Essentials of Orthopedic Surgery (eBook)

Preface 5
Contents 6
Contributors 8
1 Basic Science of Bone and Cartilage Metabolism 10
Normal Bone Growth and Development 10
Embryology 10
Postnatal Development 13
Bone: The Tissue 13
Bone Organization 15
Turnover and Remodeling 16
Cartilage: The Tissue 17
Abnormal Bone Development and Metabolism 18
Metabolic Bone Disease 19
General Concepts 19
Eucalcemic States: Osteoporosis 19
Hypercalcemic States: Hyperparathyroidism 24
Hypocalcemic States: Rickets and Osteomalacia 25
Miscellaneous Metabolic Bone Disease: Renal Osteodystrophy 25
Sick Cell Syndromes: Osteogenesis Imperfecta and Osteopetrosis 29
Paget's Disease 32
Arthritis 33
Noninflammatory Arthritis: Osteoarthritis 34
Inflammatory Arthritis: Rheumatoid Arthritis 34
Metabolic Arthritides: Crystalline Arthropathy 34
Vascular Disease 37
Circulatory Disease: Avascular Necrosis 37
Hematologic Syndromes 39
Neurodevelopmental Disorders 40
Neurologic Diseases 40
Developmental/Congenital Defects 41
Summary 43
Suggested Reading 43
2 Skeletal Trauma 44
Fractures 44
Fracture Descriptors 44
Fracture Deformities 45
Fracture Patterns 46
Fracture Mode of Loading 47
Soft Tissues 48
Vascular Injury 48
Nerve Damage 49
Muscle Injury 49
Ligament Tears 49
Classic Fractures 50
Incomplete Fractures 50
Stress Fractures 50
Pathologic Fracture 51
Physeal Fractures 51
Intraarticular Fractures 51
Fracture Healing 51
Evaluation of the Patient with Skeletal Trauma 53
Fractures: The Principles of Treatment 54
Orthopedic Emergencies 55
Complications of Fractures 55
Fractures and Dislocations by Region: The Upper Extremity 56
The Shoulder Region 56
Fractures of the Clavicle 56
Fractures of the Proximal Humerus 57
Glenohumeral Dislocation 58
Acromioclavicular Separation 60
Fractures of the Shaft of the Humerus 61
Elbow and Forearm 62
Supracondylar Fractures in Children 62
Distal Humeral Fractures in Adults 62
Dislocation of the Elbow 63
Fracture of Both Bones of the Forearm 65
Fractures of the Olecranon 65
Fracture of the Head of the Radius (Elbow) 65
Wrists and Hands 65
Wrist Fractures (Distal Radius) 65
Scaphoid (Navicular) Fractures 67
Phalangeal Fractures 68
Gamekeeper's/Skier's Thumb 68
Fractures and Dislocations by Region: The Spine 68
Fractures and Dislocations by Region: Pelvis 70
Fractures and Dislocations by Region: The Lower Extremity Femur 71
Femoral Neck Fractures 71
Intertrochanteric Fractures 72
Subtrochanteric Fractures 73
Femoral Shaft Fractures 73
Dislocation of the Hip 74
Fractures About the Knee 74
Distal Femoral Fractures 74
Fractures of the Tibial Plateau 75
Fractures of the Patella 75
Dislocation of the Knee 75
Fracture of the Tibial Shaft 76
Ligamentous Injuries to the Knee 77
Fractures Around the Ankle 77
Fractures and Soft Tissue Injuries of the Foot 79
Fractures of the Calcaneus 79
Fractures of the Talar Neck 79
Ankle Sprains 79
Achilles Tendon Rupture 80
Lisfranc Dislocation of the Tarsometarsal Joints 80
Distal Foot Fractures 80
Summary and Conclusions 80
Operative Technique: Femoral Intramedullary Nailing 81
Suggested Reading 82
3 Orthopedic Infections 83
Introduction 83
Pathophysiology of Osteomyelitis 83
Pediatric Infections 86
Acute Hematogenous Osteomyelitis 86
Diagnosis and Treatment 87
Pediatric Septic Arthritis 90
Diagnosis and Treatment 91
Adult Osteomyelitis 96
Septic Arthritis 98
Open Fractures 99
Infections Associated with Joint Arthroplasty 102
Summary and Conclusions 104
Suggested Reading 104
4 Tumors of the Musculoskeletal System 106
Overview 106
Natural History of Bone and Soft-Tissue Tumors 108
Biology and Growth 108
The Five Basic Patterns of Sarcoma Behavior 109
Mechanism of Tumor Spread 111
Sarcoma Tumor Staging 111
Clinical and Radiographic Evaluation, Staging, and Biopsy 112
Radiographic Evaluation 112
X-Rays 112
Computed Tomography 113
Magnetic Resonance Imaging 114
Bone Scans 115
Angiography 116
Computed Tomography Angiography 117
Positron Emission Tomography 117
Classification of Surgical Procedures by the Biological Margins Obtained for Bone and Soft-Tissue Tumors 117
Overview of Indications and Surgical Procedures 119
Biopsy Techniques 119
Biopsy Considerations and Importance 119
Core Needle Biopsy 119
Open Incisional Biopsy 120
Curettage of Bone Tumors 120
Cryosurgery (Adjuvant Following Curettage) 122
Resection of Bone and Soft-Tissue Tumors 122
Malignant Tumors 122
Amputation 123
Common Types and Indications of Amputations Performed 123
Principles and Technique of Limb-Sparing Surgery for Bone and Soft-Tissue Tumors 128
Malignant Bone Sarcomas 128
Soft-Tissue Sarcomas (STS) -- Wide Excision (Resection) 132
Surgical Treatment of Pathological Fractures 134
Malignant Bone Tumors 134
Classic Osteosarcoma 135
Clinical Characteristics and Physical Examination 136
Radiographic Characteristics 136
Microscopic Characteristics 137
Natural History, Prognosis, and Chemotherapy 137
Limb-Sparing Resection 139
Overall Treatment Strategy 139
Variants of Osteosarcoma 139
Parosteal Osteosarcoma 143
Periosteal Osteosarcoma 143
Chondrosarcoma 144
Central and Peripheral Chondrosarcomas 144
Clinical Characteristics and Physical Examination 144
Radiographic Findings 144
Grading and Prognosis 145
Microscopic Characteristics 146
Treatment 147
Variants of Chondrosarcoma 147
Clear Cell Chondrosarcoma 147
Mesenchymal Chondrosarcoma 147
Dedifferentiated Chondrosarcoma 148
Giant Cell Tumor of Bone 148
Clinical Characteristics and Physical Examination 148
Natural History and Potential Malignancy 148
Radiographic and Clinical Evaluation 148
Microscopic Characteristics 149
Treatment 150
Malignant Fibrous Histiocytoma 150
Clinical Characteristics 150
Radiographic Characteristics 151
Treatment 151
Fibrosarcoma of Bone 151
Clinical Characteristics 151
Radiographic Features 151
Ewings Sarcoma and Other Small Round Cell Sarcomas of Bone 151
Ewing's Sarcoma 152
Clinical Characteristics and Physical Examination 152
Radiographic Findings 152
Natural History 153
Radiographic Evaluation and Staging 153
Biopsy Considerations 154
Microscopic Characteristics 154
Combined Multimodality Treatment 154
Multiple Myeloma/Plasmocytoma 155
Clinical and Physical Examination 155
Metastatic Bone Disease and Pathologic Fracture Overview 156
Diagnosis 156
Clinical Characteristics and Physical Examination 156
Patterns of Metastases and Batson's Plexus 156
Staging Studies 156
Radiographic Findings 156
Bone Scans 159
Computed Tomography/Magnetic Resonance Imaging 159
Biopsy 159
Microscopic Characteristics 159
Treatment 160
Common Operative Procedures for Metastatic Tumors Involving Common Anatomic Site-Guidelines 160
Benign Bone Tumors 161
Solitary and Multiple Osteochondromas (Exostosis) 161
Enchondromas 162
Microscopic Characteristics 162
Chondroblastoma, Osteoblastoma, and Osteoid Osteoma 163
Osteoid Osteoma 163
Clinical Characteristics and Physical Examination 163
Radiographic Appearance and Evaluation 164
Treatment 164
Aneurysmal Bone Cysts 165
Unicameral (Simple) Bone Cysts 165
Treatment 165
Eosinophilic Granuloma (Histiocytosis X) 166
Tumors Originating from the Joint 166
Specific Diagnoses 166
Pigmented Villonodular Synovitis (Aggressive Synovitis) 166
Ganglia 168
Soft-Tissue Sarcomas 168
Clinical Findings and Physical Examination 168
Biological Behavior and Natural History 169
Pathology and Staging 169
Radiographic Evaluation 169
Magnetic Resonance Imaging 169
Angiography 170
Bone Scans 171
Treatment 171
Chemotherapy 171
Radiation Therapy 171
Surgery and Chemotherapy as a Multimodality Approach 171
Specific Soft-Tissue Sarcomas 172
Malignant Fibrous Histiocytoma 172
Liposarcoma 172
Fibrosarcoma 173
Synovial Sarcoma 173
Epithelioid Sarcoma 174
Benign Soft-Tissue Tumors 174
Benign Adipose Tumors 174
Simple Lipoma 174
Episacral Lipomas 175
Spindle Cell Lipoma 175
Intramuscular and Intermuscular Lipomas 175
Benign Tumors of Peripheral Nerves 175
Neurilemmoma (Schwannoma) 176
Neurofibroma 176
Benign Fibrous Tumors 176
Aggressive Fibromatosis 176
Benign Vascular Tumors 177
Hemangioma 177
References 177
Suggested Reading 177
5 Childrens Orthopedics 179
Introduction 179
Biological Differences 180
Growth 180
Remodeling 180
Specific Anatomic Structures 180
Bone 180
Ligament 180
Periosteum 181
Cartilage 181
The Growth Plate 181
Peripheral Structures of the Plate 183
Factors Affecting the Skeletal Growth 183
Genetic Impact 183
Nutrition 184
Endocrine 184
Environmental Factor 184
Coexistent Disease 184
Developmental Variations in Skeletal Growth 184
Torsional Variations 185
Angular Variations 187
Differential Diagnosis 188
General Affectations of the Pediatric Skeleton 190
Infection 190
Osteomyelitis 190
Septic Arthritis 193
Complications of Bone and Joint Infections 196
Arthritis in Childhood 198
Juvenile Rheumatoid Disease 198
Hemophilia 199
Lyme Disease 199
Metabolic Disease 200
Vascular and Hematologic Disease 200
Sickle Cell Disease 201
Leukemia 202
Congenital and Neurodevelopmental 204
Osteogenesis Imperfecta 204
Down Syndrome 204
Skeletal Dysplasias 207
Achondroplasia 207
Clinical Features 208
Neuromuscular Disease 209
Cerebral Palsy 209
Polio 210
Spina Bifida 211
Regional Orthopedic Problems 212
The Pediatric Hip 212
Developmental Dislocation of the Hip 214
Treatment 218
Perthes' Disease 220
Slipped Capital Femoral Epiphysis 223
Transient Synovitis of the Hip 225
The Pediatric Knee 226
Osgood'Schlatter's Disease 226
Osteochondritis Dissecans 226
The Discoid Meniscus 227
Popliteal Cysts 229
The Pediatric Foot 229
The Flatfoot 230
Congenital Hypermobile Flatfoot 230
The Rigid Flatfoot 230
Congenital Clubfoot 231
Metatarsus Adductus 232
The Pediatric Upper Extremity and Neck 234
Sprengel's Deformity 234
Congenital Muscular Torticollis 235
Radial Anomalies 236
Congenital Trigger Thumb 236
Pediatric Trauma 237
Battered Child Syndrome 240
Evaluation of a Limp 242
Conclusions 244
Pediatric Spine: William C. Lauerman 245
Scoliosis 245
Management 246
Congenital Scoliosis 250
Neuromuscular Deformity 250
Kyphosis 251
Spondylolisthesis 254
Suggested Reading 257
6 Sports Medicine 258
Introduction 258
Patterns of Injuries 258
Musculoskeletal Tissues 259
Tendons 259
Ligaments 260
Muscle 262
Articular Cartilage 263
Meniscus 265
Evaluation of Common Sports Medicine Injuries 267
History 267
Physical Examination 268
Special Tests 269
X-Rays 269
Magnetic Resonance Imaging 270
Bone Scintigraphy 270
Arthroscopy 271
Treatment of Sports Injuries 271
Macrotraumatic Injuries 272
Immediate 272
Early 272
Late 272
Microtraumic Injuries 272
Immediate 272
Early 273
Late 273
Summary and Conclusion 273
Suggested Reading 274
7 The Spine 275
Cervical Spine 275
History 275
Physical Examination 276
Diagnostic Studies 278
Plain Radiographs 278
Magnetic Resonance Imaging 279
Myelography 279
Computerized Tomography 281
Electromyography 281
Clinical Conditions 281
Neck Sprain-Neckache 282
Acute Herniated Disc 282
Cervical Spondylosis 285
Cervical Spondylosis with Myelopathy 286
Rheumatoid Arthritis 287
Cervical Hyperextension Injuries 288
Cervical Spine Algorithm 290
Conservative Treatment 292
Neck Pain Predominant 293
Arm Pain Predominant (Brachialgia) 295
Conservative Treatment Modalities 295
Immobilization 295
Drug Therapy 296
Traction 297
Trigger-Point Injection 297
Manipulation 297
Exercises 298
Lumbar Spine 298
History 298
Physical Examination 299
Diagnostic Studies 300
Plain Radiographs 301
Magnetic Resonance Imaging 302
Myelography 303
Computed Tomography 303
Electrodiagnostic Testing 305
Clinical Conditions 305
Back Strain-Lumbago 305
Herniated Disc 306
Spinal Stenosis 309
Spondylolisthesis 310
Lumbar Spine Algorithm 312
Conservative Treatment 315
Refractory Patients with Low Back Pain 316
Refractory Patients with Sciatica 318
Refractory Patients with Anterior Thigh Pain 319
Refractory Patients with Posterior Thigh Pain 320
Conservative Treatment Modalities 321
Bed Rest (Controlled Physical Activity) 321
Drug Therapy 322
Trigger-Point Injection 323
Epidural Steroid Injection 323
Traction 324
Manipulation 324
Braces and Corsets 325
Physical Therapy 326
Summary and Conclusion 326
Suggested Reading 326
8 The Shoulder 327
Introduction 327
Functional Anatomy 327
The Glenohumeral Joint 327
The Glenohumeral Ligaments 328
The Labrum 330
The Rotator Interval 330
The Long Head of the Biceps Tendon 330
The Rotator Cuff 331
The Subacromial Space 331
The Acromioclavicular Joint 331
The Sternoclavicular Joint 332
The Scapulothoracic Articulation 333
The Brachial Plexus 333
Clinical Examination of the Shoulder Girdle 333
History 334
Functional Assessment 335
Inspection 335
Palpation 336
Range of Motion 336
Strength Assessment 337
Neurologic Examination 337
Special Tests and Signs 337
Rotator Cuff 338
Biceps Tendon (Long Head and Superior Labrum) 339
Shoulder Instability 339
Imaging Studies and Other Diagnostic Tests 340
Radiographs 340
Magnetic Resonance Imaging 340
Computerized Tomography 341
Electrodiagnostic Testing 342
Evaluation and Treatment of Common Shoulder Problems 342
Rotator Cuff Disease 342
History 344
Examination 344
Differential Diagnosis 344
Radiographic Evaluation and Magnetic Resonance Imaging 345
Initial Treatment 345
Surgical Treatment 346
Osteoarthritis 347
History 347
Examination 347
Differential Diagnosis 348
Radiographs 348
Treatment 348
Miscellaneous Arthropathy 350
Adhesive Capsulitis 350
History 350
Examination 351
Differential Diagnosis 351
Radiographs 351
Treatment 351
Calcific Tendinitis 352
History 352
Examination 352
Differential Diagnosis 353
Radiographs 353
Treatment 353
Multidirectional Instability 353
History 353
Examination 354
Differential Diagnosis 354
Radiographs 354
Treatment 354
Summary 355
Suggested Reading 355
9 The Elbow 356
Introduction 356
Functional Anatomy 356
Skeletal 356
Muscles 359
Neurovascular 359
Musculocutaneous Nerve 359
Median Nerve 360
Radial Nerve 360
Ulnar Nerve 360
Brachial Artery 360
Evaluation of Elbow Problems 361
History 361
Physical Examination 362
Radiographic Evaluation 363
Stress X-Rays 364
Computed Tomography/Magnetic Resonance Imaging Examination 364
Technetium-99 Bone Scan 364
Electrodiagnostic Tests 364
Arthroscopy 364
Treatment of Elbow Problems 365
Nonoperative Treatment 365
Rehabilitation 365
Corticosteroid Injections 368
Operative Treatment 368
Evaluation and Treatment of Common Elbow Problems 368
Trauma 368
Fractures 368
Dislocations 369
Ligamentous Injuries 370
Tendon Ruptures 371
Atraumatic and Overuse Injuries of the Elbow 372
Lateral and Medial Epicondylitis 372
Ulnar Nerve Compression (Cubital Tunnel Syndrome) 373
Little Leaguer's Elbow 373
Osteochondritis Dissecans (Panners' Disease) 374
Arthritis 375
Summary and Conclusions 376
Suggested Reading 376
10 The Hand 377
Introduction 377
History 377
Physical Examination 378
Imaging 379
Arthroscopy 380
Pathophysiology 380
Congenital Hand Differences 380
Failure of Formation of Parts (Arrest of Development) 380
Failure of Differentiation (Separation of Parts) 382
Duplication 382
Other Congenital Anomalies 383
Developmental or Acquired Disease 383
Arthritides 383
Nerve Compression Syndromes 386
Tendon Compression Syndromes 388
Dupuytren's Contracture 388
Kienb'ck's Disease 389
Inflammation and Infection 389
Trauma 391
Lacerations 391
Fractures and Dislocations 391
Severe and Complex Upper Extremity Injuries 393
Other Injuries 394
Metabolic Disease 395
Vascular 395
Neoplasms 396
Skin Cancer 396
Other Soft Tissue Masses 396
Tumors of Bone 398
Management Protocols 398
Suggested Reading 401
11 The Hip and Femur 402
Anatomy 402
Development 402
Osteology and Musculature 403
Vascular Anatomy of the Proximal Femur and Femoral Head 407
Biomechanics 407
Gait 408
Patient Evaluation 408
History 408
Physical Examination 409
Radiographic Evaluation 411
Hip Pathology 416
Hip Arthritis 419
Surgical Management 422
Arthroscopy 422
Arthrotomy 422
Osteotomy 423
Arthrodesis 424
Hip Replacement Surgery 424
Complications 430
Summary 434
Suggested Reading 434
12 The Knee 436
Anatomy 436
Biomechanics of the Knee 440
Evaluation of the Painful Knee 440
History 440
Physical Examination 441
Imaging 443
Knee Pathology 444
Meniscal Tears 445
Ligament Injuries 445
Patello-Femoral Pathology 445
Arthritis 446
Surgical Reconstruction for Arthritis 447
Summary and Conclusions 450
Suggested Reading 450
13 The Foot and Ankle 451
Introduction 451
Bones and Joints 451
Ligaments 454
Muscles 457
Nerves and Vessels 459
Gait Cycle 459
Clinical Evaluation of the Foot and the Ankle 460
History and Physical Examination 460
Radiology of the Foot and Ankle 461
Diseases of the Foot and Ankle 462
Trauma 462
Ankle 462
Fractures to the Hindfoot 462
Injury to the Midfoot 465
Ankle Sprains 466
Injuries of the Forefoot 466
Acquired Deformities of the Foot and Ankle 467
Deformities of the Forefoot 467
Injuries of the Tendons of the Foot and Ankle 469
Peroneal Tendon Pathology 470
Anterior Tibial Tendon Pathology 470
Achilles Tendon Disorders 470
Posterior Tibial Tendon 471
Heel Pain 472
Arthritic Conditions of the Foot and Ankle 473
Rheumatoid Arthritis 474
Infections 475
Puncture Wounds 475
Paronychia 476
Diabetic Foot Infections 477
Tumors 477
Soft Tissue Lesions 478
Bone Tumors 478
Complex Regional Pain Syndrome 479
Summary and Conclusions 480
Suggested Reading 482
Glossary 483
Index 492