Part | 3 | Orthopaedics
Fig. 25.11 Pathology of late hallux valgus. The big toe lies
in valgus and the second toe may override it or lie beneath
it. The second metatarsophalangeal joint dislocates. The
extensor hallucis longus tendon acts as a bowstring
accentuating the deformity. An inflamed bursa develops over
an exostosis on the first metatarsal head.
wear has any influence, either good or bad, on the Fig. 25.12 Hallux valgus in an elderly patient. The great toe
development of hallux valgus, although bad shoes is overriding the second toe.
can probably aggravate the problem if it is already
there.
Two main groups of patients are affected by hallux
valgus. In the first group, which consists of adoles-
cents and young adults, the condition is often
familial and the primary pathology is a varus first
metatarsal. The articular surfaces are intact in these
patients.
The second group consists of elderly women, and
occasionally men, with degenerative changes in
the first metatarsophalangeal joint, and secondary
deformities in the adjoining toes (Figs 25.12, 25.13).
These two groups are very different and should be
treated differently.
Conservative treatment
There is no conservative management which cor-
rects the deformity. Sponge pads and splints may be
comfortable, but they do not arrest the progress of
the condition.
Surgical shoes are helpful in the old and infirm
patient, for whom surgical correction is not appro-
priate, but these shoes are unacceptable to younger
patients.
Operative treatment Fig. 25.13 Radiograph of a patient with hallux valgus and
early osteoarthritis in the first metatarsophalangeal joint with
Several operations are available (Fig. 25.14): dislocation of the second metatarsophalangeal joint.
1. Metatarsal osteotomy.
2. Exostectomy.
438
Chapter | 25 | Disorders of the ankle and foot
ab
c
Fig. 25.14 (a) Metatarsal osteotomy for correction of
metatarsus primus varus and hallux valgus in a young
patient. (b) Arthrodesis of the first metatarsophalangeal joint.
3. Excision arthroplasty (Keller’s operation). Fig. 25.15 Hallux valgus with bursa overlying prominent
joint.
4. Arthrodesis.
bunion and may become red, painful or infected
Metatarsal osteotomy is the most popular operation (see below).
in younger patients and corrects the deformity by
moving the whole toe and metatarsal head laterally. If there is a varus metatarsal the exostosis and the
The head must also be moved slightly inferiorly to bursa should be excised and an osteotomy per-
balance the load taken by the metatarsal heads. This formed. If there is no varus metatarsal or if there is
procedure is indicated in young patients with intact degenerate osteoarthritis as well as hallux valgus, an
joints. exostectomy and excision arthroplasty is better.
Exostectomy. If the main complaint is the bony Bunions
swelling over the metatarsal head, it is reasonable to
excise it but the patient must be warned that the Patients complain of ‘bunions’ but the word means
deformity is likely to progress. different things to different people (Fig. 25.15).
Strictly speaking, a bunion is a bursa over an unduly
Excision arthroplasty or Keller’s operation (see Fig. prominent first metatarsal head or an exostosis on
25.10) produces a toe that is slightly shorter and the metatarsal.
more ‘floppy’ than normal. Shortening the toe also
has the disadvantage that it allows the sesamoids to The bursa can become infected and the infection
slip backwards and leaves the metatarsal head can spread to the first metatarsophalangeal joint. In
unsupported, which in turn causes pain in the fore- patients with diabetes this may lead to gangrene; in
foot. The operation is useful for older patients with patients with rheumatoid arthritis the skin may be
arthritic joints and secondary deformities. very slow to heal.
Arthrodesis is sometimes recommended for hallux Treatment
valgus but is most useful in men with secondary
deformities of the other toes (Fig. 25.14b). A soft felt pad and comfortable shoes will solve the
problem for many patients. If this fails, operation
Choice of treatment. Management depends largely must be considered.
upon the age of the patient. Deformities in adoles-
cence are usually the result of a varus first metatar- 439
sal, with the toe lying in valgus to compensate. At
this age the condition is likely to progress rapidly;
no conservative treatment is effective and metatarsal
osteotomy is required.
In older patients the main problem is often an
exostosis and bursa overlying the metatarsal head.
This bump, with its bursa, is popularly called a
Part | 3 | Orthopaedics
‘Bunionectomy’, to remove the bump and bursa,
is a good operation if there is no hallux valgus. If
hallux valgus is present, excision of the bunion
alone is not enough and may actually make the
deformity worse.
Secondary deformities
Lateral displacement of the other toes
A valgus hallux can push the other toes laterally,
sometimes until the big toe lies transversely across
the foot with the others resting on it.
Treatment
Although correction of all these deformities is pos-
sible, surgical shoes may be preferable to extensive
corrective surgery in an elderly patient with a gross
deformity.
Dislocated second toe Fig. 25.16 Subungual exostosis.
Subluxation of the second metatarsophalangeal the hallux valgus is corrected. An untreated hammer
joint with flexion at the proximal interphalangeal toe develops a bursa over the p.i.p. joint and a corn
(p.i.p.) joint is a common deformity. In some beneath the second metatarsal head.
patients, the toe dislocates with the p.i.p. joint fixed
in flexion and the proximal phalanx lying on the Treatment
dorsum of the second metatarsal (see Fig. 25.11).
Arthrodesis of the p.i.p. joint will correct the
Treatment deformity but only if the metatarsophalangeal
joint is normal. If this joint is dislocated, as it often
Conservative treatment is not effective, but the toe is, the base of the phalanx should be excised as
can be brought into good position by excising the well.
base of the phalanx and arthrodesing the p.i.p.
joint.
As for Keller’s operation, the position of the toes
can be held with a longitudinal wire.
Subungual exostosis Mallet toe
A small exostosis on the dorsum of the distal phalanx Mallet toe (see Fig. 21.21) is a congenital abnormal-
can cause severe pain. The lesion is benign (Fig. ity of the distal interphalangeal (d.i.p.) joint, and is
25.16). usually familial. The toe interferes with shoe wear
and the terminal phalanx may develop blisters.
Treatment
Treatment
Excison of the exostosis is the only effective
remedy. Unless there are troublesome symptoms from the
toe, the deformity should be left alone, but
Hammer toe arthrodesis or amputation of the terminal phalanx
may be needed if there is excessive pressure on
Hammer toe has been described on page 359. Defor- the tip of the toe. Conservative treatment is not
mities secondary to hallux valgus will recur unless effective.
440
Chapter | 25 | Disorders of the ankle and foot
Metatarsalgia On clinical examination the web space between
the third and fourth toes is tender, there may be
Pain in the forefoot, or metatarsalgia, can be due to diminished sensibility of the toes, and sideways
many things. A prominent metatarsal head is a compression of the foot will produce a painful click.
common cause of pain and can follow any opera- Similar signs and symptoms result from a ganglion
tion on the forefoot, including Keller’s operation in the web space.
(p. 437) or dislocation of the second toe.
Treatment
Treatment
A small insole to support the metatarsal shaft is
If soft insoles are not effective, pain from prominent sometimes effective but if the symptoms persist
metatarsals may be relieved by a metatarsal osteot- despite this and cause genuine disability then the
omy, which allows the metatarsal head to ride up neuroma must be excised.
to a better position and to take a more natural pro-
portion of body weight. Freiberg’s disease
Morton’s metatarsalgia The head of the metatarsals may be affected during
adolescence by Freiberg’s disease, a vascular osteo-
The medial and lateral plantar nerves join in the sole chondritis similar to Perthes’ disease (Fig. 25.18).
between the third and fourth metatarsal heads (Fig. The second and third metatarsals are most often
25.17). At this point the nerve is subjected to par- involved.
ticular pressure and this can produce interneuronal
fibrosis within the nerve. A nerve so affected is
thickened and the thickening is called a Morton’s
neuroma.
Patients with a Morton’s neuroma characteristi-
cally complain of a feeling something ‘like a stone
in the shoe’, often accompanied by tingling in the
adjacent sides of the third and fourth toes.
Fig. 25.17 Morton’s metatarsalgia. Fig. 25.18 Freiberg’s disease of the metatarsal head.
441
Part | 3 | Orthopaedics
Treatment The metatarsal heads are then separated from the
ground only by atrophic tendons and thin skin. The
Often, no specific treatment is required. bones can erode the skin, leading to infection and
further bone destruction.
Rheumatoid arthritis
Treatment
Rheumatoid arthritis attacks small joints and the
foot is therefore vulnerable. The changes in the Conservative treatment consisting of soft moulded
foot are similar to those in the hand, with the added footwear and careful attention to the skin is very
complication that the patient must walk on the important. Prominent exostoses and metatarsal
painful joints. heads cause skin lesions which quickly extend down
to bone, particularly if the patient is receiving
Involvement of the metatarsophalangeal joints is steroids.
a special problem. As the tissues become weaker the
phalanges move dorsally, bone is destroyed and the If conservative measures are ineffective a forefoot
transverse pad of soft weight-bearing tissue which arthroplasty must be performed to remove all the
normally lies under the metatarsal heads comes to metatarsal heads and bring the soft pad of weight-
lie underneath the toes instead (Figs 25.19, 25.20). bearing skin back under the metatarsal heads. This is
a reliable operation giving good long-term results.
Fatigue fractures
The causes and treatment of fatigue fractures have
been mentioned on page 100.
Gout
Gout is described on page 305. Traditionally, the
first metatarsophalangeal joint is affected but in fact
the other joints are affected just as often.
Fig. 25.19 Rheumatoid arthritis of the feet. Note the Flat foot (pes planovalgus)
prominent metatarsal heads and the rheumatoid nodule.
Generalized ligamentous laxity affects the joints of
Fig. 25.20 Rheumatoid arthritis of the forefoot with the foot as well as the rest of the body and the arches
destruction and dislocation of the metatarsophalangeal of patients with this condition flatten when the foot
joints. is weight bearing. Children with flat feet that return
to normal when standing on tiptoe or lying on the
442 examination couch are described on page 353.
Painful flat feet are a cause of pain in older patients
with degenerative osteoarthritis of the subtalar and
midtarsal joints. This is often due to a ruptured tibi-
alis posterior tendon.
Although pes planovalgus does cause pain on
walking, corns, verrucae and prominent metatarsal
heads are more common causes of pain in the
forefoot.
Treatment
Apart from comfortable shoes and a support to the
medial arch of the foot, no conservative treatment
is effective. If the symptoms are disabling, which is
Chapter | 25 | Disorders of the ankle and foot
very rare, a triple fusion (p. 353) or calcaneal oste- Neurological disorders
otomy to correct the position of the foot may be
required, but most patients manage perfectly well One of the pitfalls of orthopaedic surgery is the
despite their deformed foot. Reconstruction of a serious but unusual condition which masquerades
ruptured tendon may not be successful and tendon as a common problem.
transfers are often needed to restore the arch. In the
older patient, a specially made ‘surgical’ shoe may Patients with Friedreich’s ataxia, peroneal muscu-
be required. lar atrophy and muscular dystrophy may all present
to the orthopaedic surgeon with a foot deformity.
Fallen arches Wasting of the calf and peroneal muscles should
alert the surgeon to the possibility of a neurological
Fallen or dropped arches are part of medical folk- condition being present.
lore. The term is widely used to mean feet that are
painful on walking even though the transverse arch Spina bifida occulta and diastematomyelia both
probably does not exist and the only arch of any cause tethering of the spinal cord and stretching of
importance is the medial. the nerve roots with growth. Deformity of the feet
is often the first clinical sign. Both conditions are
Pes cavus usually accompanied by sensory symptoms and
this, with the rapid onset, provides a clue to the
A high arched foot can be due to a congenital bony diagnosis. Beware of feet that develop a deformity
abnormality but can also be caused by neurological after being normal, and deformed feet with sensory
conditions, particularly spasticity of the flexor symptoms.
muscle groups.
Toe-walkers
Treatment
Children who persistently walk on tiptoe are
Provided that there is no underlying neurological described on page 350.
abnormality and the foot provides good service, a
comfortable shoe is the only treatment required. If Other causes of foot pain
the foot is painful or unsatisfactory for any other
reason, a corrective osteotomy or soft tissue release Do not forget that there are many other causes of
may be needed to make the foot plantigrade. painful feet that do not reach a doctor. Chiropodists
and podiatrists do an excellent job and probably
treat more foot conditions than doctors.
443
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Chapter |26|
Disorders of the spine
By the end of this chapter you should be able to:
• Differentiate between mechanical back pain and those patients with a neurological defect.
• Discuss the indications for spinal operations and also be well aware of the risks.
• Investigate the patient with a painful back by taking the history, doing a clinical examination and ordering
the appropriate radiology.
• Make a differential diagnosis of a prolapsed disc.
• Remember the cauda equina lesions and resolve never to miss these!
• Be aware of the congenital growth abnormalities and how these present.
Cervical spine Movement of the cervical spine is also restricted,
particularly flexion and rotation on the affected
Acute disc prolapse side.
The cervical spine is very flexible and the interverte- Treatment
bral discs are subjected to considerable strains. The
cervical roots cross the discs as they leave the spinal Conservative treatment. Analgesics, rest, a collar and
canal, where they are vulnerable to pressure from traction will usually produce a remission of symp-
disc protrusion (Fig. 26.1). Disc protrusions in the toms but the pain may be so severe and intractable
neck are usually more lateral than those in the that disc excision is required as an urgent
lumbar spine and affect one level only. procedure.
As in the lumbar spine, disc protrusions are Operative treatment. Disc excision may relieve pain
accompanied by pain, altered sensibility and weak- and improve neurological function but it makes the
ness. The four lowest roots are most often affected cervical spine more unstable than the corresponding
and are accompanied by pain and sensory symp- operation on the lumbar spine and the root can still
toms in the radial side of the forearm and hand, be irritated even when the disc has been excised. To
with weakness of grip (C8) and elbow flexion avoid this, operation is sometimes accompanied by
(C5–6). a cervical fusion in which a block of bone is inserted
445
Part | 3 | Orthopaedics
Fig. 26.1 Cervical disc protrusion compressing a cervical
root.
between the adjacent vertebral bodies. The role of
cervical fusion, which puts greater strain on the
intact discs, is controversial.
Cervical spondylosis Fig. 26.2 Cervical spondylosis. The patient also has
congenital fusion of C2 and C3.
Cervical and lumbar spondylosis are almost univer-
sal in patients over the age of 40 but seldom cause
symptoms.
Spondylosis is different from osteoarthritis
because it occurs around intervertebral discs instead
of in synovial joints (Fig. 26.2). The posterior facet
joints are synovial joints and may develop osteoar-
thritis but the cartilage joints between the vertebrae
cannot do so because they have no joint space. For
practical purposes, however, the two conditions can
be considered together and treated as degenerative
joint disease.
Patients with cervical spondylosis feel a dull pain
in the neck radiating across the shoulders and down
the upper part of the arm, worse on movement. The
pain can be confused with supraspinatus tendinitis
and other shoulder disorders.
Treatment Fig. 26.3 Cervical fusion. A bone block prevents movement
and holds the affected vertebrae apart.
The standard treatment consists of heat, rest, anti-
inflammatory drugs, analgesics and a supporting Rheumatoid arthritis
collar. When the symptoms have subsided, mobiliz-
ing exercises to restore movement are important but Rheumatoid arthritis, which is so destructive to the
it must be said that no properly conducted scientific small joints of the hands and feet, also affects
study has ever shown that these exercises influence the cervical spine (Fig. 26.4). The atlantoaxial
the natural history of the disease. Voltaire may have joint is especially at risk because of the complex
been right when he commented that ‘The efficient synovial folds around the transverse ligament of
physician is the man who successfully amuses his the atlas. If this ligament stretches, the atlas and
patients while Nature effects a cure’. head can slip forwards and the odontoid process
Operation is seldom required for spondylosis but
may be necessary if there is severe pain arising from
a single identifiable level (Fig. 26.3).
446
Chapter | 26 | Disorders of the spine
Acute torticollis
Severe and acute neck pain can be due to many
things, including acute disc prolapse, muscle
spasm, injury to an osteoarthritic facet joint,
inflamed lymph nodes or an undiagnosed cervical
dislocation.
Treatment
Treatment depends upon the cause. Most acute stiff
necks settle with a collar, warmth and analgesia but
serious injuries must be excluded first.
Cervical rib
A vestigial ‘rib’ of bone or fibrous tissue can run
from C7 to the first true rib. When such a rib is
present the lowest part of the brachial plexus runs
across it and neurological symptoms in the arm
may result. Pain down the inner side of the arm
in the T1 distribution should raise suspicions of a
cervical rib.
Fig. 26.4 Rheumatoid arthritis of the spine with forward Treatment
displacement at several levels.
Excision may be necessary if radiographs demon-
presses against the cervical cord, producing strate a complete or incomplete cervical rib; conser-
quadriparesis. vative treatment with physiotherapy to improve
the power of the shoulder girdle muscles has
This is especially important to anaesthetists. The been ineffective. The operation is straightforward
mouth will not open easily if the temporomandibu- but the root of the neck is ‘tiger country’ and the
lar joint is affected. If the neck is also stiff, endotra- operation must only be done by a surgeon who is
cheal intubation is difficult and the manipulation of very familiar with this area.
the neck needed to intubate the patient is hazard-
ous. Accordingly, patients with rheumatoid arthritis Congenital short neck
must always have the cervical spine examined radiologi- (Klippel–Feil syndrome)
cally before undergoing anaesthesia. All staff, particu-
larly those in the recovery room, should be aware Klippel–Feil syndrome consists of a very short neck
of the potential hazards of flexing a rheumatoid with fusion of two or more cervical vertebrae and
neck. restricted cervical movement (Fig. 26.5). The condi-
tion may be familial and is sometimes associated
Treatment with scoliosis. Richard III (‘Deform’d, unfinish’d,
sent before my time into this breathing world, scarce
A supporting collar is usually sufficient but atlanto- half made up’) may have had Klippel–Feil
axial fusion may be needed if there is a neurological syndrome.
deficit or unremitting pain.
Treatment
No specific treatment is required but the scoliosis
may need correcting.
447
Part | 3 | Orthopaedics
Fig. 26.5 Klippel–Feil syndrome. A short webbed neck with
low hairline.
Fig. 26.7 Congenital hemivertebra. There is an extra
vertebra and rib on the right side.
Congenital hemivertebra
Congenital hemivertebra (Fig. 26.7) and other
anomalies also occur and may be associated with
neurological abnormalities.
Fig. 26.6 Sprengel’s shoulder. A high fixed scapula. Neuralgic amyotrophy
Congenital high scapula Neuralgic amyotrophy is an odd condition which is
(Sprengel’s shoulder) probably due to a patchy demyelination of the bra-
chial plexus. The symptoms may follow vaccination.
Sprengel’s shoulder is a congenital deformity in Like meralgia paraesthetica, this condition is impor-
which the scapula is small and abnormally high tant because it has neurological features that may be
(Fig. 26.6). The condition may be bilateral. No confused with a spinal disorder.
cause is known except that there is a failure of devel-
opment of the shoulder and the muscles attached to Characteristic features are:
it and it is often associated with congenital spinal
anomalies. 1. Sudden severe pain down the arm, similar to that
of a disc protrusion.
Treatment
2. Paralysis of parts of the shoulder girdle as the
Some improvement in position follows release of pain eases. The nerve to serratus anterior is said
the muscles along its upper border if carried out at to be involved most frequently, producing a true
an early age. winged scapula.
448 3. Muscle wasting is seen in the affected area.
Treatment
The pain usually resolves without treatment over a
period of weeks, but the weakness may take up to 2
Chapter | 26 | Disorders of the spine
years to recover. Apart from reassurance and exclud- lesions proven beyond doubt, which limits the
ing other disorders, no treatment is required. common indications to the following conditions:
Acute stiff neck Indications for spinal operations
Not all pain in the neck is due to a disc protrusion • Disc excision for proven disc protrusions with
or cervical spondylosis. An acute stiff neck, perhaps neurological signs.
due to a small muscle tear or a derangement of the
facet joints, can occur for no apparent reason. • Instability caused by spondylolisthesis or unstable
discs.
Treatment
• Scoliosis, kyphosis and other spinal deformities.
The symptoms usually resolve spontaneously over a • Some tumours and infections.
period of days or weeks. A supporting collar eases
the pain and manipulation is sometimes helpful. Note: Backache is not included!
Torticollis in children Acute back strain
See page 363. Acute pain in the back radiating down to the knee
but not beyond and without neurological abnor-
Lumbar spine mality is usually due to an acute muscle or ligament
strain in the lumbar spine. The symptoms can be
Back pain precipitated by a sudden violent movement or by a
comparatively trivial movement following a period
In any one year, more working hours are lost from of hard work when the muscles are stiff.
back pain than from any other medical condition.
Back problems therefore take up much of the Tall slim people with willowy backs and weak
medical profession’s time. As many as 25% of refer- muscles are said to be especially prone to acute back
rals to some orthopaedic clinics are for back pain. strains, as are those in sedentary occupations, such
as medicine, who live a life of ease during the week
It is a bad principle to operate on a painful back and punish themselves at the weekend with exces-
unless a definite mechanical cause has been identi- sive gardening.
fied. In the past, painful backs were operated upon
far too often and the results were poor. Many Those who sit for a long time and then have to
patients were no better and some were made worse lift heavy weights without an adequate ‘warm-up’,
by operation. Spinal surgery, particularly spinal e.g. carriers who may drive for more than an hour
fusion, earned a bad name, richly deserved because with the spine flexed in a bumpy vehicle and then
operation was often followed by severe pain and leap out of their seat to lift a heavy weight from the
stiffness which disabled the patient more than the back of the van, are also very vulnerable.
original condition.
The sacroiliac joints are also said to be subject to
Back pain alone is not an orthopaedic problem. It acute strains, but without conclusive proof. The
is best managed conservatively by departments of joints have a large surface area, they have poor
physical medicine and rheumatology, and to refer mechanical cohesion and violent twisting strains
every patient with back pain to an orthopaedic can cause severe pain around them.
surgeon is a little like referring every patient with
headache to a dentist. Unfortunately, patients with Prevention
backache are frequently referred to orthopaedic
clinics for historical reasons. The ‘strain’ is usually the result of incorrect lifting
and most can be avoided. Workers who have to lift
Spinal surgery, however, is definitely an orthopae- heavy weights, including nurses who lift patients,
dic problem and many surgeons with a specialist should be taught correct lifting techniques (Fig.
interest in the spine also treat the painful spine. The 26.8). Four principles are important:
spine should only undergo operation for anatomical
Correct lifting technique
1. Do not lift with the spine flexed; in this position,
the weight is hanging on taut ligaments and
449
Part | 3 | Orthopaedics
Fig. 26.8 Incorrect and correct lifting. Keep the weight close Rest. The patient should rest in the most comfort-
to the body and the back straight. Lift with the knees. able position possible, which is usually on the back
or side with the knees flexed. If lying in bed is
stretched muscles, which makes them vulnerable painful it is perfectly acceptable to rest in a comfort-
to additional load. Instead, lift with the lumbar able chair.
spine extended.
2. Keep the weight to be lifted as near to the body Analgesics. Any analgesic or NSAID can be used.
as possible. The further the weight is from the Narcotics such as pethidine should not be needed.
body, the more effort that has to be expended
in lifting it. Heat, either from a hot water bottle or a heat pad,
3. Lift with the knees, not the back muscles. is very comforting for pains arising from muscles
4. Make the job as easy as possible. Ensure that and ligaments and the diagnosis should be recon-
there is good access to the load, if possible split sidered if heat does not help. The mechanism of
it into lighter loads but, if it cannot be split, share relief is obscure, but is probably nothing more than
the job with two or more people. old-fashioned counterirritation. Even if unscientific,
In the workplace, lifting can be made easier by patients find warmth helpful.
storing goods at waist height and avoiding the need
for a twisting motion while lifting or carrying or by Gradual mobilization. As the pain subsides, gradual
using lifting equipment and conveyor belts. mobilization can be started, but the patient must be
prevented from lifting weights and risking further
Treatment injury for at least 6 weeks. This may be difficult if
the patient is a hardworking self-employed worker
The following measures form the standard treat- who needs to get back to work to earn a living. It is
ment for acute back injuries and are reliable; rest, nevertheless essential if recurrent strains are to be
analgesics and gradual mobilization are the most avoided.
important:
1. Rest. Mobilization of the spine is important. If a full
2. Analgesics. range of spinal movement can be achieved, it is
3. Heat. likely that the muscle or ligament has healed and the
4. Gradual mobilization. presence of a full range of movement ensures that
5. Lumbosacral brace. loads can be borne equally throughout the spine.
6. Manipulation.
If movement is limited, further injury is probable.
450 The stiff areas of the spine are more likely to be
injured by sudden stress and the mobile areas will
be taking more strain than normal. A good range of
movement should therefore be achieved before the
patient returns to work, and the range of movement
maintained by an exercise routine.
Lumbosacral brace. If the patient insists on return-
ing to work before full movement has returned, a
lumbosacral support will lessen the risk of recur-
rence. A brace will support the back when the patient
is lifting and, perhaps more important, will ‘remind’
patients of their condition so that they lift
correctly.
Spinal supports should be worn only for pain
relief or to protect the back when it is at greatest risk.
If they are worn permanently the spine will become
stiff, the muscles will take less strain, and further
injury becomes more likely.
Manipulation. Manipulating an acutely painful
back is occasionally harmful if there is some under-
lying undiagnosed pathology but is sometimes dra-
matically successful, particularly if the sacroiliac
joint is affected. Manipulation is a skill which takes
much training and should not be attempted by the
Chapter | 26 | Disorders of the spine
inexperienced. Both osteopaths and chiropractors
are skilled manipulators.
Differential diagnosis
There are two serious conditions that can masquer-
ade as an acute back strain:
1. A lumbar disc protrusion. This can be easily dis-
tinguished from a back strain because the pain
extends below the knee and is accompanied by
neurological symptoms such as numbness, weak-
ness or altered sensibility below the knee (p. 16).
Always check sensibility, power and reflexes distal
to the knee.
2. Spinal tumours, particularly metastases. Radio-
graphs are essential to exclude tumours in the
vertebrae if there is any doubt.
Recurrent back strains Fig. 26.9 Disc prolapse and root compression at the L4–5
junction. A laterally placed prolapse may compress the L4
Patients suffering recurrent back strains should seek root, a more central prolapse will compress L5 and a central
the help of a rheumatologist or specialist in reha- prolapse the cauda equina. Osteophytes in the lateral canal
bilitation rather than an orthopaedic surgeon. will also produce root compression.
Treatment by vague low back pain. CT scans can demonstrate
the lesion, and injection of saline or contrast
Operations have no place in the management of medium may reproduce the back pain.
recurrent back strain. All the measures described for
the management of acute back strains should be As degeneration proceeds, the annulus fibrosus
used, with special attention to prevention. Spinal softens and the degenerate disc bulges the annular
fusion will make matters worse unless the disc is ligament backwards, usually just lateral to the
also unstable. midline (Fig. 26.9). If this occurs in a tight spinal
canal opposite a nerve root, the function of the root
Prolapsed intervertebral disc is affected.
Anatomy Ninety per cent of lumbar disc protrusions involve
the lowest two spaces, L4–5 or L5–S1. Lesions which
The discs are not solid lumps of inert gristle resem- press on the L5 root cause altered sensibility on the
bling rubber pads, as patients often think, but living outer side of the calf and weakness of the peronei
structures which flatten slightly during the day and and ankle extensors, while those affecting the S1 root
re-expand at night. They consist of a firm nucleus produce altered sensibility on the foot or back of the
pulposus surrounded by the annulus fibrosus, a ring calf, weak ankle flexors and a depressed ankle jerk.
of fibrocartilage and fibrous tissue which links the The resting muscle tone of the glutei, hamstrings,
two vertebrae together. The disc is a symphysis calf muscles and other posterior muscle groups may
between each pair of vertebrae and, with the two also be reduced and these muscles may waste.
posterior facet joints, allows movement between
the vertebrae. Clinical features
The tension within the disc is maintained by fluid Unless there are neurological symptoms and signs
imbibition at the cellular level. If imbibition fails below the knee, the patient probably does not have
for any reason, the pressure within the disc falls, the a true prolapsed intervertebral disc. Disc lesions
disc collapses, increased movement occurs between seldom cause severe back pain and it is quite wrong
the adjacent vertebrae, the annulus fibrosus is to use the term as a synonym for acute back strain.
exposed to increased stress and this is accompanied
451
Part | 3 | Orthopaedics
If the disc presses on a nerve root, the postural Differential diagnosis of prolapsed discs
reflexes diminish pressure on the root by holding (Fig. 26.13)
the spine curved to produce a ‘sciatic scoliosis’.
1. Tumours within the spinal canal.
Straight leg raising, which stretches the nerve, is 2. Neurofibromas in the root canal.
restricted by pain. Other tests which stretch the 3. Ependymoma and other tumours.
nerve are also positive (p. 17). 4. Intracranial tumour.
5. Ankylosing spondylitis.
Be wary of patients with no straight leg raising; the 6. Intrapelvic mass.
nerve root is not stretched until the leg is lifted 30°, 7. Osteoarthritis of the hip.
and pain before this level is reached is more likely 8. Spondylosis.
to be caused by apprehension, hysteria, malinger- 9. Malingering.
ing, or one of the conditions listed below. Beware 10. Vertebral tumours.
also of the patient who can lean forward and touch 11. Tuberculosis.
the toes on the couch yet has restricted straight leg 12. Infective discitis.
raising. These features are not compatible with a 13. Intermittent claudication.
simple organic disorder.
Treatment
Investigations
Left untreated, the symptoms disappear spontane-
It is helpful to know the exact site of the lesion if ously even if the protrusion remains. In other
operation is planned. MRI (Fig. 26.10) is the main- patients, the annulus fibrosis will rupture and disc
stay of treatment, but radiculography (Fig. 26.11) or material will be extruded into the spinal canal. This
CT (Fig. 26.12) can be used. may make the symptoms either dramatically better
or dramatically worse.
Differential diagnosis
In patients over the age of 40 a plain radiograph
Any condition that causes root irritation or pain in should always be obtained and routine investiga-
the leg can be mistaken for a disc prolapse, includ-
ing the following conditions:
Fig. 26.10 MRI scan of a prolapsed intervertebral disc at L5– Fig. 26.11 Radiculogram showing a disc prolapse on the
S1. By kind permission of the MRIS Unit, Addenbrooke’s right side.
Hospital, Cambridge.
452
Chapter | 26 | Disorders of the spine
ab
Fig. 26.12 (a) CT scan showing prolapsed disc material compressing the spinal contents. (b) A normal CT scan for
comparison.
Malingering tions carried out to exclude a spinal tumour and
systemic disease before any treatment is started. The
Brain incidence of positive findings in patients between
tumour the ages of 20 and 40 is so low that some radiolo-
gists believe a preliminary radiograph is unnecessary
Lumbar Spinal cord until conservative treatment has failed, but most
spondylosis tumour cautious doctors will wish to see a radiograph at
Vertebral tumour some stage.
Infective discitis Neurofibroma
Tuberculosis Ankylosing spondylitis Conservative treatment. Because some natural
recovery is likely, it is wrong to operate without a
Pelvic tumour OA of hip fair trial of conservative treatment unless there is a
cauda equina lesion (p. 455). Treatment consists of
Arterial disease two main measures:
causing claudication
1. Rest, analgesics and muscle relaxants.
Fig. 26.13 Differential diagnosis of disc prolapse.
OA, osteoarthritis. 2. Traction.
Rest. The patient should stay in bed in the most
comfortable position with adequate analgesia and,
if necessary, muscle relaxants such as diazepam
5 mg twice daily. Bed rest should be total, in hospi-
tal if possible. Total bed rest at home is a formidable
undertaking that places a great strain on the family.
453
Part | 3 | Orthopaedics
Most patients defy instructions and get up for meals 1. No improvement in the symptoms and signs after
and toilet purposes. 6 weeks of rest.
Traction helps to keep the patient in bed and 2. An increase in the neurological deficit.
some say that is all it does. It may also relieve muscle
spasm and pain but it does not ‘replace the disc’. 3. Bladder or bowel involvement suggesting a cauda
equina lesion.
‘Putting the disc back’. Manipulation of spines with
acute disc prolapse is very dangerous. While osteo- 4. Intractable pain.
pathic and chiropractic manipulations are excellent
for chronic back problems, manipulation in the If operation is considered, a CT or MRI scan is
presence of neurological symptoms and signs can needed to demonstrate spinal nerve roots and iden-
rupture the annulus fibrosus, extrude disc material tify the disc protrusion. If the site of the disc protru-
and cause severe neurological damage. The concept sion matches the clinical signs, the disc can either
of ‘putting the disc back’ by manipulation, as if it be softened by chymopapain injection or excised
were a piece of jigsaw, is firmly rooted in the public surgically.
mind and is quite wrong; a prolapsed disc is not a
firm, rounded lump of gristle shaped like a ‘Smartie’, Chymopapain injection (chemonucleolysis). Injection
but looks more like a piece of soggy string (Fig. with chymopapain, a proteolytic enzyme found in
26.14). Discs do not pop in and out like the cuckoo pawpaws and used commercially as a meat tender-
on a cuckoo clock (Fig. 26.15). izer, is suitable for discs that are also ideal for surgi-
cal excision. It is not helpful for patients with chronic
At operation, the disc will usually extrude itself disc lesions and no neurological signs. If the indica-
from the disc space under pressure when the annulus tions are correct, chymopapain injection is effective
fibrosus is excised, and to imagine that these discs in about 70% of patients and in some centres has
can be replaced by manipulation is a fallacy. replaced surgical excision of the disc.
Operative treatment. There are four indications for The injection must be done under image intensi-
considering operation on prolapsed discs: fier control on an inpatient basis and is accompa-
nied by quite severe back pain. There is also a small
incidence of anaphylactic reaction. Chymopapain
injection is successful in the short term but there is
some evidence that the long-term results are less
Fig. 26.14 Prolapsed disc material. The degenerate disc Fig. 26.15 Prolapsed discs are soft, as in Figure 26.14. They
material is soft and soggy. do not pop in and out of place like a cuckoo in a clock.
454
Chapter | 26 | Disorders of the spine
satisfactory than surgical treatment; however, the High lumbar discs
morbidity is still less than that of disc excision.
Disc protrusions at levels above L4 are uncommon
Disc excision is done either by neurosurgeons or and produce unusual physical signs. Any patient
by orthopaedic surgeons. The disc is approached with back pain and a neurological deficit higher
from behind after excising the ligamentum flavum than L5 should be investigated by a neurologist in
and, if necessary, the inferior portion of the lamina case a spinal tumour is present.
overlying the root. This procedure is called fenestra-
tion (from the Latin fenestra, a window). All disc Treatment
material should be removed, including any that has
sequestrated into the spinal canal. The treatment and indications for operation are the
same as those for protrusions at lower levels,
Disc excision relieves neurological symptoms in although excision is needed more often because the
about 75% of patients, provided that it is done in canal is relatively narrow in the upper part of the
the right patients and for the right indications; i.e. lumbar spine.
neurological symptoms that match the neurological
signs and a radiologically proven disc protrusion. Ankylosing spondylitis
The physical signs of muscle weakness and loss of
reflexes do not always return to normal after lami- Ankylosing spondylitis is an inflammatory disease
nectomy and disc excision. of joints which involves the sacroiliac and spinal
joints before others. The HLAb27 gene is commonly
The operation disturbs the ‘triple joint’ between found. The disease is commonest in young men and
neighbouring vertebrae and their facet joints. should be considered in any man between 15 and
Without a complete disc, the bodies move towards 30 years of age with the following features:
each other and put unnatural stresses upon the pos-
terior facet joints, which then degenerate. This is an • Diffuse low back pain or pain in a root
unavoidable problem and some degree of stiffness distribution without neurological signs.
and back pain can be expected in 30–60% of patients
after a disc prolapse, whether it is treated conser • Stiffness of the back worst in the morning.
vatively, surgically or by chemonucleolysis with • Chest expansion less than 5 cm.
chymopapain. • Raised ESR.
• Erosions of the sacroiliac joints.
Microdiscectomy. Discs can be excised through • A rapid response to anti-inflammatory drugs.
small skin incisions or under endoscopic control. • A family history of ankylosing spondylitis.
The technique is new and difficult but the results are • Painless effusions in a large joint.
encouraging. The recovery period is shorter and sur-
gical trauma is minimized. Treatment
Cauda equina lesions Untreated, the whole of the spine from coccyx to
occiput can become a single rigid bar and it is
A very small proportion of discs rupture in the important to maintain motion. Ankylosing spondy-
midline of the annulus fibrosus instead of in the litis is best managed by a rheumatologist. Treatment
lateral recesses and produce a cauda equina lesion of the acute attack is similar to rheumatoid arthritis,
with the following clinical features: with rest and anti-inflammatory drugs followed by
mobilization. In the longer term, regular physio-
• Painless retention of urine. therapy to maintain motion is essential.
• Perianal anaesthesia. Lumbar spondylosis
• Bilateral sciatica. Lumbar spondylosis is present to some extent in
everybody over the age of 40. Few have symptoms
If these signs are present, there is no place for con-
servative management and the disc must be removed 455
surgically as an emergency. Failure to do this can
result in a disabling and permanent cauda equina
lesion.
Part | 3 | Orthopaedics
1. Analgesics and anti-inflammatory drugs.
2. Physiotherapy to restore as much mobility as
possible.
3. A lumbosacral brace to support the spine, just as
a wrist support will help an osteoarthritic wrist.
4. Encouraging the patient to maintain the range of
movement that they have and to learn to accept
their disability.
Root entrapment
Osteophytes can encroach upon the root canal and
cause root compression. The symptoms and signs
are similar to those of an acute disc prolapse but less
acute and less well localized. Investigation requires
MRI or a CT scan (Fig. 26.17).
Treatment
If the nerve root lesion can be localized, the root can
be unroofed to decompress the nerve, but the osteo-
phytes are likely to recur and decompression does
not improve the underlying spondylosis and osteo-
arthritis of the facet joints.
Fig. 26.16 Lumbar spondylosis. Spinal stenosis
even when the radiographs show the characteristic The width of the spinal canal in normal individuals
changes of an osteophyte on the anterior lip of varies greatly. Some patients have narrow canals
the vertebral body and disc space narrowing which can be made still narrower by osteophytes,
(Fig. 26.16). disc prolapses or other space occupying lesions.
A narrow spinal canal is also present in
In advanced spondylosis, the lumbar spine is achondroplasia.
grossly abnormal, with large osteophytes, narrowed
disc spaces and sclerotic vertebral bodies. If the spinal canal is very narrow, congestion of
the cord and roots can occur with exercise and this
The symptoms of spondylosis are like those of can cause pain in the buttocks and legs. The symp-
degenerative joint disease elsewhere: pain or aching toms are usually brought on by extension of the
after activity, and loss of movement. spine when standing or walking and are eased by
flexing the spine or sitting. The symptoms have
much similarity with intermittent claudication, and
the condition is sometimes known as ‘spinal
claudication’.
Treatment Investigation
Unless there is a neurological deficit due to nerve CT scans and MRI demonstrate the constriction in
root compression, surgery has no place in the man- the spinal canal very clearly.
agement of lumbar spondylosis, which is best treated
in a department of physical medicine. Treatment
Operation is not needed unless there is root Conservative treatment is often helpful and
entrapment. The following conservative measures consists of weight reduction, a spinal support and
are usually sufficient to relieve symptoms:
456
Chapter | 26 | Disorders of the spine
Fig. 26.17 CT scan of the lumbar spine showing narrowing of the root canal due to osteophytes.
physiotherapy to reduce hyperextension of the I II
lumbar spine.
If these measures fail, operation to decompress
the spinal cord is usually needed. A wide laminec-
tomy will produce relief but symptoms can recur if
soft tissue forms around the site of laminectomy.
Spondylolisthesis and spondylolysis III IV V
Spondylolisthesis is such a wonderful word that Fig. 26.18 Types of spondylolisthesis: I, dysplastic; II, isthmic;
there is a temptation to use it whenever possible. In III, degenerative; IV, traumatic; V, pathological.
fact, it means only ‘vertebral slipping’ and must be
distinguished from spondylolysis which means a S1 (Fig. 26.19). The pars interarticularis becomes
‘broken vertebra’. There are several causes of spon- attenuated and may break. This is a rare condition,
dylolisthesis (Fig. 26.18). The different types are commoner in girls than boys, and causes severe
classified as follows, using Roman numerals: hamstring spasm (p. 351).
I Dysplastic – a developmental anomaly at the Isthmic. The most common type of spondylolis-
lumbosacral junction. thesis is slipping at a spondylolysis of the pars inter-
articularis caused by a fatigue fracture (Fig. 26.20).
II Isthmic – a fatigue fracture of the pars The condition is common in young vigorous
interarticularis. patients, particularly athletes who hyperextend the
spine, e.g. javelin throwers and fast bowlers, and
III Degenerative – degenerative osteoarthrosis.
457
IV Traumatic – acute trauma.
V Pathological – weakening of the pars interarticu-
laris by a tumour, osteoporosis, tuberculosis or
Paget’s disease.
Dysplastic. A congenital deficiency of the lumbosa-
cral facets allows the L5 vertebra to slip forwards off
Part | 3 | Orthopaedics
ab
Fig. 26.19 Anteroposterior (a) and lateral (b) radiographs of a dysplastic spondylolisthesis. On the anteroposterior view, the
fifth lumbar vertebra looks as if it was viewed from above. Upside down, it looks like Napoleon’s hat on a totem pole.
presents with a dull low back pain radiating to the main problem is degenerative joint disease. It is
buttocks. The cause is obscure. Five per cent of the commonest in women over the age of 55.
normal population have a spondylolysis by the age
of 5 but this figure rises to 6% in adults so it cannot Traumatic. In exceptional cases, the slip can be due
all be the result of hyperextension or violence on to an acute traumatic fracture (see Fig. 10.32).
the sportsfield.
Pathological. Both tumours and osteoporosis can
The midline of the spine is tender at the lumbo- weaken the pars interarticularis enough to allow the
sacral junction and a step can usually be felt at the upper vertebra to slip forwards.
affected level. Neurological signs are absent unless
there is root compression at the site of the lesion. Treatment
Radiographs show a defect (spondylolysis) in Restriction of activity, a lumbosacral support for use
the pars interarticularis which separates the back when the back is painful and exercises to build up
and front halves of the vertebra and allows the ver- the extensor muscles of the spine are all helpful.
tebral body to slip forwards, producing a spondylo-
listhesis. The defect is most easily seen on oblique This is one of the few spinal conditions that may
films. be helped by operation. Operation is indicated if
conservative measures are not effective or there is
Degenerative. Vertebral slipping can result from progression of the slip in a growing child. An inter-
mechanical wear of the posterior facet joints, but in transverse fusion to link the two separated halves of
this condition there is no spondylolysis and the the affected vertebra is simple and reliable.
458
Chapter | 26 | Disorders of the spine
ab
Fig. 26.20 (a) Isthmic spondylolisthesis. Note the defect (arrowed) in the pars articularis. (b) Isthmic spondylolisthesis of L5–S1
and spondylolysis of L4.
Osteochondritis Calvé’s disease
Scheuermann’s disease Calvé’s disease (p. 331) probably does not exist but
it was described as a collapse of the immature ver-
Scheuermann’s disease is described on page 331. tebral body and assumed to be an osteochondritis.
The ring apophyses of the vertebrae are affected and Some cases may perhaps be due to osteochondritis,
growth at the front of each vertebra is arrested. The but tuberculosis and spinal tumours cause the same
condition affects children, usually boys, between appearance and are more serious.
the ages of 13 and 16 and produces a smooth
rounded kyphosis. The condition is usually painless Congenital anomalies
even while it is active.
Minor congenital anomalies of the vertebrae are
Treatment exceedingly common but seldom have serious
consequences.
If the kyphosis is severe, bracing may be effective,
and in very severe cases a spinal fusion may be Lumbarization and sacralization
needed. It is not kind to keep urging the children
to ‘stand up straight’ because they are unable to The boundary between the lumbar spine and sacrum
do so. is not always precise. In some patients L5 may have
459
Part | 3 | Orthopaedics
a large transverse process either articulating with
or fused to the sacrum (partial sacralization) or S1
may be separate from the sacrum (sacralization).
Some patients with these abnormalities have
back pain but there is no hard evidence that the
abnormalities themselves cause pain. Nevertheless,
the presence of pain at the site of a congenital
anomaly is often regarded as strong circumstantial
evidence.
Treatment
Patients with transitional lumbosacral vertebrae
should be treated as if their radiographs were
normal, using anti-inflammatory drugs and physio-
therapy. Operation on the anomaly should be
avoided.
Congenital hemivertebra
A hemivertebra leaves the patient with a lateral kink
in the spine, which causes a compensatory scoliosis
above and below. This may itself cause root irrita-
tion and throw greater strain on the small joints of
the spine (Fig. 26.21).
Treatment Fig. 26.21 Hemivertebra of the lumbar spine.
Physiotherapy and analgesics are usually sufficient,
but the hemivertebra may need to be excised if the
deformity or the symptoms are severe.
Spina bifida Diastematomyelia
As many as 20% of the population have radiological Some congenital abnormalities of the lumbar spine
spina bifida occulta without serious symptoms (Fig. include a fibrous band or bony bar which tethers
26.22), perhaps accompanied by a small hairy patch the spinal cord. As growth proceeds, the spinal cord
or lipoma at the lumbosacral junction or a minor is stretched and neurological signs appear (Fig.
neurological deficit (Fig. 26.23). Others have myelo- 26.24). Children between 5 and 10 years are most
coele, meningocoele or meningomyelocoele with often affected. The sacral roots are the first to be
exposed spinal nerve roots due to a failure of tubula- involved, causing pain in the foot and a high arch
tion of the spinal cord, and these patients have to the foot. Later, numbness develops and the foot
serious problems in the neonatal period and early becomes flat as the sacral roots are more seriously
childhood (p. 356). Between these two extremes damaged.
there is a spectrum of pathology.
Any child with unexplained pain in the feet or
Treatment legs, particularly with a progressive foot deformity,
should be suspected of having a diastematomyelia.
The management of severe spina bifida in children A plain radiograph may demonstrate a bony abnor-
is described on page 356. mality and a CT scan or MRI may show a fibrous
tether. The opinion of a neurological surgeon is
460 helpful.
Chapter | 26 | Disorders of the spine
a
b
Fig. 26.22 Spina bifida occulta: (a) affecting the fifth lumbar vertebra; (b) with a hemivertebra at the lumbosacral junction.
461
Part | 3 | Orthopaedics
a bc
d ef
Fig. 26.23 Types of spina bifida: (a) normal; (b) spinal bifida occulta; (c) meningocoele; (d) meningomyelocoele with exposed
nerve roots; (e) hairy patch at lumbosacral junction; (f) neonate with meningomyelocoele.
Treatment
Less severe manifestations are best treated conserva-
tively unless there is evidence of tethering of the
roots by bony bars or fibrous bands, which should
be divided or excised by a neurological surgeon.
Other conditions
Spinal tumours Fig. 26.24 Diastematomyelia. A fibrous or bony bar splits
the spinal cord.
Metastases
1. Prostate.
The commonest spinal tumour is a metastasis 2. Breast.
and the possibility of a tumour must always be 3. Kidney.
remembered when treating any patient with back 4. Bronchus.
pain, even if the history is long. A history of back Metastatic tumours commonly go to the pedicles,
pain from other causes does not bring immunity to which are destroyed. This can easily be recognized
spinal tumours and it is quite possible for a patient radiologically by looking for an owl in each vertebra
with established back pain of many years standing on the anteroposterior view. The pedicles corre-
to develop a bone tumour in addition to the original spond to the eyes and the spinous process to the
problem. Any painful back should be examined beak. If a pedicle is destroyed, its outline cannot
radiologically if a metastasis is suspected, even be seen. Beware the winking owl!
though making the diagnosis of a spinal tumour
does not always help the patient. An ESR is useful:
if normal, a metastasis is unlikely.
The commonest tumours to metastasize to the
spine are those which usually spread to bone:
462
Chapter | 26 | Disorders of the spine
Primary tumours 5. Radiologically, there is destruction of the anterior
vertebral margin with wedging of one or more
Other bone tumours are seen in the spine, including vertebrae and widening of the psoas sheath.
osteoblastoma and giant cell tumour, but osteo-
genic sarcoma, which occurs typically around the 6. The vertebral collapse produces a sharp angled
growing end of long bones, is very rare. Tumours of gibbus, which may be the first physical sign. In
the nervous system, such as neurofibroma and late cases, the gibbus may be very marked.
meningioma, also occur and multiple myeloma
may cause vertebral collapse. Complications
Osteoporosis Complications may be serious, with the formation
of sinuses, which may become secondarily infected,
Osteoporosis is a very common condition, particu- and paraplegia (Pott’s paraplegia), which has three
larly in women after the menopause, and causes a common causes: (1) pus and intracellular pressure;
dull low back pain with a gradually increasing (2) mechanical injury to the cord from bony pres-
kyphosis (p. 320). Pathological fractures and sudden sure; and (3) vascular embarrassment to the spinal
collapse of a vertebral body can follow a trivial cord where it crosses the gibbus.
injury, or even just coughing.
Treatment
Treatment
Treatment is by oral antibacterials (p. 315), which
Apart from diagnosis and a spinal support, there is are only effective if the patient actually takes them.
little to offer; the osteoporosis is usually too far The treatment must be continued for months or
advanced to be treatable by the time the patient is years. Alternatively, operation is needed to drain the
seen (p. 320). pus, remove dead bone and fuse the affected verte-
brae to prevent future bone collapse. If bone
Tuberculosis collapse has already occurred and the spinal cord
is threatened, bone grafting and fusion is required.
Spinal tuberculosis is now rare in developed coun-
tries but still a scourge elsewhere. The characteristic Infective discitis
features of the disease are as follows (Fig. 26.25):
1. The patient is unwell and has lost weight. The intervertebral discs can become infected, often
2. The affected vertebrae are tender. by obscure bacteria or fungi. Spread can occur
3. The disease involves the vertebral body and directly from bone infection in adjacent vertebrae.
The patients have diffuse back pain, often severe,
crosses the disc space. and a raised ESR. The radiographs show erosion of
4. The infection causes abscesses within the psoas bone on both sides of the intervertebral disc. Disc
infections are more common in drug addicts and
sheath which point at the psoas insertion in the immunosuppressed patients.
groin.
a bc
Fig. 26.25 Tuberculosis of the spine:
(a) early involvement of a vertebral
body; (b) erosion of both vertebrae
and narrowing of the disc space;
(c) collapse of the vertebrae with
sharp gibbus.
463
Part | 3 | Orthopaedics
The infecting organism can sometimes be identi- combined degeneration of the cord and a host of
fied by blood or urine culture or by needle biopsy other peripheral neuropathies, it can cause neuro-
of the disc. If these measures do not succeed in logical symptoms and signs in the leg without
identifying the organism, open biopsy will be involvement of the spine and must be considered in
needed. the differential diagnosis of a prolapsed disc.
In children, discitis can occur without any appar- Treatment
ent infection and usually leads to painless fusion of
adjacent vertebrae. The condition usually resolves spontaneously and
seldom requires decompression of the nerve.
Treatment
Coccydynia
If the organism can be identified, systemic antibiot-
ics are effective, but exploration of the disc is some- The coccyx is a richly innervated structure, suppos-
times necessary. edly because it is the vestige of the tail. Whether this
is true or not, there is no doubt that it is extremely
Meralgia paraesthetica sensitive to injury and that pain in the coccyx can
be very difficult to eradicate.
The lateral cutaneous nerve of the thigh enters the
thigh just medial to the anterior superior iliac spine The symptoms often begin after a fall onto the
and may be trapped either at this point or within coccyx through missing a chair or falling onto the
the abdomen (Fig. 26.26). Meralgia paraesthetica is ice, but more often in accidents at work. The pain is
Greek for ‘pain in the thigh with altered sensibility’ severe and persistent and the position of the coccyx
and this is an excellent description of the makes sitting difficult. Coccydynia can also be
symptoms. caused by disc prolapses and pelvic disorders,
including carcinoma of the rectum and uterus,
The condition is not serious but it is important to which should always be considered.
know of it because, like disseminated sclerosis,
peripheral neuritis, tabes dorsalis, subacute Coccydynia is more common in women than men
and is more difficult to treat in neurotic and litigious
individuals, who seem particularly susceptible to
the condition.
Treatment
Injection with hydrocortisone is often effective but
if the pain is still present after three injections,
denervation of the coccyx with ultrasound or a
radiofrequency probe in a pain clinic should be
considered.
Coccygectomy is sometimes done but should only
be considered as the last resort. It may succeed in a
few patients but in many the pain remains after the
coccyx has been removed.
Manipulative medicine
Fig. 26.26 Meralgia paraesthetica. Abnormal sensibility in Osteopaths and chiropractors are skilled in manipu-
the distribution of the lateral cutaneous nerve of the thigh. lation and can produce remarkably good results in
patients with severe pain in the neck and back.
464 Anybody who can relieve pain is a friend of the
medical profession but problems can arise if
the practitioner does not look beyond the spine
Chapter | 26 | Disorders of the spine
for the cause of symptoms, or believes that spinal tor rather than a physiotherapist, if that is their
manipulation can cure diseases in other structures. preference.
Patients attending manipulative therapists without It must be remembered that most of the condi-
medical assessment are therefore the cause of some tions treated successfully by manipulation are self-
concern. Provided serious organic disease has been limiting disorders, and experienced manipulators
excluded, it is hard to find a reason why a patient readily refer patients with persistent problems to
should not be treated by an osteopath or chiroprac- orthopaedic surgeons or rheumatologists.
465
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Glossary
Many of the words used in orthopaedics can be dif- AO Arbeitsgemeinschaft für Osteosynthesefragen.
ficult to understand, particularly those describing a The Working Party for Questions Relating to the
deformity, and a few minutes self-testing to check Joining of Bone Fragments – the German for ‘ASIF’
that you know the correct meaning of the terms in – see below. Both AO and ASIF are used, but AO
the following glossary will be well spent. is more common.
Most of the words are explained in detail the first Apparent shortening. If the patient has a stiff hip
time they appear in the text. Those that the reader and the leg is held adducted, it will appear to the
might be expected to know without explanation are patient that the leg is shorter than the other side,
printed in bold type the first time they are used. A even though the limb itself is in fact of full length
few obsolescent or obscure words that are occasion- (see page 24 and Fig. 2.29).
ally used in orthopaedic conversation but which do
not appear in the text are also included in the Arthritis means any inflammation of any joint. A
Glossary. vague term of no real medical significance, often
misinterpreted by patients to mean a crippling
Abduction means moving a limb away from the disease. See ‘Rheumatism’.
midline of the body, or a digit away from the
midline of the hand or foot (Fig. 2.3). Beware of Arthro-. A prefix meaning ‘relating to a joint’.
confusion: the abductor hallucis moves the big
toe away from the midline of the foot, but towards Arthrodesis is an operation to produce bony fusion
the midline of the body, and the adductor hallucis across a joint (Figs 6.21, 6.22, 6.23).
is an adductor because it moves the big toe towards
the midline of the foot, even though this is away Arthrography is a radiological examination that
from the midline of the body. demonstrates the non-calcified structures in a
joint, usually using double-contrast techniques.
Adduction is the opposite of abduction. If a leg is
adducted so that it crosses the midline, the move- Arthroplasty. Any operation to fashion a new joint.
ment is still called adduction, even though the See page 299 and Fig. 6.24 for an explanation of
limb is actually moving away from the midline of excision arthroplasty, interposition arthroplasty
the body. and replacement arthroplasty.
Angulation is a term applied to the deformity at Arthroscopy. An operation to look inside a joint
fracture sites, and is confusing. Does ‘backward with an arthroscope.
angulation’ mean that the convexity of the bone
points backwards, or that the distal end of the Arthrotomy. Any operation in which a joint is
limb is angled backwards? opened surgically.
Ankylosis. A fibrous link, e.g. the replacement of Aseptic necrosis. Bone death without infection, as
a joint by fibrous tissue following infection opposed to septic necrosis. See also ‘Avascular
(Fig. 18.7). necrosis’.
ASIF. Association for the Study of Internal Fixation
(the English for AO). An organization based in
467
Glossary
Switzerland which develops instruments and Complicated fracture. A difficult fracture to treat, or
implants for the fixation of fractures. one in which complications have occurred. It is
not the opposite of a simple fracture.
Astragalus is an old word for the talus, perpetuated
in ‘astragalectomy’, the operation to remove the Compound fracture. A fracture in which the skin is
talus. broken. This term is now becoming obsolete and
has been replaced by ‘open fracture’. See ‘Simple
Avascular necrosis. A bad term (all necrosis is avas- fracture’.
cular) but still used to mean ‘aseptic necrosis’.
Contralateral. The limb on the opposite side of the
Back knee. A deformity in which the knee bends body, as opposed to ipsilateral, which means ‘on
backwards. the same side of the body’.
Backward angulation. See ‘Angulation’. Cortical screw. A type of bone screw used for fixing
cortical bone. See ‘Screw’.
Bone cement. Any material, but usually acrylic
cement, for fixing prostheses into bone. Coxarthrosis. Another word for osteoarthritis of the
hip, often used by European surgeons.
Bone lever. A surgical instrument used for holding
soft tissues away from bone and for manipulating CTEV. Congenital talipes equinovarus. See ‘Club
bones. foot’.
Bone wax. A wax applied to bleeding cancellous DDH. Developmental dysplasia of the hip.
bone surfaces to stop the bleeding.
Debridement. The removal of debris from a wound,
Brace. Any splint or support that can be removed or a very important but often neglected procedure.
replaced. See ‘Orthosis’. In French, débridement means incision and drain-
age of a wound. French surgeons refer to the oper-
Break. A fracture. A fracture and a break are the ation of debridement as parage.
same thing, but patients often believe that one
is worse than the other. Delayed union is a complication of a fracture in
which the bone ends join, but very slowly.
Butterfly fragment. When a long bone such as the
tibia is broken by a twisting movement, a spiral -desis. A suffix meaning fixation, e.g. ‘arthrodesis’,
fracture results. If the tip of one of the bone ends ‘tenodesis’.
breaks off, it produces a curved triangular frag-
ment that bears a fanciful resemblance to a but- Diplegia. A neurological condition involving both
terfly on some radiological views. lower limbs, usually applied to the spastic diple-
gia of cerebral palsy.
Calcaneovalgus. A deformity in which the foot
points upwards and outwards (Fig. 21.5c). Dislocation. The injury in which the components
of a joint become completely separated without
Cancellous screw. A type of screw used for fixing a fracture. See also ‘Fracture dislocation’ and
cancellous bone. See ‘Screw’ and Fig. 9.22. ‘Subluxation’.
Chisel. A carpenter’s instrument bearing a superfi- Dorsal. The side of the forearm on the same side as
cial resemblance to an osteotome. The chisel has the back of the hand. Used to describe the exten-
one flat side and one bevelled side; an osteotome sor muscles.
is curved on both sides. See ‘Osteotome’.
Equinovarus. A deformity in which the foot is point-
Circumduction. Moving the upper or lower limb ing downwards and inwards. This is the common
around in a circular movement. deformity of a club foot, often known as congeni-
tal talipes equinovarus (CTEV). See ‘Club foot’.
Closed fracture. A fracture in which the skin remains
intact. See ‘Simple fracture’. Equinus. A deformity in which the foot points
downwards. The deformity derives its name from
Club foot. A popular term for talipes equinovarus the position of a horse’s foot; the horse runs on
(Fig. 21.5), but sometimes applied to any foot its toes, the hooves being the equivalent of the
deformity. If left untreated, the foot of a patient nails on human digits (Fig. 2.47b).
with talipes equinovarus resembles a club.
Eversion is the movement of the subtalar joint in
Comminuted fracture. A fracture in which there are which the foot is turned upwards and outwards.
many small fragments of bone. The opposite is inversion. See also ‘Pronation’ and
‘Supination’.
468
Glossary
Excision arthroplasty. An arthroplasty in which the Involucrum. The expanded bony tube that contains
joint is excised. See page 299 and Figure 6.24. the sequestrum in chronic osteomyelitis.
Extensor lag. If a joint, e.g. the knee, will go straight K-nail is short for Küntscher nail, an intramedullary
passively but the muscles will not extend it fixation device. Commonly, but incorrectly,
actively, the resulting droop of the joint is known applied to any intramedullary nail. See page 134
as an extensor (or flexor, abductor, etc.) lag. It and Figure 9.24.
has nothing to do with a ‘lag’ screw.
K-wire. Kirschner wire. A narrow wire used to hold
Extra-articular. Outside the joint, as opposed to the position of healing bones after fractures or
intra-articular. operations. The wire was originally passed through
the upper end of the tibia and held on a ‘traction
Fatigue fracture. A fracture resulting from repeated bow’ to apply traction to the femur.
minor stress (see page 100, Figs 15.2, 15.3). These
fractures are also known as stress fractures, which Kirschner wire. See K-wire.
is misleading because all fractures result from
stress of one kind or another. Küntscher nail. See K-nail.
Fixed deformity. A deformity that cannot be cor- Kyphosis. Curvature of the spine in which the con-
rected by manipulation. cavity faces forwards. The thoracic spine has a
normal kyphosis (Fig. 2.8).
Flaccid. The condition of muscles which have no
tone, usually the result of damage to the lower Kyphoscoliosis. Deformity of the spine in which
motor neurone. The opposite is ‘spastic’. there is kyphosis and scoliosis (Fig. 2.7).
Forward angulation. A deformity which occurs at Lag screw. A bone screw which has threads at its
fracture sites. See ‘Angulation’. end only, so that it will apply compression across
the fracture site (see page 132, Fig. 9.22).
Fracture. The same as a break. See also Simple,
Open, Closed, Compound, Complicated, Com- LFA. Low friction arthroplasty, or Charnley total hip
minuted and Fatigue. replacement, one type of total hip replacement.
Fracture dislocation. A dislocation accompanied by Lordosis. Curvature of the spine in which the con-
a fracture involving the dislocated joint. cavity faces backwards. There is a normal cervical
and lumbar lordosis (Fig. 2.8).
Gonarthrosis. Another name for osteoarthritis of the
knee, favoured by European surgeons. Luxation. Another word for dislocation, now rarely
used. See ‘Subluxation’.
Hemiplegia. A neurological disorder involving one
side of the body, e.g. right arm and right leg, Malleolar screw. Bone screw originally used to fix
usually the result of a cerebrovascular accident. malleoli but also useful in other situations (Fig.
9.22).
Hyperextension. Movement in the opposite direc-
tion to flexion in joints where this does not nor- Malunion. A complication of a fracture in which
mally occur, e.g. the knee. the bones join solidly, but are in an unacceptable
position.
IDK. Acronym for ‘internal derangement of the knee’
– as well as ‘I don’t know’. Neurolysis. Releasing a nerve from adhesions (not
destroying it, as ‘-lysis’ sometimes means).
Interposition. The state of affairs when soft tissue is
interposed between the ends of bones. This can Non-union. A complication of a fracture in which
occur accidentally in fractures or as an interposi- the bones do not join.
tion arthroplasty (p. 299).
Open fracture. A fracture in which the skin has
Intra-articular. Within the synovial cavity of a joint. been breached either from within (e.g. bone)
The opposite is extra-articular. or without. See ‘Compound’.
Intramedullary. Within the medullary cavity of a Opposition is the movement in which the thumb
long bone. is brought across to meet the little finger (Fig.
2.24).
Inversion is downwards and inwards movement
of the foot occurring at the subtalar joint. See Orthosis. An appliance, splint, caliper or brace to
‘Eversion’. correct deformity or provide support.
Osteosynthesis. An operation to join bones, usually
fractures, by internal fixation.
469
Glossary
Osteotome. An instrument used for cutting bone. It patients, but usually implies pain around joints.
differs from a chisel by being bevelled on both flat See ‘Arthritis’.
surfaces. See ‘Chisel’.
Rotation. Movement about the long axis of a limb,
Osteotomy. An operation to cut across a bone. usually resulting from movement of the shoulder
or hip.
-otomy. Suffix indicating the surgical division of
something, e.g. osteotomy (to cut a bone) or RTA. Road traffic accident.
tenotomy (to cut a tendon).
Scoliosis. Deformity of the spine in which the con-
Overdrilling. Drilling a large enough hole through a cavity faces sideways (see page 15, Fig. 2.7).
bone fragment to prevent the screw gripping so
that a lag effect can be produced. See ‘Lag screw’. Screw. Device used for fixing fractures (Fig. 9.22).
Paraplegia. A motor abnormality of the lower half Self-tapping screw. A type of screw that cuts its own
of the body, usually the result of damage to the thread (Fig. 9.22).
spinal cord.
Sequestrum. The dead piece of bone inside the
-plasty. Suffix indicating an operation in which involucrum in chronic osteomyelitis.
something is shaped or formed, such as
arthroplasty. Sesamoid bones are small bones, shaped like a
sesame seed, lying within a tendon at points of
Pronation. Movement of the forearm so that the great pressure. The patella is the largest sesamoid
hand faces downwards. Also applied to the com- in the body.
parable movement in the foot in which the sole
faces downwards. Shin splints. Pain in front of the tibia, usually due
to a fatigue fracture of the tibia, not a brace or
Prosthesis. An appliance used to replace an absent cast.
part of the body, e.g. a lower limb prosthesis or
an artificial leg, or a total hip prosthesis which Shortening. Loss of length in a long bone.
is implanted during the operation of total hip
replacement. A removable prosthesis is an ‘exo- Simple fracture. An old term applied to a fracture in
prosthesis’; one that is implanted is an which the skin remains intact. ‘Simple’ fractures
‘endoprosthesis’. are not always easy to treat. The term derives from
ancient military surgery and indicated that ampu-
Pseudarthrosis. A false joint, usually resulting from tation was not necessary. The opposite was a com-
the non-union of a fracture. Sometimes also pound fracture, i.e. a fracture with an open wound,
applied to the result of an excision arthroplasty which was treated by amputation because of the
(see page 97, Fig. 7.7). risk of tetanus and deep infection. See ‘Compound
fracture’ and page 97.
Pyarthrosis. A joint filled with pus.
Spastic. A muscle that has excessive tone, often due
Radial. Towards the same side of the forearm as to cerebral palsy. The opposite is flaccid.
the radius. This is the same as ‘lateral’ in the ana-
tomical position, but not when the forearm is Splint. Any device to prevent movement at a fracture
pronated. or joint. See ‘Orthosis’.
Real shortening. Shortening of a limb, usually the Spondylitis. Inflammation of the spine, e.g. ankylos-
lower limb, in which there is real loss of bone. To ing spondylitis.
be distinguished from apparent shortening (Fig.
2.29). Spondylo-. Prefix that means ‘pertaining to a
vertebra’.
Recurvatum. Abnormal hyperextension, generally
applied to the elbow or knee. See ‘Back knee’. Spondylolisthesis. Slipping of one vertebra upon
another (see page 457).
Reduction. Putting a fracture or dislocation back in
its correct position. Spondylolysis. A condition in which there is a defect
in a vertebra, often the result of a fatigue fracture
Rheumatism. An old term, but still used by patients. (see page 457).
‘Rheum’ is an ancient word for watery secretions
of the body, such as tears, saliva or synovial fluid. Spondylosis. Degenerative change in the spine.
Rheumatism means different things to different
Sprain. A partial tear of a ligament.
470
Stress fracture. See ‘Fatigue fracture’.
Glossary
Stress riser. A mechanical term indicating the point TKR. Total knee replacement.
at which stress is concentrated, as at the junction
of the fixed and mobile part of the lumbar spine, Ulnar. Towards the same side of the forearm as the
or where the stiffness of a bone changes markedly, ulna. See ‘Radial’.
e.g. at the lower end of a prosthesis (see page
46). Valgus. A limb deformity in which the extremity is
moved away from the midline. The point of refer-
Subluxation. A partial dislocation. ence is always proximal; a patient with knock knee
has genu valgum. Valgus deformities always relate
Supination. Movement of the forearm so that the to the midline of the body, unlike abduction and
hand faces upwards. Also applied to the compa- adduction, which can relate to the midline of a
rable movement in the foot in which the sole faces hand or foot. The adductor hallucis, for example,
the inside edge of the opposite foot. can accentuate a valgus deformity of the big toe.
The opposite of valgus is varus. See ‘Abduction’.
Symphysis. A joint with a disc of fibrocartilage at its
centre and no cavity (see page 35, Fig. 3.6). Varus. The opposite of valgus.
Talipes. Club foot. See also ‘CTEV’. Ventral. The side of forearm on the same side as the
palm – used particularly to describe the ventral
Tenotome. A knife with a very short blade used for musculature and the flexor compartment of the
cutting a tendon. forearm.
Tenotomy. The operation of cutting a tendon. Volar. On the same side of the hand as the palm.
THR. Total hip replacement.
471
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Index
Note: Page numbers in bold refer to figures, page numbers in italic refer to tables.
A ageing, athletes, 284 osteoarthritis, 429–430
see also elderly people osteochondritis dissecans, 430,
ABC routine, 115–116
abdominal trauma, 175–176 AIDS, 81 431
abduction, definition, 13 osteoarthritis, 297 rheumatoid arthritis, 431
abduction injuries, ankle, 271 walking, 70–72, 297 tarsal tunnel syndrome, 431–432
accessory ossicles, 35, 36 toe-walkers, 350
accidents airways, immediate care, 115, 116, ankle jerk, 17
117 ankylosing spondylitis, 17, 308,
immediate care, 115–119, 267
major incidents, 119–122 Albers–Schönberg disease, 323, 326 404–405, 455
see also road traffic accidents Albright’s syndrome, 336–338 ankylosis, definition, 467
acetabulum alcoholism, 308 antalgic (pain-relieving) gait, 25, 26,
fractures, 59, 178–180, 181 algodystrophy, 107, 309
hemiarthroplasty, 404 allograft bone, 81 45, 47
protrusio acetabuli, 404 aluminium oxide implants, 48, 397 anterior cruciate ligament
total hip replacement, 398 ambulance crews, 118, 119
Achilles tendon amelia, 360 avulsion, 261, 262
paratenonitis, 286, 433 amnesia, post-traumatic, 151, 152 clinical examination, 28, 29
partial rupture, 433 ampicillin, 77, 312 instability, 420–421
rupture, 273–276 amputations, traumatic, 233–236 rupture, 28, 29, 259–261
Sever’s disease, 433 anaesthetic anterior drawer test, 28, 29
tendinitis, 433 anterior inferior talofibular
toe-walkers, 350–351 examination under, 64
achondroplasia, 324, 327 joint manipulation under, 85, ligament, 272
acromioclavicular joint anterior spinal artery syndrome, 156
clinical examination, 19 195 antibiotics
injuries, 191, 192, 287, 288 rheumatoid arthritis and, 447
instability, 370 analgesics, 76, 77, 298, 304 hand infections, 382, 383, 384
supraspinatus tendinitis, 368 anatomical position, 13 neonatal septicaemia, 315
acromion, fractures, 192 anatomical snuffbox, 22 osteomyelitis, 312
acrylic cement, 49, 397, 399, 402 anatomy, orthopaedic, 33–44 prophylactic, 77, 398
action cards, major incidents, 119 Andry, Nicolas, 3 total hip replacement, 398–399,
adducted forefoot of early aneurysmal bone cysts, 338
angulation, definition, 467 402
childhood, 31, 351–352 ankle tuberculosis, 315
adduction, definition, 13 arthrodesis, 430 anti-cyclic citrullinated peptide
adduction injuries, ankle, 272 aseptic necrosis, 430–431
adult respiratory distress syndrome clinical examination, 30–31 (anti-CCP), 303
fibular fractures, 264, 269 anticoagulants, 77–78
see shock lung Friedreich’s ataxia, 332 anti-inflammatories, 76, 77
advanced trauma life support injuries, 269–273, 274–275,
gout, 305
(ATLS), 117 429–430 osteoarthritis, 297–298
joint anatomy, 33 antirheumatic drugs, 304
ligamentous instability, 431 aortic rupture, 172–173
apophyses, 36
damage to, 328–331, 433, 459
apparent shortening, definition, 467
473
Index
appliances, surgical, 72–75 atlas cervical spine, 155
see also braces; prostheses; splints fracture, 156, 157 clavicular, 188
rheumatoid arthritis, 446–447 femoral neck, 240–241
apprehension sign, 30 humeral, 199, 200, 201
archers, 287 atrophic non-union, fractures, 97 Sudeck’s atrophy, 215
arterial injuries Austin Moore prosthesis, 244 knee dislocation, 263
autograft bone, 80 in palm of hand, 226
aortic rupture, 172–173 avascular necrosis, 468 at wrist, 226
due to knee dislocation, 263 blood volume, immediate care, 116,
fractures causing, 104, 109, 155, see also aseptic necrosis 117
avulsion injuries Blount’s disease, 349
200, 201 Bohler’s angle, 277
management, 142 anterior cruciate ligament, 261, bone
at wrist, 226 262 apophyses, 36, 328–331, 433,
arthritis, definition, 467 459
see also arthropathies lateral malleolus, 272 blood supply, 36, 37
arthrodesis, 83, 84–85 pelvis, 176 eburnation, 295
ankle, 430 trochanter, 246 electrical activity, 51, 52
foot, 432, 437, 439 upper end of the humerus, 197 epiphyses see epiphyses
hip, 83, 85, 299, 403–404 axillary crutches, 70–72 fractures see fractures
knee, 83, 298, 299, 409, 412 axis granulomatous conditions, 335,
osteoarthritis, 298–299 fractures, 156, 157 336
rheumatoid arthritis, 305, 376 rheumatoid arthritis, 446–447 growth, 36, 61
toe, 298, 437, 439 axonotmesis, 109 disorders of see bone, growth
wrist, 84, 376
arthrography, 56–58 B disorders
arthrogryposis multiplex congenita, see also epiphyses
back knee, 468 growth disorders, 317–331
363 bacteriology, 66, 67 cartilage, 324–326
arthrolysis, 83, 84 Baker’s cysts, 419 collagen, 317, 318–320
arthropathies, 301–309 balanced traction, 126, 127, 142, mineralization, 320–322
osteochondritides, 326–331,
ankylosing spondylitis, 308, 250–251
404–405, 455 Baldwin’s procedure, 216 418–419, 432–433, 459
ball and socket joints, 33, 34 osteon architecture, 322–323
gout, 64, 77, 305, 372 Barton’s fracture, 217, 219 healing, 50–51, 52, 96–97
neuropathic, 308, 316 battle injuries, 120–122, 141, 168 immediate trauma care, 117, 267
osteoarthritis see osteoarthritis bedsores see pressure sores immunology, 53–54
rheumatoid arthritis see Bennett’s fracture, 231 implants, 46–50
biceps tendon rupture, 369–370 see also internal fixation of
rheumatoid arthritis bicipital tendinitis, 18
arthroplasty, 83–84, 299–300 biochemical investigations, 64 fractures
biomechanics, 45–46 infections, 82, 311–316, 345
hip, 83, 84, 85, 86, 242–244, bipartite patella, 424 joint biomechanics, 45
299, 395–404, 427 bipolar prostheses, 244–245 magnetic resonance imaging, 60
birth trauma mineralization disorders,
knee, 408–409, 410–411
shoulder, 370, 371 brachial plexus lesions, 186 320–322
toe, 437, 439 torticollis, 363–364 see also osteoporosis
arthroscopy, 63–64, 84, 86, 260, bite wounds, 227 necrosis, 307–308, 313, 419
bladder operations on, 79–82
368, 409 injury to, 180 see also specific operations
arthrotomy, 83, 467 in paraplegia, 163 periosteum, 36
articular cartilage see hyaline bleeding see haemorrhage radioisotope scanning, 60, 61–
blood cross-matching, 64 62, 67, 402
(articular) cartilage blood dyscrasias, 307, 308 remodelling, 51, 52, 105,
artifical joints see joints, artificial blood gases 294–295
artificial limbs, 73, 74 fat embolism, 104 sports injuries, 286
aseptic necrosis, 106, 107, 181, 240, preoperative assessment, 65 transplants, 54
blood tests, 402 tumours, 335–345, 462–463
430–431 blood vessel injuries, 142 types of, 35, 36
aseptic techniques, 398, 399 aortic rupture, 172–173
asphyxia, traumatic, 174–175 due to fractures, 104, 109, 139
aspiration
joints, 85
painful hip prostheses, 402
astragalus, 468
see also talus
athletes, 283–290
474
Index
bone cements, 49, 397, 399, 402 Calve’s disease, 331, 459 cervical spine, 15, 152–158
bone ingrowth, implant fixation, Cambridge casualty cards, 121 acute disc prolapse, 445–446
Cambridge splint, 355 acute stiff neck, 449
49–50 cancellous screw, 468 ankylosing spondylitis, 308
bone islands, 336, 337 brachial plexus injuries, 185, 186
bone lever, 468 see also screws clinical examination, 14–15
bone marrow tumours, 336, 343 capsulorrhaphy, 86, 87 congenital hemivertebra, 448
bone morphogenic proteins (BMP), cardiac contusion, 173 fractures, 104, 115, 152,
cardiac injuries, 172, 174 154–157
81 cardiac tamponade, 174 Klippel–Feil syndrome, 14, 447,
bone setters, 3–4 carpal dislocations, 229–230 448
bone wax, 468 carpal tunnel, flexor tendon injuries, neuralgic amyotrophy, 448–449
‘boosted’ lubrication, 46, 47 patient handling, 117, 118, 152
boot-top fractures, 268 224 rheumatoid arthritis, 446–447
boots, 74–75 carpal tunnel syndrome, 22, 387– scoliosis, 362
Boucher’s nodes, 379 spondylosis, 14, 389, 390, 446
boundary lubrication, 46, 47 388, 390 Sprengel’s shoulder, 448
boutonnière lesion, 225–226 carpometacarpal joint, anatomy, 33, torticollis, 363–364, 447
bow legs, 348–349 vestigial rib, 447
bowel rupture, 175 34
braces, cast see cast braces cartilage Charcot joint, 308, 316
braces (orthoses), 72, 73, 450 Charnley hip replacement, 396, 397,
brachial artery, 201 abnormalities, 324–326
brachial plexus lesions, 43, 44, enchondroma, 339 398
haemophiliac arthropathy, 306 charts, immediate trauma care, 117
185–187 healing, 51, 53 chemonucleolysis, 454–455
brain injuries, 147–152 injuries to costal, 169 chest, clinical examination, 17, 18
breaks, 468 osteoarthritis, 293, 294
rheumatoid arthritis, 301 see also pleural cavity; rib,
see also fractures septic arthritis, 314 fractures
breast-stroke knee, 287, 288 synovial chondromatosis, 307
breast tumours, 343, 344, 462 transplantation, 54 chest drains, 171
British Orthopaedic Association, 4 traumatic chondromalacia, chest radiographs, 65
Brodie’s abscesses, 312 children
bronchus 106–107
types, 37, 38 anterior knee pain, 422–423
injuries, 174 cartilage joints, 34, 35 antibiotics, 77
tumours, 462 cast braces, 131, 251, 261 bone growth, 36, 61
bunions, 439–440 casts bone growth disorders, 317–318
bursae and bursitis Achilles tendon rupture,
infrapatellar, 425 cartilage, 324–326
metatarsals, 439–440 273–276 osteochondritides, 326–331,
olecranon, 372 fracture reduction, 126–130,
popliteal, 419 418–419, 433, 459
prepatellar, 425 137–139, 155 rickets, 321, 348
trochanter, 405 cervical spine, 155 bone tumours
burst fractures, vertebrae, 156, 157, greenstick, 219–220 chondroblastoma, 340
humeral shaft fracture, 200, Ewing’s sarcoma, 341–342
160, 165 osteochondroma, 339–340,
butterfly fragments, 468 202
radius and ulna, 211 344–345
C scaphoid, 229 osteogenic sarcoma, 341, 342,
tibia and fibula, 267, 268
cable grafting, nerves, 142 casualty cards, 120, 121 463
caisson disease, 308 cauda equina lesions, 455 osteoid osteoma, 339
calcaneal fractures, 276–277, 278 cements, bone, 49, 397, 399, 402 clinical examination, 11–12
calcaneovalgus, 31, 351, 353 central venous pressure (CVP) lines, deformities, 347–364
calcitonin, 318 117 amelia, 360
calcium, bone growth, 317–318, cephalosporins, 77 arthrogryposis multiplex
ceramic implants, 48, 396, 397
321 cerclage wiring, 135 congenita, 363
calipers, weight-relieving, 74 cerebral oedema, 150 bow legs, 348–349
callotasis, 82 cerebral palsy, 357–358 congenital dislocation of the
callus, bone healing, 50–51, 82, 96 scissor gait, 25–26
cerebrospinal fluid (CSF) knee, 364
rhinorrhoea/otorrhoea, 151 developmental dysplasia of
the hip, 348, 350, 354–
355, 356–357
475
Index
foot, 31, 351–354 chondrogenic bone tumours, 336, complicated fractures, 101, 102
hamstring tightness, 351 339–340, 341, 344–345 compound fractures, 97–98, 140
hand, 359, 360, 363 compression
in-toe gait, 349–350, 352 chondromalacia, traumatic,
knock knees, 348–349 106–107 of brain, 149, 150
limb length inequality, of nerves, 22, 86, 87, 387–388,
chondromalacia patellae, 423
362–363 chondromyxoid fibroma, 340 390
neurological disorders, chondrosarcomas, 341 of trunk, 174–175
chrome implants, 48 compression fractures see crush
356–359 chuck grip, 237, 238
out-toe gait, 350 chylothorax, 172 fractures
phocomelia, 360, 361 chymopapain injections, 454–455 computed tomography (CT),
pseudarthrosis of the tibia, circulation
58–59
364 cast complications, 137–138 concussion, 149
scoliosis, 361–362 immediate trauma care, 115, condyloid joints, 33
toe-walkers, 350–351 congenital dislocation of the knee,
toes, 359–360 116, 118
torticollis, 363–364 see also blood vessel injuries 364
developmental milestones, circumduction, 13 congenital hemivertebra, 448, 460
347–348 clavicular injuries, 19, 187–192 congenital high scapula, 448
fractures claw foot (pes cavus), 31, 443 congenital short neck, 447, 448
case report, 142 clergyman’s knee, 425 congenital talipes equinovarus, 31,
clavicular, 188, 189, 190 clinical examination, 11–31
at elbow, 200–204 approaching the patient, 11 351, 352–353
epiphyseal separations, 199, immediate trauma care, 117 congenital vertical talus, 353
of individual areas, 14–31 consciousness, 149–150, 152
218, 220, 233 investigations and, 55 contralateral, definition, 468
femoral neck, 247–248, 281 routine for, 11–14 contrast studies, 56–58
gallows traction, 125 closed fractures, 98 contusion
greenstick, 99, 189, 216, closed pneumothorax, 169–170
Clostridium difficile infection, 77 brain, 149
219–220 club foot, 31, 351, 352–353 cardiac, 173
healing, 51, 52, 105 club hand, 363 coral, bone grafting, 81
radius at distal end, 216, 217 cobalt implants, 48 cortical screws, 468
skin traction, 124, 142 coccyx see also screws
slipped lower femoral fractures, 183 corticosteroids see steroids
pain, 464 costal cartilage injuries, 169
epiphysis, 253 Codman’s triangle, 341 coxarthrosis, 468
slipped upper femoral colchicine, 77 see also hip, osteoarthritis
collagen, 37, 318 craniocleidodysostosis, 324–325
epiphysis, 246–247, 248, abnormalities of, 317, 318–320 cricket injuries, 287
281 osteoarthritis, 294 cruciate ligaments
upper humerus, 199 collars, 74, 152, 153, 154, 158 avulsion, 261, 262
heel bumps, 434 Colles’ fracture, 213–217 clinical examination, 28, 29, 30
intervertebral disc inflammation, coma scale, 149, 150 instability, 420–422
316 comminuted fractures, 99, 142–143, rupture, 28, 29, 259–261, 262,
irritable hip, 405
meniscus lesions, 414, 415 253 263
MRI scans, 60 common peroneal nerve crush fractures, 99
neuromuscular disorders, 332,
357–359, 362 anatomy, 43 ankle, 272–273
osteomyelitis, 311–312, 345 common injuries, 43, 44 cervical spine, 152, 154
patellar dislocation, 426 community services, 6, 75–76, 88, chest, 168
popliteal cysts, 419 lumbar spine, 165, 320
pulled elbow, 204 90 osteomalacia, 321–322
role of orthopaedic surgery, 5 compartment syndromes, 112–114, pelvis, 177–178
septic arthritis, 314 thoracic spine, 159–160, 161
chiropractors, 70, 464–465 201, 212–213 toes, 280
chisels, 468 tibial fractures, 113, 114, crush injuries
chondral flaps, 417 foot, 280
chondral separations, 417 266–267 forearm, 212–213
chondroblastoma, 340 compartments, 38–40 hand, 222, 224, 226, 236
see also crush fractures
476 sports injuries, 290 crushed tissues, care of, 139
see also compartment syndromes
Index
crutches, 70–72 disease-modifying antirheumatic ectopic ossification, 110, 111, 181,
crystal arthropathies, 305–306 drugs (DMARDs), 304 182, 206
gout, 64, 77, 305, 372 dislocations, 107–108 effusions
CT (computed tomography), 58–59 carpus, 229–230 joint aspiration, 85
CTEV see congenital talipes cervical spine, 154 knee, 27, 28
distal radioulnar joint, 212
equinovarus elbow, 204–206, 207 elbow
cutaneous nerve of forearm, 389 with fractures see fracture arthrogryposis multiplex
cystic menisci, 414, 415, 416 dislocations congenita, 363
cysts hip, 180–183 biomechanics, 45
knee, 263, 364 clinical examination, 20
aneurysmal bone, 338 mandible, 146 dislocations, 204–206, 207
Gaucher’s disease, 335 metacarpophalangeal, 231–232 fractures at, 200–204
hyperparathyroidism, 324 nose, 145 joint anatomy, 33
meniscal, 414 patellar, 255–257, 426, 427 loose bodies, 372
osteoarthritis, 295 phalangeal, 233, 235 olecranon bursa, 372
popliteal, 419–420 radial head, 206, 209, 210 osteoarthritis, 372–373
rheumatoid arthritis, 303, 304 second toe, 440 rheumatoid arthritis, 373
simple bone, 338 shoulder, 3, 17, 18, 108, 192– rheumatoid nodules, 303
196, 365–367 sports injuries, 290, 371–372
D sternoclavicular, 192 subluxation, 204
total hip prosthesis, 401
DDH see developmental dysplasia of elbow crutches, 71, 72
the hip disuse osteoporosis, 106, 320–321 elderly people, 6
divers, 308
De Quervain’s tenosynovitis, 20, dorsal, definition, 468 Clostridium difficile infection, 77
380 double-contrast arthrography, community services, 75, 88, 90
crush fractures of thoracic
debridement 56–58
osteoarthritis, 298, 409 drop foot gait, 26, 27 vertebrae, 159
wounds, 139–140, 141 drug treatments, 76–78 fracture case reports, 88–90, 143,
decompression, compressed nerves, crystal arthropathies, 77, 305, 165, 281
86, 87, 388 306 hallux valgus, 438, 440
home circumstances, 11, 88–90,
decompression sickness, 308 golfer’s elbow, 372
decubitus ulcers see pressure sores hand infections, 382, 383, 384 240
deep vein thrombosis, 77–78 olecranon bursae, 372 humeral fractures, 197
degloving injuries, 112, 226, 227 osteoarthritis, 297–298 onychogryphosis, 436
delayed primary suture, 140 osteomyelitis, 312 pelvic fractures, 176
delayed union, fractures, 95, 96, 97 rheumatoid arthritis, 77, 304 rib fractures, 169
deltoid ligament injuries, 272 supraspinatus tendinitis, 368, shock lung, 105
Denham pins, 124 shoulder dislocation, 194
dermatomes, 40, 41–42, 389 373 social problems of femoral
designated hospitals, 119–122 tennis elbow, 371
developmental dysplasia of the hip tuberculosis, 315 fractures, 239–240
Duchenne muscular dystrophy, supracondylar fracture of femur,
(DDH), 348, 350, 354–355,
356–357 332 252–253
diaphyseal aclasis, 325, 327 Dunlop traction, 202, 204 thoracolumbar tenderness, 16
diastematomyelia, 443, 460–462 Dupuytren’s disease, 384–386, 390 electrical activity, of bone, 51, 52
diffuse intravascular coagulation dynamic compression plates electrical studies, 65, 66
(DIC), 105 electrocardiograms (ECGs)
digital nerves, injuries, 222, (DCPs), 133, 134 immediate trauma care, 117
235–236 dyschondroplasia, 324, 327 preoperative, 65
digits see fingers; dysplasia epiphysealis multiplex, electrolytes, 64
thumb; electromyograms (EMGs), 65, 66
toes 326, 328 electrotherapy, 69
‘dinner fork’ deformity, 20, 213, 214 emboli, 77, 104, 105
diplegia, 468 E emergency care, 115–119
disasters, 119 major incidents, 119–122
discectomy, 455 ear, CSF otorrhoea, 151 emphysema, surgical, 171
discoid menisci, 414, 415 eburnation, bone, 295 enchondroma, 339, 340
discs see intervertebral discs economic considerations, femoral eosinophilic granuloma, 335, 336
epiphyses, 35, 36, 61
fractures, 240
477
Index
diaphyseal aclasis, 325, 327 orbital, 145–146 fibrous cortical defect, 336, 337
dysplasia epiphysealis multiplex, zygoma, 145 fibrous dysplasia, 323, 325,
fascial compartments see
326, 328 336–338
injuries, 101–102, 103, 199, 218, compartment syndromes; fibrous joints, 34, 35
compartments fibula
220, 233, 246–247, 281 fasciotomy, 113, 114
rickets, 321 fat embolism, 104, 105 aneurysmal bone cysts, 338
septic arthritis, 311, 312, 314 fatigue fractures, 100, 101, 264, 265, congenital absence, 361
simple bone cysts, 338 fractures, 57, 264, 265–268, 269,
vascular osteochondritides, 286, 287–288, 290
pars interarticularis, 457–458 272, 275
326–328 Felty’s syndrome, 303 compartment syndrome, 113
equinovarus, 31, 351, 352–353 femoral fractures, 239–254 fatigue, 286, 287
equinus, 468 arterial damage, 104 osteomalacia, 322
Erb’s palsy, 186 arthroplasty, 84, 242–245, 299, plates, 134
erythrocyte sedimentation rate (ESR) figure-of-eight bandage, 190, 191
404 fingers
painful hip prostheses, 402 aseptic necrosis, 106, 107, 181, amputations, 233–236
preoperative assessment, 64 arthrodesis, 298
rheumatoid arthritis, 303 240 cast complications, 137
ethics, sports medicine, 284 children, 246–248, 253, 281 clinical examination, 13, 21–23
eversion, 468 clinical problems, 239 compartment syndrome, 112
Ewing’s sarcoma, 336, 341–342, economic problems, 240 crush injuries, 226, 236
femoral neck, 240–245, 247– degloving injury, 112, 226, 227
343 digital nerve injuries, 222,
examination of patient see clinical 248, 281 235–236
see also acetabulum, fractures Dupuytren’s disease, 384–386,
examination femoral shaft, 248–251 390
examination under anaesthetic haemorrhage, 103–104, 250 enchondroma, 340
intramedullary nails, 134 flexor tendon injuries, 223–224
(EUA), 64 locking nails, 135 ganglia, 381–382
excision arthroplasty, 83, 85, 299, lower end of femur, 252–254 infections, 382–384
management case reports, 142– muscle length, 40
300, 400, 403, 437, 439 143, 281 naming, 21
exostectomy, 79, 82, 439 muscle group separation, 38 nerves, 43, 44
exostoses, foot, 434–435, 439 nail-plates, 136 osteoarthritis, 379
extension injuries osteomalacia, 323 phalangeal dislocations, 233
posterior dislocation of hip, 180, phalangeal fractures, 232–233,
cervical spine, 155–156, 157–158 181–183 234
thoracic spine, 158 social problems, 239–240 tendon disorders, 380–381,
extensor lag, 469 traction, 125, 131, 142, 143, 390–391
extensor tendon injuries, hand, 215, 250–251 types of grip, 237–238
trochanteric, 245–246, 247–248, fingertip amputations, 233–235
224–226, 236 281 first aid, 117–119
extensor tendon sheaths, infection, femur fixation, implants, 48–50, 396–397,
developmental dysplasia of the 399–400, 402
383–384 hip, 354, 355, 357 see also internal fixation of
extensor tenosynovitis, 380 fibrous cortical defect, 337 fractures
external fixation of fractures, 131– fibrous dysplasia, 325, 336 fixed deformities, 469
fractures see femoral fractures fixed traction, 125
132, 137, 143 in-toe gait, 349, 350, 352 flaccid, definition, 469
cervical spine, 154, 155 osteochondritis dissecans, 331 flail chest, 168
pelvic, 178 osteogenic sarcoma, 342 flat bones, 35
tibia and fibula, 267, 268 osteotomy, 403, 407–408 flat foot, 31, 353–354, 442–443
extra-articular, definition, 469 out-toe gait, 350 flexion injuries
extradural haematoma, 150–151 Paget’s disease, 324 cervical spine, 152–155, 157–
eye injuries, 145–146, 289 Perthes’disease, 326–327, 329 158, 185
eye signs, consciousness, 149–150 fibrocartilage, 37 lumbar spine, 162
fibrogenic bone tumours, 336–338, thoracic spine, 158, 160, 161
F 340–341
fibrosarcoma, 341
facet joints, 33
facial fractures
complications, 104
management, 139, 145–147
mandible, 104, 146, 147
maxillary, 146–147, 148
nasal, 145, 146
478
Index
flexor digitorum profundus, 22–23, rheumatoid arthritis, 304 slings, 130, 131
223, 224 sports injuries, 286, 287, 290 splints, 126, 127
fracture dislocations, 108 traction, 123–126, 136–137,
flexor digitorum superficialis, 23, ankle, 269, 271, 274
223, 224 cervical spine, 154–155 142, 143
hip, 180, 181, 182 see also specific bone fractures
flexor profundus longus, trigger interphalangeal, 233, 235 remodelling, 51, 52, 105
finger, 380–381 shoulder, 196, 199 segmental, 100
thoracic spine, 161 soft tissue injuries with, 93, 94,
flexor tendon injuries, hand, 222– fractures, 93–107 98, 104, 109, 110, 112, 113,
224, 236 arthroplasty, 84, 242–245, 299, 114
stable, 100, 102
flexor tendon sheaths 404 structures mistaken for, 35, 36
infection, 383–384 case reports, 88–90, 142–143, undisplaced, 100, 102, 241, 242,
pearl ganglia, 381–382 243
165, 281 violence of impact, 93, 94
flucloxacillin, 77, 312 causes, 99–100 wound debridement, 140
foot classification, 97–99 see also specific bones
complicated, 101, 102 fragilitas ossium, 318–320
Achilles tendon problems, complications, 102–107, 110, frames, walking, 70, 71
433 Freiberg’s disease, 328, 441–442
111, 113, 114 Friedreich’s ataxia, 332, 443
ankle injuries, 269–273 cross-union, 96, 97 frozen shoulder, 369
bunions, 439–440 delayed union, 95, 96, 97
clinical examination, 30–31 dislocations with see fracture G
crush injuries, 280
deformities, 31, 74–75, 351–354, dislocations gait
epiphyseal injuries, 101–102, 103, biomechanics, 45, 47
359–360, 440, 442–443 children, 347–348, 349–351,
dislocation of second toe, 440 199, 218, 233, 246–247, 281 355
dorsal exostosis, 434–435 grafts, 80 clinical examination of the hip,
enchondroma, 339 healing, 50–51, 52, 96–97 25–26
fallen arches, 443 impacted, 100, 102, 241, 243
forefoot fractures, 279–280, 286, malunion, 95, 96–97, 105, 106, Galeazzi fracture, 212
gallium-67, 61, 62, 67
290 216 gallows traction, 125
Freiberg’s disease, 328, 441–442 management principles, 123 gamekeeper’s thumb, 232
ganglia, 434 ganglia, 381–382, 434
gout, 305 see also fractures, reduction gargoylism, 324
hallux rigidus, 436–437 management stages, 94–95 Gaucher’s disease, 308, 335
hallux valgus, 437–439, 440 multiple, 101 general practitioners, 119, 120
heel bumps, 434 muscle group separation, 38, 39 general surgeons, 5, 6
hindfoot fractures, 106, 107, muscle length, 40 giant cell tumours, 336, 340, 341,
natural history, 95–96
276–278 non-union, 95, 96, 97 342
in-toe gait, 349, 352 in osteogenesis imperfecta, gibbus, 15, 16
joint anatomy, 33, 34 Girdlestone procedure, 83, 85, 400,
Köhler’s disease, 328, 432–434 318–320
metatarsalgia, 441 osteomalacia, 321–322, 323 403
midtarsal joint, 31, 432 osteosynthesis, 79, 80–81 Glasgow coma scale, 149, 150
neurological/neuromuscular paraplegic patients, 164 glenohumeral joint, 18, 19, 374
physical signs, 95 glenoid
disorders, 332, 443 radiographic investigations, 55–
peroneal tendons, 433 fractures, 192
plantar fasciitis, 433–434 56, 57, 59, 93, 102 internal derangements of
rheumatoid arthritis, 302, 442 reduction
Sever’s disease, 330, 433 shoulder, 367
subtalar joint, 30–31, 34, 432 cast braces, 131, 251 shoulder dislocation, 192, 193
subungual exostosis, 440 complications, 136–139 gold, treatment with, 76–77, 304
talonavicular bar, 434 external fixation, 131–132, golfer’s elbow, 372
tendinitis, 433 gonarthrosis, 469
toenail problems, 435–436 137, 143 see also knee, osteoarthritis
undiagnosed joint pain, 305 internal fixation, 79, 80–81, gout, 64, 77, 305, 372
footballers’ injuries, 287–289,
132–136, 139, 143 479
429–430 method selection, 136
footwear, 74–75 multiple fractures, 136
plaster casts, 126–130,
children, 354
osteoarthritis, 297 137–139
Index
grafts Dupuytren’s disease, 384–386, hinged total knee replacement, 409,
bone, 79, 80–81, 403 390 411
fingertip amputations, 235
nerves, 87, 142 dysplasia epiphysealis multiplex, hip
skin, 140–141 328 acetabular fractures, 178–179
ankylosing spondylitis, 404–405
Gram stains, 66 enchondroma, 339, 340 anterior dislocation, 183
granulomatous conditions, 308, infections, 382–384 arthrodesis, 83, 85, 299,
injuries, 221–238 403–404
335 biomechanics, 45, 46
greenstick fractures, 99 amputations, 233–236 chondroblastoma, 340
blood vessels, 226 clinical examination, 24–27, 394
upper limb, 189, 190, 216, 217, fractures and dislocations, developmental dysplasia, 348,
219–220 350, 354–355, 356–357
227–233, 236 excision arthroplasty, 83, 85,
grindstone injuries, 226, 227 joints, 227, 236–237 400, 403
growth hormone, 82, 317 nerves, 221–222 fracture management case
gunshot wounds, 122, 141 reconstruction, 237–238 reports, 88–90
gunstock deformity, 20 rehabilitation, 236–237 hemiarthroplasty, 85, 242–244,
gutter crutches, 71, 72 skin and soft tissue, 226–227 299, 404
gymnastics, remedial, 70 tendons, 215, 222–226, in-toe gait, 349
infections, 398–399, 402, 405
H 236 interposition arthroplasty, 83, 85,
neurological disorders, 386–390 404
haemarthrosis, of knee, 263–264 osteoarthritis, 378–379 investigation case report, 66–67
haematomas peroneal muscular atrophy, 332 irritable (transient synovitis), 405
prostheses, 73 joint anatomy, 33, 34
anticoagulation and, 77 rheumatoid arthritis, 302, 303, osteoarthritis, 25, 295, 296, 297,
bone healing, 50 299, 393–404
extradural, 150–151 376–377, 378 osteotomy, 403
in muscle, 285 Sudeck’s atrophy, 107, 215 Perthes’disease, 326–327, 328,
ossification in, 110 tendons, 215, 222–226, 236, 329
retroperitoneal, 175–176 posterior dislocation, 180–183
haemoglobin estimation, 64 380–382, 390–391 protrusio acetabuli, 404
haemophiliac arthropathy, 306 types of grip, 237–238 revision surgery, 402–403
haemopneumothorax, 170 undiagnosed joint pain, 305 rheumatoid arthritis, 395
haemorrhage see also fingers septic arthritis, 315, 405
fractures, 103–104, 250 Hand–Schüller–Christian disease, snapping, 405–406
haemophiliac arthropathy, 306 stress risers, 46–47, 397
hand injuries, 226 335 total replacement, 83, 84, 85, 86,
immediate trauma care, 115– hanging-arm technique, 195 395–403, 427
Hangman’s fracture, 156 trochanteric bursitis, 405
116, 118 Harris’ lines, 36, 37
into knee, 263–264 Harris and Salter epiphyseal injuries, Hippocrates, 3, 195
intracranial, 150, 151 history taking, 9–11
petechial, 174 101–102, 103, 220 HIV infection, 81, 306
under casts, 137–138 haversian systems see osteons home circumstances, 11, 88–90
haemothorax, 172 HDP (high density polyethylene) home modifications, 75
Haglund’s deformity, 434 hook grip, 237, 238
hallux rigidus, 436–437 implants, 48 hooked forefoot, 31, 349, 351–352
hallux valgus, 437–439, 440 head injuries, 104, 147–152 Horner’s syndrome, 186, 187
halo-vest traction, 154, 155 hospital organisation, 119–120
Hamilton’s ruler test, 18, 193 see also facial fractures housemaid’s knee, 425
Hamilton–Russell traction, 126 healing, 50–53 humerus
hammer toe, 359–360, 440
hamstring tightness, 351 anticoagulation and, 77 elbow dislocations, 204
hamstrings, thigh circumference fractures, 50–51, 52, 96–97 fractures, 197–206
heart injuries, 172, 173, 174
and, 27 Heberden’s nodes, 379 arterial damage, 104, 109
hand heel bumps (Haglund’s deformity), ectopic ossification, 111
traction, 125, 126, 130
arthrodesis, 298 434
clinical examination, 21–23 hemiarthroplasty, 84, 85, 242–244,
congenital deformities, 359, 360,
299, 404
363 hemiplegia, 469
hemiplegic gait, 26
480 herpetic whitlows, 383
high density polyethylene (HDP)
implants, 48
hinge joints, 33, 34
Index
osteomyelitis, 313 bacteriology, 66, 67 interposition, definition, 469
septic arthritis, 314 battle injuries, 120 interposition arthroplasty, 83–84,
shoulder dislocation, 192–193, bone, 82, 311–316, 345
delayed primary suture, 140 85, 299, 404
194, 195, 196, 199, 365, 367 draining from bone, 82 intertrochanteric fractures, 245–246
Hurler’s disease, 324 fractures, 98, 104, 105, 137, 138, intervertebral discs
hyaline (articular) cartilage, 37, 38
139, 143 discography, 58
enchondroma, 339 gunshot wounds, 141 infection, 316, 463–464
haemophiliac arthropathy, 306 in hand, 382–384 prolapse, 16–17, 156, 445–446,
healing, 51, 53 hip, 398–399, 402, 405
osteoarthritis, 294 internal fixation, 139 451–455
rheumatoid arthritis, 301 joints, 311, 312, 314–315, 316 in-toe gait, 349–350, 352
septic arthritis, 314 lumbar spine, 463–464 intra-articular, definition, 469
synovial chondromatosis, 307 pin track, 137 intramedullary, definition, 469
transplantation, 54 total hip replacement, 398–399, intramedullary nails, 134–135
traumatic chondromalacia,
402 femoral shaft fractures, 251
106–107 transmission in grafts, 81 intravenous infusion lines, 116, 118,
hydrocortisone acetate, 78, 368, under casts, 138
ingrowing toenails, 435–436 250
371, 388 injection injuries, hand, 226–227 inversion, definition, 469
hydroxychloroquine, 76–77 Insall–Burstein total knee investigations, 55–67
hyperextension, definition, 469
hyperparathyroidism, 322, 324 replacement, 411 arthroscopy, 63–64, 84, 86,
hypertrophic non-union, fractures, inspection, 12 260
97 acromioclavicular joint, 19 disc prolapse, 452–453
hypothenar space, infection, 384 cervical spine, 14 immediate trauma care, 117
hypovolaemia, 116, 117 chest, 17 painful hip prostheses, 402
hypoxia digits, 21, 22 radiographic see radiographic
elbow, 20
ABC routine, 115 hand, 21 investigations
fat embolism syndrome, 104 hip, 24 rheumatoid arthritis, 64,
knee, 27
I patellofemoral joint, 30 302–303
pelvis, 23 involucra, 312, 313
IDK, definition, 469 shoulder, 17, 18 irritable hip (transient synovitis),
ilium, fractures, 59, 176–177, 178 thoracic spine, 15–16
immediate trauma care, 115–119 wrist, 20 405
interference fit, implant fixation, ischaemia
major incidents, 119–122
tibial fractures, 267 49 compartment syndromes,
immunology, 53–54 internal fixation of fractures, 79, 80– 113
impacted fractures, 100, 102
femoral neck, 241, 243 81, 132–136, 139, 143 muscle injury, 110
implants ankle, 271 nerve injury, 110
basic science, 46–50 Barton’s, 217, 219 isotope scanning see radioisotope
investigation case report, 66–67 cervical spine, 154–155
osteosynthesis, 79, 80–81 at elbow joint, 204, 205 scanning
prophylactic antibiotics, 77, 398 femoral neck, 242, 243, 244
radioisotope scans, 61–62, 402 femoral shaft, 251 J
see also internal fixation of olecranon, 206, 208–209
pertotrochanteric, 246, 247 javelin throwers, 287, 288
fractures; joints, artificial phalangeal, 234 jerk test see pivot shift test
in-toe gait, 349–350, 352 radius and ulna, 210, 211, 212, jogger’s knee, 287
Incident Control Officers (ICOs), joints
213, 219
120 tibia and fibula, 267, 268, 269 arthrogryposis multiplex
Incident Medical Officers (IMOs), interphalangeal joints congenita, 363
ganglia, 382
120 osteoarthritis, 379 arthropathies, 301–309
incidents, major, 119–122 rheumatoid arthritis, 378 see also osteoarthritis;
indium-111, 61 stiffness, 236 rheumatoid arthritis
infections
arthroscopy, 63–64, 84, 86, 260,
antibiotic prophylaxis, 77, 398 368
arthropathies following, 308
artificial
arthroplasty see arthroplasty
deep vein thrombosis, 77
investigation case report,
66–67
materials, 48, 396
481
Index
prophylactic antibiotics, 77, arthrolysis, 83, 84 at ankle, 272
398 arthroscopy, 63, 64, 86, 260, 409 at knee, 262–263
biomechanics, 45 lateral cutaneous nerve of forearm,
radioisotope scans, 61–62 chondroblastoma, 340
stress risers, 46–47, 397 clinical examination, 27–29 389
biomechanics, 45–46 deformities in children, 348–349, lateral pressure syndrome, patella,
examination under anaesthetic,
64 364 423
infections, 311, 312, 314–315, dislocation, 263, 364 latex test, 64
316 fractures within, 104, 257–258, Le Fort classification, maxillary
injuries, 107–108
see also dislocations; subluxed 417 fractures, 146–147, 148
giant cell tumour, 340 lifting techniques, 449–450
joints haemarthrosis, 263–264 ligaments
loading, 45, 46 isotope scan, 63
lubrication, 46, 47 joint anatomy, 33, 34 clinical examination, 13, 28–29,
manipulation under anaesthetic, ligament injuries at, 258–263, 31
85, 195 287, 288, 420–422 examination under anaesthetic,
operations on, 83–85, 298–300, loose bodies, 416, 417 64
malignant fibrous hystiocytoma,
304–305, 395–404, 407–412, injuries to, 108
427 340 at ankle, 269, 270, 271, 272,
osteoarthritis see osteoarthritis meniscus lesions, 413–416, 420 431
radiographic investigations, osteoarthritis, 297, 298, 299, gamekeeper’s thumb, 232
56–58 at knee, 258–263, 287, 288,
range of movement see 406–412 420–422
movement, clinical osteochondral lesions, 308, supraspinous rupture, 153
examination whiplash, 157–158
rheumatoid arthritis see 416–419
rheumatoid arthritis osteotomy, 406, 407–408 operations on, 86, 87
skin scars, 51, 53 patellar instability, 425–426, 427 litigation, 10, 106
stiffness popliteal cysts, 419–420 liver rupture, 175
with cast immobilization, posterior dislocation of hip and, lobster claw hand, 360
locking nails, 135
138–139 180, 182 long bones, 35, 36
hand injuries, 236–237 radiographic investigations, 56, Looser’s zones, 321–322
osteoarthritis, 297 lordosis, 15, 16
in paraplegic patients, 164 58 lower limb
with shoulder dislocation, 194 reflex sympathetic dystrophy, 107
thermography, 62–63 revision replacement, 409 artificial, 73, 74
types of, 33–34, 35 rheumatoid arthritis, 412–413 congenital deformity, 360
see also specific joints septic arthritis, 413 examination, 12–13, 24
Jones, Robert, 4 sports injuries, 287, 288, 424 length inequality, 362–363
jumper’s knee, 424 total replacement, 406, 408–409, lengthening, 81–82, 105, 363
osteoarthritis, 296, 297
K 410–411 see also lower limb anatomy;
knee jerk, 17
K-nails, 469 knock knees, 348–349 lower limb injuries
K-wire, 469 knuckle kyphosis, 15 lower limb anatomy
Keller’s operation, 437, 439 Kocher’s manoeuvre, 195
key grip, 237, 238 Köhler’s disease, 328, 432–434 dermatomes, 40, 41
kidney injury, 176 kyphoscoliosis, 469 fascial compartments, 39–40
kidney tumours, 343, 344, 462 kyphosis, 15–16 nerve distribution, 41
Kienböck’s disease, 328, 330, 386 lower limb injuries, 239–281
Kirschner wire, 469 Scheuermann’s disease, 331, 459 Achilles tendon rupture, 273–276
Klippel–Feil syndrome, 14, 447, 448 ankle, 269–273
Klumpke’s palsy, 186 L compartment syndromes,
knee
laboratory investigations, 55, 64–65 113–114
anterior pain, 422–425, 427 case report, 66 extensor mechanism, 255–257
arthrodesis, 83, 298, 299, 409, painful hip prostheses, 402 femoral fractures see femoral
rheumatoid arthritis, 64, 303
412 fractures
Lachman test, 29, 421 fibular fractures see fibula,
482 lag screws, 469
fractures
see also screws forefoot fractures, 279–280, 286,
lateral collateral ligament injuries
290
haemarthrosis of knee, 263–264
Index
hindfoot fractures, 106, 107, Maisonneuve fracture, 264 meniscectomy, 413, 415, 416
276–277, 278 major incidents, 119–122 meralgia paraesthetica, 464
malignant fibrous hystiocytoma metacarpals
ligament injuries at knee, 258–
263, 287, 288, 420–422 (MFH), 340 clinical examination, 23
malleolar screws, 469 fractures, 230–231, 232
patellar dislocation, 256–257 rheumatoid arthritis, 376, 377
patellar fractures, 135, 180, 182, see also screws metacarpophalangeal joints
malleolus, injuries, 272, 273–274 dislocations, 231–232
254–255, 256 mallet finger, 225 rheumatoid arthritis, 376, 377,
peripheral nerves, 43, 44 mallet toe, 359–360, 440
prostheses, 73, 74 malunion, fractures, 95, 96–97, 105, 378
replantation, 142 stiffness, 236
tibial fractures see tibial fractures 106, 216 metal implants, 48
within knee fractures, 257–258, mandible replacement hemiarthroplasty,
417 fractures, 104, 146, 147 84, 85
lubrication, joints, 46, 47 injury management, 146 stress risers, 46, 47, 397
lumbar spine, 15, 161–162 manipulation under anaesthetic total hip replacement, 396, 397
see also internal fixation of
acute back strain, 449–451 (MUA), 85, 195
ankylosing spondylitis, 308, 455 manipulative medicine, 464–465 fractures
back pain, 449 metastatic bone tumours, 343, 344,
cauda equina lesions, 455 acute disc prolapse, 454
clinical examination, 16–17, back strain, 450–451 462
marble bone disease, 323, 326 metatarsals
452 ‘march’ fractures, 100, 101, 286, 290
coccydynia, 464 maxillary fractures, 146–147, 148 fractures, 279–280, 286, 290
congenital anomalies, 459–462 McKee–Farrar prosthesis, 400 Freiberg’s disease, 328, 441–442
disc prolapse, 451–455 McMurray test, 29, 30 hallux valgus, 439
fractures, 161, 162, 165, 320 measurements in clinical pain, 441
infections, 463–464 rheumatoid arthritis, 442
lifting technique, 449–450 examination, 12 metatarsophalangeal joints, 436–
manipulative medicine, 450–451, limb length, 24
movement in cervical spine, 437, 442
454, 464–465 metatarsus adductus, 31, 349,
meralgia paraesthetica, 464 14–15
osteochondritis, 459 movement in fingers, 22 351–352
osteoporosis, 463 movement in lumbar spine, 16 methotrexate, 76–77, 304
recurrent strains, 451 thigh circumference, 27 microdiscectomy, 455
root entrapment, 456 wounds, 117 midtarsal joint, 31, 432
sacralization, 459–460 medial compartment osteoarthritis, military injuries, 120–122, 141, 168
scoliosis, 362 Minerva casts, 155
spondylolisthesis, 457–458, 459 406, 407 molybdenum implants, 48
spondylolysis, 457–458 medial ligament of knee Monteggia fracture, 206, 209–210,
spondylosis, 455–456
stenosis, 456–457 instability, 422 212
tumours, 451, 462–463 rupture, 261 Morquio’s disease, 324
lumbosacral braces, 450 sports injuries, 287, 288 Morton’s metatarsalgia, 441
lumbosacral supports, 73–74, 75 stressing, 28 motivation, of patients, 10
lunate, Kienböck’s disease, 328, 330, median nerve anatomy, 42, 43, motor nerves
386 222 conduction studies, 65
lung injuries, 104–105, 173–174 median nerve compression, 22, paraplegia, 162, 163
lung tumours, 343, 344 movement, clinical examination,
luxatio erecta, 196 387–388, 390
luxation, 469 median nerve injuries, 43, 44, 221 12–13
ankle, 31
see also dislocations Colles’ fracture and, 215 cervical spine, 14–15
lymphoma of bone, 336, 343 fractures at elbow and, 201 chest, 17
median plantar nerve, 431–432 elbow, 20
M mediastinal injuries, 172–173 finger, 22–23
membrane bones, 35 foot, 31
Maffucci syndrome, 339 memory, post-traumatic amnesia, hip, 24–26
magnetic resonance imaging (MRI), knee, 28
151, 152 lumbar spine, 16–17
60 meningeal artery ligation, 150–151 patellofemoral joint, 30
meningomyelocoele, 356–357, 462 pelvis, 23
meniscal calcification, 306
meniscal lesions, 413–416, 420 483
tests for, 29, 30
Index
shoulder, 18–19 Nélaton’s line, 24, 25 nuclear magnetic resonance (NMR),
subtalar joint, 31 neonatal septicaemia, 314, 315 60
thoracic spine, 16 neonates
wrist, 21 O
MRI (magnetic resonance imaging), developmental dysplasia of the
hip, 354–355 oblique fractures, 98
60 obstetric trauma
MRSA swabs, preoperative, role of orthopaedic surgery, 5
nerve conduction studies, 65 brachial plexus lesions,
64 nerves 186
mucopolysaccharidoses, 324
muscle anatomy, 40–44, 187 torticollis, 363–364
healing, 53, 54 occupation
activity measurement, 65, 66 injuries, 44, 109–110
anatomy, 37–39, 40, 44 history taking, 11
arthrogryposis multiplex brachial plexus, 43, 44, resettlement, 75–76
185–187 retraining, 75, 76
congenita, 363 occupational therapy, 70, 88, 90
balance, 38 due to fracture fixation, 139 odontoid process, fractures,
congenital talipes equinovarus, finger amputations, 235–236
fractures at elbow, 200, 201, 155–156
352 old age see elderly people
electromyograms, 65, 66 202 olecranon
healing, 53, 54 in hand, 221–222
injury management principles, humeral shaft fractures, 199, bursa, 372
fractures, 81, 135, 206, 208–
110, 111 201
joint biomechanics, 45 knee dislocation, 263 209
length, 40 management, 141–142 Ollier’s disease, 339
neuromuscular disorders, 331– paraplegia, 162, 163 onychogryphosis, 436
posterior dislocation of hip, open fractures, 40, 98, 104, 142–
333, 357–359, 362
osteoarthritis, 297 180, 181–183 143, 150
power, 13–14, 69 shoulder dislocation, 193–194 open pneumothorax, 169, 170–171
rupture, 285 Sudeck’s atrophy, 215 operating theatres, 398, 399
sports injuries, 285, 289, 290, neuropathic arthropathy, 308 operative treatments, 78–90
operations on, 86–87
371–372, 424 root entrapment in lumbar spine, anterior cruciate instability, 421
traction and, 123, 124 456 anterior cruciate rupture,
Volkmann’s ischaemic see also neurological disorders;
neuromuscular disorders 260–261
contracture, 201 neuralgic amyotrophy, 448–449 disc prolapse, 454–456
muscular dystrophy, 332, 443 neurapraxia, 109 osteoarthritis, 298–300, 395–
musculotendinous ruptures, 285, neurological disorders, 356–359
ankle, 431–432 404, 407–412, 427
286 foot, 443 recurrent dislocation of shoulder,
myelography, 56 hand, 386–390
myeloma, 336, 343 lumbar spine, 460–462 365–366, 367
myositis ossificans, 110, 201 see also neuromuscular disorders rheumatoid arthritis, 304–305
neurologists, 6 spondylolisthesis, 458
N neurolysis, 87 opposition, 469
neuromuscular disorders, 331–333, orbital injuries, 289
nail-fold infections, 382–383 357–359, 362, 443 fractures, 145–146
nail-plates, 136 neuropathic arthropathy, 308, 316 orthopaedic anatomy, 33–44
nails, fracture fixation, 79, 80, 134– neurotmesis, 109–110 orthopaedic surgery
NMR (nuclear magnetic resonance), history of, 3–4
135, 251, 469 60 history taking, 9–11
nasal injuries, 145, 146 non-steroidal anti-inflammatory skills for, 6–7
navicular bone drugs (NSAIDs), 76, 77 orthopaedics
osteoarthritis, 297–298 ankle, 429–432
accessory, 35, 36 rheumatoid arthritis, 304 arthropathies, 301–309
Köhler’s disease, 328, 432–434 non-union, fractures, 95, 96, 97
neck supports, 74 nose see also osteoarthritis;
necrosis CSF rhinorrhoea, 151 rheumatoid arthritis
aseptic, 106, 107, 181, 240, injury management, 145, 146
bone growth disorders, 317–331
430–431 bone and joint infections, 311–
bone, 307–308, 313, 419
Volkmann’s ischaemic 316, 345
bone tumours, 335–345,
contracture, 201
462–463
484
Index
deformities in children, 347–364 osteomalacia, 321–322, 323 paronychia, infections, 382–383
elbow disorders, 371–373 osteomyelitis, 311–314, 315, 345 pars interarticularis, 457–458, 459
foot, 432–443 osteonecrosis see bone, necrosis patella
granulomatous conditions, 335 osteons, 318, 322–323
hand, 376–377, 378–391 osteopaths, 70, 465–466 bipartite, 424
hip, 393–406, 427 osteopetrosis, 323, 326 dislocation, 255–256, 426, 427
knee, 406–427 osteophyte removal, 298, 409, 430 fractures, 135, 180, 182, 254–
neuromuscular disorders, 331– osteopoikilosis, 323, 326
osteoporosis, 320–321 255, 256
333, 357–359, 362 instability, 425–426
shoulder disorders, 365–371, of disuse, 106, 320–321 lateral pressure syndrome, 423
elderly people, 16, 165, 176 Sinding Larsen’s disease, 330,
373–374 idiopathic, 320
spine, 445–465 lumbar spine, 463 331
wrist, 375–376, 377–378, 381, reflex sympathetic dystrophy, 107 patellar tap, 27, 28
steroid-induced, 321 patellar tendon
386, 387 osteosarcoma, 341, 342, 344, 463
orthoses (braces), 72, 73, 450 osteosynthesis, 79, 80–81 rupture, 255
os trigonum, 35, 36 osteotomes, 470 tendinitis, 286
Osgood–Schlatter disease, 328–330 osteotomy, 79, 105, 216, 299, 403, patellofemoral joint
ossifying fibroma, 339 anatomy, 33, 34
osteitis deformans see Paget’s disease 406, 407–408, 439 anterior knee pain, 422, 423
osteitis fibrosa cystica, 322, 324 -otomy, 470 clinical examination, 30
osteoarthritis, 293–300 otorrhoea, CSF, 151 osteoarthritis, 423, 424–425
out-toe gait, 350 pathological fractures, 100, 101
ankle, 429–430 overdrilling, 470 humerus, 199, 200
causes, 293–294 oxygen deprivation metastatic tumours, 343
clinical examination, 16, 25, 394 osteomalacia, 322, 323
clinical presentation, 295–296 ABC routine, 115 ribs, 169
development, 294–295 fat embolism syndrome, 104 simple bone cysts, 338
elbow, 372–373 pearl ganglia, 381–382
following fractures, 106, 181 P peg (pivot) joints, 33, 34
hand, 378–379 Pellegrini–Stieda disease, 261
hip, 25, 295, 296, 297, 299, Paget’s disease, 322–323, 324–325 pelvis
Paget’s sarcoma, 323, 325 injuries, 59, 176–184
393–404 painful arc syndrome, 367, 368, 373
knee, 297, 298, 299, 406–412 painful foot gait, 26–27 clinical examination, 23, 24
patellofemoral, 423, 424–425 pain-relieving (antalgic) gait, 25, 26, haemorrhage, 103–104, 176
radiological appearance, 295, osteomalacia, 322, 323
45, 47 Paget’s disease, 324
296, 394 palmar injuries, 224 pencillin sensitivity, 77
rheumatoid arthritis compared, palpation, 12 penicillamine, 76–77, 304
periosteum, 36
294 acromioclavicular joint, 19 peripheral nerves
shoulder, 370 cervical spine, 14 anatomy, 42–43, 44
toe, 436–437 chest, 17 conduction studies, 65
treatment, 296–300, 407–412 elbow, 20 see also specific nerves
foot, 31 peroneal muscular atrophy, 332,
arthroplasty, 84, 86, 299–300, hand, 22 443
395–403, 408–409, 427, hip, 24, 25 peroneal tendons, 433
437 knee, 28 Perthes’disease, 326–327, 328, 329
lumbar spine, 16 pertotrochanteric fractures, 245–
wrist, 377–378 patellofemoral joint, 30 246, 247
osteoblastoma, 339 pelvis, 23 pes cavus (claw foot), 31, 443
osteochondral lesions, 416–419 shoulder, 18 pes planovalgus (flat foot), 31, 353–
thoracic spine, 16 354, 442–443
fractures, 257–258, 417 wrist, 20 petechial haemorrhages, 174
osteochondritides, 326–331, 386, paradoxical respiration, 168 phalanges
paraplegia, 154, 158, 161, 162–164, clinical examination, 23
418–419, 430, 432–433, 459 dislocations, 233
osteochondritis dissecans, 331, 332, 165 enchondroma, 340
paratenonitis, 286, 433 fractures, 232–233, 234, 280
416, 418–419, 430, 431 parathyroid hormone, 317, 322
osteochondroma, 339–340, 485
344–345
osteogenesis imperfecta, 318–320
osteogenic bone tumours, 336, 338–
339, 341, 344, 463
osteoid osteoma, 338, 339
Index
phocomelia, 360, 361 implanted, 46–47, 48, 49–50 for preoperative assessment, 65
physical therapy, 69–70 investigation case report, rheumatoid arthritis, 303
66–67 radiohumeral joint, rheumatoid
see also occupational therapy; radioisotope scans, 61–62,
physiotherapy 402 arthritis, 373
replacement of femoral head, radioisotope scanning, 60–62, 63,
physiotherapy, 69–70 242–245, 395–403
osteoarthritis, 297 total knee replacement, 408– 67, 402
torticollis, 363–364 409, 410–411 radioulnar joints
see also joints, artificial
piezoelectric activity, bone, 51, 52 anatomy, 33, 34
pigmented villonodular synovitis protective sportswear, 289–290 fractures with dislocation of, 206,
protrusio acetabuli, 404
(PVNS), 307 pseudarthrosis, 50, 97, 299, 364, 470 212
pinch grip, 237, 238 pseudogout, 305–306 radius
pins, skeletal traction, 123–124, psoriatic arthropathy, 306
psychology, athletes, 283–284 dislocations, 206, 209, 210
137 PTFE implants, 48 Ewing’s sarcoma, 343
pivot (peg) joints, 33, 34 pubic rami fractures, 176, 177, 178, fractures, 52, 206–211, 212,
pivot shift test, 29, 421
plane joints, 33 323 213–217
plantar fasciitis, 433–434 pubic symphysis, footballers’ giant cell tumour, 340, 341
plasmocytoma, 343 osteomyelitis, 313
plaster casts see casts injuries, 287–289 real shortening, 470
Plaster of Paris, 127–128 pulmonary emboli, 77 rectum, injury to, 180
plastic implants, 48 pulp space infections, 383 rectus femoris, rupture, 255, 256
plastic operations, 87, 88 pyarthrosis, 470 recurvatum, 470
plastic surgeons, 6 pyrophosphate and hydroxyapatite reduction
-plasty, definition, 470 dislocated hip, 181–183
plates, 46, 79, 80, 133–134, 143 deposition, 305–306 dislocated shoulder, 194–196,
pleural cavity injuries, 169–172
plication, ligaments, 86 Q 365
pneumothoraces, 169–172 fractures see fractures, reduction
poacher’s thumb, 232 Q angle, 425–426 reflex sympathetic dystrophy, 107,
poliomyelitis, 332–333 quadriceps, thigh circumference, 27
polymethylmethacrylate see acrylic quadriceps tendon rupture, 255 215, 309
regional pain syndrome, 309
cement R
polytetrafluorethylene (PTFE) see also reflex sympathetic
radial, definition, 470 dystrophy
implants, 48 radial club hand, 363
Ponseti method, club foot, 352, 353 radial deviation, wrist, 21 rehabilitation
Popeye sign, 369 radial nerve hand injuries, 236–237
popliteal cysts, 419–420 paraplegic patients, 164
popliteal vessels, 263 anatomy, 42, 43
post-traumatic amnesia, 151, 152 common injuries, 43, 44 rehabilitation centres, 76
posterior cruciate ligament lesions, 388–389 Reiter’s disease, 308
radiculography, 56 relaxing incisions, 140
chronic instability, 421–422 radiographic investigations, 55–58 remedial gymnastics, 70
clinical examination, 28, 29, 30 bone tumours, 335–336 remodelling, bone, 51, 52, 105,
rupture, 28, 262, 263 case report, 66
posterior introsseous nerve, 389 computed tomography, 58–59 294–295
posterior sag sign, 29, 30, 421, 422 disc prolapse, 452–453 renal injury, 176
Pott’s fracture, 269 fractures, 55–56, 57, 59, 93, renal tumours, 343, 344, 462
power grip, 237 repetitive stress injuries, 289
precision grips, 237, 238 102 replacement arthroplasty, 84, 85,
preoperative assessment, 64–65, 67 see also specific bones
pressure sores head injuries, 152 242–244, 299–300, 395–404,
paraplegic patients, 163–164 osteoarthritis, 295, 296, 394 408–409, 410–411
patients with casts, 138 osteomalacia, 321–322, 323 resettlement, 75–76
patients on traction, 137, 138 painful hip prostheses, 402 respiratory failure
pronation, 470 place in examination routine, ABC routine, 115
prostate tumours, 343, 344, 462 11 lung injuries, 173–174
prostheses rib fractures, 168
artificial limbs, 73, 74 resuscitation, ABC routine, 115–116
retraining, 75, 76
486 retroperitoneal haematoma,
175–176
rheumatism, 470
rheumatoid arthritis, 301–305
Index
ankle, 431 saphenous vein, intravenous glenohumeral joint instability,
cervical spine, 446–447 infusion lines, 116 374
clinical examination, 22
clinical features, 301–302 scaphoid fractures, 228–229 internal derangements, 367
elbow, 373 aseptic necrosis, 106, 107 joint anatomy, 33
foot, 302, 442 osteoarthritis, 370
hand, 302, 303, 376–377, 378 scapula referred pain, 370
hip, 395 fractures, 192 rheumatoid arthritis, 370, 371
interposition arthroplasty, 84 Sprengel’s shoulder, 448 rotator cuff tear, 373
investigations, 64, 302–303 slings, 130, 131
knee, 412–413 scapulothoracic joint, 18, 19 Sudeck’s atrophy, 215
osteoarthritis compared, 294 scars, 51, 53 supraspinatus tendinitis, 367–
pathology, 301 Scheuermann’s disease, 15, 331, 459
shoulder, 370, 371 sciatic nerve 368, 373
systemic manifestations, supraspinatus tendon rupture,
anatomy, 43, 44
303–304 injury, 180, 181, 182 196, 368–369
treatment, 77, 304–305, 376, scissor gait of cerebral palsy, 25–26 shoulder–hand syndrome, 215
scoliosis sickle cell disease, 308
377, 395 children, 361–362 simple fractures, 97–98
synovectomy, 84, 304, 412 clinical examination, 15, 16 Sinding Larsen’s disease, 330, 331
wrist, 302, 304, 305, 375–376 screws, 46, 48, 49, 79, 80–81, 133 Sjögren’s syndrome, 304
rheumatologists, 6 scurvy, 317, 318 skeletal traction, 123–124, 137
rhinorrhoea, CSF, 151 seat belts, vertebral fractures,
rib femoral shaft fractures, 250–251
eosinophilic granuloma, 336 160–161 ski boot-top fractures, 268
fractures, 167–169 segmental fractures, 100 skill centres, retraining, 76
clinical examination, 17, 18 skin care, paraplegic patients,
complications, 104 tibia and fibula, 268
tension pneumothorax, 171 self-tapping screws, 470 163–164
vestigial, 447 skin flaps, 140, 141
rickets, 321, 348 see also screws skin grafts, 140–141
ring fixators, 131–132 sensibility, 12, 22 skin healing, 51, 53
road traffic accidents, 117–119, 140, sensory nerves, conduction studies, skin injuries, 112
142–143
abdominal trauma, 175 65 fracture classification, 98
brachial plexus lesions, 185, 186 septic arthritis, 311, 312, 314–315, with fracture fixation, 139
comminuted fractures of lower hand, 226–227
femur, 253 405, 413 immediate care, 117
hip dislocation, 180 sequestra, 312, 313, 329 management, 139–141
mediastinal injuries, 172–173 serological tests, 66 with tibial fractures, 266
patellar fractures, 254 serratus anterior, 19 skin loss, plastic surgery, 6
seat-belt fractures, 160–161 sesamoid bones, 40 skin operations, 87, 88
whiplash injury, 157–158 Sever’s disease, 330, 433 skin traction, 124, 142
Rose-Waaler test, 64 sex hormones, bone growth, 317 skull
rotation, definition, 13, 470 sheep cell agglutination test (SCAT), injuries, 147, 148, 149
rotation injuries
ankle, 272, 273–275 64, 303 fracture complications, 104
cervical spine, 156–157 shin splints, 470 management decisions,
lumbar spine, 162 shock lung, 104–105, 174–175
thoracic spine, 161 shoes, 74–75 151–152
rotator cuff, 19, 373, 374 open fractures, 150
Royal College of Surgeons, 4 children, 354 Paget’s disease, 324
osteoarthritis, 297 SLAP lesions, 367
S rheumatoid arthritis, 304 sliding joints, anatomy, 33, 34
sports injuries, 286, 287, 290 sliding traction, 125–126, 127,
sacral fractures, 178, 183 short bones, 35 250–251
sacroiliac joint fractures, 59, 178 shoulder slings, 130, 131, 189–190
sacrum, lumbarization, 459–460 acromioclavicular instability, 370 slipped lower femoral epiphysis,
arthroplasty, 370, 371 253
biceps tendon rupture, 369–370 slipped upper femoral epiphysis,
chondroblastoma, 340 246–247, 248, 281
clinical examination, 17–19 smears, 66
congenital high scapula, 448 Smith’s fracture, 217, 219
dislocation, 3, 17, 18, 108, 192– snapping hip, 405–406
196, 365–367 487
fracture dislocations, 196, 199
frozen, 369
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Essential Orthopedics and Trauma 5th Ed
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Essential Orthopedics and Trauma 5th Ed
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