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

Although pain, pallor, paresthesia, paralysis, and pulselessness are all possible signs and symptoms of compartment syndrome in children with fractures, studies have shown increasing analgesia requirement is more sensitive.
Bae et al reviewed thirty-six cases of compartment syndrome in 33 pediatric patients. Approximately 75% of these patients developed compartment syndrome in the setting of fracture. "They found pain, pallor, paresthesia, paralysis, and pulselessness were relatively unreliable signs and symptoms of compartment syndrome in these children. An increasing analgesia requirement in combination with other clinical signs, was a more sensitive indicator of
compartment syndrome."
Whitesides et al summarizes the diagnosis and treatment of acute compartment syndrome. They emphasize the need for early diagnosis, as "muscles tolerate 4 hours of ischemia well, but by 6 hours the result is uncertain; after 8 hours, the damage is irreversible." They recommend fasciotomy be performed when tissue pressure rises past 20 mm Hg below diastolic pressure.

The patient has patellar tendinitis (jumper’s knee). It is a common overuse condition seen in runners, volleyball players, soccer players, and jumpers but can be seen in any activity in which repeated extension of the knee is required. In the acute setting, the pain is well localized and there is tenderness and sometimes swelling of the tendon. MRI is recommended for evaluating chronic cases and for surgical planning. In the acute phases, ice, rest, and avoidance of the offending activity are recommended. Weakness of the quadriceps and hamstring muscle are thought to contribute to this problem; therefore, stretching and isometric exercise in a limited range of motion are important. Complete rest and intratendinous injections of steroids are detrimental to tendon physiology.
REFERENCES: Stanish WD, Rubinovich RM, Curwin S: Eccentric exercise in chronic tendinitis. Clin Orthop 1986;208:65-68.
Witvrouw E, Bellemans J, Lysens R, Danneels L, Cambier D: Intrinsic risk factors for the development of patellar tendinitis in an athletic population: A two-year prospective study. Am J Sports Med 2001;29:190-195.

Literature from Europe and North America suggests that a patient with acetabular dysplasia whose anteroposterior radiograph shows a center edge angle of Wiberg less than 15° is a good candidate for periacetabular osteotomy

In a retrospective review of 137 patients treated surgically and 153 patients treated nonsurgically for adult scoliosis, Bess and associates found that surgical treatment for patients younger than 50 years of age was driven by increased coronal plane deformity, and surgical treatment for older patients was mandated by pain and disability. They also concluded that age, comorbidities, and sagittal balance did not influence treatment decisions.
RECOMMENDED READINGS
[Bess S, Boachie-Adjei O, Burton D, Cunningham M, Shaffrey C, Shelokov A, Hostin R, Schwab F, Wood K, Akbarnia B; International Spine Study Group. Pain and disability determine treatment modality for older patients with adult scoliosis, while deformity guides treatment for younger patients. Spine (Phila Pa 1976). 2009 Sep 15;34(20):2186-90. PubMed PMID: 19752704.](http://www.ncbi.nlm.nih.gov/pubmed/19752704)[View ](http://www.ncbi.nlm.nih.gov/pubmed/19752704)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19752704)
Anderson DG, Albert T, Tannoury C. Adult scoliosis. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:331-338.

Acute lengthening is done for small defects and, if performed in this patient, may result in severe neurovascular compromise.

- Articular cartilage delamination

This patient has developed a hypertrophic non-union of his left humerus following IM nailing. This will not go on to union without surgical intervention. McKee et al. reviewed 21 cases of humeral nonunion after failed intramedullary humeral nails. Although technically difficult, open reduction internal fixation with plating and bone grafting was more successful in union in 9/9 cases, vs exchanged humeral nailing which was only successful in 4/10 cases. Seven of the nonunions were atrophic, 2 were hypertrophic in the ORIF group. The authors conclude that the extent of humeral bone loss after failure of primary humeral nailing makes open reduction internal fixation with compression and bone grafting the most acceptable method of treating this problem.
It should be noted, however, that the use of bone grafting in the presence of a hypertrophic nonunion is controversial and has not been definitively proven in the literature to increase healing rates.

DISCUSSION: Eccentric strengthening for tendinopathies has proved most helpful in the later stages of rehabilitation. Although the exact mechanism of the effect on eccentric exercises is not known, the most widely accepted theory is that the absence of concentric stretching disrupts the normal lengthing/shorten- ing cycle which may cause shearing in the tendon and injury to the collagen. Isokinetic exercise maintains a constant angular velocity of joint motion. Isotonic exercise maintains a constant force of contraction while isometric contraction develops force without changing the length of the musculotendinous unit.
All three types of these exercises have not been shown to benefit Achilles tendinitis as much as eccentric exercise.
REFERENCES: Jonsson P, Alfredson H, Sunding K, et al: New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: Results of a pilot study. Br J Sports Med
2008;42:746-749.
Maffulli N, Walley G, Say ana MK, et al: Eccentric calf muscle training in athletic patients with Achilles tendinopathy. Disabil Rehabil 2008;30:1677-1684.

Figure 67

The patient has a supple plantigrade foot that would benefit from a drop foot brace to prevent catching of the toes. Tendon transfer should not be considered until the patient has undergone bracing. Achilles tendon lengthening is not necessary because the foot is plantigrade and flexible. Nerve grafting is not indicated because of the length of time the peroneal nerve palsy has been present.
REFERENCES: Dehne R: Congenital and acquired neurologic disorders, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 1, pp 552-553.
Santi MD, Botte MJ: Nerve injury and repair in the foot and ankle. Foot Ankle Int
1996;17:425-439.

The main advantage of multicenter studies - although they are time-consuming, expensive, and often frustrating - is obtaining large numbers of patients in a relatively short time. This is important when examining statistical differences between varying results

34
The process shown in the figures is that of degenerative change adjacent to an anterior cervical discectomy and fusion. The observed rate of degenerative adjacent changes is estimated at 2% to 3% per year following a single-level fusion. These changes are partly related to the natural aging process or degenerative process and can occur regardless of an adjacent fusion, but the influence of a solid adjacent fusion with the increased stress at the next level is thought to be a contributor.
RECOMMENDED READINGS
1. [Rihn JA, Lawrence J, Gates C, Harris E, Hilibrand AS. Adjacent segment disease after cervical spine fusion. Instr Course Lect. 2009;58:747-56. PubMed PMID: 19385583. ](http://www.ncbi.nlm.nih.gov/pubmed/19385583)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19385583)
2. Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman HH. Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg Am. 1999 Apr;81(4):519-28. PubMed PMID: 10225797.
[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/10225797)
CLINICAL SITUATION FOR QUESTIONS 37 THROUGH 39
A 22-year-old woman has had right hip pain for 12 months. Her symptoms have not improved with nonsurgical treatment involving physical therapy and intra-articular injections.

A

B

35
C D E

Patellar tendinopathy is a relatively common condition in athletes for which repetitive jumping is the norm, especially volleyball and basketball athletes. The prevalence has been reported to be up to 32% in professional basketball players. Initial management is nonoperative in nature with eccentric exercises providing the most reliable clinical results. The other selections have not demonstrated consistent longterm results.

True aneurysms contain all arterial layers. As such, they occur following an arterial injury that allows the vessel to gradually dilate. A true aneurysm is more uniform in shape and is characterized by having an endothelial lining. True aneurysms result from repeated blunt trauma or vessel diseases that weaken the wall. A pseudoaneurysm, or false aneurysm, results from an arterial wall penetration. The extravasated hematoma subsequently organizes and then recanalizes. The lumen of this false aneurysm has no endothelial lining. Pseudoaneurysms result from penetrating injuries from external sources or from fractures.
RECOMMENDED READINGS
32. Koman LA, Ruch DS, Smith BP, Smith TL. Vascular disorders. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand Surgery. 4th ed. Philadelphia, PA: Churchill Livingstone; 1999:2286-2287
33. Ho PK, Weiland AJ, McClinton MA, Wilgis EF. Aneurysms of the upper extremity. J Hand Surg Am. 1987 Jan; 12(1):39-46. PubMed PMID: 3805642.

- Distal metatarsal osteotomy with a modified McBride procedure_

The posterior tibial tendon transfer is a commonly performed surgery for correction of cavus foot deformity associated with weakness of the anterior tibial muscle and varying degrees of drop foot deformity. The removal of the force of the posterior tibial tendon adds to the correction of the deformity of the foot by balancing the absent peroneus brevis. Although the extensor hallucis longus can be used as a tendon transfer, it will not be the primary muscle used or sufficient to correct deformity.

OCD is an acquired lesion of the subchondral bone. Patients with OCD initially report nonspecific pain and variable amounts of swelling. Initial radiographs help identify the lesion and establish the status of the physes. An MRI scan is useful for assessing the potential for the lesion to heal with nonsurgical treatment. Nonsurgical treatment is appropriate for small, stable lesions in patients with open physes and focuses on activity restriction for 3 to 9 months. Surgical treatment is necessary for unstable or detached lesions. Stable lesions with intact articular cartilage can be treated with subchondral drilling to stimulate vascular ingrowth, with radiographic healing at an average of 4.4 months. Fixation is indicated for unstable or hinged lesions, and stabilization of the fragment can be achieved using a variety of implants through an arthroscopic or open approach. The fragment should be salvaged and the normal articular _surface restored whenever possible._

- Abnormal femoral head-neck junction offset

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The radiograph reveals an L5-S1 spondylolisthesis secondary to L5 spondylolysis. Patients with isthmic spondylolisthesis have fibrous tissue at the pars interarticularis, which contributes to bilateral L5-S1 foraminal stenosis. This typically results in L5 radiculopathy, which is the exiting nerve root at L5-S1. Lateral recess stenosis and hypertrophic ligamentum flavum are typically seen in degenerative spondylolisthesis.

Although the woman may wish to wear shoes of varying height, there is sufficient plantarflexion occurring through the transverse tarsal joint to permit the wearing of high-heel shoes. Any plantarflexion of the fusion will cause arthritis of the transverse tarsal joint, particularly the talonavicular joint. Dorsiflexion of an ankle arthrodesis is associated with a calcaneus position and heel pain. The ankle should be fused in a similar position for both male and female patients.

Extensive posterior decompression poses a high risk of postoperative increase in kyphosis because of both the patientâs age and pre-existing kyphosis.
Observation would not be a good idea because the risk is already known to be high.
Neither a brace nor an uninstrumented fusion would prevent the deformity from developing. C orpectomy is not indicated because the kyphosis is not focal.
Posterior instrumented fusion at the time of decompression is indicated.

24
The patient has sustained an injury to the musculocutaneous nerve, which is at risk during a coracoid transfer procedure. The terminal branch of this nerve is the lateral antebrachial cutaneous nerve of the forearm. The axillary nerve provides sensation to the lateral arm. The median nerve provides sensation more distally. The radial nerve is not likely to be injured with a coracoid transfer procedure; if it is, the injury would result in numbness near the wrist.in the posterior forearm.

- Reverse total shoulder arthroplasty (rTSA)_

Growth hormone is the most abundant substance produced by the pituitary gland. Growth hormone has a direct anabolic effect by accelerating the incorporation of amino acids into proteins. It is becoming an increasingly popular anabolic steroid substitute; however, it is expensive and difficult to obtain. Androstenedione is an androgen produced by the adrenal glands and gonads. It acts as a potent anabolic steroid and is converted in the liver directly to testosterone with a resultant increase in levels after administration. DHEA is a naturally occurring hormone made by the adrenal cortex. It is converted to androstenedione, which in turn is converted to testosterone. The beneficial and adverse effects of DHEA can be correlated directly with those of testosterone. Nandrolone is also a potent anabolic steroid. It is commonly taken as 19-norandrostenedione and may be more favored because of its potent anabolic effects with less androgenic effects (no conversion to estrogen compounds). Creatine sales have skyrocketed, and it is a popular nutritional supplement. There is an expectation that creatine can increase strength and power performance; however, direct anabolic effects have not been demonstrated. Creatine serves as a substrate for hydrogen ions and contributes to the resynthesis of ATP (adenosine triphosphate) during maximal exercise. By enhancing ATP production and buffering local pH in muscle, there may be improved tolerance of anaerobic activities. Increases in muscle mass may be related to increased perception of improved training ability or an increase in muscle water content.
REFERENCES: Silver M: Use of ergogenic aids by athletes. J Am Acad Orthop Surg 2001;9:61-70.
Blue JG, Lombardo JA: Steroids and steroid-like compounds. Clin Sports Med 1999;18:667-689.

- Calcaneonavicular (CN) coalition

DISCUSSION: Staphylococcus epidermidis is the most common organism found in an infected total hip arthroplasty greater than 3 months from the origional surgery. Staphylococcus aureus is more common in acute postoperative infections, and E. coli is associated with infections of the urinary tract. Streptococcus species are less common.

REFERENCE: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL American Academy of Orthopedic Surgeons, 2006, pp 475-503.

Figure 82

Suprascapular nerve injuries are more commonly seen in athletes who participate in overhead activities. When a patient is evaluated for posterior shoulder pain and infraspinatus muscle weakness or atrophy, electrodiagnostic studies are an essential part of the evaluation. In addition, imaging studies are indicated to exclude other diagnoses that can mimic a suprascapular nerve injury. Initial management should consist of cessation of the aggravating activity along with an organized shoulder rehabilitation program. If nonsurgical management fails to provide relief within 6 months to 1 year, surgical exploration of the suprascapular nerve should be considered. Release of the spinoglenoid ligament with resultant suprascapular nerve decompression may result in pain relief and a return of normal shoulder function. In this patient, who has a chronic neuropathy and mild symptoms, surgery is indicated only if nonsurgical management fails to provide relief and he is unable to perform at his position.
REFERENCES: Cummins CA, Bowen M, Anderson K, et al: Suprascapular nerve entrapment at the spinoglenoid notch in a professional baseball pitcher. Am J Sports Med 1999;27:810-812.
Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment. J Bone Joint Surg Am 2000;82:415-424.
Ferretti A, De Carli A, Fontana M: Injury of the suprascapular nerve at the spinoglenoid notch: The natural history of infraspinatus atrophy in volleyball players. Am J Sports Med 1998;26:759-763.

The plain radiographs show a destructive lesion in the wrist in the distal radius and at the scaphotrapezial joint. The joint spaces are preserved. The histology shows the features of gout: acellular amorphous tissue, macrophages, and giant cells.
Gout is caused by the deposition of monosodium urate crystals in tissues typically around joints. Common locations include the great toe, heel, ankle, and knee. In approximately 50% of patients, the first attack is in the great toe. Gout commonly occurs inside a joint for two reasons:
The synovial fluid is a poorer solvent than plasma
Lower temperatures (as in peripheral joints) favor crystallization
Neutrophils ingest the crystals and then release potent lysosomal enzymes. Histologically, the tophi have several features: Acellular amorphous material
Macrophages
Foreign body giant cells
The first line of treatment is nonsteroidal anti-inflammatory medications. Correct Answer: Nonsteroidal anti-inflammatory medications

■
Skeletally immature patients with stable osteochondritis dissecans lesions of the knee have a very high healing rate with conservative treatment, which consists of strict non–weightbearing with or without immobilization. Healing rates are significantly lower for patients treated with unloader bracing who are allowed to continue normal activity. Physical therapy may be required later, but is not an appropriate initial treatment. Because the healing rate with conservative treatment is so high for lesions around the knee, this should be tried for several months before recommending surgical treatment.

During surgical repair of a distal biceps tendon rupture, regardless of the surgical approach or technique, an understanding of the regional anatomy is important. The tendon passes distally into the antecubital fossa. The antecubital fossa is defined by the brachioradialis radially and the pronator teres ulnarly. A sheath surrounds the biceps tendon as it passes through the antecubital fossa toward its insertion on the radial tuberosity. The lateral antebrachial cutaneous nerve lies superficially in the subcutaneous tissue of the antecubital fossa. The nerve parallels the brachioradialis. While still superficial, the tendon is contiguous with the lacertus fibrosus that becomes confluent medially with the fascia overlying the flexor-pronator mass. The brachial artery lies just beneath the lacertus fibrosus at the level of the elbow flexion crease. The tendon travels just lateral (radial) to the median nerve within the antecubital fossa and passes posterior (deep) to the recurrent radial artery before it attaches to the radial tuberosity. Full forearm supination allows visualization of the tendinous insertion on the radial tuberosity.
RECOMMENDED READINGS
23. Leslie BM, Ranger H. Biceps tendon and triceps tendon ruptures. In: Baker CL, Plancher KD, eds. _Operative treatment of elbow injuries_. New York: Springer-Verlag; 2002:110-122.
24. [Eames MH, Bain GI, Fogg QA, van Riet RP. Distal biceps tendon anatomy: a cadaveric study. J Bone Joint Surg Am. 2007 May;89(5):1044-9. PubMed PMID: 17473142. ](http://www.ncbi.nlm.nih.gov/pubmed/17473142)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/17473142)

C onservative therapy is predicted to bring a good result because biceps are returning at four months of age. However, stretching of the shoulder is indicated to maintain a range of external rotation and abduction.
Magnetic resonance imaging is only indicated if there is a need to consider microvascular repair.
Tendon transfers are performed later (at several years of age), if shoulder abduction and external rotation are significantly limited.
Microvascular repair is mainly considered in patients who do not have return of biceps function by five months.
Open reduction is indicated later (if the shoulder joint is subluxated or severely contracted) after motor recovery has reached a plateau.

Any of the above structures may be involved in a lateral patellar dislocation. However, biomechanic studies have found that the medial patellofemoral ligament is the major soft-tissue static restraint of lateral patellar displacement, providing at least 50% of this function.
REFERENCES: Desio SM, Burks RT, Bachus KN: Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med 1998;26:59-65.
Conlan T, Garth WP Jr, Lemons JE: Evaluation of the medial soft-tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg Am 1993;75:682-693.
Warren LF, Marshall JL: The supporting structures and layers on the medial compartment of the knee: An anatomical analysis. J Bone Joint Surg Am 1979;61:56-62.

DISCUSSION: The MRI scans reveal increased signal in the medial facet of the patella and the anterior aspect of the lateral femoral condyle. This pattern is typically seen in patients with acute patellar dislocations. In patients with ACL tears, the bone bruise of the lateral femoral condyle is usually seen in the central portion at the sulcus terminalis and the posterior half of the lateral tibial plateau and is not usually seen in the patella. This pattern of bone bruising is not seen with patellar tendon ruptures, LCL tears, and PCL tears.
REFERENCES: Elias DA, White LM, Fithian DA: Acute lateral patellar dislocation at MR imaging: Injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella. Radiology 2002;225:736-743.
Virolainen H, Visuri T, Kuusela T: Acute dislocation of the patella: MR findings. Radiology 1993;189:243-246.

This patient's history and physical findings are concerning for deep infection. Inflammatory markers, including ESR and CRP, should be obtained first. If the levels are elevated, knee aspiration should be performed for the synovial cell count and culture. A bone scan is not indicated in an initial investigation for deep infection; it is rarely helpful and is not cost effective. CT to assess implant rotation is an appropriate investigation for knee pain when the clinical scenario is not suspicious for a deep infection
and when infection has been excluded.

The patient has sustained a traumatic spondylolisthesis at the level below the caudal instrumented level, likely not appreciated at the index surgery. Surveillance radiographs indicate that there is significant translation in the lumbar spine on sitting, indicating an unstable injury. The lack of significant bony involvement indicates that the injury is predominantly through the anterior and posterior ligamentous complexes, and thus is unlikely to stabilize with nonsurgical management. Because the patient reduces almost completely on lying supine, the most appropriate course of action is extension of the posterior fusion to include the level of the instability. Because the patient has a complete spinal cord injury below the level of the thoracic fracture, decompression is not indicated.

This patient has a clear history of dorsiflexion injury complicated by chronic peroneal tendon dislocation. The symptoms and findings are consistent with dislocation in this particular case. Groove deepening of the posterior fibula with associated imbrication of the peroneal retinaculum is the most effective surgical procedure. Associated synovitis or tendonosis should be addressed. However, failure to deepen the groove and imbricate the retinaculum will result in continued discomfort. Consequently, both responses that involve isolated tendon surgery are not appropriate. Associated subjective instability can be noted in these patients. The examination is critical to determine the stability of the lateral collateral complex, which is intact in this case (so
imbrication is not indicated). A sense of apprehension is a common examination finding because patients sense that the peroneals will subluxate with resisted eversion. Placement of the examiner's hands on the peroneals to stabilize the tendons should relieve this apprehension. A patient may not be able to voluntarily dislocate the tendon. Dynamic ultrasound is the most sensitive radiographic examination for detection of dislocation. Intrasheath peroneal subluxation may also occur and is treated similarly.
RECOMMENDED READINGS
Raikin SM. Intrasheath subluxation of the peroneal tendons. Surgical technique. J Bone Joint Surg Am. 2009 Mar 1;91 Suppl 2 Pt 1:146-55. doi: 10.2106/JBJS.H.01356. PubMed PMID:
[19255207.](http://www.ncbi.nlm.nih.gov/pubmed/19255207)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19255207)
[Philbin TM, Landis GS, Smith B. Peroneal tendon injuries. J Am Acad Orthop Surg. 2009 May;17(5):306-17. Review. PubMed PMID: 19411642. ](http://www.ncbi.nlm.nih.gov/pubmed/19411642)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/19411642)
[Ogawa BK, Thordarson DB. Current concepts review: peroneal tendon subluxation and dislocation. Foot Ankle Int. 2007 Sep;28(9):1034-40. Review. PubMed PMID: 17880883. ](http://www.ncbi.nlm.nih.gov/pubmed/17880883)[View](http://www.ncbi.nlm.nih.gov/pubmed/17880883)[ ](http://www.ncbi.nlm.nih.gov/pubmed/17880883)[Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/17880883)
This is the last question of the exam.

Elbow flexion is central to management of brachial plexus management because it serves the most important function of feeding.

The os trigonum presented in the radiograph may be the cause of posterior ankle impingement. The flexor hallucis longus lies immediately medial to the os and must be protected during excision of this bone.

Neutral abduction is important in preventing back pain.
The flexion should be between 25° and 35°.
Any abduction beyond neutral poses increases risk of back pain. External rotation beyond approximately 5° is not needed.
Arthrodesis often produces some mandatory shortening; therefore, intentional shortening is not needed.

DISCUSSION: The patient has typical adolescent idiopathic scoliosis with a right thoracic curve. This represents a Lenke-IB curve pattern; therefore, only treatment of the thoracic curve is required. The proximal thoracic and thoracolumbar curves are very flexible. The patient is Risser 1 and has just started her menstrual cycles; therefore, she is at significant risk for further curve progression. Bracing is not appropriate for a curve of this magnitude and will not halt the progression of this curve, nor will vertebral body stapling stop this curve. Vertebral body stapling is sometimes useful in small thoracic curves of less than 35 degrees and skeletally immature patients. Anterior and

**14 • American Academy of Orthopaedic Surgeons**

posterior spinal fusion is not required because the patient has no other risk factors, such as neurofibromatosis nor is she at risk for crankshaft. Anterior fusion is an option, but it is not listed.

REFERENCES: Lenke LG, Betz RR, Harmes J, et al: Adolescent idiopathic scoliosis: Anew classification to determine extent of spinal arthrodesis. J Bone Joint Surg Am 2001;83:1169-1181.
Lenke LG, Betz RR, Haher TR, et al: Multisurgeon assessment of surgical decision making in adolescent idiopathic scoliosis: Curve classification, operative approach, and fusion levels. Spine 2001;26:2347- 2353.

This patient has a fracture dislocation through the body of C6. Because the spine is ankylosed, it is rigid and prone to injury even in the setting of low-energy incidents. This patient has ankylosing spondylitis because the anterior longitudinal ligament is ossified. Ankylosing spondylosis is a seronegative spondyloarthropathy with sacroiliac joint involvement most commonly. It has a male predilection of 3:1. In the spine, it is characterized by diffuse syndesmotic ankylosis resulting in a “bamboo spine.”
This patient also has degenerative changes found at C3-4, C4-5, but the ankylosing of the spine is the main reason for the higher fracture risk. DISH (Forestier disease) is a noninflammatory
spondyloarthropathy characterized by flowing ossifications and bone proliferations at sites of tendinous and ligamentous insertion.
RECOMMENDED READINGS
7. [El Tecle NE, Abode-Iyamah KO, Hitchon PW, Dahdaleh NS. Management of spinal fractures in patients with ankylosing spondylitis. Clin Neurol Neurosurg. 2015 Dec;139:177-82. doi: 10.1016/j.clineuro.2015.10.014. Epub 2015 Oct 23. Review. PubMed PMID: 26513429. ](http://www.ncbi.nlm.nih.gov/pubmed/26513429)[View Abstract](http://www.ncbi.nlm.nih.gov/pubmed/26513429)[ ](http://www.ncbi.nlm.nih.gov/pubmed/26513429)[at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/26513429)
8. [Lukasiewicz AM, Bohl DD, Varthi AG, Basques BA, Webb ML, Samuel AM, Grauer JN. Spinal Fracture in Patients With Ankylosing Spondylitis: Cohort Definition, Distribution of Injuries, and Hospital Outcomes. Spine (Phila Pa 1976). 2016 Feb;41(3):191-6. doi: 10.1097/BRS.0000000000001190. PubMed PMID: 26579959. ](http://www.ncbi.nlm.nih.gov/pubmed/26579959)[View Abstract at PubMed](http://www.ncbi.nlm.nih.gov/pubmed/26579959)

The radiographs show the osteophytic build-up of the posteromedial corner of the elbow that occurs with valgus extension overload in the pitching elbow. This is the result of excessive valgus forces during the acceleration and deceleration phases of throwing. These forces, coupled with medial elbow stresses, cause a wedging of the olecranon into the medial wall of the olecranon fossa. Valgus instability of the elbow may further stimulate osteophyte formation. Repetitive impact of a spur within the olecranon fossa may cause fragmentation and eventual formation of loose bodies.
REFERENCES: Azar FM, Wilk KE: Nonoperative treatment of the elbow in throwers. Oper Tech Sports Med 1996;4:91-99.
Field LD, Savoie FJ: Common elbow injuries in sport. Sports Med 1988;26:193-205.
Wilson FD, Andrews JR, Blackburn TA, et al: Valgus extension overload in the pitching elbow. Am J Sports Med 1983;11:83-88.

Distal radial fractures in children are common, and a large amount of displacement is acceptable. In general, 20° of dorsal displacement and complete bayonet apposition in girls to age 12 years and in boys to age 14 years can be expected to remodel with an excellent outcome. The potential for increased fracture displacement and subsequent malunion may exist in up to one third of patients with displaced fractures with less than anatomic reduction. Therefore, early follow-up is recommended and remanipulation is indicated should loss in reduction occur. Consideration for percutaneous pinning of isolated distal radial fracture is reasonable in patients with little growth remaining. In these patients, higher rates of redisplacement exist with little chance for remodeling.
REFERENCES: Gibbons CL, Woods DA, Pailthorpe C, et al: The management of isolated distal radius fractures in children. J Pediatr Orthop 1994;14:207-210.
McLauchlan GJ, Cowan B, Annan IH, et al: Management of completely displaced metaphyseal fractures of the distal radius in children. J Bone Joint Surg Br 2002;84:413-417.
Proctor MT, Moore DJ, Patterson JH: Redisplacement after manipulation of distal radial fractures in children. J Bone Joint Surg Br 1993;75:453-454.
Roy DR: Completely displaced distal radius fractures with intact ulnas in children. Orthopedics 1989;12:1089-1092.

■
Development of proximal tibial valgus is an uncommon, but well-documented, complication of proximal tibial metaphyseal fractures in children. There are multiple theories as to the origin, but the exact etiolgy is unknown. Management with a guide-growth procedure is rarely required, because most patients ultimately achieve spontaneous correction.

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.

**
Although a recent push for prospective, randomized trials has been advocated by multiple orthopaedic journals, many studies published continue to be of Level 4 evidence (retrospective case series). Case series represented 64% of all studies reviewed by Freedman and associates in 2001 from the British and American volumes of Journal of Bone and Joint Surgery and from Clinical Orthopaedics and Related Research.
Obremskey and associates published that
58.1% of all studies from nine orthopaedic journals were Level 4 evidence. Further investigation of more current trends is likely warranted with the
current emphasis on publishing higher level-of-evidence studies in orthopaedic journals.

When the arm is adducted, the superior structures, including the superior glenohumeral ligament, are responsible in limiting the inferior translation. With the arm abducted, the inferior glenohumeral ligament complex is responsible for limiting inferior subluxation. Rotator cuff activity can actually depress the humeral head and does not play a role in preventing inferior subluxation. The long head of the biceps and the posterior glenohumeral ligament do not play a role in protecting the shoulder from inferior instability.
REFERENCES: Warner JJ, Deng XH, Warren RF, Torzilli PA: Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 1992;20:675-685.
Harryman DT II, Sidles JA, Harris SL, Matsen FA III: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66.

Although radiofrequency devices and lasers differ fundamentally in the way they generate heat within a tissue, both classes of devices are capable of producing temperatures within the critical temperature range (65 to 75 degrees C) for collagen denaturation and subsequent tissue shrinkage. When it comes to cell viability and tissue response, heat is heat. Once critical temperatures are reached, cells will die at 45 degrees C, collagen will become denatured at 60 degrees C, and tissue ablation will occur at 100 degrees C no matter what the source of thermal energy. Therefore, claims of a better or different type of heat have little bearing on the biologic response of the tissue. Histologic, ultrastructural, and biomaterial alterations induced by laser and radiofrequency energy have been shown to be similar.
REFERENCES: Arnoczky SP, Aksan A: Thermal modification of connective tissues: Basic science considerations and clinical implications. J Am Acad Orthop Surg 2000;8:305-313.
Hayashi K, Markel MD: Thermal modification of joint capsule and ligamentous tissues: The use of thermal energy in sports medicine. Operative Techniques Sports Med 1998;6:120-125.
Naseef GS III, Foster TE, Trauner K, et al: The thermal properties of bovine joint capsule: The basic science of laser- and radiofrequency-induced capsular shrinkage. Am J Sports Med 1997;25:670-674.

The patient has a posterior dislocation. The radiograph reveals marked internal rotation, but fails to show whether the humeral head is posteriorly displaced. Therefore, an axillary radiograph should be obtained to help confirm the diagnosis. Transverse view CT or MRI scans also may be useful. The other studies will not help confirm the diagnosis. In addition to a direct posterior blow, a shoulder dislocation may be caused by a seizure disorder or electrocution.
REFERENCES: Bloom MH, Obata WG: Diagnosis of posterior dislocation of the shoulder with the use of Velpeau axillary and angle-up roentgenographic views. J Bone Joint Surg Am 1967;49:943-949.
Rockwood CA: Subluxations and dislocations about the shoulder, in Rockwood CA, Green DP (eds): Fractures in Adults, ed 2. Philadelphia, PA, JB Lippincott, 1984, vol 1, pp 806-856.