CHAPTER 41 - Orthopaedics

Randy N. Rosier
GENERAL CONSIDERATIONS Pain Anatomy and Physiology Definition The International Association for the Study of Pain defines ain as !an un leasant sensory and emotional e" erience associated #ith actual or otential tissue damage$ or descri%ed in terms of such damage&' Afferent nocice ti(e im ulses roduced %y in)urious stimulation are transmitted to the central ner(ous system$ #here they are gi(en meaning %y the erce tual state of the indi(idual& The erce tions of ain are modified %y many factors$ including ast and resent e" erience$ state of a#areness$ concomitant sensory stimuli$ and emotional status& Stimulation of eri heral rece tors %y no"ious agents roduces a s atiotem oral attern of ner(ous im ulses that is inter reted as ain #ithin the higher cere%ral centers& Teleologically$ ain ser(es the useful function of re(ention of tissue damage and is a homeostatic mechanism& It is only in the osto erati(e setting or #hen ain %ecomes chronic that it ser(es no useful function& Acute ain im lies the resence of actual tissue damage or its otential unless the no"ious stimulus is remo(ed* it may %e associated #ith autonomic hy eracti(ity such as hy ertension$ tachycardia$ s#eating$ and (asoconstriction& Chronic ain im lies the a%sence of a threat of tissue damage yet is descri%ed in terms of such damage +discomfort$ suffering,& Generally ain is considered to %e chronic #hen its duration e"ceeds - to . months& Transduction Pain is initiated %y a stimulus that is detected %y nocice tors +transduction, and is the most common manifestation of disorders of the musculos/eletal system& Pain can %e roduced %y a #ide (ariety of hysical henomena$ including ressure$ uncturing$ s0uee1ing$ tension$ and e"tremes of tem erature$ and %y chemical effects such as change of 2 or release of oly e tide mediators$ including histamine3li/e su%stances$ serotonin$ %rady/inin$ and other oly e tides& Prostaglandins may lo#er the ain threshold for some stimuli$ and inflammation accom anied %y local acidosis can enhance erce tion of ain& In addition$ a num%er of local e tide mediators such as su%stance P are released at sites of in)urious stimuli and trigger atterns of ner(ous acti(ity inter reted as ain& Transmission 4ost cutaneous sensory ner(e endings consist of unmyelinated fi%ers$ #hich roduce sensations of ressure$ touch$ or ain$ de ending on the im ulse attern in(o/ed& These ner(e endings are found also in eriosteum$ arteries$ )oint ca sules$ and syno(ium$ #ith similar myelinated fi%ers in muscle& The signal is then transmitted (ia sensory afferent ner(e fi%ers and dorsal root ganglia to the s inal cord& The smaller3 diameter myelinated A3delta and unmyelinated C afferent fi%ers are those rimarily res onsi%le for ain transmission +Ta%le 5636,& Syna ses in the dorsal horn interact #ith other afferents as #ell as the s inoreticular ath#ay and transmit information (ia the s inothalamic tract to the thalamus and somatosensory corte"&

4odulation 4odulation of the nocice ti(e information occurs in the dorsal horn through a num%er of neurotransmitters +7ig& 5636,& Descending modulating systems are generally inhi%itory and are influenced %y multi le factors$ including emotional state& Endogenous o ioid systems +en/e halins and endor hins, regulate descending modulatory acti(ity$ and multi le o ioid rece tors for these su%stances ha(e %een identified in the central and eri heral ner(ous system& These same rece tors are res onsi%le for the inhi%itory effects of o ioid analgesics on ain le(el& Additional modulation may occur #ithin the dorsal horn$ according to the gate theory of ain ro osed %y 4el1ac/ and 8all +7ig& 5639,& This hy othesis in(ol(es interacti(e influences of myelinated and unmyelinated fi%ers #ithin the dorsal horn$ determining the net le(el of nocice ti(e out ut of the transmission cells& :oth fi%er ty es are thought to directly e"cite the transmission cell$ #hile they ha(e o osing effects on the interneurons in the su%stantia gelatinosa$ #hich also regulate the le(el of transmission3cell acti(ity& Transcutaneous electrical ner(e stimulation as a ain control method is %ased on this hy othesis$ and its efficacy su orts the gate theory of ain& Selecti(e stimulation of large3diameter myelinated afferents %loc/s ain$ since the unmyelinated A3delta and C ain fi%ers ha(e a high electrical threshold and remain unstimulated& This techni0ue is innocuous$ nonin(asi(e$ and of great %enefit to some atients #ith osto erati(e or chronic ain& Perce tion The end oint in the ain ath#ay is its erce tion %y the atient& Pain occurs #ith (arious 0ualities$ such as aching$ %urning$ s asmodic$ radiating$ lancinating$ dull$ or shar & Local ain is felt at the site of in)ury$ #hile diffuse ain a ears to %e more characteristic of dee structures$ and radicular ain radiates along eri heral ner(e ath#ays$ often in association #ith neurologic deficits such as sensory or motor loss& Referred ain occurs in a location remote from the site of tissue athology$ and re resents a mis laced cortical ain erce tion& Common e"am les include /nee ain as a manifestation of hi )oint athology$ and gluteal or osterior thigh and leg ain as a manifestation of s inal athology& Referred ain tends to follo# s inal segmental inner(ation and must %e differentiated from radicular ain& 7or instance$ in)ection of saline into inters inous ligaments has %een demonstrated to cause referred gluteal and lo#er e"tremity ain +7ig& 563 -,& Radicular ain$ ho#e(er$ #ill follo# s ecific dermatomal distri%utions& Tissue Patterns :one :one is not thought to ha(e any sensory endings #ithin it$ although the eriosteum is richly inner(ated #ith %oth myelinated and unmyelinated ner(e endings& Small unmyelinated fi%ers ha(e %een identified in association #ith %lood (essels #ithin %one and ro%a%ly are sym athetic fi%ers res onsi%le for %one %lood flo# regulation& :ony lesions such as tumors or infections cause a dee $ %oring ty e of ain that may result from ressure sensation mediated %y %lood (essel3associated fi%ers* ain from fractures$ in contrast$ has a shar er 0uality and is characteristically relie(ed %y rest& 4uscle;Tendon

4uscle ain may result from direct in)ury$ o(eruse or chemical irritation from meta%olites such as lactic acid resulting from tissue ano"ia& Ty es of local in)ury causing ain include contusion$ artial or com lete tendon or muscle ru ture$ e"cessi(e stretch or load under tension +muscle strain,$ and inflammatory disorders +e&g&$ myositis,& 4uscle in)ury usually is characteri1ed %y tenderness of the muscle to al ation and soreness aggra(ated %y mo(ement or (oluntary contraction of the muscle& 4uscle s asm refers to a sustained in(oluntary muscle contraction$ #hich can cause se(ere$ aro"ysmal cram li/e ain and is a common res onse to muscle in)ury& S asm also can result from in)ury to the inner(ation of a muscle$ as in sciatica$ or from meta%olic a%normalities such as hy ocalcemia$ al/alosis$ or the resence of to"ins such as tetanus& 4yalgia$ or aching ain in muscle$ can occur as a sym tom of systemic (iral infections$ or in association #ith chronic idio athic disorders such as fi%rositis or fi%romyalgia& Ischemia of muscle causes regional lactic acidosis$ #hich can roduce aching ain& 4ore se(ere degrees of ischemia$ usually associated #ith significant trauma such as fractures$ %ut occasionally seen #ith e"cessi(e e"ertion$ can result in a com artment syndrome& Gi(en that muscle is %ounded %y inelastic fascial com artment co(erings$ ischemia that causes muscle s#elling can result in ele(ated tissue ressure #ithin muscle com artments$ #hich in turn im edes (ascular inflo# and starts a (icious cycle of #orsening ischemia& The result is se(ere ain out of ro ortion to the se(erity of the initial in)ury as #ell as ain #ith assi(e stretch of the muscle+s, in(ol(ed& Emergent surgical release of in(ol(ed com artments is re0uired to re(ent ermanent muscle and ner(e damage in this condition& Tendon3related ain is most commonly seen #ith tendinitis$ an inflammation of the tendon and associated sheath + aratenon,& Tendinitis usually is a result of o(eruse$ and as such it may reflect the result of mechanical disru tion of some of the collagen fi%ers in a tendon& Common sites include the rotator cuff tendons of the shoulder$ the tendons a%out the #rist$ the atellar tendon$ and the Achilles tendon& Local tenderness and s#elling result$ and the ain is generally in(o/ed %y contraction of the associated muscle& Tendinitis may resage a ru ture of the in(ol(ed tendon$ occasionally seen #ith the Achilles$ atellar$ and rotator cuff tendons$ and #ith the tenosyno(itis of rheumatoid arthritis in the hand and #rist& Treatment usually in(ol(es rest of the affected area and anti3inflammatory medication& Ru tures re0uire surgical re air$ and ersistent tendinitis may re0uire surgical remo(al of mechanical causes or tenosyno(ectomy& <oint <oint ain may result from hy eremia or inflammation of syno(ium$ )oint effusion roducing ca sular distention$ insta%ility causing traction on ca sular or ligamentous structures$ or degeneration of articular cartilage& Cartilage is a(ascular and lac/s ner(e endings$ indicating that ain resulting from cartilage in)ury or degeneration originates in the underlying %one or ad)acent ca sule and syno(ium (ia secondary mediators& Neurogenic Pain Peri heral ner(es may cause ain in res onse to ressure$ ischemia$ stretching$ her es 1oster infection$ to"ins +lead$ arsenic,$ or meta%olic distur%ances +(itamin deficiencies$ dia%etic or alcoholic neuro athies,& A characteristic of neurogenic ain is its radicular nature and association #ith neurologic sym toms such as aresthesias$

sensory or motor loss$ and secondary muscle atro hy& 2y eresthetic ain may %e encountered #ith her es 1oster infection or Guillain3:arr= syndrome$ or during a"onal reco(ery from mechanical in)ury& 2I> infection also has %een identified as a cause of chronic eri heral neuro athic ain& Treatment The mechanism of action of many of the commonly used nonnarcotic analgesics is un/no#n& 4ulti le rece tors that res ond to narcotic medications as #ell as endogenous analgesics +endor hins, ha(e %een identified& 7or chronic ain from conditions that are not life threatening$ efforts are made to a(oid the use of narcotics %ecause of the otential for rogressi(e de endence and de(elo ment of tolerance to the drugs& Nonsteroidal anti3inflammatory and analgesic drugs are useful$ and for chronic neurogenic ain antide ressants +amitri tyline, and anticon(ulsants +car%ama1e ine, may %e useful& Posto erati(ely$ atient3controlled analgesia techni0ues$ #herein the atient can self3 administer intra(enous narcotic medications at lo# doses as needed$ are #idely used& This method not only gi(es %etter and more e(en relief of osto erati(e ain %ut also has %een sho#n to decrease the total amount of medication needed& The use of e idural anesthesia for surgical rocedures also allo#s the use of the e idural catheter osto erati(ely for ain control& Local anesthetics or narcotics can %e used in con)unction #ith a um to deli(er minute doses of the agents directly to the e idural s ace around the s inal cord$ usually #ith total relief of ain& Im lanta%le su%cutaneous or e idural um s also are useful for continuous deli(ery of o ioids in atients #ith se(ere chronic ain such as those #ith metastatic cancer or AIDS& In selected cases of chronic se(ere ain in(ol(ing an e"tremity$ neural a%lations #ith in)ections of alcohol or henol ha(e %een used successfully to im ro(e ain control& The to ical analgesic ca saicin$ #hich is thought to de lete local tissue stores of su%stance P$ has %een used successfully for ain from arthritis and from her es 1oster infection& ? er E"tremity 8rist and 2and Radiocar al$ car ometacar al$ metacar o halangeal$ and inter halangeal arthritides fre0uently cause ain in the region of the #rist and hand$ usually #ith s#elling and stiffness of the affected )oints& Additional causes include tendinitis$ de @uer(ainAs disease$ com ression of the median ner(e at the #rist %eneath the trans(erse car al ligament +car al tunnel syndrome,$ com ression of the ulnar ner(e %eneath the (olar car al ligament +ulnar tunnel syndrome,$ or radicular ain from com ression of these ner(es at a more ro"imal le(el& Such neurogenic ain can %e accom anied %y sensory or motor deficits$ and #hen associated #ith (asomotor tro hic changes can indicate the resence of a refle" sym athetic dystro hy +RSD,& RSD$ #hich can occur in the u er or the lo#er e"tremity after an in)ury or surgery$ is a sustained a%normal refle" caused %y efferent acti(ity arising from sym athetic ner(es +7ig& 5635,& 8hen the inciting in)ury is /no#n to in(ol(e a ma)or ner(e trun/$ it is referred to as causalgia& The ain ty ically is descri%ed as %urning in character$ and there is associated hy eresthesia and dysesthesia + ainful res onse to normally non ainful stimuli,$ s#elling$ )oint stiffness$ (asomotor insta%ility$ and mar/ed osteo enia in the

region +Sudec/As atro hy,& In the u er e"tremity$ adhesi(e ca sulitis of the shoulder may occur #ith RSD of the hand +shoulder3hand syndrome,& Regional sym athetic %loc/ade aids in diagnosis as #ell as treatment %y %rea/ing the refle" arc$ and hysical thera y and corticosteroids may %e hel ful& El%o# The most common causes of el%o# ain are medial or lateral e icondylitis +!golferAs el%o#' and !tennis el%o#$' res ecti(ely,$ arthritis of the el%o# )oint$ and com ression neuro athy of the ulnar ner(e at the el%o# +cu%ital tunnel syndrome,& Treatment is rest$ anti3inflammatory medication$ and$ in refractory cases$ surgical release of the affected muscle origin or ner(e decom ression& Shoulder Common causes of shoulder ain include arthritis of the glenohumeral or acromiocla(icular )oints and im ingement syndrome$ in #hich tendinitis and %ursitis of the rotator cuff result from im ingement of these structures on the coracoacromial ligament& 7or#ard ele(ation and internal rotation +im ingement test, %ring the su ras inatus tendon in contact #ith the coracoacromial ligament$ re roducing the ain& In)ection of lidocaine and cortisone in the su%acromial %ursa is hel ful diagnostically and thera eutically& In refractory cases$ anterior e"cision of the acromion and coracoacromial ligament +Neer acromio lasty, may %e hel ful& Im ingement chronically can lead to rotator cuff tears$ the ma)ority of #hich can %e managed conser(ati(ely& Persistent sym toms or com lete ru ture in a young erson are indications for rotator cuff re air& Diagnosis of these lesions is aided %y arthrogra hy and magnetic resonance imaging +4RI, scans& :ici ital tendinitis also can resent #ith anterior acti(ity3related shoulder ain$ #ith local tenderness and ain #ith resisted %ice s muscle contraction& Conser(ati(e treatment usually suffices& Occasionally ru ture of the tendon of the long head of the %ice s can occur$ articularly in association #ith im ingement syndrome and rotator cuff athology& Cer(ical Origin Cer(ical arthritis or ner(e root irritation from osteo hytes or disc herniations can cause %oth referred and radicular ain in the shoulder area& In addition$ (isceral athology in the heart$ lungs$ or leura can %e referred to the shoulder or arm& :rachialgia +%rachial neuralgia, is characteri1ed %y u er e"tremity ain associated #ith aresthesias$ altered sensation$ #ea/ness$ and refle" changes in a radicular distri%ution of the %rachial le"us& Occasionally sym athetic le"us distur%ances are seen$ #ith (ertigo$ tinnitus$ or (isual distur%ances& Causes of %rachialgia include tumors of the s inal cord or ner(e roots$ infections$ disc herniation$ %rachial le"us trauma$ PancoastAs tumor of the a e" of the lung$ congenital anomalies of the cord such as syringomyelia$ and cer(ical (erte%ral su%lu"ations or dislocations& Another ossi%le cause of %rachialgia is the thoracic outlet syndrome$ in #hich com ression of the %rachial le"us and (ascular outflo# o%struction can result from cer(ical ri%s$ anomalous fi%rous %ands #ithin the scalene muscles$ or changes caused %y trauma to the cla(icle or scalenes& Scalene muscle or ri% resection can im ro(e the sym toms if conser(ati(e measures fail& Differential diagnosis of the causes of cer(ical and shoulder ain is aided %y radiogra hs to delineate %ony a%normalities$ and %y com uted tomogra hy +CT, or 4RI$ #hich can demonstrate %oth %ony and soft3tissue athology& Cer(ical strain syndrome +#hi lash in)ury, can result from ra id acceleration or deceleration of the head and is common in motor (ehicle accidents&

Pain ty ically is resent in the cer(ical area and often is also referred to the shoulder and arm& Treatment is conser(ati(e$ #ith a cer(ical collar for rest and a ro riate medications follo#ed %y a cer(ical isometric e"ercise rogram$ and$ in refractory cases$ intermittent cer(ical traction& Cer(ical Disc Disease Cer(ical disc herniations most commonly occur at the C5BC. le(els$ the region res onsi%le for the ma)ority of fle"ion;e"tension motion in the cer(ical s ine& Degenerati(e changes in the discs or trauma can cause herniation of the gelatinous nucleus ul osus through the annulus fi%rosus$ allo#ing im ingement on ner(e roots or the s inal cord& Nec/ ain and radicular ain in the distri%ution of the in(ol(ed root le(el+s, can result& Sym toms may %e unilateral or %ilateral$ de ending on #hether the herniation is central or lateral* in some cases central herniations can cause cord sym toms such as :ro#n3S=0uard syndrome$ hy errefle"ia %elo# the lesion$ incontinence$ and gait distur%ances& Lateral herniations are the most common$ #ith corres onding local and radicular sym toms& Local aras inous muscle s asm is common$ #ith rigidity and ain #ith motion& >ertical com ression$ articularly #ith head tilt to the affected side$ e"acer%ates the sym toms$ and (ertical traction tends to diminish them& De ending on the affected le(el$ the %rachioradialis$ %ice s$ or trice s refle"es may %e de ressed +CC$ C.$ or CD$ res ecti(ely,$ and corres onding muscle #ea/ness or dermatomal sensory changes may %e resent& Definiti(e diagnosis can %e made %y cer(ical myelogra hy or 4RI$ along #ith electromyogra hic studies to assess the degree and le(el of neurologic in(ol(ement& Treatment consists of cer(ical traction follo#ed %y anti3inflammatory medication and a cer(ical collar& If neurologic deficit does not res ond rom tly to traction$ surgical discectomy and fusion of the in(ol(ed (erte%rae may %e necessary& Cer(ical S ondylosis Degenerati(e changes in the cer(ical discs can lead to narro#ing of the inter(erte%ral foramina and osteo hyte formation in the ad)acent facet )oints& This can cause im ingement on ner(e roots$ #ith nec/ ain and neurologic sym toms as descri%ed a%o(e for disc herniations& In se(ere cases the facet )oint hy ertro hy can lead to stenosis of the cer(ical s ine$ resulting in cer(ical myelo athy as #ell as radicular sym toms& S hincter distur%ances occur in a%out one3third of atients$ %ut incontinence is unusual& The causes of the myelo athy are multifactorial %ut include ischemia to the anterior s inal cord from (ascular com ression$ ligamentous insta%ility that laces strain on the cord$ and ressure %y osteo hytes& 8hen conser(ati(e measures such as traction$ cer(ical collar$ and ostural e"ercises fail to re(ent neurologic rogression$ surgery may %e indicated& Anterior inter%ody fusion +Clo#ard rocedure, and osterior laminectomies or lamina lasty ro(ide relief of sym toms and neurologic im ro(ement in a high ro ortion of atients& :ecause of the insta%ility caused %y laminectomies$ lamina lasty is refera%le& Lo#er E"tremity 7oot and An/le The most common causes of foot ain are metatarsalgia and lantar fasciitis$ #hich result from re etiti(e loading of the metatarsal heads or of the attachment of the lantar ligament to the calcaneus& A ro riate shoe inserts to relie(e ressure +heel cu s$ metatarsal ads or %ars$ insoles,$ and anti3inflammatory medication or local cortisone in)ections generally alle(iate the sym toms& In refractory cases surgical release of the lantar fascia or metatarsal osteotomies or head resections are

occasionally indicated& Arthritis of any of the )oints in the midfoot or forefoot can cause ain$ and the first metatarso halangeal +4TP, )oint is articularly susce ti%le to acute gouty arthritis as #ell as osteoarthritis& Surgical arthrodesis +fusion, or arthro lasty is occasionally necessary #hen conser(ati(e management is unsuccessful& Additional causes of foot and an/le ain include eroneal tendon su%lu"ation$ stress fractures of the na(icular or metatarsals$ and com ression of the osterior ti%ial ner(e at the an/le or distally +tarsal tunnel syndrome,& Surgical decom ression of the ner(e in tarsal tunnel syndrome is not associated #ith as successful an outcome as it is in treating other com ression neuro athies& Lo#er Leg Re etiti(e loading of the ti%ia can lead to !shin s lints$' or acti(ity3related ain and tenderness o(er the ti%ia& Se(eral underlying causes ha(e %een identified$ including an e"ertionally induced com artment syndrome and a eriostitis in(ol(ing inflammation of the attachments of the osterior ti%ialis fascia to the ti%ia& E"ercise3induced com artment syndrome can %e diagnosed %y measuring com artment ressures in the leg %efore and after strenuous e"ercise #ith a slit catheter +see 7ig& 56399 :,& Release of the fascia may %e indicated in ersistent cases& Stress fractures of the ti%ia also can occur and resent similarly$ although radiogra hs often indicate eriosteal reaction$ and a nuclear %one scan #ill %e a%normal& Protected #eight %earing$ alone or #ith cast immo%ili1ation$ allo#s healing& 7emale runners #ith amenorrhea ha(e %een identified to %e at ris/ for osteo enic ti%ial stress fractures secondary to decreased estrogen le(els& Pain in the osterior calf can result from artial tears of the medial gastrocnemius muscle* ain #as formerly ascri%ed to ru ture of the lantaris muscle& 4uscle cram s in the calf$ commonly occurring at night$ can result from o(eruse& Dee (enous throm%osis in the calf must al#ays %e considered in the differential diagnosis of leg ain and usually is associated #ith diffuse s#elling$ #armth$ tenderness$ and ain #ith assi(e stretch of the gastrocnemius muscle or toe fle"ors +2omansA sign,& ?ltrasonogra hy and (enogra hy are im ortant diagnostic aids& Calf ain that rogresses #ith am%ulation %ut is relie(ed at rest may indicate ischemic claudication& The neurogenic claudication of s inal stenosis continues #hen the atient stands at rest$ #hich differentiates it from ischemic claudication& Enee Traumatic intraarticular derangements of the /nee$ including tears of the menisci$ ligamentous s rains$ and osteochondral fractures$ are a common cause of /nee ain& A history of loc/ing can %e found #ith intraarticular loose %odies$ osteochondral defects$ or meniscal tears& Arthritis of the /nee also can cause ain and local s#elling$ often #ith )oint s ace narro#ing or osteo hyte formation (isi%le radiogra hically& :ecause of the common inner(ation of the medial as ect of the /nee and the hi )oint %y the o%turator ner(e$ /nee ain can %e a manifestation of hi )oint athology& In these cases local tenderness and s#elling of the /nee are a%sent$ and forced assi(e rotation of the hi usually elicits the /nee ain& Anterior /nee ain is fre0uently caused %y the atellofemoral ain syndrome$ #hich is often associated #ith degeneration and fi%rillation of the articular cartilage of the atellar facets +chondromalacia,& Causes include %lunt direct trauma to the atella$ malalignment of the e"tensor mechanism$ or recurrent su%lu"ation or dislocation of

the atella& Patellar tendinitis +)um erAs /nee, also can resent #ith anterior /nee ain and focal tenderness o(er the atellar tendon& Diagnosis of chondromalacia is aided %y demonstration of atellofemoral cre itus$ ain #ith atellar com ression$ and tenderness of a atellar facet& Treatment generally is conser(ati(e$ #ith isometric 0uadrice s e"ercises& If malalignment e"ists$ lateral retinacular release or realignment of the e"tensor mechanism can %e considered$ and arthrosco ic de%ridement of chondral fi%rillations can %e hel ful& 4RI is often hel ful as a nonin(asi(e method for e(aluation of intraarticular athology$ including ligament tears$ osteochondral fracture$ meniscal tears$ and chondromalacia and is used increasingly in lace of diagnostic arthrosco y& 2i An im ortant clinical diagnostic consideration in the e(aluation of hi ain is the locali1ation of the site of athology& Intraarticular hi disorders usually resent #ith anteriorly locali1ed +inguinal, ain$ aggra(ated %y #eight %earing or %y assi(e rotation of the hi & Referred ain or radicular ain such as sciatica more commonly resents in the gluteal area$ as does ain deri(ed from sacroiliac )oint athology& 2i ain can %e secondary to osteoarthritis$ a(ascular necrosis of the femoral head$ syno(itis$ se tic arthritis$ stress fractures of the femoral nec/$ or a(ulsion fractures of the anterior inferior iliac s ine or the lesser trochanter& Lateral hi ain and tenderness can result from greater trochanteric %ursitis$ and anteromedial hi ain can %e caused %y adductor tendinitis$ ilio soas %ursitis$ or an ilio soas a%scess& 8ith soas a%scess or se tic arthritis$ the hi tends to %e held in fle"ion and e"ternal rotation& Pyriformis syndrome$ or entra ment of the sciatic ner(e under the yriformis muscle$ causes osterior hi and thigh ain +sciatica, and is aggra(ated %y internal rotation of the hi & 2i fle"ion contractures fre0uently result from chronic hi )oint athology& Lo# :ac/ The lo# %ac/ syndrome refers to a disease or in)ury of the lum%osacral s ine$ of an acute or a chronic nature& There are a #ide (ariety of causes of lo# %ac/ ain* a summary is resented in Ta%le 5639& Acute lo# %ac/ ain$ #hich is most common in the third to fifth decades$ can %e acti(ity related$ associated #ith aras inous muscle s asm$ and aggra(ated %y snee1ing or coughing& Pain usually is not radicular in nature$ %ut it can %e referred to the %uttoc/s or legs& 8hen ner(e root irritation is resent$ aresthesias$ neurologic deficits$ and radicular radiation of the ain can occur& In the ma)ority of atients #ith lo# %ac/ ain$ no s ecific athoanatomic cause can %e identified$ and treatment is sym tomatic& 7or all idio athic cases of lo# %ac/ ain$ FG ercent of atients reco(er #ithin - months$ and CG to .G ercent of atients #ith acute %ac/ ain reco(er #ithin 6 #ee/& In disease rocesses such as tumors or infections in(ol(ing the s ine$ the ain tends to %e se(ere$ unremitting$ and not relie(ed %y rest& 4echanically caused %ac/ ain is acti(ity de endent$ #hile morning ain and stiffness can %e associated #ith an/ylosing s ondylitis& E"amination of the atient should include assessment of the s inal range of motion$ straight3leg3 raising test for sciatic irrita%ility$ and a com lete neurologic e"amination& Lo# %ac/ syndrome is most effecti(ely treated %y a short eriod of %ed rest in the semi37o#lerAs osition +/nees and hi s fle"ed,$ anti3 inflammatory medication$ local heat$ and occasionally muscle rela"ants for s asm& Patients mo%ili1ed after 9 days of rest ha(e %een sho#n to reco(er more 0uic/ly than those rested D days& 8ith su%se0uent mo%ili1ation$ isometric %ac/ and a%dominal

e"ercises are hel ful$ as is the occasional use of a corset or %ac/ %race& Cardio(ascular fitness training a ears to %e im ortant %oth as a re(enti(e measure against recurrences and for im ro(ed functional ca acity& Such regimens include regular #al/ing$ s#imming$ or cycling& Occu ational lo# %ac/ ain +OL:P, is one of the most common and costly ro%lems for #or/ers in industry$ and it is the second most fre0uent cause of #or/er a%senteeism& As many as CG ercent of #or/ers in the ?nited States are affected at some time$ and lo# %ac/ ain is the most common #or/3related com laint treated %y rimary care hysicians& This disorder is the leading cause of disa%ility in ersons in the 6F3 to 5C3year3old range& Ris/ factors include re etiti(e lifting$ t#isting$ #hole %ody (i%ration$ and chronicity$ and disa%ility may also %e influenced %y sychological factors$ including #or/ stress and lo# )o% satisfaction& The natural history of OL:P is fa(ora%le$ #ith .G ercent of atients im ro(ed %y 5 #ee/s and HG ercent %y . #ee/s& Initial treatment is conser(ati(e$ as outlined in the algorithm in 7ig& 563C A& 8hen reco(ery seems (ery slo#$ further e(aluation may %e indicated as outlined in 7ig& 563C :& S ondylolisthesis S ondylolisthesis is a for#ard su%lu"ation of one (erte%ral %ody on another& It can %e caused %y +6, s ondylolysis +a defect in the ars interarticularis,$ +9, fracture of the osterior elements$ +-, congenital facet deficiency$ +5, facet deficiency caused %y degenerati(e disc disease$ and +C, isthmic elongation of the ars interarticularis& Illustrations of the ty es of s ondylolisthesis are sho#n in 7ig& 563.& Although %ac/ ain may occur along #ith hamstring tightness$ sciatica$ and$ rarely$ neurologic sym toms and signs$ s ondylolisthesis often is asym tomatic& The LCBS6 articulation is most commonly affected$ and the deformity is %est (isuali1ed on a lateral radiogra h$ as seen in 7ig& 563D& Pars interarticularis defects +s ondylolysis, are %est (isuali1ed #ith o%li0ue radiogra hs and are generally %elie(ed to result from incom lete healing of traumatic stress fractures& 7rom C to 9C ercent of atients resenting in childhood #ill demonstrate rogression of the dis lacement and can re0uire osterolateral fusion$ along #ith e"cision of the osterior elements +Gill rocedure, if neurologic deficit is resent& Other#ise treatment is conser(ati(e$ #ith rest and a%dominal e"ercises& There has %een rene#ed interest in reduction of se(erely dis laced (erte%ral %odies %efore fusion$ as #ell as in direct re air of ars interarticularis defects& Sciatica Sciatica is a sym tom rather than a disease$ and the term is used to descri%e radicular3 ty e ain in the lo#er e"tremity& Sciatica can %e caused %y ner(e root com ression %y a herniated disc$ tumor$ a%scess$ or osteo hyte$ or %y eri heral ner(e com ression #ithin the el(is or gluteal area %y tumor$ hematoma$ or a%scess& Disc herniations or degenerati(e arthritis #ith facet hy ertro hy and foraminal stenosis are %y far the most common causes& Inflammatory disorders of ner(es and ner(e roots also can cause sciatica& Alcoholic or dia%etic neuro athy$ arsenic or lead oisoning$ sy hilitic or her es 1oster infections$ and (asculitis associated #ith collagen (ascular diseases all ha(e %een associated #ith sciatica& Disc herniations occur most commonly at the LCBS6 and L5BLC le(els$ #hen a tear or degeneration in the annulus fi%rosus allo#s herniation of the soft$ gelatinous nucleus

ul osus osteriorly into the s inal canal& Im ingement on ner(e roots then causes %ac/ ain and sciatica$ sometimes #ith radicular neurologic sym toms& :ecause the osterior longitudinal ligament ro(ides su ort in the midline$ most disc herniations are osterolateral$ and hence sym toms often are unilateral& Disc herniations are uncommon in children and in older adults& The lo# incidence of disc herniations in older indi(iduals ro%a%ly is related to the age3 de endent loss of #ater content and disc (olume& Pain from disc herniations usually is aggra(ated %y sitting$ coughing$ snee1ing$ and for#ard fle"ion$ all of #hich increase disc ressures& Radicular sym toms also are elicited %y straight3leg raising$ articularly #ith additional dorsifle"ion of the foot +LasIgueAs sign,& De ressed refle"es in the affected distri%ution +/nee )er/JL5* osterior ti%ialis refle"JLC* an/le )er/JS6, as #ell as associated muscle #ea/ness and dermatomal sensory deficits can %e found& Radiogra hs may %e normal or may sho# narro#ing of the affected disc s ace& The lesion can %e demonstrated radiogra hically %y CT scan$ myelogra hy$ or 4RI +7igs& 563H and 563F,& Treatment usually is conser(ati(e initially$ #ith HG to FG ercent of atients im ro(ing s ontaneously and not re0uiring surgery& 2el ful thera eutic measures include %ed rest$ analgesics$ a%dominal isometric e"ercises$ and sitting in a reclining osition$ #ith mo%ili1ation as tolerated as the sym toms su%side& A(oidance of hea(y lifting and %ending hel s to re(ent recrudescence& Surgical e"cision of the e"truded ortion of the disc or digestion %y ercutaneous in)ection #ith chymo a ain or collagenase into the disc can %e effecti(e #hen sym toms rogress des ite conser(ati(e measures& 7usion at the time of discectomy has not %een sho#n to %e of %enefit in the a%sence of s inal insta%ility& 4icrodiscectomy and ercutaneous suction discectomy ha(e recently %een used as less in(asi(e surgical alternati(es %ut re0uire further (alidation of efficacy and delineation of indications& S inal Stenosis S inal stenosis$ a narro#ing of the s inal canal or neuroforamina$ can %e ac0uired$ as in the case degenerati(e disc disease$ or congenital$ as in achondro lasia& Patients resent #ith %ac/ or leg ain$ generally e"acer%ated %y standing and #al/ing and$ unli/e in discogenic %ac/ ain$ relie(ed %y sitting& Leg ain secondary to s inal stenosis can mimic (ascular claudication %ut is resent #hile standing still$ unli/e claudication& Neurologic signs$ including hy orefle"ia and muscle #ea/ness$ may %e resent* sciatic irrita%ility may %e e(ident& 7acet arthro athy associated #ith lum%ar s ondylosis is readily (isuali1ed on lateral and o%li0ue radiogra hs$ %ut the degree of s inal canal$ lateral recess$ or foraminal narro#ing is %etter assessed on a"ial CT or 4RI of the lum%ar s ine +7ig& 5636G,& Treatment consists of a%dominal isometrics$ fle"ion %racing$ and anti3inflammatory medication& E idural steroid in)ections can %e of some %enefit& In refractory cases$ #ide osterior surgical decom ression +laminectomies$ facetectomies$ foraminotomies, #ith or #ithout fusion can %e underta/en& >erte%ral Tumors 4alignant and %enign lesions can occur in the s ine as rimary tumors& :enign lesions include osteoid osteoma$ osteo%lastoma$ aneurysmal cyst$ giant cell tumor$ and eosino hilic granuloma& 4alignant rimary lesions are rare$ #ith the e"ce tion of multi le myeloma$ and include chondrosarcoma$ E#ingAs sarcoma$ and lym homa& Chordoma$ a rare tumor that e(ol(es from remnants of the notochord$ occurs in the sacrococcygeal and occi itocer(ical areas& The most common malignant tumor

in(ol(ing the s ine is metastatic carcinoma$ usually from a rimary tumor in the %reast$ rostate$ lung$ /idney$ or thyroid gland& :ac/ ain is the usual resenting sym tom$ %ut neurologic signs and sym toms$ including aralysis$ can occur& Lo#er3 e"tremity hy errefle"ia$ s asticity$ and ositi(e :a%ins/i signs indicate a danger of rogression to aralysis and re0uire emergent treatment& Primary %enign tumors such as aneurysmal cyst or osteo%lastoma are treated %y surgical e"cision$ #ith fusion #hen necessary& Primary malignant tumors such as chondrosarcoma or chordoma re0uire #ide surgical e"cision$ #hile more radiosensiti(e lesions such as lasmacytoma or E#ingAs sarcoma are treated #ith radiothera y and chemothera y$ as are most metastatic lesions& In the resence of s inal insta%ility +defined as a lesion causing a rogressi(e neurologic deficit$ or mechanical disru tion #ith the otential to cause such a deficit,$ surgical decom ression through an anterior or a osterior a roach$ along #ith fusion and instrumentation$ is erformed& Decom ression #ithout fusion and instrumentation can lead to insta%ility$ rogressi(e deformity$ and recurrent neurologic deficit& In cases re0uiring surgical inter(ention in #hich the atient has not had rior radiothera y$ osto erati(e treatment after #ound healing is indicated to re(ent local tumor recurrence& >erte%ral Osteomyelitis Pyogenic osteomyelitis is usually caused %y a Sta hylococcus aureus infection that starts in the (erte%ral end lates ad)acent to a disc s ace %y hematogenous s read from another infectious focus& :ac/ ain$ radiogra hically (isi%le destruction of the disc s ace$ and sometimes neurologic deficit result& Patients may ha(e systemic sym toms of infection* usually leu/ocytosis and ele(ation of the erythrocyte sedimentation rate are resent& 4ar/ed colla se of the (erte%rae #ith gi%%us deformity is unusual #ith yogenic infections and is seen more often #ith tu%erculous infection& Acute$ fulminating se sis is more common in children$ and chronic osteomyelitis is more common in adults& Radionuclide technetium di hos honate %one scans and 4RI are hel ful in diagnosis #hen radiogra hic findings are su%tle& 7igure 56366 demonstrates the radiogra hic differentiation %et#een tumor and infection$ and 7ig& 56369 sho#s the 4RI findings in similar lesions& Treatment in(ol(es identification of the organism %y %lood cultures or ercutaneous CT or fluorosco ically guided disc s ace as iration$ follo#ed %y immo%ili1ation and intra(enous anti%iotics$ usually for . #ee/s& 7ailure to res ond rom tly to conser(ati(e thera y and the resence of neurologic deficits are indications for surgical de%ridement #ith anterior %one grafting to reser(e sta%ility& Chest 8all Causes of chest #all ain include infections such as her es 1oster +shingles,$ s inal tumors #ith intercostal ner(e root com ression$ osteomyelitis$ and referred ain from (isceral disease of the underlying lung$ leura$ mediastinum$ or heart& Ri% fractures and in)uries of the costochondral )unctions can cause local ain& Inflammation of the costochondral )unctions +costochondritis or Tiet1eAs syndrome, is characteri1ed %y ainful enlargement and local tenderness$ often affecting se(eral ri%s simultaneously& Cumulati(e Trauma Disorders Cumulati(e trauma disorders encom ass a s ectrum of musculos/eletal ro%lems generally related to re etiti(e loading or in)ury to tissues$ fre0uently in a #or/ lace setting +Ta%le 563-,& These disorders may cause ain$ s#elling$ restriction of mo(ement$ or neurologic sym toms$ de ending on the s ecific condition& Treatment

generally in(ol(es rest of the affected art$ anti3inflammatory medications$ and$ #hen ossi%le$ #or/ lace modifications %ased on ergonomic considerations& DISORDERS O7 4?SCLE Anatomy and Physiology 4uscle fi%ers consist of multi le %undles of indi(idual muscle cells containing actin and myosin$ contractile elements that are regulated %y neurogenic stimulation of the motor end lates& The macrosco ic and microsco ic anatomy of muscle is sho#n in 7ig& 5636-& 4uscle fi%ers are di(ided into t#o ma)or ty es ha(ing different functional ro erties& Ty e I slo#3t#itch fi%ers ha(e lo# glycogen and glycolytic en1yme content$ %ut high mitochondrial o"idati(e hos horylation acti(ity and myoglo%in content& These fi%ers function in high3re etition and lo#3load endurance acti(ities& Ty e II fast3t#itch fi%ers ha(e higher glycolytic ca acity$ #ith su%ty es +IIA$ II:$ IIC$ and II4, differing in the form of myosin resent& Ty e II muscles are generally in(ol(ed in acti(ities re0uiring o#er and s eed& The fi%er ty es can %e distinguished histochemically and are genetically determined$ #ith different muscles ha(ing differing ro ortions of fi%er ty es$ de ending on functional re0uirements& Ty e I fi%ers are fatigue resistant and res ond to endurance training$ and ty e II fi%ers are fatiga%le$ res ond to resistance training$ and are res onsi%le for muscle hy ertro hy& Ty es of muscular contraction and associated terms are defined in Ta%le 5635& 4otor aralysis is defined as loss of (oluntary control of muscle contraction& Normal muscle has some resting tone$ or tension$ #hich is a%sent #ith lo#er motor neuron lesions$ causing flaccid aralysis& Tendon refle"es also are a%olished #ith interru tion of the lo#er motor neuron ath#ay& S asticity refers to a%normal increases in muscle tone #ith assi(e stretch and is caused %y loss of normal central inhi%itory control resulting from u er motor neuron lesions& Loss of inhi%itory control of tendon refle"es #ith u er motor neuron lesions also causes hy errefle"ia and re etiti(e refle"i(e muscle contraction in res onse to stretch$ or clonus& Lo#er motor neuron lesions$ disuse$ and immo%ili1ation result in muscle atro hy& The clinical grading of muscle strength is sho#n in Ta%le 563C& Electrodiagnosis Stimulation of a eri heral ner(e %y surface or needle electrodes results in conduction of the stimulus to the motor end lates$ #ith de olari1ation and resultant muscle contraction& The time for conduction and de olari1ation$ referred to as latency$ is rolonged in conditions of ner(e in)ury or com ression& The ner(e conduction (elocity$ #hich can %e determined %y stimulation at t#o oints a /no#n distance a art along the ner(e$ is useful in locali1ing eri heral ner(e lesions& Electromyogra hy +E4G, is the measurement of electrical otentials #ithin muscles using needle electrodes$ %oth at rest and #ith (oluntary contraction& S ontaneous electrical im ulses from indi(idual resting muscle fi%ers /no#n as fi%rillation otentials occur in muscle that has %een dener(ated& Intrinsic 4uscle Diseases Differentiating myo athies from other causes of muscle #ea/ness or aralysis re0uires consideration of family history$ age of onset$ and resence of muscle grou in(ol(ement #ithout common inner(ation& :iochemical tests for serum aldolase and creatine /inase and muscle %io sy can %e hel ful in diagnosis&

4uscular Dystro hies 4uscular dystro hies are hereditary disorders resulting in rogressi(e muscular degeneration& DuchenneAs muscular dystro hy is inherited as an K3lin/ed recessi(e disorder manifesting in male children %et#een the ages of - and . years& The genetic defect has %een identified as a deficiency of a rotein called dystro hin$ #hich functions as a calcium trans ort rotein& DuchenneAs muscular dystro hy is uniformly fatal$ usually %y the age of 9G years& Late cardiac and res iratory muscle in(ol(ement are the causes of death& The disease resents #ith difficulty standing and #al/ing$ and the child uses the u er e"tremities to ush to an u right osture +Go#erAs sign,& Pseudohy ertro hy of the gastrocnemius$ deltoids$ and 0uadrice s is common& E0uinus contractures of the an/les occur early$ as does ra idly rogressi(e scoliosis& Other forms of muscular dystro hy include lim% girdle and faciosca ulohumeral dystro hies$ #hich ha(e an higher age of onset and are inherited as autosomal recessi(e and dominant traits$ res ecti(ely& 7aciosca ulohumeral dystro hy$ #ith u er3e"tremity and facial #ea/ness and normal life s an$ is the most %enign& Pathology Loss of the integrity of the muscle cell mem%rane results in rogressi(e degeneration of muscle fi%ers& 7i%ers %ecome (aria%le in diameter and rounded rather than olygonal in cross3section and a ear hyalini1ed& 7at and fi%rous tissue re lace the degenerating muscle fi%ers$ #ith no e(idence of muscle regeneration& Diagnosis In addition to the clinical features$ serum aldolase and creatine /inase le(els are ele(ated$ articularly in the Duchenne form& ?rinary creatine and amino acid le(els are increased$ and creatinine le(el is decreased& E4G sho#s lo#er otentials and a oly hasic attern during (oluntary contraction$ and muscle %io sy e"amination confirms the diagnosis& Treatment Gi(en the recent identification of dystro hin deficiency as the cause of muscular dystro hy$ the disease is a good candidate for treatment %y gene thera y in the future& At resent$ treatment is sym tomatic$ #ith e"ercise to maintain function as long as ossi%le and %racing or surgery to control deformities& Achilles tendon lengthening is occasionally needed for e0uinus deformities$ and early aggressi(e treatment of rogressi(e scoliosis #ith cur(ature o(er 9C or -G degrees is indicated$ #ith osterior rodding and segmental #iring +Lu0ue techni0ue, to maintain sitting %alance and re(ent restricti(e ulmonary com romise& 4yotonias 4yotonic dystro hy is an autosomal dominant inherited disorder of muscle$ #hich usually resents in children or young adults #ith facial and distal e"tremity #ea/ness& Stimulation of muscle contraction results in rolonged contraction& 4yotonia congenita +ThomsenAs disease, is a hereditary disorder characteri1ed %y difficulty initiating (oluntary mo(ement& Diagnosis of these disorders is made clinically and %y E4G$ the resence of ele(ated serum muscle en1yme le(els$ and muscle %io sy e"amination& Contractures do not de(elo $ and surgical treatment is not necessary& Procainamide$ rednisone$ and 0uinine can hel atients #ith myotonia congenita& 4yositis

Inflammatory diseases of muscle can cause ain and #ea/ness and can %e associated #ith (iral$ arasitic$ or %acterial infections$ or #ith collagen (ascular diseases +e&g&$ dermatomyositis$ systemic lu us erythematosus$ scleroderma$ rheumatoid arthritis,& Polymyositis can %e treated #ith corticosteroids$ and e"ercise$ hysical thera y$ and a ro riate %racing can %e hel ful& 4uscle %io sy e"amination re(eals inflammatory cells and muscle necrosis$ and E4G demonstrates fi%rillation otentials$ distinguishing olymyositis from muscular dystro hies& In elderly atients$ an occult rimary malignancy sometimes is associated #ith olymyositis& E"trinsic 4uscle Diseases +Neurologic Disorders, Poliomyelitis Poliomyelitis is an infectious (iral disease characteri1ed %y central ner(ous system infection #ith destruction of anterior horn cells in the s inal cord causing flaccid aralysis& Poliomyelitis$ formerly one of the most common diseases causing ortho aedic deformities$ is no# rarely seen in the ?nited States$ %ecause of #ides read (accination& Deformities and leg length discre ancies can result& In a%out one3third of oliomyelitis atients an initial fe%rile illness occurs$ #ith headache$ malaise$ and fe(er$ lasting 5H h& The atient may reco(er or go on to a second acute hase after 5 or C days$ #hich also may resol(e #ithout aralysis& 2eadache$ fe(er$ nec/ stiffness$ and muscle s asms may occur during the acute hase$ #hich lasts from se(eral days to a #ee/& Paralysis can de(elo during the third or fourth day$ #ith loss of dee refle"es and muscle s asm& The lo#er lim%s are more fre0uently in(ol(ed than the u er e"tremities& Death can result from %ul%ar aralysis #ith res iratory insufficiency& The con(alescent hase follo#s$ and some motor im ro(ement may occur for u to 9 years& Treatment is su orti(e$ #ith hysical thera y to maintain )oint range of motion and (entilatory su ort #hen necessary& :racing is occasionally needed to assist function of araly1ed e"tremities& Later$ correction of )oint contractures$ sta%ili1ation of flail )oints %y arthrodesis$ and correction of leg length ine0ualities can %e underta/en during the residual hase& Tendon transfers can %e useful to im ro(e muscle %alance$ decrease contractures$ or restore functions& Only muscles #ith a strength grade of 5 or %etter are suita%le for transfer$ since one grade of muscle function is lost #ith transfer +see Ta%le 563C,& A ost olio syndrome has %een identified in older adults se(eral decades after disease onset$ consisting of increasing #ea/ness in affected muscle grou s and fatigue& The cause of this syndrome remains un/no#n& :ony Sta%ili1ation 7or flail )oints$ #hen muscles of sufficient strength for transfer are una(aila%le or %racing is unsuccessful$ surgical arthrodesis can %e erformed& <oint contractures re0uire stretching e"ercises$ s lints$ or$ for se(ere deformity$ surgical release& E i hysiodesis$ the surgical a%lation of the gro#th late$ or %one lengthening;shortening rocedures can %e used to correct significant lim% length ine0uality& Treatment of Deformity 7oot deformities are common and can %e treated in some cases %y orthoses& The most common deformities and functional losses and their corres onding surgical treatments are sho#n in Ta%le 563.& 4any of the rocedures listed are useful also for correction of deformities or functional deficits resulting from neurologic in)ury from other causes$ such as traumatic ner(e in)uries& Surgical correction of foot deformities may

%e accom lished %y e"traarticular su%talar arthrodesis +Grice rocedure, in s/eletally immature atients$ or tri le arthrodesis +fusion of the su%talar$ calcaneocu%oid$ and talona(icular )oints, in adults +7ig& 56365,& O erations must %e indi(iduali1ed according to the deficit& Patients #ith 0uadrice s muscle aralysis often are a%le to sta%ili1e the /nee in e"tension for am%ulation #ith the gluteus ma"imus and gastrocnemius muscles& 4uscle transfers a%out the hi are (aria%ly successful$ and if hi su%lu"ation or ainful degenerati(e change occurs$ arthrodesis may %e needed& Cere%ral Palsy Cere%ral alsy +CP,$ #hich occurs in a%out - %irths er 6GG$GGG$ can %e caused %y a num%er of factors$ including %irth trauma$ childhood head in)ury$ ano"ic %rain damage$ and (iral diseases such as ence halitis$ measles$ and cytomegalo(irus& Recent e idemiologic data suggest that a relati(ely small ro ortion of CP cases result from erinatal e(ents* the ma)ority are idio athic and are related to defects in central ner(ous system de(elo ment& CP is classified as s astic +CG ercent,$ athetoid +9C ercent,$ ata"ic +C ercent,$ rigid +C ercent,$ or mi"ed +6C ercent,& Si"ty ercent of atients #ith CP ha(e hemi legia +i silateral u er and lo#er e"tremity in(ol(ement,$ #ith di legia +%oth lo#er e"tremities, and 0uadri legia +all four e"tremities, %eing less common& Athetoid ty es e"hi%it in(oluntary re etiti(e motions that are dysfunctional* ata"ia +staggering$ %road3%ased gait, reflects cere%ellar dysfunction$ and rigidity results from diffuse cere%ral in(ol(ement usually associated #ith %irth ano"ia& Treatment T#o3thirds of CP atients ha(e an I@ %elo# DG$ #hich com romises treatments that re0uire atient coo eration$ such as muscle strengthening$ e"ercise$ and gait3training rograms& Treatment is directed to#ard re(ention of contractures and surgical correction of deformities that de(elo from muscle im%alance& Orthotics Orthoses are hel ful to control (arus or (algus deformities of the foot and e0uinus deformities of the an/le& Long leg %races can hel to control /nee fle"ion or (algus deformities and assist in am%ulation& ? er3e"tremity %racing can hel to re(ent fle"ion deformities of the #rist and digits and adduction of the thum%& Leg adductor s asticity is common and can cause hi su%lu"ation or dislocation$ #hich %ecomes ainful in a%out CG ercent of atients #ho de(elo it& A%duction %racing can hel to re(ent this ro%lem& Surgical TreatmentJLo#er E"tremity 8hen contractures or deformities rogress des ite conser(ati(e treatment$ an o eration sometimes is necessary& Surgery also can im ro(e function %y im ro(ing muscle %alance or remo(ing deforming forces& An im ortant ad)unct in surgical lanning is gait analysis %y (ideo recording or dynamic E4G& A ma)or em hasis in the management of the crouched$ scissoring gait of atients #ith CP has %een on correction of /nee fle"ion deformities$ %ut e(idence suggests that #hile stance hase of gait is im ro(ed$ s#ing hase is not& The rectus femoris muscle has %een sho#n %y dynamic E4G to %e more acti(e in s#ing hase$ causing inade0uate /nee fle"ion and oor toe clearance& Transfer of the rectus femoris to the medial or lateral hamstring muscles has %een sho#n to im ro(e this henomenon& E"cessi(e length of the atellar tendon also can result from the stretching effect on the rectus femoris #hen the

hamstrings are chronically tight& This can %e diagnosed %y the resence of atella alta on lateral radiogra h or greater assi(e e"tension than acti(e e"tension& Shortening the atellar tendon in con)unction #ith hamstring lengthening or release can im ro(e gait %y correcting these ro%lems& E0uinus deformities of the an/le constitute another common ro%lem that can %e corrected %y Achilles tendon lengthening& Care must %e ta/en not to o(erlengthen$ as a calcaneus deformity can result$ #hich is difficult to %race& >arus or (algus deformities of the hindfoot can %e corrected %y a Grice rocedure$ or %y tri le arthrodesis at s/eletal maturity +see 7ig& 56365,& Adduction deformities of the hi s are treated %y adductor tenotomies along #ith neurectomy of the anterior %ranch of the o%turator ner(e$ and if hi su%lu"ation is resent (arus and derotational osteotomies of the ro"imal femur #ith internal fi"ation may %e indicated +7ig& 5636C,& Surgical TreatmentJ? er E"tremity An o eration on the shoulder is almost ne(er necessary& The most common ro%lems are related to #rist and finger fle"or s asticity and thum% adduction deformities& 8rist;finger fle"ion deformities ha(e %een di(ided into three grou sL Ty e I or mild deformities +digits e"tend #ith #rist in less than 9G degrees of fle"ion, rarely re0uire surgical inter(ention& Ty e II or moderate deformities +digits e"tend #ith #rist in less than CG degrees of fle"ion, %enefit from ro"imal #rist;finger fle"or release #ith dorsal fle"or car i ulnaris transfer& Ty e III or se(ere fle"ion deformities re0uire distal #rist and finger fle"or tenotomies$ #ith transfer of the su%limis to the distal rofundus tendons& Pro"imal ro# car ectomy or #rist arthrodesis occasionally is indicated& Release of the adductor and inter halangeal fusion or tendon transfers can correct thum%3in3 alm deformities& S inal Deformity Neuromuscular scoliosis #ith a C3sha ed rogressi(e cur(e is common in se(ere cases of CP& :racing can %e of some (alue for limited or non rogressi(e cur(es& Progression can lead to im aired sitting %alance$ el(ic o%li0uity$ and ischial decu%itus ulcers$ and therefore correction of scoliosis #ith anterior and;or osterior s inal instrumentation and fusion is commonly indicated& Generally$ osterior instrumentation #ith rods and segmental fi"ation +Lu0ue rocedure, from the u er thoracic s ine to the sacrum is the referred a roach& 8ith se(ere rotational deformities in the lum%ar s ine$ anterior instrumentation also may %e re0uired& 4yelodys lasia +S inal Dysra hia, 4yelodys lasia refers to a de(elo mental defect in the (erte%ral column associated #ith a neurologic deficit& S inal dysra hia refers to defects in(ol(ing failure of fusion of midline structures and may %e resent #ithout cord in(ol(ement +s ina %ifida occulta,$ or #ith a myelomeningocele$ a neural tu%e defect at the le(el of the lesion& Eighty ercent of atients ha(e associated hydroce halus$ and aralysis is generally resent %elo# the le(el of the defect& Antenatal diagnosis of neural tu%e defects is ossi%le using amniocentesis #ith assay of al ha3feto rotein& Su lementation #ith folate during the first trimester of regnancy can dramatically reduce the incidence of neural tu%e defects& 4eningoceles +cystic enlargement of the lo#er meninges, or myelomeningoceles +cystic enlargement of the meninges and intradural contents, are treated %y early

closure and shunting for hydroce halus& Prognosis de ends on the degree of neurologic in(ol(ement and corres onding le(el of lo#er3e"tremity aralysis and disru tion of %o#el and %ladder function& Patients #ith lesions %elo# the L5 le(el #ill usually %e am%ulatory$ although lo#er3e"tremity deformities such as tali es e0uino(arus and hi su%lu"ation can occur$ re0uiring surgical correction& Additionally$ lac/ of sensory function ma/es ressure sores a common recurring ro%lem& Ortho aedic 4anagement 7unction is strongly de endent on the le(el of the neurologic lesion& Patients #ith lesions %elo# L- or L5 usually can am%ulate %ut may re0uire orthoses& 4aintenance of a lantigrade foot is essential$ and CG ercent of atients ha(e foot deformities at %irth& Lo#er3e"tremity deformities corres ond to the le(el of s inal in(ol(ement& A ro riate %racing to minimi1e rogressi(e contractures and allo# am%ulation #hen ossi%le is indicated& Moung children #ith flaccid aralysis of the lo#er e"tremities can am%ulate and maintain an u right standing osition in a ara odium& The energy costs of am%ulation #ith this de(ice are so high$ ho#e(er$ that older children and adults are una%le to use it and generally are confined to #heelchair& A reci rocating gait orthosis allo#s am%ulation in older atients #ith meningomyelocele or aralysis secondary to s inal cord in)ury& Custom3molded orthoses lined #ith ressure3 distri%uting materials such as Plasti1ote are im ortant in the re(ention of ressure sores from lac/ of sensation& 4anagement of aralytic deformities is similar to that #ith the flaccid aralysis of oliomyelitis& Tali es e0uino(arus can %e 0uite se(ere and is treated %y osteromedial release or talectomy in se(ere or recurrent cases& Contractures fre0uently re0uire release and tendon transfers to remo(e deforming forces #hen a ro riate muscles are a(aila%le& The Grice rocedure is correcti(e for (algus hindfoot deformities$ and the tri le arthrodesis is a ro riate for correction of hindfoot deformities in older children +see 7ig& 56365,& 4aintenance of concentric reduction of the hi s can necessitate ro"imal femoral osteotomies or aceta%ular osteotomies in se(ere cases& S inal deformities include se(ere /y hosis at the le(el of the lesion$ or scoliosis& >irtually all atients #ith a functional distur%ance of the s inal cord at the le(el of Lor higher #ill de(elo scoliosis re0uiring surgical inter(ention$ as com ared to a ro"imately .G ercent at the L5 le(el& Lum%ar /y hosis is seen in H to 6C ercent of atients and is almost al#ays rogressi(e& Ey hectomy #ith instrumentation and fusion can %e hel ful$ and scoliosis is corrected %y osterior rodding #ith segmental fi"ation and fusion$ occasionally in addition to anterior release and fusion& In addition$ tethering of the s inal cord can occur #ith gro#th$ usually resenting as a #orsening of the neurologic deficit& This can necessitate surgical release of the filum terminale& Degenerati(e Neurologic Diseases #ith S/eletal Deformity Peroneal 4uscle Atro hy +Charcot34arie3Tooth Disease, This is an inherited autosomal recessi(e or dominant trait leading to a degenerati(e neuro athy$ manifested initially in the distri%ution of the eroneal ner(e& Patients de(elo ca(us and (arus deformities of the feet and a dro foot gait& Intrinsic atro hy in the hands also may %e a arent& Correction of ca(us deformities %y midfoot osteotomy and cla#toe deformities %y inter halangeal fusions and e"tensor tendon recession are hel ful&

7riedreichAs Ata"ia This familial disease %egins in childhood$ in(ol(ing the s inocere%ellar tracts$ corticos inal tracts$ and osterior columns& Patients ha(e rogressi(e gait and s eech distur%ances and scoliosis and foot deformities& Inter(ention for foot deformities or scoliosis may %e indicated early in the course of the disease to maintain am%ulation& Syringomyelia This degenerati(e condition of the s inal cord in(ol(es destruction of neurons in the central ortion of the cord #ith formation of a cystic ca(ity$ or syrin"& Onset of sym toms usually is in the second or third decade& The intrinsic muscles of the hand are in(ol(ed initially$ follo#ed %y rogressi(e loss of motor and sensory function in the u er and lo#er e"tremities& Ortho aedic treatment entails %racing for re(ention of contractures$ or arthrodesis of neuro athic )oints& Laminectomy occasionally is indicated to relie(e e" anding ca(ities of the s inal cord& 4ulti le Sclerosis This is a rogressi(e demyelinating disease of the central ner(ous system of un/no#n athogenesis& The disease has a (aria%le course$ #ith e"acer%ations that are s oradic and can %e ameliorated %y use of ACT2 or corticosteroids& Ortho aedic ro%lems include contractures of the an/le$ /nee$ and hi and scoliosis& Treatment in(ol(es range3of3motion and stretching e"ercises$ s linting$ and occasionally surgical release of contractures& S inal instrumentation and fusion rarely are indicated& Death can result from rogressi(e muscle #ea/ness causing res iratory failure& Ortho aedic 4anagement of Stro/e Reha%ilitation of stro/e atients should %egin as early as ossi%le$ usually #ithin a fe# days after the cere%ro(ascular e(ent& Initially atients e"hi%it flaccid aralysis$ #hich later can gi(e #ay to s asticity and the de(elo ment of contractures& Early hysical thera y can maintain mo%ility and re(ent deformity and decu%itus ulcers& Persistent s asticity can %e tem orarily ameliorated %y eri heral ner(e %loc/s #ith henol or alcohol$ %ut more ermanent control generally re0uires release or tenotomy of the affected muscle grou s& The most common deformity is foot and an/le e0uinus$ #hich can %e corrected %y Achilles tendon lengthening& Similarly$ fle"ion contractures of the /nee and adduction contractures of the hi are corrected %y surgical release& Paralysis of the shoulder girdle musculature can lead to a ainful !fro1en shoulder$' #hich can im ede reha%ilitation& Acti(e3assisted e"ercises may hel to maintain range of motion$ and fle"ion deformities of the fingers and #rist can %e im ro(ed %y fle"or slide$ a release of the fle"or muscles in the ro"imal forearm& POST?RE Distur%ances in Gait Gait distur%ance of mechanical origin must %e distinguished from that of neurologic causation& Neurologic gait distur%ances include ata"ia$ hemi legia$ and s asticity& Ata"ia$ a #ide3%ased$ uncoordinated gait$ can result from cere%ellar lesions$ Guillain3 :arr= syndrome$ 7riedreichAs ata"ia$ or defects in eri heral sensation and ro rioce tion such as ta%es dorsalis or (itamin :69 deficiency& S astic gait$ common in cere%ral alsy$ is characteri1ed %y a crouched osition #ith scissoring of the legs& 8ith hemi legic gait$ the atient a ears to drag the affected e"tremity& 4echanical Disorders

Gait distur%ances can %e roduced %y numerous a%normalities of )oints$ including congenital hi dys lasia or dislocation$ sli ed ca ital femoral e i hysis$ a(ascular necrosis of the hi $ Legg3Cal(=3Perthes disease$ and /nee )oint a%normalities +e&g&$ arthritis$ osteochondritis dissecans$ genu (algum$ genu (arum$ meniscal in)ury,& Congenital foot and an/le deformities$ such as tali es e0uino(arus +clu%foot,$ and lim% length discre ancies also can cause a lim & Any condition causing ain on #eight %earing in a lo#er e"tremity can cause an antalgic gait in #hich the atient !short ste s' on the affected e"tremity$ minimi1ing the stance hase of gait& Pain in the hi )oint can cause an a%ductor lim $ #herein the atient lurches or leans to#ard the affected side during stance hase to mo(e the center of gra(ity of the %ody o(er the hi $ decreasing the a%ductor force across the )oint& 8ith a%ductor aralysis$ a Trendelen%urg gait results$ in #hich the el(is tilts to#ard the o osite side during stance hase on the affected e"tremity %ecause of the ina%ility of the a%ductors to maintain a le(el el(is& This also can result from ineffecti(e a%ductor contraction in congenital hi dislocation or co"a (ara& ?se of a cane in the o osite hand can reduce the force across the hi )oint %y a factor of fi(e$ the num%er of times %ody #eight the a%ductors must contract to maintain the trun/ and el(is le(el during one3legged stance& In atient #ith hi ro%lems the use of a cane thus can dramatically im ro(e gait and reduce hi ain #hen resent& Generally$ ortho aedic management of a lim re0uires a ro riate diagnostic e(aluation and treatment directed to#ard the cause& Lim% Length Discre ancy Lim% length discre ancies may %e secondary to trauma #ith gro#th late in)ury$ shortening of a %one$ or gro#th stimulation from in)ury& Additionally$ congenital a%errations in gro#th or radiation treatment for tumors can lead to significant and rogressi(e lim% length discre ancies in children& Asymmetric gro#th late distur%ances can roduce angular deformities& Ortho aedic treatment includes use of a shoe lift for discre ancies of u to 6 or 9 cm$ e i hysiodesis to sto the gro#th of the longer lim% for larger discre ancies$ or lim%3lengthening or lim%3shortening rocedures& Gro#th charts +4oseley chart, are used to lot the gro#th of the lim%s as measured %y cali%rating radiogra hs called scanograms (ersus time& Com arison to normal data allo#s rediction of the a ro riate timing for surgical disru tion of the gro#th lates +usually distal femoral and ro"imal ti%ial lates, so that the remaining gro#th in the short lim% #ill allo# leg length e0uali1ation at s/eletal maturity& Disad(antages include loss of stature$ the need to o erate on the #ell leg$ and the limitations in the amount of length e0uali1ation that can %e attained in this manner& 7or modest discre ancies$ ho#e(er$ this is a #ell3acce ted and useful method& 7or se(ere lim% length differences a ne# method of lim% lengthening$ called distraction osteogenesis or callotasis$ has %ecome o ular& This method$ first im lemented %y Ili1aro( in the So(iet ?nion$ relies on intramedullary mem%ranous osteogenesis after cortical osteotomy and gradual distraction #ith an e"ternal fi"ator using small Eirschner #ires +E3#ires, under tension and circumferential ring su orts +7ig& 5636.,& The %one can %e lengthened %y 6 mm daily$ and the multi lanar fi"ation de(ice allo#s simultaneous correction of angular and rotational deformities& Care is ta/en at the time of the corticotomy not to disru t the medullary %one$ and the rocedure is done through small incisions #ithout any eriosteal stri ing& Lengthenings of u to 6G cm are o%taina%le #ith this method$ and more than one %one can %e lengthened in an e"tremity& The method is also useful in the treatment of nonunions&

S inal Deformities The s ine is characteri1ed %y a series of cur(es that aid its hysiologic functions& The cer(ical and lum%ar s ine normally e"hi%it lordosis$ #hile the thoracic s ine has a normal /y hosis& The inter(erte%ral discs ser(e to maintain fle"i%ility of the s ine and the function of shoc/ a%sor tion& The discs consist of a tough$ fi%rous eri heral com onent$ the annulus fi%rosus$ and a gelatinous central ortion$ the nucleus ul osus& 8ith age$ loss of #ater content occurs #ith concomitant loss of disc height& Ey hosis Ey hosis is an increase in the normal osterior con(e"ity of the thoracic s ine in(ol(ing a num%er of (erte%ral %odies& A gi%%us deformity is an acute /y hotic angular deformity that may %e congenital$ osttraumatic$ or secondary to tumor or infections such as tu%erculosis& Adolescent Ey hosis Postural /y hosis$ or !round shoulders$' occurs in children$ occasionally in association #ith muscular coordination ro%lems& 8ith time$ this ha%itual /y hotic osture can %ecome fi"ed& Treatment is #ith e"tension e"ercises$ and %racing is unnecessary& A discogenic form of adolescent /y hosis that is rogressi(e$ /no#n as ScheuermannAs disease$ also occurs& This disorder is characteri1ed %y a%normalities in the gro#th lates of the (erte%ral %odies and herniations of disc material into the (erte%rae +SchmorlAs nodes,& ScheuermannAs /y hosis tends to %e rogressi(e and is generally treated %y e"tension e"ercises and 4il#au/ee %racing for more se(ere deformities& The need for surgical treatment is unusual$ %ut refractory cases #ith %ac/ ain can %enefit from staged anterior and osterior fusion #ith osterior instrumentation& Osteo orotic Ey hosis In osteo orotic /y hosis$ cumulati(e effects of com ression fractures or anterior #edging of multi le (erte%ral le(els as a result of mechanical failure of osteo enic %one lead to rogressi(e /y hosis in the thoracic s ine& 4ost commonly this is seen in #omen #ith ostmeno ausal osteo orosis& The discs often %ulge into the #ea/ened (erte%ral end lates& Com ression fractures can occur as discrete$ acute e(ents follo#ing minor trauma$ or #ith a more insidious onset and rogression$ ro%a%ly the result of multi le microfractures& :ac/ ain is the resenting com laint$ and atients may e" erience loss of height and a round%ac/ deformity +do#agerAs hum ,& Neurologic deficit %eyond intercostal radicular ain almost ne(er de(elo s des ite se(ere degrees of deformity& 4ulti le myeloma and metastatic carcinoma also can cause (erte%ral com ression fractures and must %e ruled out$ as #ell as osteomalacia$ renal osteo athy$ and other meta%olic derangements& Treatment of acute fractures is #ith rest$ analgesics$ and an e"tension orthosis$ follo#ed %y e"tension e"ercises and thera y for the underlying cause of the osteo enia #hen ossi%le +see 4eta%olic Diseases$ %elo#,& Scoliosis Any lateral de(iation or cur(ature of the s ine is referred to as scoliosis& :ecause of rotation of the s ine$ #hich is almost al#ays a com onent of the deformity$ the a%normality is %est demonstrated in hysical e"amination in for#ard fle"ion$ in #hich asymmetry of the aras inous region or ri% rominence #ill %e most a arent&

Scoliosis has %een classified as sho#n %elo# +modified from Ponseti and 7reedman$ and R&:& 8inter,L NonstructuralPostural scoliosis Ner(e root irritation 6 Disc herniation 6 Inflammatory

4uscle s asm secondary to in)ury Structural scoliosisIdio athic 6 Cer(icothoracic 6 6a Thoracic InfantileJage of onset under - years

Resol(ing Progressi(e 6a 6a 6 6 6 <u(enileJage of onset 5BF years AdolescentJage of onset 6G years to s/eletal maturity Thoracolum%ar Lum%ar Com%ined thoracic and lum%ar

Osteo athic 6 Congenital (erte%ral anomalies 6 6 6a 6a 6a 6a 6 6 Thoracogenic after thoraco lasty or em yema Osteochondrodystro hy 4uco olysaccharidosis Diastro hic d#arfism S ondyloe i hyseal dys lasia 4ulti le e i hyseal dys lasia Degenerati(e disc disease Postirradiation

Neuro athic 6 Congenital

6 6 6 6 6 6 6 6 6

Post oliomyelitis Neurofi%romatosis Syringomyelia Charcot34arie3Tooth disease 7riedreichAs ata"ia Cere%ral alsy S inal muscular atro hy 4eningomyelocele Dysautonomia +Riley3Day syndrome,

4yo athic 6 Arthrogry osis multi le" congenita 6 6 4uscular dystro hies 4yotonic dystro hy

4eta%olic 6 Osteogenesis im erfecta 6 6 6 Ehlers3Danlos syndrome 4arfan syndrome 2omocystinuria

Tumors 6 Osteoid osteoma 6 6 Eosino hilic granuloma S inal cord tumors

Traumatic Postural Scoliosis Postural scoliosis occurs in adolescent girls as a characteristically non rogressi(e mild left thoracolum%ar cur(e #ithout (erte%ral rotation that corrects in recum%ency& A similar fle"i%le scoliosis can occur #ith lim% length discre ancy and corrects #ith use of a lift on the short side& Treatment of ostural scoliosis is generally #ith e"ercises only&

Congenital Scoliosis Congenital scoliosis occurs as a result of de(elo mental anomalies during em%ryonic resegmentation of the s ine& ?nilateral hemi(erte%rae$ fusions of segments$ and osterolateral %ony %ars are the most common a%normalities& 8hen rogression of the scoliosis de(elo s$ most fre0uently #ith unilateral %ony %ars$ fusion of the in(ol(ed area is necessary& ?sually instrumentation is not used$ as it increases the ris/ of ara legia in these atients& A%out 9G ercent of atients #ith congenital scoliosis ha(e asym tomatic renal anomalies$ and these must %e e(aluated %y intra(enous yelogra hy or a%dominal CT or ultrasound studies& Neuromuscular Scoliosis Cur(es #ith neuromuscular causes such as s inal muscular atro hy$ meningomyelocele$ cere%ral alsy$ muscular dystro hies$ oliomyelitis$ or traumatic aralysis tend to %e long$ thoracolum%ar C3sha ed deformities #ith a high ro ensity for cur(e rogression& Prognosis de ends on the le(el of the lesion as #ell as on the age of the atient at the time of onset$ #ith a greater li/elihood of rogression in younger atients and higher3le(el lesions& 8ith neurofi%romatosis$ the cur(e can %e shar $ relati(ely short$ and associated #ith cutaneous ne(i$ neurofi%romas$ or caf=3au3 lait s ots& In addition$ there may %e scallo ing of the (erte%ral %odies and narro#ing of the ro"imal ri%s %ecause of neurofi%romas of the ner(e roots* these cur(es also ha(e a strong tendency to rogress& Infantile and <u(enile Idio athic Scoliosis Infantile scoliosis resents from %irth to age three$ #hile )u(enile scoliosis may resent u to age ten& The cause is unclear$ and the tendency for cur(e rogression is (aria%le& The difference %et#een the ri%B(erte%ral angles on the con(e" and conca(e sides of the cur(e has %een correlated redicti(ely #ith rogression$ #ith (alues greater than 9G degrees indicating a high ro%a%ility$ and less than 6G degrees$ a lo# ro%a%ility& Early management of the infantile or the early3onset )u(enile atients consists of casting in atients u to the age of 5 or C years$ and %racing thereafter& In atients #ith rogression des ite a ro riate casting or %racing$ surgical inter(ention is indicated& Generally$ anterior and osterior surgery is necessary$ #ith anterior fusion o(er four or fi(e a ical segments only& Su%se0uent osterior instrumentation can %e underta/en #ithout fusion using e" anda%le rods #ith re eat distractions erformed annually until the child is old enough for osterior fusion& In the late3onset )u(enile cases a%out CG ercent #ill re0uire surgical inter(ention %ecause of rogression #ith %racing alone& Surgery can %e delayed until cur(es reach a magnitude of CC to .G degrees$ in an effort to allo# ma"imal s inal gro#th %efore fusion& Anterior and osterior fusion is necessary& Idio athic Scoliosis Pathology The underlying cause of idio athic scoliosis is un/no#n& There is a familial tendency$ articularly in females& A%normalities of (esti%ular function ha(e %een demonstrated in scoliotic atients as #ell as defects in osterior column functions of (i%ratory and ro rioce ti(e sense& A%normalities in collagen synthesis and roteoglycan content in the inter(erte%ral discs also ha(e %een identified in scoliosis %ut are thought to %e secondary changes& Thus a defect in neurologic function has %een hy othesi1ed as a ossi%le cause& Progression of the cur(ature occurs during gro#th in the ma)ority of cases& The most im ortant factors in determining the ris/ of rogression are age of

onset$ location of the rimary cur(e$ and s/eletal or hysiologic age& Cur(es tend to sta%ili1e at s/eletal maturity +determined radiogra hically %y fusion of the iliac a o hyses,$ %ut rogression in adulthood of a ro"imately 6 degree er year can %e e" ected& Clinical 4anifestations Scoliosis is rarely associated #ith %ac/ ain and usually resents as an asym tomatic deformity characteri1ed %y asymmetry of the %ac/ and chest$ accentuated %y for#ard %ending& In older adults degenerati(e changes and ain can occur& Se(ere scoliosis can result in restricti(e ulmonary disease and cor ulmonale& The most common ty e of idio athic scoliosis is a right thoracic cur(e$ usually seen in girls +7ig& 5636D,& Patients fre0uently ha(e asymmetrical height of the el(is #hen standing$ or asymmetrical shoulder height or sca ular rominence& 7or#ard %ending causes rominence of the aras inous or ri% area on the con(e" side of the cur(e& Su%tle degrees of asymmetry can %e (isuali1ed #ithout radiogra hs %y using a 4oir= attern and a ro riate illumination to (isuali1e to ogra hy of the %ac/* this also has %een used as a screening tool& Radiogra hic E(aluation 7ull3length standing antero osterior +AP, and lateral radiogra hs of the thoracic and lum%ar s ine are necessary$ along #ith su ine lateral %ending radiogra hs to assess the fle"i%ility of the cur(e+s,& The rimary cur(e is defined as the longest cur(e #ith the greatest degree of angulation and;or the least fle"i%le cur(e& The degree of angulation +Co%% angle, is measured %et#een er endicular lines dra#n to the end lates of the su erior and inferior (erte%rae in the cur(e +see 7ig& 5636D,& Treatment The goal of treatment is to re(ent #orsening of the deformity& In this regard$ careful eriodic follo#3u is essential to monitor cur(e rogression& 7or idio athic scoliosis$ nomograms ha(e %een de(elo ed to redict the ris/ of rogression on the %asis of magnitude of cur(e$ s/eletal maturity$ and age& O%ser(ation is the mainstay of conser(ati(e treatment$ and general s inal e"ercises to maintain fle"i%ility are ad(ised& 7or cur(es greater than -G degrees #ith documented rogression$ %racing #ith a 4il#au/ee3ty e %race or a thoracolum%osacral orthosis is indicated& An alternati(e %ut contro(ersial treatment is electrical muscle stimulation on the con(e"ity of the cur(e$ #hich is used %y the atient at night& 7or cur(es o(er 5G degrees #ith e(idence of rogression$ fusion #ith instrumentation is indicated& In general$ 2arrington and Lu0ue rodding osteriorly #ith su%laminar or transs inous rocess #iring +segmental sta%ili1ation, are the most commonly used techni0ues& Cotrel3Du%ousset osterior instrumentation$ #hich has cross3lin/age %et#een the rods$ affording greater sta%ility and %etter reser(ation of anatomic sagittal contours$ also may %e used +7ig& 5636H,& S inal cord monitoring +somatosensory e(o/ed otentials, often is used during surgical correction of s inal deformities to decrease the incidence of neurologic deficit& Electrical stimulation of the lo#er e"tremities transmits im ulses through the s inal cord$ causing changes on the electroence halogram +EEG,& Com uteri1ed e0ui ment analy1es and monitors the EEG atterns and can gi(e early #arning of conduction a%normalities in the cord$ allo#ing re(enti(e modification of the surgical rocedure intrao erati(ely&

Anterior +D#yer or Niel/e, instrumentation occasionally is used in treatment of lum%ar or thoracolum%ar cur(es$ articularly those of neuromuscular origin$ or in adults& 4ost neuromuscular cur(es are treated surgically fairly early %ecause of the strong ro ensity for rogression* generally a long fusion from the u er thoracic s ine to the sacrum is needed #ith segmental +Lu0ue, instrumentation& The selection of the e"tent of the fusion is determined %y identifying the (erte%ra in neutral rotation at the u er and at the lo#er end of the cur(e$ )udged %y symmetry of the edicles and midline osition of the s inous rocess on an antero osterior radiogra h& 8ith 2arrington rodding and s inal fusion$ osto erati(e am%ulatory immo%ili1ation in a %ody cast or orthosis is necessary$ #hile the more rigid fi"ation #ith the Cotrel3 Du%ousset or Lu0ue techni0ue can o%(iate the need for this& Enee Deformities Genu >algum Angular de(iations a%out the /nees often are hysiologic and rarely re0uire treatment& 7rom %irth until a%out - years of age$ children ha(e a hysiologic (arus orientation of the /nees +%o#leg a earance,$ #hich generally corrects s ontaneously and con(erts to a (algus orientation from ages 5 to H +7ig& 5636F,& The normal adult (algus angle of the /nees of . degrees is o%tained during these years& Physiologic angulations in children of as great as -G degrees of (arus and 9G degrees of (algus can s ontaneously correct #ith gro#th& Thus the most common treatment a roach is arental reassurance and clinical follo#3u & Occasionally rogression of the a arent deformity occurs& Causes include (itamin D deficiency +ric/ets,$ rheumatoid arthritis$ and trauma as #ell as idio athic causes& Genu (algum also may %e seen in some genetic diseases$ such as 4or0uioAs syndrome +muco olysaccharidosis ty e I>, and EngelmannAs +or Camurati3Engelmann, disease +dia hyseal dys lasia,& 8ith rogressi(e deformity$ treatment #ith long leg %races or correcti(e osteotomy of the ro"imal ti%ia or distal femur may %e needed& Genu >arum Genu (arum occasionally fails to resol(e s ontaneously in infancy$ and rogression can occur& Physiologic genu (arum in an infant is demonstrated in 7ig& 5636F& The most common form of genu (arum is :lountAs disease$ a distur%ance of the medial ro"imal ti%ial gro#th late that is seen in infantile and adolescent forms& Persistent e"cessi(e medial #eight %earing is thought to traumati1e the medial gro#th late$ slo#ing medial gro#th and causing the deformity to #orsen& 4easurement of the meta hyseal3dia hyseal angle ro(ides a means of diagnosis +7ig& 5639G,& An angle greater than 66 degrees is consistent #ith a diagnosis of :lountAs disease& In cases #ith significant deformity or ain$ osteotomy of the ti%ia may %e indicated& Sta ling of the lateral gro#th late is an alternati(e %ut less redicta%le method& Genu (arum also may %e associated #ith renal osteodystro hy or achondro lasia$ or it may follo# trauma to the gro#th lates a%out the /nee& 7oot and An/le Deformities 7latfoot +Pes Planus, 2y ermo%ile or fle"i%le flatfoot is a %enign congenital condition that ordinarily is not ainful and does not re0uire treatment& 7le"i%ility can %e demonstrated %y ha(ing the child stand on the toes$ #hich usually #ill reconstitute a normal arch contour$ articularly if the flatfoot is in association #ith Achilles tendon tightness& Treatment

#ith an arch su ort or orthosis is indicated only for foot ain$ e"cessi(e shoe #ear$ or family history of sym tomatic flatfoot& Peroneal S astic 7latfoot Although eroneal s astic flatfoot may %e caused %y inflammatory and traumatic in(ol(ement of the tarsal )oints$ the most common cause is a%normal congenital fusion of tarsal %ones$ referred to as tarsal %ar or tarsal coalition& The %ar may %e cartilaginous$ articularly in younger children$ and may %e difficult to (isuali1e on routine radiogra hs& The most common coalition is the calcaneona(icular %ar$ follo#ed %y talocalcaneal and calcaneocu%oid fusions +7ig& 56396,& The o%li0ue radiogra h #ill %est demonstrate a calcaneona(icular %ar$ and an a"ial radiogra h of the hindfoot is most useful for identifying talocalcaneal coalition& CT scans are also 0uite hel ful #hen lain3film radiogra hs are negati(e& Conser(ati(e treatment #ith anti3inflammatory medications and orthotics can %e hel ful$ %ut if sym toms ersist$ resection of the %ar #ith fat or silicone inter osition sometimes is necessary& In older adolescents and adults tri le arthrodesis may %e indicated$ es ecially if degenerati(e arthritis is resent in the ad)acent tarsal )oints& Ac0uired 7latfoot 7latfoot can %e caused %y osseous disru tion +trauma or infection,$ ligamentous or tendinous ru ture +foot s rain or osterior ti%ialis tendon ru ture,$ or neuromuscular disorders + oliomyelitis$ cere%ral alsy$ or Charcot neuro athic arthro athy,& Ac0uired flatfoot in(ol(es medial and lantar de(iation of the head of the talus$ fre0uently accom anied %y (algus deformity of the hindfoot + es lano(algus,& Treatment in(ol(es su orti(e measures and orthotics& In cases #ith se(ere deformity$ ain$ or secondary degenerati(e changes$ o tions for surgical inter(ention include Grice su%talar or tri le arthrodesis$ calcaneal or midfoot osteotomy$ and osterior ti%ialis ad(ancement& Contracture The term contracture im lies a ermanent shortening and loss of fle"i%ility of muscles$ )oints$ tendons$ or fascia& Contractures can %e congenital or ac0uired& E"am les of congenital contractures include tali es e0uino(arus +clu%foot,$ torticollis$ and arthrogry osis multi le" congenita& Ac0uired contractures of )oints can result from eriarticular trauma$ arthritis$ muscle im%alance +as #ith cere%ral alsy,$ %urns$ muscle in)ury$ or idio athic conditions such as Du uytrenAs contracture of the almar fascia& Contractures of muscles or )oints also may occur osto erati(ely and can %e a(oided %y a ro riate strengthening and range3of3motion e"ercises #ith the assistance of a hysical thera ist& The use of continuous3 assi(e3 motion machines osto erati(ely also can hel to re(ent )oint contractures* these ha(e %een articularly useful for the /nee and also are used occasionally after surgery on the hi or el%o#& Ischemic Contractures +>ol/mannAs Contracture* Com artment Syndrome, >ol/mann first descri%ed contractures of the forearm muscles that follo#ed tight %andaging after an el%o# fracture in 6HDC& The contractures result from ischemic muscle necrosis$ no# recogni1ed as the henomenon called com artment syndrome& All muscle grou s in the e"tremities are %ounded %y tough$ fi%rous fascial en(elo es called com artments& The fascia is relati(ely unyielding to muscle s#elling$ #hich can result from fractures$ %leeding$ surgery$ %lunt trauma$ or rolonged ischemia +7ig&

56399 A,& Ele(ated ressure #ithin a com artment further com romises arterial inflo#$ and rogressi(e ischemia ensues& Ner(es and muscles #ithin the com artment suffer ischemic in)ury that can ra idly %ecome irre(ersi%le$ and se(ere ain and loss of neuromuscular function occur& The cardinal signs of com artment syndrome include +6, ain out of ro ortion to the in)ury* +9, ain on assi(e stretch of in(ol(ed muscles* +-, aresthesias$ hy esthesia$ or loss of motor function$ and +5, diminished or a%sent ulses$ along #ith coolness or allor of the e"tremity consistent #ith decreased erfusion& Circumferential dressings such as tight %andages or casts can contri%ute to the de(elo ment of a com artment syndrome %y com romising erfusion$ and they must %e s lit or remo(ed at the first signs of a com artment syndrome& If sym toms fail to resol(e immediately$ com artment ressure measurements must %e made& Direct measurement of intracom artmental ressures using a needle or slit catheter #ith a mercury or electronic manometer is the method of definiti(e diagnosis of com artment syndrome +7ig& 56399 :,& Normal com artment ressures are less than 6G mm2g& Sustained ressures a%o(e -G mm2g indicate im ending com artment syndrome$ and sustained ressures a%o(e 5G mm2g indicate the definite resence of a com artment syndrome& If untreated$ the sustained rogressi(e ischemia causes muscle necrosis and loss of (oluntary muscle function& The muscle is re laced %y fi%rous connecti(e tissue$ #hich leads to se(ere contractures of the )oints o#ered %y the in(ol(ed muscles& Su racondylar fractures of the humerus and ti%ial fractures are common causes of com artment syndromes& An e"ercise3 induced com artment syndrome occurs #ith e"ercise$ causing ain and aresthesias$ %ut is self3limited and resol(es after the acti(ity is discontinued& Diagnosis is #ith oste"ercise com artment ressure measurements$ and treatment is %y electi(e surgical fasciotomy& Contractures and ermanent muscle damage generally do not occur in this form of com artment syndrome& Com artment syndrome is an ortho aedic emergency and re0uires immediate surgical fasciotomy to re(ent irre(ersi%le ner(e and muscle damage& Se(ere damage can occur #ithin a fe# hours& Arteriogra hy often is indicated to rule out arterial damage in cases of osttraumatic com artment syndrome& The com artment ressures that #ill %e tolerated %y the e"tremity #ithout irre(ersi%le damage de end on the erfusion ressure* hence #ith relati(e hy otension a lo#er le(el of com artment ressure #ill necessitate surgery$ and slightly higher le(els can %e tolerated in a hy ertensi(e atient& Com artment ressures less than 9G mm2g %elo# diastolic %lood ressure necessitate surgical inter(ention in hy otensi(e atients& The resence of sym toms #ith com artment ressures a%o(e normal is an indication for surgery& The s/in and fascia must %e left o en$ and ressures #ithin all com artments in the e"tremity must %e measured and all in(ol(ed com artments thoroughly released& EPIP2MSEAL DISORDERS +OSTEOC2ONDROSES, The e i hysis com rises the cartilaginous end of a long %one %et#een the gro#th late + hysis, and the articular surface& E i hyses de(elo secondary centers of ossification$ #hich e" and from a central location to re lace the cartilaginous e i hysis #ith tra%ecular %one through the rocess of endochondral ossification& At maturity$ the only ortion of the e i hysis that remains as cartilage is the articular surface& During childhood$ a num%er of disorders of the e i hysis can occur$ the

etiology of #hich remains oorly understood& There are se(eral forms of e i hyses$ including articular e i hyses$ traction e i hyses +a o hyses,$ and ata(istic e i hyses& Disorders of the e i hyses #ere formerly referred to as osteochondritis$ %ut the lac/ of inflammatory changes histo athologically led to the use of the term osteochondrosis as a more accurate descri tion of the (arious derangements of gro#th or ossification occurring in e i hyses& Osteochondroses affect rimary and secondary ossification centers& Primary ossification centers +and associated disorders, includeL Sca hoid +PreiserAs disease, Lunate$ in adults +Eien%Oc/As disease, Patella +EOhlerAs disease, Talus +4ouchetAs disease, Tarsal na(icular +EOhlerAs disease, Secondary ossification centers includeL >erte%ral e i hysis +ScheuermannAs /y hosis, 2umeral head +2assAs disease, Ca itellum +PannerAs disease, Radial head +:railsfordAs disease, Pu%ic sym hysis +>an Nec/As disease, Ischio u%ic )unction +Olds%ergAs disease, 7emoral head +Legg3Cal(=3Perthes disease, Patella +Sinding3Larsen3<ohansson syndrome, Ti%ial tu%ercle +Osgood3Schlatter disease, Calcaneus +Se(erAs disease, 4etatarsal head +7rei%ergAs disease, Cause The etiology of osteochondrosis remains contro(ersial& In general$ (ascular distur%ance$ ossi%ly secondary to trauma$ is thought to result in a(ascular necrosis of the in(ol(ed e i hysis& In some osteochondroses$ such as Osgood3Schlatter disease$ there is clear e(idence that a traction in)ury to the e i hysis initiates the athologic

changes& There is some e(idence also for an underlying genetic defect in e i hyseal cartilage as a redis osing factor& Clinical 4anifestations The condition may %e unilateral or %ilateral$ #ith gradual onset and sometimes a history of antecedent trauma& Pain$ )oint effusion$ lim $ limitation of range of motion$ and muscle s asm may %e resent$ %ut the sym toms are often mild& Radiogra hic 7indings Osteo enia of the e i hyseal ossification center is resent$ #ith areas of increased density& 8ith more se(ere in(ol(ement$ fragmentation of the ossification center and deformity and flattening of the e i hysis can occur& The areas of increased density corres ond to necrotic %one& The course of the disease usually in(ol(es s ontaneous re(asculari1ation and reconstitution of the ossification center$ %ut there may %e residual deformity or gro#th distur%ance& Legg3Cal(=3Perthes Disease Osteochondrosis in(ol(ing the hi is rimarily seen in %oys %et#een the ages of C and F years and is %ilateral in a%out 6G ercent of atients& The athology is that of osteonecrosis of the ossification center of the femoral e i hysis$ %ut the cause is un/no#n& The disease has %een re orted in 6 to - ercent of atients follo#ing transient syno(itis of the hi $ a disorder clinically mimic/ing se tic arthritis in children %ut self3limited and resol(ing s ontaneously& In most cases there is no identifia%le antecedent e(ent& E idemiologically$ some ris/ factors ha(e %een identified$ including delayed %one gro#th$ lo# socioeconomic status$ %reech deli(ery$ and %eing a child of older arents& Coe"istence #ith other osteochondroses such as ScheuermannAs disease has %een re orted and suggests the ossi%ility of an underlying systemic cartilaginous defect& Attention deficit hy eracti(e disorder has %een identified in a%out one3third of atients #ith Perthes disease$ ro(iding e(idence of an underlying genetic redis osing factor& Patients resent in the rodromal stage #ith a lim and hi and;or referred /nee ain and loss of motion in the affected hi secondary to muscle s asm initially %ut later due to deformity of the femoral head& During the acti(e hase$ radiogra hic rogression of the disease occurs$ %ut sym toms and muscle s asm resol(e or %ecome intermittent& Patients e"hi%it limitation of a%duction and internal rotation$ initially due to s asm and later due to flattening and deformity of the femoral head +co"a lana,& 8ith the restoration hase the clinical sym toms resol(e and the ossific nucleus reconstitutes$ although some ermanent femoral head deformity and restriction of a%duction and hi rotation occasionally remain& Radiogra hic 7indings The Caterall classification of the radiogra hic e"tent of e i hyseal in(ol(ement is the staging system most #idely used for rognostication& This staging system has %een critici1ed as insufficiently ros ecti(e$ since accurate radiogra hic classification often is not ossi%le until . to H months after diagnosis& Caterall grou I disease e"hi%its a%sence of meta hyseal changes or se0uestrum formation$ #ith in(ol(ement of less than half of the anterior e i hysis& Grou II disease sho#s se0uestrum in(ol(ing the anterior half of the e i hysis$ #ith anterolateral meta hyseal reaction and su%chondral fracture line& Grou III disease in(ol(es more than half of the e i hysis #ith

se0uestrum and meta hyseal reaction$ and grou I> e"hi%its #hole3head in(ol(ement #ith diffuse meta hyseal reaction& A ne# classification %ased on the lateral illar of the femoral head has %een ro osed that demonstrates greater redicti(e (alue and less intero%ser(er (aria%ility +7ig& 563 9-,& 7or children #ith a %one age less than . years and lateral illar in(ol(ement of stage A or :$ the outcome does not a ear to %e affected %y treatment +i&e&$ containment,& 7or s/eletally older children #ith stage : in(ol(ement$ containment %y a%duction %racing$ or femoral or el(ic osteotomy im ro(es outcome& 8aldenstrOm has descri%ed four radiogra hic stages of the diseaseL +6, failure of ossification center gro#th and )oint s ace #idening* +9, fragmentation #ith areas of radiolucency* +-, reossification #ith areas of ne# %one formation* and +5, the healed hase #ith reconstitution of the e i hysis& The fragmentation stage in a atient #ith grou III in(ol(ement is sho#n in 7ig& 56395& Studies of the natural history of the disease indicate good$ fair$ and oor results in a%out one3third of atients each& Patients #ith artial +Caterall I and II, in(ol(ement ha(e a much %etter rognosis than those #ith more e"tensi(e in(ol(ement +Caterall III and I>,& :oth clinical and radiologic !at ris/' signs that are correlated #ith a #orse rognosis ha(e %een identified& Clinical signs include age o(er . years$ o%esity$ rogressi(e loss of hi motion$ and adduction contracture& Radiologic signs include defecti(e ossification in the lateral e i hysis$ calcification of the e i hysis lateral to the aceta%ulum$ diffuse meta hyseal reaction$ lateral su%lu"ation of the hi $ and a hori1ontal gro#th late& Treatment The differential diagnosis of the disease must include consideration of other disorders that can ha(e similar radiogra hic changes and clinical resentations$ such as hy othyroidism$ s ondyloe i hyseal dys lasia$ multi le e i hyseal dys lasia and sic/le cell disease& Treatment is %ased on containment of the diseased e i hysis #ithin the aceta%ulum until reossification is com lete$ #hich affords the %est chance of o%taining a s herical femoral head& The s/eletal age and degree of lateral illar in(ol(ement of the e i hysis are im ortant factors in identifying those atients most li/ely to %enefit from containment thera y& 7or femoral heads in #hich the diseased ortion of the e i hysis is contained #ithin the aceta%ulum in %oth neutral and a%ducted ositions$ o%ser(ation alone is needed and the rognosis is e"cellent& 7or hi s #ith e i hyseal in(ol(ement lateral to the aceta%ulum$ %ut #hich are contained #ith a%duction$ am%ulatory treatment in a #al/ing a%duction %race for the duration of the healing +69 to 6H months, is generally recommended& 7or those fe# atients #ith noncontaina%le e i hyseal in(ol(ement #ith the hi a%ducted$ surgical inter(ention is necessary to achie(e containment& Surgical o tions include (arus osteotomy of the ro"imal femur or osteotomy of the el(is to e"tend aceta%ular co(erage o(er the femoral head +Salter or Chiari osteotomy, +see 7ig& 5639H,& Outcome de ends on the staging$ final s hericity of the femoral head$ and congruity #ith the aceta%ulum& Sym toms of degenerati(e arthritis may resent in the fourth to si"th decades in atients #ith residual femoral head deformity& Osgood3Schlatter Disease

Osgood3Schlatter disease usually resents in atients 6- to 6C years of age #hose history may re(eal a reci itating in)ury& A(ulsion or fatigue fracture of the e i hysis is thought to %e the underlying cause$ #ith secondary defecti(e ossification and rominence of the tu%ercle& Pain that is aggra(ated %y 0uadrice s contraction and tenderness and enlargement of the ti%ial tu%ercle are the usual resenting com laints& Radiogra hs may %e normal$ or irregularity and fragmentation of the ossification center of the ti%ial tu%ercle may %e resent +7ig& 5639C,& Treatment Treatment is sym tomatic and conser(ati(e& Immo%ili1ation of the /nee in an e"tension or cylinder cast for 5 to . #ee/s may %e hel ful in articularly sym tomatic cases& Sym toms #ill disa ear after fusion of the ti%ial tu%ercle a o hysis$ although enlargement of the tu%ercle may %e ermanent& Occasionally a se arate ossicle remains #ithin the atellar tendon$ and e"cision can %e underta/en for ersistent sym toms& Sinding3Larsen3<ohansson syndrome is a similar condition in(ol(ing the inferior ole of the atella$ causing sclerosis and fragmentation& This disorder too is caused %y e"cessi(e tensile forces on the a o hysis and is self3limited and treated sym tomatically& Other Osteochondroses EOhlerAs disease of the tarsal na(icular occurs in children$ #ith s#elling and ain in the area of the na(icular& Radiogra hs sho# increased density in the na(icular ossification center$ and treatment is #ith casting and rotected #eight %earing until sym toms im ro(e$ follo#ed %y use of an orthotic arch su ort +7ig& 5639.,& Se(erAs disease affects the osterior a o hysis of the calcaneus in children and can %e similar to Osgood3Schlatter disease after a chronic traction in)ury& Increased radiogra hic density of the a o hysis and ain in the area occur$ and treatment is #ith a heel lift and rotected #eight %earing #hen necessary& 7rei%ergAs disease in(ol(es the e i hyses of the metatarsal heads$ usually the second or third& The cause is un/no#n$ %ut athologically$ li/e other osteochondroses$ necrosis of %one #ith re air occurs$ and the disease is self3limited and treated #ith a cast or orthosis #ith a metatarsal ad to rotect the metatarsal head from #eight %earing until healing occurs& CONGENITAL DE7OR4ITIES Congenital malformations can %e caused %y de(elo mental a%errations in utero$ en(ironmental influences Pradiation e" osure$ ru%ella$ sy hilis$ human immunodeficiency (irus +2I>,$ teratogenic drugs$ etc&Q$ or hereditary conditions& O(erall incidence of congenital malformations diagnosed #ithin C years of %irth is 9er 6$GGG +Ta%le 563D,& Some of the more common disorders are clu%foot +5&5 er 6$GGG,$ s ina %ifida +- er 6$GGG,$ and hi dislocation +G&D er 6$GGG,& 4etatarsus adductus$ (algus hindfoot$ unilateral e"ternally rotated leg$ internal ti%ial torsion$ or an adducted thigh #ith e"ternal rotation of the leg are conditions thought to result from in utero osition$ #hich also may %e a contri%uting factor in the athogenesis of tali es e0uino(arus +clu%foot,& All of these conditions e"ce t tali es e0uino(arus generally res ond to assi(e stretching e"ercises$ #ith correcti(e casts necessary only in refractory cases& 2i Dislocation

De(elo mental dys lasia of the hi +DD2, consists of artial or com lete dis lacement of the femoral head from the aceta%ulum& E idemiologically$ DD2 is more common in certain ethnic grou s +Na(a)o Indians$ northern Italians$ and <a anese,$ first%orn #hite females$ and in association #ith other anomalies +torticollis$ congenital /nee hy ere"tension or dislocation$ and foot deformities,& Contri%utory causati(e factors include multifactorial inheritance$ mechanical factors such as renatal osition$ and hormonal influences such as maternal rela"ins& Pathology In DD2 the aceta%ulum is shallo# #ith a more (ertical orientation than normal& It is filled #ith remnants of ligamentum teres$ fat$ and fi%rocartilage + ul(inar,& O(ergro#th of the lateral aceta%ular cartilage occurs in res onse to ressure of the femoral head +lim%us,$ increasing the o%struction to reduction& A false aceta%ulum may %e resent as a de ression on the ilium su erior to the true aceta%ulum$ lined #ith eriosteum and a fold of the ca sule& Ossification of the femoral head is delayed$ and the ca sule can de(elo an hourglass3sha ed constriction crossed %y the ilio soas tendon& 8ithin a fe# months of %irth$ tightness of the shortened adductor muscles de(elo s$ causing loss of hi a%duction& Clinical 4anifestations E"amination of e(ery ne#%ornAs hi s in the nursery after %irth is essential and effecti(ely detects the ma)ority of dislocated hi s& Successful treatment hinges on early diagnosis and inter(ention& On e"amination$ a hi clic/ can %e elicited as the femoral head reduces in the aceta%ulum #ith fle"ion and a%duction of the thigh +OrtolaniAs sign,& A similar clic/ occurs #ith dislocation of the hi %y adduction #ith gentle osterior ressure +:arlo#As sign,& The gluteal folds #ill %e asymmetrical$ and the affected thigh a ears shortened #hen the /nees and hi s are fle"ed to FG degrees +Galea11iAs sign,& Limitation of a%duction #ith the hi in fle"ion may %e resent at %irth %ut %ecomes rogressi(ely a arent during the first 9 or - months& If the dislocation goes undetected the child #ill ha(e a noticea%le lim or #addle #hen #al/ing %egins& Periodic follo#3u e"aminations of the hi s in ne#%orns during the first fe# months are im ortant$ and the hi clic/ #ill disa ear$ #ith the limitation of a%duction %eing the most o%(ious a%normality& Increased lum%ar lordosis #ill %e resent as the child %egins to #al/$ es ecially in %ilateral dislocations& 4ilder degrees of dys lasia$ #ith su%lu"ation or shallo# aceta%ulum #ithout fran/ dislocation$ also can occur and are a cause of sym tomatic degenerati(e hi arthritis in adolescents and young adults& Radiologic 7indings The secondary center of ossification of the femoral head is a%sent in the ne#%orn and usually a ears %y 5 to . months$ although there is a fairly #ide range +9 to 6G months,& 8hen resent$ the ossific nucleus should %e #ithin (ertical lines from the aceta%ular margin +Per/insA lines, and %elo# a hori1ontal line dra#n through the triradiate gro#th late cartilage of the aceta%ulum +2ilgenreinerAs line$ 7ig& 5639D,& The aceta%ular inde" is the angle of the aceta%ular roof #ith 2ilgenreinerAs line$ and normally is 99 degrees& 8ith DD2 this angle is greater$ and can %e as high as 5G degrees& 8ith the hi in a%duction$ the femoral nec/ fails to oint to#ard the triradiate cartilage$ and ShentonAs line +a smooth arc from the lesser trochanter on the femur continuing along the nec/ and inferior corte" of the u%ic %one, is discontinuous& If the ossific nucleus is not resent$ an arthrogram or 4RI #ill readily

demonstrate the dislocated osition of the femoral head$ although ultrasonogra hy is also an accurate and a less in(asi(e diagnostic modality& Treatment In the neonate #ith DD2$ the hi usually can %e reduced in fle"ion and a%duction$ and treatment is a s lint or %race that can maintain this osition& The Pa(li/ harness and >on Rosen s lint are t#o of the more commonly used de(ices& 7le"ion of the hi should %e FG to 66G degrees$ #ith slightly less than full a%duction& Treatment is for to . months$ until the aceta%ular de(elo ment is normal& In DD2 diagnosed in the first fe# months of life$ a%duction %racing can also %e successful$ %ut radiogra hic e(aluation is needed to %e sure that the hi remains reduced& In children under 6H months of age$ closed reduction can %e attem ted under anesthesia& The role of rereduction s/in traction$ #hich #as ad(ocated in the ast$ is currently contro(ersial& If concentric reduction can %e o%tained as )udged from radiogra hs or arthrogram$ the atient is laced in a dou%le hi s ica cast #ith the hi s fle"ed to a ro"imately 6GG degrees and slightly less than full a%duction& E"tremes of a%duction can im air the %lood su ly to the femoral head and lead to a(ascular necrosis& Adductor tenotomy can facilitate the reduction& In children in #hom closed reduction cannot %e o%tained$ o en reduction is erformed using an anterolateral a roach$ or$ in children less than 95 months of age$ using a medial a roach to the hi & The anterolateral a roach in older children facilitates femoral shortening #hen necessary to achie(e reduction& The child is laced in a %ilateral hi s ica cast #ith the hi s in the osition descri%ed a%o(e to maintain the reduction& Persistent aceta%ular dys lasia in children 9 to C years old can %e corrected %y either erica sular +Pem%erton, or innominate +Salter, osteotomy& 4ore e"tensi(e rocedures such as the Chiari innominate osteotomy are occasionally necessary to o%tain su erior aceta%ular co(erage of the femoral head in older children +7ig& 5639H,& Dislocation of the Enee The three ty es of congenital dislocation of the /nee are de(elo mental +thought to %e secondary to in utero osition,$ defecti(e em%ryogenesis +associated #ith other defects such as DD2,$ and 0uadrice s contracture caused %y arthrogry osis& The /nee is fi"ed in hy ere"tension #ith a (aria%le degree of anterior su%lu"ation or dislocation of the ti%ia on the distal femur& Treatment de ends on the degree of se(erity and ranges from stretching e"ercises to surgical 0uadrice s lengthening follo#ed %y cast immo%ili1ation& Pseudarthrosis of the Ti%ia Children #ith this disorder may ha(e a fran/ seudarthrosis at %irth +usually at the le(el of the distal and middle thirds of the ti%ia, or$ in milder forms$ anterolateral %o#ing that rogresses to seudarthrosis later& This condition must %e differentiated from congenital osteromedial %o#ing of the ti%ia$ #hich usually is self3limited& Congenital seudarthrosis of the ti%ia is fre0uently associated #ith neurofi%romatosis& 8ith %o#ing alone$ a total3 contact orthosis is used to re(ent rogression$ %ut once seudarthrosis de(elo s it can %e (ery difficult to treat& Treatment methods for esta%lished seudarthrosis include intramedullary rod fi"ation #ith %one grafting* more recently$ free (asculari1ed fi%ular grafts ha(e %een used successfully& Am utation occasionally is necessary in refractory cases&

4etatarsus Adductus 4etatarsus adductus is a common congenital foot deformity also /no#n as metatarsus (arus$ the cause of #hich is thought to %e related to intrauterine ositioning& It occurs in 6 er 6$GGG li(e %irths$ and half of the cases are %ilateral& The forefoot is angulated medially$ %ut the deformity is not associated #ith e0uinus of the heel& 8hen assi(ely correcta%le$ metatarsus adductus resol(es s ontaneously& In incom letely correcta%le deformities$ serial mani ulation and casting is the acce ted treatment& Surgical treatment rarely is necessary and is indicated only in children o(er the age of C years #ith se(ere sym tomatic residual adductus deformity& Osteotomies of the lateral column +cu%oid,$ medial cuneiform$ or metatarsals can accom lish correction& Tali es E0uino(arus +Clu%foot, Tali es e0uino(arus is a com le" deformity consisting of lantar fle"ion of the an/le$ in(ersion of the foot$ adduction of the forefoot$ and internal rotation of the ti%ia +7ig& 5639F,& The cause is un/no#n$ and theories include neurologic and (ascular defects& Inheritance is (aria%le in attern$ #ith o(erall incidence of a ro"imately 6 er 6$GGG %irths$ and a 9L6 male re onderance& Si%lings ha(e a 6 in -C ro%a%ility of the disorder$ and identical t#ins a 6 in - chance& The re(ailing theory of cause is a single gene redis osing mutation in con)unction #ith one or more unidentified en(ironmental factors& Tali es e0uino(arus is associated #ith other disorders$ including myelomeningocele$ arthrogry osis$ and diastro hic d#arfism& Pathologic Anatomy Three3dimensional com uter modeling has sho#n the talus to %e e"ternally rotated in the an/le mortise$ #ith 5C degrees of internal rotation of the talar nec/ +com ared to slight internal rotation in the mortise and a 9C3degree internal rotation of the nec/ in normals,& The talus is also smaller than normal$ and the calcaneus is internally rotated and in (arus com ared to slight e"ternal rotation in normal feet& The ti%ial tendon sheaths are fi%rotic and thic/ened$ and the na(icular is su%lu"ated medially on the head of the talus& Radiogra hically$ the calcaneus and talus are more arallel than di(ergent on a lateral (ie# +7ig& 563-G,& Treatment 8ithout treatment the condition is ermanent and am%ulation difficult& Treatment is started immediately in the neonatal eriod$ #ith stretching e"ercises and serial laster casts& Adduction of the forefoot is corrected first$ then hindfoot (arus$ and correction of e0uinus is not underta/en until these deformities are com letely corrected& Conser(ati(e treatment is successful in a%out CG ercent of atients& Surgical correction consists of osteromedial and su%talar release and usually is delayed until the atient reaches . to H months$ %ut it should not %e delayed %eyond the age of 6 to 9 years& Com lete release of the su%talar )oint is %est accom lished %y a circumferential trans(erse incision e"tending from the lateral side of the hindfoot osteriorly to the medial side$ /no#n as the Cincinnati a roach& In recurrent cases$ mani ulation #ill not suffice for correction$ and osteromedial release is necessary& Lateral transfer of the ti%ialis anterior tendon along #ith Achilles tendon lengthening may also %e hel ful in atients #ith mild degrees of recurrence& Incom lete release of the calcaneocu%oid )oint is %elie(ed to %e the most common cause of residual adduction or ca(o(arus deformities& In se(ere refractory deformities

such as those seen #ith arthrogry osis$ talectomy can %e necessary to achie(e a lantigrade foot& Con(e" Pes >algus +>ertical Talus, Congenital (ertical talus +also /no#n as roc/er3%ottom flatfoot, consists of a dorsal dislocation of the na(icular on the head of the talus$ #ith the talus in a more (ertical osition than normal +7ig& 563-6,& The sole of the foot has a roc/er3%ottom deformity and is not assi(ely correcta%le& >ertical talus may %e an isolated anomaly$ or it may %e found in association #ith meningomyelocele$ arthrogry osis$ or chromosomal a%errations& Early mani ulation and casting can %e successful$ articularly in milder deformities +referred to as o%li0ue talus$ in #hich the first metatarsal aligns #ith the talus in forced lantar fle"ion,& 2o#e(er$ the ma)ority of cases of true (ertical talus re0uire surgical correction& Diagnosis is made from the lateral forced3 lantar3fle"ion radiogra h$ in #hich the talus and the first metatarsal are not in alignment& O eration is delayed until the atient is 5 to H months old and consists of o en reduction and inning of the talona(icular )oint$ along #ith lengthening of the Achilles tendon$ osterior ti%ialis$ and$ #hen necessary$ the toe e"tensors$ eronei$ and anterior ti%ialis tendons& In older children$ a Grice su%talar arthrodesis may %e necessary& ?ndiagnosed cases in older children #ith ada ti(e %ony changes are treated #ith tri le arthrodesis +see 7ig& 56365,& Arthrogry osis 4ulti le" Congenita +Amyo lasia, Arthrogry osis in(ol(es failure of de(elo ment of muscles and resulting contractures of the e"tremities& It is not thought to ha(e a genetic %asis and is characteri1ed %y se(ere$ symmetrical contractures #ith deformities$ including scoliosis$ tali es e0uino(arus$ DD2$ /nee dislocation$ internally rotated shoulders$ and e"tended el%o#s& The indi(idual deformities are treated as descri%ed a%o(e$ %ut contractures tend to %e 0uite se(ere$ and occasionally osteotomies are needed to im ro(e function and decrease deformity& A genetic (ariant called distal arthrogry osis has %een identified$ #hich affects the digits only& 2igh Sca ula +S rengelAs Deformity, 2igh sca ula is caused %y em%ryonic failure of the sca ula to migrate to its normal osition& The sca ula may %e attached to the (erte%rae %y a athologic %and of fi%rous tissue and cartilage +omo(erte%ral mass,& Other deformities of the s ine and ri%s are often associated& The sca ula is 6 to 5 inches higher than usual$ tilted anteriorly$ and does not mo(e normally #ith shoulder motion +7ig& 563-9,& ?sually it is the cosmetic a earance rather than any functional deficit that %rings attention to the disorder& 4ild cases need no treatment$ %ut in more se(ere cases surgical correction can %e underta/en$ although it is generally delayed until the atient is - to . years old& Eli el37eil Syndrome Also /no#n as %re(icollis and congenital short nec/$ this syndrome consists of multi le fusions of cer(ical (erte%rae secondary to defecti(e resegmentation of the cer(ical s ine during em%ryogenesis and is usually not treata%le& Torticollis Torticollis$ also /no#n as congenital #rynec/$ is caused %y unilateral contracture of the sternocleidomastoid muscle$ #ith tilt of the head to#ard the affected side$ rotation to the o osite side$ and (arying degrees of facial dys lasia& The disorder is thought

to %e osttraumatic$ #ith a tender s#elling in the muscle receding the deformity& Treatment consists of stretching e"ercises and$ in refractory cases$ surgical release of the muscle #ith cast immo%ili1ation or (igorous assi(e e"ercises osto erati(ely& Cleidocranial Dysostosis Cleidocranial dysostosis is an autosomal dominant hereditary syndrome e"hi%iting cla(icular a lasia$ #idened diameter of the cranium$ and delayed fontanelle closure& Disa%ility is minimal and treatment usually not needed& Radioulnar Synostosis This disorder results from defecti(e em%ryogenesis$ #ith a fusion %et#een the ro"imal radius and ulna and a%sence of ronation and su ination& 4ost cases are %ilateral$ and the degree of deformity or hy o lasia of the ro"imal radius is (aria%le& Nonfunctional e"tremes of ronation or su ination can %e corrected %y osteotomy$ %ut resection of the fusion %ar has gi(en disa ointing results& Resection follo#ed %y lo#3dose irradiation +H to 6G Gy,$ a treatment that re(ents heteroto ic ossification after hi surgery$ has %een used #ith some success in re(ention of %ar reformation& 4adelungAs Deformity This disorder in(ol(es rogressi(e (olar and ulnar angulation of the distal radius$ causing rominence of the distal ulna and a%normality of the sha e of the distal radial articular surface& Although #rist ain can occur$ most atients are treated conser(ati(ely #ith s linting& Rarely$ osteotomy of the distal radius and shortening of the distal ulna is indicated& A lasia or Dys lasia of Long :ones These rare deformities$ #hich do not a ear to %e hereditary$ consist of a%sence of a %one or art of a %one& The term congenital s/eletal lim% deficiencies is used to descri%e these disorders collecti(ely& S/eletal deficiencies can %e intercalary +an a%sent segment #ith %ones distal to it intact, or terminal +all %ones distal to the lesion a%sent,$ and trans(erse or longitudinal& As an e"am le$ a%sence of the fi%ula alone #ould %e classified as an intercalary$ longitudinal fi%ular hemimelia& A%sence of a hand or foot #ould %e descri%ed as a terminal trans(erse defect +congenital am utation,& A%sence of the Radius The deformity /no#n as radial clu%hand is caused %y the a%sence of the radius$ #hich is sometimes %ilateral and can %e associated #ith craniofacial anomalies$ throm%ocyto enia$ or 7anconiAs anemia + ancyto enia,& If the defect is terminal rather than intercalary$ the thum% may %e a%sent& Early treatment in(ol(es mani ulation and s linting and$ %y the age of 69 months$ surgical centrali1ation of the car us on the ulna& A%sence of the ulna is much less common and is associated #ith digital a%normalities$ such as syndactyly$ in FG ercent of cases& Treatment is generally nono erati(e for the #rist and el%o# and focuses on correction of digital a%normalities that im air function& 7i%ular 2emimelia In this disorder$ the lim% is shortened and the hindfoot usually in e0uino(algus osition& In(ol(ement is %ilateral in -G ercent of cases& 7or milder cases$ lim% length

e0uali1ations may %e ossi%le using the Ili1aro( techni0ue* more se(ere deficiencies may re0uire am utation& 7emoral 2y o lasia These deformities can range from mild hy o lasia to com lete a%sence of the u er femur& 4ild cases are treated %y lim% length e0uali1ation rocedures& In more se(ere cases fusion of the femoral remnant to the ilium or am utation #ith /nee fusion and rosthetic lim% fitting has %een erformed& GENERALINED :ONE DISORDERS Com osition :one is made u of organic and inorganic materials& The organic com onents include ty e I collagen +FG ercent of the organic matri",$ hos ho roteins$ %one3s ecific roteoglycan$ sialo rotein$ osteonectin$ osteocalcin$ and gro#th factors such as transforming gro#th factor3%eta +TG73 %,$ fi%ro%last gro#th factors$ insulinli/e gro#th factors$ and %one mor hogenetic roteins& These factors and roteins incor orated into the matri" of %one are res onsi%le for the maintenance of normal %one remodeling rocesses$ and they gi(e %one matri" its osteogenic ro erties$ #hich ma/e %one grafting ossi%le& :efore it is minerali1ed$ the %one matri" secreted %y osteo%lasts is called osteoid& The inorganic hase of %one consists of hydro"ya atite$ a crystalline form of calcium and hos hate$ and #ater$ #hich ma/es u H to F ercent of %one& Citrate$ car%onate$ and magnesium also are resent& The mineral hase of %one is res onsi%le for its com ressi(e strength$ #hile collagen gi(es %one its tensile strength& 2ydro"ya atite crystals are s ontaneously de osited in the !hole 1ones' formed #ithin the 0uarter3 staggered o(erla ing array of the ty e I collagen molecules and later are s read along the fi%ers %y secondary nucleation& Osteonectin$ a glyco rotein in %one matri"$ may ha(e a role in %inding the hydro"ya atite crystals to the collagen& Osteo ontin$ a hos ho rotein in %one matri"$ may %e in(ol(ed in cell attachment to %one$ and osteocalcin$ a car%o"yglutamic acid containing glyco rotein$ is thought to %e in(ol(ed in osteoclastic recruitment for the resor tion of %one matri"& Cell :iology :one matri" is normally secreted %y osteo%lasts in discrete layers +lamellae,$ #ith the collagen in each successi(e layer oriented FG degrees to the ad)acent layer& This ly#oodli/e structure ma"imi1es the mechanical strength of the material& Osteo%lasts %ecome entra ed in the secreted matri" and %ecome more 0uiescent cells /no#n as osteocytes& Osteocytes ha(e numerous cell rocesses called canaliculi$ #hich communicate #ith each other through the %one matri"& In in)ury and re air rocesses$ %one3 forming tumors$ and diseases such as PagetAs disease$ osteo%lasts initially secrete #o(en %one$ in #hich the collagen fi%rils ha(e a random orientation& The three3dimensional structure of %one is similar to that of a s onge$ #ith all the %ony tra%eculae interconnected and the ores containing the %one marro#& Osteoclasts are multinucleated %one3resor%ing cells +also called giant cells, of monocytic lineage that attach to %one surfaces and secrete en1ymes that %rea/ do#n organic com onents of %one matri"& In addition$ a roton um in the lasma mem%rane of the osteoclast acidifies the region %et#een the cell and the %one surface$ dissol(ing the mineral hase& The ca(ity e"ca(ated %y the osteoclast is referred to as a 2o#shi As lacuna& :one is constantly formed and resor%ed in the s/eleton throughout

life& :one formation and resor tion are locally cou led$ #ith osteo%lasts al#ays follo#ing in the #a/e of an osteoclast and re lacing the resor%ed %one #ith ne# lamellar %one& Cou ling factors such as %one mor hogenetic roteins and other mem%ers of the TG73% family are thought to %e acti(ated %y the acidic en(ironment of the osteoclast and may ser(e to attract and stimulate osteo%last rogenitor cells$ accounting for the local cou ling henomenon +7ig& 563--,& 8hen cortical %one undergoes remodeling$ osteoclasts tunnel longitudinally #ithin the corte"$ forming a cutting cone& Concentric layers of lamellar %one are su%se0uently de osited$ lea(ing only a narro# central canal that contains (ascular channels su lying %lood to the %one& This structure is referred to as a ha(ersian system or osteon +7ig& 563-5,& En1ymes Osteo%lasts contain high le(els of al/aline hos hatase$ #hile osteoclasts contain glycolytic en1ymes$ collagenases$ acid hydrolases$ and acid hos hatase& E(idence suggests that some of these en1ymes$ #hich are glycosylated #ith mannose3.3 hos hate$ remain on the resor tion surface and can site3direct %one formation through interaction of mannose3.3 hos hate moieties #ith the insulinli/e gro#th factor II rece tor of osteo%lasts or osteo%last recursor cells& Al/aline hos hatase is thought to %e in(ol(ed in the minerali1ation rocess$ although its role is not yet understood& Serum le(els of al/aline hos hatase deri(ed from %one can %e ele(ated in ric/ets$ osteomalacia$ PagetAs disease$ osteosarcoma$ and metastatic carcinoma& Decreased le(els can %e found in achondro lasia$ scur(y$ hy othyroidism$ and a hereditary deficiency of al/aline hos hatase called hy o hos hatasia& Ossification Endochondral Ossification The long %ones of the s/eleton$ #ith the e"ce tion of the cla(icle$ are formed em%ryonically from a hyaline cartilage recursor& In the center of the recursor$ or anlage$ the chondrocytes undergo hy ertro hy and %egin to calcify the surrounding cartilaginous matri"* this constitutes the rimary ossification center& The rocess e"tends to#ard the ends of the long %one$ %ecoming an orderly front of roliferating$ hy ertro hying$ and calcifying cells /no#n as the gro#th late or hysis& 8ith ingro#th of the nutrient (essel into the central ortion of the forming %one$ the calcified cartilage is con(erted into tra%ecular %one& Concomitantly$ formation of the cortical ortion of the %one %egins #ith osteo%lastic %one synthesis from the eriosteum directly +mem%ranous %one formation,$ gi(ing rise to the rimary %one collar$ #hich also e"tends from the center to#ard the ends of the long %one +7ig& 563 -C,& During fetal and childhood osteogenesis$ endochondral ossification continues in the gro#th late$ accounting for gro#th in length of the %one* ossification also occurs #ithin the e i hysis #hen the secondary centers of ossification a ear& Latitudinal gro#th also occurs at the le(el of the gro#th late %y recruitment of cells from the erichondral ring of Lacroi"& The diameter of the shaft of the long %ones increases through eriosteal accretion of ne# cortical %one #ith endosteal resor tion& The rocess of endochondral ossification is an integral art of fracture healing %y callus formation& Endochondral ossification as it occurs in the gro#th late is de icted in 7ig& 563-.& The gro#th late e"hi%its a gradient of o"ygen and nutrients from the u er roliferating 1one to the 1one of ro(isional calcification$ and the chondrocytes gradually shift from an aero%ic meta%olism in the roliferating 1one to an anaero%ic

meta%olism in the hy ertro hic 1one& The hy ertro hic chondrocytes ac0uire high le(els of al/aline hos hatase$ accumulate calcium$ and secrete calcium3containing matri" (esicles from the lasma mem%rane that are thought to initially nucleate hydro"ya atite crystals in the matri"& The roliferation and maturation of the chondrocytes in endochondral calcification are controlled systemically %y gro#th hormone through insulinli/e gro#th factor I$ and locally %y autocrine gro#th factors& The most im ortant gro#th factors /no#n to control chondrocyte roliferation and hy ertro hy are TG73%$ %asic fi%ro%last gro#th factor +%7G7,$ and arathyroid hormone3related rotein +PT2rP,& %7G7 is roduced in the roliferating and resting 1ones$ and defects in 7G7 rece tors are res onsi%le for disorders such as achondro lasia and thanato horic dys lasia +7G7R- mutations,& PT2rP is roduced in the lo#er roliferating and u er hy ertro hic 1one and stimulates roliferation #hile su ressing hy ertro hy& PT2rP or PT2rP rece tor deletion causes se(ere lethal disru tions of the gro#th late$ #ith loss of the roliferating 1one$ remature hy ertro hy$ and defecti(e transformation of calcified cartilage into %one& The 1one of ro(isional calcification is mechanically the #ea/est art of the gro#th late$ accounting for the ro ensity of childrenAs fractures near the ends of long %ones to in(ol(e this region& In addition$ the hy ertro hic chondrocytes roduce a uni0ue collagen +ty e K collagen, that facilitates con(ersion of the calcified cartilage into %one in the meta hysis& Defects in endochondral ossification may %e inherited +achondro lasia, or ac0uired +(itamin D deficiency ric/ets,& Intramem%ranous Ossification This form of ossification does not in(ol(e a cartilage recursor tissue* rather$ osteo%lasts secrete osteoid and minerali1e it directly& Intramem%ranous or osteo%lastic ossification occurs in the cal(aria and$ as descri%ed a%o(e$ in the eriosteum of the long %ones& This rocess is a art of the later hases of fracture healing$ in #hich it gradually su lants endochondral ossification& Remodeling As descri%ed earlier$ %one is continuously forming and resor%ing in a locally cou led manner& During gro#th$ remodeling also changes the sha e of the long %ones$ #ith acti(ity of osteoclasts and osteo%lasts articularly in the cone3sha ed meta hyseal area resulting in a narro#ing of the diameter of the %one to#ard the dia hysis& In addition$ %one formation and resor tion are strongly influenced %y mechanical stresses in %one$ #ith net resor tion in unloaded %one and increased accretion in loaded %one& :one is an anisotro ic material and de(elo s ie1oelectric charges on its surfaces in res onse to mechanical stresses& :one cells are thought to res ond to these electrical signals$ modulating formati(e and resor ti(e acti(ities& :one Grafting 4echanisms :one grafting$ the trans lantation of %one from one site to another +autologous graft, or from one indi(idual to another +allograft,$ is an essential art of many ortho aedic surgical rocedures& :one grafts #or/ through one or %oth of t#o mechanismsJ osteoconduction or osteoinduction& 8ith osteoconduction$ the graft may ser(e to ro(ide a mechanical su ort and ser(es as a scaffolding on #hich host osteo%lasts

can form ne# %one and through remodeling e(entually re lace the graft& This mechanism redominates in cortical %one and large segmental allografts& Osteoinduction is the ro erty of release and acti(ation of %one3 inducing matri" roteins from the graft during osteoclastic resor tion& :one mor hogenetic rotein and other mem%ers of the TG73%family are among the most im ortant factors in this rocess& 8hen deminerali1ed %one matri" de(oid of %one cells is im lanted into muscle or su%cutaneous tissue$ endochondral3se0uence %one formation occurs through this osteoinduction henomenon& Sites The iliac crest is generally used as a donor site for cancellous grafting$ and the ti%ia or fi%ula for cortical %one grafts& A recent de(elo ment is the use of (asculari1ed %one grafts$ #herein an e" enda%le %one such as the mid ortion of the fi%ula is remo(ed along #ith its nutrient (essels& The (essels are then anastomosed to %lood (essels in the area of the reci ient site using microsurgical techni0ue& This allo#s %ridging of significant %ony defects #ith li(ing %one$ #hich ra idly incor orates& This techni0ue is %eing used to s eed healing of a(ascular necrosis of the femoral head %y inserting a (asculari1ed graft in the femoral nec/ and head$ and for re air of %ony defects caused %y trauma or tumor resections& Allografts :one allografts are #ell tolerated immunologically %ecause antigenic cellular roteins ma/e u only a minute fraction of %one& 7ree1ing or free1e3drying further diminishes the antigenicity of %one #ithout im airing its osteoconducti(e and osteoinducti(e ro erties& As a result %one allografts rarely incite re)ection reactions and immunosu ression is unnecessary& Osteochondral allografts are used to reconstruct )oint surfaces and contain %oth %one and articular cartilage& They generally are fro1en in the resence of a cryo rotectant such as dimethylsulfo"ide$ #hich allo#s reser(ation of a ro ortion of the chondrocytes& The collagen and roteoglycan matri" of articular cartilage does not allo# enetration of lym hocytes or anti%odies* thus cartilage is also an immunologically ri(ileged tissue& Synthetic Graft Su%stitutes Synthetic materials are %eing used e" erimentally as %one graft su%stitutes and sho# significant romise& Tricalcium hos hate and hydro"ya atite ceramics and corals ha(e %een used successfully to fill %ony defects and function as osteoconducti(e su%strates& Resor%a%le synthetic materials such as olyglycolic and olylactic acid are under in(estigation as (ehicles for gro#th factors& Purified and recom%inant %one mor hogenetic roteins and deminerali1ed %one matri" ha(e %oth %een used successfully as %one graft su%stitutes& Ta%le 563H lists %one grafting materials #ith summaries of their ro erties& Classifications De(elo mental disordersAchondro lasia Enchondromatosis 4ulti le e"ostoses Polyostotic fi%rous dys lasia Osteogenesis im erfecta Osteo etrosis Osteochondrodystro hies 4eta%olic disorders4inerali1ation defects 6 >itamin D deficiency +ric/ets or osteomalacia, 6a Nutritional

6a 6a 6a 6 6

4ala%sor tion syndromes Renal disease 2e ato%iliary disease >itamin D3resistant hy o hos hatemic ric/ets Aluminum3induced osteomalacia

2ormonal disorders 6 2y erthyroidism 6 6 6 6 6 2y er arathyroidism 2y ercortisolism +CushingAs disease, Postmeno ausal osteo orosis 2y ogonadism Pituitary disorders

:one marro# diseasesReticuloendothelial system 6 2istiocytosis K 6a 6a 6a 6 6a 6a 6a Letterer3Si#e disease Eosino hilic granuloma 2and3Schuller3Christian disease Li oid granulomatosis GaucherAs disease Niemann3Pic/ disease Kanthomatosis

Lym homas of %one 6 2odg/inAs disease 6 2istiocytic lym homa

2emato oietic system 6 Leu/emia 6 4ulti le myeloma

6 6a 6a 6a 6 6

2emolytic anemias Thalassemia +CooleyAs anemia, Sic/le cell anemia Erythro%lastosis fetalis 4yelofi%rosis 4astocytosis

>ascular disordersPagetAs disease Sudec/As atro hy 4assi(e osteolysis +GorhamAs disease$ or disa earing %one disease, De(elo mental Disorders Defecti(e cartilage roliferation$ calcification$ collagen synthesis$ and %one remodeling are the most common causes of de(elo mental disorders of %one& Some of these disorders are inherited conditions$ and recent ad(ances in molecular %iology ha(e allo#ed identification of s ecific defects in an increasing num%er of diseases& Ta%le 563F lists musculos/eletal diseases for #hich the s ecific genetic defect has %een identified& Achondro lasia The %asic defect in this inherited autosomal dominant disorder is in the roliferation of cartilage due to 7G7R- mutation& 4em%ranous %one de(elo ment +cal(aria$ ri%s$ sternum, is normal$ %ut endochondral ossification is defecti(e& The roliferating 1one of the gro#th lates is shortened and disordered& At %irth$ the infant has a normal3 si1ed %ody$ large head #ith a de ression of the %ase of the nose$ and short lim%s& Shortness of stature %ecause of deficient long3%one gro#th %ecomes rogressi(ely e(ident during childhood +7ig& 563-D,& Trun/ gro#th remains relati(ely normal$ #hile the lim%s are short$ articularly ro"imally& The hands are short and %road$ #ith digits of e0ual length& Increased lum%ar lordosis may %e resent$ as #ell as thoracolum%ar /y hosis& Intelligence is normal$ although life e" ectancy may %e diminished& Genu (arum is a common finding$ and later in life atients may de(elo s inal stenosis as a result of decreased s inal canal diameter and inter edicular distance& Enchondromatosis +OllierAs disease or Dyschondro lasia, This condition$ first descri%ed %y Ollier in 6HFF$ consists of a%normal foci of cartilage #ithin the meta hyses of the long %ones& These cartilage rests are referred to as enchondromas& The cause is un/no#n$ and the disease is not hereditary& Distur%ance of the gro#th near the ends of the in(ol(ed %ones results in foreshortening$ #ith %roadening and cystic changes in the meta hyses& The degree of deformity (aries considera%ly$ #ith some mild cases of enchondromatosis e"hi%iting no significant %ony distortions& In(ol(ement of the %ones of the hand is common& 8hen associated #ith hemangiomas$ the disease is called 4affucci syndrome& The incidence of malignant degeneration of indi(idual lesions into chondrosarcoma occurs in a%out 9C ercent of indi(iduals %y age forty and is e(en more common in 4affucci syndrome& Pathologic fractures caused %y #ea/ening of %one %y an enchondroma can heal$ %ut the enchondroma #ill ersist$ and so curettage and %one grafting is recommended&

4alignant degeneration of lesions is managed %y local resection and reconstruction #hen necessary& 4ulti le E"ostoses +4eta hyseal Aclasis$ or Osteochondromatosis, This autosomal dominant hereditary disorder in(ol(es outgro#ths of cartilaginous lesions from the meta hyses of the long %ones as #ell as occasionally from the el(is$ ri%s$ and s ine +7ig& 563-H,& E"tent of the disease is (aria%le$ and it is one of the more common s/eletal dys lasias& 2ereditary multi le e"ostoses ha(e %een ma ed to three different chromosomal locations$ %ut the s ecific genes in(ol(ed ha(e not %een identified& Cartilage3ca ed e"ostoses$ or osteochondromas$ arise from %ony surfaces and increase in si1e during childhood gro#th& The lesions gro# %y a rocess of relati(ely normal endochondral ossification$ forming tra%ecular %one in the %ase& They can cause mechanical sym toms as a result of im ingement on ner(es$ )oints$ tendons$ or muscles and$ #hen sym tomatic$ can %e remo(ed surgically& Care must %e ta/en to remo(e the cartilage ca in its entirety$ articularly in children$ or local recurrence can result& Genu (algum and rogressi(e ulnar de(iation of the hand as #ell as lim% length discre ancies %ecause of asymmetrical lim% in(ol(ement are other ro%lems that may arise& The most serious com lication is malignant degeneration into chondrosarcoma$ #hich has %een re orted in 6 to 6C ercent of affected indi(iduals& This is usually heralded %y enlargement of the lesion in adulthood$ sometimes in association #ith ain& Thic/ness of the cartilaginous ca as assessed %y CT or 4RI is a good inde" of malignant transformation$ #ith a thic/ness of 6 cm sus icious and o(er 9 cm athognomonic& Treatment is %y #ide surgical e"cision$ and metastasis is uncommon& Polyostotic 7i%rous Dys lasia This disease usually a ears in childhood$ #ith de(elo ment of e" ansile lytic lesions in the meta hyses and dia hyses of long %ones& The el(is$ s/ull$ and %ones of the hand also may %e in(ol(ed& :ending deformities from recurrent fractures of the long %ones can occur$ most commonly in the ro"imal femur$ causing a !she herdAs croo/' deformity +(arus of the u er femur,& Radiogra hically$ the dys lastic %one has a homogeneous !ground glass' a earance as a result of the lac/ of formed tra%eculae +7ig& 563-F,& Lesions that are sym tomatic or threatening athologic fracture re0uire curettage and %one grafting as #ell as internal fi"ation for sta%ili1ation& Cortical %one graft is su erior to cancellous graft$ #hich tends to %e resor%ed %y the dys lastic %one& Association #ith caf=3au3lait igmented s/in lesions and recocious u%erty is termed Al%right syndrome& 4alignant degeneration has %een re orted in these lesions %ut is e"tremely rare& 7i%rous dys lasia occurs also in a monostotic form& Osteogenesis Im erfecta Osteogenesis im erfecta is a genetically determined disorder in the structure or rocessing of ty e I collagen$ #ith a s ectrum of e" ression& :one fragility is the unifying clinical manifestation$ and four clinical grou s ha(e %een categori1ed %y Sillence +Ta%le 5636G,& 8hile the clinical classification is useful for general treatment and rognosis$ recent identification of the s ecific mutations in the ty e I collagen gene indicates a #ide (ariety of mutations #ith differing clinical manifestations& Patients may ha(e %lue sclerae$ a%normal dentition$ deafness$ and gro#th failure& The fetal form +ty e II, is se(ere and lethal$ the infantile form +ty e III, less se(ere %ut associated #ith se(ere deformities$ and the adolescent form +tarda$ ty e I, is the most common and least se(ere form&

Radiogra hically$ the %ones may a ear normal in ty e I %ut tend to %e more gracile #ith decreased tra%ecular attern& 8ith more se(ere in(ol(ement$ fractures may %e e(ident$ and enlargement of the meta hysis and e i hysis may %e resent$ #ith disorgani1ation of the gro#th late into multi le islands of cartilage& Treatment Osteogenesis im erfecta is treated #ith orthoses to re(ent fractures and correction of deformities %y multi le osteotomies #ith intramedullary sta%ili1ation using telesco ing rods +7ig& 5635G,& 7racture tendency usually decreases at u%erty& Correction of scoliosis #ith osterior instrumentation and fusion is hel ful in re(enting res iratory com romise %ut can %e difficult& A #ide (ariety of systemic thera ies$ including calcium$ hos horus$ (itamin C$ (itamin D$ fluoride$ and calcitonin$ ha(e %een used #ithout demonstra%le %eneficial effect& Osteo etrosis +Al%ers3SchOn%erg Disease, This rare s/eletal disease is associated #ith increased density of the %ones +7ig& 563 56,& It has t#o forms$ an infantile se(ere form$ #hich is inherited as an autosomal recessi(e$ and an adult +or tarda, milder form$ #hich is an autosomal dominant trait& The central defect is in osteoclastic function$ #ith failure of functional %one resor tion and therefore of remodeling& 4ulti le genetic defects in osteoclast function ha(e %een sho#n to cause osteo etrosis +see Ta%le 563F,& Conse0uently the medullary ca(ities are narro#ed$ #ith resulting deficiencies of %one marro# acti(ity causing anemia and throm%ocyto enia& The %ones sho# ersistence of calcified cartilage and #o(en %one$ and a%sence of osteonal cortical %one& Patients ha(e increased fracture tendency$ susce ti%ility to osteomyelitis$ and cranial ner(e deficits from s/ull in(ol(ement& Se(eral atients #ith infantile osteo etrosis ha(e %een cured %y %one marro# trans lantation$ #ith resum tion of %one resor tion and remodeling attri%uta%le to donor osteoclasts& :one density in these atients and hemato oietic function returned to normal& 4elorheostosis This condition$ #hich may in(ol(e one or more %ones in an e"tremity$ is characteri1ed %y endosteal cortical hy erostosis$ often descri%ed as a !candle dri ing' a earance radiogra hically& The disease is associated #ith ain and contracture of ad)acent )oints& The cause is un/no#n$ and there is no s ecific thera y %eyond sym tomatic treatment& 4eta%olic Diseases 4inerali1ation 4inerali1ation re0uires secretion %y chondrocytes or osteo%lasts of a suita%le organic matri" +osteoid or chondroid,$ #ithin #hich hydro"ya atite crystals can form& 4inerali1ation defects can result from inade0uate a(aila%ility of calcium and hos hate$ interference #ith crystal formation %y drugs or hea(y metals$ disru tion of (itamin D meta%olism$ or a%errations in the organic matri"& Scur(y

Scur(y is the clinical condition resulting from a nutritional deficiency of (itamin C$ or ascor%ic acid& Ascor%ate is crucial to the cross3lin/ing rocess in fi%rillar collagen formation$ #hich determines mechanical ro erties of collagen fi%ers& Ca illary #alls are most o%(iously affected$ #ith microsco ic hemorrhage as the hallmar/ of scur(y& Su% eriosteal hemorrhages occur ad)acent to the gro#th lates in the meta hyses of the long %ones +7ig& 56359, and in e"treme cases can cause e i hyseal se aration& 4inerali1ation in the gro#th late is defecti(e$ #ith an irregular and dense minerali1ation front #here transition of the calcified cartilage to %one is im aired& 2emorrhage from the gastrointestinal tract or mucous mem%ranes and su% eriosteal hemorrhages resent #ith ain and s#elling that can mimic osteomyelitis& Treatment #ith (itamin C ra idly cures the disease$ and #ithin 95 h ain su%sides& Protection from #eight %earing until reossification occurs is recommended& >itamin D 4eta%olism >itamin D +cholecalciferol, is essential for normal %one meta%olism and minerali1ation& >itamin D is formed from dietary recursor forms$ or from ultra(iolet irradiation of D3dehydrocholesterol in the s/in& The acti(e form of (itamin D is 6$9C3 dihydro"y(itamin D-& 9C32ydro"ylation occurs in the li(er$ and su%se0uent 63a3 hydro"ylation occurs in the /idney& The ma)or function of acti(e (itamin D- is to ena%le a%sor tion of calcium in the gut& Additional effects include a stimulation of renal tu%ular hos hate rea%sor tion and %one resor tion& The hysiologic significance of the %one resor%ing effects is un/no#n$ %ut the mechanism is through stimulation of differentiation of osteoclasts from recursor cells& The 63a3 hydro"ylation of (itamin D is u 3 regulated in the /idney %y arathyroid hormone +PT2,& Additional effects of PT2 include stimulation of %one resor tion and decreased renal tu%ular hos hate rea%sor tion& The stimulation of %one resor tion in(ol(es osteo%lasts as the target cell$ #ith secondary secretion of an un/no#n factor that then induces osteoclasts to resor% %one& Calcitonin$ on the other hand$ acti(ates osteoclast rece tors directly to inhi%it resor tion& 8hile this hormone has thera eutic uses in PagetAs disease$ hy ercalcemia$ and some forms of osteo orosis$ it is not thought to lay a significant role in normal human %one meta%olism& 7igure 5635summari1es the roles of (itamin D and PT2 in the regulation of calcium and hos hate meta%olism& Ric/ets Ric/ets is a relati(e deficiency of the acti(e meta%olite of (itamin D +6$9C3 dihydro"y(itamin D-, in children$ #hich leads to the ina%ility of chondrocytes to acti(ely minerali1e matri" in the 1one of ro(isional calcification of the gro#th lates& The defect in minerali1ation has %een resumed to %e secondary to inade0uate calcium a%sor tion in the gut$ #ith inade0uate local le(els of calcium and hos hate at the minerali1ation front& This can %e aggra(ated %y decreased rea%sor tion of hos hate in the renal tu%ules$ another effect of (itamin D& Some e(idence suggests that chondrocytes in the gro#th late ha(e (itamin D rece tors and can res ond to this hormone in a direct fashion as #ell& Nutritional (itamin D deficiency in children is no# rare in the ?nited States$ %ut disru tions of (itamin D meta%olism +renal disease$ anticon(ulsant thera y$ mala%sor tion syndromes, and inherited diseases +(itamin D3resistant hy o hos hatemic ric/ets, can cause ric/ets& Pathology

The normal gro#th late is a #ell3defined late of cartilage a ro"imately 9 mm in thic/ness that se arates the meta hysis from the e i hysis& In ric/ets$ the gro#th lates are #idened and irregular$ #ith atchy decreased minerali1ation& The roliferati(e and hy ertro hic 1ones are increased in height and some#hat disordered& The %ony tra%eculae in the meta hyses are thin$ #ith diminished %one formation& In addition there can %e #idening and cu ing of the meta hyses +7ig& 56355, and deformities such as co"a (ara$ ti%ial %o#ing$ and genu (arum or (algus& Other clinical manifestations include gastrointestinal sym toms$ irrita%ility$ o en fontanelles$ narro# chest$ and rominence of the costochondral )unctions +referred to as the !rachitic rosary',& Treatment Treatment of nutritional ric/ets is %y su lementation #ith high doses of (itamin D +-$GGG ? daily* normal daily re0uirement 5GG ?,& Calcium su lementation enhances the rate of healing& 7or ersistent deformities$ correction is delayed until the underlying meta%olic defect has resol(ed$ at #hich time osteotomies can %e erformed& Entero athic Ric/ets The most common cause of mala%sor ti(e ric/ets is celiac$ or gluten3 sensiti(e$ entero athy& Chronic diarrhea results in inade0uate (itamin D a%sor tion in the gut& The effects of the (itamin D deficiency are e"acer%ated %y eriods of ra id gro#th& The effects on %one and gro#th lates are similar to those descri%ed a%o(e$ and treatment hinges on the elimination of gluten from the diet and (itamin D su lementation& Renal Osteodystro hy Renal disease im airs the 63a3hydro"ylation of (itamin D$ causing a functional (itamin D deficiency& Inade0uate calcium a%sor tion in the gut causes slight hy ocalcemia$ #hich then leads to a secondary hy er arathyroidism& Se(ere osteo enia results$ and in children the clinical icture resem%les ric/ets& In atients on renal dialysis$ aluminum contained in hos hate3%inding agents +used chronically to decrease hos hate le(els, %inds to minerali1ation surfaces and im airs further mineral de osition$ a form of osteomalacia& :oth glomerular and tu%ular defects can cause renal osteodystro hy$ including 7anconi syndrome +glycosuria$ aminoaciduria,$ Lignac37anconi syndrome +im aired tu%ular hos hate rea%sor tion,$ and renal tu%ular acidosis& >itamin D3Resistant 2y o hos hatemic Ric/ets >itamin D3resistant hy o hos hatemic ric/ets is a familial disease associated #ith hy o hos hatemia& The syndrome resem%les nutritional (itamin D deficiency$ e"ce t that (ery high doses of (itamin D in con)unction #ith hos hate su lementation are re0uired to treat it& The atients are short in stature #ith dis ro ortionately short lim%s$ and the disease is inherited as an K3lin/ed dominant trait& The genetic cause of the disease has %een identified as a neutral endo e tidase /no#n as PEK$ although its su%strate is un/no#n& Oncogenic hy o hos hatemia is an unrelated disorder associated #ith %enign soft3tissue tumors that disa ears #ith tumor e"cision& 2y o hos hatasia

2y o hos hatasia is a rare autosomal recessi(e hereditary disease characteri1ed %y a deficiency of al/aline hos hatase and urinary e"cretion of hos hoethanolamine& The disease$ #hich is (aria%le in se(erity$ may resent in childhood or adulthood$ featuring stunting of gro#th and e"cessi(e %one fragility& 2y er hos hatasia is an e"tremely rare congenital disorder #ith mar/edly ele(ated le(els of serum al/aline hos hatase& It is also /no#n as )u(enile PagetAs disease& The s/ull and dia hyses of the long %ones are thic/ened$ and deformity and fractures can result& There is no effecti(e systemic treatment for either of these disorders& Osteomalacia Osteomalacia is defined as a defect in minerali1ation of adult %one$ generally resulting from a%normalities in (itamin D meta%olism& As in ric/ets$ causes of osteomalacia include nutritional deficiency$ mala%sor tion$ anticon(ulsant thera y$ and he atic and renal diseases& In addition$ aluminum can induce a minerali1ation defect$ as can chronic use of di hos honates +a treatment sometimes used for PagetAs disease,& Anticon(ulsants can cause osteomalacia %y interfering #ith (itamin D meta%olism in the li(er& 2istologically$ e"cessi(e unminerali1ed surfaces and thic/ness of the osteoid are o%ser(ed& The %ones %ecome osteo enic$ and fractures can result& Nutritional osteomalacia is more common in the elderly than re(iously recogni1ed$ aggra(ating in(olutional osteo orosis and the tendency for fractures& A characteristic radiogra hic finding is LooserAs 1ones$ #hich are stress fractures e"tending artly through the %one$ usually on the conca(e side$ secondary to mechanical failure in com ression& Treatment de ends on the underlying cause$ %ut generally in(ol(es (itamin D su lementation& 2y er arathyroid :one Disease +Osteitis 7i%rosa Cystica, E"cessi(e secretion of PT2 can cause %one disease as a result of the resor ti(e effects of PT2 on %one& Patients may resent #ith %one ain and tenderness$ hy ercalcemia$ and hy o hos hatemia& Common causes are an underlying arathyroid adenoma or adenocarcinoma& 4uscle #ea/ness and calcium hos hate renal stones also may %e resent& Radiogra hically osteo enia is o%ser(ed$ #ith su% eriosteal resor tion in some sites$ %est seen along the radial %orders of the digits and along the distal cla(icle& 2emorrhagic cystic lesions +%ro#n tumors, can occur in the long %ones %ut usually resol(e #ith treatment of the underlying hy er arathyroidism& Parathyroidectomy$ the treatment of choice$ results in s ontaneous resolution of the %one disease& Osteo orosis In osteo orosis$ a common disorder in the elderly$ total %one mass and tra%ecular (olume are decreased$ %ut minerali1ation is normal& S/eletal %one mass reaches its ea/ at a%out the age of thirty& :oth men and #omen su%se0uently lose %one throughout life$ though #omen achie(e a lo#er starting ea/ mass and ha(e a hormonal acceleration of %one loss due to estrogen loss at meno ause& Sym tomatic osteo orosis #ith fractures is therefore much more common in #omen& Osteo orosis can %e rimary or secondary to some other rocess$ usually a hormonal a%normality& Ta%le 56366 lists some of the ty es of osteo orosis& Ty e I and ty e II in(olutional osteo orosis are the most common& Osteo%lasts ha(e %een sho#n to ha(e estrogen rece tors and res ond to estrogen ana%olically$ #hich may e" lain the accelerated ostmeno ausal %one loss& Ty e I osteo orosis generally occurs in #omen CG to DC years of age and is characteri1ed %y loss rimarily of tra%ecular %one& PT2 le(els are

decreased in this grou & Ty e II osteo orosis has a 9L6 female re onderance and is found in atients o(er DG years of age$ #ith ro ortionate loss of %oth tra%ecular and cortical %one& It is thought to result from de ressed renal 63a3hydro"ylase acti(ity associated #ith aging$ leading to inade0uate acti(e (itamin D le(els and decreased intestinal calcium a%sor tion& Conse0uently these atients tend to ha(e a mild secondary hy er arathyroidism contri%uting to their chronic %one loss& Ty e III atients are similar to ty e I e"ce t that their serum PT2 le(els are ele(ated* this grou com rises a%out 6G ercent of the ostmeno ausal form& Secondary osteo orosis can result from a num%er of causes$ as listed in Ta%le 56366$ #hich must %e ruled out %y history$ e"amination$ and a ro riate la%oratory studies& Osteomalacia$ #ith the numerous causes listed re(iously$ must %e ruled out as a cause of osteo enia and can %e readily e(aluated %y histomor hometric analysis of a %one %io sy of the iliac crest& Additionally$ accurate serum measurements of (itamin D meta%olites and PT2 le(els are no# #idely a(aila%le$ facilitating e(aluation of calcium meta%olism& Patients #ith osteo orosis often resent #ith fractures after minor trauma as the first indication of the disorder& 7re0uently %ac/ache #ith rogressi(e /y hosis and loss of height are noted& Common locations for fractures are the distal radius$ ro"imal femur$ and (erte%rae& 8ith acute fracture$ atients may ha(e se(ere %ac/ ain$ #hich gradually su%sides as the fracture heals o(er 9 to 5 months& Often some residual aching ain ersists$ %ut neurologic deficits are e"tremely rare$ e(en #ith se(ere com ressions and /y hotic deformity& Radiology Radiogra hically$ thinning of the cortices of long %ones or (erte%ral %odies may %e noted$ #ith a loss of tra%ecular attern and %ulging of the discs into the (erte%ral end lates +7ig& 5635C,& Plain radiogra hs are notoriously inaccurate in the diagnosis of osteo orosis$ since the a arent %one density is strongly de endent on radiogra hic techni0ue& Accurate densitometric measurements ha(e %ecome #idely a(aila%le using 0uantitati(e CT scans of the s ine$ or dual3energy "3ray a%sor tiometry$ #hich can measure the density of any %one& The accuracy of these techni0ues is #ithin 6 ercent& 8ith dual3energy "3ray a%sor tiometry$ measurements of %oth the s inal and femoral nec/ density usually are made to assess the a endicular and the a"ial s/eletal mass& The analysis of s inal mass is demonstrated in 7ig& 5635.$ #hich also sho#s the age3 de endent decline in the normal female o ulation$ #ith acceleration during meno ause& :y com aring the %one density of osteo orotic atients #ith that of normal control o ulations$ an estimate of the ris/ of fractures can %e made$ #hich is (alua%le in guiding thera y& Se0uential measurements are also hel ful in assessing res onses to thera eutic inter(entions& Treatment Acute (erte%ral fractures are treated #ith a light#eight e"tension %race$ analgesics$ and early mo%ili1ation& :ed rest aggra(ates the underlying osteo enia& Other fractures are treated as are those in nonsteo orotic atients +see $ %elo#,& Endocrine causes$ multi le myeloma$ and osteomalacia must %e ruled out as descri%ed a%o(e& Calcium su lementation +6$GGG to 6$CGGmg daily, is generally recommended and can slo# the rate of loss& Physiologic doses of (itamin D +5GG ? daily, hel to ensure calcium a%sor tion& In erimeno ausal #omen$ estrogen thera y is of ro(ed %enefit& Patients #ho ha(e high3turno(er osteo orosis +e"cessi(e %one resor tion, as )udged from histomor hometric or calcium %alance studies may %enefit from antiresor ti(e agents

such as calcitonin& :is hos honates such as etidronate ha(e %een used cyclically +a 93 #ee/ course e(ery - months, to inhi%it %one resor tion& Since %one is continually forming and resor%ing$ eriodically inhi%iting resor tion can increase %one mass$ since formation continues& Second3generation %is hos honates$ such as alendronate$ ha(e %een used successfully to increase %one mass in ostmeno ausal osteo orotic atients %y continuous daily oral administration& 7luoride has %een used to increase %one formation and %one mass %ut remains contro(ersial since the ne# %one formed is #o(en %one$ #hich is structurally inferior& Pros ecti(e$ randomi1ed studies ha(e demonstrated no decrease in fracture rates #ith fluoride thera y& Synthetic androgenic steroids also ha(e %een used to increase %one formation rates$ as has human gro#th hormone$ %ut these a roaches are still e" erimental& All osteo orotic atients must %e encouraged to %egin a regular$ rogressi(e rogram of #eight3%earing e"ercise such as #al/ing$ along #ith general s inal e"tension and strengthening e"ercises to hel maintain %one mass and re(ent fractures& Pituitary Distur%ances Pituitary Short Stature There are t#o main ty es of ituitary d#arfism$ 7rOhlichAs adi osogenital ty e +short stature associated #ith o%esity$ genital hy o lasia$ and mental retardation,$ and the Lorain3L=(i ty e +short stature #ithout other mental or hysical change,& The usual cause is a tumor or cyst com ressing the ituitary gland$ although congenital a lasia also can occur& 8ith the recent a(aila%ility of recom%inant human gro#th hormone$ this form of d#arfism is no# treata%le& 2y er ituitary Syndromes Gigantism is caused %y e"cessi(e gro#th hormone secretion during childhood and can %e accom anied %y su%normal mental de(elo ment& The %ones are increased in thic/ness and length& Acromegaly refers to the syndrome associated #ith e"cessi(e gro#th hormone secretion in the adult& A%normal %one formation enlarges the al(eolar margins of the )a#s$ leading to elongation of the face and ro)ection of the chin& Prominence of the frontal region of the s/ull de(elo s as #ell as increased si1e of the thora"& The ends of the long %ones are enlarged$ and the short %ones in the hands and feet are elongated and thic/ened& The usual cause is a ituitary adenoma& Acromegalic atients also may de(elo arthritis of the s ine or other )oints that resem%les osteoarthritis& 2y othyroidism +Cretinism, Congenital hy othyroidism leads to short stature$ retardation of maturation$ and de(elo mental delay& The rinci al s/eletal changes include decreased length of the long %ones$ thic/ened cortices$ and delayed a earance of the secondary ossification centers in the e i hyses& Irregularity of the ossific nucleus resem%les osteochondroses such as Legg3Cal(=3Perthes disease in the hi s& Closure of the gro#th lates also is delayed& Thyroid hormone re lacement thera y$ if started in infancy$ cures the disease$ and it can roduce gro#th in stature e(en in adults %ecause of the delayed closure of the gro#th lates& 4uco olysaccharidoses A series of 69 hereditary disorders of muco olysaccharide meta%olism has %een descri%ed$ #ith identification of the s ecific en1ymatic defect in 6G of them& All affected atients ha(e some#hat thic/ened$ coarse facial features$ )oint stiffness$ and

short stature& Radiogra hic findings include o(al (erte%rae #ith anterior %ea/ing$ co"a (alga$ and a #ide$ flat el(is& 4any are associated also #ith thoracolum%ar /y hosis& All forms of muco olysaccharidosis are inherited as autosomal recessi(e disorders e"ce t ty e II +2unterAs syndrome,$ #hich is K3lin/ed& 4uco olysaccharidosis atients ha(e ele(ated urinary e"cretion of dermatan$ he aran$ or /eratan sulfate$ de ending on the ty e& The most common forms are ty e I +2urlerAs and ScheieAs syndromesJdeficiency of a3l3iduronidase, and ty e I> +4or0uio syndrome* ty e I>AJdeficiency of N3 acetylgalactosamine3.3sulfatase* ty e I>:Jdeficiency of %eta3 galactosidase,& Ty e I is associated #ith mental retardation and life e" ectancy of 6G to 6C years$ #hile ty e I> atients ha(e normal intelligence and sur(i(e #ell into adulthood& PagetAs Disease +Osteitis Deformans, Osteitis deformans$ first descri%ed %y Sir <ames Paget in 6HD.$ is a disorder of accelerated regional %one turno(er& ?ltrastructural studies ha(e demonstrated (iral3 li/e inclusion articles in osteoclasts of affected %one$ suggesting that the causati(e agent may %e a slo# (irus& Des ite numerous studies$ no s ecific (iral etiologic agent has yet %een identified& PagetAs disease may %e monostotic +9C ercent, or olyostotic +DC ercent,& Early in the disease there is e"cessi(e osteoclastic resor tion and (ascularity$ follo#ed %y a%normal %one formation and sclerosis$ #ith thic/ening of the tra%eculae and cortical %one& In the late hase$ dense sclerotic #o(en %one and marro# fi%rosis redominate& The disease %egins %et#een the ages of -C and CG years and is ainful in a%out -G ercent of atients& Often the diagnosis is made as an incidental finding on a radiogra h ta/en for some other reason& Resor tion and formation remain cou led in PagetAs disease$ so the e"cessi(e %one resor tion that a ears to %e the rimary defect is accom anied %y e"cessi(e formation$ causing the enlargement of in(ol(ed %ones #ith cortical and tra%ecular thic/ening& :o#ing of in(ol(ed %ones such as the ti%ia and femur may occur$ and arthritic changes may de(elo in ad)acent )oints& Common locations are the s/ull$ el(is$ lum%ar s ine$ femur$ and ti%ia& :ecause of the disorgani1ed collagen in the #o(en agetic %one$ tensile strength is oor& Therefore fractures can occur$ more often starting on the tension or con(e" side of the long %one$ and ty ically trans(erse in nature& S/ull in(ol(ement can lead to enlargement of the cranium and com ression of cranial ner(es$ roducing sym toms such as (ertigo$ deafness$ or (isual distur%ances& S inal in(ol(ement can cause %ac/ ain$ an/ylosis$ and s inal cord com ression #ith neurologic deficit& Serum calcium and hos hate le(els usually are normal$ %ut the al/aline hos hatase le(el is mar/edly ele(ated and is correlated #ith the acti(ity of the disease& The urinary hydro"y roline le(el is ele(ated as a reflection of collagen %rea/do#n during %one resor tion& In a small ercentage of atients #ith PagetAs disease$ sarcomatous degeneration$ usually to an osteosarcoma$ de(elo s later in life& Signs of malignant degeneration include radiogra hic changes #ith %one lysis or destruction$ soft3tissue mass$ and rogressi(e ain& The rognosis of agetic sarcoma is oor& Radiologic 7indings Early changes consist of lytic resor tion of tra%ecular %one& In the s/ull this is referred to as osteo orosis circumscri ta$ and in the ti%ia the henomenon resem%les a flame3sha ed area of ad(ancing %one lysis& Later$ coarsening of tra%ecular attern #ith thic/ striations and cortical thic/ening and enlargement are o%ser(ed +7ig& 563

5D,& >erte%ral in(ol(ement is characteri1ed %y #idening and s0uaring of the (erte%ral %ody and a thic/ened ! icture frame' corte"& Associated )oints e"hi%it degenerati(e changes #ith sclerosis and )oint s ace narro#ing& Treatment There is no cure for PagetAs disease$ although the sym toms and acti(ity of the disease can %e controlled harmacologically& In asym tomatic atients in #hom there is minimal concern a%out im ending fracture$ o%ser(ation alone usually suffices& 7or sym tomatic in(ol(ement$ treatment is focused on antiresor ti(e agents +e&g&$ %is hos honates such as etidronate or alendronate, or calcitonin& Treatment #ith calcitonin or di hos honate is continued until %iochemical arameters and sym toms im ro(e$ usually a%out . months& Doses of etidronate higher than C mg;/g;day$ or continuous treatment for eriods longer than . to 69 months may %e associated #ith an iatrogenic osteomalacia3li/e minerali1ation defect and redis ose to fractures& :ecause %is hos honates ha(e an anti hos haturic effect$ a slight rise in serum hos hate indicates an effecti(e dose of the medication$ #hich (aries de ending on the e"tent of %ony in(ol(ement& Patients #ho undergo ma)or surgery should %e treated in the erio erati(e eriod #ith calcitonin to re(ent osto erati(e hy ercalcemia secondary to immo%ili1ation& In cases of s inal in(ol(ement #ith neurologic deficit or im ending ara legia$ mithramycin is the drug of choice$ roducing an immediate and rofound inhi%ition of agetic acti(ity& It is not suita%le for long3term thera y %ecause of he atic and renal to"icity& 8hen fractures occur$ the incidence of nonunion is greater than normal$ and healing more relia%ly o%tains #ith surgical internal fi"ation in addition to anti agetic thera y& Sarcomas must %e treated %y radical resection and rosthetic lim% reconstruction or am utation and$ if the atient can tolerate the to"icity$ chemothera y& :one 4arro# Diseases Diseases of %one marro# constituents can ha(e secondary effects on tra%ecular %one& The reticuloendothelial tissue of %one is found mainly at the ends of the long %ones and in the cancellous %one of the a"ial s/eleton +ri%s$ s ine$ s/ull$ el(is,& Li oid Granulomatosis These disorders result from distur%ances in li id meta%olism #ithin %one$ causing accumulations that dis lace normal marro# elements& In GaucherAs disease a cere%roside li o rotein accumulates in histiocytes in the li(er$ s leen$ and %one marro#& Ortho aedic ro%lems include athologic fractures and a(ascular necrosis of the femoral head& Sym tomatic GaucherAs disease has %een treated successfully %y e"ogenous arenteral recom%inant alglucerase - times er #ee/$ #ith resolution of the %one lesions& Niemann3Pic/ disease and Tay3Sachs disease in(ol(e defecti(e hos hatide li id and cere%roside roteins$ res ecti(ely$ #ith rimarily neurologic se0uelae& All of these disorders can cause formation of tumorli/e de osits #ithin the %one marro#$ #ith dis lacement of normal marro# and tra%ecular %one& The de osits consist rimarily of li id3laden histiocytes$ or !foam cells$' and the lesions cause %one destruction #ithout much %ony reaction$ occasionally resulting in athologic fractures&

4astocytosis 4astocytosis is a systemic disorder that infiltrates %one marro# %y mast cells& Release of histamine$ serotonin$ and other mediators from the mast cells cause characteristic urticaria igmentosa$ a dermatologic condition$ as #ell as ulmonary and a #ide range of other sym toms& In the s/eleton$ mastocytosis can cause lytic or mi"ed lytic and sclerotic lesions$ #hich may %e locali1ed or #ides read& The cause of the disorder is un/no#n$ and treatment generally is sym tomatic& 2istiocytosis K This term encom asses a s ectrum of clinical disease$ #ith three ma)or forms& Letterer3Si#e disease is the infantile form$ #hich in(ol(es he atos lenomegaly and disseminated %ony lesions$ and runs a ra idly fatal course in most cases& 2and3 Schuller3Christian disease usually occurs in children %ut occasionally resents in adulthood& The se(erity (aries greatly$ and manifestations include the triad of e"o hthalmos$ dia%etes insi idus$ and s/ull lesions& In addition$ he atos lenomegaly and hy ercholesterolemia can %e resent$ and the disease tends to %e rogressi(e& Eosino hilic granuloma$ the least se(ere form of histiocytosis K$ usually resents as a solitary %ony lesion that may %e ainful or cause a athologic fracture& T#o3thirds of atients are under age t#enty& Patients #ho de(elo multi le lesions usually do so #ithin 9 years of onset$ and may go on to de(elo the 2and3Schuller3Christian (ariant of the disease& Local tenderness and s#elling may %e resent& Radiogra hically$ eosino hilic granuloma has a highly (aria%le a earance and may cause destructi(e or ermeati(e %one lysis #ith eriosteal reaction mimic/ing osteomyelitis or E#ingAs sarcoma& In general$ ho#e(er$ the radiogra h sho#s #ell3 circumscri%ed lytic lesions& In(ol(ement of a (erte%ral %ody can cause flattening +(erte%ra lana$ or Cal(=As disease, and must %e differentiated from osteomyelitis& Treatment Treatment of systemic forms of histiocytosis is #ith chemothera eutic agents such as (in%lastine and rednisone& Eosino hilic granuloma can %e treated #ith lo#3dose radiation +9 to 6G Gy,$ although in long %ones at ris/ of athologic fracture$ curettage #ith or #ithout %one grafting +de ending on the e"tent of the lesion, may %e necessary& Local in)ection of steroids into sym tomatic %ony lesions has sho#n romise in inducing healing& Chronic 4ultifocal Recurrent Osteomyelitis This is a rare disorder of children that resents #ith s#elling$ ain$ and radiogra hic findings of lysis$ reacti(e sclerosis$ and eriosteal reaction resem%ling osteomyelitis$ generally in a meta hyseal location ad)acent to a gro#th late& :io sy sho#s acute and chronic inflammatory cells resem%ling osteomyelitis$ %ut %acterial cultures are negati(e$ and the disorder is self3 limited& Anti%iotics ha(e not %een ro(ed to ha(e any efficacy in the disorder$ and multi le foci may %ecome acti(e at different times during childhood and resol(e s ontaneously& The disorder has a (aria%le course$ %ut it disa ears %y s/eletal maturity& The disease resem%les eosino hilic granuloma in radiogra hic a earance and clinical %eha(ior$ although eosino hils and he atic or s lenic in(ol(ement are a%sent& Lym hatic and 2emato oietic Systems 2odg/inAs Disease

2odg/inAs disease may in(ol(e %one marro#$ most commonly in the (erte%rae or el(is& Although %ony in(ol(ement is fre0uent$ resentation as a rimary %one lesion #ithout lym hatic in(ol(ement is unusual& The radiogra hic a earance may %e lytic$ %lastic$ or mi"ed& Generally$ dull aching ain is the initial sign of %one in(ol(ement& The %ony lesions of 2odg/inAs disease are res onsi(e to radiation treatment$ and the systemic disease res onds #ell to chemothera y& Leu/emia Lym ho%lastic leu/emia is the form that most fre0uently causes %ony changes& The ty ical radiogra hic finding is a trans(erse 1one of lucency in the meta hysis ad)acent to the gro#th late& Diffuse s otty osteo enia and (erte%ral com ression fractures occur$ and rarely large focal lytic lesions in long %ones are seen& Treatment is aimed at controlling the systemic disease #ith chemothera y& 4ulti le 4yeloma 4ulti le myeloma$ the most common rimary malignancy of %one$ is a malignant roliferation of lasma cells #ithin the %one marro#& It usually affects indi(iduals a%o(e the age of fifty& There is marro# re lacement #ith tumor cells$ and usually secretion of a%normal clonal immunoglo%ulins& The diffuse marro# in(ol(ement leads to anemia and unched out lytic lesions throughout the s/eleton +7ig& 5635H,& :ecause there is little reaction to the lesions$ %one scans may not demonstrate all lesions$ and hence this is one of the fe# s/eletal malignancies in #hich a s/eletal sur(ey using lain radiogra hs can gi(e a %etter assessment of the e"tent of the disease& The massi(e %one resor tion can cause hy ercalcemia$ and athologic fractures are common& A%normal ara roteins roduced %y the lasma cells can cause renal glomerular damage and amyloidosis& In CG ercent of atients immunoglo%ulin can %e detected in the urine +:ence3<ones rotein,& Serum electro horesis may demonstrate the resence of an a%normal glo%ulin$ although immunoelectro horesis is more relia%le in esta%lishing the resence of a monoclonal gammo athy& Clinical 4anifestations Pain in areas of %ony in(ol(ement is a common initial sym tom$ as is fatigue& :ac/ache and athologic (erte%ral com ression fractures are also fre0uent$ and the disease has a male re onderance& The multi le nature of the %ony lesions$ a%sence of ulmonary metastases$ and osteolytic character of the lesions often suggest the diagnosis rior to %one marro# %io sy or demonstration of a serum or urine ara rotein& 4ulti le myeloma is a uniformly fatal disease$ although it can %e controlled for a num%er of years %y systemic thera y& Treatment The usual regimen of chemothera eutic agents includes cyclo hos hamide$ mel halan$ rednisone$ and (incristine& The ossi%ility of %one marro# trans lantation is under in(estigation as a otentially curati(e treatment %ut remains e" erimental& Ortho aedic surgical sta%ili1ation of athologic fractures or im ending fractures lays an im ortant role in the management and maintenance of am%ulatory function& S inal sta%ili1ation and decom ression of the cord are often necessary in cases #ith neurologic deficit that fails to res ond rom tly to radiation treatment& Solitary 4yeloma +Plasmacytoma,

Occasionally solitary lasma cell lesions occur in the long %ones$ s ine$ or el(is& Se(enty ercent of these atients rogress to multi le myeloma$ and a circulating monoclonal ara rotein occasionally is found& The usual treatment in(ol(es radiation thera y #ith or #ithout surgical resection$ de ending on the antici ated mor%idity of the surgical rocedure& Chemothera y is usually reser(ed for those atients #ho rogress to the multi le form& 2emolytic Anemia :oth thalassemia +CooleyAs anemia, and sic/le cell anemia roduce %one marro# changes in the a"ial and a endicular s/eleton& In the s/ull$ the e" ansion of the hemato oietic marro# can e"hi%it a !hair on end' or !sunray' a earance$ and %one infarctions can %e o%ser(ed as ser iginous calcified densities in the meta hyses of the long %ones& The femoral head may undergo a(ascular necrosis& Rarely$ e" ansile seudotumors consisting of hy er lastic %one marro# occur in association #ith thalassemia& 7RACT?RES AND <OINT IN<?RIES General Considerations Definitions A fracture is defined as a linear deformation or discontinuity of %one roduced %y forces that e"ceed the ultimate strength of the material& Deformation #ithout fracture can occur #ith loads that e"ceed the elastic limit of the %one %ut not its ultimate strength& This is referred to as lastic deformation and is more common in children& Pathologic fractures occur #hen the strength of the %one is %elo# normal$ as in infections$ tumors$ or meta%olic %one disease$ or after the creation of surgical defects in %one& The direction and magnitude of force a lied to a %one and the rate of loading all are im ortant in determining the fracture attern that #ill result& 7ractures are descri%ed anatomically according to location in the %one +intraarticular$ e i hyseal$ meta hyseal$ dia hyseal,$ the lane of the fracture +trans(erse$ o%li0ue$ s iral,$ the num%er and ty e of fragments$ and #hether the fracture is o en +com ound, or closed& Some fracture atterns are illustrated in 7ig& 5635F& A s iral fracture is roduced %y torsional force$ and comminution refers to resence of multi le fracture fragments& In an undis laced fracture a lane of clea(age e"ists %et#een the fracture fragments #ithout se aration& 7or dis laced fractures$ the con(ention is to descri%e the direction of dis lacement of the distal fragment #ith reference to the ro"imal fragment +medial$ lateral$ osterior$ etc&,& Angulation refers to angular deformity %et#een the long a"es of the fracture fragments and is also descri%ed in terms of the distal fragmentAs relation to the ro"imal fragment& Rotational deformity also is e" ressed in terms of the mo(ement of the distal fragment +internal or e"ternal, relati(e to the ro"imal fragment& One of the most im ortant distinctions is #hether a fracture is o en or closed& If a fracture communicates #ith the surface of the s/in or mucous mem%ranes$ infection is a ris/$ and this constitutes an ortho aedic surgical emergency& A stress fracture occurs #hen a %one is su%)ected to re etiti(e stresses that indi(idually are insufficient to cause fracture %ut cumulati(ely lead to fatigue failure& A com ression fracture results from a"ial loading of %one #ith com action of %ony tra%eculae* these are seen

generally in (erte%ral %odies& A greenstic/ fracture is an incom lete fracture resulting from failure of a ortion of the corte" under tension$ #ith art of the o osing corte" still intact %ut lastically deformed* these usually are seen in children& A torus fracture also retains artial cortical continuity$ %ut #ith %uc/ling or failure in com ression of the o osing corte" +7ig& 563CG,& Diagnosis The clinical manifestations of a fracture include ain$ s#elling$ deformity$ ecchymosis$ insta%ility$ and cre itus& The diagnosis usually is confirmed radiogra hically #ith t#o radiogra hs ta/en at right angles to each other& <oints a%o(e and %elo# the fracture site should %e included in the radiogra h to rule out associated in)uries& Occasionally a com letely nondis laced fracture is not a arent on initial films* in this e(ent immo%ili1ation #ith follo#3u films 6 to 9 #ee/s later is indicated& The fracture line can %e %etter (isuali1ed after some resor tion and early eriosteal re air reaction ha(e ta/en lace& E(aluation of the In)ured Patient Immediate threat to a atientAs life from an in)ured e"tremity is unusual %ut can %e a conse0uence of hemorrhage and resulting shoc/& Associated in)uries to the chest$ head$ and a%dominal (iscera are otentially more serious and re0uire immediate e(aluation and treatment riority& 4ulti le fractures$ e(en #hen closed$ can cause shoc/ from internal hemorrhage$ articularly if ma)or el(ic in)uries are resent& A closed femoral fracture can readily result in 6 to 9 units of internal %lood loss$ and shoc/ in adult atients can occur #ith hy o(olemia of 6 to 9 L& Shoc/ is treated %y (olume re lacement emergently #ith crystalloid such as lactated RingerAs solution to restore %lood ressure and erfusion$ and as soon as ossi%le #ith #hole %lood& Early aggressi(e treatment of hy o(olemic shoc/ greatly reduces the li/elihood of mor%idity and mortality& ?se of neumatic trousers +4ASTJmedical anti3shoc/ trousers, during trans ort may hel to maintain %lood ressure and decrease %lood loss from lo#er3e"tremity in)uries& Assessment of ossi%le s inal in)ury is im erati(e$ and trans ort using a %ac/%oard and sand%ags or other head su orts hel s to minimi1e the chances of causing additional in)ury& The atient should not %e allo#ed to sit or stand until a ro riate s inal radiogra hs ha(e %een ta/en to e(aluate s inal sta%ility& E(aluation of the In)ured E"tremity The in)ured e"tremity is e(aluated as 0uic/ly as ossi%le for neuro(ascular com romise$ soft3tissue and %ony in)uries$ and )oint insta%ility& Peri heral ulses and ca illary refill are e(aluated$ and motor and sensory e"aminations are carried out to the e"tent of the atientAs a%ility to coo erate& All findings must %e carefully documented in the e(ent of later changes& Emergency S linting of 7ractures After the neuro(ascular e"amination has %een erformed and soft3tissue trauma or #ounds e(aluated$ fractured e"tremities are s linted to minimi1e further in)ury& Plaster s lints$ illo# s lints$ or air s lints can %e used to sta%ili1e the e"tremity& 7ractures in(ol(ing the humerus or shoulder can %e s linted #ith a sling& 7ractures of the femur are %est tem orarily sta%ili1ed in a traction s lint& O en 7ractures

O en fractures constitute an ortho aedic surgical emergency %ecause of the ris/ of dee infection& O en fractures are generally higher3energy in)uries$ resulting in more comminution and soft3tissue in)ury and$ conse0uently$ greater im airment of %one %lood su ly& All these factors contri%ute to the increased ris/ of osteomyelitis& Infection in a fracture$ once esta%lished$ can %e e"tremely difficult to eradicate and mar/edly increases the ris/ of nonunion& The ma)or aim in treatment of o en fractures is the re(ention of infection& This is %est accom lished %y aggressi(e and immediate de%ridement of the #ound and fracture site in a sterile o erati(e en(ironment$ and initiation of em iric intra(enous ro hylactic anti%iotic thera y& De%ridement is o timally done #ithin H h$ and a re eat intrao erati(e #ound ins ection and de%ridement #ithin 95 to 5H h is recommended if significant soft3tissue damage or loss is resent& Primary closure of o en fractures is rarely$ if e(er$ indicated$ and secondary closure after C to D days or lastic surgical soft3tissue co(erage rocedures are refera%le& Classification O en fractures are classified as ty e I$ II$ or III$ de ending on the associated soft3 tissue in)ury& A uncture #ound or communication less than 6 cm in length is a ty e I o en fracture& Ty e II fractures ha(e a #ound larger than 6 cm #ith moderate associated soft3tissue damage& Ty e III o en fractures in(ol(e se(ere soft3tissue in)ury or loss and are su%di(ided into su%ty es AJsoft3tissue in)ury only* :Jse(ere soft3tissue and %one in)ury;soft3tissue loss* and CJassociated neuro(ascular in)ury& Techni0ue The follo#ing is a general descri tion of the initial management of o en fractures& +6, The #ound is cultured and co(ered #ith a sterile %andage$ and the e"tremity is s linted& +9, Ce halos orin and$ #ith ty e III or grossly contaminated #ounds$ enicillin and an aminoglycoside are administered intra(enously& Tetanus to"oid or antito"in is administered$ de ending on tetanus immuni1ation status& +-, In a sterile o erating room en(ironment$ the atient is anestheti1ed$ and the e"tremity is re ared #ith antise tic& +5, S/in edges of the #ound are e"cised a ro"imately 6 to 9 mm$ and more if clearly a(ascular or crushed& +C, The #ound is thoroughly irrigated #ith ulsatile la(age using se(eral liters of saline solution& +., Any de(itali1ed muscle or de%ris is surgically e"cised$ and the fracture site is e" osed& The fracture surface is curetted to remo(e foreign material$ follo#ed again %y co ious irrigation of the #ound #ith ulsatile )et la(age of saline solution for a total (olume of at least FL& +D, The fracture is reduced and the s/in loosely a ro"imated o(er a drain$ lea(ing a significant area of the #ound o en$ %ut co(ering e" osed %one$ neuro(ascular structures$ or tendons if ossi%le&

+H, The fracture is sta%ili1ed #ith laster immo%ili1ation or$ more often$ an e"ternal fi"ator to allo# #ound access& Some ty e II o en fractures can %e managed %y rimary internal fi"ation #ith intramedullary de(ices in the lo#er e"tremity or lating in the u er e"tremity at the time of rimary de%ridement& Additionally$ disru ted articular surface fragments can %e ro(isionally sta%ili1ed #ith )udicious use of ins or scre#s& +F, Anti%iotics are continued for a minimum of 6G to 65 days osto erati(ely& Re eat #ound ins ection and de%ridement are recommended after 95 to 5H h$ es ecially for ty e III in)uries& +6G, If secondary #ound closure to achie(e %one co(erage is not feasi%le$ s/in grafts$ free tissue transfers$ or muscle fla s can %e used to o%tain ade0uate soft3tissue co(erage for the fracture& >ascular In)ury 4a)or arterial in)ury should %e sus ected in any fracture3dislocation or significant trauma to an e"tremity& If erfusion to the e"tremity is disru ted$ the ma"imum time that can ela se %efore onset of irre(ersi%le ischemic damage to muscle and other tissues is . to H h& Certain in)uries are more li/ely to ha(e associated (ascular damage$ including su racondylar humeral fractures$ /nee dislocations$ femoral shaft fractures$ ty e III o en ti%ial fractures$ and gunshot #ounds& The diagnosis of (ascular com romise is not necessarily straightfor#ard$ since atients often are unconscious$ and eri heral (asoconstriction or arterial s asm may %e resent& Ca illary refill must %e assessed$ and if ulses are not al a%le Do ler e"amination can %e hel ful& If there is any dou%t a%out (ascular integrity$ arteriogra hy as #ell as a ro riate surgical e" loration should %e carried out& Com artment Syndrome One of the most serious com lications of e"tremity trauma or ischemic in)ury is com artment syndrome$ #hich #as discussed earlier +see Contracture,& A %rief re(ie# is a ro riate gi(en the e"treme im ortance of early diagnosis and treatment of this com lication& The cardinal signs of ain$ allor$ ulselessness$ and aresthesias are resent to (aria%le degrees& Pain #ith assi(e stretch of muscles is one of the more relia%le indicators of com artment syndrome$ and accurate diagnosis is readily made %y measurement of intracom artmental ressures using a slit catheter& Pressures in the range of -G to 5G mm2g constitute an indication for fasciotomy& In atients #ith rolonged ischemia due to arterial com romise$ ro hylactic fasciotomies of all com artments distal to the (ascular in)ury should %e done concomitantly #ith reesta%lishment of erfusion$ regardless of #hether signs of com artment syndrome are resent& In the resence of com artment syndrome$ s/in closure is contraindicated& The s#ollen muscle #ill cause ga ing of the fasciotomy incisions$ #hich can %e treated #ith dressing changes and secondary s lit3 thic/ness s/in grafting or #ith gradual rea ro"imation of the #ound edges using #ire sutures or ta e stri s se0uentially tightened daily& 7at Em%olism and the Acute Res iratory Distress Syndrome

Patients #ho sustain multi le fractures are at high ris/ for su%se0uent fat em%olism$ in #hich fat dro lets from %one marro# enter the systemic circulation and im air ulmonary ca illary erfusion (ia a com le" mechanism& The final common ath#ay of fat em%olism and other in)uries that result in ulmonary arenchymal dysfunction after multi le3system trauma is se(ere hy o"emia$ or the acute res iratory distress syndrome +ARDS,& 7at em%olism generally occurs #ithin 95 to D9 h of in)ury and resents #ith hy o"emia$ tachycardia$ tachy nea$ fe(er$ restlessness$ and confusion& The syndrome is fatal in 6G to 6C ercent of cases& Chest radiogra hic findings are similar to those of other causes of ARDS$ #ith %ilateral atchy infiltrates& Petechiae may %e resent transiently in the a"illa$ chest$ and con)uncti(a and throm%ocyto enia may occur$ #ith fat dro lets (isi%le occasionally in %lood s ecimens and in the urine& 7at em%olism syndrome occurs after total hi and total /nee re lacement as #ell as after trauma$ %ut is seen most often follo#ing femoral fracture& Treatment of fat em%olism syndrome is similar to treatment of ARDS$ #ith administration of o"ygen$ (entilatory su ort$ and ositi(e end3e" iratory ressure as needed to maintain a artial ressure of o"ygen of .G mm2g or %etter& 4oderate3dose corticosteroids +methyl rednisolone F;mg;/g, gi(en ro hylactically after trauma has %een sho#n to reduce the incidence of fat em%olism from 9H&H to 9&C ercent& The use of corticosteroids in ARDS from causes other than fat em%olism remains contro(ersial$ ho#e(er& The other im ortant factor in the management of the multi le3 trauma atient that decreases the incidence and se(erity of fat em%olism and ARDS is sta%ili1ation of the fractures #ithin the first 95 h of in)ury& S ecific medications such as lo#3molecular3#eight de"tran$ he arin$ and alcohol ha(e not %een ro(ed to alter the outcome& Peri heral Ner(e In)uries E"tremity trauma is sometimes accom anied %y in)uries to eri heral ner(es& In the least se(ere ty e of in)ury$ neura ra"ia$ there is interru tion of ner(e conduction$ #hich #ill ultimately reco(er$ manifested %y a transient com lete or artial loss of motor and sensory function& The mechanism of in)ury is stretch or contusion$ and resolution usually occurs #ithin 9 to - months& 8ith more se(ere stretch in)uries$ a"onotmesis$ or disru tion of the a"ons #ith retention of the Sch#ann cell sheath$ can occur& A"onal regeneration may occur #ith this in)ury$ %ut only slo#ly +a ro"imately 6 mm daily,$ and reco(ery may %e incom lete& In neurotmesis$ or com lete di(ision of the ner(e$ regeneration #ill not occur s ontaneously$ and surgical re air is necessary& Assessment of the degree of ner(e damage can %e difficult unless o en reduction of the fracture is needed$ in #hich case the ner(e can %e e" lored& Careful documentation of ner(e function is essential$ as loss of function in a ner(e after closed reduction of a fracture is one indication for surgical e" loration& In cases of neurotmesis$ microsurgical rea ro"imation of the ner(e #ith fine e ineural sutures gi(es the %est chances of reco(ery& In cases of segmental ner(e loss$ ca%le grafting #ith se(eral lengths of an e" enda%le ner(e such as the sural ner(e allo#s some degree of regeneration& Ner(e re air can %e technically easier after D to 6G days$ #hen some thic/ening of the e ineurium due to scarring has de(elo ed& Persistent motor deficits in e"tremities can %e managed #ith orthoses or$ later$ tendon transfers$ de ending on the functional loss and remaining a(aila%le inner(ated muscles&

7racture 2ealing After fracture$ hematoma de(elo s at the fracture site and a clot is formed& Local mediators incite an inflammatory res onse$ and necrosis of %one ad)acent to the fracture site occurs as a conse0uence of disru tion of its %lood su ly& In fractures #ith se(ere soft3tissue in)ury or loss$ eriosteal stri ing$ or comminution$ the e"tent of %one necrosis can %e significant and the fracture may %e delayed in healing or fail to unite& Stages 7racture healing occurs in se(eral stages or hases& At the time of fracture +stage of im act,$ the energy a%sor%ed to failure determines the degree of comminution$ soft3 tissue in)ury$ and disru tion of the %one %lood su ly& The hematoma$ #hich organi1es into a fi%rin clot$ releases cyto/ines that attract inflammatory cells from the circulation$ initiating the inflammatory stage of fracture healing$ #hich lasts from a fe# days to 9 #ee/s& The cyto/ines released from latelets in the clot$ such as latelet3deri(ed gro#th factor +PDG7, and TG73%$ as #ell as other factors released from inflammatory cells$ are ro%a%ly in(ol(ed in stimulating undifferentiated mesenchymal cells +#hich a ear to %e deri(ed in large art from the eriosteum, to undergo differentiation into fi%ro%lasts$ osteo%lasts$ and chondrocytes& This is accom anied %y roliferation of fi%ro(ascular tissue +granulation tissue, in the area of the fracture ga & These e(ents signify the onset of the early re arati(e stage +or soft callus stage,& The osteo%lasts form ad)acent to the eriosteum$ #hile in the more hy o"ic area of the fracture ga $ differentiation into hyaline cartilage is fa(ored +7ig& 563C6,& This fracture callus %egins to sta%ili1e the fracture ends and limit motion$ leading to rogressi(e (ascular ingro#th& The cartilaginous callus$ #hich tolerates hy o"ia #ell and in fact undergoes cellular hy ertro hy and matri" minerali1ation under hy o"ic conditions +see Endochondral Ossification$ a%o(e,$ %egins to go through the endochondral se0uence of minerali1ation& This late re arati(e stage +or hard callus stage, results in increasing sta%ility of the fracture$ and increasing mem%ranous or osteo%lastic ossification from the eri hery of the callus gradually re laces the endochondral rocess& The #o(en %one is later remodeled into true lamellar %one$ a stage that can last from months to years& During this hase the lim% is mechanically functional and remodels along lines of stress to#ard its original sha e$ #ith reconstitution of the medullary ca(ity& Ta%le 56369 summari1es the e(ents in fracture healing %y callus formation& Teleologically it a ears that the function of the endochondral calcification is to sta%ili1e the %one$ allo#ing su%se0uent (ascular gro#th across the fracture ga to su ort the more aero%ically de endent osteo%lastic %one formation& If a fracture is rigidly internally fi"ed #ith a metal late under com ression$ no callus forms$ and the fracture heals %y rimary remodeling through the acti(ity of osteoclasts and osteo%lasts #ithout endochondral ossification& 7actors Influencing 2ealing The im ortance of the eriosteum in fracture healing is su orted %y the o%ser(ation that fracture healing is accelerated in children$ #ho ha(e much thic/er and more cellular eriosteal %ony co(erings& In adults the eriosteum is noticea%ly thinner$ and healing is slo#er& Rates of fracture healing in young and old adults are similar$ %arring that resence of meta%olic %one disease or nutritional deficiencies& 4any in(estigations in animals and human %eings ha(e attem ted to e(aluate su%stances

that stimulate fracture healing$ including gro#th hormone$ PT2$ (arious (itamins$ and rostaglandins& At this oint the e(idence is contro(ersial at %est& There is no strong e(idence that normal fracture healing is accelerated #ith these ty es of treatment$ although some %eneficial effect on delayed union or nonunion remains a ossi%ility& 2ead3in)ured atients$ #ho often form a%normal %one and cartilage in muscle or other ina ro riate tissues +heteroto ic ossification,$ ha(e accelerated healing of fractures* a factor in the serum of these atients is an ana%olic stimulator of osteo%lasts in culture$ though this factor has not yet %een identified& Articular Cartilage 2ealing ?nli/e %one$ articular cartilage has a (ery limited a%ility to undergo re air after osttraumatic damage& Articular cartilage has a (ery orderly structure$ #ith an organic matri" com osed of 5G ercent roteoglycans$ 5G ercent ty e II collagen$ and 9G ercent glyco roteins$ gro#th factors$ and minor collagens such as ty e IK and ty e KI +Ta%le 5636-,& The collagen fi%ers in the most su erficial layers of cartilage are oriented arallel to the )oint surface and gradually change direction to a radial orientation in the dee er layers$ #ith a some#hat random orientation in the transitional 1one +7ig& 563C9 A,& The roteoglycan is a large macromolecular aggregate of su%units consisting of a rotein core +aggrecan, #ith co(alently %ound %ranching sulfated car%ohydrate grou s called glycosaminoglycans +7ig& 563C9 :,& The redominant glycosaminoglycans are chondroitin and /eratan sulfate& These monomer su%units are nonco(alently %ound to a filament of hyaluronic acid %y a small glyco rotein called a lin/ rotein& Proteoglycans are res onsi%le for the com ressi%ility$ hydration$ and mechanical integrity of cartilage& The earliest res onses to an in)ury such as a laceration of the articular surface are loss of matri" roteoglycans and an attem t$ usually unsuccessful$ %y chondrocytes ad)acent to the in)ury to resynthesi1e the matri"& Progressi(e degradation of matri" macromolecules ensues$ and the cartilage may fi%rillate or s lit along the radially oriented dee er collagen fi%ers& If a defect is near the syno(ial attachment of the )oint$ cells from this area may migrate into the defect and form fi%rocartilage re air tissue& ?sually$ ho#e(er$ the defect remains and can trigger further areas of rogressi(e degeneration& If the cartilage defect enetrates the su%chondral %ony late$ cells from the %one marro# can migrate into the defect and #ill also allo# fi%rocartilaginous re air& 7i%rocartilage$ unli/e hyaline cartilage$ is mostly com osed of ty e I rather than ty e II collagen and has inferior #ear characteristics$ gradually degenerating o(er a eriod of years& 7i%rocartilaginous re air can %e augmented and some ty e II collagen formation stimulated %y continuous assi(e motion of the )oint& These ro erties form the %asis for current a roaches to treatment of chondral defects as #ell as the rationale for a%rasion arthro lasty$ or a%rading damaged areas of cartilage do#n to a %leeding %ony surface follo#ed %y assi(e motion and rotection from #eight %earing& E" erimental techni0ues ha(e e(ol(ed to enhance hyaline cartilage re air in animal models as #ell as in human %eings& An a roach de(elo ed %y Ca lan and co#or/ers in(ol(es isolation of undifferentiated mesenchymal stem cells from %one marro# as irates$ #hich are then e" anded in tissue culture and im lanted in a collagen gel into an articular defect$ and results in differentiation into hyaline cartilage& A second

a roach$ de(elo ed %y OADriscoll and Salter$ uses a eriosteal graft attached to the chondral defect %y sutures #ith the cam%ium layer of the eriosteum facing the syno(ial fluid& This leads to resurfacing of the defect #ith hyaline cartilage$ #hich can %e further enhanced %y incu%ation of the eriosteum %riefly #ith TG73% %efore reim lantation& Peterson and co#or/ers ha(e used autologous chondrocyte trans lantation to resurface defects in human /nee )oints& Cartilage is remo(ed arthrosco ically from non#eight3%earing regions of the articular surface$ and chondrocytes are isolated %y en1ymatic digestion and e" anded in tissue culture& The chondrocytes are then in)ected in a collagen gel %eneath a eriosteal fla sutured to the articular surface o(er the defect& Early clinical results are encouraging$ %ut these rocedures are contro(ersial and the long3term outcome uncertain& Ligament 2ealing :ony in)uries to the e"tremities are fre0uently accom anied %y ligamentous in)uries& ligament in)uries also can occur inde endently as a rimary in)ury to a )oint* in general these in)uries are referred to as s rains& Ligaments heal %y rogressi(e scar formation and contracture$ and recent studies indicate that re air is im ro(ed %y early motion in the a%sence of gross insta%ility& Ligament in)uries are graded as ty e I +stretch %ut no disru tion of fi%ers,$ ty e II +tear of some of ligament fi%ers,$ and ty e III +com lete mechanical discontinuity of the ligament,& Ty e I and ty e II ligament in)uries generally are treated %y immo%ili1ation$ or rotected motion& 4otion and mechanical strain enhance ligament healing& Treatment of ty e III ligament in)uries de ends on many factors and can range from noninter(ention +as for a ty e III acromiocla(icular se aration, to immediate surgical re air or reconstruction +as for a torn anterior cruciate ligament in a com etiti(e athlete,& Delayed ?nion and Nonunion Delayed union is a some#hat ar%itrarily defined term a lied to fractures that ta/e longer than a(erage to heal and must %e considered in conte"t of the ty e of fracture and age of the atient& Nonunion refers to a condition in #hich a fracture fails to sho# rogression to#ard union and in #hich healing is not e" ected e(en #ith rolonged immo%ili1ation& Radiogra hic e"amination can sho# sclerotic %one ends$ a ersistent fracture ga $ and rounding off of the fracture ends& Gross motion can %e demonstra%le clinically or under fluorosco ic stress testing& The fracture ga usually contains nonminerali1ed fi%rocartilage$ although at times a true syno(ial seudarthrosis$ or false )oint$ is resent& 7actors redis osing to nonunion include e"cessi(e motion or inade0uate immo%ili1ation of the fracture$ inter osed soft tissues$ e"tensi(e soft3tissue damage$ eriosteal stri ing$ de(asculari1ation of the %one$ and infection& Certain %ones ha(e more of a redis osition to nonunion$ ro%a%ly attri%uta%le to su%o timal orientation of the local %one (ascular su ly +such as the ti%ia$ femoral nec/$ or car al sca hoid,& Nonunion usually re0uires surgical inter(ention such as %one grafting #ith autogenous or (asculari1ed fi%ular %one& A gro#ing %ody of e(idence su orts the use of electromagnetic stimulation$ #hich can induce a certain ro ortion of nonunions to heal #ithout surgery& Also$ one re ort suggests that administration of le(odo a$ #hich is /no#n to cause a sustained increased le(el of gro#th hormone in the serum$ can %e %eneficial in stimulation of healing of ununited fractures& During a .3month treatment eriod$ o(er HG ercent of a grou of multi ly o erated atients #ith nonunion and failed %one grafts healed #ith this regimen&

Pathologic 7ractures 7ractures that occur through %one a%normally #ea/ened %y a ree"isting condition are termed athologic& Often these fractures result from significantly less than the usual degree of force needed to cause a fracture& The underlying rocess may %e either systemic +as in osteo orosis, or local +as in a %one tumor or cyst,& An e"am le of a athologic fracture secondary to metastatic carcinoma is sho#n in 7ig& 563C-& Pathologic fractures often re0uire surgical internal fi"ation to achie(e healing$ and in atients #ith carcinomas that commonly metastasi1e to %one +e&g&$ %reast$ rostate$ lung$ /idney$ and thyroid tumors,$ ro hylactic fi"ation of large lesions in #eight3 %earing %ones decreases mor%idity and im ro(es 0uality of life& Pain on #eight %earing is a relia%le clinical sign of an im ending fracture& Stress 7ractures Stress fractures are the e(entual result of re eated stress to a %one$ ultimately causing fatigue failure& The metatarsals$ ti%ia$ fi%ula$ and calcaneus are common sites& Initially radiogra hs may %e negati(e$ %ut later eriosteal reaction #ill %ecome e(ident& Nuclear %one scans or 4RI can readily demonstrate the lesion in case the radiogra hs are negati(e +7ig& 563C5,& Treatment usually is conser(ati(e$ #ith immo%ili1ation and discontinuation of the causati(e acti(ity& Gro#th Plate In)uries Longitudinal %one gro#th occurs as re(iously descri%ed in the gro#th lates$ #hich lie %et#een the e i hyses and meta hyses of the long %ones& In children$ in)uries in(ol(ing the gro#th late are relati(ely common$ and the fractures usually in(ol(e the 1one of ro(isional calcification$ the mechanically #ea/est region& Since the germinal cells in the u er gro#th late usually are not damaged$ fractures that do not cross the late tend to heal #ithout gro#th distur%ances& The most commonly used classification of gro#th late in)uries is the Salter32arris classification$ de icted in 7ig& 563CC& Ty e I is a se aration of the gro#th late and e i hysis from the meta hysis& Ty e II is similar$ #ith a meta hyseal fragment remaining #ith the e i hysis& Since the gro#th late is intact in these in)uries$ treatment is #ith closed reduction$ and gro#th distur%ance or remature closure of the gro#th late is rare& 7ortunately$ the ma)ority of e i hyseal fractures are of these t#o ty es& :ecause of the ro"imity of the fracture to the gro#th late$ a great degree of remodeling ca acity e"ists$ and significant angulations and dis lacements often heal and remodel une(entfully& Ty e III in)uries are intraarticular$ tra(erse the e i hysis and gro#th late$ and e"it through the 1one of ro(isional calcification& Ty e I> in)uries are similar$ %ut e"it through the meta hysis& Since %oth these ty es of fractures cross and disru t the gro#th late$ nothing less than anatomic reduction is acce ta%le$ or gro#th distur%ance #ill result& These fractures are usually treated %y accurate o en reduction and internal fi"ation& Ty e > in)uries are difficult to recogni1e$ and result from an a"ial load or crush in)ury to the gro#th late that later results in remature fusion& Rang has descri%ed an additional hyseal in)ury /no#n as ty e >I$ consisting of damage to the erichondral ring on one side of the gro#th late& This can lead to a %ony %ar on one side of the hysis acting as a tether and leading to a rogressi(e angular deformity& Careful follo#3u and education of the arents is necessary #ith these in)uries to ensure the %est clinical outcome$ allo# lanning of any correcti(e rocedures should gro#th distur%ance occur$ and minimi1e the ossi%ility of misunderstanding&

7ractures in Children ChildrenAs fractures resent different ro%lems from similar in)uries in adults& Nonunion is e"tremely rare$ and fracture healing is more ra id& The challenge is in recogni1ing and understanding #hat degree of dis lacement$ angulation$ and shortening is acce ta%le in relation to remaining gro#th otential& 7racture healing in a young child stimulates the %lood flo# to the e"tremity$ and this in turn stimulates increased acti(ity of the gro#th lates$ causing the lim% to gro# at a faster rate than the unin)ured e"tremity& 7urthermore$ most fractures in children are treated conser(ati(ely$ #hereas a greater degree of surgical inter(ention is used in fractures in adults& Closed (ersus O en Reduction The o timal method for handling a s ecific fracture should allo# ra id union$ reesta%lish length and alignment of the e"tremity$ restore com lete motion in ad)acent )oints$ and return the atient to functional acti(ity #ith a minimum of mor%idity& 7urthermore$ cost concerns are an increasing ressure on the health care system$ and rolonged hos itali1ation must %e at least a distant consideration$ o%(iously #ith the #elfare of the atient ta/ing recedence& 7ortunately technical ad(ances in fracture fi"ation allo# treatment of a #ider range of fractures surgically$ and rolonged traction in the hos ital is much less common than re(iously& The closed reduction of fractures has the ad(antages of minimal ris/ of infection and no further disru tion of %one %lood su ly$ and the disad(antages of less recise reduction and rolonged immo%ili1ation& Treatment must %e indi(iduali1ed to the in)ury and atient& A lication of Plaster Casts Circumferential rigid dressings of laster or fi%erglass are an im ortant tool in the treatment of fractures& Plaster is com osed of anhydrous calcium sulfate$ #hich solidifies during an e"othermic hydration reaction #ith #ater& Plaster sets u in a fe# minutes after addition of #ater %ut does not dry com letely for -. to 5H h& Com lications of Cast Treatment The ma"imum tem erature achie(ed during setting de ends on the #ater tem erature$ and use of hot #ater can result in %urns$ articularly if the cast is thic/ or laced on a surface that reflects heat$ such as ru%%er or lastic$ during setting& 8ater used in casting should %e lu/e#arm& After casting for acute in)ury or surgery$ the e"tremity should %e ele(ated$ as s#elling #ithin a rigid container can lead to com artment syndrome$ as re(iously descri%ed& This is of articular concern in atients #ho are unconscious or ha(e sensory im airment in the lim%& ?nrelie(ed ain$ allor$ loss of sensation$ de(elo ment of aresthesias$ oor ca illary refill$ or diminishing motor function are all indications to %i(al(e the cast& This should %e accom anied %y cutting the underlying soft adding layer or dressing gau1e$ #hich can also %ecome constricti(e in the face of s#elling& If the sym toms are not rom tly relie(ed$ the cast must %e remo(ed and the com artment ressures measured as re(iously descri%ed& Pressure sores$ or decu%itus ulcers$ can occur ra idly in a cast$ and tend to occur o(er %ony rominences such as the heel$ olecranon$ atella$ and ischium& Pro er molding of the cast$ as #ell as rom t attention to any com laints of ressure or %urning ain in an area %eneath the cast$ are essential to their re(ention& The cast also can %e

#indo#ed and added to relie(e the ressure and re(ent s/in %rea/do#n* the #indo# is then re laced to re(ent #indo# edema& Ty es of Cast 8hen a cast is a lied for an acute fracture$ it should include the )oints a%o(e and %elo# the fracture& A long leg cast e"tends from the u er thigh to the metatarsal %ases$ and generally the an/le is laced in neutral dorsifle"ion and the /nee in a%out -G degrees of fle"ion to more easily allo# the atient to clear the floor #ith the immo%ili1ed e"tremity #hen on crutches& Pro er molding a%o(e the femoral condyles is im ortant& A cylinder cast e"tends from the u er thigh to the an/le a%o(e the malleoli* it must %e #ell added a%o(e the malleoli and molded a%o(e the femoral condyles to re(ent it from sliding do#n#ard and causing ressure areas around the an/le& A short leg cast e"tends from the ti%ial tu%ercle to the metatarsals* it should %e #ell molded around the malleoli$ a%o(e the calcaneal tu%erosity$ in the arch of the foot$ and along the shaft of the ti%ia& A atellar tendon %earing cast is similar to a short leg cast e"ce t that it is e"tended o(er the /nee anteriorly to the mid oint of the atella and is molded o(er the anterior femoral condyles and atellar tendon to ro(ide artial #eight relief of the ti%ia #hen #eight %earing& 4ost lo#er3 e"tremity casts are used #ith a cast shoe or %oot #hen #eight %earing is allo#ed& A dou%le hi s ica cast$ used for immo%ili1ation of the hi s$ is analogous to a laster air of ants$ usually a lied #ith the hi s in some fle"ion and a%duction$ and the /nees in slight fle"ion& A single hi s ica includes only one leg$ and a one and one3 half hi s ica includes one leg to the toes and the other to )ust a%o(e the /nee& :ody casts are a lied for immo%ili1ation of the s ine and e"tend from the groin to the sternum& 8ith im ro(ed methods of surgical s inal fi"ation$ molded lastic %ody )ac/ets often can %e used instead of the more cum%ersome %ody cast& A short arm cast e"tends from %elo# the el%o# to the ro"imal almar crease$ allo#ing free fle"ion and e"tension of the digits and thum%& If the thum% is included$ the cast is referred to as a thum% s ica cast& A long arm cast e"tends from the u er arm to the ro"imal almar crease$ usually #ith the el%o# fle"ed FG degrees& A shoulder s ica cast is a %ody )ac/et that e"tends to include the shoulder and el%o#$ usually #ith the shoulder a%ducted and the el%o# fle"ed& Orthoses Orthoses and fracture %races are #idely used for nonacute treatment of fractures$ allo#ing greater functional use as the fractures heal& These are made of light#eight oly ro ylene$ Ortho last$ or fi%erglass and can %e custom molded or used in standard si1es& 2umeral$ ti%ial$ and forearm fracture %races are readily a(aila%le and can %e tightened #ith >elcro stra s as s#elling su%sides and muscles atro hy& A /nee immo%ili1er #ith metal sta(es often can %e used in lace of a cylinder cast$ and ad)usta%le3range3 of3motion /nee %races that e"tend from the thigh to the an/le can %e hel ful in reha%ilitating atients after /nee$ distal femur$ or ro"imal ti%ial surgery& E"ternal 7i"ation E"ternal fi"ation has %een used increasingly in trauma treatment in recent years& Threaded ins are inserted into the %one a%o(e and %elo# the fracture site and secured to a rigid$ ad)usta%le frame to immo%ili1e the fracture +7ig& 563C.,& E"ternal fi"ation is articularly hel ful in se(erely comminuted fractures or those #ith se(ere soft3

tissue damage or loss$ since access to #ounds is ermitted& Pin tract infections are a common com lication +incidence 6G ercent, %ut usually res ond to local #ound care and anti%iotics& Occasionally$ ersistent infection causes loosening of ins and necessitates remo(al or re lacement of one or more ins& An additional ad(antage of e"ternal fi"ation is in allo#ing early motion of the )oints a%o(e and %elo# the fracture$ decreasing )oint stiffness& E"ternal fi"ation also can %e used to hel reduce and maintain reduction of comminuted intraarticular fractures %y ligamentota"is + ro(iding traction across the )oint$ #hich reduces fracture fragments due to remaining ligamentous and ca sular attachments,& This is useful in se(erely comminuted distal radius and ti%ial lafond fractures& Another im ortant use of e"ternal fi"ation is in the treatment of acute multi le3trauma atients #ith se(ere el(ic fractures and dislocations& 2emorrhage into the el(is and retro eritoneum can %ecome a life3 threatening ro%lem& A lication of an anterior e"ternal fi"ator to ro(isionally sta%ili1e the el(is and decrease the intra el(ic (olume effecti(ely controls intra el(ic hemorrhage& This can %e done under local anesthesia in the emergency de artment$ and in(ol(es lacing t#o or three ins in each anterior iliac crest and then affi"ing them to a rigid anterior frame +7ig& 563CD,& One further a lication of e"ternal fi"ation is in lim% reconstruction using the Ili1aro( distraction osteogenesis techni0ue$ as descri%ed earlier for the correction of lim% length deficiency& Preliminary results suggest that e"ternal fi"ation may %e useful in re airing %ony defects caused %y traumatic segmental %one loss& A corticotomy is made a%o(e the defect$ and the segment is gradually trans orted distally until it a%uts the distal fragment& The resulting ro"imal defect ossifies %y the rocess of distraction osteogenesis +7ig& 563CH,& Traction Traction is used in ortho aedics to o(ercome muscle s asm and a ly distraction to fracture fragments to reduce the fracture& Additional uses include immo%ili1ation of long %one fractures until early healing occurs$ immo%ili1ation and distraction for ainful )oint conditions$ and correction of )oint deformities or contractures& S/in Traction S/in traction is a lied %y means of ta es attached to the s/in& It is used only #hen lo# le(els of force are needed$ since 6G l%s is the ma"imum amount of force that the s/in #ill tolerate #ith this method& S/in traction a lied to the foot +:uc/As traction, often is used to immo%ili1e hi fractures tem orarily %efore surgery& 8hile s/in ta es can %e used$ a foam %oot #ith >elcro stra s is more con(enient and more #idely used& RussellAs traction$ used for the treatment of femoral fractures in children$ can %e used as sho#n in 7ig& 563CF& Alternati(ely$ se arate #eights can %e a lied to the femoral sling and the longitudinal foot$ a techni0ue /no#n as s lit RussellAs traction& :ryantAs traction can %e used in infants and small children #ith femoral fractures& As originally descri%ed$ the techni0ue consists of s/in traction on %oth lo#er legs (ertically +hi s fle"ed to FG degrees #ith /nees e"tended,& 2o#e(er$ instances of serious (ascular com romise of the e"tremities ha(e %een re orted #ith this method* ne(ertheless$ safety can %e ensured %y limiting its use to children not older than 9R years of age and a lying the traction at a 5C3degree inclination rather than directly (ertically&

S/eletal Traction This in(ol(es the lacement of a Steinmann in or Eirschner #ire ercutaneously through the distal femur or ro"imal ti%ia in a trans(erse direction& A traction %o# is attached to the in and a #eight a lied& The atient is then laced in %alanced sus ension as sho#n in 7ig& 563.G& Other forms of s/eletal traction include halo traction #ith ins affi"ed to the s/ull for cer(ical s ine in)uries and olecranon traction o(erhead for humeral fractures& Electrical Stimulation The initial conce t that electromagnetic fields or electrical otentials might influence %one formation stemmed from the o%ser(ed ie1oelectric ro erties of %one$ #hich de(elo s surface charges #hen mechanically stressed %ecause of its anisotro ic nature& Areas of com ression de(elo electronegati(e otentials$ and areas of tension de(elo electro ositi(e otentials& Increasing clinical and %asic research data su ort the effecti(eness of electromagnetic %one stimulation in the healing of nonunions$ although the mechanism of action is un/no#n& The most commonly used form of electrical stimulation in(ol(es use of e"ternal coils that are attached to a cast and centered o(er the nonunion site& After - to . months$ union rates of DG to HG ercent ha(e %een re orted$ %ut the method remains some#hat contro(ersial$ #ith only a fe# controlled clinical studies& The %iologic e(ents a ear to in(ol(e stimulation of fi%rocartilage at the nonunion site to minerali1e& Significant effects of electromagnetic fields on %one formation in (arious models ha(e %een demonstrated %y :assett$ :righton$ Ru%in$ and others& This form of treatment is contraindicated in cases in #hich the fracture ga is more than 6 cm or half the %one diameter$ or in the resence of a syno(ial seudarthrosis& Syno(ial seudarthrosis can %e ruled out %y %one scan or as iration of the site$ #hich #ill contain syno(ial3li/e fluid& ? er3E"tremity In)uries Shoulder 7ull a%duction of the shoulder re0uires motion in the glenohumeral )oint$ sca ulothoracic articulation$ acromiocla(icular )oint$ and sternocla(icular )oint& Glenohumeral and sca ulothoracic motion occur in a ro"imately a 9L6 ratio& 7or e(ery 6G degrees of for#ard ele(ation of the arm$ 5 degrees of ele(ation of the cla(icle occurs& 4otion at the acromiocla(icular )oint of 9G degrees occurs during the first -G degrees of a%duction& :ecause of these com le" interacti(e motions$ any disru tion of one of these articulations can limit shoulder motion& Sternocla(icular <oint In)uries The sternocla(icular )oint can %e dislocated anteriorly or osteriorly$ although anterior dislocations are much more common& These in)uries most often occur in motor (ehicle accidents or contact s orts #hen force is a lied to the shoulder along the a"is of the cla(icle& 8hile the sternocla(icular )oint can %e difficult to (isuali1e radiogra hically$ a 5G3 degree ce halad3angled antero osterior radiogra h$ tomogram$ or CT scan can aid in e(aluation& Differentiation from a Salter ty e I e i hyseal se aration is necessary in young atients$ since the medial ossification center often does not a ear until age eighteen and fuses %y age t#enty3 fi(e& Posterior dislocations are dangerous %ecause there may %e associated serious damage to retrosternal ulmonary or (ascular structures* therefore a (ery careful e"amination of the atient should %e erformed& Closed reduction is accom lished %y shoulder retraction #ith longitudinal traction* for osterior dislocations this must %e done under

general anesthesia& Su%se0uently the atient is immo%ili1ed in a figure3of3eight harness or laster to maintain shoulder retraction& Chronic unreduced dislocations that are ainful may re0uire e"cision of the ro"imal cla(icle& 7ractures of the Cla(icle Cla(icle fractures are common in %oth children and adults and usually occur at the )unction of the middle and distal thirds& The fracture is caused %y either direct do#n#ard force on the shoulder or indirect force such as occurs in a fall on the e"tended arm& Clinically there is s#elling and tenderness at the fracture site and ain #ith mo(ement of the e"tremity& Treatment Although the cla(icle is difficult to immo%ili1e$ nonunion is unusual +incidence G&C ercent, #ith conser(ati(e treatment$ resuma%ly %ecause of the e"cellent %lood su ly in this area +7ig& 563.6,& The tra e1ius and sternocleidomastoid muscles tend to ull the ro"imal fragment su eriorly& 7ractures are treated similarly in children and adults$ #ith use of a figure3of3 eight de(ice to retract and ele(ate the shoulders +7ig& 563.9,& A study com aring figure3of3eight immo%ili1ation #ith a sim le sling sho#ed no difference in results& Immo%ili1ation is for 5 to . #ee/s$ de ending on the radiogra hic e(idence of rogression to#ard union& A cosmetic deformity #ith rominence of the fracture site is the rule$ %ut internal fi"ation trades the %ony rominence for a scar and increases the ris/ of nonunion& In the rare case in #hich nonunion does occur$ internal fi"ation #ith lating and %one grafting usually is successful& Distal Cla(icle 7ractures 7ractures of the distal cla(icle are less common +incidence 6C ercent, and ha(e %een classified into three ty es& Ty e I fractures$ #hich are lateral to the coracocla(icular ligaments +conoid and tra e1oid,$ are sta%le and treated #ith a sling& Ty e II +interligamentous, fractures e"hi%it su erior dis lacement of the ro"imal fragment and detachment of the ligaments& These are unsta%le$ may rogress to nonunion$ and are %est treated surgically %y o en reduction and sta%ili1ation #ith one or more transacromial ins& Ty e III fractures in(ol(e the articular surface& 8hile sta%le$ they may cause later arthritic sym toms that #ill re0uire distal cla(icular e"cision& Acromiocla(icular <oint In)uries In)uries to the acromiocla(icular )oint result from do#n#ard force on the shoulder and are fre0uent in contact s orts& These in)uries are rimarily ligamentous s rains of three ty es& The atient resents #ith ain$ tenderness$ and s#elling in the area of the )oint& Shoulder mo(ement is ainful$ and there can %e al a%le or (isi%le rominence of the distal cla(icle if there is disru tion of the coracocla(icular ligaments$ #hich are the ma)or sta%ili1ers of the )oint& Ty e I s rains in(ol(e artial tear of the ligamentous ca sule$ #ith no in)ury to the coracocla(icular ligaments& Ty e II s rains in(ol(e com lete tearing of the ligamentous ca sule and a grade II s rain of the coracocla(icular ligaments$ and hence they can e"hi%it slight su erior su%lu"ation of the distal cla(icle radiogra hically& Ty e III s rains in(ol(e com lete tearing of %oth the ca sular and coracocla(icular ligaments$ #ith su erior su%lu"ation of the distal cla(icle& Radiogra hic diagnosis is aided %y com arison (ie#s of the )oint %ilaterally #ith and #ithout the atient holding a 6G3l% #eight$ #hich #ill accentuate the

su%lu"ation& The rare Ty e I>$ >$ and >I s rains in(ol(e se(ere osterior or inferior dis lacements and generally re0uire surgical treatment& Treatment Ty e I in)uries are treated #ith a sling until comforta%le and then rogressi(e e"ercises& Ty e II in)uries can %e treated similarly& Ty e III in)uries cannot %e reduced nono erati(ely and lea(e a cosmetic deformity if untreated& In less acti(e indi(iduals$ conser(ati(e sym tomatic treatment generally gi(es good functional results& In atients in(ol(ed in high3demand acti(ities or #ith ersistent sym toms or ma)or concerns a%out the deformity$ surgical re air or reconstruction usually is indicated& >arious a roaches include sta%ili1ation of the cla(icle to the coracoid rocess #ith a scre# +:os#orth, and reconstruction of the coracocla(icular ligaments using the coracoacromial ligament +8ea(er3Dunn rocedure,& In atients #ith ersistent ain$ e"cision of the distal cla(icle usually ro(ides satisfactory results& 7ractures of the Sca ula Sca ular fractures are most commonly seen as a result of (iolent trauma such as motor (ehicle accidents& Conse0uently associated in)uries such as %rachial le"us in)ury and cardio ulmonary trauma are a concern$ and these in)uries ta/e recedence& Sca ular %ody fractures rarely cause sym toms and usually heal une(entfully& E(en #ith in(ol(ement of the glenoid$ gi(en the non3#eight3%earing status of this )oint results of conser(ati(e treatment are usually satisfactory$ and therefore sym tomatic immo%ili1ation of the shoulder generally is refera%le to more aggressi(e inter(ention& In indi(iduals #ith more than 6G mm of dis lacement of a glenoid rim fracture com rising more than one3fourth of the )oint surface$ or #ith se(ere se aration$ or #ith articular ste 3off of more than Cmm$ o en reduction and internal fi"ation may %e considered& Acute Anterior Shoulder Dislocations Dislocation of the humeral head can %e anterior$ osterior$ or inferior to the glenoid& Anteroinferior dislocations can %e su%coracoid or su%glenoid& Anterior or anteroinferior dislocations$ the most common in)uries$ are caused %y a com%ination of e"ternal rotation and a%duction$ #hich tears the anterior ca sular structures& Anterior dislocation of the humeral head can tear the anterior glenoid la%rum$ and a com ression fracture of the osterolateral humeral head +2ill3Sachs lesion, can result from im ingement on the glenoid& The atient usually holds the arm in slight a%duction and is una%le to lo#er it& A flattening of the deltoid rominence or indentation %eneath the ti of the acromion is fre0uently a arent& Sensation o(er the lateral deltoid must al#ays %e assessed carefully %efore reduction$ as in)ury to the a"illary ner(e can occur& :ecause of s asm$ motor function of the deltoid cannot %e e(aluated until after reduction& Radiogra hic 7indings These include inferior and medial dis lacement of the humeral head on the antero osterior (ie# +7ig& 563.-,& An a"illary (ie# may %e difficult to o%tain$ %ut a transsca ular lateral (ie# +M (ie#, #ill demonstrate the humeral head lying anterior to the glenoid& Treatment

The dislocation must %e reduced as soon as ossi%le$ and unrecogni1ed dislocations may still %e reduci%le #ithin the first 9 #ee/s& 4ore chronic dislocations and those that cannot %e reduced %y closed means often re0uire o en reduction& 8hile a num%er of different reduction maneu(ers are acce ta%le$ the %asic rinci le in(ol(es longitudinal traction and gentle internal rotation& This can %e achie(ed either %y ha(ing the atient lie su ine #hile an assistant a lies countertraction #ith a sheet around the chest$ or %y ha(ing the atient lie rone #ith the arm o(er the edge of the ta%le #ith a traction #eight attached to the forearm& Ade0uate sedation and muscle rela"ation are essential to counteract muscle s asm& After reduction$ the atient is laced in a sling and s#athe or shoulder immo%ili1er #ith the el%o# at FG degrees and the forearm across the a%domen& Postreduction antero osterior and transsca ular lateral radiogra hs are essential& Range3 of3motion e"ercises are started after - to 5 #ee/s in younger indi(iduals$ and sooner in the elderly %ecause of the redis osition to loss of motion& Recurrent Anterior Dislocations A small ercentage of atients are su%)ect to recurrent dislocations$ sometimes #ith minor trauma or e(en #ith acti(e a%duction and e"ternal rotation of the shoulder& Occasionally atients com lain of recurrent sensation of su%lu"ation #ithout fran/ dislocation& 8hen s ontaneous reduction does not occur$ the reduction maneu(er is as descri%ed a%o(e& After a %rief eriod of immo%ili1ation until comforta%le$ a ro riate reha%ilitation focusing on strengthening the internal rotator muscles is %egun& Continued e isodes lead to articular damage and are an indication for reconstructi(e surgery& 4RI or arthrosco y can %e hel ful in surgical lanning in that tears of the anterior la%rum$ #hich lead to ersistent insta%ility$ can %e identified& Surgical re air focuses on re air of la%ral tears +:an/hart rocedure,$ anterior ca sular and su%sca ularis re air or tightening +Putti3Platt rocedure,$ or a com%ination of these techni0ues& Ca sulorrha hy in con)unction #ith :an/hart re air has %een ad(ocated instead of su%sca ularis shortening rocedures %ecause of restoration of more normal shoulder %iomechanics& Arthrosco ic re air of la%ral tears +:an/hart lesions, associated #ith ain or insta%ility is increasingly common& Recurrence rates for dislocation are some#hat higher than #ith o en re air$ %ut the surgical rocedure is minimally in(asi(e& Shoulder arthrosco y also is useful in diagnosis and in decom ression of the rotator cuff %y acromio lasty& A su erior la%ral anterior and osterior +SLAP, lesion has %een descri%ed that ty ically results from a fall on an outstretched arm and can cause ain and clic/ing in the shoulder #ith o(erhead acti(ities& De ending on the si1e of the la%ral tear$ arthrosco ic de%ridement or reattachment ha(e %een successful forms of treatment& Chronic Dislocations Patients #ith ainful chronic dislocations may %enefit from arthrodesis of the shoulder in a functional osition& Occasionally these in)uries are seen in elderly indi(iduals #ith sur risingly fe# sym toms and may not #arrant surgical inter(ention& Posterior Shoulder Dislocations

Posterior dislocations are less common and are seen after sei1ures or motor (ehicle accidents& Physical findings include an ina%ility to e"ternally rotate or a%duct the arm$ #hich is held tightly at the side and in internal rotation& The osterior shoulder can e"hi%it rominence com ared to the o osite side$ and the coracoid rocess often is more o%(ious on the affected side& Radiogra hic 7indings On the antero osterior (ie# findings may %e su%tle$ #ith loss of the distinct !half moon' o(erla shado# seen on in a normal shoulder +7ig& 563 .5,& A"illary or transsca ular lateral (ie#s #ill confirm the osterior dis lacement& Associated lesser tu%ercle fractures are common$ %ecause of a(ulsion in)ury of the su%sca ularis muscle& Treatment Reduction is accom lished %y the same methods descri%ed for anterior dislocation$ e"ce t that gentle e"ternal rotation is used along #ith anterior ressure on the osterior humeral head& The shoulder can %e immo%ili1ed in a shoulder s ica cast or %race in -G degrees of a%duction and some e"ternal rotation for - to 5 #ee/s& Recurrent osterior dislocations can re0uire osterior ca sular reefing or osteotomy of the glenoid #ith %one %loc/ lacement& 7racture3Dislocations of the Shoulder Dislocation of the shoulder can %e associated #ith fracture of the ro"imal humerus& Reduction is #ith maneu(ers similar to those for sim le dislocations$ %ut usually re0uires general anesthesia& If reduction cannot %e o%tained %y closed means$ o en reduction and internal fi"ation is indicated& 2umerus 7ractures of the Pro"imal 2umerus 7ractures of the surgical nec/ + ro"imal meta hysis, of the humerus are common in)uries in adults$ #hile in children the anatomic nec/ +)unction of the e i hysis and meta hysis, is in(ol(ed$ usually in a Salter32arris ty e II configuration +7ig& 563.C,& Treatment is #ith closed reduction using longitudinal manual traction$ follo#ed %y a sling or hanging cast a lication& A significant degree of angulation can %e acce ted %ecause of the large range of motion of the shoulder )oint& In instances of unacce ta%le angulation or dis lacement$ ercutaneous inning or o en reduction is indicated& In adults fractures of the ro"imal humerus may %e comminuted$ in #hich case they are classified according to the num%er of dis laced segments +Neer classification,& The segments consist of the head$ shaft$ and greater and lesser tu%ercles$ and dis lacement is defined as more than 5C degrees of angulation or 6 cm of dis lacement& Thus fractures are three3 or four3 art if one or %oth tu%ercles are fractured and dis laced& Dis laced greater tu%ercle fractures re0uire reduction to maintain function and are re aired using 2a#/insAs tension %and #iring techni0ue& In four3 art fractures there is a high incidence of a(ascular necrosis of the humeral head$ and generally re lacement of the humeral head #ith a Neer3ty e endo rosthesis is ad(ocated$ #ith reattachment of the tu%ercles to the rosthesis %y tension %and #iring or hea(y nona%sor%a%le sutures +7ig& 563..,&

In all ro"imal humerus fractures$ early motion is essential to re(ent stiffness& Physical thera y is an im ortant art of the treatment$ and gentle assi(e endulum e"ercises usually should %e started #ithin 6 or 9 #ee/s& 7ractures of the 2umeral Shaft 2umeral shaft fractures may %e trans(erse$ comminuted$ or s iral$ de ending on the mechanism of in)ury +direct (ersus torsional force,& S#elling$ ain$ cre itus$ and insta%ility may %e resent$ and occasionally the fracture is o en$ articularly #ith high3energy trauma such as a motor (ehicle accident& Careful e(aluation and documentation of the neurologic status of the lim% is critical$ as associated ner(e in)uries$ es ecially to the radial ner(e$ are common& Radial ner(e in)ury most commonly occurs #ith o%li0ue fractures of the distal to middle thirds of the humerus& Treatment Generally humeral fractures are reduced %y gentle longitudinal traction #ith ade0uate sedation or local anesthesia and the atient laced in a coa tation s lint +from the a"illa medially$ around the el%o#$ and u o(er the shoulder laterally,$ although a long arm s lint or lastic humeral fracture %race also may %e used& The atient is then laced in a sling and s#athe +7ig& 563.D,& Neura ra"ia occurs in FC ercent of atients #ith radial ner(e in)ury$ %ut #ill resol(e #ithin a fe# #ee/s to - months& Therefore the resence of a radial ner(e alsy is not an indication for surgical inter(ention& Loss of the ner(e function after closed reduction is indicati(e of entra ment in the fracture site and #arrants e" loration& Late e" loration is indicated if reco(ery does not occur #ithin - months& If satisfactory reduction cannot %e o%tained or maintained$ surgical treatment #ith com ression lating or intramedullary rodding of the humerus is a ro riate& This is also referred in multi le3trauma atients$ #ho re0uire ra id mo%ili1ation to re(ent ulmonary and other com lications& El%o# The el%o# functions as a hinge )oint$ and the ro"imal and distal radioulnar articulations are im ortant for ronation and su ination& El%o# in)uries are notorious for causing loss of motion due to ca sular fi%rosis or ossification +myositis ossificans or$ more accurately$ heteroto ic ossification,& In addition to the routine antero osterior and lateral (ie#s$ o%li0ue radiogra hs are hel ful in delineating su%tle in)uries& :ecause the multi le ossification centers a%out the el%o# a ear at differing ages +ca itellumJ6 to 9 years* medial e icondyleJC to . years* radial headJC to . years* trochleaJF to 6G years* lateral e icondyleJF to 69 years,$ inter retation of radiogra hs in the conte"t of acute trauma in children can %e difficult& Com arison (ie#s of the o osite el%o# often are hel ful& 7ractures of the Radial 2ead and Nec/ These in)uries usually result from a fall on the outstretched hand& Patients ha(e limited range of motion of the el%o#$ locali1ed s#elling and tenderness$ articularly laterally$ and ain #ith attem ted ronation and su ination& The greatest ro%lem #ith these in)uries is su%se0uent loss of motion& As iration of the )oint and instillation of a small amount of lidocaine #ill im ro(e range of motion and relie(e ain& If the fracture is not se(erely angulated or dis laced$ the atient can %e treated #ith a sling and acti(e motion %egun #ithin 9 #ee/s to minimi1e occurrence of fle"ion contracture& If the radial head is comminuted$ e"cision may %e indicated& Long3term follo#3u of radial head e"cision demonstrates ro"imal su%lu"ation of the radius %ut

minimal sym toms& In cases of associated el%o# dislocation #ith insta%ility$ a silicone s acer can %e inserted until healing occurs$ %ut it should %e remo(ed later to re(ent silicone syno(itis and fragmentation& In children a fall on the outstretched hand causes a fracture of the radial nec/$ as o osed to the radial head fracture that occurs in adults& Closed reduction #ith (arus stress on the el%o# and ressure directed laterally on the ro"imal radius is erformed$ and the el%o# is s linted& Angulation of u to 5C degrees is #ell tolerated and #ill remodel$ %ut if greater angulation is resent$ o en reduction may %e necessary& 7ractures of the Pro"imal ?lna Olecranon fractures occur rimarily in adults$ either as a result of forced fle"ion against an acti(ely contracting trice s$ or more commonly$ from a direct force to the olecranon& In children the usual lac/ of dis lacement allo#s conser(ati(e treatment #ith immo%ili1ation in a relati(ely e"tended osition& In adults$ ho#e(er$ the fractures usually are dis laced and re0uire o en reduction and internal fi"ation& The most common a roach in(ol(es the use of tension %and #iring$ #hich con(erts the ull of the trice s into com ressi(e force at the fracture site +7ig& 563.H,& 4ore comminuted fractures re0uire e"cision of fragments and ad(ancement of the trice s a oneurosis to the remaining olecranon$ or lating #ith fi"ation of the multi le fragments& Su racondylar 7ractures of the 2umerus Su racondylar fractures are the most common fractures a%out the el%o# in children %ut are rare in adults& The fracture is caused %y a fall on the e"tended el%o#$ #ith hy ere"tension and osterior angulation of the distal condylar fragment& Less than C ercent of these fractures are of the fle"ion ty e& Su racondylar fractures are es ecially ha1ardous %ecause of the otential for neuro(ascular in)uries$ com artment syndromes$ and se0uelae such as >ol/mannAs contracture +discussed earlier under Contracture, and malunion& The %rachial artery can %e in)ured or lacerated %y the anterior ro)ection of the ro"imal fragment$ as can the median ner(e& Children #ith dis laced su racondylar fractures usually resent #ith mar/ed s#elling a%out the el%o#$ deformity$ and ecchymosis& Circulatory integrity of the forearm and hand as #ell as neurologic function must %e assessed& The distal fragment may %e dis laced osteromedially +most common, or osterolaterally$ and damage to the median or radial ner(e can occur& >igilance regarding de(elo ment of com artment syndrome is essential& Treatment ?ndis laced fractures can %e treated #ith a osterior s lint #ith FG degrees of el%o# fle"ion& 7urther fle"ion can %e ha1ardous %ecause of s#elling$ and all atients should %e o%ser(ed closely after immo%ili1ation& Dis laced fractures in the ast #ere treated #ith mani ulati(e reduction and immo%ili1ation in as much fle"ion as tolerated #ithout circulatory em%arrassment$ or %y o(erhead olecranon s/eletal traction& Today$ ho#e(er$ the method of fluorosco ically guided ercutaneous inning after closed reduction under general anesthesia is the most #idely acce ted method& This allo#s maintenance of more anatomic reduction #ithout the need for e"cessi(e fle"ion of the el%o# +7ig& 563.F,& Posto erati(ely the atient is maintained in a osterior s lint #ith not more than FG degrees of el%o# fle"ion& Circulatory com romise or e(idence of

com artment syndrome mandates immediate %rachial artery e" loration and forearm fasciotomies& Pins are remo(ed at - to 5 #ee/s$ at #hich time acti(e range3 of3motion e"ercises are started& 7ractures of the Lateral E icondyle in Children These in)uries result from el%o# hy ere"tension #ith associated (algus stress& 7ractures of the lateral condyle can %e difficult to diagnose radiogra hically$ and com arison (ie#s are useful +7ig& 563DG,& Three stages of dis lacement ha(e %een descri%edL stage IJundis laced* stage IIJminimally dis laced* less than 9 mm* and stage IIIJdis laced and rotated& These in)uries are not only intraarticular %ut also cross the gro#th late$ and therefore any dis lacement #arrants ercutaneous inning$ or o en reduction if needed& Com lications include nonunion and gro#th distur%ance& 7ractures of the 4edial E icondyle in Children >algus in)ury to the el%o# can a(ulse the medial e icondyle& The treatment of this in)ury is contro(ersial$ and there are ro onents of accurate reduction and inning as #ell as of conser(ati(e treatment& 2o#e(er$ if the fragment is entra ed in the )oint or if ulnar ner(e sym toms are resent$ o en reduction and inning is needed& Comminuted 7ractures of the Distal 2umerus Comminuted fractures of the distal humerus usually result from a direct %lo# to the fle"ed el%o#& Discontinuity of the articular surface necessitates o en reduction and internal fi"ation #ith %oth interfragmentary scre#s and medial and lateral %uttress lates through a osterior a roach& :est (isuali1ation of the articular surface is achie(ed %y che(ron osteotomy of the olecranon$ reflecting the trice s ro"imally #ith this fragment$ and fi"ing the olecranon later using an intramedullary scre#& The ma)or long3 term com lication is loss of el%o# motion& Dislocations of the El%o# These in)uries occur more commonly in children than adults and usually result from a fall on the outstretched forearm #ith osterior translocation of the radius and ulna& The anterior ca sule is torn$ as is the medial collateral ligament& These in)uries usually are sta%le after reduction #hen associated fractures are not resent& Immo%ili1ation is #ith a osterior s lint and FG degrees of el%o# fle"ion$ #ith early institution of motion& Careful neurologic assessment is necessary$ since a%out 6G ercent of atients ha(e associated ulnar or median ner(e in)ury& 7racture3Dislocations of the El%o# Posterior el%o# dislocations in con)unction #ith fractures of the ulnar coronoid rocess$ radial head$ or lateral condyle occur in adults and are much less sta%le in)uries than sim le osterior dislocations& O en reduction may %e necessary$ and if the radial head is fractured$ fi"ation or tem orary rosthetic re lacement often is necessary to ensure el%o# sta%ility in the healing eriod& Reattachment of an a(ulsed coronoid fragment also may im ro(e sta%ility %y reconstituting the %rachialis insertion& 4onteggia 7racture and Galea11i 7racture3Dislocation A 4onteggia fracture is a fracture of the ro"imal ulna associated #ith dislocation of the radial head +7ig& 563D6,& A 4onteggia3e0ui(alent fracture is fracture of the radial nec/ in addition and is seen more often in adults& The radial head dislocates

osteriorly in 6C ercent of atients and anteriorly in HC ercent& This in)ury illustrates the im ortance of the rinci le of o%taining radiogra hs of the )oints a%o(e and %elo# the le(el of a fracture& A single %one fracture in the forearm should al#ays alert one to the ossi%ility of in)ury to the radioulnar articulation distally or ro"imally& The Galea11i fracture3dislocation is an analogous in)ury #ith fracture of the radial shaft and dislocation of the distal radioulnar )oint& Closed reduction may %e ossi%le$ maintaining the el%o# fle"ed and su inated& If the ulna fracture cannot %e anatomically reduced$ the in)ury #ill %e unsta%le and the radial head li/ely to redislocate& Internal fi"ation of the ulna$ usually %y com ression lating$ may %e necessary$ %ut many of these in)uries$ articularly in children$ can %e treated closed& The Galea11i fracture3dislocation in(ol(es a distal3third radius fracture in com%ination #ith dorsal dislocation of the distal radioulnar )oint& The resultant insta%ility attern is similar to that of the 4onteggia lesion& In adults$ lating of the radius and immo%ili1ation of the forearm in su ination is necessary& This in)ury is uncommon in children$ %ut closed reduction and immo%ili1ation in a long arm cast in full su ination usually is successful& Radial 2ead Su%lu"ation in Children Also /no#n as !nursemaidAs el%o#$' this in)ury results from ulling a childAs el%o# into sudden e"tension$ and is seen in children under C years of age& The el%o# can %e fle"ed from -G to 69G degrees #ithout ain$ and the radiogra hs are normal& The lesion is a tear of the attachment of the annular ligament$ allo#ing esca e of the radial head and resulting in entra ment of the annular ligament in the radiohumeral )oint& It can %e reduced %y forceful su ination #ith the el%o# fle"ed FG degrees$ follo#ed %y sling immo%ili1ation for a #ee/& 7orearm 7ractures 7ractures of the forearm are common in children$ %ut also occur in adults in motor (ehicle accidents$ falls$ and contact s orts& Deformity$ s#elling$ and insta%ility may %e resent& Radiogra hs must include the el%o# and #rist$ and careful neuro(ascular e"amination of the e"tremity is critical& The osterolateral %o# of the radius is critical to the maintenance of ronation and su ination& In addition$ rotational malalignment can occur from the ull of the su inator and %ice s on the ro"imal radius& Anatomic reduction of the fractures #ith restoration of ro er rotation and alignment is essential to a good functional outcome& Treatment Closed reduction can %e underta/en under a"illary ner(e %loc/$ intra(enous sedation$ or general anesthesia& Longitudinal traction is a lied #ith the el%o# fle"ed to FG degrees& After mani ulati(e reduction$ the fracture is immo%ili1ed in the osition of ma"imum sta%ility& Generally su ination for ro"imal3third fractures$ neutral rotation for middle3third fractures$ and ronation for distal3third fractures are most a ro riate& A long arm cast is a lied$ #ith care ta/en to mold (olarly and dorsally along the interosseous mem%rane to hel maintain osition& In adults$ results of closed treatment are usually inferior to o en reduction and internal fi"ation$ and nonunion and malunion rates are significantly higher& Therefore$ dis laced fractures in adults

are ordinarily treated %y o erati(e reduction and rigid internal fi"ation using dynamic com ression lates +7ig& 563D9,& These lates ha(e eccentrically laced holes that allo# significant com ression at the fracture site as the scre#s are seated in the late& Posto erati(ely$ a laster long arm s lint is a lied$ %ut if sta%le fi"ation is attained$ early motion to restore su ination and ronation is a ma)or ad(antage of internal fi"ation& In cases of mar/ed comminution or soft3tissue in)ury$ early or rimary %one grafting of the fractures is #arranted& Contro(ersy remains o(er #hether the hard#are should %e remo(ed after fracture healing is achie(ed +6 to 9 years,& In young adults$ the stress shielding effect of hard#are gradually causes #ea/ening of the cortical %one %eneath the late& In time this results in a stress riser at the edge of the late$ #hich can lead to a su%se0uent fracture #ith less than normal force& On the other hand$ incidences of fracture through scre# holes +#hich are also stress risers for a num%er of months after hard#are remo(al, ha(e %een as high as 9G ercent after hard#are remo(al& There is no consensus on late remo(al at resent& Often the lates cause tendinitis or other sym toms$ and the atient re0uests remo(al des ite the ris/ of refracture& A reasona%le a roach in(ol(es +6, using only the smaller dynamic com ression lates in the forearm$ #hich re0uire -&C3mm rather than 5&C3 mm scre#s* +9, late remo(al in sym tomatic atients* +-, remo(al of hard#are in young adults* and +5, rolonged rotection after late remo(al #ith an orthosis or remo(a%le fi%erglass cast as #ell as acti(ity restrictions for . months to 6 year& 7orearm Shaft 7ractures in Children O en reduction of these in)uries is rarely indicated e"ce t #hen the in)ury occurs in a teenager #ithout much gro#th remodeling otential remaining$ in #hich case the fracture is handled as descri%ed a%o(e for adults& Greenstic/ fractures +7ig& 563D-,$ in #hich one corte" is fractured %ut the o osing corte" has undergone lastic deformation and angulation$ should %e mani ulated to com lete the fracture* other#ise reduction is hard to achie(e& The reduction maneu(ers are in other res ects similar to those for the adult& Postreduction films are im ortant$ as is careful follo#3u to ascertain that the reduction is maintained& Greater degrees of angulation can %e acce ted in fractures in younger children or fractures close to a gro#th late$ #here the otential for remodeling is greater& Distal Radius CollesA 7racture 7racture of the distal radius #ith dorsal angulation and a !dinner for/' deformity of the #rist #as descri%ed %y A%raham Colles in 6H65 +7ig& 563 D5,& This (ery common in)ury occurs as a result of a fall on the outstretched hand& The fracture is most common in atients o(er CG$ often ostmeno ausal #omen #ith some degree of osteo enia& Patients ha(e deformity$ s#elling$ ecchymosis$ and ain in the #rist area& Neurologic in)ury in(ol(ing the median ner(e occurs$ and careful neurologic e"amination of the hand %oth %efore and after reduction is im ortant& Patients occasionally de(elo an acute car al tunnel syndrome after reduction$ articularly if the #rist is immo%ili1ed in a osition of e"treme fle"ion& Radiogra hic e(aluation should e"tend to the el%o# to rule out other in)uries& Treatment

Goals of treatment include the minimi1ing of cosmetic deformity as #ell as restoration of good #rist and hand function& The usual a roach is conser(ati(e treatment #ith closed reduction and laster immo%ili1ation& Generally after regional anesthesia or sedation longitudinal traction is a lied using Chinese finger tra s #ith a counter#eight to the humerus and the el%o# at FG degrees of fle"ion& 4ani ulation then consists of e"aggeration of the deformity follo#ed %y (olar fle"ion and ulnar de(iation along #ith gentle ressure on the dorsum of the fragment to ush it anteriorly& The #rist is then immo%ili1ed in a long arm laster cast in ulnar de(iation and fle"ionJa(oiding full fle"ion %ecause of the otential for median ner(e com ression& Ele(ation is continued for a fe# days to minimi1e s#elling$ and early acti(e motion of all digits is encouraged* later shoulder range3of3motion e"ercises are %egun to minimi1e any stiffness that may occur& In the e(ent of the de(elo ment of car al tunnel syndrome$ the cast is remo(ed and the #rist laced in the neutral osition& If the sym toms fail to resol(e$ surgical car al tunnel release is indicated& There is no consensus on #hether the #rist should %e immo%ili1ed in ronation or su ination$ and hence the neutral osition is most commonly used& At - to 5 #ee/s the cast is changed to a short arm cast$ #hich is remo(ed at . #ee/s from the initial in)ury& If satisfactory reduction cannot %e attained or is lost during the first #ee/ of treatment$ other methods are used& 4ani ulation under anesthesia #ith ercutaneous inning has %een used successfully in this situation$ re(enting recurrent loss of osition& In cases #ith articular surface disru tion$ o en reduction of the fracture fragments #ith internal fi"ation is occasionally indicated to restore a congruous surface of the distal radius& 4ore commonly$ ho#e(er$ e"ternal fi"ation is used$ allo#ing ligamentota"is to achie(e reduction of the fracture fragments& One disad(antage of e"ternal fi"ation of distal radius fractures is that mar/ed stiffness of the #rist usually results& 7igure 563DC demonstrates the a lication of e"ternal fi"ation& Smith 7racture A fall on the dorsum of the #rist may cause a re(ersed CollesA fracture$ #hich is gi(en the e onym Smith fracture& These fractures are characteri1ed %y (olar angulation and dis lacement of the distal fragment& Reduction is #ith longitudinal traction and cast immo%ili1ation$ %ut osition may %e difficult to maintain$ and ercutaneous in fi"ation or o en reduction and internal fi"ation #ith a (olar %uttress late occasionally is necessary& 8rist A fall on the outstretched #rist can result in ligamentous in)uries$ #ith resultant ain$ limitation of motion$ and s#elling& Ligamentous disru tion$ articularly #hen it in(ol(es the sca holunate articulation$ can result in intercar al insta%ility atterns and must %e carefully e(aluated& In addition$ these in)uries must %e differentiated from %ony disru tions such as sca hoid fracture$ lunate dislocation$ or transsca hoid erilunate dislocation& 7ractures of the Sca hoid +Car al Na(icular, Moung adults #ho fall on the outstretched hand fre0uently fracture the sca hoid +7ig& 563D.,& Signs include tenderness in the !anatomic snuff %o"$' #hich is formed %y the

e"tensor ollicis longus and a%ductor ollicis longus tendons )ust o(er the tu%erosity of the sca hoid& In addition to standard antero osterior and lateral radiogra hs$ an o%li0ue 6D3degree (ie# +na(icular (ie#, is necessary to ade0uately (isuali1e the sca hoid& E(en #ith negati(e films$ a nondis laced fracture may %e resent #hen there is re roduci%le tenderness o(er the sca hoid& :ecause the %lood su ly to the sca hoid enters distally$ fractures de(asculari1e the ro"imal fragment to some e"tent* conse0uently healing of this fracture is slo# and the nonunion incidence significant& Therefore$ in the resence of clinical signs$ the atient is laced in a thum% s ica cast resum ti(ely and re eat films are o%tained out of laster - #ee/s later +see 7ig& 563D.,& If radiogra hs are negati(e and sym toms resol(ed$ mo%ili1ation of the #rist can %egin& Treatment If the fracture is minimally dis laced$ thum% s ica cast immo%ili1ation is initiated* authors differ as to #hether a long or short arm cast is necessary$ %ut most refer a long arm cast at least initially& A(erage healing time is 69 to 6. #ee/s$ and in some cases can ta/e longer than . months& In cases #ith dis lacement or angulation of the sca hoid$ o en reduction and internal fi"ation #ith ins or scre#s should %e erformed& In cases of late diagnosis +u to . months,$ union can still occur #ith rolonged immo%ili1ation& 8hen nonunion is not associated #ith arthritic change in the #rist$ autogenous %one grafting is the recommended a roach and has a union rate of F9 ercent& Electrical stimulation also has %een re orted to romote union& If degenerati(e changes are resent$ radial styloidectomy can ro(ide ain relief and im ro(ed function& Lunate and Perilunate Dislocations These in)uries are uncommon %ut can result from traumatic hy ere"tension of the #rist& Patients com lain of ain$ s#elling$ and limitation of motion$ and median ner(e sym toms may %e resent& The lunate is dis laced anteriorly$ %est (isuali1ed on lateral radiogra hs& On the antero osterior (ie# the normal 0uadrilateral sha e of the lunate is more triangular and larger than on the o osite side& Treatment Closed reduction can %e accom lished %y hy ere"tending the #rist and a lying ressure (olarly o(er the dislocated lunate& After#ard the #rist should %e immo%ili1ed in fle"ion& If unsuccessful$ o en reduction through a (olar a roach is carried out #ith ligamentous re air and in fi"ation& A similar a roach is ta/en #ith the treatment of transsca hoid erilunate dislocations$ in #hich the lunate remains attached to the distal radius (ia the radiolunate ligament and the car us dislocates& Closed reduction of these in)uries can %e difficult$ and o en reduction often is necessary to achie(e anatomic relationshi s of the car al %ones& Residual sca holunate dissociation resulting in dorsal or (olar intercalated segment insta%ility +de ending on the direction of relati(e fle"ion;e"tension of the lunate and sca hoid, can cause late rogressi(e car al colla se and degenerati(e arthritis& 2and 4etacar al 7ractures 4etacar al fractures can occur from direct trauma$ crush in)uries$ or stri/ing the hand against an o%)ect& 7ractures of the nec/ of the fourth and fifth metacar als commonly result from fistfights& Local s#elling mas/s the degree of (olar angulation of the

metacar al head& The angular deformity must %e assessed on the lateral radiogra h$ and rotational deformity must %e )udged clinically %y fle"ing the digit$ #hich should oint to#ard the sca hoid& Treatment 4etacar al nec/ fractures usually are treated %y closed mani ulation under local anesthesia& 7or the fourth and fifth metacar als$ an ulnar gutter s lint is a lied #ith as much metacar o halangeal +4CP, )oint fle"ion as ossi%le and the inter halangeal +IP, )oints in e"tension& An im ortant oint in immo%ili1ation of any in)ury to the hand is that the collateral ligaments of the 4CP )oints are lengthened in fle"ion$ and therefore immo%ili1ation in e"tension leads to contracture of the collaterals and difficulty in regaining fle"ion& ? to 5G degrees of residual angulation can %e acce ted in the fourth and fifth metacar als %ecause of the increased mo%ility of these rays in the antero osterior direction& If angulation is e"cessi(e or in(ol(es the more radial rays$ ercutaneous inning is necessary to maintain acce ta%le reduction& 4etacar al shaft fractures usually can %e treated conser(ati(ely$ %ut if e"cessi(e angulation$ dis lacement$ or rotatory malalignment is resent$ o en reduction and Eirschner3#ire fi"ation or lating are occasionally necessary& Comminuted fractures of the metacar al heads are difficult to treat and should %e s linted in a functional osition and early motion initiated at 9 to - #ee/s& 7racture3dislocations of the car ometacar al +C4C, )oint are rare and usually are treated #ith closed reduction and s linting& :ennett 7racture This is an intraarticular fracture of the thum% metacar al caused %y an a"ial force against the artially fle"ed %one& The fracture line ty ically lea(es a small (olar fragment #ith the tra e1ium$ #hile the rest of the metacar al is ulled dorsally and radially %y the a%ductor ollicis longus muscle& This leads to insta%ility and su%lu"ation or dislocation of the C4C )oint& >ariants include a rare comminuted ty e +Rolando fracture, and e"traarticular fractures of the ro"imal meta hysis$ #hich are the most common ty e and are more sta%le& 4inimally dis laced fractures can %e treated %y closed reduction and thum% s ica casting %ut must %e follo#ed closely %ecause of the ro ensity for dis lacement& :ecause of the inherent insta%ility of the intraarticular fractures$ the most common method of treatment in(ol(es closed reduction #ith ercutaneous inning of the metacar al to the tra e1ium +7ig& 563DD,& If significant incongruity of the )oint surface ersists des ite attem ted closed reduction$ o en reduction and in or scre# fi"ation are recommended& Rolando fractures are difficult to treat %ecause they can ha(e significant comminution& If the articular surface can %e restored %y inning after closed or o en reduction$ this is the method of choice$ %ut %ecause of the small si1es of the fragments it often is not feasi%le& In these cases %rief immo%ili1ation follo#ed %y early motion is suggested& ?lnar Collateral Ligament In)ury of the Thum% +Game/ee erAs Thum%, Sudden a%duction stress to the thum% can lead to ru ture of the ulnar collateral ligament of the 4CP )oint& The in)ury #as first descri%ed in :ritish game/ee ers$ #ho #ere noted to ha(e a chronic la"ity of the ligament caused %y chronic re etiti(e

a%duction stress #hen /illing game& 7alls and s/i ole in)uries are some of the more common causes today& Stener descri%ed a henomenon that ma/es conser(ati(e treatment of this in)ury difficult$ namely$ inter osition of the adductor insertion %et#een the ends of the ligament& This occurs in a ro"imately CG ercent of these in)uries and recludes healing of the ligament$ leading to chronic insta%ility of the )oint& The atient usually resents #ith a ainful$ s#ollen thum% 4CP )oint& The ulnar as ect of the )oint is tender$ and radiogra hs usually are normal$ although sometimes an a(ulsion fragment at the %ase of the ro"imal halan" is (isi%le& If standard radiogra hs are normal$ stress radiogra hs are recommended to demonstrate the insta%ility& This can %e a reciated on hysical e"amination as #ell& Treatment 7or grades I and II ligament s rains$ immo%ili1ation for - to . #ee/s in a thum% s ica cast #ith the thum% in slight adduction is ad(ised& :ecause of the re(alence of the Stener lesion$ for grade III +com lete, tears$ o erati(e re air is indicated& 7or ru tures diagnosed later than 9 to - #ee/s after in)ury$ rimary re airs are not feasi%le$ and reconstructi(e surgery is necessary$ #ith tendon grafts or ca sular reefing and adductor tendon ad(ancement& Phalangeal 7ractures Nondis laced halangeal shaft fractures are treated %y s linting in a osition of function +4CP )oints fle"ed a ro"imately DG degrees and IP )oints in only slight fle"ion,& Generally$ mallea%le aluminum s lints #ith foam adding held in lace #ith adhesi(e ta e can %e used& 7or dis laced fractures$ mani ulati(e reduction may %e necessary %efore s linting& Small a(ulsion fractures of the IP )oints are treated sym tomatically %y s linting for 9 #ee/s follo#ed %y range3of3motion e"ercises& Inter halangeal dislocations are usually dorsal %ut also may %e (olar or rotatory& Dorsal dislocations are accom anied %y tearing of the (olar late$ often #ith an associated chi a(ulsion& Rotatory dislocations resulting from t#isting in)uries are unusual$ and they can %e irreduci%le %ecause of soft3 tissue inter ositions such as %uttonhole ca ture of one condyle through the e"tensor a oneurosis& Occasionally dorsal IP dislocations are associated #ith intraarticular fracture of the %ase of the halan"& Inter halangeal Dislocations Treatment of IP dislocations is #ith closed reduction follo#ed %y %uddy ta ing for to . #ee/s$ or %y e"tension %loc/ s linting +a dorsal s lint that limits full e"tension %ut allo#s acti(e fle"ion, to allo# healing of the (olar late and re(ent late hy ere"tension deformity& 7racture3 dislocations in(ol(ing a ortion of the articular surface can %e treated %y closed reduction #ith su%se0uent e"tension %loc/ s linting& If closed reduction is unsatisfactory$ o en reduction #ith fi"ation of the articular fragments can %e erformed& In cases in #hich the fragments are small or comminution is resent$ a (olar late +Eaton, arthro lasty is recommended$ #ith e"cision of the fragments and ad(ancement of the (olar late into the defect #ith a ullout #ire& Distal Phalan" 7ractures Crush in)uries to the distal halan" are the most common fractures in the hand& Often there are associated in)uries of the nail and nail%ed& The most fre0uent ty es are

comminuted tuft fractures of the distal ortion of the halan"$ and trans(erse fractures of the more ro"imal %ase of the halan"$ #hich may %e angulated& The nail%ed in)uries$ #hich are often neglected$ may actually %e more of a ro%lem than the fractures themsel(es& Initial care is aimed at cleansing any #ounds to re(ent infection& Drainage of any su%ungual hematoma %y iercing the nail #ith a hot a er cli or a %attery3 o#ered hot #ire cautery affords significant ain relief& Late nail deformity is an una(oida%le com lication of crush in)uries$ and the atient should %e ad(ised of this& Careful re air of any nail%ed lacerations #ith fine a%sor%a%le sutures hel s considera%ly in diminishing these ro%lems& If the nail has %een a(ulsed$ it is re laced %eneath the cuticle after nail%ed re air to act as a s lint to rotect the nail%ed and decrease local tenderness& The nail e(entually #ill %e ushed off %y gro#th of the ne# nail& The fracture is then s linted #ith a rotecti(e metal s lint for - to 5 #ee/s& Angulated fractures of the distal halan" should %e reduced and$ if unsta%le$ inned #ith a Eirschner #ire %efore s linting& 4allet 7inger 7orci%le fle"ion of the distal halan" against acti(e contraction of the e"tensor mechanism a(ulses the distal insertion of the e"tensor tendon from the dorsum of the halan"$ usually #ith a small fragment of %one +7ig& 563DH,& The atient is una%le to fully e"tend the distal halan"& The in)ury is generally treated conser(ati(ely$ #ith a (olar or dorsal s lint across the distal inter halangeal +DIP, )oint holding it in hy ere"tension& 4ost authors %elie(e that immo%ili1ation of the ro"imal inter halangeal +PIP, )oint is not necessary& The s linting must %e maintained for . #ee/s$ and occasionally longer if acti(e e"tension has not %een regained& Some e"tensor lag may remain after treatment %ut is usually not ro%lematic& E(en if seen late +9 to - months after in)ury,$ most mallet finger in)uries #ill im ro(e #ith rolonged +H #ee/s, s linting& If the a(ulsed fragment of %one com rises more than one3third of the articular surface$ o eration is indicated$ although for small amounts of dis lacement$ conser(ati(e treatment as descri%ed a%o(e is a ro riate& 8ith (olar su%lu"ation of the distal halan"$ ho#e(er$ re air #ith a ull3out #ire or Eirschner3#ire fi"ation is recommended& 4ar/edly comminuted intraarticular IP )oint fractures are %est treated %y s linting in a osition of function and early arthrodesis if sym toms #arrant& O en fractures are treated #ith irrigation$ de%ridement$ and anti%iotics$ follo#ing the general rinci les of treatment of other o en fractures descri%ed re(iously& Lo#er3E"tremity In)uries 7emur :efore the ad(ent of internal fi"ation for fractures of the ro"imal femur$ atients #ere treated #ith %ed rest and traction$ and mortality rates #ere high& Although mortality and mor%idity ha(e significantly im ro(ed #ith modern methods of management$ hi fractures re resent a ma)or challenge to the health care system$ #ith o(er 9DC$GGG such in)uries annually in the ?nited States at an estimated cost of o(er S- %illion& These fractures generally occur in the .G3 to DG3year3old o ulation$ and the incidence continues to increase as the num%er of elderly increases& 7emoral nec/

and intertrochanteric fractures occur #ith a ro"imately e0ual fre0uency and similar e idemiology& The incidence increases #ith increasing age$ #ith o(er one3third of #omen and one3si"th of men o(er the age of FG years ha(ing sustained a hi fracture& Osteo orosis is a contri%uting factor to hi fractures$ causing decreased mechanical strength of the ro"imal femur& 4ild nutritional osteomalacia also can %e a factor %ut has %een found in only a%out 9 ercent of atients #ith femoral nec/ fractures& The mortality of hi fractures in the elderly has %een re orted to %e as high as 9G to CG ercent #ithin the first year& These fractures occur much less commonly in young adults or children$ in #hom they usually result from high3energy trauma such as motor (ehicle accidents& The most serious com lications of these fractures are osteonecrosis of the femoral head and nonunion& 7emoral Nec/ 7ractures 7emoral nec/ fractures are most commonly roduced %y a fall& The atient usually com lains of ain in the groin or thigh and is una%le to %ear #eight on the e"tremity& The leg usually a ears shortened and e"ternally rotated$ and any attem t at motion causes se(ere ain& Trochanteric ecchymosis may %e e(ident& Diagnosis is confirmed %y antero osterior and lateral radiogra hs of the hi $ and careful hysical e"amination is necessary to rule out other in)uries to the ri%s$ u er e"tremities$ or /nee& Discontinuity of the tra%eculae is seen in %oth (ie#s radiogra hically$ and usually the femoral head is angulated osteriorly on the lateral (ie#& The most #idely used classification of femoral nec/ fractures is the Garden classification +7ig& 563DF,L Ty e IJIncom lete fracture +usually im acted in (algus, Ty e IIJCom lete fracture #ithout dis lacement Ty e IIIJCom lete fracture #ith artial dis lacement Ty e I>JCom lete dis lacement of fracture 2igher incidences of osteonecrosis and nonunion occur #ith the dis laced ty e III and ty e I> fractures& The undis laced ty e I and ty e II fractures can %e difficult to diagnose$ and initial radiogra hs may %e negati(e& Some atients #ith undis laced fractures ha(e sur risingly little ain and are e(en a%le to %ear #eight& ?sually internal rotation of the hi #ill cause ain$ and ecchymosis o(er the trochanter should raise sus icion& A %one scan or 4RI should %e erformed in any atient #ith negati(e radiogra hs and une" lained hi ain after a fall and #ill readily demonstrate the fracture in essentially all cases$ although the age of the fracture may remain difficult to ascertain& Treatment The femoral head has a more recarious %lood su ly than many %ones$ gi(en the large surface co(ered #ith cartilage$ #hich has no %lood (essels& The ma)ority of the %lood su ly comes in through the nec/ and through su%ca ital e i hyseal (essels that run in the inferior ca sule$ su lied from the medial and lateral circumfle"

(essels& A small contri%ution in adults can come from the artery of the ligamentum teres& Disru tion of the %lood su ly occurs #ith fracture of the nec/$ accounting for the high incidence of osteonecrosis and nonunion& 4echanical factors such as the high loads across the femoral nec/ and the fact that little if any e"ternal callus formation occurs in these intraarticular fractures further contri%ute to nonunion& As iration of ca sular hematoma has %een ad(ocated %y some to decrease tam onade of ca sular (essels$ %ut the effect on de(elo ment of osteonecrosis remains uncertain& In elderly atients$ surgical treatment allo#s early mo%ili1ation$ significantly decreasing mor%idity and mortality& 7i"ation #ithin 95 h has %een ad(ocated #ith hi fractures to minimi1e osteonecrosis$ %ut more recent data suggest that the most im ortant consideration is achie(ing medical sta%ility of the atient %efore surgery& It is generally agreed$ ho#e(er$ that fracture fi"ation and mo%ili1ation of the atient as 0uic/ly as ossi%le are %eneficial& Internal fi"ation is indicated in nondis laced fractures and in younger$ acti(e indi(iduals e(en #ith significant dis lacement& Dis laced fractures in the elderly are treated most commonly %y endo rosthetic re lacement of the femoral head %ecause of the high incidence of osteonecrosis or nonunion& 8ith ty e I and ty e II fractures$ nonunion occurs in less than C ercent of cases$ and osteonecrosis in less than H ercent$ #hile 6G to -G ercent of atients #ith ty e III and ty e I> fractures de(elo nonunion and 6C to -- ercent osteonecrosis& Nondis laced 7emoral Nec/ 7ractures Ty e I and ty e II fractures can %e treated conser(ati(ely$ articularly #ith fractures im acted in (algus& :ecause of the fre0uent ina%ility of the elderly atient to fully coo erate #ith rotected #eight %earing and the continued otential for dis lacement$ #hich #ould significantly #orsen rognosis$ internal fi"ation generally is recommended& In demented$ nonam%ulatory atients #ith other medical ro%lems$ conser(ati(e treatment often is indicated& E(en medically ill atients$ ho#e(er$ usually can tolerate internal fi"ation$ #hich can %e done ercutaneously #ith multi le ins under local anesthesia if necessary& Com arison %et#een sliding com ression scre# #ith side late fi"ation and multi le arallel threaded3 in fi"ation has indicated su erior union rates #ith multi le ins or scre#s$ #ith three ins ro(iding ade0uate sta%ility +7ig& 563HG,& In young adults e(ery effort should %e made to reser(e the femoral head$ e(en in dis laced fractures& Accurate reduction is im ortant in minimi1ing the incidence of nonunion$ and generally (arus osition or more than 6C degrees of angulation on the lateral should not %e acce ted& If closed reduction is unsuccessful$ o en reduction through an anterolateral or osterior a roach should %e underta/en& 4uscle edicle %one grafting has %een ad(ocated to increase union rate and decrease osteonecrosis %ut remains contro(ersial& Posto erati(e 4anagement :ecause of the high incidence of throm%oem%olic disease in elderly atients after hi fracture$ many ad(ocate some form of ro hyla"is erio erati(ely& A roaches to this ro%lem include lo#3dose as irin$ #arfarin$ antiem%olism stoc/ings$ and neumatic com ression stoc/ings& 4o%ili1ation of the atient is ra id$ #ith sitting in a chair #ithin 95 h of surgery a goal& 8eight %earing is rotected until the fracture is healed$ usually #ithin 5 to . months& 7ollo#3u is needed for longer eriods$ as osteonecrosis may not %ecome radiogra hically e(ident for u to 9 years& >ia%ility of the femoral head %efore or after internal fi"ation can %e assessed %y %one scan or 4RI& 4RI changes of osteonecrosis are resent #ithin a fe# days of %lood su ly disru tion$ %ut

after surgery the metal artifact introduced %y the ins se(erely limits usefulness of 4RI& In atients #ho de(elo osteonecrosis$ su%se0uent colla se necessitates rosthetic re lacement& In atients #ith nonunion and a (ia%le femoral head %y con(entional or tomogra hic +single hoton emission com uted tomogra hy$ or SPECT, %one scan$ either rosthetic re lacement or (algus osteotomy and %one grafting can %e underta/en$ de ending on the age and acti(ity le(el of the atient& Endo rosthetic 2i Re lacement In elderly atients the relati(ely high incidence of nonunion and osteonecrosis #ith dis laced fractures argues for endo rosthetic re lacement of the femoral head& If the hi is arthritic$ total hi re lacement arthro lasty is indicated& ?sually cemented arthro lasties are recommended$ although in younger or more acti(e atients #ith com lications after attem ted femoral head sal(age$ uncemented orous3 coated rosthetic re lacement may %e considered& :i olar endo rostheses ha(e a mo(a%le articulating surface #ith a olyethylene liner ca turing a smaller s herical %all that is continuous #ith the intramedullary stem of the de(ice +7ig& 563H6,& The motion at %oth articulating surfaces decreases #ear on the aceta%ulum$ and the ro%lem of late aceta%ular migration + rotrusio, is considera%ly less #ith %i olar than #ith earlier fi"ed3head endo rosthetic designs& Additional indications for endo rosthetic re lacement as o osed to internal fi"ation include neurologic conditions + ar/insonism$ stro/e$ dementia,$ meta%olic %one disease +renal osteodystro hy$ hy er arathyroidism$ PagetAs disease,$ and athologic fractures caused %y metastatic carcinoma& 8ith cemented arthro lasty$ #eight %earing is allo#ed as tolerated& In atients #ith ree"isting degenerati(e changes in the )oint$ total )oint re lacement rather than %i olar arthro lasty is indicated& 7emoral Nec/ 7ractures in Children 7emoral nec/ fractures usually occur in children only after high3energy trauma$ such as edestrian;motor (ehicle accidents or falls from a great height& 7ractures ha(e %een classified as transe i hyseal +#ith or #ithout dislocation,$ transcer(ical$ cer(icotrochanteric$ and intertrochanteric& Transcer(ical and cer(icotrochanteric fractures account for the ma)ority& Pediatric hi fractures are associated #ith a high incidence of com lications$ including hyseal closure$ nonunion$ and osteonecrosis of %oth the femoral head and nec/& Dis laced fractures are treated %y gentle closed reduction and inning$ and nondis laced fractures %y s ica cast immo%ili1ation #ith close radiogra hic follo#3u to monitor ossi%le dis lacement& Intertrochanteric fractures usually can %e treated conser(ati(ely #ith a s ica cast& Intertrochanteric and Su%trochanteric 7ractures These fractures occur in the elderly after falls and after significant trauma in younger indi(iduals and generally are mechanically less sta%le than femoral nec/ fractures& The insta%ility of the fractures usually results from comminution of the osteromedial corte" in the area of the calcar and lesser trochanter$ #ith a tendency of the fracture to colla se into (arus& Patients resent #ith an ina%ility to %ear #eight$ shortening and e"ternal rotation of the lo#er art of the e"tremity$ and often s#elling or ecchymosis a%out the hi & The considerations for surgical treatment of intertrochanteric and su%trochanteric femur fractures are similar to those descri%ed for femoral nec/ fractures$ #ith internal

fi"ation allo#ing early mo%ili1ation and decreasing significantly mor%idity and mortality in the elderly& In younger indi(iduals #ho can tolerate %ed rest or in atients #ho ha(e medical contraindications to surgical inter(ention$ RussellAs or s/eletal traction and %alanced sus ension may %e used$ %ut internal fi"ation is the referred method of treatment& ?nion of these fractures may re0uire 5 months or more$ ho#e(er& Surgical inter(ention consists of o en reduction and internal fi"ation using a sliding com ression de(ice #ith side late +7ig& 563 H9, or an intramedullary fi"ation de(ice +Nic/el nail$ gamma nail$ or reconstruction nail,& Intertrochanteric fractures ha(e a lo#er incidence of nonunion than femoral nec/ fractures$ and osteonecrosis of the femoral head is uncommon since its %lood su ly usually is not disru ted& Treatment of unsta%le fractures #ith medial comminution has %een contro(ersial$ #ith anatomic reduction$ medial dis lacement$ or (algus osteotomies ad(ocated to im ro(e sta%ility& :ecause a sliding hi scre# allo#s controlled colla se at the fracture site$ anatomically reduced fractures often s ontaneously im act and medially dis lace to a more sta%le configuration& 7i"ation of a lesser trochanteric fragment$ #hen ossi%le$ #ill also enhance sta%ility& Intramedullary de(ices ha(e %een associated #ith a high rate of com lications in intertrochanteric fractures %ut are referred for su%trochanteric fractures& Su%trochanteric fractures ha(e a significant incidence of delayed and nonunion$ ho#e(er$ and in the resence of medial comminution rimary %one grafting may %e indicated& Posto erati(e considerations include attention to ra id mo%ili1ation$ ulmonary hygiene$ and throm%oem%olic ro hyla"is$ as for femoral nec/ fractures& Generally$ rotected #eight %earing is indicated until radiogra hic e(idence of healing is resent and #ill de end also on fracture attern and fi"ation sta%ility& 7emoral Shaft 7ractures 7emoral fractures can occur at any age and generally result from (iolent trauma& 4ulti le3trauma atients re0uire e(aluation of any associated in)uries of the head$ a%domen$ and chest& Patients e"hi%it insta%ility of the e"tremity$ ain #ith motion$ rotational deformity$ and shortening of the affected e"tremity& Neuro(ascular e"amination is essential$ since there may %e in)ury to the sciatic or femoral ner(e or the femoral artery& Associated femoral fracture or /nee ligament in)uries occur in a%out C ercent of atients& In the resence of signs of distal ischemia$ arteriogra hy is indicated$ follo#ed %y immediate (ascular e" loration for re air or reconstruction and sta%ili1ation %y internal fi"ation& Treatment Emergency treatment includes sta%ili1ation #ith a s lint or traction s lint& O en femoral fractures generally result from significant (iolence and should %e handled as descri%ed earlier for general treatment of o en fractures& In children femoral shaft fractures are almost al#ays treated conser(ati(ely$ #ith modified :ryantAs +in infants,$ RussellAs +for ages 9 to 6G years,$ or distal femoral s/eletal traction +for age 6G years and older,& If fractures in young children are minimally dis laced or shortened less than 6 to 9 cm$ immediate s ica cast treatment is a ro riate& In children 6 cm of o(erriding is acce ta%le$ since e i hyseal stimulation from the fracture #ill result in relati(e o(ergro#th of the e"tremity %y

a%out that amount& Angular or rotational deformities should %e corrected as com letely as ossi%le$ ho#e(er +7ig& 563H-,& In children treated initially in traction$ callus formation #ill occur #ithin 9 #ee/s$ and the fracture #ill %ecome nontender& The atient is then laced in a one and one3half hi s ica cast for 9 to 5 months$ until radiogra hic e(idence of union is resent& In children o(er 69 years of age #ith multi le trauma$ internal fi"ation of the fracture to facilitate mo%ili1ation is often indicated& The use of t#o -3 to 53mm diameter titanium intramedullary nails inserted across the fracture site through the distal femoral meta hysis has %een introduced %y Rang for use in children as young as C years old to allo# early mo%ili1ation and shorter hos itali1ation and to o%(iate the incon(enience of rolonged s ica cast care +7ig& 563 H5,& One disad(antage of the method is the need for a second surgical rocedure for nail remo(al$ %ut the techni0ue may ro(e to %e a con(enient and cost3effecti(e method of treatment& In adults #ith medical contraindications to surgery$ traction until callus has formed follo#ed %y lacement in a cast %race or hi s ica cast may %e a ro riate& Conser(ati(e treatment of femoral fractures in adults results in a high rate of malunion and /nee stiffness$ and so the standard method of treatment of most adult femoral fractures is no# intramedullary rod fi"ation& The ad(ent of interloc/ing nails$ #hich allo# multi le scre#s to %e laced through the femur and nail to gi(e rotational and length control ro"imally and distally$ has greatly e"tended the indications for surgery and is no# the method of choice for treatment of comminuted femoral fractures +7ig& 563HC,& This form of internal fi"ation is usually done !closed' under fluorosco ic image intensification$ #hich a(oids stri ing of the eriosteum and romotes more ra id healing& 8hether treatment is surgical or conser(ati(e$ s/eletal traction and lacement of a Steinmann in through the distal femur or ro"imal ti%ia are needed& The distal femur should %e used if /nee in)ury is sus ected$ %ut distal loc/ing is technically easier if the traction in is in the ti%ia& Intramedullary nailing facilitates mo%ili1ation of the multi le3trauma atient and is recommended #ithin 95 h of in)ury& 7at em%olism and other com lications are decreased %y early internal fi"ation& Infection rates #ith intramedullary fi"ation are G&C to 6 ercent$ and e(en #ith o en fractures are in the range of G to 5 ercent& Infections are treated %y rod remo(al$ o(erreaming to remo(e infected %one and granulation tissue$ and re eat fi"ation #ith a larger rod in con)unction #ith a ro riate anti%iotic thera y& ?nion can %e redicta%ly e" ected in internally fi"ed femoral fractures in 6. to 9G #ee/s$ and delayed union rates are a ro"imately 6 to 9 ercent o(erall& In the resence of nonunion$ fatigue failure #ill e(entually result$ and the rod should %e remo(ed and re laced #ith a larger rod$ #hich #ill result in healing in the ma)ority of cases& Su racondylar 7emoral 7ractures Su racondylar fractures occur in all age grou s as a result of motor (ehicle accidents$ falls$ and other accidents& Patients usually resent #ith ain$ s#elling$ and deformity& Su racondylar fractures may %e trans(erse$ or T or M sha ed #ith an intraarticular s lit of the condyles& Enee stiffness is a ma)or late ro%lem #ith these fractures& Treatment ty ically is #ith s/eletal traction through a ti%ial in follo#ed %y cast3 %race mo%ili1ation& Patients #ith multi le trauma should %e treated %y o en reduction

and internal fi"ation #ith a %lade late$ dynamic com ression scre# and side late$ or intramedullary de(ice& E"tensi(e comminution fre0uently necessitates rimary %one grafting$ and em hasis should %e on initial accurate fi"ation of the condyles to ensure a congruous articular surface& Traumatic Distal 7emoral E i hyseal Se aration This in)ury results from hy ere"tension of the /nee in the adolescent& Treatment is #ith closed reduction and laster immo%ili1ation& Occasionally$ ercutaneous in fi"ation to maintain an unsta%le reduction is indicated& Enee In)uries to the ligaments and menisci of the /nee )oint are common in athletic acti(ities$ including contact s orts and s/iing& Diagnosis is strongly de endent on clinical e"amination$ since radiogra hs usually are normal& 4edial Collateral Ligament In)ury The medial collateral ligament +4CL, consists of %oth su erficial and dee layers$ #hich e"tend from the medial femoral e icondyle to the medial ro"imal ti%ia$ %lending #ith the ca sule and retinacular structures anteriorly and osteriorly& The anterior ortion is tight in fle"ion$ the osterior ortion tight in e"tension$ and the middle ortion tight throughout the range of motion& 8ith (algus stress to the 4CL$ the dee ca sular ortion ru tures first$ follo#ed %y the ti%ial collateral +su erficial ortion, and$ #ith e"treme force$ the anterior cruciate ligament +ACL,& Clinical findings (ary$ %ut #ith isolated 4CL tears they are generally locali1ed to the medial as ect of the /nee& Associated hemarthrosis may %e noted$ and usually there is local s#elling and tenderness& 8ith grade I and grade II artial tears$ ain #ith (algus stress #ith the /nee in 9G to -G degrees of fle"ion$ and slight o ening of the medial )oint line can occur& A%duction #ith o ening of the )oint line of more than C mm #ith (algus stress usually is diagnostic of a grade III ru ture of the 4CL& Com arison must %e made to the other /nee$ since %aseline la"ity (aries among atients& Integrity of the other ligaments of the /nee also must %e esta%lished %y careful e"amination to rule out com%ined in)uries& >arus stress testing #ith the /nee in 9G to -G degrees of fle"ion$ as descri%ed a%o(e for (algus testing$ is used to determine com etence of the lateral collateral ligament +LCL, and associated lateral com le"& Antero osterior translation of the ti%ia on the femur is tested #ith the /nee in .G to FG degrees of fle"ion +anterior dra#er test,& Ru ture of the ACL allo#s anterior translation and can %e e(aluated manually or #ith a de(ice called the ET36GGG$ #hich more accurately measures dis lacements& The Lachman test is a sensiti(e maneu(er for e(aluating antero osterior motion& The test is erformed #ith the /nee in 9G degrees of fle"ion$ #ith the e"aminer gras ing the distal thigh #ith one hand and the ro"imal ti%ia #ith the other #hile a lying translatory force& Again$ com arison to the unin)ured side is essential& La"ity in the Lachman test indicates ACL disru tion$ as does the i(ot shift maneu(er$ #hich indicates the resence of anterolateral rotatory insta%ility& This test is conducted %y e"tending the /nee #ith (algus stress a lied* a !clun/' in the last 6C degrees of e"tension indicates anterior su%lu"ation of the lateral ti%ia& The re(erse test elicits reduction %y fle"ing the /nee from full e"tension$ #ith a !clun/' again indicating

reduction of the anterior su%lu"ation& The osterior cruciate ligament +PCL, is e"amined using the re(erse dra#er testJforcing the ti%ia osteriorly #ith the /nee in .G to FG degrees of fle"ion& An alternati(e method is to ha(e the atient acti(ely e"tend the /nee #ith the foot fi"ed and the /nee fle"ed& Anterior translation of the ti%ia #ill %e o%ser(ed if the PCL is torn& Treatment Isolated 4CL tears #ill heal #ith conser(ati(e management consisting of a hinged cast or %race to re(ent (algus stress for . #ee/s$ follo#ed %y #eight %earing as tolerated unless the atient has e"cessi(e (algus /nee alignment& 8ith com%ined in)uries$ surgical re air is #arranted& Anterior Cruciate Ligament Ru ture Isolated tears of the ACL can result from hy ere"tension$ internal rotation of the ti%ia on the femur$ or a direct %lo# on a fle"ed /nee& 7ifty ercent of atients #ith acute isolated ACL tears ha(e an associated meniscal in)ury$ and 4CL or LCL in)uries are also common& ACL tears are the most common cause of chronic /nee disa%ility among athletes& The chronic rotatory su%lu"ation of an ACL3deficient /nee can lead to e isodes of gi(ing #ay and recurrent in)ury$ and in the long term to early degenerati(e arthritis& Treatment Patients #ith isolated ACL in)uries #ho do not engage in high3demand acti(ity +e&g&$ older atients and nonathletes, are treated #ith a eriod of immo%ili1ation to allo# healing of secondary restraints follo#ed %y an acti(e reha%ilitation rogram stressing hamstring strengthening and graduated 0uadrice s e"ercises& If sym tomatic insta%ility does not de(elo $ further inter(ention is unnecessary& In cases of com%ined insta%ility$ surgical re air of the collateral ligament along #ith rimary re air or reconstruction of the ACL is indicated$ es ecially in atients in(ol(ed in high3demand acti(ities& 4idsu%stance ACL ru tures$ #hich are the most common$ are difficult to re air rimarily and usually re0uire reconstruction #ith a tendon graft$ either from the semitendinosus or the middle third of the atellar tendon& Patellar tendon grafts are also used for late reconstructions and ha(e the ad(antage that %ony %loc/s remo(ed #ith each end of the graft can %e securely attached #ithin tunnels in the femur and ti%ia #ith scre# fi"ation& Synthetic materials +dacron$ car%on fi%er$ etc&, and allografts also ha(e %een used$ %ut the autologous atellar tendon remains the most often used su%stitute& Isometric lacement of the graft is essential to re(ent tension or la"ity throughout the range of motion& Arthrosco ic reconstruction of the ACL using a atellar tendon graft or other material is no# a routine a roach and allo#s recise lacement of the graft tunnels in the femur and ti%ia& A small anterior incision is used to har(est the atellar tendon graft #ithout re0uiring full arthrotomy& This less in(asi(e rocedure allo#s earlier reco(ery from surgery and earlier mo%ili1ation& 4eniscal athology can %e treated arthrosco ically at the same rocedure& Lateral Collateral Ligament In)ury

The LCL is disru ted %y (arus stress to the /nee$ usually in association #ith in)ury to the associated lateral com le" + osterolateral ca sule$ arcuate com le"$ o liteus tendon,& The eroneal ner(e also may %e in)ured #ith this mechanism& 8ith com lete in)uries$ surgical re air is generally recommended& Posterior Cruciate Ligament In)ury The PCL can %e in)ured %y a direct %lo# to the anterior /nee$ as in hitting a dash%oard$ or in com%ination #ith the ACL in hy ere"tension in)uries& The ratio of PCL to ACL in)uries is a%out 6L6G$ and isolated in)uries do not necessarily cause significant insta%ility& 4idsu%stance re airs ha(e %een associated #ith oor results$ %ut reattachment of a %ony a(ulsed fragment is recommended #hen resent& Chronic atellofemoral sym toms can result from PCL insufficiency$ and if sym toms are significant or if PCL ru ture is associated #ith an LCL disru tion$ surgical reconstruction$ usually #ith a atellar tendon graft$ is ad(ised& The same a lies to com%ined PCL;ACL in)uries$ in #hich chronic insta%ility usually follo#s conser(ati(e treatment& Com%ined In)uries Com%ined multi le3ligament in)uries not only increase the li/elihood that surgical re air #ill %e necessary %ut also raise the ossi%ility of /nee dislocation& Dislocation can %e associated #ith (ascular in)ury to the o liteal artery #ith intimal tear or intraluminal throm%us& >ascular in)ury may %e e(ident immediately or may %ecome e(ident se(eral days after the in)ury& Com artment syndrome in the leg also is a serious concern& Arteriogra hy is recommended in all cases of in)ury to %oth cruciate ligaments in com%ination #ith a collateral ligament in)ury$ in /no#n /nee dislocation$ and in cases #ith any suggestion of (ascular com romise& Chronic Ligamentous Insta%ility Persistent la"ity can cause ain and e isodic gi(ing #ay or loc/ing and re(ents artici ation in s orts and other acti(ities& 4inor degrees of insta%ility are managea%le #ith an e"ercise rogram and limitation of high3 demand acti(ities& 8ith sym tomatic insta%ility$ ligamentous reconstruction is indicated& ACL and PCL insta%ilities are reconstructed as descri%ed for acute in)uries& Stress radiogra hs are hel ful in defining la" structures causing the insta%ility #ith 4CL and LCL insufficiency$ and ca sular reefing or other reconstructi(e rocedures are hel ful& Reha%ilitation and osto erati(e care are e"tremely im ortant in o timi1ing the results of /nee ligament surgery$ %ecause of the tendency for /nee stiffness to de(elo & 7or /nees #ith inade0uate motion after osto erati(e reha%ilitation$ mani ulation under anesthesia$ or arthrosco ic lysis of adhesions follo#ed %y mani ulation and osto erati(e continuous assi(e motion can significantly im ro(e motion& Continuous3 assi(e3motion machines also are useful in im ro(ing osto erati(e /nee motion follo#ing fracture fi"ation and other routine /nee surgeries& 4eniscal In)uries The medial and lateral menisci of the /nee are com osed of fi%rocartilage$ triangular in cross3section$ and ser(e functions of load transmission$ sta%ility$ shoc/ a%sor tion$ and lu%rication& The eri heral 6G to -G ercent of the menisci and the anterior and osterior horn attachments are #ell (asculari1ed and allo# healing of tears& The inner t#o3thirds of the menisci$ ho#e(er$ are a(ascular$ recluding healing& The ti%ia

rotates laterally on the femur #ith /nee e"tension$ and medially #ith fle"ion& If this rotation is %loc/ed or forci%ly re(ersed$ the meniscus can %e in)ured& E"am les include catching a cleated shoe #ith #eight a lied to the fle"ed /nee$ or t#isting the /nee #hile in a s0uatting osition& The medial meniscus is in)ured more fre0uently than the lateral$ %ecause of its more constrained %y ca sular attachments& Se(eral atterns of meniscal in)ury are illustrated in 7ig& 563H.& 4eniscal tears are common as s orts in)uries and can resent #ith effusion$ a history of catching or loc/ing$ and /nee ain& Patients may ha(e )oint line tenderness$ limited /nee motion$ and a catching or !clic/' associated #ith ain during assi(e e"tension of the /nee in con)unction #ith manual rotation of the ti%ia and (arus or (algus stress +4ac4urrayAs test,& Clinical diagnosis sometimes is difficult& Arthrogra hy of the /nee is fairly relia%le in the diagnosis of medial meniscal tears +incidence FC ercent,$ %ut su%stantially less accurate in diagnosis of lateral meniscal tears +incidence DG ercent,$ o#ing to the distortion caused %y the o liteus tendon& 4RI$ ho#e(er$ ro(ides e"tremely accurate diagnosis of internal derangements of the /nee of all ty es$ including meniscal tears$ osteochondral in)uries$ and ACL or PCL tears& 2igh signal seen #ithin the menisci also can indicate my"oid degenerati(e change$ #hich is o(erinter reted as a tear& Treatment Diagnostic arthrosco y ro(ides another means of diagnosing meniscal in)ury accurately$ and surgical arthrosco y may %e erformed to re air or e"cise the torn fragment simultaneously& The menisci are im ortant sta%ili1ers of the /nee$ and retention of as much #ell3contoured eri hery of the meniscus as ossi%le is desira%le& Com lete meniscectomy is associated #ith late degenerati(e arthritic changes in the affected com artment& 7or the same reason$ eri heral tears in the (asculari1ed ortion of the menisci$ #hich #ill heal$ are treated %y re air or immo%ili1ation& If the )oint is unsta%le$ o erati(e re air of the tear #ith nona%sor%a%le sutures arthrosco ically or %y arthrotomy is indicated& If a eri heral tear is of artial thic/ness or the )oint is sta%le$ arthrosco ic de%ridement of the tear follo#ed %y immo%ili1ation often results in healing& In either case the function of the meniscus can %e retained& 4eniscal tears in association #ith insta%ility should not %e re aired unless the insta%ility is addressed also$ such as %y ACL reconstruction for anterolateral rotatory insta%ility& 8hen intraarticular athology has %een locali1ed %y 4RI or diagnostic arthrosco y$ surgical inter(ention often can %e carried out using arthrosco ic techni0ue$ and the ma)ority of meniscal lesions$ osteochondral lesions$ loose %odies$ syno(ial %ands$ de%ridement of fi%rillated articular cartilage$ and a%rasion arthro lasty rocedures are no# done arthrosco ically& The ad(antages of arthrosco ic surgery are minimal mor%idity$ decreased /nee stiffness and osto erati(e ain$ and more ra id reha%ilitation and return to function& ?sing a small diagnostic arthrosco e in con)unction #ith a (ideo camera allo#s documentation of the athology and (ie#ing of the rocedure %y others& Small ortals are used to introduce the arthrosco e and surgical instruments into the )oint& ?sing the techni0ue of triangulation$ the surgeon can mani ulate o%)ects #ithin the /nee$ e"cise torn menisci$ and sha(e or de%ride cartilage&

4ost surgeons use anterolateral and anteromedial ortals for diagnosis and most routine rocedures& The /nee is distended #ith saline solution in)ected through a ortal in the su ra atellar ouch& 4otori1ed sha(ers and cutting tools allo# ra id resection of syno(ial$ meniscal$ or cartilaginous tissue and a%rasion of %one to romote fi%rocartilage re air& The general techni0ue of surgical /nee arthrosco y is illustrated in 7ig& 563 HD& This techni0ue has more recently %een a lied to a num%er of other )oints$ including the shoulder$ hi $ an/le$ and el%o# for diagnosis$ and to a limited e"tent$ treatment& 7or se(ere meniscal in)uries$ meniscal trans lants +allografts, ha(e %een used$ %ut this rocedure is e" erimental and a#aits further e(aluation of outcome& Patellar 7ractures 7ractures of the atella usually occur as a result of direct trauma to the anterior /nee %ut also can occur #ith forced fle"ion of the /nee against acti(e contraction of the 0uadrice s muscle& The atella is an integral art of the e"tensor mechanism$ and disru tion of the continuity of the mechanism results in ina%ility to acti(ely e"tend the /nee& Ru tures of the 0uadrice s tendon or atellar tendon result from the same mechanism of in)ury and also resent #ith lac/ of acti(e e"tension and #ith tenderness and al a%le defect o(er the ru tured tendon& 7ractures may %e trans(erse$ comminuted$ or stellate& Treatment Nondis laced fractures are treated %y immo%ili1ation in a cylinder cast in full e"tension for . to H #ee/s& If se aration of the fragments is resent at the time of resentation or during later treatment$ surgical treatment is indicated& If the fracture is comminuted$ e"cision of the smaller fragments$ #ith attachment of the atellar or 0uadrice s tendon to the larger fragment using #ires or hea(y nona%sor%a%le sutures through drill holes$ is erformed& 7or trans(erse fractures$ the tension %and #iring techni0ue is recommended$ #ith t#o arallel Eirschner #ires laced longitudinally through the fragments and a figure3of3eight #ire loo ed o(er these anteriorly& This arrangement con(erts tensile force of 0uadrice s contraction into com ressi(e force at the fracture site& The retinaculum is re aired and the /nee immo%ili1ed in a cylinder cast or /nee immo%ili1er in e"tension& In cases of e"treme comminution$ rimary e"cision of the atella #ith retinacular re air is recommended& In all in)uries$ during e"tension immo%ili1ation acti(e 0uadrice s e"ercises are started immediately& Range3 of3motion e"ercises are started at 5 to . #ee/s& Tendon Ru tures Ru tures of the 0uadrice s and atellar tendons are similarly treated$ using hea(y #ire or nona%sor%a%le sutures through drill holes in the atella$ follo#ed %y immo%ili1ation in e"tension& After 5 to . #ee/s$ immo%ili1ation is discontinued and range3of3motion e"ercises started& Patellar Dislocation Lateral dislocation of the atella is relati(ely common$ articularly in young #omen and girls& 4edial dislocation is uncommon %ut occasionally occurs #ith se(ere in)ury or after oliomyelitis& The higher incidence in females is related to the increased

(algus of the /nee in #omen& 2y o lastic de(elo ment of the lateral femoral condyle also can cause atellar dislocations& The atient com lains of the /nee gi(ing #ay as the atella dislocates laterally and usually then s ontaneously reduces& Occasionally the atella %ecomes entra ed lateral to the femoral condyle and re0uires mani ulati(e reduction& After reduction the atient may ha(e effusion and mild ain& 7or an acute first3time dislocation$ treatment is #ith immo%ili1ation in a cylinder cast in full e"tension to allo# healing of the torn medial retinaculum$ #hich may decrease the li/elihood of recurrence& In some cases a small osteochondral fracture of the atella is resent and should %e re aired arthrosco ically& 7or recurrent dislocations$ initial efforts are directed to#ard strengthening the 0uadrice s mechanism #ith straight3leg3raising e"ercises& If sym toms of su%lu"ation ersist$ either a %ony or soft3tissue realignment rocedure is indicated& Soft3tissue rocedures include lateral retinacular release #ith or #ithout medial reefing of the retinaculum and InsallAs ro"imal tu%e realignment rocedure +lateral release #ith im%rication of the lateral retinaculum o(er the 0uadrice s tendon to the medial retinaculum,& In s/eletally mature indi(iduals$ the medial ad(ancement of the ti%ial tu%ercle of 2auser$ or in cases #ith atellofemoral ain and chondromalacia$ the anteromedial ele(ation of the ti%ial tu%ercle of 4a0uet is a lica%le& 8hile these rocedures all im ro(e the incidence of dislocation and su%lu"ation$ ain relief has not %een nearly as redicta%le& The rocedure of sim le lateral retinacular release has come under greater scrutiny in light of e" erimental results suggesting that it may %e less effecti(e than re(iously ur orted& Posto erati(ely$ a ro riate 0uadrice s reha%ilitati(e e"ercises are im ortant& Progressi(e chondromalacia necessitates further surgical inter(ention such as arthrosco ic chondral de%ridement or$ in se(ere cases$ atellectomy& Ti%ial Plateau 7ractures 7ractures of the ti%ial lateau most commonly occur in the middle3aged or elderly o ulation$ although falls from a height or motor (ehicle accidents can cause this in)ury in younger ersons& 4ost often the in)ury results from a (algus stress to the /nee #ith a"ial loading& The lateral lateau is more fre0uently in(ol(ed +.G ercent* medial 6C ercent* %icondylar 9C ercent,& Associated in)uries to the medial collateral ligament often occur& The ma)or ty es include local com ression$ s lit fractures of the lateral lateau$ de ressed fractures of the lateral lateau$ comminuted +s lit3 de ression, lateral lateau fractures$ and %icondylar fractures& Tomograms or CT scans often are hel ful in assessing the e"tent of the in)ury$ articularly if internal fi"ation is contem lated& Treatment Patients #ith intact collateral ligaments and less than 6G degrees of insta%ility +less than 6G mm )oint line de ression, can %e treated conser(ati(ely$ #ith %race or cast immo%ili1ation and rotected #eight %earing$ es ecially in atients o(er CG years of age and those #ith osteo enia$ lo#3demand acti(ity le(el$ or medical contraindications to o eration& Patients #ith more than 6G degrees of insta%ility in e"tension or ma)or ligamentous in)uries$ younger atients$ and those #ith high3 demand acti(ity le(els are candidates for surgical treatment&

Surgical inter(ention consists of ele(ation of de ressed articular surfaces$ #ith su orti(e %one grafting if necessary$ and internal fi"ation ranging from one or more large cancellous scre#s to medial$ lateral$ or %ilateral %uttress lates in more se(erely comminuted fractures& Ru tured collateral ligaments are re aired rimarily& E(ery effort should %e made to a(oid (arus alignment$ #hich is associated #ith a #orse rognosis& Posto erati(ely$ continuous assi(e motion aids in reco(ery of range of motion$ and a hinged orthosis or cast %race is used in con)unction #ith rotected #eight %earing$ #hich must %e continued for H to 69 #ee/s$ de ending on the 0uality of the %one$ comminution of the fracture$ and sta%ility of the internal fi"ation& Lo#er Leg Ti%ial Shaft 7ractures Ti%ial shaft fractures result from direct trauma such as in motor (ehicle and motorcycle accidents$ s orts$ s/iing$ and falls& All age grou s are affected$ and a%out -G ercent are o en in)uries and DG ercent closed& >arious fracture atterns occur$ de ending on the mechanism of in)ury +7ig& 563 HH,& The rate of healing is slo#er in fractures that are o en$ comminuted$ or associated #ith significant soft3tissue in)ury& ?ndis laced fractures resent #ith local ain$ s#elling$ and the ina%ility to %ear #eight$ %ut #ithout o%(ious deformity& Dis laced or angulated fractures e"hi%it o%(ious deformity on hysical e"amination& Attention must %e gi(en to careful neuro(ascular e"amination of the e"tremity$ #ith es ecial attention to any signs of com artment syndrome& Treatment Closed ti%ial shaft fractures are %est handled %y conser(ati(e treatment$ #ith closed reduction and long leg casting& Early #eight %earing can e" edite healing and function& In general$ some angulation in the antero osterior direction is acce ta%le gi(en the com ensatory motion of the /nee and an/le in the same lane& >arus or (algus angulation of more than C degrees should %e corrected if ossi%le %y mani ulation or #edging of the cast& If ade0uate alignment cannot %e achie(ed$ internal fi"ation #ith lating or$ refera%ly$ #ith unreamed intramedullary loc/ed or unloc/ed nailing is ad(isa%le& Internal fi"ation is indicated in the multi le3trauma atient to facilitate immediate mo%ili1ation& If significant s#elling is resent$ the atient is admitted to the hos ital for ele(ation and o%ser(ation of the e"tremity& Progressi(e ain or neuro(ascular sym toms mandate s litting the cast and underlying soft adding$ and if the sym toms fail to rom tly resol(e$ measurement of com artment ressures as re(iously descri%ed& The ma)ority of these fractures can readily %e treated closed& The cast is changed to a atellar tendon %earing cast or fracture orthosis at - to . #ee/s$ and #eight %earing is ermitted as tolerated& Closed ti%ial fractures generally unite in 69 to 6. #ee/s$ de ending on fracture attern and atient age& O en fractures of the ti%ia are treated %y rimary de%ridement as re(iously descri%ed& E"ternal fi"ation is the most common a roach to fracture sta%ili1ation$ articularly in grade III in)uries +7ig& 563HF,& Grade I or grade II fractures can %e treated %y cast$ %ut if satisfactory alignment cannot %e o%tained$ e"ternal or internal fi"ation is a ro riate& The recent de(elo ment of unreamed loc/ed ti%ial nails has greatly e"tended the indications for surgical treatment* se(eral series ha(e sho#n rates of infection to %e no higher than #ith closed management of grade I and grade II

in)uries& In cases of significant soft3tissue loss$ early co(erage #ith a local gastrocnemius fla +in ro"imal fractures,$ a soleus fla +in midshaft fractures,$ or free (asculari1ed tissue transfers +latissimus dorsi or rectus a%dominis, is recommended and decreases the infection rate& Pro hylactic fasciotomies at the time of rimary de%ridement decrease the ris/ of de(elo ment of com artment syndrome$ and neuro(ascular status should %e follo#ed closely osto erati(ely& Second3loo/ dressing change and de%ridement is recommended in all grade II and grade III in)uries #ithin 95 to 5H h$ and intra(enous anti%iotics should %e continued for D to 65 days& In cases of delayed healing$ #hich is relati(ely common #ith o en ti%ial fractures$ early osterolateral cancellous %one grafting or fi%ular osteotomy to im ro(e load transmission across the fracture can %e considered& Electrical stimulation is useful in delayed union and nonunion& An/le The ti%iotalar articulation functions as a hinge )oint$ #ith nearly all rotational motion in in(ersion and e(ersion occurring at the su%talar )oint& The mortise of the an/le is formed %y the do#n#ard ro)ecting medial and lateral malleoli$ #hich constrain the motion of the talus& The talus is largely co(ered #ith articular cartilage$ #ith the %lood su ly rimarily coming through a ring of (essels surrounding the nec/& A normal mortise is re0uired for sta%ility of the an/le and ainless motion& Additional sta%ility of the talus in the mortise is ro(ided %y the distal ti%iofi%ular ligaments +syndesmosis,$ interosseus mem%rane$ calcaneofi%ular ligament laterally$ and the deltoid ligament medially& An/le in)uries are caused %y a sudden force that e"ceeds the strength of either the malleoli or ligaments& An/le in)uries are classified according to the osition of the an/le and foot at the time of the in)ury$ %ased on e" erimental #or/ %y Lauge3 2ansen& These ositions include su ination3 adduction$ su ination3e(ersion +e"ternal rotation,$ ronation3a%duction$ and ronation3e(ersion& Su ination3adduction fractures result in trans(erse fracture of the lateral malleolus #ith or #ithout adduction fracture of the medial malleolus& Su ination3e(ersion fractures are descri%ed in four stages of rogressi(e in)ury in(ol(ing tear of anterior ti%iofi%ular ligament$ s iral o%li0ue fracture of the lateral malleolus$ fracture of the osterior li of the ti%ia$ and fracture of the medial malleolus or deltoid ligament tear& Pronation3 a%duction fractures se0uentially result in medial malleolar fracture or deltoid ligament ru ture$ syndesmosis disru tion$ osterior ti%ial li fracture$ and su ramalleolar fracture of the fi%ula& Pronation3e(ersion in)uries cause medial malleolar;deltoid disru tion$ anterior ti%iofi%ular disru tion$ s iral su ramalleolar fi%ular fracture$ and osterior ti%ial li fracture& The in)ured an/le should %e carefully e"amined for locali1ation of tenderness$ s#elling$ and deformity& A%ility to %ear #eight does not rule out significant in)ury& The an/le can %e s linted #ith a laster s lint or air s lint until radiogra hs are o%tained& Antero osterior$ lateral$ and mortise radiogra hic (ie#s are necessary for ade0uate e(aluation of an/le in)uries& The mortise (ie# is an AP film ta/en in -G degrees of internal rotation$ #hich laces the malleoli in the same coronal lane& Ligamentous In)uries

The most common in)ury is in(ersion s rain of the lateral ligaments of the an/le& The anterior talofi%ular ligament usually is in(ol(ed$ #ith local tenderness and ecchymosis o(er it& 7or grade I and grade II s rains$ am%ulatory treatment #ith ta ing or an air s lint is ade0uate& 7or more se(ere grade III s rains$ rotected #eight %earing and cast or s lint immo%ili1ation are indicated for 9 to 5 #ee/s$ follo#ed %y range3of3motion and muscle strengthening e"ercises& 7or recurrent in(ersion s rains$ re air of the anterior talofi%ular and fi%ular collateral ligaments follo#ing the :rostrom3Gould method may ro(ide satisfactory sta%ility #ithout e"cessi(e su%talar )oint stiffness +7ig& 563FG,& Preo erati(ely$ in(ersion insta%ility is identified %y in(ersion stress radiogra hs demonstrating more than 6G degrees of difference in the talar tilt as com ared to the unin)ured side& 7or atients #ith generali1ed ligamentous la"ity or failed re airs$ reconstruction of the calcaneofi%ular and anterior talofi%ular ligaments using a sli of the eroneus %re(is tendon can %e erformed +E(ans or Chrisman3Snoo/s rocedures,& Distal Ti%iofi%ular Diastasis E(ersion in)uries to the an/le can result in disru tion of the anterior and osterior ti%iofi%ular ligaments +syndesmosis,$ #ith #idening of the an/le mortise& 4aintenance of an ade0uate closed reduction is difficult$ since more than 6 to 9 mm of talar shift in a young erson causes significant alteration of stresses in the articular cartilage of the an/le )oint and is unacce ta%le& A 4aisonneu(e fracture is a fracture of the ro"imal fi%ula in association #ith syndesmotic diastasis$ resulting from ro"imal ro agation of the e"ternal rotation force from the talus along the interosseus mem%rane& Surgical treatment of ti%iofi%ular diastasis consists of closed or$ rarely$ o en reduction #ith lacement of a syndesmosis scre# through the fi%ula )ust a%o(e the syndesmosis$ affi"ing it to the ti%ia& The foot should %e in the neutral osition and not in lantar fle"ion$ as the narro#er #idth of the osterior talus #ould allo# o(erreduction and su%se0uent limitation of dorsifle"ion& A short leg cast is a lied and #eight %earing a(oided for H #ee/s to re(ent scre# %rea/age$ and then the scre# is remo(ed and #eight %earing ermitted as tolerated& 4alleolar 7ractures and Dislocations ?ndis laced fractures of the malleoli re0uire immo%ili1ation in a cast for a ro"imately H #ee/s& The most common fracture is an isolated$ minimally dis laced o%li0ue fracture of the lateral malleolus caused %y e"ternal rotation& Dis laced fractures are treated %y closed reduction$ re(ersing the direction of a lied force that caused the in)ury& If anatomic restoration of the mortise is not accom lished$ o en reduction and internal fi"ation #ith scre#s or a small %uttress late is recommended& 4edial 4alleolar 7ractures ?ndis laced fractures are treated #ith laster immo%ili1ation& :imalleolar fractures #ith disru tion of the mortise re0uire accurate reduction$ and the ma)ority can %e treated conser(ati(ely& Closed reduction is erformed under local anesthesia or #ith intra(enous sedation$ #ith the leg hanging o(er the end of the ta%le& Longitudinal manual traction is a lied and the foot is in(erted and internally rotated as it is %rought u to FG degrees& A #ell3 molded long leg cast is a lied and chec/ radiogra hs o%tained& 4ore than 6 to 9 mm of dis lacement usually re0uires o en

reduction and internal fi"ation& The medial malleolus usually is fi"ed #ith one or t#o scre#s and the fi%ula #ith interfragmentary scre#s or a small %uttress late +7ig& 563 F6,& Posterior 4alleolar 7ractures The osterior malleolus usually is fractured in com%ination #ith the medial or lateral malleolus& If the fragment com rises less than -G ercent of the articular surface$ accurate reduction is not im ortant$ %ut #ith larger fragments$ antero osterior insta%ility #ill result from residual dis lacement& Therefore$ #ith larger fragments$ scre# fi"ation after o en or indirect closed reduction is indicated& Pilon 7ractures Pilon fractures are se(erely comminuted fractures of the an/le and distal ti%ia$ usually resulting from high3energy a"ial in)ury$ and often in(ol(ing rimarily the anterior li of the ti%ial lafond& >ertical com ression dri(es the talus into the ti%ial lafond$ and the entire distal ti%ia can %e comminuted& If e"cessi(e comminution is not resent$ o en reduction and internal fi"ation of the fragments is a ro riate& In the face of osteo enia or se(ere comminution$ e"ternal fi"ation$ augmented in some cases %y limited fi"ation of one or more larger fragments$ is the treatment of choice& Pro%lems #ith osttraumatic arthritis and an/le stiffness are common #ith these in)uries$ and later arthrodesis is often necessary& 7oot 7ractures and Dislocations of the Talus Talus fractures usually occur through the nec/$ although the %ody can %e in(ol(ed& The usual mechanism is forci%le dorsifle"ion of the foot$ im inging the nec/ on the anterior li of the distal ti%ia& In more se(ere in)uries$ su%talar dislocation is associated #ith the talar fracture& The most se(ere fracture3dislocations in(ol(e dislocation of the talus from %oth the su%talar and an/le )oints$ usually #ith osterior e"trusion of the talar %ody& Isolated su%talar dislocations can also occur #ithout talar nec/ fractures$ either medially or laterally from lantar fle"ion forces #ith in(ersion or e(ersion& 2a#/ins has classified talar fractures as follo#sL Ty e IJnondis laced fracture of the nec/ of the talus Ty e IIJdis laced fracture of the talar nec/ #ith su%talar dislocation Ty e IIIJdis laced talar nec/ fracture #ith su%talar and an/le dislocation of the %ody of the talus Ty e I>Jdis laced talar nec/ fracture #ith su%talar$ an/le$ and talona(icular dislocation The ma)or com lication of these in)uries is osteonecrosis of the %ody of the talus$ #hich is rimarily su lied #ith %lood through the nec/ of the talus& Osteonecrosis has %een re orted to occur in G to 6- ercent of ty e I fractures$ 9G to CG ercent of ty e II fractures$ and H- to 6GG ercent of ty e III fractures& The %est indication of

(ia%ility of the talus after treatment of the in)ury is su%chondral lucency in the talus$ #hich should %e resent . to H #ee/s %ecause of disuse resor tion& Treatment Ty e I fractures are treated closed$ #ith short leg cast immo%ili1ation for - months& Ty e II fractures are treated similarly$ %ut if anatomic reduction of the talar nec/ is not achie(ed$ o en reduction and internal fi"ation are recommended& All ty e II in)uries re0uire o en reduction and internal fi"ation& In cases in #hich osteonecrosis de(elo s$ rolonged rotected #eight %earing in a atellar tendon %earing %race has %een ad(ocated& If colla se of the %ody occurs$ secondary arthritis #ill de(elo $ and an/le arthrodesis is often necessary& The :lair3 ty e fusion$ in #hich a strut of anterior ti%ial corte" is slid do#n into the talar nec/ +#ith or #ithout scre# fi"ation,$ is used for this condition& Isolated su%talar dislocations usually are treated %y closed reduction& Occasionally the talar head is %uttonholed through the anterior ca sule$ or inter osition of the e"tensor %re(is muscle +medial dislocations, or osterior ti%ial tendon +lateral dislocations, %loc/s closed reduction& The dislocations generally are fairly sta%le after closed or o en reduction$ and immo%ili1ation in a short leg cast for - to 5 #ee/s is follo#ed %y range3of3 motion e"ercises& Calcaneus 7ractures 7ractures of the calcaneus usually result from falls from a height$ #ith a"ial loading of the lo#er e"tremity& Ten ercent of calcaneal fractures are associated #ith com ression fractures in the thoracic or lum%ar s ine$ and 9. ercent #ith other lo#er3e"tremity in)uries& The fi(e ma)or ty es of calcaneus fractures are e"traarticular fractures$ a(ulsion fractures$ tongue ty e fractures$ )oint de ression fractures$ and comminuted fractures +7ig& 563F9,& Treatment Treatment is contro(ersial$ ranging from %rief immo%ili1ation #ith early range3of3 motion e"ercises to internal fi"ation #ith %one grafting& Pro%lems caused %y fractures of the calcaneus include #idening of the heel$ loss of height of the hindfoot$ and disru tion of the su%talar )oint$ #hich can result in loss of in(ersion;e(ersion and su%talar arthritis& In general all atients #ith significant calcaneus fractures should %e hos itali1ed$ as se(ere s#elling and s/in %rea/do#n can occur& Nondis laced fractures can %e treated #ith 9 #ee/s of immo%ili1ation follo#ed %y acti(e range3of3 motion e"ercises$ and rotection of #eight %earing for . to H #ee/s$ de ending on the fracture ty e& The most se(ere fractures in(ol(e the su%talar )oint$ #ith t#o ma)or ty es$ tongue and )oint de ression& In %oth ty es$ incongruity of the su%talar )oint can result$ and ad(ocates of no reduction$ closed reduction$ and o en reduction and internal fi"ation disagree as to #hich a roach to ta/e #ith these in)uries& :OhlerAs angle +the angle measured %et#een a line across the calcaneal tu%erosity and a line across the anterior and osterior su%talar )oint* normal range is 9C to 5G degrees, is usually flattened %y intraarticular fractures +see 7ig& 563F9,& CT scans may hel to %etter define the fracture attern& There has %een rene#ed interest in internal fi"ation to anatomically restore the su%talar )oint& In young$ acti(e atients #ith intraarticular fractures$ current

recommendations are for ele(ation of the su%talar )oint #ith o en reduction through a lateral a roach$ and %one grafting if necessary& The lateral #all is reduced and fi"ed #ith a %uttress late$ #hich also sta%ili1es the medial sustentaculum and sagittal disru tion of the calcaneus& Com%ined medial and lateral a roaches can %e used& Pro%lems remain$ though* lateral #ound healing is the most significant early ro%lem$ and ersistent long3term su%talar stiffness and ain may occur& 7or se(ere late su%talar arthritis$ su%talar fusion or tri le arthrodesis is a ro riate& Intraarticular calcaneus fractures re0uire strictly rotected #eight %earing for a full - months& 4etatarsal 7ractures 7ifth 4etatarsal 7ractures A(ulsion fractures of the %ase of the fifth metatarsal are commonly associated #ith in(ersion in)uries of the foot& The contraction of the eroneus %re(is muscle causes the a(ulsion& The atient often has an associated lateral an/le ligament s rain and resents #ith ain and s#elling laterally$ local tenderness$ and ina%ility to %ear #eight& Treatment ranges from sym tomatic +elastic PAceQ %andage #ra ing and rotected #eight %earing on crutches until comforta%le, to short leg cast immo%ili1ation for 5 to . #ee/s& 7i%rous union of the a(ulsed fragment is common %ut rarely causes ro%lems& The dia hyseal or meta hyseal fracture of the fifth metatarsal +<ones fracture,$ usually caused %y torsional force on the forefoot$ can ha(e mar/edly delayed healing$ and nonunion is common& Some ad(ocate rimary internal fi"ation of the <ones fracture using an intramedullary scre# or a small late$ #hile others endorse conser(ati(e treatment #ith cast immo%ili1ation and rotected #eight %earing for 9 to - months$ #ith surgical inter(ention +internal fi"ation and local %one grafting, only if nonunion occurs& Other 4etatarsal 7ractures Single metatarsal fractures are readily treated #ith short leg cast immo%ili1ation for . #ee/s& 7racture3dislocations occur at the tarsometatarsal )unction$ often in association #ith metatarsal %ase fractures& Generally$ closed reduction is recommended$ %ut o en reduction #ith Eirschner3#ire fi"ation is indicated in some cases& :uc/le fractures of the cu%oid may %e associated #ith dislocation or su%lu"ation of the tarsometatarsal +Lisfranc, )oint& These in)uries are unsta%le and re0uire o en or closed reduction #ith Eirschner3#ire fi"ation of %oth the medial and lateral columns of the foot& Phalangeal 7ractures Phalangeal fractures commonly result from direct trauma$ such as %eing struc/ %y a dro ed o%)ect or stri/ing the toe against an o%)ect& Dislocation of the IP or 4TP )oints also can occur& Treatment is directed at alignment and ain relief& Generally closed reduction can %e accom lished$ and %uddy ta ing of the affected toe to an ad)acent toe is ade0uate for rotection& Pel(ic In)uries Aceta%ular 7ractures and 2i Dislocations Dislocation of the hi is caused %y force a lied to the femur and can %e associated #ith fractures of the aceta%ulum or femoral head& The most common mechanism of in)ury is motor (ehicle accidents$ although falls from a significant height can cause hi dislocations& Position of the lim% and direction of a lied force determine the

direction of the dislocation& 7orce a lied to an a%ducted hi can result in anterior dislocation$ and stri/ing the /nee on a car dash%oard #ith the hi fle"ed and adducted causes osterior dislocations$ often #ith fracture of the osterior #all of the aceta%ulum +7ig& 563F-,& Direct trauma to the greater trochanter can result in medial #all fractures or central aceta%ular fracture3dislocations& Thorough e(aluation of aceta%ular fractures re0uires 5C3degree o%li0ue (ie#s +<udet (ie#, of the el(is to assess the integrity of the anterior +ilio u%ic, and osterior +ilioischial, columns and the anterior and osterior #all +aceta%ular rim,& In addition$ CT scans are hel ful$ articularly #ith the ne#er three3dimensional reconstructions$ in fully delineating fracture atterns and demonstrating the resence of any intraarticular %one fragments& Aceta%ular fractures ha(e %een classified %y Tile$ as sho#n in Ta%le 56365$ #ith trans(erse forms re resenting a dissociation of the anterior and osterior columns& Patients #ith aceta%ular fractures often ha(e other ma)or in)uries$ and careful e(aluation of the chest$ a%domen$ s ine$ and neurologic status is necessary& Prom t reduction of hi dislocations is essential in minimi1ing the incidence of osteonecrosis of the femoral head& Anterior 2i Dislocations These in)uries result from forced a%duction or antero osterior force to an a%ducted thigh* they are much less common than osterior dislocations +6G to 6H ercent of hi dislocations,& There are t#o %asic ty esJthe su erior or u%ic ty e and the inferior or o%turator ty e& The anteriorly dis laced femoral head can com romise neuro(ascular structures& :oth ty es result from a%duction and e"ternal rotation$ %ut #ith additional e"tension for the u%ic ty e and fle"ion for the o%turator ty e& 7emoral head fractures occur in a significant ercentage of cases$ and late osteonecrosis occurs in a%out 6G ercent& There is a high incidence of late osttraumatic arthritis& The atient resents #ith the lo#er e"tremity a%ducted and e"ternally rotated& Reduction is accom lished$ usually under general anesthesia$ %y longitudinal traction #ith su%se0uent fle"ion and internal rotation& If the CT scan or radiogra hs demonstrate intraarticular fragments$ arthrotomy and fragment remo(al is indicated& Posto erati(ely the atient is maintained in light traction for 6 to 9 #ee/s$ and range3of3 motion e"ercises are initiated& The atient is mo%ili1ed on crutches$ #ith rotected #eight %earing for . #ee/s& Posterior 2i Dislocations Posterior hi dislocations can %e associated #ith osterior #all fractures +7ig& 563F5,$ #hich significantly im airs sta%ility of the dislocation after reduction if the fragment is large& The atient resents #ith the thigh adducted$ internally rotated$ and fle"ed& 7emoral head or nec/ fractures are sometimes associated$ and sciatic ner(e in)uries are resent in 6G ercent& Reduction usually is accom lished %y longitudinal traction$ follo#ed %y gentle a%duction and e"ternal rotation& If the reduction is unsta%le$ fi"ation of the osterior #all is indicated +see 7ig& 563F5,& A CT scan to rule out the resence of intraarticular fragments is im ortant$ and if any are resent$ surgical remo(al is necessary& Prom tness of reduction is im ortant to minimi1e the chances of late osteonecrosis of the femoral head$ #hich has %een re orted to range from 6G to CG ercent and is often not e(ident for se(eral years after the in)ury& After reduction the atient is laced in light traction for 6 to 9 #ee/s$ or until comforta%le range of

motion is reco(ered& Protected #eight %earing and use of crutches are re0uired for 5 to . #ee/s& Posttraumatic arthritis de(elo s in a high ercentage of atients from C to -G years after in)ury& 7ractures of the 4edial and Su erior Aceta%ulum If the su erior dome of the aceta%ulum is intact$ the fracture can %e treated #ith s/eletal traction for H to 69 #ee/s$ although more aggressi(e treatment of dis laced aceta%ular fractures is also racticed& In young$ acti(e atients$ restoration of an anatomic aceta%ulum resents or decreases the se(erity of osttraumatic arthritis$ and lea(es %etter %one stoc/ for later reconstructi(e o tions such as arthrodesis or total hi arthro lasty in the e(ent that arthritic change does occur& 7or o en reduction and internal fi"ation of aceta%ular fractures$ anterior +ilioinguinal,$ osterior +Eocher3Langen%ec/,$ or com%ined a roaches can %e used$ de ending on the fracture attern& Remo(al of the greater trochanter %y osteotomy ma/es reduction easier$ articularly if there is a trans(erse intercolumn fracture com onent$ and internal fi"ation is facilitated %y use of ne#er de(ices such as el(ic reduction force s$ a femoral distractor$ and readily contoura%le reconstruction lates& Through these a roaches$ accurate reduction and internal fi"ation of com le"$ se(erely dis laced fractures is ossi%le +7ig& 563FC,& Generally$ the o eration is delayed C to D days until the atient is sta%ili1ed$ %ecause immediate surgery can %e associated #ith significant %lood loss& Posto erati(e com lications include throm%oem%olic disease$ heteroto ic %one formation$ hi stiffness$ and late osteonecrosis of either aceta%ular fragments or the femoral head& Pel(ic 7ractures The el(is is an intact ring that rotects the (iscera and transmits mechanical #eight3 %earing force from the s ine and a"ial s/eleton to the lo#er e"tremities& Li/e aceta%ular fractures$ el(ic fractures most commonly result from relati(ely high3 energy trauma such as motor (ehicle accidents$ although a significant num%er of u%ic ramus fractures occur from sim le falls$ articularly in the elderly& Patients resent #ith ain in the el(ic area$ ina%ility to %ear #eight$ ecchymosis$ and local tenderness& Often these indi(iduals are (ictims of multi le trauma and are hemodynamically unsta%le& 8hen the el(is is fractured or disru ted$ a large amount of %leeding into the el(is and retro eritoneum can occur$ aggra(ated %y the fact that the intra el(ic (olume is no longer constrained and the tam onade of (enous %leeding that #ould occur #ith an intact el(ic ring cannot occur& Inlet and outlet (ie#s of the el(is are essential to assess the integrity of the ring$ and CT scans are e"tremely hel ful in e(aluating the e"tent of %ony and ligamentous disru tion& Treatment Sta%ili1ation of the atient and assessment of associated in)uries are essential& If the atient is in shoc/ and does not res ond to standard (olume re lacement thera y$ a lication of an anterior e"ternal fi"ator in the emergency de artment #ith t#o or three ins in each iliac crest can hel significantly to contain hemorrhage and sta%ili1e the atient for further diagnostic e(aluation& A ro"imately 6G ercent of atients ha(e %ladder or urethral in)uries$ necessitating urologic e(aluation& Neurologic function also must %e carefully assessed %ecause of ossi%le lum%osacral le"us in)uries& Pel(ic fractures ha(e %een classified %y Moung into four ma)or ty es

according to the mechanism of in)uryL lateral com ression +LC,$ antero osterior com ression +APC,$ (ertical shear +>S,$ and com%ined mechanism +C4,& LC fractures in(ol(e u%ic rami fractures$ #ith or #ithout sacral com ression in)ury$ iliac #ing fracture$ or disru tion of the sacroiliac )oint on one side& APC in)uries in(ol(e sym hysis diastasis$ #ith (arying degrees of sacroiliac )oint disru tion& >S in)uries in(ol(e (ertical dis lacement of one side of the el(is& A similar classification system has %een ro osed %y Tile$ #ith ty e A +sta%le, e0ui(alent to lo#3grade LC in)uries* ty e : +rotationally unsta%le %ut (ertically sta%le, e0ui(alent to higher3grade LC in)uries or APC in)uries* and ty e C +rotationally and (ertically unsta%le, e0ui(alent to >S and C4& The ma)ority of el(ic fractures can %e treated #ithout surgical inter(ention& Ty e A or LC fractures usually are sta%le and can %e treated conser(ati(ely #ith %ed rest and su%se0uent rotected #eight %earing& APC in)uries are (ertically sta%le %ut not rotationally sta%le& 7ractures #ith significant sym hysis diastasis +greater than - cm, can %e treated #ith lacement of an anterior fi"ator or lating& In multi ly in)ured atients$ this a roach facilitates ra id mo%ili1ation& In APC in)uries #ith significant sacroiliac )oint disru tion or %ilateral disru tion$ osterior internal fi"ation #ith lates or sacral %ars often is indicated& >S in)uries re0uire s/eletal traction$ %ut if there is more than 6 to 9 cm of su erior dis lacement$ internal fi"ation anteriorly and osteriorly should %e considered +7ig& 563 F.,& Sacral and coccygeal fractures generally are treated sym tomatically& Neurologic deficits associated #ith sacral fractures usually occur in traction in)uries$ and reco(ery often is oor and not im ro(ed %y surgical decom ression& S inal In)uries 7ractures and dislocations of the cer(ical$ lum%ar$ and thoracic s ine most commonly follo# ma)or trauma such as motor (ehicle accidents or falls from a height& O(erall rognosis de ends on associated s inal cord or ner(e root in)uries& Any atient #ho com lains of nec/ or %ac/ ain or tenderness after an accident should %e assumed to ha(e an unsta%le s ine until ade0uate radiogra hic e(aluation can %e carried out& 7or nec/ in)uries$ sand%ags can %e used for tem orary sta%ili1ation and trans ort$ follo#ed %y a lication of a hard cer(ical collar such as a Philadel hia collar& Patients #ith thoracolum%ar in)uries are laced on a rigid %ac/%oard for trans ort& Neurologic e"amination should %e conducted as soon as ossi%le$ after attention to chest$ a%dominal$ and other in)uries& Antero osterior and lateral radiogra hs of the cer(ical$ thoracic$ and lum%ar s ine are o%tained %efore mo(ing the atient from the %ac/%oard& Lateral radiogra hs of the cer(ical s ine must include the CD le(el$ and generally a%normal findings on the lain radiogra hs are further delineated %y CT scan of the in)ured area& Cer(ical 7ractures and Dislocations 7le"ion in)uries of the cer(ical s ine occur most often at the le(el of CC and CD$ and can in(ol(e anterior com ression fracture of the (erte%ral %ody$ osterior longitudinal ligament tear$ and unilateral or %ilateral facet su%lu"ation or dislocation& 7acet dislocation or fracture resents radiogra hically #ith anterior dis lacement of u to 9C ercent #ith a unilateral facet dislocation +associated also #ith a rotational difference in the (erte%ra a%o(e as com ared to the (erte%ra %elo# the lesion,* %ilateral facet dislocation can e"hi%it anterior dis lacement of u to CG ercent& Cord in)ury may %e resent$ de ending on the degree of canal com romise&

8ith an a"ial load to the cer(ical s ine$ %urst fractures of the %ody can occur$ #ith retro ulsion of fragments into the s inal canal causing neurologic deficit +7ig& 563FD,& De ending on the resence of rotation$ fle"ion$ and lateral %ending$ fractures of the edicles or lamina occur& CT scans can readily delineate these in)uries& In)uries of the s inous rocesses +clay sho(elerAs fractures, can occur as an a(ulsion caused %y a sudden stress to the su ras inous ligament& A"ial com ressi(e force can cause fractures of the ring of C6 +<effersonAs fracture,& This in)ury$ often su%tle on lain radiogra hs$ can %e identified %y asymmetric #idening of the distance %et#een the lateral masses and the odontoid rocess on the o en3mouth antero osterior (ie#& 7ractures of C9 in(ol(ing the odontoid rocess or osterior elements +hangmanAs fracture, result from fle"ion or e"tension and rotational forces& In children under the age of . years$ odontoid in)uries can result in an e i hyseal dis lacement and associated dis lacement of the atlas u on the a"is& Treatment ?nsta%le fractures are defined as those #ith neurologic deficit or otential to cause a neurologic deficit& These in)uries must %e reduced rom tly$ usually using tong or halo s/eletal traction& The halo consists of four ins inserted under local anesthesia into the outer ta%le of the s/ull and affi"ed to a circular ring through #hich traction can %e a lied& Additionally$ the halo can %e attached to a %ody cast or lastic (est$ allo#ing mo%ili1ation of the atient after treatment of the acute in)ury& Dislocations #ith fractures are reduced #ith s/eletal traction and confirmed radiogra hically& Immo%ili1ation in a halo (est is maintained for - months& :efore discontinuation of the (est$ fle"ion;e"tension lateral radiogra hs are o%tained to %e sure that the in)ury is sta%le& 7or %ony in)uries$ healing #ith immo%ili1ation can %e antici ated& 7or se(ere ligamentous disru tions that do not %ecome sta%le #ith immo%ili1ation$ osterior surgical fusion #ith s inous rocess #iring is indicated& This may also %e necessary in cases in #hich satisfactory closed reduction cannot %e accom lished& Patients #ho resent #ith minimal %ut rogressi(e neurologic loss may re0uire anterior decom ression +for disc herniation, or osterior decom ression +for e idural hematoma or de ressed laminar fracture,& The use of osterior decom ression for atients #ith neurologic deficit is contro(ersial& Late anterior decom ression for atients #ith a com lete lesion allo#s regaining of one root le(el in a%out CG ercent of atients& ?nsuccessful reduction #ith ersistence of fragments in the s inal canal constitutes another indication for o erati(e e" loration& 4RI and CT scans can greatly assist in the diagnosis of o era%le lesions in such situations& Thoracolum%ar 7ractures and Dislocations 7ractures and dislocations in the u er thoracic s ine are unusual %ecause of the sta%ili1ing effect of the ri% cage& 7le"ion forces can cause com ression fractures* this is articularly common in osteo enic fractures$ #hich often are the result of relati(ely minor trauma& 7le"ion;rotation in)uries result in fracture3dislocations$ most commonly in the (icinity of the thoracolum%ar )unction& A"ial loading also can cause %urst fractures of the thoracic or lum%ar (erte%rae$ and retro ulsion of fragments into the canal #ith neurologic deficit can result& 7le"ion;distraction in)uries occur in seat%elted assengers in motor (ehicle accidents and can cause trans(erse fractures through the osterior elements and %ody +Chance fracture,&

Treatment After the atient is sta%ili1ed and other acute in)uries assessed$ a ro riate radiogra hs are o%tained #ith the atient on a %ac/%oard as descri%ed a%o(e$ and a careful neurologic e"amination is carried out& Treatment of the fracture de ends on the degree of sta%ility& Com ression fractures are treated sym tomatically$ #ith a %race and early am%ulation& :urst fractures #ithout neurologic deficit are treated #ith recum%ency and a %ody cast$ and s ontaneous fusion across the in(ol(ed discs #ill often result& Indication of sta%ility of thoracolum%ar s ine fractures is %ased in art on the three3column assessment as #ell as on the neurologic status& Sta%ility is conferred %y the (erte%ral %odies$ anterior longitudinal ligament$ and discs +anterior column,* the osterior longitudinal ligament$ osterior annulus$ and osterior (erte%ral %ody +middle column,* and the osterior elements + osterior column,& The middle column is thought to %e the /ey to sta%ility$ and disru tion of this column increases the li/elihood that surgical sta%ili1ation #ill %e necessary& 8hich columns are in(ol(ed lays a role in determining #hether an anterior or osterior surgical a roach #ill %e used& In unsta%le fractures or those #ith neurologic deficit and canal com romise$ o en reduction #ith 2arrington distraction rodding and indirect reduction or direct anterior decom ression and sta%ili1ation should %e carried out& Patients #ith ara legia ersisting %eyond the eriod of s inal shoc/ +assessed %y return of refle"es such as the %ul%oca(ernosus$ usually a%out 95 h after in)ury, re0uire osterior sta%ili1ation #ith rodding and fusion$ most often #ith 2arrington rods +7ig& 563FH,& 4etal slee(es +Ed#ards slee(es, o(er the rods ha(e %een used to im ro(e /y hotic correction$ and recently the more rigid fi"ation of segmental instrumentation +Lu0ue or segmentally #ired 2arrington rods, has %een ad(ocated$ articularly in com lete neurologic lesions& This allo#s ra id mo%ili1ation of the atient and minimal e"ternal su ort& The cross3lin/ed Cotrel3Du%ousset instrumentation also has %een used increasingly in trauma$ and edicle scre#3fi"ed rods ha(e %een used for lo#er lum%ar fractures& DISEASES O7 <OINTS Afflictions in(ol(ing )oints are #ides read& Degenerati(e )oint disease affects most indi(iduals o(er the age of CG #ith decreased range of motion$ although only a small ro ortion are sym tomatic& In)uries that cause fractures also fre0uently in(ol(e )oints$ and the immo%ili1ation associated #ith rolonged casting for fractures in(aria%ly causes some tem orary )oint dysfunction& Anatomy <oints can %e diarthrodial +in(ol(ing articulating cartilage surfaces,$ or synarthrodial +in(ol(ing the fi%rous )unction,& 4ost ma)or )ointsJthe shoulder$ /nee$ and hi Jare diarthrodial& Synarthroses include the inter(erte%ral discs$ sym hysis u%is$ and an/le syndesmosis& Diarthrodial )oints are surrounded %y a fi%rous ca sule that is lined #ith syno(ium& The syno(ium secretes the )oint fluid$ #hich lu%ricates the )oint and ro(ides nutrition to the articular cartilage& Articular Cartilage

Normal articular cartilage is %lue3#hite$ smooth$ glistening$ and slightly com ressi%le& The matri" of articular cartilage consists mainly of ty e II collagen and roteoglycan$ #ith a smaller amount of glyco roteins and minor collagens such as ty e IK +#hich coats the ty e II collagen fi%rils and %inds them to the roteoglycan in the matri", and ty e KI$ #hich regulates fi%ril diameter& One of the glyco rotein com onents$ chondronectin$ %inds chondrocytes to the matri" ty e II collagen& Normal articular chondrocytes do not re licate$ although they do synthesi1e and turn o(er matri" com onents& After in)ury or in degenerati(e disease$ chondrocytes ha(e a limited a%ility to attem t re air$ and they re licate to a limited degree +cloning,& ?nder such conditions they also increase roduction of roteoglycan& Articular cartilage has no %lood (essels and must deri(e its nutrition from the syno(ial fluid& The collagen and roteoglycan are maintained in a constrained molecular configuration in cartilage$ ro(iding its (iscoelastic com ressi%ility and load transmission characteristics& The collagen has a s ecific orientation in articular cartilage$ as has %een re(iously discussed& Syno(ium The syno(ium in a normal )oint is only a fe# cell layers thic/& O(er ligaments the syno(ium is 0uite thin$ %ut in areas of fat ads and loose ca sule there is considera%le areolar tissue %eneath the syno(ial layer& The syno(ium is #ell (asculari1ed from a le"us of (essels %eneath the syno(ial layer& The cells are of three ty esL ty e A +macro hage3li/e$ secretory cells,* ty e : +fi%ro%last3li/e cells,$ and ty e C +dendritic cells of uncertain function,& The secretory cells roduce the hyaluronic acid of the syno(ial fluid$ #hich contri%utes to its lu%ricati(e (iscosity& Syno(ial fluid also contains some lasma roteins$ #ater$ and electrolytes& Normal syno(ial fluid is clear$ yello#ish$ and (iscous and contains a%out 9GG nucleated cells + olymor honuclear leu/ocytes$ lym hocytes$ and monocytes,& The syno(ium is inner(ated$ as is the )oint ca sule$ #hich in addition to unmyelinated sensory fi%ers contains ro rioce ti(e fi%ers& Generally the ner(e su ly to a )oint is from the ner(es inner(ating muscles that act across the )oint& Ner(e fi%ers accom any arteries into the su%chondral %one and ro(ide the %asis for %one ain in some inflammatory conditions of )oints& The ro rioce ti(e fi%ers in the ca sule and associated ligaments are im ortant in ro(iding information regarding )oint osition& There are no ner(es in articular cartilage& Articular Cartilage Degeneration As already noted$ articular cartilage has a limited re air ca acity& Loss of roteoglycans occurs early after any insult +trauma$ chemical$ inflammatory$ infectious$ autoimmune, to a )oint& This causes loss of elasticity of the cartilage and s#elling #ith athologic hydration& Load transmission %ecomes defecti(e$ causing rogressi(e damage to the articular chondrocytes$ #hich res ond %y re licating and synthesi1ing matri" molecules& The cells also arado"ically synthesi1e matri" metallo roteinases +collagenase$ stromelysin$ and gelatinase,$ #hich mediate further matri" %rea/do#n& The mechanical forces on the )oint in the conte"t of no# a%normal mechanical ro erties result in fi%rillation of the cartilage$ and de%ris from the fragments of matri" induces an inflammatory res onse& The syno(ium res onds to this #ith inflammatory infiltration and hy ertro hy& Secretion of metallo roteinases

from the syno(ial cells also occurs$ further contri%uting to the matri" %rea/do#n& The (icious cycle of cartilage degradation continues in a self3 ro agating manner& The final common ath#ay for all inflammatory$ degenerati(e$ and traumatic afflictions of )oints is thus rogressi(e cartilage degradation& Ne# thera eutic a roaches to the treatment of arthritis in(ol(es inhi%itors of metallo roteinases or harmacologic stimulation of the roduction of the endogenous tissue inhi%itor of matri" metallo roteinases& In res onse to the acti(ation of latent endochondral calcification in the dee layer of the articular cartilage$ the su%chondral late %egins to thic/en +su%chondral sclerosis,& This contri%utes to acceleration of the %rea/do#n of matri" %ecause of stiffening of the su%chondral %one #ith increased loading of the cartilage& The se0uence of e(ents in cartilage degeneration is sho#n schematically in 7ig& 563FF& E"amination The diagnosis of )oint disease de ends on the follo#ingL +6, Clinical history +9, Physical e"amination of all )oints +-, Radiogra hs +5, Syno(ial fluid analysis +C, Serologic tests +., Other imaging modalities$ such as 4RI and %one scans Locali1ation of ain$ identification of aggra(ating factors and traumatic incidents$ and the resence of s#elling$ stiffness$ and mechanical sym toms of loc/ing are im ortant as ects of the history& Other considerations include the resence of systemic diseases or sym toms& Clinical E"amination In(ol(ed )oints should %e ins ected for s#elling$ effusion$ #armth$ and erythema$ and unilateral cases should %e com ared #ith the o osite side& Range of motion$ acti(ely and assi(ely$ is assessed and ligamentous sta%ility tested& Presence of muscle atro hy is noted and measured$ and regional adeno athy$ neurologic e"amination$ and (ascular e"amination of the e"tremity are carried out& Other )oints in %oth the u er and lo#er e"tremities also should %e e"amined$ and the range of motion of the cer(ical and thoracolum%ar s ine should %e assessed& Radiogra hic E"amination Standard antero osterior and lateral radiogra hs of any in(ol(ed )oint+s, are o%tained& If ligamentous insta%ility is resent$ stress radiogra hs can %e hel ful& <oint s ace narro#ing* resence of effusion$ intraarticular calcified loose %odies$ osteo hytes$ su%lu"ation$ su%chondral sclerosis$ articular cartilage or meniscal calcification +chondrocalcinosis,* and su%chondral cyst formation are some of the more im ortant findings that can %e detected radiogra hically& Arthrogra hy and 4RI are used to

e(aluate the ossi%ility of meniscal or rotator cuff lesions& 4RI is increasingly useful in the diagnosis of nonosseous lesions in )oints$ and it can allo# assessment of chondral lesions and degenerati(e changes that are not a arent on lain radiogra hs& Syno(ial 7luid Analysis The a%normalities in the syno(ial fluid are s ecific or nons ecific$ de ending on the cause of the )oint ro%lem& A s ecific diagnosis can %e o%tained for infection$ gout$ and seudogout +calcium yro hos hate de osition disease,& The techni0ue of as iration de ends on the in(ol(ed )oint and local anatomy& As iration through any cellulitic or fluctuant areas suggesti(e of infection must %e strictly a(oided to re(ent the introduction of %acteria into a )oint& The /nee is as irated either medial or lateral to the atella$ the an/le anterolaterally at the corner of the mortise$ the shoulder anteriorly$ the el%o# laterally at the radiohumeral )oint$ the hi anterolaterally or anteriorly$ and the #rist dorsally& Sterile re aration and dra ing and meticulous sterile techni0ue are necessary to re(ent infection or contamination of cultures if infection is already resent& 7luid is collected in +6, a culture tu%e$ +9, a tu%e #ith EDTA to re(ent clotting$ and +-, an em ty tu%e for chemistry or immunologic analyses& Normal syno(ial fluid is slightly stra# colored and clear& In inflammatory conditions or infection the fluid ranges from tur%id to fran/ly urulent& In inflammatory conditions$ the hyaluronate in the fluid is de olymeri1ed and has decreased (iscosity& Adding syno(ial fluid to CT acetic acid should form a firm mucin clot that does not se arate or fragment #ith agitation& In inflammatory conditions$ a clot might not form or might fragment as a result of %rea/do#n of glyco roteins and muco olysaccharides in the fluid& The syno(ial fluid analysis in (arious disorders is sho#n in Ta%le 5636C& 7luid should %e cultured for aero%ic and anaero%ic organisms as #ell as myco%acteria$ fungi$ and gonococci$ #ith rimary lates$ chocolate agar +for gonococcal infection,$ and %roth cultures to detect fastidious organisms& A total cell count and differential count is erformed on fluid in an anticoagulated tu%e& <oint fluid is e"amined also for the resence of urate or calcium yro hos hate crystals after collection in a tu%e #ithout EDTA or o"alate& After centrifugation of the fluid to concentrate the cells$ the sediment is e"amined using olari1ed light microsco y& ?rate crystals are negati(ely %irefringent and rod3sha ed& Calcium yro hos hate crystals are rhom%oidal and #ea/ly ositi(ely %irefringent& Glucose in )oint fluid #ill also %e significantly lo#er than serum (alues if large num%ers of inflammatory cells are resent& Pyogenic Arthritis 8ith early diagnosis of se tic arthritis and a ro riate treatment$ the rognosis for maintenance of normal )oint function is e"cellent& The lysosomal en1ymes released from #hite cells in the )oint$ ho#e(er$ can ermanently destroy the articular cartilage and lead to rogressi(e degenerati(e change if inade0uately treated& <oint infections can result from hematogenous s read from se ticemia$ direct infection from ad)acent traumatic #ounds or surgery$ or e"tension of an ad)acent meta hyseal osteomyelitis&

Sta hylococcus aureus and hemolytic stre tococci are the t#o most common organisms that cause yogenic arthritis& Gonococcal and coliform organisms$ 2emo hilus influen1ae +in infants,$ neumococci$ meningococci$ and :rucella are other causati(e agents& 8ith the ad(ent of #ides read 2& influen1ae (accination in children$ the incidence of infections %ecause of this organism has dramatically declined& Se tic arthritis occurs in children and adults and is more common in de%ilitated atients or those undergoing steroid thera y or immunologic su ression& In atients #ith hematogenous s read from %acteremia se(eral )oints may %e in(ol(ed& Com laints include fe(er$ ain and s#elling in the affected )oint$ chills$ and malaise& Ele(ation of the #hite %lood count and erythrocyte sedimentation rate are common& The affected )oint+s, are s#ollen$ tender$ erythematous$ #arm to touch$ and ainful during range3of3motion maneu(ers& The hysical findings (ary greatly and often de end on the (irulence of the organism* indolent infections resent #ith a nearly normal e"amination& Radiogra hs re(eal effusion& In more ad(anced infections$ erosions and )oint s ace narro#ing occur as conse0uences of the destruction of the articular cartilage +7ig& 563 6GG,& 8ith chronic infection or a large a%scess$ su%lu"ation of the )oint also may %e e(ident& Diagnosis is made %y as iration of the )oint #ith culture$ Gram stain$ and analysis of the syno(ial fluid& The resence of organisms and an ele(ated #hite cell count in the fluid are diagnostic& The #hite cell count in the fluid may range from 9C$GGG;mm- to more than 9GG$GGG;mm-$ usually #ith a high ercentage +greater than FG ercent, of leu/ocytes& Treatment In the resence of an ele(ated syno(ial #hite cell count and other signs and sym toms of se tic arthritis$ anti%iotic thera y is started em irically$ usually #ith co(erage for S& aureus +ce halos orin,$ stre tococci +ce halos orin or a enicillin,$ and$ in children$ 2& influen1ae +am icillin,& Contro(ersy e"ists as to #hether surgical drainage$ arthrosco ic drainage$ or re eated daily as iration re resents the %est treatment o tion& Generally it is agreed that for hi infections$ #hich can result in ra id destruction and secondary osteonecrosis and can %e difficult to as irate$ emergent surgical drainage is indicated& Chronic infections #ith loculation or thic/ urulence also re0uire surgical drainage& In chronic infections remo(al of hy ertro hic infected syno(ium can %e ad(antageous& 7or the /nee$ arthrosco ic drainage may %e a ro riate& Shoulder and an/le infections can %e managed either %y se0uential as iration or surgical drainage& In general$ atients #ho undergo surgical drainage undergo defer(escence and im ro(e clinically more ra idly& De ending on the organism$ intra(enous anti%iotic thera y is indicated for 9 to 5 #ee/s& If the se tic arthritis results from e"tension from an ad)acent osteomyelitis$ intra(enous anti%iotic thera y for . #ee/s or longer is needed& Early )oint motion is encouraged to restore nutrition to the articular cartilage and re(ent stiffness& 7or cases in #hich articular cartilage destruction rogresses des ite treatment$ late secondary degenerati(e arthritis can result& O tions for treatment #hen sym toms are

se(ere include arthrodesis$ resection arthro lasty$ and$ in rare cases$ )oint re lacement arthro lasty& :one and <oint Tu%erculosis Tu%erculous Arthritis Although s/eletal tu%erculosis has %een rare in the ?nited States since the ad(ent of a ro riate anti%iotic thera y$ the incidence is increasing among immigrants$ atients #ith 2I> infection +AIDS,$ and atients on chronic immunosu ressi(e thera y& In addition$ drug3resistant strains of tu%erculosis are no# emerging& The most common site of s/eletal in(ol(ement is the s ine& The infection starts ad)acent to the disc s ace and s reads across the disc to in(ol(e contiguous (erte%rae& In the lum%ar s ine the infection can dissect into the soas muscles$ #ith su%se0uent a%scess formation& Peri heral )oint in(ol(ement affects the syno(ium$ %one$ and cartilage& 2y ertro hic infected syno(ium + annus, gradually co(ers the cartilage surface and erodes the su%chondral %one$ e(entually destroying the cartilage as #ell& The articular cartilage +radiogra hically$ the )oint s ace, is #ell reser(ed until late in the course$ unli/e in yogenic arthritis$ in the course of #hich articular cartilage destruction occurs early& The result is com lete destruction of the )oint #ith fi%rous an/ylosis& Tu%erculosis can affect any large )oint$ and any chronic monarthritis should %e sus ected of %eing tu%erculous& Pulmonary disease is not necessarily resent& The clinical onset is insidious$ and sym toms are often resent for #ee/s or months& Limitation of motion and s#elling can occur$ %ut mar/ed signs of inflammation generally are a%sent& Radiogra hs usually sho# soft3tissue s#elling and$ later$ marginal erosions$ %ut the )oint s ace is maintained initially +7ig& 5636G6,& In children enlargement of the ad)acent e i hysis occurs$ and in adults #ith long3 standing disease com lete destruction of the )oint results& The diagnosis de ends on reco(ery of the organisms from the )oint& Demonstration of ulmonary lesions or a ositi(e urified rotein deri(ati(e test is hel ful %ut not athognomonic& <oint as iration and;or syno(ial %io sy is essential$ #ith demonstration of acid3fast %acilli on smears or ositi(e cultures& Syno(ial fluid analysis usually demonstrates a leu/ocytosis of less than 9G$GGG;mm-& If as iration is not diagnostic$ o en syno(ial %io sy is necessary& Treatment Thera eutic measures include anti%iotic thera y$ sym tomatic treatment of the in(ol(ed )oint$ and surgical de%ridement& General su orti(e measures include hydration$ rest$ and ro er caloric and rotein inta/e& Antitu%erculous chemothera y is %egun$ and the treatment is highly successful if initiated %efore significant necrosis and a%scess formation ha(e occurred& ?sually tri le3drug thera y #ith rifam in$ isonia1id$ and etham%utol is used& In resistant infections$ a fourth drug such as stre tomycin or ara3 aminosalicylic acid +PAS, is added& Treatment is for . to 69 months& In(ol(ed )oints should %e immo%ili1ed %y traction or s linting& If there is su%chondral %one in(ol(ement or if

the )oint fails to res ond to drug treatment$ surgical de%ridement often is indicated& In )oints #ith se(ere destruction$ arthrodesis is the treatment of choice& Patients #ith disease that has %een inacti(e for 6G years can %e considered for total )oint arthro lasty$ although reacti(ation rates of infection may run as high as 9C ercent& Tu%erculosis of the S ine Tu%erculous s ondylitis +PottAs disease, is the most common form of s/eletal in(ol(ement +7ig& 5636G9,& The infection can in(ol(e the thoracic or lum%ar s ine& >erte%ral destruction results$ and multi le le(els can %e in(ol(ed$ often #ith /y hotic deformity& Neurologic deficit or aralysis results in se(ere cases& Treatment in(ol(es a ro riate chemothera y and anterior surgical de%ridement$ #ith a%scess drainage and sta%ili1ation of the s ine #ith anterior ri% strut %one grafts& Anti%iotic thera y is continued for . to 69 months after o eration$ and atients are immo%ili1ed in laster %ody casts until fusion has occurred& Tu%erculosis of the 2i Initial treatment of tu%erculous in(ol(ement of the hi )oint consists of a ro riate anti%iotic thera y and light traction& If sym toms continue$ o en de%ridement and syno(ectomy$ or in cases of se(ere destruction$ arthrodesis$ are a lica%le& Gonococcal Arthritis Gonococcal arthritis is more common in females and results from s read from cer(icitis or (aginitis& Sym toms often %egin #ith migratory olyarthralgias$ follo#ed %y locali1ation in one or t#o )oints& The /nee is commonly affected$ and systemic sym toms are (aria%le$ as is the se(erity of the local findings& Diagnosis de ends on identification of gonococcal organisms %y )oint as iration and culture& Syno(ial fluid analysis is com ati%le #ith a moderate inflammatory rocess& Radiogra hs often re(eal no a%normality& Intramuscular enicillin G 6 to 9 million ?;day for 9 #ee/s is sufficient to eradicate the infection& If ersistent urulent effusions are resent$ serial as iration may %e hel ful$ %ut usually this is not needed& If the atient fails to res ond to anti%iotic treatment$ then other diagnoses such as ReiterAs syndrome or early rheumatoid arthritis$ should %e considered& 8ith ro er treatment$ normal reco(ery of )oint function usually results& Lyme Arthritis Lyme disease is a tic/3%orne +deer tic/$ I"odes dammini, illness caused %y the s irochete :orrelia %urgdorferi& Affected atients may ha(e intermittent attac/s of s#elling in one or more large )oints$ accom anied %y a characteristic s/in rash +erythema chronicum migrans, that often recedes the arthritis& The intermittent attac/s and rash com rise stage I Lyme disease and ha(e an onset - to -G days after a tic/ %ite& Stage II can in(ol(e cardiac manifestations and neurologic sym toms such as :ellAs alsy& In stage III a chronic lo#3grade se tic arthritis de(elo s& The /nee )oint is most often in(ol(ed& Treatment includes tetracycline$ enicillin$ or erythromycin for 5 #ee/s& Rheumatoid Arthritis Rheumatoid arthritis is a systemic disease that affects not only the )oints %ut the cardio(ascular$ ner(ous$ and res iratory systems as #ell& Rheumatoid arthritis affects

diarthrodial )oints and all the su orting structures$ including syno(ium$ tendons$ tendon sheaths$ and %ursal tissues& The syno(ium characteristically undergoes inflammatory infiltration and hy ertro hy& The hy ertro hic syno(ium + annus, cree s o(er the articular surface$ destroying the cartilage& At the )oint margins the inflamed syno(ium induces osteoclastic %one resor tion and creates eriarticular erosions& The cartilage undergoes symmetrical thinning$ and the ligamentous structures and ca sule of the )oints also erode and %ecome la"$ allo#ing )oint su%lu"ation& The ad)acent %one %ecomes osteo enic from a com%ination of increased %lood flo#$ immo%ility due to ain$ and accelerated osteoclastic acti(ity ossi%ly related to inflammatory cyto/ines& ?ltimately the rocess in a gi(en )oint can %ecome !%urned out$' #ith su%sidence of the inflammation and an/ylosis of the )oint& In a%out 9C ercent of atients su%cutaneous nodules de(elo along the ulna$ the olecranon$ or the dorsal as ect of the fingers or feet& Tendon ru tures from attrition of in(ol(ed tenosyno(ium are common$ es ecially in the shoulder and hand& Pericarditis and (al(ular in(ol(ement can occur$ and granulomatous lesions can occur in the lungs& ?(eitis also is common in rheumatoid atients& The diagnosis of rheumatoid arthritis in a atient #ith long3standing disease and deformity is not difficult$ %ut in early stages it may not %e straightfor#ard& Arthritis associated #ith collagen (ascular diseases$ systemic lu us erythematosus$ soriasis$ or dermatomyositis can ha(e a similar resentation& 4easurement of rheumatoid factor may %e hel ful& Rheumatoid arthritis may resent #ith morning stiffness$ one or more s#ollen$ tender$ or ainful )oints that ersist continuously for #ee/s to months$ su%cutaneous nodules$ iritis$ and symmetrical )oint s#elling& The differential diagnosis includes lu us$ olyarteritis$ erythema nodosum$ rheumatic fe(er$ gout$ tu%erculous arthritis$ ReiterAs syndrome$ hy ertro hic ulmonary osteoarthro athy$ ochronosis$ multi le myeloma$ and lym homa& Ninety ercent of rheumatoid atients ha(e an immunoglo%ulin in the serum called rheumatoid factor$ although in )u(enile rheumatoid arthritis only 9G ercent are ositi(e& The erythrocyte sedimentation rate is a good inde" of the disease acti(ity& Syno(ial fluid analysis re(eals leu/ocytosis of greater than CG$GGG;mm-& Radiogra hic findings include )oint s ace narro#ing$ eriarticular erosions$ soft3tissue s#elling$ osteo enia$ and )oint su%lu"ations +7ig& 5636G-,& The )oint s ace narro#ing tends to %e symmetrical or concentric$ as o osed to the eccentric narro#ing seen #ith degenerati(e arthritis& Treatment in(ol(es a team effort on the art of the rheumatologist$ ortho aedist$ hysical thera ist$ occu ational thera ist$ and social #or/er& The aim of ortho aedic treatment is to halt disease rogression$ restore or maintain function$ and relie(e ain& 4edical 4anagement Numerous anti3inflammatory medications are a(aila%le for treatment of the rheumatoid atient& Drugs include analgesics +codeine$ as irin,$ mild anti3 inflammatory;analgesics +i%u rofen$ na ro"en,$ high3 otency anti3 inflammatory;analgesics + henyl%uta1one$ indomethacin,$ corticosteroids$ and drugs that a ear to modify the immune res onse +gold salts$ enicillamine$ antimalarials$ a1athio rine$ cyclo hos hamide$ methotre"ate,& Corticosteroids are #idely used in

the management of rheumatoid atients$ %ut usually are reser(ed for acute e"acer%ations or life3threatening situations such as (asculitis& Ortho aedic 4anagement Efforts should focus on maintenance of muscle strength and range of motion of )oints and a(oidance of deforming forces& Protection of sym tomatic )oints #ith #al/ing aids or s lints is hel ful& >arus and (algus deformities of the lo#er e"tremities can %e treated #ith orthoses& The initial a roach should focus on o timi1ation of medical management of the disease& 7or ersistent sym tomatic syno(itis$ surgical syno(ectomy is hel ful in slo#ing rogression of the disease& In the /nee$ arthrosco ic syno(ectomy can %e underta/en and ro(ides similar results to those o%tained %y arthrotomy& Radiation syno(ectomy %y intraarticular in)ection of short3 half3life isoto es such as dys rosium36.C ferric hydro"ide has ro(ided results com ara%le to those of surgical syno(ectomy& E"ternal %eam radiation syno(ectomy too has %een re orted to ha(e some success in early rheumatoid arthritis& Enee 8ith )oint s ace narro#ing and collateral ligament la"ity in the /nee$ insta%ility results& Syno(ectomy at this stage is ineffecti(e$ and generally total /nee re lacement arthro lasty is indicated& Total /nee arthro lasty has e(ol(ed to a degree of success com ara%le to that of total hi arthro lasty +H. to FC ercent good and e"cellent results at C years in total /nee and total hi arthro lasty$ res ecti(ely,& Total /nee re lacement relie(es ain and im ro(es am%ulatory function +7ig& 5636G5,& Com lications include infection$ dee (enous throm%osis$ and late loosening& Infection re0uires remo(al of the rosthesis and all cement and the institution of a ro riate intra(enous anti%iotic thera y$ after #hich e"change arthro lasty can %e underta/en$ although the success rate is su%stantially lo#er than for rimary arthro lasty& 2i Syno(ectomy generally is not erformed for hi in(ol(ement in rheumatoid arthritis& 7or the atient #ith disa%ling ain and stiffness$ total hi re lacement arthro lasty has %een 0uite successful +see Total 2i Re lacement Arthro lasty under Osteoarthritis$ %elo#,& Com lications include infection and loosening of the im lants& Although most rheumatoid atients undergoing total )oint re lacement are treated using cemented com onents$ in younger atients the use of uncemented com onents$ #hich ha(e orous coatings allo#ing %ony ingro#th$ may ro(e to %e acce ta%le$ es ecially on the aceta%ular side& An/le and 7oot 4ost rheumatoid deformities a%out the an/le can %e controlled %y a ro riate %racing& Patients #ith se(ere ain or deformity can %enefit from arthrodesis& Total an/le )oint re lacements ha(e had a high rate of loosening and unsuccessful outcomes and are not currently recommended& In(ol(ement of the feet #ith rheumatoid arthritis is 0uite common& Cla#toe occurs$ #ith dislocation of the 4TP )oints and fle"ion of the IP )oints$ and the resulting ainful lantar rominence of the metatarsal heads interferes significantly #ith am%ulation& The 2offman rocedure is used for this ro%lem and has an e"cellent success rate& It consists of resection of all of the metatarso halangeal )oints$ #ith

realignment and tem orary Eirschner3 #ire fi"ation& Correction of hallu" (algus %y arthrodesis of the first 4TP )oint also can %e hel ful$ and in con)unction #ith the 2offman rocedure on the other toes hel s to re(ent recurrent lateral drift +7ig& 563 6GC,& 2and The hand is one of the most common areas of ro%lematic rheumatoid in(ol(ement& The 4CP$ PIP$ and car al )oints and the tenosyno(ium of %oth the fle"or and e"tensor tendons can %e affected& La"ity of ca sules allo#s ulnar drift of the digits& Ru tures of in(ol(ed tendons can occur$ %ut can %e re(ented %y early tenosyno(ectomy& Common tendon ru tures include the e"tensor digiti minimi$ common e"tensors to the ring and little fingers$ e"tensor ollicis longus$ fle"or ollicis longus$ and finger fle"ors& Associated car al tunnel syndrome can occur #ith fle"or tenosyno(itis in the car al tunnel and fre0uently re0uires car al tunnel release #ith tenosyno(ectomy& Se(ere in(ol(ement of the 4CP )oints necessitates silicone re lacement arthro lasties& Thum% deformities also are common and re0uire sta%ili1ation of the 4CP or IP )oint %y arthrodesis& Similarly$ ainful in(ol(ement of the thum% C4C )oint often re0uires e"cisional arthro lasty$ #ith tendon or silicone inter osition arthro lasty& Other ? er E"tremity Deformities El%o# in(ol(ement can occur in rheumatoid arthritis$ #ith ain$ restriction of motion$ and insta%ility& S linting is hel ful along #ith a ro riate medical management& In selected cases$ arthro lasty is necessary& 7ascial inter osition arthro lasties ha(e %een some#hat successful$ %ut recent ad(ances #ith unconstrained total el%o# re lacement suggest im ro(ed results o(er rior de(ices& Shoulder in(ol(ement also is common$ as is in(ol(ement of the rotator cuff #ith the syno(itis$ often leading to attrition or ru ture of the rotator cuff& Results of total shoulder arthro lasty are not as successful as #ith osteoarthritis$ in #hich the cuff in(ol(ement tends to %e less se(ere$ %ut may ne(ertheless afford ain relief and im ro(ed function& S ine :ac/ ain is common in rheumatoid atients$ and com ression fractures and /y hosis de(elo as a result of osteo enia$ often aggra(ated %y chronic steroid use& 4ore serious otential ro%lems result from in(ol(ement of the cer(ical s ine$ #ith insta%ility and the otential for neurologic deficit& Destruction of )oints and ligaments can result in %asilar in(agination or cranial settling$ su%a"ial su%lu"ation$ and atlantoa"ial su%lu"ation& Cranial settling and atlantoa"ial su%lu"ation can result in neurologic deficit$ and osterior fusion$ decom ression$ and #iring may %e necessary to re(ent 0uadri legia& E(aluation of the cer(ical s ine in rheumatoid atients is articularly im ortant #hen considering surgical inter(ention re0uiring general anesthesia and intu%ation$ #hich can %e dangerous #ith insta%ility of the u er s ine& Neurologic e(aluation of the rheumatoid atient as a art of routine follo#3u is also im ortant for this reason& Osteoarthritis Osteoarthritis is a term used to descri%e degenerati(e changes in diarthrodial )oints& The rimary change is in the articular cartilage$ #hich %ecomes soft$ loses elasticity$

and fi%rillates$ ultimately resulting in e%urnated %one de(oid of cartilage& It is the final common ath#ay of degeneration of )oints from nearly all insults$ and occurs secondarily in )oints re(iously damaged %y trauma$ inflammation$ or se sis& The early changes in articular cartilage degeneration include loss of metachromatic staining$ #hich is a result of the loss of roteoglycans in the territorial matri" of the chondrocytes& S#elling of the cartilage and fi%rillation occur su%se0uently$ as re(iously descri%ed& The cartilage grossly a ears more yello# and is softer than normal cartilage& 4echanical attrition then causes fla/ing of de%ris from the damaged cartilage$ #hich induces mild inflammatory changes in the syno(ium$ contri%uting to the rogressi(e %rea/do#n %y secretion of cyto/ines and roteases& 8ith loss of cartilage and e%urnation of the underlying su%chondral %one$ marginal osteo hytes de(elo $ often at sites of ligamentous attachments& Reacti(ation of endochondral ossification in the dee layer of the cartilage as #ell as the increased a%normal mechanical stresses in the su%chondral %one contri%ute to su%chondral thic/ening and sclerosis& This also su orts the (icious cycle of degeneration %y increasing mechanical stresses in the cartilage& Su%chondral degenerati(e cysts de(elo #here the su%chondral %one marro# has undergone mucoid degeneration$ %ut the mechanism of cyst formation is un/no#n& Scarring and fi%rosis of the ca sule occur$ #ith loss of range of motion& 4ild (illous syno(itis may %e resent$ %ut syno(ial fluid cell counts are only mildly ele(ated +less than 9$GGG;mm-,& :ecause of the relati(ely noninflammatory nature of osteoarthritis$ many refer the term osteoarthrosis& Osteoarthritis can result from derangement of a )oint %y any of a #ide (ariety of mechanisms$ including congenital hi dys lasia$ Legg3Cal(=3 Perthes disease$ sli ed ca ital femoral e i hysis$ ase tic necrosis$ se tic arthritis$ hemo hilia$ gout$ seudogout$ and trauma& If no redis osing factor e"ists$ the degenerati(e rocess is considered rimary& Structural mutations ha(e %een identified in the ty e II collagen gene in atients #ith osteoarthritis$ #hich may e" lain at least some forms #ith familial tendencies& Primary osteoarthritis affects mainly the large #eight3%earing )oints such as the hi s and /nees +7ig& 5636G.,$ %ut generali1ed forms e"ist$ most often in ostmeno ausal females$ in(ol(ing multi le )oints$ including the DIP )oints& Osteo hytes along the DIP )oints are called 2e%erdenAs nodes& In generali1ed rimary osteoarthritis the course often is more ra idly rogressi(e$ #ith more ronounced clinical signs of inflammation& Clinical 4anifestations Radiogra hically$ the e(idence of degenerati(e changes in )oints increases #ith age$ %ut only a small ro ortion of these changes are associated #ith sym toms& Only C ercent of atients o(er the age of CG years and 9G to -G ercent of atients o(er the age of .G years are estimated to ha(e clinical sym toms& The onset of osteoarthritis usually is insidious$ #ith radiogra hic changes often receding sym toms& Stiffness is noted after rest and resol(es #ith mild e"ercise of the )oint& S#elling and effusion are often a%sent& There is no s ecific diagnostic test for osteoarthritis$ although the disease usually is diagnosed radiogra hically on the %asis of eccentric )oint s ace narro#ing$ osteo hyte formation$ su%chondral sclerosis$ and su%chondral cyst

formation +7ig& 5636GD,& The radiogra hic findings and clinical sym toms fre0uently are oorly correlated& Treatment Thera eutic measures include +6, modification of acti(ities to a(oid high3 im act forces on the )oint* +9, anti3inflammatory analgesic medications* +-, #eight loss* +5, range3of3motion e"ercises to minimi1e contractures* +C, #al/ing aids such as a cane +%ecause of the moment arm of the hi a%ductors$ use of a cane in the contralateral hand results in a fi(efold reduction in the forces acting across the )oint* +., orthoses to control insta%ility if resent* and +D, a(oidance of aggra(ating acti(ities& Osteoarthritis tends to %e only (ery slo#ly rogressi(e$ and sym toms can %e satisfactorily managed conser(ati(ely for many years& 8hen sym toms %ecome intolera%le$ surgical inter(ention might %e indicated& Procedures include osteotomy$ arthrodesis$ )oint re lacement arthro lasty$ and resection arthro lasty& Arthro lasties ro(ide ain relief and im ro(ed range of motion$ and osteotomy alters #eight3 %earing forces to decrease ressure on damaged cartilage and slo#s rogression& Thum% Car ometacar al <oint Osteoarthritis of the thum% C4C )oint is much more common in #omen$ articularly after meno ause& Patients ha(e ain #ith motion of the thum% and interference #ith gras %ecause of ain& Conser(ati(e measures include the use of an orthosis to restrict C4C )oint motion in addition to the a roaches mentioned a%o(e& Rarely$ surgical inter(ention +such as arthrodesis, is necessary& Im lant arthro lasty also is useful$ %ut loosening and silicone syno(itis can occur& If %oth the C4C and the intercar al )oints are in(ol(ed$ resection of the tra e1ium #ith inter osition of a folded segment of fle"or car i radialis tendon has %een successful& 8rist$ El%o#$ and Shoulder The need for surgical treatment of osteoarthritis in these )oints is relati(ely uncommon& 8rist ain can %e treated %y arthrodesis$ and for locali1ed intercar al osteoarthritis limited intercar al arthrodeses are fre0uently used& Total re lacement arthro lasty is rarely used& De(elo ment of unconstrained el%o# rosthetic re lacements has im ro(ed the results of total el%o# re lacement arthro lasty$ and fascial inter osition arthro lasty too has %een successful in younger atients& 4anual la%orers can %e treated %y arthrodesis of the el%o#$ %ut this is less commonly done than re(iously& Posttraumatic degenerati(e change in the acromiocla(icular or sternocla(icular )oints can %e treated %y resection of the )oint& ?nconstrained total shoulder re lacement arthro lasty has ro(ided acce ta%le results in osteoarthritic atients$ and arthrodesis is also 0uite successful for shoulder arthritis& 2i Osteoarthritis of the hi can %e rimary or secondary to causes mentioned a%o(e$ including de(elo mental a%normalities of the femoral head or aceta%ulum& Patients may resent #ith stiffness and ain in the inguinal area or referred ain in the /nee$ usually aggra(ated %y #eight %earing& Patients often ha(e an a%ductor lim +leaning to#ard the affected side on #eight %earing to decrease hi a%duction force,$ and the affected e"tremity can e"hi%it shortening from %oth loss of )oint s ace and hi fle"ion contracture& Internal and e"ternal rotation are limited and ro(o/e ain$ articularly #ith the hi in fle"ion&

Conser(ati(e treatment in(ol(es the measures descri%ed re(iously$ and use of a cane on the contralateral side may decrease ain and lim dramatically& If conser(ati(e measures fail$ surgical inter(ention often is a ro riate& Surgical o tions include osteotomy$ arthrodesis$ and total hi re lacement arthro lasty& Arthrodesis 7or young atients #ith se(ere osteoarthritis$ the increased ris/ of long3 term failure of total hi re lacement militates against this a roach& Arthrodesis of the hi ro(ides e"cellent ain relief and function& Patients re0uire s ica cast immo%ili1ation for - to . months& Possi%le long3term ro%lems include de(elo ment of lo# %ac/ ain and /nee ain from increased stresses on these )oints& Pree"isting degenerati(e change or sym toms in these )oints contraindicate hi arthrodesis& :ilateral hi in(ol(ement also is a contraindication to fusion& Arthrodesis is useful in cases of yogenic or tu%erculous infection of the hi $ in #hich the ris/ of reacti(ation after total hi re lacement is significant& 7emoral Osteotomy A num%er of osteotomies a%out the hi ha(e %een used for osteoarthritis$ including medial dis lacement osteotomy$ and (arus or (algus osteotomies& These rocedures ha(e %een more o ular in Euro e than in the ?nited States$ and significant ain relief has %een re orted in a ro"imately HG ercent of atients& One disad(antage of osteotomies is that su%se0uent total hi re lacement is made technically much more difficult if disease rogresses des ite osteotomy& Total 2i Re lacement Arthro lasty Reconstructi(e rocedures a%out the hi must %e com ared #ith the e"cellent results o%tained %y total hi re lacement& Total hi re lacement has %een used for rimary or secondary osteoarthritis$ as #ell as rheumatoid arthritis& Long3term studies ha(e indicated u to F6 ercent im lant sur(i(al at 6C years for con(entional cemented arthro lasties& The ma)or ro%lem #ith total )oint arthro lasty is related to loosening of the rosthetic com onents$ usually at the %one3cement interface +7ig& 563 6GH,& 7ailure and re(ision rates as high as 9G to 9C ercent at C years ha(e %een re orted in some series& 7ailure rates are significantly higher in acti(e atients under 5G years of age& A significant factor contri%uting to late loosening is #ear de%ris of olyethylene and methyl methacrylate cement articles$ #hich incite an inflammatory and macro hage res onse& Secondary release of local cyto/ines is thought to lead to %one resor tion and conse0uent loosening& The redominant %one3resor ti(e cyto/ines identified in reacti(e mem%ranes and fluid surrounding loose arthro lasties are IL36$ IL3.$ and tumor necrosis factorBal ha& Perio erati(e or late infection oses the most serious com lication of hi arthro lasty$ often necessitating remo(al of the rosthetic com onents and cement in order to treat the ro%lem definiti(ely& ?ncemented Prosthetic <oint Re lacement :ecause of the ro%lems associated #ith rosthetic loosening$ efforts ha(e %een focused on the de(elo ment of uncemented$ orous3coated rosthetic designs that allo# %ony ingro#th to ro(ide ermanent sta%ility& Designs include sintered metal %eads +co%alt3chrome or titanium,$ sintered titanium #ire mesh$ and lasma3s rayed titanium %ead coatings& Pore si1es of CG to 5GG mm ha(e demonstrated o timum %ony ingro#th e" erimentally$ %ut in retrie(al studies$ significant areas of orous

rostheses ha(e %een found to ha(e only fi%rous ingro#th& 4icromotion greater than 6CG mm a ears to %e associated #ith fi%rous rather than %ony ingro#th& Another ro%lem is dissociation of %eads from the de(ice$ #hich may %e a result of loosening& In an effort to enhance fi"ation$ hydro"ya atite coatings ha(e %een introduced$ allo#ing direct %ony %onding& The use of recom%inant gro#th factors also has %een e" lored& Se(eral clinical studies of uncemented hi re lacements ha(e %een u%lished$ and #hile o(erall results are acce ta%le$ mild ersistent thigh ain and lim a ear to %e more common than #ith cemented arthro lasty +7ig& 5636GF,& Radiolucent lines are fre0uent around these rostheses$ %ut re(ision rates ha(e %een lo#& ?ncemented /nee arthro lasty has %een fairly successful on the femoral side$ %ut ro%lems #ith loosening ha(e occurred #ith ti%ial and atellar com onents& Infections The most serious com lication of total hi re lacement is infection$ #hich may occur immediately after o eration or after se(eral months or years& In addition$ hematogenous seeding %y %acteremia from other causes can result in infection of any total )oint arthro lasty& Pro hylactic anti%iotics in atients #ho undergo in(asi(e rocedures such as dental #or/$ colonosco y$ or cystosco y is recommended& The use of clean air laminar flo# o erating rooms$ ro hylactic erio erati(e anti%iotics +ce halos orin,$ and ultra(iolet lights during surgery all ha(e %een associated #ith a dro in infection rates to less than 6 ercent& Acute infection is treated %y immediate de%ridement$ suction;irrigation drainage for 95 to D9 h$ and a full .3#ee/ course of intra(enous anti%iotics& If infection recurs or is chronic$ single3stage or t#o3stage e"change arthro lasty is underta/en& This in(ol(es remo(al of hard#are and cement$ de%ridement$ and intra(enous anti%iotic thera y& 8ith rimary e"change the arthro lasty is re(ised using anti%iotic3im regnated cement at the time of the de%ridement& 4ore commonly$ secondary e"change is carried out #ith re(ision after anti%iotic treatment for . #ee/s +for sta hylococcal or stre tococcal infections, to a year +for gram3negati(e organisms,& In infected total /nees or hi s$ the lacement of anti%iotic3im regnated cement %eads in the )oint at the time of rimary de%ridement can enhance eradication of the infection& A cement s acer has %een used in /nee arthro lasties also to maintain the )oint s ace until secondary re(ision is carried out& In some cases$ loss of %one stoc/ or resence of (irulent organisms recludes re(ision surgery& In these instances resection arthro lasty +Girdlestone rocedure,$ lea(ing a seudarthrosis$ ro(ides satisfactory function and ain relief$ although #al/ing aids usually are needed ermanently& 2eteroto ic Ossification 2eteroto ic ossification +myositis ossificans, is a fre0uent com lication of total hi arthro lasty +re orted incidence (aries from H to FG ercent, and consists of a%normal %one and cartilage formation in the soft tissues ad)acent to the )oint& This can limit )oint motion and rogress to an/ylosis in a small ro ortion of atients& 2istologically$ endochondral ossification and mem%ranous %one formation are %oth resent and resem%le fracture callus& Ris/ factors include male gender$ ast history of ha(ing formed heteroto ic %one$ hy ertro hic osteoarthritis$ an/ylosing s ondylitis$ and diffuse idio athic s/eletal hy erostosis& 2eteroto ic %one formation often is seen in head3in)ured and s inal cordBin)ured atients as #ell& Posttraumatic heteroto ic

ossification can follo# muscle contusion and can %e mista/enly diagnosed as an osteosarcoma& Patients at ris/ for heteroto ic ossification can %e treated ro hylactically #ith lo#3 dose radiation +H to 6G Gy, administered #ithin the first - or 5 days after o eration& This is thought to o%literate the cellular roliferati(e res onse& Indomethacin treatment for . #ee/s osto erati(ely also has %een sho#n to significantly decrease the incidence of heteroto ic %one formation& An/ylosis of )oints secondary to heteroto ic ossification can %e treated %y surgical e"cision after the ossification has matured$ if osto erati(e radiation is used to re(ent recurrence& Osteonecrosis of the 7emoral 2ead +A(ascular Necrosis, Certain eriarticular %ony areas are rone to de(elo ment of osteonecrosis %ecause of their relati(ely recarious %lood su ly& The humeral head$ femoral condyles$ ti%ial lateau$ talus$ lunate$ sca hoid$ and femoral head are the most fre0uent areas of in(ol(ement& Osteonecrosis of the femoral head is the most common and serious of these& Disru tion of the %lood su ly can result from trauma +femoral nec/ fracture or hi dislocation,$ sic/le cell anemia$ a%normalities of fat meta%olism +associated #ith alcoholism$ li id storage diseases$ and corticosteroids,$ and decom ression sic/ness +!the %ends$' secondary to nitrogen %u%%les causing intraosseous (ascular occlusion, and can also %e idio athic& The su erior lateral 0uadrant of the femoral head is most often initially in(ol(ed$ and infarction causes marro# edema and (enous outflo# o%struction$ rogressi(ely increasing local intramedullary ressure and #idening the area of the infarction& The dead %one is gradually re(asculari1ed and re laced %y cree ing su%stitution$ %ut during re(asculari1ation %one resor tion can lead to mechanical failure$ #ith su%chondral fractures +crescent sign, indicati(e of im ending )oint surface colla se& The net result is flattening of the femoral head$ #ith incongruity of the )oint and$ usually$ ra id rogression of secondary osteoarthritis& Patients com lain of hi ain$ articularly #ith #eight %earing or rotation of the hi * the infarction also may %e clinically silent& 8hen colla se occurs$ ho#e(er$ atients almost al#ays ha(e ain and limitation of #eight %earing and motion& A high ro ortion of cases #ith systemic causes +such as steroid use, ha(e %ilateral in(ol(ement& The rogression may %e ra id$ o(er 6 to 9 months$ or it may ta/e years for flattening and colla se to cause sym toms& Steroid3induced osteonecrosis has %een sho#n to rogress to colla se in essentially all atients& In atients at ris/$ the diagnosis should %e sus ected #ith a resentation of une" lained hi ain& Radiogra hs may %e normal initially$ %ut sclerotic changes soon de(elo in the femoral head$ follo#ed %y su%chondral lucency$ flattening of the )oint surface$ and$ later$ secondary degenerati(e changes& Although %one scans can demonstrate decreased erfusion early in the e(olution of osteonecrosis$ 4RI is the most sensiti(e method for detection of early necrosis #hen radiogra hs are normal& Treatment Treatment of osteonecrosis has %een contro(ersial and disa ointing o(erall& Earlier literature su orted the use of cortical strut %one grafting +Phemister$ Enne/ing rocedures, using ti%ial or fi%ular segments laced through the femoral nec/ to the

su%chondral %one to su ort the necrotic segment and re(ent colla se& In steroid3 induced a(ascular necrosis$ ho#e(er$ a high ro ortion of atients rogress des ite this inter(ention& 7icat and 2ungerford ha(e o ulari1ed the rocedure of core decom ression$ in #hich a channel is drilled through the femoral nec/ into the femoral head to decrease the ele(ated %one marro# ressure and facilitate healing& Pre(ention of rogression in FG ercent of atients has %een re orted$ %ut su%se0uent series ha(e had failure rates as high as HG ercent$ ma/ing this rocedure (ery contro(ersial& The rocedure does ro(ide good relief of rest ain$ and$ if done early$ %efore there is any e(idence of colla se or su%chondral lucency$ it a ears to re(ent rogression in the ma)ority of atients& Patients are /e t on crutches #ith no #eight %earing for - months after surgery& ?r%ania/ has ro osed the use of a (asculari1ed fi%ular graft #ith micro(ascular anastomosis to the femoral circumfle" (essels to allo# more ra id and relia%le healing of the strut #hile mechanically su orting the necrotic segment& This rocedure has gi(en satisfactory results e(en in atients #ith su%chondral lucency or slight colla se$ although it is still too early to fully e(aluate efficacy& Diagnosis and treatment of osteonecrosis are summari1ed in 7ig& 56366G& 8hen secondary degenerati(e arthritis occurs$ total hi re lacement often is necessary& Arthrodesis has not ro(ed (ery successful$ #ith a high seudarthrosis rate$ resuma%ly secondary to the %one necrosis& If colla se has occurred %ut no secondary degenerati(e changes are e(ident$ %i olar endo rosthetic arthro lasty may %e considered$ although this is contro(ersial& In general$ results of total hi arthro lasty for osteonecrosis are not as good as those for rimary osteoarthritis$ #ith a higher loosening rate& In art this is a result of comor%idity caused %y steroid use or underlying medical disease& Enee Chondromalacia of the Patella Patellar ain and mild degenerati(e changes are (ery common$ articularly in young females& Chondromalacia refers to the early changes of degenerati(e arthritis$ #ith softening and fi%rillation of the articular cartilage& The medial facet is most often in(ol(ed& Chondromalacia may %e related to atellar su%lu"ation$ dislocation$ or chondral contusion from a direct trauma& Patients com lain of ain$ es ecially #ith stair clim%ing and /neeling$ #hich increase atellofemoral )oint contact forces& Physical e"amination may re(eal atellofemoral cre itus$ ain #ith atellar com ression$ effusion$ and tenderness of the atellar facets& Radiogra hs sho# atellar tilt or narro#ing of the )oint s ace$ and articular cartilage degeneration and thinning is readily discerni%le on 4RI& The e(olution of chondromalacia to fran/ osteoarthritis is uncommon& Treatment Isometric 0uadrice s +straight3leg3raising, e"ercises and use of anti3 inflammatory medications$ along #ith a(oidance of aggra(ating acti(ities$ often suffice to ermit resolution of sym toms& A atellar slee(e3ty e %race also hel s& In refractory cases #ith 0uadrice s malalignment$ rocedures to correct the alignment +as discussed earlier under Patellar Dislocation, can %e hel ful& Arthrosco ic de%ridement of fi%rillated cartilage is hel ful in some cases$ although the resultant degree of cartilage healing remains a su%)ect of contro(ersy& Arthrosco ic de%ridement of either the atellofemoral or ti%iofemoral )oint does decrease inflammatory de%ris in the /nee and usually im ro(es sym toms$ at least tem orarily& In cases in #hich se(ere cartilage degeneration is resent #ith e" osed su%chondral %one$ a%rasion

arthro lasty of the %one surface to %leeding %one is recommended& As discussed re(iously +see Articular Cartilage 2ealing,$ gro#th of fi%rocartilage in the defect then occurs$ #hich allo#s resolution of sym toms for a num%er of years& Treatment of end3stage atellofemoral arthritis is #ith atellectomy& Osteoarthritis of the Enee Osteoarthritis of the /nee is common in the aging o ulation and can %e associated #ith (arus or (algus deformity$ #hich accelerates the articular cartilage degeneration& Conser(ati(e thera y includes nonsteroidal anti3 inflammatory medications* an elastic /nee %race$ #hich can decrease s#elling and ain* and e"ercises to maintain range of motion and re(ent contracture& Patients #ith (arus and medial com artment degeneration +the more common attern, may %enefit from a lateral #edge in the shoe& In cases of unicom artmental +medial or lateral, in(ol(ement in the younger atient$ osteotomy of the femur or ti%ia to effect realignment and decrease mechanical stress in the degenerated ortion of the )oint often is hel ful& 7or (arus deformities$ (algus osteotomy of the ro"imal ti%ia is a ro riate$ although a significant num%er of atients rogress later& 8ith (arus deformities$ osteotomy of the distal femur is referred$ %ecause osteotomy of the ti%ia can result in the )oint lineAs not %eing arallel to the floor %ecause of the normal (algus of the femur& Total /nee re lacement arthro lasty is the treatment of choice for se(erely sym tomatic older atients$ #ith o(er FG ercent successful results at C to 6G years& The considerations are similar to those for total hi re lacement arthro lasty$ #ith the ma)or ro%lems %eing rosthetic loosening and infection& In atients #ith unicom artmental in(ol(ement$ unicom artmental /nee arthro lasty has %een ad(ocated %ecause more %one stoc/ is reser(ed com ared to total /nee re lacement& Although results of unicom artmental re lacement series (ary$ and loosening remains a significant ro%lem$ this is an o tion for the younger atient& Osteochondral allograft re lacement for osttraumatic defects and arthritis a%out the /nee also has %een recommended %y some$ %ut these techni0ues remain contro(ersial& An/le and 7oot Osteoarthritis in the an/le and foot most often results from trauma& Immo%ili1ation of the )oint #ith an an/le lacer or %race and use of a roc/er3 %ottom shoe sole is hel ful in controlling ain& In se(ere cases$ arthrodesis of the an/le may %e successful& Similarly$ su%talar arthritis can %e handled %y su%talar or tri le arthrodesis if %racing is ineffecti(e& 2allu" >algus +:union, Lateral de(iation of the great toe +hallu" (algus, is a disease of shoe3 #earing o ulations& The incidence is higher in females& 8ith rogressi(e de(iation of the toe caused %y ill3fitting shoes$ the lateral dis lacement of the fle"or and e"tensor tendons contri%utes to rogression of the deformity& Ca sular traction on the 4TP )oint from the deformity and ressure medially from shoe #ear cause e"ostosis$ or osteo hyte formation$ on the medial metatarsal head$ accentuating the deformity and causing ain& The articular cartilage res onds to the mechanical incongruity of the )oint %y rogressi(e degenerati(e change$ and the stiffening of the )oint aggra(ates ain on ush3off& Initial treatment efforts are directed at more a ro riate shoe #ear #ith #ide toe %o" shoes and insoles or metatarsal ads to alle(iate metatarsalgia& In refractory cases$ surgical inter(ention often is indicated&

O(er 6GG surgical rocedures ha(e %een de(ised$ suggesting the inade0uacy of many of these o erations in resol(ing the deformity and sym toms& One of the most fre0uent rocedures is the Eeller %unionectomy$ #hich is a resection of the )oint and osteo hyte$ resulting in a shortened %ut ainless toe +7ig& 563666 A$:,& Che(ron osteotomy of the distal first metatarsal has %een used in mild to moderate deformities in the a%sence of significant arthritic change$ #ith satisfactory results +7ig& 563 666 C,& If metatarsus rimus (arus e"ists$ ro"imal osteotomy of the metatarsal %ase #ith or #ithout a distal rocedure may %e hel ful& In adolescents$ soft3tissue rocedures to release adduction contracture and tighten the medial ca sule +4itchell rocedure, are fa(ored& Gout Gout is a disease resulting from a%normalities in the meta%olism of urate that cause de osition of urate crystals in )oints$ /idneys$ and musculos/eletal soft tissues& <oint de osition is e isodic and is associated #ith acute inflammation and ain& De osits of urate crystals$ called to hi$ can occur in %one$ cartilage$ and syno(ium& The most common locations are the e"ternal ear$ olecranon %ursa$ and around tendons of the distal e"tremities& Renal e"cretion can cause stones$ and de osition in renal arenchyma can lead to renal damage& Secondary degenerati(e changes in )oints can follo# re eated inflammatory e isodes& Clinical 4anifestations The classic resentation is a middle3aged man #ith an acute$ se(ere monarticular arthritis$ usually in(ol(ing the 4TP )oint of the great toe + odagra,& S#elling$ erythema$ and se(ere ain #ith mo(ement of the )oint are ty ical& The diagnosis is confirmed %y demonstration of urate crystals in the syno(ial fluid& The serum urate le(el also may %e ele(ated& In chronic gouty arthritis$ unched3out eriarticular erosions due to to hi may %e resent radiogra hically$ and later secondary degeneration$ #ith )oint s ace narro#ing and su%chondral sclerosis$ is o%ser(ed& Treatment Colchicine has %een used for acute gout e isodes since the days of 2i ocrates& A dose of G&.C mg is gi(en e(ery 6 to 9 h until acute sym toms su%side* the effect is usually ra id and dramatic& 7or less acute sym toms$ nonsteroidal anti3inflammatory medications such as indomethacin or na ro"en are effecti(e& Allo urinol$ a "anthine o"idase inhi%itor #idely used ro hylactically to lo#er the serum urate le(el$ is hel ful in re(enting recurrent attac/s and reducing to haceous de osits& In se(ere chronic secondary degenerati(e arthritis$ treatment as for osteoarthritis$ including )oint re lacement arthro lasties$ is a ro riate& Calcium Pyro hos hate De osition Disease +Chondrocalcinosis, Li/e gout$ calcium yro hos hate de osition disease occurs more commonly in males than in females$ and usually in middle3aged atients& Acute inflammatory e isodes$ termed seudogout %ecause of their resem%lance to gout$ are associated #ith this disease& The /nee )oint is most commonly in(ol(ed$ and radiogra hs #ill demonstrate the calcification of articular or meniscal cartilage& The diagnosis is confirmed %y syno(ial fluid analysis under olari1ed light$ #hich #ill demonstrate the #ea/ly ositi(ely %irefringent rhom%oidal crystals of calcium yro hos hate& The distal radioulnar )oint$ u%ic sym hysis$ and aceta%ular or glenoid la%rum can also %e

in(ol(ed& Treatment is #ith as iration and cortisone in)ection$ or #ith systemic anti3 inflammatory thera y in milder cases& 2emo hilic Arthritis In atients #ith hemo hilia acute hemorrhage in )oints e" osed to minor trauma leads to )oint stiffness and articular cartilage degeneration$ articularly #ith re eated e isodes& S ontaneous %leeding occurs only #hen factor >III le(els are G$ and %leeding #ith minor in)ury occurs #ith le(els of 6 to C ercent& The syno(ium e"hi%its (illous roliferation #ith mar/ed %ro#nish staining from hemosiderin& The most commonly in(ol(ed )oint is the /nee$ follo#ed %y the el%o#$ an/le$ and shoulder& The )oint assumes a osition of ma"imal (olume +/neeJfle"ion of 9G degrees* hi Jfle"ion$ adduction$ e"ternal rotation,$ and the atient #ill not mo(e the )oint %ecause of ain and muscle s asm& 8ith rogressi(e e isodes$ )oint contractures and e(entual destruction of the articular cartilage occur& The characteristic radiogra hic findings include enlargement of e i hyses in children$ and a s0uared3off a earance of the inferior atella and femoral condyles +7ig& 563669,& An additional concern in hemo hiliac atients is 2I> infection$ #hich has %ecome the leading cause of death in this grou & Conse0uently$ infectious rocesses such as tu%erculosis or yogenic arthritis may ha(e to %e considered in the differential diagnosis& Treatment 4inimi1ing )oint hemorrhage decreases the li/elihood of chronic arthritis& Patients should %e treated #ith factor >III$ s linting$ and com ression #ra ing of the )oint& 8eight3%earing )oints are rotected on crutches until ain and effusion resol(e and motion returns& :racing may %e needed to re(ent deformity$ and dynamic s lints may hel to im ro(e contractures& In se(ere cases of )oint destruction$ total )oint re lacement arthro lasty is no# feasi%le$ #ith a ro riate coagulation factor re lacement to 6GG ercent le(els in the erio erati(e eriod& Syno(ial Lesions Pigmented >illonodular Syno(itis Pigmented (illonodular syno(itis is an inflammatory syno(ial rocess of un/no#n cause that causes monarticular arthritis in children and young adults& Patients resent #ith ain and intermittent$ often chronic$ s#elling& E"amination sho#s s#elling and syno(ial thic/ening$ and as iration of the )oint re(eals %loody or %ro#nish hemosiderin3stained fluid& Cytologic e"amination of the fluid may re(eal the resence of hemosiderin3containing macro hages& Early in the course of the disease the radiogra hs are normal e"ce t for soft3tissue s#elling or effusion& Later$ eriarticular erosions and cyst formation occur$ and ultimately degenerati(e change of the articular surfaces #ith the radiogra hic features of osteoarthritis su er(ene& 2isto athologic ins ection of the syno(ium re(eals nodules and (illous ro)ections$ %ro#nish in color$ containing fi%rous tissue$ giant cells$ and monocytic cells #ith hemosiderin granules and hy er lasia of the syno(ial layer& :oth nodular and diffuse forms ha(e %een descri%ed$ #ith the diffuse form ha(ing a higher recurrence rate +a ro"imately CG ercent, than the nodular form +9C ercent, after syno(ectomy& Treatment of the lesion in(ol(es syno(ectomy& Radiation syno(ectomy using dys rosium36.C has %een re orted to gi(e satisfactory results$ as has arthrosco ic

syno(ectomy of the /nee& In )oints such as the hi $ or in the resence of large masses of the syno(ial tissue$ o en surgical syno(ectomy usually is refera%le& Syno(ial Chondromatosis Syno(ial chondromatosis is a neo lastic3li/e condition of syno(ium in #hich the syno(ial tissue undergoes chondroid meta lasia$ forming nodules of cartilage and %one that can detach and %ecome loose %odies in the )oint& The most commonly in(ol(ed )oints are the hi $ /nee$ and shoulder& Three hases ha(e %een descri%ed$ #ith an initial roliferati(e hase$ a secondary hase of loose %ody formation$ and an inacti(e hase in #hich mechanical damage to the )oint leads to rogressi(e secondary degenerati(e arthritis& Patients resent #ith mild ain$ effusion$ and e isodes of loc/ing& Radiogra hs usually demonstrate the loose %odies$ #hich often are calcified& 4RI also is diagnostic and can demonstrate the lesions %efore calcification of the cartilage& Surgical syno(ectomy is the treatment of choice& An/ylosing S ondylitis An/ylosing s ondylitis is one of the grou of seronegati(e s ondyloarthro athies #ith un/no#n causes& Other mem%ers of this grou include soriatic arthritis$ ReiterAs syndrome$ and entero athic arthritis& Characteristics include sacroiliac and s inal in(ol(ement and a higher than normal incidence of human leu/ocyte antigen +2LA, :9D ositi(ely& The incidence of an/ylosing s ondylitis is 6L6$GGG$ and there is a male redominance& Progressi(e %ac/ ain$ stiffness of the s ine rogressing to an/ylosis +%am%oo s ine,$ morning stiffness$ associated hi arthritis$ and age of onset under 5G are common features& Treatment consists of nonsteroidal anti3inflammatory agents and hysical thera y to maintain range of motion& If se(ere s inal deformity +most commonly se(ere fle"ion deformity of the cer(ical s ine, de(elo s$ correcti(e osteotomy occasionally is necessary& Total hi arthro lasty is hel ful in cases #ith se(ere arthritis of the hi s$ and care must %e ta/en to consider ro hylactic treatment for heteroto ic ossification in these atients using indomethacin or osto erati(e lo#3dose radiation treatment& Transient Syno(itis of the 2i in Children Children - to 6G years of age may resent #ith sudden onset of hi ain and an ina%ility to #al/ that can mimic sym toms of se tic arthritis& A lim may %e noted for se(eral days$ and often there is a history of an antecedent (iral illness& Radiogra hs usually are normal$ and ultrasonogra hic e"amination #ill demonstrate effusion in the )oint& As iration is mandatory for cultures and Gram stain to rule out se tic arthritis& The #hite cell count in the as irate is ele(ated$ in some cases o(er CG$GGG;mm-& The erythrocyte sedimentation rate and eri heral #hite cell count also may %e slightly ele(ated& If cultures are negati(e$ a %rief eriod of %ed rest #ith light traction #ill allo# s ontaneous resolution& A small ro ortion of these children +9 ercent, later de(elo Legg3Cal(=3Perthes disease$ and some de(elo recurrences of transient syno(itis$ %ut long3term ro%lems generally do not occur& Sli ed Ca ital 7emoral E i hysis Sli ed ca ital femoral e i hysis$ #hich occurs in children +girls aged 6G to 6- years* %oys aged 69 to 6C years,$ consists of a dis lacement of the ca ital femoral e i hysis osteriorly and medially #ith res ect to the femoral nec/& :oys are affected more fre0uently +ratio CL6,& The sli age can occur acutely or gradually$ and the incidence

of %ilaterality is 6C to 9C ercent& Patients #ith endomor hic %ody ha%itus tend to %e affected& Pathology ?nli/e in Salter ty e I and ty e II fractures$ in #hich the e i hysis se arates through the 1one of ro(isional calcification of the gro#th late$ in this disorder the se aration occurs through the hy ertro hic 1one a%o(e the calcified cartilage& The cause is un/no#n$ and mechanical$ endocrine$ immunologic$ and genetic causes ha(e %een ro osed& 2istologically$ the hy ertro hic 1one of the gro#th late is disorgani1ed$ and similar disorgani1ation has %een identified in resli ed gro#th lates& 4uch of the e(idence suggests an a%normality in the collagen of the gro#th late as the underlying ro%lem& Clinical 4anifestations The most common resentation is ain in the inguinal area or referred ain in the /nee& The atient may ha(e an antalgic gait$ and hysical e"amination re(eals ain on motion of the )oint #ith loss of internal rotation& 8ith fle"ion of the hi the thigh e"ternally rotates& Diagnosis Diagnosis is made radiogra hically #ith %i lanar films& :oth hi s should %e included %ecause of the incidence of %ilaterality& Presli radiogra hic findings include #idening of the gro#th late& A minimal sli resents #ith only su%tle radiogra hic findings$ %ut a line ro)ected along the su erior femoral nec/ on the antero osterior film usually #ill not intersect the e i hysis& 8ith an acute sli $ a tu%e lateral (ie# is safer than a frog3leg (ie#$ #hich #ill dis lace the e i hysis further& Chronic sli s e"hi%it some meta hyseal remodeling$ #ith ne# %one formation inferior and osterior to the )unction of the head and nec/& Treatment Treatment is aimed at re(enting further dis lacement of the e i hysis& 4ild to moderate acute sli s are treated %y in situ inning #ith threaded ins or scre#s across the hysis and into the femoral head +7ig& 56366-,& Great care must %e ta/en to ensure that enetration into the )oint does not occur$ as this can lead to chondrolysis and a oor outcome& It has %een demonstrated that a single scre# is effecti(e if laced centrally in the e i hysis& 8eight %earing is rotected until fusion of the gro#th late occurs$ usually #ithin se(eral months& Se(erely dis laced acute sli s +less than 6 to 9 #ee/s old, can %e reduced %y gentle traction and then inned& 4ani ulati(e reduction is contro(ersial$ %ecause it is associated #ith an increased incidence of chondrolysis and a(ascular necrosis& 7or se(ere chronic sli s$ osteotomy of the ro"imal femur and cuneiform osteotomy of the femoral nec/ ha(e %een recommended& The com lication of chondrolysis occurs more fre0uently in %lac/s and females #ith a sli ed e i hysis and leads to ra idly degenerati(e arthritis& Patients #ith higher grades of dis lacement are rone to de(elo ment of secondary osteoarthritis in the fifth to si"th decades& 2y ertro hic Pulmonary Osteoarthro athy 2y ertro hic ulmonary osteoarthro athy is associated #ith ulmonary diseases and consists of e"cessi(e %one formation ad)acent to )oints$ clu%%ing of the distal digits$

and eriosteal ne# %one formation along shafts of the long %ones& Arthritic changes resem%ling osteoarthritis can de(elo $ and treatment is sym tomatic& Occasionally resolution of the ulmonary athology +as occurs after e"cision of a neo lasm, results in regression of the sym toms& Neuro athic +Charcot, Arthro athy A neuro athic$ or Charcot$ )oint is a conse0uence of diseases that result in dener(ation or loss of ro rioce ti(e sense in )oints& Etiologic conditions include dia%etes mellitus$ sy hilis +ta%es dorsalis,$ le romatous neuro athy$ ara legia$ and syringomyelia& Affected )oints are characteri1ed %y rogressi(e$ se(ere$ and total destruction$ often follo#ing minor trauma& 7ragmentation of )oint surfaces and mar/ed deformity can occur +7ig& 563665,& 4assi(e s#elling is resent$ and )oint (olumes are large$ #hich is a hel ful oint in differentiating these conditions from chronic se tic rocesses$ in #hich the ca sule is scarred and fi%rotic and )oint fluid (olume small& These changes may %e attended %y gross ligamentous insta%ility& The foot and an/le commonly are in(ol(ed$ although the /nee$ shoulder$ and$ rarely$ the hi may %e affected& Pathologically$ syno(ial %io sy analysis sho#s moderate hy ertro hy$ minimal inflammatory infiltration$ and fragments of articular cartilage or su%chondral %one em%edded in the syno(ial mem%rane$ #hich are athognomonic for Charcot arthro athy& :racing for control of insta%ility and ain is the mainstay of treatment$ and total )oint arthro lasty is relati(ely contraindicated& Arthrodesis is hel ful in sym tomatic )oints #hen conser(ati(e thera y fails$ %ut it is difficult to achie(e& 8ith foot and an/le arthro athy in dia%etics$ %elo#3/nee am utation is a common long3term outcome& T?4ORS O7 T2E 4?SC?LOSEELETAL SMSTE4 General Considerations Primary tumors of the musculos/eletal system are rare& The histogenetic ty e of the tumor is de endent on the tissue of origin& In addition$ s ecific ty es of lesions tend to occur in articular %ones or areas of %ones$ usually in areas of ma"imal gro#th or remodeling& Giant cell tumors +osteoclastomas, occur near the gro#th late$ #here a high le(el of resor tion ta/es lace as art of remodeling* osteosarcomas occur in the meta hysis$ #here ne# %one formation is ma"imal* cartilage tumors in(ol(e the meta hysis near the gro#th late$ and round cell tumors occur in the meta hyseal;dia hyseal %one marro# +7ig& 56366C,& These neo lastic rocesses are thought to re resent a derangement of normal gro#th and %one remodeling functions$ #hich %ecome uncontrolled& Etiology The cause of most %one and soft3tissue neo lasms is un/no#n$ %ut recent molecular %iology studies romise to elucidate these mechanisms$ #ith identification of s ecific genetic mutations and chromosomal a%errations in some tumors$ derangements of tumor su ressor gene function$ and e" ression of oncogenes& 4ost histogenetic tumor ty es ha(e (aria%le le(els of aggressi(eness and occur in %enign and malignant forms& Ta%le 5636. illustrates the range of incidence and histogenesis of musculos/eletal neo lasms& The %iologic %eha(ior of tumors can (ary$ as reflected %y the athologic grade of the tumor& 8hile (arious grading systems e"ist for different

tumors$ in general the sim lified system ado ted %y the 4usculos/eletal Tumor Society reflects o(erall gross %eha(ior differences$ #ith %enign$ lo#3grade malignant$ and high3grade malignant forms& Characteristics 4usculos/eletal neo lasms are characteri1ed %y initial centrifugal gro#th from a single focus$ seudoenca sulation +formation of a 1one of reacti(e tissue around the e" anding lesion$ #hich in malignant lesions can %e focally in(aded %y the tumor,$ and a tendency to res ect anatomic %oundaries early in the e(olution of the lesion& These tumors thus tend to s read along fascial lanes and tend to remain contained in anatomic com artments$ a crucial characteristic in strategies for staging and surgical treatment of these lesions& Anatomic com artments include %ones$ muscle com artments$ )oints$ s/in and su%cutaneous tissue$ and in some cases$ ma)or neuro(ascular sheaths& 4etastasis 4etastasis of malignant musculos/eletal neo lasms is associated #ith a oor rognosis& 4etastases are most often ulmonary$ although some tumors tend also to in(ol(e regional lym h nodes$ and %ony metastases also occur& :rain and (isceral metastases are unusual$ generally occurring only in terminal end3stage disseminated disease& Staging The most #idely used staging system for musculos/eletal neo lasms$ sho#n in Ta%le 5636D$ has %een a lied to %oth soft3tissue and %one lesions& :enign lesions are graded as latent$ acti(e$ or aggressi(e& 4alignant lesions are staged on the %asis of #hether they are high grade +stage II, or lo# grade +stage I,$ and intracom artmental +A, or e"tracom artmental +:,& 4etastatic tumors are all stage III regardless of local e"tent and ha(e a dismal rognosis& This staging system has sho#n great (alue in redicting sur(i(al +7ig& 56366.,& Clinical 4anifestations Patients ty ically resent #ith a history of ain that is often #orse at night and usually is not acti(ity related& A mass or s#elling may %e resent$ %ut constitutional sym toms +#eight loss$ fe(ers$ night s#eats$ malaise, usually are a%sent$ e"ce t in cases #ith disseminated disease& Lesions ad)acent to )oints can cause effusion$ contractures$ and ain #ith motion& Soft3tissue tumors often are ainless unless there is in(ol(ement of neuro(ascular structures& Com ression of (eins or lym hatics in a lim% can cause distal edema$ and larger masses e"hi%it a attern of o(erlying (enous distention& 4alignant soft3tissue masses can %e firm and fi"ed to su%cutaneous tissue$ muscle$ or %one$ and usually are nontender& Local #armth is e(ident %ecause malignant lesions induce local angiogenesis& Patients may also resent #ith a athologic fracture as a manifestation of %enign or malignant intraosseous lesions$ #ith %one destruction and su%se0uent mechanical failure& Pain on #eight %earing is an ominous clinical sym tom that often indicates an im ending fracture& E(aluation should include a thorough history and hysical e"amination of the affected region$ #ith attention to )oint$ muscle$ neurologic$ and (ascular structures& E"amination of regional and distant lym h nodes is essential$ as are ulmonary and a%dominal e"aminations to assess the ossi%ility of metastatic disease&

Radiogra hic 7indings The lain radiogra h is the single most useful study in differential diagnosis of %one lesions& Considerations include the follo#ingL +6, E(idence of matri" roduction +%one formation$ calcification, +9, Pattern of gro#th + ermeati(e$ geogra hic$ moth3eaten$ loculated$ e" ansile$ e"o hytic, +-, Presence of %ony reaction to the lesion + eriosteal reaction$ sclerotic margination, +5, None of transition %et#een the host %one and lesion +narro# or #ell3 marginated (ersus #ide or oorly defined, +C, Age of the atient +., :one in(ol(ed +flat %one$ long %one$ s/ull$ (erte%rae$ acral %one, +D, Location #ithin the %one +e i hyseal$ meta hyseal$ dia hyseal, +H, Associated soft3tissue mass$ clinical sym toms +F, Presence of solitary (ersus multi le lesions ?sing these criteria$ an accurate differential diagnosis can %e formulated in most cases& Infection +osteomyelitis, must al#ays %e considered gi(en its highly (aria%le radiogra hic a earance& 4eta%olic$ inflammatory$ dys lastic$ traumatic$ congenital$ and degenerati(e conditions also are al#ays considered& Soft3tissue lesions are %etter e(aluated %y 4RI than any other ty e of radiogra hic study& Diagnostic E(aluation Routine la%oratory studies include com lete %lood count and differential* erythrocyte sedimentation rate* serum al/aline hos hatase$ calcium$ and hos hate le(els$ renal and li(er function studies$ and urinalysis& If multi le myeloma is #ithin the differential diagnostic ossi%ilities$ determination of serum rotein le(el or immunoelectro horesis should also %e erformed& In most instances of rimary tumors the ma)ority of these studies are normal& The al/aline hos hatase le(el may %e ele(ated in osteosarcoma$ and the %lood count and erythrocyte sedimentation rate are hel ful in e"cluding infection& 7urther staging studies (ary according to the location of the lesion$ diagnostic ossi%ilities$ age of the atient$ and li/elihood of malignancy& A %one scan almost al#ays is indicated to assess the acti(ity and e"tent of the rimary lesion as #ell as to e"clude the resence of other lesions& 8ith soft3 tissue tumors %one scan is reser(ed for lesions close to %one or sus ected of malignancy& 7or sus ected malignant lesions$ other recommended studies include chest radiogra h +or refera%ly CT scan, and a%dominal CT scan to e"clude metastatic disease& A diagnostic staging algorithm is sho#n in 7ig& 56366D& :io sy

7or lesions #ith a radiogra hically %enign a earance$ imaging studies of the lesion usually are unnecessary$ and the a ro riate ne"t ste is tissue diagnosis %y %io sy& 7or any otentially malignant lesion$ three3dimensional imaging studies +CT or$ refera%ly$ 4RI, %efore %io sy are recommended to fully assess the e"tent of the lesion and to lan the %io sy rocedure$ minimi1ing otential contamination of com artments$ #hich could com romise su%se0uent definiti(e surgery& De ending on the e" erience of the surgeon and athologist$ needle or trocar %io sy is a ro riate for the ma)ority of soft3tissue and %one tumors& General rinci les of the %io sy rocedure include the follo#ingL +6, :io sy incisions should al#ays %e longitudinal on e"tremities& +9, Needle %io sy tracts and incisional %io sy should %e laced so that they can %e e"cised en %loc at the time of resection& +-, Radiogra hic locali1ation should %e done to ensure accuracy& +5, 7ro1en3section e"amination should %e done to %e sure that ade0uate tissue has %een o%tained& +C, Cultures and a ro riate micro%iologic studies should %e erformed& +., The %one %io sy cortical #indo# should %e as small as ossi%le and o(al in sha e to minimi1e the ris/ of athologic fracture& +D, Central or necrotic areas should %e a(oided* %io sy at the eri hery of the lesion is most hel ful& +H, E" osure of any ma)or neuro(ascular structures should %e a(oided& +F, 2emostasis must %e o%tained to re(ent hematoma$ #hich could seed other com artments* for %one lesions sus ected of malignancy$ the %io sy site should %e lugged #ith methacrylate cement to re(ent hematoma& +6G, Tourni0uet use is hel ful for intrao erati(e accuracy of dissection& +66, ?se of a drain #ith its tract in line #ith the %io sy incision and near it #ill facilitate later en %loc resection& +69, Contamination of any unin(ol(ed com artment must %e a(oided& +6-, In general$ the surgeon ro(iding definiti(e treatment should also erform the %io sy #hene(er ossi%le* this #ould usually in(ol(e a tertiary care referral center& Treatment In the treatment of %enign and nonmetastatic malignant musculos/eletal tumors the rimary goal is eradication of the disease* reser(ation of lim% function is an im ortant %ut secondary consideration& Long3term results ha(e im ro(ed dramatically in the ast t#o decades$ and the treatment a roach for malignant lesions has changed$ #ith a shift a#ay from am utations and to#ard lim% sal(age rocedures&

The s ecific treatment (aries #ith the lesion %ut usually includes a com%ination of se(eral modalitiesL surgery$ chemothera y$ and radiothera y& :enign lesions usually are treated surgically& 7or malignant tumors the rimary treatment usually is surgery$ #ith chemothera y or radiothera y as a secondary +ad)u(ant, treatment& Commonly used chemothera eutic agents include do"oru%icin$ methotre"ate$ cyclo hos hamide$ ifosfamide$ (incristine$ and actinomycin D& Radiation treatment may %e gi(en reo erati(ely$ osto erati(ely$ or %y im lantation of catheters at o eration follo#ed %y osto erati(e loading #ith short3range isoto es +%rachythera y,& Effecti(e doses for control of microsco ic disease are generally in the range of CG to .C Gy& Surgical Procedures Surgical rocedures used in treatment of tumors are defined as follo#sL +6, IntralesionalL lea(es microsco ic and macrosco ic residual$ as in curettage of a %enign lesion& +9, 4arginalL remo(al through the reacti(e 1one of the tumor* may lea(e microsco ic residual in malignant tumors& +-, 8ideL remo(al #ith some normal tissue %eyond reacti(e 1one in all directions& +5, RadicalL com lete remo(al of all com artments +%one$ muscle$ )oint, in(ol(ed #ith the tumor or its reacti(e 1one& These surgical rocedure definitions are summari1ed in 7ig& 56366H& 7or %enign stage I or stage II lesions$ intralesional or marginal e"cision is ade0uate$ #hile stage III aggressi(e lesions re0uire marginal to #ide resection for cure& Lo#3grade +stage I, malignant tumors can %e treated #ith #ide surgical resection$ #ith a high ro%a%ility of local control& 2igh3 grade +stage II, malignant lesions can %e treated %y radical surgical e"cision$ or #ide e"cision lus ad)u(ant treatment$ #ith com ara%le lo# recurrence rates +C to 6G ercent,& In the treatment of tumors #ith similar margins the results of am utation (ersus resection are also com ara%le$ forming the %asis for the redominance of lim% sal(age surgery in recent years& Technological ad(ances also ha(e contri%uted to this change in treatment a roach$ gi(en the a(aila%ility of custom com uter3designed rosthetic im lants$ #hich can re lace all or art of a %one or )oint* osteochondral allografts* ne# lim% lengthening techni0ues* and micro(ascular techni0ues for free tissue transfers of %one and soft tissue& Am utation may still %e necessary for tumors in #hich in(ol(ement of ma)or neuro(ascular structures or multi le com artments recludes resection #ith reser(ation of useful lim% function& S ecific treatment and ad)u(ant thera ies (ary according to the histogenetic tumor ty e and grade$ and are summari1ed in Ta%le 563 6H& Prognosis 4alignant musculos/eletal tumors remain serious and life3threatening diseases$ although the rognosis has im ro(ed significantly o(er the ast t#o decades& 7or stage II lesions C3year sur(i(al rates range from 5G to HG ercent$ #hile for stage I lesions C3year sur(i(al rates are in the DG to FG ercent range& Local control rates of

FG ercent or %etter can %e antici ated in the ma)ority of tumor ty es& Local recurrence of %enign lesions (aries #ith stage and tumor ty e& Gi(en that the ma)or ro%lem in the treatment of s/eletal malignancies remains late metastatic disease$ further scientific ad(antages in this area are needed& Recent research has identified multi le drug resistance gene e" ression in atients treated #ith chemothera y #hose tumors %ecome resistant to the drugs& These genes lead to the roduction of an ATPase +P3glyco rotein, that um s a #ide (ariety of drugs out of the tumor cells$ maintaining su%lethal intracellular le(els& Other mechanisms of drug and radiation resistance also e"ist& E" erimental harmacologic a roaches to the enhancement of chemothera eutic effecti(eness %y inhi%iting these resistance mechanisms are currently under study and sho# romise for im ro(ing outcomes of sarcoma treatment& Other e" erimental methods of metastatic sarcoma treatment under in(estigation include the use of immunothera y$ in #hich the atientAs immune system is sensiti1ed to tumor antigens$ and %one marro# trans lantation$ in #hich high3intensity chemothera y is follo#ed %y the reintroduction of autologous marro# o%tained in ad(ance& S ecific 4usculos/eletal Tumors :one37orming Tumors Osteoma This small$ sessile %enign %ody tumor occurs most often in the s/ull and neither causes sym toms nor re0uires treatment& It consists of an a%normal e"crescence of surface %one& Similar lesions occur osttraumatically on the femur in the area of the adductor magnus insertion +riderAs %one,$ or in relation to the medial collateral ligament of the /nee +Pellegrini3Stieda lesion,& Osteoid Osteoma This %enign %one3forming lesion rimarily affects atients under -G years of age and has a male re onderance& Patients resent #ith local ain$ #hich can %e 0uite se(ere and is often relie(ed %y as irin& Radiogra hically$ a small +less than 6 cm, lucent lesion +nidus, is seen$ ty ically surrounded %y mar/ed reacti(e sclerosis +7ig& 56366F,& Sometimes areas of radiodensity are seen #ithin the lucent lesion$ corres onding histologically to disorgani1ed #o(en %one formation& The lesion gradually regresses o(er a eriod of C to 6G years$ %ut most atients are una%le to tolerate the sym toms and o t for surgical resection of the lesion$ #hich usually is curati(e if the entire nidus is remo(ed& Osteo%lastoma Osteo%lastoma is a %enign %one3forming tumor affecting rimarily children and young adults& Any %one may %e in(ol(ed$ %ut the s ine$ articularly its osterior elements$ is most often affected& The lesions are e" ansile and ha(e a mi"ed lytic and %lastic radiogra hic a earance& Patients usually resent #ith ain$ and treatment in(ol(es marginal resection or curettage and %one grafting if resection is not feasi%le #ithout e"cessi(e mor%idity& 2istologically$ (ascular stroma$ #o(en %one formation$ giant cells$ and osteoid may %e resent$ and differentiation from osteoid osteoma is %ased on clinical and radiogra hic criteria +i&e&$ a lesion greater than 6 cm in diameter$ #ithout reacti(e cortical sclerosis, rather than histology& Cellular lesions can easily %e confused #ith osteosarcoma$ and careful e(aluation %y a 0ualified athologist is essential to a(oid misdiagnosis&

Osteosarcoma +Osteogenic Sarcoma, Osteosarcoma is the most common rimary %one malignancy a art from multi le myeloma$ although it is nonetheless a rare disease +incidence 9&H;6$GGG$GGG,& Patients 6G to 9C years of age are most often affected$ and the most common sites are areas of ma"imal %one gro#th +distal femurJC9 ercent* ro"imal ti%iaJ9G ercent* ro"imal humerusJF ercent,& ?sually the lesions are meta hyseal& Although any %one can %e in(ol(ed$ the disease seldom occurs in the small %ones of the distal e"tremities and in the s ine& This disease has a num%er of (ariantsL$ +6, !classic' central or medullary high3grade osteosarcoma* +9, eriosteal osteosarcoma* +-, arosteal osteosarcoma* +5, osteosarcoma secondary to malignant degeneration of PagetAs disease$ fi%rous dys lasia$ or radiation* and +C, telangiectatic osteosarcoma& Osteosarcoma e"hi%its a %lastic radiogra hic a earance in most cases %ecause of the neo lastic #o(en %one formation& The eriosteum may %e raised off the %one %y the tumor mass$ causing a fusiform s#elling #ith reacti(e eriosteal %one at the eriosteal margins +CodmanAs triangle,& The malignant %one formation may ha(e a sun%urst a earance +7ig& 56369G,$ #ith in(asion into ad)acent com artments& Pathologic fractures can occur %ut are unusual& 2istologically$ the tumor consists of small leomor hic s indle cells$ #ith osteoid and #o(en %one formation$ and there is often cartilage formation as #ell& Cartilage formation is a rominent feature of eriosteal and arosteal (ariants of osteosarcoma& Telangiectatic (ariants are lytic and e" ansile$ resem%ling an aneurysmal %one cyst$ and ha(e rominent (ascular s aces and relati(ely s arse %one formation& Patients resent #ith ain that often is nocturnal and a mass or s#elling& 4etastatic s read usually is ulmonary$ and e(aluation of the chest %y CT is necessary& Serum al/aline hos hatase le(els may %e mar/edly ele(ated$ %ut la%oratory studies are other#ise usually negati(e& E(aluation also should include %one scan to rule out %one metastases$ and CT or$ refera%ly$ 4RI of the region for surgical lanning& 4ost osteosarcomas resent as stage II: lesions& Osteosarcoma is not articularly sensiti(e to radiation$ %ut it does ty ically res ond #ell to com%ination chemothera y& De ending on the e"tent and location of the lesion$ treatment ty ically in(ol(es #ide surgical resection or am utation$ usually after reo erati(e +neoad)u(ant, chemothera y& :one resected in lim% sal(age o erations can %e reconstructed %y custom rosthetic re lacement$ arthrodesis$ or allografting +7ig& 563696,& Results of com%ination chemothera y #ith resection are %etter than e(en radical surgical am utation #ithout ad)u(ant thera y$ #ith CG to DG ercent C3 year sur(i(al rates and usually %etter than FG ercent local control +com ared #ith 9G ercent C3year sur(i(al rates #ith radical surgery alone,& Pathologic fracture$ #ith contamination of all com artments$ can reclude lim% sal(age surgery& Chemothera y is continued after surgery for 6 year& Prosthetic designs that can %e eriodically lengthened %y a minor surgical rocedure allo# lim% sal(age e(en in relati(ely young children #ith osteosarcoma$ in #hom rogressi(e lim% length discre ancy might other#ise %e a se(ere ro%lem& Preo erati(e intraarterial chemothera y and radiothera y ha(e %een used instead of neoad)u(ant systemic chemothera y$ and results a ear to %e com ara%le& Parosteal Osteosarcoma

These tumors occur in a slightly older age grou and start ad)acent to the eriosteum rather than in the %one& The osterior as ect of the femur and ro"imal humerus and ti%ia are the most fre0uent sites& The tumor tends to %e #ell circumscri%ed and slo#3 gro#ing and metastasi1es only late$ usually to the lungs& 2istologically$ %land s indle cells #ith #o(en %one formation$ fi%rous stroma$ and focal cartilage formation are the ty ical characteristics& These lesions are not sensiti(e to ad)u(ant treatments and are treated %y #ide surgical resection and a ro riate reconstruction$ or %y am utation& Prognosis is significantly %etter than for con(entional high3 grade osteosarcoma& Secondary Osteosarcoma In older atients$ osteosarcoma can arise secondary to a chronic redis osing condition& The most common of these is PagetAs disease +malignant degeneration re orted in 6 to 6G ercent of cases,$ %ut osteosarcoma has also %een re orted in fi%rous dys lasia$ and rarely #ith chronic osteomyelitis& As many as C to 6G ercent of atients su%)ected to high3intensity radiation thera y for other cancers +sarcoma$ lym homa$ etc&, may de(elo secondary sarcomas 6G to 9G years later$ of #hich one ty e is osteosarcoma& Secondary osteosarcomas in(aria%ly are high3grade aggressi(e tumors$ and rognosis is oor$ #ith a tendency for early metastasis& 4ost atients in this age grou are una%le to tolerate the to"icity of intensi(e chemothera y$ and the usual treatment consists of surgical resection or am utation& Cartilaginous Tumors Osteochondroma +E"ostosis, This lesion is a common e"o hytic %enign lesion that occurs during childhood$ usually in the meta hyses of the long %ones +7ig& 563699,& It is thought to result from an a%errant fragment of the gro#th late that is left %ehind and undergoes s ontaneous gro#th& The lesions ha(e a %ony %ase #ith a cartilaginous ca $ from #hich the gro#th occurs as it does in normal gro#th lates during childhood& A multi le hereditary form occurs and #as discussed earlier +see 4ulti le E"ostoses under De(elo mental Disorders,& The lesions may cause ain from im ingement on tendons$ ner(es$ or muscle and fre0uently re0uire surgical e"cision& Gro#th of the lesion$ #hile not of concern in children$ may indicate malignant transformation in adults& A cartilaginous ca thic/ness of more than 6 cm +assessed %y CT or 4RI, should arouse sus icion of malignancy& In solitary lesions the ris/ of malignant degeneration is less than 6 ercent$ #hile in multi le lesions it may %e as high as 6C ercent& 4arginal to #ide e"cision of %enign or malignant lesions usually is curati(e if all the cartilage is remo(ed& Enchondroma Enchondromas are intramedullary cartilage lesions$ often e"hi%iting calcification and e" ansion of the %one& The small %ones of the hands and feet are commonly in(ol(ed$ %ut long %one in(ol(ement also occurs +7ig& 56369-,& The disease occurs in solitary and multi le forms& Patients may resent #ith ain or athologic fracture& The usual treatment is intralesional resection +curettage, and %one grafting& The most serious concern is the ossi%ility of malignant degeneration$ and careful sam ling at the time of %io sy is necessary to e"clude the ossi%ility of chondrosarcoma& Parosteal Chondroma This is a rare %enign cartilage lesion arising su% eriosteally$ often in the humerus or small %ones of the hand or foot& The lesions are some#hat more aggressi(e than

enchondromas and are rone to local recurrence& Accordingly$ marginal or #ide resection and %one grafting is indicated and is curati(e in the ma)ority of cases& Chondro%lastoma This is one of the fe# e i hyseal tumors and occurs most often in the first and second decades of life$ #hen the gro#th late is still o en& Patients resent #ith ain$ )oint effusions$ or contractures$ and radiogra hs sho# a lytic lesion #ith calcifications in the e i hysis +7ig& 563695,& The lesion is com osed of chondro%lasts$ cartilage$ giant cells$ and (ascular stroma& Treatment is %y curettage and %one grafting and is often challenging %ecause of the intraarticular location of the lesions& A rare malignant e i hyseal cartilage tumor in older adults$ clear cell chondrosarcoma$ ro%a%ly re resents the malignant degenerati(e counter art of chondro%lastoma& Chondromy"oid 7i%roma This rare meta hyseal tumor affects children and young adults$ ty ically arising in the femur or ti%ia& The lesion is %enign$ %ut it e"hi%its aggressi(e local %eha(ior$ #ith a high ro ensity for local recurrence and s read& The radiogra hic a earance is rimarily geogra hic and lytic #ith occasional calcifications* an e" ansile or multilocular a earance #ith a relati(ely #ell3 defined 1one of transition %et#een the tumor and host %one also is found& 2istologic e"amination re(eals a lo%ular configuration #ith three com onentsL cellular fi%ro%lastic areas$ chondroid areas$ and my"oid areas #ith ty ical stellate tumor cells& Treatment is %y #ide or marginal resection and %one graft reconstruction$ although aggressi(e curettage #ith grafting also has %een associated #ith satisfactory results& Chondrosarcoma Chondrosarcoma can %e rimary or secondary +as discussed a%o(e, and affects a %road age range +age 9G to .G years,& The el(is$ femur$ ti%ia$ and other long %ones can %e in(ol(ed$ and lesions closer to the a"ial s/eleton are more li/ely to %e malignant& Intramedullary calcifications are usually e(ident& Differential diagnosis includes %one infarction and enchondroma& 7eatures of cortical destruction and ain are im ortant indicators of ossi%le malignancy +7ig& 56369C,& The tumors are graded as lo#$ intermediate$ or high grade of malignancy on the %asis of cytologic features and resence of matri" roduction& Lo#er3grade lesions can %e treated %y #ide resection$ %ut #ith high3grade lesions metastatic disease is fre0uent and the rognosis is oor& Lim% sal(age surgery often is feasi%le$ %ut ad)u(ant treatments are not articularly hel ful since these lesions tend to %e resistant to chemothera y and radiothera y& 7i%rous Lesions 7i%roma Small intracortical fi%rous lesions$ referred to as fi%rous cortical defects$ are common incidental radiogra hic findings in the long %one meta hyses of children and tend to disa ear s ontaneously at s/eletal maturity& Larger (ariants$ #hich can rogressi(ely enlarge into the medullary ca(ity and occasionally cause athologic fractures$ are referred to as nonossifying fi%romas& The tumor consists of %land fi%ro%lastic and histiocytic cells$ #ith osteoclasts and cholesterol clefts from li id3laden macro hages& A (ariant of this tumor that ossifies occurs in the mandi%le +ossifying fi%roma,& In larger or sym tomatic lesions$ curettage and %one grafting is indicated$ and recurrences after this treatment are uncommon&

Desmoid This is a rare aggressi(e fi%rous tumor of %one that is analogous to its soft3tissue counter art$ aggressi(e fi%romatosis& 4arginal to #ide resection is indicated rather than curettage %ecause of the tendency for local recurrence& 8ith aggressi(e fi%romatosis of soft tissues$ local in(asi(eness causes fre0uent and rogressi(ely ro%lematic recurrences after surgical treatment& The lesions do not metastasi1e and ha(e %een treated #ith #ide surgical resection or radiation treatment$ #ith local control rates of a ro"imately CG ercent& Significantly %etter results ha(e %een o%tained %y marginal to #ide local resection in con)unction #ith moderate3dose +5C to CC Gy, radiation thera y& Systemic thera y #ith methotre"ate also has %een re orted to control or cause regression of aggressi(e fi%romatosis& 7i%rosarcoma Primary fi%rosarcoma of %one is rare and is characteri1ed %y a geogra hic lytic radiogra hic a earance #ith cortical destruction and associated soft3 tissue mass +7ig& 56369.,& Some of these lesions are %etter classified as malignant fi%rous histiocytomas$ #ith a mi"ed cell o ulation& The tumors are moderately radiosensiti(e$ and ad)u(ant chemothera y can %e effecti(e in im ro(ing sur(i(al rates& Surgery consists of #ide or radical resection and reconstruction rather than am utation$ often in con)unction #ith ad)u(ant radiation treatment& These tumors also arise as secondary lesions in fi%rous dys lasia and PagetAs disease and after radiation treatment for other cancers& Cystic Lesions ?nicameral +Solitary, :one Cyst This lesion occurs in children in the meta hysis of the long %ones ad)acent to the gro#th late$ most often the humerus or femur$ although the radius$ calcaneus$ and ti%ia also can %e affected& ?sually the lesions are ainless and may resent #ith a athologic fracture as the initial manifestation of the disease& The lesions are lytic$ e" ansile$ and #ell marginated +7ig& 56369D,$ and may %e found in the dia hysis in older children as a result of continued gro#th of the gro#th late a#ay from the lesion& In young children fractures heal$ %ut the lesions usually recur$ causing recurrent fractures during childhood& The cyst fluid contains high le(els of %one resor ti(e cyto/ines$ resuma%ly roduced %y the li(ing tissue and accounting for the aggressi(e %one resor tion in these lesions& At s/eletal maturity the cysts tend gradually to disa ear& In older children and young adults$ the lesions %ecome latent +stage I, and do not rogress& Recurrence rates in acti(e +stage II, lesions in younger children after surgical treatment +curettage and %one grafting, a(erage CG ercent& Partial or com lete healing of the ma)ority of these lesions has %een o%tained after intraosseous in)ection of methyl rednisolone$ currently the referred treatment +DG to FG ercent effecti(e #ith u to three se0uential in)ections,& In older children or adults #ith latent cysts$ curettage and %one grafting is effecti(e$ and steroid in)ections a ear to ha(e little effect& Aneurysmal :one Cyst This tumor$ found most often in children or young adults$ consists of a cystic lesion #ith large (ascular s aces$ characteri1ed %y aggressi(e$ e" ansile lysis of %one& The tumor is com osed of fi%rous tissue$ (ascular s aces #ith a lining resem%ling endothelium$ giant cells$ and reacti(e %one formation at the eri hery& Aneurysmal cysts can arise as a secondary degenerati(e (ascular lesion #ithin another rimary %enign or malignant %one tumor$ such as giant cell tumor or chondro%lastoma*

ho#e(er$ a%out half are thought to re resent rimary lesions& :ecause recurrence is relati(ely fre0uent #ith sim le curettage$ local resection #ith %one grafting is refera%le& Em%oli1ation has %een used successfully in unresecta%le s inal or el(ic lesions$ as has intermediate3dose radiation treatment& Preo erati(e em%oli1ation of large lesions is hel ful in decreasing the ris/ of hemorrhage& Round Cell Tumors E#ingAs Sarcoma E#ingAs sarcoma is a highly malignant rimary %one tumor of children +age range C to 6C years, that tends to arise in the dia hyses of long %ones& The s ine and el(is also may %e rimary sites& The radiogra hic a earance usually is that of an aggressi(e lesion$ #ith a ermeati(e attern of %one lysis and eriosteal reaction +7ig& 56369H,& Often there is an associated large soft3tissue mass$ and atients ha(e systemic sym toms +fe(er$ #eight loss, in addition to local ain$ #hich tends to %e #orse at night& A soft3tissue (ariant of E#ingAs sarcoma$ rimiti(e neuroectodermal tumor +PNET,$ occurs as #ell$ usually e"hi%iting e(idence of neural differentiation immunohistochemically& Differential diagnosis includes osteomyelitis$ lym homa$ and eosino hilic granuloma& Diagnostic e(aluation includes chest and a%dominal CT scans and %one scan to rule out metastases& Treatment consists of a com%ination of local radiation thera y and systemic chemothera y& 7i(e3year sur(i(al rates #ith this a roach are around CG ercent& A multimodality treatment that uses ad)u(ant surgery +#ide or marginal resection, has resulted in C3year sur(i(al rates of DC ercent& In young children am utation may %e necessary %ecause of the se(ere com romise of %one gro#th that can result from the effect of the re0uired le(els of radiation on the gro#th lates& 2istiocytic Lym homa +Reticulum Cell Sarcoma, This tumor occurs in atients 9G to 5G years of age$ usually affecting the dia hyses of long %ones& Its radiogra hic a earance is similar to that of E#ingAs sarcoma$ #ith ermeation$ eriosteal reaction$ and fre0uently a large associated soft3issue mass& Pathologic fracture may occur& A significant ro ortion of atients resent #ith or de(elo regional or distant lym h node in(ol(ement& Treatment consists of radiation to the local lesion in con)unction #ith systemic chemothera y& If feasi%le$ resection of the rimary tumor im ro(es sur(i(al and decreases the ris/ of local recurrence& Other Tumors Giant Cell Tumor +Osteoclastoma, These tumors arise in the e i hyses of young adults$ most commonly in the ro"imal ti%ia$ distal femur$ ro"imal femur$ and distal radius& Characteristically the lesion is radiogra hically urely lytic$ #ell circumscri%ed$ and occasionally e" ansile #ith cortical destruction& The lesion often e"tends to the su%chondral surface and can e(en in(ade the )oint +7ig& 56369F,& Although usually %enign$ a malignant (ariant occurs in a small ro ortion of cases$ and e(en the %enign lesions are stage III tumors$ #ith local aggressi(e %eha(ior and a high tendency to recur after surgical treatment& Patients usually resent #ith ain$ and athologic fracture may occur& The tumor consists of monocytic stromal cells$ (ascular tissue$ and sheets of large$ multinucleated osteoclast3li/e cells& The /ey feature in differentiating these tumors from other tumors that can contain large num%ers of giant cells +eosino hilic granuloma$ %ro#n tumor of hy er arathyroidism$ aneurysmal %one cyst$ chondro%lastoma$ osteo%lastoma$ nonossifying fi%roma, is that the o(al nuclei of the monocytic stroma resem%le those of the giant cells$ suggesting a common origin& The

most common cause of malignant giant cell tumors is rior radiation thera y for a %enign giant cell tumor$ #hich #as a former mode of treatment and can %e associated #ith malignant recurrence in u to 6G ercent of cases& :ecause of this radiation is no longer used in the treatment of giant cell tumor e"ce t in dire circumstances +such as unresecta%le lesions in the s ine #ith threat of neurologic deficit,& The most common treatment of giant cell tumor$ curettage of the lesion$ is associated #ith recurrences in 9C to CG ercent of cases& Alternati(e treatments therefore ha(e included #ide resection +usually reser(ed for recurrent cases, and ad)u(ant local treatments such as cryothera y #ith li0uid nitrogen or henol and$ most recently$ filling the defect #ith methyl methacrylate& The lo#est recurrence rates ha(e %een #ith cryothera y and methyl methacrylate cementation& Cementation causes a thermal /ill of tissue #ithin se(eral millimeters of the margin in %one as a result of the e"othermic reaction that occurs during olymeri1ation of the cement& If local recurrence occurs after cementation$ it is readily detecta%le radiogra hically as a lucency ne"t to the cement& 8ith %one grafting$ remodeling changes in the graft can o%scure signs of recurrence& :ecause these are e i hyseal lesions$ the resence of cement ne"t to the articular cartilage may redis ose to cartilage degeneration$ and in young atients$ some ad(ise remo(al of the cement and %one grafting after 9 years if the atient remains free of recurrence& Gi(en an incidence of )oint degeneration of only 6C to 9G ercent in long3term follo#3u studies$ the indications for cement remo(al are contro(ersial& Control of the lesion #ith this treatment a roach has %een successful in FG ercent of cases& >ascular Tumors 2emangioma 2emangiomas of %one often are noted in the s ine as an incidental finding& These %enign lesions are characteri1ed %y endothelial (ascular s aces$ and %ecause they ty ically do not cause sym toms management usually is sim ly o%ser(ation& A more aggressi(e lesion is the hemangioendothelioma$ #hich can occur in %one or in the soft tissues and generally is characteri1ed as a lo#3grade malignancy& In %one the lesions a ear cystic and #ell marginated$ #ith increased local erfusion on %one scan or angiogra hy& Occasionally lesions occur in se(eral %ones& Treatment is #ith #ide local resection$ although curettage #ith radiothera y has %een successful in some cases& Angiosarcoma Angiosarcoma is a highly malignant sarcoma of the %one or soft tissues& The rognosis of this lesion is oor$ #ith early hematogenous s read to the lungs the rule& Am utation or radical resection in nonmetastatic cases is a ro riate& Tumors Arising from Included Tissues Adamantinoma Adamantinoma is a rare e ithelial tumor occurring in the )a# and occasionally in the ti%ia or fi%ula of young adults& The tumor$ although malignant$ is slo# gro#ing and resents #ith ain and a lytic$ multiloculated or %u%%ly radiogra hic a earance& The dia hyseal ortion of the %one tends to %e in(ol(ed& Treatment is #ith #ide resection or am utation$ and ad)u(ant thera ies ha(e not %een sho#n to %e effecti(e& 4etastasis to the lungs occurs in a%out CG ercent of cases&

Chordoma
This rare$ lo#3grade malignant neo lasm arises in the sacrococcygeal or occi itocer(ical area and is thought to de(elo from em%ryonic remnants of the notochord& Si"ty ercent of cases occur in the sacrum or coccy" +7ig& 5636-G,& Patients resent #ith a mass$ neurologic sym toms$ or ain& The lesions are slo# gro#ing and occur usually in older adults& Differential diagnosis includes lasmacytoma$ giant cell tumor$ and metastatic carcinoma& The tumor is com osed of cords and nests of cells resem%ling chondrocytes$ #ith ty ical highly (acuolated !%as/et' or hysaliferous cells& The stroma consists of a %aso hilic$ mucoid$ or my"oid ground su%stance& The location ma/es #ide resection difficult and causes significant mor%idity$ %ut #ithout treatment the lesion is uniformly fatal$ #ith late ulmonary metastases& The lesions are not res onsi(e to radiothera y or chemothera y$ and surgical resection is the treatment of choice& Some recent e(idence suggests that this tumor may %e some#hat res onsi(e to roton %eam irradiation& Soft-Tissue Sarcoma Soft3tissue sarcomas are more than t#ice as common as malignant rimary %one tumors& 4alignant fi%rous histiocytoma is the most common ty e$ %ut a #ide (ariety of other histogenetic ty es e"ist$ including fi%rosarcoma$ li osarcoma$ malignant ner(e sheath tumors +neurofi%rosarcoma or malignant sch#annoma,$ rha%domyosarcoma$ syno(ial sarcoma$ lym homa$ rimiti(e neuroectodermal tumor +PNET,$ and e"tras/eletal chondrosarcoma& In general these lesions occur in atients o(er CG years of age$ and the treatment is similar for all tumors des ite the differences in histogenesis& Soft3tissue sarcomas are as a rule some#hat sensiti(e to radiation& 8hile chemothera y has ro(ed %enefit in controlling disease in atients #ith metastasis and rolonging their sur(i(al$ its role as an ad)u(ant thera y is contro(ersial$ #ith the ma)ority of recent data indicating only minimal efficacy in im ro(ing outcome& E"ce tions to this include rha%domyosarcoma$ PNET$ and lym homa& Treatment usually in(ol(es a ro riate staging follo#ed %y a com%ination of surgery and radiation thera y& Achie(ing #ide to radical surgical margins is necessary$ and in most cases can %e accom lished %y a lim% sal(age o eration& 4RI is essential in treatment lanning and in assessment of local com artment in(ol(ement +7ig& 563 6-6,& Radiation thera y may %e administered reo erati(ely or osto erati(ely %y %rachythera y or e"ternal %eam irradiation& 8ith this a roach FG to FC ercent local control can %e antici ated$ %ut a significant ro ortion of atients +a%out one3third, succum% to later metastatic disease& In selected cases of soft3tissue and other sarcomas$ resection of ulmonary metastases has led to cures in a ro"imately -G ercent of those treated& etastatic !one Tumors Carcinomas often metastasi1e to the s/eleton$ and metastatic lesions are much more common than rimary %one lesions in general ortho aedic ractice& The fi(e rimary cancers #ith a strong ro ensity to metastasi1e to %one are those originating in the %reast$ rostate$ lung$ /idney$ and thyroid& 4ulti le myeloma$ although technically a

rimary %one tumor$ also must %e considered in this grou %ecause of its similar age distri%ution + atients o(er age CG years,$ radiogra hic resentation$ and ortho aedic ro%lems and treatment + athologic fractures,& O(er FG ercent of atients #ith metastatic %reast or rostate carcinoma ha(e at least microsco ic %one in(ol(ement& The a"ial s/eleton$ including the s/ull$ thoracic s ine$ ri%s$ lum%ar s ine$ and el(is$ is most commonly in(ol(ed& The ro"imal long %ones$ articularly the humerus and femur$ also are affected fre0uently& Acral +distal, metastases are uncommon and are almost al#ays secondary to lung carcinoma #hen they do occur& The redilection of articular tumors for %one$ and for articular regions of s ecific %ones$ is thought to %e caused %y cyto/ines$ local gro#th factors$ or matri" com onents that attract and su ort gro#th of these lesions in s ecific areas& Lesions can %e %lastic +%reast$ rostate,$ lytic +%reast$ lung$ myeloma$ /idney$ thyroid,$ or mi"ed +%reast$ lung, in radiogra hic a earance& :lastic or sclerotic lesions are less rone to athologic fractures& Patients #ith multi le lesions may ha(e ele(ated al/aline hos hatase le(els and occasionally are hy ercalcemic$ a result of secretion of PT23li/e rotein %y some tumors$ or more fre0uently$ secondary to massi(e osteolysis %y the tumor cells& The resenting com laint usually is ain in the affected area& Patients #ith s inal lesions may resent #ith neurologic deficit or %ac/ ain& The ma)or ortho aedic ro%lem is that of fracture or im ending fracture$ #ith resulting functional disa%ility and ain& The mainstay of treatment of metastatic disease is radiation thera y$ #hich often controls sym tomatic lesions #ith relati(ely moderate doses +-C Gy,& Larger lesions +larger than - cm in a #eight3%earing %one,$ lesions that rogress des ite radiation$ lesions that in(ol(e more than one3third of the corte"$ and lesions that resent #ith ain on #eight %earing +im ending fractures, should %e internally fi"ed ro hylactically& 7ractures are treated surgically if the atient is a%le to tolerate the rocedure medically$ since aggressi(e mo%ili1ation significantly im ro(es 0uality of life& Ne#er rosthetic im lants for )oint reconstruction and fracture fi"ation allo# sta%ili1ation in the ma)ority of cases +7igs& 5636-9 and 5636--,& :racing or casting is rarely successful for athologic fractures$ since ain control remains a ersistent ro%lem$ and fractures usually #ill not heal %y closed means if irradiated %ecause of the su ression of callus formation %y radiation thera y& E"ce tions include s inal fractures$ #hich res ond to %racing and radiation treatment$ %ut if neurologic deficit occurs they re0uire surgical decom ression and internal fi"ation either anteriorly or osteriorly& If large areas of %one are destroyed$ sta%ili1ation often necessitates filling the defect #ith methyl methacrylate cement to su lement hard#are fi"ation& The goals of treatment are maintenance or restoration of function and ain relief$ since carcinoma metastatic to the %ones is essentially al#ays incura%le& Rarely$ a solitary metastasis is amena%le to curati(e resection if the rimary tumor has %een remo(ed* this situation can occur #ith renal cell carcinoma& Resection or am utation is also considered for ain relief or control of %ul/y$ fungating lesions& E" erimental treatments under in(estigation for metastatic disease$ including immunothera y and %one marro# trans lantation$ may offer future alternati(es to current alliati(e treatment a roaches&