Humeral Shaft Throwing Fractures in Overhead Athletes: Advanced Epidemiology, Biomechanics, and Surgical Anatomy

This patient sustained a greater trochanteric (GT) fracture. Evaluation with MRI is the next best step in treatment to evaluate for intertrochanteric (IT) extension.
Isolated fractures of the GT are uncommon. They may be diagnosed on radiography, but the extent of this injury is difficult to ascertain based on radiography alone. MRI has found a role in defining the extent of the fracture line. Though isolated GT fractures are often treated conservatively when they occur in isolation, operative fixation is necessary if there is IT extension. If the extent of the injury is not identified, it may lead to delayed rehabilitation and decreased long-term survival rates.
Kim et al. performed a systematic review to determine what proportion of GT fractures had IT extension and what are the treatment options of GT with occult IT extension. Patients included had an isolated GT fracture on radiographs and underwent MRI scans to determine IT extension. In 99/110 patients (90%), MRI revealed IT extension and surgical fixation followed in 61 patients. They conclude that MRI should be performed in patients presenting with an isolated GT fracture on plain radiograph.
Lee et al. examined the pattern and extent of an injury shown by MRI and radionuclide bone scan (RBS) in patients whose radiographs revealed fractures
limited to the GT. 25 patients were found sustaining a low-energy injury. They found that 3 patients had ITC extension that was not visualized with radiographs or RBS. 8 patients had fractures with MRI evidence of complete extension across the ITC region and 12 had incomplete extension. 11/12 patients with incomplete extension had extension more than 50% to the medial cortex. They recommend that all patients presenting with an isolated GT fracture on the plain radiographs should undergo MRI examination.
Collin et al. performed a study to evaluate the efficacy of CT in diagnosing occult hip fractures compared to MRI. They evaluated 44 consecutive elderly patients with trauma to the hip. All patients had negative CT scans while MRI changed the diagnoses in 27 cases. They conclude that MRI is a more reliable modality for hip fracture diagnosis in comparison to CT and negative CT finding cannot rule out a hip fracture in patients with a clinical suspicion for a hip fracture.
Figure A is an AP pelvis radiograph demonstrating a fracture of the left greater trochanter. Illustration A is a radiograph demonstrating a GT fracture and Illustration B is a T1-weighted MRI of the same patient demonstrating IT extension.
Incorrect Answers:
Answers 1 and 2: Treatment should not be performed until more information with an MRI is obtained.
Answer 3: Traction, internal rotation views are obtained in displaced intertrochanteric fractures to visualize the fracture fragments more accurately and to assess the efficacy of a closed-reduction maneuver.
Answer 4: CT scan of the proximal femur is not the best study to rule out IT extension of this fracture.

This is a classic example of a flexor tendon sheath rupture with gradual loss of active and passive extension and an unremarkable radiograph. Originally described by Bollen in 67 British rock climbers, closed ruptures of the digital flexor pulley system often appear in a delayed fashion with PIP joint flexion contractures. The mechanism of injury is a rapidly applied extension force in the acutely flexed digit, resulting in a closed rupture of the retinacular sheath, rather than a flexor profundus avulsion. In the setting of a significant PIP flexion contracture, a rupture of multiple pulleys including A2, A3, and A4 most commonly is found. In such a scenario, significant flexor tendon bowstringing results, precluding successful nonsurgical management. The proper treatment includes release of the sheath scar and pulley reconstruction. Temporary PIP joint pinning also may be required.
This patient already has participated in a prolonged course of hand therapy with worsening and a fixed PIP contracture, so continued therapy is not recommended. Response 2 is incorrect because the flexor tendons are functioning well with reasonable active DIP motion. Similarly, Response 3 is incorrect because there are no findings consistent with flexor tendon adhesions.
RECOMMENDED READINGS
62. Bollen SR. Soft tissue injury in extreme rock climbers. Br J Sports Med. 1988 Dec;22(4):145-7. PubMed PMID: 3228682.
63. Bowers WH, Kuzma GR, Bynum DK. Closed traumatic rupture of finger flexor pulleys. J Hand Surg Am. 1994 Sep;19(5):782-7. PubMed PMID: 7806800.

Ankle replacement is a treatment alternative that is widely recommended today, although it is still not as reliable as an ankle arthrodesis in terms of predictability and absence of complications. One must consider the option of arthrodesis and replacement carefully with each patient.

The radiograph reveals a Charcot shoulder. The atraumatic dissolving of the humeral head is concerning for a neuropathic etiology and necessitates MR imaging of the cervical spine to evaluate for the presence of a syrinx.
RECOMMENDED READINGS
71. [Drvaric DM, Rooks MD, Bishop A, Jacobs LH. Neuropathic arthropathy of the shoulder. A case report. Orthopedics. 1988 Feb;11(2):301-4. PubMed PMID: 3357846. ](http://www.ncbi.nlm.nih.gov/pubmed/3357846)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/3357846)
72. [Patel AY, Eagle KA, Vaishnava P. Cardiac Risk of Noncardiac Surgery. J Am Coll Cardiol. 2015 Nov 10;66(19):2140-8. doi: 10.1016/j.jacc.2015.09.026. Review. ](http://www.ncbi.nlm.nih.gov/pubmed/26541926)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/26541926)

This patient has likely sustained an isolated PCL injury. The examination is consistent with a grade II injury to the PCL. In patients with isolated PCL injuries, such as this scenario, the best initial option is nonsurgical treatment and return to play as symptoms subside and strength improves. Physical therapy and delayed PCL reconstruction is not the
ecause this patient can likely be treated without surgery. The absence of valgus laxity and negative dial testing findings suggest that an injury to the posteromedial and posterolateral corners has not occurred. Initial nonsurgical treatment is indicated for this patient. If he completes rehabilitation and experiences persistent disability with anterior and/or medial knee discomfort or senses the knee is "loose," PCL reconstruction should be considered at that time.
Correct answer : A

The peroneus brevis tendon plantarflexes and everts the foot and ankle. The peroneus longus tendon plantarflexes the foot, is a mild evertor of the foot, and plantarflexes the first metatarsal. The peroneus brevis tendon is prone to tears or splits at the level of the distal fibula and lies anterior to the peroneus longus tendon at this level.

The most commonly injured neurovascular structure during an anterior approach for the repair of a distal biceps tendon rupture is the lateral antebrachial cutaneous nerve. This structure is located lateral to the biceps tendon and in a superficial location just deep to the subcutaneous layer. The antecubital vein is medial and superficial with the brachial artery and median nerve also medial to the biceps tendon but deep to the common flexors. The posterior interosseous nerve is deep within the supinator muscle and can be injured in the deep dissection or through the posterior approach when using a two-incision approach.
REFERENCES: Kelly EW, Morrey BF, O’Driscoll SW: Complications of repair of the distal biceps tendon with the modified two-incision technique. J Bone Joint Surg Am 2000;82:1575-1581.
Ramsey ML: Distal biceps tendon injuries: Diagnosis and management. J Am Acad Orthop Surg 1999;7:199-207.

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The images are of a chronic, missed Monteggia lesion. MRI demonstrates that the head is still concave, so reconstruction is still feasible. In late deformity, the ulna has to be overcorrected to pull the radial head back into appropriate alignment, making up for the elongation of the previously torn interosseous ligament, and stabilizing it. Osteotomy of the radius is not indicated, as there is no deformity present.
Excision of the radial head is inappropriate for a traumatic condition such as a Monteggia, which will continue to develop radial-ulnar mismatch and progressive wrist and elbow deformities if this is done while significant growth remains. Reconstruction is preferable in this case to salvage.
Annular ligament reconstruction alone will not restore stability in this injury; persistent deformity of the ulna is present.

The patient has sustained a displaced lesser tuberosity fracture with medial displacement following a posterior shoulder dislocation. Nonoperative management would risk long-term loss of normal subscapularis function, as well as anterior shoulder instability. An ORIF of lesser tuberosity is recommended. The current radiographs do not demonstrate any obvious compromise of glenoid bone stock that would necessitate a coracoid transfer. The humeral head is not compromised; therefore, a hemiarthroplasty is not indicated.
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This patient has cam-type femoroacetabular impingement. Decreased internal rotation and a positive impingement test (forced flexion, adduction, and internal rotation) are classic findings. The lack of pain with resisted hip flexion makes hip flexor strain unlikely, and the lack of tenderness at the greater trochanter renders trochanteric bursitis unlikely. Although athletic pubalgia can be a source of longstanding groin pain, he lacks the pain with a resisted sit-up and tenderness along the pubic ramus that is frequently noted in patients with pubalgia. His radiographs reveal a focal femoral neck prominence consistent with cam impingement, although pistol grip deformities and flattening of the lateral femoral head are often present as well. His MRI scan shows a labral tear, which is common in cam impingement. Surgical treatment for cam impingement can be effective for symptomatic patients. Even among high-level athletes, open surgical dislocation of the hip has been shown to have good results. Most patients with cam impingement can be treated with arthroscopic osteoplasty and achieve results comparable with those realized with open surgical dislocation. The literature describes success in terms of athletes returning to sports (even professional athletes) to be approximately 90% after arthroscopic treatment. Byrd and Jones described five patients who developed transient neurapraxias that resolved uneventfully. The patients in his series who had concomitant microfracture had a 92% return to sports within the follow-up period. Cam impingement has long been thought to be associated with a history of a slipped capital femoral epiphysis. The capitis in these patients is displaced posteriorly, resulting in a prominent anterior femoral neck and decreased hip internal rotation. Pincer impingement is associated with a deep acetabulum, such as protrusion acetabula and acetabular retroversion. A patient who underwent a _periacetabular osteotomy can develop a more retroverted acetabulum as well._

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Children who have developing compartment syndrome rarely show the typical physical exam findings that adults do. Instead of paraesthesias; pain on passive stretch; pallor; pulselessness; poikilothermic; and paralysis that adults show, children typically demonstrate agitation, increased analgesic requirement, and anxiety (three As). The first-line treatment in developing compartment syndrome is to remove circumferential bandages/casts. Invasive compartment measurements should rarely be used in cooperative patients but are an adjunct in preverbal, confused, or obtunded patients who do not cooperate with an exam, in those children with regional nerve blocks.

This patient has classic intrinsic tightness following a severe crush injury to the hand. It is possible that there has been an unrecognized compartment syndrome of the hand as a result of the trauma. An examination reveals findings consistent with intrinsic tightness with limited PIP flexion while the MP joints are fully extended, with greater PIP flexion with the MP joints flexed. Considering
that this patient’s condition has not improved with 12 weeks of supervised therapy, it is unlikely that further therapy will be of benefit. Because his stiffness is not associated with pain, complex regional pain syndrome is not a consideration. Extensor tenolysis is not an appropriate treatment option because the examination is not consistent with extensor tendon tightness. The most appropriate treatment consists of distal intrinsic releases followed by supervised hand therapy. Subtle degrees of intrinsic tightness are often missed, and a high index of suspicion must be maintained when patients describe weakness and stiffness following hand trauma.
RECOMMENDED READINGS
12. BUNNELL S. Ischaemic contracture, local, in the hand. J Bone Joint Surg Am. 1953 Jan;35-A(1):88-
101/. PubMed PMID: 13022710. View Abstract at PubMed
13. HARRIS C Jr, RIORDAN DC. Intrinsic contracture in the hand and its surgical treatment. J Bone Joint Surg Am. 1954 Jan;36-A(1):10-20. PubMed PMID: 13130583.Abstract at PubMed
14. Smith RJ. Balance and kinetics of the fingers under normal and pathological conditions. Clin Orthop Relat Res. 1974 Oct;(104):92-111. PubMed PMID: 4412165.Abstract at PubMed

The muscles involved have C 5, C 6 root innervations. There are multiple findings that rule out a preganglionic lesion: positive Tinel sign, functioning rhomboids and serratus anterior, absent Horner syndrome. The electromyogram finding confirms the clinical finding (it does not show subclinical involvement of any other muscle). Neuropraxia usually resolves in 6 weeks and EMG shows fibrillation, both of which are inconsistent with neuropraxia. Brachial plexus neuritis (Parsonage-Turner syndrome) has an acute presentation following a painful episode involving the whole arm. There is significant history of fall from an all terrain vehicle in
this case.

Figure A shows a significantly displaced, high-energy proximal tibia fracture with intra-articular extension. Appropriate initial treatment includes application of a spanning external fixation device with fasciotomy if needed.
The referenced article by Egol et al noted a low rate of wound infection, improved access to soft tissues, prevention of further articular damage, and osseous stabilization. They reported the downside being residual knee stiffness.

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Bisphosphonates have been shown to decrease osteolysis after total joint replacement surgery.
Aseptic loosening and osteolysis are the primary causes of implant failure in total joint arthroplasty. Early findings indicate that bisphosphonates upregulate bone morphogenetic protein-2 production and stimulate new bone formation, leading to decreased osteolysis in total joint replacement surgery. While
further investigation is required, bisphosphonates may play a future role in improving the long-term duration of joint arthroplasties.
Shanabhag et al. reviewed the use of bisphosphonates and reported that they had the potential to enhance bone ingrowth into implant porosities, prevent bone resorption under adverse conditions, and dramatically extend the long- term durability of joint arthroplasties. They recommended further investigation into the subclasses to determine which ones are most beneficial.
Arabmotlagh el al. performed a prospective study on use of alendronate after total hip arthroplasty. They reported that the alendronate-treated patients had significantly less periprosthetic bone loss on DXA scans after 6 years.
Illustration A shows evidence of osteolysis (arrows) around a total hip arthroplasty.
Incorrect Answers:
2-5: These medication classes do not decrease osteolysis after total joint arthroplasty.

According to the referenced study by Folk et al, the risk of early wound complications is highest in open injuries, diabetics, and smokers.
No significant differences were seen in complication rates in terms of: age, sex, other pre-existing medical conditions, social history, mechanism of injury, time from injury to surgical stabilization, the type of incision used, use of preoperative antibiotics, or type of wound closure.
Notably, 25% of the patients had some sort of early wound complication, and 21% of the patients required surgical treatment due to their wound complication.
Their conclusion: "Smoking, diabetes, and open fractures all increase the risk of wound complication after surgical stabilization of calcaneus fractures.
Cumulative risk factors increase the likelihood of wound complications."

DISCUSSION: In the normal adult, the distance between the basion and the tip of the dens is 4 mm to 5 mm. Any distance greater than 5 mm is considered abnormal. This is one way to detect occipitocervical dissociation other than using the Power’s ratio, which relies on an anterior dislocation.
REFERENCES: Wiesel SW, Rothman RH: Occipitoatlantal hypermobility. Spine 1979;4:187-191.
Wholey MH, Browner AJ, Baker HL Jr: The lateral roentgenogram of the neck: With comments on the atlanto odontoid-basion relationship. Radiol 1958;71:350-356.

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This patient has progressive myelopathy secondary to ossification of the posterior longitudinal ligament. Diagnostic imaging reveals multilevel cervical cord compression from C4-6. The patient has maintained reasonable cervical lordosis. A posterior procedure such as multilevel laminoplasty decompresses the spine, is motion preserving, and has a low complication rate. Observation and cervical epidural injections are not viable options in patients with progressive myelopathy. Anterior cervical decompression, including corpectomy, is an option; however, anterior procedures have an increased risk of complications such as dural tear or cerebrospinal fluid leak. The axial CT image shows a "double layer" sign, which is consistent with dural ossification and increases the risk of dural injury with anterior decompression.

DISCUSSION: In a recent evidence-based review of the literature, the only consistent factor predicting outcome after arthroscopic partial meniscectomy was the extent of osteoarthritis as classified by the modified Outerbridge cartilage score at the time of surgery. All other factors listed (ie, location of meniscal tear, patient age, patient BMI, and amount of meniscal resection) were shown to not predict outcome following partial meniscectomy. While not provided as an
hoice, female gender was shown to be a predictor for slower recovery in the short term. The Preferred Respon # 114 is 5.

DISCUSSION: The hindfoot varus in this individual with a cavovarus deformity is nonstructural as shown by the “block test”. Therefore, surgical procedures directed at correcting the hindfoot deformity are not necessary. Observation is not in order and shoe modifications have not been shown to be effective in managing this problem. The patient is symptomatic; therefore, the treatment of choice is plantar release with first metatarsal osteotomy and possible tendon transfers.
REFERENCES: Paulos L, Coleman SS, Samuelson KM: Pes cavovarus: Review of a surgical approach
using selective soft-tissue procedures. J Bone Joint Surg Am 1980;62:942-953.
McCluskey WP, Lovell WW, Cummings RJ: The cavovarus foot deformity: Etiology and management. Clin Orthop Relat Res 1989;247:27-37.
Ward CM, Dolan LA, Bennett DL, et al: Long-term results of reconstruction for treatment of a flexible
cavovarus foot in Charcot-Marie-Tooth disease. J Bone Joint Surg Am 2008;90:2631-2642.

50 • American Academy of Orthopaedic Surgeons
Figure 60a Figure 60b Figure 60c

Figure A shows a mildly comminuted tibia fracture, which is a fracture highly associated with compartment syndrome. However, in this scenario, the delta p (difference between compartmental pressures and diastolic pressure) is greater than 30 preoperatively, with a decrease to less than 30 intraoperatively, due to the hypotension associated with anesthesia.
The referenced article by Kakar et al notes that the delta p may be spuriously
low intraoperatively, and with tibial nailing, it is safe to assume the delta p will return to a higher level postoperatively. They recommended continued monitoring in the postoperative period with clinical examination and measurements as needed.
The McQueen referenced article showed that the delta p is more important than absolute pressures, as an absolute threshold of 30mmHg would have led to unnecessary fasciotomies in 43% of their cohort.

The normal porosity of cortical bone is 10% compared to trabecular bone, which is 50% to 90%. Cortical bone porosity occurs because of the Haversian and Volkman canals and, to a lesser extent, from the osteocyte lacunae and canaliculi.
Trabecular bone is arranged as a series of interconnecting small plates and rods. The porosity may vary between 50% to 90%. This porosity is secondary to the spaces between the trabecular pieces of bone rather than voids in the actual pieces of trabecular bone.

Knowledge of the anatomy and pathophysiology of compartment syndrome of the foot is important to plan adequate and correct treatment. The exact number of compartments is not as relevant as the location and ability to decompress the compartment through fasciotomy. The medial compartment contains the abductor hallucis and the flexor hallucis brevis muscles. The quadratus plantae is more posteriorly located and considered to be in a separate calcaneal compartment.

One should remember the important mutations that occur in musculoskeletal conditions: FGFR3 mutation: Achondroplasia
Type IX collagen mutation: Multiple epiphyseal dysplasia (MED)
WISP3 mutation: Spondyloepiphyseal dysplasia with progressive osteoarthropathy
Type II collagen mutation: Stickler syndrome
Sulfate transporter gene mutation: Diastrophic dysplasia
Fibrillin gene mutation: Marfanâs syndrome
Type V collagen mutation: Ehlers-Danlos syndrome
Type I collagen mutation: Osteogenesis imperfecta
C orrect Answer: WISP3 mutation

There has been an abundance of studies designed to compare ORIF with IMN of humeral shaft fractures. When the most well-designed and rigorous studies are pooled and reviewed, the only consistent difference that can be found is a higher incidence of shoulder complications with IMN compared with ORIF. No significant differences have been shown with regard to nerve injury, union, or infection.
Recommended reading:
1. [Carroll EA, Schweppe M, Langfitt M, Miller AN, Halvorson JJ. Management of humeral shaft fractures. J Am Acad Orthop Surg. 2012 Jul;20(7):423-33. doi: 10.5435/JAAOS-20-07-423. Review. PubMed PMID: ](https://www.ncbi.nlm.nih.gov/pubmed/22751161)22751161.
2. [Zhao JG, Wang J, Wang C, Kan SL. Intramedullary nail versus plate fixation for humeral shaft fractures: a systematic review of overlapping meta-analyses. Medicine (Baltimore). 2015 Mar;94(11):e599. doi: 10.1097/MD.0000000000000599. Review. PubMed PMID: ](https://www.ncbi.nlm.nih.gov/pubmed/25789949)[2578994](https://www.ncbi.nlm.nih.gov/pubmed/25789949)

The most frequent complication is posttraumatic arthritis. With talar neck fractures,osteonecrosis is relatively common, occurring in up to 50% of patients. Fracture nonunion occurs in 10%to 12% of patients. Varus malunion can occur with medial comminution. Wound dehiscence and deep infection are much less frequently encountered.

The patient has a loose acetabular component, which explains her pain and progressive shortening. She has a history of inflammatory arthritis, elevated ESR and C-reactive protein, and has recently been treated for an infection. Thus, the suspicion for infection is high and must be ruled out. A triple phase bone scan can assist in the identification of component loosening but cannot differentiate infection from noninfectious causes. Indium-111 scans have been shown to have limited utility, although a negative scan can be helpful in ruling out infection. The selective preoperative use of aspiration of the hip joint has been shown to be effective and is most likely to identify infection; however, the patient must be off of antibiotics for a minimum of 2 weeks prior to her aspiration to avoid a false negative culture.
REFERENCES: Della Valle CJ, Zuckerman JD, Di Cesare PE: Periprosthetic sepsis. Clin Orthop Relat Res 2004;420:26-31.
Lachiewicz PF, Rogers GD, Thomason HC: Aspiration of the hip joint before revision total hip arthroplasty:
Clinical and laboratory factors influencing attainment of a positive culture. J Bone Joint Surg Am 1996;78:749-754. Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 475-503.

Figure 73

Neurilemoma (Schwannoma) is a benign tumor of nerve sheath (Schwann cell) origin.It is usually a solitary, well-encapsulated lesion located on the surface of a peripheral nerve. Careful excision without damaging the underlying nerve is the treatment of choice. Neurofibroma is a spindle cell tumor arising within a peripheral nerve. Due to its location, it can interfere with distal nerve function.Neurofibromas can be solitary or multiple. A portion of these patients have von Recklinghausen’s disease.Because of the invasive nature of the tumor, resection requires removal of the affected nerve, resulting in distal nerve dysfunction. This lesion does not show the MRI characteristics of either a lipoma or a ganglion.

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A stress fracture of the femoral neck or pelvis should be ruled out in this patient. She should be placed on crutches and not allowed to run. The consequences of missing such a diagnosis can be devastating. Superior cortical femoral neck stress fractures are tension injuries and can progress to a complete fracture and avascular necrosis. Surgical fixation may be indicated. Plain radiographic findings often do not appear until late in the clinical course. MRI is more accurate, more specific, and is superior to radionuclide bone scanning for the diagnosis of stress fracture in young endurance athletes. MRI detects early changes in osseous
stress injury and allows precise definition of the anatomy and extent of injury. This patient may have the female athletic triad: disordered eating, amenorrhea, and osteoporosis. However, the workup for this condition (including a possible DEXA scan) may be delayed until after the stress fracture is diagnosed and treated.

Figure 87a

Figure 87b

Figure 88

Figure 89

Figure 90
CLINICAL SITUATION FOR QUESTIONS 87 THROUGH 90
Figures 87a and 87b are the clinical photograph and radiograph of a 14-year-old high school football player who fractured his dominant right clavicle. The skin is closed and vascular and neurologic examination findings are normal.

The ulnar nerve is the continuation of the medial cord of the brachial plexus containing fibers of the C 8 and T1 nerve roots. Radiculopathy at the C 8-T1 level may mimic a more distal compression of the nerve in the cubital tunnel. The axillary and radial nerves come off the posterior cord. There is no lateral trunk of the brachial plexus. The nerve to the rhomboids comes directly off of the C 5 nerve root and its presence is often helpful in differentiating pre-ganglionic from post-ganglionic lesions of the brachial plexus.
The lateral cord forms the musculocutaneous nerve. The medial cord forms the ulnar nerve. The medial and lateral cords form the median nerve. The radial nerve arises from the posterior cord.

Although a successful UKA can eliminate pain and improve the patientâs function, heavy labor and high impact athletiCactivities are not encouraged. High tibial osteotomy allows a patient to perform more aggressive activities

A residual deficit in muscle performance and anterior knee pain are expected in the majority of patients at 6 months after surgical fixation of their patella fractures.
Anterior knee pain is reported to be a common symptom following treatment of patellar fractures. A likely contributing factor to the anterior knee pain is scarring and tightness of the structures surrounding the knee, as well as patella maltracking due to quadricep/hamstring weakness and/or poor muscle synchrony. Other factors for anterior knee pain may include symptomatic hardware, which may be treated with removal of fixation after union has been achieved.
Lazaro et al. looked at the outcome data on thirty patients with isolated unilateral patellar fractures. Anterior knee pain during activities of daily living was experienced by twenty-four (80%) of the patients. The knee extensor mechanism on the injured side had deficits in strength (-41%), power (-47%), and endurance (-34%) as compared with the uninjured side.
Lebrun et al. reviewed a series of 40 operatively treated patella fractures and found that at over 6 years postoperatively, significant symptomatic complaints and functional deficits persisted based on validated outcome measures as well as objective physical evaluations. Removal of symptomatic fixation was required in 52% of the patients treated with osteosynthesis, whereas 38% of those with retained fixation self-reported implant-related pain at least some of the time.
Figure A and B show AP and lateral radiographs of a comminuted patella fracture treated with a tension band repair construct. The articular surface looks well reduced.
Incorrect Answers:
Answer 1: Osteonecrosis of the patella is rare, occurring in less than 5% of patella fractures. It most commonly occurs in the inferior pole of the patella. Answer 3: Re-fracture is rare after osteosynthesis with retained hardware.
Answer 4: Hardware failure is more common with poor surgical technique. Short term reported data shows prominent and symptomatic implants as a
result of breakage to occur in <50% of patients.
Answer 5: Non-union is rare in minimally displaced patella fractures.

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1. Reference(s)
2. Patzakis MJ: Management of osteomyelitis, in Operative Orthopaedics. Philadelphia, PA, JB Lippincott, 1993, p 3335.
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The plantar flexion-dorsiflexion motion of the ankle can be partially mimicked with a rocker-bottom shoe adaptation. A carbon fiber insert would not provide any improvement in her gait. An ankle-foot orthosis, Arizona brace, and double upright drop-lock brace would immobilize the ankle, which is already achieved with the ankle fusion.

DISCUSSION: The T2-weighted sagittal MRI scan shows the classic “bone bruise” pattern seen with an anterior cruciate ligament (ACL) tear. These lesions are thought to represent subcortical trabecular hemorrhages and are manifested as an increase in signal intensity on T2-weighted images and diminished signal intensity on Trweighted images. They are classically located in the mid-portion of the lateral femoral condyle and posterior aspect of the lateral tibial plateau. This is due to the fact that an ACL tear typically is the result of a valgus- extemal rotation of the femur on the fixed tibia. This places most of the weight-bearing stress on the lateral femoral condyle, which rotates laterally and impacts the posterior lip of the lateral tibial plateau. This may result in an impaction fracture if the force is great enough, but more frequently causes merely a microfracture of the involved subcortical trabeculae.

REFERENCES: Vellet AP, Marks PH, Fowler PJ, et al: Occult posttraumatic osteochondral lesions of the knee: Prevalence, classification, and short-term sequelae evaluated with MR imaging. Radiology 1991;178:271-276.
Cone R: Imaging sports-related injuries of the knee, in DeLee J, Drez D, Miller M (eds): DeLee & Drez’s Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, vol 2, pp 1595-1652.

In patients who have radial nerve dysfunction associated with a closed humeral fracture, nerve function usually will return to normal without surgical exploration. If clinical findings or electromyographic studies show no improvement at 3 months, surgical exploration and repair can be performed. Tendon transfers are performed if nerve repair is deemed unsuccessful.
REFERENCES: 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.
Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 237-247.

In a recent analysis of 200 patients with tibial fractures, Bhandari and associates attempted to identify variables that were predictive of reoperation. The variables in the study were type of injury (fracture pattern), degree of open injury, mechanism of injury, cortical bone contact, postoperative complications, polytrauma, anti-inflammatory drug use, nail insertion technique (reamed versus nonreamed), smoking history, alcohol use, diabetes mellitus, peripheral vascular disease, age, disability status pre-injury, gender, surgeon, time to surgery, steroid use, phenytoin use, antibiotic use, anticoagulant use, and type of fixation used. Three variables were statistically significant predictors of reoperation to achieve bone union in the first postinjury year: transverse fracture pattern, open fracture, and cortical contact of 50% or less. Using these three variables, four reoperation risk groups were identified based on the number of these three variables present: 0, 1, 2, or 3. The risk for reoperation was 0%, 18%, 47%, and 94%, respectively. The authors concluded that these statistics can provide prognostic information to patients and help identify those high-risk patients where early intervention to achieve union is indicated. In addition, the data highlights the significance of achieving cortical contact at the time of initial fixation.
REFERENCE: Bhandari M, Tornetta P III, Sprague S, et al: Predictors of reoperation following operative management of fractures of the tibial shaft. J Orthop Trauma 2003;17:353-361.

The coupled action of the rotator cuff prevents superior migration and controls anterior and posterior translation by depressing the humeral head.

Scientific References

: Poppen NK, Walker PS: Normal and abnormal motion of the shoulder. J Bone Joint Surg Am 1976;58:195-201.
Abrams JS: Special shoulder problems in the throwing athlete: Pathology, diagnosis, and nonoperative management. Clin Sports Med 1991;10:839-861.

The timely administration of antibiotics has been shown to be the best initial treatment to reduce the incidence of infection following an open fracture. Life threatening injuries must first be addressed. But in this isolated open pilon fracture, antibiotics should be initiated early along with tetanus prophylaxis. Reduction and splinting would stabilize the fracture but these interventions should follow antibiotic coverage. Emergency department irrigation is controversial. Closed reduction and splinting, external fixation, CT scan, and delayed open reduction internal fixation would be the preferred sequence of management. External fixation to provide provisional limb stabilization would be indicated in this length unstable C type injury to provide soft tissue stabilization and prevent further chondral injury. Splinting alone would not prevent shortening and would not allow soft tissue recovery. CT scans prior to limb stabilization are not warranted because the patterns make more sense after the restoration of gross length, rotation and alignment in the external fixator. Initial fibular fixation is also not recommended in this case because the location of incisions could affect the definitive surgical tactic. In this multi-fragmentary fibular injury, anatomic reduction would be challenging and malreduction could occur and influence subsequent reconstructions. Delayed open reduction internal fixation is ideal after the resolution of soft tissue swelling.
Anterolateral buttress plating of the tibial component and lateral plating of the fibula would best resist the valgus compression failure of the lateral column. The medial side failed in tension and plating in this location would not biomechanically resist the valgus displacement. Articular reduction could also be carried out from the anterolateral side with joint reconstruction building back to the posterolateral fragment. Secondary to the central articular impaction, isolated screw fixation would
not provide stability to the metaphyseal comminution. Medial columnar screws could be used to secure the medial tension failure and would limit surface implants in the location of the open wounds.
Failure to attain a high school diploma has been related to poorer outcomes following treatment of high-energy pilon fractures. Quality of reduction does lead to better overall results but still has a drastic impact on functional outcomes. The complexity of the initial fracture also does not lead to differing outcomes at longterm follow up.

Neurotization has not been shown to produce successful results for lower root involvement and is performed for preganglionic lesions. At 18 months, exploration and nerve grafting must still be carried out. Neurolysis is reserved for cases in which the recovery is partial or plateaus. Tendon transfers in children younger than 3 years of age do not work as well. Younger children do not cooperate well in their rehabilitation and it is also difficult to decide upon the functioning motors for transfer.

A large prospective, randomized study showed a reduction in vertebral and nonvertebral fractures when patients were treated with intravenous (IV) zoledronic acid within 90 days of a hip fracture, followed up with annual treatment.
Important points to remember about this study:
Study: Zoledronic acid (5 mg, IV) within 90 days of hip fracture and then annually (1,000 patients in each group) New fractures: 8.6% vs 13.9% (absolute risk reduction, 5.3%; relative risk reduction, 35%)
New fractures
  o   Vertebral: 1.7% vs 3.8% (P = .02)
  o   Nonvertebral: 7.6% vs 10.7% (P = .03)
  o   Hip: 2.0% vs 3.5% (relative risk 30%, not significant)   o   Divergence of fracture-free survival at 12 months BMD
  o   12 month: 2.6% vs -1.0%   o   24 month: 4.7% vs -0.7%   o   36 month: 5.5% vs -0.9% Death
  o   Hazard ratio: -0.72 (0.56 to 0.93 C I, P = .01) Adverse advents
  o   Pyrexia: 8.7% vs 3.1%   o   Myalgia: 4.9% vs 2.7%
  o   Bone pain: 3.2% vs 1.0%
C orrect Answer: Decreased vertebral fractures, decreased nonvertebral fracture, and improved survival

The radiograph shows a volarly dislocated lunate. Initial emergent treatment of perilunate dislocations should consist of closed reduction and splinting, especially if the patient exhibits median nerve compression. Open reduction and pinning or ligament repair are necessary but are not emergent. A dorsal approach is sometimes required for ligament repair or bony visualization; however, this can be done in a more semi-elective manner.
REFERENCES: Isenberg J, Prokop A, Schellhammer F, et al: Palmar lunate dislocation. Unfallchirurg 2002;105:1133-1138.
Ruby LK: Fractures and dislocations of the carpus, in Browner BD, Jupiter JB (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 1367-1372.

- Anterior_

Severe valgus deformity, flexion contracture, and epidural anesthesia are risk factors associated with peroneal nerve palsy following TKR. Previous lumbar laminectomy and previous valgus osteotomy of the tibia also increase a patientâs chance of peroneal nerve palsy

DISCUSSION: The 2007 AAOS guidelines for thrombophlebitis prophylaxis for patients undergoing total hip and knee arthroplasty includes preoperative risk assesment for deep venous thrombosis, pulmonary embolism, and

bleeding. Regional anesthesia when appropriate is suggested. Inferior vena cava filters may be appropriate in selected patients. When warfarin is used as a chemoprophylactic agent, the goal INR is less than or equal to 2 to minimize the risk of bleeding. This is in contrast to the 2004 ACCP guidelines for warfarin with a goal INR of 2-3.
-

REFERENCE: American Academy of Orthopaedic Surgeons Guideline on the Prevention of Symptomatic Pulmonary Embolism in Patients Undergoing Total Hip or Knee Arthroplasty. [www.aaos.org/Research/](http://www.aaos.org/Research/) guidelines/PEguide.asp

Figure 46

This patient presents with ankle instability and progressively worsening flatfoot, with the hindfoot in valgus. Although a rare condition, this is caused by a talonavicular tarsal coalition, with increasing stress on the ankle likely.

- Palliative spinal cord decompression and stabilization

There are 3 types of fifth metatarsal fractures. Zone 1 is an avulsion fracture. Zone 2 fractures, also known as Jones fractures, occur in the watershed area of the fifth metatarsal. A fracture must exit the intermetatarsal articulation between the fourth and fifth metatarsals to be considered a Jones fracture. Zone 3 fractures are distal to the articulation in the diaphysis of the fifth metatarsal. Jones fractures are associated with a 15% to 20% nonunion rate with nonsurgical care. Surgical intervention is preferred in athletic patients. Fixation with a solid screw is mechanically stronger than fixation with a cannulated screw. Nonunions or failure of hardware can be attributable to inadequate fixation or an unrecognized varus heel alignment leading to lateral column overload.
RECOMMENDED READINGS
[Zenios M, Kim WY, Sampath J, Muddu BN. Functional treatment of acute metatarsal fractures: a prospective randomised comparison of management in a cast versus elasticated support bandage. Injury. 2005 Jul;36(7):832-5. Epub 2005 Mar 21. PubMed PMID: 15949484. ](http://www.ncbi.nlm.nih.gov/pubmed/15949484)[View](http://www.ncbi.nlm.nih.gov/pubmed/15949484)[ ](http://www.ncbi.nlm.nih.gov/pubmed/15949484)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/15949484)
[Fetzer GB, Wright RW. Metatarsal shaft fractures and fractures of the proximal fifth metatarsal. Clin Sports Med. 2006 Jan;25(1):139-50, x. Review. PubMed PMID: 16324980. ](http://www.ncbi.nlm.nih.gov/pubmed/16324980)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/16324980)
[Zwitser EW, Breederveld RS. Fractures of the fifth metatarsal; diagnosis and treatment. Injury. 2010 Jun;41(6):555-62. doi: 10.1016/j.injury.2009.05.035. Epub 2009 Jun 30. Review. PubMed PMID: 19570536. ](http://www.ncbi.nlm.nih.gov/pubmed/19570536)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19570536)
Hunt KJ, Goeb Y, Esparza R, Malone M, Shultz R, Matheson G. Site-Specific Loading at the Fifth Metatarsal Base in Rehabilitative Devices: Implications for Jones Fracture Treatment. PM
R. 2014 May 28. pii: S1934-1482(14)00243-3. doi: 10.1016/j.pmrj.2014.05.011. [Epub
[ahead of print] PubMed PMID: 24880059. ](http://www.ncbi.nlm.nih.gov/pubmed/24880059)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24880059)
[Nunley JA. Fractures of the base of the fifth metatarsal: the Jones fracture. Orthop Clin North Am. 2001 Jan;32(1):171-80. Review. PubMed PMID: 11465126. ](http://www.ncbi.nlm.nih.gov/pubmed/11465126)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/11465126)
Orr JD, Glisson RR, Nunley JA. Jones fracture fixation: a biomechanical comparison of partially threaded screws versus tapered variable pitch screws. Am J Sports Med. 2012 Mar;40(3):691-
8/. doi: 10.1177/0363546511428870. Epub 2012 Jan 6. PubMed PMID: 22227846.
[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/22227846)

**DISCUSSION** : A quadriceps snip is performed by extending a medial parapatellar approach superiorly and laterally across the quadriceps tendon. It is then repaired primarily at the end of the procedure. The primary advantage of this technique over other surgical maneuvers that improve exposure at the time of revision total knee arthroplasty is that the postoperative regimen for physical therapy does not need to be altered.

**

Scientific References

: Younger AS, Duncan CP, Masri BA: Surgical exposures in revision total knee arthroplasty. J Am Acad Orthop Surg 1998;6:55-64.
Della Valle CJ, Berger RA, Rosenberg AG: Surgical exposures in revision total knee arthroplasty. Clin Orthop Relat Res 2006;446:59-68.
Barrack RL, Smith P, Munn B, et al: The Ranawat Award. Comparison of surgical approaches in total knee
arthroplasty. Clin Orthop Relat Res 1998;356:16-21.

Question 2
A healthy 72-year-old woman is seen 14 days after cemented total knee arthroplasty. She reports increasing pain and swelling for the last 4 days accompanied by 4 days of wound drainage. Examination reveals that she is afebrile, and has erythema and moderate serosanguinous drainage from the wound. The knee is moderately swollen. Aspiration of the knee reveals no organisms on Gram stain. Culture results are expected back in 48 hours. Optimal management should consist of

1. ### initiation of a first-generation cephalosporin while awaiting culture results.
2. ### initiation of broad-spectrum antibiotics while awaiting culture results.
3. ### ultrasound to evaluate for fluid collection around the knee.
4. ### surgical debridement of the knee before culture results are available.
5. ### inpatient observation and no antibiotics until culture results are available.

PREFERRED RESPONSE: 4**

**DISCUSSION** : Increased pain, swelling, erythema, and drainage 2 weeks removed from the primary arthroplasty are all signs of a probable infection. Erythrocyte sedimentation rate and C-reactive protein may not be helpful as they are elevated postoperatively even in the absence of infection. Even in the absence of infection, persistent wound drainage is an indication for surgical debridement to prevent subsequent infection. When a postoperative infection is easily recognized by clinical examination, there is no need to wait for a positive culture before proceeding with debridement.

REFERENCES: Weiss AP, Krackow KA: Persistent wound drainage after primary total knee arthroplasty. J Arthroplasty 1993;8:285-289.
Jaberi FM, Parvizi J, Haytmanek CT, et al: Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty. Clin Orthop Relat Res 2008;466:1368-1371.
Insall JN, Windsor RE, Scott, WN: Surgery of the Knee, ed 2. New York, NY, Churchill Livingstone, 1993, pp 959-964.

Figure 3a Figure 3b

Hip stability is augmented by thickened portions of the articular capsule. A sectioning study of the hip capsular ligaments identified the ischiofemoral ligament to have the most significant effect in limiting hip internal rotation in both extension and flexion. The strongest of the capsular ligaments is the iliofemoral ligament. The medial arm of the iliofemoral ligament provides the most significant restraint against anterior hip translation with hip extension and external rotation. The lateral arm of the iliofemoral ligament provides restriction to both internal and external rotation with the hip in extension. The pubofemoral ligament augments stability of the hip against external rotation in extension.
RECOMMENDED READINGS
1. Martin HD, Savage A, Braly BA, Palmer IJ, Beall DP, Kelly B. The function of the hip capsular ligaments: a quantitative report. Arthroscopy. 2008 Feb;24(2):188-95. doi: 10.1016/j.arthro.2007.08.024. Epub 2007 Nov 26. PubMed PMID: 18237703.
[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/18237703)
2. Wasielewski RC.The Hip. In: Callaghan J, Rosenberg A, Rubash H, The Adult Hip. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:53.
CLINICAL SITUATION FOR QUESTIONS 22 THROUGH 25
A 22-year-old man sustains an injury to his right knee in a motor vehicle collision. Figure 22a is the posterior stress radiograph of the involved knee, and Figure 22b is a selected MR image that identifies the injured structure.
A

B