Orthopedics Hyperguide Review | Dr Hutaif General Ortho -...

- aspiration.

The images reveal a solitary pedunculated osteochondroma. Malignant degeneration of solitary osteochondromas occurs in fewer than 1% of patients. A reasonable approach would be to inform the patient of the rare (less than 1%) incidence of malignant degeneration and to return for evaluation if symptoms develop or if the patient notices growth of the lesion.
RECOMMENDED READINGS
104. Schwartz AJ. Benign cartilage tumors. In: Biermann JS, ed. _Orthopaedic Knowledge Update Musculoskeletal Tumors 3_. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2013:97-106.
105. [Aboulafia AJ, Kennon RE, Jelinek JS. Benign bone tumors of childhood. J Am Acad Orthop Surg. 1999 Nov-Dec;7(6):377-88. Review. PubMed PMID: 11505926.](http://www.ncbi.nlm.nih.gov/pubmed/11505926)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/11505926)

A prospective randomized study compared intraarticular lidocaine injection to conscious sedation for analgesia during reduction of ankle fracture-dislocations. There was no difference in the amount of analgesia provided by the two methods. Time for reduction and splinting was less in the local anesthetic group. Quality of reduction was similar in both groups.

DISCUSSION: Schilders and associates reported their results of treating adductor-related groin pain in competitive athletes. They reported that a single corticosteroid injection into the pubic cleft can be expected to provide at least 1 year of relief of adductor-related groin pain in a competitive athlete with normal findings on MRI. In contrast, when there is evidence of enthesopathy on MRI in this competitive- athlete population, these injections are not therapeutic and are associated with a high likelihood of recurrence of symptoms. Hip arthroscopy is generally reserved for intra-articular problems. Percutaneous adductor tenotomy is not indicated for this condition. A bone scan is unlikely to provide any useful information for clinical decision-making. Rheumatology consultation is also not indicated in the absence of any evidence of inflammatory arthropathy.
REFERENCES: Schilders E, Bismil Q, Robinson P, et al: Adductor-related groin pain in competitive athletes: Role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J Bone Joint Surg Am 2007;89:2173-2178.
Robinson P, Barron DA, Parsons W, et al: Adductor-related groin pain in athletes: Correlation of MR imaging with clinical findings. Skelet Radiol 2004;33:451-457.

Giant-cell tumor of bone (GCTB) is characterized by numerous multinucleated osteoclast-type giant cells. Giant cells are known to express receptor activator of nuclear factor ?B ligand (RANKL) and are responsible for the aggressive osteolytic nature of tumors. Denosumab is a human monoclonal antibody that targets and binds with high specificity to RANKL. Although generally benign, GCTB may be associated with multiple local recurrences, multicentricity, pulmonary metastases, or lesions that cannot be removed surgically without causing substantial morbidity. In a recent phase 2 study, denosumab administered to patients with surgically salvageable and unsalvageable GCTB was well tolerated and associated with inhibited disease progression (99%) and a reduced requirement for surgery. Methotrexate and adriamycin are common chemotherapeutic drugs used in the treatment of osteosarcoma of bone, but they have shown no efficacy in the treatment of GCTB. NSAIDs are useful for treating pain associated with osteoid osteomas, but they have no effect on GCTB.
RECOMMENDED READINGS
20. [Xu SF, Adams B, Yu XC, Xu M. Denosumab and giant cell tumour of bone-a review and future management considerations. Curr Oncol. 2013 Oct;20(5):e442-7. doi: 10.3747/co.20.1497. Review. PubMed PMID: 24155640.](http://www.ncbi.nlm.nih.gov/pubmed/24155640)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/24155640)
21. [Chawla S, Henshaw R, Seeger L, Choy E, Blay JY, Ferrari S, Kroep J, Grimer R, Reichardt P, Rutkowski P, Schuetze S, Skubitz K, Staddon A, Thomas D, Qian Y, Jacobs I. Safety and efficacy of denosumab for adults and skeletally mature adolescents with giant cell tumour of bone: interim analysis of an open-label, parallel-group, phase 2 study. Lancet Oncol. 2013 Aug;14(9):901-8. doi: 10.1016/S1470-2045(13)70277-8. Epub 2013 Jul 16.](http://www.ncbi.nlm.nih.gov/pubmed/23867211)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/23867211)
22. Balke M, Hardes J. Denosumab: a breakthrough in treatment of giant-cell tumour of bone? Lancet Oncol. 2010 Mar;11(3):218-9. doi: 10.1016/S1470-2045(10)70027-9. Epub 2010 Feb 10. PubMed
[PMID: 20149737.](http://www.ncbi.nlm.nih.gov/pubmed/20149737)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/20149737)

The radiograph and MR images show an osteoblastic lesion in the T9 and T8 vertebral bodies. In an older man, this finding most likely reveals metastatic prostate cancer. The first and least invasive diagnostic step is to order a PSA level. Gleave and associates found in a retrospective review of patients with prostate cancer that isolated levels of PSA lower than 10 to 20 micrograms per liter are rarely associated with bone metastasis. Vis and associates documented that 10-year prostate cancer survival in a screened population was higher than 60%, and in an unscreened population it was 24%. In a neurologically intact patient with no evidence of neural compression or instability, surgery is not indicated. Fine-needle aspiration may be performed, but the diagnostic yield in a blastic lesion is low. A bone scan may be indicated to complete the metastatic workup, but it will not aid in the diagnosis of tissue source.
RECOMMENDED READINGS
[Gleave ME, Coupland D, Drachenberg D, Cohen L, Kwong S, Goldenberg SL, Sullivan LD. Ability of serum prostate-specific antigen levels to predict normal bone scans in patients with newly diagnosed prostate cancer. Urology. 1996 May;47(5):708-12. PubMed PMID: 8650870. ](http://www.ncbi.nlm.nih.gov/pubmed/8650870)[View ](http://www.ncbi.nlm.nih.gov/pubmed/8650870)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/8650870)
[Vis AN, Roemeling S, Reedijk AM, Otto SJ, Schröder FH. Overall survival in the intervention arm of a randomized controlled screening trial for prostate cancer compared with a clinically diagnosed cohort. Eur Urol. 2008 Jan;53(1):91-8. Epub 2007 Jun 12. PubMed PMID: 17583416. ](http://www.ncbi.nlm.nih.gov/pubmed/17583416)[View ](http://www.ncbi.nlm.nih.gov/pubmed/17583416)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/17583416)
Cronen GA, Emery SE. Benign and malignant lesions of the spine. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:351-366.
CLINICAL SITUATION FOR QUESTIONS 26 THROUGH 29

Figures 26a and 26b are the MR images with gadolinium enhancement of a 40-year-old man who arrives at the emergency department with a 4-day history of fevers and severe back pain without radiation. He is normotensive at presentation with a heart rate of 86 beats per minute. Upon examination he is neurologically intact with normal sensory and motor function. He has a history of alcohol and cocaine abuse. His white blood cell (WBC) count is 12000 (reference range [rr], 4500-11000 /µL) and his C-reactive protein (CRP) level is 100 mg/L (rr, 0.08-3.1 mg/L)

Of the factors listed only the use of an un-reamed intramedullary nail for an open tibia fracture has not been shown to increase the risk of adverse outcome or need for reoperation.
The treatment of open tibia fractures with intramedullary nailing can be complicated by many factors. High energy mechanism of injury, use of a stainless steel nail, residual fracture gap greater than 1 cm, and a history of smoking have all been shown to increase the risk of adverse outcome. The use of reamed and un-reamed nails for open tibia fractures have been studied, and no significant difference in outcome has been found.
Schemitsch et al. present data from a prospective randomized trial of tibia fractures treated with reamed or unreamed intrameduallry nails. They found no difference in risk of adverse outcome between reamed and un-reamed nails in open tibia fractures. They did, however, find an increased risk of adverse outcomes in high-energy mechanisms, use of stainless steel (versus titanium) rods, and a residual fracture gap of greater than 1 cm. They comment that their data did not show a significant increase in risk due to history of smoking, but cite other studies that have demonstrated such a relationship.
Bhandari et al. present data from a prospective randomized study of patients with tibia fractures randomized to reamed or un-reamed tibial nails. For closed fractures they found a lower rate of primary events (most commonly need for dynamization) in the reamed group. However, they found no difference in outcomes for either technique in open fractures.
Incorrect answers:
Answers 1, 3, 4, 5: Each of these factors have been shown to increase the risk of adverse outcome when treating an open tibia fracture with an intramedullary nail.

A terrible triad of the elbow includes dislocation of the elbow with associated fractures of the radial head and the coronoid process. Ring et al. stressed that these injuries are prone to complications and advised against resection of the radial head due to instability, and instead recommended a radial head replacement if too comminuted for ORIF. Coronoid fractures compromise elbow stability as well and require open reduction and internal fixation as with the lateral collateral ligament. McKee et al. showed stable elbows in 34/36 with mean Mayo elbow score of 88 when the standard protocol of coronoid ORIF, radial head repair/replacement, and LCL repair were employed.

The images show a left posterior stabilized knee prosthesis and a right cruciate sacrificing (ultracongruent / dished type) knee prosthesis. Posterior stabilized designs have a risk of patellar clunk due to the presence of the femoral box with some designs, such as the one shown, exhibiting higher rates. Clinical outcomes are similar between cruciate-retaining, cruciate- sacrificing and posterior stabilized designs.

DISCUSSION: The patient requires emergent revascularization with signs of ischemia of unknown duration. The leg has shortened substantially and initial management requires traction to return the leg to length. This should be followed by revascularization of the leg. A temporary shunt may be helpful until the fracture has been stabilized (revision total hip arthroplasty) with the leg at full length. Definitive vascular bypass should then be performed.

REFERENCES: Calligaro KD, Dougherty MJ, Ryan S, et al: Acute arterial complications associated with total hip and knee arthroplasty. J Vase Surg 2003;38:1170-1177.
Brady OH, Garbuz DS, Masri BA, et al: Classification of the hip. Orthop Clin North Am 1999;30;215- 220. Question 83
During normal human knee flexion (beginning with the knee fully extended), which of the following statements best describes tibial rotation with respect to the femur?

1. ### Rotation is constantly occurring in both directions during the flexion cycle.
2. ### The tibia initially externally rotates, then progressively internally rotates.
3. ### The tibia initially internally rotates, then progressively externally rotates.
4. ### The tibia initially internally rotates, then remains in that rotational position until deep flexion when further internal rotation occurs.
5. ### The tibia initially externally rotates, then remains in that rotational position until deep flexion when further external rotation occurs.

PREFERRED RESPONSE: 4

DISCUSSION: During knee flexion, the tibia initially rotates internally in approximately the first 20 degrees and generally maintains this rotational position until flexion past 90 degrees when significantly more internal rotation occurs.

REFERENCE: Coughlin KM, Incavo SJ, Churchill DL, et al: Tibial axis and patellar position relative to the femoral epicondylar axis during squatting. J Arthroplasty 2003;18:1048-1055.

A positive lift-off test and increased passive external rotation are diagnostic of a subscapularis tear or detachment. Although a similar injury could produce anterior instability, this will test the integrity of the subscapularis. A locked dislocation has limited passive movement. A ruptured biceps tendon will most likely produce ecchymosis and findings similar to supraspinatus trauma. Internal impingement is not associated with subscapularis weakness.
REFERENCES: Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapularis muscle: Clinical features in 16 cases. J Bone Joint Surg Br 1991;73:389-394.
Hawkins RJ, Bokor DJ: Clinical evaluation of the shoulder, in Rockwood CA, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 149-177.

Metacarpals and phalanges are the most common areas of hand involvement, and the hand is involved in 40% to 65% of cases. Enchondromas are also the most common primary benign bone tumor of the hand (90% cases).

Indications for open reduction of glenoid intra-articular fractures include those fractures with a 5-mm articular surface displacement or when the humeral head is subluxated with the fracture fragment. Kavanaugh and associates and Leung and Lam have shown that the posterior approach with plate fixation is best for most glenoid fractures, including the Ideberg type II fracture shown here. The anterior approach is best used for anterior rim and transverse fractures.
REFERENCES: Kavanagh BF, Bradway JK, Cofield RH: Open reduction and internal fixation of displaced intra-articular fractures of the glenoid fossa. J Bone Joint Surg Am 1993;75:479-484.
Leung KS, Lam TP: Open reduction and internal fixation of ipsilateral fractures of the scapular neck and clavicle. J Bone Joint Surg Am 1993;75:1015-1018.
Ideberg R: Unusual glenoid fractures: A report on 92 cases. Acta Orthop Scand 1995;66:395-397.

The history and physical examination are consistent with a monoarticular joint condition but not typical of joint sepsis. The arthroscopic appearance of brownish proliferative synovium is typical of PVNS. PVNS is a monoarticular synovial disease of unknown etiology and is treated with total synovectomy. The proliferative synovitis is not consistent with chondromalacia. Synovial cell sarcoma is an extracapsular disease. Rheumatoid arthritis typically is polyarticular, and the synovial appearance is not associated with hemosiderin deposition.
REFERENCES: Flandry FC, Hughston JC, Jacobson KE, Barrack RL, McCann SB, Kurtz DM: Surgical treatment of diffuse pigmented villonodular synovitis of the knee. Clin Orthop 1994;300:183-192.
Zvijac JE, Lau AC, Hechtman KS, Uribe JW, Tjin-A-Tsoi EW: Arthroscopic treatment of pigmented villonodular synovitis of the knee. Arthroscopy 1999;15:613-617.

This patient’s examination and history indicate recurrent patellar dislocations. Radiographs show an osseous or osteochondral loose fragment. There is no evidence of an obvious nondisplaced fracture or physeal changes. In the setting of suspected patella dislocation or subluxation with loose fragment seen on radiograph, an MRI is indicated. Lateral release alone is seldom indicated in a knee that is normal before injury. The examination and MRI do not indicate a need for medial collateral ligament repair.
Treatment should consist of arthroscopy or arthrotomy and attempted internal fixation of this fragment. If fixation is not possible, the loose body can be removed. Normal TT-TG values, an increased lateral patellar glide, and a history of recurrent patellar dislocations after trauma suggest MPFL incompetence _and the need for reconstruction._

This patient has neurogenic claudication and spinal stenosis. On this axial image, the spinal canal is narrowed. The arrow points to the ligamentum flavum (yellow ligament). The ligament connects the laminae of adjacent vertebrae and blends in with the facet caspule. In spinal stenosis, the ligamentum flavum is the primary cause of spinal nerve root compression, and surgical removal of the ligamentum flavum is a critical component of treatment. The inferior articular process is dorsal to the ligament on this axial image, while the inferior articular process is lateral to the arrow. The cauda equina refers to the lumbosacral nerve roots distal to the conus medullaris.
RECOMMENDED READINGS
6. Lurie JD, Tosteson TD, Tosteson A, Abdu WA, Zhao W, Morgan TS, Weinstein JN. Long-term outcomes of lumbar spinal stenosis: eight-year results of the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976). 2015 Jan 15;40(2):63-76. doi: 10.1097/BRS.0000000000000731.
[PubMed PMID: 25569524.](http://www.ncbi.nlm.nih.gov/pubmed/25569524)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/25569524)
7. [Weinstein JN, Lurie JD, Tosteson TD, Zhao W, Blood EA, Tosteson AN, Birkmeyer N, Herkowitz H, Longley M, Lenke L, Emery S, Hu SS. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009 Jun;91(6):1295-304. doi: 10.2106/JBJS.H.00913. PubMed PMID: 19487505. ](http://www.ncbi.nlm.nih.gov/pubmed/19487505)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19487505)
**

There was no difference observed in the healing of tendon to bone when comparing healing to cortical bone and to a cancellous trough.
REFERENCE: St Pierre P, Olson EJ, Elliott JJ, et al: Tendon healing to cortical bone compared with healing to a cancellous trough. J Bone Joint Surg Am 1995;77:1858-1866.

| Category | Requirement | |---|---| | Children | 500 mg to 700 mg | | Growth spurt to young adult (10 to 25 years of age) | 1,300 mg | | Adult male | 750 mg | | Adult female | 1,500 mg | | Postmenopausal Elderly | 1,200 mg | | Pregnancy | 1,500 mg | | Lactation | 2,000 mg |

At 3 years of age, children do well with nonsurgical treatment with early spica casting and early mobilization. There is no indication to perform surgical stabilization in such a closed isolated injury. The fracture is not shortened unacceptably according to clinical practice guidelines, and traction for this fracture is unnecessary. Traction also may be problematic for the family and healthcare system.
RESPONSES FOR QUESTIONS 57 THROUGH 62
1. Cortical thickening in the region of the lesion
2. Erosive metaphyseal lesion with loss of cortical integrity
3. Normal bony anatomy on radiographs
4. Diffuse articular erosion with loss of joint space
5. Round, expansive, well-circumscribed metaphyseal lesion with thinning of the cortex
6. Eccentric well-circumscribed metaphyseal lesion with a scalloped border
Match the orthopaedic condition described below with the expected radiographic finding listed above.

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According to several consensus statements, no child or adolescent athlete with a concussion should be allowed to return to play on the same day, regardless of severity. Second-impact syndrome refers to a second traumatic head injury that occurs while an athlete is still experiencing symptoms from the first injury. Young athletes are particularly vulnerable to second-impact syndrome. The mechanism by which this syndrome occurs likely is disruption of cerebral autoregulation, which may result in cerebral vascular congestion, diffuse brain swelling, and death.

DISCUSSION:
End-stage posttraumatic or inflammatory elbow arthritis in active, high-demand patients remains difficult to treat. Traditional total elbow arthroplasty is discouraged in this demographic secondary to concerns about implant longevity. Soft-tissue interposition arthroplasty does not necessitate the same activity and weight
restrictions for patients after surgery and remains a reasonable salvage procedure. Larson and Morrey published their findings on 38 patients with a mean age of 39 years following soft-tissue interposition arthroplasty for posttraumatic and inflammatory end-stage elbow arthritis. These investigators reported a significant improvement in Mayo Elbow Performance Score in addition to improvement in the flexion- extension arc from 51° to 97° after surgery. They reported worse results and elevated incidence of complications for patients with presurgical elbow instability upon examination; retained hardware from prior
surgery was not deemed a contraindication.

DISCUSSION: Injuries to the anterior and middle column in gymnasts occur but are far less common than posterior column injuries such as spondylolysis and spondylolisthesis. The data on injuries to the anterior and middle columns are more limited. Long-term gymnastics exercise is associated with disk degeneration and other anterior and middle column abnormalities as reported by Katz and Scerpella. They identified a series of anterior and middle column abnormalities, including vertebral compression fractures, Schmorl’s nodes, disk degeneration, and disk herniation in young competitive female gymnasts with back pain. Therefore, the differential diagnosis of back pain in these athletes should include abnormalities of the anterior and middle column. Although diagnostic imaging should begin with radiographs, MRI is the best way to diagnosis these abnormalities. A bone scan is more useful for imaging bony abnormalities of the posterior elements. Flexion-extension radiographs are not indicated in this patient. Treatment such as physical therapy or a lumbosacral corset should not be initiated prior to a complete work-up.
REFERENCES: Katz DA, Scerpella TA: Anterior and middle column thoracolumbar spine injuries in young female gymnasts: Report of seven cases and review of the literature. Am J Sports Med 2003;31:611-616.
Tertti M, Paajanen H, Kujala UM, et al: Disc degeneration in young gymnasts: A magnetic resonance imaging study. Am J Sports Med 1990;18:206-208.

DISCUSSION: Whereas the choice of a particular option may seem controversial in this scenario because all
answers seem possible, the literature favors a femoral osteotomy of the femoral canal with a cementless prosthesis that offers some form of distal fixation. Such implants are widely available and allow for healing of the reconstructive osteotomy. Custom implants are problematic because bone assessing algorithms may not be accurate with the dysplastic hip. Hip arthrodesis is not a good option in this age group because ipsilateral spine and knee arthritis can be aggravated. Finally, cemented femoral stem placement has given way to cementless prosthetics in younger patients because the results of cement in osteotomy cases are inferior.

REFERENCES: Parsch D, Jung AW, Thomsen M, et al: Good survival of uncemented tapered stems for failed intertrochanteric osteotomy: A mean 16 years followup study in 45 patients. Arch Orthop Trauma Surg 2007;128:1081-1085.
Suzuki K, Kawachi S, Matsubara M, et al: Cementless total hip replacement after previous intertrochanteric valgus osteotomy for advanced osteoarthritis. J Bone Joint Surg Br 2007;89:1155-1157. Zadeh HG, Hua J, Walker PS, et al: Uncemented total hip arthroplasty with subtrochanteric derotational osteotomy for severe femoral anteversion. J Arthroplasty 1999;14:682-688.

This is a rupture of the anterolateral ligament complex and a portion of the IT band. This injury is highly correlated with a complete ACL injury. In the MRI, the curvilinear or elliptic bone fragment (Segond fracture) projected parallel to the lateral aspect of the tibial plateau, the lateral capsular sign, is seen. The lateral capsular sign is also associated with ACL tears. Thus, this is an MRI showing a complete ACL _tear._

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The radiographs reveal an Ogden type 4 tibial tubercle fracture. The clinical examination of the patient is highly suggestive of compartment syndrome.
Tibial tubercle fractures have been associated with the development of compartment syndrome, with rates as high as 10% reported in literature. It is caused by disruption of the branches of the recurrent anterior tibial artery, which travels on the lateral border of the tubercle. At the time of injury, the artery may be injured and retract under the fascia in the anterior compartment of the leg, leading to excessive bleeding in the anterior compartment. Patients with compartment syndrome should be emergently taken to the OR for fasciotomy and ORIF of the fracture.
Emergent fasciotomy of the leg with posterior splint is not called for, as this fracture needs anatomic reduction and fixation to prevent procurvatum deformity of proximal tibia. CT scan of the knee is not appropriate because this is compartment syndrome, which needs emergent fasciotomy.
This situation needs ORIF for anatomic reduction of the fracture with emergent fasciotomy for compartment syndrome of the leg. Closed reduction and percutaneous screw fixation is not the right option here.

The radiograph shows an olecranon fracture with articular comminution and depression of a large intra-articular fragment. This pattern is best treated with plate fixation to support the articular reduction.
Bailey et al reviewed 25 cases of olecranon fractures (simple and comminuted fracture patterns) treated with plate fixation. All 25 went on to union. There were no major complications reported. Twenty percent of patients underwent hardware removal at a later date for prominence.
Hak et al review the treatment options available for olecranon fractures. Simple intra-articular fractures without comminution are suitable for tension band fixation. Comminution of the articular surface is an indication for plate fixation and may benefit from bone graft to support depressed articular segments. Osteoporotic patients or fractures with severe comminution may do better with fragment excision and advancement of the triceps.

Various options exist to treat thumb CMC arthritis: trapezial resection alone, trapezial resection with ligament suspensionplasty or tendon interposition, trapezial resection with both ligament suspensionplasty and tendon interposition, CMC fusion, and CMC replacement. MCP hyperextension can develop in long-standing CMC arthritis, contributing to CMC instability as well as thumb pain and weakness. In patients with concomitant MCP hyperextension that exceeds 30°,
correction of the deformity of the MCP joint must also be addressed and can be done with MCP capsulodesis, extensor pollicis brevis tendon transfer, or MCP fusion. Fusion of both the thumb CMC and MP joints is not recommended as this would result in marked stiffness and dysfunction.

Humphreys and associates in a retrospective review of TLIF vs PLIF found fusion rates, surgical time, and length of hospital stay were similar with both procedures. The only benefits associated with TLIF were less blood loss and preservation of the paraspinal muscle sleeve. Manos and associates in a cadaver study found no difference in the volume of disk material evacuated or the area of endplate exposed in either procedure.
RECOMMENDED READINGS
[Humphreys SC, Hodges SD, Patwardhan AG, Eck JC, Murphy RB, Covington LA. Comparison of posterior and transforaminal approaches to lumbar interbody fusion. Spine (Phila Pa 1976). 2001 Mar 1;26(5):567-71. PubMed PMID: 11242386. ](http://www.ncbi.nlm.nih.gov/pubmed/11242386)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/11242386)
Manos R, Sukovich W, Weistroffer J: Transforaminal lumbar interbody fusion: Minimally invasive versus open disc excision and endplate preparation. Presented at the 12th International Meeting of Advanced Spine Techniques, Banff, Alberta, Canada, July 7-9, 2005.

Figure 1 reveals medial scapular winging secondary to weakness of the serratus anterior, which is innervated by the long thoracic nerve. Damage to the long thoracic nerve can occur via repetitive stretching, compression, or iatrogenic injury during a surgical procedure. Lateral thoracic winging is caused by weakness of the trapezius, which is innervated by cranial nerve XI (spinal accessory nerve). The direction of scapular winging is judged by the upper medial border of the scapula. Observation of a period of at least 6 months with serratus anterior strengthening while the nerve recovers is the mainstay _of treatment for medial scapular winging._

DISCUSSION: The MRI scans show a large superior labral cyst. Impingement of the cyst on the suprascapular nerve is implied by the visible atrophy of the infraspinatus muscle as seen in Figure 19c. Clinically, this is manifested by atrophy of the posterior aspect of the shoulder inferior to the scapular spine. The suprascapular nerve provides only motor function and does not provide any sensory function to the shoulder girdle; therefore, sensory deficits will not be present in this patient.
REFERENCES: Westerheide KJ, Dopirak RM, Karzel RP, et al: Suprascapular nerve palsy secondary to spinoglenoid cysts: Results of arthroscopic treatment. Arthroscopy 2006;22:721-727.
Schroder CP, Skare O, Stiris M, et al: Treatment of labral tears with associated spinoglenoid cysts without
cyst decompression. J Bone Joint Surg Am 2008;90:523-530.
Piatt BE, Hawkins RJ, Fritz RC, et al: Clinical evaluation and treatment of spinoglenoid notch ganglion cysts. J Shoulder Elbow Surg 2002; 11:600-604.

- Observation

A closed mid-diaphyseal humerus fracture with a radial nerve palsy on presentation is not a contraindication to functional brace management.
Commonly accepted parameters for closed treatment include less than 30 degrees of varus angulation, 20 degrees of anterior/posterior angulation, and 3 cm of shortening. Operative indications are: associated vascular injuries, bilateral humeral shaft fractures, polytrauma patient (including paraplegia), segmental fractures, injury to the brachial plexus, pathological fractures, floating elbow, and floating shoulder.
The article by Rutgers and Ring found that proximal one-third oblique humeral shaft fractures had an unacceptably high 29% rate of nonunion treated with a functional brace.
The article by Sarmiento et al found a 97% rate of union, a radial nerve palsy incidence of 11%, and no contraindication to the use of functional braces in humeral shaft fractures associated with radial nerve palsy.
The review article by Defranco and Lawton states that 70% of these radial nerve injuries recover spontaneously. They note that it "seems reasonable, however, to consider surgical intervention (radial nerve exploration) between 4 and 6 months based on the patient’s clinical course."

The patient is demonstrating signs of septic shock. Administration of antibiotics should not be delayed. Aspirating the knee joint and obtaining blood cultures can be rapidly accomplished to obtain accurate specimens. This should be followed immediately by administration of broad spectrum IV antibiotics. Patients with septic shock can be identified with a clinical construct of sepsis with persisting hypotension requiring vasopressors to maintain mean arterial pressure (MAP) ≥ 65 mmHg and having a serum lactate level > 2mmol/L (18 mg/dL) despite adequate volume resuscitation. With these criteria, hospital mortality is in excess of 40%.

The guidelines for the daily elemental calcium requirement are as follows:
Children 500 mg to 700 mg
Growth spurt to young adult
(10 to 25 years of age)
1,300 mg
Adult male 750 mg
Adult female
Postmenopausal Elderly Pregnancy Lactation
  Â
1,500 mg
1,200 mg
1,500 mg
2,000 mg
Note: 1 daily equivalent = 250 mg elemental calcium (one glass of milk) Correct Answer: 1,500 mg

The patient has exposed bone and tendon and a partial tendon injury. The remaining radial tendon is satisfactory and no tendon repair is required. The exposed bone and tendon necessitate vascularized tissue coverage. A reversed cross-finger flap from the ring finger is suitable for coverage of the dorsal surface of an adjacent digit.

The video shows the lack of tenodesis caused by the incompetence of the FDP tendon to the ring finger, which can be attributable to a laceration, tendon rupture, or avulsion. Note how the ring finger stays extended (compared to the other digits) when the extensor tendons are tightened during wrist extension. The other fingers are pulled into flexion by the FDP tendons when the extensor tendons are relaxed during wrist extension. With the wrist flexed, the extensor mechanism to all fingers appears to be functioning normally. Findings indicating a trigger finger would be locking in flexion of the proximal interphalangeal joint. FDS incompetence can only be detected by blocking FDP function of the other fingers and actively flexing the examined finger.

With the exception of physical therapy and a rigid orthotic support, most of the treatment alternatives would be helpful in the initial treatment of plantar fasciitis. Achilles stretching combined with a soft, gel-type heel cushion is consistently the most successful modality.

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Instrumentation of the osteoporotic spine is becoming more common as the population ages. Some intraoperative options to reduce pedicle screw failure rates include augmenting the pedicle screw with PMMA, using a fenestrated screw designed for injection of the PMMA through the screw, and using hydroxyapatite coated screws. Teriparatide is a parathyroid hormone analogue used as a second-line treatment for osteoporosis. Preoperative administration potentially can increase bone quality. Postoperative administration of teriparatide has been shown to increase lumbar fusion rates. In the setting of osteoporosis, multilevel interbody fusion can increase the risk of implant subsidence. Although iliac crest bone graft is the gold standard graft used to obtain fusion, it does not have immediate impact on the rate of implant failure in osteoporosis.

- Figure 59b is the radiograph of a 45-year-old man with acromiohumeral distance equal to 7 mm. He is able to actively raise his arm above shoulder level, has lateral arm pain, and abduction and external rotation weakness.

Initial treatment of thoracic outlet syndrome is non-operative. Aggravating activities are modified and shoulder girdle strengthening is initiated. Surgery is considered for patients who have failed conservative therapy and suffer intractable pain, and for those who have significant neurologic or vascular deficits. Operative procedures must be tailored to the presumed pathological anatomy; there is no single best procedure.

Loss of external rotation following stabilization procedures can result in progressive degenerative joint disease. A tight anterior capsule results in posterior humeral translation and progressive posterior glenoid wear. Patients with early degenerative joint disease and pain can be treated with anterior release to restore more normal glenohumeral biomechanics. This procedure not only improves function but also decreases pain in most patients. Closed manipulation at 15 years after surgery is unlikely to be successful and carries the risk of complications. Acromioplasty, posterior release, and removal of osteophytes do not address the pathology. Arthroscopic releases are favored for intra-articular procedures that have addressed the pathology of instability. Open releases are recommended for nonanatomic extra-articular repairs that include subscapularis tightening procedures.
REFERENCES: MacDonald PB, Hawkins RJ, Fowler PJ, et al: Release of the subscapularis for internal rotation contracture and pain after anterior repair for recurrent anterior dislocation of the shoulder. J Bone Joint Surg Am 1992;74:734-737.
Warner JJ, Allen AA, Marks PH, et al: Arthroscopic release of postoperative capsular contracture of the shoulder. J Bone Joint Surg Am 1997;79:1151-1158.

Measurement of congenital scoliosis has an intraobserver variation of 8°. Measurement accuracy decreases with decreased level of training, increased curve size, and decreased clarity of the endpoints. A coned and centered film would give better detail.

This neuropathic ulcer is stable. There is minimal drainage and no clinical findings to suggest an active infection. C ulture of the ulcer yields multiple nonpathogenic organisms and antibiotic therapy is not indicated. Treatment is initiated with either a total contact cast or a total contact walker boot.

DISCUSSION:
The patient has an acute avulsion fracture of the medial epicondyle, which can occur in response to the valgus load placed on the elbow while throwing. Diagnosis is confirmed by radiograph, with comparison views of the uninjured elbow to evaluate for physeal closure versus injury. In older pitchers, the UCL fails rather than the bone of the medial epicondyle. Advanced imaging may be necessary to confirm the diagnosis of an UCL
injury and/or bony injury.

This patient has no known history of active malignancy. The radiograph shows a lesser trochanteric avulsion fracture (a fracture routinely associated with an underlying neoplasm). The bone scan reveals no other bone lesions. The femur fracture is statistically most likely to occur because of metastatic disease, but, without other evidence of metastasis, a primary bone sarcoma is possible, and biopsy is recommended before surgical fixation. Observation of this fracture, which is pathognomonic for neoplastic disease, is strongly discouraged.
RECOMMENDED READINGS
17. Adams SC, Potter BK, Mahmood Z, Pitcher JD, Temple HT. Consequences and prevention of inadvertent internal fixation of primary osseous sarcomas. Clin Orthop Relat Res. 2009 Feb;467(2):519-25. doi: 10.1007/s11999-008-0546-3. Epub 2008 Oct 21. PubMed PMID: 18937020.
[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/18937020)
18. [Herren C, Weber CD, Pishnamaz M, Dienstknecht T, Kobbe P, Hildebrand F, Pape HC. Fracture of the lesser trochanter as a sign of undiagnosed tumor disease in adults. Eur J Med Res. 2015 Sep 4;20:72. doi: 10.1186/s40001-015-0167-8. PubMed PMID: 26336955. ](http://www.ncbi.nlm.nih.gov/pubmed/26336955)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/26336955)
19. Rouvillain JL, Jawahdou R, Labrada Blanco O, Benchikh-El-Fegoun A, Enkaoua E, Uzel M. Isolated lesser trochanter fracture in adults: an early indicator of tumor infiltration. Orthop Traumatol Surg Res. 2011 Apr;97(2):217-20. doi: 10.1016/j.otsr.2010.11.005. Epub 2011 Feb 26. PubMed PMID:
[21354885/. ](http://www.ncbi.nlm.nih.gov/pubmed/21354885)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/21354885)

A recent systematic review compared silicone replacement, pyrocarbon replacement, and surface replacement arthroplasty for PIP arthritis. Silicone arthroplasty through a volar approach showed the greatest gains in arc of motion and had the lowest rate of revision surgeries. The rates of revision surgeries from low to high for each type of arthroplasty were 6% for silicone volar, 10% for silicone lateral, 11%
Surface replacement arthroplasty through a volar
for silicone dorsal, 18% for surface replacement dorsal, and 37% for surface replacement volar. Revision surgeries include implant replacement (to silicone or maintaining the surface replacement), arthrodesis, explantation, amputation, and other procedures.
approach showed the highest revision rate, the worst gain in arc of motion, and the greatest extension lag. However, substantial pain relief and higher satisfaction still were reported after surface replacement arthroplasty, regardless of the complications.

Medoff described the radiographic teardrop of the distal radius. This radiographic landmark matches the critical volar ulnar corner of the distal radius. A malreduction of the volar ulnar corner of the distal radius in an intra-articular distal radius fracture leads to volar subluxation of the lunate and the rapid development of posttraumatic arthritis at the distal radioulnar and radiolunate joints. Knowledge of the specific shape and appearance of this radiographic landmark helps the surgeon when he or she is critically analyzing postreduction imaging.
The volar portion of the ulnar head may be mistaken for this teardrop sign and should be separately identified as distinct from the distal radius. The radial styloid and Lister tubercle are not part of the volar aspect of the lunate facet.
RECOMMENDED READINGS
1. Medoff RJ. Essential radiographic evaluation for distal radius fractures. Hand Clin. 2005 Aug;21(3):279-88. Review. PubMed PMID: 16039439.
2. Harness NG, Jupiter JB, Orbay JL, Raskin KB, Fernandez DL. Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius. J Bone Joint Surg Am. 2004 Sep;86-A(9):1900-8.

of the mechanism mediating this effect. Whereas all of the above have been postulated as explanations, more recent studies have
demonstrated that nicotine delivered via a transdermal patch significantly enhanced posterior spinal fusion in rabbits. Thus it appears that the effects of smoking on fracture healing are multifactorial and not yet fully understood.

Multiple exostoses is transmitted in an autosomal dominant pattern. This condition is transmitted by both sexes with incomplete penetrance in females. This condition is more common in males.