100 Orthopedic MCQs: Trauma, Spine, Adult Reconstruction & Pediatrics | Comprehensive ABOS Review

The iliacus muscle is a frequent site of hemorrhage in patients with severe or moderate hemophilia. In patients with moderate hemophilia, hemorrhage into the iliacus muscle often follows play or sporting events that include forceful contraction of the hip flexor muscles. An expanding iliacus hematoma compresses the adjacent femoral nerve, with one study reporting 60% complete femoral nerve palsy in hemophiliacs with an iliacus or iliopsoas hemorrhage. Femoral nerve compression typically includes paresthesias in the distribution of the terminal saphenous nerve branch. Hip joint hemarthrosis may occur, but this condition is not as frequent in hemophiliacs as muscle hemorrhage into the iliacus muscle. More importantly, a hip joint hemarthrosis is not associated with significant compression of the femoral nerve. Avulsion fractures of the anterior superior iliac spine typically occur during adolescence and are not associated with saphenous nerve paresthesias. Slipped capital femoral epiphysis does not have an increased association with hemophilia and usually occurs during the adolescent years. Greene WB: Diseases related to the hematopoietic system, in Morrissy RT, Weinstein SL (eds): Lovell and Winter's Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 379-426.

Giant cell tumor of bone has about a 2% risk of benign pulmonary metastasis in all cases and 6% risk in recurrent cases. The radiograph and MRI scans show a lytic destructive lesion in the distal radius with no matrix mineralization. The lesion extends up to the subchondral bone. In a young woman, the most likely diagnosis is giant cell tumor of bone, which is supported by the pathology results that show monotonous fibrovascular stroma with numerous multinucleated giant cells where the nuclei that make up the giant cells are identical to the nuclei that make up the background stromal cells. Athanasian EA, Wold LE, Amadio PC: Giant cell tumors of the bones in the hand. J Hand Surg Am 1997;22:91-98.

Sternoclavicular joint sepsis is a rare condition that is most often restricted to patients who are immunocompromised, diabetic, or IV drug abusers. Examination commonly reveals a tender, painful, and possibly swollen sternoclavicular joint. If suspicion remains high following a thorough history, physical examination, radiographs, and routine blood tests, joint aspiration should be performed prior to incision and drainage or administration of antibiotics. Bremner RA: Monarticular noninfected subacute arthritis of the sternoclavicular joint. J Bone Joint Surg Br 1959;41:749-753.

The patient has a stage II posterior tibial tendon tear with a supple foot; therefore, the treatment of choice is flexor digitorum longus transfer with medial displacement calcaneal osteotomy. Triple arthrodesis is not indicated, and isolated tendon transfer will stretch out in the face of persistent heel valgus. Direct repair of the posterior tibial tendon or repair of the spring ligament is not sufficient to correct the deformity. Myerson MS, Corrigan J: Treatment of posterior tibial tendon dysfunction with flexor digitorum longus tendon transfer and calcaneal osteotomy. Orthopedics 1996;19:383-388.

The radiograph reveals that the femoral component is grossly loose as evidenced by disruption of the cement column; therefore, retention of the original components will not yield a successful outcome. A cementless revision is the procedure of choice. A strut graft and/or plate may be added at the surgeon's discretion. A resection arthroplasty would only be considered in a nonambulatory patient. Cemented fixation of the revision component would be problematic given the numerous fracture fragments and the inability to contain the cement. Springer BD, Berry DJ, Lewallen DG: Treatment of periprosthetic fractures following total hip arthroplasty with femoral component revision. J Bone Joint Surg Am 2003;85:2156-2162.

It is often tempting to assign a diagnosis of plantar fasciitis in patients with hindfoot pain. In this patient, the radiographs confirm a diagnosis of a calcaneal insufficiency fracture. The dense condensation of bone on the lateral view confirms the diagnosis. There is no radiographic evidence of a heel spur, osteochondral lesions, or chondrocalinosis. Resnick D: Diagnosis of Bone and Joint Disorders, ed 3. Philadelphia, PA, WB Saunders, 1995, p 2591. Kearon C: Natural history of venous thromboembolism. Semin Vasc Med 2001;1:27-37.

Osteochondritis of the capitellum is characterized by pain, swelling, and limited motion. Catching, clicking, and giving way also can occur. It commonly affects athletes who participate in competitive sports with high stresses, such as pitching or gymnastics. Krijnen MR, Lim L, Willems WJ: Arthoscopic treatment of osteochondritis dissecans of the capitellum: Report of 5 female athletes. Arthroscopy 2003;19:210-214.

Anteversion of the humeral component may result in anterior instability of the component. Posterior instability after total shoulder arthroplasty is usually the result of some combination of the following factors: untreated anterior soft-tissue contractures, excessive posterior capsular laxity, and excessive retroversion of the humeral and/or glenoid components. Cofield RH, Edgerton BC: Total shoulder arthroplasty: Complications and revision surgery. Instr Course Lect 1990;39:449-462.

Spinal shock typically ends after 48 hours with the return of reflexes, including the bulbocavernosus reflex. Lack of motor or sensory recovery in the lower extremities with the return of reflexes generally indicates a complete cord syndrome. Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 179-187.

While most pathologic fractures are in the lower extremity in patients treated for soft-tissue sarcomas by wide excision and adjuvant radiation therapy, risk factors for such fractures are bone resection associated with excision of the tumor and soft-tissue sarcomas of the thigh that require periosteal stripping at the time of resection. Such fractures can occur late, often more than 6 months after surgery, are difficult to treat, and often result in nonunion. Bell RS, O'Sullivan B, Nguyen C, et al: Fractures following limb-salvage surgery and adjuvant irradation for soft-tissue sarcoma. Clin Orthop 1991;271:265-271.

The patient has a symptomatic os trigonum caused by impingement that occurs with maximal plantar flexion of the ankle in the demi-pointe or full-pointe position. Patients frequently report posterolateral pain localized behind the lateral malleolus that may be misinterpreted as a disorder of the peroneal tendon. Pain with passive plantar flexion (the plantar flexion sign) indicates posterior impingement, not a problem with the peroneal tendon. The symptoms are not characteristic of a stress fracture, nor do the radiographs show a stress fracture or an osteochondritis dissecans lesion. The os trigonum is modest in its dimensions. The incidence or magnitude of symptoms does not correlate with the size of the fragment. Large fragments may be asymptomatic, while small lesions may create significant symptoms. Marotta JJ, Micheli LJ: Os trigonum impingement in dancers. Am J Sports Med 1992;20:533-536.

The orthosis shown is a carbon reinforced Morton's extension, and it is commonly used for hallux rigidus. It decreases motion of the first metatarsophalangeal joint and subsequently decreases pain.

Documenting the status of recovery at this time is appropriate; therefore, repeat EMG studies should be conducted to check for early signs of reinnervation. Timing of nerve exploration in this setting is debated, with authors suggesting exploration if there is no sign of recovery at 6 to 9 months. Perlmutter GS: Axillary nerve injury. Clin Orthop 1999;368:28-36. Artico M, Salvati M, D'Andrea V, et al: Isolated lesions of the axillary nerves: Surgical treatment and outcome in twelve cases. Neurosurgery 1991;29:697-700. Vissar CP, Coene LN, Brand R, et al: The incidence of nerve injury in anterior dislocation of the shoulder and its influence on functional recovery: A prospective clinical and EMG study. J Bone Joint Surg Br 1999;81:679-685.

Necrotizing fasciitis is a rapidly progressive soft-tissue infection with the potential to threaten both life and limb. Patients who are immunocompromised (HIV infection, diabetes mellitus, alcohol abuse) are at increased risk. However, any patient in the immediate postoperative phase is susceptible to wound infection. Early detection is the key. Necrotizing fasciitis is primarily a surgical problem that requires urgent debridement and broad-spectrum IV antibiotics. Rapid diagnosis and prompt treatment help to reduce mortality, which may approach 30%. Debridement of the bullae and observation are not indicated. Although elevation and close follow-up may be warranted early on, in this patient, surgical debridement is the next step. Ault MJ, Geiderman J, Sokolov R: Rapid identification of group A streptococcus as the cause of necrotizing fasciitis. Ann Emerg Med 1996;28:227-230.

Children with spastic diplegic cerebral palsy often have contractures of multiple joints. Because the gait abnormalities can be complex, isolated surgery is rarely indicated. To avoid compensatory deformities at other joints, it is preferable to correct all deformities in a single operation. Isolated heel cord lengthening in the presence of tight hamstrings and hip flexors will lead to progressive flexion at the hips and knees, thus worsening a crouched gait. Split posterior tibial tendon transfer is used for patients with hindfoot varus, which is not present in this patient. Gage JR: Distal hamstring lengthening/release and rectus femoris transfer, in Sussman MD (ed): The Diplegic Child. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1992, pp 324-326.

The elongated anterior process of the calcaneus reaching distally toward the navicular is an abnormal finding. Instead of viewing the rounded, blunt distal anterior process of the calcaneus, a bridge extends to the navicular, albeit incomplete. These findings are consistent with a fibrous coalition. CT can reveal a stress fracture of the calcaneus, arthritis of the subtalar joint with subchondral cysts, or an os peroneal bone disruption in the peroneus longus, but those entities are not shown here. The plantar fascia is intact. Richardson EG: Sesamoids and accessory bones of the foot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 702-732.

Cervical myelopathy involves compression of the spinal cord and presents as an upper motor neuron disorder. Patients commonly have extremity spasticity and problems with ambulation and balance. Hoffman's sign is often present and is elicited by suddenly extending the distal interphalangeal joint of the middle finger; reflexive finger flexion represents a positive finding. The extremities are usually hyperreflexic with myelopathy. With cervical radiculopathy (lower motor neuron disorder), reflexes are hyporeflexic, and patients report pain along a dermatomal distribution. A hyperactive jaw jerk reflex indicates pathology above the foramen magnum or in some cases, systemic disease. Flaccid paraparesis suggests a lower motor neuron problem. Sachs BL: Differential diagnosis of neck pain, arm pain and myelopathy, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 741-742.

The first branch of the lateral calcaneal nerve innervates the abductor digiti minimi. It is reported to be trapped at the interval between the abductor hallucis and the quadratus plantae muscles.

Osteochondrosis of the tarsal navicular (Kohler disease) is an infrequent cause of midfoot pain in children, and the etiology is unknown. The typical radiographic findings include flattening and irregular ossification of the tarsal navicular. The medial cunieform and talus maintain their normal articular contours. The acute process is best treated with rest and immobilization. A short leg walking cast results in relief of pain and a quicker return to activity compared with orthotics, although long-term success is similar with either method of treatment. Children may return to activities when the symptoms subside. The radiographic appearance of the talus begins to normalize by about 8 to 10 months following the onset of symptoms.

Studies show that degenerative arthritis of the spine associated with a hip arthrodesis can be decreased with conversion to a total hip arthroplasty. The pain associated with degenerative arthritis of the knee usually persists after arthrodesis take-down procedures, and often requires total knee arthroplasty. Pain in the contralateral hip is not resolved by converting the arthrodesis. Improving range of motion of the hip and correcting a limb-length discrepancy are not good indications for take-down procedures. Strathy GM, Fitzgerald RH Jr: Total hip arthroplasty in the ankylosed hip: A ten-year follow-up. J Bone Joint Surg Am 1988;70:963-966.

The loss of consciousness indicates a grade 2 concussion, which necessitates a 4-week period out of sport. The last week prior to return must be symptom-free and the athlete should not have symptoms in practice. Cantu RC: Return to play guidelines after a head injury. Clin Sports Med 1998;17:45-60.

The patient has a nonunion of the distal fifth of the tibia. The nonunion appears to be oligotrophic, somewhere between atrophic and hypertrophic. Management requires stabilization and stimulation of the local biology, which can be accomplished with open reduction and internal fixation with bone grafting. Bracing or casting does not provide enough stability. Ultrasound bone stimulation has been shown to speed fresh fracture repair but is not indicated in nonunions. The distal segment is too short for intramedullary nailing. A fibular osteotomy alone would increase instability and, even with prolonged casting, would be unlikely to lead to successful repair. Carpenter CA, Jupiter JB: Blade plate reconstruction of metaphyseal nonunion of the tibia. Clin Orthop 1996;332:23-28. Lonner JH, Siliski JM, Jupiter JB, Lhowe DW: Posttraumatic nonunion of the proximal tibial metaphysis. Am J Orthop 1999;28:523-528. Stevenson S: Enhancement of fracture healing with autogenous and allogeneic bone grafts. Clin Orthop 1998;355:S239-S246.

The radiographs reveal a geographic, diaphyseal lesion with very subtle cortical expansion, cortical thinning, relatively sharp demarcation, and angular rather than rounded borders, suggesting a fibrous bone lesion. This lesion demonstrates the classic ground glass appearance of fibrous dysplasia. Ewing's sarcoma, metastases, and aneurysmal bone cyst all typically have a more aggressive appearance. Parsons TW: Benign bone tumors, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1027-1035.

The patient has osteonecrosis of the humeral head. The radiographs show increased density in the superior subchondral region of the humeral head. The MRI scans reveal a central collapse of the humeral head. The patient's history of severe asthma and long-term prednisone use predisposes her to this condition. The MRI scans show no evidence of a full- or partial-thickness rotator cuff tear. Without a history of fevers, chills, or other systemic signs or symptoms, there is no indication of septic arthritis. The radiographs do not reveal periarticular erosions, commonly seen in rheumatoid arthritis. Matsen FA III, Rockwood CA Jr, Wirth MA, et al: Glenohumeral arthritis and its management, in Rockwood CA Jr, Matsen FA III (eds): Rockwood and Matsen The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 871-874.

Patients require prophylaxis for heterotopic bone after resection to prevent recurrence. The optimal management has been found to be a dose of 700 cGy in one dose delivered either pre- or postoperatively. A dose of 2,000 to 3,000 cGy is considered excessive. Radiation therapy consisting of 1,000 cGy in five doses is an acceptable prophylaxis; however, it will require an extended hospital stay of 3 to 4 days and is more problematic for the patient who must be transported for radiation therapy for 5 days. A dose of 400 cGy is not as effective in prophylaxis for heterotopic bone formation. Healy WL, Lo TC, DeSimone AA, Rask B, Pfeifer BA: Single-dose irradiation for the prevention of heterotopic ossification after total hip arthroplasty: A comparison of doses of five hundred and fifty and seven hundred centigray. J Bone Joint Surg Am 1995;77:590-595. Pelligrini VD Jr, Gregoritch SJ: Preoperative irradiation for the prevention of heterotopic ossification following total hip arthroplasty. J Bone Joint Surg Am 1996;78:870-881.

Localized PVNS is a form of the disease in which synovial proliferation is restricted to one area of a joint and causes the formation of a small mass-like lesion. The true incidence of this is unknown but is probably less common than the diffuse form of the disease. PVNS presents as a usually painful discrete mass. The anterior compartment of the knee is the most common location. Tyler WK, Vidal AF, Williams RJ, et al: Pigmented villonodular synovitis. J Am Acad Orthop Surg 2006;14:376-385.

The radiographic and clinical findings suggest a scapulothoracic dissociation with a widely displaced clavicular fracture and a laterally displaced scapula. These injuries have a high association with neurovascular injuries to the brachial plexus and subclavian artery. Emergent vascular evaluation with arteriography and possible vascular repair are indicated. This repair can be combined with open reduction and internal fixation of the clavicle to improve stability. Delay in treatment of these vascular injuries can be devastating. Iannotti JP, Williams GR (eds): Disorders of the Shoulder. Philadelphia, PA, Lippincott, 1999, pp 632-635.

The posterior interosseous nerve is located adjacent to the radial neck, placing it at risk for a traction injury with a dislocation of the proximal radius. The typical neurapraxia that results can be expected to resolve with observation within the first 6 to 12 weeks. If recovery is not clinically evident by 3 months, neurophysiologic studies are indicated. Jessing P: Monteggia lesions and their complicating nerve damage. Acta Orthop Scand 1975;46:601-609.

Aneurysmal bone cyst may be either a "pattern" or a "diagnosis." Therefore, aneurysmal bone cyst should be viewed as a diagnosis of exclusion. Hemorrhage into a variety of primary bone lesions (eg, giant cell tumor of bone, chondroblastoma, osteoblastoma, fibrous dysplasia, osteosarcoma, or vascular neoplasms) may result in intralesional, membrane-bone blood-filled cysts. Such secondary changes may be confused with aneurysmal bone cyst, resulting in inappropriate therapy because assessment should be focused on identifying the underlying primary process. The entire specimen should be examined histologically in an effort to locate an underlying primary bone tumor. Bonakdarpour A, Levy WM, Aegerter E: Primary and secondary aneurysmal bone cyst: A radiological study of 75 cases. Radiology 1978;126:75-83. Levy WM, Miller AS, Bonakdarpour A, Aegerter E: Aneurysmal bone cyst secondary to other osseous lesions: Report of 57 cases. Am J Clin Pathol 1975;63:1-8.

A recent review of 200 consecutive distal radius fractures noted that the overall incidence of extensor pollicis longus rupture was 3%. The causes are believed to be mechanical irritation, attrition, and vascular impairment. The fracture is usually nondisplaced and the patient notes weeks to months after injury the sudden, painless inability to extend the thumb. Treatment involves extensor indicis proprius tendon transfer or free palmaris longus tendon grafting. Skoff HD: Postfracture extensor pollicis longus tenosynovitis and tendon rupture: A scientific study and personal series. Am J Orthop 2003;32:245-247. Bonatz E, Kramer TD, Masear VR: Rupture of the extensor pollicis longus tendon. Am J Orthop 1996;25:118-122.

The patient has a both-bone fracture with a comminuted radial shaft. Open reduction and internal fixation of both bones is the treatment of choice. In the past, Chapman and associates recommended bone grafting radial shaft fractures with more than 30% comminution of the circumference. This has remained the recommendation in most textbooks. More recent studies, where modern biologic plating techniques were used, found that the addition of bone graft to comminuted fractures was not necessary because the union rate did not differ from that of nongrafted comminuted fractures. Anderson LD, Sisk TD, Tooms RE, Park WI III: Compression-plate fixation in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg Am 1975;57:287-297. Chapman MW, Gordon JE, Zissimos AG: Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna. J Bone Joint Surg Am 1989;71:159-169. Wright RR, Schmeling GJ, Schwab JP: The necessity of acute bone grafting in diaphyseal forearm fractures: A retrospective review. J Orthop Trauma 1997;11:288-294.

Indications for surgery in spinal infections include progressive destruction despite antibiotic treatment, an abscess requiring drainage, neurologic deficit, need for diagnosis, and/or instability. This patient has a progressive neurologic deficit. Debridement performed at the site of the abscess should effect canal decompression. Once the debridement is complete back to viable bone, the defect can be reconstructed with a strut graft. Additional posterior stabilization is used as deemed necessary by the degree of anterior destruction. CT-guided needle aspiration, while occasionally useful in the earliest phases of an infection, produces frequent false-negative results and would provide little useful information in the management of this patient. Emery SE, Chan DP, Woodward HR: Treatment of hematogenous pyogenic vertebral osteomyelitis with anterior debridement and primary bone grafting. Spine 1989;14:284-291. Lifeso RM: Pyogenic spinal sepsis in adults. Spine 1990;15:1265-1271.

The patient has a subperiosteal abscess. Because aspiration revealed 10 mL of purulent fluid, the treatment of choice is surgical incision and drainage of the abscess, followed by immobilization to reduce the risk of pathologic fracture. With an adequate response to IV antibiotics and a susceptible bacteria, the patient may then be switched to oral antibiotics.

Only the flexor sheaths of the thumb and small finger are continuous from the digit through the carpal canal and into the distal forearm. If one of the sheaths ruptures from synovitis, it may contaminate the other sheath through Parona's space in the distal forearm. This potential space lies superficial to the pronator quadratus and deep to the flexor tendons. Green DP, Hotchkiss RN, Pederson WC (eds): Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, pp 1044-1045.

Malunion of the talus is a devastating complication that leads to malpositioning of the foot and subsequent arthrosis of the subtalar joint complex. This is considered an avoidable complication in that accurate surgical reduction will minimize its development. Posttraumatic arthritis of the subtalar joint, osteonecrosis of the talus, posttraumatic arthritis of the ankle joint, and complex regional pain syndrome all may develop as a result of the initial traumatic event and may not be avoidable despite anatomic reduction. Rockwood and Green's Fractures in Adults, ed 5. Philadelphia, PA, Lippincott, Williams and Wilkins, 2001, pp 2091-2132.

The CT scans show a burst fracture that results from an axial load injury. The radiographic hallmark of a burst fracture is compression of the posterior cortex of the vertebral body with retropulsion of bone into the spinal canal. AP radiographs often show widening of the interpedicular distance with a fracture of the lamina. Theiss SM: Thoracolumbar and lumbar spine trauma, in Stannard JP, Schmidt AH, Kregor PJ (eds): Surgical Treatment of Orthopaedic Trauma. New York, NY, Thieme, 2007, pp 179-207.

Traditionally, patients have been viewed as ignorant about medical matters and ill-equipped to determine what is in their best interest. This has been especially true for minors. However, recent informed consent policies are now based on the patient's right to self-determination. While most spinal surgeons would agree that spinal fusion improves pulmonary function, sitting balance, and comfort, they would also agree that this comes at considerable risk in a patient with compromised pulmonary function and ultimately, a terminal condition. With increasing frequency, young people older than age 14 years are gaining greater autonomy in decision making about their health care matters. This includes do not resuscitate orders when young patients are terminally ill, as well as in less serious situations. Surgery could be performed with the permission of the legal guardians; however, in this situation it is preferable to follow the patient clinically until he consents to surgery along with the legal guardians. Bracing is contraindicated. Reich WT (ed): Encyclopedia of Bioethics. New York, NY, Simon and Schuster, 1995, pp 1256-1265. Confidential health services for adolescents. Council on Scientific Affairs, American Medical Association. JAMA 1993;269:1420-1424.

Vascular injury most commonly occurs at L4-L5, followed by L5-S1 and are associated with use of the pituitary rongeur. Hohf reported that 17 of 58 patients died as a result. Early recognition and treatment of this complication is vital; unfortunately, intraoperative bleeding from the disk space may occur in up to 50% of these patients. Some may be first recognized in the recovery room. Common clinical findings include hypotension, tachycardia, and a rigid abdomen. Formation of an arteriovenous fistula is the most common vascular injury resulting from lumbar disk surgery but is usually not recognized until months after surgery. Cardiomegaly and high output cardiac failure are common presenting symptoms. Hohf RP: Arterial injuries occurring during orthopaedic operations. Clin Orthop 1963;28:21-37. Montorsi W, Ghiringhelli C: Genesis, diagnosis and treatment of vascular complications after intervertebral disk surgery. Int Surg 1973;58:233-235.

The patient has transient osteoporosis of the hip. Transient osteoporosis is usually a self-limited condition that is most frequently seen in women in the third trimester of pregnancy and in men in the sixth decade of life. Transient osteoporosis is best treated with protected weight bearing.

The patient has multiple hereditary exostoses and a secondary chondrosarcoma arising from a proximal femoral exostosis. The radiograph of the knee shows multiple osteochondromas typical in a patient with multiple hereditary exostoses. Patients with this diagnosis are at an increased risk for malignant degeneration of an osteochondroma. The lateral radiograph of the hip shows a bony lesion emanating from the anterior aspect of the femoral neck that is not well defined in the surrounding soft tissues. There are punctate calcifications and a large soft-tissue mass. The most likely diagnosis is a secondary chondrosarcoma developing from a benign osteochondroma. An enchondroma is an intramedullary benign cartilage lesion. Ollier's disease and Maffucci's syndrome involve multiple enchondromas. Scarborough M, Moreau G: Benign cartilage tumors. Orthop Clin North Am 1996;27:583-589.

The initial management of a lumbar strain should consist of 2 to 3 days of bed rest when symptoms are severe, activity restrictions, and nonsteroidal anti-inflammatory drugs. It has been estimated that 60% to 80% of the adult population experiences back pain, with 2% to 5% affected yearly. Spontaneous improvement generally will occur within 4 weeks. Further study is indicated by the presence of radiculopathy, weakness, trauma, or suspicion of malignancy. Bigos S, Boyer O, Braen GR, et al: Acute low back pain in adults: Clinical practice guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD, Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services, December, 1994.

The ulnar collateral ligament is often difficult to visualize during elbow arthroscopy. It can be seen clearly in only 10% to 30% of elbow arthroscopies. All of the other structures should be easily and thoroughly seen and palpated during elbow arthroscopy. Johnson LL: Arthroscopic Surgery: Principles and Practice. St Louis, MO, CV Mosby, 1988.

The structure enclosed by the circle is the acetabular labrum. It is visible as the white point of tissue outlined by the darkly radiopaque contrast. The appearance of the contrast surrounding the sharp white point of a normal labrum is called the "rose thorn sign." The limbus is the term reserved for a rounded, infolded labrum seen with arthrography. The pulvinar is the fatty tissue seen in the empty acetabulum when the hip is dislocated. The ligamentum teres is seen as a white stripe outlined by contrast coursing from the central acetabulum to the dislocated femoral head. The transverse acetabular ligament courses across the inferior portion of the acetabulum and is not clearly seen with arthrography. Herring JA: Tachdjian's Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 532-533.

A superior labrum, when intact, stabilizes the shoulder by increasing its ability to withstand excessive external rotational forces by an additional 32%. The presence of a SLAP lesion decreases this restraint and increases the strain in the superior band of the inferior glenohumeral ligament by over 100%. Rodosky MW, Harner CD, Fu FH: The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med 1994;22:121-130.

Mechanical loosening of the hip is best revealed by serial radiographs of the prosthetic joint. None of the other methods of evaluation is considered reliable in diagnosing mechanical loosening. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 455-492.

Osteosarcoma is the most common primary malignant tumor of bone in childhood, followed by Ewing's sarcoma. Rhabdomyosarcoma is a soft-tissue sarcoma of childhood. Chondrosarcoma rarely occurs in childhood. Osteochondromas are benign tumors of the bone. Simon M, Springfield D, et al: Osteogenic Sarcoma: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 226.

The MRI scans show a rupture of the sternocostal portion of the pectoralis major tendon. This is the most common site of rupture and bench pressing is the most common etiology. Surgical repair yields better functional outcomes and patient satisfaction for tears not only at the tendon/bone interface but also at the myotendinous junction. Bak K, Cameron EA, Henderson IJ: Rupture of the pectoralis major: A meta-analysis of 112 cases. Knee Surg Sports Traumatol Arthrosc 2000;8:113-119.

In patients with radial nerve injuries with closed humeral fractures, it has been reported that 85% to 95% spontaneously recover. Based on this premise, most surgeons favor expectant management of these injuries. Even if there is no evidence of recovery at 6 weeks, repeat electromyography at 12 weeks is advocated. If there is no clinical or electromyographic signs of recovery at 6 months, exploration is recommended. If the nerve is in continuity at the time of exploration, nerve action potentials are useful in helping determine the need for neurolysis, excision, and grafting, or if excision and repair is the best option. Pollock FH, Drake D, Bovill EG, et al: Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am 1981;63:239-243.

Cotler and associates reported on the use of awake skeletal traction to reduce facet fracture-dislocations in 24 patients. Seventeen patients required more than 50 pounds of traction (the "traditional" limit) to achieve reduction. More than 100 pounds of traction was safely used in one-third of the patients in this study. A cadaver study has supported the safe use of traction with weights in excess of 100 pounds. Cotler JM, Herbison GJ, Nasuti JF, et al: Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds. Spine 1993;18:386-390.

The femoral nerve is the most lateral structure in the anterior neurovascular bundle. The femoral artery and vein lie medial to the nerve. Retractors placed in the anterior acetabular lip should be safe, although neurapraxia of the femoral nerve may occur if retraction is prolonged or forceful leading to quadriceps weakness. The femoral artery and nerve are well protected by the interposed psoas muscle. Damage to the lateral femoral cutaneous nerve, causing numbness over the anterolateral thigh, can occur while developing the interval between the tensor fascia latae and sartorious in the anterior (Smith-Petersen) approach but less likely in the Watson-Jones approach. Superior gluteal injury and accompanying abductor insufficiency may occur during excessive splitting of the glutei during the direct lateral (Hardinge) approach. Foot drop secondary to sciatic injury is more common with a posterior exposure or posterior retractor placement. Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, p 325.

Congenital dislocation of the radial head is often confused with posttraumatic dislocation. The distinguishing feature here is the dome-shaped radial head. Some patients with congenital anomalies fail to recognize their limitations until an injury occurs. Soft-tissue contractures do not cause radial head dislocation nor do they usually cause this pattern of motion restriction (mainly flexion and rotation without significant loss of extension). There is no deformity of the ulna to suggest an old Monteggia lesion. Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, p 196.

Approximately one half of patients with juvenile rheumatoid arthritis (JRA) have the pauciarticular form, which by definition includes only patients with fewer than five joints involved. The peak period of onset is between the ages of 2 and 4 years, with half of the affected children coming to medical attention before age 4 years. The knee is most often affected, with the ankle-subtalar and elbow joints next in frequency. The average duration of the disease is 2 years and 9 months, with half the cases lasting less than 2 years. Arthritis, in Herring JA (ed): Tachdjian's Pediatric Orthopaedics, ed 3. St Louis, MO, WB Saunders, 2002, pp 1811-1839.

Four years after surgery, more than 90% of patients are satisfied with the cosmetic appearance of the iliac donor site scar. Approximately 25% still have pain and/or functional difficulty, including 12.7% who still report difficulty with ambulation, 11.9% difficulty with recreational activities, 7.5% with sexual intercourse, and 11.2% require pain medication for iliac donor site symptoms. Silber JS, Anderson DG, Daffner SD, et al: Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion. Spine 2003;28:134-139.

Boden and associates' recent article presents significant evidence that patients with rheumatoid arthritis, neurologic deterioration, and C1-2 instability are more likely to improve after surgery if the posterior alanto-odontoid interval is greater than 10 mm preoperatively. The accepted safe range for the posterior atlanto-odontoid interval is 14 mm. This measurement is believed to better represent the space available for the cord than the anterior alanto-odontoid interval. Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 273-279. Boden SD, Dodge LD, Bohlman HH, Rechtine GR: Rheumatoid arthritis of the cervical spine: A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am 1993;75:1282-1297.

The flexor hallucis longus tendon is at risk during a Chevron-Akin osteotomy because of its close relationship to the base of the proximal phalanx. The radiograph reveals a reduced ability to flex the interphalangeal joint secondary to the flexor hallucis longus laceration. The other complications are not supported by the radiograph. Tollison ME, Baxter DE: Combination chevron plus Akin osteotomy for hallux valgus: Should age be a limiting factor? Foot Ankle Int 1997;18:477-481.

As a side effect of treatment, phenytoin induces osteomalacia, or rickets, in growing children, through interference with metabolism of vitamin D. Oral supplementation of vitamin D can minimize this effect in patients who are undergoing prolonged treatment with phenytoin.

The MRI scan shows near complete involvement of the femoral head with bone marrow changes and some collapse of the necrotic segment. This is most suggestive of osteonecrosis.

Delayed wound healing and wound dehiscence is the most common complication of surgical management of calcaneal fractures through an extensile lateral approach, occurring in up to 25% of patients. Most wounds ultimately heal with local treatment; the deep infection rate is approximately 1% to 4% in closed fractures. Posttraumatic arthritis may develop despite open reduction and internal fixation, but the percentages remain low. Peroneal tendinitis may occur from adhesions within the tendon sheath or from prominent hardware but is relatively uncommon. Nonunion of a calcaneal fracture is rare. Sanders RW, Clare MP: Fractures of the calcaneus, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby-Elsevier, 2007, vol 2, pp 2017-2073.

The scans show a disk herniation in the far lateral region of the disk. In particular, the sagittal view shows the herniation adjacent to the exiting L4 nerve root. Disk herniations in this area that cause symptoms are more likely to compress the nerve exiting at the same level rather than the next most caudal level. McCulloch JA: Microdiscectomy, in Frymoyer JW (ed): The Adult Spine: Principles and Practice. New York, NY, Raven Press, 1991, vol 2, pp 1765-1783.

Giant cell tumors occur near articular surfaces in young adults. The histology shows abundant giant cells with nuclei resembling the surrounding cells. Although the MRI scan shows soft-tissue involvement, curettage is still the preferred treatment. Chemotherapy is not necessary for benign lesions, and amputation is too aggressive. Cementation, phenol, and cryosurgery (liquid nitrogen) are all acceptable local adjuvants to curettage. Packing the cavity with bone graft rather than cement is also acceptable. Dahlin DC, Unni KK: Bone Tumors: General Aspects and Data on 8,542 Cases. Springfield, IL, Charles C. Thomas, 1986.

Giant cell tumors typically occur in a juxta-articular location involving the epiphysis and metaphysis of long bones, usually eccentric in the bone. The radiographs show a destructive process within the distal tibia and an associated soft-tissue mass. The histology shows multinucleated giant cells in a bland matrix with a few scattered mitoses. Osteosarcoma can have a similar destructive appearance but a very different histologic pattern with osteoid production. Ewing's sarcoma also can have a diffuse destructive process in the bone. The histologic pattern of Ewing's sarcoma is diffuse round blue cells. Aneurysmal bone cysts typically are seen as a fluid-filled lesion on imaging studies and have only a scant amount of giant cells histologically. Metastatic adenocarcinoma does not demonstrate the pattern shown in the patient's histology specimen. Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 198-199.

Although there is no significant alteration in motion with a corset, studies have shown a decrease in intradiskal pressure. Nachemson A, Morris JM: In vivo measurements of intradiscal pressure: Discometry, a method for determination of pressure in the low lumbar disc. J Bone Joint Surg Am 1964;46:1077-1092.

Informed consent is generally considered to be a process of mutual decision making between the physician and patient. The physician is required to provide to the patient all material information that is needed for the patient to make an informed decision. The courts have held that a patient's choice of surgeon is as important to the consent as the procedure itself. Assistance by a surgical trainee with adequate supervision is permissible when there has been adequate disclosure. Adequate supervision may be defined as active participation by the attending during the essential parts of the procedure. Allowing a substitute surgeon to operate on a patient without the patient's knowledge "ghost surgery" may result in charges of battery against the substitute surgeon and malpractice against the surgeon to whom the patient gave consent. Kocher MS: Ghost surgery: The ethical and legal implications of who does the operation. J Bone Joint Surg Am 2002;84:148-150.

The MRI scan reveals a large chronic rotator cuff tear with retraction and fatty infiltration atrophy of the supraspinatus and infraspinatus tendons. This tear is responsible for the patient's severe weakness and inability to elevate the arm.

The radiograph shows bilateral flattening of the femoral heads with mottling and "fragmentation" suggestive of Legg-Calve-Perthes disease. However, when these changes occur bilaterally and are symmetric, multiple epiphyseal dysplasia or spondyloepiphyseal dysplasia should be suspected. Skeletal survey will show irregularity of the secondary ossification centers. With these conditions, there is no true osteonecrosis and no evidence that orthotic or surgical "containment" will alter the outcome of progressive degenerative arthritis. Cardiac anomalies and coagulopathies are not associated with the epiphyseal dysplasias. Crossan JF, Wynne-Davies R, Fulford GE: Bilateral failure of the capital femoral epiphysis: Bilateral Perthes disease, multiple epiphyseal dysplasia, pseudoachondroplasia, and spondyloepiphyseal dysplasia congenita and tarda. J Pediatr Orthop 1983;3:297-301.

In the absence of vascular compromise, there has been no proven value to proceeding immediately to surgery, especially when the patient has a full stomach and runs a significant risk of perioperative aspiration. It would be more prudent to wait until the next morning with a surgical plan of closed reduction and pinning. Open reduction should be reserved for the unusual case of where closed treatment has not been successful. The implication that there may be a radial nerve injury associated with this fracture does not alter the treatment plan, and with a high level of certainty would be expected to resolve. Attempting closed reduction in the emergency department creates the opportunity for uncertain results and is not tolerated well by most patients. Skeletal traction, with its associated lengthy hospitalization and the technical difficulties associated with both the traction and radiographic evaluations, has fallen into disfavor for typical clinical situations. Iyengar SR, Hoffinger SA, Townsend DR: Early versus delayed reduction and pinning of type III displaced supracondylar fractures of the humerus in children: A comparative study. J Orthop Trauma 1999;13:51-55.

Following failure of physical therapy and pharmacologic management in a patient with complex regional pain syndrome, the management of choice is sympathetic blocks. While continued physical therapy would be assistive, sympathetic blocks allow a more rapid relief of symptoms. Neurostimulation is not appropriate at this stage because of its invasive nature. Cepeda MS, Lau J, Carr DB: Defining the therapeutic role of local anesthetic sympathetic blockade in complex regional pain syndrome: A narrative and systematic review. Clin J Pain 2002;18:216-233. Perez RS, Kwakkel G, Zuurmond WW, et al: Treatment of reflex sympathetic dystrophy (CRPS type 1): A research synthesis of 21 randomized clinical trials. J Pain Symptom Manage 2001;21:511-526. Tran KM, Frank SM, Raja SN, et al: Lumbar sympathetic block for sympathetically maintained pain changes in cutaneous temperatures and pain perception. Anesth Analg 2000;90:1396-1401.

Owens and Thordardson cautioned surgeons not to release the conjoined tendon from the base of the proximal phalanx of the great toe because of an increased risk of iatrogenic hallux varus. Release of the transverse and oblique heads of the adductor hallucis is largely accomplished by releasing the soft tissue adjacent to the lateral sesamoid, without releasing tissue from the base of the proximal phalanx. The conjoined tendon is made up of the flexor hallucis brevis and the adductor hallucis. Owens S, Thordardson DB: The adductor hallucis revisited. Foot Ankle Int 2001;22:186-191.

The radiograph shows the development of a rocker-bottom foot deformity. A rocker-bottom foot occurs in the treatment of clubfoot when casting is continued in the presence of a very tight gastrocnemius-soleus complex and an uncorrected hindfoot. While there are some preliminary reports on using Botox injection and continued casting for the equinus deformity, most authors recommend posterior or posterior medial release. Percutaneous tenotomy has been recently recommended with the resurgence of the Ponsetti technique. Lehman WB, Atar D: Complications in the management of talipes equinovarus, in Drennan JC (ed): The Child's Foot and Ankle. New York, NY, Raven Press, 1992, pp 135-136. Herring JA: Tachdjian's Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002, pp 927-935.

The radiograph shows developmental dysplasia of the hip with the hip reduced and congruent. The treatment of choice is a periacetabular osteotomy because it can improve hip biomechanics and prolong the function of the hip joint. This procedure should be performed prior to the development of severe degenerative changes. Observation will not alter the patient's natural history or the biomechanics of the hip. A total hip arthroplasty should be delayed until severe degenerative changes are present. A Chiari osteotomy is a salvage osteotomy used for a noncongruent subluxated hip. A Pemberton osteotomy requires an open triradiate cartilage; therefore, it is not an option in an adult. Trousdale RT, Ekkernkamp A, Ganz R, Wallrichs SL: Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips. J Bone Joint Surg Am 1995;77:73-85.

Fractures of the hook of the hamate frequently are not identified in the acute phase. Because the fracture can be difficult to see on plain radiographs, the lack of findings can lead to a painful nonunion. A carpal tunnel view may show the fracture, but a CT scan will best detect the injury. Immobilization is the treatment of choice and will result in union in most patients unless the diagnosis is delayed. However, excision of the fragment may be necessary for patients who have nonunion, persistent pain, or ulnar nerve palsy. Carroll RE, Lakin JF: Fracture of the hook of the hamate: Acute treatment. J Trauma 1993;34:803-805.

Flexor hallucis longus tendinitis is a common cause of posterior ankle pain in dancers. It tends to be more posteromedial and is characterized by a clicking or catching sensation posteromedially with motion of the great toe. A painful os trigonum typically causes more posterolateral ankle pain and may occur after an ankle sprain or plantar flexion injury where there may be a fracture of the os trigonum. Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 249-261.

The radiographs show a bone-producing lesion in the femoral diaphysis. The radiographic appearance of small round cell tumors is more permeative with an elevated periosteum and no matrix production. The appearance of this lesion is most consistent with osteosarcoma. Patients who carry the Rb gene are predisposed to osteosarcoma. However, Ewing's sarcoma, primitive neuroectodermal tumor, and osteomyelitis can all occur in this location. Unni KK: Dahlin's Bone Tumors: General Aspects and Data on 11,087 Cases, ed 5. Philadelphia, PA, Lippincott-Raven, 1996, pp 143-160.

Flexor tenosynovitis of the thumb flexor tendon sheath can spread proximally and form an abscess within the thenar space of the palm. The flexor pollicis longus tendon does not pass through the central space of the palm or the hypothenar space of the palm. The flexor pollicis longus tendon does pass through the carpal tunnel, but this is not a palmar space. The three palmar spaces include the hypothenar space, the thenar space, and the central space. The posterior adductor space would likely only be involved secondarily after spread from a thenar space infection. Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, vol 3, pp 478-479.

The rate of revision has been found to be significantly increased in patients with a dislocated hip preoperatively compared with patients with a subluxated hip. This may be the result of compromised acetabular bone stock. The rate of nerve palsy may be increased because of the greater degree of lengthening required to reduce the reconstructed hip. Numair J, Joshi AB, Murphy JC, Porter ML, Hardinge K: Total hip arthroplasty for congenital dysplasia or dislocation of the hip: Survivorship analysis and long-term results. J Bone Joint Surg Am 1997;79:1352-1360.

Because the radiographs demonstrate severe arthritis, hallux metatarsophalangeal arthrodesis is the treatment of choice. Cheilectomy alone will not relieve pain because the entire joint is degenerative. Joint replacement has not been shown to be a long-term solution. Keller resection arthroplasty is not indicated in younger active patients. Hallux valgus correction will not address arthritis of the joint and could stiffen the joint further. Smith RW, Joanis TL, Maxwell PD: Great toe metatarsophalangeal joint arthrodesis: A user-friendly technique. Foot Ankle 1992;13:367-377.

The most likely diagnosis is osteosarcoma. The imaging studies show an aggressive primary tumor of bone, and the histology slide shows a typical chondroblastic osteosarcoma, with osteoid deposited along the surface of bone trabeculae. Ewing's sarcoma histologically consists of small round blue cells. Osteochondroma and periosteal chondroma can occur near the knee but have different radiographic and histologic patterns. Chondrosarcoma rarely occurs in children. Simon M, Springfield D, et al: Osteogenic sarcoma: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 267.

The radiographs show an osteochondritis dissecans (OCD) lesion in the medial femoral condyle of a skeletally immature patient. The lesion is not displaced from its bed. Nonsurgical management of a stable OCD lesion in a patient with open physes consists of a period of activity limitation and occasional immobilization. Unstable lesions, loose bodies, and patients with closed physes require more aggressive treatment. Most of the surgical procedures can be done arthroscopically. Because the radiographic appearance is typical, biopsy is unnecessary. The radiographs do not show an osteocartilaginous loose body, and the patient reports no catching or locking; therefore, removal of the loose body is not indicated. Linden B: Osteochondritis dissecans of the femoral condyles: A long term follow-up study. J Bone Joint Surg Am 1977;59:769-776. Cahill BR: Osteochondritis dissecans of the knee: Treatment of juvenile and adult forms. J Am Acad Orthop Surg 1995;3:237-247.

The peroneus brevis and peroneus longus muscles are the main evertors of the hindfoot. As they descend along the posterior fibula, they pass through the retromalleolar sulcus, formed by the concavity of the retromalleolar fibula. This sulcus is deepened by a fibrocartilaginous rim. The superior peroneal retinaculum covers the fibular groove and stabilizes the peroneal tendons within the retromalleolar sulcus. It originates from the posterolateral ridge of the fibula and inserts onto the lateral calcaneus. Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 81-89.

The radiographs show an isolated posterior malleolus fracture which, given the injury mechanism, is highly suspicious for a Maisonneuve injury. As with any suspected extremity injury, radiographs including the joints above and below the level of injury are acutely indicated. Although MRI may reveal a ligamentous injury to the ankle and CT may show asymmetry of the ankle mortise or syndesmosis, both studies are considerably more costly and are not indicated in the absence of a complete radiographic work-up. Technetium bone scan is nonspecific and would be of limited value in this instance, as would repeat radiographs of the ankle. Walling AK, Sanders RW: Ankle fractures, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby-Elsevier, 2007, vol 2, pp 1973-2016.

In a study of 19 patients with compartment syndrome of the hand, all had tense swollen hands with elevated compartment pressures. Most patients were neurologically compromised so pain with passive stretch may be difficult to illicit. Arterial inflow is present in the arch and thus pallor is not present. The typical posture of the hand is not clenched, rather it is an intrinsic minus posture of metacarpophalangeal joint extension and flexion of the proximal and distal interphalangeal joints. Oullette EA, Kelly R: Compartment syndromes of the hand. J Bone Joint Surg Am 1996;78:1515-1522.

The patient has a moderately displaced distal diaphyseal fracture of the fifth metatarsal, and the most appropriate treatment is brief immobilization and symptomatic management. Attempts at closed reduction are unlikely to appreciably alter the position of the fracture. Surgical techniques for either reduction of the fracture or fixation have not been shown to result in improved functional outcomes. O'Malley MJ, Hamilton WG, Munyak J: Fractures of the distal shaft of the fifth metatarsal: "Dancer's Fracture." Am J Sports Med 1996;24:240-243. DeLee JC: Fractures and dislocations of the foot, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, CV Mosby, 1993, pp 1465-1703.

The patient has a dislocation of the elbow with displaced coronoid process and radial head fractures. The elbow is extremely unstable after this injury, and recurrent dislocation in a splint is the most common early complication. Skeletal stabilization of the fractures is required to restore stability of the joint. Characteristics of the fractures will determine the techniques required to restore stability. Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 2002;84:547-551.

Progressive weakness is a common sign with a large differential diagnosis. Nerve, muscle, and joint problems should be excluded when a patient has diffuse weakness and atrophy. Fascioscapulohumeral dystrophy is a rare disease characterized by facial muscle weakness and proximal shoulder muscle weakness. The weakness is usually bilateral, and scapular winging is common. If the scapular winging becomes pronounced, elevation of the shoulder can be affected. In severe cases, scapulothoracic fusion or pectoralis muscle transfer to the scapula may be indicated. Duchenne muscular dystrophy is typically severe and progressive. The other diagnoses are not compatible with the history or the physical findings. Shapiro F, Specht L: The diagnosis and orthopaedic treatment of inherited muscular diseases of childhood. J Bone Joint Surg Am 1993;75:439-454.

The dorsal digital cutaneous nerve of the great toe is a branch of the medial branch of the superficial peroneal nerve. The deep peroneal nerve supplies the first web space. McMinn RMH, Hutchings RT, Logan BM: Color Atlas of Foot and Ankle Anatomy. Weert, Netherlands, Wolfe Medical Publications, 1982, p 50.

The most likely diagnosis is a stress fracture of the calcaneus and is supported by the history of running, female gender, and amenorrhea. Reproducing pain with medial and lateral compression of the heel also supports the diagnosis. A bone scan or MRI would most likely confirm the diagnosis. Plantar fasciitis would result in pain on the bottom of the heel with point tenderness. The lack of other areas of involvement or other symptoms does not support a seronegative inflammatory arthritis. Tarsal tunnel syndrome and peripheral neuropathy are unlikely because of the normal neurologic examination. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 597-612.

The acromial branch of the thoracoacromial artery courses along the medial aspect of the coracoacromial ligament and may be encountered when performing an open or arthroscopic subacromial decompression. Bleeding can be controlled by ligation of its branch from the thoracoacromial artery. The other arteries may be injured in other surgical exposures of the shoulder. Esch JC, Baker CL: The shoulder and elbow, in Whipple TL (ed): Arthroscopic Surgery. Philadelphia, PA, JB Lippincott, 1993, pp 65-66.

Avulsion fractures of the tibial spine are rare injuries that result from rapid deceleration or hyperextension of the knee in skeletally immature individuals. This injury is the equivalent of ruptures of the anterior cruciate ligament in adults. These fractures are classified as types 1 through 3. Type 1 is a minimally displaced fracture, type 2 fractures have an intact posterior hinge, and type 3 fractures have complete separation. The radiograph demonstrates a completely displaced, or type III, tibial spine avulsion. Surgical reduction is indicated in type 2 fractures that fail to reduce with knee extension and in all type 3 fractures. Reduction may be arthroscopic or open, with fixation of the bony fragment using a method that maintains physeal integrity and prevents later growth arrest. Preferred techniques would be with suture or an intra-epiphyseal screw Wiley JJ, Baxter MP: Tibial spine fractures in children. Clin Orthop 1990;255:54-60. Mulhall KJ, Dowdall J, Grannell M, et al: Tibial spine fractures: An analysis of outcome in surgically treated type III injuries. Injury 1999;30:289-292. Owens BD, Crane GK, Plante T, et al: Treatment of type III tibial intercondylar eminence fractures in skeletally immature athletes. Am J Orthop 2003;32:103-105.

The radiograph shows an atrophic nonunion of the humeral shaft. The management of humeral nonunions has been studied with compression plates and bone graft, as well as intramedullary nailing and bone graft. Compression plating with bone graft results in the highest rate of union. Compression plating by itself is not adequate, given the bone loss and lack of callous in this nonunion. Pulsed electromagnetic fields is a viable option for hypertrophic nonunions where there is inherent stability. Intramedullary nailing does not provide as much compression and stability as that achieved with compression plating. Pugh DM, McKee MD: Advances in the management of humeral nonunion. J Am Acad Orthop Surg 2003;11:48-59.

Angular deformities of the ankle can occur following physeal injury. While an orthosis may be beneficial, the deformity is at the level of the ankle rather than the hindfoot. An epiphysiodesis or physeal bar resection would not be indicated as the growth plates are closed. Correction of the angular deformity should level the ankle joint and normalize the weight-bearing stresses on the ankle. This is most easily achieved with a closing wedge distal tibial osteotomy with or without concomitant osteotomy of the fibula. Thompson DM, Calhoun JH: Advanced techniques in foot and ankle reconstruction. Foot Ankle Clin 2000;5:417-442. Ting AJ, Tarr RR, Sarmiento A, Wagner K, Resnick C: The role of subtalar motion and ankle contact pressure changes from angular deformities of the tibia. Foot Ankle 1987;7:290-299.

Posterior screw fixation of the upper cervical spine has gained a great deal of popularity due to its stable fixation, obviating the use of halo vest immobilization, and its high fusion rates. The use of screws in this location, however, has introduced a whole new set of potential complications. Vertebral artery injury is one of the most feared complications associated with screws in the C1/C2 region. This structure, however, is lateral and posterior at the C2 level and then penetrates the foramen transversarium of C1 to lie cephalad to the arch of C1 before entering the foramen magnum. It is the internal carotid artery that lies immediately anterior to the arch of C1 that is particularly at risk by anterior penetration of C1 lateral mass or C1-C2 transarticular screws as demonstrated by Currier and associates. The internal carotid artery lies posterior to the pharynx. The external carotid artery and the glossopharyngeal nerve are not at risk with this method of fixation. Currier BL, Todd LT, Maus TP, et al: Anatomic relationship of the internal carotid artery to the C1 vertebra: A case report of cervical reconstruction for chordoma and pilot study to assess the risk of screw fixation of the atlas. Spine 2003;28:E461-E467. Grant JC: Grant's Atlas of Anatomy, ed 6. Baltimore, MD, Williams & Wilkins, 1972.

The vascularity of the dorsal portion of the digital flexor tendons is considerably richer than the volar portion. The other regions are not preferentially more vascular. Hunter JM, Scheider LH, Makin EJ (eds): Tendon Surgery in the Hand. St Louis, MO, Mosby, 1987, pp 91-99.

The optimum treatment is cementing the implant to the allograft. Press-fit stability is unreliable. Wires and screws may be used for an incomplete proximal femoral allograft but cannot be used to anchor a complete proximal femoral allograft. Allan DG, Lavoie GJ, Rudan JF, et al: The use of allograft bone in revision total hip arthroplasty, in Friedlaender GE, Goldberg VM (eds): Bone and Cartilage Allografts: Biology and Clinical Applications. Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1991, pp 263-264. Gross AE, Lavoie MV, McDermott P, Marks P: The use of allograft bone in revision of total hip arthroplasty. Clin Orthop 1985;197:115-122.

The lesion is a variation of a type I superior labrum anterior and posterior lesion; therefore, appropriate treatment is simple debridement. Biceps tenodesis or release is not indicated because the biceps tendon and anchor are intact. There is no indication for labral repair or capsulorraphy. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 261-270.

Prosthetic shoulder arthroplasty has been shown to provide predictable results for treating stage III and stage IV osteonecrosis of the humeral head. The decision to resurface the glenoid (total shoulder arthroplasty versus humeral hemiarthroplasty) usually is made based on the radiographic and intraoperative appearance of the glenoid. Core decompression of the humeral head has been reported to be effective for earlier stages (pre collapse) but would not be appropriate for a patient with stage IV disease. Hattrup SJ, Cofield RH: Osteonecrosis of the humeral head: Results of replacement. J Shoulder Elbow Surg 2000;9:177-182. L'Insalata JC, Pagnani MJ, Warren RF, et al: Humeral head osteonecrosis: Clinical course and radiographic predictors of outcome. J Shoulder Elbow Surg 1996;5:355-361.

Patients older than age 40 years at the time of initial anterior dislocation have low rates of redislocation; however, 15% of these patients experience a rotator cuff tear. Moreover, there is a dramatic increase (up to 40%) in the incidence of rotator cuff tears in patients older than age 60 years. Axillary nerve injury may occur but is less common than rotator cuff tear. Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 273-284.

Persistent Horner's sign (ptosis, myosis, and anhydrosis) is a sign of proximal injury, usually avulsion of the roots from the cord which disrupts the sympathetic chain. Root rupture or avulsion proximal to the myelin sheath has less chance of healing. Two-month-old infants with persistent weakness in the other areas described may still have a good prognosis for recovery. Concurrent clavicle fracture has been shown to have no prognostic value. Clarke HM, Curtis CG: An approach to obstetrical brachial plexus injuries. Hand Clin 1995;11:563-581.

The definitive surgery would be removal of the entire resection bed, and in this case of dedifferentiated chondrosarcoma, a hemipelvectomy was performed. The MRI and CT scans show an aggressive cartilage lesion. The histology, representative of a dedifferentiated chondrosarcoma, shows a bimorphic low-grade cartilage lesion with high-grade spindle cell sarcoma. The cartilage lesion is usually an enchondroma or low-grade chondrosarcoma. The dedifferentiated portion is typically a malignant fibrous histocytoma, osteosarcoma, or fibrosarcoma. Weber KL, Pring ME, Sim FH: Treatment and outcome of recurrent pelvic chondrosarcoma. Clin Orthop Relat Res 2002;397:19-28.

The CT scan reveals a hook of the hamate nonunion with irregular resorption at the fracture site, which is at the base of the hamate. Symptomatic relief of the pain and discomfort has been well documented after excision of the hook of the hamate. Ultrasound therapy will not provide long-term symptomatic relief or induce nonunion healing. MRI for further soft-tissue evaluation is inappropriate because this is a bony problem; the bony architecture of the wrist is best visualized by CT. Open reduction and internal fixation of the hook of the hamate does not provide the symptomatic relief that is found with excision of the hook of the hamate. In addition, the technical difficulties and relative risk of persistent nonunion after open reduction and internal fixation are not merited when hamate excision can be effected easily and causes no long-term untoward effects. Electrodiagnostic evaluation is inappropriate because there is no history of the persistent numbness and tingling that is found in peripheral compression neuropathies. Stark HH, Chao EK, Zemel NP, Rickard TA, Ashworth CR: Fracture of the hook of the hamate. J Bone Joint Surg Am 1989;71:1206-1207. Failla JM: Hook of hamate vascularity: Vulnerability to osteonecrosis and nonunion. J Hand Surg Am 1993;18:1075-1079. Carter PR, Easton RG, Littler JW: Ununited fracture of the hook of the hamate. J Bone Joint Surg Am 1977;59:583-588.

Extensor pollicis longus tendon rupture can occur after a fracture of the distal radius, even a minimally displaced one. Poor vascularity of the tendon within the third dorsal compartment is the suspected etiology, not the displaced fracture fragments. Tendon transfer will suitably restore active extension of the thumb interphalangeal joint. Christophe K: Rupture of the extensor pollicis longus tendon following Colles fracture. J Bone Joint Surg Am 1953;35:1003-1005.