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

Hepatocellular necrosis often occurs in response to high levels of metal in the body, as observed after acute ingestion of Cr (VI) in humans

Lateral meniscal tears are most commonly associated with Schatzker II tibial plateau fractures (split/depressed).
Soft tissue pathology is common in tibial plateau fractures. In general, fractures that are largely displaced and/or a result of high energy trauma are more likely to have associated soft tissue pathology. A majority of meniscal injuries that occur in the setting of tibial plateau fractures are meniscocapsular detachments. This has important implications for healing (more reliable healing in the vascular zone). Additionally, the meniscus usually remains in close contact with the femoral condyle, while the tibial plateau widens around it. It is generally agreed upon that meniscal tears should be repaired, if possible, at the time of internal fixation to decrease the likelihood of postraumatic arthritis.
Gardner et al. review 62 patients with Schatzker II tibial plateau fractures that had an MRI preoperatively. For displaced fractures, the incidence of lateral meniscal tears was 83%, while the incidence of lateral collateral and posterior cruciate ligament injuries was 30%.
Ringus et al. attempted to determine if the degree of lateral tibial plateau fracture depression on computed tomography (CT) images predicted the presence of lateral meniscus tears. Fractures with > 9mm depression had an eight-fold increase in lateral meniscal tears, and those younger than 48 years-old had a four-fold increase in lateral meniscal tears.
Illustration A shows an MRI of a Schatzker II tibial plateau fracture with a lateral meniscal detachment and a medial meniscal tear. Illustration B shows the Schatzker Classification, I-VI.
Incorrect Answers:
Answers 1, 3, 4, 5: While these soft tissue injuries may occur, lateral meniscal tears are more common for this particular fracture pattern.

There are two conditions that cause osteonecrosis secondary to the marrow cavity becoming packed with abnormal cells â
Gaucher disease and sickle cell disease. There is probable occlusion of the intraosseous arteries with both of these conditions.
With Gaucher disease, the marrow cavity is filled with Gaucher cells (macrophages filled with cerebroside). In sickle cell disease, the marrow cavity is filled with sickled red blood cells.

In adults, 70% to 85% will experience an episode of low back pain at some period during their life. Most recover quickly and without residual functional deficits. Of those patients with symptoms severe enough to require absence from work, 60% to 70% return within 6 weeks and 80% to 90% return within 12 weeks. After 12 weeks of symptoms, return to work is much slower.

C alcaneovalgus foot has all of these findings and resolves spontaneously.
Fibular hemimelia typically has less calcaneus attitude and more valgus and shortening. Vertical talus entails loss of an arch and loss of cohesive movement of the foot as a whole. There is no evidence of muscle weakness.
There is no evidence of a neuropathic component.

**
Dkk-1 and sclerostin are proteins that inhibit the binding of the Wnt molecule to receptors LRP5/6. In the absence of sclerostin and Dkk-1, Wnt binds to its receptor, which in turn inhibits phosphorylation of the ß-catenin. The unphosphorylated ß-catenin then builds up in the cytoplasm of the cell, allowing it to be transported to the nucleus of the cell. Once in the nucleus, ß- catenin will lead to upregulation of a series of proteins involved in osteoblast formation differentiation. Knocking out or inhibiting sclerostin or Dkk-1 results in increased bone mass secondary to constitutive activation of the Wnt/ß- catenin pathway. The other responses are not directly affected by Dkk-1 or sclerostin. RANKL and RANK are expressed on osteoblasts and osteoclasts, respectively, and are involved in osteoblast-mediated osteoclast activation. BMPs work through SMADs to cause osteoblastic differentiation, and there is reported crosstalk between the Wnt and BMP pathways (but this is an indirect link). Finally, PTH at physiologic levels binds to osteoblasts, causing a series of events that lead to osteoblast-mediated osteoclast activation and subsequent increased bone resorption.

**
There is legal precedent for banning a scholarship athlete from participation in college athletics if the physician feels that it presents a significant physical risk to the athlete. The courts have decided that the athlete has no constitutional right to participate in NCAA sports, and as a team physician you must advise your athlete and the school as to the best course of action. The athlete must be allowed to keep his or her college scholarship.

49
This is a young patient who has sustained an elbow dislocation with a radial neck and coronoid fracture to her dominant extremity. Her current radiographs reveal a considerably displaced radial head fragment, along with a small coronoid fracture, and potentially some residual ulnohumeral joint incongruity. A repeat closed reduction is unlikely to be successful, as the radial head is significantly displaced and can block a congruent reduction. Open reduction is required to successfully address this complex injury pattern. Although removal of the radial head can be considered, fixing or replacing the radial head with repair of the lateral collateral ligament is often recommended in the setting of acute trauma to restore adequate stability to the elbow, decrease long-term risk for progressive ulnohumeral arthrosis, and limit sequelae in the setting of an unappreciated longitudinal forearm axis injury.

This patient has a substantial nascent malunion of his distal radius. Although a distal ulna excision would likely improve his ulnar-sided wrist pain, the Darrach procedure is more appropriate for older, somewhat less active individuals. In addition, the distal radius malunion is substantial, and it would be preferable to address the malunion given the major loss of radial length, inclination, and increased palmar tilt. The joint surface of the distal radius is uninvolved, and there is no evidence of arthrosis. It is preferable to osteotomize the distal radius sooner rather than later. Delayed osteotomy is often more difficult with more severe soft-tissue contractures, and improved results have been demonstrated following surgical treatment of nascent rather than mature distal radius malunions. Advantages include easier correction, no need for structural bone grafts, less overall total disability, and earlier return to work.
RECOMMENDED READINGS
30. Bilgin SS, Armangil M. Correction of nascent malunion of distal radius fractures. Acta Orthop Traumatol Turc. 2012;46(1):30-4. PubMed PMID: 22441449.
31. Jupiter JB, Ring D. A comparison of early and late reconstruction of malunited fractures of the distal end of the radius. J Bone Joint Surg Am. 1996 May;78(5):739-48. PubMed PMID: 8642031.

DISCUSSION: Flattening of the femoral condyles indicates the onset of significant arthritis of the joint
and is a contraindication to meniscus allograft transplantation. Criteria to proceed with allograft transplantation includes prior total meniscectomy, age of 50 years or younger, BMI of less than 30, clinical symptoms of pain in the involved tibiofemoral compartment, 2 mm or more of tibiofemoral joint space on a 45-degree weight-bearing AP radiograph, ligamentous stability, normal alignment, and no radiographic evidence of advanced arthrosis. Recurrent effusions are associated with chronic meniscus deficiency, and is one criteria for meniscal transplantation. High tibial osteotomy is often considered in conjunction with meniscal transplantation to correct tibiofemoral malalignment.
REFERENCES: Noyes FR, Barber-Westin SD: Meniscus transplantation: Indications, techniques, clinical outcomes. Instr Course Lect 2005;54:341-353.
Kang RW, Lattermann C, Cole BJ: Allograft meniscus transplantation: Background, indications, techniques, and outcomes. J Knee Surg 2006;19:220-230.

Posterior partial articular tibial plateau fractures are rare. Failure to recognize this pattern can lead to poor patient outcomes secondary to poor surgical decision making. Pathognomonic findings on the lateral radiograph include maintenance of continuity between the anterior articular surface and tibial shaft along with subluxation of the knee joint with excessively anterior tibial station (the femoral condyles remain with the fractured posterior articular pieces while the remainder of the tibia subluxes anteriorly).
Initial management of axially unstable tibial plateau fractures with soft tissue swelling should consist of spanning external fixation and closed manipulative realignment. This allows for soft tissue recovery with the knee joint provisionally stabilized in reduced station. It also provides time for pre-operative planning, which is typically empowered via a CT scan with reconstructions. If the pattern was initially misdiagnosed as a more typically bicondylar tibial plateau fracture, the CT scan will clarify the misconception and allow for better surgical decision making.
Attempting to visualize, reduce, and stabilize a posterior partial articular pattern in the supine position from an anterior approach is fraught with difficulties. Prone positioning is preferred for definitive fixation. Surgical approaches vary, but
typically incorporate a posteromedial interval deep to the popliteus and soleus to provide buttress plating to the posterior column of the tibia.

- tarsal bones.

End-to-end repair of a chronic rupture of the Achilles tendon may not be considered if the gap is greater than 2 cm. Equinus positioning is never acceptable. Although each of the other alternatives above may be considered, each has its proponents and potential disadvantages.

Biomechanical stability of zone II flexor tendon repairs can be improved by increasing the suture spread distance at the repair site (near-far), increasing the number of strands at the repair site, increasing the caliber of the suture, using sutures that lock the tendon, and adding an epitendinous repair circumferentially around the tendon. Although maintaining the flexor tendon pulleys and initiating early active motion benefits the functional outcome, these steps do not impact the biomechanical stability of the flexor tendon repair. However, they add more biomechanical stress on the repair site.
RECOMMENDED READINGS
29. [Barrie KA, Wolfe SW, Shean C, Shenbagamurthi D, Slade JF 3rd, Panjabi MM. A biomechanical comparison of multistrand flexor tendon repairs using an in situ testing model. J Hand Surg Am. 2000 May;25(3):499-506. PubMed PMID: 10811755. ](http://www.ncbi.nlm.nih.gov/pubmed/10811755)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/10811755)
30. [Lee SK, Goldstein RY, Zingman A, Terranova C, Nasser P, Hausman MR. The effects of core suture purchase on the biomechanical characteristics of a multistrand locking flexor tendon repair: a cadaveric study. J Hand Surg Am. 2010 Jul;35(7):1165-71. doi: 10.1016/j.jhsa.2010.04.003. Epub 2010 Jun 11. PubMed PMID: 20541326. ](http://www.ncbi.nlm.nih.gov/pubmed/%2020541326)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/%2020541326)
31. Miller B, Dodds SD, deMars A, Zagoreas N, Waitayawinyu T, Trumble TE. Flexor tendon repairs: the impact of fiberwire on grasping and locking core sutures. J Hand Surg Am. 2007 May-Jun;32(5):591-
[6/. PubMed PMID: 17481994. ](http://www.ncbi.nlm.nih.gov/pubmed/17481994)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/17481994)
32. [Boyer MI, Strickland JW, Engles D, Sachar K, Leversedge FJ. Flexor tendon repair and rehabilitation: state of the art in 2002. Instr Course Lect. 2003;52:137-61. Review. PubMed PMID: 12690845. ](http://www.ncbi.nlm.nih.gov/pubmed/12690845)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/12690845)

The patient demonstrates true acetabular retroversion, with deficient posterior and lateral coverage. While acetabular rim-trimming may be indicated for correction of retroversion deformities in volume-sufficient acetabulae, the risk of creating a secondary instability may preclude this treatment in volume- deficient hips (CEA <20, positive posterior wall sign). Arthroscopic and open techniques of acetabular rim-trimming have reported good results, equaling survivorship for periacetabular osteotomy at 5 years, but 10-year results suggest an advantage to periacetabular osteotomy for correction of retroversion.

The reported recurrence rate following excision of a primary interdigital neuroma is approximately 15%. The recurrence rate should always be communicated to the patient preoperatively.

- Total elbow arthroplasty (TEA)

Nonsurgical management of OCD of the talus in skeletally immature individuals frequently results in a fairly rapid decrease in symptoms, but radiographic abnormalities can frequently be found even 6 months after treatment. Spontaneous resolution of this condition is rare. Hyperbaric oxygen treatment has not been shown to be beneficial for this condition. Progression of the condition to the point of requiring ankle fusion is rare.
REFERENCES: Perumal V, Wall E, Babekir N: Juvenile osteochondritis dissecans of the talus. J Pediat Orthop 2007;27:821-825.
Letts M, Davidson D, Ahmer A: Osteochondritis dissecans of the talus in children. J Pediatr Orthop 2003;23:617-625.

Reamed, statically locked nailing is the standard treatment for diaphyseal femur fractures. In this patient with an ipsilateral lower extremity fracture, retrograde nailing allows for supine positioning to address both injuries.
Antegrade, reamed, statically locked intramedullary nailing is the treatment of choice for the majority of diaphyseal femur fractures. Relative indications for retrograde nailing include multi-injured patients, ipsilateral lower extremity trauma, morbid obesity, and infra-isthmal fracture patterns.
Brumback and Virkus review the current concepts and controversies regarding the management of femoral shaft fractures with reamed and unreamed nailing. The authors highlight the benefits of reaming including deposition of local autograft, stimulation of periosteal blood supply and increased nail diameter.
They note that there is a subset of trauma patients, specifically those with pulmonary injury, that may be adversely affected by nailing.
Figures A and B demonstrate AP and Lateral views of a comminuted mid-diaphyseal femoral shaft fracture. Illustrations A and B demonstrate the same fracture that progressed to uneventful union after treatment with a reamed, statically locked retrograde nail supplemented with blocking screws to correct angular alignment.
Incorrect answers:
Answers 1 and 3: Unlocked nailing is rarely indicated and is mainly of historical significance
Answer 2: Antegrade nailing would not necessarily allow for the tibia fracture to be addressed simultaneously. Dynamic interlocking is contra-indicated in this length unstable fracture pattern
Answer 5: Dyamic interlocking is not typically used for femoral shaft fractures. It would be contra-indicated in this length unstable femur fracture.

Posterior shoulder instability is a rare form of instability that often presents with pain rather than feelings of instability. It often occurs in young athletes during activities that put the shoulder in an “at-risk position” (flexion, adduction, internal rotation). Repetitive microtrauma can lead to posterior shoulder instability such as seen in football linemen. Swinging a bat or golf club places the lead arm in a flexed, adducted, and internally rotated position, which can lead to posterior translation of the humeral head that is forcibly reduced in follow-through, as seen in this patient. The glenohumeral joint relies on static and dynamic stabilizers. Static stabilizers help prevent instability at the end ranges of motion when the ligaments are taut. Dynamic stabilizers work to prevent subluxation at midranges of motion, at which the ligaments are lax. The rotator cuff is integral as a dynamic stabilizer of the shoulder. It works through a process called concavity compression. The four muscles of the rotator cuff compress the humeral head into the concavity of the glenoid-labrum. This prevents the humeral head from subluxing during the midranges of motion. Of the four rotator cuff muscles, the subscapularis is most important at preventing posterior subluxation. This patient has posterior instability, and various surgical techniques may be indicated depending on findings. Arthroscopic labral repair is indicated for anterior instability. Arthroscopic posterior labral repair is indicated for this patient because he has a posterior labral tear and posterior instability. If a patient has ligamentous laxity (not seen in this scenario because sulcus and Beighton sign findings would be negative), a posterior capsular shift with rotator interval closure is indicated. If a patient has excessive glenoid retroversion (not seen in this scenario with 5 degrees of retroversion), a posterior opening-wedge osteotomy is appropriate. The most common complication seen after arthroscopic posterior labral repair is stiffness, followed by recurrent instability
and degenerative joint disease.

An osteoid osteoma is a benign bone tumor. Osteoid osteomas tend to be small—typically <1.5 cm. Regardless of their size, they cause a large amount of reactive bone to form around them, and they make a new type of abnormal bone material called osteoid bone. This osteoid bone, along with the tumor
cells, forms the nidus of the tumor, which is easily identified on CT scans.

The most reliable test for a relatively isolated posterolateral complex (PLC) injury is the asymmetric tibial external rotation or “dial test.” It can be performed with the patient prone or supine. When greater than 10 degrees of external rotation at 30 degrees of flexion is present when compared with the opposite knee, it indicates significant damage to the posterolateral structures. Asymmetric external rotation, which is also present at 90 degrees of flexion, indicates injury to the posterior cruciate ligament (PCL) as well. Varus laxity may indicate significant damage to both the PLC and PCL. Approximately 35% of the normal population may have a reverse pivot shift when examined under anesthesia; therefore, it is considered a less specific test. The external rotation/recurvatum and posterolateral drawer tests are adjunctive in assessing isolated posterolateral laxity but are not thought to be as reliable.
REFERENCES: Veltri DM, Warren RF: Isolated and combined posterior cruciate injuries. J Am Acad Orthop Surg 1993;1:67-75.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont IL, American Academy of Orthopaedic Surgeons, 2002, pp 489-511.

DISCUSSION: Despite the negative aspiration preoperatively, intraoperative findings are suspicious for infection. Additionally, the preoperative blood work is also concerning for infection with an elevated CRP and ESR. The frozen section is also positive. Most important is the unreliability of the Gram stain. Numerous investigators have show high false negative rates for Gram stain in chronic periprosthetic infection. The Gram stain should not be relied on for decision-making in revision surgery, particularly when other investigations point to infection. With the information available, the diagnosis is deep infection. The best course of action is to obtain cultures, remove the implants, and insert an antibiotic spacer. Only obtaining cultures and closing would require a second operation to remove the implants if the cultures are positive.

REFERENCES: Sanzen L, Sundberg M: Periprosthetic low-grade hip infections: Erythrocyte sedimentation rate and C-reactive protein in 23 cases. Acta Orthop Scand 1997;68:461-465.
Spangehl MJ, Hanssen AD, Osman DR: Diagnosis and treatment of the infected hip arthroplasty, in Morrey BF(ed _A_)_L_ :_-M_ Jo _a_ i _d_ n _e_ t _na_ R _C_ e _o_ p _p_ l _y_ acement Arthroplasty, ed 3. Philadelphia, PA, Churchill Livingstone, 2003, pp 856-874. Question 71

A 79-year-old patient has a history of peripheral vascular disease and reports chronic knee pain. She has had coronary artery disease treated with angiography and stents on two occasions. Peripheral pulses are absent in both lower extremities, but the patient is disabled by advanced chronic degenerative arthritis in her right knee and would like to proceed with a total knee arthroplasty. The next most appropriate evaluation should include which of the following?

1. ### Ankle-brachial index of the affected lower extremity
2. ### Femoral popliteal angiography
3. ### Venous Dopplers of both lower extremities
4. ### MRI of the popliteal fossa

5. ### Radiographs to identify calcified plaques in the femoral artery

PREFERRED RESPONSE: 1
DISCUSSION: This question is designed to draw attention to the fact that peripheral vascular disease carries an increased risk of complications for the patient and should be carefully evaluated. The vascular surgeon will make the choice of revascularization or surgical clearance for knee reconstruction based on the initial results of the ankle-brachial index.

REFERENCE: Smith DE, McGraw RW, Taylor DC, et al: Arterial complications and total knee arthroplasty. J Am Acad Orthop Surg 2001 ;9:253-257.

Figure 72

This patient likely is experiencing failure of the UKA secondary to poor patient selection. In this young, heavy man, the component likely loosened due to the ongoing varus alignment of the knee and his elevated
weight. Despite this likely scenario, the next step is determining whether an infection is the cause of his pain. Prior to obtaining an aspiration, the surgeon can order ESR and CRP studies to determine whether aspiration is warranted. If the laboratory studies are unremarkable, the surgeon likely can forgo the
aspiration and proceed to a revision TKA with possible augments on standby.

Supervised exercise therapy with static or dynamic progressive elbow splinting over a 6 month period has shown to have the greatest improvement on DASH scores and functional range of motion (ROM) in patients with post-traumatic elbow stiffness.
The goal of treatment in post-traumatic stiffness is to restore a functional range of elbow motion (30° to 130°). Non-operative modalities are considered the first-line of treatment. Aggressive physical therapy has traditionally been advocated. However, the use of static or dynamic progressive elbow splinting with a turnbuckle has shown to provide better functional outcomes. Treatment is usually maintained over a period of 6-12 months. Surgery is considered when nonoperative therapy fails.
Gelinas et al. treated 22 patients with an elbow contracture using a static progressive turnbuckle splint for a mean of 4.5 +/- 1.8 months. The mean range of motion improved from 32 - 108, to 26 - 127 degrees (p = 0.0001). Their results suggest that static progressive splinting is an effective modality for postoperative elbow stiffness.
Lindenhovius et al. randomized sixty-six patients with post-traumatic elbow stiffness into static progressive elbow splint therapy or dynamic elbow splinting over a 12 month period. There was no significant difference in outcomes between treatment modalities. ROM increased by 40° vs. 39° at six months, respectively. DASH scores improved from 50 vs 45 at enrollment to 32 vs. 25 at six months, respectively.
Illustration A shows an image of a static progressive elbow splint.
Incorrect Answers:
Answer 1: Intra-articular and extra-capsular cortisone injection have not shown to improve ROM in this scenario.
Answer 2: Closed manipulation under anesthesia may worsen elbow stiffness and cause intra-articular damage. Manipulation causes significant swelling and inflammation with tearing of soft tissues, causing hemarthrosis and additional fibrosis in the joint.
Answer 3: Aggressive home exercise program are not effective when formal physiotherapy has failed.
Answer 4: Continuous passive motion machines have a limited role in treating established contractures. They do not seem to improve end-range mobility in these patients.

Anteromedial displacement of the tibial tubercle unloads the distal and lateral facets of the patella and shifts the forces to the proximal and medial facets. Therefore, if findings indicate arthrosis predominately in the medial and proximal areas of the patella, this is considered a relative contraindication because it may accentuate arthritic symptoms.
REFERENCES: Fulkerson JP: Anteromedialization of the tibial tuberosity for patellofemoral malalignment. Clin Orthop 1983;177:176-181.
Bellemans J, Cauwenberghs F, Witvrouw E, et al: Anteromedial tibial tubercle transfer in patients with chronic anterior knee pain and a subluxation-type patellar malalignment. Am J Sports Med 1997;25:375-381.
Kuroda R, Kambic H, Valdevit A, et al: Articular cartilage contact pressure after tibial tuberosity transfer: A cadaveric study. Am J Sports Med 2001;29:403-409.

The sequence of injury according to the Lauge-Hansen classification system in supination-external rotation injuries is AITFL disruption, spiral oblique fracture of the lateral malleolus, PITFL disruption or posterior malleolus fracture, and finally stage IV, which is a deltoid ligament disruption or medial malleolus fracture.

The MR image shows medial subluxation of the biceps tendon, which can be confused with an articular loose body. In the clinical scenario of biceps instability/subluxation, the rationale regarding tenodesis is to address the painful dislocation and subluxation of the biceps tendon from the bicipital groove. Biceps tendon subluxation is most frequently associated with subscapularis tendon pathology, which is indicated by the MRI and by a positive lift-off test. The MR image does not show a loose body or Bankart lesion. Patients with irreparable rotator cuff tears with a severe external rotation deficit and a deficient teres minor _may experience a better functional result with latissimus dorsi transfer._

De Quervain disease affects the tendons in the first dorsal compartment, the extensor pollicis brevis and the abductor pollicis longus (consisting of 2 to 7 individual tendon slips). The extensor pollicis longus traverses the third dorsal compartment. The abductor pollicis brevis and the opponens pollicis are thenar muscles and do not lie within any of the dorsal compartments.

The pectoralis major tendon inserts lateral to the biceps tendon, which runs in the bicipital groove. The primary vascular supply of the articular surface of the humeral head is derived from the anterior circumflex humeral artery, which continues into the arcuate artery once it enters the bone. The entry point is on the anterolateral aspect of the humerus just medial to the greater tuberosity within the bicipital groove. To avoid compromising circulation, the blade plate should be placed lateral to the bicipital groove and pectoralis major tendon insertion.
REFERENCES: Loebenberg M, Plate AM, Zuckerman J: Osteonecrosis of the humeral head. Instr Course Lect 1999;48:349-357.
Gerber C, Schneeberger AG: The arterial vascularization of the humeral head: An anatomical study. J Bone Joint Surg Am 1990;72:1486-1494.

Compression plating remains the treatment of choice for most established humeral nonunions. Autograft is felt to be superior to allograft. Electrical stimulation has not been found to improve healing rates in patients with nonunion after intramedullary nailing. Retrograde nailing with flexible nails gives inadequate rotational control to promote healing in this patient. Adding cancellous graft alone will not stabilize the nonunion site. Dynamic locking has been successful only in the lower extremity because the bone can be loaded axially.
REFERENCES: McKee MD, Miranda MA, Riemer BL, et al: Management of humeral nonunion after the failure of locking intramedullary nails. J Orthop Trauma 1996;10:492-499.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.

Squamous cell carcinoma and basal cell carcinoma do not commonly metastasize to the lungs. Actinic keratoses are premalignant lesions that progress into squamous cell carcinomas. Schwannomas are common benign nerve tumors.

The initial radiographs reveal a fourth and fifth carpometacarpal (CMC) joint fracture dislocation. The injury is associated with a shear fracture of the dorsal rim of the hamate. Further assessment with CT might be helpful in fully evaluating the extent of injury. Extensor carpi ulnaris is a deforming force at the base of the fifth metacarpal. This unstable fracture dislocation could be treated with closed reduction and pinning if the patient presented within a few days of injury. However, because he presented in a delayed fashion (3 weeks after injury), open reduction with internal fixation was required (Figures 4 and 5). In the series by Zhang and associates, patients with fourth and fifth CMC fracture dislocations presenting in a delayed fashion and treated nonsurgically had suboptimal results. Therefore, closed reduction and casting are not appropriate. An arthrodesis and resection arthroplasty are salvage procedures considered for a painful arthritic joint and would less likely should not be considered for this acute injury.

---

---

Suprascapular nerve palsy is a fairly uncommon yet well-known cause of shoulder pain and weakness. A variety of causes have been described, including compression by a ganglion cyst, an anomalous or thickened superior transverse scapular ligament, a humeral and scapular fracture, and traction or kinking of the nerve in the suprascapular notch.
In this patient, the injury is most likely caused by traction or compression of the nerve in the suprascapular notch as the result of positioning during abdominal surgery; therefore, the studies of choice are electromyography and nerve conduction velocity studies. While MRI of the cervical spine may be of some value in ruling out a radiculopathy, the clinical history does not support such a cause for this condition.
REFERENCES: Rengachary SS, Neff JP, Singer PA, Brackett CE: Suprascapular entrapment neuropathy: A clinical, anatomical, and comparative study. Part 1: Clinical study. Neurosurgery 1979;5:441-446.
Rengachary SS, Burr D, Lucas S, Hassanein KM, Mohn MP, Matzke H: Suprascapular entrapment neuropathy: A clinical, anatomical and comparative study. Part 2: Anatomical study. Neurosurgery 1979;5:447-451.
Bigliani LU, Dalsey RM, McCann PD, April EW: An anatomical study of the suprascapular nerve. Arthoscopy 1990;6:301-305.

DISCUSSION
As the indications for reverse shoulder arthroplasty have expanded, the role for shoulder hemiarthroplasty appears to be narrowing. Several recent systematic reviews have evaluated outcomes of shoulder hemiarthroplasty and reverse shoulder arthroplasty for acute proximal humerus fractures. Their results suggest that reverse arthroplasty results in superior functional results and comparable elevation, at the expense of increased complication rates and decreased shoulder rotation. One of the benefits of reverse shoulder
arthroplasty in the setting of fracture is that forward elevation is independent of tuberosity healing and relies mainly on the deltoid muscle. Active external rotation following a reverse total shoulder for fracture, however, does appear to depend on successful union of the greater tuberosity. In a randomized controlled trial, the incidence of tuberosity healing was higher and the incidence of tuberosity resorption was lower in reverse arthroplasty compared with hemiarthroplasty. Forward elevation following a hemiarthroplasty for fracture generally follows a bimodal distribution, whereas outcomes following a reverse total shoulder have been more
consistent.

■
Septic arthritis accounts for approximately 6.5% of all childhood arthritis and is common in children <2 years. Infected joints are swollen, red, hot, and have restricted range of motion. The child limps or refuses to bear weight on the affected lower extremity. There is often an associated infection of the adjacent bone, especially in shoulder; elbow; hip; and ankle joint, as the metaphysis is intracapsular in these joints.
Aspiration is the best next step in management of a child with acute unexplained monoarthritis, as septic arthritis is associated with devastating morbidity if not treated appropriately. A cloudy or serosanguinous tap is highly suggestive of septic arthritis. The synovial fluid often has high polymorphonuclear cell count (50,000 to 300,000/mm3), or a Gram stain is positive. The culture is positive in 60% to 70% of cases with Staphylococcus aureus and Streptococcus pyogenes the most commonly isolated organisms beyond neonatal period.
Empiric antibiotics should be started after the diagnostic evaluation. MRI is not the first diagnostic test when the history and examination are highly suggestive of an acute septic joint. However, MRI is helpful to make a diagnosis of associated osteomyelitis.

Cauda equina syndrome is a lower-motor neuron deficit. Hyperreflexia, clonus, and other upper-motor neuron findings would not be seen. Saddle anesthesia, motor weakness, and neurogenic bladder are elements critical to the diagnosis of cauda equina syndrome.
RECOMMENDED READINGS
[Kostuik JP, Harrington I, Alexander D, Rand W, Evans D. Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg Am. 1986 Mar;68(3):386-91. PubMed PMID: 2936744. ](http://www.ncbi.nlm.nih.gov/pubmed/2936744)[View](http://www.ncbi.nlm.nih.gov/pubmed/2936744)[ ](http://www.ncbi.nlm.nih.gov/pubmed/2936744)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/2936744)
[Spector LR, Madigan L, Rhyne A, Darden B 2nd, Kim D. Cauda equina syndrome. J Am Acad Orthop Surg. 2008 Aug;16(8):471-9. Review. PubMed PMID: 18664636. ](http://www.ncbi.nlm.nih.gov/pubmed/18664636)[View Abstract at](http://www.ncbi.nlm.nih.gov/pubmed/18664636)[ ](http://www.ncbi.nlm.nih.gov/pubmed/18664636)[PubMed](http://www.ncbi.nlm.nih.gov/pubmed/18664636)
CLINICAL SITUATION FOR QUESTIONS 78 THROUGH 80
Figures 78a and 78b are the axial and sagittal MR images of an otherwise healthy 24-year-old woman who has had 8 weeks of severe leg pain without weakness.

A B

When substantial lengthening of a dysplastic hip will occur because a high dislocation is relocated into a considerably lower acetabulum, a femoral shortening may be necessary to reduce the hip and avoid a stretch injury to the sciatic nerve. No other choice specifically addresses the need for femoral shortening, and high offset stems and lateralized liners may exacerbate the problem if used alone and without femoral shortening.

---

---

---
EXPLANATION:
This patient has end-stage arthritis in conjunction with ligament insufficiency. The treatment for arthritis is arthroplasty or fusion. Given that her ring finger is affected, arthroplasty is recommended to preserve motion and grip. Two types of arthroplasties are available: silicone and surface replacement. The prerequisites are the same for both and include good bone stock, good sensibility of the joint, adequate soft-tissue coverage, and normally functioning tendons. Adequate collateral ligaments are required for surface replacement arthroplasty. This patient has a deficiency of the radial collateral ligament, evidenced by her clinical examination. Thus, silicone arthroplasty is the recommended option for joint replacement in this patient.

A large number of etiologies of rotator cuff injury have been proposed. Both intrinsic and extrinsic mechanisms have been suggested. In the young athlete the common underlying mechanism is overuse. Contributing factors include increased laxity, anatomic variation in the coracoacromial arch, and altered kinematics.
REFERENCES: Wilkins KE: Shoulder injuries: Epidemiology, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 175-182.
Sher JS: Anatomy, biomechanics, and pathophysiology of rotator cuff disease, in Iannnotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams and Wilkins, 1999, pp 3-30.

This patient has a recurrent tumor after limb salvage resection for low-grade chondrosarcoma. In addition to recurrence, the biopsy specimen shows transformation to a higher-grade chondrosarcoma (but not a dedifferentiated chondrosarcoma). There is no evidence of infection or a metal-on-metal–related pseudotumor.
Treatment that results in the highest likelihood of cure involves wide/radical resection of the area and frequent conversion to external hemipelvectomy. There is no defined role for chemotherapy or radiotherapy in the treatment of conventional chondrosarcoma, even when it is high grade.
RECOMMENDED READINGS
60. [Pring ME, Weber KL, Unni KK, Sim FH. Chondrosarcoma of the pelvis. A review of sixty-four cases. J Bone Joint Surg Am. 2001 Nov;83-A(11):1630-42. Review. PubMed PMID: 11701784. ](http://www.ncbi.nlm.nih.gov/pubmed/11701784)[View](http://www.ncbi.nlm.nih.gov/pubmed/11701784)[ ](http://www.ncbi.nlm.nih.gov/pubmed/11701784)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/11701784)
61. [Mavrogenis AF, Angelini A, Drago G, Merlino B, Ruggieri P. Survival analysis of patients with chondrosarcomas of the pelvis. J Surg Oncol. 2013 Jul;108(1):19-27. doi: 10.1002/jso.23351. Epub 2013 May 16. PubMed PMID: 23681650. ](http://www.ncbi.nlm.nih.gov/pubmed/23681650)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23681650)
62. [Weber KL, Pring ME, Sim FH. Treatment and outcome of recurrent pelvic chondrosarcoma. Clin Orthop Relat Res. 2002 Apr;(397):19-28. PubMed PMID: 11953591. ](http://www.ncbi.nlm.nih.gov/pubmed/11953591)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/11953591)

Although this is a fracture of the medial and lateral malleoli, the degree of displacement and comminution of the medial dome indicate that this injury is similar to a pilon fracture. Initial management should consistent of stabilization to allow for soft-tissue healing. The use of temporizing spanning external fixation should be the initial step, followed by limited or more extensive open reduction and internal fixation when the soft-tissue status will allow. Initial placement in either a short or long leg cast does not provide the needed stability and does not allow for care and monitoring of soft tissues. In addition, maintaining reduction of the talus may be very difficult. Immediate open reduction and internal fixation through an injured soft-tissue envelope adds the risk of difficulties with incision healing and a higher risk of deep infection. In the acute setting, a primary ankle fusion through this soft-tissue envelope is
not indicated.
REFERENCES: Marsh JL, Bonar S, Nepola JV, et al: Use of an articulated external fixator for fractures of the tibial plafond. J Bone Joint Surg Am 1995;77:1498-1509.
Wyrsch B, McFerran MA, McAndrew M, et al: Operative treatment of fractures of the tibial plafond: A randomized, prospective study. J Bone Joint Surg Am 1996;78:1646-1657.
Thordarson DB: Complications after treatment of tibial pilon fractures: Prevention and management strategies. J Am Acad Orthop Surg 2000;8:253-265.

This patient demonstrates several upper extremity issues including possible carpal tunnel syndrome, cervical radiculopathy, and pronator syndrome. The electrodiagnostic testing is equivocal, and a corticosteroid carpal tunnel injection should be performed prior to surgical intervention to assess its effectiveness in eliminating the patient's symptoms. Positive response (meaning improvement in symptoms), after corticosteroid injection at the carpal tunnel correlates well with symptom relief following surgery. Trigger-point injections are not indicated for carpal tunnel syndrome. Ultrasound and carpal tunnel view radiograph can provide diagnostic information but would not be helpful in determining _treatment in this specific case._

From the following options, a short working length of the construct is a known risk factor for femoral plate failure.
Implant failure is common in distal femur fractures stabilized with plate fixation. Contributors to failure include a short working length of the construct, plate-screw density more than 0.5 and short plate lengths. This will lead to failure as it causes increased strain on the plate over a short segment, and
does not allow enough motion at the fracture site to form bone for healing by secondary intention.
Ricci et al. reviewed 355 cases of distal femur plate fixation. 64 patients (19%) required reoperation to promote union, including 30 that had a planned staged bone grafting. Risk factors for proximal implant failure included open fracture, smoking, increased body mass index, and shorter plate length.
Kregor et al. reviewed 119 patients with distal femoral plate fixation. They found that 93% fractures healed without acute bone grafting. Complications included 5 losses of proximal fixation, 2 nonunions, and 3 acute infections.
Illustration A is an AP of the distal femur demonstrating a comminuted distal femur fracture which has failed fixation with a laterally based distal femur locking plate. It has undergone varus collapse which is a common mechanism of failure for these injuries. Illustration B is a series of AP radiographs of the distal femur of the same patient that was revised to an intramedullary retrograde nail. Illustration C and D show the concepts of plate length, plate-to-screw density and the working length of the plate.
Incorrect Answers:
Answer 1: Early postoperative knee range of motion has not been associated with failure of this construct.
Answer 2: Early weight-bearing can put too much force across the plate, causing fatigue failure of the plate.
Answer 4: Bridge plate fixation would have been the proper technique to use in this situation.
Answer 5: Plate-screw density less than 0.5 would have been the proper technique to use in this situation. This would have helped to avoid this complication.

The patient has developed mechanical failure as evidenced by the lucency surrounding the proximal phalanx component. His pain has correlated with his return to work as a manual laborer.Although septic arthritis is a possibility, it is less likely based on the normal laboratory studies and lack of infectious signs. Periprosthetic fracture is unlikely because of the lack of a traumatic event or a sudden change in symptoms rather than a persistent inability to progress his activities. A transfer lesion from metatarsal shortening would result in pain from mechanical overload at areas adjacent to the first
metatarsal. Aseptic loosening from polyethylene debris would imply that the implant has previously been stable and well-fixed, and subsequently loosened over an extended period of time.

This patient has sustained a Pipkin II femoral head fracture with associated anterior hip dislocation. An open reduction with internal fixation of the femoral head fragments with direct visualization is indicated to restore stability and congruity of the hip joint. These fractures can be treated with mini-fragment screws with excellent reduction and purchase without risks of extensive chondral injury or screw prominence.
Femoral head fractures are uncommon injuries usually associated with hip dislocations. They are classified using the Pipkin Classification (Illustration B). While resection of small femoral head fracture fragments can be considered (Pipkin I) as sufficient and satisfactory treatment, this fragment is large and displaced and thus should be treated with ORIF for optimal results. Regarding the surgical approach, advocates for the direct anterior approach state direct access to the anterior portion of the femoral head with decreased overall complication rates. Other approaches, including surgical hip dislocation and Kocher-Langenbeck, are also useful depending on associated injuries (acetabulum fractures, etc.) and location of the head fragment. ORIF of these fractures can be performed with the use of countersunk mini-fragment screws, headless screws and even bioabsorbable pins to avoid prominence or extensive chondral injury.
Marecek et al. authored a review article on femoral head fractures. They described these injuries as being generally associated with hip dislocations and require prompt reduction. They noted that the surgical fixation of the femoral head is generally done through the direct anterior approach or via a surgical hip dislocation depending on associated injuries. The authors also discussed the importance of using mini-frag screws to avoid hardware prominence. They also noted that while heterotopic ossification is a common finding after the anterior approach for these injuries, it is rarely proven to be symptomatic.
Giannoudis et al. reviewed femoral head fractures focusing on management, complications and clinical results. They reported on 453 femoral head fractures in 450 patients. Regarding Pipkin Is, they noted that fragment excision gave better results compared to ORIF (p=0.07), while Pipkin IIs showed improved outcomes with ORIF. Regarding complications, they noted the following rates: wound infection (3%), sciatic nerve palsy (4%), AVN (11.9%), post-traumatic OA (20%) and HO (16.8%). They also noted the anterior approach was associated with promising long-term functional results and a lower incidence of major complication rates.
Figure A is an AP pelvis radiograph revealing a left hip dislocation with a large femoral head fracture extending into the weight-bearing zone of hip joint
(Pipkin II). Figures B and C are CT scan images revealing an anteriorly dislocated hip with a large femoral head fracture without associated acetabulum fractures. Illustration A is the post-op fluoroscopy showing ORIF of femoral head with multiple 2.7 cortical screws. Illustration B demonstrates the Pipkin classification for femoral head fractures.
Incorrect Answers:
Answer 1: HO is a common complication noted after surgical fixation of femoral neck fractures (~15-20%)
Answer 3: The direct anterior (Smith-Peterson) approach is the preferred approach for the management of femoral head fractures that allows direct visualization of the fracture fragments.
Answer 4: For Pipkin II femoral head fractures, ORIF has improved outcomes compared to excision. For Pipkin 1, fragment excision leads to improved outcomes compared to ORIF.
Answer 5: 1 millimeter, not 2mm, is generally considered the cutoff for nonoperative management of femoral head fractures. This is in contrary to other articular fractures, where 2 mm is considered the general cutoff.

The radiographs and CT scan images show a depressed lateral tibial plateau fracture, which is correctly classified as a Schatzker III tibial plateau fracture. This fracture typically occurs as the result of the femoral condyle directly impacting the articular surface in older patients with osteopenia.
The referenced article by Bennett et al reviews the associated soft tissue injury with tibial plateau fractures. They found a 56% frequency of associated soft tissue injuries overall, with MCL injured in 20%, the LCL in 3% , the menisci in 20%, the peroneal nerve in 3%, and the anterior cruciate ligaments in 10%.
Schatzker type IV and type II fracture patterns were associated with the highest frequency of soft tissue injuries.

The correct approach to measure pressures in the central compartment of the foot is by directing the needle lateral and plantar through the abductor hallicus, just under the base of the first metatarsal. Abnormal values indicating the need for decompression are an absolute value of 30-45 mmHg or a Δp < 30mmHg (the difference between the patient's diastolic blood pressure and compartment pressures).
The most common symptom of compartment syndrome in the extremities is intense pain. However, compartment syndrome can be difficult to diagnose in children and patients who are comatose, nonverbal, and/or mentally compromised because they may not be able to properly express their level of pain. Additionally, in compartment syndrome of the foot, pain on passive extension of the toes may or may not be present, and swelling and absence of the dorsalis pedis pulse may be expected findings with extensive trauma to the foot, making the clinical diagnosis even more difficult. Thus, for patients with equivocal findings on physical exam, foot compartment pressures should be measured in order to confirm the diagnosis. There are 8 compartments in the foot: lateral, medial, central, and 4 interosseous. The lateral compartment
contains the abductor digiti minimi and flexor digiti minimi brevis, and is measured by directing the needle 1cm medial and plantar under the midshaft of the 5th metatarsal. The medial compartment contains the abductor hallicus and flexor hallicus brevis, and is measured by directing the needle lateral and plantar under the base of the first metatarsal. The central compartment contains the oblique head of the adductor hallucis, and is measured through the same approach as the medial compartment after advancing the needle more deeply. The 4 interosseous compartments entail the 2nd, 3rd, and 4th web spaces, and can be measured by directing the needle plantar into each respective dorsal webspace.
Ojika et al. performed a systematic review on foot compartment syndrome. They found that the most common cause of foot compartment syndrome was crush injury to the foot, and that diagnosis was mostly made through a combination of clinical findings and compartment pressure measurements.
Badhe et al. reported 4 cases where competent sensate patients developed compartment syndromes without any significant pain. They found that pain is not a reliable clinical indicator for underlying compartment syndrome, so in a competent sensate patient, the absence of pain does not exclude compartment syndrome. They concluded that a high index of clinical suspicion must prevail in association with either continuous compartment pressure monitoring or frequent repeated documented clinical examination with a low threshold for pressure measurement.
Flynn et al. looked at the diagnosis and outcome of acute traumatic compartment syndrome of the leg in children. They found that a delay in diagnosis may occur because acute traumatic compartment syndrome manifests itself more slowly in children or because the diagnosis is harder to establish in this age group. They state that the results of the present study should raise awareness of late presentation and the importance of vigilance for developing compartment syndrome in the early days after injury.
Figures A and B are lateral and Harris radiographs of the foot demonstrating a calcaneus fracture. Figure C is a cross-sectional image of the foot. Illustration A is an image depicting the compartments of the foot.
Incorrect Answers:
Answer 1: Path A is the incorrect approach for measuring the central compartment. Additionally, a Δp < 30mmHg (not > 30mmHg) is considered abnormal.
Answer 2: A Δp < 30mmHg (not > 30mmHg) is considered abnormal. Answer 4: Path C is the incorrect approach for measuring the central
compartment. Additionally, a Δp < 30mmHg (not > 30mmHg) is considered abnormal.
Answer 5: Path C is the incorrect approach for measuring the central compartment.

Figure 52
Used with permission from Benson LS, Williams CS, Kahle M. Dupuytren’s contracture. J Am Acad Surg. 1998
Jan-Feb;6(1):24-35. Review
The spiral cord seen in Dupuytren disease arises from the confluence of abnormal fascial thickening of the spiral bands, lateral digital sheet, and Grayson’s ligament. The orientation of these contributing structures results in a continuous band of fibrous tissue spiraling around the neurovascular bundle. As the developing spiral cord contractures from distal to proximal, the cord itself becomes increasingly linear and shorter, causing displacement of the neurovascular bundle both centrally and superficially. This displacement of the neurovascular bundle brings it closer to the skin and midline, making it more vulnerable to surgical trauma.
Studies have demonstrated a high association between a PIP joint flexion contracture and a spiral cord (Figure 52). Spiral cords are also seen in association with a soft, fleshy mass between the proximal digital flexion crease and distal palmar crease in the interdigital space referred to as an interdigital soft-tissue mass. This represents displacement of normal subcutaneous tissues by contracture of the diseased fascia associated with the spiral cord. Dupuytren diathesis, MCP joint contracture, and the presence of knuckle pads are not indicative of a spiral cord.
A complication following surgical treatment of Dupuytren contracture is trauma to the neurovascular bundle. This can be a consequence of blunt or sharp trauma. In the case of traumatic stretch injury from retraction, vasospasm may develop. The treatment of vasospasm includes flexion, warming the digit, and application of topical medication to treat vasospasm. Allowing the newly extended digit to flex is an important first step, particularly in the case of chronic and severe PIP joint contractures. In these cases, the vessel may have shortened over time, and full extension may cause intimal trauma and secondary vasospasm. Cold is also a stimulus for reactive vasospasm, so warming the digit with warm saline irrigation can be helpful. Finally, topically applied lidocaine (without vasoconstrictive additives) can help diminish vasospasm and lead to digital reperfusion. Phentolamine is useful in cases of prolonged vasospasm secondary to administration of anesthetics containing epinephrine. Streptokinase is a thrombolytic agent that may be useful in treatment of embolic or thrombotic vascular disease. Systemic heparin is useful for digital vessel repair but should not be necessary to treat simple vasospasm.
Copious bleeding in the region of the neurovascular bundle following palmar fasciectomy is an indication of potential arterial trauma. In the setting of arterial laceration, direct repair is necessary, particularly when the digit is dysvascular. This means that both digital vessels are involved or that the intact vessel is insufficient to adequately perfuse the digit. During surgery, the vessels can be directly visualized, and arteriography is unlikely to add additional information of value. Streptokinase is not indicated in this situation because it is useful for thrombolysis rather than vascular repair. Ligation of a traumatized digital artery might be appropriate for a digit that is otherwise well perfused; however, this is not appropriate in the setting of a dysvascular digit. Direct suture of the arterial laceration or segmental grafting necessary to restore adequate digital perfusion in this scenario.
RECOMMENDED READINGS
1. [Rayan GM. Dupuytren disease: Anatomy, pathology, presentation, and treatment. J Bone Joint Surg Am. 2007 Jan;89(1):189-98. Review. PubMed PMID: 17256226. ](http://www.ncbi.nlm.nih.gov/pubmed/17256226)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/17256226)
2. [Watson HK, Paul H Jr. Pathologic anatomy. Hand Clin. 1991 Nov;7(4):661-8. Review. PubMed PMID: 1769988. ](http://www.ncbi.nlm.nih.gov/pubmed/1769988)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/1769988)
3. [Jones NF, Huang JI. Emergency microsurgical revascularization for critical ischemia during surgery for Dupuytren's contracture: a case report. J Hand Surg Am. 2001 Nov;26(6):1125-8. PubMed PMID: 11721263. ](http://www.ncbi.nlm.nih.gov/pubmed/11721263)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/11721263)