Surgery_Schwartz

Surgery_Schwartz. of the elbow are common and typically occur posteriorly after a fall on an outstretched hand. A dislocation results in injury to the joint capsule and rupture of the lateral collateral ligament, with possible involvement of the medial collateral ligament, as well as possible fractures of the radial head and coronoid. This combination of injuries is called the “terrible triad,” which is a challenging injury and carries the Figure 43-8. A. Posterior shoulder dislocation showing limitation of external rotation. B. Axillary view sowing posterior dislocation of the shoulder.Figure 43-9. Four-part proximal humeral head fracture.Figure 43-10. Radial nerve palsy due to humeral shaft fracture causing wrist drop.Brunicardi_Ch43_p1879-p1924.indd 188522/02/19 10:40 AM 1886SPECIFIC CONSIDERATIONSPART IIworst prognosis. Simple elbow dislocations should be urgently reduced with the patient under sedation and treated with a short period of immobilization, utilizing a posterior splint. Stiffness


Surgery_Schwartz

Surgery_Schwartz. prognosis. Simple elbow dislocations should be urgently reduced with the patient under sedation and treated with a short period of immobilization, utilizing a posterior splint. Stiffness of the elbow is a common complication following elbow dislocations and therefore only short-term immobiliza-tion (about 7–10 days) followed by early range of motion is recommended.Dislocations associated with fractures may be treated sur-gically if there is any instability of the elbow joint. The “terrible triad” is an unstable injury comprising of an elbow disloca-tion as well as fractures to the radial head and coronoid, which requires surgery. Surgery includes repair of the torn lateral col-lateral ligament, fixation or replacement of the radial head, and possible fixation of the coronoid, depending on the size of this fracture fragment.Radial Head FracturesMost fractures of the radial head can be treated nonoperatively, simply with a sling for 1 to 2 days followed by motion exercises. Surgery is


Surgery_Schwartz

Surgery_Schwartz. the size of this fracture fragment.Radial Head FracturesMost fractures of the radial head can be treated nonoperatively, simply with a sling for 1 to 2 days followed by motion exercises. Surgery is recommended if there is a displaced fracture, if the fracture blocks pronation or supination of the forearm, if there is an associated dislocation of the elbow, or if the patient has associated wrist pain (Essex-Lopresti fracture). Surgery can be fixation or replacement. If the fracture can be well reduced, it is fixed with 1 or 2 screws. If the radial head is fractured into multiple pieces, the treatment of choice is a radial head replace-ment with a metallic implant. Simple excision of the radial head can also be performed in low demand patients with an isolated radial head fracture; otherwise, it may lead to instability of the elbow and the wrist over time.Olecranon FracturesOlecranon fractures usually occur following a fall directly onto a flexed elbow (Fig. 43-11). Nondisplaced


Surgery_Schwartz

Surgery_Schwartz. it may lead to instability of the elbow and the wrist over time.Olecranon FracturesOlecranon fractures usually occur following a fall directly onto a flexed elbow (Fig. 43-11). Nondisplaced fractures are treated with a splint in 45° to 90° of flexion for a short time followed by range of motion exercises to prevent stiffness. Because the triceps inserts on the olecranon, the pull of the muscle often causes active extension of the elbow and displacement of the fracture, and therefore the olecranon fracture should be fixed surgically. Simple transverse fractures can be fixed with a tension band construct, which consists of wire passing through the ulna, distal to the fracture, and wrapped in a figure-of-8 fashion around two or more pins placed proximally into the olecranon, crossing and stabilizing the fracture. This tension band construct creates a compressive force across the articular aspect of the fracture that will promote healing. Fractures that are comminuted or have large


Surgery_Schwartz

Surgery_Schwartz. stabilizing the fracture. This tension band construct creates a compressive force across the articular aspect of the fracture that will promote healing. Fractures that are comminuted or have large fragments are usually treated with plate and screw fixation. Excision of the olecranon with advancement of the triceps can be done in elderly patients when the fracture involves less than 50% of the joint surface. Because of the subcutaneous location of the olecranon, symp-tomatic hardware is a frequent complication, causing irritation to the patient; it may need to be removed after the fracture has healed. Stiffness of the elbow is another complication seen in a large number of patients.Forearm FracturesForearm fractures are common injuries that result from high-energy trauma or from falls onto an outstretched arm. Both bone forearm fractures generally require surgery with plate and screw fixation. The radius has a bow and rotates around the straight ulna for proper pronation and supination


Surgery_Schwartz

Surgery_Schwartz. an outstretched arm. Both bone forearm fractures generally require surgery with plate and screw fixation. The radius has a bow and rotates around the straight ulna for proper pronation and supination of the forearm, and therefore this anatomic relationship needs to be restored to maintain function. An isolated fracture of the ulna shaft, or a “nightstick fracture,” occurs from a direct blow to the side of the forearm. These can usually be treated in a cast, splint, or brace. Fractures that are angulated or displaced can be treated with open reduction and plate fixation. A Monteggia fracture is a fracture of the proximal third of the ulna associated with a radial head dislocation. The radial head dislocation may be missed. Careful evaluation of the radiograph, especially the relation-ship with the radial head to the capitellum is necessary for the diagnosis of this injury. These fractures are common in children and rare in adults. These injuries require surgery to fix the ulna fracture


Surgery_Schwartz

Surgery_Schwartz. the radial head to the capitellum is necessary for the diagnosis of this injury. These fractures are common in children and rare in adults. These injuries require surgery to fix the ulna fracture with plate and screw fixation and to reduce the radial head dislocation. A Galeazzi fracture is a fracture of the distal third radial shaft associated with distal radioulnar joint (DRUJ) injury at the wrist. If the fracture of the radius is less than 7.5 cm from the joint, the distal radioulnar joint is injured in a large number of cases. After the radius is fixed with plate and screw fixation, the DRUJ is assessed for stability and may need wires placed across the joint temporarily.Distal Radius FracturesDistal radius fractures commonly occur in older patients due to a fall or osteoporosis. In younger patients, these fractures usu-ally occur due to high-energy trauma. A Colles fracture is a low energy fracture that is extra-articular and usually dorsally displaced. It has a characteristic


Surgery_Schwartz

Surgery_Schwartz. younger patients, these fractures usu-ally occur due to high-energy trauma. A Colles fracture is a low energy fracture that is extra-articular and usually dorsally displaced. It has a characteristic appearance of a fork, naming the fracture the “dinner-fork” deformity. A Smith’s fracture is a reverse Colles fracture, usually extra-articular and volarly displaced. A Chauffer’s fracture involves the radial styloid process and may cause occult carpal disruption. A Barton’s fracture can be either volar or dorsal. It is a fracture dislocation of the radiocarpal joint, with an intra-articular volar or dorsal fracture.Every attempt should be made to rule out fractures that extend intra-articularly into the wrist joint or involve the DRUJ. Patients should be evaluated for a median nerve injury and osteoporosis if suspected. Loss of thumb extension from extensor pollicus longus tendon rupture can occur especially in nondisplaced distal radius fractures. Treatment is often a closed Figure


Surgery_Schwartz

Surgery_Schwartz. and osteoporosis if suspected. Loss of thumb extension from extensor pollicus longus tendon rupture can occur especially in nondisplaced distal radius fractures. Treatment is often a closed Figure 43-11. Displaced olecranon fracture.Brunicardi_Ch43_p1879-p1924.indd 188622/02/19 10:40 AM 1887ORTHOPEDIC SURGERYCHAPTER 43reduction and immobilization. Surgery utilizing a variety of sur-gical techniques is done for unstable fractures as well as those with significant intra-articular involvement.Scaphoid FracturesScaphoid fracture is the most common fracture of the carpal bone. Its diagnosis can be easily missed, and the fracture can lead to nonunion and avascular necrosis. It usually occurs in the waist of the scaphoid but can occur in the proximal or distal pole. Proximal scaphoid fracture will have a higher inci-dence of avascular necrosis due to interruption of the retro-grade blood supply. Tenderness in the anatomic snuffbox after trauma should be considered a scaphoid fracture


Surgery_Schwartz

Surgery_Schwartz. will have a higher inci-dence of avascular necrosis due to interruption of the retro-grade blood supply. Tenderness in the anatomic snuffbox after trauma should be considered a scaphoid fracture until proven otherwise. Magnetic resonance imaging (MRI) will be help-ful in early diagnosis if no fracture is visible on an X-ray. A thumb spica cast is used for stable nondisplaced fracture, while reduction and screw fixation of the fracture is usually done for displaced fractures. The dorsal approach is used for proximal fractures, and the volar approach is used for the majority of other fractures.Pelvic FracturesPelvic fractures are indicative of high-energy trauma and are associated with head, chest, abdominal, and urogenital injuries. Hemorrhage from pelvic trauma can be life-threatening and patients can present with hemodynamic instability, requiring significant fluid resuscitation and blood transfusions. The bleed-ing that occurs is often due to injury to the venous plexus in the


Surgery_Schwartz

Surgery_Schwartz. and patients can present with hemodynamic instability, requiring significant fluid resuscitation and blood transfusions. The bleed-ing that occurs is often due to injury to the venous plexus in the posterior pelvis or from the fracture itself. It can also be due to a large vessel injury such as the superior gluteal artery at the greater sciatic notch. Immediate resuscitation with fluids and blood is critical. In hemodynamically unstable patients, blood, fresh frozen plasma, and platelets are given in a 1:1:1 ratio. These patients may require surgical exploration or interven-tional radiology embolization to stop the bleeding. An important first-line treatment in the emergency department is the application of a pelvic binder or sheet that is wrapped tightly around the pelvis to help control bleeding. This is important when there is an increase in the volume of the pelvis by the anteroposterior compression mechanism (an open book mechanism). The pelvic binder is clearly the initial


Surgery_Schwartz

Surgery_Schwartz. bleeding. This is important when there is an increase in the volume of the pelvis by the anteroposterior compression mechanism (an open book mechanism). The pelvic binder is clearly the initial management of an unstable open book fracture of the pelvis with bleeding. Traction pins may be applied in the emergency department if there is vertical migration of the hemipelvis. An external fixator may also be placed in the operating room, but it is less fre-quently used. Other associated injuries are bladder and urethral injuries that manifest with bleeding from the urethral meatus or blood in the urinary catheter, and these need to be assessed with a retrograde urethrogram.The pelvis is a ring structure made up of the sacrum and the two innominate bones that are held together by strong liga-ments. Because it is a ring, displacement can only occur if the ring is disrupted in two places. This may occur either from frac-tures of the bones or tears of the ligaments that can cause dis-location.


Surgery_Schwartz

Surgery_Schwartz. Because it is a ring, displacement can only occur if the ring is disrupted in two places. This may occur either from frac-tures of the bones or tears of the ligaments that can cause dis-location. When you see an anterior fracture of the ring, check for a posterior injury (Fig. 43-12). There are three main fracture patterns that occur from trauma to the pelvis. An anteroposterior force to the pelvis causes an “open book” injury pattern in which the pelvis springs open, hinged on the intact posterior ligaments with widening of the pubic symphysis. A lateral compression pattern results from a crush injury that causes fractures to the ilium, sacrum, and pubic rami. Vertical shear injuries are very unstable since they result from disruption of the strong posterior pelvic ligaments and are associated with significant blood loss and visceral injuries. Fractures of the sacrum may be difficult to see on X-ray, and therefore CT scans are often needed to completely visualize the fracture


Surgery_Schwartz

Surgery_Schwartz. associated with significant blood loss and visceral injuries. Fractures of the sacrum may be difficult to see on X-ray, and therefore CT scans are often needed to completely visualize the fracture pattern. The sacral nerves pass through foramen in the sacrum, and therefore fractures that are close to the foramen can result in nerve injuries. Fractures that involve the sacral canal have a high incidence of nerve injuries and cauda equina syndrome. Fractures that involve the ala of the sacrum may involve the L5 nerve root. Vertical fractures of the 7ABFigure 43-12. A. Pelvic fracture showing anterior and posterior disruption of the pelvis. B. Image depicting a vertical shear fracture with cephalad migration of the hemi-pelvis.Brunicardi_Ch43_p1879-p1924.indd 188722/02/19 10:40 AM 1888SPECIFIC CONSIDERATIONSPART IIsacrum can be highly unstable even after fixation and may be associated with sacral nerve root injuries.Treatment of pelvic fractures depends on the fracture pat-tern.


Surgery_Schwartz

Surgery_Schwartz. CONSIDERATIONSPART IIsacrum can be highly unstable even after fixation and may be associated with sacral nerve root injuries.Treatment of pelvic fractures depends on the fracture pat-tern. Stable, minimally displaced fractures such as many lower energy lateral compression fractures can be treated nonopera-tively with protected weight-bearing. Open book injuries in which the pubic symphysis is widened more than 2.5 cm may require an anterior plate, and if the posterior pelvic ligaments are also injured, the patient will need posterior fixation. Pos-terior stabilization is typically performed with screws placed percutaneously through the ilium into the sacrum to stabilize the pelvis posteriorly, and a plate is applied over the pubic symphy-sis for anterior stabilization. Displaced sacral fractures and iliac wing fractures are treated with screws or plates, while pubic rami fractures can usually be managed nonoperatively. While most pelvic fractures are caused by high-energy trauma,


Surgery_Schwartz

Surgery_Schwartz. fractures and iliac wing fractures are treated with screws or plates, while pubic rami fractures can usually be managed nonoperatively. While most pelvic fractures are caused by high-energy trauma, elderly patients with osteoporotic bone can also suffer pelvic fractures after a fall, usually fracturing the pubic rami. Since these are stable injuries, they can be managed nonoperatively with pro-tected weight-bearing.Acetabular FracturesThe acetabulum forms the socket of the hip joint, and fractures occur when the femoral head is driven into the acetabulum in the setting of high-energy trauma. Sciatic nerve function should be examined carefully after an acetabulum fracture. It is impor-tant to rule out dislocation of the hip, which should be reduced immediately to prevent avascular necrosis of the femoral head. Usually 45° oblique views, called Judet views, are utilized. CT scans are very important to visualize the fracture pattern. According to Judet and Letournel, there are ten


Surgery_Schwartz

Surgery_Schwartz. of the femoral head. Usually 45° oblique views, called Judet views, are utilized. CT scans are very important to visualize the fracture pattern. According to Judet and Letournel, there are ten acetabular fracture patterns: five simple and five complex fracture types (Fig. 43-13). These fractures often require surgery in order to obtain anatomic reduction and to minimize the development of degenerative arthritis.Hip DislocationsHip dislocations almost always result from high-energy trauma; they most commonly occur posteriorly and less commonly ante-riorly (Fig. 43-14). They can cause injury to the sciatic nerve, which runs directly posterior to the hip joint. Examine the patient for foot drop and numbness at the top of the foot. Hip dislocation can be simple, or it may be associated with a fracture of the acetabulum or femoral head. Hip dislocations need to be emergently reduced because of the risk of osteonecrosis of the femoral head if the reduction is delayed. Closed reduction is


Surgery_Schwartz

Surgery_Schwartz. a fracture of the acetabulum or femoral head. Hip dislocations need to be emergently reduced because of the risk of osteonecrosis of the femoral head if the reduction is delayed. Closed reduction is usually successful with adequate sedation or under general anes-thesia. Once reduction is done, a CT scan is ordered to define the extent of the injury. A CT scan will show associated frac-tures, trapped intraarticular fracture fragments, and the congru-ity of the reduction. If the reduction is unsuccessful, or if there is a fracture fragment inside the joint, then an open reduction is indicated. Hip dislocations that are associated with a femoral head fracture are at increased risk for osteonecrosis of the femo-ral head and posttraumatic osteoarthritis. The femoral head frac-ture associated with hip dislocation is called a Pipkin fracture. If the dislocation is associated with posterior wall fractures, the stability of the hip joint should be assessed carefully, even if the fragment is


Surgery_Schwartz

Surgery_Schwartz. with hip dislocation is called a Pipkin fracture. If the dislocation is associated with posterior wall fractures, the stability of the hip joint should be assessed carefully, even if the fragment is small. This is usually done by an examination of the patient under anesthesia.Hip FracturesHip fractures are an extremely common injury seen in orthope-dics and are associated with significant morbidity and mortal-ity. They most often occur in elderly patients after ground level falls, are much more common in women than men, and occur more commonly in patients with osteoporosis. The three most common fractures in the elderly are those of the wrist, spine, and hip. Patients who suffer hip fractures are at increased risk for many complications, including deep vein thrombosis, pul-monary embolism, pneumonia, deconditioning, pressure sores, and even death. The mortality rate in the first year following a hip fracture is around 25%. One of the most important rea-sons for performing surgery is


Surgery_Schwartz

Surgery_Schwartz. pneumonia, deconditioning, pressure sores, and even death. The mortality rate in the first year following a hip fracture is around 25%. One of the most important rea-sons for performing surgery is to prevent these complications because getting patients out of bed and walking as soon as pos-sible diminishes their risk for many of these adverse events. Performing early surgery also decreases the complications in these patients. Therefore, surgery is almost always the treat-ment of choice for hip fractures. The type of surgery performed is determined by the anatomic location of the fracture and the fracture pattern. Surgery should be performed as soon as pos-sible, typically within 24 to 48 hours; however, since many of these patients suffer other comorbidities, they must be properly medically optimized before surgery. The goals of surgery are to minimize pain, restore hip function, and allow early mobi-lization, the importance of which cannot be overemphasized. The functional outcome


Surgery_Schwartz

Surgery_Schwartz. optimized before surgery. The goals of surgery are to minimize pain, restore hip function, and allow early mobi-lization, the importance of which cannot be overemphasized. The functional outcome for patients following a hip fracture is largely based on their level of mobility and independence Figure 43-13. Types of acetabular fractures.Figure 43-14. Posterior and anterior dislocation.Brunicardi_Ch43_p1879-p1924.indd 188822/02/19 10:40 AM 1889ORTHOPEDIC SURGERYCHAPTER 43before their injury. Many patients become less independent, may require assistive devices to help them walk, and some may require a long-term nursing or rehabilitation facility. Hip frac-tures can be femoral neck fractures, intertrochanteric fractures, or subtrochanteric fractures (Fig. 43-15).Femoral Neck Fractures. Femoral neck fractures occur within the capsule of the hip joint. The main blood supply to the femo-ral neck and head comes from the deep branches of the medial femoral circumflex arteries, which run


Surgery_Schwartz

Surgery_Schwartz. neck fractures occur within the capsule of the hip joint. The main blood supply to the femo-ral neck and head comes from the deep branches of the medial femoral circumflex arteries, which run along the femoral neck, and when the fracture is displaced, there is an interruption in the blood supply of the femoral head, which can lead to osteonecro-sis. Femoral neck fractures that are nondisplaced have a low risk of disruption of blood flow and therefore can be treated with in situ internal fixation. Three partially threaded cancellous screws are placed through a small incision over the lateral proximal femur, directed through the femoral neck and into the femoral head. Patients can usually begin protected weight-bearing imme-diately after surgery. Displaced femoral neck fractures will likely disrupt the blood supply and therefore need to be treated with a prosthetic replacement in older adults. Most commonly a hemi-arthroplasty is performed in which the femoral head and neck are replaced


Surgery_Schwartz

Surgery_Schwartz. disrupt the blood supply and therefore need to be treated with a prosthetic replacement in older adults. Most commonly a hemi-arthroplasty is performed in which the femoral head and neck are replaced with a metal head and neck into the femoral canal. Higher demand patients and those who have osteoarthritis of the hip joint and hip pain before their fracture may receive a total hip replacement, in which the acetabulum is also replaced with a prosthesis, typically a plastic cup inside a metal shell. Patients can begin weight-bearing immediately after surgery. Displaced femoral neck fractures in young patients are the result of a high-energy trauma and are usually treated by reduction with screw fixation. The reduction may be closed or open.Intertrochanteric Hip Fractures. Intertrochanteric hip frac-tures occur between the greater and lesser trochanters of the proximal femur. Because the blood supply to this area is abun-dant, osteonecrosis is uncommon, and therefore these fractures can


Surgery_Schwartz

Surgery_Schwartz. hip frac-tures occur between the greater and lesser trochanters of the proximal femur. Because the blood supply to this area is abun-dant, osteonecrosis is uncommon, and therefore these fractures can be treated with reduction and internal fixation. Displaced fractures need to be realigned, and this often involves placing the patient on a fracture table where traction and rotation can be applied to the affected leg to reduce the fracture. There are two devices that can be used. In stable fractures, a sliding hip screw includes a large screw placed from the lateral cortex of the proximal femur across the fracture and into the femoral neck and head, followed by a side plate along the lateral cortex of the femur, which is then fixed to the shaft with screws. A cephalom-edullary nail includes a nail placed down the medullary canal of the femur and a large screw that engages the nail as it is passed from the lateral cortex up into the neck and head. Nails are usually used in unstable


Surgery_Schwartz

Surgery_Schwartz. a nail placed down the medullary canal of the femur and a large screw that engages the nail as it is passed from the lateral cortex up into the neck and head. Nails are usually used in unstable fractures and allow protected weight-bearing postoperatively. The reverse oblique intertrochanteric fracture is a specific type of fracture that exits on the lateral cortex (Fig. 43-16). This is best treated with a cephalomedullary Figure 43-15. Types of hip fractures.Figure 43-16. Classic intertrochanteric fracture and reverse oblique fracture. Notice that the fracture line of the reverse oblique fracture exits on the lateral cortex.Brunicardi_Ch43_p1879-p1924.indd 188922/02/19 10:40 AM 1890SPECIFIC CONSIDERATIONSPART IInail; a dynamic hip screw is the wrong device to be used in reverse oblique fractures because it will lead to sliding, shorten-ing, and medial displacement of the fracture.Subtrochanteric Hip Fractures. Subtrochanteric hip frac-tures occur in the proximal femoral shaft just


Surgery_Schwartz

Surgery_Schwartz. fractures because it will lead to sliding, shorten-ing, and medial displacement of the fracture.Subtrochanteric Hip Fractures. Subtrochanteric hip frac-tures occur in the proximal femoral shaft just distal to the lesser trochanter in an area of high biomechanical stresses. While they can occur in older adult patients after a fall, they are also seen in high-energy trauma. Because of the forces of muscles attached to the fractured segments, they tend to be significantly displaced (Fig. 43-17) and may be difficult to reduce. They are most often treated with a long cephalomedullary nail that includes a screw distally to lock the nail in place and prevent rotation of the femur. Fixed angle plates or blade plates are sometimes used in the treatment of subtrochanteric fractures. In most cases, pro-tected weight-bearing can begin soon after surgery. Complica-tions usually include malunion and nonunion of the fracture.Bisphosphonate-related subtrochanteric fractures are an example of


Surgery_Schwartz

Surgery_Schwartz. cases, pro-tected weight-bearing can begin soon after surgery. Complica-tions usually include malunion and nonunion of the fracture.Bisphosphonate-related subtrochanteric fractures are an example of insufficiency fractures that may be related to the long-term use of bisphosphonates. These fractures have been recently identified. An intramedullary nail is the treatment of choice for this fracture.Femoral Shaft FracturesFractures of the femoral shaft are caused by high-energy trauma and may be associated with other severe injuries. Long bone fractures, such as femoral shaft fractures, put these patients at risk for complications such as thromboembolic events and acute respiratory distress syndrome (ARDS), and therefore it is important to fix these quickly, typically within 24 hours. They are most commonly fixed with an intramedullary nail that can be placed antegrade (from the piriformis fossa or greater tro-chanter down the canal) or retrograde (through an incision into the knee joint


Surgery_Schwartz

Surgery_Schwartz. most commonly fixed with an intramedullary nail that can be placed antegrade (from the piriformis fossa or greater tro-chanter down the canal) or retrograde (through an incision into the knee joint and up the canal), with screws placed through proximal and distal holes to lock the nail in place, creating a stable construct to allow weight-bearing. Trauma patients who are hemodynamically unstable or who have other life-threatening injuries are treated temporarily with an external fixator until they can safely undergo surgery. This is called “damage control orthopedics.” The base deficit and lactic acid levels are moni-tored and used as guides to indicate if the patient is adequately resuscitated. When their levels are normal, it means the tissue is adequately oxygenated and the patient can undergo definitive fixation of the femur.Distal Femur FracturesDistal femur fractures are the result of a fall from a height or from high-energy trauma. They can also occur in elderly patients with


Surgery_Schwartz

Surgery_Schwartz. undergo definitive fixation of the femur.Distal Femur FracturesDistal femur fractures are the result of a fall from a height or from high-energy trauma. They can also occur in elderly patients with osteoporotic bone after a fall onto the knee. While nondisplaced fractures in the elderly may be treated nonoper-atively with a hinged knee brace and early motion exercises, most require surgery. These fractures can involve the articu-lar surface of the knee joint, so anatomic reduction of the joint surface is crucial. They are fixed with plates and screws, often utilizing a locking construct. The plate is placed over the lateral, or rarely the medial cortex depending on the fracture pattern. A retrograde intramedullary rod inserted through the knee can also be used, especially in extraarticular fracture patterns. The goal of surgery is to achieve anatomic reduction, stable fixation, and allow early knee range of motion. Intra-articular fractures require the patient to be non–weight-bearing


Surgery_Schwartz

Surgery_Schwartz. fracture patterns. The goal of surgery is to achieve anatomic reduction, stable fixation, and allow early knee range of motion. Intra-articular fractures require the patient to be non–weight-bearing until the frac-ture shows signs of healing. Complications of these fractures include nonunion, malunion, and stiffness of the knee. Be aware of Hoffa fractures, a coronal fractures that usually involve the lateral femoral condyle. They can be missed on X-rays, but they are easily diagnosed by CT scan. It may need a different fixa-tion than that required for the associated supracondylar fracture component.Knee DislocationsDislocation of the knee is a rare but devastating injury that can be limb-threatening. Some dislocations spontaneously reduce and can be underdiagnosed. When the knee dislocates, the anterior cruciate ligament (ACL) and posterior cruciate liga-ment (PCL) are torn, and various degrees of injury occur to the lateral collateral ligament (LCL), medial collateral ligament


Surgery_Schwartz

Surgery_Schwartz. the anterior cruciate ligament (ACL) and posterior cruciate liga-ment (PCL) are torn, and various degrees of injury occur to the lateral collateral ligament (LCL), medial collateral ligament (MCL), posterolateral corner, joint capsule, and menisci. How-ever, the danger is due to the close proximity of the popliteal artery, which runs directly behind the knee and may kink or sustain a tear of the intimal wall when the knee dislocates. A neurovascular exam is extremely important, focusing on the common peroneal nerve and the vascular status of the extrem-ity, followed by immediate reduction of the knee and repeat neurovascular exam. If the pulses are normal, the ankle brachial index (ABI) should be measured. If the ABI is more than 0.9, then the patient should be monitored with serial examination. If the ABI is less than 0.9, then a CTA or an arterial duplex ultra-sound should be performed. If there is evidence of diminished pulses after reduction, an angiogram must be performed. If the


Surgery_Schwartz

Surgery_Schwartz. If the ABI is less than 0.9, then a CTA or an arterial duplex ultra-sound should be performed. If there is evidence of diminished pulses after reduction, an angiogram must be performed. If the pulses are absent after reduction, immediate surgical explora-tion and/or repair should be done by a vascular surgeon. Pro-phylactic fasciotomy of the leg is usually done. Time is critical to reestablish the circulation of the limb. If ischemia time is more than 8 hours, then there is a very high rate of amputation. With regard to the ligamentous injuries, an external fixator may be initially used to stabilize the unstable knee and protect the reduction. Subsequently, an MRI will identify what structures have been torn. Because a dislocation causes so much damage to the knee, a delayed multiligamentous reconstruction is recom-mended on an elective basis in order to stabilize the knee joint. Figure 43-17. Illustration showing subtrochanteric fracture with the deforming forces of the


Surgery_Schwartz

Surgery_Schwartz. reconstruction is recom-mended on an elective basis in order to stabilize the knee joint. Figure 43-17. Illustration showing subtrochanteric fracture with the deforming forces of the muscle.Brunicardi_Ch43_p1879-p1924.indd 189022/02/19 10:40 AM 1891ORTHOPEDIC SURGERYCHAPTER 43Stiffness and instability of the knee are common complications after this injury.Patella/Extensor Mechanism InjuriesThe extensor mechanism is comprised of the quadriceps ten-don, the patella, and the patella ligament. This mechanism func-tions to extend the knee. Injuries can result after a fall directly onto the knee or from forcible contraction of the quadriceps. It is important to examine the knee for the ability to actively extend the knee. Quadriceps tendon ruptures, patella fractures, or patella ligament ruptures can result in a loss of active knee extension requiring surgery. Nondisplaced patella fractures with intact active knee extension can be treated nonoperatively with a cast or knee immobilizer,


Surgery_Schwartz

Surgery_Schwartz. can result in a loss of active knee extension requiring surgery. Nondisplaced patella fractures with intact active knee extension can be treated nonoperatively with a cast or knee immobilizer, holding the knee in full extension, and weight-bearing is permitted. Displaced or comminuted frac-tures require surgery with tension band wiring and/or screws. Symptomatic hardware is a common complication. Acute osteo-chondral fractures can be managed with internal fixation. Quad-riceps tendon and patella tendon ruptures with loss of active knee extension are treated with suture repair. After surgery, the knee is held in extension, and knee flexion is slowly increased over several weeks using a hinged knee brace.Patella dislocations are common injuries that occur when the femur is forcibly internally rotated on an externally rotated tibia while the foot is planted on the ground. They typically dislocate laterally and often relocate spontaneously. The medial patellofemoral ligament is the


Surgery_Schwartz

Surgery_Schwartz. rotated on an externally rotated tibia while the foot is planted on the ground. They typically dislocate laterally and often relocate spontaneously. The medial patellofemoral ligament is the primary stabilizer of the patella. Patients present with a significant knee effusion and medial-sided tenderness. During the physical exam, these patients may elicit a positive apprehension test, in which a lateral force to the patella elicits pain and the sensation of an impending dis-location. Dislocated patellas can be reduced by extending the knee and manual reduction and are treated with temporary knee immobilization. Make sure that there is no fracture or loose bod-ies, which would be an indication for surgery. MRIs will show the classic bone bruise and edema involving the medial facet of the patella and the lateral condyle of the femur. There is a high rate of recurrent dislocation with nonoperative treatment, which may require surgical intervention.Tibial Plateau FracturesThe tibial


Surgery_Schwartz

Surgery_Schwartz. the patella and the lateral condyle of the femur. There is a high rate of recurrent dislocation with nonoperative treatment, which may require surgical intervention.Tibial Plateau FracturesThe tibial plateau is comprised of the articular surfaces and underlying cancellous bone of the medial and lateral plateaus of the proximal tibia. Fractures of the plateau result from axial loads sustained in falls from a height or high-energy trauma, and they are often associated with injuries to the menisci and cartilage of the knee. Fractures can involve the medial, lat-eral, or both plateaus with significant comminution, angula-tion, and depression, creating a challenging injury to fix. The Schatzker classification is commonly used in tibial plateau fractures (Fig. 43-18).• Type I: Lateral split fracture• Type II: Lateral split-depressed fracture• Type III: Lateral pure depression fracture• Type IV: Medial plateau fracture• Type V: Bicondylar fracture• Type VI: Metaphyseal-diaphyseal


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Surgery_Schwartz. split fracture• Type II: Lateral split-depressed fracture• Type III: Lateral pure depression fracture• Type IV: Medial plateau fracture• Type V: Bicondylar fracture• Type VI: Metaphyseal-diaphyseal disassociationMeniscal tears occur more on the lateral side and tend to be peripheral tears, especially if there is more than 6 mm depres-sion or separation of the joint. Type IV, which is the medial tibial plateau fracture, could be a variant of a knee dislocation. The ankle brachial index (ABI) should be used in this situation and in more complex types of tibial plateau fractures. Clinically, laxity of more than 10° may indicate instability of the fracture; however, the test may be painful and hard to perform. A CT scan is important to visualize the intra-articular involvement of the fracture. Minimally displaced fractures may be treated nonoperatively with strict non–weight-bearing until the fracture heals. Fractures associated with displaced articular fragments require surgery in order


Surgery_Schwartz

Surgery_Schwartz. Minimally displaced fractures may be treated nonoperatively with strict non–weight-bearing until the fracture heals. Fractures associated with displaced articular fragments require surgery in order to restore the smooth contour of the articular surface. They are treated with plates and screws placed medially, laterally, or both. Stabilization of a posteromedial fragment may require a separate posteromedial approach. Since there is often a depression of the cancellous bone, bone graft or bone substitutes, particularly calcium phosphate which resists compression, may be needed to buttress the articular surface and restore the anatomic alignment of the tibia. Patients are kept strictly non–weight-bearing for several months until the fracture begins to heal, though early range of motion is encouraged to prevent stiffness. Repair of ligament or meniscus injuries may also be indicated at the time of surgery. Knee stiffness and osteoarthritis are common complications of these injuries. The


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Surgery_Schwartz. to prevent stiffness. Repair of ligament or meniscus injuries may also be indicated at the time of surgery. Knee stiffness and osteoarthritis are common complications of these injuries. The goal of the surgery is to restore joint stability and alignment.Tibial Shaft FracturesTibial shaft fractures are the most common long bone frac-tures and occur following high-energy trauma, direct blows, and severe twisting injuries. Trauma and direct blows to the Figure 43-18. Tibial plateau fracture classification.Brunicardi_Ch43_p1879-p1924.indd 189122/02/19 10:40 AM 1892SPECIFIC CONSIDERATIONSPART IItibia result in transverse or comminuted fracture patterns, while torsional injuries cause spiral fractures. Fractures with minimal angulation can be treated with reduction and casting, followed by transition to a functional brace and slow return to weight-bearing. Such fractures may need to be immobi-lized for several months since these fractures can be slow to heal. Most tibial shaft


Surgery_Schwartz

Surgery_Schwartz. by transition to a functional brace and slow return to weight-bearing. Such fractures may need to be immobi-lized for several months since these fractures can be slow to heal. Most tibial shaft fractures, especially comminuted and angulated fractures, are treated with an intramedullary nail placed down the tibial canal, with interlocking screws placed proximally and distally. Weight-bearing can begin soon after surgery. Proximal third tibial fractures are challenging and can result in malalignment, usually valgus and apex anterior angulation. Knee pain is common after intramedullary rod placement. Plate and screw fixation can also be used; how-ever, since the tibia is subcutaneous, hardware placed along the shaft can increase the risk of wound complications, mak-ing intramedullary nailing the preferred treatment. Fibula shaft fractures often occur along with tibial shaft fractures, though they usually heal well without surgery. Tibial frac-tures, both closed and open, can be


Surgery_Schwartz

Surgery_Schwartz. nailing the preferred treatment. Fibula shaft fractures often occur along with tibial shaft fractures, though they usually heal well without surgery. Tibial frac-tures, both closed and open, can be associated with compart-ment syndrome. Patients usually have pain out of proportion with swelling of the leg and pain with passive stretch. Com-partment pressure within 30 mmHg of the diastolic pressure is diagnostic of compartment syndrome.Tibial Plafond (Pilon) FracturesThe tibial plafond is the distal tibial articular surface of the ankle joint. Pilon fractures are typically high-energy injuries that usu-ally result from axial compression. These injuries can cause significant soft tissue injury, severely comminuted intra-articular and metaphyseal fragments (Fig. 43-19A,B), and wound heal-ing problems, making these fractures very difficult to treat. Due to the soft tissue injury, these fractures are initially treated with external fixation until the swelling subsides, which may take


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Surgery_Schwartz. problems, making these fractures very difficult to treat. Due to the soft tissue injury, these fractures are initially treated with external fixation until the swelling subsides, which may take several days to weeks. The wrinkle test is helpful in this situation to assess when the soft tissues are amenable to defini-tive fixation. A CT scan is usually obtained after the fracture is stabilized by an external fixator. The CT scan will clearly define the fracture fragments and helps in planning the surgical approach and fixation. Minimal incision techniques and mini-mal fixation are becoming popular in some situations. The main goal of surgery is to restore the articular surface. Fixation of the fibula in order to maintain and establish anatomic length is done in some cases. Bone grafts or bone substitutes may be used to fill the void in the metaphyseal region. A variety of fixation techniques may be used including plates to stabilize the metaphysis to the diaphysis. Patients are kept


Surgery_Schwartz

Surgery_Schwartz. bone substitutes may be used to fill the void in the metaphyseal region. A variety of fixation techniques may be used including plates to stabilize the metaphysis to the diaphysis. Patients are kept non–weight-bearing for many months until the fracture heals. Despite best efforts, patients may suffer from ankle pain and stiffness, arthri-tis, wound healing problems, infection, nonunion, and some patients may eventually require ankle fusion. Early fixation of pilon fractures with plates can increase the incidence of wound complications significantly.Ankle and Subtalar DislocationsAnkle Dislocations. The ankle joint is a complex hinge joint comprised of the distal tibial plafond, medial malleolus, and lateral malleolus and their articulation with the talus. Several ligaments also contribute to the stability of the ankle joint, including the deltoid ligament medially, the syndesmotic liga-ments between the tibia and fibula, and the anterior talofibular, posterior talofibular, and


Surgery_Schwartz

Surgery_Schwartz. to the stability of the ankle joint, including the deltoid ligament medially, the syndesmotic liga-ments between the tibia and fibula, and the anterior talofibular, posterior talofibular, and calcaneofibular ligaments laterally. Dislocations of the ankle joint result from a severe twisting injury and often occur with fractures. At times, dislocations FibulaTibiaTalusABFigure 43-19. A. Tibial pilon fracture with comminution. B. Pilon fracture and its main fracture fragments.Brunicardi_Ch43_p1879-p1924.indd 189222/02/19 10:40 AM 1893ORTHOPEDIC SURGERYCHAPTER 43can place significant pressure on the overlying skin and can cause neurovascular compromise; therefore, prompt reduction is extremely important followed by splinting.Subtalar Dislocations. Subtalar dislocations can be medial or lateral, depending on the position of the foot. The medial dislocation is more common. Lateral dislocations are less com-mon, can be open, and are more likely to be associated with fractures.


Surgery_Schwartz

Surgery_Schwartz. or lateral, depending on the position of the foot. The medial dislocation is more common. Lateral dislocations are less com-mon, can be open, and are more likely to be associated with fractures. Irreducible lateral subtalar dislocations may occur from a trapped tibialis posterior tendon, which will block the reduction. The main complication of subtalar dislocations is subtalar arthritis.Ankle FracturesAnkle fractures are very common and result from a twisting injury to the ankle. The patterns of ankle fractures depend on the direction of force and the position of the foot and ankle at the time of injury. The goals of treating ankle fractures are to restore the anatomy of the ankle joint and to restore the length and rota-tion of the fibula. Initial treatment includes closed reduction and placement of a well-padded splint in order to protect the skin. Swelling can be a significant problem, so elevation of the foot is encouraged. Surgery may be delayed until the skin condition permits.


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Surgery_Schwartz. placement of a well-padded splint in order to protect the skin. Swelling can be a significant problem, so elevation of the foot is encouraged. Surgery may be delayed until the skin condition permits. Fractures of the ankle may be:1. Isolated malleolar fractures, usually the lateral malleolus or the medial malleolus.2. Bimalleolar fractures that involve the lateral and medial malleolus. Please note that the deltoid ligament may be in-jured instead of the medial malleolus.3. Trimalleolar fractures that involve the lateral malleolus, medial malleolus, and posterior malleolus.Lateral Malleolus Fractures. Isolated fractures of the lateral malleolus with less than 3 mm displacement and no talar shift may be stable. An external rotation stress radiograph or a grav-ity test is used to assess the competency of the deltoid ligament, with the goal of the test to exclude deltoid injury. If the patient has a deltoid injury, in addition to the fibular fracture, then the patient will need surgery.


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Surgery_Schwartz. competency of the deltoid ligament, with the goal of the test to exclude deltoid injury. If the patient has a deltoid injury, in addition to the fibular fracture, then the patient will need surgery. The fracture will require anatomic reduction in order to restore normal ankle joint congruity. The talus can sublux laterally following lateral malleolus fractures, and even 1 millimeter of talar shift decreases the surface contact between the talus and the tibia by 40%, increasing the risk of developing arthritis. Open reduction and internal fixation of the fibula is usually done with plate and screws.Medial Malleolar Fractures. An isolated fracture of the medial malleolus is usually an avulsion-type injury. Minimally displaced fractures can be treated with a cast or walking boot, while displaced fractures are usually fixed with screws.Bimalleolar Fractures. Fractures to both the medial and lat-eral malleoli usually require surgery. These injuries are more unstable, and the talus will


Surgery_Schwartz

Surgery_Schwartz. fractures are usually fixed with screws.Bimalleolar Fractures. Fractures to both the medial and lat-eral malleoli usually require surgery. These injuries are more unstable, and the talus will often sublux or completely dislo-cate laterally. They are treated by reducing and fixing both malleoli during surgery. Occasionally, the posterior articular surface of the distal tibia, or posterior malleolus, can be frac-tured as well, resulting in a trimalleolar ankle fracture. Often it is a small fragment and does not need to be fixed; however, if it involves a significant amount of the articular surface, the posterior malleolus should be fixed with screws placed either anteriorly, posteriorly, or with an antiglide plate. In all ankle fractures, especially in ones associated with deltoid rupture, a syndesmotic injury should be considered. After the fixation of the fractures, an intraoperative external rotation stress test will diagnose syndesmotic injury.Syndesmosis Injuries. The syndesmosis


Surgery_Schwartz

Surgery_Schwartz. a syndesmotic injury should be considered. After the fixation of the fractures, an intraoperative external rotation stress test will diagnose syndesmotic injury.Syndesmosis Injuries. The syndesmosis is comprised of several ligaments between the distal tibia and fibula that pro-vide stability to the ankle joint by resisting axial, rotational, and translational forces. The syndesmosis can be disrupted at the time of ankle fractures and requires special attention (Fig. 43-20). Widening of the space between the distal tibia and fibula after fixing the fractures is indicative of a syndesmo-sis injury, and an intraoperative external rotation stress radio-graph can be helpful for evaluation. Such injuries are treated with one or two screws placed laterally from the fibula into the tibia, parallel to the ankle joint. Patients are kept non–weight-bearing for several weeks. The screws are often removed after 3 to 6 months, though they can be left in place and are typically


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Surgery_Schwartz. the tibia, parallel to the ankle joint. Patients are kept non–weight-bearing for several weeks. The screws are often removed after 3 to 6 months, though they can be left in place and are typically asymptomatic.Maisonneuve FracturesA Maisonneuve fracture is a fracture of the proximal fibula associated with fracture of the medial malleolus or rupture of the deltoid ligament. There is always an associated syndesmotic injury (Fig. 43-21). Diagnosis may be difficult, and the injury may be missed. These injuries require surgical treatment with fixation of the syndesmosis by screws from the fibula to the tibia.Calcaneal FracturesCalcaneal fractures usually occur following a fall from a height and are often associated with other injuries, including lum-bar spine fractures. There is a high incidence of compartment Figure 43-20. Ankle fracture with syndesmotic injury (white arrow).Brunicardi_Ch43_p1879-p1924.indd 189322/02/19 10:40 AM 1894SPECIFIC CONSIDERATIONSPART IIsyndrome of the foot


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Surgery_Schwartz. of compartment Figure 43-20. Ankle fracture with syndesmotic injury (white arrow).Brunicardi_Ch43_p1879-p1924.indd 189322/02/19 10:40 AM 1894SPECIFIC CONSIDERATIONSPART IIsyndrome of the foot associated with calcaneal fractures. These injuries are often intra-articular and can result in collapse of the weight-bearing posterior facet of the calcaneus. The Bohler angle, which is normally between 20° and 40°, would be reduced or even flattened. CT scans are useful to better visualize the fracture pattern. Some fractures can be treated nonoperatively in a well-padded splint with patients being kept non–weight-bearing for up to 12 weeks. Displaced intraarticular fractures can be treated surgically once the swelling subsides and the wrinkle test is positive. Surgery can be done with lag screws or with plate and screw fixation. Despite adequate treatment, calcaneal fractures can be debilitating injuries, leading to significant heel pain and arthritis. The outcome of surgery depends on


Surgery_Schwartz

Surgery_Schwartz. or with plate and screw fixation. Despite adequate treatment, calcaneal fractures can be debilitating injuries, leading to significant heel pain and arthritis. The outcome of surgery depends on the com-minution of the fracture and degree of articular involvement. The more fragments seen on a CT scan, the worse the outcome for the patient. Wound complications are a problem for calca-neal fractures with the risk being even higher in diabetics, smok-ers, and in open fractures. Open calcaneal fractures have a high rate of amputation.Talus FracturesFractures of the talus commonly result from forced dorsiflexion of the ankle, causing the talar neck to impact on the anterior distal tibia. The dominant blood supply is the artery of the tarsal canal. The blood supply to the talus can be jeopardized after a displaced fracture and may lead to osteonecrosis (Fig. 43-22), which is an unfortunately common complication following talus fractures. The incidence of osteonecrosis depends on the degree


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Surgery_Schwartz. after a displaced fracture and may lead to osteonecrosis (Fig. 43-22), which is an unfortunately common complication following talus fractures. The incidence of osteonecrosis depends on the degree of displacement of the fracture. The Hawkin’s sign is a sub-chondral lucency that is seen on the mortise X-ray at 6 weeks and indicates that there is vascularity of the talus. This indicates that there is no avascular necrosis. Nondisplaced fractures are treated with a cast and have a 15% risk of osteonecrosis, while displaced fractures are often treated surgically with screw fixa-tion. There is a high risk of osteonecrosis, ranging from 30% to 100%. Subtalar arthritis is the most common complication from this injury. Varus malunion that results from inadequate reduc-tion is the most preventable complication. This complication leads to a decreased subtalar range of motion and eversion. With varus malunion, the patient will walk with the foot internally rotated.Foot FracturesThe tarsal bones,


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Surgery_Schwartz. complication. This complication leads to a decreased subtalar range of motion and eversion. With varus malunion, the patient will walk with the foot internally rotated.Foot FracturesThe tarsal bones, including the navicular, the cuboid, and the three cuneiform bones, link the hind foot to the metatarsals and provide mechanical stability to the arch of the foot. Isolated fractures to these bones are rare and are often treated nonopera-tively with a cast or boot. Cuboid fractures are also known as “nutcracker fractures” and may indicate a Lisfranc injury. Stress fractures of the navicular can be occult, and a diagnosis may be challenging to make in a patient that complains of foot pain. An MRI may be needed for diagnosis. Treatment is often a short leg non–weight-bearing cast. The Lisfranc ligament, which con-nects the second metatarsal base to the medial cuneiform, is an important stabilizer of the midfoot. Lisfranc injuries can be seen following torsional forces to the foot or from


Surgery_Schwartz

Surgery_Schwartz. ligament, which con-nects the second metatarsal base to the medial cuneiform, is an important stabilizer of the midfoot. Lisfranc injuries can be seen following torsional forces to the foot or from crush injuries. These injuries can be missed and often require surgery because anatomic reduction is extremely important for a successful outcome. Open reduction and internal fixation is the technique used for Lisfranc fractures. Primary arthrodesis is often used for purely ligamentous injuries. The main complication of Lisfranc injuries is posttraumatic arthritis. Metatarsal fractures similarly result from twisting or crush injuries and most can be treated Figure 43-21. Maisonneuve fracture showing proximal fibular fracture and associated ankle injury with disruption of syndesmosis.Figure 43-22. Displaced talar neck fracture. Notice the interrup-tion of the blood supply in the talus.Brunicardi_Ch43_p1879-p1924.indd 189422/02/19 10:40 AM 1895ORTHOPEDIC SURGERYCHAPTER 43nonoperatively


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Surgery_Schwartz. talar neck fracture. Notice the interrup-tion of the blood supply in the talus.Brunicardi_Ch43_p1879-p1924.indd 189422/02/19 10:40 AM 1895ORTHOPEDIC SURGERYCHAPTER 43nonoperatively with a hard-soled shoe and weight-bearing as tolerated. The base of the fifth metatarsal, however, warrants close attention. Fifth metatarsal fractures at the metaphyseal-diaphyseal junction (fourth and fifth metatarsal articulation) are called Jones fractures. These fractures can jeopardize blood flow, are at risk for nonunion, and may be associated with cav-ovarus hindfoot. Jones fractures need close follow-up to assess for healing if treated by short-leg cast and non–weight-bearing. In athletes and active young patients, screw fixation is usually used to stabilize the fracture. Injuries to the metatarsal-phalangeal joints and phalangeal fractures can be treated symptomatically or with buddy taping with weight-bearing as tolerated in a hard-soled shoe.SPORTS MEDICINEIntroductionSports medicine deals


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Surgery_Schwartz. joints and phalangeal fractures can be treated symptomatically or with buddy taping with weight-bearing as tolerated in a hard-soled shoe.SPORTS MEDICINEIntroductionSports medicine deals with the prevention and treatment of inju-ries related to sports and exercise. These injuries encompass various areas in the musculoskeletal system. In recent years, sports-related injuries have increased, and the sports medicine field has been expanding. There are multiple factors leading to this increase in sports-related injuries. They include athletes participating in one sport year-round, more “weekend warriors” participating in sporting activity, and increased expectations for higher performance.The orthopedic subspecialty of sports medicine treats a broad spectrum of patients, ranging from children who have just started participating in their first sports to the specialized care of professional athletes. Medical treatment of athletes, recreational or professional, can be complex as shortand


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Surgery_Schwartz. who have just started participating in their first sports to the specialized care of professional athletes. Medical treatment of athletes, recreational or professional, can be complex as shortand long-term outcomes are influenced by the higher demand that athletes put on their bodies. Additionally, the orthopedic sports medicine specialist does not only treat the patient’s injuries but also has to consider the patient’s attempted return to his or her previous level of activity. “Getting back in the game” is sometimes subject to pressure and competing interests from third parties (e.g., team members, coaches, parents, fans). This can make the athlete’s treatment and the rehabilitation a chal-lenging process.Surgical intervention for ligament and cartilage injuries in sports medicine patients is usually done using arthroscopic techniques. The most frequently injured joints are the shoulder, knee, and hip. Therefore, treatment of common injuries in these joints will be the scope of this


Surgery_Schwartz

Surgery_Schwartz. is usually done using arthroscopic techniques. The most frequently injured joints are the shoulder, knee, and hip. Therefore, treatment of common injuries in these joints will be the scope of this section.SHOULDERRotator CuffRotator cuff injuries are among the most common reasons to visit an orthopedic sports specialist. Often, these injuries are associated with forceful or repeated overhead and pulling movements. The rotator cuff provides shoulder movement and glenohumeral joint stability, and injuries can typically lead to pain, weakness, and restricted movement of the arm. Over recent years, improvement of surgical indications, operative techniques, and rehabilitation protocols has led to better out-comes. Studies suggest that arthroscopic techniques are equal or superior to open techniques for most indications. Contro-versies surrounding rotator cuff repair remain and include use of acromioplasty, enhancement of healing with orthobiologics (Fig. 43-23), singlevs. double-row


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Surgery_Schwartz. techniques for most indications. Contro-versies surrounding rotator cuff repair remain and include use of acromioplasty, enhancement of healing with orthobiologics (Fig. 43-23), singlevs. double-row fixation, and the treatment ABrotator cuff teargreater tuberosity/RC attachment siterotator cuff repairCFigure 43-23. Imaging and treatment of rotator cuff tears. A. Magnetic resonance imaging coronal T2 image showing a full-thickness and moderately retracted tear (arrow) of the supraspinatus tendon. B. Arthroscopic image showing the supraspinatus tendon tear as viewed from a posterior portal during the surgery. C. Arthroscopic image showing completion of repair of the supraspinatus tendon tear using suture anchors imbedded in the greater tuberosity of the humerus and attached sutures that capture and reduce the torn tendon to its native insertion site.Brunicardi_Ch43_p1879-p1924.indd 189522/02/19 10:40 AM 1896SPECIFIC CONSIDERATIONSPART IIof massive or large tears. Rehabilitation


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Surgery_Schwartz. capture and reduce the torn tendon to its native insertion site.Brunicardi_Ch43_p1879-p1924.indd 189522/02/19 10:40 AM 1896SPECIFIC CONSIDERATIONSPART IIof massive or large tears. Rehabilitation after surgery plays an important role to restore strength, motion, and function and, ultimately, to return the patient to his or her previous level of activity. The standard rehabilitation protocol is made up of three consecutive stages: immobilization, passive exercise, and active exercise. Immobilization can be established by using a sling, and passive exercises should be initiated by the therapist in the first 4 to 6 weeks after surgery. The therapist moves the arm in different positions to improve range of motion (ROM) while providing support. After 4 to 6 weeks, active exercises can be gradually introduced. At 8 to 12 weeks, muscle strength and improvement of arm control are increased by starting a strength-ening exercise program.Shoulder InstabilityThe most common etiology for


Surgery_Schwartz

Surgery_Schwartz. be gradually introduced. At 8 to 12 weeks, muscle strength and improvement of arm control are increased by starting a strength-ening exercise program.Shoulder InstabilityThe most common etiology for shoulder instability is related to trauma, especially shoulder dislocation. After a shoulder has dislocated, it becomes vulnerable to repeat episodes of instability and may develop into a chronic problem. Most of the shoulder’s stability is provided dynamically by the rotator cuff and stati-cally by the shoulder capsule and ligaments. The most com-mon dislocation is in the anterior-inferior direction. Typically, patients with an anterior dislocation present with pain and an externally rotated shoulder. Younger patients are more sus-ceptible to suffer from repeat dislocations than older patients. The position of the humeral head with respect to the glenoid and other bony pathology can be identified with radiographs. Views from different angles should be obtained to thoroughly evaluate the


Surgery_Schwartz

Surgery_Schwartz. The position of the humeral head with respect to the glenoid and other bony pathology can be identified with radiographs. Views from different angles should be obtained to thoroughly evaluate the patient; an anterior-posterior (AP) view, a glenoid (axillary) view, and a “Y” view of the shoulder are recom-mended in assessing this injury. Immediate reduction of the glenohumeral joint is paramount to the initial treatment of this injury. Repeat radiographs should be attained to ensure that the humeral head is appropriately positioned. As soft tissue struc-tures are typically damaged in these injuries, an MRI can be obtained to evaluate these structures.Relocation of the shoulder is generally accomplished with the patient in supine position and the arm under gentle traction and slight abduction. Some sedation is helpful as it relaxes the patient’s musculature. Whether or not to immobilize a first-time-dislocated shoulder remains controversial, as does the position of immobilization.


Surgery_Schwartz

Surgery_Schwartz. Some sedation is helpful as it relaxes the patient’s musculature. Whether or not to immobilize a first-time-dislocated shoulder remains controversial, as does the position of immobilization. Additionally, some surgeons argue that early surgical repair of capsulolabral structures is appropri-ate as the recurrence rate in the young population is high and may lead to more extensive bony involvement and ultimately more invasive open procedures.Prolonged immobilization is not recommended because this will often lead to substantial stiffness in the shoulder and does not appreciably decrease the redislocation rate. Unfor-tunately, many patients experience recurrent dislocations, in which case surgical stabilization of the shoulder should be con-sidered. Arthroscopic stabilization procedures have been the gold standard treatment for the majority of injuries related to shoulder dislocations, typically a tear of the anteroinferior cap-sulolabral complex (Bankart lesion). There are a subset of


Surgery_Schwartz

Surgery_Schwartz. been the gold standard treatment for the majority of injuries related to shoulder dislocations, typically a tear of the anteroinferior cap-sulolabral complex (Bankart lesion). There are a subset of inju-ries, typically involving large glenoid bony lesions, that require more extensive intervention with a Latarjet procedure or bone grafting. After surgery, the shoulder is temporarily immobi-lized with a sling. When the sling is removed, exercises will be started to rehabilitate the shoulder, improve ROM, and prevent scarring. Strengthening exercises will gradually be added to the rehabilitation plan.Posterior Dislocation of the ShoulderPosterior dislocations of the shoulder are rare and could be missed. This dislocation can occur due to electric shock or sei-zures. Examination of the patient will show limitation in exter-nal rotation of the shoulder. The shoulder will be locked in an internally rotated position. The posterior dislocation could be missed on the AP view of the shoulder,


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Surgery_Schwartz. will show limitation in exter-nal rotation of the shoulder. The shoulder will be locked in an internally rotated position. The posterior dislocation could be missed on the AP view of the shoulder, and an axillary view should be obtained to avoid missing the injury.Superior Labrum and Biceps TendonThe labrum is a structure that helps to deepen the shoulder socket and stabilize the glenohumeral joint. Additionally, it serves as an attachment point for many of the shoulder ligaments, as well as the long head of the biceps tendon. A superior labrum ante-rior and posterior (SLAP) lesion may occur in the superior part of the labrum, usually anterior and posterior to the attachment of the biceps tendon, with occasional involvement of the biceps tendon in certain cases. Injuries to the superior labrum can be caused by trauma or by repetitive shoulder motion, such as in throwing athletes. Radiographs are generally obtained to evalu-ate for concomitant bony injuries or osteoarthritic changes.


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Surgery_Schwartz. labrum can be caused by trauma or by repetitive shoulder motion, such as in throwing athletes. Radiographs are generally obtained to evalu-ate for concomitant bony injuries or osteoarthritic changes. The labrum itself, and other soft tissue, is better visualized with MRI with addition of a gadolinium arthrogram adding sensitivity for labral injury detection (Fig. 43-24). A coronal view MRI will clearly show the condition of the superior labrum.Conservative and operative treatments have had mixed results depending on the patient’s age, activity level, type of tear, and presence of concomitant injuries. If symptoms do not improve with adequate physical therapy and/or nonsteroidal anti-inflammatory drugs (NSAIDs), surgical intervention is usu-ally indicated. Some SLAP injuries involve the biceps tendon, which may require either tenotomy or tenodesis.After surgical repair, the shoulder needs to be immobilized to protect the repair and allow for healing. Usually a sling is used for 4 weeks


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Surgery_Schwartz. tendon, which may require either tenotomy or tenodesis.After surgical repair, the shoulder needs to be immobilized to protect the repair and allow for healing. Usually a sling is used for 4 weeks after surgery. Then a physical therapy program will gradually start improving range of motion and prevent scar formation and stiffness from developing. As healing progresses, exercises to strengthen the shoulder muscles and the rotator cuff will gradually be added to the program typically around 4 to 6 weeks after surgery. Return to early interval throwing can generally be allowed around 3 to 4 months after surgery.Impingement SyndromesAfter minor trauma or repetitive injury, patients may experi-ence pain and discomfort which can be due to irritation of the tissues in the subacromial space. In many cases these shoulder impingement syndromes are caused by simple bursitis or ten-donitis of the long head of the biceps or supraspinatus tendon. Occasionally, impingement syndromes can progress to


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Surgery_Schwartz. cases these shoulder impingement syndromes are caused by simple bursitis or ten-donitis of the long head of the biceps or supraspinatus tendon. Occasionally, impingement syndromes can progress to tears of the supraspinatus tendon, which can be confirmed by MRI or ultrasound.The goal of treatment is to reduce pain and restore func-tion. Initial treatment is generally nonsurgical and involves rest, NSAIDs, and physical therapy. If pain is not adequately relieved, an injection of a local anesthetic and corticosteroid may be helpful, for both therapeutic and diagnostic purposes.If conservative treatment does not relieve pain, surgery is recommended, with the goal to excise the bursa and create more subacromial space. Generally, surgery is performed arthroscopi-cally and encompasses bursectomy and subacromial decompres-sion via acromioplasty. If the rotator cuff (supraspinatus tendon) is also injured, arthroscopic repair is usually indicated to restore Brunicardi_Ch43_p1879-p1924.indd


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Surgery_Schwartz. and subacromial decompres-sion via acromioplasty. If the rotator cuff (supraspinatus tendon) is also injured, arthroscopic repair is usually indicated to restore Brunicardi_Ch43_p1879-p1924.indd 189622/02/19 10:40 AM 1897ORTHOPEDIC SURGERYCHAPTER 43function and can be accompanied by a bony resection of the inferior portion of the acromion.The Acromioclavicular JointThe acromioclavicular joint is a gliding synovial joint com-prised of the lateral end of the clavicle and medial facet of the acromion, and it has limited mobility. The joint is stabilized by three ligaments: the superior acromioclavicular ligament, the inferior acromioclavicular ligament, and the coracoclavicular ligament. Injuries to these ligaments are commonly sustained by a lateral blow to the shoulder while playing contact sports such as football and ice hockey and may cause displacement of the joint. An acromioclavicular sprain is also referred to as a shoul-der separation. The least severe, types I and II, are


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Surgery_Schwartz. sports such as football and ice hockey and may cause displacement of the joint. An acromioclavicular sprain is also referred to as a shoul-der separation. The least severe, types I and II, are typically treated conservatively. Treatment of type III injuries, where the clavicle is displaced up to 100%, is controversial. Some advo-cate for early surgical intervention, while others recommend symptomatic treatment followed by ligament reconstruction if symptoms persist. Types IV to VI, where the coracoclavicular ligaments are completely torn and the clavicle is significantly displaced, are often treated surgically.KNEEThe knee is the largest joint in the human body and is a pivotal hinge joint, which allows flexion and extension as well as some medial and lateral rotation. The knee bears tremendous axial loads as well as torsional and sheer forces, making it vulnerable to both acute injury and the development of osteoarthritis. In sports, the major stabilizing structures such as the ACL


Surgery_Schwartz

Surgery_Schwartz. axial loads as well as torsional and sheer forces, making it vulnerable to both acute injury and the development of osteoarthritis. In sports, the major stabilizing structures such as the ACL and the medial collateral ligament (MCL) are frequently injured. Other common knee injuries involve the menisci, posterolateral corner (PLC), posterior cruciate ligament (PCL), and patellofemoral joint.MenisciThe menisci are crescent-shaped pieces of fibrocartilage that provide joint stability, shock absorption, load distribution, and proprioception to the knee. Sudden meniscal tears often happen during sports, usually during contact or twisting injuries to the knee. Symptoms associated with a meniscus tear include pain, swelling, stiffness, catching, and locking of the knee. Radio-graphs are typically obtained to assess for a concomitant bony injury, the presence of (early) osteoarthritis, and leg alignment abnormalities. However, since menisci are radiolucent and are not seen on radiographs, an


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Surgery_Schwartz. obtained to assess for a concomitant bony injury, the presence of (early) osteoarthritis, and leg alignment abnormalities. However, since menisci are radiolucent and are not seen on radiographs, an MRI is obtained to assess the status of the menisci and the soft tissue surrounding the knee joint (Fig. 43-25). Small tears on the outer edge of the meniscus may not cause symptoms, and provided the knee is stable, nonsurgi-cal treatment may be sufficient.The most commonly performed surgical procedure for meniscus tears is partial (subtotal) meniscectomy. However, it has become increasingly clear over recent years that pres-ervation of the load-distributing function of the meniscus is important in preventing the development of early osteoar-thritis. Research into the use of orthobiologics (e.g., micro-fracture of the notch, fibrin clot) for meniscal repairs has expanded the indications for repair rather than excising the torn fragment, especially if the fragment is large. Tears have been


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Surgery_Schwartz. micro-fracture of the notch, fibrin clot) for meniscal repairs has expanded the indications for repair rather than excising the torn fragment, especially if the fragment is large. Tears have been reported in virtually all portions of the meniscus, with radial and longitudinal tears being the most common. Menis-cal root tears are less common, but they are increasingly being recognized as devastating injuries that cause serious alterations of knee contact forces. Surgical techniques are developing to repair the root to restore its function. Meniscus transplantation may be an option for young patients with a largely deficient meniscus.ABLIGHTlabral repairglenoidhumeralheadCFigure 43-24. Imaging and treatment of a shoulder glenoid labrum tear. A. Magnetic resonance imaging axial T1 image showing a tear of the posterior superior labrum (arrow). B. Arthroscopic image with the patient in the lateral decubitus position showing detachment of the torn labrum away from the glenoid. C.


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Surgery_Schwartz. image showing a tear of the posterior superior labrum (arrow). B. Arthroscopic image with the patient in the lateral decubitus position showing detachment of the torn labrum away from the glenoid. C. Arthroscopic image demonstrating repair of the labrum to its attachment site using anchors in the glenoid and sutures that fixes the labrum to the glenoid.Brunicardi_Ch43_p1879-p1924.indd 189722/02/19 10:41 AM 1898SPECIFIC CONSIDERATIONSPART IIThe paradigm of treatment of torn menisci is shifting thanks to the development of superior surgical techniques, use of orthobiologics, and promising first results with root repair and meniscus transplantations. Nowadays, physicians are well informed on the significance of meniscal preservation when there is potential for healing.Directly after surgery, the knee is immobilized with a brace and weight-bearing is protected to allow the meniscus to heal. When healing is complete, range of motion and strength will need to be regained. Physical


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Surgery_Schwartz. surgery, the knee is immobilized with a brace and weight-bearing is protected to allow the meniscus to heal. When healing is complete, range of motion and strength will need to be regained. Physical therapy is an integral com-ponent of healing and return to play, which usually is allowed between 4 and 6 months after surgery.Collateral LigamentsThe MCL is the most frequently injured knee ligament, which usually occurs after excessive valgus stress of the knee. In more severe injuries, tearing of the meniscus and ACL can also occur, which is known as the “unhappy triad.” This is most often seen in contact sports with a lateral blow to a planted leg, causing a significant valgus force.The MCL has good healing potential, and grade I and II injuries usually improve with bracing and activity modifica-tion. Grade III injuries may also improve with conservative treatment, and often these injuries are initially treated non-operatively. The majority of MCL injuries occur in the mid-substance or


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Surgery_Schwartz. Grade III injuries may also improve with conservative treatment, and often these injuries are initially treated non-operatively. The majority of MCL injuries occur in the mid-substance or at the femoral insertion side. There is a small subset of tibial-sided grade III tears that are associated with worse clinical outcome following conservative treatment, and therefore surgical repair is often recommended. Recon-struction is rare because surgical repair is usually effective in restoring the MCL. LCL injuries are much less common than MCL ligament injuries, but, similarly, most are man-aged conservatively.With return of range of motion and normal gait pattern, patients are functionally progressed towards return to sports. A functional brace during sports is often advised.Cruciate LigamentsThe cruciate ligaments are situated centrally within the intercon-dylar notch of the knee. The biomechanical function of both the ACL and the PCL is complex and three-dimensional, but both play an


Surgery_Schwartz

Surgery_Schwartz. cruciate ligaments are situated centrally within the intercon-dylar notch of the knee. The biomechanical function of both the ACL and the PCL is complex and three-dimensional, but both play an important role in providing anteroposterior and rota-tional stability of the knee.ACL tears are a common sports injury, especially in sports involving sudden stopping and cutting (e.g., soccer, basketball) or contact (e.g., football). A torn ACL will result in altered knee biomechanics and kinematics and thus can potentially lead to the early development of degenerative changes. Since a torn ACL will not heal on its own, surgical ACL reconstruction is generally the treatment of choice in patients who are young and active. Patients with a more sedentary lifestyle and who experi-ence no persisting or disabling instability in daily life may be effectively treated with conservative management (i.e., bracing and physical therapy).ABCFigure 43-25. Imaging and treatment of a knee lateral and meniscus


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Surgery_Schwartz. disabling instability in daily life may be effectively treated with conservative management (i.e., bracing and physical therapy).ABCFigure 43-25. Imaging and treatment of a knee lateral and meniscus tear. A. Magnetic resonance imaging sagittal T2 image of the knee showing a displaced bucket-handle lateral meniscus tear (arrow). B. Arthroscopic image showing the remnant rim of the lateral meniscus prior to reduction and fixation of the torn bucket-handle fragment. C. Arthroscopic image after the torn segment is reduced and fixed to the remaining meniscus and the lateral capsule using suture.Brunicardi_Ch43_p1879-p1924.indd 189822/02/19 10:41 AM 1899ORTHOPEDIC SURGERYCHAPTER 43A patient with an ACL tear typically presents with pain and swelling, instability, loss of ROM, joint line tenderness (if there is an associated meniscus injury), and discomfort while walking. The Lachman’s exam is the best clinical test for an ACL tear. Radiographs are obtained to evaluate joint condi-tion


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Surgery_Schwartz. (if there is an associated meniscus injury), and discomfort while walking. The Lachman’s exam is the best clinical test for an ACL tear. Radiographs are obtained to evaluate joint condi-tion and possible associated osseous injuries. To visualize the ACL and other soft tissue in the knee, an MRI should be obtained. Although an MRI is not required to make the diag-nosis, the information it provides is invaluable with regard to objectifying anatomic characteristics by taking measurements, assessing concomitant injuries, and presurgical planning in gen-eral (Fig. 43-26).Reconstruction is performed with use of a tendon-graft that will replace the native ACL. Commonly used graft sources include the patellar, hamstrings, and quadriceps tendons. These tendons can be harvested from the same knee (i.e., autografts) during the same procedure. Alternatively, a cadaver graft (i.e., allograft) can be used. Both have their associated benefits, including the absence of donor site morbidity with an


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Surgery_Schwartz. (i.e., autografts) during the same procedure. Alternatively, a cadaver graft (i.e., allograft) can be used. Both have their associated benefits, including the absence of donor site morbidity with an allograft and better healing potential with an autograft. As such, it is important to have a discussion with the patient and provide the necessary information for them to make an informed decision regarding graft type.Injuries of the PCL are less common than other knee ligaments. Frequently seen causes are a bent knee hitting a dashboard in a car accident or falling on a knee that is bent during running. A rupture of the PCL is usually better tolerated than ACL rupture, since many tears (i.e., grades I and II) have the potential to heal on their own and do not result in much knee instability. Most grade I and II injuries are treated non-operatively. Combined PCL/PLC, PCL/MCL, and grade III PCL injuries do present a challenge with regard to appropriate management. Chronic PCL-deficient


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Surgery_Schwartz. Most grade I and II injuries are treated non-operatively. Combined PCL/PLC, PCL/MCL, and grade III PCL injuries do present a challenge with regard to appropriate management. Chronic PCL-deficient (grade III) knees have an increased incidence of osteoarthrosis, particularly in the patel-lofemoral and medial knee compartments. Indication for sur-gery is influenced by age, activity level, and the presence of concomitant injuries. Different surgical techniques have been proposed; the most common are the “inlay” technique and the transtibial technique.The goal of cruciate ligament (both ACL and PCL) reconstruction is to restore native knee kinematics, provide the patient with the best potential for a successful outcome, and to prevent the development of long-term complications, such as osteoarthrosis.Posterolateral CornerCritical structures of the posterolateral corner are the LCL, pop-liteus tendon, and popliteofibular ligament. These structures each contribute to the static and dynamic


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Surgery_Schwartz. CornerCritical structures of the posterolateral corner are the LCL, pop-liteus tendon, and popliteofibular ligament. These structures each contribute to the static and dynamic stability of the knee and are commonly seen in combination with other ligamentous injuries, most notably the ACL. It is important to evaluate the PLC after any knee injury as a deficient PLC causes altered knee biomechanics and subsequently increases the stress on sur-rounding stabilizing structures. As such, it has been shown that a deficient PLC is a primary cause of graft failure in cruciate ligament reconstruction.Acute high-grade injuries of the PLC with obvious defi-cient structures require surgical intervention. Since primary repair becomes increasingly difficult as time between injury and surgery increases, a cut-off of 2 to 3 weeks is usually the limit to repair the deficient structures. With more chronic PLC injuries or midsubstance tears, reconstruction is recommended to restore knee


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Surgery_Schwartz. increases, a cut-off of 2 to 3 weeks is usually the limit to repair the deficient structures. With more chronic PLC injuries or midsubstance tears, reconstruction is recommended to restore knee stability.HIPFemoroacetabular ImpingementFemoroacetabular impingement (FAI) is a pathologic condi-tion that refers to impingement of the anterior femoral head-neck junction against the anterosuperior acetabular labrum. This is frequently caused by abnormal bony offset at the femoral head-neck junction and is called CAM impingement, which usually affects young males. On the other hand, a Pincer lesion usually occurs due to abnormal acetabular version and excessive anterolateral acetabular bony rim coverage, or a combination of these, which usually occurs in females. Recognition of FAI can be clinically and radiologically dif-ficult. However, familiarity with this disorder is essential AxyzBCDEFigure 43-26. Magnetic resonance imaging of a torn anterior cruciate ligament (ACL). A–C. Proton


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Surgery_Schwartz. clinically and radiologically dif-ficult. However, familiarity with this disorder is essential AxyzBCDEFigure 43-26. Magnetic resonance imaging of a torn anterior cruciate ligament (ACL). A–C. Proton density sagittal cuts, showing antero-posterior tibial insertion site length measurement “x,” intra-articular ligament length measurement “y,” and ACL inclination angle measure-ment “z.” Oblique (in the same plane as the ACL runs) coronal cuts showing a complete ACL tear with separate images of a PL bundle tear (D) and an anteromedial bundle tear (E).Brunicardi_Ch43_p1879-p1924.indd 189922/02/19 10:41 AM 1900SPECIFIC CONSIDERATIONSPART IIbecause FAI can lead to labral tears, cartilage delamination, and, if untreated, osteoarthritis.Commonly, patients present with anterior groin pain exacerbated by activities involving hip flexion or pain over the greater trochanter, as well as grinding or popping. Patients report pain with flexion and internal rotation, and after pro-longed sitting.


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Surgery_Schwartz. by activities involving hip flexion or pain over the greater trochanter, as well as grinding or popping. Patients report pain with flexion and internal rotation, and after pro-longed sitting. On examination, there is a decrease in internal rotation that appears out of proportion to the loss of the other ranges of motion, and flexion can also be limited. The impinge-ment test, elicited by 90° of flexion and adduction and internal rotation of the hip, is almost always positive, signified by pain in the groin region.The imaging findings of FAI can be seen on plain radio-graphs, CT scan, MRI, and magnetic resonance angiography. Some of the abnormalities seen include abnormal lateral femo-ral head/neck offset seen as a lateral femoral neck bump, os acetabuli, synovial herniation pits, acetabular over-coverage, hyaline cartilage abnormalities, and labral tears.Treatment of FAI has traditionally been surgical and has evolved from open surgical treatment with acetabuloplasty, to combined


Surgery_Schwartz

Surgery_Schwartz. over-coverage, hyaline cartilage abnormalities, and labral tears.Treatment of FAI has traditionally been surgical and has evolved from open surgical treatment with acetabuloplasty, to combined open-arthroscopic–assisted techniques, to all arthroscopic techniques. Hip arthroscopy is becoming increas-ingly popular and is being more frequently applied for this indi-cation. This popularity is largely the result of studies reporting on improvement of functional outcome measures with follow-up of 10 years in some studies and with relatively low compli-cation rates.SPINESpinal TraumaIn spinal injury, spinal stability must be assessed and the patient immobilized until the spine is cleared. CT scan is more reliable in assessing spine injury than plain radiographs. In patients with ankylosing spondylitis, an MRI is the best study to rule out occult fracture and epidural bleeding. When neurologic deficits are present a decompressive procedure may be indi-cated. In spinal cord compression, prompt


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Surgery_Schwartz. an MRI is the best study to rule out occult fracture and epidural bleeding. When neurologic deficits are present a decompressive procedure may be indi-cated. In spinal cord compression, prompt decompression should be performed. Spinal cord injuries should be triaged to trauma centers since trauma center care is associated with reduced paralysis.Occipital Cervical DislocationMotor vehicle accidents can cause dislocation of the occiput on the condyles of the atlas (C1). Most patients with this injury suffer cervical cord injury and do not survive. Traction on the spine is contraindicated. Treatment consists of stabilization and fusion in situ using a screw plate from the mid cervical spine to the occiput.Fractures of C1 (Jefferson Fracture)Fracture of the C1 ring was described by Jefferson in 1920. The thin anterior and posterior rings of the C1 vertebra fracture with axial loads. C1 fracture causes the lateral masses of C1 to spread, which can be visible on an open-mouth view. A


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Surgery_Schwartz. in 1920. The thin anterior and posterior rings of the C1 vertebra fracture with axial loads. C1 fracture causes the lateral masses of C1 to spread, which can be visible on an open-mouth view. A lateral view of the C-spine may show the fracture; however, this injury could be missed due to inadequate visualization of the occipitocervical junction. CT scan is the ideal study for a Jefferson Fracture. The transverse ligament may be ruptured with a Jefferson fracture, and this will render the fracture unstable, which can cause injury to the spinal cord (Fig. 43-27). Jefferson fractures may be associ-ated with other spine fractures. This injury is rarely associated with neurologic injury. The treatment of a Jefferson fracture is based on the integrity of the transverse ligament. The integrity of the transverse ligament is assessed by the amount of C1 lat-eral mass displacement determined by open-mouth radiograph and CT scan. Significantly displaced fractures (less than 7 mm) indicate


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Surgery_Schwartz. of the transverse ligament is assessed by the amount of C1 lat-eral mass displacement determined by open-mouth radiograph and CT scan. Significantly displaced fractures (less than 7 mm) indicate disruption of the transverse ligament. An increase in the atlanto-dense interval (ADI) may indicate a transverse ligament injury. Normally, the ADI is less than 3 mm, as seen on the lat-eral view. An unstable injury with a rupture of the transverse ligament may need a posterior C1-C2 fusion.Bracing with a cervicothoracic orthosis or a halo ring and vest is the recommended treatment for nondisplaced and mini-mally displaced fractures; significantly displaced unstable frac-tures require more definitive surgical treatment.Fractures of C2 (Odontoid Fracture)Half of normal cervical rotation occurs at the atlantoaxial joint. The odontoid (Dens) is a small bony process which arises from the body of C2, and articulates with the body of C1 (the Atlas). There are three types of odontoid fractures (Fig.


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Surgery_Schwartz. atlantoaxial joint. The odontoid (Dens) is a small bony process which arises from the body of C2, and articulates with the body of C1 (the Atlas). There are three types of odontoid fractures (Fig. 43-28). Type I fractures are the most common and are avulsion fractures off the tip of the dens. Type I fractures occur when there is tension applied to the alar ligaments (which span from the tip of the odontoid to the skull bypassing the C1 vertebra). Type I frac-tures are stable and managed nonoperatively.Type II fractures, at the base of the odontoid, results from lateral loading forces. Operative stabilization in patients with a high risk of fracture nonunion is the preferred treatment since immobilization in a halo vest results in nonunion rates ranging 89Figure 43-27. Jefferson fracture with and without ligamentous injury. Note the increased ADI and the potential compression of the spinal cord (orange color).Brunicardi_Ch43_p1879-p1924.indd 190022/02/19 10:41 AM 1901ORTHOPEDIC


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Surgery_Schwartz. with and without ligamentous injury. Note the increased ADI and the potential compression of the spinal cord (orange color).Brunicardi_Ch43_p1879-p1924.indd 190022/02/19 10:41 AM 1901ORTHOPEDIC SURGERYCHAPTER 43from 20% to 80%. The risk of nonunion includes displacement greater than 5 mm, angulation greater than 10 degrees, age over 50 years, smoking, and delayed diagnosis more than 4 weeks. Nonunion occurs due to interruption of the blood supply. Trans-fixing the odontoid fracture with a screw maintains rotational movement. Posterior fusion of C1 on C2 is another option, but this results in decreased cervical spine rotation; 50% of rotation of the cervical spine comes from C1 and C2 joint.Type III fractures extend into the body of C2, below the origin of the odontoid process. The cancellous bone is rich in blood supply and usually heals well. Type III fractures are gen-erally treated with a halo brace.Hangman’s Fractures of C2Hangman’s Fractures are a bilateral fracture of the


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Surgery_Schwartz. bone is rich in blood supply and usually heals well. Type III fractures are gen-erally treated with a halo brace.Hangman’s Fractures of C2Hangman’s Fractures are a bilateral fracture of the pars inter-articularis (Fig. 43-29). The spinal canal is usually widened, and neurological deficits rarely occur (Fig. 43-30). It results from sudden extension forces on the neck. Treatment is simple immobilization in a halo vest. Higher energy injuries causing severe extension forces can dislocate the C2-3 facet complex and damage the C2-3 disc. Significantly displaced Hangman’s fractures are managed by internal fixation and bone grafting between C2 and C3. When the fracture is severely angulated, it may indicate a flexion distraction injury, and traction on the C-spine may exacerbate the injury.Compression Fracture of the Cervical SpineIn C3 to C7 an axial load can cause fracture of the endplate while preserving the posterior cortex of the vertebral body. These fractures generally heal well and


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Surgery_Schwartz. Fracture of the Cervical SpineIn C3 to C7 an axial load can cause fracture of the endplate while preserving the posterior cortex of the vertebral body. These fractures generally heal well and are treated nonopera-tively with analgesics and a cervical brace.Burst Fractures of the Cervical SpineBurst Fractures of the cervical spine usually result from axial loads such as in diving and motor vehicle accidents. The injury results in displacement of bony fragments into the canal, injur-ing the spinal cord. Burst fractures are treated surgically by anterior decompression (corpectomy) and reconstruction using a bone graft strut stabilized with a plate and screws.Unilateral and Bilateral Facet DislocationThis injury is usually associated with motor vehicle accidents. A restrained passenger can suffer forced flexion with distrac-tion resulting in dislocation of the facets. The diagnosis can be made on lateral radiographs. Unilateral facet dislocation can be missed on an X-ray. It usually shows


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Surgery_Schwartz. forced flexion with distrac-tion resulting in dislocation of the facets. The diagnosis can be made on lateral radiographs. Unilateral facet dislocation can be missed on an X-ray. It usually shows less than 25% sublux-ation on an X-ray, and it affects the nerve roots. Bilateral facet dislocation will have more than 50% subluxation on an X-ray and may cause severe spinal cord injury. Treatment consists of closed reduction with axial traction utilizing cranial tongs, grad-uated application of weight, and periodic X-rays. The patient is kept awake for safety concerns. A closed reduction should not be done if the patient is not awake. Facet dislocations could be associated with disc herniation. An MRI is the study of choice to rule out disc herniations and should be done prior to reduc-tion in an unconscious patient or prior to open reduction and/or surgical fixation. When a reduction is obtained, the patient is taken to surgery for fusion, which may be performed anteriorly Figure


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Surgery_Schwartz. in an unconscious patient or prior to open reduction and/or surgical fixation. When a reduction is obtained, the patient is taken to surgery for fusion, which may be performed anteriorly Figure 43-28. The three types of Odontoid fractures.Figure 43-29. Lateral view shows displaced hangman’s fracture.Figure 43-30. Hangman’s fracture cross-section view shows wid-ening of the canal, and therefore the spinal cord is not affected.Brunicardi_Ch43_p1879-p1924.indd 190122/02/19 10:41 AM 1902SPECIFIC CONSIDERATIONSPART IIor posteriorly. Anterior surgery is necessary if the patient has an associated herniated disc.Clay-Shoveler’s InjuryClay-shoveler’s injury can result from a motor vehicle accident or from shoveling soil or clay. The injury (of C6, C7, T1, and T2) is the result of avulsion fracture of the spinous process by the paraspinal muscle forces (Fig. 43-31). The fracture is treated nonoperatively with analgesics and a soft collar.FRACTURES OF THE THORACIC AND LUMBAR SPINEThoracic