometimes fatal and are often accompanied by severe spinal cord injury, this is not always the case. Although the dens-basion distance should be less than 10 mm and the power ratio should be less than 1 in normals, these are not always abnormal in children with such injuries. C linical and radiographic correlation, with computer tomography or magnetic resonance imaging if needed, are called for to maximize diagnosis.

As the foot matures, it passes through a normal stage when it resembles a clubfoot in the eighth to tenth week. After this, the foot normally corrects itself.

C ongenital pseudarthrosis of the clavicle and tibia may present in infants with a gap between two tapered, atrophic bone ends. However, they are dissimilar in other respects. Pseudarthrosis of the clavicle is seen almost exclusively on the right side, while that of the tibia is seen on either side. Pseudarthrosis of the clavicle may be seen in cleidocranial dysostosis, although tibial pseudarthrosis is not. Pseudarthrosis of the clavicle has a high rate of union with simple bone graft, while that of the tibia does not. One-half of patients with pseudarthrosis of the tibia have neurofibromatosis, while this is almost never seen in congenital pseudarthrosis of the clavicle.

This is an unstable slip. It has a much higher chance of avascular necrosis than a stable slip. Since the degree of the slip will increase the shear forces across the healing physis and decrease the function of the hip, some method of improving this is justified. Gentle reduction of the epiphysis, without forceful internal rotation, may increase the risk of avascular necrosis. Avascular necrosis is a significant risk in many series of cuneiform (metaphyseal; Fish) osteotomies. Subtrochanteric osteotomy is not justified in patients with an acute slip until it is healed. It has a high rate of chondrolysis. Free vascularized bone graft may be an option if avascular necrosis develops, but is not indicated at this time. A hip spica cast is also often followed by chondrolysis
and delayed epiphyseodesis.

Unstable slipped capital femoral epiphysis places the patient at a high risk of avascular necrosis (up to 47%). Fortunately, it comprises only about 5% of all slips.

The angle between the first metatarsal and its proximal phalanx is normally one of mild (10° to 20°) valgus. It is not normal for it to be too straight. An increase in this angle beyond this value is often noted by the patient as a bunion.

Bunions may often be treated conservatively, and it is impossible to predict which ones will later develop symptoms. Surgical reconstruction of bunions in adolescents has a higher rate of recurrence than in adults in many reported series. For all of these reasons, nonoperative treatment is preferred for asymptomatic patients.

A vertical talus is a fixed dorsolateral dislocation of the talonavicular joint. The forefoot is in calcaneus and the hindfoot is in equinus. Therefore, all of the tendons listed except for the posterior tibialis are contracted.

Accessory navicular is seen in 10% to 14% of normal children. Sometimes, it becomes symptomatic in juveniles or adolescents, but this usually resolves by skeletal maturity. C onservative treatment, such as activity restriction, arch support, and stretching the Achilles if tight, will usually alleviate symptoms.

C harcot-Marie-Tooth disease is due to a defect in peripheral nerves; Duchenne muscular dystrophy is due to a defect in dystrophin, affecting the muscle cell membrane; Friedreich ataxia is a degeneration of the spinocerebellar tracts. Rett syndrome is due to a defect in MEC P-2 protein, affecting the brain. Only spinal muscular atrophy is due to a defect in anterior horn
cells.

Becker muscular dystrophy has a defect in the same gene as Duchenne muscular dystrophy, namely the protein dystrophin. The mutation in Becker dystrophy results in a truncated protein that retains some function, whereas the mutation in Duchenne dystrophy is different and results in an unstable protein, which is degraded quickly.

In facioscapulohumeral dystrophy, the facial muscles are affected first, commonly presenting with an inability to whistle. The serratus muscles and scapular stabilizers are affected next. The deltoid, supraspinatus, and infraspinatus are typically not affected in this disease.

Emery-Dreifuss muscular dystrophy is an x-linked disorder of emerin, which is a cell-membrane protein. Symptoms and signs develop within the first decade in most cases. A unique deformity, neck extension contracture, develops, in addition to elbow flexion contractures and peroneal wasting. The other deformities listed above are common in many dystrophies.

Electrodiagnostic testing in myopathy typically shows low amplitude, polyphasic EMG potentials with a decreased duration of response. Nerve conduction velocity is normal, in contrast to findings in neuropathies. Fibrillations are not typically seen; these are more characteristic of neuropathy.

The metaphysis of the proximal humerus lies partially within the shoulder joint; similarly, that of the proximal radius lies within the elbow. The metaphysis of the proximal femur lies within the hip joint and that of the distal lateral tibia within the ankle joint. There is no intra-articular metaphysis about the knee, however.

McKusick dysplasia is commonly associated with immune and gastrointestinal disorders. Hurler syndrome is associated with progressive mental retardation, hepatosplenomegaly, and cataracts. Morquio syndrome is associated with cardiorespiratory difficulties. C hondroectodermal dysplasia, or Ellis van C reveld syndrome, is associated with congenital heart disease. Multiple epiphyseal dysplasia, however, is not associated with systemic non-orthopaedic complications.

Surgery is indicated in situations in which antibiotics alone will not be curative, including subperiosteal abscess, sequestrum, intramedullary abscess, and adjacent septic arthritis. Fever alone is not an indication for surgery.

C hronic recurrent multifocal osteomyelitis is believed to be an idiopathic noninfectious inflammatory disease. It has gradual onset of symptoms, and sites most commonly involved are the spine, long bones, and feet. Nonsteroidal anti-inflammatory drugs typically improve symptoms. C ultures are negative.

Prompt tick removal is recommended because Lyme disease is more likely if the tick is attached for more than 24 hours. Immediate antibiotic administration is not recommended because the incidence of Lyme disease is low after any single tick bite and treatment is equally effective once the disease is diagnosed. Doxycycline is not recommended in children younger than 8
years old because of dental discoloration. Immediate testing for antibodies (ELISA) is not useful because antibodies do not rise for at least several weeks. Steroids are not recommended in this setting.

Knee braces have been shown not to reduce injury rates for children for children with sound knees. All other measures have been shown to reduce injury rates.

Bicycles are the leading cause of musculoskeletal injury in American children, with 415,000 injuries per year, followed by basketball, football, and roller sports.

A limb length discrepancy of as little as 2 cm has shown to increase perceived exertion as well as oxygen consumption in older adults.

Anterior elbow release consists of lengthening of the lacertus fibrosus and the brachialis fascia. It may or may not include lengthening of the biceps tendon itself. Anterior elbow release effectively decreases the excessive flexion posture of the elbow during use, which one author has termed the âflexion posture angle.â It does not result in decreased (or increased) strength of elbow flexion if the biceps tendon is preserved. Unfortunately, increased use during bimanual activity and increased grip strength are usually not observed.

Percutaneous tendoachilles lengthening is most likely to resolve idiopathic toe walking in a single treatment. The other methods have a higher likelihood of persistent toe walking.

C bfa1 is a transcription factor that causes cells to differentiate into osteoblasts. An abnormality in its gene causes cleidocranial dysplasia.

Patients with lumbosacral agenesis often have knee flexion contractures as compared with controls. All of the other features listed are common in patients with lumbosacral agenesis.

Pars interarticularis defects are not found in newborns, whereas the incidence is 5% in patients who are in the first grade. It remains close to this figure throughout later life.

Spondylolysis is the most common cause of back pain in young athletes, accounting for approximately 50% of cases. The other causes are significantly less common.

Pain in the spastic patient with subluxation without head deformity is most appropriately treated by reduction. Adductor tenotomy alone is not recommended when the hip subluxation exceeds 50% or the age is greater than 5 to 6 years. Femoral osteotomy should be added. Salvage procedures such as proximal femoral resection, arthrodesis, or arthroplasty are not indicated.