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Old Unreduced Dislocations

Any dislocation should be reduced as soon as reasonably possible. While a joint is dislocated, the metabolism of its hyaline cartilage is disturbed and synovial fluid functions are impaired. Hyaline cartilage may begin to degenerate during this brief period, and irreversible changes rapidly occur. Consequently, when old unreduced dislocations are finally reduced, normal and painless joint motion and function should not be expected. When old unreduced…

Acute Dislocations

Open techniques are occasionally necessary for acute dislocations. Closed reduction with intravenous analgesia or sedation with general anesthesia should be attempted first for most uncomplicated dislocations. If general anesthesia is necessary, operating room personnel should prepare for the possibility of an open surgical procedure if closed reduction is unsuccessful. Excessive force should not be used in closed reduction because soft tissue or bone sometimes becomes interposed…

Delayed Union and Nonunion of Fractures

Approximately 2 million long bone fractures are treated in the United States each year. Of this number, about 100,000 result in nonunion. Nonunions can be very problematic not only to the patient but also to society in general. Patients with nonunions have significant disability, and the associated cost of treatment is burdensome on the patient and society. Brinker reported significant physical ( Fig. 59.1 ) and…

Malunited Fractures

A malunited fracture is one that has healed with the fragments in a nonanatomic position. Whether the deformity is unsightly or not it can impair function in several ways: (1) an abnormal joint surface can cause irregular weight transfer and arthritis of the joint, especially in the lower extremities; (2) rotation or angulation of the fragments can interfere with proper balance or gait in the lower…

Fractures of the Shoulder, Arm, and Forearm

Trauma to the upper extremity often presents a difficult challenge for orthopaedic surgeons; whether the problem encountered is a fracture, fracture with dislocation, or severe injury to the soft tissues or neurovascular elements. The ultimate functional results after injuries in the upper extremity often depend as much on the status of the surrounding soft tissues as on the status of the bone. A fracture to the…

Fractures of the Acetabulum and Pelvis

Acetabular Fractures The management of acetabular fractures is one of the most, if not the most, complex aspect of orthopaedic trauma. It involves a definite learning curve, probably best documented in a report by Matta and Merritt of the first 121 acetabular fractures treated operatively by Matta. Grouping the surgical reductions chronologically in groups of 20 clearly showed that experience improved the ability to avoid unsatisfactory…

Fractures and Dislocations of the Hip

As the number of hip fractures continues to increase in the United States (with an estimated 458,000 to 1,037,000 hip fractures per year by 2050 in patients 45 years old or older), orthopaedic surgeons will be called on to help deal with this impending public health crisis. Although most hip fractures occur in the geriatric population, more and more young patients are surviving motor vehicle accidents…

Fractures of the Lower Extremity

This chapter discusses the surgical management of common fractures in the lower extremity in adults. Basic techniques of fixation are discussed in Chapter 53 . The treatment of lower extremity fractures in children is discussed in Chapter 36 . Nonoperative treatment generally is restricted to stable, minimally displaced fractures or to fractures in patients with significant comorbidities that preclude surgery. Intramedullary nailing has become the treatment…

General Principles of Fracture Treatment

Accidental injury is the most common cause of death in the United States in individuals between the ages of 1 and 45 ( Table 53.1 ). In 2017 nearly 8.6 million accidental (unintentional), nonfatal falls were reported in the United States in all age groups. In adults older than 65 years of age, one in three experiences a fall that results in serious injury or death.…

Arthroscopy of the Upper Extremity

Diagnostic and surgical arthroscopy of the upper extremity has become much more common as surgeons have developed proficiency with the arthroscope and appropriate instrumentation has been developed. A thorough knowledge of the anatomy, disorders, arthroscopic variations, and pathologic findings of each joint is essential to perform the procedures successfully and to minimize complications. This chapter discusses indications for arthroscopic treatment, patient preparation, portal anatomy, specific arthroscopic…

Arthroscopy of the Lower Extremity

Knee The knee is the joint in which arthroscopy has its greatest diagnostic and intraarticular surgical application. The usefulness of arthroscopic techniques in diagnosis and treatment of intraarticular pathology has been well documented. Arthroscopy should be considered a diagnostic aid used in conjunction with a good history, complete physical examination, and appropriate radiographs. It should serve as an adjunct to, not as a replacement for, a…

Arthroscopy of the Foot and Ankle

Ankle Arthroscopy The most common current indications for ankle arthroscopy include soft-tissue or bony impingement and treatment of osteochondral lesions of the talus. These patients often have continuing ankle pain after injuries such as sprains that have not responded to the usual conservative therapy, and tenderness is noted specifically at the ankle joint line on physical examination. A definite diagnosis should be made before arthroscopy is…

General Principles of Arthroscopy

During the past five decades, arthroscopy has dramatically changed the orthopaedic surgeon’s approach to the diagnosis and treatment of a variety of joint ailments. A high degree of clinical accuracy, combined with low morbidity, has encouraged the use of arthroscopy to assist in diagnosis, to determine prognosis, and often to provide treatment. Arthroscopic procedures should serve as adjuncts to and not as replacements for thorough clinical…

Traumatic Disorders

Compartment Syndrome Compartment syndrome is an elevation of the interstitial pressure in a closed osteofascial compartment that results in microvascular compromise. Compartments with relatively noncompliant fascial or osseous structures most commonly are involved, especially the anterior and deep posterior compartments of the leg ( Fig. 48.1 ) and the volar compartment of the forearm. Compartment syndrome can develop anywhere skeletal muscle is surrounded by substantial fascia,…

Recurrent Dislocations

Recurrent instability can result from congenital, developmental, or traumatic ligamentous or bony containment deficiencies or from deformities caused by muscular imbalance, joint incongruity, or joint malalignment in one or more planes. Proper treatment begins with knowledge and skillful evaluation of deformities before initiating a specific treatment plan. Patella Patellar instability results from a direct or indirect valgus-producing force. When significant force results in dislocation, a tear…

Shoulder and Elbow Injuries

Shoulder Injuries Anatomy and Biomechanics The shoulder joint is composed of four articulations: the sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic that work together to allow smooth shoulder function. Together, they allow the shoulder joint to have the greatest range of motion of any joint in the body, and the relationship between these articulations must be considered when treating shoulder dysfunction. Normal function of the shoulder is a…

Knee Injuries

Anatomy The knee is one of the most frequently injured joints because of its anatomic structure, its exposure to external forces, and the functional demands placed on it. Basic to an understanding of knee injuries is an understanding of the normal knee anatomy. Although much emphasis has been placed on the ligaments of the knee, without the supporting action of the associated muscles and tendons, the…

Scoliosis and Kyphosis

Scoliosis The word scoliosis is derived from the Greek word meaning “crooked.” Scoliosis is defined as a lateral deviation of the normal vertical line of the spine. The lateral curvature of the spine also is associated with rotation of the vertebrae. This produces a three-dimensional deformity of the spine that occurs in the sagittal, frontal, and coronal planes. The Scoliosis Research Society (SRS) recommends that idiopathic…

Pediatric Cervical Spine

A variety of diseases and congenital anomalies may affect the pediatric cervical spine and increase the risk for neurologic compromise from instability or encroachment of the spinal cord. Multiple anomalies of the upper cervical spine are common within a single patient, so when a single anomaly is seen in a patient, others should be sought. An average of 3.4 cervical spine osseous anomalies per patient has…

Infections and Tumors of the Spine

Infections of the Spine Spinal infections are relatively uncommon but serious conditions, accounting for 3% to 5% of all osteomyelitis cases. Unfortunately, delays in diagnosis and treatment are common due to the manner in which these infections present. Symptoms may be vague, and there are no pathognomonic clinical signs or definitive laboratory tests to make the diagnosis. Spinal infections can be categorized into different groups based…