Banaskewiz 2017

Cambridge University Press
978-1-107-45164-3 — Postgraduate Orthopaedics

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Postgraduate Orthopaedics
The Candidate’s Guide to the FRCS (Tr & Orth) Examination
Third edition
© in this web service Cambridge University Press www.cambridge.org

3rd Edition
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Postgraduate Orthopaedics
The Candidate’s Guide to the FRCS (Tr & Orth) Examination
Third edition
Edited by
Paul A. Banaszkiewicz FRCS (Glas) FRCS (Ed) FRCS (Eng) FRCS (Tr & Orth)
MClinEd FAcadMEd FHEA
Consultant Orthopaedic Surgeon
Queen Elizabeth Hospital and North East NHS Surgical Centre (NENSC), Gateshead, UK
Visiting Professor
Northumbria University, Newcastle-upon-Tyne, UK
Associate editor
Deiary F. Kader FRCS (Glas) FRCS (Ed) FRCS (Tr & Orth) MFSEM (UK)
Consultant Orthopaedic Surgeon
Academic Unit South West London Elective Orthopaedic Centre
Visiting Professor in Sport and Exercise Science
Northumbria University, Newcastle-upon-Tyne, UK

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© Cambridge University Press (2009, 2012) 2017
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no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published 2009
Second edition published 2012
Third edition published 2017
Printed in the United Kingdom by Clays, St Ives plc
A catalogue record for this publication is available from the British
Library
Library of Congress Cataloguing in Publication data
Names: Banaszkiewicz, Paul A., editor. | Kader, Deiary F., editor.
Title: Postgraduate orthopaedics : the candidate’s guide to the FRCS
(TR & Orth) examination / edited by Paul A. Banaszkiewicz,
Deiary F. Kader.
Description: Third edition. | Cambridge, United Kingdom :
Cambridge University Press, 2016.
Identifiers: LCCN 2016000281 | ISBN 9781107451643 (paperback)
Subjects: | MESH: Orthopedic Procedures | Examination Questions
Classification: LCC RD732.6 | NLM WE 18.2 | DDC 616.70076–dc23
LC record available at http://lccn.loc.gov/2016000281
ISBN 978-1-107-45164-3 Paperback
Cambridge University Press has no responsibility for the persistence
or accuracy of URLs for external or third-party internet websites
referred to in this publication, and does not guarantee that any
content on such websites is, or will remain, accurate or appropriate.
.............................................................................
Every effort has been made in preparing this book to provide accurate
and up-to-date information which is in accord with accepted stand-
ards and practice at the time of publication. Although case histories
are drawn from actual cases, every effort has been made to disguise the
identities of the individuals involved. Nevertheless, the authors,
editors and publishers can make no warranties that the information
contained herein is totally free from error, not least because clinical
standards are constantly changing through research and regulation.
The authors, editors and publishers therefore disclaim all liability for
direct or consequential damages resulting from the use of material
contained in this book. Readers are strongly advised to pay careful
attention to information provided by the manufacturer of any drugs
or equipment that they plan to use.

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The third edition of Postgraduate Orthopaedics is dedicated to the

memory of Professor Andrew P. Sprowson. He was one of the strongest
early supporters of Postgraduate Orthopaedics and shared the same goals
and visions that founded the development of the book series. He intui-
tively recognised the importance of developing a UK-based orthopaedic
textbook for UK graduates sitting their FRCS (Tr & Orth) examination,
rather than having to rely on dissimilar North American counterparts.
His basic science chapters in the Postgraduate Orthopaedics Viva Guide
will be fondly remembered for their uniquely differing approach to a
difficult dry subject area of the exam syllabus. He was very keen to
continue his involvement with the book series for the third edition and
co-authored two chapters. He will be sadly, yet fondly, remembered for
his enthusiasm, energy and larger-than-life character.

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Contents
List of contributors ix
Foreword by Bill Ledingham xii
Preface xiii
Acknowledgements xiv
List of abbreviations xv
Interactive website xx
Section 1 The FRCS (Tr & Orth) examination 12 Knee clinical cases 161
1 General guidance 1 Francois Tudor and Deiary F. Kader
Niall Breen, Benjamin W. T. Gooding and Jonathan 13 Foot and ankle clinical cases 174
R. A. Phillips Rajesh Kakwani
2 What to read 9 14 Paediatric clinical cases 195
Jonathan R. A. Phillips and Benjamin W. T. Gooding Sattar Alshryda and Philip Henman
Section 2 The written paper Section 4 The general orthopaedics

3 MCQ and EMI paper guidance 15 and pathology oral
Mark Dunbar, Andrew P. Sprowson and David Limb
15 General viva guidance 225
Abhijit Bhosale and Stan Jones
Section 3 The clinicals 16 Hip oral core topics 228
4 Introduction to clinical examination techniques 25 Sammy A. Hanna and Paul A. Banaszkiewicz
Karen Robinson and Fazal Ali
17 Knee oral core topics 292
5 The short cases 31 Khaled M. Sarraf and Deiary F. Kader
Mark Dunbar and Andrew P. Sprowson
18 Foot and ankle oral core topics 339
6 The intermediate cases 35 Kailash Devalia and Jane Madeley
Neil E. Jarvis, Puneet Monga and Stan Jones
19 Spine oral core topics 369
7 Shoulder clinical cases 39 Joseph S. Butler and Alexander D. L. Baker
Yusuf Michla and David Cloke
20 Tumour oral core topics 391
8 Elbow clinical cases 51 Thomas Beckingsale and Craig H. Gerrand
Ramnadh S. Pulavarti, Mohan K. Pullagura and
Charalambos P. Charalambous
9 Hand and wrist clinical cases 70
Section 5 The hand and
John E. D. Wright and John W. K. Harrison upper limb oral
10 Spine clinical cases 88 21 Hand oral core topics 421
Prasad Karpe David R. Dickson and John W. K. Harrison
11 Hip clinical cases 113 22 Elbow oral core topics 495

Suresh Thomas and Paul A. Banaszkiewicz Matthew Jones and Asir Aster
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Table of contents
23 Shoulder oral core topics 502 Section 8 The basic science oral
Matthew Jones and Asir Aster
30 Basic science oral topics 685
24 Brachial plexus core topics 515 Kevin P. Sherman
David R. Dickson and Chye Yew Ng
31 Applied basic science oral topics 761
Paul A. Banaszkiewicz and Stan Jones
Section 6 The paediatric oral

25 Paediatric oral core topics 521
Section 9 Miscellaneous topics
Kathryn Price and Antoine de Gheldere 32 Surgical exposures oral core topics 813
Anish Kadakia and Jonathan Loughead
33 Anatomy for the FRCS (Tr & Orth) 848
Section 7 The trauma oral Apurv Sinha and Fazal Ali
26 General principles, spine and pelvis 583 34 SAS doctors and the FRCS (Tr & Orth) exam 889
William Eardley and Paul Fearon Ramnadh S. Pulavarti and Kevin P. Sherman
27 Upper limb trauma oral core topics 610 35 Candidates’ accounts of the examination 893
Nirav K. Patel and Charalambos P. Charalambous Jibu J. Joseph and Shariff Hazarika
28 Lower limb trauma oral topics 629 36 Examination failure 909

Jonathan R. A. Phillips and Gunasekaran Kumar Andrew Port and Mike Reed
29 Applied trauma oral topics 660

Jonathan R. A. Phillips, William Eardley and
Paul Fearon Index 912
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Contributors
Fazal Ali FRCS (Tr & Orth) Joseph S. Butler BMedSc MB BCh BAO MA PhD MFSEM
Chesterfield Royal Hospital FEBOT FRCS (Tr & Orth)
Chesterfield, UK Mater Misericordiae University Hospital and
Tallaght Hospital
Sattar Alshryda MBChB MRCP (UK) MRCS SICOT EBOT Dublin, Ireland
FRCS (Tr & Orth) MSc PhD
Royal Manchester Children’s Hospital Charalambos P. Charalambous BSc MBChB MSc MD
Manchester, UK FRCS (Tr & Orth)
Blackpool Teaching Hospitals NHS Trust
Asir Aster MBBS, FRCS (Surg) MSc (Orth Eng) Blackpool, UK
FRCS (Tr & Orth) School of Medicine and Dentistry
Oaklands Hospital University of Central Lancashire
Ramsayhealth Preston, UK
Salford
David Cloke BMedSci (Hons) MBBS (Hons) MSc
Alexander D. L. Baker BSc MBChB MRCS MSc (Sports Med) MFSEM (UK) FRCS (Tr & Orth)
FRCS (Tr & Orth) Northumbria Healthcare NHS Trust
Lancashire Teaching Hospitals
Royal Preston Hospital Kailash Devalia FRCS (Tr & Orth)
Preston, UK Northern General Hospital
Sheffield, UK
Paul A. Banaszkiewicz FRCS (Glas) FRCS (Ed) FRCS (Eng)
FRCS (Tr & Orth) MClinEd FAcadMEd FHEA David R. Dickson BSc FRCS (Tr & Orth)
Queen Elizabeth Hospital and NENSC Bradford Royal Infirmary
Gateshead, UK Bradford, UK
Thomas Beckingsale MSc FRCS (Tr & Orth) Mark Dunbar MA PhD FRCS (Tr & Orth)
Freeman Hospital University Hospital of Coventry and Warwick
Newcastle-upon-Tyne, UK Coventry, UK
Abhijit Bhosale FRCS (Tr & Orth) MD MRCS (Ed) William Eardley MBChB MSc DipSEM (UK & I) FRCS
MS (Orth) DNB(Orth) MBBS (Tr & Orth)
Barnsley Hospital NHS Foundation Trust James Cook University Hospital
Barnsley, UK Middlesborough, UK
Niall Breen MBBCh, BAO MRCS (Ed) MSc (Tr & Orth) Paul Fearon BSc (Hons) MB Bch BAO (Hons)
FRCS (Tr & Orth) FRCS (Tr & Orth) MD
Musgrave Park Hospital Freeman Hospital
Belfast, UK Newcastle-upon-Tyne, UK
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List of contributors
Craig H. Gerrand MB ChB FRCS (Ed) MD MBA Rajesh Kakwani MBBS MRCS MS (Orth) FRCS
Freeman Hospital (Tr & Orth)
Newcastle-upon-Tyne, UK Northumbria Healthcare NHS Trust
Antoine de Gheldere MD Prasad Karpe FRCS (Tr & Orth)
Freeman Hospital University Hospital of North Tees
Newcastle-upon-Tyne, UK Stockton-on-Tees, UK
Benjamin W. T. Gooding FRCS (Tr & Orth) Gunasekaran Kumar FRCS (Tr & Orth)
Circle and Nottingham University Hospitals Royal Liverpool University Hospital
Nottingham, UK Liverpool, UK
Sammy A. Hanna MD (Res), PgDip (Clin Ed) FRCS (Tr David Limb BSc FRCS Ed (Orth)
& Orth) Leeds Teaching Hospitals Trust
Barts and The London NHS Trust Leeds, UK
London, UK
Jonathan Loughead MSc FRCS (Tr & Orth)
John W. K. Harrison MSc FRCS (Ed) FRCS (Tr & Orth) Queen Elizabeth Hospital and NENSC
MFSEM (UK) Gateshead, UK
Queen Elizabeth Hospital and NENSC
Gateshead, UK Jane Madeley FRCS (Tr & Orth)
Glasgow Royal Infirmary
Shariff Hazarika MRCS FRCS (Tr & Orth) Glasgow, UK
Royal Alexandria Hospital
Paisley, UK Yusuf Michla MRCSEd FRCS (Tr & Orth)
Sunderland Royal Hospital
Philip Henman FRCS (Tr & Orth) Sunderland, UK
Freeman Hospital
Newcastle-upon-Tyne, UK Puneet Monga FRCS FRCSEd (Tr & Orth) Dip Sports
Med MSc MS Orth DNB MBBS
Neil E. Jarvis FRCS (Tr & Orth) Wrightington Hospital
Wrightington Hospital Wigan, UK
Wigan, UK
Chye Yew Ng MBChB (Hons) EBHS (Dip), BSSH (Dip)
Matthew Jones MBChB (Hons) FRCS (Tr & Orth) FRCS (Tr & Orth)
Dip Hand Surg Wrightington Upper Limb Unit
University Hospitals Coventry and Warwickshire Wigan, UK
Leicester, UK
Nirav K. Patel FRCS (Tr & Orth)
Stan Jones MBChB MSc BioEng FRCS (Tr & Orth) North West Thames (Imperial College) Orthopaedic Rotation
Sheffield Childrens Hospital London, UK
Sheffield, UK
Jonathan R. A. Phillips MB ChB, MSc (Sports Medicine)
Jibu J. Joseph FRCSGlasg (Tr & Orth) MBChB (Comm) FRCS (Tr & Orth)
BSc Med Sci (Hon) Princess Elizabeth Orthopaedic Centre
Royal Alexandria Hospital Exeter, UK
Paisley, UK
Andrew Port MBChB BSc (Hons) FRCS (Ed)
Anish Kadakia FRCS (Tr & Orth) FRCS (Tr & Orth)
Northampton General Hospital James Cook University Hospital
Northampton, UK Middlesborough, UK
Deiary F. Kader FRCS (Glas) FRCS (Ed) FRCS Kathryn Price MMedSci FRCS (Tr & Orth)
(Tr & Orth) MFSEM (UK) Queen's Medical Centre
Academic Unit South West London Elective Nottingham, UK
Orthopaedic Centre

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List of contributors
Ramnadh S. Pulavarti MS Orth DNB Orth MSc Orth Apurv Sinha FRCS (Tr & Orth)
FRCS Ed FRCS Ed (Tr & Orth) Chesterfield Royal Hospital
Airedale General Hospital Chesterfield, UK
Keighley, UK
Andrew P. Sprowson MD FRCS (Tr & Orth)
Mohan K. Pullagura MS Orth, MRCS (Ed) FRCS Ed University Hospital of Coventry and Warwick
(Tr & Orth) Coventry, UK
Whiston Hospital
St Helens, UK Suresh Thomas MBBS MRCSEd MSc (Orth)
FRCS (Tr & Orth) Fellow EBOT
Mike Reed FRCS (Tr & Orth) MD Wrightington Hospital
Northumbria Healthcare NHS Trust Wrightington, UK
Karen Robinson BMedSci (Hons) FRCS (Tr & Orth) Francois Tudor MBBS MSc FRCS (Tr & Orth)
Chesterfield Royal Hospital Gold Coast University Hospital
Chesterfield, UK Queensland, Australia
Khaled M. Sarraf FRCS (Tr & Orth) John E. D. Wright FRCS (Tr & Orth)
St Mary’s Hospital, Imperial College Healthcare, Chesterfield Royal Hospital
London, UK Chesterfield, UK
Kevin P. Sherman MA BM BCh FRCS PhD MEd
Spire Hull and East Riding Hospital
Hull, UK
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Foreword
It is a pleasure to be asked to write a foreword for the third the useful knowledge contained within the text and, moreover,
edition of this now very well-known textbook. It builds on the for the invaluable advice on exam techniques that will help in
tradition of the previous two editions and it is easy to see why the presentation of that knowledge.
Postgraduate Orthopaedics is the best-selling orthopaedic text The flavour of the book is unchanged, and the recipe is still
in the UK. There are contributions from over 50 surgeons, and very successful. There is freshness about this edition and a
Banaskiewicz and Kader have edited it into a hefty but very confidence in the presentation, which comes from the
readable single volume. The changes and additions make it undoubted success of the first two editions. Dip into it, or read
even more comprehensive than the previous editions. It will it from cover to cover. Enjoy.
continue to be an essential read for orthopaedic trainees espe-
cially those with the FRCS Orth looming. Its strength lies in Bill Ledingham, Aberdeen, March 2016
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Preface to third edition
There was a big jump-up in detail and quality between the first book unmanageable and is perhaps best saved for a later date
and second editions of Postgraduate Orthopaedics, so when the in the future.
second edition was released we felt confident we could rest up a An interesting addition was the chapter on what books to
little before we undertook a third edition. read for the FRCS (Tr & Orth) exam. This had always been
After each new book release the general feeling for the first included in the general introduction chapter but just seemed to
few months is that we will never do another book as we really have outgrown it. This part of the chapter continually surprises
don’t need all the hassle all over again. However, events took us in how popular it is with candidates.
over very quickly in that soon after the second edition’s release In short, each chapter has been thoroughly reviewed,
it won a highly commended prize at the BMA book awards in revised and updated. We have again included a number of
London 2012. We realized that evening that a third edition was new contributors who have used the Postgraduate Orthopaed-
inevitable and probably would be needed sooner rather than ics book series to pass the exam. The continued success of the
later! book relies on involving these newly qualified trainees who
As time went by and the book’s popularity increased we keep the book relevant and current.
began to notice more closely deficiencies within the second We again make no claim for the originality of the text. We
edition. We needed some extra illustrations; some tidying-up are distilling orthopaedic knowledge from the wider ortho-
of chapters that could have read better; and additional specific paedic community specifically for exam-related subjects and
details for the trickier areas of the syllabus, like basic science. material.
The anatomy and surgical approaches section definitely Our popular examination corner section had to be
needed more professional illustrations and the text also tweaked. For various reasons we have omitted any new
required polishing-up. The clinical section needed additional second-hand accounts of specific detailed examination dia-
cases and more precise exam-focused details. Despite the sig- logues. This has been compensated for by Postgraduate Ortho-
nificant learning potential of the old-style long case, the general paedics now running its own courses which provide similar
consensus was that this material now had to be completely material for use.
dropped. We decided to include an applied basic science chapter A special word of thanks again to Cambridge University
where we specifically worked on basic science viva questions in Press for their help and support. The grass is not always
more detail. The trauma chapter needed expanding and for ease greener elsewhere.
of purpose was broken down into separate sections. Finally as we become more established in our clinical
Despite writing a separate paediatric book we still needed practice we may have said ‘poacher turned game keeper’ a
to review this section but without any unnecessary repetition few years ago but now prefer the term ‘gatekeeper’. It will be
of material. interesting to see if we make it to a fourth edition.
The part one MCQ/EMI section was revised and updated
but we decided against including large numbers of MCQ/EMI Paul A. Banaszkiewicz
questions at the end of each chapter. This would have made the Deiary F. Kader
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Acknowledgements
Our special thanks to Caitlin Monney and Emily McDougall

for drawing illustrations at short notice for the surgical
approaches and basic science chapters. Likewise, special thanks
to Steve Atkinson who photographed a large portion of the
orthopaedic implants, again at very short notice. Publishing a
book is much more than just writing the text!
Caitlin C. Monney BSc (Hons) MSc MIMI RMIP

Biomedical illustrator at CSIXSTUDIOS
caitlinmonney.com
Emily McDougall BA (Hons) MSc MIMI RMIP
Biomedical illustrator at CSIXSTUDIOS
emilymcdougall.com
Steve Atkinson Creative Photography
steveatkinsoncreativephotography.com
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Abbreviations
1,2-ISCRA 1,2-intercompartmental supraretinacular artery ATLS® Advanced Trauma Life Support®

A&E Accident and Emergency ATP adenosine triphosphate
AA ankle arthroplasty AVN avascular necrosis
AACP American College of Chest Physicians BDGF bone-derived growth factor
AADI anterior atlanto-dens interval bFGF basic fibroblast growth factor
AANS American Association of Neurological Surgeons BHR Birmingham Hip Resurfacing
AAOS American Academy of Orthopaedic Surgeons BMD bone mineral density
ABC airway, breathing, circulation BMES bone marrow oedema syndrome
ABPI Ankle : Brachial Pressure Index BMG bone matrix gelatin
AC acromioclavicular BMI Body Mass Index
ACDF anterior cervical decompression and fusion BMP bone morphogenetic protein
ACEA anterior centre edge angle BMU basic multicellular unit
ACL anterior cruciate ligament BOA British Orthopaedic Association
AD autosomal dominant BOAST British Orthopaedic Association Standards for
ADI atlanto-dens interval Trauma
ADL activities of daily living BP Buechel–Pappas
ADM abductor digiti minimi BPI brachial plexus injury
AER apical ectodermal ridge BPTB bone–patella–tendon–bone
AFO ankle–foot orthosis BR brachioradialis
AIDS acquired immunodeficiency syndrome BW body weight
AIIS anterior inferior iliac spine CAP Clubfoot Assessment Protocol
AIN anterior interosseous nerve CC costoclavicular
AIS Abbreviated Injury Scale CCT Certificate of Completion of Training
AITFL anterior-inferior tibiofibular ligament CDH congenital dislocation of the hip
AJCC American Joint Committee on Cancer CEA carcinoembryonic antigen
AKP anterior knee pain CEO common extensor origin
ALL anterior longitudinal ligament CESR Certificate of Eligibility for Specialist Registration
ALVAL aseptic lymphocyte-dominated vasculitis-associated CFL calcaneofibular ligament
lesions CFO common flexor origin
AM anteromedial CI Clearance Interval
ANOVA analysis of variance CIA carpal injury adaptive
ANT artery–nerve–tendon CIC carpal instability complex
AOFAS American Orthopaedic Foot and Ankle Society CID carpal instability dissociative
AP anteroposterior CIND carpal instability non-dissociative
APB abductor pollicis brevis CJD Creutzfeldt–Jakob disease
APTT activated partial thromboplastin time CL capitolunate
AR autosomal recessive CMAP compound muscle action potential
ARCO Association Research Circulation Osseous CMC carpometacarpal
ARDIS adverse reaction to metal debris CME continuing medical education
ARDS acute respiratory distress syndrome CMT Charcot–Marie–Tooth
ARMD adverse reactions to metal debris CMV cytomegalovirus
ARR absolute risk reduction CNS central nervous system
AS ankylosing spondylitis CNS Congress of Neurological Surgeons
ASA American Society of Anesthesiologist CO2 carbon dioxide
ASB anatomical snuffbox CoC ceramic on ceramic
ASIA American Spinal Injury Association CoP ceramic on polyethylene
ASIS anterior superior iliac spine COPD chronic obstructive pulmonary disease
ATD articular–trochanteric distance COR centre of rotation
ATFL anterior talofibular ligament CORA centre of rotational angular
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Abbreviations
CP cerebral palsy ESWL extracorporeal shock wave lithotripsy

CPM continued passive motion ETC early total care
CPN common peroneal nerve ETC early trauma care
CPPD calcium pyrophosphate dihydrate EtO ethylene oxide
CR cruciate retaining ETO extended trochanteric osteotomy
CRP C-reactive protein EUA examination under anaesthesia
CRPS complex regional pain syndrome FABER flexion, abduction and external rotation
CSF cerebrospinal fluid FAI femoroacetabular impingement
CSISS Cervical Spine Injury Severity Score FAST focussed assessment with sonography in
CSM cervical spondylotic myelopathy trauma
CT computed tomography FBC full blood count
CT2 core trainee 2 FCF four-corner fusion
CTEV congenital talipes equinovarus FCR flexor carpi radialis
CVA cerebrovascular accident FCU flexor carpi ulnaris
CVP central venous pressure FDB flexor digitorum brevis
DAB dorsal abducts FDG fluorodeoxyglucose
DCO damage control orthopaedics FDL flexor digitorum longus
DCP dynamic compression plate FDP flexor digitorum profundus
DCS dynamic condylar screw FDQ flexor digiti quinti
DD Dupuytren’s disease FDS flexor digitorum superficialis
DDH developmental dysplasia of the hip FEAR flexion, extension, abduction and adduction, external
DEXA dual energy x-ray absorptiometry and internal rotation
DHS dynamic hip screw FFD fixed flexion deformity
DI dorsal interosseous FFP fresh frozen plasma
DIC dorsal intercarpal FGF fibroblast growth factor
DIP distal interphalangeal FGF23 Fibroblast Growth Factor 23
DIPJ distal interphalangeal joint FGFR3 Fibroblast Growth Factor Receptor gene 3
DISH diffuse idiopathic skeletal hyperostosis FHB flexor hallucis brevis
DISI dorsal intercalated segment instability FHL flexor hallucis longus
DMAA distal metatarsal articular angle FPA foot progression angle
DMARDs disease modifying anti-rheumatoid drugs FPB flexor pollicis brevis
DP distal phalanx FPL flexor pollicis longus
DRC dorsal radiocarpal FTA foot–thigh angle
DRUJ distal radioulnar joint GA general anaesthetic
DV dorsoventral GAGs glycosaminoglycans
DVT deep vein thrombosis GCS Glasgow Coma Score
ECA extensor compartment artery GCT giant cell tumour
ECM extracellular matrix GHJ glenohumeral joint
ECR extensor carpi radialis GHL glenohumeral ligaments
ECRB extensor carpi radialis brevis GI gastrointestinal
ECRL extensor carpi radialis longus GMC General Medical Council
ECU extensor carpi ulnaris GMFCS Gross Motor Function Classification System
ED emergency department GRAFO ground reaction ankle foot orthosis
ED extensor digitorum GRF Ground Reaction Forces
EDB extensor digitorum brevis GT greater trochanter
EDC extensor digitorum communis HA hyaluronic acid
EDL extensor digitorum longus HA hydroxyapatite
EDM extensor digiti minimi HAGL humeral avulsion of inferior glenohumeral ligament
EDQ extensor digiti quinti HbA1c glycated hemoglobin
EF external fixation HBO hyperbaric oxygen
EGF epidermal growth factor HEA Hilgenreiner’s epiphyseal angle
EHL extensor hallucis longus HHS Harris Hip Score
EI extensor indicis HIV human immunodeficiency virus
EIP extensor indicis proprius HMSN hereditary motor sensory neuropathies
EJS effective joint space HNP herniated nucleus pulposus
EMG electromyography HO heterotopic ossification
EMIs extended matching items HOOD hereditary osteo-onychodysplasia
ENT ear, nose, throat HOTS higher order thinking skills
EPB extensor pollicis brevis HPT hyperparathyroidism
EPI epicondylitis HPV human papillomavirus
EPL extensor pollicis longus HRT hormone replacement therapy
EQA Examination Quality Assessment HSMN hereditary motor and sensory neuropathies
ER external rotation HTO high tibial osteotomy
ERCB extensor carpi radialis longus HU Hounsfield units
ESR erythrocyte sedimentation rate HV hallux valgus
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Abbreviations
HVA hallux valgus angle MC metacarpal

ICD International Classification of Diseases MCFA medial circumflex femoral artery
ICSRA intercompartmental supraretinacular MCL medial collateral ligament
artery MCP metacarpophalangeal
IDGF insulin-derived growth factor MCQs multiple choice questions
IGF insulin-like growth factor MCSF macrophage-colony stimulating factor
IGHL inferior glenohumeral ligament MDP methylene diphosphonate
Ihh Indian hedgehog MDT multidisciplinary team
II image intensifier MED multiple epiphyseal dysplasia
IL interleukin MEN multiple endocrine neoplasia
IM intramedullary MEPs motor-evoked potentials
IMA intermetatarsal angle MESS Mangled Extremity Severity Score
IMHS intramedullary hip screw MFC medial femoral condyle
IMN intramedullary nailing MFH malignant fibrous histiocytoma
IMT intermetatarsal MH medial hamstring
INR International Normalized Ratio MHRA Medicines and Healthcare products Regulatory
IOTFL interosseous tibiofibular ligament Agency
IP interphalangeal MIC minimum inhibitory concentration
IPJ interphalangeal joint MIPO minimally invasive plate osteosynthesis
IPR inferior peroneal retinaculum MLA medial longitudinal arch
IQR interquartile range MMP metalloproteinase
IR internal rotation MOA mechanism of action
ISAKOS International Society of Arthroscopy, Knee Surgery MOA mode of action
and Orthopaedic Sports Medicine MoM metal on metal
ISB Intercollegiate Specialty Boards MoP metal on polyethylene
ISS Injury Severity Score MP migration percentage
ITB iliotibial band MPFL medial patellofemoral ligament
ITU Intensive Care Unit MR magnetic resonance
IV intravenous MRA MR arthrogram/ arthroscopy
IVC inferior vena cava MRC Medical Research Council
IVP intravenous pyelogram MRI magnetic resonance imaging
JBJS Journal of Bone and Joint Surgery MS multiple sclerosis
JCA juvenile chronic arthritis MSTS Musculoskeletal Tumor Society
JCIE Joint Committee on Intercollegiate Examinations MSU monosodium urate
JRA juvenile rheumatoid arthritis MT metatarsal
JRF joint reaction force MTC Major Trauma Centre
KAFO knee–ankle–foot orthosis MTP metatarsophalangeal
KD knee dislocation MTPJ metatarsophalangeal joint
LA local anaesthetic MTP-PE muramyl tripeptide phosphatidylethanolamine
LAT lateral MUA manipulation under anaesthetic
LBP low back pain MUPs motor unit potentials
LCDCP low-contact dynamic compression plates NAI non-accidental injury
LCE lateral centre edge NAP nerve action potential
LCEA lateral centre-edge angle of Wiberg NBM nil by mouth
LCFA lateral circumflex femoral artery NCS nerve conduction studies
LCL lateral collateral ligament NDI Neck Disability Index
LCP low compression plates Nf neurofibromatosis
LCS low contact stress Nf-1 neurofibromatosis type 1
LFTs liver function tests Nf-2 neurofibromatosis type 2
LHB long head of biceps NICE National Institute for Health and Clinical Excellence
LIPUS low intensity pulsed ultrasound NIPE Newborn Infant Physical Examination
LISS less invasive stabilisation system NJR National Joint Registry
LLA lateral longitudinal arch NOF Neck of femur
LLD limb length discrepancy NOGG National Osteoporosis Guideline Group
LMN lower motor neuron NPV Negative Predictive Value
LOTS lower order thinking skills NSA neck shaft angle
LRL long radiolunate ligament NSAIDs non-steroidal anti-inflammatory drugs
LRP5 low-density lipoprotein receptor-related protein 5 OA osteoarthritis
LRTI ligament reconstruction tendon interposition OBPI obstetric brachial plexus injury
LTL lunotriquetral ligament OCD osteochondritis dissecans
LUCL lateral ulnar collateral ligament OCL osteochondral lesions
MACTAR McMaster-Toronto Arthritis patient Preference ODEP Orthopaedic Data Evaluation Panel
Disability Questionnaire ODF osteoclast differentiation factor (aka RANK ligand)
MARS metal artifact reduction sequence OI osteogenesis imperfecta
MBD metastatic bone disease OITE Orthopaedics In-Training Exam
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Abbreviations
OK Outerbridge and Kashiwagi RANKL receptor activator of nuclear factor kB ligand

ON osteonecrosis RC radial collateral
OP opponens pollicis RCT randomised controlled trial
OP out-patient RHK rotating-hinge knee
OPG osteoprotegerin RICE rest, ice, compression and elevation
OPLL ossification of the posterior longitudinal ligament RL radiolunate
ORIF open reduction internal fixation RLL radiolucent line
ORL oblique retinacular ligament RLT radiolunotriquetral
OSCAR Orthosonics System for Cemented Arthroplasty ROM range of movement
Revision ROTEM rotational thromboelastometry
PA posterior anterior RR relative risk
PAO periacetabular osteotomy RRR relative risk reduction
PCL posterior cruciate ligament RS radioscaphoid
PCP perimeniscal capillary plexus RSA radiostereometric analysis
PD proximodistal RSA reverse total shoulder arthroplasty
PDGF platelet-derived growth factor RSC radioscaphocapitate
PDP personal development plan RSD reflex sympathetic dystrophy
PE polyethylene RSL radioscapholunate ligament
PE pulmonary embolism RSWP radial side wrist pain
PEEK polyetheretherketone RT radiotriquetral
PER pronation–external rotation RTA road traffic accident
PET positron emission tomography RTSA reverse shoulder arthroplasty
PF patellofemoral RU radioulnar
PFFD proximal focal femoral deficiency RUL radioulnar ligaments
PFO proximal femoral osteotomy RVAD rib vertebral angle difference
PGE2 prostaglandin E2 SAC space available for the cord
PICU paediatric intensive care unit SAC Specialty Advisory Committee
PIN posterior interosseous nerve SACH solid ankle cushion heel
PIP proximal interphalangeal SAS specialty and associate specialist
PIPJ proximal interphalangeal joint SBA single best answer
PIS pinning-in-situ SC sternoclavicular
PITFL posterior-inferior tibiofibular ligament SC supracondylar
PJI periprosthetic joint infection SC synovial chondromatosis
Pl palmaris longus SCA single correct answer
PL posterolateral SCC squamous cell carcinoma
PLAD posterior lip augmentation device SCD sickle cell disease
PLC posterolateral corner SCFE slipped capital femoral epiphysis
PLIF posterior interbody lumbar fusion SCIWORA spinal cord injury without radiological abnormality
PLL posterior longitudinal ligament SD standard deviation
PLRI posterolateral rotatory instability SEMLS single event multiple level surgery
PMMA polymethylmethacrylate SEPs sensory-evoked potentials
PNET primitive neuroectodermal tumour SER supination external rotation
POP plaster of Paris SERMs selective oestrogen receptor modulators
PP proximal phalanx SHH sonic hedgehog
PPV Positive Predictive Value SI sacroiliac
PQ pronator quadratus SJ sternoclavicular
PR per rectum SL scapholunate
PRC proximal row carpectomy SLAC scapholunate advanced collapsed
PROSTALAC prosthesis of antibiotic-loaded acrylic cement SLAP superior labrum from anterior to posterior
PRP platelet-rich plasma SLE systemic lupus erythematosus
PRUJ proximal radioulnar joint SLL scapholunate ligament
PS posterior stabilised SLR straight leg raise
PSA prostate specific antigen SMAC Standing Medical Advisory Committee
PSIS posterior superior iliac spine SNA stem-neck angle
PSO pelvic support osteotomy SNAC scaphoid non-union advanced collapsed
PT pronator teres SNAP sensory nerve action potential
PT prothrombin time SOL space occupying lesion
PTFL posterior talofibular ligament SPECT single photon emission computed tomography
PTH parathyroid hormone SPN superficial peroneal nerve
PTHrP Parathyroid hormone-related peptide SPORT Spine Patient Outcomes Research Trial
PVD pelvic disease SPR superior peroneal retinaculum
PVD peripheral vascular disease SRS Scoliosis Research Society
PVL Panton–Valentine leukocidin SSA stem-shaft angle
PVNS pigmented villonodular synovitis SSEPs somatosensory evoked potentials
RA rheumatoid arthritis SSSC superior shoulder suspensory complex
xviii

3rd Edition
Frontmatter
More Information
Abbreviations
ST scaphotrapezial TORCH toxoplasmosis, other, rubella, cytomegalovirus,

ST3 surgical trainee year 3 herpes simplex
ST6 surgical trainee year 6 TP tibialis posterior
STAR Scandinavian total ankle replacement TT tibial tubercle
STC Specialist Training Committee U&E urea and electrocytes
STIR short tau inversion recovery UCL ulnar collateral ligament
STR soft-tissue realignment UFD unilateral facet dislocation
STS soft-tissue sarcoma UHMWPE ultra-high-molecular-weight polyethylene
STT scaphotrapeziotrapezoid UKA unicompartmental knee arthroplasty
SUFE slipped upper femoral epiphysis UKITE UK in Training Examination
TA tibialis anterior UKR unicompartmental knee replacement
TAD tip apex distance UL ulnolunate ligament
TAL transverse atlantal ligament UMN upper motor neuron
TAR total ankle arthroplasty US ultrasound
TB tuberculosis USMLE United States Medical Licensing Examination
TBW tension band wiring USS ultrasound scan
TCC total contact casting USWP ulnar side wrist pain
TEA total elbow arthroplasty UT ulnotriquetral ligament
TENS transcutaneous electrical nerve stimulation UTI urinary tract infection
TER total elbow replacement UV ultraviolet
TFA thigh–foot angle VACTERL vertebral, anorectal, cardiac, tracheal, oesophageal,
TFC triangular fibrocartilage renal and limb
TFCC triangular fibrocartilage complex VATER vertebral, anorectal, tracheal, oesophageal, renal
TGF transforming growth factor VIP vasoactive intestinal polypeptide
TGF-β transforming growth factor-beta VISI volar intercalated segment instability
THA total hip arthroplasty VITO valgus intertrochanteric osteotomy
TIMPs tissue inhibitory metalloproteinases VMO vastus medialis obliquus
TKA total knee arthroplasty VP ventriculoperitoneal
TKR total knee replacement VTE venous thromboembolism
TLHKAFO thoraco–lumbar–hip–knee–ankle–foot orthosis VVC varus–valgus constrained
TLICS Thoraco-Lumbar Injury Classification and WBC white blood cell
Severity Score WCC white blood cell count
TLIF transforaminal lumbar interbody fusion WHO World Health Organization
TLSO thoracolumbar spinal orthosis WOMAC Western Ontario and McMaster Universities
TMA transmalleolar thigh angle Arthritis Index
TMJ temporomandibular joint Y-TZP yttria-stabilised tetragonal zirconia particles
TMT tarsometatarsal ZPA zone of polarizing activity
TNF tumour necrosis factor
xix

3rd Edition
Frontmatter
More Information
Interactive website
The website to accompany the book team provides a profile of authors who were involved in writing
www.postgraduateorthopaedics.com the books. There is also a list of Postgraduate Orthopaedics
courses available for candidates to fine-tune their examination
This website accompanies the textbook series: Postgraduate
skills. Details of the next diet of exams is also provided.
Orthopaedics.
There is a link to additional orthopaedic websites that are
It includes:
particularly exam focused.
Postgraduate Orthopaedics: The Candidates Guide to the It is very important our readership gives us feedback.
FRCS (Tr & Orth) Examination, third edition Please email us if you have found any errors in the text that
Postgraduate Orthopaedics: Viva Guide for the FRCS (Tr & we can correct. In addition, please let us know if we haven’t
Orth) Examination included an area of orthopaedics that you feel we should cover.
Postgraduate Paediatric Orthopaedics Likewise, any constructive suggestions for improvement would
The aim is to provide additional information and resources in be most welcome.
order to maximize the learning potential each book.
Additional areas of the website provide supplementary
orthopaedic material, updates and web links. Meet the editorial
xx

Section 1 The FRCS (Tr & Orth) examination
General guidance
Chapter
1 Niall Breen, Benjamin W. T. Gooding and Jonathan R. A. Phillips
The FRCS (Tr & Orth) is the major obstacle in higher surgical or the paper 2 EMI section. We are unsure why it was
training. It is regarded as a fair but very probing examination. scrapped, perhaps it was more difficult to standardize from
Passing depends on knowledge, performance on the day and a exam to exam and/or it did not prove to be a good differen-
bit of luck. However, as with all exams, preparation is the key tiator of candidates. Possibly it may have been too time con-
to success. That preparation should encompass not only read- suming to construct a separate statistical section for each diet
ing to accumulate facts, but should include clinical experience, of exams with the time better invested in building up a more
history taking, clinical examination and, most of all, practice. substantial SBA/EMI bank.
The exam constantly evolves and opinions and views con- This section is delivered via computer-based testing at
tinually move forward and change. We hope the chapter acts as Pearson VUE Test Centres throughout the UK and Ireland.
an introduction to the current format of the FRCS (Tr & Orth) This environment can be unsettling, with people taking their
exam and serves to provide prospective candidates with some driving theory test either side of you, although once absorbed
useful preparation tips and tricks. in the exam this shouldn’t be a concern. It is possible to finish
this exam before the time ends and you can leave once you are
Examination format happy you have completed it.
These papers may probe any part of the vast T&O syllabus.
The current FRCS (Tr & Orth) encompasses two sections.
A solid knowledge of the theory is required, but exam tech-
Section 1 is the written test and section 2 is the clinical exam.
nique is also essential for this part, which can only be
The Joint Committee on Intercollegiate Examinations
developed through practice questions. Preparation for section
(JCIE) published regulations in 2012 that govern the current
2 is very different and requires a change in revision strategy,
FRCS (Tr & Orth) examination. Candidates have 7 years to
but the basic knowledge learned from section 1 is extremely
complete the examination process. For section 1, candidates
important and should not be underestimated.
will have a 2-year period from their first attempt, with a
maximum of four attempts with no re-entry. If successful,
they can then proceed to section 2, where candidates have a Section 2: Clinicals and orals (vivas)
maximum of four attempts and up to one further exceptional This section comprises clinical cases and structured oral
attempt. interviews (also known as ‘vivas’ – The terms being inter-
For further details and to ensure no further changes have changeable for the purpose of this book but referred to
been made following this publication, we suggest all candidates officially as orals by the Intercollegiate Specialty Board). This
carefully review the JCIE websitea. section is held usually at a hospital for the clinical component
on day 1 and a nearby hotel or conference venue for the oral
Section 1: The written test component.
The clinical component is broken down into three upper
The written section of the exam covers the ‘theory’ of trauma
and three lower limb short cases, each of 5 minutes’ duration
and orthopaedics and is comprised of two separate computer-
(30 minutes in total) and two intermediate cases of 15 minutes
ized papers sat back to back on the same day. Paper 1 is a two-
each (which can be upper limb, lower limb or spine).
hour long Single Best Answer (SBA) paper whereas paper 2 is
The oral component, comprises four, 30-minute orals in:
made up of Extended Matching Items (EMIs) over 2.5 hours.
The statistical analysis of an orthopaedic paper that was Adult elective orthopaedics, including spine
previously part of paper 1 is no longer a part of the exam. Trauma, including spine
Candidates will still be expected to know about statistics and Paediatric orthopaedics/hand and upper limb
methodology and this will be tested in either the paper 1 SBA Applied basic sciences related to orthopaedics, including
anatomy and surgical approaches, pathology,
biomechanics, audit, methodology and outcome-based
a
https://www.JCIE.org.uk medicine
Downloaded from https:/www.cambridge.org/core. Columbia University Libraries, on 17 Jun 2017 at 16:00:10, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms.
1
004
Section 1: The FRCS (Tr & Orth) examination
The current exam format has now had time to bed in and compensate for a nervous performance on the first, thus,
provides a fairer and more structured assessment than previ- paving the way for section 2.
ous iterations. Candidates should feel confident that the pro- It has been suggested that up to 20% of questions are
cess is predictable and can focus on displaying their knowledge discarded along the journey from being developed by the
rather than being caught out. Examination Board. Questions can still be rejected after being
In the past, the spot diagnosis was a significant part of the used in the real exam paper following item analysis and trainee
clinical component. Some candidates could move through feedback. The main point stressed by examiners involved in
numerous cases if they made quick diagnoses whilst others writing the MCQ paper is that a question will be discarded if
would only see a few cases. The current format of short cases it is deemed ambiguous.
ensures that 5 minutes is spent with each of the six cases. For
example, in a case of Dupuytren’s contracture you may state Section 2
the diagnosis within seconds, but you will still be expected to
The scoring in this section is less straightforward, and little
examine the hand, discuss issues such as indications for sur-
information is publicly available. The following is our own
gery and consent, as you will not move on until the 5 minutes
interpretation of the marking system (Figure 1.1). It makes a
is up.
few assumptions, but we believe it to be fairly representative.
Each clinical case and viva question is marked from 4 to 8,
Marking equating to the following:
Many candidates waste valuable time fretting over the complex- 8 (exceptional pass)
ities of the marking system for the FRCS exam. It is important 7 (good pass)
to note that the scoring systems used are devised by statisticians 6 (pass)
and educationalists and standardized by the examiners, with
5 (fail)
the intention of making the marking as reproducible and as fair
4 (poor/complete fail)
as possible. Rather than worrying, your time is better spent
In more detail:
reading, practicing your examination technique and your ability
to deliver succinct answers in a viva situation. 8 – Gold medal standard. Difficult for the average standard
There is no set percentage pass rate; the examiners meet the candidate to achieve. At ease with higher order thinking.
evening before to set the standard and establish a cut-point for Flawless knowledge
passing or failing candidates. This is a standardized method for Excellent understanding/knowledge/management/prioritisa-
marking examinations and if you are interested in the theory tion of complex issues. Demonstrates excellent command
behind this, please refer to references at the end of the chapter. of the literature. Able to apply the literature to justify manage-
That said, nervous curiosity among candidates would ment decisions. Instils confidence. Patient rapport very good.
naturally lead to speculation about how their performance is Well-rehearsed keeps talking without prompting but
graded. We, therefore, offer the following advice. discussion still relevant and pertinent to topic. Not fazed by
questions, able to deal with them consummately. Able to
intuitively know where the questions are going. Well-trained
Section 1 all round performance.
A combined pass mark between paper 1 and paper 2 is neces-
sary to progress to the next stage of the exam. We understand
that the examination board raised the pass mark for section 1
in 2013 to make it more likely that candidates progressing
to section 2 will pass. The reason for this is that section 2 is
difficult to organize and doubly difficult to organize well. The
clinical cases need to be of a uniform high standard that will
stretch candidates. There is no point in organizing these com-
plex examinations and allowing candidates to sit them if they
have very little chance of passing. There is a world of difference
between passing an MCQ paper and examining a patient
with a difficult knee condition.
We know from the JCIE that a process of ‘standard setting’
is performed, where a group of experienced and trained exam-
iners sit the exact same examination, and subsequently set
a pass mark for each paper. A question may be excluded
if considered too ambiguous or unclear by the examiners
following this process so try not to ponder too much over
what you have submitted. Remember, a good second paper can Figure 1.1 Marking system for the FRCS (Tr & Orth) examination
2
004
Chapter 1: General guidance
7 – Good pass. Very good answer, no hesitation or gaps in questions in each viva; three from each examiner. Each exam-
knowledge. Able to demonstrate good command of the iner marks each scenario meaning there are 12 scoring oppor-
literature to the examiners. Polished and articulate answers. tunities (6 × 2 = 12) at each station. In 2 hours (120 minutes)
Quotes from the literature 8 examiners can independently assess each candidate on a total
Able to prioritize. Goes beyond the competency questions. Gives of 24 topics, with each topic represented by a clinical scenario,
patient confidence quickly. Good awareness of patient’s reaction. and generate 48 test scores, which should provide a valid
Not as thoroughly conversant with the literature as an 8 and reliable measure of a candidate’s ability in terms of pro-
candidate, some gaps. Not able to fully grasp the viva oppor- fessionalism, patient care, knowledge and judgement and qual-
tunity presented requiring some prompting as to where the ity of response.
topic is going.
6 – Satisfactory pass. Good working knowledge of the subject. Clinical
Covers the basics well. Copes with competence questions. The scoring here is a little less clear; however, the short and
Important points mentioned. No major errors. Treats all intermediate cases are weighted equally, implying 24 scoring
patients appropriately. Observes patient expression opportunities for each section.
Cannot get to the next level, draws blanks with the more The scoring system is open to considerable speculation and
difficult probing viva questions. interpretation. Whatever way you look at the scoring system
5 – Some hesitation, not answering the point of the there is a concern amongst examiners that some candidates
question. Waffling a bit. Surface knowledge and not able may be getting the wrong advice regarding examination
to go beyond the basics. Has rote learnt rather than tactics. It appears that candidates at various courses have been
understood the topic. This mark gives a candidate a instructed to aim for a steady 6 where, in fact, they should be
reasonable chance to recover. Demonstrates a lack of aiming for a 7. In our opinion, candidates should aim high so
understanding. Confused and disorganized answers. that even if their performance drops, the candidate should still
Hesitant and indecisive answers. Lack of an organized achieve a safe pass. It is extremely easy for a candidate to drop
structure to the answer. No introduction to patient. down to a 5 at one viva question or clinical examination case
Does not listen to patient so you need to score some 7s along the way to counter balance
4 – Unsafe. A miserable failure. Difficult to salvage. Poor this. A steady 6 all along the way in the exam with a couple of
knowledge with gaps. Gross basic mistakes. Not knowing 5s will mean you fail the exam.
a topic expected for this level of senior exam (calcium The examiners also stress that the oral examination is
metabolism, anatomy). Not able to get past the basic about the principles of orthopaedic practice and management
viva question asked. Difficult to pull it back and not about stalling for time or evading the answer. For
Abrupt, brusque manner with patients. Arrogant and rude. example, if a scenario of polytrauma is presented by the exam-
Inappropriate attitude. Rough handling of patients. Poor basic iners of an open comminuted tibial fracture and coexisting
knowledge and judgement. Unpersuadable – Prompts do not pelvic fracture, the first comment should not be that you
work. Did not get beyond default questions. Lacks insight. would send it to a trauma centre. This answer will just irritate
the examiners – Far better to go through the principles of how
you would actually manage this patient. The second comment
‘96 opportunities to score’ should not be an attempt to stall and focus exclusively on
There are 96 scoring opportunities for each candidate in ATLS® principles, especially if these have already been covered
section 2 – 48 in the clinical and 48 in the viva, and the total in an earlier question or the examiners mention the injury is a
mark attainable is 768, with a pass mark of 576. This is implied ‘closed isolated fracture’.
from the fact that a 6 at each scoring opportunity indicates a Another point to make is that immediately after each inter-
pass, and the pass mark is 576 (6 × 96 = 576). Note that there is mediate case, shorts or viva, the marking sheet is collected.
no deliberation in these marks. If you get 575 you will fail! This Hence, subsequent examiners do not know how you’ve per-
has happened to candidates in the past. formed previously. So if you think a case has gone badly, put it
The reason for the high number of scoring opportunities is behind you and move on – You still have everything to play for!
that if there is an issue with a particular examiner or section
the effect on the candidates overall score will be diluted by the
large number of other examination marks. There are equal
Preparation advice
The aim of the exam is to assess whether you have the know-
marks available for the orals and clinicals.
ledge and understanding to practice safely as a Day 1 Consult-
ant Orthopaedic Surgeon in a District General Hospital. This is
Orals the standard reference setting criteria to fall back on. However,
There are two examiners marking at each of the four viva the syllabus is vast that you can be asked almost anything!
stations, although there can be lay observers, examiner asses- The following are some helpful tips in organizing your
sors or trainee examiners also present. There are at least six approach to the exam.
3
004
‘Plan, prepare, practice, perform’ Prepare

Plan Form a study group. If others are sitting the exam at the
same time then team up (three is an ideal number). Choose
It is important to start revising early. Although everyone has
like-minded individuals with whom you get on! A group
their own individual style of study, the general consensus is
will allow you to compare your progress and share your
that a minimum of 6–12 months intense preparation is
anxieties. It is also useful to focus your studying and
needed to talk with confidence to your examiners
bounce ideas off each other. When it comes to studying
Consider the available exam dates and apply early for the
for section 2, your reading group can provide you with
one you need. The examination application process is
clinical and viva practice
structured and requires references. You don’t want to add
Don’t worry, however, if you find yourself studying on
to the stress of the event by risking a late application!
your own. According to the questionnaire quoted above,
Avoid taking on time-consuming extra-curricular tasks
candidates studying alone seem to do just as well as those
(e.g. research/paper write-ups) in the 6 months prior to the
who prepare in groups. (Group work does, however,
exam in order to give yourself a clear run at it without extra
definitely make the whole process less lonely!)
unnecessary pressure
The reading material you choose to utilize is down to
Controversially, some candidates may be advised to take up
individual preference. Some choose key textbooks while
a less busy registrar post in the 6 months or so prior to the
others prefer to use orthopaedic websites. Choose your
exam to give themselves more time for study. This can work
‘poison’ early and try to avoid swamping yourself with too
the opposite way in that a busy post may provide a lot of
many sources of information (more on this towards the
additional clinical experience that may prove useful in the
end of this chapter)
exam. What probably isn’t a good idea is to be travelling long
Source the latest versions of important national guidelines
distances to and from home each day in the 6 months before
(in topics such as fractured neck of femur patients, open
the exam. Even in this situation, previous candidates have still
tibial fracture management and osteoporosis, for example)
managed to use travelling time effectively by listening to
and KNOW these. This will easily convert a pass to a
orthopaedic discussion/tutorial type CDs in the car
good pass and can act as a structure to help you build an
Plan your training if possible. Most training programs will
answer if you are stuck
be designed to expose you to the general breadth of trauma
Although it is not essential to quote specific papers from
and orthopaedics; however, if you feel you have a weakness
the literature, it is helpful to know a couple of key papers
or deficit in a certain area, and have the opportunity to
in each topic, especially in controversial areas
request a specific subspecialty, this is worthwhile considering
It is probably fair to say that candidates focus the majority
Alternatively, if you are lacking in experience in a
of their time preparing for the oral component (for
particular subspecialty, attend clinics in those areas and
example with this book). To ensure you pass and pass
enrol on specific courses
well, do not neglect the clinical component, which carries
Book your study leave early and avoid the hassle and stress
the same number of marks as the oral and in which a
of late rota swaps to facilitate attending courses
good performance on day 1 will set you well on track
Plan your attack of the syllabus! It is so vast that you
could literally spend years reading around it. Make realistic Practice
goals and set timetables
Make it known amongst your colleagues and the
Revision is a very personal issue. Most people have developed
consultants at your unit that you are preparing for the
their own style of studying but it is important to pace yourself.
exam. Try to avail of any interesting exam cases they know
You do not want to burn out. Make time for your family
of and utilize any opportunity to be put in an ‘exam
and maintain a social life (albeit a somewhat less busy one!) –
scenario’
At times you will need the support of your friends and family
Each time you see a patient try and deal with him/her as
Maintain your momentum. It is important to sit section 2
a short or intermediate case. Practise getting straight to
of the exam as soon as possible after passing section 1.
the point in your history, as you only get five minutes for
An anonymized questionnaire of 156 orthopaedic surgeons
this in the intermediate cases, and become slick at doing
who passed the FRCS (Tr & Orth) exam showed a 90%
a thorough examination. Have someone examine you,
first-time pass rate for those who took the second part
keeping to the allotted time; be it your consultant,
at the earliest opportunityb.
educational supervisor or study group partner. Be
confident in eliciting clinical signs without hurting the
b patient; this is a deadly sin and you will be failed. Always
http://postgraduateorthopaedics.com/books/pg-orthopaedics-
second-edition/chapter-1/frcstrorth-risk-factors/. Additional
be courteous and respectful to the patient
material for exam preparation is contained on the Postgraduate PRACTICE, PRACTICE, PRACTICE your clinical skills.
Orthopaedic website. On patients. On your study group. On your parents.
4
004
On your friends! It is essential to look slick in the clinical Table 1.1 Suggested potential diagrams for FRCS (Tr & Orth)
section. There is no time to pause to think of what comes Basic science Stress/strain curves
next in a hip or knee examination. It needs to flow and look : Including ligaments and tendons
like you have done it a thousand times. Have a S–n curve
reproducible method for examining each system, but be Young’s modulus curves for different
aware that you may need to focus your examination or materials
adapt it in the real thing according to the examiners’ Scratch profiles
instructions Viscoelasticity graphs
If possible, arrange mock clinicals and vivas with consultants : Creep
from each subspecialty. This is possibly one of the most : Stress relaxation
useful things you can do to practice for the real thing. The
: Hysteresis loop
Screw anatomy
exam is an expensive way to practice if you fail first time! Collagen structure
There is no point in doing this too early, however, when Micro- and macro-structure
your knowledge is still lacking. Best to leave it until the run : Nerve
up to section 2 when you are practicing ‘polishing’ your : Cartilage
answers. If this is not possible, there are excellent clinical : Ligament
and viva courses for the FRCS (Tr & Orth) exam which : Tendon
candidates have found to be extremely beneficial : Bone
Be confident at interpreting x-rays and scans. This will help : Skeletal muscle
improve your confidence in a viva situation Proteoglycans
Cutting cone
Practice drawing pictures and diagrams to demonstrate Osteoclast
your knowledge. It is not uncommon in the viva to be Menisci
asked to illustrate certain concepts; for example, stress- Intervertebral disc
strain curves/free body diagrams. A list of diagrams to Action potential
consider familiarizing yourself with is provided in Reflex arc
Table 1.1. This is by no means exhaustive but it has been Gait cycle
compiled from suggestions by previous candidates and Clotting cascade
consultants alike Free body diagrams
The annual UK in Training Examination (UKITE) : Hip ± stick
provides a ‘mock’ type experience in preparation for
: Knee up/down stairs
section 1. Although the questions are of a somewhat
: Elbow
: Ankle
different style, it provides an opportunity to track your : Spine
learning progress and allows practice with SBA format and Prosthesis components
exam timing Statistics
: Sensitivity/specificity table
Perform : Table of levels of evidence
Unlike section 1, where you could probably sit the written
: Survival curve
papers in your pyjamas, your appearance actually matters Anatomy Brachial plexus
in the clinical and viva sections! This part of the exam is Cross-sections
somewhat like an interview. You need to present a well- : Upper limb, inc. carpal tunnel and
extensor compartments
rounded, professional ‘package’ to your examiners, i.e.
smartly dressed and polite with good communication
: Lower limb, inc. compartments
: Spinal cord
skills – And this is even before you have answered any Hands
questions! : Flexor/extensor tendon zones
Make the examiners job easier. It is like taking your driving : Finger extensor apparatus
test again. You need to make your assessment of the patient : Finger pulleys
obvious to your examiners, such as checking for insoles in : Incision for carpal tunnel
shoes or acknowledging the walking stick propped in the decompression and associated
corner of the examination cubicle landmarks
Never hurt the patient! Make it obvious that you are Blood supply
looking at the patient’s face for a painful reaction as you
: Femoral head
examine, and ask them to say if you are causing discomfort
: Talus
: Scaphoid
Listen carefully to the examiner’s instructions. For : Humeral head
example, in the short cases, if an examiner says, ‘I’d like
5
004
Table 1.1 (cont.)

The event itself
Attachments to the coracoid
Spaces posterior to shoulder and what Section 1
passes through them Follow the instructions given to you by your designated
Relations to piriformis examination centre
Hip trabecular patterns Be sure you know how to get there on the day and allow
Femoral triangle time for traffic delays or unexpected problems
Paediatrics Physis and zones Get a good night sleep the night before and try to get lunch
Salter–Harris classification between papers – The day is long and you will need all of
Selenius graph your energy
Genetics Pennett squares for inheritance patterns
Misc. Z-plasty Section 2
Tendon repair methods, e.g. Kessler Book yourself into a decent, comfortable hotel and ask for a
Traction types, e.g. Hamilton–Russell/ quiet room. Day 1 of the exam is currently usually held on
Thomas splint a Sunday
External fixation Remember that you’ve already forked out near-enough
Tension-band principle £2K, so now isn’t the time to start being cheap – You’re
worth it! Beware, however, that the nicest hotel is usually
YOU to examine this patient’s right great toe’, don’t start where the examiners stay. Get an early night and go easy
by taking a history and looking at the hands for signs of on the coffee and alcohol, as you want to be at your best
systemic disease. This will only waste vital time and irritate On the day give yourself plenty of time to get to the venue.
your examiner. If the examiner guides you by suggesting Consider a ‘trial run’ the day before so that you know
that you ignore your systemic assessment and concentrate where you are going. The last thing you need is added
on the big toe, listen to the advice! stress if you get lost or stuck in traffic
If the examiner asks ‘Are you sure?’ take the hint you may Dress conservatively and avoid outspoken ties or
have answered wrongly – Why else would they say this? ostentatious suits. You want to look smart. Be aware that
The short cases are exactly that – SHORT! The 5 minutes you may need to comply with local infection-control
seem to last a blink of an eye, so don’t delay in eliciting policies such as ‘bare below the elbows’
those important clinical signs and relay them to the Watch what you eat before the exam – You don’t want
examiner to stink of garlic or cigarettes – Nor do you want to reek
If permitted, narrate as you perform your examination. of too much aftershave or perfume
Most examiners don’t seem to mind this technique and it Once you get there you will soon realize that the exam is
makes it clear what you are trying to demonstrate. Don’t run with military precision. This in itself is confidence
waffle, however, try to keep what you say succinct inspiring, as there can be a lot of candidates sitting the
In the intermediate cases you will have 5 minutes to take a exam at any one time. Just listen to the instructions given
history, 5 minutes to perform a focused examination and and concentrate on delivering what you have practiced
5 minutes to discuss the case. Get off to a good start when when it is your turn to show off your knowledge!
presenting your findings for both the history and Come prepared with any props you might need for
examination. For example: ‘Mr Jones is a 45-year-old, examination purposes. You may not have the opportunity
right-hand dominant electrician who presents with a to use them, but if you have time, a quick demonstration
6-month history of pain and weakness in his right shoulder of transillumination of a soft-tissue lump with a pocket
which is now beginning to affect his work’. Already you torch, for example, can look pretty slick and add useful
will have delivered a succinct summary of vital points of information to your examination. Other suggested props
information. It does not look slick if you have forgotten the include a tape measure for leg length discrepancy, and coin
patient’s name or occupation when you come to relay the and key for testing hand function. Again, however, be
history you have just taken. Again, a polished delivery of guided by the examiners and use your discretion. Don’t
your findings comes with practice waste time utilizing props just because you have them in
Make sure that you answer the question that is asked of you your pocket, and it certainly doesn’t look good if you
Finally, it has been suggested that you should try to cannot find your prop!
imagine the vivas and oral discussions as a conversation
between consultant colleagues discussing a case. This can The short cases
be extremely difficult under pressure, but remember that Today’s exam format means that you examine 6 short cases
the examiners for the orals are no longer specialized within only (3 upper limb and 3 lower limb) and spend 5 minutes
that subject with each case. You may spot the diagnosis immediately and
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can tell the examiners what it is but you will still spend management of a potentially limb-threatening associated vas-
5 minutes examining and discussing the case regardless. cular injury is what the examiners will hope to elicit from a
‘Common conditions are common’. There are usually very candidate who has what it takes to be a safe, independently
few surprises in the clinical cases. Spend time talking to previ- practicing consultant.
ous candidates about their experiences and obtain advice from It is best to enter the oral examination with the intention
senior consultants where possible. of answering the questions as clearly as possible, in a struc-
tured, sensible manner, demonstrating a safe and methodical
The intermediate cases approach to the problems presented.
With 15 minutes allocated for each of the two cases, these tend For the oral component, from experience of the current
to feel a little less hectic. Take a slick but focused history and format, the following assumptions can be made:
examination and deliver the relevant points succinctly to the Questions chosen must contain enough material for the
examiner. candidate and examiners to discuss for 5 minutes without
Again, there are unlikely to be any surprises in the inter- running out of steam
mediate cases. You may, however, get a patient with more
If you can’t respond to a question because you don’t know
than one orthopaedic complaint. If this occurs simply listen the answer and only 30 seconds have elapsed out of the
to the examiners question carefully and cater your approach as 5 minutes, the examiners can ask you a reserve question.
necessary. If you are completely stumped by a case from the In practice this situation is very uncommon and the
start, simply go back to the beginning and rely on your meth- examiners may still stick with the first question, only
odological history and focussed examination according to the asking you very basic perhaps even unrelated questions to
patient’s complaint. You may not always be expected to get get some sort of discussion going. With a reserve question
an accurate diagnosis in an uncommon syndrome but you will you will generally only be scored a 4, at the very best with a
be expected to discuss the orthopaedic issues pertaining to the superb answer you will only a score 5. It becomes difficult
case in question. to make up these lost marks in the exam. Again to reiterate,
Orals this is a very uncommon situation and perhaps more
Many candidates find the orals the most intimidating aspects theoretical than practical as reserve questions are very
of the FRCS exam. Again, lots of practice of viva technique rarely asked with the examiners preferring to stick with the
with colleagues and consultants prior to the event is the key to original question
passing this part. If you are doing really well you may reach the reserve
The current oral exam format is comprised of 3 standard- fourth question and you will be picking up bonus marks.
ized questions per examiner (6 questions per viva, 5 minutes This is not tending to happen now as there is usually
each), where you are marked on each question by both exam- enough to talk about with each question for the full
iners. This happens for each of the four viva stations. 5 minutes even with a score 8 candidate and, if needed, the
Since November 2014 examiners have had the viva ques- examiners will move onto the next question slightly earlier
tions pre-prepared for them by the Examination Board. This than planned
means that all the examiners will be asking the same questions Examiners have a list of points that they need to cover with
at each viva station. In the afternoon the questions will get each question and a model answer for reference. Marks are
changed presumably to prevent candidates discussing the scored when candidates answer correctly the points that
questions amongst themselves at lunch. This change is made are asked
to further improve exam consistency and ensure it is as fair as There may be a series of candidate prompts to which the
possible to all candidates. examiners can refer on the model answer form. The
In addition, the same clinical photographs and radiographs examiners use them if the candidate is straying widely off
for a particular question are shown to each candidate. This the mark with their answer to bring the candidate back to
again improves the standardization of the examination and the main thrust of the question
indirectly ensures only good quality props are used. The exam- Some examiners believe that it is more difficult to examine
iners are very quick to point out any unclear or confusing candidates using this new system than the old ad-hoc
clinical pictures or radiographs. method. Spontaneity is lost and examiners may refer too
Questions are not deliberately set to catch you out, much to the model answer for guidance rather than let the
but some are designed to extract ‘higher order thinking’ from discussion take its course
the candidates. This does not mean that you need to know the Most candidates prefer the new system as it is perceived to
intricacies of every operation for reconstructing a dislocated be more impartial and fairer than the older method
knee following a motorcycle accident, for example. Whilst Candidates will be compared to their peers. Ten or so
awareness of operative management options in such an injury candidates being asked the same set of questions by the
is clearly desirable, a safe, methodical approach to a suspected examiners will invariably mean they will be ranked in order
polytrauma patient, with knowledge of the emergency of performance
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FRCS (Tr & Orth) dry run examination as professionally very well-run and organized.
The viva stations roughly alternate between elective and
The exam is an expensive way to practise, but there are
trauma questions, but there is less rigidity in the number of
other exams that can be used to practise for the FRCS (Tr
viva questions asked, varying between 3 and 7–8 depending on
& Orth), namely the SICOT diploma and the EBOT. Several
the quality of a candidate’s response. The spinal section can be
candidates use these exams as preparation for the FRCS
quite difficult and candidates really should have spent some
(Tr & Orth) exam and pass them. The advantage is more
time in a spinal unit to do justice to this viva.
letters after your name as well as preparation for the FRCS
In some specialties the European examination is treated as
(Tr & Orth) exam.
equivalent to the UK specialty exam. In trauma and orthopaed-
ics this is not the case, the EBOT exam has no clinical compon-
EBOT examination ent. The whole question of a European-wide examination in
orthopaedics has recently been explored by David Limb BOA
The EBOT examination has developed into a prestigious
secretary in an article for the Journal of Orthopaedic Trauma1.
orthopaedic qualification in recent years. Exam applicants have
Recently the EBOT committee has been exploring the possibil-
increased significantly since 2011. The exam consists of two
ity of providing parts of the exam in different languages
sections. Section 1 is a written MCQ paper completed online of
other than English. In addition they are keen to assess skills
100 MCQs in the format of a single correct answer (SCA).
as well as knowledge in the final exam. Essentially they are
Section 2 is the viva component composed of five viva (oral)
eager to include an additional clinical component to the exam.
stations. The sections examined are:
High stakes clinical exams are difficult to organize. Practicalities
Adult orthopaedic and trauma surgery – Upper limb include finding a suitable venue, sufficient number of patients
Adult orthopaedic and trauma surgery – Lower limb with good clinical signs and examiners thoroughly trained in
Adult orthopaedic and trauma surgery – Spine clinical assessment etc.
Children's orthopaedic and trauma surgery
Basic sciences related to orthopaedics, including References
biomechanics, statistics, audit methodology and outcome- 1. Limb D. A European curriculum for trauma and orthopaedic
based medicine surgery? J Orthop Trauma. 2014;2:4.
Applicants need to be successful in section 1 in order to gain
eligibility to proceed to section 2. Candidates regard the
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Section 1 The FRCS (Tr & Orth) examination
What to read
Chapter
2 Jonathan R. A. Phillips and Benjamin W. T. Gooding
Gone are the days where a single ‘classic’, multi-volume text- Table 2.1 Useful websites
book read cover to cover will provide all of the information MCQs
you need. Modern communication techniques and in par-
ticular the Internet have transformed the way to revise for Orthobullets: www.orthobullets.com
postgraduate examinations. Reference
The following are a number of resources that you may find Wheeless: www.wheeless.com
useful.
Instant anatomy: www.instantanatomy.net
Exam revision
Textbooks and websites
BJJ exam corner: www.boneandjoint.org.uk
Our predecessors sought to fill the shelves of their offices with
grand orthopaedic textbooks with leather bound covers. How- Trauma
ever, big textbooks are too heavy to take anywhere! Modern AO surgery reference: www.aofoundation.org
textbooks, especially those from the large publishing groups
Foot and ankle
now allow access online, enabling the purchaser to gain access
whenever or wherever they are. Many also offer multimedia Hyperbook: www.blackburnfeet.org.uk/hyperbook
such as videos and extra illustrations to complement their text. Video calls
Many excellent textbooks have been written aiming specifically
Skype: www.skype.com
for the FRCS (Tr & Orth) exam.
There is another problem with textbooks; as soon as the Google Hang Out: www.google.com
textbook is published, its content is out of date. Certain web- Meeting planner
sites aim to avoid this problem through real-time updates.
Doodle: www.doodle.com
Many of these websites have a huge amount of content, with
much of it being delivered in an easy to read, summarized Shared online storage
format. Table 2.1 lists some of what we found the most useful Dropbox: www.dropbox.com
revision websites.
iCloud (Apple): www.icloud.com
However, such websites have significant limitations.
There is little or no peer-review, the content is frequently OneDrive (Microsoft): www.onedrive.com
unregulated and plagiarism may be a problem. Authorship
is generally not reported, and one must be careful to not
put too much faith into everything that is read. Many web- content will be in line with the Applied Clinical Knowledge
sites are commercial enterprises or sponsored by implant Syllabus of the Specialist Training T+O Curriculum, in order
companies (or law firms!), and many other websites are to provide trainees with a sound and logical instructional aid.
self-promotion websites by enterprising orthopaedic sur- Internet search engines are also invaluable tools that can be
geons seeking fame and fortune. They can, however, form a used to answer specific questions. Once again, care must be
fantastic quick reference tool. taken to ensure that the answer is factually correct. Bookmark
An exciting new development is the Wikipaedics website useful websites once found to build a library of online resources.
currently being developed by the BOA. This is a project to There are a number of review articles published in the
update the old orthoteers website material that had been used major orthopaedic journals, and there is a review journal
in the past by trainees preparing for the exam. The website aimed specifically at the UK FRCS (Tr & Orth) examsa.
material was passed on to the BOA around 2012 for further
development. The material is being radically updated as an on a
Orthopaedics and Trauma journal. Available from:
line learning platform and media interaction. The platform’s www.orthopaedicsandtraumajournal.co.uk.
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005
The content in these review articles is reliable, although unless sends out daily emails to cover a topic each day with relevant
you have access to the journal through a university or library, questions. The website is American in origin, however, and the
it may be expensive. questions may seem less relevant to British exams. Despite this,
practice is practice so they are still recommended (and free!).
Multimedia
Textbooks, whether paper or online, form only part of the Revision groups and communication
arsenal of the modern student. The Internet has developed a Many people find gathering into small groups of like-minded
new format called ‘Webinars’. These web-based seminars are individuals a great way of studying, especially for viva practice.
normally put on by experts in their field, and enable interaction One of the difficulties with organizing revision sessions
and questions both during and after the session. These are is trying to bring busy people together. Other commitments
useful ways of gaining expert opinion on specific topics. Most and on-calls frequently get in the way. Doodle is one of a
of these are hosted in the USA, which unfortunately means number of free websites that allow people to organize dates
they take place when we in the UK are at work or asleep! for meetingsg.
Most of us honed our examination skills by learning from Another difficulty was that such sessions were often incom-
experienced consultants. Now you can learn even the most patible with family life. We’re sure that we weren’t the only
obscure clinical tests off video-streaming sites such as YouTubeb people revising for exams with newborn babies; in fact one
or VuMedic. Students must be warned though that there is no of the people in my revision group had just had twins. For us, it
point being able to perform the test for Piriformis syndrome was impractical to meet up in early evenings. We started to
when they have not mastered the Thomas’ test. have revision sessions on our iPads over Skype or Facetimeh,i.
Audiobooks and podcasts are a different format of acquir- Having the face-to-face contact during revision sessions, while
ing a breadth of knowledge. Lectures from both the American both still being able to access our own computers for notes was
Academy of Orthopaedic Surgeons and the Miller textbook invaluable. When there are more than two of you, certain
can be purchased onlined. Most of us have to commute to work websites also offer video conference tools (often at a charge).
so why not combine commuting with revising? Many ortho- The ability to share content and revision notes online
paedic podcasts can also be downloaded for free or for small is now possible. Sites such as Dropbox, iCloud and Onedrive
fees from iTunes. Once again, investigate the publishers of any allow users to upload notes that can be shared between
information for potential bias. members of the revision groupj,k,l. Having a shared ‘useful
papers’ folder can be extremely helpful in keeping up to date.
Apps
A variety of apps can be bought or downloaded for free for Revising at work
many types of smartphone. One of the better ones available Laptops, tablets and phones have now become the favoured
is that provided by the AO Foundation, providing useful way to work and gain access to the Internet. Many with young
information on trauma procedures and surgical approachese. families find the demands of family life get in the way of study,
Unfortunately many of these apps are online-only and, there- meaning that working on the move whenever a spare moment
fore, do not work in big hospitals with thick walls where phone arises becomes necessary. We found mobile phones too
reception is poor (such as in theatre!). small to do any effective work on, but mobile broadband via
‘Dongles’, mean that laptops and tablets can be used on the
Interactive case discussions and discussion move. Be careful with your usage though as large volume use
can be expensive. Most phones can now be used as a “hotspot”
forums which is another great way to get on line.
Online question banks are invaluable when studying for the
written part of the exam. Doing well at MCQs comes from lots
and lots of practice. One of the largest online ‘free’ resources is
Important papers
Orthobulletsf. We found Orthobullets an extremely easy web- It is helpful to know a couple of key papers in each topic,
especially in controversial areas. It is important to know
site to use, with detailed explanations presented with each of
national guidelines (such as on hip fractures, open tibial frac-
the answers. The ability to monitor your progress and compete
ture management and osteoporosis). This will easily convert a
with your peers helps to maintain motivation. Orthobullets
pass into a good pass.
also offers a study programme (for a fee); a feature of which
g
Doodle. Available from: www.doodle.com.
b h
YouTube . Available from: www.youtube.co.uk. Skype. Available from: www.skype.com.
c i
VuMedi. Available from: www.vumedi.com. Facetime. Available from: www.apple.com/uk/ios/facetime.
d j
AAOS. Available from: www.aaos.org. Dropbox. Available from: www.dropbox.com.
e k
AO Foundation. Available from: www.aofoundation.org. iCloud. Available from: www.apple.com/uk/icloud.
f l
Orthobullets. Available from: www.orthobullets.com. OneDrive. Available from: www.onedrive.live.com.
10
005
Chapter 2: What to read
Recommended reading learning styles more than others, so this may bias the personal
review of the book. Amazon also lists whether the reviewer has
The choice of reading material is very much a matter
made a verified purchase of the book; these reviews are likely
of personal preference. There is no official reading list and
to be more reliable than from non-verified sources.
there is currently a plethora of orthopaedic exam textbooks on
Included below is a list of suggestions for the various
the market, of varying quality. Unfortunately, because of the
categories. Full details are given at the end of the chapter.
diverse nature of the exam, no perfect book exists for the FRCS
(Tr & Orth), and it will be necessary to glean information from General textbooks
a variety of different sources. Miller’s Review of Orthopaedics1
Orthopaedic textbooks are expensive, and it is worth taking
This is the standard text used by most trainees. It is very compact,
time before choosing. Get advice from trainees who have
but extremely terse, and not necessarily easy to read except in
recently sat the exam and, if possible, borrow books to look
small doses. Because of its size, it does assume a fair bit of prior
through and decide whether they suit your style of learning.
knowledge. Some topics are covered in more depth than others,
Failing that, you can browse in a good bookshop or using the
but it is reasonably comprehensive, with chapters covering basic
‘look inside’ facility available on some online bookshops.
Probably your most important purchases will be a good sciences, anatomy and statistics as well as the more ‘clinical’
topics. Most people find it more useful later in their reading,
general textbook and a surgical atlas. Make these choices early
when they already have a bit of knowledge to build on.
and get to know them. Most people need around 12 months of
intensive revision before sitting the exam, so make these two Oxford Textbook of Trauma and Orthopaedics2
major purchases 2–3 years before you plan to sit it. That way The second edition pulled off a masterstroke by reducing the
you can become familiar with your books in plenty of time, and three-volume set to one. However, the content seems to have
still have time to change them if they don’t suit you. You can been summarized and the text detail disappoints in places.
then supplement them as required with smaller, more special- We never felt there was quite enough detail in certain sections
ized books as time goes on. Of course, if you buy all your and generally end up looking elsewhere afterwards for the
textbooks right at the beginning of your training, they may information. It’s a large book and also expensive to buy.
begin to become dated by the time you actually sit the exam. Reviews have been mixed.
There is a definite balance to be struck between using too
many sources of information superficially and concentrating AAOS Comprehensive Orthopaedic Review3
on too few. As a general rule, change books or add to them This book is at the other end of the spectrum. It comes in three
only if there are significant advantages to be gained. If the style volumes and, although more comprehensive, is much more
or content of a book does not agree with you (it is sometimes expensive and less compact. It’s probably worth looking at and
difficult to tell until you start actually to use it), discard it considering as an addition to Miller’s if you struggle with the
quickly and move on to something more suitable. In the early note-like form of the latter. The American Academy of Ortho-
stages of training, it is worth reading up on the specialties to paedic Surgeons publishes a large number of textbooks and it
which you are attached – What you are reading will make is a well-oiled machine. They are generally of a high standard
much more sense, and will be more likely to ‘stick’ if it although can be quite expensive and have a slant towards the
correlates with what you are seeing during the day. As you American audience.
approach the exam, however, most people find it helpful to At the beginning of training, Apley’s System of Orthopaedics
work out a study schedule to avoid running out of time and and Fractures4 is a good introduction, but you will need some-
missing important topics. thing much more detailed for the exam. It has a great series of
One major difference since the second edition of this book pictures that can be used for viva practice prop picture revision.
was published is the almost exponential increase in the amount
of FRCS (Tr & Orth) material now available. Some of this Current Orthopaedic Practice – A Concise Guide for Postgraduate Exams5
material is extremely good whilst other bits are of dubious This book has very favourable trainee feedback and comes
quality. Self-publishing a book used to be annoyingly difficult highly recommended. The author has managed to include
time-consuming process, but in recent years it has become many current literature references, which candidates find
much more streamlined. Some candidates are now self- useful in their exam preparation.
publishing their revision notes. This muddies the water as
some of this material can be of a high standard whilst other Surgical atlases
books are disappointing and poor quality. Hoppenfeld’s Surgical Exposures in Orthopaedics6
This has become the standard atlas used for the FRCS (Tr &
Amazon reviews Orth) exam, and it is good. Having said that, Tubiana’s Atlas
Amazon orthopaedic book reviews can be helpful in guiding of Surgical Exposures of the Upper and Lower Extremities7 was
candidates in their choice of book. However, be cautious, as a personal favourite owing to the clarity of the illustrations, text
they can also be misleading. Certain books suit particular and layout. Orthopaedics Surgical Approaches by Miller et al
11
005
has a slightly different style to Hoppenfield that some candi- That said, we have come across a number of candidates who
dates may prefer. It is a more exam revision-friendly book with swear by the Secrets series and found this book good for viva
good illustrations and a relaxed style of text. practice It has had good reviews.
Briggs’ Operative Orthopaedics8 Joseph et al.’s Paediatric Orthopaedics17

This is a fairly basic textbook that some people have found This book is disappointing as it promises a lot but doesn’t
useful in tying things together. If you need a little bit of quite deliver the goods. That’s not to say it isn’t a good book,
anatomy revision, it’s worth looking at a copy of Whitaker it’s just the hype that doesn’t quite match the contents. The
and Borley’s Instant Anatomy9. It has very succinct summaries book is targeted at higher surgical trainees and younger
of the courses and branches of nerves and blood vessels, and consultants. It can be difficult to extract a viva answer out
other such reminders. of some of the material. It is written by Pediatric Orthopedic
surgeons from four different continents, which gives the
Clinical examination book an international flavour. However, in the very focused
The second edition of Harris and Ali’s Examination Tech- world of FRCS (Tr & Orth) exams this isn’t that relevant
niques in Orthopaedics10 is a significant improvement on the or important.
first edition. Each chapter has been extensively revised. It has
had excellent candidate feedback and is now firmly established Hand Secrets
as the clinical examination book of choice for candidates
Hand Secrets17 is an option, although again the format of
sitting the FRCS (Tr & Orth) exam. It has had excellent
this series appeals more to some people than to others. An
candidate reviews on Amazon.
alternative is to use relevant chapters from a reference book
Reider’s The Orthopaedic Physical Examination11 is useful
such as Green’s Operative Hand Surgery,19 but you will need to
as a reference if you’ve got it in your library, but it’s probably a
be selective.
bit too expensive to recommend buying. It also is a bit over-
long and exam unfocused in places.
Trauma
Basic sciences Egol et al.’s Handbook of Fractures20 is recommended as a
Ramachandran’s Basic Orthopaedic Sciences12 has become the reasonably concise and up-to-date text. Most trainees find that
standard book, and is well worth getting. It is reasonably clear trauma is one of their stronger areas, and many people simply
and detailed, particularly if you supplement it with the basic supplement their experience by looking up specific topics in a
sciences chapters from a general book such as Miller’s. We reference text such as Rockwood and Green’s Fractures in
eagerly await the second edition that promises to be fully Adults and Rockwood and Wilkins’ Fractures in Children21,22
updated and revised to cover the latest breadth of topics in or Browner’s Skeletal Trauma23. Be careful not to get lost in
orthopaedic basic science these massive tomes, however!
Einhorn et al.’s Orthopaedic Basic Science13 is a more
detailed text. If you have access to a copy, it may be useful as Orthopaedic Trauma: The Stanmore and Royal London Guide24
a reference source where you need more explanation, but it This book was published in November 2015 to generally very
probably doesn’t need to be read cover to cover. positive reviews. Although not as detailed as Egol et al.’s
The basic science section of Oncology and Basic Science. Handbook of Fractures20, it has more of an FRCS (Tr & Orth)
Orthopaedic Essentials Series14 is excellent. It is easily readable exam feel to it. It can be easily read in a week and provides a
and manages to clarify complicated information in a way that solid framework that candidates can use as a basis for trauma
simplifies revision. revision. It is a slightly awkward book in that although it is not
AAOS Orthopaedic Basic Science, 4th edition provides an completely comprehensive it is also not a weak flimsy throw-
excellent overview of basic science with some great diagrams. away excuse of copied material from elsewhere. The material
However, it is quite heavily priced and geared towards the is original and exam focused and is a welcomed addition to the
American market thereby missing somewhat the FRCS (Tr & FRCS (Tr & Orth) armament. It has had excellent candidate
Orth) exam focus. reviews on Amazon.
Paediatrics Trauma for the FRCS (Tr & Orth) Examination25

15
Staheli’s Practice of Pediatric Orthopaedics This book was published in December 2015 to cover the
This book is fairly easy to read and comprehensive. It has had trauma viva component of the exam. It is extremely well-
good reviews and the illustrations are excellent. written and focused on trauma viva topics that regularly
appear in the exam. This book is published by the Oxford
Pediatric Orthopaedic Secrets16 Higher Speciality group and is a significant upgrade in content
We are not great fans of the Secrets series as some of the detail on the general viva equivalent book that was published
material is not well-matched to the FRCS (Tr & Orth) syllabus. by Oxford University Press in 2012.
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Chapter 2: What to read
Statistics and can be expensive to buy, but this does not seem to put
Many basic sciences or general orthopaedic books (including candidates off.
Ramachandran24 and Miller14, respectively) have useful chapters
1000 EMQs in Trauma and Orthopaedic Surgery32
on statistics. We also found selected chapters from Greenhalgh’s
How to Read a Paper26 useful. This book does not reliably recreate the questions found in the
real exam and has been found to be of limited use by those
MCQ books who have used it. Some trainees have found the questions
The AAOS Comprehensive Review16 comes with a useful MCQ confusing and over complicated.
practice book. There is an increasing number of websites with banks
of questions that can be useful practice. See, for example,
Orthopaedic Basic Science for the Postgraduate Examination: Practice Orthobullets6 or some of the websites run by large implant
MCQs and EMQs27 companies for which your local rep will give you a password.
Basic science can be difficult with the main textbooks as they
Viva books
can be either too notebook-like without sufficient explanation
or too long and drawn-out. This is an excellent book for FRCS (Tr & Orth): MCQs and Clinical Cases33
revision purposes as the questions are representative of the The content has been selected from the examination corner
level and scope required for part 1 of the exam. However, you section of the JBJS British volume. There are a few MCQs,
will still need to use the larger textbooks, as you also need to but it’s really the viva section that is quite excellent – very
understand the fundamental principles of basic science and thorough and comprehensive. A couple of minute criticisms
not just rote learn facts. This book has had excellent feedback. are that some answers are just too detailed for the real exam,
perhaps only achievable if you are a score 8 candidate,
Succeeding in the FRCS T&O Part 1 Exam28 and a small number of mid viva questions go off the mark
This book has had mixed candidate reviews. Explanations can and lose their thread, as you are unlikely to be asked these
be confusing, and often contradict the answers given. It’s questions in the real test unless perhaps you are a gold medal
perhaps a book to borrow rather than buy for an evening to candidate.
look through as light reading if you are bored, but no more
than this and nothing to base any significant preparation for FRCS Trauma and Orthopaedics Viva (Oxford Specialty Training Higher
the exam on. Revision)34
This is generally a very good viva book. A few of the questions
Practice Questions in Trauma and Orthopaedics for the FRCS29 would have benefited from a more thorough work out but
This is for MCRS preparation not the FRCS (Tr & Orth) part 1 overall it is very useful for trainees in their preparation.
exam; hence, the consistently poor candidate reviews. It still
sells but do not expect to be challenged as it is way off the exam Reference books
standard Campbell’s Operative Orthopaedics35
First Aid for the Orthopaedic Boards, Second Edition (First Aid Specialty This is a useful reference source when you can’t find the
Boards)30 answer elsewhere!
This is an American book that has been primarily written for
European Surgical Orthopaedics and Traumatology: The EFORT Textbook36
the in-service exam (Orthopaedics In-Training Exam (OITE)).
It has had some good reviews from trainees, more as a last- This book is seven volumes and is expensive. It is aimed
minute exam crammer before the part 1 exam than as anything at higher orthopaedic trainees preparing for exams within
else. It is easy to read and may help you score a few extra and beyond Europe. It doesn’t really have an exam feel
points; however, it is expensive for what it is. about it and, despite the publicity, is definitely a deflating
experience.
Review Questions in Orthopaedics31
This book has been written for orthopaedic residents pre- Summary
paring for the in-training examinations of the American There are now many tools to aid in the preparation for
Board of Orthopaedic Surgery. Despite the American the orthopaedic FRCS exams. You have to find out what
bias, it is exceptionally highly recommended by the vast is right for you. However, it is extremely important that
majority of candidates sitting the FRCS (Tr & Orth) exam. any non-peer-reviewed information is viewed with a heavy
It is the quality of the explanations of the answers that amount of cynicism, as it may potentially be incorrect or
seems to set the book apart. It is fairly dated now (2001) subject to bias.
13
005
References 13. Einhorn TA, O’Keefe RJ, Buckwalter

JA. Orthopaedic Basic Science:
London Guide. Boca Raton, FL: CRC
Press; 2014.
1. Miller MD. Review of Orthopaedics, Foundations of Clinical Practice, Third
Sixth Edition. Philadelphia, PA: 25. Trompeter A, Elliott D. Trauma for the
Edition. Rosemont, IL: American
Elsevier/Saunders; 2012. FRCS (Tr & Orth) Examination. Oxford
Academy of Orthopaedic Surgeons;
Speciality Training Higher Revision.
2. Bulstrode C, Wilson-MacDonald J. 2007.
Oxford: Oxford University Press; 2015.
Oxford Textbook of Trauma and 14. Damron TA, Morris CD, Tornetta P,
Orthopaedics, Second Edition. Oxford: 26. Greenhalgh T. How To Read a Paper:
Einhorn TA. Oncology and Basic
Oxford University Press; 2011. The Basics of Evidence-Based Medicine,
Science (Orthopaedic Essential Series).
Fourth Edition. Oxford: Wiley-
3. Boyer M. AAOS Comprehensive Review Philadelphia, PA: Lippincott Williams
Blackwell; 2010.
2, Second Edition. Rosemont, IL: & Wilkins; 2007.
American Academy of Orthopaedic 15. Staheli LT. Practice of Pediatric 27. Dawson-Bowling SJ, McNamara IR,
Surgeons; 2014. Orthopedics. North Wales, PA: Ollivere BJ, et al. Orthopaedic Basic
Springhouse Publishing Co; 2006. Science for the Postgraduate
4. Solomon L, Warwick D, Nayagam S, Examination: Practice MCQs and
Apley AG. Apley’s System of 16. Staheli LT, Song KM. Pediatric EMQs. Gloucester: Orthopaedic
Orthopaedics and Fractures, Ninth Orthopaedic Secrets, Third Edition. Research UK Publishing, 2012.
Edition. London: Hodder Arnold; Philadelphia, PA: Mosby; 2007.
2010. 28. Gulam Attar F, Ibrahim T. Succeeding
17. Joseph B, Nayagam S, Loder RT, in the FRCS T&O Part 1 Exam. London:
5. Agarwal S. Current Orthopaedic Torode I. Paediatric Orthopaedics: BPP Learning Media; 2011.
Practice – a Concise Guide for A System of Decision-Making. London:
Postgraduate Exams. Harley, UK: TFM Hodder Arnold; 2009. 29. Sharma P. Practice Questions in
Publishing Ltd; 2013. Trauma and Orthopaedics for the FRCS
18. Jebson PJL, Kasdan ML. Hand Secrets, (Master Pass Series). Milton Keynes:
6. Hoppenfeld S, DeBoer P, Buckley R. Third Edition. Philadelphia, PA: Hanley Radcliffe Publishing Ltd; 2007.
Surgical Exposures in Orthopaedics: & Belfus; 2006.
The Anatomic Approach, Fourth 30. Mallinzak RA, Albritton MJ, Pickering
19. Wolfe SW, Hotchkiss RN, Pederson TR. First Aid for the Orthopaedic
Edition. Philidelphia, PA: Wolters WC, Kozin SH. Green’s Operative Hand
Kluwer/Lippincott Williams & Boards, Second Edition. Bronson, TX:
Surgery, Sixth Edition. Philadelphia, McGraw-Hill Medical; 2009.
Wilkins Health; 2009. PA: Churchill Livingstone; 2010.
31. Wright JM, Millett PJ, Crockett HC,
7. Tubiana R, Masquelet AC, McCullough 20. Egol KA, Koval KJ, Zuckerman JD. Craig EV. Review Questions in
CJ. An Atlas of Surgical Exposures of the Handbook of Fractures, Fourth Edition. Orthopaedics. Rosemont, IL: American
Upper and Lower Extremities. London: Philadelphia, PA: Lippincott Williams Academy of Orthopaedic Surgeons;
Martin Duntz; 2000. & Wilkins; 2010. 2001.
8. Briggs T, Miles J, Aston W. Operative 21. Rockwood CA, Green DP, Bucholz RW. 32. Sharma H. 1000 EMQs in Trauma and
Orthopaedics: The Stanmore Guide. Rockwood and Green’s Fractures In Orthopaedic Surgery. FRCS Orth Exam
London: Hodder Arnold; 2009. Adults, Seventh Edition. Philadelphia, Education; 2008.
9. Whitaker RH, Borley NR. Instant PA: Wolters Kluwer Health/Lippincott
33. Khanduja V. FRCS (Tr & Orth): MCQs
Anatomy, Fourth Edition. Oxford: Williams & Wilkins; 2010.
and Clinical Cases. London: JP Medical
Wiley-Blackwell; 2010. 22. Rockwood CA, Beaty JH, Kasser JR. Ltd; 2014.
10. Harris N, Ali F. Examination Rockwood and Wilkins’ Fractures In 34. Davies N, Jackson W, Price A, et al. FRCS
Techniques in Orthopaedics, Second Children, Seventh Edition. Philadelphia, Trauma and Orthopaedics Viva (Oxford
Edition. Cambridge: Cambridge PA: Wolters Kluwer/Lippincott, Specialty Training Higher Revision).
University Press; 2014. Williams & Wilkins; 2010. Oxford: Oxford University Press; 2012.
11. Reider B. The Orthopaedic Physical 23. Browner BD, Jupiter JB, Levine AM, 35. Canale ST, Beaty JH, Campbell WC.
Examination, Second Edition. Trafton PG, Krettek C. Skeletal Campbell’s Operative Orthopaedics,
Philadelphia, PA: Elsevier Saunders; Trauma, Fourth Edition. Philadelphia, Twelfth Edition. St Louis, MO: Mosby;
2005. PA: Saunders; 2008. 2012.
12. Ramachandran M. Basic Orthopaedic 24. Dawson-Bowling S, Achan P, Briggs T, 36. Bentley G. European Surgical
Sciences: The Stanmore Guide. Boca Ramachandran M. Orthopaedic Orthopaedics and Traumatology: The
Raton, FL: CRC Press; 2006. Trauma: The Stanmore and Royal EFORT Textbook. Berlin: Springer; 2014.
14
005
Section 2 The written paper
MCQ and EMI paper guidance

Chapter
3 Mark Dunbar, Andrew P. Sprowson and David Limb
Section 1 is the theory part of the Intercollegiate Examination in There is NO negative marking; therefore, all questions
Trauma and Orthopaedics and consists of two papers. It is no should be attempted. Sample questions can be viewed at
longer a ‘written’ examination and instead is a computer-based www.jcie.org.uk, although candidate feedback suggests these
assessment taken in a local Pearson VUE Test Centre. One are neither particularly helpful nor representative of the real test.
major change is that there is no longer a published paper to A candidate’s final mark is determined by the mean com-
read and the questions applicable to that section have been bined (SBA/EMI) marks achieved in paper 1 and paper 2.
replaced by multiple choice questions (MCQs) and extended Experienced examiners perform a formal process of ‘setting
matching items (EMIs) on statistics and research methodology. the standard’ and this sets the pass mark for each paper.
Section 1 examinations are delivered at Pearson VUE Test Eligibility to proceed to the clinical component of the exam-
Centres throughout the UK and Ireland to avoid the need for ination (section 2) will be the mean of the two marks set by the
candidates to travel and incur hotel costs. Candidates will be standard setting process. The details of criterion referencing/
able to choose the one that is most convenient for themselves. standard setting is complicated and not made public. There
Be aware that many different types of tests may be going on at needs to be a spread of difficulty to the questions to differentiate
the same time as your exam (e.g. driving theory, USMLE) and between candidates. An easier paper will require a higher mark
so be prepared to focus so as not to be distracted by the to pass. A question can be graded on difficulty by what propor-
movements of others. Some candidates have chosen to travel tion of candidates just passing the exam would be expected to
further to a quieter testing centre or to take the test at the achieve the correct answer. During the last few examinations,
same place as their colleagues to minimize the likelihood of the pass mark has been between 65% and 68%.
disturbance. The SBAs/EMIs are subject to quality assurance procedures
You will be required to bring photograph identification through both examiners comments and candidates feedback.
and the exam conditions are strict. Video surveillance of can- Difficulty level, content coverage, discrimination index and
didates is common and no mobile devices will be allowed in internal consistency are analysed.
the examination room. It is also wise to bring along a packed The Joint Committee on Intercollegiate Examinations
lunch to keep yourself refreshed in between papers, as you (JCIE) site contains a link to advice on format and structure
won’t be able to buy food from most test centres. of test questions1. It is useful to have some idea of how MCQs
As this exam is now computer-based questions involving are constructed, what they set out to test, avoiding ambiguity
multimedia (radiographs, slides, pictures) can be expected. with stems, use of distracters placed in the stem to change the
You will also not be able to read ahead, but you will have the entire meaning of the question, etc, but the book is very
facility to flag difficult or ambiguous questions for review at detailed and complicated and is perhaps more relevant for
the end. the examiners constructing the questions than for candidates.
The part 1 examination is designed to test knowledge
across the whole cirruculum and does so as far as possible by
Overview using questions that require higher order thinking. Rather
than asking for a fact, it looks for the application of knowledge
Paper 1 to solve problems usually clinical scenarios. There has been a
Single best answer (SBA) paper (2 hours) progressive rewriting of the question bank to reflect this
110 MCQs (SBA format; one from five) change in emphasis.
Paper 2 Paper 1
EMI paper (2 hours 30 mins) The first paper is 2 hours long and comprises MCQs (SBA,
135 MCQs (EMI format) 1 from 5). The paper consists of 110 single-response questions.
15
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Section 2: The written paper
Since the middle of 2014 the 12 questions on the published one is the most likely suited answer to the question. SBA
paper comprehension have been replaced by SBI/EMI ques- questions are exactly what the name suggests. A question will
tions on statistics and research methodology. We are unsure be set and the candidate has to choose the best from five
why this has occurred. This part of the paper was always possible answers. It is important to note that this is not a
unpredictable and it may have been too difficult to consistently ‘Single Correct Answer’ question but a ‘Single Best Answer’.
standardize this section from one exam sitting to the next. The In fact all five possible answers could be ‘correct’, but candi-
examine committee’s time was probably better spent on dates are asked which is the ‘Best’ answer given the information
developing and improving the SBA/EMI question bank. presented in the stem. As questions are designed to test higher
This may have unsettled a few candidates who had order thinking, this may mean that not all of the information
obtained higher research degrees. In theory these candidates needed is in the stem – Some of it may need to be judged from
would be at a slight advantage in this section. However, spe- your knowledge of the available evidence. Questions about
cialist knowledge at the level of a higher degree is not expected. which some candidates complain ‘There was more than one
Instead candidates should be able to demonstrate they have correct answer’, the question was ambiguous, etc, can often be
sufficient knowledge to critically appraise evidence and to the best performing questions on the paper.
decide whether or not to allow it to influence their future A few examples are given below.
practice as consultant leaders.
The range of potential questions is wide, but it would be
1. A 30-year-old woman presents to you with a commin-
sensible for candidates to expect at least some of the questions uted fracture of radial head. What is the best manage-
to cover: ment option for this lady?
Sensitivity/specificity A. Conservative method
Screening tests B. Open reduction and internal fixation
Contingency tables C. Radial head replacement
D. Closed reduction and percutaneous K-wiring
P-values and confidence intervals
E. Early mobilization
Data presentation methods 2. A 73-year-old woman is seen in the clinic with a
Central tendency and measures of dispersion pathological fracture of the first lumbar vertebra.
Sample-size calculation and power analysis She has previously been diagnosed with metastatic
Types of data and appropriate tests for them breast disease and has been given a life expectancy of
Correlation and regression 1 month. What is your treatment plan?
A. Pain relief and supportive care
Outcome measures
B. Radiotherapy
Validity and reliability C. Chemotherapy
Levels of evidence D. Vertebroplasty
Survival analysis E. Posterior instrumentation
Sources of bias 3. A 23-year-old sustained a penetrating injury to the
Impact factors sole of the foot while playing a game of tennis. What
are the commonest infecting organisms?
Most of these topics are adequately addressed in the commonly
A. Staphylococcus aureus
used basic science revision texts, but to date there are no statis-
B. Pseudomonas spp.
tics books specifically targeted towards the FRCS Orth exam. C. Escherichia coli
The remaining questions are from various aspects of ortho- D. Proteus spp.
paedics and trauma. There will be questions based on clinical E. Staphylococcus epidermidis
scenarios, basic sciences, anatomy and surgical approaches. 4. What is the root value of adductor longus?
A number of questions will be trauma-related, especially spine A. L1
and pelvic trauma. Anatomy accounts for a large number of B. L1 and L2
questions. C. L1, L2 and L3
It is equally important to have a good knowledge of medico- D. L4 and L5
legal and medical ethics aspects. In both parts of the FRCS (Tr E. L4, L5 and S1
5. A 43-year-old man has back pain associated with EHL
& Orth) exam candidates have been asked to discuss topics
weakness. Which intervertebral disc is likely to be
such as confidentiality, consent, GMC good medical practice,
prolapsed?
Jehovah’s witnesses (blood transfusion) and child protection. A. L2/L3
B. L3/L4
Single best answer questions (SBA 1 from 5) C. L4/L5
D. L5/S1
The SBA question consists of an introductory theme, a ques- E. L1/L2
tion stem followed by five possible responses (A–E), of which
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Chapter 3: MCQ and EMI paper guidance
They are easy to administer and mark as a computer-based

6. The radial nerve passes between which two muscles:
assessment
A. Long and medial head of triceps
B. Biceps and brachialis Disadvantages of SBAs include:
C. Pronator teres and FDS The trainee’s reasons for selecting a particular option/
D. Brachialis and brachiradialis response cannot be assessed
E. Teres major and teres minor Although a wide sample of assessment material can be
7. Which has the highest Young’s modulus? assessed, there is no opportunity for an in-depth
A. PMMA assessment of the content
B. Titanium
C. Stainless steel
Constructing good SBAs needs considerable examiner
D. Cortical bone training
E. Ceramic SBAs developed to test trivial knowledge should be avoided
8. The most common cause of dropped little and ring as this may lead to rote learning and fragmentation of
fingers is: knowledge
A. Tendon rupture
B. Radial subluxation of extensor tendon
C. Ulnar subluxation of extensor tendon Advice for paper 1
D. Neurological causes There are only 120 minutes for 110 questions so don’t
E. Trigger fingers spend too long on the easier questions to allow you more
9. Which of the materials below is used as a bone graft time on the ones you find more difficult
substitute? There is no negative marking so you must finish
A. Tantalum the paper
B. Titanium
C. Co–Cr Read the question carefully and understand fully what the
D. Aluminium SBA question is asking of you. In an SBA all of the options
E. Ceramic available may not be ideal, but you still have to select the
10. Which muscle has a dual nerve supply? best of those available
A. Brachioradialis
B. Brachialis
C. Abductor pollicis brevis Paper 2
D. Pronator teres
E. FDS Extended Matching Item (EMI) questions
The second paper is ‘extended matching items’ (EMIs). This
section comprises 135 questions and the time given to answer
The time management in this section is very important. You these questions is 2 hours and 30 minutes. EMI questions lend
have only 1 minute to read the question, which in some cases themselves to clinical scenarios – For example, data is given on
will have a long stem, and to mark your answer. If you do not a patient’s history and examination findings along with test
know the answer, flag the question, so that you can come back results and a diagnosis. You will be given a theme or a stem
later if time permits or mark an answer that you guesstimate is and about 10 matching options. There will be three questions
the correct answer. based on the theme or stem. Again the information provided
Candidate feedback suggests that approximately 20% of may be incomplete and what is needed is the most likely
questions are straightforward. These questions test standard correct response from the list when you combine the infor-
textbook knowledge and answers can be easily narrowed down mation provided with your knowledge of the evidence and
to two choices. The remaining questions are less obvious, clinical experience (just like the decision-making process that
stems are tricky and the question needs thinking about, i.e. you will have to undertake as a consultant, and that has to
they are difficult questions especially if you are underprepared. be safe).
Advantages of SBA’s include: The typical evolution of an EMI question is that the first
SBAs can assess a wide sample of curriculum content time it is used in an exam it is flagged up as ‘too easy’. It is
within a relatively short time period. This leads to high removed from the exam, comes back to the question-writing
reliability and improved validity committee, and a debate takes place about what information is
They are a highly standardized form of assessment essential and what is provided but could differ in the real world
where all the trainees are assessed with the same questions. without altering the correct response. Information is stripped
It is a fair assessment in that all the trainees sit the out, the question returned to the exam and its performance
same exam reviewed. In general it is a better question but if the two were
SBA marking is automated, removing examiner looked at side by side, the original would have looked
subjectivity from the assessment process superficially to be preferable
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006
A few examples are given below.

1. The structures best visualized by the oblique obturator
Judet view
Low back pain 2. Has the highest association with major haemorrhage
A. Scoliosis 3. Fractures associated with the poorest functional
B. Spina bifida outcome
C. Central canal stenosis
D. Degenerative spondylolisthesis With regard to elbow fracture/dislocations
E. Isthmic spondylolisthesis A. Ulnar nerve palsy
F. Spondylolysis B. Radial head excision
G. Spondylosis C. Posterolateral rotatory instability
H. Cauda equina syndrome D. Medial collateral ligament injury
I. Spinal dysgraphism E. Essex–Lopresti injury
J. Osteoid osteoma F. Monteggia fracture dislocation
1. A 60-year-old man presents with pain in the back that G. Medial epicondyle fracture
is relieved with sitting and leaning forwards and H. Posterolateral elbow dislocation
aggravated by walking uphill I. Galeazzi fracture
2. A 20-year-old gymnast complains of sudden onset of J. Radial head replacement
pain in the back after a practice session K. Intra-articular loose body
3. A 23-year-old woman has back pain with sciatica 1. A 10-year-old boy fell from a trampoline. He was
and her mother has noticed a step in her lower back brought to the A&E department with an isolated left
elbow injury. On examination the left elbow was
Shoulder pain swollen and deformed with some bruising medially.
A. Rotator cuff tear Neurological examination showed loss of finger
extension
B. Subacromial bursitis
2. A 34-year-old woman presented to a wrist surgeon
C. SLAP lesion
complaining of right wrist pain for 3 years.
D. Glenohumeral OA
Examination of the right wrist showed tenderness of
E. Secondary impingement
the distal radioulnar joint. There was a lateral
F. Internal impingement longitudinal scar at the right elbow and some
G. Acromioclavicular OA tenderness at the scar
H. Instability 3. A 28-year-old man presented to the elbow clinic with a
I. Frozen shoulder history of painful clicking and intermittent locking of
J. Cervical spondylosis his left elbow. There was a history of a sprain of the
K. Acute calcific tendinitis same elbow 3 years previously. He doesn’t feel
1. A 55-year-old man presents complaining of right confident with this elbow, especially when doing push
shoulder pain for 3 months with difficulty in ups at the gym
abducting. On examination Hawkins’ sign was
positive
2. A 23-year-old man sustained a traction injury to this The time for the EMQ session is 2 hours and 30 minutes.
left shoulder. Movement of the shoulder was Candidates should have enough time to answer all the ques-
preserved tions without having to hurry through it. Most of the questions
3. A 60-year-old man presents with sudden onset of are based on clinical scenarios but candidates should have
severe shoulder pain. On examination all his shoulder reasonable core knowledge of the subject to answer it. The
movements are painfully restricted content of both examination papers is mapped to the curricu-
lum and the curriculum content.
With regard to fractures of the acetabulum and pelvis Advantages of EMIs include:
A. Anteroposterior compression injuries with symphysis EMIs provide a convenient method for assessing
widening >2 cm and anterior/posterior SI ligament rupture application of knowledge
B. Both anterior and posterior columns
They can assess a reasonable range of the curriculum
C. The acetabular dome content in a relatively short time
D. The anterior column
They are high in reliability
E. The anterior column and posterior acetabular wall
All trainees are assessed identically; hence, examiner
F. The posterior column
subjectivity is removed
G. The posterior column and anterior acetabular wall
H. Unilateral ramus fracture with ipsilateral fracture of EMIs are easy to administer, score, mark and store
posterior iliac crest EMIs are designed to assess clinical diagnostic skills and
thinking processes relevant to clinical practice
18
006
Due to the large number of options the likelihood of EMI questions aren’t covering exactly the same material. They
randomly guessing the correct answer is reduced will also check that, for example, knee questions do not include
Disadvantages of EMIs include: the same trauma component that a trauma question covers
There is less opportunity for the examiner to assess the when it deals with the knee. Similar and overlapping questions
trainee in-depth on a given topic are removed to bring the paper down to the correct number of
Writing EMIs is difficult and time consuming. Ambiguity questions while maintaining balance.
needs to be avoided This second draft is then considered by a convened EQA
group meeting who go through the paper with a fine tooth-
Examiner training is necessary to construct good
comb and pick up potential problems that can be ironed out
quality EMIs
before the exam. Even at this stage questions can be removed
Agreement on the correct/preferred answer may be difficult
and substituted. Even with several read-throughs spelling mis-
to achieve especially with ‘choice of management’ options
takes and typos can creep through.
Advice for paper 2 MCQ writing

If you are not too sure of an answer then do not dwell for
too long deliberating on the answer. Eliminate obviously The Examination Board has a bank of about 1000 questions to
wrong answers then either do some intelligent guessing or choose from for each exam. Questions come into the bank
flag the question for later from many sources, but always through the question writing
committee. The MCQ writing committee takes proposed ques-
If you have flagged questions keep a close eye on the time
tions from all sources and identifies those that can be written
remaining. As a safety mechanism 5 minutes before the
into a format consistent with best educational practice before
end you should stop everything give an answer to all
being placed into the question bank.
flagged questions
The MCQ examination committee meets every 3 months
There is no negative marking so you must answer all the
for a day to prepare new material. Constructing SBAs needs
questions
considerable examiner training. A question will be proposed –
Keep a record of how many questions you are answering in It may be brought to the question writing committee by a
a given time. Don’t get behind and have to rush your member who has been asked at the previous meeting to write
answers at the end. Read the instructions of the EMIs first an SBA on a specific curriculum topic where a question is
before answering. Candidates need to watch the clock on a needed. The question will be projected for the committee to
regular basis. Check every 30 minutes that you have review and about a half will, after 15 minutes or so of debate,
answered 30 questions and, if not, speed up. Reading the be rejected. Otherwise the debate will continue with numer-
instruction and stems (which can be as many as 12) is still ous edits being made, and over the course of typically an
very time consuming hour, the question will be rewritten until it satisfies the
Just before the end quickly look through the exam paper to committee. The question is then coded and banked as a
make sure every question has been answered and nothing new question.
has been left unanswered Some potential SBAs can be deliberated over for 2–3 hours
It is a test of time management, examination technique and finally (to the sheer frustration of the committee) to be rejected
English language comprehension as much as a test of ortho- usually for being too ambiguous. The examination bank is
paedic knowledge and clinical judgement. continually being added to and refreshed. The Examination
Board is pushing towards developing a much bigger bank of
questions that can be utilized for the exams, but this process
Exam generation takes a considerable investment of time, effort and organisa-
An exam is compiled by ‘random’ selection of questions from a tion. Some other specialties, in particular General Surgery,
bank by a computer – Random in parentheses, as rules are have a much larger bank. Questions in the bank are coded to
followed. The proportion of questions from each coded section the curriculum so that the bank can be more easily scrutinized
of the curriculum is the same for all exams and each exam has and question writing can be focused to address areas of relative
blocks of established well-performing questions, new questions deficiency.
and rewritten questions. Candidate feedback after every exam As part of the quality assurance process a set number of
always contains self-cancelling comments, e.g. ‘there were too MCQ panel members are asked to act as volunteers and sit the
many lower limb questions’ and ‘there were too many upper proposed next sitting of the SBA/EMI papera. From this sitting
limb questions’, etc.
The first draft, which always contains a few more questions
than needed, is securely sent to the chairman of the Examin- a
Although a useful learning experience, it can be stressful for them
ation Quality Assessment (EQA) Group. Their job is to check worrying that they may score a low mark with gaps in their
that there are no duplication of questions and that SBA and knowledge exposed.
19
006
a number of questions are discardedb. Banked questions may

need to be updated or ditched in the light of fresh new infor-
mation available.
When a new question is used in the exam it is flagged up as
new and its performance compared to established ‘superbank’
questions that have a track record of solid performance.
A large amount of statistical data is produced on the perfor-
mance of each and every question. Only if the new question
performs adequately will it count towards the final mark of
candidates in the exam and be available for use in subsequent
exams. If its performance falls short it is removed from the
exam and does not affect the final mark of any candidate and
with this returned to the question writing committee for
review.
The over-riding message is that at any stage if there is any Figure 3.1 Miller’s pyramid. Different levels of assessment
ambiguity whatsoever with a question it has to be discarded.
Creating: Use information to create something new.
Educational theory Construct, compile, develop, design, produce, improve,
To ensure adequate content coverage and, therefore, that the change, devise and propose
exam is a valid test of the breadth of knowledge of orthopaed-
ics, the process of blueprinting occurs. A spreadsheet is created Bloom’s taxonomy is a hierarchical classification, with the
that maps each of the questions to a learning objective on the lowest cognitive level being ‘remembering’ and the highest
curriculum. Miller in 1990 introduced an important frame- being ‘creating’. The lower three levels can be attained with
work that can be presented as four tiers/levels of a pyramid to superficial learning so called Lower Order Thinking Skills
categorize the different levels at which trainees needed to be (LOTS) such as memorisation. The upper three levels involve
assessed2. Although SBAs and EMI can be used to test appli- Higher Order Thinking Skills (HOTS) and can only be
cation of knowledge and higher order thinking, their construc- attained by deep learning.
tion is difficult and in general they assess the bottom two levels EMIs are used to assess clinical aspects at the level of
of ‘knows’ and ‘knows how’ in Miller’s pyramid (Figure 3.1). ‘knows how’ in Miller’s pyramid and Bloom’s levels 3–6 (appli-
Bloom et al., in 19563, described six levels in the cognitive cation, analysis, synthesis and evaluation). They can, however,
domain. These were: (1) knowledge recall; (2) comprehension; also be used to test factual recall of knowledge and understand-
(3) application; (4) analysis; (5) evaluation; and (6) synthesis. ing (the first two levels of Bloom’s taxonomy) and the ‘knows’
This was revised in 2001 with the use of verbs rather than level of Miller’s pyramid.
nouns for each of the categories and a rearrangement of the An ongoing development of the examination is the pro-
sequence within the taxonomy (Figure 3.2). gressive rewriting of questions in the bank that are currently
Remembering: Reproduces previously learned material by recorded as level I questions (factual knowledge) into higher
recalling facts, terms, basic concepts and answers. List, order questions.
name, label, identify and match
Understanding: Understanding and making sense out of Standard setting
information. Compare, contrast, explain, discuss, After the papers have been sat they are automatically marked
demonstrate, describe, summarize, classify and illustrate and at this stage there is simply a raw mark indicating how
Applying: Use information in a new (but similar) situation. many correct responses each candidate achieved. As men-
Construct, draw, demonstrate, apply, calcualte and illustrate tioned previously, extensive data is kept on how each and every
Analysing: Take information apart and explore question is answered. As an example of the sort of data col-
relationships. Categorize, compare/contrast, examine and lected, the final scores of candidates are ranked and divided
make distinctions into quintiles. For each possible response to each question,
Evaluating: Critically examine information and make data is generated on how each quintile of candidates
judgements. Defend, determine, justify, rate, recommend, responded. One measure of question reliability will be to look
appraise, prove, test, critique and assess at how it predicts the final result of a candidate – A ‘good’
question will be answered correctly by almost all of the candi-
b
Usually if too many committee members fail a particular question.
dates who end up in the top 20% and incorrectly by most
Causes may include the question being too difficult, unclear, candidates who end up in the bottom 20%. All of this data is
ambiguous or obscure, or new evidence challenging a previously stored in the bank with the questions and is available when
credited correct answer. questions are reviewed.
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Figure 3.2 Bloom’s revised taxonomy. Asking thinking questions
Facility refers to how easy a question is – If 90% of all decide whether it is a fair question that should stay in the
candidates get a question right or wrong it is too easy or too exam, or is flawed and should be removed and returned to the
hard and is a worthless question. Such questions are removed question writers. Reasons include unrecognised ambiguity,
from the exam and do not count towards a final mark, but are new evidence challenging previously held beliefs or simply
sent back to the question-writing committee. If the purpose of the answer in the question bank is incorrect. Some very good
the exam was to identify the best and worst candidates in the questions end up being flagged up as having possibly the
country reliably, giving a national rank, then these questions wrong answers yet are absolutely fine. For example, if a ques-
would be essential. However, the exam has to discriminate tion is hard so that only 20% of candidates answer it correctly
reliably around a pass mark based on specialty standards and then 80% will choose the wrong response. If, say, 40% chose
by removing ‘too easy’ and ‘too difficult’ questions from the one of the incorrect stems – This flags as a possible wrong
final consideration the middle ground becomes ‘stretched out’ answer automatically, as more candidates have chosen a spe-
and separates candidates better around the pass mark. cific incorrect response that the correct one
The process of standard setting is quite a time-intensive The mark for eligibility to proceed is that which would be
process involving around 20 or so experienced examiners. obtained by the candidate who just meets the standards required
They will be first split into two groups to look at some of the by the specialty and the GMC. This is often loosely defined as
SBA and EMI questions that have been flagged statistically as a Day 1 Consultant working in a District General Hospital
poor performers. Some questions will already have been who has spent an appropriate period of time revising for the
removed automatically – For example all the questions that specialty exam. This is somewhat ambiguous and contradictory.
proved too difficult or too easy (usually new questions, as any A criterion-referenced method is used, which means that
question previously used would have passed through this theoretically if everyone performed well there could be a 100%
hurdle already). The examiners will review each question and pass rate. However, recently the pass mark has been rising and
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perhaps an understanding of the standard setting process will It is critical to decide what type of revision you are going to
demonstrate how the exam attempts to be fair. use your MCQs for during each session and to only review the
The most common method used is a modified Angoff answers at the appropriate time. Incorrect answers should
method in which a panel of examiners reviews each question stimulate a review of the entire topic so that a deeper under-
and is asked what proportion of borderline candidates would standing can be approached.
be expected to answer this question correctly. Each examiner
works independently and considers each question in turn. The
examiners are not told the answers – They do not need the UK in Training Examination (UKITE)
answer paper to recognise how a borderline candidate will The UKITE is a national curriculum-based examination for a
behave faced with a particular question, each having had trainee that provides practice for the ‘real’ FRCS (Tr & Orth)
considerable experience of borderline candiates both in their exit examination.
role as trainers and as examiners. Their judgements are com- It is a voluntary optional exam held during December every
bined and then reviewed in light of the results of previous year. That said it is becoming increasingly more difficult to opt
examinations. A further round of discussion and altering of out of the exam. Trainees will appear on the radar of the TPD
original estimates occurs before the final pass mark is decided. if they choose not to sit the exam. It is sat online and is free,
To simplify matters, if we consider that the whole exam had but to be eligible to sit you have to be registered to elogbook
only 10 questions and all of the examiners independently con- and submit one MCQ and one EMI question in advance.
cluded that 6 of every 10 borderline candidates would get each The exam was originally set up for specialty registrars
question correct, then a pass mark of 6 out of 10 (60%) would but now CT2 trainees are encouraged to sit. Any SAS doctors
mean that 50% of borderline candidates would pass and 50% wishing to take the test should contact their regional programme
would fail. The pass mark, therefore, divides the borderline director. This should not be a big issue and the majority of SAS
candidates down the middle. If the pass mark has a lot of hard doctors should be allowed to sit the test if they wish to do so.
questions the pass mark will be lower. If there are a lot of easy The test originated in the Northern Deanery in 2007 and
questions the pass mark will be higher. The pass mark is unique each year the number of trainees taking the exam has grown.
to each diet. Nearly all deaneries now participate and most deaneries usu-
In some high stakes examinations the pass mark is ally conduct the exam in the stipulated curriculum teaching
increased by one standard error of measurement (Standard time so that trainees do not have to arrange time off work. In
deviation × √(1–reliability)) in order to reduce the chances 2014 the British Orthopaedic Association (BOA) integrated
that a truly borderline candidate will pass the exam. This the UKITE examination into the BOA membership; thereby
occurs for the FRCS (Tr & Orth) exam as the exam is set for trainees sit this examination through its website.
a standard of competence, not for a certain percentage of The test has not been validated and there are a lot of disclaim-
candidates to pass. For patient safety reasons the GMC would ers on the website. It cannot be used as a summative assessment
not want incompetent candidates being allowed to proceed, tool during annual reviews, but it is excellent as a tool for
even if removing them means some potentially competent monitoring your own progression of learning. Most trainees
candidates are prevented from doing so. When this step was (80%) think the questions are equivalent to the actual standard
first introduced the historical performance of candidates of the FRCS (Tr & Orth) exam, while 10% think it is harder and
scrapping through was reviewed and it was noted that they the remaining 10% consider it easier. Scores are fairly consistent
went on to fail section 2. from ST3 to ST6 but jump up considerably just prior to the
The FRCS (Tr & Orth) exam has data on its reliability actual exam and dip down again in the final year of training.
including Kronchbach alpha values. For high stakes examin- Once you have made your EMI/MCQ choice and formally
ations the standard aspired to be is a Kronchbach Alpha submitted it during the UKITE exam, you are given the correct
around +0.8. Very few professional examinations, particularly answer with an explanation provided during the test. As time
in the medical specialties, achieve this. Part 1 of the FRCS (Tr is tight most candidates just get on with the exam and don’t
& Orth) has never dropped below +0.9. read over the answers. You are allowed later to access the test
and can go through the answers in a more leisurely fashion. At
the end of the test you are given an immediate score.
MCQ revision resources Candidates can practice refining their MCQ tactics in a less
Using MCQs for revision can impact positively or negatively nervous environment than the real exam. It should encourage
on the final outcome. As a tool for summative assessment, trainees to read more formally and consistently through the
appropriate questions will reliably demonstrate progression in various orthopaedic textbooks earlier than the usual 6–12
understanding. When used as a revision guide having answers months before the actual exam.
available during the perusal of the questions can lead to a false The test contains 140 questions that are a combination of
sense of security for the ill-disciplined student. Additionally, SBAs and EMIs. The maximum time for the exam is 2 hours
getting an SBA question right does not necessarily indicate that and 45 minutes. The questions cover different topics from the
you know that topic particularly well. whole orthopaedic curriculum.
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The questions, answers and their explanations are available proposed to make sure factual information out there on the
online for 3 months after the exam for further revision and this website is correct.
is a good opportunity for candidates to review the material of
their incorrect answers.
MCQ terminology
It is important to understand the terminology used for MCQs:
UKITE and the FRCS (Tr & Orth) exam ‘Always’ means 100% of the time and is unlikely to be true
Some of the questions in the UKITE bank have been sent to the ‘Never’ is another absolute term and may often be wrong
FRCS (Tr & Orth) examination board for possible use. The ‘Occasionally’ can make many options potentially viable as
actual FRCS (Tr & Orth) MCQ/EMI questions are difficult and correct answers and confuse you
time consuming to write. Questions are in short supply with a ‘Commonly’ means >75% or even more of the time
small bank of verified questions. ‘Rarely’ is equivalent to something that occurs <1% of
The FRCS (Tr & Orth) committee is unsure whether the the time
submitted questions are worth the extra effort required to
‘Associated with’ means that there is a definable link
reach the FRCS (Tr & Orth) standard. They still spend a long between the theme and this option
time reworking and refining questions put forward by UKITE
‘Pathognomonic’ means that if this particular item is not
to avoid any ambiguity in their wording, and believe it may be
present in the stem it would cause the diagnosis to be
easier and less hassle for the committee to simply construct
in doubt
them from scratch.
As ‘always’ means 100% and ‘never’ means 0%, they both are
often wrong. Some advice given by ex-candidates is not too
Online resources spend too long on very difficult questions as they will be
Question banks and past questions can often be acquired from rejected by the exam board. We are not entirely sure about
recent successful candidates, but two large online question this guidance, inherently it seems wrong. It is highly unlikely
banks currently stand out as potentially useful resources. these difficult questions would get past the exam-setting com-
Over the last few years Orthobulletsc has become a most mittee in the first place if there were any concerns with them.
useful resource for both revision and for questions. It is con- Questions are written to avoid cues being taken to allow
stantly being updated and reflects a lot of what has been guessing. For instance, the order of possible answer choices is
written in Miller. The topics are related to MCQs and there simply alphanumeric. The possible answer choices are adjusted
are several cases presented that stimulate lively debate amongst to be of similar length (in lesser exams the possible answer that
the worldwide orthopaedic community. is longer or shorter than the rest is the correct one!) and all
Orthobullets is presented as a revision resource with infor- possible answers will be of the same nature (e.g. if being asked
mation provided as bullet points. A deep understanding of all about a diagnostic test the possible answers will all be radio-
the topics is not possible without further reading. On its own it logical investigations rather than four radiological tests and
is probably not enough to confidently secure a pass in the one blood test). The bottom line is that candidates should not
exam. The anatomy in particular is not detailed enough to try to look for clues or patterns. If you have to guess you have
give confidence for the exam. to guessd. There are no negative marks.
The American Academy of Orthopaedic Surgeons (AAOS)
has a large data bank of MCQs. This question bank is geared Books
towards the American exams and the structure and question There are few decent MCQ books on the market for the FRCS
style of the FRCS (Tr & Orth) MCQs are quite different. Despite (Tr & Orth) exam. It is very difficult and time consuming to
this, they are a very popular resource for FRCS (Tr & Orth) construct good quality, relevant MCQ questions that meet the
candidates preparing for their part 1 exam. required standard for the exam. There have been concerns
One word of caution. Questions in the FRCS (Tr & Orth) raised that some candidates may use these types of books as
bank evolve from exam to exam – Subtle changes make big a major tool for learning the material for the examination.
differences to the correct answer. If you practice on a website This will not get you through the exam, especially the orals,
and think you recognise the question in an exam be very careful as at best these types of books are really only useful for
indeed as there are a number of questions which, when used, quick revision near the end of your preparations, a sort of
generate very interesting responses. Clearly there is a correct confidence boost.
answer that is agreed by all the examiners present, but when a A word of caution about MCQ practice books – The
whole cohort of otherwise sensible candidates plump for the examiners are not allowed to write these books, so any pub-
same incorrect answer – Now why are they doing this? Unoffi- lished book is written by someone with no experience of the
cially these websites are consulted when a question is being FRCS (Tr & Orth) writing group.
c d
www.orthobullets.com But just don’t guess randomly- try at least to have an intuitive guess.
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Courses personality over analyze SBAs/EMIs and fail this part of the
exam despite excellent knowledge. Get professional guidance if
There are some MCQ practice courses available that give
necessary, as exam attempts are limited.
trainees the opportunity to assess their knowledge in an exam
On the day of the exam most of us thought we had failed
setting. Some candidates felt they were worth attending to
when in fact we had passed. Try not to get too disheartened, as
improve technique and confidence. They are helpful for last
there is nothing left to do for section 1 at this point. As it is
minute quick revision but are not a substitute for adequate
computer based, the results can be released quite quickly and it
overall preparation. Regular practice of answering MCQs/
usually takes around a week to find out if you passed or failed
EMQs using Orthobullets or, even better, UKITE experience
with the breakdown of your marks for each paper following in
would be more fruitful than attending these courses and
the post a few days later.
spending unnecessary money.
Final thoughts about the part 1 exam is that every question
As has been announced on the Joint Committee on Inter-
in every exam is statistically dissected and each exam is com-
collegiate Examinations (JCIE) specialty board websitee, the
pared to all previous exams. Do not go into the exam thinking
allowed number of attempts for both parts will be restricted
you may be treated unfairly – You are a number and enormous
with no re-entry, so the best plan of action is proper prepar-
effort is put into making sure sound decisions are made on
ation, starting very early before applying for the examination,
your eligibility to proceed.
asking as many colleagues who have previously done the exam
about their experiences and setting up a study group. This is a
demanding exam and the examiners expect a good standard of References
knowledge and experience to pass you. Remember, however, 1. Case SM, Swanson DB. Constructing Written Test
that the majority of candidates who work hard pass the exam- Questions for Basic and Clinical Sciences, Third Edition.
ination in one or two attempts. Philadelphia, PA: National Board of Medical Examiners
If you are one of a small number of candidates who has (NBME), 2001.
difficulty answering the SBA/EMI format then you will need to 2. Miller G. The assessment of clinical skills/competence/
prepare more thoroughly for this part of the exam than the performance. Acad Med. 1990;65(Suppl): S63–7.
average candidate. Spend as much time as possible answering 3. Bloom BS, Englehart MD, Furst EJ, Hill WH, Krathwohl DR.
practice questions. Do not cut corners and learn the subject A Taxonomy of Educational Objectives: Handbook I: Cognitive
as comprehensively as you can. Some candidates may by Domain. New York, NY: David McKay; 1956.
e
www.jcie.org.uk
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Section 3 The clinicals
Introduction to clinical examination techniques

Chapter
4 Karen Robinson and Fazal Ali
Perfecting the art of clinical examination provides the ortho- examining so you know if what you’re doing is uncomfortable
paedic surgeon the necessary skills to pass examinations but or painful. Avoid hurting the patient.
more importantly forms the basis on which accurate diagnosis
and improved patient care will result. In this chapter we have Equipment
laid out a general approach to clinical examination to use as a You will need some basic equipment for clinical examination
foundation to build upon as you learn. and it is best to have this ready to use when needed.
A tape measure used commonly for leg length
General principles measurements, but can also be used as a plumb line and to
It does not matter in which situation clinical examination is quantify muscle wasting
taking place. There are certain basic rules that should be A key, a 50 pence coin and a pen for a functional
mandatory on every occasion. examination of the hand
A goniometer to quantify range of motion
Respect the patient Two pens to demonstrate range of forearm pronation and
supination
Make the patient feel comfortable and at ease. Be polite and
respect their dignity at all times. A tendon hammer for a neurological examination
Expose the patient Sequence of examination

The area being examined must be adequately exposed whilst The majority of orthopaedic examination is based on the
maintaining the patient’s dignity. Expose the patient as much sequence of look, feel and move. The elbow and wrist joints
as possible from the joint above to the joint below, which you may flow better if performed as look, move then feel.
are examining. If you think scars may be hidden under
clothing, ask the patient if they have any scars in that area Stand the patient
and ask if they would show them to you. Start every examination (except the hand and wrist) by asking
the patient to stand. Ask them to stand up straight and put
Give clear instructions their feet as close together as possible. In the lower limb,
Give clear and unambiguous instructions to the patient. It is standing the patient allows a deformity to be seen on weight-
often easier to demonstrate what you want them to do rather bearing that cannot be seen when sitting. By asking them to
than try to explain. Patients are not exam trained. They may put their feet together, varus/valgus deformity is easier to see
not understand exactly what it is you want them to do. and limb length discrepancy is harder to hide. In the upper
limb, it is easier to examine the shoulder and elbow with the
patient standing as you can move around the patient and get a
Observe all the time clearer view of the movements.
Start your observations from initial contact with the patient and
observe the whole patient before focusing on the area to be Look
examined. Are they young or old? Do they have a walking aid?
Start with inspection, look carefully at the patient from all
Do they have difficulty standing or undressing? Store this gen-
angles and comment on your positive and important negative
eral information away to help you build your clinical picture.
findings as you go along. Point out what you see so the
examiner knows what you are doing, e.g. pointing at supras-
Don’t cause pain pinatus ‘I can see wasting of supraspinatus, I would like to go
Be careful not to get so engrossed in the examination that you on to test the range of motion and the integrity of the rotator
forget to engage with the patient. Look at the face when cuff’. If the diagnosis is clear from inspection, tell the examiner
18 Apr 2017 at 19:48:25, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms.
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Section 3: The clinicals
what it is and go on to confirm your diagnosis with the rest of Table 4.1 Beighton’s scoring
the examination, e.g. in the rheumatoid hand. Try to put your Points Movement
findings together, like a jigsaw in your mind, to settle on the
diagnosis. Inspection will give you the clues you need to focus 1–2 1 point for each thumb that will bend backwards and
the rest of your examination on. Make sure you see what you touch the forearm
are looking at, be confident and move on. 3–4 1 point for each little finger that bends beyond 90° at
the MCP joint
Feel 5–6 1 point for each elbow that hyperextends
Palpate in an ordered fashion and make defined moves. Dem- 7–8 1 point for each knee that hyperextends
onstrate clearly to the examiner that you know the surface
9 1 point for bending over and touching the floor with
anatomy and can elicit any signs, explain what you are palpat- palms of hands and without bending the knees
ing and why. Remember that some joints like the knee, hand,
wrist, foot and elbow are superficial and a tender spot will be a
clue to the underlying pathology. The shoulder, spine and hip
joints are deeper; therefore, palpation is less rewarding in
helping to make a diagnosis.
Move
Range of motion and special tests are performed as part of
movement. Test all joint movements as active movements
followed by passive movements. Assessing the joint in this
way will tell you if it is stiffness or weakness that limits the
range of motion and guides you to what the patient can do
before you touch them. A stiff joint will be restricted in both
active and passive testing, whilst weakness will allow you to
perform a full passive range of motion.
Further examination
Although the majority of information is gained from the basic
steps it is sometimes necessary to perform tests specific to a
particular joint in order to confirm findings. In addition, there
are certain generalized conditions that affect the musculoskel-
etal system that may result in pathology. These will need to be
assessed.
Beighton’s score
Instability or excessive passive movement may be a sign of gen-
eralized ligamentous laxity (Figure 4.1). This can be assessed
by Beighton’s scoring system (Table 4.1). A score of 4 or more
indicates hypermobility. These patients present occultly with
joint pain for example anterior knee pain. They may present with
Figure 4.1 Excess passive movement suggestive of hypermobility
subluxing or dislocating joints, most commonly the shoulder
and patella. A positive sulcus sign (shoulder) and a positive ‘J’
sign (patella) are also characteristically seen in these patients.
Tips on learning clinical examination
Grading muscle power Phased learning
Neuromuscular disorders affect muscle strength and should be Under the pressure of an exam it is commonly clear to the
assessed and commented on using the MRC scale (Table 4.2). examiner which candidate has not practiced the routine and is,
It is important to distinguish between grade 2 and grade 3 therefore, thinking what the next step is in the sequence rather
power. Make sure you know how to eliminate gravity for each than trying to pick up the pathology. It is virtually impossible
of the muscle groups as this can get confusing in the heat of the to pick up subtle pathology if one is thinking about the steps in
moment (Figure 4.2). In the lower limb, this usually involves examination. The authors, therefore, recommend that clinical
placing the patient on their side. examination is learnt in four phases of preparation:
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Chapter 4: Introduction to clinical examination techniques
Table 4.2 MRC grading practiced their routine to the point where it becomes
Grade Observation automatic
Feedback is a vital way of evaluating your performance.
0 No muscle contraction Ask a colleague or your consultant to watch your
1 Flicker of muscle contraction examination and give you structured feedback that you can
2 Movement with gravity eliminated use to improve your performance. Are you demonstrating
tests clearly? Are they confident that you look like you
3 Movement against gravity know what you’re doing?
4 Movement against resisted gravity
5 Full power Treat it like a dance
A dance is a choreographed sequence of events. Treat the
clinical examination the same. Learn the steps, repeat them
the same way each time and practice the technique. This way,
under the pressure of an examination situation, well-rehearsed
routines will not suddenly be forgotten.
Treat it like a driving test

Like the ‘mirror–look–manoeuvre’ in a driving test it is some-
times beneficial to over exaggerate a technique in order to
visibly demonstrate it to the examiner. Tell the examiner what
you are doing and be seen to be doing it, e.g. look at the face
for Horner’s and say ‘I am looking for signs of ptosis, myosis
and enopthalmos’, indicating the presence of Horner’s syn-
drome or not. Other situations where this method can be used
include squaring of the pelvis when laying the patient on the
couch for hip examination and looking at the shoes and soles
of the feet in a foot and ankle examination.
Special situations
Figure 4.2 Testing triceps whilst eliminating gravity There are many situations in an exam where an uncommon
presentation faces the candidate. Dealing with this sometimes
takes some thought. It is best, therefore, to think of how you
1. Be able to recite the steps
would approach these cases beforehand. A few examples of
Know the steps of each examination and be able to repeat these situations are presented:
them clearly, concisely and swiftly to yourself. You will 1. A patient with an adduction deformity of the hip presents
need to be able to pick up the routine at different points to with apparent shortening
proceed with the examination
This patient will compensate by using a shoe raise on the
2. Practice on yourself
affected side, tilting the pelvis and trunk or by bending
Once you can vocalize the steps, practice them alone. Work the other knee. For every 10° of adduction deformity there
out clear and concise instructions to confirm how you will be 2.5 cm of apparent shortening
would ask a patient to do something. Get used to 2. A patient with an abduction deformity of the hip presents
the routine and moving from one test to another with apparent lengthening on that side
3. Practice on family and friends
This patient will compensate by using a shoe raise or
This is the opportunity to practice your routine on the stand on tiptoe on the contralateral side, tilting the
‘normal patient’. Do your instructions make sense? Did pelvis and bending the ipsilateral knee. For every 10° of
they do what you asked them to do? Become confident abduction deformity there is about 2.5 cm of apparent
in knowing what is normal lengthening
4. Practice on patients 3. A patient presenting with a fixed flexion deformity of
Without mastering the previous three stages it is extremely the hip may be compensating by increasing the lumbar
difficult to examine a patient and appreciate abnormalities lordosis. Up to 30⁰ of fixed flexion deformity of the
that are not gross. In patients with multiple deformities hip can be compensated for by an increased lumbar
most will be missed if the candidate has not repeatedly lordosis
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4. How do you do Thomas’ test in a patient with a fixed spine

such as ankylosing spondylitis?
Proceed as normal and flex the contralateral hip as far as
possible. This will remove any remaining compensatory
movement there is in the lumbar spine. The lumbar spine
does not need to be flat on the bed as long as any
compensatory movement is obliterated
5. How do you do Thomas’ test in a patient with an
arthrodesis of the contralateral hip?
Lift the arthrodesed contralateral hip until the lumbar
curve flattens. At this point measure the fixed flexion
deformity of the hip being tested
6. How do you do Thomas’ test in a patient with a total hip
replacement on the contralateral side?
Figure 4.3 Testing serratus anterior without a wall
Proceed as normal but in a controlled manner. Place your
hand underneath the lumbar spine of the patient and
slowly flex the hip. Do not flex past 90⁰ or risk dislocating what you are testing and why. By relating the anatomy and
the hip. Once the lumbar curve is obliterated, measure the pathology to the signs that you are eliciting you will be able to
fixed flexion deformity of the hip being tested piece together the information and make a diagnosis. A good
7. How do you measure limb length in a valgus deformity of example of this is the brachial plexus examination. A clear
the knee? understanding of the plexus anatomy and understanding how
to examine each nerve will help you to pinpoint where along
This should be done in segments, measuring from the the brachial plexus the injury is likely to be.
anterior superior iliac spine to the lateral condyle and from Some other examples include:
the condyle to the malleolus. It is impossible to recreate the
a. Abdominal reflexes
deformity in the contralateral limb and, therefore,
measuring in segments is the only way to comment if a Abdominal reflexes are tested by stroking the abdomen in
limb length discrepancy is present each of the quadrants with the sharper end of a tendon
8. In what situation would you not want to use a tape measure hammer. The umbilicus is T10 dermatome and is used as
as a means of assessing leg length? the centre point of the four quadrants. Light dermatomal
touch is transmitted via the sensory afferent nerve to a
If the patient has any evidence of pathology in the foot then
short spinal arc. The efferent nerve is to the segmental
there may be shortening below the level of the malleoli
myotome innervation of the abdominal muscles and,
such as with subtalar arthritis or previous calcaneal
therefore, a visible muscle contraction underneath the
fracture. In this case it is more accurate to measure leg
point being stroked occurs. In the presence of a
discrepancy using standing blocks
syringomyelia or other thoracic spine pathology there is a
9. In what situation would you not want to use standing block of the electrical conduction and the contraction is not
blocks as a means of measuring leg length discrepancy? seen. For example, if there is no abdominal contraction
If there is a fixed flexion deformity in any lower limb joint the above and to the right of the umbilicus then the
use of standing blocks will not accurately measure the pathological lesion is above T10 and on the right side
discrepancy. A tape measure should be used in this case as the b. Allen’s test
contralateral limb needs to be placed in a similar position of
Allen’s test looks at the integrity of the ulna and radial
deformity to comment on leg length discrepancy
arteries distal to the wrist. It is based on the fact that
10. How do you test Serratus anterior when there is no wall to the ulna and radial arteries contribute to both the
push against? superficial and deep palmar arches. It is particularly
Stand at 90⁰ to the patient and ask them to push against your important when assessing the patient prior to excision of a
hand with the affected arm. Apply a counter pressure and look volar ganglion. Establishing the presence of a good
at the scapula for winging as they do this (Figure 4.3) collateral circulation from the ulna artery in case of damage
to the radial artery at time of excision is important
c. O’Brien’s test
How special tests relate to anatomy O’Brien’s test can be used to detect superior labrum from
and pathology anterior to posterior (SLAP) tears. When the arm is placed,
The basis of special tests is to utilize the damage to an anatom- at 90° forward flexion, adducted 15° and internally rotated
ical structure in order to elicit a sign. It is important to know the long head of biceps tendon is subluxed from the
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Chapter 4: Introduction to clinical examination techniques
Table 4.3 Sensitivity of clinical tests
Name of test Sensitivity

5
Hawkins–Kennedy test 0.74
6
Neer’s test 0.79
3
Tinel’s sign 0.27
7
Phalen’s test 0.77
8
Trendelenburg’s test 0.94
9
Anterior draw 0.55
9
Lachman’s 0.85
9
Pivot shift 0.24
The Coleman Block test demonstrates if the varus

Figure 4.4 Provocative test for Golfer’s elbow deformity of the foot is forefoot driven (due to a plantar-
flexed first ray) with a flexible hindfoot or a fixed
hindfoot deformity. Ask the patient to stand with their
foot on the edge of a block with the head of the first ray
off the side (it may be easier to demonstrate to the
patient what you want them to do). Observe the foot
from the back, does the hindfoot swing into valgus? If so
the hyperflexed first ray is driving the hindfoot into
varus and the hindfoot is flexible. If the hindfoot
remains in varus, then the deformity is fixed in the
hindfoot. The Coleman Block test. Therefore. has a
significant role in helping to decide surgical treatment
f. Testing for Golfer’s elbow and Tennis elbow
Provocative tests for Golfer’s elbow and Tennis elbow are
based on the knowledge the forearm flexors attach onto the
Figure 4.5 Provocative test for Tennis elbow
medial epicondyle and extend across the wrist joint and
into the hand. Similarly the forearm extensors attach to the
lateral epicondyle and extend across the wrist joint.
Resisted flexion and extension are, therefore, used to test
bicpital groove. As a consequence, resisted shoulder flexion for Golfer’s elbow and Tennis elbow respectively
is painful. When the arm in kept in the same position but (Figures 4.4 and 4.5)
externally rotated, the biceps tendon relocates into the
groove and the pain is no longer present with resisted
shoulder flexion Reliability/sensitivity of tests
d. Dial test There are many special tests in orthopaedic clinical examin-
The dial test tells you whether there is an isolated ation. Many of them have no routine place in everyday clinical
posterolateral corner (PLC) injury or whether this practice and are never tested in examinations. Many of them
is combined with a posterior cruciate ligament have poor reliability and sensitivity. On the other hand there
(PCL) injury. It utilizes the fact that the PCL is active are some clinical tests that have great importance in diagnostic
when the knee is in 90° of flexion but inactive at 30°. The evaluation and are tested in clinical examinations.
PLC resists the external rotation forces; therefore, the In addition to the sensitivity of a single test in isolation,
foot will externally rotate more than the contralateral the use of tests in combination has shown to increase the
side with a PLC injury. Hence, if the PCL is also likehood ratio (sensitivity/1–specficity) and, therefore, increase
ruptured there will be no restriction at 90° and the foot the probability of a pathology being present. For example, in
will continue to externally rotate indicating a combined a full thickness rotator cuff tear, the combination of a positive
PCL and PLC injury. If the PCL is intact it will restrict painful arc sign, Hornblower’s sign and infraspinatus muscle
movement and rotation will be much less at 90° test raises the post-test probability to 0.91 from 0.33 if only one
e. Coleman Block test of these is positive2.
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007
Some commonly used tests have a low sensitivity. Tinel’s bundle) ACL rupture, although it cannot distinguish between
sign is an example of this. It has a high specificity and, them. The posterolateral bundle (PLB) does not contribute
therefore, good at identifying the true negatives, but a poor to anterior tibial translation; therefore, the Lachman’s test may
sensitivity3. In contrast, Phalen’s test has a better sensitivity be negative with a PLB tear4. Table 4.3 lists clinical tests that
and, therefore, the two tests can be used together to help build have great importance in diagnostic evaluation and are tested
a clinical picture. in clinical examinations.
Anterior tibial translation elicited with a positive Lachman’s
test has good sensitivity for a complete or partial (anteromedial
References 4. Christel PS, Akgun U, Yasar T, Karahan

M, Demirel B. The contribution of each
7. Wainer RS, Fritz JM, Irrgang JJ, et al.
Development of a clinical prediction
1. Beighton PH, Horan F. Orthopaedic anterior cruciate ligament bundle to the rule for the diagnosis of carpel tunnel
aspects of Ehlers–Danlos syndrome. Lachman test: A cadaver investigation. syndrome. Arch Phys Med Rehabil.
J Bone Joint Surg 1969;51:444–53. J Bone Joint Surg Br. 2012;94(1):68–74. 2005;86:609–618.
2. Park HB, Yokota A, Gill HS, El Rassi G, 5. Silva L, Andreu JL, Munoz P, et al. 8. Woodley SJ, Nicholoson HD,
McFarland EG. Diagnostic accuracy of Accuracy of physical examination in Livingstone V, et al. Lateral hip pain:
clinical tests for the different degrees of subacromial impingement syndrome. Findings from magnetic resonance
subacromial impingement syndrome. Rheumatology (Oxford). imaging and clinical examination. J Orth
J Bone Joint Surg Am. 2005;87 2008;47:679–83. Sports Phys Ther. 2008;38:313–328.
(7):1446–55.
6. Hegedus EJ, Goode A, Campbell S, et al. 9. Benjamin A, Gokeler A, Van der Schans
3. Kuhlman KA, Hennessey WJ. Physical examination tests of the CP. Clinical diagnosis of an anterior
Sensitivity and specificity of carpal shoulder: A systematic review with cruciate ligament rupture:
tunnel syndrome signs. Am J Phys Med meta-analysis of individual tests. A metaanalysis. J Orthop Sports Phys
Rehabilitation. 1997;76(6):451–7. Br J Sports Med. 2008;42:80–92. Ther. 2006;36:267–88.
007
The short cases

Chapter
5 Mark Dunbar and Andrew P. Sprowson
Having spoken to many candidates about their experience in nervousness but, if this continues into the second or third case,
the short cases, almost all regard this as the most difficult part the examiners will quickly lose patience and fail you.
of the FRCS (Tr & Orth) examination. Simply, you have very The usual advice applies –‘Be smart and look the part’. As
little time to show the examiners your competence with each one of the examiners explained to me, if you stand out from
particular diagnosis. The skill is being able to demonstrate that the crowd it wakes the examiner from his semi-conscious
knowledge in a succinct and effective way. Examiners often say slumber to concentrate his efforts on this poor nervous candi-
that there are few surprises in the short cases as a ‘rheumatoid’ date. It goes without saying that you should dress appropri-
or ‘Dupuytren’s’ hand is certain to be present in the examin- ately and conservatively. The chance for you to be extravagant
ation hall. This is often true, but unfortunately you may not and stand out from the crowd is at a party afterwards to
see any of these cases and, therefore, cannot simply learn these celebrate your successful performance. Have a clean handker-
two diagnoses! There are also a number of more complex cases chief available to wipe away the sweat as it pours off your
and these can catch you out if you are not familiar with them. forehead down your face at the most inopportune time.
First you must be able to confirm the diagnosis and secondly The examination is usually conducted in the style of a
be able to talk around the topic. If you have nothing at all general outpatient clinic. The key to the short cases is being
to say to the examiners, it makes it very difficult to achieve that able to reproduce your examination technique under the
pass. The examiners will ask you questions on a particular immense pressure of the exam. The best way to do this is to
short case especially if there isn’t much to find on clinical practice your exam technique over and over and over again
examination. For example, you may have finished your so that you perform exactly the same examination of the major
Dupuyten’s exam after 2 minutes but you then have 3 minutes joints each time. You should be able to perform these exam
of grilling on the management, consenting issues and compli- routines blindfold and without hesitation as if you have done
cations from surgery of this condition. them 1000 times. It is also unnecessary and unhelpful to learn
The new format of the short cases exam is divided into all 100 different tests for ACL deficiency of the knee. Stick to
upper and lower limb sections. These last for 15 minutes each a simple and reproducible exam regime with one test for each
and you have a different pair of examiners. You will see only important part of the case. If you stumble through the case
three cases each for upper and lower limb, having 5 minutes trying tests for the first time you will look unprofessional and
for each. At 5 minutes you move onto the next case, so if rarely elicit the correct signs.
you know nothing about the diagnosis it’s going to be a long 5 Listen to what the examiners ask – If they specifically ask
minutes. There is a random allocation of short cases, although you to perform a Trendelenburg test do so and do not start
in fairness there is usually a balanced mix of cases. You are examining gait because this comes before the Trendelunburg
extremely unlikely to see three hand cases, at the very least a test. This will annoy the examiners and lose you scoring points.
shoulder or elbow case would be included to allow a more The examiners are asking you to perform a targeted specific
thorough assessment of your overall examination technique. examination. You may still be asked to examine a knee or hip
In the heat of the moment we can all say stupid things to but this is more likely to be a focused exam based on the
the examiners when unsure. Easy cases can be ruined and history or presentation information guided by the examiner
failed if the candidate rushes into his/her answer. There is For example, you may be asked to examine a knee, but the
undoubtedly pressure for candidates to start talking as soon examination should differ significantly for an arthritic knee as
as possible, but try to pause for a few moments if uncertain opposed to a sports knee injury or patellofemoral instability.
about the best way to tackle the problem. Some candidates The good candidate will have prepared and be practiced for all
claim that the key to the short cases is a good start with the of these examination situations and will effortlessly be able to
opening first case. A poor start can easily deteriorate into a fail pull out of his/her examination lexicon a slick technique that
if you are unable to turn it around. Avoid the downward spiral. demonstrated the appropriate signs. For the safety conscious it
Try not to become demoralized, take a deep breath and attack may be appropriate to explain that based on the history given
the next case anew. Allowances are usually made for first case you are going to concentrate on the PF joint, for example.
31
008
You will usually have two examiners with perhaps a third Always stick to the look, feel, move, neurovascular then
person present if the examiners are also being assessed or an special tests routine
observer present. They are not actually trying to fail you, but Be friendly, courteous and polite to patients and
are trying to give you the space to demonstrate what you know. professionals, but moreover relax and be yourself during
Explain to them what you are doing as it gives them a chance the examination
to course correct you. For instance if you are given a patient Stay calm and talk sensibly even when the diagnosis
with pes cavus, you may wish to do a full neuromuscular appears unclear
examination and if you believe this to be the case you should The short cases are very artificial but you have to feel
announce it, this then gives the examiner the chance to adjust comfortable with your technique. If you feel embarrassed
your plan if in fact what they wanted you to concentrate on or lack confidence in your approach you will flounder
was the foot and to demonstrate your understanding of hind- Do not rush a case
foot mobility using the Coleman block test. If you are unsure of the diagnosis then describe the
findings and give them a differential diagnosis
Useful tips and hints Try not to be obtuse in the short cases or to pick on
The following tips and hints may seem a bit tired and cliché- unimportant details, as the examiners may then draw you
ridden, but you may find some of them useful. into a frustrating and often irrelevant discussion as to what
Practise, practise and practise. It is easy to spot candidates you mean and side-track you away from the main issue
who have not practised as they suffer from a lack of polish Get down to eye level with children and try to make them
and fluidity, which affects the examiner’s opinion of the feel at ease
overall clinical competence of a candidate This is where you need your wits about you. The questions
Look the examiners in the eyes, both of them (and both eyes)! are straightforward but it is an unnatural situation
Imagine that you are seeing cases in the clinic and Always thank the patient afterwards, just before you move on
presenting your findings to your boss. Treat them like it’s No amount of bookwork can prepare you for the short
your first week in your next post and you want to impress – cases. As much experience as possible beforehand under
Don’t miss any salient information out examination conditions is the best preparation. Volunteer
The most important part is to look slick, as though you at teaching, every week!
have done it a hundred times, even if you haven’t Although candidates should be fully prepared for an Apley
Take any opportunity you have to practise; ask more senior approach this may not be what the examiners want, so be
colleagues, fellows, keen consultants and volunteers at flexible
teaching. It’s better to look a fool with any of those listed Do not argue with the examiners and be polite to patients
above than fail the exam Do not panic. This is greatly helped if you have practised
Go to the wards and the day surgery unit to see as many a lot of short cases under pressure and have seen most
short cases as possible in the 12 weeks before the exam things before
Elicit the relevant clinical signs clearly and talk as you go Keep your head and think before you speak
The short cases should be fine as you should have seen In my experience, the examiners seemed to vary in terms of
them all before – There are no tricks, really there are none, their expectations from candidates for the short cases. In
the examiners want to pass everybody! my examination all candidates saw just three cases, so you
I am sure they assess you very quickly as to whether they had the full 5 minutes with each patient
would let you fix their grandmother’s fractured hip or not. In previous examinations, examiners wanted the candidate
Show the examiner that you have a logical and methodical to see patients for a spot diagnosis and then discuss the case
manner whilst walking to the next patient. As the examination
Certain favourite topics always appear in the short cases. becomes more standardized this approach is becoming
Make sure you know these extremely well. (See Chapter 3) much less common
Listen to the instructions: It’s easy to go down the wrong Do not take the exam unless you can prepare properly for it
track, which may take you into an area you didn’t want to Make sure your answers conform to safe practice. If there
go into are guidelines and you know them, let the examiners know
Look fascinated and grateful if the examiners make a point! The right tone to strike is friendly, efficient and business-
Take note of the examiner’s guiding comments; they are like
trying to help you The short cases seem to fly by – Remember the obvious
Smile, be pleasant with patients things such as be nice to your patients and introduce
Never make the patient wince. If you are examining a yourself. If you don’t know something, say so and do not
rheumatoid hand, ask the patient where it is sore today – waffle – The examiners don’t like people who waste time on
Show your compassion things they know nothing about
008
Chapter 5: The short cases
If you say something stupid, simply retract the statement Rare You would normally see very few in clinic, but
immediately and explain that you made a mistake and there may be one in the exam hall. You don’t
apologize need to be a world expert, but have a few basics
You need to work out how quickly your examiner wants to hand
you to go but if you are not sure go through the look, feel
and move plan. The examiner will guide you firmly
At the end of your short cases try not to dwell too much on Elbow
your own performance even if it has fallen short of • Acromioclavicular (AC) joint dislocation Common
expectations. Refocus and move on to the next part of the • AC joint pain Common
examination – Don’t get downbeat • Brachial plexus muscle power testing Frequent
Keep positive; it’s amazing how many candidates feel they • Clavicle non-union Frequent
have failed, yet have a good pass • Erb’s palsy Rare
Do not assume that you have failed and not turn up for the • Frozen shoulder Rare
remaining part of the examination. There are legendary • Impingement tests Frequent
tales of candidates not bothering to turn up to the orals • Instability of the shoulder post trauma Frequent
• Instability testing – Unidirectional and Frequent
thinking they had failed the clinical only to have
multidirectional
subsequently found out they had comfortably passed the
• Klippel–Feil syndrome Rare
clinical • Long head of biceps rupture Frequent
Most importantly, believe in yourself and the skills you • Osteoarthritis (OA) shoulder Frequent
have gained over your training • Pseudoarthrosis clavicle Rare
• Pseudoparalysis shoulder (septic arthritis) – Rare
Short case list Destruction of the humeral head as an infant
• Rotator cuff pathology and testing of muscle Common
This is a list of common cases that are likely to come up in the strength
exam and stir up uncomfortable feelings of hard work ahead. • Voluntary posterior dislocation of the shoulder Frequent
Try to imagine the typical scenario of each case, the likely
positive clinical findings and possible questions the examiners
will ask afterwards. This is not an exhaustive list. In the chapter
Wrist and hand
we have commented on the likely frequency, so you can grade
your efforts toward each topic. If you have left things late, then • Bilateral congenital radial head dislocation Rare
concentrate on the common topics first and finish with the • Congenital dislocation of the radial head Rare
rare. Think about the sort of patients that would be regularly • Congenital absence of forearm Rare
available for an examination. Conditions that are painful will • Cubitus valgus Common
not be present, as 10 candidates cannot examine a painful • Cubitus varus Frequent
• Madelung deformity plus osteochondromas Frequent
condition. Make a list over the 6 months prior to the exam
• Osteoarthritis elbow post trauma Frequent
of conditions that candidates may encounter. • Radioulnar synostosis Frequent
A number of short cases may have many positive clinical • Rheumatoid elbow Frequent
findings present especially if there is dual pathology. This makes • Rheumatoid nodules Common
them equally applicable to be used as intermediate cases and it is • Distal biceps rupture Rare
just the way the dice has rolled that they have been chosen as a • Tennis elbow – Demonstration of tests Common
short case. There is a lot of get through in these patients but the
examiners will focus you on what they want you to examine.
Hip
Shoulder • Congenital abnormality – Cleft hand, Frequent
Common You need to have an in-depth understanding of syndactyly, etc
the topic, including surgical procedures. You are • Bilateral Dupuytren Common
likely to get one of these topics in either the short • Bilateral Dupuytren’s plus peripheral Common
or intermediate cases. Neglect this topic at your neuropathy
peril! • Base of thumb OA Common
Frequent You need a good grasp of the topic. Not a dead • Carpometacarpal OA Frequent
certainty as above, but not rare. All our short • Combined nerve lesions Frequent
cases fell into this category, as we did not get any • Deformed hands due to Ollier’s disease Frequent
of the dead certain • Demonstration of Allen’s test Frequent
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008
• Extensor pollicis longus (EPL) rupture Common • Post surgery for high tibial osteotomy (HTO) Common
• Ganglion Frequent • Post-compartment syndrome release of the leg Frequent
• Kienböck’s disease Common • Pigmented villonodular synovitis (PVNS) knee Rare
• Madelung’s disease Frequent • Semi-membranosus bursa Rare
• Non-union of radius and ulna Frequent • Testing for ACL and posterior cruciate ligament Common
• Psoriatic arthropathy fingers with nail changes Rare (PCL) injury
• Quadriga effect Rare
• Rheumatoid hand Common
• Reflex sympathetic dystrophy (RSD) post-ulnar Frequent
fracture Spine
• Severe carpal tunnel syndrome Common • Ankle arthrodesis Common
• Scapholunate advanced collapsed wrist (SLAC) Frequent • Arthrogryposis with bilateral clubfoot Rare
and scaphoid non-union advanced collapsed • Calcaneal fracture with Volkmann’s ischaemic Frequent
(SNAC) wrist contracture
• Spaghetti wrists Rare • Drop foot Frequent
• Ulnar claw hand Common • Gout ankle Frequent
• Wrist drop Frequent • Growth arrest after physeal injury Frequent
• Haglund’s deformity Frequent
• Hallux rigidus Common
• Hallux valgus Common
Knee
• Hereditary motor and sensory neuropathy Rare
• Arthrodesed hip Frequent (HMSN)/bilateral foot drop
• OA secondary to avascular necrosis (AVN) post- Frequent • OA ankle Common
open reduction internal fixation (ORIF) • Pes cavus: HMSN, spinal dysraphism Frequent
acetabular fracture • Polio Frequent
• Perthes’ with secondary OA Common • Rheumatoid foot Common
• Untreated developmental dysplasia hip Frequent • Synostosis of tibia/fibula and degenerative ankle Frequent
• OA hip Common • Tarsal coalition Frequent
• Post-traumatic slipped upper femoral epiphysis Frequent • Tibialis posterior tendon rupture Common
(SUFE) hip
• Polio with limb length discrepancy (LLD) and Rare
Trendenlenburg gait
• Healing stress fracture hip Rare Paediatrics
• Neurofibromatosis and scoliosis Frequent
• Spinal stenosis Common
Ankle and foot
• Anterior cruciate ligament (ACL) plus Rare
• Cerebral palsy with foot and knee problems Common
posterolateral instability
• Curly toes Common
• ACL rupture Common
• Erb’s palsy Rare
• Blount’s disease Frequent
• Arthrogryposis multiplex congenital Rare
• General examination including checking for Frequent
(post-fusion)
effusion/synovial thickening
• Genu varum/valgus Common
• Lateral meniscal cyst Common
• Osteogenesis imperfecta Rare
• Medial collateral ligament (MCL)/ACL laxity Frequent
• Overriding fifth toe Frequent
post-knee dislocation
• Proximal femoral focal deficiency Frequent
• Open tibial fracture treated with external Frequent
• Lateral subluxing patella Frequent
fixation (EF) and then circular frame with free
• Posteromedial bowing with LLD Rare
flap. Stiff knee
• Surgically treated clubfoot Frequent
• Osteochondral defect of the knee Frequent
• Femoral anteversion Frequent
• Patellectomy Frequent
008
The intermediate cases

Chapter
6 Neil E. Jarvis, Puneet Monga and Stan Jones
Two intermediate cases replaced a single long case in 2009, back your mark, but remember each section is marked inde-
each case lasting 15 minutes, and subdivided into history, pendently. A good history will arrive at a number of differen-
examination and discussion. Usually a candidate will be tial diagnoses, and will ‘relax’ the examiner who will likely
examined on an upper and lower limb case, although they listen to 20 candidates in a day, but a poor history will obvi-
may get any combination of cases (UL/LL, LL/LL, paeds/LL, ously put off the examiner.
etc) depending upon the patient mix available. There are Your examination needs to be slick and polished, too.
96 individual scoring opportunities in part 2 of the FRCS Passing this exam means you are fit to practice as a day
(Tr & Orth) examination; 12 are in each intermediate case 1 Orthopaedic Consultant in a District General Hospital.
(24 marks in total). There will be two examiners for each If all else fails, remember Apley’s – Look, Feel Move, Special
intermediate case, and a candidate will never be left alone tests. In the lower limb case always get the patient to stand, and
with the patient; all parts of the history and examination will comment from the shoulders, spine, pelvis, knees, ankles and
be directly observed. feet both the positive and negative findings. Ask the patient
A well-rehearsed and slick technique is essential for the to walk, and have a short speech ready about their gait. Prac-
intermediate cases as this is a stressful experience. Don’t worry tice this, from cadence, initial contact, the three rockers,
if you finish the history and examination quickly as long as it and foot progression angle. If you are lucky enough to get a
is thoroughly done, there will be more time to pick up points hip examination, perform a slick Trendelenberg’s test (you get
in the discussion. You walk into the intermediate case with a 6, one go only to impress), don’t forget to measure the limb
and your mark will go up if you are polished, conversely down lengths, and perform a Thomas’ test. With knee examination
if your technique is not up to pat. The first two parts of the start by rolling the leg in extension to rule out hip pain, check
intermediate case you are in control and it will be down to you for a lack of hyperextension by comparing it to the normal
to show what you know. side, look for an effusion, active then passive movements, and
The examiners will not interrupt during the history unless perform all the special tests (varus/valgus stressing, Lachman’s,
it is rambling or the patient is garrulous, but it is easy to pick McMurray’s, a gentle pivot test). With foot and ankle examin-
up points here and score a 7 by establishing a rapport, and ation, check the shoes first for inlays, or comment if they are
pretending that you are in clinica. Gel your hands. Be polite custom made, and abnormal wear. If they’re new shoes
and make eye contact. Introduce yourself and shake the state this, but that is what you are looking for. Finish with a
patient’s hand, there are marks available for all of the above. quick distal neurovascular status, or at least mention you
Begin with their age, occupation or hobbies if retired, and would perform it.
hand dominance. Then ask about their chief complaint and In an upper limb examination ensure adequate exposure,
how it all started, and its effect on their activities of daily living. but bear in mind the patient’s modesty! With the shoulder
Ask about previous operations and medical history – The exam, stand behind and comment on the supra- and infra-
patient may give you the diagnosis! Don’t forget to complete scapular fossae, deltoid wasting, regimental badge sensation,
your history as normal with allergies, social and family history. then gently palpate the SC and AC joints. Go through active
Listen to the patient, but keep in mind that you only have then passive forward flexion, abduction, external and internal
5 minutes. If the patient is garrulous, ask direct questions rotation. Check the power of the rotator cuff. In a hand
but don’t be rude. Practice in clinic is essential and repetition examination, put the patient at ease by placing a pillow under
with consultants will bear fruit. If you are incoherent, erratic their hands. Practise inspection and have a speech ready to go.
and unstructured and miss the basics it will be hard to pull Starting from the nails, comment on any positive and negative
findings, through all the joints of the hand to the wrist,
a then ask the patient to turn their hand over and comment on
We always keep hearing from various sources that candidates
the thenar eminences and any Dupytren’s disease. Comment
should treat the clinicals as though you’re in clinic with your
consultant. The senior editor (PAB) doesn’t buy this. The exam about the position of the fingers and thumb, before gently
experience is nothing like clinic! palpating all the joints in the hand. Then ask the patient to
35
009
perform all the five grips, and functionally assess them with If this even fails the default position is Apley’s – ‘Look, Feel,
holding a pen, doing buttons up. Basically, do what you do Move’, and this can be used to get you started until you recover
every day in clinic. your composure and remember your examine sequence.
You will probably be asked to perform a focused exam, To the examiners it is obvious when observing a candidate
dependent upon your history differential diagnoses. It is after how many times they have performed that test previously.
all only 5 minutes. Clinical signs may be specifically asked for, If you have written down an exam technique and practiced
but only demonstrate special tests if you are practised, and can it a bit – It is probably not enough to get you through the
describe how they work. You need to be aware of normal and exam. How you examine in clinic day in day out reflects more
abnormal findings in your examination. You should ensure about how you will get on in the real exam. If you are skimpy,
that the examiner has noticed the important components of flimsy and inconsistent without a regular routine in the stress
the clinical sign using verbal and expressive body language. of the exam you may revert to this usual technique instead
If they haven’t noticed you demonstrating these, you will not of your more polished practised approach that you have learnt
score the points! This is a bit like your driving test, you need in the previous 6 weeks.
to show that you can perform an accurate examination, but A summary should be two, at maximum three, sentences,
don’t be put off if the examiner asks for a specific sign to be you don’t want to keep repeating yourself again, and you will
demonstrated. lose scoring opportunities. This is irritating to the examiners
The discussion usually begins with your differential diag- and they may pick you up on this if you start waffle on at the
noses if not already given from the history. You will then either summaryb.
be asked for management – Don’t forget to start with conser- Clinical signs need to be demonstrated as asked. Listen to
vative, then surgical, or which investigations you would like. what the examiner asks and be guided by him/her.
Start simple and work your way up, don’t ask for an MRI first! Be able to differentiate and appreciate what is normal and
Usually a radiograph is presented to you, and present it as you what is abnormal.
always have. The salient features will start a discussion about You can predict what clinical patients will be present in the
the surgical options and potential difficulties during surgery. examination hall – You know there will be a rheumatoid hand
As the discussion is only for 5 minutes, try and answer what or an old clubfoot. Define your topics by:
is asked straightaway, i.e. listen to the question carefully. You Definitely
will be scoring marks immediately if you do this, and failure Very likely
to do so will be tedious for the examiner. When discussing Maybe
treatment, do not offer or mention clever techniques which
Possibly
you have read recently but never seen or heard about. Instead
Unlikely
stick to what is done in routine clinical practice. If you are
You will not have too many painful patients in the examin-
going for an 8, mention recent randomised controlled trials
ation hall or patients who will tire and fatigue easy. They may
or seminal papers but only if you are sure.
end up sitting out part of the day and this creates an organisa-
Don’t be worried if you have a complex case, you will not
tion headache for the exam committee in finding replacement
be expected to demonstrate every single sign, but on the other
patients.
hand if you are lucky enough to get something as simple as
You need to bank/store up marks with your history and
osteoarthritis, your history examination and discussion
examination to compensate for any score 5s that you may pick
must be perfect. Ensure you are rested and get a good night’s
up elsewhere.
sleep. The most important thing is practise. Practise a concise,
You want to/need to score 6 on 96 occasions.
structured and focussed history. Practise your examination
You enter the room with a 6 and if you do well your
routines for all parts with colleagues, consultants and go on
score increases whilst if you do badly your mark will go down.
FRCS courses. They’re worth the money as they replicate the
It’s all up to your own performance how you will get on.
examination, putting you under pressure, and making the real
You need to maximize the marks you are in control of.
thing less of a shock. Offer treatments, as you would suggest to
a patient in standard clinical practice. People who have fared
badly in this section have had varying combinations of a shaky History
start, haphazard history, inability to reach a reasonable set You are in control when taking the history, the examiner isn’t
of diagnosis at the end of history, poor examination technique going to interrupt and get involved if there are no uncertainties –
or significant communication problems. you just need to keep practicing extracting a history from
patients. You can easily score a 7 from this with some work.
Multiply this for the four examiners and you have gone a long
Top tips and tricks way forwards towards passing the FRCS (Tr & Orth) exam.
Learn a technique so that if you get caught like a rabbit in
headlights and your mind goes blank and you panic you will
still have a system to get yourself out of jail. b
Presenting the history all over again to the examiners!
009
Chapter 6: The intermediate cases
Therefore, you need to get good at extracting a history from a Make sure you take the hint from the examiner that you are
patientc. Very occasionally it may be difficult to fully flow with wrong – ‘I have been examining all day – it is sometimes not a
the patient in getting that 7 with the history, but it really nice day examining so listen carefully to my instructions and
shouldn’t fall below a 6. take my hints.’
Concentrate when taking the history. You may need to
remember a complicated past history of orthopaedic oper- Discussion
ations from a patient. Do not forget these at the end when
It is, therefore, only with the discussion that the examiners can
you are summarizing the history as this creates a very bad
start to ask you questions you can’t anticipate or always predict
impression to the examiners and will lose you marks:
so you are not in control of this situation. It is the only part of
EXAMINER: The patient has told you what operations she has had the examination you will/should be unsure ofg.
performed so tell me them instead of saying she has had several operation
around the elbowd. Intermediate list case
You are allowed to write down some notes as you go along but Here is a list of intermediate cases, which have been put up in
it is better if you can avoid this as it can also be a distraction. the exams in the past. This is not an exhaustive list but the cases
However, if you are going to forget something at the end when with a (*) next to them have been spotted frequently. Patients
summing up such as drug history or previous operations then may have more than one region involvement and candidates
it is worth it (see above). have been asked to examine and present them simultaneously.
The examiners may ask you to take a focused history from
Hips
the patient. What this means is that whilst the patient may
have a complicated past medical history they want you to focus Hip osteoarthritis (OA) (*)
on the relevant details from this. They want candidates to Avascular necrosis (AVN) of hip (*) (post-traumatic/post-
succinctly get the information togethere. steroid/alcohol-related)
Listen careful to the patient as they go through their history Sequel of developmental dysplasia of the hip (DDH)/
and appear empathic. Despite being very stressed, avoid at all Perthes’ in adult (*)
costs being aggressive with the patient if they go off track with Arthrodesed hip with no symptoms (*)
their story into irreverences. This will fail you this section and Fracture neck of femur with failed internal fixation
leave an overall bad impression with the examiners. Total hip arthroplasty (THA), which was now becoming
compromised by heterotopic ossification (HO), on a
Clinical examination background of Paget’s
If you keep practicing your examination technique you again can Mal-united slipped upper femoral epiphysis (SUFE)
still become in control of this part of the exam and score highly. Mal-united femoral fracture
You will/should know what to do and, therefore, the examiners Early painful total hip arthroplasty (<1 year)
should not be able to catch you out by testing you on things you Paget’s disease hip
haven’t come across. You need to think when examining a Loose painful total hip arthroplasty requiring revision
patient of what you are doing and why you are doing it. You Tuberculosis hip
can still be in control if you have done your homeworkf. Learn to
examine well and completely. Take hints from the examiner: Knees
EXAMINER: ‘Are you sure that’s what you really mean’? (This is coded OA of knee (*)
language to say that you are wrong.) The examiner is checking that he Medial OA knee in a younger patient (*)
really did hear what he thought he heard – He maybe didn’t quite catch Valgus deformity in an arthritic knee (*)
correctly what you said. Rheumatoid arthritis (RA) affecting the knee (*)
CANDIDATE: ‘Absolutely’. Post-traumatic valgus knee, multiple surgeries
Previous traumatic knee dislocation with multiple
c
We think advice on history taking is OK and fairly reasonable. surgical scars
d
The candidate gave the impression he wasn’t really listening to the Painful total knee arthroplasty: Check hip, spine and
patient. If you have difficulty remembering in the stress of the vessels
examination, write down some notes as you go along.
e
The examiners may say that they want you to take a focused history
from the patient accepting that you will not be able to get all the
details from the history because of time constraints. This is coded
language to tell you to get to the money fast!
f g
We disagree with advice on clinical examination, as no matter how One could say if you learn everything for the discussion you will be
much you practice it is still very difficult to be absolutely in control in control as well, so making advice on discussion void, but we are
of everything that can happen. becoming a bit too flippant.
37
009
Foot and ankle Tumour prosthesis of the humerus

Clubfoot in adult (previous surgery) Post-traumatic stiff elbow with compromised shoulder
Ankle arthrodesis and hand function from coexisting rotator cuff disease and
Kohlers’ and congenital vertical talus wrist fracture with EPL tendon rupture/transfer
Spine Paediatric
Adolescent idiopathic scoliosis (*) Neurofibromatoses with pseudoarthrosis of the tibia
Cervical myelopathy Congenital absence of forefoot and limb length discrepancy
Spinal stenosis (LLD) in a 9-year–old
Lumbar disc prolapse Cerebral palsy
Kippel–Feil and Sprengel shoulder
Upper limb
General
Brachial plexus injury
Rotator cuff arthropathy Ankylosing spondylitis
RA with shoulder, elbow (dislocated radial head), wrist Diaphyseal aclasia
involvement Polyarticular RA
Instability (traumatic and atraumatic) Polio with LLD
009
Shoulder clinical cases

Chapter
7 Yusuf Michla and David Cloke
Introduction There are a large number of specialized shoulder examination

techniques described in the literature. This can be quite con-
Although there are always exceptions to the rule for the shoul-
fusing as they are often described with slight variations in
der, think age:
different textbooks! Stick to one or two tests for each specific
Young age – Instability, acromioclavicular (AC) joint condition and learn them well rather than try and remember
dislocation, superior labrum from anterior to posterior the 16 different tests for a SLAP lesion! Concentrate on the
(SLAP) tears, biceps tendinitis common ones, rather than obscure ones that the examiners are
Middle age – Calcific tendonitis, adhesive capsulitis, unlikely to have heard of.
impingement, rotator cuff tear
Older age – Cuff tear arthropathy (combination of rotator AC joint arthritis
cuff tear and arthritis), glenohumeral joint osteoarthritis, The AC joint may be prominent due to osteophytes or a chronic
rotator cuff tear AC joint dislocation. The patient will point with a finger to the
The younger athletic person in their second decade of life more joint if it is the cause of the pain. Pain is felt over the AC joint
likely has instability, whereas the 60-year-old golfer with a and may radiate into the trapezius area causing spasm.
painful shoulder more likely has rotator cuff disease.
Common cases include: long head of biceps (LHB) rupture
with the resultant popeye sign, older patients with chronic cuff
History
tears and a pseudoparalysed arm with lag signs. Patients may complain of a sharp or catching pain, especially
Less common cases may include Sprengel’s shoulder/ when working or lifting overhead as projecting spurs may
Klippel–Feil syndrome, arthrogryposis, as well as brachial cause typical rotator cuff symptoms. Patients may also com-
plexus lesions. plain of instability of the clavicle. Ask about a history of
It is rare to need to carry out a comprehensive shoulder previous injury to the shoulder and the patient’ s diagnosis,
examination even for an intermediate case. Start with a general treatment and recovery.
shoulder examination and then go on to test for rotator cuff Patients may complain of a sharp or catching pain, espe-
strength. By that stage you may have picked up clues to suggest cially when working or lifting overhead as projecting spurs
which area to concentrate on, but more likely the examiners may cause typical rotator cuff symptoms. Patients may also
are going to guide you into the part they want you to focus on. complain of instability of the clavicle. Ask about a history of
But, even if not instructed, as long as you follow a specific previous injury to the shoulder and the patient’s diagnosis,
sequence as suggested below it is highly likely you will pick up treatment and recovery.
the required signs.
With many of the short cases your examination technique Clinical Examination
will be diagnosis specific and you are more likely be instructed The most reliable signs that will guide you to AC joint path-
to examine the shoulder for instability or impingement. ology are: Point tenderness over AC joint, prominence of
General examination. Look, feel, move. In palpation, feel AC joint, and demonstrable instability of the clavicle on arm
the acromioclavicular (AC) joint, subacromial space, elevation.
bicipital groove, trapezius, cervical spine Direct palpation will reveal well-localized tenderness and
Rotator cuff strength testing crepitus over the AC joint. Palpation may reveal asymmetry or
Impingement tests irregularities within the joint.
Symptoms and clinical findings of significant AC joint
Instability tests
arthritis are similar to rotator cuff pathology and often coexist.
Proximal biceps tests
It is, therefore, important to test for active range of shoulder
AC joint tests
movement and rotator cuff muscle strength.
39
010
A number of provocative manoeuvres that load the Acromioclavicular resisted extension test: This starts with
AC joint have been described. However, these tests are the upper limb elevated 90° in the sagittal plane, the elbow
not very specific for the joint and may overlap with other flexed to 90° and internal rotation to 90°. With the examiners
painful shoulder conditions such as rotator cuff tears or hand fixed in space against the posterior elbow, the patient
tendinitis, labral pathology or biceps pathology. Pain elicited extends the shoulder in the transverse plane, meeting the
by these manoeuvres should be localized to the AC joint examiners resistance. The test is positive if pain occurs in the
rather than being non-specifically localized to the posterior AC joint
or lateral shoulder. Suggest to the examiners a local diagnos- Buchberger’s test: This combines an inferiorly directed
tic anaesthetic injection directly into the joint if any clinical force to the lateral clavicle with passive forward elevation of a
uncertainty. slightly adducted and externally rotated upper limb. The test
Terminal impingement pain: When full movement of the is positive if pain occurs in or near the AC joint
shoulder is possible a terminal impingement pain (pain above
120°) can be demonstrated on both active and passive
movement.
Investigations
Crossed arm adduction test or (Apley) Scarf test: The AP radiograph shoulder (marginal osteophyte formation,
patient’s arm is passively adducted across the body horizon- subchondral bone loss, cystic resorption of the distal clavicle,
tally approximating the elbow to the contra-lateral shoulder. generalized osteopenia distal clavicle): Osteolysis of the lateral
An augmented AC compression test can be performed if end of the clavicle is seen in weightlifters and will have clinical
the examiner’s thumb pushes the lateral end of the clavicle findings similar to AC joint arthritis.
anteriorly. MRI shoulder (look for rotator cuff and other subacromial
Active compression test (O’Briens test): This test was pathology): MRI may also demonstrate impingement of the
developed for assessment of AC joint pathology but O'Brien superior cuff by an inferior AC joint osteophyte, suggesting
noted in a series of pateints it was excellent for detecting labral that removal of this should be included in decompression
pathology (sensitivity 100%, specificty 98.5%). The patient’s surgery.
affected arm is forward flexed to 90° while keeping the elbow
fully extended. The arm is then adducted 10–15° across the Management
body and maximally internally rotated so the thumb is Conservative: Anti-inflammatory medication, modification of
pointing down. The patient should resist the examiners down- activities. Cortisone injection (usually x-ray or ultrasound
ward force to the arm. The test is repeated with the forearm guided) can be very effective in the short to medium term, and
supinated so that the thumb points upwards. A positive is also helpful in confirming the working diagnosis.
O’Brien’s sign is present when pain is elicited with the first Surgery: For persistent and significant symptoms that have
manoeuvre and reduced or eliminated by the second man- failed conservative management consider AC joint excision
oeuvre. Pain localized to the AC joint or ‘on top’ of the
Open (direct superior approach) or arthroscopic (isolated or
shoulder suggests an AC joint abnormality, whilst pain or
combined with subacromial decompression): There is a split
painful clicking ‘inside the joint’ suggests a labral disorder.
between surgeons using the open and arthroscopic techniques.
It is important to ask the patient if the pain is felt on the
With open techniques, excessive resection or failure to repair
outside over AC joint or deep inside the shoulder; patients
the capsule may lead to instability. With the arthroscopic
usually will reliably distinguish between the two.
technique inadequate resection (especially the superior and
Below are some additional small print pain exacerbating
posterior part of the joint) is more common.
examination manoeuvres that imply AC joint pathology. It is
unlikely you will be asked to demonstrate them, but sometimes
a score 8 candidate will speed through a short case such that Subacromial impingement
the examiners have to find additional material to test on so as The clinical picture can be confusing if coexistent shoulder
to use the full 5 minutes allocated. pathology, such as a rotator cuff tear is present. In younger
Dugas’ test: The patient is seated or standing and touches patients, think about possible underlying causes such as
the contra-lateral shoulder with the hand of the 90° flexed instability. Current aetiological theories include the classical
arm of the affected side. If painful the test suggests AC joint anatomical impingement (Neer’s), and more recent functional
pathology. theories, i.e. cuff weakness causing dynamic impingement.
Paxinos’ test: Shear type test for the AC joint. The exam-
iner’s hand rests over the top of the shoulder with the thumb
under the posterolateral aspect of the acromion and the index History
and middle fingers resting on top of the lateral third of the Onset, duration, location and quality of pain
clavicle. The thumb applies an anterior and superior pressure Weakness, loss of motion (especially elevation), inability
to the acromion and the fingers push the clavicle inferiorally. to sleep on the affected side, night pain, catching, crepitus
A positive test occurs with an increase in AC joint pain. Interference with activities of daily living (ADL)
010
Chapter 7: Shoulder clinical cases
Classic history is of shoulder pain felt over the deltoid, on the by a thickened bursa and tendonitis. However, current think-
lateral part of the arm, exacerbated with overhead activities. ing includes the phenomenon of impingement caused by poor
cuff control in the absence of an anatomical lesion. Poor cuff
Clinical examination control may lead to superior sublaxation of the humeral head,
with resultant impingement. Consider poor cuff control, or os
In pure impingement there is minimal rotator cuff wasting;
acromiale in a young patient presenting with impingement
marked wasting should alert to the possibility of cuff tear. The
symptoms.
acromion is palpated along its posterior, lateral and anterior
margins. In impingement syndrome there is often tenderness Difference between Neer’s sign and Neer’s test
at the anterolateral corner of the acromion. There may be mild
Neer’s sign: Reproduction of the patient’s symptomatic
tenderness over the greater tuberosity, which is best demon-
pain with the arm in the scapular plane, internally rotated
strated by extending and internally rotating the arm. The
(thumb pointing down) and then taken through abduction to
greater tuberosity is brought anteriorly from under the acro-
demonstrate painful arc. Repeating abduction but with arm
mion. It and the inserting supraspinatus tendon can be pal-
in external rotation will improve pain.
pated. Tenderness and crepitus may be present with tears or
Neer’s test: Local anaesthetic injection into the subacromial
tendonitis.
space eliminates pain when testing for Neer’s sign.
From behind check active abduction and forward flexion
and assess scapula rhythm. Ideally there will be a mirror in Impingement tests
front of the patient so any pain on active movement can be
There are three classic tests for impingement that require
seena. On elevation the initial 60° is glenohumeral, 60–120° is
a confident, well-rehearsed slick technique and three obscure
both glenohumeral joint and scapulothoracic, and above 120°
impingement tests that you probably will never be asked about
is scapulothoracic. To check for capsular tightness, stabilise the
unless you are gold medal candidate.
scapula with a hand on the acromion and abduct then forward
flex the arm Neer’s sign
With impingement, there is classically a painful arc of
As above
active elevation between 70° and 120°, but this may be more
or less in some patients. There may be an alteration of scapular Hawkins’ impingement reinforcement testb
rhythm. There may be soft crepitus when the arm passes
Passive internal rotation in 90° flexion
through this arc. The pain is usually localized to the anterior
External rotation: Unlimited
region of the shoulder but may often radiate down to the
deltoid insertion. There may also be pain at the anterior edge Internal rotation: Limited, exhibits painful endpoint
of the acromion on forced elevation Need to have full passive movement of the shoulder to be
Formally test the power of the rotator cuff muscles: able to demonstrate impingement
You will see either normal power or a minor weakness on A positive test occurs with shoulder pain and apprehension.
resisted movements of the rotator cuff. This perceived loss The test jams the supraspinatous against the anterior portion
of power may be secondary to pain inhibition, rather than a of the coracoacromial ligament
true cuff tendon tear. If a coexistent large cuff tear is present,
significant weakness of abduction and external rotation can Abduction test
be demonstrated. Classically painful between 70° and 120° – A painful arc as
Do not forget to mention examination of the cervical spine the rotator cuff is placed under maximum tension
at some point during your shoulder examination.
Yocum’s test
Discussion This test was described in 1983 to selectively test the function
Definition of impingement of supraspinatous tendon and is very similar to the Jobe
Difference between Neer’s sign and test supraspinatous test. It is performed with abduction of the
Impingement tests patient’s arm to 90°, forward flexion to 30° and maximal
internal rotation. In this position, the examiner resists active
Definition of impingement shoulder abduction and reproduction of pain and/or weakness
Impingement is pain emanating from the subacromial space in this position suggests the supraspinatous tendon as the site
and is caused by either narrowing owing to a subacromial of injury and implies impingement tendonitis.
bony spur and thickening of the coracoacromial ligament or
a b
Whilst clinic may be OK, there is virtually nil chance of having a Be careful with false positives. Analysis of this test in patients with
mirror available in the exam. AC joint OA reported that 90% had a positive Hawkin’s result.
41
010
Internal rotation resistance stress test

This test differentiates between intra-articular (internal Examination corner
impingement) and classic outlet impingement. Internal
To be asked straight up by the examiners to ‘examine this
impingement is commonly seen in overhead athletes with subtle gentleman for impingement’ can be off putting. Candidates
glenohumeral instability. These patients have impingement of normally expect to be greeted with the instruction to ‘examine
the posterior rotator cuff along the posterior superior labrum in this patient’s shoulder’. This upsets our normal routine as we
the late cocking phase of the throwing motion and pain in the anticipate starting with inspection looking for wasting, scars,
region of the infraspinatous insertion with abduction and max- deformity etc and not with specific tests for impingement such
imal external rotation. If the patient has with a positive as the Hawkin’s test.
impingement sign and good strength in external rotation, this It is important to note that the above tests can give
test is positive and predictive of internal impingement. similar findings in different subacromial pathologies (suba-
A negative test (more weakness in external rotation) is suggest- cromial bursitis, isolated impingement, impingement along
ive of classic outlet impingement (external impingement). with a small rotator cuff tear, calcific tendionosis). Small-/
medium-size rotator cuff tears may not produce any clinically
demonstratable weakness, whereas substantial subacromial
Subcoracoid impingement test
pain may give weakness like findings when testing the
The test produces compression of the rotator cuff between rotator cuff.
the humeral head and the coracoid. Although uncommon,
the condition has been described in patients with a long or
laterally placed coracoid process and should be considered in Rotator cuff tears
patients with negative classic impingement signs that describe
anterior/lateral pain with overhead activities and have similar History
complaints to classic outlet impingement. These patients have Chronic large full thickness tears usually occur in middle-aged
impingement of the coracoid process on the proximal or elderly patients. Symptoms include chronic aching and
humerus with forward flexion and internal rotation of the arm. shoulder weakness that worsens with abduction and external
rotation. Patients may complain of catching or locking.
Management Symptoms are noticeably worse a night with significant sleep
Conservative disturbance.
Physiotherapy to improve cuff strength and improve shoulder
mechanics
Steroid injection therapy (but be aware of current
Clinical Examination
controversies over steroid effects on the cuff – There is some Look
basic science evidence from rats of a detrimental effect of Look at the shoulder posture, notably for the presence of any
repeated steroids on cuff tendon healing1) shoulder asymmetry, alterations in position and muscle
wasting. Prominence of the AC joint indicates possible AC
Operative joint osteoarthritis. Look at shoulder movements whilst the
Open or arthroscopic decompression – Surgery is generally patient is undressing. If the injury is acute there is unlikely
felt to be indicated following failed conservative management. to be significant muscle wasting unless there is a pre-existing
It is not uncommon for steroid injections to give a temporary shoulder problem. In the exam you are more likely to be given
relief; such temporary relief confirms the subacromial origin a chronic (possibly massive) tear in which there will be obvious
of symptoms, and if short-lived, points towards the need for muscle wasting.
more definite surgical treatment. Most surgeons use an arthro- Inspect the shoulder girdle, particularly the deltoid
scopic approach to preserve the deltoid attachment. Contro- muscle, the supraspinatus and infraspinatus fossa. A com-
versy surrounds the proposed mechanism of action of bined supraspinatus/infraspinatus tear leads to prominence
subacromial decompression – physical removal of the cora- of the scapular spine and indicates a large tear. Look for
coacromial ligament and acromial spur or removal of pain anterosuperior escape, where the humeral head subluxes
fibres in the bursa are sighted as potential mechanisms. The with attempted elevation, and ‘pseudo-paralysis’, when the
CSAW trial (Can Shoulder Arthroscopy Workc) is currently attempted elevation results in a shrug because of isolated
randomizing impingement patients in the UK to structured deltoid action.
physiotherapy, conventional arthroscopic decompression, or
sham arthroscopic surgery. Feel
Compress the lateral end of the clavicle to identify symptom-
atic arthritic change in the AC joint. There may be coexistent
subacromial impingement caused in part by AC joint
c
www.situ.ox.ac.uk/surgical-trials/csaw osteophytes.
010
In thin individuals defects in the cuff may be palpated. This 2. Full can teste. This involves repeating the test with the
is controversial as there are some shoulder surgeons who arm in 45° of external rotation so that the thumb points
believe that the presence and extent of rotator cuff tears cannot upwards which is less painful but has equal diagnostic
reliably be elicited by palpation. accuracy
Move Subscapularis
There may be loss of active elevation and a disparity between Patients with subscapularis tears have internal rotation weak-
active and passive ranges of movement. Significant loss of ness, variable excessive passive external rotation (as compared
passive shoulder movement is uncommon even in the presence to the opposite side) and a positive lift off test or belly-press
of a massive rotator cuff tear. You may, however, find abnor- maneuver. Three commonly used tests are described.
mal scapular rhythm, especially on lowering the arm, owing to 1. Lift-off testf: Place the patient’s hand behind their
eccentric contracture. Motion will be segmented and irregular. back and ask them to push backwards against the
A large chronic rotator cuff tear will lead to a severe limitation examiner’s hand. This tests the strength of further
of active abduction mainly achieved by scapulothoracic rather internal rotation and is the most reliable test for
than by glenohumeral motion subscapularis. This test is difficult to perform when
It is important to recognise shoulder stiffness in the pres- there is pain or limited shoulder motion that prevents
ence of a rotator cuff tear. Strength is more difficult to evaluate positioning of the arm and hand behind the back (which
when there is significant stiffness. In addition, the cause of is often encountered in this group of patients). If the
stiffness (adhesive capsulitis, capsular contracture or gleno- patient cannot place their hand behind the back go on
humeral arthritis) may be the cause of the patient’s symptoms. to the belly press test
Which tendon is torn? Assess rotator cuff strength and
integrity. An internal rotation lag sign is also described whereby
the examiner removes their hand and the patient is asked to
Rotator cuff musculature testing maintain their hand away from the back. The lag sign
Patients with rotator cuff tear arthropathy often demonstrate is positive is the patient can not maintain the hand in this
severe pain and weakness with attempted strength testing of position and it falls back onto the lumbar spine
the rotator cuff musculature. 2. Belly press test: Both hands are placed on the abdomen
The supraspinatus can be assessed by applying a resisted (belly) with flat wrists. The elbows should remain
downward pressure with the shoulder abducted 30° in the anterior to the trunk while the patient pushes posteriorly
plane of the scapula, the elbow in extension, and the arm in against the belly (to ensure that belly push is not
maximal internal rotation. compensated by active wrist flexion giving a false
The infraspinatus can be assessed by testing external rota- negative result). Patients with subscapularis weakness
tion strength with the arm in 0° of abduction and the elbow demonstrate a dropped elbow because they use shoulder
flexed to 90°. extension to compensate for weak internal rotation.
The lift-off test, can be used to assess subscapularis This is probably the most reliable and reproducible in
strength. With the arm in maximal internal rotation and the clinical practice
dorsum of the hand resting on the mid-lumbar region, resisted 3. Bear hug test: This involves the patient placing their
movement away from the body is assessed. hand on the opposite shoulder while elevating their elbow.
Teres minor can be assessed by testing resisted external The examiner attempts to elevate the patients hand off the
rotation of the arm with the shoulder in 90° of abduction in shoulder and a positive test occurs when this is easierly
the plane of the scapula and the elbow in 90° of flexion. achieved
Supraspinatus Infraspinatus/teres minor

Two further tests of supraspinatous function can be performed: There will be a loss of external rotation (ER), positive ER lag
1. Empty can testd: The shoulder is elevated to 90° in the sign, drop sign and a positive Hornblower’s sign.
scapula plane and taken into full internal rotation with the Hornblower’s sign: This demonstrates the difficulty in
forearm in pronation so that the thumb is pointing to the raising the hand to the mouth in the absence of external
floor. Downward pressure is applied to the arm while the rotation of the shoulder. A positive test occurs if the patient
patient maintains this position. Pain without weakness is is unable to do so without fully abducting the shoulder. This
suggestive of supraspinatous tendinopathy while painful allows the weak arm to fall into internal rotation, so that the
weakness suggests a partial or complete supraspinatous tear arm assumes a position like a hornblower
d e
This is also known as Jobe’s test and was originally described by Kelly's modification of the Jobe and Moynes test
f
Jobe and Moynes. This test is also known as Gerber's test and Gerber's lift off test
43
010
Lag signs Management

Lag signs represent a mismatch between active and passive Conservative
ranges of motion, are indicative of substantial rotator cuff
Small tears or irreparable tears in the elderly
weakness (and, hence, massive rotator cuff tears) and may be
more sensitive and specific than standard muscle strength Physiotherapy (strengthening exercises for the rotator cuff,
testing. Several lag sign tests have been described to assess anterior deltoid and shoulder girdle). Steroid injections,
the integrity of the rotator cuff: but be aware of some current thinking on the effect of
steroid on the cuff1
1. External rotation lag sign (infraspinatus): With the
shoulder held at 20° of elevation (in the scapula plane) and Surgery
the elbow passively flexed 90°, the arm is placed in full
Open, mini open or arthroscopic repair, often combined
external rotation, and then the patient is asked to actively
with biceps tenotomy or tenodesis
maintain this position. If the arm starts to drift into
internal rotation when the examiner releases the wrist, the :
There is no good evidence for one technique.
test is positive Proponents of the arthroscopic technique cite the
2. Drop arm test (supraspinatous)g,h: The arm is held in 90° preservation of the deltoid as a major factor. Mini open
of abduction, and the patient is asked to actively maintain surgery minimizes deltoid injury. The results of the
this position. The test is positive when weakness or pain UKUFF trial (United Kingdom rotator cuff study) that
causes them to drop the arm to the side. Be careful to warn randomised rotator cuff tear patients into open or
the patient, and don’t suddenly let go with a resultant arthroscopic repair, are awaited
painful drop of the patient’s arm. Consider letting go but : Surgery is generally indicated for failed conservative
moving your arm slightly down and catching the patient’s management, or truly acute cuff tears
arm if it was to give way : Complications include postoperative adhesive capsulitis
3. Internal rotation lag sign (subscapularis): Stand behind and re-tear, with a rate increasing with tear size,
the patient. Flex the elbow to 90°, hold the shoulder at 20° although even with re-tear outcomes appear improved
elevation and 20° extension. The patient is unable to hold compared to non-operative treatment
their hand away from their lumbar spine in near full Arthroplasty for rotator cuff arthropathy
internal rotation : Standard total shoulder arthroplasty contraindicated
Despite severe rotator cuff deficiency, some patients have good owing to abnormal glenoid loading and loosening
elevation strength owing to compensatory deltoid strength. : Hemiarthroplasty (stemmed or resurfacing), or reverse
Therefore, some patients with chronic massive rotator cuff geometry prostheses – Be aware of the principles, i.e.
tears have full active shoulder elevation. Park et al.2 found that medialisation and distalisation of the centre of rotation
three positive tests made the diagnosis of full thickness rotator with reverse arthroplasty, along with a degree of
cuff tear likely: Positive painful arc sign, drop arm sign and constraint, allowing deltoid to act as the prime mover in
weakness of external rotation. abduction
Impingement and ACJ osteoarthritis often coexist with
rotator cuff pathology, so suggest to the examiners that you Postoperative management includes physiotherapy.
would also like to test for these entities as part of your com-
plete shoulder examination.
Examination corner
Differential diagnosis of a rotator cuff tear includes adhe-
sive capsulitis, calcific tendinitis, superior labral tears, bicepital Short case 1: Elderly man with cuff arthropathy
tedinopathy, glenohumeral and AC joint OA. GP letter
‘This 74-year-old man has been referred to the orthopaedic
Investigations clinic with a 10-year history of shoulder pain and weakness.’
Radiographs – Three standard projections: True Muscle wasting within the supraspinatous and infraspinatous
anteroposterior, supraspinatus outlet, axillary view fossa is common. Supraspinatous atrophy is more difficult to
detect as it is underneath trapezius. Sometimes a palpable
Ultrasound – Cheap and non-invasive but operator- defect at the supraspinatous insertion at the anterolateral
dependent aspect of the shoulder. Swelling due to subdeltoid synovial
MRI – Most sensitive and allows assessment of muscle fluid may be present. Occasionally the humeral head can be
quality (fatty infiltration) in large/massive full thickness palpated in the anterior-superior aspect of the shoulder in its
tears subluxed position. Active forward flexion is limited to 50°.
Passive forward flexion is 125° with external and internal
rotation actively and passively limited to10°. He has 4/5 MRC
g
There are a number of subtle variations of this test. supraspinatous and external rotation strength.’
h
Infraspinatous weakness can also result in a positive test.
010
Describe the radiograph (superior head migration

CANDIDATE: I am palpating the shoulder from a medial to lateral
combined with severe degenerative changes of the
glenohumeral joint) – Chronic subluxation humeral head direction feeling for any areas of tenderness or crepitus. There
often causes ‘acetabularisation’ as secondary erosions of is no pain over the sternoclavicular joint, clavicle or AC joint.
the glenoid, acromial undersurface and clavicle occur to She is sore over the supraspinatus tendon and also the greater
accommodate the humeral head tuberosity, to which she pointed previously. The anterior and
Had MRI – Describe (note absent of cuff . . .) posterior joint line is non-tender. I would now like to test this
Discussion of management options – Treatment of lady’s range of movement at the shoulder. Can you swing your
patients with a massive irreparable rotator cuff tear arms out by your side and then upward into the air (abduction)?
associated with severe glenohumeral degeneration and The patient only has 80° of active abduction and it is painful with
humeral head collapse presents a difficult clinical loss of normal scapulothoracic rhythm. Passively there is very little
challenge
extra movement and this provokes more pain. Can you swing
Management – Reverse vs limited goals hemi depending
your arms forward now (flexion)?
on patient expectations and objectives, and adequacy of
glenoid for arthroplasty EXAMINER: You need to stabilise the scapula when there is a
discrepancy between active and passive movements of the
Short case 2: Massive rotator cuff tear in an elderly man shoulder.
Ask a short history – Age, dominance, pain, stiffness and CANDIDATE: I usually test active and passive movements of the
weakness shoulder first and then go back and stabilise the scapula if there is
Examination of cuff power, lag signs, pseudoparalysis limitation of movement in order to differentiate between
(due to pain inhibition-make a dramatic improvement scapulothoracic and glenohumeral movement. There is a
with cortisone injection)
restricted range of active forward flexion to 90° that I can’t
External rotation weakness is characteristic of chronic
improve passively, and most of this movement is scapulothoracic.
massive tears. Elevation weakness is a less consistent
finding. Some patients have sufficient deltoid (Hand stabilising the scapula when the movement was performed)
strength to mask the absence of supraspinatous Can you swing your arms backwards?
strength Again, active extension is limited to 20° and painful.
Differential diagnosis for chronic massive rotator cuff Likewise, external rotation is painful and is only about 30°
tear – Cervical spondylosis, stenosis and radiculopathy can compared to the opposite side. I’d like to go on to test her rotator
cause shoulder pain that mimics the pain of rotator cuff cuff muscles for power, testing supraspinatus, infraspinatus, teres
pathology. Shoulder girdle weakness can be the result of minor and subscapularis in both the normal and the abnormal
brachial plexus disorders (Parsonage–Turner syndrome,
shoulder. She has a marked loss of power in her right rotator cuff
brachial neuritis) or suprascapular neuropathy. Septic
muscles compared to the left side.
arthritis
Factors in surgical decision-making – Expectations, EXAMINER: What do you think the diagnosis is?
stiffness, cuff retraction and fatty atrophy on CANDIDATE: I think she may have an impingement syndrome.
MRI or US (I have no idea why I said this, as she certainly did not
demonstrate any impingement signs and I did not specifically test
Short case 3: Chronic rotator cuff tear shoulder in a middle-aged for them. I chose to ignore the fact that we had alluded to the
woman (approx. 45 years) sitting in chair
diagnosis of a rotator cuff tear during the examination. I just felt
EXAMINER: This lady is complaining of right shoulder pain. Just that she was the wrong age for a rotator cuff tear and that I had
examine her shoulder and tell us what you’re doing. not clinically demonstrated a significant difference between
CANDIDATE: Is your shoulder painful? active and passive movements of the shoulder typical of a rotator
PATIENT: Yes. cuff tear.)
CANDIDATE: I’ll try not to cause you any pain. Please let me know if EXAMINER: You demonstrated a loss of power in her rotator cuff
it’s sore and I will stop. muscles. These findings would suggest a rotator cuff tear. What
On inspection of the shoulder from the front there are no investigations would you perform to confirm the diagnosis?
obvious scars, muscle wasting or asymmetry. The shoulders are of CANDIDATE: I would order some x-rays of her shoulder.
symmetrical height. There are no other obvious features of note. EXAMINER: What would you expect to find?
From behind there is some wasting of supraspinatus and CANDIDATE: There would be degenerative changes in the
infraspinatus (mild but definite wasting). acromioclavicular joint, a decreased coracohumoral interval, a
EXAMINER: Whereabouts is this wasting? break in Shenton’s line with superior migration of the humeral
CANDIDATE: There is wasting over the right supraspinatus and head and possibly cystic changes in the greater tuberosity.
infraspinatus muscles compared to the left side. (Demonstrate the EXAMINER: What is the investigation of choice?
wasting. An important physical sign to pick up if present.) CANDIDATE: An MRI.
Where is your shoulder painful? EXAMINER: OK. How are you going to operate on this lady’s
PATIENT: Over here (points to greater tuberosity). cuff tear?
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010
(pain predominant phase) and then improves leaving substantial

CANDIDATE: We need much more information than this. I need limitation of movement (stiffness predominant phase). With
to know how large the tear is, whether it is full thickness or partial time movement begins to improve (thawing phase), with reso-
thickness and the state of the surrounding muscles. lution of symptoms over 1–2 year period in many.
EXAMINER: It is 4 cm and full thickness.
CANDIDATE: Then I would refer her on to an experienced shoulder
surgeon who repairs these cuff tears on a regular basis. Clinical examination
(With this we moved onto the next case.) On examination there is a normal shoulder contour, except
The examiner was trying to speed up the pace of the examin- perhaps some slight deltoid wasting. Tenderness may be pre-
ation. It is important to take the hint and get on with it as sent around the glenohumeral joint. There is no swelling or
swiftly as possible but not at the expense of appearing rushed warmth around the shoulder.
or hurried. Try to remain professional and composed at all ‘The patient demonstrates marked restriction of both active
times during your clinicals. Defend yourself if you are being and passive movements of the shoulder when compared to
challenged but be sensible about it and try not to be too the opposite normal side. In particular her active forward flexion is
aggressive in your reply. To this day I am still unsure exactly 100° and passive forward flexion is 110°. A firm endpoint to
what was wrong with this patient’s shoulder. On clinical exam- motion with pain was present. Her passive external rotation
ination she did not present with the classic findings of a rotator is 10° and active external rotation is 0°. Examine the true
cuff tear and we are still not entirely convinced that she had a glenohumeral range with a hand stabilising the scapula.
rotator cuff tear. We went down the path of assuming it was a It can be difficult to test power because of the restriction in
tear and discussed further management of it. shoulder movement.’
Short case: Examiner: “You can ask two questions only”

Adhesive capsulitis must be thought of as a diagnosis of exclu-
‘Weak, painful shoulder with numbness, neck scar from sion. Differential diagnosis includes large rotator cuff tears,
lump excision. Asked to examine shoulder movements, subacromial impingement, posterior shoulder dislocation, and
then asked diagnosis. Patient had full abduction, restricted degenerative joint disease
internal and external rotation. Said likely neurological lesion There is an important association with diabetes. Frozen
due to scar and numbness but difficult as no chance to do shoulder refers to idiopathic stiffness, but stiffness may also
any further examination. Then quiz on rotator cuff. I found be post-surgical or post-traumatic.
out later that patient had a C6 root problem and previous
excision of neurilemmoma – Didn’t feel I was given much
chance to examine.’ Investigations
Radiographs are normal and the diagnosis is usually clinical.
Rotator cuff tear MRI arthrography can be used to assess capsular thickening
Obvious massive cuff tear and biceps rupture. Test for rotator
and will show a reduction in capsular volume. Suggest a fasting
cuff power and lag signs. Discussion of investigation and
blood glucose level in primary care to rule out frozen shoulder
management. Any new surgical techniques for massive cuff
tears (Inspace Balloon procedure, Platelet rich plasma). as first presentation of diabetes. The diagnosis is based on
clinical demonstration of global loss of active and passive
movements, with normal radiographs (i.e. absence of gleno-
humeral arthritis, proximal humeral fracture mal-union which
Frozen shoulder may cause mechanical loss of motion)
GP’s letter handed to the candidate to read before the start of the
intermediate case: ‘A 53-year-old woman who presents with a
6-month history progressive shoulder pain without any specific
predisposing injury. She complains only of shoulder pain with
Management
some loss of motion. She has occasionally very painful episodes Conservative: Physiotherapy (in the form of stretching
while trying to perform certain activities as at the limits of her exercises), glenohumeral injections in early stages of disease.
effective shoulder motion.’ Some advocate hydrodilatation as a useful treatment modality.
Operative: Surgery aims to hasten recovery (as the natural
history per se is in many that of spontaneous resolution).
History Surgery may be in the form of manipulation under anaesthetic
Is the pain intermittent, constant, only with use or predomin- (MUA), arthroscopic or open release. Most surgeons advocate
antly at night? The time course over which the stiffness developed intervention in failed conservative management and no range
should be explored. The magnitude of the functional disability of movement (ROM) improvement over 3 months. No
related to the stiffness should be noted. Any history of previous evidence for MUA vs release. Advocates of arthroscopic release
shoulder trauma. Any previous treatments and outcome. Typical cite the controlled nature of specifically addressing the rotator
history is that of severe, acute onset pain that lasts for a few weeks interval pathology. The UK FroST study (UK Frozen Shoulder
010
trial) is currently randomizing patients to structured Gross restriction of shoulder motion (active but also pas-
physiotherapy, MUA or arthroscopic arthrolysis. sive) in an elderly patient (>60 years) should be considered as
glenohumeral arthritis until proven otherwise.
Glenohumoral osteoarthritis Management options

History Physiotherapy, intra-articular steroid injections
Pain, stiffness, loss of motion Arthroscopic debridement, subacromial decompression,
Objective assessment of the patient’s functional biceps tenotomy/tenodesis
impairment ‘Biological resurfacing’ (e.g. meniscal allograft) in young
: Difficulty getting dressed patients: Small series only in the literature
: Brushing teeth Resurfacing or stemmed hemiarthroplasty: resurfacing
: Reaching the top or the back of the head supposedly restores anatomy by placing the prosthesis in
the native anatomical location, and is bone preserving,
: Reaching the opposite axilla
but requires a reasonably well-preserved head
: Washing the perineum
Total shoulder arthroplasty: Concerns regarding glenoid
: Washing the face
longevity
: Combing the hair
Reverse polarity arthroplasty for arthrosis in the presence
: Writing or turning a key of cuff insufficiency or as a salvage for cuff failure with a
‘In summary, Mrs Smith is a 73-year-old retired right-handed pre-existing total shoulder arthroplasty
headmistress who presents with several years history of Resection arthroplasty: Salvage for failed arthroplasty
intermittent shoulder pain. In the past year she has experienced
increasing pain and stiffness of this shoulder. She denies any
Arthrodesis: Again, salvage procedure with better
specific history of trauma. She has difficulties with activities of functional results than resection
daily living particularly brushing her teeth, washing her face, etc.
In general, there is evidence for improved pain relief with total
My provisional/working diagnosis is of glenohumeral
shoulder arthroplasty compared to hemiarthroplasty, but this
osteoarthritis and I would like to examine the shoulder to
confirm this.’ is more technically challenging.
Examination Shoulder instability

On inspection from the front there may be muscle wasting. History
There are no obvious scars but there is loss of the normal
shoulder contour. The anterior shoulder may appear swollen Did the shoulder come out because of a significant injury, or
due to an effusion. due to minor injury?
Asymmetry of the shoulder may be present owing to gross What position was the arm in when it came out?
muscle wasting and distortion of the bony anatomy. The Did the shoulder slide out of joint or did it pop out?
displacement of the humeral head and severe erosion of the Did you have to go to hospital to have the shoulder put
head or of the glenoid can markedly distort the contour of back in?
the shoulder. Did you feel any numbness or tingling in the arm or hand?
How frequent does the shoulder feel it wants to come out?
‘The posterior joint line is tender to palpation. There is gross
painful restriction of shoulder movement with crepitus on Is there a sense of looseness in the shoulder in between?
glenohumeral joint movement.’ Non-descript level of discomfort and diffuse pain around the
shoulder, discomfort is poorly localized and may be more
There will be a slight difference between active and passive
scapular in location. This can be associated with paresthesias
movements of the shoulder because of pain, but this difference
down the arm.
is never as distinct as in the case of a chronic rotator cuff tear.
Does the sense of instability occur with the arm only in certain
With progression of the disease shoulder movement
positions or is it present regardless of arm placement or position?
becomes restricted to scapulothoracic movement, which does
What activities and arm position provoke the symptoms?
not allow much rotation. Therefore, external and internal
rotation are limited the most. Pain is a more common symptom with shoulder instability
Power could be difficult to test smoothly because of the secondary to ligamentous laxity (AMBRI) and apprehension is
marked restriction of shoulder movement and pain (do not hurt more common with multidirectional instability
the patient). The strength of the rotators and of the deltoid The classic patient with traumatic instability is a male
within the limited range may be surprisingly good. Pain rather athlete with an identifiable traumatic event in the course of
than muscle wasting may cause some of the weakness. violent sporting activity. Conversely, the typical patient with
47
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multidirectional instability describes non-descript shoulder glenoid bone loss, especially with Hill–Sachs lesion, is
pain that also involves the scapula and provokes paresthesias indication for coracoid transfer (Latarjet procedure) or iliac
down the arm occurring in the absence of a traumatic event. crest bone block procedures.
Clinical examination Examination corner

Be aware of the spectrum of instability, from traumatic lesions
to overuse injuries and more generalized capsular and muscle Possibly a intermediate case, much more likely a short case.
patterning disorders. Young male, with normal musculature, and normal movement
and power of the shoulder. Diagnosis rests on demonstrating
The shoulder should be palpated for any areas of tender-
instability tests. You may be asked simply to demonstrate
ness. Patients with anterior subluxation often have tenderness instability tests rather than examine the whole shoulder.i
over the posterior capsule, whereas in multidirectional
instability tenderness may be present along the medial angle EXAMINER: What are the signs of instability and how do you elicit
of the scapula. Shoulder dislocation may have injured the them? Do you know any instability tests?
axillary nerve, so it is important to evaluate for deltoid atrophy
Short case 1: A short case of voluntary posterior dislocation of the
and weakness, and sensory deficit.
shoulder
Both active and passive range of shoulder movement should
The patient was able to spontaneously dislocate the humeral
be tested noting any dyskinesia and whether accessory muscles head and then reduce it painlessly. No evidence of generalized
are activated with range of motion testing. Look particularly joint laxity. The dislocation occurred with abduction and
for scapular dysrhythmia and winging, as well as any evidence extension associated with clicking.No history of shoulder
of overactivity of pectoralis major or lattisimus dorsi. trauma. No evidence of connective tissue disorder such as
Look for signs of generalized hyperlaxity (Beighton score) Ehlers–Danlos syndrome. The examiner asked whether I would
and the inferior sulcus sign. In a patient with gross instability, want to perform surgery on this patient. I said no i would treat
a depression may be seen inferior to the anterior aspect of the him conservatively as surgery would probably have a high
acromium when the arms of a sitting patient are positioned failure rate. The examiners implied the correct answer with
along the side of the body. It is usually necessary to apply a their question
traction force along the longitudinal axis of the humerus by
Short case 2: Recurrent anterior dislocation of the shoulder
pulling the humerus in an inferior direction. A measurement
Examination of the shoulder
of >2 cm or an asymmetrical symptomatic sulcus sign is
Apprehension test
positive for inferior instability. Arthroscopy portals and the role of arthroscopy
Anterior draw test – Grade and compare to other side. Bankart and Hill–Sachs lesions
Perform apprehension and Jobe’s relocation test, load and shift Bankart repair
test. Test for posterior shoulder instability (posterior drawer
test, posterior apprehension test, jerk test).
The patient is most likely to have normal musculature or, Rupture of the long head of biceps
at worst, minimal shoulder wasting. Examine external rota-
tion, internal rotation and abduction strength to rule out (proximal)
rotator cuff weakness. Chronic subscapularis, or supraspinatus A spot diagnosis in the short casesj. Usually male, elderly.
tears may lead to anterior instability. A bulbous mass is seen in the middle to distal anterior arm
(‘Popeye sign’) that typically appears when the elbow is
flexed.
Investigations ‘There is a large bulge 4 cm by 3 cm in the anterior flexor
Plain x-rays – Bony Bankart , Hill–Sachs, previous anchors compartment of the arm suggestive of long head of biceps
MRI arthrogram – ‘gold standard’ – Evidence of labral rupture’. A hollowness is evident in the anterior portion
avulsion especially on abduction external rotation of the shoulder. Test for power of flexion/extension. During
sequence (ABER) active flexion the biceps retracts, producing the classic
CT/CT arthrogram – Useful with previous metallic
anchors on to look for glenoid bone loss (cause of failure of i
soft-tissue stabilisation, and indication for bony procedure) We struggle to recruit the young male patient with shoulder
instability for our own clinical course. In clinic the shoulder may be
painful and we would worry about the joint being examined on 10
Management or so occasions during the day. Also (although generalising) young
male patients can be unreliable at turning up for a course (or exam)
Conservative: Physiotherapy for scapular and glenohumeral
(PAB comment).
control, especially in ‘atraumatic’ instability j
A spot diagnosis does still exist in the UL short cases only you do
Operative: Open and arthroscopic Bankart’s repair, bony not move on to another case after 1 minute. The 5 minutes is spent
procedures for glenoid bone loss or revision. Presence of on a more thorough shoulder examination and dicussion.
010
deformity of the biceps contour. It is important to look care- Speed’s test, Yergarson’s test, Ludington’s test, de Anquin’s
fully for any atrophy of the rotator cuff musculature because test and Lippman’s test. Nobody can be expected to know or
often there is an associated attrition-type tear in the superior perform all these testsk.
rotator cuff or an associated subscapularis tear. Such tears In the exam setting we suggest performing two clinical tests
often preceed the biceps rupture and may/may not have been only to confirm a clinical diagnosis. The Speed and Yergarson
symptomatic before the biceps rupture. Mention to the exam- tests are probably best known to most examiners.
iners that you would like to formally test range of shoulder
movement and rotator cuff strength. A palpable click or catch Sources of LHB tendon pain
in the shoulder through a range of motion may occur due to
1. Attritional tendonitis from degenerative or post-traumatic
secondary inflammation of the rotator cuff tendon or a
osteophytes in the biceps groove
retained proximal biceps tendon stump.
2. LHB instability (secondary to a pulley lesion, cuff tear or
rupture of the transverse ligament)
Management 3. Partial traumatic tear
Management is usually non-operative, but look for associated 4. Intrinsic LHB tendinopathy
cuff tears. If young, healthy, active individual consider repair 5. Primary synovitis
for acute rupture or if chronic suggest possible tenodesis in the 6. Post-traumatic scarring (e.g. with proximal humeral
subpectoral area. fractures)
CANDIDATE: I had a proximal long head of biceps rupture turned around
om me in the short cases and was asked about the bony attachments, Investigations
nerve supply and action of the short head of beceps tendon which
Ultrasound scan – This demonstrates extra-articular LHB
I struggled through. To make matters worse I was then asked about distal
pathology only. Fluid in the sheath can be seen, along with
biceps tendon repair about which I knew nothing. (FAIL)
biceps hypertrophy and tendinosis. Irregularity of the
biceps groove, associated cuff tears. Dynamis scanning may
Distal biceps rupture demonstrate subluxation/dislocation of the tendon with
An acute biceps rupture recently pitched up for the short cases arm motion.
that was going to be operated on the following week. More MRI scan
likely the case will be a chronic neglected rupture or a rupture Arthroscopy – Not very suitable for extra-articuar LHB.
in an elderly patient that has been treated conservatively. Gold standard for intra-articular LHB pathologies
SLAP tearsl
One- or two-incision repair SLAP tears are traumatic injuries, most common in athletes,
One incision: The modified Henry approach. Make a generally caused by overload trauma of the superior labrum.
curvilinear incision over the anterior aspect of the elbow. A common cause is a fall on an outstretched arm.
Locate the ruptured distal biceps tendon. Insert bone suture
anchors into the radial tuberosity and reattach the tendon.
Alternatively endobutton fixation coupled with unicorical
History
interference screw. Traumatic episode involving arm hyperextension, or axial
Two-incision approach of Boyd and Anderson: Make a loading
3-cm transverse incision over the distal biceps tendon Vague shoulder pain often with painful clunking, clicking,
sheath. Insert a core tendon suture through the end of the snapping and popping of the joint
tendon. Make a second incision on the posterolateral aspect Pain exacerbated with overhead sports, lifting, throwing
of the elbow. Locate the tunnel between the radius and the (late cocking phase) or with extremes of motion
ulna through which the tendon originally passed. Make Pain is described as deep and may be associated with
drill holes through the radial tuberosity to allow anchoring generalized shoulder weakness when a concomitant rotator
of the tendon. Retrieve the biceps through the distal incision, cuff tear is present
then pass sutures through the tuberosity drill holes and tie
them down
Long head of biceps (LHB) tendon pathology k

Attempting to learn all the known tests with all the different subtle
variations between tests would complicate your revision to the
Many different tests have been described to detect proximal
point of being unmanageable. It suggests being unfocused about
biceps pathology. However, establishing an exact clinical diag- what the exam is setting out to test for.
nosis can be difficult. These tests can be falsely positive in the l
Unlikely as a clinical case although the exam keeps moving on and
presence of rotator cuff disease. Tests described include you can never discount it.
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Clinical examination gross muscle wasting. Examination of shoulder movements

There are numerous clinical tests described for SLAP lesions. revealed elevation to 100° although rotation was grossly
These tests attempt to reproduce the force of the injury mech- restricted. In particular, when stabilising the scapula it was
anism. They are divided into two categories: apparent that all movement was scapulothoracic; no
1. Tests that reproduce a torsional traction force to the glenohumeral movement was appreciated.
superior labrum (active tests): (O’Brien test, anterior slide EXAMINER: What operation do you think he has had?
test (Kibler)) CANDIDATE: I haven’t seen this before but the length of the scar
2. Tests which reproduce a compressive force to the superior would suggest a shoulder arthrodesis. I’d like to confirm this
labrum (passive tests): (compression rotation test (crank clinically. To do this I stabilise the scapula with one hand and
test), Mayo Shear/O'Driscoll's SLAP test) move the shoulder with my other hand: I see gross restriction of
Similar to AC joint pathology, you are not expected to know all abduction, forward flexion, etc.
the tests for SLAP lesions for the exam. This will just unneces-
sarily complicate your revision. The O’Brien’s test is a reliable
test for SLAP tears. Indications
Infection unresponsive to conservative treatment
Investigations Stabilisation of painful, paralytic disorders of the shoulder
Standard shoulder radiographs (AP, axillary, scapular-Y Post-traumatic brachial plexus injury
and Styker notch views) Salvage for a failed shoulder arthroplasty
MRI arthrogram Stabilisation after resection of a neoplasm
Shoulder arthroscopy Recurrent dislocations
Remember bilateral glenohumeral fusions are poorly tolerated
Management functionally and relatively contraindicated
Conservative: Cessation throwing activities , physiotherapy,
NSAIDs, etc
The majority of patients with symptomatic SLAP lesions will
Position of fusion
25°–40° abduction
fail conservative management
20°–30° flexion
Operative: Arthroscopic labrum debridement or labrum
repair. Biceps tenotomy or tenodesis are alternative options 25°–30° internal rotation
Or 30°, 30°, 30° is the classic exam answer
Shoulder arthrodesis References

1. Tillander B, Franzén LE, Karlsson MH et al. Effect of steroid
Short case 1 injection of the rotator cuff: An experimental study in rats.
J Shoulder Elbow Surg. 1999;8:271–4.
CANDIDATE: On inspection there is a large scar extending from the
2. Park HB, Yokota A, Gill HS, Rassi E, McFarland EG. Diagnostic
spine of the scapula over the top of the shoulder down the arm.
accuracy of clinical tests for the different degrees of subacromial
There is gross distortion of the normal shoulder contour with impingement syndrome. J Bone Joint Surg Am. 2005;87:1446–55.
010
Elbow clinical cases

Chapter
8 Ramnadh S. Pulavarti, Mohan K. Pullagura and Charalambos P. Charalambous
Introduction Occupation
EXAMINER: ‘As the elbow is a superficial joint, everything of what you need As per any upper limb case. Get this out of the way on
to see is there.’ autopilot.
With a careful visual inspection because much of the joint is Presenting compliant
subcutaneous any appreciable alteration in skeletal anatomy is Most patients with elbow disorders present with pain. This is
usually obvious. Gross soft-tissue swelling or muscle atrophy is often associated with reduced elbow movement. Patients may
easily observed. occasionally complain of recurrent instability, intermittent
Look particularly at the inside of the elbow and at the back swelling or locking.
for scars.
Avoid circumnavigating the patient during your Pain
examination. Site (where?)
As with other joints in the body, a candidate must be Medial, lateral or posterior?
thoroughly familiar with elbow anatomy and with the abnor-
mal conditions that may be encountered. The site of the pain may provide valuable clues. Conditions
There are patterns of examination for each joint. Every involving the lateral compartment (radiocapitellar joint) pro-
joint examination sequence is a unique dance. voke pain that typically extends over the lateral aspect of the
Introduce yourself to the patient; ask them if they have pain. elbow, with radiation proximally to the mid humerus and
Don’t talk too much – Talking too much with too many distally over the forearm. Distinguish pain at rest from pain
negative findings can be irritating to the examiners: ‘I cannot on movement (former due to arthiritis). Also distinguish from
see any muscle wasting; I cannot see any scars; there are no pain in mid-range of elbow motion to that felt at extremes
swellings seen.’ of motion (former due to arthritis, latter due to osteophyte
Do not say ‘obviously’. impingement).
If you elicit pain – Stop – Empathize with the patient – You Type
may be forgiven. Hurt the patient again and it’s goodbye. :
Aching – degenerative arthrosis
:
Sharp pain/catching-loose body
History :
Pain after activity – Tendinosis
Most elbow conditions for the FRCS (Tr & Orth) exam will be Onset (How did it all start?)
seen as short cases. Candidates will usually be asked to just get Duration
on and examine the elbow without the opportunity to take a Radiation
detailed history. With the intermediate cases the elbow is more :
To hand and forearm (tendinous, nerve pain)
likely to appear as part of an upper limb polytrauma or
generalized inflammatory arthritis case rather than a stand-
:
To shoulder
alone case. The examiners may ask candidates to mainly focus
:
To neck
on the elbow joint and take a more detailed history Aggravating/relieving factors
Stiffness
Introduction Early morning stiffness – Rheumatoid arthritis
Age
Sex Swelling
Dominance Onset
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011
Duration If the elbow pain has a radicular pattern it is important

Localized to examine the patients cervical spine. Look at spinal
: Posterior alignment, check range of motion and perform neuro-
logical testing of the entire upper limb. Elbow pain may be
– Rheumatoid nodules referred from the shoulder; therefore, a visual inspection of
– Olecranon bursitis the shoulder for muscle wasting and appearance should be
– Gouty tophi done.
Generalized CANDIDATE: In everyday clinical practice I would start by examining the

Spontaneous neck and shoulders to rule out referred pain or radiculopathya.
Deformity Do look at the patient as a whole paying particular attention

Congenital vs acquired to the contours of the neck and shoulders.
Associated with trauma
Look
Instability Front
Clicking, catching, locking like symptoms ‘Can you show me your elbows, please?’
History of elbow dislocation ‘Can you put your arms out for me?’
It is much easier if you simultaneously demonstrate this to
the patient to make it obvious what you want them to do.
Neurological symptoms
Arms are held straight alongside the body with palms facing
Altered sensation forwards.
Weakness ‘Can you put your arms out in front, palm facing out, can you lift
Paraesthesiae of the hand may, in some cases, be related to your arms up in front of you?”
ulnar nerve compromise at the level of the elbow CANDIDATE: The shoulders are demonstrating a smooth movement with
Clunk/locking no pain or apparent restriction of movement. I’m inspecting the elbows
from the front, there is a normal carrying angle, no fixed flexion deformity
of the elbow /normal full extension. (Look from the side as it is easy to
Activities of daily living
miss subtle loss of full extension.)
Hand to mouth
Perineal hygiene, comb When the elbow joint is extended in the normal anatomical
Lifting and carrying objects position with the palms facing anteriorly, the longitudinal
Dressing axis of the forearm is at a slight valgus (lateral) deviation to
: Coat the longitudinal axis of the arm. This is known as the carry-
ing angle of the elbow. The normal carrying angle is 11–14°
: Bra
in males and 13–16° in femalesb. The elbow moves from a
valgus to varus alignment with flexion. In a post-traumatic
History of injury condition abnormalities in the carrying angle cannot be
Mechanism of injury accurately assessed in the presence of a significant flexion
Treatment contracture
Outcome ‘I can’t comment on the carrying angle of the elbow as the arm
Sporting activities has a fixed flexion deformity. The carrying angle cannot be
assessed.’
Examination Angular deformities such as cubital varus or valgus should

be easily identified. Rotational deformities following supracon-
Preliminaries dylar fractures or other fractures of the humeral shaft are more
Introduce yourself and ask permission to examine the elbow. difficult to distinguish
Get the patient to stand up if possible.
CANDIDATE: I would like to start by examining the elbow in the standing
position. Can you please stand up for me, sir.
a
Adequately expose the shoulders, elbows, wrist and hands2
Safer to mention although the examiner will probably tell you not to
bother and to just concentrate on the elbow
CANDIDATE: I would like to more adequately expose the patient. b
The carrying angle helps the upper limb to clear the pelvis while the
EXAMINER: That’s alright we are happy with this. arm swings during walking
011
Chapter 8: Elbow clinical cases
‘There is a valgus deformity of the elbow suggestive of possibly an increase in synovial fluid, synovial tissue proliferation or
an old lateral condylar fracture non-union or mal-union. I would radial head pathology such as fracture, subluxation or
like to go on and check for any associated ulnar nerve palsy.’ dislocation.
‘There is a varus or gunstock deformity suggestive of an old There is loss of the normal concavities (hollows) on either
mal-united supracondylar fracture occurring when a child or early side of the olecranon process. The lateral recess, or soft spot, is
physeal closure medially.’
the most sensitive area to detect a joint effusion and can be
With cubital varus the angle is <5° whilst with cubital valgus palpated between the olecranon tip, the radial head, and the
the angle is >15°. lateral epicondyle. If you see a rheumatoid nodule mention
Popeye deformity is a spot diagnosis. A biceps bulge in the this to the examiners, otherwise they will not know if you have
anterior arm above the elbow. Distinguish a popeye sign due to noticed it. It may be barn-door obvious to everyone but still
long head of biceps rupture from that seen in distal biceps mention it.
tendon avulsion. ‘The skin condition is papery thin/normal.’
CANDIDATE: Please bend your elbows. Thin, taut, adherent, pale discoloured skin over the lateral
CANDIDATE: Can you show me the back of your elbows please? epicondyle may suggest lipodystrophy due to repeated corti-
sone injections in this area for resistant lateral epicondylitis.
The above will allow you to inspect the back of the elbow. Watch that you do not go through a checklist of negative
Again show the patient what you want them to do. Look for clinical findings on inspection and come across as though you
scars, swelling, skin discolouration. Muscle wasting of the are examining a patient but that you are not inspecting the
radial muscles (mobile wad-brachioradialis, extensor carpi patient correctly and miss subtle positive clinical signs.
radialis longus and brevis), ulnar muscles of the forearm or
small muscles of the hand.
Anterior
Scars The popeye deformity is a common clinical finding in patients
with distal biceps tendon ruptures due to proximal retraction
‘I can see no obvious scars over the medial or lateral epicondyles,
no excessive fullness of the medial or lateral recess, the medial and
of the muscle belly. A popeye sign with distal retraction of the
lateral recesses being well preserved.’ muscle belly is suggestive of long head of the biceps rupture
‘There is a linear well-healed surgical scar over the posterior at the elbow. A spot diagnosis but be prepared for what comes
aspect of the elbow.’ nextd.
Posterior – This is the gateway to the elbow surgically –
Therefore, look for a scar. Lateral aspect
CANDIDATE: I am looking for any obvious scars on the posterior aspect of
A normal depression in the contour of the skin in the infra-
the elbow, the recesses are preserved there is no obvious effusion.
condylar recess becomes obliterated in the presence of synovitis
or effusion. Look for dimpling consisting with lipoatrophy.
Swelling
Swelling around the elbow can be either localized or generalized. Posterior aspect
Causes include an effusion, synovial thickening, periarticular A prominent olecranon suggests a posterior subluxation or
soft-tissue inflammation or osteophytes. migration of the forearm on the ulnohumeral articulation.
General swelling of the elbow is usually due to an effusion. Look for a swollen olecranon bursa.
The prominent subcutaneous olecranon bursa is easily observ-
able posteriorly if it is inflamed or distended. Rheumatoid Medial aspect
nodules are frequently seen on the subcutaneous border of
Few landmarks are seen from the medial aspect of the joint.
the ulnar. Also look for psoriatic patches, seen in extensor
The prominent medial epicondyle is usually seen unless the
surfaces of joints.
patient has a large BMI.
CANDIDATE: There are no obvious rheumatoid nodules (ulna border
forearm) or an olecranon bursitis. There is a filling out of the normal
hollow seen on the lateral side of the elbow.
Move
The look feel and move sequence is altered to look, move and
c
Fullness about the infracondylar recess just inferior to the feel, as this seems to flow better. It is important to compare
lateral condyle of the humerus; the ‘soft spot’ suggests either both sides so as to detect any subtle differences in movement.
d
Proximal and distal attachments of the biceps tendon. Techniques
for biceps tendon repair both proximally and distally. Testing for
c
Landmarks are lateral epicondyle, subcutaneous tip of the olecranon rotator cuff pathology. Nerve supply and actions of the rotator cuff
and radial head. muscles.
53
011
‘Can you raise your arms out to the side?’ (Show the patient what Prime supinators of the elbow are:
you want them to do.) Biceps
‘Can you just bring your elbows out to the side and can you now
Supinator
bend your elbows up?’
‘I am checking his active range of movement and it is slightly Prime pronators of the elbow are:
reduced on the left side by about 5°’ Pronator quadratus
‘Can you touch your shoulders now?’ (Excellent way to Pronator teres
demonstrate passive range of elbow movement, any loss of flexion With pronation the end feel should be elastic due to the resist-
is easily seen.) ance of the interosseous membrane and flexor muscles. There
is a limited hard end feel in advanced osteoarthritis and pain
Flexion/extension with limitation of movement of the proximal radioulnar
The principal flexors of the elbow are articulation. The movement may compress the median nerve
Brachialis (C5, C6 – Musculocutaneous nerve) in the presence of pronator syndrome. Pain at the end of range
Biceps brachii (musculocutaneous nerve) may be due to tendinopathy at the insertion of the biceps
Brachioradialis (radial nerve) tendon on the radial tuberosity.
The prime extensors of the elbow are With supination there should be a normal elastic end feel
caused by the interosseous membrane and ligaments.
Medial head of triceps
Painful reductions in range of movement (ROM) may be
Lateral and long heads of the triceps are considered
due to effusion, soft-tissue swelling, or bony impingement.
accessory muscles
Locking or mechanical symptoms may be due to loose bodies
Begin with the forearm supinated and extended.
in the joint. Crepitus may occur throughout ROM in patients
The normal range of active movement is from 0° to 145°.
with osteoarthritis, in addition to decreased ROM in all direc-
Passive flexion is approximately 160° limited by bony struc-
tions. Soft blocks to motion may represent capsular contrac-
tures (head of the radius against radial fossa, coronoid process
tures, effusions, or soft-tissue swelling.
against the coronoid fossa), posterior capsule tension and
‘Active pronation from the mid prone position is 40° compared to
passive tension in the triceps. A functional range is 30–130°.
90° on the normal left side. Extension is passively full and painless.
If there is a fixed flexion deformity (FFD) of 50°, movement is
I am checking for subluxation and any flexion impingement signs,
recorded as 50° FFD – 145° flexion. Up to 10° of hyperexten- which occur in early osteoarthritis including osteophyes. With full
sion is acceptable. Anything more suggests either hyperlaxity flexion and extension of the elbow this would exclude early
or injury. Has the patient got a flexion or extension block? Is osteoarthritis.’
the loss of movement due to muscle weakness, capsular con-
striction, deformity of the joint? Test passive and active move-
ments to distinguish between muscle weakness and mechanical
Rotational deformity
block. The examiner stands behind the patient with the elbow flexed
to 90° and the forearm behind the back. With the shoulder
‘The patient has a fixed flexion deformity of 45° with a further
bent forward and the shoulder in full extension the forearm
range of movement to 100° compared to 0–130° on the opposite
normal side.’
is lifted maximally, resulting in maximal internal rotation.
Differences between the two sides can be measured by the
Passive extension should have a normal bone to bone end angle between the forearm and the horizontal of the back.
feel due to restriction by the anterior capsule and the olecra-
non contracting the humerus. On the medial side with flexion
of the elbow subluxation of the ulnar nerve anteriorly with a Feel (palpation)
palpable snap can occur in 10% of the population. A subluxing ‘Does it hurt, is it painful?’
ulnar nerve may give rise to medial elbow pain. Palpate the Develop a defined approach to palpation. Know the anatomical
ulnar nerve whilst flexing/extending the elbow to feel for structures encountered and dry run your technique until it
anterior subluxation/relocation. flows smoothly. Palpation can be divided into four zones.
Supination/pronation Lateral
Active supination and pronation should be assessed with the It is usual to start from the lateral side palpating the lateral
elbow flexed 90° tucked to the side of the body to prevent supracondylar ridge, lateral epicondyle, common extensor
compensation for forearm rotation by shoulder motion. origin, lateral collateral ligament, radiocapitellar joint and
Normal supination is about 85° and pronation is around 80°; supinator. It is important to be able to distinguish between
however, a minimum of 50° in both directions is enough for tenderness in these areas (which are in close proximity) to
daily function. work out the source of pain. Showing that you are specifically
‘Can you tuck your elbows into your side, turn your hands palms palpating these also demonstrates you appreciate possible dif-
down and then palms up?’ ferential diagnoses of lateral elbow pain.
011
The lateral epicondyle is smaller and less well defined than The ulnar nerve is located in the sulcus behind the medial
the medial epicondyle. The radial head is best felt while pro- epicondyle and the olecranon. It should be palpated beginning
nating/supinating the forearm. Assess for tenderness or above the medial epicondyle, through the cubital tunnel and
clicking which may suggest a fracture, arthrosis, symptomatic distally as far as possible into the flexor carpi ulnaris muscle
posterolateral synovial plica or radial bursa. Congenital or mass. Gentle palpation or percussion of the ulnar nerve should
post-traumatic dislocation or subluxation of the radial head not cause any significant pain or discomfort. It is round, soft
will be appreciated at this stage. The anconeus ‘soft spot’ and tubular in nature. Perform Tinel’s test on the nerve –
should be palpated to evaluate for fullness, which could signify Assess for pins and needles or sharp sensations along the ulnar
joint effusion, haemarthrosis, or even a subluxed or dislocated nerve distribution. Remember to palpate the nerve whilst
radial head. The radiocapitellar joint can be easily assessed for passively flexing/extending the elbow, to look for ulnar nerve
tenderness or clicking over the radial head with supination and subluxation.
pronation. Tenderness directly over the lateral epicondyle can
be secondary to trauma or lateral collateral ligament injury.
The common extensors originate on the lateral epicondyle,
Posterior
but tenderness due to lateral epicondylitis (tennis elbow) is In the midline posteriorly the olecranon process and fossa on
generally elicited just distal and anterior to the epicondyle at either side of the triceps tendon should be assessed for tender-
the origin of the extensor carpi radialis brevise, even though it ness, swelling, thickening, crepitus, or bony fragments.
maybe felt directly over the lateral epicondyle, or even distally The triceps muscle can be palpated along with the olecra-
over muscle bellies. non bursa. The two epicondyles and the apex of the olecranon
Palpate for tenderness over the supinator, which may sig- form an equilateral triangle when the elbow is flexed 90° and a
nify a posterior interosseous nerve entrapment, a differential straight line when the elbow is in extension. Feel for the ulnar
diagnosis of lateral epicondylitis. nerve, test for mobility, perform Tinel’s test.
With the elbow flexed to 90°, the medial epicondyle, tip of ‘I’m palpating for any crepitus, nodules, lumps, thickenings, loose
the olecranon and the lateral epicondyle form an isosceles bodies.’
triangle. These form a straight line when the elbow is extended. There are several important structures that must be palpated
There is a sieve you will need to go through in order to and assessed medially. Pain with palpation of the medial
narrow the diagnosis down as to why it is painful on the lateral supracondylar ridge and medial epicondyle may be caused by
side of the elbow. medial epicondylitis, medial collateral ligament (MCL) strain
or tear, or fracture.
Anterior
Know the anatomical structures around the cubital fossa. Pal- Special tests
pate the brachioradialis muscle, biceps tendon, brachial artery, Tennis elbow
median nerve, lymph nodes, anterior elbow joint (either side of Golfer’s elbow
the biceps tendon) passing from lateral to medial. Distal biceps
Instability
tendinosis may be detected, and is a common enough condi-
tion to be encountered in the exam.
Stiff elbow
Medial Most likely a short case. The majority of cases will be second-
ary to trauma. Morrey et al.1 defined the concept of a func-
The medial epicondyle is easily palpable at the medial side of
tional range of arc motion between 30° and 130° extension/
the distal end of humerus. It is subcutaneous throughout and
flexion and 50° pronation/supination necessarily for an indi-
may be tender (along with the origin of the common flexors)
vidual to perform 90% of normal daily activities. There is
with medial epicondylitis. The ulnar collateral ligament can be
significant disability when these 100° range of motion arcs
palpated with the elbow flexed 50–70°. The ligament is pal-
are lost. A loss of 50° in the arc of motion causes up to an
pated from its origin at the inferior medial epicondyle along
80% loss of function. An average functional arc may, however,
the ligament to its insertion on the proximal medial ulna at a
not be acceptable in some professions or activities that require
tubercle on the medial margin of the coronoid process. Pain
full extension of the elbow; hence, enquire what specific
may indicate anything from a partial intrasubstance injury to a
disability the patient experiences.
complete tear.
Distal and slightly anterior to the medial is the origin of
pronator teres and flexor carpi radialis (FCR) tendons. Aetiology
Broadly divided into post-traumatic, atraumatic and
congenital.
e
If you suspect medial epicondylitis drill down on to the provocative Atraumatic causes include inflammatory arthritis,
tests for the condition. osteoarthritis (coronoid/olecranon/radial osteophytes),
55
011
loose bodies, burn injury, triceps/biceps adhesions, It is essential to examine both elbow flexion–extension
heterotopic ossification, chronic infection, hemarthroses and pronation–supination arc of motion and compare to the
in hemophiliacs opposite side.
Post-traumatic stiff elbow causes include distal humerus Types of stiffness include loss of elbow flexion, loss of
fractures. complex elbow fracture dislocations and radial elbow extension and loss of forearm rotation. The character
head fractures of the endpoint at the extremes of motion should be noted.
Congenital causes include arthrogryposis, cerebral palsy While a firm endpoint suggests a bony block to motion, a soft
and congenital radial head dislocation endpoint is indicative of a soft-tissue contracture. A soft end-
Post-traumatic elbow stiffness is challenging to treat and often point may also signify that the contracture may be prone to
involves young, active patients. Several classifications exist: stretching out with bracing. Crepitus appreciated during elbow
range of motion may signify degenerative changes or synovitis.
Early or late from the time of the injury
The typical post-traumatic elbow stiffness is painless. Pain
According to the structure impeding elbow range of
at mid-motion suggests an intrinsic component to stiffness.
motion (soft tissue, osseous or combined)
2 Pain at the extremes of motion suggests impingement between
Intrinsic, extrinsic, or mixed causes . Intrinsic contractures
the olecranon or coronoid process and the distal end of the
are secondary to involvement of the articular surface
humerus, usually due to osteophyte formation. Rotational
(articular mal-alignment, loose bodies, osteophytes,
stability, motor strength and neurovascular status of the
intra-articular adhesions). Extrinsic are those not involving
extremity. The ulnar nerve should be assessed for irritability,
the articulation (skin, muscle, capsule, collateral ligaments,
subluxation and sensory and motor function as it is commonly
heterotopic ossification (HO)) whilst mixed involves
involved in elbow trauma. With previous open reduction with
extrinsic contractures developing secondary to intrinsic
internal fixation (ORIF), the possibility of infection should
pathology
be considered. Assess muscle strength and co-lateral stability.
The severity of stiffness is graded according to the arc of
flexion, with very severe stiffness defined by an arc <30°,
severe stiffness defined by an arc of 31–60° and moderately Investigations
severe stiffness defined by an arc of 61–90°, although these may Standard workup of AP, lateral and oblique radiographs.
not directly correlate with the severity of functional disability CT with three-dimensional reconstruction may accurately
experienced by the patient. localize loose bodies and/or impinging osteophytes and assist
in planning arthroscopic debridement.
MRI is generally unhelpful.
History Rule out infection before any planned surgery with aspir-
Age, hand dominance, occupation. Some activities in labourers ation if needed.
require full elbow extension, and, hence, even small loss of Nerve conduction studies if any neuropathy identified.
elbow extension can be disabling.
Onset, duration, character, and progression of symptoms.
If trauma establish the exact injury of mechanism, type
Management
of fractures or instability and subsequent treatments. The old A multidisciplinary approach among patient, surgeon, physio-
hospital notes should be obtained to determine previous sur- therapist and others for optimal treatmentf.
gical exposures, nerve transposition, metalwork used and any 1. Non-operative
complications. Ask about infection. Serial bracing. Either dynamic or static. Dynamic splinting
Risk factors for stiffness after trauma include length of based on creep (an increase in length with the application
immobilization, associated fracture with dislocation, intra- of a constant load for prolonged time), static based on stress
articular derangement, delayed surgical treatment, associated relaxation (a decrease in load required to maintain a certain
head injury, heterotopic ossification. length over time). Splinting usually has a role to play in early
Functional limitations stiffness (<6 months), but not in chronic established stiffness.
Recreational interests Stiffness with ‘softer’ endpoints may also be more amenable to
splinting. Splinting can aim to improve flexion, extension or,
by using alternating splints, both.
Examination 2. Operative treatment
Inspection of the skin for scarring, open wounds, and previous Only after failure of non-operative treatment.
surgical incisions. All bony prominences are palpated to detect Examination under anesthesia along with gentle manipula-
areas of tenderness that may limit motion secondary to pain. tion for early contractures, followed by splinting.
Look for deformity and swelling.
The elbow should be put through extension–flexion and
pronation–supination arcs of motion and these ranges quanti-
fied with a goniometer both actively and passively. f
Buzz sentence to keep the examiners happy.
011
Chronic contractures may require surgical release. young high demand patient, in whom replacement arthro-
Extrinsic contractures are usually managed with open or plasty is not indicated due to its short longevity.
arthroscopic release. Those with a large intrinsic component
are managed with release combined with arthroplasty. Replacement arthroplasty
Open release is considered by many as the gold standard. This has a limited role in the stiff elbow. It is generally used
Several approaches may be utilized for open capsular release, in patients over the age of 60 with advanced arthritis or post-
depending on the location of the main capsular contracture. traumatic destruction of the joint.
Lateral column procedure. This involves arthrotomy,
capsular release, and osteophyte excision. It allows release
Examination corner
of the anterior and posterior capsule. The incision is
centered over the lateral humeral epicondyle, elevating the History: A 23-year-old man who presented to A&E with a
brachioradialis muscle from the humerus, the common rugby injury 8 months previously. A dislocated elbow on the
extensor origin from the lateral collateral ligament (LCL), dominant side, manipulation under sedation in, given a back
and the brachialis muscle off the anterior elbow capsule. slab. He missed his fracture clinic appointment and delayed
The lateral capsule is excised, and the medial capsule is elbow mobilization by 7 weeks, Did not attend physiotherapy
as went back to university.
incised. Intra-articular adhesions as well as coronoid
osteophytes are removed. Elevation of triceps and anconeus EXAMINER: Examine this man’s elbow.
muscles from the distal end of the humerus and proximal CANDIDATE: The elbow in an attitude of 40° flexion, with some
part of the olecranon allows release of the posterior fullness around the olecranon and cubital fossa. There is some
capsular and debridement of the olecranon fossa wasting of triceps and biceps when compared to the opposite
Medial approach. Pronator teres is elevated from the elbow. There are no visible scars. There is no local tenderness to
common flexor mass, to expose and release the anterior palpation around the elbow structures, the bony relationship
capsule. The triceps muscle is elevated off the humerus and between the epicondyles and olecranon is maintained with the
olecranon, allowing release of the posterior band of MCL elbow at 90° flexion and this is comparable to the normal
and posterior capsule and removal of any olecranon opposite side. The range of movement is from 40° to 100°.
osteophytes. This approach does not give adequate access Supination and pronation are full. His elbow is grossly stable for
to the lateral part of the joint valgus and varus stresses, although I would prefer to exam for this
Anterior approach. This accesses the anterior capsule to under GA and image intensifier guidance. Sensation in the
better manage flexion contracture. Used for isolated autonomous zones for median, ulnar and radial nerves are
anterior ectopic bone excision normal.
Posterior approach. Allows extensive medial and lateral EXAMINER: These are the radiographs pre- and post-manipulation.
releases. Midline posterior incision. The ulnar nerve is CANDIDATE: The AP and lateral radiographs show a posterolateral
decompressed and the posterior part of the MCL is released elbow dislocation in pre-reduction films, with no associated
Complications include neurovascular injury, inadequate fractures noted. Post reduction through the back slab
release, instability if excessive release (may need to protect demonstrates a well-reduced elbow immobilized in about 100° of
elbow with an external fixator post release) and recurrent flexion.
stiffness. Protect against heterotopic ossification (HO) forma- EXAMINER: How would you manage a patient with a closed
tion with NSAIDs. posterolateral elbow dislocation following a successful
manipulation?
Arthroscopic surgical release CANDIDATE: I would try and assess stability in about 30° of flexion
Arthroscopic osteocapsular release involves the removal of after achieving reduction. If unstable, I would immobilize the arm
osseous components, such as osteophytes and ectopic bone, in an above elbow back slab with the elbow in 90° flexion and the
and capsular release. This is a challenging procedure because forearm in full pronation. This is followed by checking x-rays.
of the close proximity of the neurovascular structures. Steep I would try and limit the period of immobilization to <2 weeks
learning curve, associated with serious complications. and initiate early ROM exercises and physiotherapy. I would warn
the patient about the possibility of stiffness and residual terminal
Distraction arthroplasty restriction of extension and the importance of complying
Distraction arthroplasty is used for instability following con- physiotherapy.
tracture release and reattachment of the collateral ligaments EXAMINER: This gentleman is struggling with elbow stiffness and all
and following interposition arthroplasty to protect the graft. conservative measures have failed to improve his ROM. What
would you do?
Fascial interpositional arthroplasty CANDIDATE: I would ask for some updated elbow radiographs and
Various interpositional materials including autograft fascia in addition request a CT scan to look for any bony blocks to
lata or Achilles tendon allograft. Possible treatment option in
57
011
When used the graft should be directed away from the inter-
movement, such as post-traumatic ossification, loose intra-
osseous membrane.
articular bony fragments or joint irregularity. An MRI may also be
helpful in demonstrating intra-articular damage, cartilaginous
loose bodies or impingement but generally less so than a CT scan. Clinical assessment
EXAMINER: Ok, the x-rays and CT scan do not show any abnormality. History to include original injury, any associated head injury,
What are you going to do? timing from initial injury to surgical management, postopera-
CANDIDATE: This gentleman would be best managed by a Shoulder tive complications, previous surgeries in the same bone.
and Elbow surgeon with a plan to perform an EUA and gentle Hand dominance, occupation, recreational activities, patient’s
manipulation followed by physiotherapy, and stretching bracing. expectations and functional demands. Any residual deficit
The stiffness in this case could be due to soft-tissue contracture from a head injury may preclude the ability to comply with
including capsular and ligamentous involvement. If this failed to postoperative rehabilitation.
significantly improve his range of movement then an open or Patients with post-traumatic RU synostosis usually present
arthroscopic release followed by CPM or physiotherapy would be with decreased ROM, specifically forearm rotation. It is
the next step. important to assess the position of the forearm, because fixed
EXAMINER: Yes, the evidence with CPM is not robust, but I suppose,
pronation is associated with much less function than is fixed
nothing wrong in getting some passive motion early after
supination. Synostosis may interfere with elbow flexion and
surgery. Let’s move on!
extension, as well, if the heterotopic ossification bridges to
the humerus. A through neurovascular examination should
be performed including looking for anterior and posterior
interosseous nerve dynsfunction.
Stiff elbow mainly involving loss of supination Forearm rotation is important in most tasks, and complete
and pronation loss of pronation and supination can result in severe impair-
ment of activities of daily living.
Think of rotation problems secondary to involvement of Most positional and functional tasks can be achieved
the superior or inferior RU joint such as congenital or within a rotation arc of 100° (50° pronation and 50° supin-
acquired radial head dislocation, distal ulnar dislocation or a ation). More contemporary tasks such as using a keyboard,
mal-united fractured radius and ulna with distorted interosse- usually require an even greater arc of forearm rotation. Again
ous anatomy. A congenital or traumatic synostosis especially enquire about disability experienced by the patient, as this
in proximal third forearm injuries is a fairly common elbow will be influenced by activities the patient is involved in (dif-
short case. ferent in a keyboard user, from a manual worker carrying
weights).
Management of post-traumatic RU synostosis Radiographs will confirm the diagnosis with bridging het-
A rare complication following fracture of the forearm and erotopic bone between the radius and ulna. Serial radiographs
elbow. Risk factors for synostosis are related to the initial may be helpful in assessing the progression of lamellar bone
injury and surgical management of the fracture. Typically, formation and eventual maturation. CT should help with the
patients present with complete loss of active and passive fore- anatomy, size and location of the synostosis and three-
arm pronation and supination. Evidence of bridging hetero- dimensional CT may aid surgical planning in terms of surgical
topic bone between the radius and ulna can be seen on plain approach. Serial bone scans and alkaline phosphatase levels are
radiographs. Typically surgical excision is required. The no longer routinely requested for monitoring, serial x-rays
timing of surgical intervention remains controversial. Early are sufficient.
resection between 6 and 12 months after the initial injury Non-surgical management: A thorough assessment of
can be safely performed in patients with radiographic evidence functional loss is required for each patient. Mild functional
of bony maturation. Surgical management consists of com- disturbance may be managed non-operatively. Also consider
plete resection of the synostosis with optional interposition conservative management in low demand patients, recurrence
of biologic or synthetic materials to restore forearm rotation. following previous surgery, frail and unfit patients and
The rate of synostosis is higher in patients following a head those patients with the forearm in a fixed but functional
injury, occurring in as many as 18%. position.
Risk factors: (1) Comminuted fractures of both the radius Surgical management: It is important to warn the patient
and ulna at the same level in the proximal third; (2) Head about the risks of neurovascular complications and that the
injury; (3) Iatrogenic trauma – Single incision technique, bone results from surgery can often be disappointing. Compli-
fragments or reamings, bone graft or hardware in the inter- cations of surgery include neurovascular injury, infection,
osseous space; (4) Disruption of the interosseous membrane; fracture, incomplete restoration of the forearm pronation-
(5) Severe soft-tissue injury; (6) Surgical delays in fracture supination arc, recurrence of synostosis, risk of instability at
fixation. Primary bone grafting should be used judiciously. either the proximal or distal RU joint.
011
Timing of surgery: This remains controversial. Surgical left side. Looking from back with the elbow flexed to 90°, the normal bony
intervention is safe within 1 year of injury in a patient relations are maintained. There is tenderness over the lateral aspect of
with radiographic evidence of bony maturation (a well- elbow . . . (not very comfortable for the patient).
defined margin and bridging trabeculi). Early resection EXAMINER: . . . Ok, there is nothing much to palpate any more, would you
(6–12 months) has been performed safely without an increase like to comment on his ROM?
in recurrence in patients with radiographic evidence of bony CANDIDATE: The elbow lacks about 20° of terminal extension but further
maturation. flexion to about 130° is possible and painless. Almost full supination and
pronation is noted with the elbow in 90° flexion compared to
opposite elbow.
Examination corner
EXAMINER: What do you think his symptoms are due to?
Short case 1 CANDIDATE: It appears that he is getting symptoms when he takes weight
EXAMINER: Would you examine this man’s forearm? on the elbow, I suspect there is an element of injury to the lateral ulnar
collateral ligament with instability?
CANDIDATE: This was the first short case and I just wasn’t expecting
this. I was completely unnerved and froze. Examine this man’s EXAMINER: Is there a simple clinical test to find out the instability?
elbow – Yes, examine the wrist – Yes, examine the forearm – No CANDIDATE: I would like to do varus stress test, pivot shift test . . .
never ever been asked to do this ever! There was reduced EXAMINER: A simple test the patient can do it actively himself?
forearm rotation and I was asked what I thought the diagnosis CANDIDATE: Oh, yes, rising from chair actively pushing his weight on
was. I said traumatic radioulnar synostosis but was then asked both elbows the patient would be reluctant to extend their elbow fully
to examine the opposite forearm, which also had markedly (elbow chair rise test) or the floor push-up test?
restricted rotation. It was a congenital radioulnar synostosis. Part EXAMINER: Yes, it is easy to do if you have a chair with arm rests! Go on,
of the examiner’s amusement when candidates say traumatic is demonstrate that!
to then make them examine the opposite forearm. I was then . . . .. so, does this help with your clinical diagnosis?
shown radiographs which demonstrated the synostosis and COMMENT: The elbow chair test is easy and quick to perform in a clinical
then asked about management. (Fail – 5) setting (Figure 8.1). A patient is asked to push off the arm rest to stand up
with both forearms in supination and the arms abducted. In this situation
the patient is reluctant to fully extend the elbow since the maneuver
applies an axial load, valgus and supination force which causes
Painful elbow with instability posterolateral instability. Apprehension, subluxation or frank dislocation
Patients with a history of trauma and multiple postoperative may occur as the elbow is extended, depending on the severity of the
scars around the elbow following trauma may have had their instability.
radial head replaced, medial epicondyle fixed, soft tissues
repaired by suture anchors, etc. Remember the terrible triad With the (floor) push-up test the patient pushes off the
(radial head and coronoid fracture with a posterolateral elbow floor with the forearms maximally supinated, elbow flexed
dislocation) that often requires surgery and usually has some 90° and arms abducted (Figure 8.2). The test is positive
sequelae or residual problem. for posterolateral rotary instability if apprehension, sublux-
ation or frank dislocation occurs with terminal elbow
extension.
Posterolateral elbow rotatory instability following CANDIDATE: Yes, I can see the posterolateral subluxation of radial head
previous open elbow dislocation over the end of distal of humerus.
EXAMINER: Take a brief history and examine this gentleman’s right elbow. EXAMINER: How would you manage this?
CANDIDATE: (After 2 minutes) In summary, this 22-year-old right-hand CANDIDATE: Confirmation of diagnosis by means of review of all
dominant man, supermarket worker, fell down from his bike 11 months radiographs performed from day 1 and further testing for posterolateral
ago sustaining an open injury to his elbow. This was operated on the same instability with examination under GA and image intensifier. MRI with
day with wash out, and primary closure. He had plaster immobilization contrast may show a torn LUCL (lateral ulnar collateral ligament). Some
for 3 weeks followed by physiotherapy. His main complaint is of clicking form of reconstruction of LUCL using a autologous/synthetic graft by an
and pain especially when stacking shelves at work and also with gym experienced surgeon.
activities such as bench pressing or doing parallel bars, etc. He is otherwise EXAMINER: OK, let’s move on to the next case . . .
fit and well, a keen sports person.
EXAMINER: Ok, go on and examine the elbow. A more recent test is called the table-top relocation test
CANDIDATE: The right elbow is in an attitude of flexion and slight (Figure 8.3). The patient performs a press-up on the edge of
pronation, with a healed irregular scar over the posterolateral aspect of a table using one arm, with the forearm in supination. In the
elbow suggestive of the open wound with no signs of infection or presence of instability, apprehension or pain occurs at about
inflammation. There is slight wasting of the triceps muscle compared to 40° flexion.
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Figure 8.2 Photograph showing the active floor push-up sign
Figure 8.1 Photograph showing the chair sign. In the presence of instability,
on attempting to rise from a chair pushing down only with the arms, and with
the forearms supinated apprehension or radial head dislocation occurs as the
elbow extends
Elbow instability
Valgus instability (ulnar collateral ligament injury)
Valgus stress testing is performed with the forearm fully exter-
nally rotated. Opening up of the elbow, local pain and tender-
ness suggest ulnar collateral ligament injury.
Varus instability
A varus stress is applied across the elbow joint with the
shoulder fully internally rotated to lock the shoulder. If
instability is present a gap between the capitellum and radial
head increases.
Both valgus and varus stress testing are performed with the
elbow in full extension and in 30° of flexion that unlocks the
olecranon from the olecranon fossa.
Rotatory instability
Posterolateral rotatory instability (PLRI) results from insuffi-
ciency of the lateral ulnar collateral ligament (LUCL). It is the
Figure 8.3 Photograph showing the table-top relocation test. A press-up on
commonest instability pattern encountered in clinical practice. the edge of a table with the forearm in supination causes apprehension at
Patients complain of lateral elbow pain with recurrent clicking, about 40° flexion if instability is present
011
popping, snapping or locking of the elbow accompanied as possible would earn candidates a good safe 6 pass. There will
by a sense of elbow instability. Pushing down with the upper be time for review of radiographs and also discussion and
extremity to rise from a seated position, performing press-up/ plenty of opportunity to score extra marks with this cases.
push-up exercises, and pushing heavy objects with an extended
arm are common activities that reproduce symptoms. These Terrible triad injury of elbow
activities place the elbow in an unstable position of external
A fall on outstretched arm resulting in valgus, axial and poster-
rotation of the forearm with valgus and axial loading of the
olateral rotatory loads across the extended elbow joint. Most
elbow. Examination of a patient with PLRI is often unremark-
often follows a fall from motorbikes, injuries during contact
able. Often range of motion is within normal limits, and varus
sports, etc. Besides radial head and ulnar coronoid process
and valgus stress tests are usually not provocative. Tests to
fractures (which are often multifragmentary), the LCL is often
confirm the diagnosis include:
torn. The anterior bundle of MCL may also be torn in the most
1. Lateral pivot shift (O’Driscoll)
severe injuries.
Patient is supine, affected limb overhead. With forearm Fixation or replacement of radial head and ORIF of the
supinated, valgus and axial loading applied, the elbow is coronoid process adds to static stability. However, it is the
flexed from full extension. In posterolateral rotatory repair of lateral collateral ligament complex that is the key
instability as the elbow is flexed the radial head subluxes element of the whole reconstruction of the terrible triad. An
or dislocates and is seen as a prominence posterolaterally. assessment for stability under image intensifier should be
With flexion beyond 40° the radial head suddenly reduces made at this point of surgery and if needed, a repair of MCL
with a palpable and visible clunk. The test is best performed should be performed.
under GA for radial head dislocation and relocation to be The results from these injuries are often poor because of
seen. When this maneuver is performed with the patient associated stiffness or instability. Careful reconstruction of all
awake, the test is positive in presence of apprehension the bony and ligamentous injuries is, therefore, important to
2. Drawer test allow early mobilization using a hinged brace with a block to
With the elbow flexed to 40°, anteroposterior force is terminal extension.
applied to the radius and ulna with the forearm in external
rotation. This aims to sublux the forearm away from the
humerus on the lateral side, pivoting on the intact medial Elbow instability following previous elbow surgery
ligaments. Under GA the radial head is seen dislocating, (tennis elbow release, surgical approaches to the
whereas with patient awake apprehension occurs. This is
often the easiest test to perform lateral side elbow and radial head)
3. Arthroscopic examination Over aggressive release of the LUCL, the release extending
This reveals a widening of lateral joint space and/or beyond equator of radial head can potentially make the elbow
posterior subluxation of the radial head, but not as accurate unstable in a varus or posterolateral direction. The scar may be
as EUA similar to a typical tennis elbow scar. Sometimes, instability
may follow an arthroscopic soft-tissue release (inadvertent
Elbow instability following previous trauma lateral ligament complex release). It is important to describe
the type and location of a scar to help differentiate between
(terrible triad) either a traumatic or elective procedure.
This is also a common presentation, with either failure to
repair LCL at the time of fracture fixation or failed reconstruc-
tion with persistent instability. Complications of a terrible
Cubital valgus/ulnar nerve
triad injury include chronic elbow instability as well as stiff- The carrying angle cannot be assessed fully when there a fixed
ness, infection, pain, ulnar neuropathy, mal-union, non-union, flexion deformity Causes include: Non-union of lateral mass in
heterotopic ossification arthrosis, osteoarthritis, and children; non-union of intercondylar fractures in adults; injur-
contracture. ies or infection in parts of distal humeral epiphysis in child-
In most cases, the examination will, therefore, be limited to hood leading to differential growth on either side of elbow;
LOOK, FEEL AND MOVE within the limits of pain and epiphyseal dysplasias such as Ollier’s or multiple exostosis.
comfort. Special tests such as stress and instability tests are A thorough examination of the ulnar nerve is required keep-
rarely tolerated, but a knowledge of underlying principles ing in mind the ulnar paradox, high or low ulnar nerve features.
behind these tests is important. ‘Can you show me your elbows, please?
These are cases where a candidate may be asked to take part (Demonstrate what you want the patient to do.)
of a history from the patient. A good summary of the history, a ‘A spot diagnosis: This patient demonstrates a cubital valgus
methodical description of what you see, a gentle feel of struc- deformity of the elbow. There is also a suggestion of loss of full
tures around the elbow including the bony relations along with extension. There are no scars present over the medial or lateral
careful demonstration of ROM with as little distress to patient epicondyle.’
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Go straight to the hand to look for ulnar nerve signs (wasting

not sure. Managed in sling for 6/52. Since then has had an
of the interossei, hypothenar muscle wastage, sensory increasingly stiff, aching elbow with pins and needles along
changes, etc). ulnar border of hand.’
‘Is there any weakness of your hand or numbness and tingling
of your fingers?’ Examination
‘The most common cause is a lateral condylar mass non-union ‘Very stiff, but not so painful, elbow. Explained I would start
from childhood leading to a valgus deformity of the elbow (Milch with neck and shoulder, etc, but told to concentrate on the
type II fracture). There is usually marked prominence of the elbow. Tinel’s test very sensitive over cubital tunnel. Neuro
medial epicondyle.’ examination distally. Motor fine, altered ulnar nerve
sensation. Talked through functional assessment of hands
(grips, etc).’
Examination corner Discussion
Short case: Cubitus valgus elbow in a 65-year-old male ‘Investigations – x-rays (very poor quality). They were
Milch type II fracture of the lateral condyle missed at the age of pushing me towards nerve conduction studies but I said
6 years. it was obvious where the pathology was (? brave?!).
Features of tardy ulnar nerve palsy. Diagnosis of tardy ulnar nerve palsy 2-years post injury.
I said there was nothing to suggest it was due to
EXAMINER: Would you examine this gentleman’s elbows and cubitus valgus but, apparently, you can’t comment on
describe what you are doing as you go along? this if the elbow won’t extend! Discussed surgical
CANDIDATE: Can you show me your elbows, please, sir? On approach for decompression, pros/cons of transposition
examination there is an obvious left cubitus valgus of the elbow (increased risk of late complications owing to nerve
present with a suggestion of loss of full extension. ischaemia).’
EXAMINER: Come on, where else do you want to look? You look at
his hands. Does he have evidence of ulnar nerve dysfunction?
CANDIDATE: Looking at his hands there appears to be hypothenar Cubitus varus with hyperextension deformity
muscle wasting.
EXAMINER: Examine this girl’s right elbow.
EXAMINER: Come on, where else do you have wasting? What about
CANDIDATE: (Introduces himself) . . . Could I ask you how old are you?
the back of his hands? You should be jumping to examine it.
What about his interosseous muscles? This 11-year-old girl has a varus deformity involving her right elbow
with some hyperextension in right elbow when compared to left elbow.
CANDIDATE: There is wasting of his dorsal interossei, particularly the
There are two tiny mature scars on either side of elbow, the one on medial
first dorsal interosseous. Can you feel me touching your little
side slightly larger (about 2–3 cm), no swelling noted, the normal bony
finger? Does it feel normal? He has reduced sensation over
relations maintained both in 90° flexion and extension when compared to
his ulnar 1½ digits and also over the ulnar, dorsal aspect of
left elbow. There is slight bony irregularity in supracondylar ridge over
his wrist.
lateral aspect with no tenderness around the elbow. She can demonstrate
EXAMINER: Do you need nerve conduction studies to confirm your
good range of movements from –10° of extension to about 140°; flexion is
clinical findings?
slightly limited when compared to left elbow. Full and painless range of
CANDIDATE: No.
rotations of forearm with elbow in 90° flexion. Elbow appears to be stable
EXAMINER: Good. What do you think of his x-rays?
and painless in both full extension and 30° flexion.
CANDIDATE: These are AP and lateral radiographs of the left elbow.
EXAMINER: What would you do?
They demonstrate an old lateral condylar fracture, which has
CANDIDATE: Can I ask some history?
gone onto a non-union. There are severe secondary arthritic
EXAMINER: She has been telling a similar story to all the previous
changes present in the radiocapitellar and humeroulnar joints.
candidates. She had a fall when she was 7 years old and had some surgery.
In view of his sensory and motor ulnar nerve symptoms
Deformity noted about 1 year after injury, no pain and quite a keen
and non-union present with secondary degenerative changes,
gymnast!
I would offer him ulnar nerve decompression with medial
CANDIDATE: She is most likely to have a malunited supracondylar fracture
condylectomy and anterior transposition of the nerve. I do not
with no neurovascular deficit. This is an isolated deformity to right elbow,
think a simple decompression is adequate management for this
no evidence of hypermobile joints, functionally she seems to be doing well
gentleman.
and I would like to know what bothers her and the family.
Intermediate case EXAMINER: Being a girl, it is obviously the cosmoses that she is bothered
about! What are the causes of this deformity in general?
History
CANDIDATE: In general terms, the most common cause especially
‘A 50-year-old woman with long-standing, well-controlled
following injury in childhood is a mal-united SC fracture, but injuries to
(methotrexate) rheumatoid arthritis in hands and wrists.
lateral condyle with consequent overgrowth, any injury or infection to
Fell onto right elbow 6/12 ago – Told it may be fractured,
medial side with growth arrest can lead to a varus deformity. Commonly,
011
it failure to correct the internal rotation and varus displacement during maintain the global movements of the arm and her hand-grip strength
manipulation of supracondylar fractures which leads to a varus deformity appears to be good.
with some degree of hyperextension. EXAMINER: OK, let’s concentrate on the elbow. What is her most disabling
EXAMINER: How do you manage? problem now? What is she going to struggle with?
CANDIDATE: I would like to look at all the available radiographs and CANDIDATE: (The candidate asks the patient whether she is struggling to
determine the degree of deformity. However, since it functionally not get her face washed.) Looking at her both forearms that are in fixed
causing any problems and also she is actively growing, I would explain pronation, her main problem seems to be getting her hand to her face.
that all surgery should be postponed until she is skeletally mature. EXAMINER: Yes, a supination deformity can easily be compensated by
EXAMINER: What are the surgical options then? internal rotation of shoulder, but a pronation deformity like she has
CANDIDATE: Either a closed- or open-wedge osteotomy; A closed-wedge can be very troublesome. OK, these are the x-rays of this lady’s
osteotomy with intact medial hinge, even though inherently stable and right elbow.
simple to perform, has been reported to have a lateral prominence in the CANDIDATE: AP and lateral radiographs of the elbow show marked soft-
longer term. Alternatives such as step-cut osteotomy or reverse step-cut, tissue swelling and some periarticular osteopenia and erosions, mild
dome osteotomies have been described that reduced such the lateral reduction in the joint space mainly radiocapitellar and no architectural
prominence with good stability, but are technically demanding. The distortion.
surgery be best performed by a specialist with expertise in such deformity EXAMINER: Good, what is your diagnosis?
correction. CANDIDATE: Poly-articular rheumatoid arthritis (RA) with possibly
stage 2–3 Larsen grade, symptomatic in the form of pain and restricted
supination and functional impairment with ADLs. Because it is at an
Rheumatoid elbow early stage and she maintains a good range of flexion and extension,
synovectomy either arthroscopic or open may help to control pain and
Short case 1 improve her ability to supinate, which is the major disabling restriction
‘On examination the patient has features of a generalized for her.
polyarthropathy, probably rheumatoid arthritis. There is an old EXAMINER: OK, we will go the next case.
well-healed scar over the lateral aspect of the elbow suggestive of
previous surgery to the radial head. There are large rheumatoid
Nearly 50% of RA patients have elbow involvement and in the
nodules overlying the olecranon bursa. There are no features of
majority of cases, it is bilateral. In the early stages, synovitis
either PIN (posterior interosseous nerve) or ulnar nerve
neuropathy.’ causes pain and tenderness, especially over the radiohumeral
Mention coexistent assessment of shoulder and hand function. joint line, with associated loss of elbow extension. Later, the
whole elbow may become swollen and stiff. Finally, when bone
destruction is severe, instability and capsular rupture result
Short case 2 in a flail elbow. Ulnar collateral ligament incompetence
EXAMINER: Examine this lady’s right elbow please. (Woman in her may cause valgus ulnar humeral instability and ulnar nerve
late 40s.) dysfunction. Annual ligament incompetence can lead to radial
CANDIDATE: (After greetings and introduction.) This lady’s right elbow is
head subluxation.
in an attitude of flexion with subcutaneous nodules over olecranon,
Symptoms from the rheumatoid elbow include pain, stiff-
generalized swelling obliterating all the normal bony landmarks around
ness, swelling, instability and ulnar nerve dysfunction.
the elbow. The skin is very thin and shows areas of ecchymosis and
Examination of RA elbow: Look for scars, deformity,
vasculitic skin lesions. The forearm is in an attitude of pronation.
muscle wasting, rheumatoid nodules, swelling, composite
Generally, I can see a polyarticular arthritis of both hands and wrists with
movement of the whole upper limb into positions of function.
some wasting of the forearm and upper arm muscles. There is a slight
Feel for rheumatoid nodules, any swelling, tenderness, ulnar
local increase in temperature around her elbow, she seems to be in a
nerve irritation. Movements: Flexion/extension, pronation/
degree of pain; therefore, I am going to feel for bony land marks as gently
supination, crepitus and joint instability.
as possible. I can feel a bony rounded mass over the posterolateral aspect
Larsen grading for RA elbow:
that appears to be the radial head. Gentle rotations of forearm confirm Stage 1: Involves the soft tissues and has near-normal
this. She is generally tender around the elbow joint with an effusion and radiographs
some soft-tissue swelling over the ante-cubital fossa. She maintains a good Stage 2: Presents with periarticular erosions and mild
range of flexion and extension in her elbow from about 40° to 130°g, but cartilage loss, there may be evidence of soft-tissue swelling
the forearm is in almost full pronation with painful rotatory movements. and osteopenia on radiographs
Despite the involvement of other joints in the right arm, she seems to Stage 3: Radiographs show marked joint space narrowing
Stage 4: Progresses to advanced erosions penetrating the
subchondral bone plate
Stage 5: Radiographs show advanced joint damage and loss
g
Get the goniometer out for a more precise measurement. of articular contour
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Stage 1 and 2 may respond to synovectomy 3. Reproduction of pain when the forearm and wrist extensor
Limited flexion–extension is an independent risk factor for a muscles are actively extended or passively flexed
poor result. Therefore, it is important to demonstrate a good
flexion and extension arc before surgery. Pathology
In the early stages of RA elbow, synovectomy is expected to Uncertain – There are several theories:
improve pronation and supination better than flexion and Avascular degenerative process
extension. Humeroradial bursitis
Surgery is indicated when appropriate non-surgical man- Inflammation of the annular ligament of the radius
agement has failed, giving rise to functional limitations due to Secondary trauma
pain or loss of motion. The primary aim of surgery on the Or, it may present as part of a ‘generalized mesenchymal
elbow is to relieve pain and/or restore joint function. Pain is syndrome’.
the most common primary indication for elbow surgery. The
pain relief is most predictable and complete after total elbow Clinical features
arthroplasty (TEA). A range of movement of <100° that does Gradual onset of pain over the lateral epicondyle with radi-
not allow the patient to reach their mouth or perineum and is ation down the proximal forearm in line with the extensor
an indication for surgery. TEA is generally effective at restor- muscles.
ing a functional arc of motion. A linked TEA may be effective
in patients with instability and pain as major symptoms. Differential diagnosis (may coexist with tennis elbow)
Larsen stages 3–5 may require TEA. There are two basic Radiocapitellar arthritis/synovitis/plica
types of elbow (TEA) implants:
Radial tunnel syndrome
1. Linked implants are joined together by a ‘sloppy hinge’
to allow for some varus and valgus laxity during range of Provocative tests
motion of the elbow; early loosening is a concern with There are several provocative tests for lateral epicondylitis,
these implants. However, they provide stability and do not but of the ones described below, the first two are the ones
rely on intact collateral ligaments which may be attenuated recommended for the exam.
in rheumatoid elbows, or compromised at surgery. In
patients with inflammatory arthritis, the soft tissues are Pain with the resisted wrist extension test
often attenuated and there is a lower threshold for using a
With their elbow extended, ask the patient, ‘Could you make a
linked prosthesis
fist, please; can you cock your wrist backwards’ (getting the
2. Unlinked implants, the humeral and ulnar components patient to extend their wrist) ‘and resist me now? (Try to flex
are not joined together and stability is provided by the the wrist against resistance, feeling the lateral epicondyle at the
surrounding soft tissues. Instability is the main concern same time.) This should reproduce the patient’s symptoms.
with this implant construct
Complication rates can be as high as 40–45% and include infec- Middle finger extension test (Maudsley’s test)
tion, instability, loosening, wound healing, ulnar neuropathy,
Extending the middle finger against resistance reproduces
triceps insufficiency, periprosthetic fractures. In RA, 10-year sur-
pain by stressing extensor carpi radialis brevis (ECRB).
vival rates of TER of between 80% and 92% have been reported.
Chair lift test
Medial-sided elbow pain with ulnar neuritis This involves picking up a chair with an adducted shoulder,
Causes of medial elbow pain including osteochondritis disse- extended elbow and pronated wrist.
cans, loose bodies, ulnohumeral osteoarthritis, Golfer’s elbow,
Bowden’s test
snapping elbow (painful ulnar nerve subluxation).
The patient is requested to squeeze together a blood pressure
measuring cuff inflated to around 30 mmHg held in their
Tennis elbow (lateral epicondylitis) hand. Pain over the lateral epicondyle is suggestive of lateral
Typically a short case in which a candidate would be asked to epicondylitis.
demonstrate provocative tests for tennis elbow.
This is a syndrome/symptom complex characterized by the Mill’s test
following: The patient is asked to pronate the forearm and flex the wrist.
1. Pain over the lateral epicondyle and proximal forearm The patient is then asked to supinate their arm against
exacerbated by movements involving a combination of a resistance.
gripping hand and a forearm rotation Grip strength can be tested and compared with the con-
2. Tenderness on palpation of the extensor muscle origin at tralateral side as patients often report weakness when gripping
the lateral epicondyle items.
011
Figure 8.5 Fixed flexed deformity of 40°
Figure 8.4 Truck driver, 60 years old, struggling with shaving and carrying lateral epicondyle of the humerus and possibly weakness of grip
shopping bags on the right side. Active elbow flexion of 90° (normal strength.
value is 145°)
EXAMINER: Can you demonstrate some provocative tests for tennis
elbow?
Radiographs Osteoarthritis elbow
Radiographs of the elbow are usually normal.
EXAMINER: This is Mr Simpson, he is a 60-year-old truck driver who
is having problems with his dominant (right) elbow. Could you
Management please examine his elbow?
Conservative CANDIDATE: Mr Simpson holds his right elbow in an attitude of 45°
Initially conservative as 90% of cases settle by 12 months flexion. There is a suggestion of soft-tissue swelling around the
Rest, modification of activities, non-steroidal anti- elbow, especially around the lateral and posterior aspects. The
inflammatory drugs (NSAIDs), physiotherapy, forearm held in a mid pronation. I can see altogether five small
epicondylitis (EPI) clasp, steroid injection well-healed scars, two on the posterior aspect, two on the medial
aspect and one laterally suggestive of previous arthroscopic
Surgery portal scars. Palpation reveals some tenderness especially over
Release of ECRB either open or arthroscopic (it is often the radiocapitellar joint with crepitus and also a soft-tissue
difficult to solely release ECRB) effusion as revealed by a fluctuant swelling in the ‘soft spot’
Extensor origin may or may not be repaired (usually not laterally. The passive range of elbow movement is between 40°
repaired) and 90° (Figures 8.4 and 8.5). Active movement was only
A short period of elbow immobilization in a plaster or marginally increased and this was associated with some pain in
splint postoperatively is used by some surgeons the terminal range of movement. Any attempt at further passive
On average, 85% of patients will attain complete relief of movement causes elbow discomfort. Supination and pronation
symptoms with surgery, 5% will see no benefit and 10% will was 60° bilaterally. There was no obvious instability associated
have residual symptoms with this range of movements and no distal neurovascular deficit
in particular he has normal motor and sensory ulnar nerve
Complications include iatrogenic LUCL injury, radial
function.
nerve injury, missed radial nerve entrapment (5%)
EXAMINER: What is the crepitus due to? (The examiner
places his hand on the back of elbow and asks the patient to
Examination corner move.)
CANDIDATE: It could be due to a loose body or generalized
Short case
osteroarthritis within the joint.
EXAMINER: Would you like to examine this lady’s elbow? EXAMINER: Yes, you can actually feel a loose body mobile apart from
CANDIDATE: On inspection the elbow looks normal. Flexion is full the joint! OK, what is your diagnosis, given this patient has no
from 0° to 140° and painless. Full extension at its extreme point is, history of trauma to the elbow, is fit and well, a hard-working
however, painful. There is definite point tenderness over the plumber all his life?
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Treatment
CANDIDATE: Osteroarthritis elbow. Non-operative management
EXAMINER: Take a look his x-rays.
This includes analgesics, life-style modification, splinting,
CANDIDATE: AP and lateral radiographs of the elbow show physiotherapy and viscosupplementation.
multiple osteophytes along medial aspect of olecranon and
olecranon fossa, with a loose body just above the olecranon Operative interventions
posteriorly. 1. Arthroscopic surgery
EXAMINER: This gentleman had some loose bodies removed from Arthroscopic removal of loose bodies, excision of
his elbow 5 years ago with a successful outcome. However, he has osteophytes and release of capsular contractures to
been struggling with his work for the last 1year and recently had improve motion, relieve pain and reduce locking episodes.
difficulty with his personal care, such shaving, washing his face, Arthroscopic radial head excision in selected cases with
etc. He is keen to go back to work as soon as possible. What do lateral elbow pain secondary to radiocapitellar arthritis
you advise? may be indicated
CANDIDATE: Given his symptoms and high demands of his job, 2. Open procedures
I would recommend arthroscopy and removal of loose bodies Outerbridge–Kashiwagi procedure. A posterior triceps
with additional osteocapsular release, ideally performed by an splitting approach, the capsule is incised. Loose bodies
experienced elbow arthroscopist. Open procedures such as the removed and ostephytes around olecranon excised.
Outerbridge and Kashiwagi (OK) procedure allow removal of A fenestration made in the floor of the olecranon fossa
loose bodies and excision of impinging osteophytes at the providing an opening into the anterior compartment of the
extremes of motion. I would explain about the possibility of elbow. Loose bodies can then be removed from anterior
recurrence as well as risks such as neurovascular damage compartment. Osteophytes around the coronoid process
especially with arthroscopic interventions. and coronoid fossa can be excised using a Kerrison
rongeur. A partial release of the anterior capsule can
This is fairly short common case, either primary or secondary be performed through this bony window
osteroarthritis. Column procedure. Some patients with OA of the elbow
present predominantly with symptoms of loss of motion.
They develop progressive loss of extension with a
Primary osteroarthritis (OA) reasonably pain-free mid arc of motion. This is due to a
This is often in the dominant elbow of middle-aged men predominantly extrinsic contracture involving periarticular
involved in heavy manual labour. Loss of motion is the common- capsule ligamentous structures. The column procedure is
est presenting feature, generally patients maintain a functional useful in such patients in order to gain a functional range
range of motion in flexion and extension, forearm rotation is of motion especially of the extension deficit. The procedure
less frequently involved. Pain is mainly aching in nature, unless involves a lateral Kocher incision with elevation of the
occurring with episodes of locking when a more acute sharp brachiradialis and ECRB in order to gain exposure to the
localized pain is described. Pain is more common in terminal anterior aspect of the joint. The anterior capsule is then
extension than terminal flexion because of impingement. excised with removal of loose bodies and osteophytes. The
In advanced cases, pain can be constant and even at rest and triceps is then elevated to gain access to the posterior aspect
through the whole range of motion. Locking of the joint can of the joint and a similar procedure is repeated posteriorly
be episodic and associated with acutely painful flare ups. Interposition arthroplasty. This procedure involves
Always look for ulnar neuritis, as osteophytes tend to reshaping the distal humerus and proximal ulna,
impinge into the cubital tunnel. interposition of a membrane between the elbow joint
surfaces, and suturing it to the humeral side. Skin, fascia,
Secondary OA and Achilles tendon allograft are some of the materials
used to interpose between the re-shaped joint surfaces. The
This can occur in both sexes. Causes include trauma, infection,
collateral ligaments are either preserved or reconstructed
bleeding disorders, neuropathic diseases, osteochondritis
and a unilateral hinged fixator may be used to keep the
dissecans.
joint slightly distracted and to allow early ROM. This a
Radiographs show osteophytes at the tip of olecranon
good salvage procedure for young active patients with
and coronoid processes. The olecranon and coronoid fossae
severe inflammatory or post-traumatic arthritis, especially
also demonstrate ossification and osteophytes. Reduction in
with limited elbow motion. The procedure may lead to
the joint space and loose bodies may also be present(Figure 8.6
problems with instability and, therefore, is not be suitable
a and b).
for heavy manual workers
A CT scan, especially three-dimensional, is useful to iden-
tify all potential osteophytes needing debridement. Nerve con- Total elbow replacement (TER). Ideally suited for inflamma-
duction studies may help to confirm an ulnar neuritis. tory arthritis. It is recommended that after TER patients do not
011
(a) (b)
Figure 8.6 AP (a) and lateral (b) radiographs demonstrating advanced OA elbow
lift >4–5 kg with the operated arm as a single event or >1 kg

b. Neuro exam (nothing)
repeatedly. Currently, TER is only indicated in patients with
c. Function problems (nil)
primary OA of the elbow who are older than 65 years of age
d. What other problems would he have – Wanted
(this is not absolute), have low activity levels, experience pain instability, got there eventually
throughout range of motion or who have substantial deficits e. X-ray of recent posterior dislocation, hence, instability!
in motion in whom all other interventions have failed. Com- f. Clinical testing for varus/valgus instability including
pliance with postoperative restrictions and life style is essential. posterolateral pivot shift
The OK procedure and arthroscopic osteophyte excision
and capsular release for osteoarthrosis are now common pro-
cedures(Figure 8.7 a and b).
Candidates must be familiar with x-ray appearances of
an elbow following such procedures (especially the OK pro- Painful elbow with previous surgery for cubital
cedure with a fenestration in the olecranon fossa in both AP
and lateral views). Candidates should also be familiar with the
tunnel syndrome
x-ray appearances of a lateral elbow replacement and total Often in the exam, candidates may come across a case
elbow replacements. of ulnar nerve dysfunction with or without an old surgical
scar over medial aspect of elbow. Apart from possible
previous surgery for cubital tunnel release, the scar may
Examination corner be secondary to a previous fracture fixation (i.e. medial
epicondyle), a MCL repair with ulnar nerve injury, a delayed
Short case
ulnar nerve dysfunction secondary to callus formation or
1. Cubitus varus (adult)
an angular deformity such as cubital valgus especially in
a. Describe deformity and old lateral scars
children.
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011
(a) (b)
Figure 8.7 AP (a) and lateral (b) radiographs elbow after arthroscopic osteocapsular release for advanced OA elbow
Distal biceps rupture scar over the lateral aspect of elbow. The carrying angle is less when
compared to opposite elbow. There is no tenderness around the elbow
This is usually a short case and may be an acute or chronic
with palpation, the relationship between the three bony points around the
rupture. An acute week-old rupture has been known to be
elbow appears well maintained. She can freely flex to 90° and there is some
brought up the examination hall 2 days or so before planned
degree of hyperextension by about 10–15° when compared to the opposite
surgery.
side. There is some bony crepitus when testing for ROM and instability
The examination should also include hook test, lag test and
that was not associated with any major discomfort. The composite
squeeze test as part of look, feel and move. Also important to
movement of the shoulder, elbow and hand appears to be intact and
determine the loss of strength in supination and elbow flexion
functional. No distal neurovascular problems were noted with ulnar,
when compared to opposite arm (very accurate in clinical
radial and median nerve functioning well. Varus and valgus stressing
practice –rotate the distal forearm rather than the hand to
of the elbow in 30° of flexion suggested a degree of elbow instability
avoid compensating by wrist motion). Distinguish between
but with no obvious associated pain . . .
long head of biceps rupture and distal biceps tendon avulsion,
EXAMINER: What do you think Mrs Parkinson’s elbow range of
based on direction of retraction of muscle belly.
movements are due to?
Discussion would be on the timing of operation, approach,
CANDIDATE: Given the clinical findings, with an associated scar,
one and two incision techniques, postoperative rehabilitation,
slightly obliquely placed, I suspect the condition is post-traumatic
delayed presentation and grafts that can used, etc.
with resulting instability either due to a combination of fractures and
Non-union, pseudoarthrosis of distal humeral fracture ligaments injuries such as terrible trial or non-union of a distal humeral
fracture. In reality, I would like to take a thorough history and
EXAMINER: Please examine this woman’s left elbow. perform complete neurological assessment to rule out Charcot joint as
CANDIDATE: (After introduction) Mrs Parkinson’s left elbow appears to be well given the free and painless ROM, swelling around the elbow and
straight with some swelling/fullness of the elbow obliterating the normal some bony crepitus
fossae around the elbow. There is a 5-cm well-healed longitudinal surgical EXAMINER: Have a look at the x-rays.
011
CANDIDATE: AP and lateral elbow radiographs demonstrate a transverse Mrs Parkinson’s radiographs reveal a particularly low fracture in the
fracture pattern in the distal metaphyseal portion of humerus with signs distal humerus with doubtful collateral ligament functional integrity;
of non-union and exuberant callus. The distal fragment is in slight therefore, a semi-constrained hinge arthroplasty would be needed
recurvatum. The elbow joint itself shows gross OA changes with reduced in her case.
joint space with multiple osteophytes.
EXAMINER: Yes, a typical fracture in an OA elbow will predictably go
onto a non-union with or without operation intervention. What would
References
1. Morrey BF, Askew LJ, Chao EY. A biomechanical study of
you like to do?
normal function elbow motion. J Bone Joint Surg Am. 1981 63
CANDIDATE: I would like a full assessment including the main symptoms 872–7.
from the elbow and any functional disability. It appears from
2. Morrey BF. Post-traumatic contracture of the elbow. Operative
examination, that Mrs Parkinson has a good and painless functional
treatment, including distraction arthroplasty. J Bone J Surg Am.
ROM and if her activities involve low demands on a non-dominant 1990;72:601–18.
side, I would advise no intervention. If on the other hand any functional
3. Charalambous CP, Morrey BF. Posttraumatic elbow stiffness.
problems were associated with significant pain, I would then consider J Bone Joint Surg Am. 2012;94:
TEA but once again this would only be suitable for low-demand activities. 1428–37.
69
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Hand and wrist clinical cases

Chapter
9 John E. D. Wright and John W. K. Harrison
Introduction Screening examination

To confidently approach the hand and wrist clinical cases you Ask the patient to place their hands in front of them with their
need two main examination approaches. The first is to deal elbows by their side. Get them to copy what you do. In
with the case that on first inspection looks normal; this is in pronation, ask them to make a fist and open their fingers, then
contrast to the case where the pathology is glaringly obvious – ask them to fully supinate and again make a fist. Then ask
For example, advanced Dupuytren’s disease. A structured gen- them to raise their hands above shoulder height to show you
eral screening when asked to examine a hand or wrist should the ulna border keeping their fingers straight. All the time you
lead you swiftly to the underlying condition. You can then are inspecting for clues to the diagnosis, such as scars, swell-
focus your examination. Classic cases where the diagnosis is ings and asymmetrical movements.
immediately obvious, such as Dupuytren’s and rheumatoid
arthritis, should be ones you relish and can score highly on. Look
A crucial part of hand examination is an assessment of Splints
function. A brief confident assessment of hand function can be Elbow – Cubitus valgus, rheumatoid nodules, cubital
very impressive and can put you at ease at the start of a tunnel scar
complex case. You should have a key, coin and pen in your Forearm – FCU wasting, scars – Nerve decompressions,
pocket to complete this. fracture plating
Common cases Fingers – clawing, boutonnière deformity, swan-neck

The following upper limb cases are likely to appear (not in deformity, mallet finger deformity, Wartenberg’s sign
order of frequency): Nails – clubbing, pitting
Arthritis – Rheumatoid hand, psoriatic arthritis, Muscle wasting – Hypothenar, thenar, interossei – Guttering
osteoarthritis
Nerve lesions – Ulnar nerve, radial nerve, median nerve Swellings – Ganglia, giant cell tumour (GCT), Dupuytren’s,
Dupuytren’s disease rheumatoid nodules
Swelling – Ganglion, giant cell tumour, lipoma, carpal boss Congenital – Camptodactyly, clinodactyly (Figure 9.1 a
Tendon rupture – Extensor pollicis longus (EPL), and b), polydactyly, syndactyly
Vaughan–Jackson syndrome, Mannerfelt lesion
Intrinsic minus hands (Charcot–Marie–Tooth) Feel
Stiff finger – Trigger finger, volar plate contracture Ask where it is tender
Kienböck's Feel for swellings and tenderness
Congenital – Brachydactly, cleft hand, Madelung’s Feel palm for nodules
deformity
Move
Examination of the hand Mass movement (make fist) – Look for speed, smoothness and
When asked to examine a hand or wrist it is important to symmetry
expose to above the elbows. An initial screening test allows for Digits – MCP joint 90°, PIP joint 100°, DIP joint 70°, ‘tip-to-
identification of most pathology and looks impressive. The palm’ distance
skill is to know when to leave the general screening and focus
Thumb – Opposition, flexion, abduction, adduction,
in on a specific pathology. In complex cases and advanced
retropulsion (lift thumb with palm flat on table)
rheumatoid arthritis an early functional assessment is a good
way to get started. EDC/EI/EDQ – extend MCP joints
012
Chapter 9: Hand and wrist clinical cases
(a) (b)
Figure 9.1 Clinodactyly. In this case a uniplanar deformity (a) which corrects on finger flexion (b)
Interossei – ‘DAB & PAD’ (mnemonic for Dorsal ABduct,

Palmar ADduct)
Quadriga effect – Middle to little finger FDP have common
muscle belly; flexion of other digits is limited by the shortening
of an injured or repaired FDP
Functional assessment
Preparation is vital. Have a key, a pen and a coin easily
available.
Ask them to hold the key (key), pick up the coin from your
palm (tripod), hold the pen (tip to tip) and then grasp your
forearm (power).
Grip (6) – Power – Cylindrical, spherical, hook
Figure 9.2 ‘OK’ sign – Testing anterior interosseous nerve
precision – Tripod, key (thumb to side index), fine – (tip to tip)
Neurology Ulnar – FCU, FDP (little finger), ADM, first dorsal

Sensation interosseous, Froment’s test
Median – Index finger pulp/thenar eminence (superficial Radial – brachioradialis, ECRL – Posterior interosseous
sensory branch) nerve – ECU, EI, EPL
Ulnar – Little finger pulp/dorsum fifth metacarpal (dorsal
sensory branch)
Pulses
Radial – Dorsum first web space Allen’s test – For intact palmar arch. Make fist, compress radial
Dermatomes – C6 – Thumb, C7 – Middle finger, C8 – Little and ulnar arteries at wrist. Relax fingers. Release over one pulse
finger to see if hand reperfuses.
Motor Special tests

Median – FCR, FDS, APB Flexor tendons
Anterior interosseous nerve – Supplies FDP (index), FPL, ‘OK’ FDP – Test each individually, resisted DIPJ flexion with PIPJ
sign (Figure 9.2) held extended
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012
rupture of the central slip (PIPJ extends indirectly due to pull

of lateral bands)
Boyes’ test (chronic) – Hold PIPJ hyperextended; there is
failure of DIPJ flexion if the central slip is retracted and
adherent.
Examination of the wrist

Initial inspection is often unhelpful in wrist cases, with palpa-
tion and special tests being more revealing. Potential diagnoses
can be grouped into radial sided, central or ulna sided. The
order of look, move, feel and special tests is suggested.
Four articulations (DRUJ, radiocarpal, mid-carpal, carpo-
Figure 9.3 Testing for FDS metacarpal)
Radial side wrist pain (RSWP)

FDS – Test by holding neighbouring digits extended (to Tendon entrapments
exclude FDP) (Figure 9.3). Index finger has a separate FDP so
keep DIPJ extended while testing FDS. FDS to little finger is De Quervain’s (Finkelstein’s test)
absent in 10% of people Intersection syndrome
Arthritis
FPL – Resist IPJ flexion of the thumb with the MCP joint held
First carpometacarpal joint arthritis (grind and
extended
distraction–relocation tests)
Tenodesis test (for intact extrinsics) STT joint arthritis (pronate wrist against resistance)
Passive flexion wrist causes MCP joints to extend, then pas- Radioscaphoid arthritis
sively extend wrist and MCP joints flex. Scaphoid non-union
Wartenberg’s neuritis (entrapment of the superficial
Intrinsics (lumbricals and interossei) branch of the radial nerve deep to brachioradialis)
Intrinsic muscles actively flex MCP joints and extend IP joints
by direct action across the joints. Extrinsic muscles actively Central
extend the MCP joints and flex the IP joints.
Kienböck’s
Plus deformity = MCP joints flexed, IP joints extended Ganglion – Related to scapholunate ligament
Minus deformity = MCP joints hyperextended, IP joints Carpal boss
flexed
Scapholunate advanced collapsed (SLAC) wrist
1. Bunnell–Littler test (for intrinsic tightness). Hyperextend
MCP joint. If cannot flex IP joint = intrinsic tightness or Ulnar side wrist pain (USWP)
tight capsule, so flex MCP joint; if still tight = joint Distal radioulnar joint (DRUJ)
contracture Triangular fibrocartilage complex (TFCC) tear
2. Intrinsic vs extrinsic flexor tightness – Flex wrist (this Ulnar impaction
relaxes long flexors); if you can flex IP joints = tight Lunotriquetral instability
intrinsics Extensor carpi ulnaris (ECU) – Tendonitis/instability
3. Bouvier’s test (to determine in intrinsic minus hand if the Pisotriquetral OA
extensor mechanism is working normally). Blocking
hyperextension MCP joints = allows extension of IP joints
by EDC Look
4. Lumbrical plus finger. Paradoxical IP joint extension on Splints
attempted finger flexion. Due to laceration of FDP distal to Nails – Clubbing, pitting
the origin of the lumbrical Deformity – Congenital (Madelung’s), distal radius mal-union,
thumb base ‘squared off’
Central slip extensor tendon Swellings – Ganglion, prominent ulnar head – Caput ulnae,
Elson’s test (acute injury) – Flex PIPJ over the table edge. synovitis
Resisted PIPJ extension is weak and the DIPJ hyperextends = Scars
012
Dorsal – Midline/transverse/arthroscopy/first extensor However, this is still a frequent case in exams and may be an
compartment intermediate case. These patients can have pain and the exam
Volar – Scaphoid surgery/carpal tunnel release/radial is essentially passed by description and a good functional
(ganglion) assessment. The appearance of an established rheumatoid
hand is very typical and usually easy to identify, the difficulty
Move lies in how to proceed with the examination.
Standard screening assessment allows initial diagnosis to be
Observe both wrists together, ask the patient to press their
made, and with arm elevation inspection of the elbows for
palms together to assess wrist dorsiflexion, then the back of the
scars and nodules, plus importantly to comment on the shoul-
hands together to assess palmer flexion. In pronation assess
der and elbow function. Performing a hand functional assess-
radial and ulna deviation and finally assess supination.
ment before addressing the specific deformities can be an
Look for subtle asymmetry to suggest pathology in the
easier way to proceed.
wrist with reduced movement.
One strategy is a phrase such as – ‘On inspection I can
see this patient has bilateral, symmetrical, polyarthropathy
Feel suggestive of inflammatory arthritis. It is most likely to be
Have a logical sequence starting dorsal and then volar, palpat- rheumatoid arthritis. I would first like to perform a functional
ing specific anatomic sites (NB. Lister’s tubercle is most easily assessment before looking at the specific deformities.’
palpable bony landmark on dorsum of wrist.):
First extensor compartment, ASB, SLL (1 cm distal to Lister’s
tubercle), DRUJ, ECU tendon, TFCC (foveal soft spot),
History
pisiform, hook hamate, median nerve, FCR, first CMC joint Pain – Site, severity, night pain
Weakness
Special tests – Provocative and instability Paraesthesia
Finkelstein’s test – Ask the patient to place thumb across Neck symptoms – Neck pain, radicular pain, myelopathy
palm, then wrap fingers around thumb, finally gently ulnarly Previous surgery
deviate the wrist. Take care this is painful! Function
TFCC tear – Ulna deviate the wrist, and compress and Activities of daily living:
rotate hand – Shop independently
DRUJ – Compress midshaft radius and ulna, and rotate – Stairs
forearm. ‘Piano keys’ test – Dressing (buttons)
Pisotriquetral joint – Palpate for using index finger tip, – Washing (face, hair)
compress and move radial and ulna – Eating
Scapholunate instability Previous medical history (and DVT)
Kirk–Watson’s test – ‘Arm wrestling position’ – Patient’s Medications (and allergies)
elbow resting on table and flexed 90°. Examiner’s thumb Social – Smoking, alcohol, job, hobbies, partner, stairs
over scaphoid tubercle, index finger over SLL dorsally, Family history
examiner’s other hand around metacarpals. As moving
patient’s hand from ulnar to radial deviation, exert
pressure with the thumb to prevent scaphoid flexing. Examination
Positive test if there’s click or pain. Compare to opposite Perform screening assessment of hands, elbow and shoulder.
(20% positive in normal) State the diagnosis.
Scaphoid thrust test – Similar to above but with more
rapid ‘thrusting;’ of the scaphoid which is felt to move Look
dorsally Swelling over the dorsum of the wrist (tenosynovitis ± caput
Midcarpal instability – Hold forearm and hand, with thumb ulnae). Caput ulnae – As carpus volar subluxed and supin-
on dorsum of capitate and pressing volarwards, as wrist is ated. ECU volar-ulnar subluxed, metacarpals radially angu-
ulnarly deviated a clunk is felt late, swellings over MCP joints, volar-ulnar subluxation
Lunotriquetral instability (volar intercalated segment instability of MCP joints, dropped fingers, swan-neck and boutonnière
(VISI) deformity on radiographs) – Reagan’s ballottement. deformities of the digits, Z-thumb, palmar erythema, muscle
Pain and laxity felt on dorsal/volar stressing of the lunate wasting.
The three most common rheumatoid scars – Wrist arthrodesis,
Rheumatoid hand and wrist MCP joint replacements, thumb MCP joint fusion.
The medical management of rheumatoid arthritis has signifi- Move

cantly reduced the requirement for orthopaedic treatment. Mass movement – Ask the patient to make and open a fist.
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012
Functional assessment previous surgery over the wristb, thumbc and fingersd. There are
– Pick up a coin (tripod pinch) boutonnière deformities of the index and middle fingers. There are
firm subcutaneous nodules at the elbow, over the extensor tendons
– Hold a pen (end pinch)
and in the palm. The flexor aspects of the fingers appear bulky due
– Hold a key (side pinch) to chronic synovitis. There is wasting of the small muscles of
– Power – Grip around your wrist (grip strength) the hand. There is thin bruised skin; pale nail beds and nail fold
infarcts are present. There is no nail pitting or scaly rash seene. In
Feel the palms I am looking for pallor in the palmar creases indicating
Tenosynovitis; feel the digits to gauge whether they are floppy anaemiaf and palmar erythemag.’
(arthritis mutilans), and the subcutaneous border ulnar for
nodules. Identify MCP joint subluxation. Sensation specific Examiner questions
to carpal tunnel syndrome.
Can you explain the reasons for the ulna deviation of the
Specific lesions
digits?
What causes a caput ulnae deformity?
Dropped fingers (NB. IPJ extension due to

What are the important functions of the hand?
What is a boutonnière deformity?
lumbricals) What is a rheumatoid nodule?
Causes ‘Are your hands painful?’
Vaughan–Jackson – Ruptured EDM/EDC, tenodesis test ‘I would now like to palpate the hands feeling for any
Ulnar subluxed extensor tendons (sagittal band rupture) areas of tenderness, boggy swellingsh. There is evidence of
bony destruction of the PIP and MCP joints with sparing of
– Finger extension maintained if MCP joint passively the DIP joints. I cannot feel any rheumatoid nodules or
extended and tendon centrally relocated Heberden’s nodules in the hand. None of the joints is
– Posterior interosseous nerve (PIN) palsy – Tenodesis tender or warm at present.’
test, radial deviation (ECRL) on wrist extension ‘Can you make a fist and now straighten your fingers and
– Dislocated MCP joints – Reduce and take radiographs thumb?’i
‘There is limitation of flexion and extension of all digits.
Locked trigger finger
PIP joint deformities are only partly correctable. There is no
extensor tendon rupture. This patient has severe
Mannerfelt lesion
rheumatoid disease affecting both hands. I would like now
Ruptured FPL by attrition on scaphoid bone spur causes to assess function of the hands and review radiographs of
loss of thumb IPJ flexion (treatment: FDS tendon transfer or the hand. To complete my examination I would like to
fuse IPJ). examine the cervical spine and look for extra-articular
Differential diagnosis is anterior interosseous nerve (AIN) manifestations of rheumatoid arthritis.’
palsy or trigger thumb.
Memorandum or dislocation, PIN palsy or flexor contracture produced by intrinsic

‘This patient has features of a symmetrical polyarthropathy of tightness.
b
the small joints of the hand typical of rheumatoid arthritis. There Usually arthrodesis of the wrist for strength and stability.
c
are swellings over the dorsum of both wrists and the MCP joint. Usually arthrodesis of the MCP joint for strength and stability.
d
There is spindling of the fingers due to soft-tissue swelling at the Usually silastic joint replacements for movement and pain relief.
e
PIP joints and MCP joints but the DIP joints are spared.’ Psoriatic arthropathy is an asymmetrical arthropathy involving
‘There is significant restriction of elbow and shoulder mainly the DIP joints with pitting of the finger nails and
movement.’ hyperkeratosis. There is a red, scaly rash over extensor surfaces
‘Functional assessment reveals weakness of grip strength, but or scalp.
f
There are five main causes of anaemia in rheumatoid arthritis:
they have functional key, end and tripod pinch.’
Anaemia of chronic disease, GI bleed, bone marrow suppression,
‘On closer inspection I can see ulnar deviation of the fingers
associated with pernicious anaemia and Felty’s syndrome.
at the MCP joints, volar subluxation of the MCP joints, radial g
Redness around the palm sparing the central area is associated with
deviation of the wrists and a prominent ulnar head. There is a rheumatoid arthritis, pregnancy and liver disease.
Z-deformity of the thumb, swan-neck deformity of the left little h
Talk to the examiners – Tell them what you are doing as you go
and ring fingers.’ along. Do not let the examiners assume/think that because you are
‘There is drooping of the right little and ring fingers suggestive not saying anything you know nothing. It is useful to communicate
of possible long extensor tendon rupturea. I can see scars of your findings to the examiners at each stage.
i
Try not to get bogged down in describing one abnormality in the
hand; work through problems systematically and be guided by the
a
Dropped finger suggests tendon rupture but remember dropped examiner as to what they specifically want you to concentrate on,
fingers may also be a result of tendon subluxation, joint subluxation particularly with special tests.
012
Other possible features Short case 6: Young rheumatoid female. Right wrist fused. Left
Carpal tunnel syndrome: Caused by flexor synovitis. wrist replaced – Discuss
Check for thenar muscle wasting and test the power of Performing bilateral wrist arthrodeses in patients with inflam-
abductor pollicis brevis (APB). Don’t miss the scar matory arthritis is controversial. Patients with bilateral wrist
fusions are believed to have less dexterity and greater func-
from previous decompression
tional compromise than those with one wrist fused and arthro-
Triggering of digits: Secondary to tenosynovitis. plasty of the other. There is disagreement as to which wrist
May cause loss of flexion especially in the thumb should be fused. Arthrodesis of the non-dominant hand and
Palmar erythema: Non-specific change indicative of a arthroplasty of the dominant hand is generally recommended.
hyperdynamic circulation
Arterial pulses: Do Allen’s test
PIN palsy: May occur at the elbow in rheumatoid patients Dupuytren’s disease (DD)
due to anterior dislocation of the radial head. The patient Commonly occurs in the short cases and hand oral. Pattern
will present with an inability to extend the fingers and recognition is important – A Dupuytren’s hand can easily be
thumb although the wrist can be extended, albeit into summarized in a few lines. Don’t forget to say the diagnosis
radial deviation. (Radial nerve innervates ECRL.) The early in your examination if it is obvious.
differential diagnoses are rupture of the extensor tendons Take care not to diagnose a fixed flexion deformity on
at the wrist, ulna subluxation of extensor tendons at inspection; it may be passively correctable on examination.
MCP joint, subluxation/dislocation of MCP joint or Cords can be very minimal but cause significant contracture,
flexor contracture secondary to intrinsic tightness. requiring careful fingertip palpation to identify them. Con-
Tenodesis test will differentiate between ruptured or intact versely if you can’t feel any cords in a fixed flexed finger think
extensor tendons. If the extensor tendons are intact the of another diagnosis.
fingers will passively extend upon wrist flexion. If the
extensor tendons are ruptured the fingers will not extend.
Management depends on symptoms, functional assessment Differential diagnosis of DD
and any previous or ongoing treatment Locked trigger finger
Camptodactyly
Skin contractures (secondary to burns or scarring)
Examination corner PIP joint volar plate contracture
Short case 1: Florid rheumatoid hands, elderly female
Tendon contracture (thickened cord moves on passive
Time spent discussing clinical features, assessment, manage- flexion of the finger)
ment, etc. Arthrodesed joint
Short case 2: Rheumatoid hands

General discussion and classification (Nalebuff) of the classic History
deformities seen. Patient also had scar from previous elbow Age, hand dominance
arthroplasty. Age of onset of the disease
Rate of progression of the disease
Short case 3: Atlanto-axial subluxation
Functional deficit: Difficulty putting hand in pocket,
The candidate was asked to examine a woman’s hand. Clinical
features were of rheumatoid hands. The examiners did not
washing face, wearing gloves,
want a description, only the spot diagnosis. The examiner then Foot or penile involvement
asked the candidate, ‘Why is she wearing a cervical collar?’ Family history
The candidate, who had noticed it but not mentioned it, Previous medical history: Diabetes, epilepsy, alcohol,
said it could be because of atlanto-axial subluxation. smoking, trauma
Short case 4: Extensor tenosynovitis in the rheumatoid hand
Occupation, hobbies
Diagnosis Previous hand surgery
Differential diagnosis
Complications
Tendon rupture and caput ulnae Inspection
Principles of tendon reconstruction in a rheumatoid hand Look
Pits (Dupuytren’s inserting vertically into the skin) and
Short case 5: Rheumatoid hand after a Swanson MCP joint nodules – Early changes
replacement operation
‘How would you perform the operation?’ Cords – Pretendinous (Figure 9.4), natatory, lateral, spiral,
abductor digiti minimi, commissural
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Figure 9.4 Pretendinous cord causing a MCP joint contracture. Assess for PIP
joint contracture with MCP joint flexed fully. If skin is mobile over the cord, this
can be treated with percutaneous needle fasciotomy or collagenase injection
Scars – Brunner, Z-plasty, amputation!

Dermofasciectomy – Look for hairs in graft and scar for
donor site
Garrods pads – Thickening on dorsum of proximal
interphalangeal joints
Ask the patient to straighten out their fingers, palms up.
‘The hand is held with a flexed posture to the little and ring finger
at the MCP and PIP joints. There are skin pits and nodules present
in the palm. There are no obvious scars suggestive of previous
surgery present in either the palm or fingers.’
Ask the patient to flex their fingers fully.
Figure 9.5 Digital Allen’s test
Feel
Palpate with your index finger across the palm and then surgery). Assess the circulation with a digital Allen’s test
distally following any cords identified. (Figure 9.5 – Press either side of the fingertip and milk the
‘There is an abductor cord to the little and a pretendinous cord to blood out proximally to the base. Release pressure on one side
the ring finger causing contractures at the MCP and PIP joints. and observe if the finger perfuses. Repeat for other digital
There are no Garrod’s pads present’j.
artery).
Measure EXAMINER: What else would you like to examine?
CANDIDATE: The soles of the feet (Ledderhose’s),k the dorsal knuckle
As the cords cross more than one joint, flex the PIP joint fully
pads.10 DD is also associated with Peyronie’s disease.l
to measure an MCP joint contracture (place a goniometer on
the back of the digit), then flex the MCP joint fully to measure EXAMINER: How would you decide on management?
a PIP joint contracture. Rarely is the DIP joint involved. The CANDIDATE: I would perform a Hueston’s tabletop test. More precisely
true contracture for each joint can be much less than the I would offer intervention for an MCP joint contracture >30°, or for
apparent contracture on initial inspection. any significant PIP joint contracture >15°. Other factors such as age,
functional deficit, rate of progression and previous surgery are also
Sensation and vascularity relevant.
It is very important to test for sensation distal to any proposed EXAMINER: Consent me for a partial fasciectomy.
site of surgery especially if there are scars from previous
surgery present (1.5% risk of digital nerve injury for first-time k
Can affect the plantar aponeurosis.
l
Fibrosis of the corpus cavernosum causing curvature of the penis.
j
The knuckle pads(dorsum proximal interphalangeal joints) The examiners are unlikely to expect you to confirm this
(Garrod’s pads) can often be thickened. association!
012
CANDIDATE: The aim is to excise diseased tissue and restore movement

appears to be a cord running between the thumb and index
through a zigzag incision. It is performed under general anaesthetic. You
finger, which I hadn’t noticed.
will wake up with your hand in a bulky dressing and go home on the same
EXAMINER: What do you call that cord?
day. A therapist will see you at 48 hours and remove the dressing and
commence splinting. Your sutures are taken out at 10–12 days, then you CANDIDATE: Commissural cord. ‘Can you put your hand down flat
have wound management to soften the skin and splinting at night for 6 on the table, please, sir?’ The patient is unable to put his hand
months. Surgery is to control the disease and not cure it, and recurrence down flat on the table, the so-called Hueston’s tabletop test,
can occur. Complications include wound infection, haematoma, digital indicating that we may need to consider surgery in this
nerve injury (1.5%), stiff hand, reflex sympathetic dystrophy (RSD) and, gentleman’s case. ‘Can you feel me touching the side of your
rarely, amputation. finger? Does that feel normal?’
EXAMINER: Why may a PIP joint contracture not correct fully? The candidate continued to test digital nerves of each finger
whilst the examiners in background were heard to mutter, ‘Yes,
CANDIDATE: The question relates to the position of safety for splinting the
good’.
hand (wrist extended 20°, MCP joints flexed 90°, IP joints extended fully).
Flexion contracture of the PIP joint leads to shortening of the volar plate. CANDIDATE: There is normal sensation present in each digit.
An extensive release (check-rein ligaments, sheath, accessory collaterals, ± EXAMINER: What are the various bands in the hand?
volar plate) may be needed for a marked contracture (>70°) and this is CANDIDATE: The normal bands in the hand are the longitudinal
controversial as it can lead to further scarring, even limiting flexion pretendinous bands, spiral bands, natatory ligaments, Cleland’s
postoperatively. In the MCP joint, a 90° flexion contracture does not ligaments, Grayson’s ligaments and the lateral digital sheath.
shorten the collaterals due to the cam shape of the metacarpal head, and EXAMINER: And what are the diseased cords?
the joint will always straighten after excision of the Dupuytren’s tissue. CANDIDATE: Central cord, spiral cord, lateral cord, retrovascular cord
EXAMINER: What is the incidence of nerve injury at recurrent surgery? and abductor digiti minimi cord.
CANDIDATE: Usually about 1.5% for primary surgery with anything up to EXAMINER: Yes, the abductor digiti minimi cord; a lot of people
20% reported for recurrent surgery. forget about this cord and, as you can see, this gentleman has an
abductor digiti minimi cord that should be excised at surgery or
else you will not get full correction of the digit.
Examination corner How are you going to manage this gentleman?
CANDIDATE: I would perform a partial fasciectomy using a Brunner’s
Short case 1: Elderly man, bilateral DD
Spot diagnosis zigzag incision.
Asked to examine hands and comment on typical features EXAMINER: This patient is listed for surgery next week. What would
of DD. A few minutes of general discussion about DD you be concerned about from an anaesthetic point of view?
What are the various cords and what are the bands that CANDIDATE: There is a higher incidence of ischaemic heart disease,
contribute to each? (‘band’ is normal, ‘cord’ is diseased) chronic pulmonary tuberculosis, chronic lung disease, diabetes
Various finger incisions (Brunner’s allows excellent exposure and excessive alcohol intake in patients with DD.
of the neurovascular bundles – Z-plasties allow lengthening
EXAMINER: How would you obtain informed consent of the patient?
of the skin)
Role of open palm technique CANDIDATE: I would mention that surgery is not curative; there may
Diathesis be a recurrence. We are unlikely to achieve full correction of the
Recurrence rate finger and there is a small possibility of loss of sensation of
the digit owing to digital nerve injury. There is also a possibility
Short case 2: Elderly man, DD right hand that the blood supply to the finger can be compromised
EXAMINER: Would you examine this gentleman’s hands, please? because of stretching, spasm or division and very occasionally
CANDIDATE: On inspection there is a flexed attitude of the little and the finger may have to be amputated if the circulation does
ring finger of the right hand. Looking at the palm there are cords not recover. The wound can look very alarming postoperatively
extending into the little and ring fingers. There are no obvious but this is normal. The hand can become stiff and take several
surgical scars present. ‘Can you turn your hands around for weeks to recover. There is the possibility of a wound
me, sir?’ haematoma and infection developing in the hand. I would
On inspecting the dorsal surface of the hand there are also mention that the hand would need to be splinted at night
thickenings of skin over the PIP joint knuckles suggestive of for several months afterwards to lessen the chance of the
Garrod’s pads. This gentleman has DD and I would like to assess deformity recurring.
the degree of flexion contracture of the little and ring fingers.
Short case 3: Elderly man with DD and ring finger MCP joint
I took out a goniometer and made a show of measuring angles.
contracture with isolated palmer cord
He has a 30° flexor contracture of his little finger MCP joint and
Asked to examine hands.
20° of the PIP joint. In the ring finger there is a 20° MCP joint Discussion regarding treatment options. As the cord was
contracture and the PIP joint is minimally affected. There also well defined in the palm and only causing MCP joint
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contracture, treatment options lies between a needle aponeur-

History
ectomy or collagenase injections. The recent NICE guidelines Age/hand dominance
were explained and supported a needle aponeurectomy. This Occupation/hobbies
would achieve good correction, avoid general anaesthetic Previous trauma/surgery
and the chance of recurrence was less important at the Co-morbidities
patient’s age.
Diabetes/endocrine disorders
Short case 4: Young man with bilateral DD Alcohol/smoking
Anatomical and temporal distribution of symptoms
Describe the condition?
What questions would you ask in the history to evaluate Functional dexterity
this particular patient for aetiology, prognosis and
management? Examination
Logic of treatment? This is the suggested order of examination:
Indication for surgery? Inspection, sensory testing, palpation, motor testing,
What are the indications for a dermofasciectomy? What do provocation tests.
we mean by ‘firebreak’?
Look – Inspection
Short case 5: DD digital contracture
Often the limb can look normal on initial inspection.
Spiral cord components? Following the routine screening described earlier will identify
Surgical approach to a spiral cord to avoid damaging a peripheral nerve lesion.
the nerve?
How to release a PIPJ contracture? Muscle wasting
What is Dupuytren’s diathesis?
Ulnar: Ulna side forearm (FCU/FDP)/hypothenar
Short case 6: Elderly man with bilateral DD
eminences/first dorsal interosseous/guttering from interossei
wasting
CANDIDATE: On examination there is DD of both hands with a Radial: Wasting of radial side of proximal forearm
severe fixed flexion deformity at the PIP joints of the little and
Median: Thenar wasting – Most radial side specifically
ring fingers.
abductor pollicis brevis (APB)
EXAMINER: What do you think?
NB. Anterior and posterior interosseous nerve lesions show no
CANDIDATE: muscle wasting in the hand.
No Garrod’s pads
Positive family history Attitude
No ectopic disease
Neglected DD or diathesis.
Ulnar: Cubitus valgus, ulna clawing (MCP joint extension
EXAMINER: What treatment would you offer this patient?
and IP joint flexion), Wartenberg’s sign (loss third palmar
interosseous, with unopposed action of EDM causing little
CANDIDATE: My preferred option would be a multidigit partial
finger abduction)
fasciectomy. I explained this is complex surgery and may require
Radial: Dropped wrist, splints
skin grafts from the medial forearm. I would expect a tourniquet
time of 2 hours when planning my list. Amputation of the Scars
involved digits should certainly be considered although this may
Ulnar: Elevate the arms at the shoulders to inspect behind
be a bit drastic and wouldn’t be my first option, but should be
the medial epicondyle for a scar from cubital tunnel release.
discussed with the patient.
Traumatic or surgical scar in forearm. Scar from Guyon’s
canal release over volar aspect wrist
Radial: scar posteriorly over triceps from plating of
Peripheral nerve lesions humerus. Radius plating with scar from anterior approach
These are very common exam cases, often being chronic and (Henry) causing superficial radial nerve injury
painless, but with good clinical signs. The main causes are Median: carpal tunnel scar. Scar radial proximal forearm
compression neuropathy or traumatic injury (sometimes iat- from pronator syndrome release
rogenic!). Knowledge of the anatomy of the brachial plexus,
Sensation
the peripheral nerves and the specific dermatomal and sensory
nerve cutaneous supply is essential. A clear understanding of Ulnar nerve
how both motor and sensory testing distally relates to the Test the tip of the little finger and the dorsum of the hand over
proximal pathology produces a competent and efficient the fifth metacarpal. This differentiates between a high or low
examination. lesion. If the nerve is injured at the elbow sensation will be
012
lost in both places tested, but if the injury is at the wrist the Special test – OK sign (Kiloh–Nevin sign for anterior
sensation over the fifth metacarpal will be preserved as the interosseous nerve palsy) (Figure 9.6)
dorsal sensory branch arises 5 cm proximal to the wrist.
Provocative testing
Radial nerve These are done last in clinical practice and are unlikely to be
The superficial branch of the radial nerve arises at the level of performed in the clinical examination, but you should be able
the elbow and supplies the dorsum of the first web space. The to describe them and their significance.
posterior interosseous nerve has no cutaneous distribution. Ulnar: Tinel’s test over cubital tunnel and Guyon’s canal
Median nerve Elbow hyperflexion test (Wadsworth)
Test the tip of the middle finger and over the thenar eminence. Median: Tinel’s test over carpal tunnel
A lesion above the wrist will cause sensory loss in both areas, Phalen’s and reverse Phalen’s test. McMurtry compression test.
but sensation will remain over the thenar eminence if the
Provocation tests for pronator syndrome
lesion is in the carpal tunnel. The anterior interosseous nerve
has no sensory distribution. Radial: Resisted supination with elbow in extension
(compression under arcade of Frohse)
Palpation
Ulnar: differentiate tenderness over the cubital tunnel from
over the medial epicondyle (Golfer’s elbow) Peripheral Neuropraxia Physiological,
Radial: differentiate compression over the lateral epicondyle nerve injuries demyelination
(tennis elbow) from radial tunnel/PIN syndrome which is (Seddon)
5 cm more distal Axonotmesis Endoneural tubes in
continuity, Wallerian
Median: tenderness over the sites of compression for
degeneration
pronator syndrome in the proximal forearm Neurotmesis Epineurium divided, surgery
Sunderland Grade I–V (III – Scarring
Motor testing endoneurium, IV –
It is important to have a logical sequence of muscles tested and Complete scarring)
to be able to test each part of the peripheral nerves. This allows Myotome Muscle mass supplied by a spinal nerve
identification of the level of the injury or dysfunction.
Ulnar: Muscles in forearm – FCU and FDP to little finger
(Pollock’s test)
Intrinsic muscles – ADM and first dorsal interosseousSpecial Dermatome Skin area supplied by a spinal nerve
test – Froment’s Erb’s palsy Long-standing traction palsy to upper trunk
Radial: Main radial nerve – BR and ECRL C5/6
Arm internally rotated (suprascapular nerve)/
Posterior interosseous nerve – ECU, EI and EPL elbow extended/forearm pronated/wrist-digits
Median: Muscles in Forearm – FCR and FDS flexed
Intrinsic muscles – APB and OP. Klumpke’s Claw hand, decreased sensation medial arm
palsy (C8, T1)
Claw hand Combined median/ulnar nerve palsy,
rheumatoid arthritis, Volkmann’s contracture
Ulnar nerve lesions

Memorandum 1 (stabbing injury forearm)
‘On inspection there is a well-healed longitudinal surgical scar
over the volar-ulnar aspect of the mid forearm. There is abduction
of the little fingerm and hypothenar muscle wastingn. The
attitude of the hand is suggestive of ulna claw hand with flexion
of the ring and little finger PIP joints. The distal IP joints are also
m
Due to denervation of ADM.
n
Figure 9.6 Kiloh–Nevin sign (anterior interosseous palsy) Due to denervation of the hypothenar muscles.
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012
flexed; suggesting that the FDP is intacto. There is also Tinel’s test should be performed where the nerve enters the
hyperextension of the MCP joints of the little and ring fingers. two heads of FCU, but again can be positive in many ‘normal’
There is no obvious skin ulcerationp, brittleness of the nailsq or subjects.
tropic changes.’
‘Can you stretch both arms out please, and then bend them and Motor testing
lift them above your head?’
Practice a routine to test the nerve in a logical sequence. So test
‘There are no obvious deformities such as cubitus valgus or
the muscles supplied in the forearm first. FCU (resisted wrist
varus suggestive of an old elbow fracturer. There are no obvious
scars around the elbow’ flexion, palpate the FCU tendon) and FDP to little finger (test-
‘I would now like to test for sensation. Can you feel me touch resisted DIPJ flexion of little finger).
you here and now here? Does it feel the same as here on the Then test the nerve as it supplies the ulnar side of the hand
other hand?’ (ADM – Resist little finger abduction with your index finger
‘The sensation is lost over both the tip of the little finger and the while palpating the muscle belly with your thumb) and finally
dorsum of the fifth metacarpal suggesting the lesion occurred the terminal supply of the first dorsal interosseous muscle
proximal to the origin of the dorsal sensory branch.’ (place the patients hand in neutral forearm rotation then ask
them to lift the index finger, then resist as you press with your
Memorandum 2 (cubital tunnel syndrome – Post index finger and palpate the muscle belly with your thumb)
surgery) (Figure 9.7). Perform Froment’s test (for adductor pollicis)
‘Would you roll up your sleeves and put your hands palm down
last. Practice explaining how it works:
out in front of you please?’ ‘Can you make a fist and then ‘The patient is asked to hold the piece of paper or book between
straighten your fingers and turn your hands over please?’ ‘Please their extended thumb and index finger. If the ulnar nerve is
can you bend your elbows and lift your arms above your head?’ intact they can grasp it using the adductor pollicis (Figure 9.8a),
‘On inspecting the dorsal surface of the hand there is marked but if these are weak they will try to resist the paper being
interosseous muscle wasting, particularly of the first dorsal pulled away by recruiting the anterior interosseous nerve
interosseous muscle, with hollowing on the dorsal aspect of the innervated flexor pollicis longus and flex the IPJ of their thumb
first web space. There is some ulna clawing but no muscle wasting (Figure 9.8b).’
on the medial side of the forearm. There is a recent surgical scar on
the medial side of the elbow that is compatible with ulnar nerve Palmar interossei
decompression. Sensory testing reveals loss of sensation at both
Card test
the tip of the little finger and in the region of the dorsal sensory
branch. Palpating gently in the region of the scar I can feel the ‘Hold your hand out. Palm down, fingers together please. I’m
nerve posterior to the medial epicondyle suggesting it has not been just going to slide this card between your fingers (middle and
transposed. FCU and FDP have full power, but there is significant index). Keep your fingers straight. Can you grip the card
weakness of abductor digiti minimi, and the first dorsal between your fingers and stop me pulling it out? Now between
interosseous. Froment’s test is also positive. I believe this patient your middle and ring fingers and finally ring finger and little
has had severe cubital tunnel syndrome and a recent finger.’
decompression. Recovery may take 12–18 months.’ In the case of weak palmar interossei it is easy to pull the
card out.
Examination points for ulnar nerve lesions
Palpation
‘I would now like to palpate the nerve at the elbow. Please tell me if
this is painful or uncomfortable. I can feel the nerve posterior to
the medial epicondyle and as I flex and extend the elbow it does
not sublux anteriorly.’
The ulna nerve subluxes in 16% of normal subjects. Occasionally
there will be a snap as the nerve dislocates with elbow flexion.
o
Ulna paradox: Clawing of the hand is more obvious in low ulnar
nerve lesions because the FDP is intact and less obvious in high
lesions.
p
Caused by unnoticed trauma on the desensitized medial skin of the
dorsum and palm and the medial (ulnar) 1½ digits.
q
Due to denervation.
r
Cubitus varus deformity occurs most often with supracondylar
fractures whilst cubitus valgus deformity is more suggestive of an Figure 9.7 Testing first dorsal interosseous – Place index finger in abduction
old malunited lateral condylar mass fracture. and ask patient to resist pressure while feeling muscle belly
012
(a) (b)
Figure 9.8 (a, b) Froment’s test
Dorsal interossei
‘Can you cross your fingers?’ Sites of potential compression neuropathy at the elbow
‘Can you move your middle finger from side to side?’
Arcade of Struthers Formed by superfcial muscle fibres
First dorsal interosseous muscle of the medial head of triceps
attaching to the medial epicondylar
Support the patients hand with the index finger uppermost. ridge by a thickened condensation
Ask them to lift the index finger. If there is significant wasting of fascia
lift the finger yourself and see if the patient can hold it Cubital tunnel Formed by fascia from the
abducted. If they can lift it span the index finger and the medial epicondyle to the
muscle and while you try to adduct the finger palpate the olecranon (thickened Osborne’s
muscle for bulk and contracture. ligament)
Fascia of FCU Fascial bands connecting the two
Abductor digiti minimi heads of FCU
‘Now push your little finger out against my finger.’ Anconeus An accessory muscle
epitrochlearis Exit of the ulnar nerve from FCU
Again test for power but also feel the bulk of ADM while it Deep flexor-pronator
contracts. aponeurosis
Or
‘Can you push your little fingers together?’ (More sensitive test.)
FDP little fingers (Pollock’s test)

If FDP weak, nerve abnormality at elbow (high lesion).
Causes of ulnar nerve palsy (proximal–distal)
Brachial plexus
Differential diagnosis Trauma
Cervical radiculopathy
Thoracic outlet syndrome At the elbow
Cervical rib Bony abnormalities: Osteophytes, bony spurs, cubitus
Cervical spondylosis valgus (tardy ulna nerve palsy)
Pancoast’s tumour Scarring
Benediction hand (high median nerve lesion with FDP Anomalous muscles (anconeus epitrochlearis
paralysis to the index and middle finger) vs claw hand muscle)
(high ulnar nerve lesion with little and ring finger MCP Tumours
joint hyperextension and IP joint flexion) Ganglions
Trauma: Old fractures (lateral condylar mass
s fracture), lacerations, iatrogenic
Differentiates a high from a low (distal) nerve lesion.
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At the wrist
EXAMINER: Would you care to examine the motor function of the
Lacerations
ulnar nerve?
Ganglia
CANDIDATE: Examination included FCU and FDP little finger
which were both working, ADM, first dorsal interosseous
Ulnar tunnel syndrome (rare) muscle and Froment’s test (positive). I, therefore, explained that
Ulnar nerve compression in Guyon’s canal. it was a low ulnar nerve lesion affecting motor function but
not sensory function. My mind went blank as I didn’t know any
Signs of distal ulnar nerve lesion (low lesion) obvious causes for this condition but luckily the examiners didn’t
No muscle wasting of forearm probe me
Sensation over the dorsum of fifth metacarpal is intact I am also sure I jumbled up ulnar motor testing in a haphazard
Decreased sensation in ulnar 1½ digits (sensation of the random way(Not proximal to distal) and in fact began with ADM.
dorsum of the hand preserved) The examiners let me off with this as well!
Tender over Guyon’s canal EXAMINER: Let us move on to another case. (Pass)
FCU intact
Ulnar half of FDP intact (ulnar paradox), marked clawing Short case 2: Isolated ulnar nerve palsy with no scars present
over limb
Tendon transfers for a distal ulnar nerve
What is the commonest cause of an ulnar nerve palsy?
1. For weak pinch between the thumb and index finger Common sites of nerve compression?
(thumb adduction and index finger abduction) Clinical tests?
Split insertion of middle finger FDS to adductor pollicis Management (conservative and surgical)?
EIP to first DI muscle
Short case 3: Ulna claw hand
2. For loss of the interossei and ulnar two lumbricals
(clawing hand) EXAMINER:
Describe the appearance.
Zancolli capsulodesis to stabilise the MCP joint in 20°
Examine the nerves.
of flexion)
What is the differential diagnosis and why?
Or split tendon transfers of FDS ± EIP to the radial Level and why?
dorsal extensor apparatus. Carried out to restore MCP What is a Martin–Gruber anastomosis?
joint flexion and IP joint extension CANDIDATE: The Martin–Gruber anastomosis occurs when
motor fibers normally carried entirely by the ulnar nerve enter
Examination corner the ulnar nerve from the median nerve via branches in the
forearm. Disruption of the ulnar nerve above the level of
Short case 1: Ulnar claw hand, low lesion with pathology at
anastomosis may not necessarily result in motor loss of ulnar-
Guyon’s canal, no sensory change
innervated muscles.
EXAMINER: Would you care to examine this man’s right hand and
tell me what you see?
CANDIDATE: There were various well-healed traumatic and surgical
scars over the dorsal surface of the wrist. The volar–ulnar border
Radial nerve palsy
of the wrist had a recent longitudinal surgical scar over Guyon’s Radial nerve palsy is a classic clinical case. Patients with radial
canal. Gross interosseous muscle wasting and gross clawing of nerve injury and fracture fixation are frequently brought to
the hand were evident. I examined for sensory deficit; however, exams. Look for scars of humeral or radius fixation!
none was present.
EXAMINER: What difference would you expect to find in sensation Memorandum
between a high and low ulnar nerve lesion? ‘Would you roll up your sleeves and stretch your arms out in front
CANDIDATE: There would be decreased sensation at the tip of the of you please?’
little finger but normal sensation on the dorsum of the fifth ‘On inspection there is an obvious left wrist dropt. There is gross
metacarpal area if the lesion is low as the dorsal branch of the wasting of the left forearm musclesu. There does not appear to be
ulnar nerve is spared. any gross wasting of the triceps musclev. There are no scars or
swellings visible. Sensation over the first web space dorsally is
EXAMINER: What is the ulnar paradox?
CANDIDATE: Less clawing of the hand with a more proximal nerve
lesion. A more proximal lesion will paralyse FDP to the little and t
Due to loss of extensor muscles.
ring fingers, reducing the amount of IPJ flexion. u
Due to loss of extensors, the muscle bulk of which is in the forearm.
v
In high lesions.
012
reduced. I would now like to test the motor function of the Extensors of the fingers
radial nerve.’ ‘Can you bend your elbow into your side and give me your hand
Scars facing down (palm down)? I will support your wrist. Can you try
to straighten your fingers please? Straighten them. Don’t let me
If you identify a wrist drop ensure that you look for surgical push them down.’
scars from humeral fixation. In particular a posterior midline ‘He is able to extend his IP joints because of the action of his
scar over triceps, but also an anterior scar from a brachialis interossei and lumbrical muscles. He is, however, unable to
splitting approach and scars from humeral nailing. straighten his MCP joints.’
A scar over the volar forearm may be from a radius plating It is very important to appreciate that extension of the finger
with associated superficial radial nerve injury. Iatrogenic injury IP joints is from ulnar and median nerve function and MCP
to this nerve as it runs under brachioradialis is not uncommon. joint extension requires radial nerve function.
Sensation Test EPL
‘I would now like to test sensation.’
‘Please place your palm flat on the table. Can you lift up your
‘Can you feel me touch you here? Here? Here? Does it feel the
thumb?’
same as here on the other hand?’
‘There is sensory loss over the first dorsal interosseous muscle. Tests retropulsion.
This patient has features suggestive of superficial radial nerve
injury. There is evidence that this may have been caused by . . .’ Test EI and EDM
Ask the patient to flex their middle and ring finger and keep
Test tricepsw
their index and little finger extended at the MCP joint. It is
Extend the shoulder easiest to demonstrate and ask the patient to copy you. This is
‘Can you straighten your elbow?’ (Gravity excluded) possible due to the independent function of EI and EDM.
Then test resistance. Test triceps reflex.
‘He has normal triceps power and no loss of his triceps reflex. Radial nerve vs PIN palsy
Weakness of the supinator and brachioradialis muscle suggests a Radial nerve palsy
lesion above the supinator tunnel. Weakness of the triceps suggests Sensation lost over dorsum first webspace
a lesion at or above the mid humerus.’
Inability to extend elbow (triceps) if very high lesion
Test brachioradialis Triceps intact but wrist drop if lesion between triceps and
Flex the elbow in the mid prone position ECRL innervation
‘Can you bend your elbow and stop me straightening you arm?’
PIN palsy
‘I am now testing brachioradialis muscle. There is a definite
contraction of the brachioradialis muscle.’ No sensory loss
Remember – Brachioradialis does not cross the wrist joint. Nerve supply to ECRL and brachioradialis intact
Wrist extends with radial deviation
Test supinator Unable to extend MCP joints, no thumb
Elbow must be extended, to exclude the action of biceps. Place retropulsion (EPL)
the forearm in full pronation. It is difficult to isolate supinator.
‘Can you turn your hand over (against me)? Don’t let me stop
Causes of a radial nerve palsy
you.’ Axilla
‘I am testing the supinator muscle. There is a definite weakness Saturday night palsy: Neuropraxia from prolonged local
of supination compared to the other side.’x pressure
Ill-fitting crutches
Extensors of the wrist
Midhumerus
Place patient’s wrist in extension, look for radial deviation.
Fracture of the humeral shaft (or Holstein-Lewis type
‘Don’t let me pull it down.’
injury)
‘I am testing the extensor muscles of the wrist. He has weakness
of wrist extension MRC grade 4 minus.’ Tourniquet palsies
Lacerations, gunshot wounds
At and below the elbow

w
Triceps weakness suggests a lesion at the midhumeral level. Loss of Entrapment syndromes (FREAS; a mnemonic for Fibrous
all triceps activity suggests a high (plexus) lesion. tissue bands, Radial recurrent vessels, fibrous Edge of
x
Loss of supinator suggests a lesion proximal to the supinator tunnel. ECRB, Arcade of Frohse, Supinator)
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Rheumatoid elbow Median nerve

Dislocated elbow
The common compression syndromes are carpal tunnel syn-
Monteggia fracture drome and the less common pronator syndrome. An isolated
Surgical resection of the head of the radius anterior interosseous nerve palsy is frequently brought to
Mass lesions (ganglions) exams.
Tendon transfer (Jones’ transfer) Memorandum 1 (low median nerve lesion)

Wrist extension: Pronator teres to ECRB ‘On inspection of the left hand there is obvious thenar muscle
MCP joint extension: FCU (around ulna) to EDC or FCR wasting. The thumb appears to be lying in the plane of the palm –
(through interosseous membrane) A simian thumb (ape-thumb deformity). There is atrophy of the
Extension and abduction thumb: Palmaris longus to EPL pulp of the index and main fingers, dystrophic nail changes
present, generalized nicotine-stained fingers and possibly a
Supinator tunnel cigarette burn over the radial border of the distal phalanx of the
index finger. There is no obvious ulceration seen in the hand or
The fibres of the supinator muscle are arranged in two planes, fingers and no visible scars are present.’
between which lies the deep branch of the radial nerve (PIN). ‘The thumb cannot be opposed to the fingertips to produce
The supinator arises from the lateral epicondyle of the useful function. Testing for APB revealed MRC power grade
humerus, the elbow joint and superior radial ulnar joint and 4 minus compared to the opposite normal side with reduced
the supinator crest and fossa of the ulna. It inserts into the muscle bulk and tone present. However, testing for FPL revealed
posterior, lateral and anterior aspects of the neck and shaft of normal power.’
the radius as far as the oblique line.
Memorandum 2 (higher lesion)
Examination corner ‘In addition, there is wasting of the left forearm. The index finger
is held in a position of extension – Benediction attitude. On asking
Short case 1: Humeral shaft fracture with associated radial the patient to make a fist the index finger remains pointed – Finger
nerve palsy pointing sign.’
Demonstration of clinical signs – Posterior midline ‘I would now like to test for sensation.’
humeral scar ‘Can you feel me touch you here? Here? Does it feel the same as
When do you operate on humeral fractures? here on the other hand?’
What method? ‘There is sensory loss over the palmar aspects of the lateral 3½
What approach? digits and thenar eminence.’
What size of plate do you use? ‘I would now like to test for power.’
‘Lay your hand on the table, palm up please.’
Short case 2: Resolving radial nerve palsy (Saturday night palsy)
‘I identified on inspection that the patient had a wrist Median nerve motor testing
drop, I could not see any scars to suggest surgery. Flexor carpi radialis
I tested his sensation in the distribution of the first
dorsal web space and this seemed to be intact. ‘Can you bend your wrist and stop me pushing it back?’
I then proceeded to demonstrate the function of the Feel the tension in the FCR tendon
radial nerve from proximal to distal. Explaining to the
examiner why I was doing so. There was full power of Flexor digitorum superficialis
triceps.’ ‘I am going to hold your fingers out straight, and can you bend
‘When I asked the patient to flex their elbow I could your middle finger.’
detect some contraction in brachioradialis and on wrist
extension the wrist went into radial deviation suggesting Flexion at the PIP joint is from FDS function
that ECRL was intact but not ECRB or ECU. There was no
function in EI, EDC or EPL. I suggested to the examiner Abductor pollicis brevis
that I felt the patient had a resolving radial nerve palsy ‘I am going to hold your wrist so you don’t move your hand.
with the muscles supplied by the main radial nerve Now lift your thumb up off the table to touch my finger. Push
trunk functioning, but the posterior interosseous was against it.’
yet to recover.’
Resisted thumb abduction and feel for contraction and
‘We had a discussion about the use of external
bulk (Figure 9.9). The APB is the most radial of the thenar
wrist splints vs the use of a temporary internal
tendon transfer (PT to ECRB) to maintain wrist muscles and most specifically median nerve innervated. This
extension.’ is, therefore, the best muscle to test for the median nerve in the
hand.
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For flexion IP joint thumb

Interposition graft with Pl to FPL
FDS (ring) to FPL
For thumb opposition

EIP to APB
Pl to APB (Camitz)
Causes of a median nerve palsy

At the elbow
Fractures
Elbow dislocations
Figure 9.9 Testing APB – Resisted thumb abduction while feeling muscle Distal to the elbow
belly of APB
Pronator entrapment syndromes
Opponens pollicis In the forearm
‘Please can you touch the tip of your little finger with your thumb?
Now stop me from pulling them apart.’
Lacerations
Gunshot wounds
OK or Kiloh–Nevin sign Forearm bone fractures
‘Please can you make a circle with your thumb and index finger
like this? And pinch them together?’ Wrist
This is the test for the anterior interosseous nerve. If it is intact, Especially lacerations
the FPL and index finger FDP will flex the thumb IP joint and Colles’ fractures
index finger DIP joint, and it is possible to pinch while making Carpal tunnel syndrome
the OK sign. If the anterior interosseous nerve is deficient the
IP joints will collapse into extension on pinching. The differen-
tial diagnosis for loss of thumb IPJ flexion is an FPL rupture. Carpal tunnel syndrome
This is the commonest hand condition and although rarely
Low nerve lesion would be an isolated hand case, its frequency means it may be
Loss of APB and variable loss of FPB (and opponens present with another pathology. You are, therefore, likely to be
pollicis) asked about it at some point in the exam.
Weakness of thumb abduction and opposition
History
High nerve lesion Age/occupation
Low lesion plus: Hand dominance
Loss of flexion IP joint thumb (FPL) Numbness
Loss of flexion index and middle fingers (FDS, FDP) Pins and needles
FCR Night symptoms
Clumsiness
Tendon transfers for low lesion Diabetes, hypothyroid, neck symptoms
For thumb opposition (loss of APB)
Ring finger FDS transfer to APB, or EIP to APB Examination
MCP ± IP joint fusion Routine hand examination with particular attention to:
Muscle wasting
Tendon transfer for high lesion Sensory deficit
For index and middle finger flexion Motor deficit
FDP index and middle finger sutured side-to-side Decreased sweating
(tenodesed) to the neighbouring intact FDP of the ring and Ulnar nerve signs
little fingers (FDS cannot be used, as it is supplied by the Provocative tests: Tinel’s sign, Phalen’s sign, median nerve
median nerve) compression test
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Check that the patient is adequately exposed before starting Congenital

your examination. Make sure their shirt is rolled above their Persistent median artery (thrombosis of such an artery can
elbows. cause an acute onset of carpal tunnel syndrome)
‘In normal clinical practice I would start by examining the cervical High origin of lumbrical muscles
spine, shoulders and elbows but for the moment I will just
concentrate on the hands.’ Acquired
‘This (middle-aged) lady complains of pain, numbness
Inflammatory: Synovitis, rheumatoid arthritis, gout
and paraesthesia in the palm and fingers. This is particularly
severe at night and causes her to get up and shake her Traumatic: Colles’ fracture
hands to relieve symptoms. There is thenar muscle wasting Fluid retention: Pregnancy, renal failure, myxoedema,
and sensory loss over her radial 3½ digits. There is definite diabetes, congestive cardiac failure, steroids
weakness of abductor pollicis brevis compared to the Space-occupying lesion: Lipoma, ganglion
opposite side.’
‘Can you pull your thumb into your palm and now push your
thumb up to the ceiling?’
Differential diagnosis
Resist this movement with the index finger of one hand whilst
simultaneously feeling for the contraction of abductor pollicis Collagen vascular disorders
brevis with your thumb of the same hand. Thoracic outlet syndrome
‘There is also weakness of opposition of the thumb. The presence
Raynaud’s disease
of the long flexor and variability of the nerve supply makes testing RSD
for flexor pollicis brevis of doubtful value.’ Spinal cord lesions – Tumour, syrinx
‘Tinel’s sign is positive for median nerve irritation and, likewise, Peripheral neuropathy: Alcohol, diabetes
Phalen’s sign is also positive at 20 seconds.’
Look and be seen to be looking at your watch and test for at
least a minute before saying it is negative. Examination corner
‘The median nerve compression test was positive. The flexor Short case 1: A 60-year-old woman
muscles of the forearm are not involved, suggesting a distal ‘I was directed to her left hand, which had marked APB
median nerve lesion.’ muscle wasting, and was told she had had some tingling/
Or: pain in her index/middle fingers. I said I would like to
‘The symptoms the patient describes are suggestive of carpal commence the examination proximally from the neck but
tunnel syndrome. There is normal sensation in the palm, was told to concentrate on the hand. Comparing both
particularly over the thenar eminence. Tinel’s and Phalen’s tests hands I commented on unilateral thenar eminence wasting
were positive for median nerve compression but the nerve itself with no dorsal interosseous wasting.’
showed no motor deficit.’ ‘The examiners asked what I thought the diagnosis could
be. I answered carpal tunnel syndrome and was asked what
Signs I would want to examine – I mentioned sensation, motor
power and provocation tests.’
Wasting thenar eminence (LOAF: Mnemonic for lateral two
‘I was then asked then to examine motor power: APB was
lumbricals, opponens pollicis, abductor pollicis brevis, flexor
very weak but (ulnar) intrinsic power normal, which
pollicis brevis) I commented on.’
Decreased sweating and increased temperature at the thenar ‘I then tested FDP to index, which appeared to be a little
eminence weaker than in the opposite hand. Challenged, I said that
Decreased sensation in the radial 3½ digits (palmar branch non-dominance plus relative disuse may make it weaker
proximal to tunnel) although the possibility of proximal median nerve
Reduced power APB compression should be considered.’
‘I was then asked to demonstrate the carpal tunnel
Carpal compression (Durkin’s test) – Most sensitive
syndrome provocation tests, which were all strongly positive.’
‘Whilst walking to the next patient I was asked about
management. I mentioned that conservative measures
Test Sensitivity (%) Specificity (%) were unlikely to help given the marked wasting, which was
Tinel’s 74 91 suggestive of chronicity – Therefore, carpal tunnel
Phalen’s 61 83 decompression would be indicated. Asked what I would
advise her about the outcome, I mentioned that there was a
good likelihood of early night-pain relief but numbness
Causes could take up to 1 year to settle and the wasting could be
permanent.’
Can be congenital or acquired. Majority of cases are idiopathic.
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of the right thumb is one of flexion at the IP joint, and reduced

Short case 2: Bilateral carpal tunnel syndrome
span. Active dorsiflexion of the wrist is reduced to 30° compared
History/exam
to almost 80° on the opposite normal side. Similarly, palmar
Benefits of simultaneous vs sequential surgery
flexion of the wrist was 50° compared to 70° on the opposite side.
Pronation and supination are normal. There was no active
Short case 3: A 35-year-old woman with carpal tunnel syndrome
retropulsion of the right thumb, suggestive of EPL rupture. I was
Short history
not able to feel any contracture of the EPL tendon. There was some
Examination starting with the neck
mild swelling and tenderness around Lister’s tubercle in the line of
Provocation tests
the EPL tendon. The index finger can point in isolation indicating
Tests for proximal sites of compression of median nerve
the extensor indicis is present.’
Pronator syndrome Management

Entrapment of the median nerve around the elbow. Initially non-operative management to see if patient is func-
tionally limited or if the thumb is catching due to lack of span
before considering surgery.
History Surgery is an EIP to EPL tendon transfer. Requires a GA or
Ache or discomfort of the forearm after heavy use regional block and the patient will need hand therapy for super-
Weakness or clumsiness of the hand vised mobilization and a splint for 4–6 weeks postoperatively.
Paraesthesia in all or part of the median nerve
Three incisions
Examination Transverse over index finger metacarpal head (remember
Local tenderness to deep compression with reproduction of EIP lies ulnar to EDC)
symptoms Transverse or longitudinal incision proximal to extensor
Tinel’s sign is negative at the wrist but may be positive at retinaculum
the proximal anterior aspect of the forearm Oblique incision over the thumb MCP joint to identify EPL
Negative Phalen’s tendon distal to the rupture
Weakness of thenar muscles but sparing of AIN innervated
muscles
Short case 1
Provocation tests EXAMINER: What tendon is used to replace the function of EPL?
Elbow flexed, forearm pronated, resisted forearm CANDIDATE: EIP.
supination (bicipital aponeurosis) EXAMINER: How do you test for the presence of EIP?
Elbow extended, forearm supinated, resist forearm CANDIDATE: By asking the patient to point with the index finger.
pronation (two heads of pronator teres)
EXAMINER: How many incisions do you do in this tendon transfer?
Resisted middle finger PIP joint flexion (proximal arch of FDS)
CANDIDATE: Three.
EXAMINER: Show me where exactly on my hand you would place
Sites of compression (four sites) these incisions and what you are trying to achieve with each.
Supracondylar process humerus (ligament of Struthers) CANDIDATE: At this stage the oral deteriorated rapidly as I got
Bicipital aponeurosis mixed up with the reason for the various skin incisions. (Fail)
Between heads of pronator teres
Proximal arch of FDS
EPL rupture Hand oral 2

A classic clinic case: Either a rheumatoid patient or post- What tendon rupture can you get after distal radius
Colles’ fracture. A traumatic laceration is unlikely. fracture?
Which type of fracture is particularly associated with it?
Memorandum An undisplaced or minimally displaced colles fracture
Which tendon would you transfer?
‘On inspection there is generalized soft-tissue swelling over the
Show me the incisions.
dorsum of the right wrist joint. There is also a deformed
appearance of the wrist suggestive of a recent fracture. The attitude
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Spine clinical cases

Chapter
10 Prasad Karpe
Introduction It is uncommon to have a cauda equina or acute fracture

case for the clinicals but these are frequently asked for the
Over the last few years, spinal cases have become more relevant
vivas.
in the FRCS exam. Although candidates will not be expected to
manage complex spinal conditions as a Day 1 General Ortho-
paedic Consultant working in a District General Hospital, Preparation
knowledge of emergency management of important spinal 1. History
conditions is a must. Also, many patients with spine com- 2. General examination of the spine
plaints like limb radiculopathy or neurogenic claudication 3. Neurological examination
may be referred to your general orthopaedic clinic. 4. Upper and lower motor neuron lesion
All candidates not necessarily may have done a spine job 5. Investigations – MRI, CT, plain x-rays, nerve conduction
and some may find the spine cases quite perplexing. But like studies
everything in life, it’s all about planning. Just like the old 6. Management – non-operative or operative
saying, ‘If you fail to plan, you plan to fail.’ 7. Evidence-based practice: current literature, NICE
In other words, with adequate preparation, spine cases guidelines, British Orthopaedic Association Standards for
should be an area for scoring marks. Trauma (BOAST) guidelines, Spine Patient Outcomes
It is essential to know two kinds of scenarios for the FRCS Research Trial (SPORT) trial, etc
exams:
1. Common cases, e.g. prolapsed intervertebral disc
presenting with leg pain and/or back pain History
2. Rare but cannot be misdiagnosed scenarios like cauda
To get the right answers, one needs to ask the right questions.
equina or discitis
Time limitations further add to the problem. For the FRCS
Spine case could be an intermediate case (15 min with 5 min Orth exams, one gets only 5 minutes for history taking and
each for history, examination and management) or a 5-minute that sometimes includes summary too. But, if you ask the right
short case. questions, 5 minutes are more than enough!
By the end of your history, you should have a diagnosis, if
Intermediate case not a differential diagnosis. There are many factors running in
1. Cervical spondylotic myelopathy the background that do help in your history taking like:
2. Prolapsed cervical disc with radiculopathy and/or weakness Clinical letter provided to you just prior to you entering the
(usually chronic) examination room. (Please read it carefully)
3. Lumbar canal stenosis Patient age
4. Prolapsed lumbar disc with radiculopathy and/or weakness Adolescent girl – Adolescent idiopathic scoliosis
(usually chronic) Middle age – Prolapsed disc
5. Scoliosis – congenital, idiopathic, or any other type Old patient – Lumbar canal stenosis, osteoporotic fracture
6. Kyphosis (ankylosing spondylitis) or tumors
7. Spondylolisthesis Calipers, foot drop splint point towards neurology
Syndromic patient with obvious features should ring a bell
Short cases to alert you if you are dealing with non-idiopathic scoliosis
Any of the long cases can pop up as short cases with focused or kyphosis
examination like inspection, palpation or check neurology. A word of advice. After you introduce yourself to the patient,
You should be slick enough to do it within 3–4 minutes with focus entirely on the patient/family maintaining eye contact.
at least a minute for discussion. Pretend as though the examiners do not exist. Treat it is just
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Chapter 10: Spine clinical cases
like an everyday clinical scenario. It helps to focus on the case g. What’s worse: Is it the radiculopathy or back/neck pain?
and looks more professional.
This is an important question as the treatment differs.
The following is a format for history taking for a spinal
Discectomy helps radiculopathy but may worsen back
intermediate case like lumbar canal stenosis or prolapsed
pain in the long run. So also, neuropathic pain
intervertebral disc. Some questions may change depending
modulators like pregabalin are preferred over simple
upon the case, but format should essentially remain the same.
analgesics to treat radiculopathy
Specific scenarios are covered later.
After the introduction, handshake, name, age, etc, the first 2. Walking
question is usually an open question like:
a. How far can you walk? (In terms of minutes /blocks
‘Mr ABC, How can I help you today?’ or ‘Mr ABC, your GP writes or yards)
to me (clinical letter) that you are suffering from low back pain,
can you please tell me something more about it?’ If the patient says he/she can walk only for 5 minutes, it
1. Pain is important to know what stops the patient from
walking further. Is it the cramping in the legs
a. Neck/low back pain
(claudication) or breathlessness/chest pain or
– Where? palpitations? It is not uncommon for old patients to
have other co-morbid conditions. Patients with
Ask patient to point out with one finger. Low neurogenic claudication may also experience worsening
back pain (LBP) could be sacroiliac joint, lumbar of numbness, paresthesias rather than pain alone
spine, buttock pain (neurogenic or vascular
claudication). Site itself is a very important clue b. If there is claudication history
Lumbar facet pain is central back pain or may be Differentiate between neurogenic and vascular
paravertebral or sometimes radiate to buttocks or claudication. Neurogenic Neurogenic claudication
posterior thighs up to the knees. (Below knees improves with bending forwards (shopping-cart sign),
radiation points to radiculopathy due to nerve improves on cycling and climbing stairs is better than
root irritation) descending them. Pulses will be normal and there may
Sacroiliac joint pain is usually one-sided and located be neurology. Vascular on the other hand improves on
in the buttock, just to the side of the midline. The standing, worsens on going uphill due to increased
pain may radiate down the back of the thigh to the metabolic demand, pulses are weak, neurology will be
knee. Typically, it is difficult to find a comfortable normal and there may be associated skin changes.
position when lying in bed Associated skin changes in peripheral vascular disease
Shoulder pain can be confused with cervical include thin shinny skin with hair loss or trophic
neck pain associated with radiculopathy. changes in the nails
However, shoulder pain does not radiate
below elbows c. Has the walking distance reduced?
b. Duration: Acute (trauma or infection), subacute or This means that nerve compression is worsening. Rest
chronic pain implies critical compression. (Does this patient
c. Aggravating and relieving factors: Discogenic pain is need early surgery?)
worse with sitting and bending forwards, relieved when 3. Weakness in any of the limbs?
lying down
d. Treatment for pain: Analgesics, acupuncture, etc. You Foot drop: L4 and/or L5
don’t want to offer same treatment in your Hand/grip weakness: C8 or T1
management if it hasn’t worked in the first place Triceps weakness: C7
e. Pain in any other joints: Are you dealing with In other words, knowing your myotomes and
polyarticular disease like ankylosing spondylitis or, say, dermatomes helps in history taking and arriving at a
rheumatoid arthritis diagnosis with the history itself
f. Radiculopathy (arm or leg pain)
4. Bowel or bladder weakness
Ask specifically where does the arm pain or leg pain
This question cannot be missed. ‘Do you have any
radiate: E.g. middle finger radiation means C7
problems passing water?’ If the answer to this is yes then:
radiculopathy or C7 nerve root compression that can be
due to prolapsed disc at C6–C7 ‘Can you feel your bladder filling up?’
Or pain radiating to dorsum of the foot means L5 nerve ‘Can you feel your back passage when you’re cleaning
root compression due to poster lateral disc at L45 or far yourself?’ (Loss of perianal sensations)
lateral disc at L5–S1 ‘Do you have control when you pass water?’
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Incontinence is usually a last sign of cauda equina, which 1. Inspection

usually means irreparable damage a. General appearance of the patient
Loss of bladder control on coughing, standing or
straining, usually in females, signifies stress incontinence Does the patient have features suggestive of a
due to weak sphincter control. This should be syndrome, e.g. café-au-lait spots in neurofibromatosis?
differentiated from cauda equina. There is no other Or long arm span with long slender fingers suggestive
neurology in stress incontinence of Marfan’s syndrome?
5. ‘Are you able to …?’ questions Look in the vicinity for walking sticks, calipers,
braces or custom-made shoes and comment
These questions help us to assess how disabled the
on them
patient is or is able to do his/her activities of daily living.
Similar to questions asked in Harris Hip Score for hip b. From front
history:
Both shoulders appear same level?
‘Are you able to do your washing and dressing?’ Both anterior superior iliac spine (ASIS), knees same
‘Are you able to stand for prolong period of time?’ level? (Leg length discrepancy can lead to scoliosis)
‘Are you able to sit for prolong period of time?’
c. From sides
‘Are you able to sleep comfortably?’
‘Is you social life restricted or normal?’ Normal or loss of cervical and lumbar lordosis?
‘Do you use a walking stick or crutch?’ Flexion in knees? (Compensation for loss of lumbar
lordosis)
6. Red flags: Night pain, weight loss, fever and history of
Exaggerated thoracic kyphosis? (ankylosing
malignancy
spondylitis)
7. What treatment have you had already? Physiotherapy,
braces, injections, surgery. If yes, did it help? And for how d. From back
long? Details of surgery?
Step sign? (Spondylolisthesis)
8. Past history: Four questions
Scoliosis? Describe which side, what level and how
Medical: Diabetes, hypertension, etc many curves; e.g. single right-sided convex thoracic
Major past operations scoliosis with/without both shoulders at same level and
Medications: Steroids, blood thinners, with/without pelvic obliquity
immunosuppressant’s (affect surgery) Any obvious skin abnormalities like café-au-lait spots,
Allergies previous scars, lipoma, etc
9. Social history: Four questions again Ask patient to bend over to see for Adam’s forward
Occupation? bending test to see for prominence of scoliosis and/or
Smoking? rib hump
Alcohol? e. Gait
Where do you live? House or a bungalow? Are there any
stairs? Symmetrical, presence of all three rockers, adequate
10. What are your expectations or what do you want step length with or without any assistance
from me? Comment on any abnormalities like crouched gait in
lumbar canal stenosis or presence of foot drop in L4–L5
There’s no point in discussing complex surgeries when
root involvement
the patient wants relief from his/her radiculopathy that
can be managed with neuropathic medications or root 2. Palpation
blocks
Gently tap over the midline with a fist and ask for any
The last five questions are similar for all intermediate cases. spinal tenderness. Also look into the patients’ eyes when
Please do not miss these, otherwise it may be embarrassing in doing this. Some spine surgeons do palate facet joints
management if the examiner tells you later that the patient is bilaterally to elicit tenderness.
smoker or is on steroids, some important points that can alter
Step sign of spondylosisthesis is better palpated than
management!
inspected.
3. Movements
General examination of the spine CERVICAL FLEXION : Can you please touch your chin to
Follow basic orthopaedic concept: Look, Feel and Move. Only your chest?
additions are neurological examination and special tests. EXTENSION : Can you please look up to the ceiling?
013
LATERAL FLEXION : Can you try touching your ear to your Table 10.1 Upper limb reflexes
shoulder? Reflex Nerve segments
ROTATION : Please look towards the right and left?
Biceps jerk C5–C6
LUMBAR FLEXION : Can you please bend forwards? Keep
hand on the back to feel for the spine bending forwards to Triceps jerk C7–C8
check if it’s the hip or spine that flexes. Some patients use Brachioradialis jerk C6–C7
hip flexion to compensate for the spine. Discogenic back
pain is worse with flexion.
EXTENSION : Can you please bend backwards? Painful Table 10.2 Lower limb reflexes
extension is one of the few positive signs in degenerative
Reflex Nerve root segments
lumbar canal stenosis and facet arthritis.
LATERAL FLEXION : Please bend on either sides? Check how Knee jerk L3–L4
far the hands reach up to the knees. Ankle jerk S1–S2
ROTATION : Can you please turn to either side with hands on
your hips?
4. Special tests on both limbs. A sensible question would be ‘Does this feel
Straight leg raise test for prolapsed lumbar disc the same on both sides?’ If sensations are reduced in lower
FABER test for sacroiliac joint pathology limb dermatomes, then check dermatomes in abdomen
Shoeber’s test for ankylosed spine and thorax. Sensory level is suggestive of cord compression
These are discussed later with each scenario. Non-dermatomal pattern of loss of sensations is seen in
peripheral neuropathy like diabetes (glove and stocking) or
psychogenic disorders
Neurological examination 5. Reflexes (Tables 10.1 and 10.2)
By the time you approach the exams, you should be able to do Never forget the Babinski test in lower limbs and
a complete neurological examination in under 5 minutes. Hoffmann’s sign in upper limbs that help to differentiate
Make the patient lie on a couch to make patient comfortable. between upper and lower motor neuron lesions.
This examination can be further divided into: Hoffmann’s is like the Babinski reflex of the upper limb.
1. Nutrition: Presence or absence of any wasting. Wasting is Flicking the terminal phalanx of the middle finger
more marked in a lower motor neuron lesion produces a flexion of the terminal phalanx of the thumb
2. Tone: Normal, increased or decreased (positive Hoffmann’s). If there is time, check joint
3. Power: As per Medical Research Council (MRC) grading position and vibration sense especially in cervical
spondylotic myelopathy.
Some candidates waste time checking each movement at At the end of neurological examination, don’t forget
every joint. In spine, this is not rewarding. At the end of the to check both pedal pulsations and mention to the
examination, you should be able to tell what root/spinal examiner that you would like to examine the hips,
level is involved. Following is easy and quick way to sacroiliac joints and may be the knees. It is preferable to
check power: check both pedal pulsations and do a FABER test (flexion,
C5 – Shoulder abduction abduction and external rotation) prior to doing
C56 – Elbow flexion neurological examination. A negative FABER test suggests
C7 – Elbow extension that the hips, knees and sacroiliac joints are essentially
C8 – Finger flexion or ask patient to press on your normal
fingers
T1 – Finger abduction
L12 – Hip flexion Upper and lower motor neuron lesion
L34 – Knee extension This is medical school knowledge, absolute basics.
L4 – Ankle dorsiflexion with some contribution Why is this important? It helps in localizing the site of the
from L5 lesion.
L5 – Big toe extension Following are the rules:
S1 – Ankle plantar flexion 1. In an upper motor neuron (UMN) lesion, the tone is
increased, there is hyperreflexia and there is extensor
4. Sensations plantar response. There is wasting, but the wasting is
Check both sides simultaneously to compare and save time. less marked as compared to lower motor neuron (LMN)
In other words, stroke your finger on identical dermatomes lesion.
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In a LMN lesion, wasting is marked, tone is reduced a. AP view

and there is hyporeflexia. Also, there is no extensor plantar
Are the vertebral bodies and spinous processes aligned?
response. So:
Are the vertebrae with pedicles intact? (Winking owl
sign for pedicle destruction)
UMN: Reflexes LMN: Reflexes Is there loss of disc height?
Tone Tone
Plantar Muscle mass
Is there facet arthritis?
response Is there a scoliosis? If yes, describe the curve; e.g. single
(extensor) thoracic left-sided convex scoliosis with apex roughly at
T5 vertebrae
Risser’s grade in scoliosis to check for curve
progression?
2. Any lesion up to the spinal cord just short of anterior horn
cell is an UMN lesion. So, a stroke affecting the brain or b. Lateral view
syringomelia affecting the cervical central cord is a UMN
lesion. Peripheral neuropathy or, say, poliomyelitis Normal curves? (i.e. thoracic kyphosis (primary curve)
affecting anterior horn cells in the spinal cord is a LMN with cervical and lumbar lordosis(secondary curves))
lesion In utero, spine assumes a C-shaped (kyphosis – primary
3. The spinal cord ends at lower part of L1 or upper part of curve) to cope for the small space. During the first few
L2. So, if clinical examination suggests a UMN picture, the months of life, once the child develops neck control, the
lesion has to be above L1–L2 cervical lordosis or secondary curve develops to allow
So, neurological presentations could be: infant to visually access his environment. The
a. Normal upper limbs and LMN picture lower limbs: secondary lumbar curve (lordosis) develops after the
Lesion below L1–L2; e.g. cauda equina, peripheral fifth month when the child starts unsupported sitting.
neuropathy or lumbar plexus injury This curve, which is well-suited to upright posture,
continues to develop till child starts standing, walking
b. Normal upper limbs and UMN picture lower limbs:
and running
lesion above L12 and below cervical spine. In other
words, lesion should be in the thoracic spine Is there any loss of cervical or lumbar lordosis?
c. UMN picture in both upper and lower limbs: Is there any exaggerated thoracic kyphosis?
lesion in either brain and or cervical spine. Note, Presence of fractures, lysis, listhesis; reduced disc height
there could be an additional lesion in the or fuzzy end plates? (?Discitis)
thoracic spine
c. Sagittal balance
The whole purpose of a standing whole spine x-ray is to
Investigations see for sagittal balance, pelvic incidence, sacral slope and
1. Blood investigations pelvic tilt. It is more important to correct sagittal
Depending on what you suspect at the end of your history imbalance (kyphosis) than coronal imbalance (due to
and examination, talk about blood investigations. In some scoliosis) or else surgery may fail. Sagittal imbalance shifts
cases, you may take the examiner directly to radiological the center of gravity either in the front or back of the body
investigations and makes locomotion difficult. A normal or neutral
sagittal balance means a plumb line falling from center of
Examples for blood tests in a patient with suspected
C7 should fall on the posterosuperior edge of S1 vertebra.
metastatic region in spine with unknown primary are:
If the C7 line falls in front of S1 then it is positive sagittal
a. Baseline bloods (including infective markers): FBC, balance and if it falls behind S1 then its negative sagittal
U&E, ESR, CRP, LFT balance. The osteoporotic thoracic spine with previous
b. Metabolic markers: Ca, PO4, vitamin D, Serum fractures easily illustrates this. These patients have
Alkaline PO4 positive sagittal balance and, hence, their center of gravity
c. Tumor markers: PSA, myeloma screen, Bence Jones shifts forward. This in turn predisposes them for further
protein, CEA, etc wedge compression fractures with worsening of kyphotic
deformity (Dowager’s hump)
2. X-rays
Like foot and ankle, almost always standing x-rays 3. Magnetic resonance imaging (MRI)
preferably the whole spine unless contraindicated. Views Closer to your exams, you should be well-prepared
asked are anteroposterior (AP) and lateral (and bending regarding MRI in terms of uses, how it works, T1 and T2
views in scoliosis for preoperative planning only). images, etc. You may be given a spine MRI scan for the
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clinical or vivas and asked to talk about it. After

commenting on what spine level it is, the following points
Management
Based on the history, patient expectations, examination and
should be of help:
investigations, you will be asked to offer a plan for manage-
a. Is this a sagittal, parasagittal or axial image? ment of your patient.
Axial images are obvious but learn to differentiate 1. Non-operative
sagittal and parasagittal images. Sagittal images Unless there is instability (like fracture) or neurology,
pass through the center of the spine and unless almost always the first line is non-operative management
there’s no scoliosis , one should be able to see the that includes:
entire spinal cord and thecal sac. Parasagittal
Analgesia
images are useful to detect nerve root compression
Activity modification
on either side
Physiotherapy
b. Is this a T1, T2 or STIR image?
Cognitive behavior therapy
T1 image water is dark and fat is bright. T1 is better
Braces, e.g. scoliosis
for anatomy. So if there is compression (after seeing
T2 image), T1 helps to precisely see what’s the Injection treatment (facet joint, epidurals, nerve root
extent of compression. So also, in metastases, once blocks)
cancer cells replace the fat marrow, loss of fat signal 2. Operative
is seen on T1 images. So for checking metastases, Indications
see T1 images.
– Neurology
T2, water is bright (cerebrospinal fluid (CSF)) and
– Worsening of neurology
fat is bright as well to some extent. An easy way to
– Instability
remember is that water is H20, which has a 2. Young
disc has more water content and, hence, is bright on – Failure of non-operative treatment
T2. Water is seen more in inflammation-like
infections/fractures. Hence, a bright signal in T2 in Evidence-based practice
a vertebral body could mean fracture or infection Please read the current literature on common spinal condi-
Ask for STIR (short tau inversion recovery) images, tions. Quoting literature does improve your final score.
which is fat-suppressing imaging that helps to Following are some of important literature for spine:
localize infections or fractures BOAST guidelines
c. Then comment on any thecal sac compression, disc NICE guidelines for osteoporotic spinal fracture, cervical
protrusion, extrusion, sequestration, and any disc replacement, suspected spinal metastases, etc
fractures, evidence of osteomyelitis SPORT trial for lumbar canal stenosis, prolapsed lumbar
disc, spondylosisthesis
4. Computerized tomography (CT) scan
Knowledge of current literature about fusion for low back
If there is any fracture or difficult to visualize region, like pain, cervical disc replacement vs fusion for cervical disc
the cervicothoracic spine, request a CT scan. A CT scan protrusion and recent concepts about vetebroplasty and
also helps see for bony compression, like ossified posterior kyphoplasty should be known for the exams.
longitudinal ligament, or to get more detail of the bony
anatomy and fractures. Also, a CT myelogram is
performed in patients when MRI is contraindicated
Prolapsed lumbar disc
5. Bone scan Prolapsed lumbar disc is a common spine pathology, so a
common case in exam. It is usually an intermediate case
For infections, primary tumours (osteoid osteoma) and and, therefore, 5 minutes each for history, examination and
metastases management.
6. Biopsy Know the types of disc based on location – Central, poster-
Suspected tumors or infections. You may be asked the olateral (commonest) and far lateral. The L45 posterolateral disc
principles of biopsy here will compress on the L5 nerve root (traversing root), while the
7. Nerve conduction studies L45 far lateral disc compresses on the L4 nerve root (exiting root).
Nerve conduction studies help to localize a lesion or Also know the difference between protrusion, extrusion
confirm a diagnosis. These are not always necessary, and sequestrated disc.
but may be helpful in certain scenarios like double-crush
syndrome with carpal tunnel or ulnar nerve compression History
associated with nerve lesions in neck. They also help in Follow the usual questions asked in history taking:
diagnosing peripheral neuropathy or motor neuron Male preponderance (3 : 1) with peak incidence in the
disease (along with electromyography) fourth and fifth decade of life. Ninety per cent of these
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patients improve with non-operative management in the comment on the level. See the axial T2 to see for the central,
first 3 months. (In other words, an exam case may be a posterocentral or far lateral location of the disc
patient who belongs to the latter 10%.)
Low back pain and or radiculopathy (enquire about the Management
specific location or dermatome – Clue of the root involved) Ninety per cent of disc prolapses are at L5–S1 or L4–L5. Ninety
Motor weakness if any per cent of disc prolapse sciatica improves within 3 months
Bladder or bowel disturbances – Cauda equina(rare without surgery, so you may have a patient with no signs but a
in exams) big disc on MRI scan
Activities of daily living
Red flags Non-operative
Treatment had so far – Physiotherapy, epidural or nerve The first line is non-operative management that includes:
root injections, surgery, medications
Analgesia
Past history, social history and expectations – Patient wants
Activity modification
to get rid of back or leg pain or both?
Physiotherapy (extension exercises)
Medications like pregabalin and gabapentin help relieve leg
Examination pain. Ninety per cent of patients improve with these
Usual orthopaedic examination – Look, Feel, Move, Special interventions.
tests and Neurology. The second line of treatment if the above fails is epidural or
Look: May have a list away from the side of pathology to selective nerve root blocks. These have long lasting improve-
take the pressure off the nerve. Gait may be altered if there is ment of about 50% and better outcomes are with extruded
weakness, e.g. L4–L5 weakness presents as a high steppage or discs than contained discs.
foot drop gait. So also a Trendelenberg gait in L5 weakness
(gluteal) Operative
Feel: Central or paraspinal tenderness
Indications:
Move: Flexion reduced in discogenic back pain (also sitting
and axial loading) while extension reduced if there is facet Neurology (cauda equnina – Emergency)
arthritis Worsening of neurology
Special tests: In other words the nerve root tension signs. Failure of non-operative treatment (after 6 weeks)
Many are described, but it is not feasible for all Indications, procedure and complications of microdiscectomy
are frequently asked. Approximately 90% patients have long
a. L5 or S1 prolapse: Straight leg raise (SLR) test is
lasting outcomes with surgery. SPORT trial outcomes at 2 years
best done supine. Reproduces leg pain and paresthesias
suggest that there were no significant differences in the pri-
in 30–70° of leg flexion. The Lesegue sign is SLR
mary outcome measures for operative compared with non-
aggravated by forced ankle dorsiflexion, while the
operative groups. However, statistically significant outcomes
bowstring sign is SLR aggravated by compression on
for surgical intervention if sciatica is bothersome. Leg pain and
popliteal fossa
positive sciatic stretch test are good predictors for positive
b. L2, L3 and L4 discs (higher disc prolapse): The femoral outcome after surgery.
nerve stretch test, which is done in prone position
Neurological examination: As mentioned previously in this
chapter, check for motor and sensory weakness, but don't
Intermediate case: Lumbar disc
forget reflexes and Babinski. If reflexes are brisk, then start GP note: ‘Forty-five-year-old Mr Smith c/o LBP and right leg pain
doing a neurological examination of the upper limbs. Always since past 4 months. Can you please take a history, examine this
gentleman and discuss management.’
mention that you would like to do a neurological
examination of the upper limbs as well for the sake of CANDIDATE: Hello Mr Smith, I am Mr K, one of the exam candidates, is it
completion OK if I ask you some questions and examine you?
MR SMITH: Sure doctor, its nice meeting you.
Investigations CANDIDATE: Your GP tells me you have back and right leg pain. Can you
AP x-ray: Scoliosis, facet arthritis, count number of lumbar tell me something more about it? (Open-ended question)
vertebrae (T12 rib helps) to see for lumbarisation of S1 or MR SMITH: I never had any problems with my back anytime in the past, but
sacralisation of L5 about 4 months ago when I was bending forward to lift my suitcase, I felt a
Lateral x-ray: Loss of lumbar lordosis, facet arthritis, cramp go down my right leg. This pain was quite severe, worse than a
reduced disc height toothache and is the same since then. This was followed with low back
MRI: Sagital T2: Loss of high signal in the disc pain, which is not as bad as the leg. This leg pain concerns me and is
(degeneration) with prolapse, extrusion or sequestration and affecting my daily routine.
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CANDIDATE: Can you point and show me where is your low back pain and MR SMITH: If only you could somehow take this leg pain away, I will be
how does your leg pain radiate? grateful.
MR SMITH: Points to lumbosacral region and showing leg pain radiation EXAMINER: So, what do you think is happening?
along L5 CANDIDATE: A 45-year-old gentleman is complaining of leg pain along
CANDIDATE: (Thinking about L5 root . . . means posterolateral L5 dermatome as well as back pain. Leg pain is worse than his back, I am
L4–L5 disc or far lateral L5–S1.) Anything that worsens or helps thinking of a prolapsed disc at L4–L5 or a far lateral disc at L5–S1.
your pain? EXAMINER: Please go ahead with the examination.
MR SMITH: My back pain is worse with sitting but standing and on lying CANDIDATE: (After making the patient stand.) . . . On inspection from the
down it is OK (discogenic back pain). My leg pain though is constant. back, the pelvis appears at the same level but there is a listh towards the
I have tried many pain medications, physiotherapy, but this leg pain is left. The skin on the back appears normal. On inspection from the sides,
showing no signs of going away. I can’t walk too far without pain and my there is loss of normal lumbar lordosis.
sleep is also disturbed. I have no social life now and this leg pain is Mr Smith can you please walk for me? His gait is unassisted, but
affecting me mentally as well. I notice that he is taking steps very cautiously.
CANDIDATE: Do you have pain in any other joints? Mr Smith, can you walk tiptoes and on your heels?
MR SMITH: No. He can do heel and toe walking that suggests that he has no gross
CANDIDATE: How far can you walk? weakness of L4–L5 and S1.
MR SMITH: I can walk non-stop for about 15 minutes but can feel this leg On palpation form the back, (looking at the patients face) he has central
pain constantly. and paraspinal tenderness.
CANDIDATE: Do you have any weakness in any of your limbs? On checking movements, all his movements including flexion,
MR SMITH: No. extension lateral flexion and rotations are reduced.
CANDIDATE: Do you have any problems with your waterworks? I am now doing the special tests (making the patient lie down) SLR on
MR SMITH: No. the left is around 80° but on the right it’s reduced to 40°. Faber’s test is
CANDIDATE: Have you lost weight recently or had episodes of fever? bilaterally negative and both pedal pulsations are well felt.
MR SMITH: No. Neurological examination reveals normal tone, no motor deficit but he
CANDIDATE: What treatment have you had so far? has reduced sensations in his right L5 dermatome. Reflexes are normal
MR SMITH: Physiotherapy and painkillers. Not much help though. and plantars are down going.
CANDIDATE: Clearly you are struggling. These examination findings suggest a disc prolapse involving a right
L5 nerve root.
(Past history: four questions)
EXAMINER: What would you like to do?
Any medical problems like diabetes, hypertension, etc?
CANDIDATE: I would first like to have standing x-rays of his lumbar spine
MR SMITH: No.
followed by an MRI.
CANDIDATE: Any major past operations?
EXAMINER: These are his x-rays. (Figure 10.1 a and b)
MR SMITH: No.
CANDIDATE: Standing AP x-ray of full spine shows coronal tilt towards
CANDIDATE: Do you have any allergies?
the left. Lateral x-rays shows loss of lumbar lordosis and reduced disc
MR SMITH: No.
height at L4–L5.
CANDIDATE: Are you on any medications like steroids, blood thinners?
EXAMINER: What is the cause of his scoliosis?
MR SMITH: Apart from pain medications like ibuprofen, paracetamol, I am
CANDIDATE: This is a compensatory scoliosis to take the pressure away
not on any other medications. My GP started me on gabapentin, but I did
form the right L5 root.
not take them due to work issues.
EXAMINER: These are his MRI images. (Figure 10.2 and 10.3 a and b)
(Social history: four questions again)
CANDIDATE: MRI T2 sagittal image showing a disc protrusion at L45,
CANDIDATE: What do you do for a living?
with loss of disc height and low signal suggesting dehydration. There is
MR SMITH: I am a bus driver but I have not worked for the past 4 months.
also loss of disc signal at L5–S1 suggesting dehydration.
(Clearly, gabapentin or pregabalin should be used with caution due to side
The axial T1 and T2 images shows a posterolateral disc at L4–L5 on the
effects of sedation.)
right compressing on the L5 nerve root.
CANDIDATE: Do you smoke?
EXAMINER: So what would you like to do now?
MR SMITH: No.
CANDIDATE: He has tried the initial non-operative measures that have
CANDIDATE: Do you have alcohol socially or everyday?
failed. I will now offer him selective right L5 nerve root block explaining to
MR SMITH: No, I don't fancy alcohol. him the complications and 50% chance of success.
CANDIDATE: Do you live alone? And in a house or a bungalow? EXAMINER: What are the complications of blocks?
MR SMITH: In my house with my partner. CANDIDATE: No relief, worsening of symptoms, infection, bleeding, nerve
CANDIDATE: What are your expectations or what do you want from damage with paralysis, further treatment may be needed.
me now? EXAMINER: Nerve block has failed, what will you do now?
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(a) Lateral spine (b) AP spine Figure 10.1 (a, b) Standing x-rays of lumbar spine
CANDIDATE: I will discuss surgery with him. I will refer him to a spinal Lumbar canal stenosis
surgeon for right-sided microdiscectomy at L4–L5. This is a very common intermediate case for exams.
(The examiner could ask you to consent a patient for the surgery, Diagnosis is mainly based on history, as there are few phys-
complications, procedure and outcomes.) ical signs. It is frequently associated with arthritis of the
EXAMINER: The patient wants to know what will be the success of the lower limbs (degenerative process) and, hence, always men-
operation? tion to the examiner that you will like to examine the hips
CANDIDATE: This operation is primarily meant for relief of leg pain. and knees as well. It is vital to distinguish between vascular
Ninety per cent of operated patients have long-lasting improvement, and neurogenic claudication, as the treatment for each is
more so as he has positive predictors of good outcome following entirely different. Sometimes, both may coexist in the same
surgery, like chief complaint of leg pain and a positive sciatic stretch patient.
test. While he will realize the benefit of no leg pain early, there is no Neurogenic claudication improves with bending forwards
difference in outcomes between operative and non-operative after (shopping-cart sign), worsens climbing downhill, pulses will be
4 years. normal and there may be neurology. Cycling has no effect and
Bell rings. often symptoms of pins and needles are bilateral in both legs
EXAMINER: Thank you. with back pain as well.
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Vascular claudication on the other hand improves on

standing, worsens on going uphill or cycling due to increased
Classification of lumbar canal stenosis
a. Primary: 10% of cases. Congenital short pedicles with
metabolic demand, pulses are weak and neurology will be
medially displaced facets. Present from birth with the short
normal. Symptoms are felt in the calf and bending forwards
pedicles seen on lateral x-rays
has no effect.
b. Secondary (or acquired): More common and can be due to:
Degenerative – Due to disc protrusion, facet
hypertrophy, ligamentum flavum hypertrophy or
spondylolisthesis
Iatrogenic or post surgical
Trauma
Inflammatory – Paget’s, ankylosing spondylitis
Also know the anatomical classification of lumbar canal sten-
osis, which includes central, lateral and foraminal stenosis.
Intermediate case: Lumbar canal stenosis

GP note: ‘Fifty-nine-year-old Mr Jack c/o LBP and difficulty in
walking since past 8 months. Can you please take a history,
examine this gentleman and discuss management.’
(NB. In this scenario, only a summary of the history.)
EXAMINER: Can you summarize your history please?

CANDIDATE: Mr Jack is a 59-year-old retired plumber who complains of
low back pain and bilateral neurogenic claudication. I say it’s neurogenic
claudication because his leg symptoms improve on bending forwards and
climbing uphill. Cycling has no effect on his leg symptoms and he has no
history of previous peripheral vascular disease and he is a non-smoker.
His walking distance has gradually reduced from 15 minutes 6 months
ago to rest pain now. His sleep is disturbed now due to leg pain and his leg
Figure 10.2 MRI scan T2 sagittal view
(a) (b)
Figure 10.3 MRI scans (a) T2 Axial L4/L5 (b) T1 Axial L4/L5
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(a) AP (b) Lateral Figure 10.4 (a) AP and (b) lateral x-rays
symptoms are worse than his back. He has no bowel or bladder symptoms CANDIDATE: Lumbar canal stenosis or peripheral neuropathy due to
but has a past history of diet controlled diabetes for 10 years. He has tried diabetes. Also, age-related nerve degenerative process could also lead to
physiotherapy, analgesics and caudal epidural injections that have given loss of reflexes.
him no great relief. He wants to improve his walking and relief from his EXAMINER: What would you like to do?
leg pain. CANDIDATE: I would like to investigate him with baseline blood
EXAMINER: (interrupting) What are you suspecting based on your history? investigations including blood sugar levels and HbAc to confirm he has
CANDIDATE: Lumbar canal stenosis had good control of his diabetes. Also, standing AP and lateral x-rays of
EXAMINER: Please carry on with your examination. his lumbar spine along with an MRI of his lumbar spine.
CANDIDATE: On inspection, Mr Jack has difficulty in standing erect, EXAMINER: Please comment on his AP and lateral x-rays? (Figure 10.4 a and b)
adopting a simian stance with hips and knees slightly flexed. He walks with CANDIDATE: Standing AP lumbar spine x-ray showing mild scoliosis with
a stooped gait and has generalized lumbar spinal tenderness on palpation. loss of disc height and osteophyte formation. The lateral x-ray also shows
There is normal spinal flexion but moderate and painful restriction of loss of disc height with anterior and posterior osteophyte formation.
spinal extension. There is grade 1 listhesis at L34 with facet arthritis at L4–L5 and L5–S1.
Both pedal pulsations are well felt and he has no nail changes or loss of EXAMINER: Please comment on his MRI scans. (Figure 10.5 a–c)
hair suggestive of any vascular involvement (Never forget this in a lumbar CANDIDATE: T2 sagittal MRI lumbar spine showing significant central
canal stenosis case.) stenosis at L3–L4 and also some compression at L4–L5. Axial T2 again
SLR bilaterally is 80° suggestive of no root irritation (though disc suggests significant central stenosis with ligamentum flavum and facet
prolapse does not usually occur in this age group, rarely patients with hypertrophy at L3–L4 and moderate stenosis at L4–L5.
canal stenosis can have acute disc prolapse in background of lumbar canal EXAMINER: With these investigations, how would you now manage this
stenosis with exacerbation of their symptoms. Such patients can have root patient?
irritation signs. So also, patients with foraminal stenosis can present with CANDIDATE: Though his MRI scan can explain all his symptoms, I would
nerve root signs.) consider nerve conduction studies to rule out peripheral neuropathy due
Neurological examination reveals normal nutrition, normal tone and to diabetes especially if his blood investigations show poor control of his
no motor or sensory deficit. His reflexes are absent in both knees and diabetes.
ankles and Babinski is equivocal. EXAMINER: I would like to argue otherwise, as he has no glove and
EXAMINER: What is the cause of loss of reflexes in this patient? stocking type of sensory loss. Consider that the nerve studies are normal.
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(a) T2 Sagittal (b) Axial L4/L5
(c) Axial L4/L5
Figure 10.5 (a–c) MRI scans
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CANDIDATE: He has tried non-operative measures as well as injections

and now has rest pain. I will now refer him to a spinal surgeon for
Intermediate case: Cervical spondylotic myelopathy
GP note: ‘Mr Cooke, a 61-year-old electrician c/o LBP and
decompression and/or fusion.
difficulty in walking in the last 8 months. Can you please take a
EXAMINER: Would you offer fusion or not for this patient? history, examine this gentleman and discuss management.’
CANDIDATE: I will need flexion extension x-rays to help me with that (NB. Don't be surprised with the above scenario. Cervical
decision. Fusion is indicated if there is instability like degenerative spondylotic myelopathy (CSM) is easily missed as it's a degenerative
scoliosis, spondylolisthesis or removal of >50% of the facets during process associated with low back pain (LBP). In this scenario, only a
decompression. This patient probably needs fusion as he would need a summary of the history is provided.)
large portion of the hypertrophied facet removed during surgery, as his
EXAMINER: Can you summarize your history please?
compression is due to facet hypertrophy as well. Besides, he also has grade
CANDIDATE: Mr Cook is a 61-year-old electrician who complains of low
1 spondylolisthesis at L3–L4.
back pain, mild neck pain and gait disturbances since the past 8 months.
EXAMINER: What are the outcomes after surgery?
He also has weakness in both his hands dropping objects and difficulty
CANDIDATE: In most patients there is 80% likelihood of excellent-to-good
manipulating fine objects. He feels unstable on his feet, using a Zimmer-
outcome 2 years after surgery. The SPORT trial provided a level
frame to walk and is presently housebound. He has no bladder or bowel
2 evidence that patients with symptomatic spinal stenosis treated
disturbances and does not complaint of any sensory loss.
surgically compared to those treated medically/interventionally maintain
He has tried physiotherapy in past. He has no significant past medical
substantially greater improvement in pain and function through 4 years.
problems and his main concern is loss of balance that is progressively
EXAMINER: Thank you.
getting worse.
EXAMINER: (interrupting) What are you suspecting based on your history?
Cervical spondylotic myelopathy CANDIDATE: Lumbar canal stenosis, cervical spondylotic myelopathy or
This is classic intermediate case material. This topic could very peripheral neuropathy. I need do a neurological examination to arrive at a
easily catch you out if you are not familiar clinically with either final diagnosis.
examination of the neck or specifically the clinical findings you EXAMINER: Please carry on with your examination but focus on
would look for in cervical myelopathy. his neck.
Nerve lesions in the upper limb could be due to: CANDIDATE: On inspection from the sides there is loss of cervical lordosis.
There are no scars on the back or front of the neck. He walks with a broad
1. Cervical radiculopathy (spinal nerve root)
based ataxic gait and Romberg’s test is positive.
2. Cervical myelopathy (spinal cord)
EXAMINER: What is the cause of ataxic gait and positive Romberg’s?
3. Peripheral nerve lesions (median, ulnar nerve or radial)
CANDIDATE: Joint position sense (or proprioception) is carried by the
4. Brachial plexus
dorsal columns of the spinal cord. As these signals do not reach the brain,
5. Thoracic outlet syndrome (cervical rib)
the patient suffers from sensory ataxia and to maintain balance walks with
The symptoms of cervical spondylotic myelopathy may
a broad based gait.
include gait difficulties, decreased manual dexterity, paresthe-
Romberg’s test relies on the brain (cerebellum) receiving three sensory
sias or numbness of the extremities, urinary frequency or
inputs. These are vision, vestibular apparatus in the inner ear and joint
urgency, generalized and extremity weakness.
position (proprioception) carried by the dorsal columns of the spinal cord.
Besides the routine history, of neck and/or arm pain ask for
If the visual pathway is removed by closing the eyes but the proprioceptive
questions that help to find out sensory loss, ability to walk,
and vestibular pathways are intact, balance will be maintained. But if
bladder/bowel function and fine/gross motor loss in upper and
proprioception is defective, two of the sensory inputs will be absent and
lower limbs:
the patient will sway and lose balance.
Can you write? EXAMINER: Please carry on with the examination.
Do you drop things? CANDIDATE: Cervical spine flexion, extension, rotation and lateral flexion
Can you dress yourself? are moderately reduced. Shoulder movements are normal.
Has there been any change in passing urine (urinary Neurological examination reveals normal nutrition but increased tone
frequency or urgency)? in both upper and lower limbs . He has grade 5 power in both C5, but
Has there been any disturbance in bowel function grade 3 power in C6, C7, C8 and T1 bilaterally. Power is grade 4 both
(sphincter disturbance)? lower limbs. Sensations are normal both upper limbs and lower limbs but
Can you walk independently? Do you need aids to walk? reflexes are brisk in all four limbs with up going plantars and positive
Do you tend to lose balance? Hoffmann’s in both upper limbs. Joint position is lost in all four limbs.
Do you have any loss of sensations? This is suggestive of upper motor neuron type of picture with the lesion
Sometimes, the only symptom a myelopathy patient presents is being either in the brain or cervical spine. However, since he has no brain
loss of balance. Their diagnosis is then confirmed by clinical symptoms like headaches or weakness in cranial nerves, I would consider
examination with upper motor neuron signs in lower limbs cervical myelopathy as my first diagnosis.
and upper or lower motor neuron signs in upper limbs. EXAMINER: What would you like to do?
1 18 Apr 2017 at 19:12:35, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms.
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CANDIDATE: Anterior surgery is indicated if the compression is mainly

anterior (e.g. ossification of the posterior longitudinal ligament (OPLL))
or there is compression at two or fewer disc segments. Also, if there is
fixed cervical kyphosis, anterior surgery should be considered.
Posterior cervical decompression with laminectomy and fusion should
be considered in patients with multilevel compression and there is no
fixed kyphosis.
This patient has two-level compression, mainly anteriorly; hence, I will
offer anterior cervical discectomy and fusion with cage and bone graft.
EXAMINER: What about isolated laminectomy without fusion?
CANDIDATE: Isolated laminectomy is rarely indicated due to the risk of
post-laminectomy kyphosis.
EXAMINER: The patient has read about cervical disc replacement for
treatment of his neck problems over the Internet?
CANDIDATE: Although NICE recommends cervical disc arthroplasty in
cervical radiculopathy and myelopathy, this patient has significant facet
arthritis as seen on his x-rays and MRI. Besides kyphosis and probably
osteoporosis at his age are contraindications.
EXAMINER: What are the outcomes after anterior surgery with fusion?
CANDIDATE: Although the primary goal of surgery in myelopathy is
to prevent progression, most patients actually note neurological
improvement after successful decompression and fusion. Ikenaga et al.1
showed stable clinical results of >10 years in his series of 31 patients with
anterior decompression and fusion. Adjacent disc degeneration had
minimal effects on the long-term outcome.
The term implies compression on the nerve root with no
compression of the central spinal cord. Radiculopathy can be
Figure 10.6 Lateral cervical spine x-ray
due to disc osteophyte complex or a soft disc. Most common
levels are C5–C6 and C6–C7. Remember that C5–C6 disc
herniation will compress on the C6 nerve root while C6–C7
CANDIDATE: I would like to investigate him with x-rays and MRI of his
herniation compresses on the C7 nerve root.
cervical. Ideally, MRI of his entire spine as he still could have additional
Patients present with arm and /or neck pain. There will be
compression in his thoracic and lumbar spine.
no upper motor signs. If there are upper motor signs, suspect
EXAMINER: Consider MRI thoracic and lumbar is normal. Please comment
myelopathy due to cord compression.
on this lateral cervical spine x-rays? (Figure 10.6)
Besides the routine history of neck pain, ask for more
CANDIDATE: Lateral cervical spine x-ray showing some loss of cervical details about the radiculopathy. In other words, for exact path
lordosis with anterior and posterior osteophyte formation at C5–C6. of radiation and to which fingers. For example, C6 radiation is
There is loss of disc height at C5–C6. There is no evidence of listhesis. to thumb, C7 to middle finger and C8 to little finger.
I would like to see an x-ray AP view and MRI cervical spine. Enquire about sensory and motor loss and loss of function.
EXAMINER: The AP view is normal; these are his MRI scans (Figure 10.7 a Find out what all treatment has ben provided so far. This is of
and b). course apart from the routine history. Do not forget double
CANDIDATE: T2 sagittal MRI cervical spine showing significant central crush syndrome with nerve lesion in neck and peripheral
stenosis at C4–C5 and C5–C6. There is evidence of bright signal of the compression like carpal tunnel.
spinal cord at this level suggestive of myelomalacia. Axial T2 again shows
significant central stenosis at these levels. Intermediate case: Cervical disc prolapse with
EXAMINER: With these investigations, how would you now manage this
patient?
radiculopathy
GP note: ‘Thirty-seven-year-old Mrs Brown who works as a
CANDIDATE: He has significant functional impairment with 2 level
receptionist c/o neck and left arm pain 6 months. Can you please
disease. The compression is mainly at the disc level with no compression
take a history, examine this lady and discuss management.’
at the vertebral level. I will refer him to a spinal surgeon for
decompression and fusion. EXAMINER: (After the history taking) Can you summarize your history
EXAMINER: Would you offer anterior or posterior decompression and why? please?
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(a) T2 Sagittal (b) T2 Axial C5/C6
Figure 10.7 (a, b) MRI scans
CANDIDATE: Mrs Brown is a 37-year-old receptionist who complains of

Neurological examination reveals normal nutrition and normal tone.
neck and left arm pain along C6 distribution. Arm symptoms are worse
She has grade 3 power in her left biceps. Rest of the motor examination
than the neck. She has no weakness in the arm and has tried
was normal. She also has reduced sensation in left C6 dermatome.
physiotherapy and pain injections in her neck. She denies any bowel or
Reflexes are normal. Hoffmann’s is negative in both upper limbs
bladder disturbances or gait disturbances.
suggestive of no upper motor neuron lesion.
EXAMINER: (interrupting) What are you suspecting based on your
I would like to examine both shoulders to complete my examination.
history?
EXAMINER: Consider both shoulders are normal, what would you like
CANDIDATE: C5–C6 disc prolapse with left C6 nerve compression.
to do?
EXAMINER: Why not a central disc protrusion with cord compression?
CANDIDATE: I would like to investigate with x-rays and an MRI of her
CANDIDATE: She denies any symptoms in her legs, no bowel or bladder
cervical spine.
disturbances or gait disturbances suggestive of myelopathy. However,
EXAMINER: Please comment on this lateral cervical spine x-rays?
I need to do a clinical examination to check for any long tract signs to rule
CANDIDATE: Lateral cervical spine x-ray (Figure 10.8) showing
out upper motor neuron lesion or central cord compression.
straightening of the cervical spine. There is reduced disc height at C56
EXAMINER: Please carry on with your examination.
with posterior osteophyte formation. I would like to see AP view and
CANDIDATE: On inspection from the sides there is loss of cervical lordosis.
MRI cervical spine.
There are no scars of previous surgeries on the back or front of the neck.
EXAMINER: AP view is normal. These are his MRI scans. (Figure 10.9 a
Her gait is normal.
and b)
Palpation reveals mild paraspinal tenderness.
CANDIDATE: T2 sagittal MRI cervical spine showing disc protrusion at
Cervical spine flexion, extension, rotation and lateral flexion are
C56. Axial T2 again shows left-sided disc protrusion at C56. The disc
moderately reduced.
bulge is not dark suggesting this is a soft disc. There is no compression
Spurling’s test is positive on the left (simultaneous extension, rotation
of the spinal cord or any altered cord signal.
to affected side, lateral bend, and vertical compression reproduces
EXAMINER: How would you now manage this patient?
symptoms in ipsilateral arm).
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CANDIDATE: She has tried analgesics, physiotherapy and injections. Her EXAMINER: What surgery?
symptoms are for 8 months now and she is struggling with her activities of CANDIDATE: Options include anterior cervical discectomy and fusion,
daily living as well as her job. I will discuss surgery with her and refer her anterior cervical discectomy and disc replacement or posterior
to a spinal surgeon. foraminotomy.
Her main concern is arm pain with no or mild neck pain. Target level is
C5–C6. She has no facet arthritis at C5–C6. I will offer her a C5–C6
discectomy and disc replacement.
EXAMINER: I would offer her C5–C6 discectomy with fusion.
CANDIDATE: This is debatable. Some surgeons consider fusion as gold
standard. NICE has published guidelines for cervical disc replacement.
They have also provided evidence for the same. In a randomised
controlled trial of 541 patients, patients reported greater improvement
from baseline in the mean Neck Disability Index (NDI) score in patients
treated with prosthetic cervical disc insertion compared with fusion at 3-
month follow-up; but this difference was not significant at 6-, 12- or 24-
month follow-up. The arthroplasty group had lower rate of secondary
surgeries as well.
EXAMINER: You mentioned about posterior foraminotomy?
CANDIDATE: Ideal indication for a posterior foraminotomy is a soft one-
level disc with unilateral compression. This has a good success rate
avoiding risk of anterior injury. This is also an option in this case, but type
of surgery is dependent on surgeon choice.
EXAMINER: If this were a revision anterior surgery, would you have any
concerns?
CANDIDATE: Yes. I will refer her to ENT specialist for laryngoscopy to
check vocal cord function. She could have asymptomatic damage to the
unilateral recurrent laryngeal nerve on the side of the previous approach.
If that nerve is damaged, anterior approach on the non-operated side
could lead to damage of the recurrent laryngeal nerve on that side,
Figure 10.8 Lateral cervical spine x-ray
(a)
(b)
Figure 10.9 (a, b) MRI scans
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resulting in bilateral recurrent nerve palsy. This can be catastrophic Respiratory: Pulmonary fibrosis
leading to difficulty in breathing and inability to speak. Checking the vocal Renal: Amyloid nephropathy
cords by laryngoscopy is vital for medicolegal purpose too. Gastrointestinal: Associated with Crohn’s disease and
EXAMINER: Thank you. ulcerative colitis
Besides orthopaedic complaints, take a history regarding the
You may then be asked to consent a patient for anterior
non-articular manifestations as since these may significantly
surgery, talk about the approach or complications of anterior
affect the outcome.
cervical spine surgery.
Ankylosing spondylitis Intermediate case: Ankylosing spondylitis

GP note: ‘Forty-year-old Mr Smith complains of LBP and back
Ankylosing spondylitis is a chronic autoimmune inflammatory
stiffness. Can you please take a history, examine this gentleman
spondyloarthropathy primarily affecting the axial skeleton
and discuss your management.’
with variable involvement of peripheral joints and non-
articular tissues. It is seronegative arthritis (Rh factor negative) EXAMINER: Can you summarize your history please? (after history taking)
with positive HLA B27 (90% of patients). It usually affects CANDIDATE: Mr Smith is a 40-year-old gentleman complaining of back
males and has a strong genetic predisposition. pain since the past 17 years, insidious on onset and gradually getting
worse. Pain is in his entire spine, worse in the sacroiliac region and
Diagnosis thoracolumbar spine, and accompanied by stiffness. He has developed a
As per the Modified New York criteria2 (NICE guidelines), for stooping posture of his spine that causing difficulty in seeing forwards
diagnosis of ankylosing spondylitis one radiological criterion when he walks. He has no weakness in any of his limbs or problems with
and at least one clinical criterion are to be satisfied. his waterworks.
Radiological criterion: He has no major complaints form his hips, but has occasional pain in
his heel. However, his spine is his main concern.
Sacroiliitis at least grade 2 bilaterally or grade 3 or 4
unilaterally Mr Smith has difficulty in breathing but has no eye, heart or renal
problems. He has no allergies . . .
Clinical criteria: EXAMINER: (Interrupting) Please go ahead with the examination.
Low back pain and stiffness for >3 months that improves CANDIDATE: (After making the patient stand) On general inspection we
with exercise but is not relieved by rest have a male patient who is somewhat stooped as he walks into the room.
Limitation of motion of the lumbar spine in both the On examination from behind the shoulders are at same level, there is
sagittal and frontal planes loss of normal lumbar lordosis, a fixed kyphosis of his thoracic spine.
Limitation of chest expansion relative to normal values The chin to brow angle appears normal indicating no cervicothoracic
correlated for age and sex kyphosis. His visual axis does not appear to be horizontal. His pelvis is
All reasonable measures should be taken to ensure that symp- level but he tends to stand with a slightly flexed attitude of his hips and
toms are due predominantly to ankylosing spondylitis and that knees. The patient has a classic question mark posture with pronounced
alternative causes, including spinal fracture, disc disease and thoracolumbar kyphosis and flexion attitude of the hips and knees.
fibromyalgia, are excluded. On palpation, he has no significant tenderness of his spine, but he does
have tenderness of his left sacroiliac joint.
Orthopaedic manifestations On examination of his neck movements there was very limited flexion
Bilateral sacroiliitis progressing to frank ankyloses and extension present. There is almost no lateral movement of his cervical
Spine: loss of movements, ankyloses, kyphotic deformity, spine. Examining his lumbar spine reveals a gross restriction of all
fractures movements. In particular he tends to flex his hips when bending forwards
Other joint involvement: hips, knees, shoulders and ankle to compensate for a stiff spine.
Enthesopathy: inflammation of enthuses or tendon Schober’s test for lumbar forward flexion was 3 cm (normal 5 cm or
insertion (tendoachilles most commonly affected) more), which is markedly reduced. The wall test unmasks a fixed kyphotic
As evident above, there are many orthopaedic facets to this deformity of the spine. He is unable to stand with his back flush against
condition. Examiners can focus on one or two of these for a the wall. Flexion, abduction and external rotation of the hip joint
short case, or a more thorough assessment can form the basis (FABER test) produces severe pain of the sacroiliac joints.
of an intermediate case. There are good clinical signs present Maximum chest expansion from full expiration to full inspiration
with a lot to discuss. measured at the level of the nipples is reduced to 3 cm compared to a
normal expansion of 7 cm. The patient is breathing predominantly by
Non-articular manifestations diaphragmatic excursion, which is the cause of his protuberant abdomen.
Eyes: Acute anterior uveitis Neurological examination of both lower limbs reveals normal tone,
Heart: Conduction defects, aortitis, aortic regurgitation or power, sensations and reflexes.
stenosis I would now like to do a detail examination of his hips.
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EXAMINER: Do you want a MRI scan of the spine in this patient?

CANDIDATE: No. He denies any history of trauma; there is no
neurology, acute onset of pain or point tenderness in his spine.
MRI is indicated if suspecting fracture, or presence of any
neurology especially since patients of ankylosing spondylitis are
known to have epidural hemorrhage. MRI of the sacroiliac joint
is also indicated in early part of the disease process to identify sacroiliitis.
EXAMINER: So, how do you manage this patient?
CANDIDATE: MY main concerns in this patient are pain and
thoracolumbar deformity. I would like to have a multidisciplinary
approach involving the rheumatologist, physiotherapist, orthotics, pain
team and a spinal surgeon as well.
EXAMINER: Consider that his pain is now under control but he has
problems regarding his posture with loss of horizontal gaze.
CANDIDATE: I will refer him to a spinal surgeon for considering a
kyphotic deformity correction. The spinal team may consider
osteotomy at the thoracolumbar region, like a pedicle
Figure 10.10 AP and lateral radiographs demonstrating bamboo appearance
subtraction osteotomy. Indications for osteotomy are poor function,
AS spine
lack of horizontal gaze, cosmesis and fatigue pain from neck and
hip extensors.
EXAMINER: Consider that the hips are asymptomatic and are normal on
EXAMINER: If this patient presents with acute back pain, are you
examination. So what is your diagnosis?
concerned?
CANDIDATE: I would first like to have standing x-rays of his entire spine
CANDIDATE: Yes, this could be due to a vertebral fracture especially
with sacroiliac joints to make a diagnosis?
if history of fall or trauma. Fractures are not uncommon due to
EXAMINER: Why?
altered biomechanical properties of the spine. The ossified spine
CANDIDATE: Mr Smith has sign and symptoms of ankylosing spondylitis.
creates long lever arms limiting the ability to absorb even small
However, to label a patient with this diagnosis, I need one radiological and
impacts. Besides, there is osteoporosis due to stress shielding,
any one of the clinical criteria. He has all three clinical criteria, which are:
immobility and inflammatory process. These fractures are invariably
Low back pain and stiffness for >3 months that improves with exercise missed and are associated with high incidence of neurological
but is not relieved by rest complications and pseudoarthrosis.
Limitation of motion of the lumbar spine in both the sagittal and EXAMINER: Thank you
frontal planes
Limitation of chest expansion Other points for discussion
I need one radiological criteria that is sacroiliitis. 1. Preoperative anesthesia concerns
EXAMINER: These are his x-rays (Figure 10.10) 2. Consenting a patient for spinal surgery
CANDIDATE: AP x-ray showing left sacroiliac joint erosion and right 3. Approaches and complications of spinal surgery
sacroiliac joint ankylosis. The spine AP x-ray shows syndesmophytes 4. Medical management of ankylosing spondylitis
formation with ossification of the spinal ligaments leading to
5. Patient with spine and hip involvement, order of surgery
‘Bamboospine’ appearance. The lateral x-ray shows squaring of the
6. Cervicothoracic fractures and deformity management
vertebrae with marginal syndesmophytes. I can’t appreciate any
fractures on the x-rays.
I need to see full spine x-rays to see for sagittal balance as well as pelvis
Scoliosis
with both hips. This AP x-ray has limited view of the sacroiliac joints as Scoliosis is defined as spinal curvature in the coronal plane
well. >10°. However, there is usually associated deformity in sagittal
EXAMINER: What is the difference between osteophytes and plane and transverse plane (vertebral rotation). It can feature
syndesmophytes? as intermediate case or a short case in the exam.
CANDIDATE: Osteophyte formation begins at the site of Sharpey
fibers attachment between the annulus fibrosis and anterior margin of Etiology
vertebral body just above or below the vertebral endplate. Osteophytes Scoliosis is a descriptive term and not a diagnosis.
begin typically by growing outward and finally meet the osteophyte on 1. Idiopathic (80% cases)
the other side of the disc space forming bridging osteophytes.
a. Infantile: 0–3 years
Syndesmophytes on the other hand are ossifications of the
b. Juvenile: 3–10 years
annulus fibrosis and are more vertically oriented attaching right
c. Adolescent: 10+ years
at the endplate margin.
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2. Congenital (present at birth) the horizontal. Cobb angle is the angle between these
a. Failure of formation – Hemi vertebrae two vertebrae
b. Failure of segmentation – Unilateral unsegmented bar Risser’s sign – Ossification of the iliac apophysis begins
c. Mixed laterally (anterior superior iliac spine (ASIS)) and proceeds
medially (posterior superior iliac spine (PSIS)) to
3. Neuromuscular
eventually cap the entire iliac crest. Risser’s 1–5 is a
a. Upper motor neuron: Cerebral palsy measure of skeletal maturity and, therefore, a predictor of
b. Lower motor neuron: Polio curve progression. Risser’s 0 means no ossification center
c. Muscular weakness: Muscular dystrophies visible. Risser 0 and Risser 5 are similar on x-rays with no
4. Others appearance of ossification centers. However, they are easily
a. Syndromes: Marfan’s, Ehlers–Danlos, distinguished by age with Risser’s 0 at 5 years and Risser’s
neurofibromatosis 5 after 16 years of age
b. Tumours: Osteoid osteoma
c. Trauma What are the indications of MRI?
d. Compensatory: Leg length discrepancy Presence of neurology
Abnormal abdominal reflexes
Questions to be answered in assessing a case Severe curves or rapid progression of curves
of scoliosis Severe kyphosis
1. Etiology? Idiopathic or non-idiopathic (neurology, Atypical curve: left thoracic, apical kyphosis, short
syndromic features) angular curve
2. Region involved? Lumbar, thoracic, thoracolumbar, Foot deformities
involvement of pelvis or cervical spine
3. Structural or non-structural scoliosis? Structural Intermediate case: Idiopathic adolescent scoliosis
scoliosis is irreversible lateral curvature of the spine with This is the commonest form of scoliosis, usually a female
rotation of the vertebral bodies. Non-structural scoliosis is patient accompanied by her parent. Most common is right
a reversible lateral curvature with no rotation of the thoracic curve. This form of scoliosis is not associated with
vertebral bodies significant back pain, fatigue or neurological symptoms. If
4. Neurological involvement? Asymmetric abdominal present, it is non-idiopathic scoliosis that needs to be investi-
reflexes, weakness in any of the limbs, upper motor gated to find the cause. Some patients with adolescent idio-
neuron signs pathic scoliosis (AIS) may have low back pain that is common
5. Risk of progression? Age of the patient, menarche in in adolescence in general. However, it is felt that the curvature
females, Risser’s grading of pelvis or PA view of hand itself does not result in back pain.
and wrist GP note: ‘Referring to you 12-year-old Ms Leanne who’s mum is
6. Severity of the curve? Mild (10–25°), moderate (26–40°), concerned about a curvature in her back. Mum and daughter both
severe (>40°) are worried if this may worsen. Can you please take a history,
7. Other systems involved? Syndromic scoliosis may have examine this pleasant girl and discuss management.’
significant cardiorespiratory decompensation, sufficient (In this scenario, only a summary of the history.)
to be unfit for major surgery EXAMINER: Can you summarize your history please?
8. Is it painful? Painful scoliosis is always pathological, CANDIDATE: Ms Leanne is a 12-year-old girl, otherwise fit and well.
e.g. osteoid osteoma Her mum noticed Leanne developed a spinal curvature when she was
10 years of age. This has gradually progressed but is not associated with
Reading x-rays of the spine in scoliosis any pain. She denies any difficulty in breathing or any chest pain.
Confirm if standing and make sure entire spine is in She has no weakness in her legs or problems with her bowel or bladder.
view with PA, lateral and side-ending films (to assess Leanne has noticed that her clothes don’t fit well as they did previously.
flexibility of the curve) There is no family history of similar problems. She has tried a brace which
Region involved – Lumbar, thoracic, thoracolumbar curve her mum feels is not helping. She had her menarche at 11 years of age.
Number of curves – Single or double The family’s main concern is cosmesis and progression of the deformity.
Apex of the curve – Vertebrae furthest away from the EXAMINER: (interrupting) What are you suspecting based on your
midline history?
Cobb angle measurement – Identify the end vertebrae CANDIDATE: Adolescent idiopathic scoliosis
that have the pedicle levels with the greatest tilt from EXAMINER: Why not non-idiopathic scoliosis?
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CANDIDATE: Female, age of presentation, no back pain, no neurological Figure 10.11 Standing
complaints, no symptoms of other systems. Besides AIS is the most AP spine x-ray
common type of scoliosis. However, I need to do examination and
investigations to confirm my diagnosis.
EXAMINER: Please carry on with your examination.
CANDIDATE: On general examination, she is moderately built with
no obvious features of any syndrome. On inspection from the back, the
left shoulder appears to be at a higher level. There is waistline
asymmetry with the body shifted to the right. There is a right convex
thoracolumbar scoliosis. There is a rib hump on the right that
becomes more prominent on bending forward. The skin over the
back appears normal with no café-au-lait spots, tuft of hair or
lipoma. On inspection from the sides, there is hypokyphosis of the
thoracic spine with normal lumbar and cervical lordosis. On
inspection from the front, the chest appears to be normal with no
deformity.
The gait appears normal and she is able to do heel toe walking.
On palpation, there is no localized or generalized tenderness in the
spine. The spinal ROM is reduced in all three planes.
On sitting the curve does persist. On laying her supine, there is no
leg length discrepancy. There is no motor, sensory deficit in both
lower limbs and tone is normal. Reflexes are normal and plantars are
down going. Abdominal reflexes are normal.
EXAMINER: What is the significance of normal abdominal reflexes?
CANDIDATE: It suggests there is no intra-spinal cord pathology like a
syringomyelia, diastometamyelia, tethered cord and Arnold–Chiari
malformation. If they are abnormal, she will need an MRI scan of her Figure 10.12 Lateral
spine x-ray
spine to rule out any intraspinal pathology. Syrinx may cause the scoliosis
in the first place. The syrinx needs to be surgically treated by a
neurosurgeon prior to scoliosis correction. If scoliosis correction is carried
out first, then it carries a risk of temporary or permanent neurological
damage.
EXAMINER: What would you like to do?
CANDIDATE: I would like to have standing full spine PA, lateral and side-
bending views.
EXAMINER: Please comment on these x-rays? (Figures 10.11, 10.12,
10.13 a and b)
CANDIDATE: Standing AP spine x-ray shows a single right-sided convex
thoracolumbar scoliosis with the apex at T12. There is loss of coronal
balance with the C7 plumb line falling to the right of central sacral line. The
Cobb angle roughly measures around 50°. The pelvis shows Risser’s 1 stage
base of <25% of the calcification of the lateral iliac apophysis.
The lateral spine x-ray shows loss of thoracic kyphosis but the sagittal
balance is well maintained.
The side-bending x-ray shows that the curve does not correct fully on
the side of the convexity.
EXAMINER: Do you need a MRI scan?
CANDIDATE: No. MRI scan is not indicated. She has no features of any
syndrome, there is no neurology, abdominal reflexes are normal, its not a
atypical curve like a left-sided curve, acute angular curve, there are no foot
abnormalities or presence of significant kyphosis. If she had any of these,
I would have requested an MRI scan of the full spine.
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(a) (b) Figure 10.13 (a, b) Side-bending spine x-rays
EXAMINER: How would you manage her now? the operating team to prevent iatrogenic damage. If neurological
CANDIDATE: I would refer her to a spinal surgeon for considering scoliosis injury is suspected, then the operating team may consider a Stagnara
correction surgery. wake-up test.
EXAMINER: Why not bracing? EXAMINER: Thank you.
CANDIDATE: This is a severe curve, more then 40° and this needs surgery.
Other points for discussion
Besides, she is Risser’s 1 with menarche just about a year ago, she is definitely
likely to progress. Besides, she is not happy with the shape of her back.
1. Preoperative anesthesia concerns – Respiratory
compromise
EXAMINER: What do you think they will do?
2. Consenting a patient for scoliosis spinal surgery
CANDIDATE: They will consider correction with posterior spinal fusion.
If the curve is very severe, like 70°, they would consider anterior +
3. Approaches and complications of scoliosis spinal surgery
posterior spinal fusion.
4. Neurophysiological monitoring
EXAMINER: You mentioned Risser’s sign as to progression of the curve.
5. Estimating residual growth (Risser’s, Tanner’s stages, hand
Is there any other investigation that can help?
and wrist x-ray, menarche)
CANDIDATE: Yes, PA x-ray of the hand and wrist. It helps in
6. Classification of AIS (Lenke, King classification)
determining skeletal maturity. Skeletal maturity is defined as Risser’s 4,
2 years post menarche or <2 cm change in height in two visits 6 Short case: Non-idiopathic scoliosis
months apart.
EXAMINER: Please examine this 8-year-old boy focusing mainly on the spine.
EXAMINER: What is the role of SSEP (somatosensory evoked potential)
CANDIDATE: On general examination, the left lower limb appears to be
during scoliosis correction?
smaller than the right. He has a short limb gait.
CANDIDATE: SSEP is intraoperative neurophysiological monitoring that is
indicated in corrective spinal surgery procedures when there is potential On inspection from the back, there are multiple café-au-lait spots measuring
risk to the spinal cord, like severe curve corrections. They provide >15 mm. I would like to examine for axillary and inguinal freckling that would
information about the central and peripheral nervous system and guide suggest type 1 neurofibromatosis.
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Figure 10.14 Standing AP and lateral spine x-rays
EXAMINER: Yes, it is neurofibromatosis; now please focus EXAMINER: How would you manage him?
on the spine. CANDIDATE: I need to take a detail history to find out his symptoms.
CANDIDATE: On inspection from the back, there is a right convex thoracic I also need investigations like full spine standing x-rays and MRI scan
scoliosis with the apex roughly at T10. Both shoulders appear to be at the of the spine. I also need to know if this is dystrophic or non-dystrophic
same levels. type of neurofibromatosis scoliosis. Dystrophic scoliosis is short-
On inspection from the sides, there appears to be normal sagittal segmented sharp curve with involvement of ribs and vertebrae.
balance. On inspection from the front, the chest appears to be normal It is associated with kyphosis and high rate of post-surgery
with no deformity. pseudoarthrosis. Non-dystrophic curves behave like adolescent
He is able to do heel–toe walking. idiopathic scoliosis.
On palpation, there is no localized or generalized tenderness in the This curve appears to be dystrophic being short segment.
spine. The spinal ROM is reduced in all three planes. Also, I need to know if he has other orthopaedic complaints like tibial
On sitting the scoliosis persists, suggesting it’s not due to leg length pseudoarthrosis. I can already see that he has hemi-hypertrophy of his
discrepancy. right lower limb.
On laying him supine, there is leg length discrepancy; the left limb is EXAMINER: Please comment on these standing x-rays
shorter than the right. There is no motor deficit in both lower limbs and (Figure 10.14)?
tone is normal. Sensations are reduced in right L4, L5 and S1 dermatome. CANDIDATE: Standing AP spine x-ray shows a short right-sided convex
Reflexes are normal and plantars are down going. Abdominal reflexes thoracolumbar scoliosis with the apex at T10. There are features of
are normal. dystrophic vertebral scalloping, pencilling of ribs. The Cobb angle roughly
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measures around 70°. It is difficult to comment on Risser’s grading as CANDIDATE: I need to check the knee extensors (L3–L4) and the hip
I can’t see the entire iliac crest. abductors (L4–L5, mainly L5). If the power is normal in the hips and
The lateral x-ray depicts normal coronal balance. There is evidence of knees, with history of trauma to the fibula neck, it would suggest common
thoracic hypokyphosis. peroneal nerve involvement and not spinal etiology.
I need an MRI scan of his spine to see for any intraspinal lesions. EXAMINER: If it’s coming from the spine, what level is the compression?
EXAMINER: Consider his MRI scan to be normal. CANDIDATE: L4 nerve root involvement due to posterolateral disc L3–L4
CANDIDATE: Unusual for the MRI scan to be normal considering the or far lateral disc L4–L5.
x-ray changes of enlarged neural foramina, scalloping of vertebrae EXAMINER: What are other causes of foot drop?
and sensory deficit. CANDIDATE:
However, if MRI scan shows no intraspinal lesions and spine cosmesis Brain: cerebral palsy, stroke, multiple sclerosis
is his main concern, I will refer him to a spine-deformity correction Spine: Prolapsed disc, polio, syringomelia
surgeon.
Nerve: Peripheral neuropathy (diabetes), hereditary motor and sensory
EXAMINER: What are the associated complications? neuropathies (HSMN), fibula neck fracture, total hip arthroplasty/total
CANDIDATE: High rate of pseudoarthrosis up to 40% with posterior knee replacement iatrogenic injury, knee dislocation, nerve tumors
surgery. Some surgeons recommend bone grafting as well in same Muscle: Muscular dystrophies
sitting. EXAMINER: Do you think he will benefit from spinal surgery if he had
EXAMINER: Thank you. prolapsed disc?
CANDIDATE: He denies any leg pain now and SLR is not restricted. In
Short case: Foot drop other words, this is a painless foot drop that I feel will not benefit from
lumbar discectomy or decompression.
EXAMINER: Can you please examine the right foot of this 40-year-old
Management now is mainly orthotics and physiotherapy. In rare
patient? You can ask one question if you like.
circumstances surgery in the form of tendon transfer or arthrodesis.
CANDIDATE: Hi, My name is Mr K, one of the exam candidates. Can you
please tell me what’s wrong with your right foot?
PATIENT: I have weakness in my right foot since past 1 year. It all started
with back and right leg pain that is not there anymore; however, this
weakness concerns me.
Short case: Spondylolisthesis
EXAMINER: Please carry on with the examination. EXAMINER: Can you please examine this pleasant 17-year-old girl focusing
CANDIDATE: On inspection, there is wasting of the muscles in the anterior on her spine?
and lateral compartment of the leg. He is using ankle foot orthotic splint CANDIDATE: Hi, My name is Mr K, one of the exam candidates. Can you
on the right side. There are callosities in the forefoot over the plantar please walk for me?
aspect. Her gait appears normal.
Can you please walk for me? On inspection from the back, both shoulders and pelvis are at same
He walks with a high steppage gait with exaggerated flexion of the hip level. There is no evidence of any scoliosis. There are no scars of previous
and the knee to prevent toes from catching on the ground during the surgery. On inspection from the sides, there is loss of lumbar lordosis with
swing phase. There is absence of the first rocker on the right and his foot positive sagittal balance. The knees and hips are in flexed posture,
slaps on the ground at initial contact. Heel walking is absent on the right. probably trying to maintain sagittal balance.
There are no scars in the low back, buttocks or around the neck of On palpation, there is a step, roughly at L5–S1 level. There is central and
fibula suggestive of previous surgery or trauma. paraspinal tenderness at this level. Spinal flexion and extension are reduced.
I would like to perform a detail neurological examination. On lying down supine, there is no leg length discrepancy. SLR is about
EXAMINER: Please focus in the foot. 50° bilaterally with hamstring tightness.
CANDIDATE: Ankle dorsiflexors (L4–L5, mainly L4) is grade 1/5, plantar Neurological examination reveals normal tone. EHL (extensor hallucis
flexion 5/5 (S1, S2), EHL 5/5 (L5), eversion (L5–S1) 5/5, inversion(L4–L5) longus) and ankle dorsiflexors on the right are 4/5; power is normal in
3/5. Sensations are reduced over the L4 dermatome (medial aspect of the remaining myotomes. Sensations are reduced in right L5 dermatome.
foot). Tone is normal and Babinski is downgoing suggesting the lesion is Reflexes are normal bilaterally.
LMN type. EXAMINER: What’s your diagnosis?
SLR bilaterally is 80°. CANDIDATE: Considering her age with a positive step sign and positive
Examination suggests a L4 nerve root involvement, most probably from sagittal balance L5–S1 spondylolisthesis.
his spine as he had back and leg pain. However, to confirm this, I need to EXAMINER: Please comment on her lateral x-ray (Figure 10.15).
do a detail neurological examination. CANDIDATE: Assuming this is a standing x-ray, there is L5 lysis with
EXAMINER: I say it’s coming from a common peroneal nerve injury spondyloptosis of L5 over S1. Pelvic incidence is also increased. I need full
following a fibula neck fracture. Am I right in saying so based on your spine x-rays to check for sagittal balance besides her spine AP x-rays.
examination? Clinically and based on this lumbar spine lateral radiograph, she seems to
013
Figure 10.15 Lateral have positive sagittal balance which is expected to be present in this high
x-ray grade of listhesis. I will need MRI of her lumbar spine as well.
EXAMINER: This is her MRI scan (Figure 10.16 a and b).
CANDIDATE: MRI T1 and T2 sagittal image showing spondyloptosis at
L5–S1.
EXAMINER: Unfortunately, I don't have her axial images. What do you
expect in those images?
CANDIDATE: I would expect to see L5 nerve root compression more on the
right as she does have right leg pain.
EXAMINER: How would you treat her?
CANDIDATE: I need to take a history first. I need to know her symptoms.
EXAMINER: You can ask her two questions.
CANDIDATE: Can you please tell me if you have any problems with
your back?
PATIENT: I have back and nasty right leg pain for the past 2 years.
CANDIDATE: What all treatment have you had?
PATIENT: Painkillers, rest, physiotherapy. I am sick of it now. It’s affecting
my life. I used to be a gymnast before. No more.
EXAMINER: Would you offer her surgery?
CANDIDATE: Yes I would refer her to a spinal surgeon to consider surgery.
She has tried non-operative measures so far. Surgery would be in the form
of reduction of the listhesis and fusion with bone grafting. This is high
grade and will probably need fusion up to L4.
(a) (b)
Figure 10.16 (a, b) MRI T1 and T2 sagittal images
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013
EXAMINER: Can you think of any differences in isthmic spondylolisthesis 2. Non-operative management
like this one and a degenerative spondylolisthesis? 3. Indications for surgery
CANDIDATE: Degenerative spondylolisthesis usually affects older patients. 4. Reduction or in-situ fusion
Isthmic spondylolisthesis on the other hand affects children and 5. Define pelvic incidence, sacral slope and pelvic tilt; what’s
adolescents especially those involved in repetitive hyperextension, like their significance?
gymnasts, weightlifters. 6. Degenerative spondylolisthesis and its management.
L4–L5 is most common level in degenerative spondylolisthesis while Presentation similar to lumbar canal stenosis ± back pain.
L5–S1 is the most common level in pediatric spondylolisthesis. Decompression alone or with fusion?
And finally, the exiting nerve root in involved in isthmic listhesis while 7. SPORT trial outcome for spondylolisthesis
the traversing nerve root is usually involved in degenerative listhesis. So,
L5–S1 lytic listhesis will involve L5 root while S1 root will be involved in References
degenerative listhesis L5–S1. 1. Ikenaga M, Shikata J, Tanaka C. Radiculopathy of C-5 after
EXAMINER: Thank you. anterior decompression for cervical myelopathy. J Neurosurg
Spine. 2005;3:210–17.
2. van der Linden S, Valkenburg HA, Cats A. Evaluation of
Other points for discussion diagnostic criteria for ankylosing spondylitis. A proposal for
1. Spondylolisthesis classification: Wiltse–Newman, modifcation of the New York criteria. Arthritis Rheum.
Meyerding grading 1984;27:361–8.
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Hip clinical cases

Chapter
11 Suresh Thomas and Paul A. Banaszkiewicz
Clinical examination of the hip removing socks. They will probably indicate that this is
not necessary
During the exit fellowship examination a candidate will have to
Although glaringly obvious at all times be careful to
demonstrate not only that he/she knows how to examine the
maintain the patient’s modesty, because very occasionally
hips of a patient but to also ensure that the examiner is able to
candidates can become so focused on some minutiae finer
see and appreciate each part of the examination. It will become
detail of the examination process that they forget this.
immediately apparent to the examiner if the candidate has a
This is a pass/fail issue that will be discussed between
routine for examining the hip. It is useful to have a set stand-
examiners
ard system that is second nature to you so that you appear
competent and no steps are forgotten. Don’t forget to wash your hands between EVERY case
Examination of the hip in the month prior to the FRCS When examining the hip:
Orth exam should become a subconscious act to you. This Think about what you will find
means that even during the most stressful of situations in the Listen to what the examiner says
real exam it will flow naturally, without one having to think Look as though you know what you are doing and have
about what comes up next or worry that one has missed some examined a hip beforehand
vital test out. If you are able to achieve this competency in your Appear confident to the examiners
examination technique you will be more relaxed during the Examine in turn:
real exam and will be able to appreciate the significance of the Inspection (Figure 11.1)
clinical findings that you elicit. Gaita
In its most evolved form this involves anticipating expected
Trendelenburg’s test
clinical findings based on what you have already uncovered
Palpation
clinically and formulating ideas about the possible diagnosis as
you go along. Thomas’ test
By all means develop your own routine that works best for Movements (active and passive)
you but don’t stray too far from the norm. Just as important, Limb length inequality
do not jump around and get the order of the hip examination Neurovascular status
out of sync. This is particularly annoying to examiners and
suggests a disordered thought process and a lack of a system- Trendelenburg’s test
atic approach in your clinical practice. This is performed to assess the integrity of the abductor
mechanism of the hip, which consists of a fulcrum, lever arm
Preliminaries and power. This is a first order lever mechanism. The fulcrum
Preliminaries are very important in the exam setting even for is taken to be at the centre of the hip joint, lever arm repre-
the short cases where time is tight: sented by the neck of the femur and power represented by the
controlling group of muscles. In practice it is easier if you first
Always introduce yourself to the patient demonstrate the Trendelenburg test to the patient showing
Ask permission to examine the hip them what you want them to do. It avoids any misunderstand-
Ask if their hip is painful ing (Figure 11.2).
Explain to the patient that you are going to be moving their
hip about and will do your best not to hurt them
Make sure that you watch their face throughout the
examination and avoid sudden movements a
Keep the patient walking; it is difficult to take everything in
Tell the examiner that you would like to start by immediately. Equally don’t keep the patient walking forever if you
undressing the patient to his/her underwear including can’t work out the gait pattern – Move on with the exam.
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Figure 11.1 Inspection

from the side. An
increased lumbar lordosis
suggests a compensatory
mechanism to conceal a
fixed flexion deformity of
the hip
Figure 11.2 Trendelenburg’s test. There are several modified methods of

performing Trenedelenburg’s test. Learn one method well and stick to it. Be
very clear about what you are testing and be able to talk your way through the
test as you perform it in front of the examiners. If all else fails remember the
True positive “sound side sags”.
Power failure (weakness of abductors)

Generalized muscular weakness or paralysis (polio,
Duchene muscular dystrophy)
If pain is not considered a true positive. Hip pain makes
Generalized neurological weakness (spinal cord lesions, proper assessment of these cases difficult. It has been suggested
myelomeningocele) that a 10% rate of false positives occur.
Localized gluteal muscle paralysis or weakness (superior
gluteal nerve injury, post-total hip arthroplasty (THA)
exposure with failure of adequate repair, trochanteric False negative
osteotomy Arthrodesed or ankylosed hip
The patient is able to maintain hip abduction with no abductor
Lever failure function. Sometimes the hip can be so arthritic that it will not
Intracapsular neck of femur fracture (NOF); extracapsular move when standing on the affected leg and, therefore, the
NOF, short neck in coxa vara, Perthes disease pelvis will stay level.
False-positive and false-negative responses may occur, but
Fulcrum (pivot) failure their interpretation can be clarified if the test is properly
Dislocation hip performed.
The test is invalid if:
Developmental dysplasia of the hip (DDH)
Femoral head destruction secondary to septic arthritis Poor balance
Lack of co-ordination
Unable to understand instructions
False positives The presence of pain, poor balance and either lack of
Gluteal inhibition due to pain secondary to: co-operation or understanding by the patient can lead to
OA false-positive tests, because the test cannot be properly per-
Avascular necrosis (AVN) formed. The reason for some false-negative tests is that the
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Chapter 11: Hip clinical cases
subject uses muscles above the pelvis to elevate the non-weight- At the point where this occurs, bend the patient’s knee so
bearing side of the pelvis, or shifts the torso well over the that their heel touches the couch and measure the angle
weight-bearing side; these can be called ‘trick movements’. So between the couch and thigh = angle of flexion deformity.
long as you know the principles of the Trendelenburg test and
appear confident in your approach this should be enough to
score a basic pass. The examiners may ask ‘if you know any Leg length inequality
other ways to perform the test’ so be prepared to be at least able Identify any obvious leg length difference:
to discuss alternative methods. An increasingly popular slick Is it real or apparent?
method of performing the test is with the examiner seated in a If it is real is it in the femur or tibia?
chair but beware this may not always be possible in the short If in the femur is it above or below the greater trochanter?
case examination hall. Shortening of a limb could be compensated by tilting the pelvis
There has been a recent update of the description of the test (ipsilateral anterior superior iliac spine (ASIS) down), flexing
calling it a “single leg phase stance phase.” This requires the the opposite limb at hip and/or knee, equinus position of
patient to stand with feet shoulder width apart raising the the ankle.
unaffected leg to 45° knee and 45° hip flexion. The test is
completed after 6 sec and is positive if the trunk falls more True shortening
than 2 cm. The affected leg is physically short compared to the opposite
side. This could be above or below the trochanter. Measure-
Thomas’ test (Figure 11.3) ment is taken from ASIS to the medial malleolus. If there is a
This is classic test material. The examiners will almost certainly deformity in one leg, the other leg must be placed in an
ask you to demonstrate Thomas’ test as part of an intermediate identical (mirror equivalent) position and the pelvis square.
or short-case examination of a hip condition. The test is
usually well described by most candidates but often poorly Apparent shortening
performed in the pressure/stress of the real exam. Candidates Apparent shortening is measured from the xiphisternum
should practice this test repeatedly and be prepared to demon- to medial malleolus (pelvis need not be square). It is taken as
strate it well. Do not hurt the patient. and generally best to the sum of true shortening plus shortening from any fixed
avoid the test if THA on the opposite side for fear of deformity.
dislocation. This measurement helps in assessing the extent of natural
Perform the test on the good side first. Ask the patient to compensation developed for concealing the actual disparity
hold their affected limb with both hands. Place your left hand at the hip joint especially by tilting the pelvis sidewards
under the patient’s lumbar spine. With your other hand hold- (fixed abduction and fixed adduction deformity). On many
ing the good leg, control full extension of the limb. Full occasions this natural compensation improves cosmetic
extension is normally achieved with the lumbar lordosis still appearance.
obliterated. If the true shortening is equal to apparent shortening it
If there is a fixed flexion deformity the patient will arch indicates no compensation
their lumbar spine and the lumbar lordosis will reappear If the true shortening is more than apparent shortening it
(pressure is relieved in your left hand). indicates that part of the shortening has been compensated
If the true shortening is less than the apparent shortening it
suggests a fixed adduction deformity besides shortening
without compensation
In recent exam sittings there has been less concern with measur-
ing for apparent shortening and a more concentrated focus on
true shortening. A safe middle ground approach would be to
measure for true shortening and reserve measuring for ‘apparent’
discrepancy only when there is an incorrectable tilt of the pelvis.
Examination of leg shortening standing

Blocks can be used to measure for any leg length difference
in the standing weight-bearing position
Figure 11.3 Thomas’ test. The angle subtended between the back of the
The pelvis is tilted to a lower position on the short side
thigh and the bed will be the angle of fixed flexion deformity. Do not maximally Correct the pelvic tilt and when the ASIS is at the same
flex up the opposite hip as this may flex the pelvis and lead to a false impression level place blocks under the foot. This gives the length
of a FFD. It is perhaps easier to perform the test kneeling down to the side of
the couch rather than standing rigidly bolt upright disparity. Many clinicians regard this as a better method
of assessment of length discrepancy than measuring
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supine as the patient is actively involved in this assessment. This is difficult and cannot be done simultaneously. The most
Be careful if a fixed obliquity is caused by lumbosacral practical way is to cross the legs sequentially. Cross one leg and
disease, as this cannot be corrected for by using this measure and then cross the other leg and measure.
method Again comment to the examiners on the presence of an
A more accurate method that may be brought up in a abduction contracture:
discussion is either a scanogram or spiral CT scout film ‘I am unable to place the legs perpendicular to the pelvis because
If a patient has a fixed deformity of a joint the Block test is of the abduction contraction and must place the normal leg in the
not accurate and, therefore, the limb needs to be measured same position.’
in the position of deformity using a tape measure Abduct the unaffected hip to the same degree. Measure leg
lengths.
Examination of leg shortening supine
Apparent shortening is roughly estimated measuring
Flexion contraction knee
the distance from xiphisternum to the medial malleolus. Comment on this to the examiners:
The lower limbs are kept parallel to one another and in ‘I am unable to place the legs straight because of the fixed flexion
line with the trunk. The pelvis need not be square. of the knee.’
Next go on to measure for true shortening. Ensure the You must place the other leg in the same position. One would
pelvis is square flex the unaffected knee over a bolster or pillow to the same
Legs should be kept in identical position if possible degree and then measure leg lengths.
It may not be possible to do this if there is a pelvic tilt with
adduction contraction Valgus knee
A deformity is usually unmasks on squaring the pelvis Comment on this deformity to the examiners:
Measurement is taken from ASIS to medial malleolus with ‘I am unable to place the leg straight because of the valgus knee.
the limb in the deformed position I am unable to place the opposite leg in the same position.’
When the normal limb is measured, it is necessary to keep
it in the same position as the affected limb Note the difficulty and, therefore, you must measure compon-
ent parts of the leg. This approximates to a true leg length. You
Any pelvic tilt due to postural scoliosis should be adjusted
measure from the ASIS to the tibial tuberosity and then from
by the position of the patient
the tibial tuberosity to the medial malleolus.
In simple terms the distance between the ASIS and the
medial malleolus is ‘less’ in adduction and ‘more’ in abduc-
tion and not the ‘same’. Therefore, both the limbs should be
either in ‘adduction’ or ‘abduction’ to get the true length of Examination corner
the lower legs. This can be done by bringing both the ASIS For a short case the examiners may just specifically ask a
at the same level by ‘squaring’ the pelvis before recording candidate to examine for leg length inequality. This is not
the real lengths. always performed well by candidates whilst the textbooks
can be often misleading and contradictory.
Abduction/adduction contracture In the ideal world the legs should be parallel to each other
and the sides of the examination couch and be perpendicular
Deformity is unmasked by squaring the pelvis. to an imaginary line joining the ASIS.
A patient with an adduction deformity compensates and
may appear straight by tilting the pelvis on the affected side up. Apparent leg length discrepancy
Hence, the ASIS is raised and the leg appears short. Measure for apparent leg length discrepancy first. The patient
A patient with an abduction deformity compensates and should be lying supine in a comfortable position with the
may appear straight by tilting the pelvis on the affected side affected leg in the line of the trunk. The lower limbs should
down. Hence, the ASIS is lowered and the leg appears long. be in a parallel position. To achieve this the unaffected leg is
If the pelvis is square and ASIS are at the same level, there moved to make the limbs parallel. No attempt is made to
is no deformity. correct any pelvic tilt or abnormal limb position. The measure-
ment is taken from any central fixed point on the trunk (central
Comment to the examiners on the presence of an adduc-
point of the suprasternal notch, xiphisternum) to the medial
tion contracture:
malleolus. Textbooks also mention the umbilicus but some old
‘I am unable to place the legs perpendicular to the pelvis because of school examiners may comment that it is not a fixed structure
an adduction contracture and, therefore, I must place the other leg and may not be midline if diseased or had previous umbilical
in the same position.’ surgery.
014
Limitations to extension are generally secondary to

True leg length discrepancy
With measurement of true leg length the pelvis will then need pathology in the intercondylar notch region. Limitations of
to be squared up to reveal any concealed fixed abduction or knee flexion are generally secondary to scar tissue within
adduction deformity. The legs are put into equivalent/identical the medial and/or lateral gutters or within the suprapatellar
positions. The affected leg is moved to square up the pelvis pouch region.
(level the pelvis) by exaggerating the noted deformity. The In a patient who has significant pain, consider infection and/
normal limb is then moved to make it in an identical position or complex regional pain syndrome (CRPS) as a
to the affected leg. Check the level of the malleoli. contributing cause of knee stiffness.
Measure from the ASIS to the medial malleolus. The ASIS can Discussion of the Ilizarov frame correction of the deformity.
be difficult to reliably identify in obese patients or if distorted
from iliac chest bone graft harvesting. Make sure you accurately
define the ASIS by hooking your fingers up from below. Level 2
Difficulty may also be encountered with fixed deformities The femur and tibia of the involved limb are short but no
of either the hips or knees. If necessary sequentially measure attempt has been made to lengthen either of them.
from ASIS, greater trochanter, medial joint line of the knee and The clubfoot or polio case of a hypoplastic femur and tibia
tip of the medial malleolus. causing a leg length discrepancy. There is shortening in the
tibia and femur so Galleazzi’s test is more complicated to
interpret. The knee of the longer leg is projecting more towards
Shortening cases for the FRCS (Tr & Orth) exam you from the end of the bed and higher up from the side.
Level 1 difficulty
This may involve a femoral fracture with mal-union and
Level 3
shortening. The mal-union usually will involve a rotatory The femur and tibia of the involved limb are short but there
element. has been an attempted lengthening of one or both bones.
There could be an associated arthrofibrosis of the knee with Candidates may get confused as they are instinctively
limited knee movement and knee pain. expecting both bones to be shortened because the leg is
hypoplastic with poor musculature.
Examples would include:
History 1. The clubfoot case with a short femur but longer tibia
The patient may have been involved in a road traffic accident than the opposite normal side from an Ilizarov
(RTA) and so a full history is required concerning the lengthening procedure.
mechanism of injury.
2. The polio case where there has been an attempt at
It is important to know all the various surgical treatments lengthening the tibia using a monolateral external
undertaken. fixator to correct the limb length discrepancy (LLD)
What are the current on going problems? (Figure 11.4). This is puzzling as you would normally
expect the tibia to be both hypoplastic and short. The
Examination give away clues are healed external fixator scars in the
lower leg. Galleazzi’s test is difficult to interpret if a
There will generally be various surgical and non-surgical
candidate does not appreciate what’s been done
scars present.
(Figures 11.4–11.6).
Get slick at describing the scar patterns present.
Left lower limb external rotatory position at rest with
equinous position of the ankle.
Level 4
Two long bones of the same limb are shortened with possible
lengthening attempted of one or both bones. The normal
Discussion opposite limb has been shortened to reduce the LLD either
Know your definitions of true and apparent leg length the femur or tibia or both.
discrepancy. The hypoplastic left leg of clubfoot. Multiple scars of clubfoot
What can be done about post-trauma painful arthrofibrosis surgery on the actual foot itself. A long surgical scar posteriorly
of the knee in a young male patient? over the tendo Achilles from previous lengthening of the soft
There has presumably been a failure of conservative tissues. The left foot is small and hypoplastic.
treatment and, therefore, arthroscopic lysis of adhesions The normal right femur is shorter than the involved left
should be considered. Distension of the capsule, excision of femur as epiphysiodesis has been performed on the distal right
adhesive bands and release of scar tissue is performed in a femoral epiphysis. The normal right tibia is longer than the
systematic fashion. If this is not successful or the opposite tibia as no epiphyisiodesis of the proximal right tibia
arthrofibrosis severe then an open release may be indicated. has been performed as well as no lengthening of the left tibia.
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Figure 11.5 Galleazzi’s test

performed on patient in
Figure 11.4 with polio disease
right leg. Shortened right femur
with lengthened right tibia.
Figure 11.4 Clinical picture of polio affecting the right leg with previous
external fixator lengthening of the right tibia. Note residue valgus deformity,
right foot.
Galeazzi’s test is confusing as the femur is shorter on the

normal side and the tibia longer than the involved limb
Look for the scars from the epiphysiodesis surgery, these are
not always obvious and you can end up concentrating on the
involved hypoplastic leg missing the epiphysiodesis scar on Figure 11.6 AP pelvis radiograph of patient in Figure 11.4 with polio disease
the normal leg right leg. Underdeveloped femur, pubis and ischium.
A plantigrade foot with mild heel varus. The arch of the foot
was well maintained potential scenarios and may struggle to work out what is going
The other common scenario is the polio leg, which is on from first principles. It is sometimes difficult to think fast
equivalent/similar to clubfoot in all of the various combinations on your feet working out leg length combinations from scratch
in the stress of the exam. Better to have worked through these
Level 5 assorted scenarios beforehand.
Both lower limbs are hypoplastic and this involves both the
femur and tibia but there is usually a more affected leg and all
Ankylosing spondylitis
combinations of lengthening of the short leg and shortening of Introduction
the longer leg may have been attempted
AS is a seronegative inflammatory disease of unknown aeti-
COMMENT: Some very good candidates seem to intuitively be ology primarily affecting younger men. Peripheral joint
able to work out all these possible clinical combinations and do involvement is less common than spinal disease. The hip joint
well. Borderline candidates may not be aware of all these is involved in 30–50% patients and is usually bilateral
014
(50–90%). The typical age of onset is between 15 and 25 years.

The younger the age at onset the more severe the disease is
Indications for THA
Indications include severe disabling debilitating pain and cor-
likely to be and the more likely the need for THA.
rection of severe hip flexion deformities.
The aims of THA are pain relief, eradication of flexion
History contractures, increased range of hip joint, movement,
As for any inflammatory joint disease. The onset often is improved mobility and correction of posture2.
insidious with low back pain and stiffness, chest wall pain, Consider bilateral surgery for severe bilateral fixed flexion
enthesopathy involving the Achilles’ tendon and plantar deformities. The patient will not be able to stand up straight
tendons. Occasionally may present with no pain but increasing until both hips have been operated upon and if more than a
stiffness in the hips and spine. Ask about ocular pain and few months is left between the two sides the deformity will
problems with chest expansion. reoccur. Another relative indication for bilateral surgery is if
there are risks and difficulties associated with the anaesthetic,
Clinical features e.g. need for fibre optic awake intubation.
The characteristic spinal deformity is a combination of a
thoracic hyperkyphosis and a flattening of the lumbar lordosis, Technical difficulties
causing the patient’s head and neck to thrust forward. Over Many surgeons consider THA in AS patients to be a particu-
time, the kyphotic deformity causes a downward and forward larly demanding procedure. In the exam it is reasonable to
shift of the patient’s trunk, mention that you would seek the advice of a senior hip
A functionally disabling advanced stoop develops with surgeon and ensure adequate preoperative anaesthetic assess-
limitation of forward vision (question mark posture). The chin ment before surgery.
brow angle, occiput to wall distance and gaze angle are used to Spinal and epidural anaesthetic may be difficult due
evaluate functional deformity involving the cervical spine. to ossified ligaments (bamboo spine). Restricted chest expan-
There is severe loss of motion at the hip joint, a fixed flexion sion, ITU bed back-up and echocardiography for any valvular
deformity or ankylosis. heart disease.
Chest expansion should be at least 5 cm, but is often Difficulties relating to positioning of patients on the
limited in ankylosing spondylitis due to costochondral arthro- operating table, the correction of longstanding contractures,
sis. Not a reliable sign in the elderly or COPD. accurate placements of the acetabular component in the pres-
Wall test: Heels, buttock and scapulae all should be able to ence of pelvic obliquity or tilting and delicate skin and soft
touch the wall, but if decreased extension unable to do this tissues have all served as deterrents.
Schober’s test: Mark two points, one 10 cm above and one AS patients with a fixed kyphotic spine tend to hyperextend
5 cm below the level of the posterior superior iliac spines and their hips once they stand upright, in an attempt to look
forward flex the spine, the distance should lengthen 5 cm forward. If the cup is inserted according to the anatomy of
the acetabulum, it becomes abnormal when the patient
Radiographs resumes an upright position.
The pelvic hyperextension brings the cup to a more open
Radiographs show ossification of the ligamentous origins and
position with an exaggerated anteversion and may lead to
insertions about the trochanters, iliac crest and ischial tuber-
anterior instability and dislocation. Exaggerated anteversion
osities. Later on radiographs become similar to end-stage
may lead to intraoperative difficulties including impingement
primary OA.
of the prosthetic neck or the greater trochanter posteriorly or
difficulties in reducing the hip.
Management options There is a higher incidence of ectopic bone formation
If there is any uncertainty whether pain is arising from the hip after THA leading to a reduction in the postoperative range
joint or spine then a local anaesthetic injection into the hip joint of movementb. This is more common when trochanteric
may be useful. Hip involvement ranges from flexion contrac- osteotomy is performed. There are concerns regarding the
tures to complete ankylosis, often in a disabling flexed position. young age of patients, they may place greater demands on
Total hip arthroplasty (THA) may be considered before spinal the prosthesis that results in increased rates of wear and
osteotomy because improvement in hip’s range of movement loosening. In addition, AS tends to spare upper limbs
and pain relief may obviate the need for spinal osteotomy in resulting in higher demands on hip prostheses because over-
patients with severe hip flexion deformity. Others take the all function is better.
opposite view and recent evidence has shown higher dislocation
rates when spinal osteotomy is done after total hip arthroplasty
(THA)1. In addition, hyperextension of immobile spine during b
Controversial. Recent reviews of the literature suggest that
THA could lead to intraoperative thoracic vertebral body exten- heterotopic ossification (HO) rates may not be that dramatically
sion fractures with resultant acute traumatic paraplegia. higher compared to age- and sex-matched counterparts.
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Examination corner
Intermediate case 1: Ankylosing spondylitis
Patient’s age, activity levels and expectations from THA
surgery
Document spinal involvement, pelvic obliquity and LLD,
status of the contralateral hip, bilateral knees and integrity of
sciatic nerve
Loss of normal lumber lordosis
Stiff spine with gross restriction of all spinal movement
Abnormal Schober's sign: Lack of at least 5 cm increase in
distance from a midline point 5 cm below and 10 cm above
the posterior superior iliac spine
Some flexion at the knee to maintain erect posture
Thomas’ test to demonstrate fixed flexion deformity both
hips. Candidates will be quizzed on the principles of Thomas’
test and various steps such as keeping your hand under the
spine. Ensure you know how to assess patients which
ispilateral knee and hip flexion deformity. A patient can be
moved to the edge of the bed and the knee with a flexion
deformity is dropped down to unmask any hip deformity.
Keep the knee outside the edge of the couch
Methotrexate is generally not withheld in the perioperative
period but the risk of infection with anti-TNF is well
recognised and, therefore, usually stopped
Preoperative templating is important to estimate
component size and positioning
Operating surgeon should be present to position the patient
to familiarize themselves with deformities of the pelvis and
spine and reduce risk of component mal-positioning
THA survival rates in AS patients are similar to that in other
young patients with THA. There has been a move towards Figure 11.7 AP and lateral radiograph bamboo AS spine
using uncemented components in young active patients
with AS
Hip resurfacing in generally contraindicated in the
presence of an inflammatory arthropathy. Li et al.3 in a
small study from China recommended their use in AS as
ROM was significantly better than THA, with the same pain
relief and a low dislocation risk. Hip resurfacing has fallen
out of favour due to concerns with adverse reactions to
metal debris (ARMD) pseudotumours etc. If a candidate
decides to mention resurfacing arthroplasty in the exam
they must follow through with referral on to a specialised
hip resurfacing surgeon performing reasonable numbers
each year. This may lead on to “Getting in right first time”
(GIRFT) Tim Briggs recommendations and increased
complications with low volume high risk procedures.
Intermediate case 2: Complicated case of 72-year-old male with AS

‘Presented with bilateral hip pain. Difficulty walking with
a walking distance of 200 yards. Had right hip fused
several years previously for AS and established AS left
hip. The history of the pain suggested referred pain from Figure 11.8 Fused right hip in AS
the spine into both hips especially as it radiated down
past his knee into both feet. There was, however, groin
pain bilaterally.’
‘The discussion was tricky and seemed to focus on suggested a diagnostic steroid injection into the left hip,
taking down the fused right hip to relieve the patient’s investigation for possible referred pain from the spine with
right hip pain. I was surprised with this approach, as I had an MRI scan, rheumatology review. I mentioned
014
femoral head in the acetabulum. Abductor muscle weak-

considering THA on the left side if the patient had
experienced a good response to his steroid injection.’ nesses may be present secondary to proximal femoral migra-
(Figures 11.7 and 11.8) tion or reduced femoral offset. Functional abductor strength
is evaluated with a Trendelenburg’s test and side-lying
COMMENT: ‘I don’t think the candidate was necessarily
abduction strength testing.
wrong, but perhaps the emphasis should have been the fusion
causing LBP and secondary left hip pain rather than the AS per Examination of gait reveals a waddling gait. There is
se. Common indications for the conversion of an arthrodesed increased lordosis of the spine and the body is swaying from
hip to a THA include pain arising from the lower back, side to side on a wide base. The patient lurches on both sides
ipsilateral knee or contralateral hip, a painful non-union or whilst walking and is Trendelenburg positive.
mal-positioned arthrodesis and planned ipsilateral knee
replacement. It is important that the origin of pain is accurately
defined.’
Technical considerations
The aim of THA in DDH is to restore the centre of hip
rotation and proximal femoral anatomy to allow optimal
abductor function. Implant options must cover the need for
Developmental dysplasia of the hip (DDH) small acetabular components and small/short femoral stem
Adequate preoperative planning such as clinical assess-
History ment, CT scan, preoperative templating and arrangements
Indications for surgery include persistent pain affecting rou- for bone grafts are required. The patient should be forewarned
tine daily activities. Women are more affected than men, that the operation might be abandoned if either abductor
family history and birth history are important. DDH may musculature is poor or the bone of the pelvis is inadequate.
affect hip movements, problems with sexual intercourse and Decide on anatomical (true acetabulum) or non-anatomical
personal hygiene. Hip symptoms must be defined in detail. (high hip centre) acetabular cup positioning. The proximal
Buttock pain, back pain and an abnormal gait are usually the femur is typically smaller, narrower, straighter, weaker and
primary symptoms unlike typical groin pain of OA. more anteverted than in normal hips. Diffuse osteoporosis and
Unilateral hip disease may cause secondary problems with thin cortices increase the risk of intraoperative femoral fracture
leg length discrepancy, ipsilateral knee pain, pelvic obliquity, when reducing the THA, especially if reduction is tight because
scoliosis, limp, muscle weakness and LBP. of leg lengthening. The level of the true acetabulum needs to
be defined for placement of the cup (the surgical landmark is the
Examinations findings obturator foramen). A drill hole may be used to perforate the
‘On examination the left leg appears shortened. The muscle bulk of medial part of the acetabulum and a depth gauge may be used
the left thigh is markedly reduced. There is a compensatory pelvic to decide how far to ream the acetabulum. Be aware of the
obliquity/scoliosis/lordosis because of the leg length discrepancy/ possibility of sciatic nerve injury from excessive lengthening.
fixed flexion deformity. The attitude of the left leg appears Avoid >4 cm lengthening.
externally rotated compared to the opposite side. The patella is not
facing forward suggesting that the rotation is occurring in the
femur. The pelvic obliquity can only be partially corrected with
Discussion
wooden blocks. Examination of gait demonstrates an obvious limp Surgery is only indicated if there is disabling pain and all
with a short stride, toe walking and increased lumbar lordosis. conservative management options have been exhausted. Pre-
When sitting on the bed the scoliosis of the spine only partially arthritic patients may be candidates for hip arthroscopy or
corrects, which means that there is an element of both a flexible periacetabular osteotomy.
and a fixed deformity of the spine. The peripheral pulses are Investigations include full-length standing bilateral lower
palpable with good capillary refill of the toes.’ extremity radiographs and CT scannogram if large LLD
If the scoliosis is not fully correctable, full correction of a leg exists. CT scan of the pelvis is valuable in assessing acetab-
length disparity can lead to persistent problems. When exam- ular position, version, bone stock, femoral anteversion and
ining the patient supine on the couch attempt to square the femoral canal diameter. MRI is seldom useful in the pres-
pelvis if possible. Comment to the examiners if you can or ence of established OA changes about a dysplastic hip.
cannot do this. If the patient has a fixed pelvic obliquity then Subluxation or significant adduction deformity can cause
apparent leg lengths (measured from the xiphisternum to the functional shortening of the leg and secondary long leg
medial malleolus) should be calculated. Galeazzi’s test and arthritis in the opposite knee (owing to walking on a flexed
Bryant’s triangle should be performed if there is any sugges- knee to compensate for a LLD). A valgus OA of the ipsilat-
tion of true shortening (previous femoral osteotomy). It is eral knee caused by severe adduction deformity of the ipsi-
important to differentiate between true and apparent lateral hip may develop. Knee arthroplasty in these patients
shortening and to be able to explain this to the examiners if will accentuate their scissoring gait and lead to early failure
asked. Check for a difference in rotation of the hip when of the TKA if the adduction deformity at the hip is not
flexed or extended due to discrepancy in the shape of the corrected first
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014
Hip reconstruction becomes more technically challenging uncemented femoral component by providing increased tor-
as the grade and extent of dysplasia increases. sional stability for the implant; this helps to maintain more
normal proximal femoral anatomy and avoids the need for a
Subtrochanteric femoral shortening osteotomy greater trochanteric osteotomy, which may not unite. It avoids
the need for sequential proximal resection, which results in a
(Figures 11.9 and 11.10) small straight femoral tube with a small metaphyseal flare,
Indications which is usually unsuitable for an uncemented femoral implant.
Crowe type IV and selected Crowe type III hips with DDH
and secondary arthritis that would lead to unacceptable
lengthening of the limb if managed with THA without femoral Examination corner
shortening and concern with sciatic nerve injury. Intermediate case 1: Developmental dysplasia of the hip (DDH)
Advantages Discussion
Allows simultaneous shortening and correction of rotational EXAMINER: What is your preferred placement of the acetabular cup
abnormalities, protects the sciatic nerve and preserves the for a hip congenital dislocation of the hip (Hartofilakidis grade
proximal femoral metaphysis. The preservation of the 3 hip)?
proximal femoral metaphysis facilitates the placement of an CANDIDATE: At the anatomical position.
EXAMINER: What’s wrong with placing the cup in a high
hip centre?
CANDIDATE: At the level of the false acetabulum the lever arm for
body weight is much longer than normal, which results in
excessive load on the hip joint and at the non-anatomical level
the shearing forces on the acetabulum may lead to early
loosening.
A high hip centre compounds abductor insufficiency, limping
and leg length discrepancy. Bone stock is better at the level of the
true acetabulum.
EXAMINER: So why do surgeons sometimes place the cup high?
CANDIDATE: It may be difficult to fully cover the acetabular cup at
the anatomical level. A femoral head allograft can be used to
augment the superolateral aspect of the acetabular rim or a
cotyloplasty performed medially but these are technically
difficult. Cotyloplasty involves creating a comminuted fracture of
the entire medial wall, autogenous bone graft and a cemented
Figure 11.9 Preoperative AP pelvis radiograph bilateral Crowe IV DDH hip acetabular cup.
EXAMINER: What about cup size?
CANDIDATE: Poor bone stock at the anatomical position usually
requires the use of a small acetabular cup. It is sometimes not
possible to use a ceramic bearing surface and there has been
concerns with inadequate thickness of polyethylene (PE),
especially in young patients.
EXAMINER: Would you use a cemented or uncemented cup?
CANDIDATE: In recent years cemented acetabular cups have fallen
out of favour because of reported high revision rates. Porous
tantalum implants provide excellent initial stability with
osteoconductive and osteoinductive properties and this would be
my preferred choice of implant.
EXAMINER: These are expensive implants. Would you not want to
choose a more cost-effective implant?
CANDIDATE: I would be slightly concerned about the possibility of
poorer or unpredictable results for younger patients with
compromised bone stock in the acetabulum if using standard
Figure 11.10 Postoperative right THA with subtrochanteric shortening. The shell liners
opposite left side will require a similar procedure
014
patients presenting with mild hip dysplasia and hip pain. These
Intermediate case 2: Young female with unilateral left DDH
Main symptoms of left hip pain, low back pain and latter cases are more likely to end in the clinicals.
shortening Not all acetabular dysplasia is caused by DDH. A concave
acetabulum cannot develop without a concentric force
On examination
being exerted by a reduced femoral head. Other causes of
The pelvis is not level, there is pelvic obliquity
dysplasia include polio, cerebral palsy, hyperlaxity and
With the pelvis straight with blocks there is a leg length
discrepancy of 4 cm shortening of the left leg
Perthes’ disease.
There is a compensatory scoliosis with convexity towards Mechanical disorders of the hip can be divided into
the left; it is a combination of both structural and postural two major categories: Structural instability (dysplasia) and
elements femoroacetabular impingement, or combinations of the two.
The patient has a short-leg gait Osteoarthritis commonly occurs secondary to repetitive
Trendelenburg’s test is positive and/or chronic shear stress at the acetabular rim. Acetabular
Sit the patient to check if the scoliosis deformity corrects dysplasia and femoroacetabular impingement are the two most
Ask the patient to lie supine common causes of excessive shear stress and acetabular rim
Carry out the Thomas’ test to test for any fixed flexion syndrome.
deformity of the hips In DDH, inadequate osseous coverage of the femoral head
Check hip range of movement
results in mechanical overload of the anterolateral acetabular
Measure apparent and real leg lengths
Galeazzi’s sign
rim and labrum. As a result, patients with DDH commonly
Bryant’s triangle test for supratrochanteric shortening have anterolateral labral tears, anterolateral acetabular chon-
dromalacia, acetabular rim fractures, and synovial cysts. This
acetabular rim overload syndrome progresses to arthrosis with
Intermediate case 3: Middle-aged lady with bilateral DDH
time unless the hip joint pathomechanics are corrected.
Take a detailed history of the DDH
Femoroacetabular impingement is characterized by dec-
Demonstrate various signs: Thomas’ test, Trendelenburg’s
test, hip range of movement (ROM)
reased clearance and abnormal contact between the femoral
Describe the technical difficulties in performing THA in head–neck junction and the acetabular rim. These disorders
DDH, explaining the role of the CT scan in planning the are due to proximal femoral and/or acetabular rim deformity
operation and are now recognised as common causes of pre-arthritic hip
Describe the effect of anteversion on THA (component pain and secondary OA. Abnormal femoroacetabular abut-
mal-alignment, dislocation proximal femoral fracture, ment, particularly in positions of hip flexion and internal
internal rotational contracture hip) rotation, predispose affected patients to labral tears, articular
Describe correction of leg length inequality in DDH cartilage damage and premature OA. Impingement abnormal-
(decide preoperatively, how much LLD to correct what ities can be divided into two major categories: Cam-type and
method to use). Do not over correct as sciatic nerve pincer-type impingement disorders and hip instability symp-
dysfunction may occur. Explain the use of bone grafts
toms secondary to dysplasia.
when performing THA
Describe the long-term results of THA in patients with prior
DDH. When properly performed, THA for DDH can result in History
good long-term results. McKenzie et al. reported 85% Sharp activity-related groin pain increasing affecting lifestyle
survival at 15 years4
activities. The onset of pain may be insidious. Alternatively, it
Revision of patients who have undergone THA for DDH is
extremely difficult, particularly when the acetabulum has
may start acutely after a period of increased activity, such as
been placed high and revision has been delayed. There is sports training or following an activity holiday (ski-ing,
often no anterior wall, little posterior wall and only the climbing). Pregnancy and weight gain may also cause a dys-
remnants of a medial plate. Femoral revision can be plastic hip to deteriorate.
difficult, as the prosthesis may have been inserted with an Initially the pain may only affect running and sporting
uncorrected deformity. If a trochanteric osteotomy has activities, but as symptoms progress the pain intrudes on
gone on to develop a non-union, trochanteric drift is everyday activities.
difficult to correct. Soft-tissue balance in these patients is Symptoms may be worsened by rising from a seated pos-
extremely difficult and, therefore, dislocation rates are high ition, getting in or out of a car, going downstairs or sudden
rotational movements. These symptoms arise from the anter-
ior labral tear and adjacent articular cartilage damage
Mild hip dysplasia and, therefore, are similar to those of femoroacetabular
impingement (FAI).
Background Additional features may include instability, weakness and
There is a changing pattern of hip dysplasia presentation. We the feeling of a 'dead leg'. Trochanteric symptoms may also be
are seeing less and less Crowe 3/4 hips and more younger present because of abductor dysfunction and patients may also
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014
describe clicking at the front of the hip, commonly originating treated as a child. However, be quick and focused about
from the psoas tendon. it, be careful with your time and know the questions to ask
beforehand. Did they have surgery; were they admitted to
hospital at any time; did they use an ambulation abduction
Clinical examination brace, etc. Alternatively the examiner may want you to
Sometimes there can be very little to find on clinical examination. jump over this part of the history for lack of available time
Candidates would be expected to demonstrate and explain and also so that you can go on to examine the hip, but it is
the impingement tests (anterior and posterior impingement important to cover these questions unless they indicate
tests and FABER test). otherwise.
There may be a mild antalgic gait or a delayed Trendelen-
burg’s positive sign. There may also be some mild shortening, Examination
but generally this should not be excessive or else the case is most Standing
likely adult DDH (Crowe 2 or 3) with developing arthritis.
Carefully look for mild/moderate thigh or gluteal muscle
Hip range of movement of the hip is often normal, although
wastage and comment on this finding to the examiners. Do
internal rotation in flexion may be painful. A painful, reduced
not miss obvious muscle wasting. The thigh musculature may
ROM suggests developing OA.
be normal if the individual is bulky with minimal disease. It is
Instability may be demonstrated by apprehension on exter-
unlikely that a significantly LLD will be present; at worst
nal rotation of the extended abducted hip. There may be
possibly some mild shortening of the affected leg by 1–2 cm.
additional signs of previous hip surgery (scars), hypermobility
If by chance the shortening is >2 cm look for a flexed attitude
or an underlying neurological disorder.
of the uninvolved limb or equinus posture of the involved foot.
Possible mild external rotation deformity of the affected leg.
Discussion Mild or moderate antalgic gait with a short leg component – If
Imaging shortening present and clinically significant. A Trendelenburg’s
Standing AP pelvic radiograph. Lateral centre edge (LCE) positive or delayed Trendelenburg’s positive test.
angle >25° normal, below 20° dysplastic
Supine
CT scan
Comment on any additional features not apparent on initial
MRI arthrogram occasionally indicated for the diagnosis
inspection of the leg when standing. Mention any feature even
of labral tears and in assessing the condition of the articular
if already mentioned, particularly if it is more apparent supine.
cartilage
Comment on the attitude of the leg, especially if it lies in
external rotation. Do Thomas’ test.
Management Look at the relative position of heels/medial malleolus as a
Hip arthroscopy. Occasionally indicated to treat labral rough guide to shortening. (Make sure the pelvis is square.)
pathology; however, results can be unpredictable and may Measure leg lengths and if shortening is present continue on
lead to worsening of symptoms, as the stabilising effect of and perform Galleazzi’s test and digital Bryant’s test. Flex the
the labrum may be lost. Concern also exists regarding hips to 45° and the knees up to 90° and place the heels together.
accelerating arthritis When one knee projects farther forwards than the other,
Femoral osteotomy. Seldom used in isolation where either that femur is longer or more usually the contra-lateral
periacetabular osteotomy (PAO) is available as it is less femur is shorter. When one knee is higher than the other,
effective, does not address the main deformity and either the tibia of that side is longer or the contra-lateral tibia is
complicates subsequent THA shorter.
PAO. The surgical goal is correction of the acetabular Although not always performed in a focused hip examin-
insufficiency by repositioning the weight-bearing surface ation ask the examiners if they would like you to palpate
laterally and anteriorly to improve femoral head coverage. the hip for any areas of tenderness, any lumps or swellings.
The hip joint center is medialised One difficulty is that the hip joint is too deep to assess for the
THA. For advanced end-stage painful dysplastic hip presence of an effusion or synovial thickening.
Measure ROM of the affected hip and compare it to the
opposite normal side. Comment if it is painful and be careful
Perthes’ disease with moderate/severe not to hurt the patient.
secondary OA ‘There is a mild/moderate/gross painful restriction of all ranges of
movement in the hip.’
History Go on to perform a neurovascular examination of the lower leg.
It is important when taking the history to go into as much ‘Examination of the spine was normal with good forward flexion,
detail as possible about how the Perthes’ disease was extension and lateral flexion demonstrated. Similarly, examination
014
of both knees was unremarkable Peripheral pulses were palpable catching suggests an intra-articular mechanical problem,
with good capillary refill.’ such as an acetabular labral tear or chondral flap.
Radiographs Clinical examination

AP radiographs may demonstrate old features of Perthes’ dis- Gait
ease: An elongated, deformed and flattened femoral head (coxa Limb lengths
plana) with subluxation, a sagging rope sign (a classic radio- Hip range of movements
graphic feature of Perthes’ disease, edge of the flattened femoral Patients with classic hip dysplasia usually have good flexion
head) and coxa vara (femoral neck angle <120°). Mention the and internal rotation in flexion whilst patients with femoral
radiographic differential diagnosis for Perthes’ disease and, if acetabular impingement have restricted hip flexion and
possible, Stulberg’s radiographical classification of residual reduced internal rotation in flexion. With more advanced
deformity and degenerative joint disease (but be sensible – If OA there will be a FFD and limitation of flexion, and the
you are only vaguely familiar with it, don’t go there). leg tending to go into external rotation (ER) with flexion
Anterior impingement test. Passively flex, adduct and
Management options internally rotate the hip. If reproduction of groin pain
The examiners may ask about treatment options of Perthes’ considered a positive test. A positive test may be accompanied
disease during childhood as part of an intermediate case dis- by a crepitus, clicking or a popping sensation. The test
cussionc. With patients in their early 40s, the choice is between compresses the anterior surface of the labrum. It is a sensitive
continuing conservative management and THA. screening test for patients with acetabular labral disease and
impingement. It can also be used as a non-specific screening
tool for intra-articular disease and hip joint irritability
Technical difficulties with THA in Perthes’ disease
An anteverted femoral neck may mislead the surgeon during
stem insertion and lead to component malpositioning and Management
increased risk of dislocation or proximal femoral fracture. Proximal femoral deformity may be corrected with a proximal
A previous femoral osteotomy may cause difficulties in femoral valgus osteotomy using a lateral approach and osteo-
reaming the femoral canal. If prior hip surgery has been chondroplasty of the head–neck junction via a separate anter-
performed there is an increased risk of HO, infection, scarring, ior arthrotomy. Alternatively, a transtrochanteric surgical hip
distorted anatomy, contracted musculature, etc. If significant dislocation provides good exposure for full surgical correction
hip shortening exists pre-operatively aim to equalize leg of the proximal femoral deformity.
lengths. Avoid over-lengthening as generally not well tolerated. Patients with pre-existing acetabular dysplasia may develop
Pre-operative templating, intra-operative assessment (leg notable instability, necessitating surgical correction with PAO.
length calipers, ruler). The procedures may be staged, with surgical hip dislocation
performed first to address FAI and with PAO done later
Pre-arthritic and early arthritic hip disease to restore hip joint stability. Secondary hip instability may be
apparent intraoperatively following surgical hip dislocation
in a young adult with Perthes’ disease and osteochondroplasty. In this situation, it may be preferable
History to perform both procedures at the same setting.
In Perthes’ disease the head heals with coax magna and/or Examination corner
asphericity. In time, the acetabulum remodels and appears
dysplastic. Young adults with Perthes’ disease may present Intermediate case 1: Perthes’ disease
with anterior impingement pain and hip instability symptoms, History
which occurs as a result of secondary acetabular remodelling in EXAMINER: Can you briefly summarize your history?
response to the development of coax magna.
CANDIDATE: In summary, we have a 43-year-old man with Perthes’
Get a detailed description of pain characteristics, activity
disease of his right hip. His hip has become increasingly painful in
level, associated co-morbidities and any previous hip surgery.
the last 3 years with a walking distance of 1 mile, interfering with
Are symptoms mainly associated with weight-bearing
his work as a railway engineer and also activities of daily living.
activities or hip flexion positions such as sitting? Hip pain
STOP STOP STOPd
exacerbated by sitting is commonly associated with femor-
oacetabular impingement. A history of true locking or
d
Summarize in two to three sentences maximum. The examiners
wants this to act as an end to the history and focusing point for the
c
Please see website for additional information beginning of the clinical examination. Do not get over excited or
www.postgraduateorthopaedics.com. nervous and start repeating the full history you have obtained.
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014
He is able to put his shoes and socks on, get in and out of a His spinal movements are unrestricted and pain free.
bath and car. He sometimes has difficulty getting up and EXAMINER: Are there any other causes of referred pain to
downstairs at home. He is taking analgesia intermittently when the hip?
his hip is particularly painful. When he needs analgesics he usually CANDIDATE: The pain is arising from the hip joint. I have
takes paracetamol but occasionally needs dihydrocodeine. He checked his spinal movements and these are normal. Forward
does not use any walking aids. flexion, extension, lateral rotation and lateral flexion are all full
EXAMINER: I have asked you to summarize the history not repeat it! and pain free and straight leg raising was normal. These tests
would seem to exclude the spine as a source of referred pain.
Examination The limb was neurovascularly intact with good peripheral
pulses palpated and normal capillary refill. There are no
EXAMINER: We would like you to examine his hip and talk us
clinical signs to suggest peripheral vascular disease
through it as you go along.
EXAMINER: Is there anything else that could be causing his pain?
CANDIDATE: On examination we have a patient of muscular build,
CANDIDATE: Examination of the right knee was unremarkable.
average height. Turning towards his right hip he has mild right
I can’t think of anything else in particular that could be a cause
proximal thigh muscle wasting, but from the back his gluteal
of his pain.
muscles seem reasonably well preservede.
EXAMINER: You have excluded the main causes of referred pain to
EXAMINER: If you look very closely there is in fact a small amount of
the hip. Can you think of anything else?
gluteal wasting, which is apparent when you compare it to the
CANDIDATE: No, sir.
opposite side.
EXAMINER: Have you heard of the piriformis syndrome?
CANDIDATE: (I didn’t look closely enough and missed this subtle
CANDIDATE: No sir, sorry, I have not.
clinical finding.) Examining his gait he walks reasonably
comfortable without any obvious abnormality present.
Piriformis test
EXAMINER: I don’t think that’s quite the case. Could you just walk The piriformis test is performed with the patient in the
for us again, sir, away from us and then towards us. He lateral decubitus position with the side to be examined
demonstrates a mild antalgic right gait (not particularly facing up. The patient’s hip is flexed 45° with the knee
obvious). flexed about 90°. The examiner stabilises the patient’s
CANDIDATE: I will go on now and perform Trendelenburg’s test. He pelvis with one hand to prevent rocking. The other hand
is Trendelenburg positive on the right; I can feel his right hand then pushes the flexed hip towards the floor. This man-
push down on my left hand and his pelvis descends down to the oeuvre stretches the piriformis muscle and elicits pain
right, indicating abductor muscle dysfunction.
when the muscle is tight or involved with tendonitis. If
the pain is not localized to the piriformis tendon but radi-
EXAMINER: That’s a good demonstration of the Trendelenburg’s test
ates in a manner suggestive of sciatica, a piriformis syn-
except that you have tested the wrong legf,g. drome should be suspected. The piriformis syndrome is an
CANDIDATE: I would like now to examine the hip supine. Could uncommon cause of sciatica in which the radiation of pain
you lie down on the couch for me now, sir? His pelvis is level, along the course of the sciatic nerve is caused by entrap-
the anterior superior iliac spines are at the same level and the ment within the piriformis muscle instead of lumbar disc
legs are square with the pelvis and straight. The right leg is disease.
shorter than the left. I’d like to confirm this by measuring leg This is not your everyday test performed in clinic. As such
lengths formally. I’m measuring from the anterior superior iliac candidates may be under-rehearsed and find it difficult to
spine to the medial malleolus – On the right side the leg
perform smoothly in the exam setting.
Overview of clinical case:
measures 91 cm; the left is 92 cm. Thomas’ test reveals no fixed
Detailed history of the treatment of Perthes’ disease
flexion deformity of either hip. There is a restricted range of
as child
movement of the right hip compared to the left. Flexion 70°,
Demonstration of full hip examination
abduction 20°, adduction 10°, almost no internal or external Discussion about causes of referred pain to the hip (Did you
rotation in flexion. Movements of the hip are painful, especially check his spinal movements?)
at the extremes of movement. Piriform syndrome and how to test for it (irritation of the
sciatic nerve by the edge of the piriformis muscle)
Discussion
e General discussion about the radiographs of the
Do not miss obvious wasting!
f right hip: Moderate OA, features of old Perthes’
I got left and right mixed up but luckily the examiners let
disease, sagging rope sign. Shown arthrogram
me off.
g pictures and asked to comment on them, which led
This happens with alarming frequency in the exam. If your
performance is otherwise good it isn’t a big issue, but if you on to general discussion about the principles of
are ropey this really doesn’t go down well at all with the arthrogram
examiners.
014
Full discussion on the classification of Perthes’ disease

(Catterall, Salter and Herring). ‘I went through each one in
turn and then mentioned which one I preferred and why.’
Discussion of Stulberg’s5 rating system of the femoral head
at maturity and Herring treatment guidelines for Perthes6
Management: The patient’s hip arthritis was too good for
THA so continue with conservative treatment for the time
being. Is there a possible role for periacetabular osteotomy
in the arthritic hiph? Discuss the figures for survival of THA
in the young arthritic male (results from Wrightington7 and
Swedish Hip Register). In the Swedish Registry, the 15-year
survival rate following THA was 77% for patients aged <45
years and 92% for patients aged over 65 years. THA in
young patients remains a procedure associated with high
risks of conventional polyethylene wear and osteolysis
EXAMINER: What type of THA would you perform and why?
CANDIDATE: I discussed the choice of cemented vs uncemented THA
Figure 11.11 AP radiograph Perthes’ disease right hip
and ceramic on ceramic-bearing surface vs metal on polyethylene
(MoP). The advantages of ceramic on ceramic (CoC) articulations
include reduced wear, scratch resistance, reduced osteolysis,
with each other!) Abduction and adduction. (Don’t forget
improved maintenance of lubrication with the wettability of to stabilise the pelvis)
ceramics producing excellent fluid film lubrication and excellent Examination of LLD (2-cm shortening). Questioned about
biocompatibility. CoC articulation is a very attractive option for difference between real and apparent shortening
young active patients in whom there are concerns with the long- Galeazzi’s test
term consequences of wear and osteolysis with MoP articulations.
Discussion
The main disadvantages of ceramic-bearing surface relate to Radiographic features (Figure 11.11):
catastrophic head and liner fracture, squeaking (stripe line) Management options: THA required
and cost. I didn’t go into specifics, but if you are potentially a Consenting issues (DVT, PE, sciatic nerve injury/foot drop,
score 7 or 8 you would need much more detailed knowledge LLD, dislocation, aseptic loosening, neurovascular injury,
about these complications. infection)
Preoperative radiographic templating: Why do we bother
‘After everything we discussed I still think the examiners
with this? Select implants of appropriate size, recreate
wanted me to say I would use a cemented MoPTHA.’ correct offset, and equalize leg lengths
Revision rate for cemented THA in young patients How to correct a LLD. Correct a real leg discrepancy but
Numerous studies have shown a revision rate not an apparent one
significantly correlated with high activity level, unilateral
disease, the number of preoperative hip operations,
weight (>60 kg) and aetiology (DDH, trauma, AVN,
juvenile idiopathic arthritis). All series have highlighted The hip needing revision surgery
the greater risk of revision compared with that in older This is usually intermediate case material. Have a practised
and/or less active populations focused history relating to a painful THA prepared, as time
Intermediate case 2: A 44-year-old man with OA hip secondary to is tighti. It is very easy to end up jumping about with the
childhood Perthes’ disease history without succinctly nailing down what the specific
complaints are.
Standard history
(See above)
Clinical examination
History
Trendelenburg’s – Positive. Quizzed about causes and
History of the implantj
significance When was the initial surgery performed?
Thomas’ test. Fixed flexion deformity 10°. Scrutinized and How has the hip been since the operation?
quizzed during this test Detail history of all prior hip operations
Demonstration of ROM hip. Reduced internal and external
rotation in flexion. (Don’t get the movements mixed up i
This will score you a 7 rather than a 6, or a comfortable 6 rather
than a borderline 6.
j
The history of the implant is the most obvious lead in question at
h
Know the prerequisites for a periacetabular osteotomy as the the beginning of the history. Focus then on taking a good pain hip
examiners could easily lead into this with follow-up questions. history as that is probably the principle complaint.
127
014
Any historic factors to suggest infectionk. Co-morbidity factors: Patients requiring revision are often
Any complications in the postoperative period? elderly with medical co-morbidity factors
Enquire about any delays in wound healing, haematoma
evacuation, excessive or persistent wound drainage and antibi-
otic usage at the time of primary surgery. Is there any history
of urinary catheterization following surgery? Look, feel, move.
Has the hip always been painful or just in the last year or so? Carry out a general inspection to include general stature,
Any recent chest or urine infections or generalized systemic height and weight. Examine the quality of skin overlying the
upset? joint. Note any previous skin incisions, signs of infection.
The infective hip questions are important and failure to ask Mention any obvious muscle wasting, clinical deformity/
them will suggest that a candidate hasn’t considered infection shortening.
as a possible cause of hip pain. Gait should be carefully observed to look for antalgic gait,
Pain. Most patients complain of as aching type of pain, which limb-length discrepancy or abductor deficiency. A marked
is mechanical in nature. It is typically provoked by activity and Trendelenburg gait suggests non-functioning abductors that
relieved by rest. The intensity is usually variable although not may be due to paralysis or loss of continuity.
often great. Groin and/or buttock pain is typical of acetabular Trendlenberg’s test could be positive.
component loosening. Femoral stem loosening more often Wound inspection is important to help plan operative
causes thigh pain. Aseptic loosening is often associated with incision relative to previous incisions. It is not advisable to
an initial marked exacerbation of discomfort when the patient make a second, parallel incision, especially if the previous
first stands up (start up pain) which reaches a steady state over incision was posterior.
the next few minutes and thereafter the pain may reduce. It is The onset of limb length inequality should be related to the
characterized by a pain-free interval following the initially time of the operation, as progressive shortening and muscle
successful arthroplasty surgery. weakness may indicate subsidence of one of the components.
Patients with septic loosening may give a history of pain, If leg length shortening is present ensure you do an apparent
which has persisted since the time of the original operation. and true measurement. Galleazzi’s sign and Bryant’s triangle
Alternatively, there may be a sudden onset of pain following to identify the area of shortening.
spread of infection from some distant septic focus. The pain Assess movements both active and passive and comment
itself is typically insidious in onset and both gradually and on range and if any pain is present (do not hurt the patient
relentlessly progressive. any further if he/she has pain). Be careful not to dislocate
the hip.
Ambulation capacity: How far can you walk? Patients may
complain of a limp and a progressive reduction in walking ‘I will go on now to test for hip range of movement but I will be
distance. They have difficulty in climbing stairs careful not to hurt the patient or be too forceful in my movements
to avoid any risk of hip dislocationl.’
Shortening: Do you feel short or that your leg lengths are
equal? Progressive shortening may be noticed by the patient. Specific restrictions in ranges of movement may be related
This may be caused by proximal and medial migration of the to impingement, contracture or heterotopic bone formation.
acetabular component with or without subsidence of the Pain at the extremes of movement may indicate impingement
femoral component or loosening of prosthetic components. Pain with the leg
Stiffness: Difficulty in donning shoes, putting on socks, cutting jerking into internal or external rotation is suggestive of fem-
toenails bending down to pick objects off the floor, etc oral component loosening. Pain in the groin with resisted
Instability: Recurrent episodes of subluxation or dislocation. straight leg raising is suggestive of acetabular loosening. Exam-
Instability can cause pain from capsular stretch and soft-tissue ination should be completed with assessment of neurovascular
impingement. Sympoms can usually be reproduced by placing status in particular assessment of sciatic nerve function.
the limb in a certain position and usually recur each time that
position is re-created Radiographs
Sepsis: Easier if this is dealt with during the history of the While describing the radiographs (AP/lateral) look for dates,
implant type of prosthesis (primary/revision, cemented/uncemented),
Referred pain: Lumbar spondylosis, spinal stenosis and evidence of femoral loosening (Gruen zones), acetabular
sciatica, peripheral vascular disease may all provoke
discomfort, which resembles hip pain
l
It is probably safer to say this comment in the exam as it covers you
to a certain extent and reassures the examiners that you are aware of
k
The infective hip questions are important to ask. If a candidate possible dislocation. What you want to avoid is being a bit rough
doesn’t ask them it suggests that a candidate hasn’t considered with the patient forcing hip movements, perhaps causing pain and
infection as a possible cause of hip pain and is likely to lose them appearing not to appreciate that you may dislocate the hip. This
a mark. scores a 4 or 5 at best.
014
loosening (De Lee and Charnley zones) and for any cement cement column fractures and the development of
extrusion. Compare with old radiographs. progressive radiolucencies
Any medial migration of the component or placement of 2. Array of full surgical equipment should be available
the cup medial to the Kohler's line should be mentioned. 3. Position of previous skin incisions, check old notes for
Further investigations such as a CT scan or angiogram may approach used
be required. Areas of cortical thinning, perforation or scallop- 4. Decide on the choice of surgical approach beforehand
ing should be mentioned. Assess the bow of the femur (lateral (personal preference of surgeon, nature of osseous defects,
view), which may have implications on using a long femoral type of implant, previous skin incision)
stem. Look for any hetrotrophic ossification. It is useful to 5. Order bone graft if needed
know of the classifications for femoral and acetabular bone 6. Large prosthetic inventory needed
loss (Praposky classification, AAOS classification). 7. Ensure access to the original operation note if possible and
information about the prosthesis to be removed, e.g. head
Discussion size, bearing surface etc
Mechanisms of failure 8. If intrapelvic cement is present or the acetabulum
The principle causes of failure may be related to patient spe- markedly protruding may require an intravenous
cific features, implant design features or variations in surgical pyelogram (IVP) and angiography
technique. 9. Complex acetabular defects may require accurate
Patient-related factors. Variables such as young age at assessment with three-dimensional CT scan reconstruction
primary procedure, increased physical activity, male gender, of defects
obesity, primary joint replacement following pelvic or femoral 10. Implant company representative to be present at time of
fractures all result in higher revision rates. Rheumatoid arth- surgery
ritis (RA) or OA secondary to childhood disorders such as 11. Possible need for ITU bed
slipped capital femoral epiphysis (SCFE), Perthes’ or DDH
may similarly compromise the long-term results of primary Surgical approaches used and equipment necessary
arthroplasty.
Implant-related factors. Faulty design, inferior material Equipment issues to consider would be:
implant characteristics, implant fracture, periprosthetic frac- 1. Stem extraction instruments
ture, delamination of the porous coating. 2. Screws, pelvic reconstruction rings, porous tantalum
Surgeon-related factors. Inadequate preoperative aseptic revision shell with augments
precautions, prolonged operating time, mal-positioning of 3. Allograft bone (fresh frozen femoral head and/or freeze
components, inadequate cementing techniques surgeon and dried bone chips)
hospital volume. 4. Trochanteric fixation devices and circlage wires
5. Hand or motorized cement removal instrumentation
Indications and contraindications for revision hip surgery 6. Flexible medullary reamers
Indications include aseptic loosening, deep sepsis, peripros- 7. Fibreoptic lighting may be especially useful for
thetic fracture, catastrophic implant failure, osteolysis, PE wear visualisation of the distal part of the femoral canal
and recurrent dislocation. Contraindications include medically 8. Pneumatic drills and burrs
unfit patient, compromised bone and soft tissues, etc. 9. Cement chisels and splitters
Differentiation between aseptic loosening and infection 10. Flexible thin osteotomes
11. Canal plug removal instruments
Blood tests, hip aspiration, bone scan, intra-operative frozen
section histology, intraoperative tissue culture etc. 12. Cell saver equipment
13. Bone graft mincer
Preoperative planningm
Essential for the successful outcome of surgery and to avoid Revision considerations
complications: Cement in cement revisions
1. Good quality serial radiographs of the hip and pelvis If the cement mantle is well fixed with no apparent defects
including lateral views of the femur to allow longitudinal it may be possible to cement a new stem into the
comparison and evaluation of component migration, existing cement mantle, downsizing the stem. Meticulous
surgical technique is required to ensure a clean, dry
femoral canal as a thin layer of blood or marrow may cause
up to an 85% reduction in shear strength and 80%
m
Similar to the core hip topics section. There will be slight variations reduction in tensile strength of the cement–cement
on a theme with the individual case that is being discussed. interface
129
014
Examination corner with experience and knowledge of the implant (promimally

Intermediate case 1: A 77-year-old male, uncemented loose THA or extensively coated). An extended trochanteric osteotomy
at 18 months (ETO) is usually required
The ExplantTM system allows safe penetration at the metallic
History cup bone interface of the acetabulum. Clear bone in path of
Uneventful postoperative recovery femoral implant with flexible osteotomes, extraction kit.
Walking distance restricted to 200 yards Gigli saw on medial border stems. Do not remove femoral
Mid-thigh pain, dullish painn at rest, reaching peak in the implant until all ingrowth interfaces are divided. Be careful
start-up phase, diminishing over movement with osteotomes. They tend to fracture cortical bone rather
Clinical examination than cut it
As per hip examination
Little to find
Trendelenburg’s test, Thomas’ test, ROM Paget’s disease
Differential diagnosis Hip pain associated with Paget’s disease may cause diagnostic
Infection, radicular pain, trochanteric or iliopsoas bursitis problems. It can be difficult to distinguish whether the pain is
due to active Paget’s disease or to degenerative hip arthritis.
Discussion9
Failed early osseo-integration of an uncemented THA Both can give a dull, aching pain that may worsen with weight-
Superficial discussion without any probing in detail bearing. Relief of discomfort with intra-articular local anaes-
Failure to appreciate the possibility of infection was a thetic hip injection suggests coxarthrosis as the source of pain.
significant omission and a negative marking point A therapeutic trial of calcitonin may also be helpful to differen-
Radiographs of the hip were essentially normal without any tiate between the two causes.
features of frank loosening (subsidence, pedestal formation, Exclude other sources of pain such as referred pain from
cortical hypertrophy, and increasing radiolucencies) spinal stenosis or radiculopathy, stress fracture and other
Bone scan was hot but this is non-specific for loosening and causes of musculoskeletal pain. If the character of the pain
did not differentiate from infection changes consider the possibility of sarcomatous change.
A CT scan was shown which demonstrated failure of osseo-
intergration. Discussion about the metal artefact from the
femoral stem making interpretation difficult. The possibility
of the CT being used to diagnose infection–periosteal
reaction would be typically seen ‘On general inspection there is enlargement of the skull. There is
PET scan is another new imaging modality used to diagnose also bowing of both the femur and tibia in both legs in both an AP
an infected THA and lateral direction. The sharp anterior edges of both tibias are
thickened and curved, making them very prominent and giving an
Discussion topics for score 8 candidateso,p almost sabre tibia appearance to them.’
Aetiological models-tip micromotions and tip overload ‘On palpation of both lower legs there was no suggestion of
Rigidity mismatch increased warmth present (due to increased vascularity).’
Engh’s biological fixation classification into bone ingrowth ‘The spine has a uniform even kyphosis present (vertebral
fixation, stable fibrous fixation or unstable10 involvement leads to loss of height and kyphosis from disc
Extensively coated porous stems degeneration and vertebral collapse).’
Factors associated with Stress shielding. Main factor is stem ‘The shoulders are rounded and the head and neck protrude
stiffness affected by stem diameter, metallurgy, stem anteriorly. The skull enlargement occurs in the vault and the
geometry. enlarged frontal bones make the forehead bulge forwards. His
Characteristic features of an uncemented stem arms appear to be disproportionately long (because of the
How do you revise an uncemented THAq? kyphosis).’
Removal of well-fixed uncemented femoral stem is difficult ‘Examination of his left hip revealed gluteal and thigh muscle
requiring specialized equipment, time and patience along wastage. He had a marked stoop present, attenuated by bowing
of both his femurs. Examination of gait revealed that it was
antalgic in nature. Trendelenburg’s test was markedly positive on
the right side, delayed positive on the left side. Examination supine
n
In typically cases the thigh pain is absent at rest. revealed equal leg lengths. On palpation of the hip there were
o
Score 8 candidates by definition will fly through the initial material no obvious areas of tenderness. Thomas’ test revealed a fixed
to discuss progressing onto more advanced topics that will stretch flexion deformity of 30°. Flexion of the hip was painful and
both candidates and examiners. reduced to 70° actively and could not be increased appreciably
p
Some of these topics may be more at home with a basic science viva. passively. Internal rotation in flexion was zero whilst external
The clinicals should be more biased towards testing candidates on
rotation in flexion was grossly reduced to a jog of movement only.
clinical relevant material.
q Similarly, adduction was limited to 20° and abduction 30°
This is a 1-minute answer in either the vivas or clinicals in which
passively, and was also painful. Distal pulses were palpable with
candidates just need to keep talking. Much better if they have some
practical knowledge of the potential difficulties. good capillary refill, and neurological examination of the lower
014
legs was normal. There was marked restriction of all spinal oversized hemispherical cup as well as the availability of offset
movements, in particular forward flexion – He was only able to liners to compensate for a medialized cup position in a
touch his knees. Straight leg raising reproduced low back pain protrusio defect. Cement fixation in combination with a cage
but no true sciatic nerve root irritation.’ or an uncemented cup-cage construct with a cement liner,
may be required if extremely poor bone quality or significant
Discussion bone loss is found.
Paget's disease is a chronic deforming metabolic bone disease A widened femoral canal can either be dealt with by using
characterized by increased osteoclastic bone resorption and extra cement or by primary impaction grafting with cancellous
compensatory increases in bone formation. In the later stages allograft chips. Obliteration of the femoral canal with bone as
of the disease the involved bone becomes enlarged, dense, opposed to cement is thought to provide a much more durable
sclerotic with an irregular trabeculae pattern, obliterated anchorage of the stem but is time consuming and technically
medullary canal and thickened cortices. The poor structural difficult. A large cement restrictor or bone plug may be
integrity of the bone renders it prone to either pathological required. Use of a long cemented stem, an extensively coated
fracture or repetitive stress fractures. Progressive deformity uncemented stem or a modular tapered stem may be required
and secondary OA of the hip affects between 30% and 50% of to bypass mechanically insufficient proximal bone and achieve
patients. For Paget’s disease that involves the hip with secondary diaphyseal fixation.
degenerative changes, surgery is indicated to manage significant There is an increase incidence of heterotrophic ossification;
pain, joint stiffness, deformity or a pathological fracture. therefore, consider prophylatic measures.
Preoperative treatment with bisphosphonates or calcitonin Concern exists with the use of uncemented implants
is recommended to reduce the incidence of intraoperative in Paget’s disease due to possibility altered bony ingrowth.
bleeding, heterotrophic ossification and loosening although Wegrzyn et al.11 reported 84% excellent or good medium-
no randomised control trial exists. There is a potential for term outcome in 39 uncemented hips performed for Paget’s
significant intraoperative bleeding from hypervascular and disease of bone (PDG) at an average of 7 years follow up. No
osteoporotic bone, technical difficulties prolonging the length revisions performed.
of surgery or the possible need for concomitant procedures
(osteotomy). Excessive bleeding may require additional cross-
matching of blood. Consider using tranexamic acid.
Radiographs
Proper preoperative templating and planning is necessary Sclerotic appearance of bone with cortical thickening; trabecu-
to size an enlarged medullary canal and determine the correct lae are coarse and widely separated.
component size and the amount of cement to be used. Differential diagnosis: Osteitis fibrosa cystica, fibrous
A broad spectrum of deformities of the proximal femur or dysplasia, osteoblastic secondaries, osteopetrosis and lymphoma.
acetabulum may hamper dislocation of the hip, exposure of
Examination corner
bone or component alignment. Trochanteric osteotomy may
be required for adequate exposure and beware the sciatic Intermediate case 1
nerve is nearer the joint than normal. In the presence of EXAMINER: What are the indications for therapy in Paget’s disease?
protrusio acetabulum combined with coxa vara dislocation
CANDIDATE:
of the hip can be extremely difficult and the neck may need to
Bone pain
be cut in situ. Coxa vara predisposes to a varus femoral stem Deformity
position. Fracture
A marked deformity of the proximal femur with coax vara Osteolytic lesions in weight-bearing bones
or anterolateral bowing of the femoral shaft may require a Immobilization hypercalcaemia
corrective osteotomy prior to THA. This will allow correct Markedly increased alkaline phosphatase
alignment of the femoral component at the time of THA. Nerve compression
The presence of dense sclerotic bone may make reaming and Young age, especially if disease very active
bone preparation difficult. Sharp reamers will be necessary to Before orthopaedic surgery
shape the femoral canal. Ineffective for:
If protrusio acetabulum exists ream to expand the periph- Deafness
Fissure fracture
ery without deepening the socket to avoid causing added
Sarcoma
protrusio. Consider what method of cup fixation to use either
EXAMINER: What are the causes of a bowed tibia?
uncemented acetabular fixation with supplementary screws to
CANDIDATE: True bowing caused by softening of bone occurs in
prevent cup migration and allow for boy ingrowth or a
Paget’s disease and rickets. Apparent bowing owing to thickening
cemented cup. Inability to produce a dry acetabular bed
of the anterior surface of the tibia secondary to periostitis occurs
may compromise cement interdigitation with bone. Recon-
in congenital syphilis and yaws.
struct the acetabulum with the hip centre in the anatomical
location with medial acetabular bone grafting or the use of an EXAMINER: What are the complications of Paget’s disease?
131
014
CANDIDATE: Progressive closure of skull foramina may lead to:

Headaches
Deafness
Blindness (optic atrophy)
Tinnitus
Vertigo
Other complications include:
High output cardiac failure
Pathological fractures
Sarcoma change in bone
Urolithiasis
Spinal stenosis
Hypercalcaemia
A variable pattern of presentation. Only a minority of
patients become symptomatic.
EXAMINER: How common is sarcomatous change in bone?
CANDIDATE: It is very rare, probably <1%, but it carries a very poor
prognosis. The patient presents with increase in pain and swelling.
Figure 11.12 Paget’s hip Cortical thickening and coarse trabeculations
EXAMINER: What biochemical abnormalities occur in Paget’s
disease?
CANDIDATE: Serum alkaline phosphatase and urinary appropriate). Also, this is not strictly correct, as sabre tibia can
hydroxyproline are elevated except sometimes in very early also be associated with syphilitic disease of bone. Syphilitic
disease. Serum calcium and phosphate are usually normal in osteoperiostitis occurs late in the disease, on average 6 years
mobilized patients but can occasionally be increased or after untreated syphilis. Usually one bone becomes painful
decreased. Urinary calcium rises in immobilized patients. and tender. Often the bone gives an illusion of being bent,
because new bone is deposited beneath the periosteum on
Intermediate case 2: Paget’s disease
one aspect.
Discussion
A radiograph is shown of Paget’s hips. (Figure 11.12). Intermediate case 3: Paget’s disease
EXAMINER: These are the radiographs of a 78-year-old female who is Pathogenesis of Paget’s disease
complaining of predominantly left-sided hip pain. Complications
Radiographic features
Discussion of Paget’s hip Cause of bone bowing
Radiographic features Management of pathological fractures
How to manage Problems encountered in joint replacement – How do you
Bisphosphonates – How do they work? control bleeding?
Precautions prior to THA
The control of Paget bone activity in the preoperative Post-traumatic OA hip

period reduces the risk of implant loosening and the Accidents involving high-energy trauma may cause fractures
abnormal intraoperative blood loss. of the acetabulum and fractures/dislocation of the hip joint.
Technical difficulties of THA The treatment of choice for post-traumatic OA in patients over
50 is THA, but a younger patient is more likely to place higher
Short case 1: Paget’s tibia
demands on any implant.
EXAMINER: Examine this man’s leg. What is the diagnosis?
CANDIDATE: Bowed, enlarged leg, no other deformities, only other
clue was hearing aid (look around for any clues which may point
History
you in the right direction). The leg is bowed because new bone is
Age
deposited beneath the periosteum on one aspect giving the Occupation
illusion of being bent. A full history should be obtained starting with the
CANDIDATE: The examiner wanted me to mention ‘sabre tibia’.
presenting complaint and any symptoms or disability
In the tibia the forward bowing confirmed in lateral
experienced by the patient
radiographs may be referred to as a sabre tibia (since the Full details of the original accident including the
front of the tibia is blunt rather than sharp this is hardly mechanism, all injuries sustained and the time course of
subsequent treatment
014
The timing and nature of all operative procedures and the

over the right proximal thigh. There are other numerous scars,
development of any complications should be documented
both surgical and non-surgical present over the left and right
with specific enquiry about any systemic or wound
lower legs. Her pelvis is not level when standing: The ASIS is lower
infections or thromboembolism
on the left side. She appears to have a leg length discrepancy: The
left leg appears to be shorter than the right. I didn’t appear very
Progress since the injury confident when asking the patient to level up her pelvis as I was
The onset, nature, progression and aggravating and getting confused trying to formulate a diagnosis . I also omitted
relieving factors or symptoms should be established to mention using blocks to level up her pelvis
Social (smoking, alcohol) and general history CANDIDATE: She walks with an antalgic gait. ‘Can you lie down for
Systematic enquiry us now so that we can continue with the examination?’ ‘On
Expectation and ambitions of the patient inspection supine . . .’
EXAMINER: What about Trendelenburg’s test. I completely forgot
Examination about Trendelenbug’s test and then made a hash of it .
Comment on the patient’s posture, stance and gait The patient had a severe adduction contracture of her left leg,
patterns. Scars inspected for site as this may interfere with which gave the erroneous impression of severe shortening on
subsequent surgery, any evidence of infection. the left side. However, most of this was apparent shortening.
Trendelenburg’s test for abductor function True shortening of the left leg was minimal and probably not
significant.
True and apparent leg lengths for adduction contracture.
The mechanical axis of the legs and true leg lengths should EXAMINER: How do you know the left leg is short? There was a
be compared for the effects of the hip pathology or any femoral fracture on the right side. Could the left leg not be a
associated injury to either lower leg normal length and the problem be a longer right leg secondary to
Thomas’ test is used to detect a fixed flexion deformity. the right femoral fracture? In fact, the right leg could be shorter
Examine ROM of the hip and the presence of pain or fixed than normal but the left leg could be even shorter because of the
deformity hip condition.
Muscle power, tone and distal neurovascular status should EXAMINER: Could you demonstrate Thomas’ test for me?
be checked for evidence of impairment due to nerve palsy EXAMINER: You must put your hand properly behind the lumbar
or vascular injury spine. Let me show you: This is where your hand should be. It
Knees, the contra-lateral hip and the lumbar spine should should go all the way behind the small of the patient’s back. The
be thoroughly examined especially if arthrodesis is being patient has a fixed flexion deformity of 20°.
considered EXAMINER: Can you measure movements of the hip?
CANDIDATE: She flexes the hip from 20° to 100°.
EXAMINER: You must stabilise the pelvis when testing for flexion of
Examination corner the hip as the pelvis moves a lot sooner than you realize.
Intermediate case 1: Post-traumatic AVN hip
A 16-year-old girl who had been involved in a RTA 1 year Discussion
previously and had developed AVN with secondary OA of her Discussion centered on the management of this patient. She
left hip. was too young for a THA and unlikely to be happy with a
She had sustained a closed fracture of the right femoral fusion. Secondary OA was too far advanced for an osteotomy
shaft, which was treated with skeletal traction, and a trau- and the condition was too painful to do nothing. No definite
matic posterior dislocation of her left hip. The left hip had management plan was agreed upon.
been reduced under GA fairly promptly after admission. Radiographs of the initial dislocation were shown. The day
However, she continued to complain of left hip pain 4 radiographs showed a transepiphyseal fracture of the fem-
following relocation and 4 days later a further radiograph oral head through the proximal femoral physis. The examiner
was taken, which showed a displaced fracture of the femoral described it as a type of SUFE. Delbert's classification of hip
head. This was fixed with a cannulated hip screw the fractures in children was briefly mentioned. Discussion then
following day. followed of the postoperative radiograph, which showed the
Essentially her presenting complaint was severe constant fracture adequately fixed with a single cannulated hip screw.
pain in her left hip, interfering with every aspect of her life. Her The candidate was asked about the entry point for cannulated
walking distance was reduced to a few hundred yards, sleep screw fixation for SUFE (it is not the dynamic hip screw (DHS)
was severely affected and she was taking regular analgesia entry point for a proximal femoral fracture, which is much
with minimal benefit. more anterior).
Transepiphyseal fractures represent about 8% of all hip
CANDIDATE: On general inspection we have a young girl of average fractures in children. They may occur with or without disloca-
height and build. There is an old longitudinal lateral scar present tion of the femoral head, and results are generally poor owing
133
014
to a combination of AVN and premature closure of the physis.

No movement
The diagnosis is often delayed because of concomitant injur- Check nerve function
ies. The patient had developed AVN of the left hip but we
didn’t discuss this. Pitfalls
Fail: Most of the intermediate case can go very well but the
Whatever method you use to measure hip movement you must
differentiating feature is the three or four mistakes that are
made with a candidate sometimes not appreciating their full stabilise the pelvis to detect its movement. It is absolutely vital
significance: (1) there was a silly mix up in the history sum- to keep one hand over the ASIS when measuring flexion so as
mary – She was a pedestrian not a passenger in a car; (2) a to detect tilting of the pelvis. It is possible to ‘flex’ a completely
poorly performed Thomas’ test (this is a very common mis- fused hip by 30–40° – the movement actually occurring at the
take); (3) Failure to stabilise the pelvis when testing for flexion; spine. One will not pick up the diagnosis of a fused hip in this
(4) Forgetting Trendelenburg’s test and then not properly situation.s
explaining the test to the patient. The candidate was at the The patient can sometimes have a pseudo-arthrosis of
end of the day so the patient intuitively knew what to do, but if the hip, which allows some movement to occur at the hip,
the candidate had been first one in – A waiting disaster! and this may create confusion. If the good leg is flexed up
and the patient holds their knee, use one hand to palpate
the lesser trochanter and iliopsoas and then with the other
Arthrodesed hipr hand smartly abduct the arthrodesed leg. If there is pro-
This is classic material for the hip intermediate case, in tective contraction of the muscle group then the arthrod-
which there are good clinical signs to demonstrate and esis is not sound – the unsound arthrodesis (spasm of
enough to talk about in the discussion afterwards. At least muscles).
one arthrodesed hip is usually present in the short case An arthrodesed hip is often seen with tuberculosis and a
examination hall. fixed contracture of the ipsilateral knee. Be careful when meas-
uring leg lengths to place the opposite leg in the same position.
Memorandum This may require the use of pillows to flex up the opposite leg.
‘On general inspection the patient has a walking stick visible in the
It may even require you to measure the component parts of the
corner. He also has a shoe raise in the right foot. Looking at his legs separately. Anterior superior iliac spine to medial joint
right leg he has gross muscle wasting of the thigh and gluteal line, medial joint line to ankle, etc. With fixed knee flexion
muscles. There is a well-healed extended longitudinal scar over the when checking hip flexion move the patient to the end of the
right proximal thigh. He has an obviously shortened flexed right couch to eliminate the effect of a fixed flexion deformity at
leg. His pelvis is not level with stance. The ASIS is hitched up on the knee.
the left side and he has a compensatory scoliotic curve of his spine Often the ipsilateral knee is limited in motion and is
apex to the right. He demonstrates a short leg walk with a slow painful on weight-bearing in a strained valgus position.
asymmetrical and arrhythmic gait. He is Trendelenburg positive When performing Thomas’ test in a patient with an arthro-
on the right side. There is increased motion in the normal (sound) desed hip lift the ipsilateral hip until the lumbar curve flattens.
hip and increased flexion of the knee throughout the stance phase
At this point this measures the fixed deformity of the hip.
on the fused side.
‘Sitting down on the bed the pelvic obliquity does not fully
correct and he still demonstrates a scoliotic curve of his spine Discussion
suggesting an element of fixed deformity to the spine.’ Indication
‘On inspection supine we can see the quite obvious leg length
May be indicated in patients with severe femoral or pelvic
inequality on the right side. On measuring leg lengths there is a
5 cm true difference. Thomas’ test reveals a fixed flexion deformity that precludes THA, in neurological cases where
deformity of his right leg of 30°. On attempting to flex the hip the risk of dislocation is high or with an increased risk of
the pelvis moves immediately, which is very suggestive of a THA failure in a young highly active patient with monoar-
fused hip. In addition, there is no adduction/abduction possible throsis of the hip. The ideal candidate is an adolescent or
at the hip joint’. young adult with a history of multiple hip surgeries, post-
traumatic arthritis, and/or post-infectious hip disease. Should
be minimal pre-existing arthritis of the lumbar spine, ipsilat-
Salient clinical features eral knee or contra-lateral hip
Scar
Fixed flexion deformity
Shortening s
This is regarded as an absolutely classic examination error. If
one mentions that there is 30–40° of flexion in the hip when it is
fused one will definitely fail a short case, whilst in the
r
Please see website for additional information: intermediate case you will be on the back foot and have your
www.postgraduateorthopaedics.com work cut out to recover.
014
Not a popular procedure because patients are familiar with Complications

the impressive results from arthroplasty and often find it diffi- Neurovascular injury
cult to accept hip arthrodesis. Femoral fracture in the first year following surgery
Arthrodesis may be mentioned as a possible management Failure of internal fixation

option in the young patient with severe osteoarthritis affecting
Non-union (pseudoarthrosis rate 15–25%)
the joint.
Mal-union
‘I would at least discuss the option of hip fusion with the patient
OA contralateral hip, both knees, spine
even if they were likely to refuse it’
Instability ipsilateral knee
Position of fusion
20–30° flexion Revision arthrodesis to THA (taking down
Neutral or slight adduction (0–5°) the hip)
5–10° external rotation The older patient requesting conversion to THA following
Avoid abduction and internal rotation previous arthrodesis is a much more likely intermediate case
LLD <2 cm than a young patient in whom a hip fusion is being considered.
Abduction creates pelvis obliquity Conversion for severe persistent low back pain
Painful pseudo-arthrodesis
This position is design to minimize excessive lumbar spine
motion and opposite knee motion which helps minimize pain Mal-positioned arthrodesis
in these regions. Excessive adduction in women will cause Ipsilateral knee pain
difficulties with sexual intercourse and wetting the inside of Contralateral hip pain
the thigh during urination. Insufficient flexion makes sitting Limitation of walking distance
extremely difficult and excessive flexion accentuates LLD. Difficulty in performing ADL mainly involving hip flexion
Increased hip flexion best suited for a patient with a desk such as bending, putting shoes and socks on and tying
job, less flexion if the job is manual labour. shoe laces
Sitting can be uncomfortable for prolonged periods or in
Methods of arthrodesis cramped places
AO Cobra plate. Involves osteotomy of the greater
trochanter. Stable fixation but disrupts hip abductors The origin of pain should be accurately defined, and the
which may be problematic if subsequent THA functional demands and expectations of the patient
explored. It is important to make sure the back or knee
Trans-articular sliding hip screw. The lag screw is inserted
pain is not caused by other pathology, which would not
across the joint and just superior to the dome of the
acetabulum. Poor fixation achieved due to large lever arm be improved by THA. The original reason why the
and the resulting torque on the lever arm arthrodesis was performed should be sought. If the
arthrodesis was performed following infection make sure
Combined intra-articular and extra-articular fusion. Some
active infection has been excluded. Ensure that the patient
form of bone graft is required
has a good indication for conversion. In patients with
long-standing ankylosis from childhood infections, there
is extensive scar formation, limb shortening and decreased
size of the hemipelvis and proximal femur. This will
necessitate the use of smaller components.
Examine whether the hip is soundly fused, the amount of
limb shortening (this can be difficult to assess). Palpate the hip
abductors for bulk and defects and test for hip abductor
strength. Good quality radiographs to identify bone stock,
hardware, status of the greater trochanter. A CT scan can
sometimes be helpful for identifying bone stock, the proximity
of heterotopic bone to neurovascular structures and the
abductor muscle mass. The abductors may be inadequate.
The sciatic nerve is closure than normal during surgery and
one may need to release psoas with or without adductor
tenotomy if abduction is <15°. Surgery is technically challen-
ging and associated with a higher infection rate. Meticulous
preoperative planning for acetabular position abductor
Figure 11.13 Fused right hip moment arm restoration and leg length restoration.
135
014
Prophylatic measures for HO (NSAIDs). Preoperative CT can before puberty had less improvement in hip muscle function
be helpful to determine adequacy of bone stock and the pres- following THA because of underdevelopment of the greater
ence of a pseudoarthrosis. trochanter. Leg length is improved in most patients but accur-
ate restoration of leg length can prove difficult due to anatomic
Surgeryt deformity and bone loss.
Principles of surgical technique involve12:
Identify and preserve hip abductor muscles Results
Accurately identify the hip rotation center of the Correction of LLD was an important element in overall patient
acetabulum satisfaction. Relief of back symptoms more pronounced than
Perform concentric reaming of the acetabulum to achieve ipsilateral knee, fused hip or contralateral knee and hip. ROM
medialisation and sizing of the component is slightly less than after primary THA.
Avoidance cup placement in an excessive cephalic Risk factors for early failure include surgically fused hips,
position age <45 years, patients with two or more operations before
Optimize leg length surgery.
Restore ideal femoral offset to avoid impingement and Hamadouche et al.13 reviewed 45 consecutive con-
instability version THA in 45 patients with ankylosed hips. Mean dur-
Patient positioning may be difficult, bone often osteoporotic, ation from initial hip ankylosis 35.7 years. The mean
difficulty with locating native acetabulum (obturator fora- functional hip score of Merle d’Aubigné significantly
men useful landmark). Exposure difficult because prior inci- improved from 11.3 points preoperatively to 16.5 points at
sions, distortion anatomic planes, medialisation hip centre last follow up.
and soft-tissue contractures. Sciatic nerve often embedded in
scar tissue. Line of neck resection identified, avoid cutting
into greater trochanter or dividing the posterior acetabular Examination corner
wall. Identification orientation acetabulum can be difficult.
Short case 1: Fused hip
Careful acetabular reaming to preserve anterior and poster-
Examining this hip:
ior columns. Adductor tenotomy, iliopsoas muscle release
Scar over a stiff hip (surgical arthrodesis)
and anterior capsulectomy oftern required to correct severe
Stiff leg gait
contractures. Tredelenburg’s: False positive, able to maintain abduction
with no abduction function
Complications following conversion Measurement of real and apparent leg length discrepancy
Patients must be made aware of the higher rate of compli- with tape measure
Shortened leg with no hip movements
cations compared to primary THA:
Ensure you stabilise the pelvis while checking hip
Deep infection 1.9–15.3% (higher in conversion of surgical movements. Failure to do this will lead to incorrect
fusion) diagnosis
Dislocation 1.7–6.25%
Sciatic nerve palsy 1.8–13.4%. Leg length correction has to Short case 2: Hip arthrodesis
be limited (max. 4 cm) ‘Examine this man’s gait.’
Femoral nerve palsy 3.6% Difficult to describe as not the classic gait described of
shortened stance phase and prolonged swing phase:
The gluteal muscles are atrophied and usually require the use
A gait dysrhythmia due to a slower gait velocity with a
of crutches for 3–6 months until the abductor function is shortened stride length, a greater than normal anterior
strengthened. It may take 2 years to gain the full benefit of pelvic tilt and lumbar lordosis. The increase in lumbar
surgery. Normal abductor power may not be regained. The lordosis and change in pelvic tilt resulted in the mobile hip
knee has a tendency for a valgus deformity if the hip is fused. If having a greater flexion/extension excursion than normal.
the hip is fused in a poor position consider corrective osteot- Also real inequality in limb length (fused hip) and apparent
omy first before arthrodesis. Patients whose hips were fused leg length discrepancy (hip position in the frontal plane
caused by adduction 0–5°) adversely affected walking
performance. There was irregular forward progression with
lateral motion of the head and trunk and a tendency to
t
walk slower
As a candidate you may not have seen this surgery. It is sensible to
let the examiners know this, but you should know the principles of ‘This was all above my head and I remember saying that he
the operation. ‘I haven’t personally seen this type of surgery was walking with some difficulty with a gait suggestive of a
performed and have limited clinical experience of this complex
stiff hip.’
operation, but some of the difficulties may include . . .’
014
Intermediate case 1: arthritic knee below a fused hip In addition, femoral and sciatic nerve function, vascular
Discussion usually centres on the pros and cons of whether to status, pelvic obliquity, kyphoscoliosis lumbosacral spine
take down the fused hip first and perform a THA and then and ROM and stability of the contralateral hip and knee
afterwards perform a TKA vs going ahead and performing a and ipsilateral knee. Functional integrity and strength of
TKA above a fused hip. hip abductor muscles
TKA in patients with an ipsilateral hip fusion leads to a reduced
ROM and the frequent need for manipulation under anaesthetic Discussion
(MUA) because of stiffness. More over these artificial joints func- Why convert the arthrodesis to arthroplasty?
tion under abnormal overstress leading to early failure. Is hyperlordosis the cause of low back pain?
Studies on the results of TKA in the presence of a fused hip Should antituberculosis treatment be used preoperatively?
have reported high complication rates with unpredictable out- If so for how long?
come. Thus, the only exception to performing a TKA before What are the side effects of antituberculosis drug
converting the fused hip would be a patient with a satisfactor- treatment?
ily positioned hip in whom abductor muscle function was What consent issues are there preoperatively?
questionable. In these patients, the results of THA are known Neurovascular problems, in particular the need to expose
to be inferior, with poor gait patterns and a decreased likeli- the sciatic nerve or not
hood of adequate knee pain relief. If the hip is fused in a poor Hip instability
position and the patient has significant knee pain, the conver- Infection
sion THA is preferable because of the notably inferior results of Results of conversion
a TKA in that setting. Preoperative planning of the arthroplasty
Plain films, CT scan
Implant considerations relevant to a stable hip
Intermediate case 2: arthrodesis left hip (post-SUFE fixation with
LLD), left THA and then periprosthetic fracture
Intermediate case 4: Older patient with fibrous ankylosis of the hip
Discussion following SUFE and previous proximal femoral osteotomy
Position of arthrodesis Discussion on:
Work up of the infected hip SUFE
Classification of periprosthetic fractures Osteotomies
Management of periprosthetic fractures Surgical approaches to the hip
Taking down the arthrodesis Demonstration of the flexor contracture of the hip
TKA with hip arthrodesis THA
Risk of low back pain Surgical approaches
Other joint arthrosis Management of difficulties in this case
Intermediate case 3: elderly patient in good health Intermediate case 5: young female who had presented with
DDH aged 4
History
The patient had open reduction, Salter’s osteotomy and a
Index aetiology
femoral osteotomy. She developed AVN and growth arrest of
Indications for hip arthrodesis
capital femoral epiphysis. She had an arthrodesis aged 14 com-
Type of ankylosis (spontaneous or surgical)
plicated by sciatic nerve palsy.
Age since the ankylosis
Previous complications (infection, venous Discussion points
thromboembolism (VTE), non-union, sciatic nerve injury) Diagnosis?
Indication for conversion THA What operations has she had?
Low back and ipsilateral knee pain Measurement of the centre-edge angle?
Right hip arthrodesis post tuberculosis aged 15 How would you do an arthrodesis of the hip?
Intra-articular arthrodesis What do you think of the position of this patient’s
arthrodesis?
Examination
Why did she develop a sciatic nerve palsy
Location of previous incisions – postoperative scars over
Options for further management
the anterolateral aspect hip and right iliac crest
Outcome following revision to THA (taking down
Measurement of leg lengths the hip)
Demonstration of gait
Demonstration of Trendelenburg’s test (false negative)
Short case 3: arthrodesis of the hip
Perform Thomas’ test
No pain on attempted hip movement EXAMINER: Examine this man’s hip.
Position of fusion: 35° flexion, 5° adduction and neutral CANDIDATE: I mentioned that I would start by examining the
rotation patient’s gait. The examiner said ignore the gait and, therefore,
137
014
OA hip is classically felt in the groin, around the greater

I said I would like to perform a Trendelenburg’s test. Again, the
trochanter and occasionally in the buttock (suspect either the
examiners said ignore Trendelenburg’s testing. They wanted me
lumbar spine or sacroiliac (SI) joints). Is the pain getting worse
to go straight on to hip movements and deformities. There were
or staying the same? Does the pain radiate anywhere – radi-
absolutely no movements in the hip and there was a healed scar
ation to the front of the thigh and knee commonly occurs and
on the lateral aspect. I told the examiners the diagnosis could be
at times pain may present solely in the knee. Was the pain
an arthrodesis of the hip. They agreed with this and showed me
insidious or sudden in onset – OA or AVN. Aggravating and
the x-ray to confirm it.
relieving factors, etc.
The examiners asked me what I would do about management.
Quality of life/limitation: How the symptoms are affecting
I said I would ask the patient if he had any pain with the hip. The
the patient such as daily activitites (dressing up, putting on
patient said that he had no symptoms at the moment so I said
shoes shoes, cutting toenails).
nothing should be done with the arthrodesis. The examiners were
Decreased walking distance: How far can you walk
happy with that. They gave me a scenario: If the patient came to
before you have to stop – sometimes patients do not have
see me with pain, what management would I offer? I said that we
a restricted walking distance but get pain after 10 minutes
could convert an arthrodesis of the hip into THA but that the
or so. Does the pain stop you from walking any further or is
patient should be warned about failure and also weak abductors
it shortness of breath or chest pain – concerns about fitness
and neurovascular injury. The examiners were again happy with
for surgery.
this answer. By that time 5 minutes were up and the bell went.
Sleep disturbance: Does the pain stop you sleeping at
Before answering the scenario question I should have perhaps night? How many times do you have to get up in the night
clarified with the examiners that the pain was definitely arising because of the pain? Night pain can be particularly distressing
from the hip and not referred from elsewhere. to patients and is an important and strong indication for
surgery.
Analgesia: What painkillers are you taking and how often
Primary OA hip are you taking them. When was the last time you took a
painkiller?
Introduction Limp: Limp may be noticed early, but more often than not
Most likely an intermediate case but equally a candidate could comes on later than pain or stiffness. It can be due to a variety
be asked to demonstrate the Trendelenburg’s test, Thomas’ test of cause including pain, muscle weakness and stiffness (capsu-
or ROM in a short case. Examiners view a straightforward lar contractions).
intermediate case of primary hip OA as an easy case. Be Stiffness: Inability to put shoes, socks or stockings on,
professional and thorough in your presentation. The expect- inability to cut toenails, get in and out of a bath, in and out
ations from examining a primary hip OA case are high and it of a car. Stiffness and limp are relative indications for surgery
is very easy to loose marks. It is a condition that candidates will and should not be regarded as the sole indication for surgery in
see on a day-to-day basis in clinic and they would be expected the absence of pain.
to know it inside out for an exit exam. Drug history and past medical history: Fitness for sur-
The examiners have a very low threshold for any minor gery. Need for anaesthetic assessment.
mistakes or errors made. This is a high stakes exit exam and Miscellaneous and social history: Do you use a walking
if you miss subtle details out of the history, do not demon- stick – for how long – which hand? Previous treatments tried
strate Trendelenburg’s test particularly well, botch-up the and success. Smoking and alcohol. Do not forget the social
Thomas’ test or say something ‘not quite correct’ in the history – do you have stairs in your house, home help, meals
discussion you well end up scoring poorlyu. In comparison, on wheels, etc. Look for any walking aids, etc, next to the
a very difficult intermediate case may mean that the exam- patient.
iners are more likely to be forgiving if you should make the
odd mistake during the history and examination.
Examination
History Make sure the pain is arising from the hip joint – NOT
back pain; – NOT knee pain. Moving knee in the plane of
Pain: The predominant and most important symptom. How knee (pain = knee). Move knee as pendulum (pain = hip).
long have you had pain? Where is the pain felt – pain from an Be suspicious if back movements reproduce pain. Occa-
sionally patients are referred for THA with arthritis of the
hip but examination and observation of gait will show that
u the patient is more limited by peripheral vascular disease,
This could be a one gaff mistake in the discussion (analgesia pain
ladder) or more subtle, such as the candidate giving the impression peripheral neuropathy or Parkinson’s disease than by the
they have read about the subject in a book but haven’t come across arthritic hip. Under these circumstances THA is relatively
it much practically in the OP clinic. contraindicated.
014
Discussion Candidates should know about the Orthopaedic Data

Discussion would usually start with a description of the Evaluation Panel (ODEP) ratings. These are the criteria for
patient’s radiographs. Be able to describe typical features of product categorisation of prostheses for primary THA against
hip OA. NICE benchmarks:
This would lead onto a discussion of conservative manage- Pre-entry benchmark (products commercially available
ment of hip OA. What painkillers to use, the role of physio- that are involved in post-market clinical follow-up
therapy, when to list for an intra-articular steroid injection. studies but have failed to meet NICE’s 3-year entry
Be fairly neutral with this and don’t say anything too benchmark)
controversialv. Entry benchmark (after 3, 5 and 7 years: Level A –
Acceptable evidence; level B – Weak evidence)
EXAMINER: How would you consent the patient? What would you tell Full benchmark (10 years: Level A – Strong evidence; level
them about the risks of the procedure? B – Reasonable evidence; level C – Weak evidence)
For each year, there is a level for unacceptable evidence, where
This may lead on to what approach ‘YOU YOURSELF’ would products should only be used as part of a clinical trial.
use for a primary THA possibly followed by the advantages
Discussion of hip registers
and disadvantages of two of three other common surgical
approaches used. National Joint Registry (NJR) data has shown Discussion may cover funding and maintenance of the
a significant increase in the use of the posterior approach in register, performance of implants, revision rates,
THA along with use of larger diameter heads and a lower stratification of variables (age, indications, gender, etc)
dislocation rate14.
EXAMINER: What type of THA would you use and why?w

Examination corner
This may lead to potential discussion of cement vs uncemented Intermediate case 1: A 56-year-old woman with a painful right hip
hip designs. There has been a recent trend towards performing History
more cemented THA as NJR data suggests a lower early revi- As per hip OA
sion rate using cement and lower cost. ‘The patient wasn’t the best historian. I was first candidate
The viva may then move on to long-term published results to examine in the morning.’
of THA in the literature and end with survival analysis curves
or how to set up a study to assess the long-term outcome of a Clinical examination
particular THA. Shoulders level, and symmetrical stance. No pelvic tilt with
Three main factors influence the outcome and survival ASIS level and no LLD.
time of a primary THA: Mild antalgic gait not marked, positive Trendelenburgs test.
1. The surgeon’s skill and experience Thomas’ test. No FFD hip.
Marked restriction of internal and external rotation in
2. The implant design and method of fixation flexion with only a jog of movement present.
3. Patient characteristics such as sex, age, weight, underlying Abduction restricted to 30°, adduction similarly restricted to
disease and activity level 20°; both were painful.
It is important to know current NICE guidelines regarding Mentioned neurovascular and spine examination.
primary THA and have read the British Hip Society hip I was then asked to measure for true leg length, which as
replacement booklet15. expected was normal. I am not sure if the examiners were
finding their feet being the first case and hadn’t quizzed me
in enough detail on the earlier positive finding and had to
find something for me to do to use up the remaining time.
v
‘Physiotherapy is generally a waste of time with advanced OA hip.’ Discussion
Avoid any sweeping generalized controversial statements. About
The approach I would use (posterior) and asked to describe
1 in every 10 candidates, whether through nerves or whatever, will
in detail.
say something that in hindsight is really not very sensible or helpful
Implant – I played safe and suggested using a cemented
for them.
w
CANDIDATE: I use the Exeter prosthesis because I am most Exeter hip replacement. I was lucky, as the examiners
familiar with this design from my training. The instrumentation is didn’t push me on this choice as I had thought about an
relatively straightforward; the neck cut is not critical. Most uncemented THA with ceramic on ceramic bearing
importantly it has successful long-term peer-reviewed published surface.
results. The collarless, highly polished, double taper stem allows Consent – quite detailed grilling of potential complications
controlled insertion. . . etc. The Exeter femoral component has a and incidence compared to the previous question.
94–98% 10-year survival rate and a 10A Orthopaedic Data Benefits of the NJR.
Evaluation Panel (ODEP) rating.
139
014
Intermediate case 2: Primary OA of the hip

‘The history and examination were relatively
straightforward. In the discussion section I was asked
virtually everything possible there was to know about THA
in great detail.’
Slipped upper femoral epiphysis

History
‘Sixty-five-year-old man. He had a severe left SUFE in-situ
fixation as a 14-year-old boy.’
‘His main complaint now is of left hip stiffness. Limited
activities of daily living. He has difficulty putting his shoes and
socks on and getting in and out of the bath. His walking
distance is not restricted but he needs to take his time getting
from place to place. Pain is not a significant feature and there is
no sleep disturbance and he is on no regular medication. He is Figure 11.14 Severe SCFE disease right hip with coexisting OA
otherwise fit and healthy.’
Clinical examination Dunn and Loder classification of SUFE

Radiological finding in SUFE
‘On general examination the patient is of average height and
build. He looks well for his years. On examination standing there Treatment options of severe slips
is a well-healed left lateral hip scar present from his previous hip Various osteotomies
surgery. He stands up straight with a flexion attitude of his right
leg, which on straightening up the pelvis revealed a left LLD. Management of this particular case
A mild external rotation deformity of the affected leg was In the absence of significant pain this patient is not a candidate
present. There is marked left thigh muscle wastage. He walked for THR, as ROM is rarely significantly improved. Advanced
with an antalgic short left leg gait. He was Trendelberg’s positive
changes of OA are too severe for osteotomy. Therefore, con-
on the left side.’
tinue with conservative treatment at present.
‘Suggest to the examiners using a block test to assess LLD
prior to supine examination.’
Technical difficulties of performing a THA in SUFE
An anteverted femoral neck may mislead the surgeon
Supine
during stem insertion and lead to component mal-
‘Thomas’ test demostrated a FFD of 15°. Measure apparent leg positioning. There could be problems with metalwork
length. Square pelvis to measure true length. The ASIS on the
removal – Have special instruments available. Consider a
left side was elevated, squaring the pelvis (bringing the ASIS to
same level unmasked a fixed adduction contracture of the left
2-stage procedure – Metalwork removal first followed by
hip). Measurement of leg lengths using a tape measure THA 3 months later.
confirmed 2 cm of real shortening. Galleazzi’s test revealed this
to be in the femur. Digital Bryant’s test suggested the
shortening was above the trochanter. If there is fixed flexion
Young patient with painful hip post SCFE16
deformity , do not mention extension at the hip as this is absent. Slipped capital femoral epiphysis (SCFE) deformity often
Flexion was from 15° to 90°, with the leg tending to go into fixed results in significant femoroacetabular impingement (FAI),
external rotation as it was flexed up (axis deviation). There was which may lead to the development of OA at an early age.
virtually no internal rotation (IR) or external rotation (ER) at 90° Posterior and inferior slippage of the epiphysis results in a
flexion. Abduction was limited to 30° and similarly adduction metaphyseal bump – A Cam lesion that leads to FAI. Post-
limited to 20°. Check active and then follow on with passive SCFE cartilage and/or labral damage develops in patients with
movement. Pain was present at the extremes of movement. The symptomatic mild to moderate SCFE deformity.
leg was neurovascularly intact and examination of the spine,
opposite hip and both knees were unremarkable.’
History
Pain often with activities that force the hip into flexion
Discussion Usually groin pain (83%) but also can present with lateral
AP radiographs (Figure 11.14) hip, thigh, buttock and low back pain
Aetiological factors of slipped upper femoral Sitting may be difficult, flexing only with marked external
epiphysis (SUFE) rotation
014
Pain is usually activity related-running, pivoting and walking

I was put off by the fact he was overweight and in a lot of
Mechanical symptoms such as popping, snapping, catching, pain struggling when walking.
locking and/or instability present in about two-thirds of I performed Trendelenburg’s test but wasn’t particularly
patients slick with it.
I examined hip ROM which was painful and limited.’
Clinical examination I didn’t comment on the leg going into external rotation
when flexed and he was in quite a lot of pain with any hip
Gait: Patients often walk with out-toeing of the affected leg movement.
because the slip results in external rotation of that leg They asked me whether I would normally perform
Trendelenburg’s test: Often positive Thomas’ test when examining a hip. Instead of saying that
Evaluation of ROM: Internal rotation, flexion and the patient was in a lot of pain and it wasn’t appropriate,
abduction is often limited because of the position of the I said yes I would and then went on to perform the test.
epiphysis. External rotation is often increased with SCFE. However, the examiners stopped me after I started flexing
Flexion is always reduced whilst abduction is usually up the opposite hip as even this seemed to cause him
reduced severe pain.
I was asked about the possible diagnosis and I mentioned
Provocative hip tests: Usually positive anterior
old slipped SCFE.
impingement sign (pain on forced flexion, adduction I really didn’t do very well with a straightforward case,
and internal rotation). The metaphyseal bump it didn’t seem to flow very well at all.
impinges within the acetabulum or against the rim of the (5 – fail)
acetabulum
Leg lengths: Often the affected leg is shortened
Test for hip abductor muscle strength: Usually reduced.
Test side lying Rheumatoid patient with hip disease
Discussion Background
Imaging: Despite numerous medical advances in the treatment of
AP pelvis and frog-leg lateral. This assesses external rotation, RA, severe involvement of the hips is common. Fortunately,
metaphyseal bump, prominence impingement on the THA provides excellent reliable relief of pain and functional
acetabulum and varus or valgus deformity improvement. Between 6% and 15% of THA are carried out
for RA. The average age of onset of rheumatoid disease
False positive view to obtain better view of metaphyseal
is 55 and the average patient has had hip symptoms for
bump and anterior coverage acetabulum
4 years.
CT to visualise SCFE deformity and better plan surgical
In general, forefoot deformity should be the first corrected
management
to ensure they are capable of comfortable weight-bearing and
MRI. Metal artefact if screw still in situ
reduce sources of infection at a later date.
Thereafter, the hip should take priority over the knee and
Management hindfoot. Knee pain referred from the hip is abolished and
Arthroscopic femoral neck osteochondroplasty the restoration of knee anatomy and ligament balance at sub-
Limited open osteochondroplasty sequent TKA is easier and more reliable when the hip above
Moderate or severe slips may require redirectional flexion is mobile. Rehabilitation of TKA is difficult with a stiff, painful
intertrochanteric osteotomy or deformed hip. The hindfoot should be corrected last as
THA correction of hip and knee deformities may alter the dynamic
position of the hindfoot.
There are concerns regarding:
Examination corner Polysystemic/multiple joint nature of the disease
Short case 1: SCFE
Polypharmacy as patients often take a variety of medication
A middle-aged man in his 40s. Huge protuberant abdomen
that can affect surgery
who struggled to do anything much during the Immunosupression either from the disease or by their
examination. treatments
Asked to examine his hip. Difficulties with rehabilitation
I commented that he had an external rotatory deformity of Check for neck symptoms (cervical instability)
the leg with shortening, muscle wasting and a lateral scar. Enquire if the patient is on any biological therapy that may
He had an antalgic gait.
have to be stopped prior to surgery
141
014
Memorandum with RA, demonstrated no increased infection risk from elective

orthopaedic surgery. They recommended that methotrexate
History
therapy should not be stopped before surgeryx,y,18.
Insidious onset groin, buttock or thigh pain. Subject to acute In general, it is recommended that biological disease modi-
flare-ups’ fying anti-rheumatoid drugs (DMARDs) should be withheld
before and after surgery.
Examination A get-out clause, if the examiners are cornering you, would
Shake hands and see skin condition – Dry, eczema, psoriasis be mentioning a multidisciplinary approach to the rheumatoid
scars, etc. patient. Medication management requires a risk–benefit dis-
‘On general inspection the patient has features of extensive cussion between patient, surgeon and rheumatologist. A local
rheumatoid disease affecting many joints. The buttock and hospital protocol may have been developed for guidance and it
thigh are markedly wasted with the limb held in external would be worth mentioning this as wellz.
rotation and fixed flexion. The skin overlying the joint may Management options include:
appear shiny, thin and atrophic with evidence of spontaneous Intra-articular injection of steroid/local anaesthetic
bruising. All movements of the hip joint are restricted and
Open synovectomy – Not popular, risk of AVN
painful. Hip flexion and adduction contractures of various
femoral head
degrees may be present. It is important to examine the upper
extremities to evaluate the patient’s ability to use walking aids. Arthroscopic partial synovectomy – Becoming more
The knees, ankles and feet should be examined for arthritic widely practiced, may have a role in the young rheumatoid
involvement. Look for any walking aids, footwear and any patient
braces.’ Osteotomy – contraindicated as the disease is generalized
Beware of the patient in a wheel chair. throughout the joint
Some patients with severe multiple lower extremity Arthrodesis – contraindicated, requires good functioning
involvement may be confined to a wheelchair. not diseased neighbouring joints
Can they walk? THA
How?
Operative issues
Do they use a stick?
Careful position on the operating table is vital due to poor skin
When did they last walk?
and other painful joints, padding of all pressure areas. Care
Make the patient walk if possible
must be taken with the neck during patient transfer and
positioning. Temporomandibular disease may make intub-
Radiographs ation difficult. Bone stock is often poor being soft and osteo-
Radiographic findings in the rheumatoid hip can often be porotic, so great care is required during dislocation and
subtle. Osteopenia is seen in most cases. Typically there is relocation of the hip to avoid fracture of the femur. Dislocation
concentric joint space narrowing due to generalized loss of may be difficult if protrusio is present. Care is needed not to
articular cartilage without evidence of osteophytes or cyst bruise the skin and soft tissues of the leg. The femoral head and
formation. With progression of the disease, medial and/or neck may be partially absent. Due to the reported high rates of
superior migration of the femoral head with protrusio deform-
ity occurs especially if steroids are used.
x
We suggest when quoting papers a so called ‘four-corner approach’
Management should be used. Author, institution, year of publication and journal.
Often rheumatoid patients are generally disabled having vari- If you remember all four corners this is an excellent solid use of
ous degrees of osteopenia, skin fragility, vasculitis and poor evidence. Three corners are still good whilst two corners are OK-ish
musculature. It is important to ensure the patient is in as fit a and one corner is not so good.
y
There was a 10-year follow up of the Grennan paper in which they
state as possible for surgery. Synovitis should be as well con-
adhere to their original advice. A lot of patients, however, were lost
trolled as possible and no chest, urinary, dental or skin sepsis to follow up – See reference 17.
should be present. Anaesthetic risks such as neck instabilty z
There are several local hospital policy guidelines that usually have
should be excluded. Medical management of RA may be dis- been developed. These could include antibiotic use in open fractures
cussed. Biological medications generally have to be stopped. or elective orthopaedic surgery, massive blood transfusion or the
Methotrexate should be continued as it has been shown not to septic joint. ‘We have a hospital protocol in place based on NICE
increase the rate of infection in THA. Stopping methotrexate guidelines. I would refer to this protocol to guide to my treatment
decision.’ These are guidelines only to help with treatment decisions
can increase the risk of associated disease flare up and associ-
and perhaps not to be absolutely rigidly adhered to. Have an answer
ated complications. preplanned in case the examiner is dubious about their usefulness
Grennan et al.17 in 2001 in the Annals of Rheumatoid Dis- and starts challenging you about using them or starts having a rant
ease, in a prospective randomised control trial of 388 patients about the over importance placed on NICE guidelines.
014
non-union in RA the transtrochanteric approach should gen-

erally be avoided. Reaming can compromise the edges of the
History
As with any diagnosis, the history is critical. A high index of
acetabulum and the acetabular bone is soft and easily pene-
suspicion is essential especially if the patient has one of the
trated. If protrusio acetabuli present (20–40%) bone grafting of
atraumatic conditions associated with AVN.
the medial wall (with a bulk autograft or packed reamings
The standard hip questions should be asked. In addition,
from the femoral head) and in severe cases mesh and shell
the history should include a search for possible aetiological
re-inforcement may be required.
factors. Inquire about steroid use, alcohol intake and history of
The rate of deep infection is approximately double (2.6)
previous hip trauma, deep sea diving and any blood disorders.
that of osteoarthritis. Late infection is more common in
The clinical presentation is of gradual onset of intermittent
rheumatoid disease, possibly related to immune suppression
groin and/or thigh pain. The pain is typically deep seated;
or other sources of infection. Fitzgerald et al. reported a deep
throbbing, felt at night and is unremitting and similar to bone
infection after hip replacement in 3.1% of 223 RA patients19.
tumour pain. Pain is usually worse with ambulation, although
There is some debate as to whether the incidence of
some patients progress to have pain at rest. Very occasionally
thromboembolism is reduced in rheumatoid disease due to
the pain presents abruptly. A few patients may remain rela-
a mild coagulopathy. Evidence in the literature is sparse.
tively asymptomatic despite radiographic evidence of advanced
HO is less common in RA. The dislocation rate has been
progression of the disease.
reported as more common but there is little evidence
for this.
Implants should in general be cemented as poor bone stock Examination
may not support cementless fixation. Uncemented compon- The clinical findings on examination can be unremarkable or
ents have not been widely used in the treatment of RA. Ortho- can include pain on internal rotation of the hip, a decreased
paedic surgeons have been concerned that the osteopenia, range of motion, an antalgic gait and clicking of the hip when
contractures and bony deformity often seen in RA would make the necrotic fragment has collapsed. Pain with internal rota-
it difficult to obtain safely and reliably the initial stability tion of the hip and a limited range of hip motion are often
necessary for bony ingrowth. In addition, there has been signs that the femoral head has already collapsed.
concerns relating to the how much bony ingrowth will occur
in the presence of systemic inflammatory disease and the Memorandum
effects of antirheumatic medications. Cemented implants On general inspection the patient looks well for his years. He is
may be a wiser move but there is little evidence in the literature standing up straight with his pelvis level and taking weight
to support this opinion. equally through both legs. Possible left gluteal and thigh
Mixed results have been reported for the survival of pri- muscle wasting.
mary THA compared to OA. In the Swedish Hip Registryaa an Examination of gait revealed that he walked with an antal-
increased rate of revision of acetabular cups in rheumatoid gic gait. Trendelenburg’s testing of his lower limbs revealed a
patients both young and old was noted. Other studies have delayed positive response on the left side and negative Tren-
found no difference in survival between RA and OA. delenburg test on the right sidebb.
Formal measurement of leg lengths supine revealed 2 cm of
AVN of the hip true shortening of the left leg. Galleazzi’s test confirmed that
AVN of the hip is an ideal intermediate case. There would be the shortening was arising from the femur. Bryant’s triangle
emphasis on history taking, differential diagnosis and treat- testing suggested that the shortening was above the trochanter.
ment planning. The patient typically would be young or Movements of the left hip were painful and grossly restricted
middle aged and present with early AVN and worsening particularly abduction and internal rotation in flexion. The left
hip pain. Another possible scenario would be progression hip demonstrated almost full internal rotation in extension but
of AVN with worsening hip pain following unsuccessful with the hip flexed it was grossly restrictedcc. The left hip had a
core decompression. In a short case you may be asked to tendency to twist into fixed external rotation during passive
demonstrate fairly specific hard clinical signs such as hip flexion.
Trendelenburg test, Thomas’ test or a restricted painful
range of hip movement rather than go through a complete
hip examination.
bb
Some surgeons doubt the significance of a delayed Trendelenburg’s
test, citing the fact that even a normal patient’s pelvis will dip down
after 30 seconds.
cc
If internal rotation is full with the hip extended but restricted in
flexion this suggests pathology in the anterosuperior portion of the
aa
www.shpr.se/Libraries/Documents/AnnualReport_2013-04-1_ femoral head, which is probably AVN – the so called ‘sectorial
1.sflb.ashx sign’.
143
014
Examination corner
Intermediate case 1
Discussion
How do you assess the rheumatoid patient in general for

THA surgery?
What about the cervical spine? When do you order new x-
rays?
What about methotrexate? Would you stop it before sur-
gery in order to decrease the risk of infection
Discussion
Discussion will probably begin by reviewing hip radiographs
(Figure 11.15). A candidate would be expected to describe
the typical radiographic findings of AVN (can be very subtle)
and then stage the disease. In the current FRCS (Tr & Orth)
exam classification systems are not asked for directly by the
examiners. One may, however, benefit by knowing various Figure 11.15 Bilateral osteonecrosis hips
radiological and MRI classifications and volunteering this
additional knowledge to score extra points. Discuss classifi-
cations only if you are sure about them. The examiners may
also have an MRI scan of both hips available and there are
several possibly lines of questions which can emanate from
this (Figure 11.16).
The aetiology of AVN will generally be discussed and, if you
are doing well, the latest theories of pathogenesis for AVN.
Management options of AVN is probably the pass/fail area.
A candidate will need to decide whether to simply go through
a list of possible options or be more specific in his/her man-
agement plan for his/her particular casedd. Recent advances
such as stem cells and bisphosphonates could be brought into
the conversation.
The discussion can lead to:
The advantages and disadvantages of performing either a
cemented or uncemented THA in a young patient
How you would perform a THA? What approach would you
use and why? What implant would you use and why? What
are the long-term results of this implant? Do you know of
any published results of this implant?
Discuss the current NJR data on THA for AVN
What are the results like for THA in AVN compared to a Figure 11.16 Coronal T1-weighted MRI image of bilateral ON of differing age.
normal standard group with OA? The low signal intensity in the superior weight-bearing area of the right femoral
head is typical for osteonecrosis
Short case 1: psoriatic arthropathy with AVN secondary to
steroid use
EXAMINER: Examine this lady’s hips:
Bilateral AVN of the hips with scars on each side of the
proximal thigh for core decompression Short case 2: Middle-age man with pain/limited hip movements
Shown AP pelvis radiograph of patient and asked to pass EXAMINER: This man was involved in a RTA; just examine the range
comment: of movements of the right hip.
Radiographic features of AVN CANDIDATE: I examined his hip movements and found a
Discussion on Ficat and Steinberg’s classification system restricted and painful range of movement in his right hip,
ee
Mechanism of action (MOA) probably from altered fat
metabolism. Steroids cause osteoblastic stem cells to become fat
dd
If you are asked about your management plan it is preferable to cells (apidogenesis). Existing marrow fat cells undergo hyperplasia
discuss your own preferred treatment choice for the case rather and hypertrophy. Capillary occlusion and intraosseous
than mentioning a whole list of management options. hypertension results.
014
particularly abduction (15°) and internal rotation in flexion swing. The classic finding in a stiff hip gait of rotating the
(virtually nil). I mentioned the large proximal thigh scar pelvis and swinging the leg in a circular fashion was
present. For some reason, and I have no idea why , I asked the markedly absent
patient two or three questions about his hip pain. ‘How severe Trendelenburg’s testing was false negative. The patient
was able to maintain abduction with an ankylosed hip
was his hip pain? How far was his walking distance? Did it
Demonstration of Thomas’ test. There was a fixed flexion
keep him awake at night?’ The examiner then led me through
deformity of 20°
his radiographs.
‘Demonstration of ROM, but not done particularly well as
EXAMINER: These are his radiographs. He had a severe posterior I didn’t stabilise the pelvis and significantly overestimated
pelvic fracture, which has been fixed with pelvic reconstruction hip movement’
plates. The diagnosis is obvious looking at the femoral head. He ‘Measurement of true and apparent leg lengths using tape
has developed AVN. measure, asked by the examiners to describe what I was
CANDIDATE: (It wasn’t that obvious and I may have struggled to get doing as I went along. Grilled by the examiners to explain
to it.)
exactly what I meant by true and apparent shortening of
the leg’
EXAMINER: What would you do for the patient?
CANDIDATE: His pain is not too severe at present and he seems to Discussion
be coping reasonably well with things. He can walk up to 2 miles Radiographic features of AVN: Cysts, sclerosis and crescent
without too much difficulty. He isn’t kept awake at night with this
sign, etc.
General discussion about potential management options
pain. I wouldn’t do anything with him at the moment. I would
without really deciding anything at all.
review him regularly in the clinic, and if his symptoms
deteriorated significantly I would offer him a total hip
Treatment of AVN following SCFE is difficult and often unre-
warding. Articulated hip distraction (arthrodiastasis) used in
replacement.
adolescents with AVN may reduce pain and limitation in
EXAMINER: Yes, you are quite right. There is no need for any surgery
daily activities. However, it is less effective for AVN second
at present as his symptoms are minimal. to SCFE and is not the final solution to AVN.
CANDIDATE’S COMMENT: If your luck is with you it is with you in Salvage procedures include proximal femoral osteotomy
incredibly large amounts. I do not know why I started to ask and shelf acetabuloplasty. Arthrodesis for advanced
the patient questions. The examiners certainly didn’t ask me deformity with arthroplasty at a later date when the patient
to but it gave me the information needed to answer the is older is another potential option.
question about his current management plan correctly. The Investigate by examination under anaesthesia and
examiner assumed that I had picked up on the fact he had
dynamic arthrography. Under anaesthesia fixed deformities
can be assessed, the size and shape of the femoral head and
developed AVN.
joint congruity determined, presence of hinged abduction and
most congruent position femoral head within the acetabulum
Intermediate case 1: Male aged about 60 years with history of evaluated.
Caisson’s disease
Painful left hip – Moderate OA secondary to AVN Intermediate case 3: AVN
Right THA History
Moderate bilateral varus OA knees
‘A 62-year-old woman with a history of left hip pain. I was
Most of the clinical findings above were demonstrated to
asked to take a history. I started off by asking her age,
the examiners. In particular they were interested in the
occupation and presenting complaint. She told me she has
difference between true and apparent shortening of the
pain in the left hip and also difficulty walking for the past 6
right leg
months. I asked her in detail about her pain – the site,
Discussion variation, character, aggravating and relieving factors, and
The discussion focused mainly on the differential diagnosis, also enquired about the limping. I also asked whether she
pathology, aetiology, classification, grading and management had any significant past medical history and she mentioned
of AVN (detailed discussion on core decompression). she suffered from persistent lupus erythematosus and had
Results of THA for AVN was also discussed. been on long-term oral steroids for many years. I more or
less got a diagnosis from the history itself. I went on to her
medications, social and family history. At this point the
Intermediate case 2: 14-year-old boy with AVN and collapse with
ankylosis of the left hip following pinning of severe SUFE
Clinical findings included

ee
Gluteal and buttock muscle wastage Mechanism of action (MOA) probably from altered fat
Shortening of the left leg metabolism. Steroids cause osteoblastic stem cells to become fat
Short leg antalgic gait and stiff hip gait. There was a subtle cells (apidogenesis). Existing marrow fat cells undergo hyperplasia
increased motion of the pelvis on the lumbar spine during and hypertrophy. Capillary occlusion and intraosseous
hypertension results.
145
014
grade infection or have been revised because of previous

examiner stopped me and asked me to carry on with the
examination.’ infection and had complications postoperatively such as a
dislocation or periprosthetic fracture. The best way to deal
Examination with this type of case is to go back to basics and keep things
‘I told the examiners that I would like to see her walking simple. Think in terms of how you would normally
and they agreed with me. The patient took a few steps approach this type of case if you had seen it in the outpa-
but it was very painful so I mentioned to the examiners tient clinic.
that she had an antalgic gait. The examiners agreed with
this. I continued on to Trendelenburg’s test. The
examiners helped me with this because the lady needed
Historyff
a lot of support as she was in a lot of pain. I carried on to History of the original index THA:
inspection and LLD. The examiners cut me short here and Where was the operation performed, who performed the
advised me that there was no LLD and to proceed with surgerygg and how long was follow up for?
the deformities. I proceeded to examine for a flexion
How long has the hip been painful?
deformity. The examiners also helped me out with the
Thomas’ test. I then began to look for an abduction and
Was the hip always painful after surgery (low grade
adduction deformity but they said not to bother and infection) or was there a pain-free interval (aseptic
asked me to demonstrate hip rotations. I mentioned that loosening, late onset infection)?
i would also want to check and examine the knee and Is the pain getting worse?
spine for any evidence of disease. The examiners asked There is an increased risk of deep prosthetic infection as a
me to ignore this.’ result of delayed wound healing or large haematoma forma-
tion. Therefore, specific inquiry should be made about wound
Discussion
drainage, persistent fever, prolonged antibiotic administration
‘We then proceeded on to the discussion section. They
asked me what the diagnosis was. I told them it could be
or delayed hospital discharge. Has the patient had a recent
AVN of the femoral head with secondary osteoarthritis urine or chest infection? Reduction in walking distance and/or
and they asked me why I said this. I told them she has a are walking aids now necessary. Pain at night or at rest sug-
past medical history of systemic lupus erythematosus gests infection (or tumour).
and she has been on steroids. They agreed with this and Mention that you would obtain old records to check for
asked me how AVN of the femoral head develops in surgical approach, implants used and postoperative review
steroid therapy.’ records.
‘I explained that steroids cause abnormally elevated
lipid levels which lead to microemboli and endothelial
cell changes resulting in venous stasis, increased
Examination
intraosseous pressure and bone necrosisee. I also told ‘On examination this elderly male gentleman has difficulty
them that she has systemic lupus erythematosus so standing upright unaided. There is an old well-healed left lateral
there was a possibility that she has minor coagulation hip scar. The surrounding skin and soft tissues appear normal.
defects in addition to the steroid intake. They were There is no evidence of a discharging sinus in the wound. There
happy with that.’ is marked left thigh and gluteal muscle wastage.’
‘They asked me about additional sites that can be ‘Examining of gait revealed that it was antalgic with a marked
affected with AVN and I mentioned femoral condyles, tibial Trendelenburg’s positive test on the left side but negative on
plateau, talus and humeral head.’ the right side. Formal measurement of leg lengths with a
measuring tape revealed 0.5 cm true shortening in the left
leg. Thomas’ test failed to reveal any fixed flexion deformity of
the left hip. Examination of the left hip movement
The infected THA demonstrated a global decreased range of movement, which
Introduction was painful but not stiff.’
This topic is generally not well-suited for use as a short

case. As an intermediate case you will not get a acutely Investigations
infected hip draining pus in the examination hall. More Radiographs
likely the hip will be painful due to either a chronic low- Suggest AP and lateral radiographs and look for radio-
graphic features suggestive of infection such as endosteal
scalloping, multilamellar periosteal new bone formation in
ee
Mechanism of action (MOA) probably from altered fat
metabolism. Steroids cause osteoblastic stem cells to become fat
ff
cells (apidogenesis). Existing marrow fat cells undergo hyperplasia History is quite similar to the painful hip requiring revision but
and hypertrophy. Capillary occlusion and intraosseous don’t forget to focus more heavily on the infection questions.
gg
hypertension results. Perhaps relevant in real life much less so for the exam.
014
the femur and rapidly progressing llosening or osteolysis. It studies reported that there was no difference in re-infection
would be wise to compare with old radiographs. rates between the two procedures. They concluded that ran-
domised trials were needed to establish optimum management
Bloods strategies.
FBC, ESR, CRP and IL-6 Most surgeons prefer a two-stage revision as it gives the
surgeon the opportunity for repeat debridement and exchange
Bone scan of PROSTALAC® spacer if the infection is still present. The
In practical terms, a bone scan isn’t particularly helpful in results from most single-stage revisions have been from spe-
differentiating between aseptic and septic loosening. The value cialized hip centres dealing with a lot of periprosthetic infec-
of bone scan is limited in the early postoperative years. tions, which may not be applicable to an average hip surgeons
A radioactive-labelled WBC scan (leucocyte scan) is more practice.
sensitive and specific but its value is still somewhat limited. Know the principles and operative technique for a two-
stage revision21. Several recent studies have called into ques-
Aspiration hip tion the use of laminar flow theatres and body exhaust suits in
In theatre, sterile conditions, blood culture bottles ± arthro- reducing the incidence of periprosthetic joint infection (PJI)22.
gram. It is important not to pick up skin flora during the Hooper et al. reviewed 10-year results of the New Zealand
aspiration. Any antibiotics must be stopped 2 weeks or so Joint Registry and found no benefit with using laminar flow
beforehand as they may affect the results of the aspirate giving theatres on the rate of revision for early deep infection in total
negative values in the presence of ongoing infection. joint replacement 23.
Several new strategies for the prevention of PJI have
emerged including the beneficial affects of UV light ,pros-
Management thetic antibiotic and antibiofilm coatings and biofilm
The FRCS Orth exam is much more than just presenting facts eradication24.
to the examiners. Just as important are the linking of words
and sentences, which connect these facts.
‘My management would be directed towards trying to identify The painful THA
a cause for this painful hip. There are numerous possibilities;
the most common causes would be infection, aseptic loosening
History
or referred pain from elsewhere. Other causes could include The hip is painful
impingement, instability or fracture. Features suggestive of The patients walking distance has become less and/or
infection would include . . . It is potentially a very difficult walking aids are necessary
problem to treat especially if deep infection is present in the The hip is stiff or does not move at all
medullary canal. There are several ways to treat deep
Duration: how long has the hip been painful
prosthetic infection, which may include . . . I would perform a
two-stage procedure, as that’s what I can do safely in my Progression: is the pain getting worse
hands.’ Site of pain. Pain localized to the trochanter region suggests
bursitis, irritation secondary to underlying wires or
sutures, osteolysis or fracture. Pain felt in the buttock or
Discussion groin suggests vascular or neurogenic claudication,
A large topic with plenty to discuss. Keep the discussion acetabular loosening or osteolysis. Less frequently it may
simple, straightforward and non-controversial and avoid get- indicate iliopsoas impingement or tendinitus secondary to
ting yourself into a corner. Examiners can sometimes focus in acetabular cup retroversion, hernia or gynaecological
on fairly minor details. Five minutes discussing the sensitivity/ cause. Thigh pain may be secondary to a loose femoral
specificity of ESR/CRP measurements in the diagnosis of implant or modulus mismatch between the stem and bone
infection can become very uncomfortable. Most candidates Pain felt at rest or during the night raises the possibility of
would dry up within a couple of minutes. infection or malignancy
For an intermediate case discussion you may spend some Any problems with the wound postoperatively. A history of
time discussing various treatment option that may include: persistent wound drainage, haematoma, prolonged course
Antibiotic suppression therapy of antibiotics following the operation or return to theatre
One-stage revision for wound washout should increase the index of suspicion
Two-stage revision for infection as a cause of the pain
Girdlestone excision arthroplasty Any recent bacterial infection or possible bacteremia: urine
Evidence of the effectiveness of one- and two-stage surgical or chest infection, dental procedure, etc
revision is mainly based on interpretation of longitudinal Has pain been present since the original index operation:
studies. Beswick et al.20 in systematic review of published subclinical infection
147
014
Pain-free interval following the initial successful THA: neuroma or an area of osteolysis. Tenderness over the
aseptic loosening, late-onset infection pubic rami may suggest a stress fracture. Pain at the
Is the pain new or similar to preoperative symptoms. Pain extremes of hip motion suggests aseptic loosening. Extreme
similar to the preoperative symptoms suggests the original pain with any hip range of motion suggests active synovitis
problem may not have been addressed with the THA and and raises the concern of infection. Pain over the greater
alternative diagnoses should be considered trochanter is suggestive of bursitis or trochanteric pain
With aseptic loosening a triphasic pattern is classic. Pain is syndrome. Medial pain over the lesser trochanter could
sharp with the first few steps of ambulation, is reduced be secondary to ilio psoas impingement
after the patient has walked a moderate distance and then Pelvic obliquity and leg length discrepancy must be
gradually increases after the patient has walked a still determined
greater distance Straight leg raising causing groin pain raises the possibility
Pain that is constant suggests inflammation caused by of psoas impingement
infection whilst activity mechanical pain suggests implant Check both lower limbs for neurovascular status.
loosening or impingement Peripheral vascular disease may occasionally present as
discomfort in the hip or thigh area. The spine must be
The possible causes for pain are divided into extrinsic or intrin- evaluated for areas of tenderness or deformity and range of
sic aetiologies. Additionally, whether the source of pain is eman- movement
ating from the soft tissues, bone, implant or a combination.
Extrinsic Investigations
This can be further subdivided into local extrinsic-relating to Radiographs
the hip region (but not the implant) and remote extrinsic – Obtain up to date good-quality AP pelvis and true lateral
unrelated to the hip area but the source of the pathological radiographs of the relevant hip and if possible compare these
condition may cause pain to radiate to the hip region. to previous radiographs as this may document migration of
either the acetabular of femoral component, which is pathog-
Remote extrinsic
nomonic for loosening.
Referred pain from elsewhere. A history of back pain with Look for radiographic signs of aseptic looseninghh. Look
radicular symptoms radiating down the lower extremity again for any radiographic features suggestive of infectionii.
well past the knee into the foot more likely relates to spinal
pathology. Spinal stenosis, facet arthropathy and Bloods
radiculopathy can all cause pain in and around the hip ‘I would then want to perform some routine bloods – ESR/CRP,
and thigh FBC and WCCjj.’
Local extrinsic Bone scan

Trochanteric bursitis, abductor tear, suture irritation, Reasonable option to suggest but be careful to follow through
broken trochanteric wires, herniation of the vastus lateralis and mention that a bone scan may not always be particularly
and HO helpful in differentiating between aseptic and septic loosen-
ingkk. Consider a leucocyte scan or radioactive-labelled white
Intrinsic cell scan if infection is suspected.
Aseptic loosening: one or both components
Infection is present: subclinical, acute, delayed, etc
Soft tissue or bony impingement hh
If you want to spin out the discussion talk about the Harris
Modulus mismatch classification of loosening (definite, probable or possible), but do
not make it too obvious as it will irritate the examiners.
ii
A general comment to the examiners that radiographs are not
Examination particularly helpful in diagnosing infection but features suggestive
of infection would include periostitis, osteopenia, endosteal
Look at the hip wound, skin and soft tissues noting any reaction and rapidly progressing loosening or osteolysis but in this
inflammation, healed sinus tracks, ulcers, scars or particular case none of these features are present.
discolouration. Note if there is marked thigh atrophy from jj
It is not unreasonable to explain why you are performing these tests
disuse and what you are looking for. Be prepared to discuss sensitivity,
Gait: Is there any asymmetry or abnormality of gait? Is specificity, etc. Throw a couple of recent references in if you can but
there an antalgic, LLD or abductor deficiency pattern? be sensible – It may not be particularly appropriate do so.
kk
Easy for the examiners to back you into a corner with this one,
Is the patient Trendelenburg test positive? especially if you don’t get your phrasing just right. Again, be
Palpation: Are there any hernias or defects in the deep prepared to talk about sensitivities, specificities, etc. ‘What is the
fascia? Is there tenderness on palpation? This may suggest a sensitivity of a test? What is specificity? What do we mean by
014
Hip arthrography and aspiration Table 11.1 Differential diagnosis of pain following THA
In theatre, sterile conditions, ensure skin flora is not picked Intrinsic causes Remote extrinsic causes
up – Blood culture bottles ± hip arthrogramll. Arthrography of
Aseptic loosening Lumbar spine disease: Stenosis,
the hip can demonstrate pocketing of the radiopaque medium spondylolysis/spondylolisthesis
in the area of the pseudocapsule, which suggests infection. herniated nucleus pulposus (HNP)
Unfortunately this finding is uncommon. Culture and cell
count obtained. Infection Pelvic disease (PVD)
Wear debris synovitis Stress/insufficiency fracture
Differential diagnosis Instability Metabolic disease
Divided into intrinsic and extrinsic causes (Table 11.1). An Component Complex regional pain
extrinsic aetiology is defined as pain emanating from outside impingement syndrome (CRPS)
the hip joint. It is further sub-classified into local extrinsic –
Tip of stem pain Metabolic (Paget’s, osteomalacia)
relating to the hip region (but not the implants) – and remote (modulus mismatch)
extrinsic – unrelated to the hip area, but the source of the
pathological condition may cause pain to radiate to the hip. An Stess/periprosthetic Malignancy, metastases
intrinsic aetiology is defined as emanating from the hip joint fracture
itself. Local extrinsic causes
Heterotopic ossification
Remote extrinsic causes
Spinal stenosis and nerve root irritation can cause pain in Trochanteric bursistis
the buttock, thigh and sometimes the groin. Vascular disease Iliopsoas tendinitis
commonly causes buttock or thigh pain. Metabolic disorders
such as Paget disease can occasionally cause symptoms on its
own that may persist after THA. Choice of implant
Complications of revision surgery
Local extrinsic causes
The psoas tendon may become irritated by a prominent anterior
flange of an insufficiently anteverted acetabular component.
Metal on metal (MoM) hips
This is very much intermediate case material. There are
Intrinsic causes enough patients around with painful MoM hips (either resur-
Instability can result in pain from capsular stretch and from facing or total) to bring in for the exam. It is a good quality
soft-tissue impingement. case with plenty to discussmm.
Nothing wrong with the hip History

Salient feature was that the pain was never relieved by the Similar to the painful THA
THA. Examination may show features suggestive of a problem Be slick in your history extraction
with the THA, such as a limp and some limitation of motion, Time interval since primary surgery
but nevertheless none of these signs are likely to be gross. Initial diagnosis
Review of case notes and plain radiographs of the original
Make of MoM hip/resurfacing and head size (<46mm
hip may reveal that the hip before replacement was minimally,
higher failure rate)
if at all arthritic, so that with the retrospectoscope it is clear
Pre-operative level of activity and expectations from surgery
that the original symptoms did not come from the hip.
Management Examination
Obviously dependent on the cause. The examiners can now Scar
choose a number of paths to go down: Anatalgic gait
Preoperative planning for revision hip surgery Trendelenburg positive test
Surgical approaches used Restricted painful ROM
accuracy? What are the typical values quoted in the literature for
mm
the various scans, etc.?’ It doesn’t suit the ‘shorts cases’ that well unless there are strong
ll
All cases or just selectively – Have an opinion – You will have to positive clinical findings or there is a shortage of patients for the
decide yourself in 2 years or so if you become a consultant. shorts.
149
014
Discussion CANDIDATE: I would assess for cup abduction and anteversion

All symptomatic patients should have either a metal artifact
angles, radiolucencies about the metaphyseal stem, narrowing of
reduction sequence (MARS) MRI performed. MRI is able to
the neck (compare with postoperative radiographs) and
diagnose periprosthetic collections, abductor muscle detach-
radiolucent zones suggestive of osteolysis. (Figure 11.17)
ment, pseudotumours and the extent of osteolysis.
COMMENT: Attempt to mention to the examiners (subtly or
The Medicines and Healthcare products Regulatory
otherwise) three angles: The neck shaft angle (NSA), the stem-
Agency (MHRA) recommend measurement of whole blood
neck angle (SNA) and the stem-shaft angle (SSA). (Figure 11.18)
cobalt–chromium–metal ion levels. If levels on the initial
A higher NSA of the femur reduces the risk of fractured femoral
blood test are >7 parts per billion then blood tests should
neck. Look for evidence of repetitive impingement demonstrated
be repeated at 3 months. This equates to 199 nmol/l cobalt
by radiographic signs of repetitive bone-to-component
or 134.5 nmol/l chromium. If levels are rising on a second
abutments such as a depression in the neck or a contour just
sample and the hip is painful then revision is
below the junction with the component (divot sign) often
recommended. There has been some indecision and con-
associated with a reactive exostosis.
troversy on the setting of normal threshold values.
EXAMINER: What was the mode of failure of the ASR®?
Remember to mention non-hip-related causes of pain such
CANDIDATE: The mode of failure was closely linked to design
as low back pain (LBP), PVD etc.
features. The implant has a subhemispherical acetabular
Indications for revision surgery following MoM resur-
facing include fracture, loosening/lysis, pseudotumour, component and a lower diametrical clearance between
metal hypersensitivity, pain, avascular necrosis, infection and components. The low clearance caused lubricant fluid lockout
instability. greatly increasing metal wear and the subhemispherical design
increased the risk of edge loading of the acetabular component,
especially in mal-positioned, small components. There was a
reduced arc of cover compared to other MoM implants.
Examination corner
Therefore, in components matched for size and inclination,
Intermediate case 1: Painful MoM hip resurfacing implant articular contact takes place closer to the rim of an ASR®
History component, resulting in edge loading, which is strongly
When was the index procedure performed?
Were there any postoperative complications such as
wound infection or washout or need for antibiotics?
What is the pain like: Is it sharp, dull or like a knife?
How far can you walk?
Is there sleep disturbance at night?
Is the pain the same as it was before the index surgery?
Do you have low back pain?
What makes the pain better?
What brings on the pain?
Examination
Demonstration of gait
Trendelenburg test
Discussion
EXAMINER: How do you investigate a painful MoM hip

resurfacing?
CANDIDATE: I would take a full history and perform a detailed
clinical examination. As per MHRA guidelines I would order a
MARS MRI scan of the hip and blood cobalt–chromium level
measurements
EXAMINER: What are the causes of pain in an MoM hip resurfacing?
CANDIDATE: Excluding extrinsic referred causes of pain such
referred pain from the spine intrinsic causes include fracture,
osteolysis, AVN, loosening, adverse reactions to metal debris
(ARMD), hip impingement, iliopsoas tendinopathy and
pseudotumours.
Figure 11.17 AP radiograph hip demonstrating zones 1, 2 and 3
EXAMINER: These are the radiographs. What do you see? around the peg of a hip resurfacing arthroplasty implant as described by
Amstutz et al.25
014
Figure 11.18 AP radiograph hip demonstrating MoM hip angles. Neck shaft
angle (NSA), Stem neck angle (SNA) and stem shaft angle (SSA)
Figure 11.19 AP radiograph of bilateral severe protrusio hip
associated with articular wear. In simple terms the design of the

positive bilaterally. Thomas’ test revealed a fixed flexion deformity
cup was too shallow. The ASR® implant had higher-than-
on the right of 20° and 10° on the left.’
expected revision rates in the UK NJR and Australian registry. The
revision rate at 5 years in the NJR was 12% for ASR® resurfacing Square up the pelvis with the bed and make sure the legs
and 13% for stemmed ASR® components. This compares with a are parallel with the pelvis. Measurement of leg length revealed
5% cumulative revision rate at 8 years for the Birmingham hip true right leg shortening of 2 cm. Galeazzi’s sign suggested the
from the Australian registry. This has led to its withdrawal. shortening was in the femur. Digital Bryant’s triangle palpa-
EXAMINER: Is a resurfaced MoM hip a better functioning hip than a tion suggested that the shortening was above the trochanter.
conventional hip? There was a reduced distance between the thumb and tip of the
CANDIDATE: Current data suggests that there is very little clinical
index finger on the right side compared to the leftnn.
difference in outcome between resurfacing hip arthroplasty and
Right hip movements were grossly restricted and painful in
conventional THA. However NJR data does suggest resurfacing
particular abduction. Active flexion was limited to 60° with
hip arthroplasty may perform slightly better in males aged below
only 70° obtained passively. There was no internal or external
55 years.
rotation in flexion. Passive abduction was markedly limited to
only 10° whilst adduction was greater at 20°.
On the left side movements were again restricted and
painful but to a lesser degree. Active flexion was only possible
to 90°. No internal or external rotation in flexion was possible.
Protrusio acetabuli (Figure 11.19) Passive abduction was again markedly limited to 10° with
adduction restricted to 20°.
History All hip movements become progressively painful and
‘Middle-age female patient with progressively worsening bilateral limited, especially abduction as the trochanter starts impinging
hip pain. Pain worse on the right side. Pain dull in nature worse
on the superior acetabular margin. Often a better arc of flexion
with activity.’
is preserved. The hip may even become ankylosed in severe
‘Typical complaints are of increased stiffness and lack of hip
flexibility rather than pain (anatomical abnormality-deepened cases with PR revealing a globular mass on the lateral rectal wall.
socket).’
‘As secondary OA develops pain and limp become more Discussion
pronounced.’
Aetiology of the condition: Idiopathic or secondary
Enquire about any family history of hip disease. (rheumatoid, Paget’s, osteomalacia, osteoporosis, AS,
Symptoms due to causative disease – Rheumatoid, osteo- trauma, Marfan’s, etc)
malacia, Paget’s, etc.
Clinical examination nn
Talk to the examiners during your clinical case. Do not examine in
‘There is increased lumbar lordosis due to the flexion deformity at silence. In this case the candidate is indirectly letting the examiners
the hips. Gait was analgic. Trendelenburg’s test was strongly know that he understands Bryant’s triangle.
151
014
Radiological classification – Hirst: The ilioischial line is Tuberculosis hip

often used to measure the amount of protrusion. The
A case of old tuberculosis of the hip enrolled for the
ilioischial (Kohler’s line) line represents the
examination.
quadrilateral plate of the acetabulum that projects over
the medial acetabular wall due to the tangency of the
x-ray beam Memorandum
Preoperative planning including investigations, implant ‘On examination we have an elderly man of average height and
choice and bone grafts build. There are several well-healed scars over lateral aspect of the
left hip There is a discharging sinus present in the groin/greater
If bilateral leave the index leg longer with a plan to equalize trochanter There are puckered scars suggestive of healed sinuses.
leg lengths at the second procedure. Discuss LLD The left leg is shortened with gross generalized wasting particularly
preoperatively with patient to avoid dissatisfaction. Avoid of the thigh and buttock. There is a pelvic obliquity with the ASIS
offset and significant LLD issues. CT scan evaluates defects lower on the left side and a compensatory scoliosis which does not
in the posterior and medial wall prior to surgery. Preferred fully correct when sitting down on the couch suggestive of a fixed
option is to restore hip center of rotation using an element to the scoliosis.’
uncemented cup with or without bone graft. Template to ‘Inspection of gait revealed a short leg gait. There was also a
determine size and location cup and femoral offset. Avoid suggestion of lack of movement of the left hip with the trunk being
thrown forwards to aid walking.’
excessive femoral lateralisation as this may cause excessive
‘There is a gross left leg length shortening. The left leg has a
tension on the iliotibial band/abductors, resulting in an
flexed attitude and in order to measure leg lengths correctly both
abduction contraction and a significant functional leg limbs need to be placed in equivalent positions; therefore, using a
lengthening pillow to fix the right leg in the same position of flexion as the left.
Principles of THA reconstruction There is a combination of real and apparent shortening of the left
Restoration of the hip center of rotation to optimize ROM leg. Galeazzi’s test demonstrated that most of the shortening is in
the femur, but there is, however, a suggestion of a small amount of
Maximize efficiency of hip musculature
tibial shortening. Bryant’s triangle suggests most of the femoral
Minimize adverse loading conditions across the shortening is above the trochanter. There is a definite decreased
articulation difference between my thumb over the ASIS and fingers over the
Surgical technique trochanter on the left side compared to the right. The hip is flexed,
Femoral neck may need to be osteotomised in situ before adducted and medially rotated. All movements are grossly
dislocation. Mobilization of the femur may be difficult due restricted by pain and spasm.’
to inward migration femoral head and stiffness. Do not Muscle spasm in the early stages can be elicited by rotating the
forcefully attempt to dislocate hip or else a fracture of the extended hip when the muscles around the joint as well as the
posterior wall acetabulum, fracture proximal femur or abdominal muscles exhibit spasmodic contraction (Gauvain’s
major ligamentous injury knee can occur. The acetabulum signoo) If no hip movement occurs at all consider bony anky-
does not need to be deepened, but a bleeding cancellous loses. Usually a combination of real and apparent shortening
bony bed for graft placement is preferred to encourage exists. In the initial stages of the disease there is slight flexion,
healing of the graft to host bone. Sciatic nerve is often abduction and lateral rotation. Earliest clinical sign is a limp,
nearer the operative field due to medial migration of the which comes on after walking. Flexion is concealed by an
femur associated with the deformity. A femoral stem with exaggerated lumbar lordosis. Adduction is corrected by tilting
increased offset may be required to reduce likelihood of pelvis upwards which results in a scoliosis of the lumbar spine
bony or component impingement but avoid excessive with convexity towards normal side. If the hip has been fused
offset (see above) the patient may develop back or hip pain several years later.
Results of THA In a young patient if there is mal-position of the fusion
consider corrective osteotomy rather than arthroplasty. If a
Baghdadi et al.26 in a restrospective review of
painful pseudoarthrosis exists consider fusion rather than
162 hips with protrusio reported 89% survival rate for
arthroplasty.
uncemented cups at 15 years compared to 85% for
cemented cups. There was a 24% increase in the risk
of aseptic cup revision for every 1 mm medial or
lateral distance away from the native hip centre to oo
Described by Sir Henry Gauvain in 1910. This test is of value in
the prosthetic head centre. Lateralized hips were early doubtful cases of tuberculosis of the hip. In active
equally at risk of failure, so bone graft when not tuberculosis of the hip, on initiating rotatory movements the
needed should be avoided muscles around the hip and lower abdomen go into spasm. The
lower end of the thigh is rotated internally and externally. The
Complications of THA
movement is then checked and any further slight sharp rotation is
Loosening, medial migration of the acetabular component, followed by spasmodic contraction of the joint muscles as well as
dislocation, infection and LLD those of the lower abdomen.
014
Radiographs and scoliosis of the lumbar spine with convexity towards the
affected side.
The earliest sign is a general haziness of the bones as seen in a
As the pelvis tilts downwards to compensate for the abduc-
bad film but with a normal joint space and line with or
tion deformity, the affected limb looks longer (apparent
without an area of rarefaction in Babcock’s triangle (inferior
lengthening) than the normal opposite hip, though on meas-
aspect of the femoral neck). Increased joint space due to an
uring true limb lengths the two limbs are found to be equal.
effusion.
This stage lasts only short length of time and it is rare to see a
Later on there is gross enlargement of the acetabulum roof
patient in such an early stage of the disease.
with the femoral head migrating into the dorso-ilium (travel-
ling or wandering acetabulum). The combination of partially
destroyed femoral head, destroyed acetabulum and muscle Stage 2. Arthritis: The stage of apparent shortening
spasm can lead to a posterior dislocation of the hip. In some The effusion subsides There is involvement of the articular
situations the femoral head is destroyed and becomes small cartilage. This leads to spasm of the powerful muscles around
and contained in an enlarge acetabulum giving rise to a mortar the hip to protect its movement. Since the flexors and adduct-
and pestle appearance. Softening and destruction of the medial ors are stronger muscle groups than the extensors and abduct-
wall of the acetabulum can lead to protrusio. With healing ors the attitude of the hip is one of flexion, adduction and
bony ankylosis may occur. internal rotation. The flexion and adduction may be con-
cealed by the compensatory tilt of the pelvis but the internal
rotation of the leg is obvious.
Clinical features Adduction is corrected by tilting the pelvis upwards
Presenting complaint: Disease insidious in onset and runs a resulting in scoliosis of the lumbar spine with convexity
chronic course. One of the first symptoms is stiffness of the towards the sound side.
hip. A child may be pale, apathetic with loss of appetite As the pelvis tilts upwards to compensate for the adduction
before definite symptoms pertaining to the hip appear. Pain the affected limb appears shorter (apparent shortening) than
may initially be absent or be referred to the knee. Pain occurs the normal opposite hip, although on comparing the limb
around the hip particularly with weight-bearing lengths in similar positions, true shortening is usually absent
Gait: Stiff hip gait. While walking the hip is kept stiff and or not >1 cm.
forward – Backward at the lumbar spine is used for
propulsion of the lower limb. Because of the flexion
Stage 3. Erosion: The stage of real shortening
deformity of the hip the patient stands with a compensatory
exaggerated lumbar lordosis Later on an anatalgic gait may In this stage, the cartilage is destroyed and there is erosion of
develop to quickly take the weight off the affected side the upper part of the acetabulum and the femoral head
becomes dislocated by the by the spasm of the adductors.
Muscle wasting: The thigh and gluteal muscles are wasted
(Wandering acetabulum or pathological dislocation.) The atti-
Swelling: There may be swelling around the hip because of a
tude is similar to that seen in stage 2 but exaggerated. There is
cold abscess
true shortening of the limb because of the actual destruction of
Discharging sinus: There may be discharging sinuses in the
bone. In addition, the apparent length of the limb is further
groin or around the greater trochanter. More likely there
reduced because of the adduction deformity.
may be puckered scars from healed sinuses
Shortening: There is a true shortening of the hip in
tuberculosis except in stage 1. There may be a combination Management
of true and apparent shortening of the limb. Be able to Total hip arthroplasty
measure true and apparent lengths of a limb and be quite
Consider:
clear on the difference between the two
Possibility of reactivation of infection following THA
Stage 1. Synovitis: The stage of apparent lengthening Shortening of the limb
Initially the clinical features are common to all diseases produ- Deformed greater trochanter
cing synovitis. There is a joint effusion, which demands the hip Distorted anatomy placing sciatic nerve and femoral artery
to be in a position of maximum capacity and comfort. This is at risk of injury
obtained by a position of flexion, abduction and external Acetabular defect
rotation of the hip. Antituberculosis treatment 3 months pre-surgery and 9–12
Since the flexion and abduction deformities are only months post surgery
slight and are compensated for by tilting of the pelvis, Disease-free interval 10 years recommended
these do not become obvious. Flexion is concealed by a Preop confirmation with biopsy/aspiration. Rule out other
lumbar lordosis and by tilting of the pelvis forwards. focci of TB such as chest
Abduction is corrected by tilting the pelvis downwards Both uncemented and cemented THA can be used
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014
Excision arthroplasty ‘There was a recent paper from India27 published in the
This is an option for a patient who will not accept stiff joint. Journal of Bone and Joint Surgery, which suggested that
Culturally will allow them to sit cross-legged and also squat. It THA/TKA in the presence of active tuberculosis hip/knee is a
provides a mobile and painless hip joint but produces shortening safe procedure when preoperative chemotherapy is
and instability leading to tiredness and a need for a walking aid. commenced and continued for an extended period after
operation. I would, however, have severe reservations in
Arthrodesis adopting this policy for UK patients. I would adhere to
standard UK protocols and guidelines if arthroplasty is
This is a possible option in a young patient with a deformed
indicated.’
painful hip. The rate of pseudoarthrosis is high (up to 70%)
because of poor bone stock. It produces a painless, stable and
Short case 1: Tuberculosis hip
immobile joint with a slow asymmetrical and arrhythmic gait.
‘I got a case of tuberculosis of the hip in a 12-year-old
boy with a painful limp. The examiners asked me to take
a brief history from the parents, which I started off by
Examination corner
asking about presenting complaints, which were of hip
Intermediate case 1: Tuberculosis left hip as child pain and limping.’
Underwent arthrodesis left hip aged 20 ‘They cut me short and asked me to examine the hip.
Deformity of spine I made the child walk. They asked me what type of gait it
Leg length discrepancy was. I mentioned it was an antalgic gait and then said
Valgus deformity left knee I would like to go on and perform Trendelenburg testing
OA right knee but the examiners said not to bother with this. I proceeded
on to movements and deformities. The child had a 40° FFD,
Intermediate case 2: Arthrodesis left hip with ispsilateral knee OA and further flexion up to 90° was possible. All other
movements, including adduction and abduction as well as
Examination
rotation, were restricted. The examiners asked me for a
Flattening of the buttock and gluteal fold secondary to differential diagnosis. I said that it could be old septic
muscle wasting of glutei and adductors. arthritis or even tuberculosis as there was still some hip
Wasting thigh muscles. movement preserved. The examiners showed me an x-ray
Adduction deformity with pelvic tilt. that showed collapse of the femoral head and asked me
Long discussion about real/apparent shortening. I had to be what differential diagnosis I could think of. I said that it
slick with the tape measure whilst also answering the could be an AVN secondary to an old femoral neck fracture
examiner’s questions. Shortening was a mixture of true and or Perthes’ disease. The examiners were happy with that.
apparent shortening owing to the adduction deformity. Before they could go on to the management, the bell rang
Stiff hip with no movement. and the 5 minutes were up.’
Thomas’ test.
Knee had a semiflexed deformity with posterior
subluxation. It was stiff to move.
Knee effusion with synovitis. Asked to test for knee Young patient with rheumatoid hip disease
effusionpp. This is classic intermediate case material with a lot to talk
I had to be slick with the tape measure with the FFD when about and discuss with the examiners. In juvenile RA the
measuring true and apparent leg lengths. problems relates to the onset of the disease. The younger the
Discussion onset the more severe the growth retardation and deformity.
‘TKA alone in a patient with an arthrodesed hip is unlikely These patients are often severely affected with multiple joint
to provide a satisfactory result. Patients with severe knee disease and severe osteoporosis. In the FRCS (Tr & Orth)
disease below a hip arthrodesis require THA followed examination a patient seen, as a intermediate case may be
by TKA.’ under consideration for surgery; therefore, a specific general
‘There is a need for anti-tuberculosis treatment for at physical examination should be undertaken.
least 3 months before surgery and continued for a total of Specific attention should be paid to the following.
18 months. Generally a long period of quiescence is
Anaesthetic concerns:
recommended before TKA. There are concerns with
reactivation of the infection, loosening of the TKA. As a Cervical spine instability. It is important to access stability
minimum, posterior-stabilised (PS) knee should be used.’ cervical spine preoperatively and exclude the presence of a
cervical mylopathyqq. Evaluate for neck pain, neurological
signs and symptoms and radiographic changes
pp
Be careful with this, get it slick. The examiners weren’t happy with
qq
my method. I am not sure why, perhaps not performing the test Intermediate case of rheumatoid disease mainly affecting the
with the confidence that one should have with doing it everyday in shoulder and elbow. A large part of the clinical examination was
clinic. Possibly they were being picky. directed towards examining a cervical myelopathy present.
014
Hypoplasia of the mandible and stiffness of the TMJ may occur. If acetabular protrusio is present avoid penetration of
make intubation difficult the medial wall and be prepared to bone graft if necessary.
Pulmonary involvement Some authors suggest it is preferable to avoid trochanteric
Restriction in movement upper limb so to avoid injury osteotomy since during re-wiring of an osteoporotic
whilst establishing IV access trochanter there is a risk the bone may become fragmented.
Others would suggest trochanteric osteotomy decreases the
Orthopaedic concerns: risk of femoral shaft fracture or perforation from
Medication (steroids, etc) malposition of the femoral reamers. Increased risk of
Biological medications is usually stopped prior to surgery trochanteric displacement (15%) and non-union (10%)28.
Rheumatoid disease distorting hip anatomy When the acetabular floor is extremely thin bone grafting
with multiple morselized segments cut from the excised
Implanting THA in a young patient
femoral head may help to preserve bone stock. If there is a
Steroid use: large medial wall deficiency a single solid bone graft
fashioned from the femoral head may be used for
General debility
reconstruction.
Fragility skin
If the roof of the acetabulum is deficient then it can be
Osteoporosis reconstructed by screwing on segments of the patient’s
Poor musculature femoral head or similar allograft bone to reconstruct the
Increased risk of wound infection roof. Where the acetabular floor has become completely
Wound healing takes longer fragmented or destroyed but the rim of the acetabulum
remains intact use of an acetabular ring may prove useful.
Distorted anatomy:
Hypoplasia of the pelvis and femur Results:
Gross anteversion and valgus angulation of the femoral The survival of the prosthesis is less than that seem in elderly
neck may lead to difficulty controlling alignment of a rheumatoid patients, and just under 50% are loose at 5 years
femoral component and the 10-year survival as measured by revision is
Generalized severe osteoporosis and marked soft-tissue approximately 75%.
contractures
Marked anterior bowing upper femoral shaft
Acetabular dysplasia – Small size but possible protrusio
Recurrent dislocation THA
Coxa magna and/or subluxed femoral head This is more likely to be a viva topic than a clinical case. The
hip may dislocate during examination and this would be a
Premature closure of the growth plate
disaster.
Fibrous ankylosis hip necessitating in-situ osteotomy
of the neck
History and examination
Implanting THA in a young patient: The history should begin with details of the last episode of
Polyarthritic, often underweight, often put less stress on dislocation and any previous episodes of instability. When
their components, wear less than expected was the index hip procedure performed and what was the
original diagnosis? What approach was most likely used (check
Indications: scar) and which components were used (check operation
note)? What was the direction of the dislocation (anterior,
Pain is the major indication for surgery. Loss of function
posterior, other)? What was the prior management of the
and reduced ROM are secondary indications. Mobility may
dislocation?
not be greatly improved post-THR because of limitations
Any patient-specific risk factors for late dislocation, such as
due to disease in other joints and an improvement in
younger age (greater wear), female gender (decline in muscle
mobility may depend on replacement of other joints in the
mass), AVN, preoperative diagnosis of fractured neck of
lower limb.
femur, etc.
Technical concerns when performing THA:
Great care is needed when dislocating the hip to prevent a Clinical examination
femoral shaft fracture or damage to the to ipsilateral knee. This should include a full bilateral lower extremity examin-
Reaming the femur is easy because the femoral canal is ation with particular attention to scar, gait, hip contractures,
usually wide but the cortex is soft and easily penetrated or ROM, strength of muscles (particularly abductors) and neuro-
fractured. The femur is often underdeveloped and a smaller vascular examination. Look for clinical evidence of infection.
implant may be required. Intraoperative pelvic fracture can Limb length discrepancy can be associated with component
155
014
malpositioning because intraoperative instability secondary to

suboptimally positioned components such as a retroverted
socket may have been addressed by lengthening of the femoral
neck to increase soft-tissue tension.
Operative notes should be reviewed to determine surgical
approach, type of soft-tissue repair, specific implants used and
any technical difficulties encountered.
Imaging
AP view of the pelvis, AP view of the hip and a cross-table
lateral view of the hip are required. Check for component
mal-alignment, evidence of wear by eccentric seating of the
femoral head inside the acetabular liner, osteophytes, bone
quality and integrity, femoral offset and leg length, compon-
ent geometry, trochanteric non-union, osteolysis and com-
ponent loosening. Component identification must be carried
out (must confirm).
CT is sometimes necessary to assess component position Figure 11.20 AP pelvis demonstration: Type III failure of the femoral head
more accurately, especially acetabular version. locking mechanism
Classification of dislocation
Early dislocation (weeks or months) suggests problems with 4. Predisposing factors for dislocation Divide these into:
soft-tissue tension, such as muscle weakness and inadequate
Patient-specific risk factors (female sex, AVN, obesity,
capsular healing and scarring, component malposition, infec-
increased age, co-morbidities, femoral neck facture)
tion or patient non-compliance. Late dislocation (beyond 5
years) is usually multi-factorial and can include stretching of Variables under the surgeon’s control (surgical
approach, component position and orientation, femoral
the soft tissues, polyethylene wear, neurological impairment and
head size, restoration of offset, preservation of soft
trochanteric avulsion fractures secondary to wear and osteolysis.
tissue integrity, leg length and prosthetic impingement)
Dislocation occurring between 6 months and 5 years is
classified as intermediate. Surgeon experience (risk of dislocation inversely related
to the case volume of the operating surgeon)
5. Component alignment
Discussion Unrecognised subtle component mal-alignment is
Discussion would start with a review of the radiographs. This common and difficult to detect on plain radiographs.
will lead on to the causes of recurrent dislocation. There may Ascertain the direction of dislocation as a possible clue
be an obvious cause but often the reason is complex and (excessive cup anteversion associated with anterior
multi-factorial. Next would be management of recurrent dislocation, etc). The role of CT is to more accurately assess
dislocation in general and in this particular patient. component positioning, especially cup version
1. Incidence 6. Early vs late dislocation
2. Classification (early, intermediate, late, with discussion of
Early dislocation is often successfully managed non-
aetiology for each category)
operatively. Late dislocation generally requires surgery
3. Mechanism of dislocation
7. Management options
Type 1: Cup malposition (33%)
These include closed reduction with or without bracing,
Type 2: Stem malposition THA component revision, exchange of modular parts,
Type 3: Abductor insufficiency (37%) bipolar hemiarthroplasty, tripolar unconstrained
Type 4: Impingement acetabular component (dual motion), elevated rim liners,
Type 5: Wear and head penetration use of a large femoral head, use of a constrained acetabular
Type 6: Unclear aetiology liner, greater trochanter advancement and soft-tissue
Management specific to the mechanism is identified and augmentation. The choice depends very much on the
consists of component revision (type 1 and 2), insertion of aetiology of the problem. Revision arthroplasty for
constrained liner (types 3 and 6), removal of the source of recurrent dislocation is much more likely to be successful
impingement, and insertion of a larger head (type 4) or when a cause has been identified
liner exchange (type 5) 8. Posterior vs anterolateral approach
014
For patients at high risk for posterior dislocation (elderly, Type I failures can be avoided by using supplemental
mild cognitive impairment, etc), an anterolateral approach screw fixation for the cementless shell before inserting the
may reduce the risk. Woo and Morrey29 demonstrated a constrained acetabular component. Type II failures can be
significantly higher dislocation rate after a posterior minimised when cementing the constrained liner into the
approach 5.8% compared to 2.3% for an anterolateral cementless shell by seating the liner fully into the shell.
approach. The safe acetabular zone concept of Lewinnek Scoring or roughening the polyethylene lightly with a
et al.30 is worth knowing burr enhances the grouting bond of the cement and may
9. How do you perform a posterior approach to the hip? minimize debonding of the cement–polyethylene
Favourite surgical approach for examiners to ask. May lead interface. Type III failures can be minimised by ensuring
on from previous question that range of motion does not lead to component–
component or component–bone impingement
10. Modular component exchange
13. Bipolar arthroplasty
This involves exchanging the acetabular liner and the
femoral head, with the main intention being to ‘upsize’ the This is not a first-line choice as there is potential for medial
femoral head and/or use an elevated liner. This is only or superior migration of the prosthesis with time. In
successful if the patient has well-positioned and well-fixed addition, groin pain is not an infrequent problem
acetabular and femoral components. The acetabular 14. Dual motion (tripolar arthroplasty)
component in place must be sufficiently large to allow an This involves the use of a large bipolar head articulating
adequate thickness of polyethylene to be used with the with a large acetabular shell. The large femoral head and
larger femoral head the potential for motion at two interfaces increases hip
11. Constrained acetabular liner range of movement until impingement occurs and
This is used as a salvage procedure in a difficult subset of accounts for the high rate of success of this prosthesis in
patients which includes the following: Management of addressing recurrent instability
recurrent dislocation secondary to soft-tissue (abductor) 15. Jumbo heads
dysfunction, recurrent dislocation of unknown aetiology, The arc of motion required to dislocate a prosthetic head is
patients with neurological impairment and elderly directly related to the diameter of the head (jump or
patients in whom components are well fixed. It is excusion distance). Reasonably successful early results have
designed to hold the head captive within the acetabular been reported but there is concern about the use of a thin
component by means of a locking mechanism. Forces PE liner and osteolysis32
which would otherwise cause dislocation are transferred 16. Soft tissue reinforcement and advancement of the greater
to the locking mechanism and the liner-shell and shell– trochanter
bone interface. They can be either bipolar (single The main issue is variability in outcome of technically
articulation) or tripolar (double articulation) and demanding surgery, which is likely to fail with component
cemented or uncemented design. A constrained liner can malposition. It is best suited for young high demand
be cemented into a well-fixed cementless acetabular shell. patients
The retained acetabular component should be large
enough to allow an adequate cement mantle around the
constrained liner. It is important to make sure before Multiple epiphyseal displasia
using a constrained liner than components are well This is one of the more common skeletal dysplasias. It is
positioned and that subtle malpositioning is not the characterized by abnormal maturation of the epiphyses,
cause for the dislocation affecting the hips, knees and ankles to a greater extent than
12. What are the problems associated with the use of the shoulders, elbows and wrists.
constrained liners?
The problems are early wear and dislodgment of these History
liners. Cooke et al.31 classified three types of early failure There is deteriorating hip pain interfering with activities of
– Type I failures (of the bone-prosthesis interface) daily living (ADL). Patients are characterized by mild
– Type II failures (of the liner locking mechanism) asymmetric short stature, short limbs relative to their
– Type III failure (of the femoral head locking trunks, short stubby digits, early onset osteoarthritis and a
mechanism) (Figure 11.20) waddling gait
Hip arthritis is bilateral and symmetrical and requires THA
In addition, a fourth failure mechanism – Complete at an early age
dissociation of the pelvis (type IV) has been described Femoral abnormalities include an expanded metaphysis, a
when a constrained liner is used in combination with narrow isthmus and a varus femoral neck–shaft angle. The
a cage acetabulum is dysplastic with deficiency of the dome and
157
014
anterior wall predisposing to various degrees of proximal

femoral displacement
Leg length discrepancy and THA
This is estimated at approximately 15% after primary THA
The femoral stem used has to take into account the
and is the commonest cause of litigation in the USA. It forms a
metaphysis/diaphysis mismatch
possible focal point of discussion for complications arising
Patients are prone to heterotopic ossification from THA. For an intermediate case there are more interesting
causes of leg length discrepancy and perhaps not enough
Radiological features of multiple epiphyseal clinical signs to demonstrate unless it is part of a more com-
dysplasia (MED) plex case A stand-alone short case is possible, but patients are
generally not happy with leg length discrepancy after THA and
This is an AP radiograph of the pelvic and both proximal
so are unlikely to volunteer for the exam unless awaiting
femora. Both metaphysis are expanded, the isthmus is
revision surgeryss.
narrowed and there is a varus femoral neck shaft angle. Both
acetabuli are dysplastic
History
Preoperative planning Take a complete surgical and medical history
This is mandatory to predict the implant size, position and A history of previous fracture, infection, physeal arrest
orientation and alignment; to restore the centre of rotation of and various dysplasias may result in leg length
the arthroplasty; to equalize limb length; and to anticipate discrepancy
complications. Get a CT scan to look for femoral head and Abnormalities of the axial skeleton such as previous
acetabular version spinal fusion, scoliosis, neuromuscular disorders or
soft-tissue contractures of the hip or knee may
S-ROM® uncemented femoral stem contribute to the subjective impression of leg length
There are challenges performing THA in patients with MED. discrepancy and account for differences in true and
The S-ROM® Modular Hip System femoral stem is a good apparent shortening
option as it will address the atypical femoral geometry seen in
this type of patientrr.
It is a proximally loading modular stem designed for max- Examination
imal proximal fit without distal ingrowth in order to promote ‘On examination standing there is a pelvic obliquity present
proximal stability and ingrowth. with the ASIS not level which is suggestive of a leg length
It is a good option for a complex primary hip replacement discrepancy. An equinus position of the left foot levels the ASIS
and although it can be used in a revision setting, this is and squares the pelvis. The two dimples overlying the PSIS
generally avoided. If there is poor proximal bone stock directly above the buttocks are not lying horizontal, which again
is consistent with pelvic obliquity. The iliac crest is
ingrowth is less likely to occur which may result in subsidence
subcutaneous and easily felt; normally they are level in
and loosening of the stem. relationship to each other but if not this is usually due to pelvic
Rotational stability is achieved by using flutes. Coronal obliquity. The posterior edge of the greater trochanter is easily
slots reduce bending stiffness and the risk of femoral felt and is usually level.’
fracture on insertion. The design feature significantly reduces ‘I would like to correct the leg length discrepancy with wooden
thigh pain. blocks.’
The modularity between the S-ROM® stem and the True leg length is determined by measuring the leg from the
sleeve allows optimal engagement, both at the diaphysis ASIS to the tip of the medial malleolus. These landmarks may
and at the metaphysis of the femur, which are mismatched be difficult to feel in obese individuals. The apparent leg length
in patients with MED. One possible disadvantage of using is determined by adding the effects of pelvic obliquity and soft-
an S-ROM® implant in patients with a small stature is the tissue contractures.
relative length, which may cause anterior impaction due to A compensatory flexible mobile scoliosis may develop with
proximal femoral bowing. Thus, preoperative templating on a true leg length discrepancy. The scoliosis deformity will fully
both the anteroposterior and lateral radiographs is necessary correct when a block is placed under the shorter extremity or
to identify the appropriate entry point for the femoral when the patient sits down on an examination couch. A rigid
component. coronal deformity remains unchanged.
Other possible skeletal dysplasias include spondyloepipy-
seal dysplasia and pseudoachondroplasia.
ss
Ten or so candidates telling the examiners the hip was put in short/
rr
The examiners may quiz you about the specifics of this implant if long in front of a patient is not conducive to low medical
you are a score 8 candidate. defence fees.
014
When measuring leg lengths look as though you have used

hip in childhood but wasn’t sure of any further details, and he
a tape measure before and not as though in the exam it is for explained that this is why the leg was short. There were no
the first time. Make sure the tape measure is easy to carry issues whatsoever with the left resurfaced hip, it was pain free
about, neat if the foldaway variety and make sure it is long and functioning well. Because of the significant LLD the left hip
enoughtt. resurfacing procedure would have been relatively contra-indi-
EXAMINER: What is happening with a partial correction of the cated. I mentioned that perhaps there was a worry with dis-
location risk and that’s why it had been performed.
scoliosis curve?
CANDIDATE: This suggests the scoliosis is a mixture of both a fixed and Examination
flexible deformity. Huge shoe raise on the right side
Scars
AP radiographs: A line is drawn at the most inferior Measurement of true and apparent leg length discrepancy.
portions of the ischia, providing the pelvic reference line. The shortening was in the femur
A perpendicular line is drawn bilaterally from the transischial Galeazzi’s test. Knees at different levels. The femora were
line to the superior aspect of the lesser trochanter to determine parallel so the discrepancy was in the femur (not below
the knee)
length difference.
Bryant’s triangular test. There was a difference in the
Accurate preoperative planning and templating of radio- perpendicular distance between ASIS and the greater
graphs is critical to the proper selection and positioning of trochanter (GT). This suggested the discrepancy was
components. This should reduce the possibility of a leg length proximal to the GT on the right side
discrepancy following THA. Discussed Nelaton’s and Schoemaker’s lines very briefly. ‘The
Intraoperatively, there should be a reproducible method for examiners just wanted the name rather than anything else’
determining limb length. Palpation of the heels and patella is a
Discussion
relatively crude method. Other methods include measuring the ‘I was shown an AP radiograph. The cup on the right side
distance between fixed pins into the ilium and greater trochan- was cemented and had been put in very superiorly. The
ter, callipers and measuring from the lesser trochanter to the cement mantle was thin but didn’t appear loose. The
centre of the femoral head. cemented femoral stem had been inserted very distally.
The left hip resurfacing looked fine. I was asked what
Examination corner I thought of the radiograph. I mentioned possible DDH
Intermediate case 1: Elderly male with cemented right THA and left with the cup placed in a high hip centre. I was asked if
hip resurfacing. Leg length discrepancy 5 cm with short right leg I would revise the right hip. I said in the absence of pain
I wouldn’t because it would be a complex revision case
History that may end up with complications. The patient had a
The right hip replacement had been performed 15 years pre- number of significant co-morbidity factors, which meant
viously. The hip resurfaced 6 years previously. I didn’t think revision would be the correct answer. My
The main compliant was of the leg length discrepancy. The guess was correct.’
patient mentioned that they had had a problem with the right
References 4. MacKenzie JR, Kelley SS, Johnston RC.

Total hip replacement for coxarthrosis
7. Wroblewski BM, Siney PD, Fleming
PA. Wear of the cup in the Charnley
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Y. Decision making regarding spinal dislocation of the hip. Long-term Surg Br. 2004;86:498–503.
osteotomy and total hip replacement results. J Bone Joint Surg Am.
for ankylosing spondylitis experience 8. Barrack RL, Burnett SJ. Preoperative
1996;78:55–61. planning for revision total hip
with 28 patients. J Bone Joint Surg Br.
2014;96:360–5. 5. Stulberg SD, Cooperman DR, arthroplasty. J Bone Joint Surg Am.
Wallensten R. The natural history 2005;87:2800–11.
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with ankylosing spondylitis. Orthop 9. Pierannunzii L. Thigh pain after total
J Bone Joint Surg Am. hip replacement: A pathophysiological
Muscul Syst. 2013;3:149. 1981;63A:1095–108. review and a comprehensive
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spondylitis J Arthroplasty. of the literature. J Bone Joint Surg Am. 10. Engh CA, Bobyn JD, Glassman AH.
2009;24:1285–91. 1994;76:448–58. Porous-coated hip replacement. The
tt
Don’t use a short tape that doesn’t cover the distance between ASIS
and medial malleolus or cheap and cheerful paper tape, which gets
torn during use.
159
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factors governing bone ingrowth, stress 18. Sreekumar R, Gray J, Kay P, Grennan arthroplasty: 2 to 6-year follow-up
shielding, and clinical results. J Bone DM. Methotrexate and post operative study. J Bone Joint Surg Am.
Joint Surg Br. 1987;69:45–55. complications in patients with 2004;86:28–39.
11. Wegrzyn J, Tebaa E, Jacquel, et al. Can rheumatoid arthritis undergoing elective 26. Baghdadi YMK, Larson AN, Sierra RJ.
dual mobility cups prevent dislocation orthopaedic surgery – a 10 year follow- Restoration of the hip center during
in all situations after revision total hip up. Acta Orthop Belg. 2011;77:823–6. THA performed for protrusio acetabuli
arthroplasty? J Arthroplasty. 19. Fitzgerald RH, Jr, Nolan DR, Ilstrup is associated with better implant
2015;30:631–40. DM, et al. Deep wound sepsis following survival. Clin Orthop Relat Res.
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Acad Orthop Surg. 2011;19:737–45. 20. Beswick AD, Elvers KT, Smith AJ, et al. replacement in active advanced
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A, Courpied JP, Kerboull M. Total hip surgical treatment of infected hip Br. 2009;91:1301–4.
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up study. J Bone Joint Surg Am. patients. BMC Med. 2011;10:18. arthroplasty in young patients who have
2001;83:992–8. 21. Cooper HJ, Valle Della CJ. The two- congenital dislocation, degenerative
14. Jameson SS, Lees D, James P, et al. stage standard in revision total hip osteoarthrosis, or rheumatoid arthritis.
Lower rates of dislocation with replacement. Bone Joint J. J Bone Joint Surg Am.
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primary total hip replacement: A 5- 22. Miner AL,Losina E, Katz JN, et al. Deep 29. Woo RY, Morrey BF. Dislocations after
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20fsh%20nov%202012.pdf infection after total hip and knee Early failure mechanisms of
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014
Knee clinical cases

Chapter
12 Francois Tudor and Deiary F. Kader
Clinical examination Feel

General guidance: Skin temperature
Introduce yourself to the patient Effusion test. For small effusion use the bulge, sweep or
milk test
Ask for permission to examine the knee
Adequately expose both knees, thighs and feet Empty the suprapatellar pouch and displace the knee fluid
Ask if the knee is painful laterally. Compress the lateral side and watch for a bulge
Always ask the patient to walk medially. Use the patellar tap or cross-fluctuation test for
Always remember to check spine, hip and pulses large effusion. Pinch any synovial thickening to
differentiate it from effusion
You must have a well-rehearsed system to examine
the knee Assess extension (particularly hyperextension)
Fixed flexion deformity. Slide your hands behind the
patient’s knees and ask him/her to press the knees into the
Standing couch or lift up both legs. If present, ALWAYS assess hips
Look for clues (brace, sticks, callipers, rheumatoid arthritis for fixed flexion
(RA) hands and shoe raise) Ask patient to straight leg raise (SLR) (check for
Inspection (front, side and behind) quadriceps lag)
General posture (leg length, rotation, varus, valgus or Look for posterior tibial sag (look from the side with the
windswept knees, recurvatum, fixed flexion, patella knee at 90˚ of flexion). The anterior tibial surface normally
rotation, legs and feet disorders) lies 1 cm anterior to the distal end of the femur. Double-
Quadriceps wasting, especially vastus medialis obliquus check with the card test or palpate a step-off at the
(VMO) (ask patient to tense quads whilst standing) anteromedial joint line - the medial tibia should sit 1cm
Skin changes (psoriasis, varicose veins) anterior to the medial femoral condyle.
Scars are very helpful but sometimes they are not visible Palpation; move the knee to 70–80° flexion and check for
especially arthroscopic (get closer) tenderness on the joint line, collateral ligaments, femoral
Skin grafts or flaps and sinuses condyles, tibial tuberosity, patellar tendon, patella,
Swelling (position in relation to patella) retropatella, quadriceps insertion
Look at the popliteal fossa
Move
Extensor mechanism integrity assessed by active SLR
Walking Check active and passive knee flexion/extension and
Gait pattern compare to opposite side
Is the knee kept in flexion or moving freely? If flexed Check collateral ligaments in 20–30° flexion
posture – Cannot comment on ‘fixed flexion’ until full Anterior and posterior drawer tests
examination of knee and hip
Anterior drawer (always in comparison to opposite side)
Varus/valgus thrust. Thrust = increased deformity in
stance phase Grade I: 0–5 mm translation
Grade II: 6–10 mm translation
Grade III: 11–15 mm translation
Supine
Look Posterior drawer (always in comparison to opposite side)
Check again for any skin discoloration, sinuses, scars, quads Grade I: 0–5 mm in posterior translation (greater than
wasting, joint swelling and osteophytosis. the uninvolved side)
161
015
Grade II: Anterior surface of the tibia and femoral

condyles are flush (>5–10 mm of relative posterior making me look a bit stupid and I had to quickly recover my
translation) composure. I went straight for examining the patella femoral
joint which was instinctively the right decision. The patella was
Grade III: Tibia can be translated posterior to the
dislocated laterally when the knee was flexed to 90°m, which
anterior femoral condyles (>1 cm)
I commented on. The patella reduced with knee extension.
Lachman’s test and pivot shift There was quite a big meal made of how I examined for a knee
Lachman’s test effusion. The examiners weren’t happy with my technique but
I didn’t think it was that bad. I didn’t argue with them but stood
Grade I: 0–5 mm translation my ground a little.
Grade II: 6–10 mm translation The examiners asked me what surgery I thought she had had.
Grade III: 11–15 mm translation I mentioned medial patellofemoral ligament (MPFL)
reconstruction.
Pivot shift test
They asked if it had worked and I said no.
Grade I: Pivot glide The examiners then asked what I would do next. I mumbled
Grade II: Pivot shift something about it being a difficult case and I would refer it to an
Grade III: Clunk/explosive pivot (gross shift after experienced knee surgeon (Pass – 6: I think I must have just
momentary locking) scraped through.)
McMurray test if meniscal injury is suspected

Hip and knee flexed 90°. Apply axial compression while Patellofemoral joint examination
internally and externally rotating the tibia whilst extending
You may be asked by examiner specifically to ‘test the patella-
knee. Reproduction of pain and/or clicking indicates
femoral joint’ during a short case, or else this should be at the
meniscal tear
end of your normal knee examination routine.
Load the medial and lateral compartments and check for
crepitus and pain Check for hypermobility syndrome (Beighton’s score)
Dial test in prone position if you suspect posterolateral Assess lower limb alignment and rotation
corner/posterior cruciate ligament (PCL) injury Sit the patient on edge of bed and check patellar tracking
through range of movement (ROM), J sign (abrupt lateral
Externally rotate the knee at 30° and 90° flexion: >10° deviation of patella when nearing terminal extension when
difference in external rotation between sides is abnormal. moving knee from flexion) and feel for crepitus
Abnormal rotation at 30° suggests posterolateral corner
In extension with leg relaxed
injury. Abnormal rotation at 90° suggests combined
posterolateral corner (PLC) and PCL injuries :Feel and measure the quadriceps bulk (10 cm above
superior pole of patella)
: Assess for tenderness around the patella
: Patellar tilt test – Holding patella between thumb and
Short case 1: Chronic patella instability fingers, attempt to tilt patella by elevating lateral edge
EXAMINER: This is a 15-year-old girl who sustained an injury to his
and lowering medial edge. Normal range is 0–20°.
right knee. Examine her knee for instability.
If you cannot get the patella to a horizontal position
(<0°), this implies a tight lateral retinaculum
CANDIDATE: I examined patella tracking, Q angle, J tracking, tilt,
translation. Brief discussion on potential anatomical abnormalities In 30° flexion with muscles relaxed: Please note that the
causing instability (high Q angle resulting in lateral vector of
Q angle could be measured in many different ways. In
quads pull, deficient MPFL and trochlea and any rotational
supine, sitting or standing with muscles contacted or relaxed
abnormalities in the limb). : Measure Q angle (quadriceps pull angle) – The angle
I would normally start my examination by asking the patient to between anterior superior iliac spine (ASIS), centre of
walk. patella and tibial tuberosity. <15° is normal. (Ask
patient to place finger vertically on ASIS to aid
Short case 2: Patella hypoplasia with instability. Previous
calculation of angle)
surgery to knee
: Patellar glide – Divide patella into imaginary quarters,
EXAMINER: This young girl is complaining of left knee pain. Would grasp patella between thumb and fingers and assess
you examine her knee? lateral mobility compared to the normal side (lateral
CANDIDATE: There was an obvious surgical scar over the lateral shift of <25% width of patella is normal, >25% implies
aspect of her knee. I didn’t initially comment on this as it deficient medial restraints ie. medial patellofemoral
seemed so obvious but the examiners had to prompt me ligament (MPFL))
015
Chapter 12: Knee clinical cases
Patellar apprehension test (ask the examiners if they want Memorandum

you to proceed as this can be painful)
a ‘This patient is a young, typically male, sporty type of person in
Patellar grind test and Clarke’s test are best left to the end shorts. (They usually have obvious quadriceps wasting with possible
as they may be painful medial and lateral arthroscopic portal scars.) The patient has a
Ober’s test to check for iliotibial band tightness normal gait and knee motion, possibly minor effusion and no
specific areas of tenderness in the knee. The anterior drawer test
and Lachman’s test revealed an increase in translation of the tibia
on the femur compared to the opposite side and no firm endpoint
Knee examination: Quick reference was felt. (When there is an increase in translation always think
Introduction, ask about pain ACL/PCL or both.) The pivot shift test was positive for anterior
Scan room for patient aids/accessories cruciate deficiency (describe what you are doing as you are
Look at knee while standing (from front, side, back) doing it). A pivot shift demonstrates a non-functioning ACL.’
Comment on scars, alignment, posture, muscle wasting
Assess gait. Comment if obvious varus or valgus thrust

History
Lie on couch, look closer for scars/quadriceps wasting/other Important details to elicit from the patient:
abnormalities Nature of injury (~70% are non-contact, typically during
Assess for effusion and temperature change sudden change of direction with the leg planted and valgus,
Palpate joint (easiest at 90°) for tenderness external-rotation or hyperextension)
Assess range of motion of knee (active and passive)
Ensure to examine hip at same time and demonstrate
Effusion/hemarthrosis (usually large, within a few hours of
painfree hip motion injury)
Further instability episodes (with risk of further meniscal/
Assess ligament stability (anterior cruciate ligament, ACL; chondral damage)
posterior cruciate ligament, PCL; lateral collateral ligament, Treatment so far
LCL; MCL, medial collateral ligament) Sporting activity level and plans to continue sports
Special tests based on the above findings into either
1. Ligaments(dial, quads active)
2. Meniscal pathology(McMurray’s) Examination
3. Assess patella–femoral joint(patella grind test/patella Clinical examination MAY reveal:
apprehension test) Antalgic gait
Offer examination of spine, ankles, neurovascular status Quadraceps wasting
of limb
Effusion
Investigations (x-ray, MRI) Joint line tenderness (consider associated meniscal
pathology)
Positive anterior drawer, Lachman’s and pivot shift tests
PCL–quadriceps active test Assess MCL, LCL, PCL, posterolateral corner
The patient is supine with knee flexed to 80–90° in the drawer
test position. While the examiner holds down the foot the
Pivot shift analysis
patient is asked to attempt to lift their foot off the table. This can be quite a painful test and at best can only be
Contraction of the quadriceps in a PCL-deficient knee results performed on one occasion, as the patient will thereafter
in an anterior shift of the proximal tibia1. tense up. It is best performed under general anaesthetic
(GA). Suggest performing the test to the examiners but they
ACL deficiency may ask you to omit it for the above reasons.
With the leg extended there is an anterior subluxation of
ACL-deficient knees might be found in the short cases or
the tibia on the femur. Slight knee flexion with a valgus stress
possibly a combined ligament injury in the intermediate cases. and axial load to the knee causes the anteriorly subluxed knee
In an exam in the ACL-deficient knee setting, the anterior to reduce spontaneously into its normal position with respect
drawer and Lachman’s tests are usually glaringly obvious. to the femur with a sudden visible jump or shift at 20–30°
There is no subtleness about these test signs unlike in everyday flexion. The iliotibial band (ITB) plays an important role in the
clinic where they are not always obvious. reduction of the tibia as its pull moves posterior to the axis of
flexion. The medial collateral ligament, on the other hand,
bears the axis of rotation of the pivot shift; therefore, it should
be kept tight by applying valgus force.
a
Controversial – Perhaps safer to mention to the examiners rather Matsumoto, in cadaveric knees, showed that sectioning of
than perform as this will hurt the patient. the ITB in the ACL-deficient knee diminished pivot shift but
163
015
not internal rotation, and sectioning of the medial collateral

ligament in the ACL-deficient knee diminished both pivot shift
and the degree of internal rotation2. However, anterolateral
ligament injury accentuates pivot shift.
Requirements for a pivot: Intact MCL to pivot around, ITB
to reduce knee upon flexion and no fixed flexion deformity.
The pathological motion elicited by the pivot shift is
graded as:
Grade I = Glide
Grade II = Clunk
Grade III = Gross clunk with locking. Explosive pivot
Discussion
Indications for ACL reconstruction
Symptomatic instability following adequate rehabilitation. Figure 12.1 AP and lateral radiographs of ACL reconstruction. The graft is
Frobell et al.3 randomised patients to either reconstruction suspended in the femur using an endobutten (Smith & Nephew) and fixed with
an RCI screw (Smith & Nephew) and PushLock® SP (Arthrex) in the tibia
or rehab. and delayed reconstruction – No early difference
in outcome but lower activity scores and higher not vertical tunnel. Aim for tibial tunnel 40–50% from
meniscectomy rate in rehab. patients the front of the tibial plateau on a lateral x-ray and slightly
Consider early reconstruction in young patients who wish medial on AP (also 40–50% from medial plateau margin)5.
to continue participating in high level pivoting sports or BEWARE: A PCL injury may have a false positive anterior
high demand occupations. Sri-Ram et al.4 identified that drawer and Lachman’s (tibia sits in a subluxed position pos-
delay in reconstruction of >5 months in younger patients terior to femur; these tests will reduce the tibia to a normal
results in a higher incidence of medial meniscal tears position, appearing to indicate ACL deficiency). ALWAYS
and/or chondral damage listen to the history (PCL injury typically occurs with anterior
Early reconstruction for ACL in association with repairable blow to shin with planted foot), assess femoral–tibial step off to
meniscus tear determine resting position of tibia and assess posterior drawer.
Early reconstruction when associated with high-grade MRI will also be helpful in these cases, but mixing up an ACL
other ligament injury with a PCL injury means you generally fail that particular
short case as you have been unable to correctly interprete your
Technique – Hamstrings vs patella tendon clinical exam findings.
Currently there is no evidence to suggest one is better than the Combined ACL and PCL injuries are rare – Often due to
other with most studies reporting similar function and stability knee dislocation with higher energy injury and associated with
with either graft type. LCL or MCL injury. Follow routine early management vascu-
lar monitoring, reduction and stabilisation. Most surgeons
Patella tendon – Bone to bone healing is quicker. Higher
incidence of kneeling pain prefer early surgical treatment (within 3 weeks from injury)
with ACL and PCL reconstruction and repair or reconstruc-
Hamstrings – Possibly slower healing with risk of tunnel
tion of LCL if present. With a combined ACL and PCL injury
widening in early rehab protocols
you are less likely to fail the case if you only diagnose the ACL
Surgical complications injury but it doesn’t look very clever missing the PCL injury!
Stiffness/arthrofibrosis – Often due to reconstruction
before the knee has settled. Can be avoided by waiting until Short case 1
the swelling has settled and normal range of motion has EXAMINER: This is a 20-year-old male who sustained an injury to his
been regained. right knee 1 year ago. Examine his knee for instability.
Graft failure (3–5%) – May be due to fixation failure, poor CANDIDATE: I would normally start my examination by asking the
tunnel position, graft impingement in femoral notch, poor patient to walk.
rehabilitation EXAMINER: Don’t bother, just examine him on the couch.
Infection, deep vein thrombosis (DVT), numbness (injury CANDIDATE: Mentioned quadriceps wasting. Knee flexed to 90°,
to infrapatellar branch of saphenous nerve) negative sag, normal step-offs. The anterior drawer test was
Be prepared to comment on postoperative radiographs of positive and there was a soft endpoint on Lachman’s test. Varus
and valgus stressing the knee at 0° and 30° of flexion was normal.
ACL reconstruction (Figure 12.1). Aim for posterior femoral
tunnel placement >80% along Blumensaat’s line with oblique, The candidate continued by asking the patient to lie prone to
015
demonstrate dial test at 30° and 90° (external rotation was settled. Many surgeons would now perform a single procedure having
symmetrical). warned the patient of the risk of stiffness and possible need for
EXAMINER: How do you manage an ACL-deficient knee? subsequent MUA/arthrolysis.
It was agreed that the role of an MRI scan should not be routine but
only used to confirm findings following an equivocal pivot shift test or PCL injury
to identify any associated meniscal injury. Noyes’ ‘rule of thirds’.
Physiotherapy initially and, if this is unsuccessful, then consider ACL Memorandum
reconstruction. ‘On examination there is a young athletic gentleman of average
height and build. What we can see from the front is fairly marked
Intermediate case 1: 38-year-old man sitting on a couch quadriceps muscle wasting of his right knee. There appear to be
EXAMINER: This patient is 38 years old injured his knee 9 months well-healed arthroscopic portal scars over the medial and lateral
ago. Now he is complaining of pain and instability. Would you like
joint lines.
On inspection of his gait he demonstrates a varus thrust of the
to check his knee ligaments?
right knee during walking.
CANDIDATE: Asked the patient to walk and then examined him Examination supine reveals a small effusion present in this
on the couch. Told the examiners that the patient has ACL and knee. There is no fixed flexion deformity. There is a range of
MCL laxity. movement of 0–110° flexion compared to 0–130° flexion on the
EXAMINER: Demonstrate Lachman’s test and pivot shift. opposite, normal side. Palpation reveals no specific areas of
CANDIDATE: Showed both tests. tenderness. On flexing his knees to 90° there appears to be a
EXAMINER: What else would you check for?
posterior sag sign. The tibial tubercle appears less prominent
than usual whilst the patella appears more prominent than
CANDIDATE: Medial joint line tenderness.
normal. Placing a flat card over the front of the right knee reveals
EXAMINER: What is it called when you have all thee injuries a subtle concavity present with a gap between the card and the
together? front of the knee. Also, the step-off sign is negative (the tibial
CANDIDATE: O’Donoghue’s triad. plateau is flush with the medial femoral condyle), suggesting PCL
disruption.
The quadriceps active drawer sign was positive for PCL
Discussed further investigation with MRI (not obligatory but used to disruption. The tibia moved anteriorly when the
confirm findings). quadriceps contracted, actively extending the knee from a flexed
Discussed treatment options – Noyes’ ‘rule of thirds’ – One third of position.’
patients would compensate well with conservative treatment; one
third would avoid symptoms of instability through ‘modification or
substitution’ of activities; and one third would do poorly and require Discussion
reconstructive surgery12. Some surgeons are now more aggressive Acute PCL injury – Non-operative management with
with early reconstruction in active patients who are keen to continue bracing and quadriceps rehabilitation is standard practise
in pivoting sports, particularly considering the risk of developing fur-
Surgical reconstruction for symptomatic chronic PCL
ther chondral or meniscal damage if remaining active on an
injuries – Patients who suffer recurrent instability may
unstable knee.
benefit from PCL reconstruction. A systematic review
Intermediate case 2: 21-year-old male very sporty with knee injury reported reconstruction improved stability by 1 grade
History – 21-year-old sports man (not high level but keen to keep with 75% returning to normal or near normal activities
playing rugby/soccer/cricket). Injury 5 months ago, physio. Given way but reconstruction does not prevent development
since (got the impression of poorly compliant patient). of OA13
Examination – Lateral joint line mildly tender, mild effusion, full ROM Acute bony avulsions – Should always be repaired when
but pain deep flexion. Ant. drawer, Lachman’s +ve. Demonstrate pivot possible (via direct posterior approach or athroscopic with
(difficult and pt guarding/resistant). Examine other ligaments. 70° scope and posteromedial and lateral portals)
Discussion – MRI to determine if other pathology (high risk due to
Acute combined injuries – Usually in combination with
continued playing/giving way and lateral pain). Single slice T2 sagital
MRI – I think lateral meniscus – Posterior horn tear. Symptomatic
posterolateral corner injury. Usually require early repair
instability in active person – Discussion about ACL recon. Surgical and reconstruction in active patients
options (hamstrings vs Pat tendon). Debate about the long-term history of the PCL-deficient
Asked – What would I do if patient presented with acute injury with knee: Studies suggest that there can be significant
swollen, stiff knee and locked bucket handle tear meniscsus/ACL tear? activity-related pain and possibly degenerative
Two options are acute reconstruction and meniscal repair or isolated changes, especially in the anterior (due to lack of
meniscal repair protecting the knee with a brace, mobilization and restraint of posterior translation) and medial
then performing a delayed ACL reconstruction when the knee had compartments14,15
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Examination corner Intermediate case 3: 81-year-old man with bilateral varus

Intermediate case 1: Gentleman sitting on a chair in hospital gown osteoarthritis of the knees
Gross deformity present with associated fixed flexion deformity of
EXAMINER: Mr Jones is 63 years old and has a knee problem. You approximately 20° in each knee. Thorough history, including recre-
have 5 minutes to obtain a history. ation, social, stairs in house, etc.
CANDIDATE: Introduced himself and started asking about the Demonstration of:
knee pain, its site, nature, duration, severity, radiation, Varus/valgus instability
aggravating factors and its effect on the patient’s sleep and Anterior drawer test
walking distance. Lachman’s test
EXAMINER: What else would you like to do? The usual questions were asked on possible spinal/vascular/hip aeti-
CANDIDATE: I would like to examine Mr Jones’ knee. ology for knee pain.
Asked to take informed consent for TKA in front of the examiners.
EXAMINER: Please do.
CANDIDATE: Started by walking the patient, commenting Discussion
on his gait, diffuse swelling, previous scars and deformity. Shown radiographs of both knees
Then examined the knee, pointing out that there are signs What type of TKA would you do?
of arthritis. What problems do you anticipate (patellar eversion, rectus
EXAMINER: What else would you like to examine? snip, etc)
CANDIDATE: Hip and spine. How do you sequentially release the medial structures?
EXAMINER: Anything else? How do you correct for a fixed flexion deformity intraoperatively?
How do you recreate the joint line in TKA?
CANDIDATE: Had to be prompted to say peripheral pulses. (Losing
points.)
Intermediate case 4: 67-year-old female with severe varus
EXAMINER: This gentleman is 63 years old and has 15° varus
osteoarthritis of knees with fixed flexion deformity
deformity in the knee and restricted range of movement. What is
Typical history of painful arthritis limiting activities and quality of life.
your management plan?
No major medical problems. Tried physio, steroid injections. Now
CANDIDATE: I would offer him total knee replacement. greatly affecting life with severe pain and progressive deformity.
EXAMINER: Even if his pain is mild! Examination: ROM, deformity (was a valgus knee), previous TKR
CANDIDATE: Tries to change the plan, which the examiners did other side, hip above arthritic knee also slightly painful (remember to
not like. examine joint above), no evidence of RA.
OUTCOME: Failed.
Discussion
Intermediate case 2: 55-year-old man lying on a couch EXAMINER: So here are some x-rays. Talk me through your thoughts.
CANDIDATE: AP radiograph of knee showing complete loss of lateral
EXAMINER: Examine this gentleman’s knee.
joint space and valgus angulation of >20°.
CANDIDATE: Started by commenting on large anterior scar and
EXAMINER: What do you mean valgus angle?
wanting to test effusion.
CANDIDATE: The femoro-tibial anatomical angle is typically around
EXAMINER: How do you do a patellar tap?
6° of valgus. It is greatly increased in this patient due to the
CANDIDATE: While trying to demonstrate it he realized that the
arthritis and there appears to be some lateral bone loss.
patient has had patellaectomy.
EXAMINER: Yes. So what are you thinking about for treatment?
EXAMINER: Examine the main ligaments.
CANDIDATE: Well, options for treatment include non-surgical
CANDIDATE: Demonstrated posterior sag and loss of step-off.
modalities and . . .
EXAMINER: When PCL is injured what else do you need to examine?
EXAMINER: I think its pretty obvious she’s exhausted non-surgical
CANDIDATE: Dial test at 30° and 90°.
modalities. (Obviously keen to move on to surgical discussion.)
EXAMINER: What is your management plan?
CANDIDATE: Yes. The only real surgical option would be total knee
CANDIDATE: This gentleman has post-traumatic arthritis. He had
replacement.
patellaectomy for comminuted patellar fracture and also has a
EXAMINER: So tell me more . . . (getting a bit pushy) What difficulties
PCL-deficient knee. His pain is mild to moderate at this stage.
do you anticipate?
I would, therefore, treat him conservatively as long as possible
CANDIDATE: For exposure I would use a medial parapatellar
before offering him TKR.
approach. I would perform my distal femoral cut using a 5° block.
EXAMINER: What type of knee replacement would you use?
The lateral femoral condyle may be deficient and so I would
CANDIDATE: I would use PS type TKR in patients with patellaectomy
concentrate on getting my femoral rotation correct.
and/or PCL deficiency.
EXAMINER: How would you measure this?
015
CANDIDATE: I would estimate the correct axis using Whiteside’s line EXAMINER: And leave yourself with a big hole in the tibia? I would
and the intercondylar axis. normally take them out 6–8 weeks prior to the surgery, but I’m
EXAMINER: Yes, typically the correct rotation can be achieved using sure they could come out on the day too. Do you expect trouble
3° of external rotation on the cutting block. What else with the approach?
concerns you? CANDIDATE: Yes, the patient may have patella baja leading to
CANDIDATE: Ligament balancing can be problematic. difficulty with eversion and the approach may be challenging.
EXAMINER: So tell me about the releases . . . EXAMINER: How do you measure patella height?
CANDIDATE: Lateral osteophytes, capsule and PCL are released first. CANDIDATE: Measurements are taken from lateral radiographs.
For tightness in extension, I would perform release of ITB and in Insall–Sulvati compares the length of the patella to the length of
flexion, I’d release popliteus. the tendon from distal pole of patella to tibial tubercle. Erm . . .
EXAMINER: You go to the ward postoperatively and they patient has EXAMINER: (losing interest and aware of time) Yes, there is also the
a foot drop. Have you cut the nerve? Blackburne–Peel ratio. Tell me about your tibial cut.
CANDIDATE: This is often due to a large correction and the majority CANDIDATE: This can be difficult as both joint heights have been
will resolve with release of bandages and elevation. altered. I believe you would typically reference off the
Bell rings medial side.
(Also consider patella maltracking due to contracted lateral EXAMINER: Are you aware of any differences in knee replacements
retinaculum – Possible need to release.) after osteotomy?
(Examiner could have gone into discussion of anatomical CANDIDATE: I believe that, although the operation is more
vs mechanical axis.) challenging, the results are similar to primary knee replacements.
Intermediate case 5: 53-year-old male with medial osteoarthritis

and previous HTO Bell rings
History: 53-year-old male, previous open meniscectomy (around
Intermediate case 6: 69-year-old woman with painful total knee
30 years ago) then HTO (>10 years ago). Now severe pain. Works as
replacement
a plumber.
History: Total knee replacement 2 years ago. Prolonged wound ooze
Past medical history: gout, hypertension
(warfarin for AF), 1× wound washout but no prolonged antibiotics, not
Examination: Obese, mature open medial meniscectomy scar, lateral
sure of poly-exchange (vague historian). Knee ‘never felt right’. Now
scar (from closing wedge osteotomy), osteophytes, 15° FFD, fixed varus
always swollen and painful. Smoker, diabetic.
5°. Hip OK
Examination: large effusion, limited ROM, mildly warm, no erythema,
Discussion no sinuses (reminded to look all around knee by examiner), painful
knee to move. Hip OK. Evidence varicose veins (eczema, discoloration),
EXAMINER: What is your next step? poorly palpable pulses and diminished sensation feet.
CANDIDATE: I would like to see weight-bearing AP, lateral and Discussion: high suspicion of infection. Investigate with CRP, ESR,
skyline x-rays (shown a poor quality AP radiograph). This is an AP WCC. X-rays – No obvious loosening/lysis. Implant slight varus on tibial
radiograph showing medial osteoarthritis with lateral side. Discussed use of bone scan at 2 years postop. Usefulness of
osteophytes and joint space narrowing. There are staples in situ aspiration/synovial biopsy. Probably two-stage revision (discussed
from the previous closing wedge osteotomy. single-stage). Risks of amputation discussed with the patient.
EXAMINER: Yes, treatment options?
CANDIDATE: The patient should exhaust non-operative methods Short case 1: A 41-year-old woman with post-traumatic
due to his age. If the pain is too severe that it is greatly affecting osteoarthritic left knee
everything he does then he may need to proceed to total knee Varus mal-alignment
replacement although I would prefer to hold off as long as Antalgic gait
possible. No fixed flexion deformity, effusion or patellofemoral (PF) joint
tenderness
EXAMINER: Sadly he cannot carry on like this. Tell me how you
Normal range of movement
would plan his knee replacement.
Tenderness limited to medial joint line
CANDIDATE: My concerns are the previous scars and leaving a skin
Varus was correctable
bridge. I would curve my incision into the medial scar distally Cruciates and collaterals were stable
rather than go midline. The staples may be an issue for the
tibial cut. Management
EXAMINER: When would you take them out? ‘I suggested conservative management and then, if there was
CANDIDATE: At the time of surgery? (more of a question than an significant severe symptomatic deterioration, either osteotomy or
answer) unicompartmental arthroplasty (UKA).’
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Intermediate case 7
CANDIDATE DEBRIEF: I jumped in with initially using NSAIDs for
‘This was a gift. The patient was an otherwise fit and healthy 79-
pain control. The examiners weren’t happy at all with this. They
year-old woman with predominantly right-sided osteoarthritis of
then grilled me about the WHO pain ladder. A silly simple mistake
the knee. I took a full history. I examined her back and hips
but a BIG issue was made of it.
thoroughly and noted that she had bilateral varus knees with a
mild fixed flexion deformity on the right. I was asked to
demonstrate the Thomas’ test and correctable varus. The second
examiner discussed investigation, long leg films, non-operative Osteoarthritis (OA) of the knee
options, evidence for the benefit of arthroscopic washout and UKA. This can be a short or intermediate case. There is little room
I was asked what type of knee prosthesis I would offer her, which for any error. The candidate would be expected to be very
led to a discussion of PCL retaining vs posterior stabilised total familiar with this type of case from clinic.
knee replacement.’
Memorandum
Intermediate case 8: 37-year-old male with chronic knee pain10 ‘On examination from the front, with the patient adopting a
weight-bearing stance, I see that this is an elderly gentleman of
History
average height and build. There is a bilateral varus deformity of
Patient is 37 years old. Knee pain limiting walking, stairs, crouching.
both knees. There are no scars, no skin discoloration or varicose
Taking multiple painkillers every day. Done ‘some physio’ few years
veins. He walks in a slow moving manner suggestive of loading
ago. Played a lot of sport when young – Multiple minor ‘sprains’ of the his knees on the medial compartment.’
knee. No major injury. 2 previous arthroscopies – Told ACL was torn ‘There is no effusion present in either knee but generalized
but continued sport. Works as a manual labourer – Keen to continue. synovial thickening. He has a fixed flexion deformity in both
No past medical history. knees of 10° and demonstrates a range of movement from 10°
to 70° flexion.’
Examination
‘The knees are tender globally, with osteophytes over the
Effusion (ensure thorough examination for small and moderate effu-
joint lines. There is a grating sound with crepitus when the
sion), stands with varus alignment around 5°, medial tenderness and knees are moved. Both knees are stable when the anterior
crepitus, patella–femoral crepitus, palpable medial osteophytes, MCL drawer, posterior drawer and Lachman’s test are performed,
stable, varus only partially correctible, ACL laxity. with a firm endpoint noted. The varus deformity is not fully
Discussion correctable.’
‘Hips have full, pain-free ranges of motion at 90° and in
‘What is your management of a young, active person with knee
extension. The distal circulation is good, with dorsalis pedis and
osteoarthritis who is not yet ready for arthroplasty?’
tibialis posterior pulses strongly palpable, good capillary refill,
Discussed exhausting non-surgical methods first with physiotherapy, no dystrophic changes in the nails and no distal hair loss.
off-loading brace, activity modification (reducing impact activities, Likewise, sensation to fine touch is normal.’
more muscle strength, control and endurance work such as static bike)
and weight-loss. Role of injections, especially to provide a short-term
‘buffer’ for a special event or holiday. History
Surgical options: Arthroscopy only if mechanical symptoms, and Important details to elicit from the patient:
patient aware that it will not necessarily improve arthritic pain or
Age and activities
prevent progression of symptoms. Will also allow assessment of rest
of joint if considering further surgery. If pain severe enough, HTO
Nature of pain and disability caused by it (mobility, ability
to self-care, get around house/shops, night pain)
(medial opening – May require bone-graft but can be used to tension
MCL if necessary; lateral closing – More stable initially), provided the Walking distance, functional difficulties (ability on stairs,
lateral compartment is intact – Determine this with MRI and/or arthro-
crouching, uneven ground)
scopy. Significant lateral articular damage will lead to poor outcome Mechanical symptoms (catching, locking, swelling,
from osteotomy. There is better long-term data for lateral closing instability)
osteotomy but numerous studies report improvement in pain and Treatment so far (analgesia, physiotherapy, joint injections,
function with good mid- to long-term survival for both types of arthroscopy/other surgery)
osteotomy16. Medical history (cardiac, pulmonary, diabetes, previous
There is no current evidence for stem-cell or platelet-rich plasma DVT/pulmonary embolism (PE))
(PRP) injections. Social history (housing status, partner, stairs, support)
If all options have been exhausted, the patient must decide
whether his symptoms are affecting his quality of life enough to
warrant the risks of arthroplasty. He should consider changing to a Examination
less labour-intensive job if possible due to the higher risk of failure of a Clinical examination may reveal:
knee replacement placed under high loads.
Varus/valgus deformity on standing
015
Scars of previous surgery Goals of surgery – Improve joint pain and function whilst
Antalgic gait restoring mechanical axis, achieving balanced ligaments,
Quadraceps wasting preserving/restoring the joint line and a normal Q angle
Effusion Technical considerations from preoperative x-rays –
Joint line tenderness and osteophytes Alignment (varus/valgus), extra-articular deformity, bone
Limited range of movement (ROM), possible fixed flexion loss, patella baja (making exposure difficult)
deformity, limited flexion (assess hip ROM) Joint line restoration – Lies approximately 15 mm above
Crepitus (particularly patella–femoral) fibular head radiographically and can be approximated
Correctability of varus/valgus deformity (fully, partially from the residual meniscal roots intraoperatively (roughly
correctible or not) two finger-breadths above tibial tubercle). Elevation of
the joint line results in patella baja, lowering the joint line
Examination of hip
often occurs with over-resection of the tibia and may
Examination of spine (SLR)
lead to instability in flexion. Preoperative planning is
Examination of distal pulses, neurological examination
important to avoid changing the joint line, along with
controlled resection of bone and cartilage equivalent only
to the thickness of the implants
Discussion Fixed flexion contracture: It is vital that the knee can achieve
Treatment options stable full extension by the end of the procedure. Walking
Analgesia, weight loss, modify life-style, physiotherapy with a flexion contracture increases the work of the quads
Intra-articular injections (a Cochrane review in and is a cause of pain and poor function in TKA. A knee
2006 concludes good evidence of short-term benefit from with significant deformity may require an extra 1–2 mm
steroid injection and response to hyaluronan/hylan may be bone resection from the distal femur. Excision of posterior
more durable, with few side-effects6 osteophytes after the chamfer cuts and careful release of the
Arthroscopy – Increasing evidence this will not be capsule around the posterior edge of the femoral notch and
beneficial to patients (Kirkley et al. randomised 90 patients posterior condyles will also improve extension
to physiotherapy or arthroscopy in moderate/severe OA, Limited flexion – Flexion may be improved by down-sizing
showing no difference in outcome7, Herrlin et al. femoral implant size (to increase flexion gap) and
randomised 96 patients with degenerate medial meniscal increasing tibial slope cut
tears to physiotherapy or arthroscopic debridement with Varus knee – ACL ± PCL excision, sequential subperiosteal
no difference in outcomes, although one-third of the medial release depending on degree of deformity (with
exercise group patients eventually required arthroscopy for removal of osteophytes), continue posteromedially as
continued pain8) necessary, including semi-membranosus. Most of the time
Osteotomy – High tibial for varus, distal femoral for the deformity is well corrected by just pie-crusting the
valgus knees. Typically reserved for younger, higher superfacial MCL
demand patients. Finnish Registry data of 3190 knees Valgus knee – Results in possible contracture of ITB,
suggests high tibial osteotomy (HTO) survival at 5 years LCL, popliteus, posterolateral capsule, lateral head
89%, and 73% at 10 years using arthroplasty as the gastrocnemius, lateral patellar retinaculum with stretching
endpoint and, similarly, a systematic review of femoral of medial structures. Be aware of hypoplastic lateral
osteotomy suggests a 10-year survival of between 64% femoral condyle (BEWARE – May lead to internal rotation
and 82%9 of femoral component if posterior referencing – Check
with Whiteside’s line and intercondylar axis). To balance
Knee arthroplasty tissues, resect PCL, remove osteophytes
This may be offered to a patient whose quality of life is :
Tight in flexion – Release popliteus from femur,
significantly affected by pain despite other efforts to manage posterolateral capsule from tibia
symptoms. The patient must be fully informed of risks and : Tight in extension – ‘pie-crust’ or release ITB from
complications of surgery. tibial insertion ± lateral gastrocnemius from femur
± Z-lengthening biceps tendon
Total knee arthroplasty (TKA) : Patellar tracking – May require lateral release. If
Reliably relieves pain and improves function in the resurfacing, place button medially
majority of patients. The National Joint Registry (NJR) in Implant choice
2014 reported that cemented TKA have a 10-year : PCL retaining (cruciate retaining (CR)). Advantages:
cumulative risk of revision of 3.3% and uncemented Retains PCL proprioception, no post-wear/jump, less
implants 4.5% femoral bone resection, slightly increased congruence
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015
(theoretically less wear). Disadvantages: More difficult may be suggestive of implant loosening. Determine the exact
balancing, deficient PCL location of the pain and whether it is well localized or radiat-
: PCL substituting (posterior-stabilised (PS)). ing. When the pain most commonly occurs, how long it lasts
Advantages: Easier to balance, more reproducible and any precipitating or relieving factors.
results, slightly increased constraint. Disadvantages: Ask for problems with wound healing, prolonged dis-
Post-wear/jump, elevate joint line, possible patella clunk charge, superficial wound infections, etc. If the patient was free
of pain initially following TKR and developed pain months to
NJR reports 10-year risk of revision for all causes for
years later think component loosening, late ligamentous
CR implants as 3.1% and PS as 3.6%. Choose an implant
instability or haematogenous based infection. If the patient
that you are familiar with as this may be asked in the
was never pain free following TKA think deep infection,
discussion
instability, prosthetic mal-alignment or non-articular causes.
Patients with previous PCL injury or patellectomy should
During examination look for hallmarks of infection,
receive a PS implant. After patellectomy, the PCL is the
including sinuses, effusion, warmth and generalized tender-
only structure resisting posterior tibial translation and
ness. Inspect the skin for erythema or warmth. The knee
tends to stretch, leading to AP instability. A number of
should be examined for alignment, stability, range of motion
studies have reported better pain and functional outcomes
and the presence of an effusion, synovitis or crepitus. The
in those patients receiving PS in comparison to CR
stability of the knee to varus-valgus and anterior-posterior
implants following patellectomy
stress should be tested in flexion and extension. Posterior
Surgical complications: nerve or vessel injury; stiffness/ cruciate ligament (PCL) dysfunction can be assessed with a
arthrofibrosis (up to 10%), infection (1–2%, commonly positive posterior sag sign or quadriceps active test. The knee
Staphlyococcus epidermidis or S. aureus); DVT (no should be palpated for areas or points of tenderness which may
treatment DVT ~70%, symptomatic PE 0.5–3.0%, death represent tendonitis, bursitis or cutaneous neuroma. Assess
~0.2%10), numbness (skin lateral to the wound), poly wear patella tracking as this may suggest an issue with component
and aseptic loosening mal-alignment. Examine gait for limp or varus thrust suggest-
ive of mal-alignment or ligamentous instability.
Unicompartmental knee arthroplasty (UKA) Examine the spine and hip to exclude potential sources of
Reported to combine quicker rehabilitation with better referred pain. Check neurovascular status.
ROM and function in comparison to TKA. Higher revision Surgical diagnosis (intrinsic):
rate (NJR 2014 reports 12.7% probability of revision by Prosthetic loosening and failure
10 years) in comparison to TKA although lower rates Infection
observed in high-volume practices Patellofemoral tracking problems
Must have intact ACL, fixed flexion deformity <5°, flexion Instability
>90° (probably more 110–130°), maximum varus 15° Recurrent intra-articular soft-tissue impingement/
which is correctable to neutral, older age group (>60 component overhang
years), lower weight <82 kg. Contraindicated in unstable
knees, evidence of OA in other compartments (with risk of Non-surgical diagnoses (extrinsic):
progression and subsequent failure) or inflammatory Referred pain – Hip or back
arthritis Reflex sympathetic dystrophy
Complications (other than those seen in TKA): Bursitis or tendonitis – Pes anserine/patella/popliteal
Bearing dislocation, other compartment OA bursitis
progression, tibial component subsidence (possibly Persistent gout or pseuodogout
due to over-aggressive tibial resection or tibial stress Neurovascular problems
fracture), patellar impingement Expectation/Result mismatch – Multiply operated knee or
Surgical complications: nerve or vessel injury, stiffness/ unrealistic expectations
arthrofibrosis, infection, DVT, numbness (skin lateral to Psychiatric disorders and depression
the wound), poly wear, aseptic loosening X-rays may be normal. Serial comparison is important for
long-term monitoring for loosening.
Painful knee arthroplastyb A bone scan is very sensitive but not specific to one path-
ology. There may also be increased flow for upto 2 years after
It is important to detect infection. History may reveal pain-free
joint replacement surgery.
intervals and rest or night pain. Start-up and mechanical pain
Other tests: Blood tests – ESR >30 is 80% sensitivity and
specific for infection, but may be raised due to other causes.
b
This is also a viva question and requires a worked-out answer CRP >10° is 90% sensitivity and specific and has negative
beforehand as the topic is complicated. predictive value of 99%. Aspiration – synovial fluid white blood
015
cell counts >1700 cells/μl and a differential >69% polymorpho- statistically greater posterior tibial slope, mean angle of correc-
nuclear cells should raise suspicion of infection11. Intraopera- tion and incidence of patella baja18.
tive gram stain has sensitivity <20% but is very specific.
Technical issues during arthroplasty

Previous HTO (Figure 12.2)
Patella baja
The need to respect a longitudinal scar: At least 3 cm should
Memorandum be allowed between a new midline scar and a lateral scar
‘A lateral scar or an L-shaped lateral or a medial vertical Ideally use a PCL-sacrificing implant
or oblique scar suggests that the patient may have had
Abnormal tibial slope that may require adjustment of
an HTO.
tibial cut
Controversy remains as to whether the outcome after TKA
following HTO is less successful than conventional TKA. Outcome of TKR following previous HTO – Recent literature
Conversion to TKA may be technically demanding owing to reports that, although technically more demanding, TKA
difficulty with patella eversion, soft-tissue balancing and infection.’
following HTO has similar complication rate and mid-term
outcomes to primary TKA19,20.
Discussion
The goals of an HTO are to relieve pain and improve function
with minimal restriction of activity, allowing heavy functional Pigmented villonodular synovitis
demands, often in a patient under 60 years of age. Memorandum
Indications for HTO ‘The knee is the most commonly involved large joint. Two types
of pigmented villonodular synovitis exist: A localized form
Medial compartment osteoarthritis with varus characterized by a solitary lesion and a diffuse form aggressive in
mal-alignment nature usually involving the entire synovial membrane. Local
o o
Typically male, <60 years old, flexion >90 , FFD <15 , disease presents with mechanical symptoms such as locking and
o
vaurs <15 with no lateral subluxation and intact ACL. catching, whilst the diffuse type is characterized by pain, swelling,
HTO may also be performed to protect meniscal allograft stiffness and deformity.’
or chondral graft implantation
Long-term results of HTO tend to deteriorate with time. The
Intermediate case 1: 39-year-old male with chronic knee injury
Finnish Registry data of 3190 knees suggests high tibial osteot-
History: 39 years old. Playing social hockey – Blow from front of knee
omy survival at 5 years 89%, and 73% at 10 years17 using
2 years ago. Pain and swelling, settled. Knee doesn’t feel right, medial
arthroplasty as the endpoint. pain now.
HTO medial opening wedge vs lateral closing wedge – Examination: Posterior sag, no effusion, medial tenderness, posterior
A recent meta-analysis reported similar functional outcomes drawer +ve, dial –ve at 30°.
and complication rates, but opening wedge osteotomies had Discussion: PCL injury – Acute treatment with brace if isolated. PCL
deficiency progression to medial wear. Discussion of PLC and PCL
injuries (and dial test results with each) – Dial tests for increased ER
of tibia (abnormal is >10° compared to the other side). If increased at
30° knee flexion – Likely isolated PLC injury. If increased at 30° and 90°
knee flexion – Likely both PCL and PLC injured.
Brief discussion on multiligament injuries – Evidence supports
early operative treatment over late surgery, revealing better functional
scores and earlier return to work and sport21. This systematic review
also reports that reconstruction of the posterolateral structures yields a
lower failure rate than repair (9% and 37% respectively).
Valgus knee
Look for walking aids. Typically this would be a rheumatoid
patient or a young patient post trauma.
Rheumatoid arthritis
The patient presents with polyarthropathy. Look for hand and
Figure 12.2 AP and lateral radiographs of a closing wedge HTO wrist signs. Weight-bearing leads to marked valgus deformity
171
015
of the knee. Fullness of the knee suggests soft-tissue swelling

Risk of recurrence. Possibly treat with concomitant
due to a synovitis. radiotherapy
Discussion
Radiographs of the knee
Examination corner
Cervical spine evaluation
Medical evaluation of the rheumatoid patient and Short case 2
management in a multidisciplinary team is vital. The Examine this man’s knee
combination of polypharmacy and the systemic effects Look at the patient (middle-aged, body-builder)
Ask the usual questions about knee pain
of RA, including anaemia, pulmonary and cardiac
problems, require careful management in the Assess
perioperative period Gait: Look for varus thrust
Methotrexate (continued perioperatively), biological agents The degree of varus deformity. Is it correctable?
should be stopped The range of movement in the knee
Sequential release of the valgus knee as necessary Ligament laxity
Use a cemented PCL sacrificing (no clear evidence Leg length discrepancy
but reduces risk of early instability) with patella Examine the hip and foot for fixed deformity
replacement (which is associated with improved
Radiographs
outcomes in RA)22
Medial compartment OA
A stemmed implant may be necessary in severe valgus What are you going to do?
deformity – Bone is often softer and more constraint Why not carry out a unicompartmental knee replacement?
may be required, leading to greater forces through the (Age and ACL are possible main factors to consider here.)
implant bone interface. A stem will share these forces
If the patient is <50 years old and has some articular surface
and protect from periprosthetic fracture
preserved, in addition to the previous prerequisites, one can
offer HTO. However, if the patient is older and the degenera-
tive arthritis is severe (bone on bone), unicompartmental knee
Examination corner replacement would be a better choice.
Short case 1: Pigmented villonodular synovitis (PVNS) of the knee
Examine the knee for effusion and history of
recurrent bleed Hereditary multiple exostoses
Clinical differentiation of effusion from synovial thickening
Palpable exostosis around knee. Risk of malignant trans-
Differential diagnosis of PVNS
PVNS: Clinical presentation, joints affected (80% knee) and formation. Indications for investigation (increasing size or
management. Localized – Arthroscopic debridement, worsening pain – organize MRI) and excision (pain from
diffuse – Arthroscopic ± open synovectomy. Diffuse – impingement or compression of local structures). Inheritance
pattern (autosomal dominant with almost 100% penetrance).
References 4. Sri-Ram K, Salmon LJ, Pinczewski LA,

Roe JP. The incidence of secondary
7. Kirkley A, Birmingham TB, Litchfield
RB, et al. A randomised trial of
1. Daniel DM, Stone ML, Barnett P, pathology after anterior cruciate arthroscopic surgery for osteoarthritis
Sachs R. Use of the quadriceps ligament rupture in 5086 patients of the knee. N Engl J Med.
active test to diagnose posterior requiring ligament reconstruction. Bone 2008;359:1097–107.
cruciate-ligament disruption and Joint J. 2013;95:59–64.
measure posterior laxity of the 8. Herrlin SV, Wange PO, Lapidus G,
knee. J Bone Joint Surg Am. 5. Noyes FR, Matthews DS, Mooar PA, et al. Is arthroscopic surgery beneficial
1988;70:386–91. Grood ES. The symptomatic anterior in treating non-traumatic, degenerative
cruciate-deficient knee. Part II: The medial meniscal tears? A five year
2. Matsumoto H. Mechanism of the pivot results of rehabilitation, activity follow-up. Knee Surg Sports Traumatol
shift. J Bone Joint Surg Br. modification, and counseling on Arthrosc Off J ESSKA. 2013;21:358–64.
1990;72:816–21. functional disability. J Bone Joint Surg 9. Saithna A, Kundra R, Modi CS,
3. Frobell RB, Roos EM, Roos HP, Am. 1983;65:163–74. Getgood A, Spalding T. Distal femoral
Ranstam J, Lohmander LS. 6. Bellamy N, Campbell J, Robinson V, varus osteotomy for lateral
A randomised trial of treatment et al. Intra-articular corticosteroid for compartment osteoarthritis in the
for acute anterior cruciate treatment of osteoarthritis of the knee. valgus knee. A systematic review of the
ligament tears. N Engl J Med. Cochrane Database Syst Rev. 2006;2: literature. Open Orthop J.
2010;363:331–42. CD005328. 2012;6:313–19.
015
10. Stulberg BN, Insall JN, Williams GW, injuries. Curr Opin Rheumatol. 19. Ramappa M, Anand S, Jennings A.
Ghelman B. Deep-vein thrombosis 2002;14:142–9. Total knee replacement following high
following total knee replacement. 15. Boynton MD, Tietjens BR. Long-term tibial osteotomy versus total knee
An analysis of 638 arthroplasties. follow up of the untreated isolated replacement without high tibial
J Bone Joint Surg Am. 1984;66:194–201. posterior cruciate ligament- osteotomy: A systematic review and
11. Moyad TF, Thornhill T, Estok D. deficient knee. Am J Sports Med. meta analysis. Arch Orthop Trauma
Evaluation and management of the 1996;24:306–10. Surg. 2013;133:1587–93.
infected total hip and knee. Orthopedics. 16. Wolcott M, Traub S, Efird C. High 20. Preston S, Howard J, Naudie D,
2008;31:581–88. tibial osteotomies in the young active Somerville L, McAuley J. Total knee
12. Noyes FR, Matthews DS, Mooar PA, patient. Int Orthop. 2010;34:161–6. arthroplasty after high tibial
Grood ES. The symptomatic anterior osteotomy: No differences between
17. Niinimäki TT, Eskelinen A, Mann BS, medial and lateral osteotomy
cruciate-deficient knee. Part II: The Junnila M, Ohtonen P, Leppilahti J.
results of rehabilitation, activity approaches. Clin Orthop.
Survivorship of high tibial osteotomy in 2014;472:105–10.
modification, and counseling on the treatment of osteoarthritis of the
functional disability. J Bone Joint Surg knee: Finnish registry-based study of 21. Levy BA, Dajani KA, Whelan DB, et al.
Am. 1983;65:163–74. 3195 knees. J Bone Joint Surg Br. Decision making in the multiligament-
13. Kim Y-M, Lee CA, Matava MJ. Clinical 2012;94:1517–21. injured knee: An evidence-based
results of arthroscopic single-bundle systematic review. Arthroscopy.
18. Smith TO, Sexton D, Mitchell P, 2009;25:430–8.
transtibial posterior cruciate ligament Hing CB. Opening- or closing-
reconstruction: A systematic review. wedged high tibial osteotomy: 22. Clement ND, Breusch SJ, Biant LC.
Am J Sports Med. 2011;39:425–34. A meta-analysis of clinical and Lower limb joint replacement in
14. Allen CR, Kaplan LD, Fluhme DJ, radiological outcomes. The Knee. rheumatoid arthritis. J Orthop Surg.
Harner CD. Posterior cruciate ligament 2011;18:361–8. 2012;7:27.
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Foot and ankle clinical cases

Chapter
13 Rajesh Kakwani
A significant number of the short cases in the lower limb Looking from the front, side and behind (If the examination
section are generally from the foot and ankle subspecialty. room is small, it is sometimes prudent for a candidate to ask
These conditions are generally painless and easy to find. the patient to turn around rather than they look clumsy and
Although the FRCS Orth exam short cases are generally spot awkward trying to jump around in a small space)
diagnosis, they can be sometimes tricky due to lack of oppor- Standing tiptoe, one leg at a time, observe the heels and
tunity to take a detailed history prior to clinical examination. comment on the movement of the heel, e.g. Valgus heel
The time constraint of 5 minutes for the short cases makes it going into varus on tiptoeing (Figure 13.1 a and b)
essential for the candidate to practice a much focused examin- Gait: Antalgic, high stepping, externally rotated, foot
ation technique and be slick at it. An attempt has been made to progression angle, patient walking on the outer border of
provide the reader with a general guidance for foot and ankle the foot
clinical case examination, with special tests for specific cases. Deformities: Rheumatoid, curly toe, hammer toes, etc
The basic habits of a humble introduction to the patient, Callosities: Locations
development of a rapport and hand-washing/gel application Scars: Location, primary/secondary healing
between cases would go miles towards a successful outcome to Footwear: Including the location of the wear of the shoe, any
the exams. We thank and acknowledge Mr Chris Blundell, insoles
Sheffield, for allowing us to share the examination template
Walking aids: Stick, crutches, calipers, etc
used through the chapter.
Feel
Foot and ankle examination template summary Temperature: Especially in diabetic foot
Have a system Tenderness: Exact location, this needs a lot of practice to be
able to accurately position the finger at the important
Look
landmarks whilst maintaining eye contact with the patient to
Stand – Including tiptoe, range of movement (ROM),
be able to remark on any wincing. At the same time, look
walking aids
slick and professional. Depending on the location of the
Walk–don’t get bogged down
Sit – Including shoes, insoles, etc obvious pathology, you may wish to start the palpation from
the forefoot working back wards or the vise-versa
Feel Pulses
Bony landmarks Sensations
Tendons

Sensation
Pulses
Move
Range of movements: Ankle, subtalar, midtarsal,
Move metatarsophalangeal
Passive ROM
Proximal to distal/distal to proximal
Special tests
Foot and ankle clinical examination system Hallux valgus
Look
Look Stand (hallux valgus/ medial bunion/pronation, hammer
Attitude of the forefoot and hindfoot – Sitting as well as toes, heel valgus, pes planus)
standing position: cavus, planovalgus, hallux valgus, etc
016
Chapter 13: Foot and ankle clinical cases
(a) (b)
Figure 13.1 (a, b) Foot and ankle examination
big toe. Be confident describing your management and reasons

Gait (walks on outer border of the foot)
Sit: incl shoes (wear over the bunion) behind it. Be able to roll off a list of possible surgical compli-
cations. Do not forget to mention conservative management if
Feel appropriate.
Bony landmarks (bunion/tender first MTPJ)
Tendons Short case 1
Sensation
CANDIDATE: May I examine your feet please sir? Is there any area of
Pulses
soreness? If it is sore at any stage through the examination, please stop
Move me!a
Could I ask you to please stand up with feet close to each other.
Passive ROM (first TMT stability, pain/crepitus on MTP joint
movements, mobile IP, tendo-Achilles tightness) On inspection of the foot and ankle from the front is a moderate degree
Distal to proximal of hallux valgus deformity of the right big toe. The first metatarsal head is
prominent medially with thickening of the overlying skin, slight erythema
but no ulcerations. No previous surgical scars seen (If there is a dorso-
medial scar over the MTP joint, it is important to check for sensations in
Hallux valgus (Figure 13.2) the dorso-medial cutaneous nerve distribution to the big toe, which is a
common iatrogenic injury, especially if the scar is a curved one). The big toe
Hallux valgus is a frequently included short case in the exams,
is pronated. There is a hammer toe deformity of the second toe with a
a spot diagnosis. It is a very common condition, often not
painful. It is important to identify deformities that commonly
coexist with hallux valgus, i.e. Hammer toes, pes planus, and a
These are general courtesies that you must extend to the patient.
gastrocnemius tightness. Essentially be comfortable describing There are no excuses for rudeness or just forgetting manners with a
what you see and also what you are doing when examining the patient as this will score you a 4.
175
016
2. Hallux valgus angle of ___ (Normal value: <15°)

3. Distal metatarsal articular angle of ___ (Normal value: <15°)
Management options:
Conservative: Wide-toe box shoes, silicon spacer between the first and
second toe, etc
Operative management: I would not operate for cosmetic reason
The further discussion could go onto distal/shaft/proximal meta-

tarsal osteotomies, lateral soft-tissue release and medial capsular
plication, tarso-metatarsal fusion, metatarso-phalangeal fusion.
As first-ray surgery is an essential component of the Joint Com-
mittee on Surgical Training recommendations for CCT, a fair
degree of knowledge would be expected from a candidate in a
first-ray clinical case. It is advisable to be able to draw out the
metatarsal osteotomy on a bone model or piece of paper– Espe-
cially if you intend to perform a Scarf osteotomy of the metatarsal.
Figure 13.2 Hallux valgus
Example answer: ‘I would perform a Scarf osteotomy of the
first ray and an akin osteotomy of the proximal phalanx with
callosity over its proximal interphalangeal joint. The arches of the foot are lateral soft-tissue release and medial capsular plication’.
well maintained and the heel is in slight valgus.
Could you please stand tiptoe for me: It is important to ascertain that there Hallux rigidus
is support available for the patient if she/he loses balance. It may be a good
idea to make them stand facing a wall, with fingertips touching the wall, whilst Look
requesting them to tiptoe. The two important findings to note are: Stand – Inc. tiptoe, reduced First MTP extension
Gait (walks on outer border of foot)
1. The heel moves from slight valgus into varus (hindfoot is mobile)
Sit – Inc. shoes (wear of the outer border, insoles, etc.)
2. Whether the big toe hyperextends at the MTP or IP joint during this
manoevre Feel
Can you please walk for me? Bony landmarks (osteophytes/tender first MTP joint)
Tendons
The gait may be normal (not antalgic) or have a slightly reduced big toe push-off Sensation
Can you please sit down/lie down on the couch? Pulses
Sole: There are callosities under the first metatarsal head as well as the
Move
medial border of the base of the big toe distal phalanx (due to the
abnormal pressure caused by the pronation deformity of the toe) There Passive ROM (first TMT stability, stiff MTP, mobile IP)
Proximal to distal
are no callosities under the lesser toe metatarsal heads.
There is no tenderness over the medial prominence or the sesamoids, and
the deformity is partly correctible. The range of movement of the MTP joint
is well-preserved with no pain or crepitus. (If present, suggestive of arthrosis.)
Hallux rigidus
Special test: Examination corner
1. There is no tarso-metatarsal instability of the first ray (check by attempting
Short case 1
to ballot the joint – If positive, remember to also assess for generalized
laxity by Beighton’s score. This has important implications on your EXAMINER: Please examine this patient’s left foot.
management options – You may prefer doing a lapidus fusion in such case A slim middle-aged lady standing with overall normal-looking feet
to correct the hallux valgus deformity) CANDIDATE: The attitude of the forefoot and hindfoot appears
2. Silverskiold’s test: To rule out gastrocnemius tightness normal, with the arches of the foot well maintained. There
EXAMINER: How are you going to manage this patient? appears a swelling on the dorsum of the great toe
metatarsophalangeal joint.
CANDIDATE: I would take a full detailed history to find out the patient
complaints and functional limitations Could you please stand tiptoe for me? Look for whether the
big toe dorsiflexes at the MTP or IP joint during this manoevre.
EXAMINER: Oh! She is painful in the big toe!
(In case of concomitant big toe MTP arthritis, the MTP joint may
CANDIDATE: I would like to have weight-bearing radiographs of the foot.
remain straight.)
The radiographs show a moderate hallux valgus with:
Would you mind walking across the room, please?
1. Intermetatarsal angle of ___ (Normal value: <9°)
016
The patient tends to walk along the outer border of the left foot and
EXAMINER: Why not a cheilectomy?
avoids touching the big toe to the ground
CANDIDATE: Because the x-ray shows complete joint degeneration
EXAMINER: What is your differential at this stage? throughout and I think that it is likely that she would have poor
CANDIDATE: The patient shows a hallux limitus, with restricted MTP pain relief from the operation.
joint movement. I don’t see any scars to suggest that this lady has
had any surgery. Notes
EXAMINER: Go on. Remember that first MTP joint arthrodesis is a relative
contraindication in the presence of DIP joint OA
Patient sits and positions foot on conveniently situated footstool. The Silastic® implant: Not recommended because of the
candidate kneels before patient but positions himself to look directly at possibilities of transfer metatarsalgia, implant breakage,
the patient’s face at the same time as examining the foot (anticipating silicon synovitis, cock-up toe and stress fracture
a painful response to examination) Keller’s excision arthroplasty: Generally reserved for the
very elderly low demand patient
CANDIDATE: On palpation there are bony dorsal and medial
osteophytes at the level of the great toe metatarsophalangeal
Mild hallux rigidus: Surgical options
joint. The movements of the great toe MTP joint are grossly
Cheilectomy: Especially for dorsal osteophytes and dorsal
restricted, especially dorsiflexion and are associated with pain and impingement. Excision of the proliferative bone about the
crepitus throughout the range. metatarsal head, removing approximately 30% of the
EXAMINER: What would you like to do now? metatarsal head and lateral osteophytes flush with the
CANDIDATE: I would request a weight-bearing foot x-ray series. metatarsal shaft. The bone is resected to obtain 70–80° of
EXAMINER: Come and have a look at this x-ray. dorsiflexion and to eliminate dorsal impingement. If severe
arthrosis is present, a cheilectomy may lead to
X-ray reveals end-stage osteoarthritis (OA) with near-complete unsatisfactory results
obliteration of the joint space and large dorsal osteophytes. The Dorsal Closing wedge osteotomy of the proximal
intermetatarsal angle is normal and there is a slight hallux valgus phalanx Moberg): Carried out if there is loss of
EXAMINER: What are you going to offer this patient? dorsiflexion but no dorsal impingement
CANDIDATE: I would engage with the patient and find out what her Manipulation under anaesthetic (MUA) and steroid
injection: Only for mild disease
problems and expectations are. In the first instance management
may be conservative, offering analgesia and modified footwear, Short case 2: Arthrodesed left hallux in a middle-aged woman with
with a large toe box to accommodate the swelling, a sole stiffener continuing difficulties
to offload the hallux and a forefoot rocker to facilitate function.
Short history: Instructed to ask three or four questions
EXAMINER: This lady has tried all that – She wants an operation.
What was the original problem with the big toe that
What operations do you have to help her? required you to have surgery?
CANDIDATE: Metatarsophalangeal fusion. (Gold standard) What is wrong with your big toe now?
Dorsal approach, protect the EHL, excision of the cartilage upto Is it painful?
subchondral bone using nibblers and osteotomes, temporary Do you have trouble walking?
stabilisation with K-wires and the compression using two cross Examination
3.5 mm cortical screws in interfragmentary compression mode (or What has gone wrong?
compression plate). The position of the arthrodesis would be What is the optimum position for arthrodesis of the great
5–10° of valgus (no impingement of the second toe) and 25° toe MTP joint?
dorsiflexion compared to the metatarsal shaft (or 10° dorsiflexion What are the complications from surgery?
to the floor). Intraoperatively, the best way to assess this is to
press the foot against a flat surface, such as the undersurface of a
kidney dish. There should be roughly 5 mm clear space between Hammer toe
the plantar surface of the pulp and the ground to prevent the toe A short case spot diagnosis. Generally accompanied by first-
jamming when the patient walks and to facilitate toe-off. ray deformities
EXAMINER: Are you aware of any toe joint arthroplasties?
CANDIDATE: I have to say that an arthroplasty would not be my
operation of choice, but I am aware of the Silastic arthroplasty Memorandum
and of Moje toe joint replacements. There are others on the ‘A hammer toe refers to a toe with flexion at the PIP joint and
market but I’m not familiar with them. extension at the MTP joint. The DIP joint is usually flexed
although occasionally it is held in extension. The deformity can be
EXAMINER: What do you know about the Moje?
flexible or fixed. Usually there are painful corns over the dorsum
CANDIDATE: Intermediate-term survivorship data was poor, with
of the flexed PIP joint and callosities under the plantarly
significant proportions being revised to arthrodesis. prominent metatarsal head.’ (Table 13.1)
177
016
Table 13.1 Lesser toe deformities
MTP joint PIP joint DIP joint

Hammer toe Hyperextended Flexed Extended
Mallet toe Extended Extended Flexed
Claw toe Hyperextended Flexed Flexed
Curly toe Extended Flexed Flexed
Management
Flexible
Girdlestone procedure (fallen out of favour)
Fixed
Figure 13.3 Claw toes
PIP joint arthrodesis
Partial proximal phalangectomy. It relieves symptoms but
has poor cosmesis
Excision arthroplasty of the PIP joint ± extensor tenotomy Surgery
plus MTP joint capsular release The goal is to bring the MTP joints and PIP joints into a
Du Vries metatarsal head arthroplasty neutral position.
If there is a flexible deformity, consider a Weil’s osteotomy
Complications of lesser toe surgery include swelling, reoccur- or Girdlestone flexor–extensor transfer. With Weil’s there is a
rence of deformity, infection and neurovascular compromise. functional shortening of the skeletal tissue relative to the
shortened soft-tissue envelope. Problems include stiffness of
Clawing of the lesser toes (Figure 13.3) the MTP joints and plantar displacement of the metatarsal
A claw toe refers to a toe with flexion at the DIP and PIP joints heads, which can be corrected by an additional BRT osteot-
and extension at the MTP joint. Rarely occurs in isolation. omy. The principle is to preserve the anatomical parabola of
Generally the condition is neurological in origin. the relative lengths of the metatarsals. Thus, several Weil’s
A flexible deformity indicates an imbalance between extrin- osteotomies may be required to preserve this relationship
sic and intrinsic muscle forces, whilst a fixed deformity may across the forefoot. To correct the MTP joint deformity, exten-
result from joint damage, capsular and/or tendon /ligamentous sor tendon Z-lengthening and dorsal capsulotomy may be
shortening. required.
Causes include neuromuscular disorders such as Charcot– If there is a fixed deformity of the PIP joint this will not be
Marie–Tooth disease, cerebral palsy and diabetic neuropathy. corrected with a soft-tissue procedure. Again, the principle is
Other causes include compartment syndrome, poliomyelitis, to shorten the skeleton relative to the soft tissues, whilst cor-
cerebrovascular accidents and multiple sclerosis. recting the fixed deformity by excision and then arthrodesis of
the PIP joint. Thus, one solution is to undertake EDL Z-
lengthening with EDB tenotomy, dorsal MTP joint capsulot-
Memorandum omy with collateral release and relocation of the plantar plate,
‘On examination there is hyperextension at the MTP joints, in combination with shortening excision of the PIP joint and
plantar displacement of the metatarsal heads and distal migration K-wire arthrodesis.
of the fat pad. There are also plantar keratotic lesions under the
metatarsal heads and callosities present over the dorsal surface of
the PIP joints of the second, third and fourth toes of the right/left
foot. There is plantarflexion of the PIP joints and the DIP joints. Short case 1
The deformity is fixed/flexible.’ Claw toes and mild claw foot
Mild pes cavus deformity described to examiners
Big toe MTP hyperextension and PIP joint flexion
Management Examined for metatarsalgia (tenderness when metatarsal
heads palpated) with associated skin changes of keratosis
Try to identify an underlying cause if possible.
I confirmed that the claw toe deformities of the lesser toes
Conservative were fixed. I assessed flexibility of the toes in dorsiflexion
and plantarflexion. The deformity remained static with
Padding and protection of specific callosities, metatarsal pads, etc.
016
plantarflexion – If it had disappeared then the deformity is

Ankle OA

considered flexible
Discuss the differential diagnosis of this condition.
History
(Rheumatoid arthritis, diabetes, compartment syndrome, Pain is usually felt anteriorly and is mechanical:
polio, cerebrovascular accident, Charcot–Marie–Tooth) Made worse with activity and long periods of standing.
Resting generally eases the pain. In severe arthritis, one can
have night pain. Difficulty in walking on uneven terrain
Curly toe There is impingement due to osteophytes developing
anteriorly on the joint line, first on the tibia, and then
Background later kissing lesions develop on the talus, with
This is a common condition affecting one or more toes. It is often impingement occurring in full dorsiflexion. It is worse in
bilateral, symmetrical and familial. It involves mal-rotation of situations of increased dorsiflexion such as ascending
the toe with a digit flexion deformity at the PIP and DIP joints. slopes and stairs
Deformity may resolve as the child grows. It is usually asymp- Deformity
tomatic but may occasionally cause discomfort if rotation of the Restriction of movement (stiffness)
toe is such that the nail becomes weight-bearing. It can cause Occasionally there is instability or weakness of the ankle
difficulty with shoe wear or may catch when putting socks on.
Examination
Memorandum Both feet should be examined and range of movement com-
‘On examination the third to fifth toes are curled medially and pared. Any restriction of dorsiflexion is significant. Passive
plantarflexed with lateral rotation at the DIP joint. The third toe is movement will often reveal crepitus. Active and passive
flexed and deviated medially to under ride the second toe, pushing movements are usually both restricted in ankle arthritis, and
it dorsally.’
dorsiflexion is typically more affected than plantarflexion. An
effusion may be present, which can be felt either anterome-
Management dially in the notch of Harty or anterolaterally. Osteophytes
Manage conservatively if possible. Surgery is indicated if there along with synovial thickening and swelling may be palpated.
are significant symptoms and deformity such as toes under- Pain is usually present on palpation of the anterior joint line.
riding adjacent medial toes. Delay surgery until after 4 years of There is no significant valgus or varus deformity of the ankle.
age as at that stage the toes are bigger and the condition may Test for ankle stability using the anterior drawer and tilt
have improved in a number of patients. testsb.
Having assessed the ankle joint, assess both the subtalar
Open flexor tenotomy of both FDL and FDB via incision
and midtarsal joints for signs of degenerative changes as this
beneath the proximal phalanx
will influence management options. Finally, assess the neuro-
Additional flexor skin Z-plasty may be required
vascular status of the foot.
Transfer of flexors to extensors (Girdlestone transfer)
No longer recommended; this has fallen out of favour as it is
technically difficult and produces a toe stiff in extension Memorandum
A typical case would possibly be a middle-aged or elderly
Ankle OA patient or a young patient post trauma.
Look The deformity would be either a valgus or varus deformity
of the ankle (best seen from behind). There may be scars from
Deformity/swelling/scars/erythema
previous surgery in a trauma case. There may be swelling of
Stand – Inc. tiptoe, ROM
Walk – Externally rotated (foot progression angle) the medial or lateral malleoli, or of both. Assess the patient
Sit – Inc shoes, walking stick, etc with them standing on tiptoe, and then ask them whether they
can roll back onto their heels.
Feel ‘On inspecting this patient’s gait, he does not demonstrate any
Bony landmarks – tenderness asymmetry or abnormal contact with the ground. The patient
Tendons walks with an externally rotated gait to avoid tibiotalar
Sensation movements. The patient demonstrates a restricted painful range of
Pulses dorsiflexion/plantarflexion of the ankle. The subtalar movements
are well preserved. Tibialis posterior function is normal.’
Move
Passive ROM – Stiffness: Ankle/subtalar
b
Proximal to distal Go to www.youtube.com (You Tube Broadcast Yourself™) and
search for anterior drawer test to find some useful videos of this.
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Management
Conservative Short case 1: Post-traumatic OA of the ankle
Conservative management consists initially of rest, physiother- Examine this gentleman’s feet
apy, shoe modification (stiff sole and rocker bottom shoes),
Short case 2: OA of the ankle
steroid injections, splints and orthosis, etc.
Diagnosis
Surgery Management
Open or arthroscopic ankle debridement with cheilectomy Short case 3: Ankle pain in an elderly woman
Joint distraction using Ilizarov fixator Why are you making her stand on her toes?
Ankle fusion Assessment of tibialis posterior function
Ankle arthroplasty Demonstration of active and passive ROM of the ankle
Position of ankle fusion Demonstration of subtalar range of movement
Neutral dorsiflexion (10° plantar flexion in cerebral palsy)
5° valgus – Any more results in a stiff gait owing to poor
push-off Arthrodesed ankle
5–7° external rotation This one can be a difficult one sometimes as the patient may have
There are many methods of ankle fusion but the key point is a near normal gait. As in a short case, with the time constraint and
that, if you are considering ankle fusion, ask the patient to no opportunity to take a history, awareness of the possibility of
wear an ankle–foot orthosis (AFO) for a few weeks. If it this diagnosis is necessary to score in this relatively simple case
relieves pain then one is much happier to go ahead and Short case 1
perform an arthrodesis. Postoperatively, keep the patient in a Examination of ankle and subtalar movements
plaster, non-weight-bearing for 6–8 weeks and then allow Complications of arthrodesis
partial weight-bearing for a further 6–8 weeks in plaster until Position of fusion
there are radiographic signs of bony union. Try to delay Describe the rockers of the foot
arthrodesis in post-traumatic osteoarthritis for at least 2 years. What approach would you use to arthrodese an ankle, how
Advantages of ankle fusion: Stable joint, proven long-term will you stabilise it?
pain relief, tolerates heavy activity Ankle arthroplasty
Disadvantages of ankle fusion: Loss of motion and late Various third-generation ankle arthroplasty implants are avail-
degenerative effects on joints adjacent to and distal to the ankle able in the UK market like the STAR®, Salto®, Zenith®, Hinte-
Approaches for ankle fusion: gra® and Inbone®.
The implants can be either two components with the
1. Arthroscopic using the standard anterolateral and plastic insert bonded onto the tibial base plate, or else three
anteromedial portals with separate stab incisions for the components with a freely mobile plastic insert.
compression screws Extramedullary jigs are used to make a flat tibial cut first –
2. Anterior approach between the tibialis anterior and Perpendicular to the mechanical axis of the tibia, and then the
EHL – Protect the neurovascular bundle – Generally talus jigs are used. Both the tibial and talar components are
found deep to or just lateral to the EHL uncemented.
Postoperatively, most surgeons prefer to keep the patient
3. Lateral approach with excision of the distal 8–10 cm of
in a plaster, non-weight-bearing for 2 weeks and then allow
the fibula partial weight-bearing in a boot for a further 4 weeks.
4. Posterior approach – Used rarely. Reflecting the
tendoachilles and using the interval between the FHL and Contraindications:
peroneal tendons 1. Infection
Fixation methods used can be either two cannulated compression 2. Avascular necrosis of the talus
screws from the medial distal tibia into the talus, cross screws 3. Younger patient (relative contraindication)
from distal tibia into the talus, with or without a neutralisation 4. Severe mal-alignment of the tibio-talar joint (>20%)
plate. Overall successful fusion rates published are around 90%.
Complications:
Complications

Wound breakdown
Residual pain
Wound breakdown Malleolar fracture
Non-union Loosening of implants
Delayed union Infection
Infection Peripheral neurovascular complications
Peripheral neurovascular complications
016
Evidence corner: Management options for Pain can be a feature despite the presence of neuropathy.
Differential diagnosis includes sepsis, gout, chondrocalcinosis
end-stage ankle arthritis and cellulitis.
1. SooHoo NF, Zingmond DS, Ko CY. Comparison of re- Although it is unlikely to get a case of acute Charcot
operation rates following ankle arthrodesis and total ankle arthropathy in the clinical exam, the discussion can always
arthroplasty. J Bone Joint Surg Am. 2007;89:2143–9. happen either during the clinical case or in the viva stations.
a. The rates of major revision surgery after ankle
replacement were 23% at 5 years compared with 11% Examination corner
following ankle arthrodesis
EXAMINER: How will you differentiate between an acute Charcot
b. Patients treated with ankle arthrodesis had a higher
arthropathy and septic arthritis of the foot?
rate of subtalar fusion at 5-years postoperatively
(2.8%) than did those treated with ankle replacement CANDIDATE:
(0.7%) 1. Clinically: Both the conditions are likely to have local
warmth, erythema and swelling. Charcot arthropathy is
2. Gougoulias N, Khanna A, Maffulli N. How successful
likely to be have minimal or no pain. Elevation of the
are current ankle replacements? A systematic leg is likely to slightly reduce the erythema in case of
review of the literature. Clin Orthop Relat Res. infection
2010;468:199–208. 2. Haematalogically: the inflammatory markers (WCC, ESR
a. Residual pain was common (range: 27–60%) and CRP) are likely to be normal or slightly raised in
b. Ankle function improved after total ankle arthroplasty Charcot compared to being sky high in sepsis
c. The overall failure rate was approximately 10% at 5 3. Radiologically
years
a. MRI shall show edema in soft tissues as well as in the
subchondral region in both cases. Collections of pus
Charcot foot are likely to point towards infection
b. Isotope bone scan shall show a hot spot in both these
Memorandum conditions. An addition of a hot WBC-labelled scan may
Make a quick scan of the surroundings for possible clues to the be point towards sepsis
diagnosis. There may be a foot orthosis present.
4. Bone biopsy: May be needed for a definitive diagnosis in
‘The ankle joint is grossly deformed and swollen. There is loss of cases of doubt, with the obtained tissue being subjected to
the normal medial longitudinal arch of the foot and a rocker both culture as well as histology
bottom deformity of the foot. There is a chronic painless ulcer
present on the plantar surface of the collapsed midfoot caused by
excessive pressure in this area (mal-perforans). It does not appear
infected. No ulcers or blisters/skin breakdown are seen over the
first, third or fifth metatarsal head. Movement is abnormally
Three stages of Charcot arthropathy
increased and associated with loud audible crepitus, but it is Fragmentation stage
painless. There is loss of light touch and vibration sense in the foot. Plain radiographs demonstrate osteopenia, periarticular
There is wasting of the intrinsic muscles of the foot and clawing of fragmentation and subluxation or frank joint dislocation.
the lesser toes.
The foot is warm and oedematous and may demonstrate
This is a Charcot joint.’
increased laxity
A Charcot joint (neuropathic arthropathy) is gross arthroses Hypertrophic or reparative stage
with new bone formation. It is caused by repeated minor
trauma without the normal protective responses that accom- The oedema and warmth decrease. Radiographs show
pany pain sensation. The joint is painlessly destroyed. absorption of debris, fusion of bony fragments and early
bony sclerosis
Consolidation or residual stage
Charcot arthropathy Absence of inflammation and progression to a more stable,
Charcot arthropathy is defined as a non-infectious, destructive deformed foot or ankle. Radiographs show osteophytes,
process culminating in eventual dislocation and periarticular subchondral sclerosis and narrowing joint spaces
fracture in patients with peripheral neuropathy and the loss of
protective sensation. Causes
Any loss of sensation in a joint may render it susceptible to the
Clinical presentation development of a neuropathic arthropathy. It is seen most
Presents with acute or subacute inflammation with the car- commonly in diabetic neuropathy, but is also associated with
dinal signs of inflammation. spinal cord injury, cerebral palsy, meningomyelocele,
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syringomyelia, leprosy, syphilis, renal, failure congenital injury limits inflammation. The lack of pain in neuropathic
insensitivity to pain and chronic alcohol abuse. patients drives the inflammation as the patient continues to
use the limb2.
Radiographs
Radiographs reveal bone fragmentation, joint subluxation, Brodsky and Rouse classification
resorption and coalescence of the bony fragments. The bone This system describes three anatomical Charcot joints:
surrounding the joint becomes sclerotic1. Type 1: Charcot joints affect the midfoot area, including the
metatarsocuneiform and naviculocuneiform joints
Management Type 2: Charcot joints affect the triple joint complex
Bisphosphonates Type 3A: Ankle joint
Immobilization in total contact cast Type 3B: Fractures of the tubercle of the calcaneus
Midfoot or ankle arthrodesis
Aims of management in Charcot neuroarthropathy
Pathology Stop the inflammation
The natural history of Charcot neuroarthropathy is of bone Protect and maintain the architecture of the foot (prevent
demineralisation with loss of the bony architecture, fracture, deformity formation)
fracture dislocation, progressive deformity, foot ulceration and Relieve pain
infection. Arrest and reverse bone demineralisation
Although the exact nature of Charcot arthropathy remains Judicious use of fracture fixation, osteotomy and
unknown, two main theories exist regarding the pathophysiol- arthrodesis to prevent and limit deformity
ogy of the condition.
Neurotraumatic theory: Sensory–motor neuropathy The cornerstone of management is protective supportive
results in abnormally high plantar foot pressures, atrophy of immobilization. This can be achieved either with total contact
the intrinsic muscles, and both intrinsic/extrinsic imbalance casting or with one of a number of proprietary total contact boots
and flexor/extensor imbalance. available on the market. However, the mean time of immobiliza-
Proprioceptive dysfunction combined with sensory–motor tion during the acute inflammatory phase is 18 months.
dysfunction leads to loss of protective function and repetitive EXAMINER: How long will you continue the total contact cast for?
microtrauma, resulting in ligament dysfunction and joint frac-
CANDIDATE: Till the skin temperature in the affected region reaches
ture dislocation.
normal level.
Neurovascular theory suggests that autonomic neuropathy
leads to a hyperaemic state, with vasodilatation and arteriove-
nous shunting creating a hyperdynamic circulation, which Medical management
results in a mismatch in bone destruction and synthesis, New understanding of the biological pathways involved has
leading to osteopenia and subsequent fractures. provided some medical tools to reduce the cytokine-mediated
It is the combination of these mechanisms, and the ability demineralisation.
of the patient to walk with indifference upon a failing foot, Randomised controlled trials exist that have demon-
which leads to the destruction of the foot architecture. strated measurable improvement in markers of bone demin-
More recently, an inflammatory theory has also been eralisation, e.g. the bisphosphonate pamidronate given over
proposed. A triggering factor, such as an injury, which often a 12-month period as a 90 mg infusion to 39 diabetic
times goes unnoticed, sets up an inflammatory process with patients with evidence of acute-onset Charcot neuroarthro-
the elaboration of cytokines (such as interleukin-1 and tumour pathy3. In addition to standard limb immobilization
necrosis factor-alpha), which, in addition to causing inflam- techniques, this led to an improvement in pain, to a signifi-
mation, increases RANK-L expression, leading to osteoclast cant reduction in limb temperature and to a measurable
differentiation and bone resorption. reduction in the patients’ markers of bone turnover, urinary
RANK-L overexpression has been noted in Charcot suffer- deoxypyridinoline and serum bone-specific alkaline
ers. RANK-L stimulates the expression of nuclear factor kappa phosphatase.
B (NF κB), which causes pro-osteoclasts to differentiate. Similarly, the bisphosphonate alendronate given as a
However, simultaneously, NF κB increases expression of weekly 70-mg dose over 6 months led to significant reduction
osteoprotegerin, which neutralizes the effect of RANK-L and in pain scores and limb temperature, as well as a reduction in
avoids excessive osteolysis. markers of bone resorption, serum collagen COOH-
It is thought that genetic factors and osteoprotegerin poly- telopeptide of type 1 collagen and hydoxyproline. DEXA
morphism increases the risk of developing Charcot. In normal scanning showed a significant increase in bone mineral
individuals immobilization of the limb in response to painful density.
016
Surgery for Charcot foot deformity

The surgical aims of treatment are to maintain and support bone
and joint alignment, stabilise fractures, to prevent deformity and
prevent soft-tissue breakdown and secondary ulcer infection.
Principles of surgery
Fracture and fracture dislocation stabilisation
Excision of bony prominences which threaten the soft-
tissue envelope
Arthrodesis and osteotomy to realign deformity and
maintain foot architecture
Diabetec ulcer (Figure 13.4)

Despite being a common condition, this does not appear to be
a particularly common short or long case.
Memorandum
‘There is an ulcer on the sole of the right foot (most commonly at
the site of maximal pressure under the head of the first metatarsal).
The ulcer does not appear to be infected; there is no surrounding
cellulitis or discharge from the ulcer base. There is thick callus
formation over the pressure points of the feet. Two toes have
previously been amputated and the remaining toes are clawed.
There is loss of the normal medial longitudinal arch of the foot.
Both the metatarsal and heel pads are atrophied. There appears to
be reduced sweating of the foot. There is loss of sensation to light
touch, vibration and pinprick in a stocking distribution. The feet
are cold, the pulses are not palpable and there is loss of hair on the Figure 13.4 Neuropathic ulcer
lower legs, which are shiny.’
‘The toenails have no chronic changes present such as
onychomycosis, ingrowing or incurvated changes onchymycosis, Small vessel disease
ingrowing or incurvated changes. Large vessel disease
The patient has a peripheral neuropathy, a neuropathic ulcer on
Increased susceptibility to infection
the sole of his foot and evidence of peripheral vascular disease. It is
likely he has diabetes.’
Foot deformity leading to increased possibility of
mechanical stress and trauma
The neuropathic ulcer Causes of a peripheral neuropathyc

Thick hyperkeratosis Diabetic foot
Pink punched-out base, which readily bleeds Tabes dorsalis (lower extremity)
Painless Syringomyelia (upper extremity)
Hansen’s disease (leprosy)
The ischaemic ulcer Myelomeningocele (ankle and foot)
Congenital insensitivity to pain
Not surrounded by hyperkeratosis
Dull fibrotic base, does not bleed easily Other neurological problems

Peripheral neuropathies (alcohol, amyloidosis, pernicious
Painful to touch
anaemia)
Ulcers present over the curve on the first and fifth
metatarsal heads Infection (yaws, tuberculosis)
Factors that may contribute to the development of the diabetic

foot lesion include: c
In the neuropathic foot the pulses may be palpable or even
Injury bounding. The foot is warm, dry and insensate with pulses and
Neuropathy distended veins.
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Pes cavus
Look
Stand – Heel varus, cavus
Walk – Recruits toe extensors
Sit – Inc. shoes, etc
Feel
Bony landmarks
Tendons
Sensation
Pulses
Move
Special –
Coleman’s block
Hands
Spine Figure 13.5 Pes cavus
There is classically selective anterior compartment

Charcot–Marie–Tooth disease (Figure 13.5) weakness, which is associated with peroneal compartment
Commonest cause of bilateral cavus foot deformity weakness (peroneus brevis more than peroneus longus).
Exclude spinal cord pathology with MRI EHL may be spared
The posterior compartment is spared until late in the
disease
Differential diagnosis includes poliomyelitis, cerebral palsy, Frie- Foot deformity
dreich’s ataxia, spinal muscular atrophy, spinal cord tumour,
Foot intrinsic wasting/extrinsic sparing produces a clawed
syringomyelia, spinal dysraphism and diastematomyelia. toe posture. The intrinsics normally flex (plantarflex) the
MTP joints and extend the IP joints. Unopposed
Heritance/aetiology extrinsics extend (dorsiflex) the MTP joints and flex the
Charcot–Marie–Tooth (CMT) disease comprises a family IP joints
of heritable neurological diseases, owing their pathology to Cavus foot deformity is attributed to a continued
defective peripheral nerve myelin sheath proteins imbalanced pull of extrinsics, in particular tibialis posterior
It is variously named CMT, peroneal muscular atrophy and and peroneus longus, in combination with deficient
hereditary motor sensory neuropathy types 1–7 intrinsics
The genetic nomenclature describes four major subgroups: Peroneus longus sparing causes plantarflexion of the first
CMT 1(a, b, c) (50%); CMT 2 (20%); CMTX (20%); and ray, effectively pronating the forefoot in the absence of the
CMT4 (10%), with CMT1a being the commonest (40%) supinating effect of the tibialis anterior, producing an
increase in arch height. The forefoot deformity drives the
: CMT1a (AD inheritance) is associated with defective
hindfoot varus
‘peripheral myelin protein 22’ (PMP-22), which is
If the first ray is plantarflexed relative to the adjacent rays,
associated with a recombination error, causing a
when it strikes the ground first this will cause the foot to
segmental trisomy on chromosome 17. The
roll from a pronated position to a supinated position. This
defect produces a shortage of normal protein in the
rotation will be transmitted along the foot and will twist the
myelin sheath, rather than a completely defective
hindfoot from neutral to a varus position. This mechanism
protein
is the basis for the Coleman block test
Clinical features Coleman block test

CMT1 is associated with a progressive deterioration in This test is applied to a patient with a cavovarus foot
peripheral neurological function. Patients are apparently deformity. A block is applied to the lateral border of the
normal in infancy but develop weakness, ankle instability forefoot and the hindfoot, such that the first ray (which is
and cavovarus deformity in their teens or early adulthood pronated) is off the block and can plantarflex fully. This
An early sign, symmetrical reduction in lower limb reflexes eliminates the twisting moment through the foot and allows
precedes symptoms the hindfoot to assume a normal position
016
If, with the block in place, the hindfoot corrects to

neutral, this shows that the subtalar joint is mobile and
the forefoot deformity is driving the hindfoot
deformity. The hindfoot varus is potentially correctable
with a dorsiflexion osteotomy of the first metatarsal. If,
with the block in place, the hindfoot remains in varus,
this shows that the subtalar joint is fixed and not
correctable with a dorsiflexion osteotomy of the first
metatarsal
In addition, the hindfoot is inverted by the tibialis
posterior, the action of which is unopposed by its
normal antagonists, wasted by disease, namely tibialis
anterior and peroneus brevis
Foot drop occurs as a consequence of loss of tibialis
anterior
Clawed great toe: In the absence of tibialis anterior,
EHL functions as an accessory dorsiflexor of the foot
and, as such, its overaction winds the MTP joint up into
an extended posture
Foot deformity summary

Clawed lesser toes (intrinsic/extrinsic imbalance)
Clawed great toe (EHL acts as an accessory dorsiflexor in
absence of tibialis anterior)
Forefoot cavus (unopposed peroneus longus)
Hindfoot cavus (unopposed tibialis posterior)
Foot drop (loss of tibialis anterior)
Ankle instability or a high stepping case; new-onset cases Figure 13.6 Wasting of interossei
may present with a history of ankle instability or foot drop
gait
Claw toe correction through PIP joint shortening
Upper limb involvement (Figure 13.6) arthrodesis, with EDL lengthening and EDB tenotomy,
Upper limb involvement can lead to intrinsic minus deformity with relocation of the plantar plate
with small muscle atrophy, thenar and hypothenar muscle
Bony procedure, arthrodesis and ostetotomy
atrophy, interossei wasting.
Dorsiflexion osteotomy of the first metatarsal
Operative planning Lateral displacement calcaneal osteotomy. This corrects
hindfoot varus and to some extent helps to stabilise the
Lower limb MRI can be used to assess muscle group atrophy in
hindfoot (and ankle)
preparation for tendon transfer planning.
Where hindfoot varus is associated with increased
calcaneal pitch, a crescentic osteotomy can correct both
Conservative management deformities
Bracing in combination with physiotherapy can be used to Triple arthrodesis can be used for fixed cavovarus
treat symptomatic foot drop and ankle instability, treating deformity, treating both fixed deformity and attendant
symptoms and maintaining range of motion. joint degeneration in a single procedure. Rebalancing of
the foot with tendon transfer should be considered in
Surgery4,5 combination with triple arthrodesis, to prevent late ankle
Soft-tissue reconstruction with tendon transfer instability or forefoot-driven deformity
Peroneus longus to peroneus brevis transfer
Gastrosoleus lengthening Short case 1
Jones transfer (transfer of EHL from the great toe to the History
neck of the first metatarsal, with DIP joint arthrodesis) Patients complain of having tired feet and having difficulty
Plantar fascia release buying shoes that accommodate their high arch and the
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clawing of their toes; they have metatarsalgia and callosities CANDIDATE: This is a hereditary neurological disorder characterized by
secondary to lateral weight-bearing. weakness and wasting of intrinsic muscles of the foot, the peroneal
muscles, the dorsiflexors and plantarflexors of the foot and toes.
Examination The end result is a progressive equinocavovarus foot with:
‘On inspection, there is distal wasting of the lower limb muscles
Clawing toes
that stop abruptly (state where). The legs are spindle-shaped, and
Forefoot valgus
the calves have an inverted champagne bottle appearance. The feet
show a pes cavus-type of deformity with associated clawing of the Plantarflexed first ray
lesser toes. The patient has a bilateral drop foot gait (steppage Midfoot and hindfoot cavus
gait). There is recruitment of the extensors of the long extensors of Ankle equinus
the toes during forward propulsion. Ankle jerks are absent. The
ankle is in equinus; there is midfoot and hindfoot varus and cavus. Management
The forefoot is in valgus and there is a plantarflexed first ray. Conservative
Weakness of the foot intrinsics and contracture of the plantar
fascia add to the fixation of the cavus deformity and secondary Conservative management includes the use of insoles, ortho-
clawing of the toes. There are no neuropathic ulcers present. tics, physiotherapy, etc.
The patient also demonstrates wasting of the small muscles of
the hands. There is a tendency for the fingers to curl and the Soft-tissue procedures
patient has difficulty in straightening and abducting them. Achilles tendon lengthening
The spine does not show any cutaneous manifestation of spinal Split anterior tibial tendon transfer
dysraphism.’ Plantar fascia release
Claw toe procedures
Short case 2 Bony procedures
History
Dwyer’s calcaneal osteotomy
The presenting complaint is of walking on the outer
Jones procedure: Interphalangeal arthrodesis of the hallux and transfer of
borders of the feet, difficulty in wearing shoes and painful
the EHL tendon into the distal first metatarsal (to decrease clawing of the
callosities
big toe)
Walking distance is reduced to 100 yards
Previous surgery of Jones procedures and PIP joint fusions
No regular medication Examination corner
Otherwise fit and healthy
Short case 3
Examination A candidate was asked to examine a patient’s gait and his
lower legs. As soon as the patient walked, the bilateral foot
‘On inspection, this gentleman stands with some difficulty. He has
drop and wasted anterior muscle compartments were obvious,
obvious wasting of both calves. On the left foot, he has a varus
but the candidate failed to pick up the sign. The examiners
heel. Both feet are in equinus. Looking from behind, one can again
were critical of the candidate’s neurological examination of the
see the obvious varus left heel.’
lower legs as the candidate insisted on performing a myotomal
‘Just tell me if you have any discomfort on palpation.’
type of power assessment – He required prompting and
‘There are thick callosities over the lateral border of both feet.
appeared hesitant. The candidate failed to appreciate that
The hindfoot will not come to neutral. The subtalar joints will not
the small muscles in the hand can be affected in this condition.
correct to a neutral position; they are fixed in 10° of inversion.
There is a jog of movement of the hindfoot. He has grade 4 power
Short case 4: Cavus feet, young man with hereditary sensory–motor
of tibialis posterior. There is almost no power of eversion.’
neuropathy
‘Push your big toe down.’
Differential diagnosis and management
‘He does appear to have good peroneus longus power. The
Types of hereditary sensory–motor neuropathy
Coleman block test does not improve the hindfoot varus,
Surgical management: Jones procedure
suggesting that it is fixed.’
EXAMINER: Can you explain the principles of the Coleman block test?
CANDIDATE: Initially the hindfoot is in varus. The Coleman block test is Other causes of pes cavus
performed by placing a block under the lateral column of the foot and
allowing the first metatarsal to drop to the floor. Heel varus correction Aetiology
indicates that the hindfoot deformity is flexible and that the varus position Idiopathic
is secondary to the plantarflexed first ray, or valgus position of the Congenital: Arthrogryposis, residue congenital talipes
forefoot. A fixed hindfoot deformity will not correct. equinovarus (CTEV)
EXAMINER: What is Charcot–Marie–Tooth disease? Traumatic: Compartment syndrome, crush, burns
016
Neuromuscular: Disorder of muscles, peripheral nerves, Two main patterns of deformity tend to occur: Calcaneo-
spinal cord, central nervous system cavus and cavovarus.
Calcaneocavus
History This mainly involves hindfoot abnormalities. Dorsiflexion of
Congenital or acquired? When did you notice this the calcaneum occurs because of a weak Achilles tendon with
deformity? Were you born with it? When did it develop?
normal tibialis anterior. There is no pronation of the forefoot
Progression: Is it getting worse? and, therefore, no varus deformity of the hindfoot. It is more
Full family history: This often runs in families, so check the common in polio.
family history for neurological disease/neuromuscular
disease Cavovarus
Any problems with your back? This mainly involves forefoot abnormalities. The forefoot is
Any problems with the bladder or bowel? (Bladder or pronated and the heel is in varus. This is more common in
bowel dysfunction) hereditary motor sensory neuropathies (HMSN).
Have you any pins or needles or loss of power in your legs?
(Sensation and motor power) Investigations
Any difficulty with walking, weakness or tremor? Weight-bearing lateral radiograph
Patient may complain of difficulty with footwear, of tired X-ray spine for spina bifida
aching feet, of metatarsalgia and lateral foot pain because
MRI scan of the spine
of the area of contact with the floor, pressure over the
dorsum of the PIP joints, or recurrent giving way of the Neurological referral
ankle
Management
Memorandum Conservative
Look for orthosis, splints and special shoes. Moulded insoles, heel pads, etc
‘On inspection of the feet there is a unilateral/bilateral
Surgery
accentuation (exaggeration) of the medial longitudinal arch of the
foot. There is clawing of the lesser toes with callosities over the Jones procedure: Fusion of the IP joint and proximal
dorsal PIP joints and heads of the metatarsals (examine the soles of transfer of EHL to the neck of the first metatarsal
the feet). There is clawing of both hallux and prominence of the IP joint fusions as part of claw toe correction
EHL, which is overactive as a dorsiflexor to compensate for a weak Calcaneum osteotomy – Closing wedge lateral osteotomy
tibialis anterior. There is a varus of the hindfoot, as well as a high Plantar fascia release (Steindler release) if mobile
arch, clawing of the toes and callosities. There are no visible ulcers
Triple arthrodesis as a salvage procedure for a severe
or surgical scars present. There is a generalized wasting of the calf
muscles. On the double heel raise test, the hindfoot remains fixed
deformity
in varus.’
‘I would like to examine this gentleman’s spine, please. On
inspecting this man’s spine, there are no obvious hairy patches, Examination corner
skin discoloration or swelling suggestive of either occult spina
Short case 1: Multiply operated bilateral cavovarus feet
bifida or diastematomyelia.’
Examination features
Carry out a full neurological examination of the lower legs, Differential diagnosis
testing for sensation, muscle power and reflexes. Suggest further surgery options
‘On examination of gait, the patient demonstrates a drop foot gait.
Examining his hands, he demonstrates intrinsic muscle wastage.’ Short case 2: Bilateral pes cavovarus due to diastematomyelia
Candidate asked to take a short history
Assessment of gait
The Coleman block test Examination of motor and sensory function of the lower
The Coleman block test is used to check whether the subtalar legs to locate the level of the lesion
joint is mobile or rigid. It is performed by placing the patient’s Demonstration of knee reflexes and ankle clonus
Surgical scar from a previous Jones procedure: ‘What is this
foot on a wooden block with the heel and the lateral border of
scar suggestive of, why is the operation performed?’
the foot on the block full weight-bearing whilst the first,
second and third metatarsals are allowed to hang freely into Short case 3: Young woman in her early 20s, sitting down on a chair;
plantar flexion and pronation. If the heel varus corrects while unilateral pes cavus deformity
the patient is standing on the block, the hindfoot is considered Candidate asked to examine left foot.
flexible.
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an antalgic gait with an externally rotated attitude of both feet.

CANDIDATE: On inspection of the left foot there is an obvious A roll-over gait is present.’
severe pes cavus deformity present with clawing of the lesser ‘On inspection of the plantar surfaces of both feet, there are
toes. There are callosities present over the dorsal surfaces of her callosities present over the metatarsal heads. There are no ulcers,
PIP joints. There is a well-healed longitudinal surgical scar present scars or sinuses. There is crepitus, tenderness and swelling present
over both malleoli. Movement, both actively and passively, of the
over the dorsal surface of her big toe.
ankle and subtalar joint is reduced. Specifically, dorsiflexion is
CANDIDATE: I would like to examine her spine now.
painful and limited both actively and passively to neutral.
EXAMINER: The spine is normal – Don’t bother. What operation has Similarly, plantarflexion is limited to 20° bilaterally both actively
she had on her big toe and why? and passively.’
CANDIDATE: She has had a Jones procedure; this is where the IP ‘The left/right subtalar joint is irritable with only a jog of
joint is fused and the EHL tendon is transferred to the metatarsal movement present. There is reduced power of dorsiflexion,
neck to prevent hyperextension of the hallux. plantarflexion, inversion and eversion, probably MRC grade 4.’
Check the vascular status of the foot. Perform a careful neuro-
The candidate was not asked to demonstrate anything else
logical assessment as there may be a neuropathic component.
clinically, particularly the Coleman block test, gait or
neurological examination.
Management
Short case 4 The general surgical principles applicable to the rheumatoid
Postoperative resection of a spinal tumour foot depending upon the severity of disease include:
Bilateral wasted calves with resolving neurology
Forefoot reconstruction with hallux valgus and claw toe
Stiff cavovarus foot – Differential diagnosis and
management
reconstruction
Management Forefoot arthroplasty, e.g. Hoffman excision arthroplasty
lesser MT heads and first MTP joint fusion (A stable
first ray)
Rheumatoid foot Subtalar or triple arthrodesis
A classic short case. It is unlikely that you would go much Ankle arthrodesis
further than a general inspection of the feet. You may then be Pan talar arthrodeses
asked about the management principles of the rheumatoid Ankle arthroplasty
foot. Remember to mention the need to assess the hip and
knee first before considering foot surgery. Intermediate case 1: Rheumatoid foot oral
EXAMINER: Examine this patient’s foot.
Memorandum The patient, an elderly lady, sat in a chair with both feet
(Examination tip is to start from the ankle and work distally.) exposed below the knee. There are scars from bilateral total
‘On general inspection there is a bilateral symmetrical deforming knee replacement. The left foot has severe clawing of all the
arthropathy. There is a hindfoot valgus and localized swelling over lesser toes and severe hallux valgus. The right forefoot bears
both the medial and lateral malleoli. This could be due to surgical scars on the dorsum of the forefoot, with neutrally
tenosynovitis of the tibialis posterior and peroneal tendons. There aligned lesser toes which appear somewhat foreshortened and
is also collapse of the medial longitudinal arch of the foot, the hallux is neutrally aligned, though slightly extended, the
suggestive of possible tibialis posterior tendon rupture.’ pulp not quite touching the ground.
‘There is pronation of the forefoot (forefoot abduction). There Her hands, resting on her lap, have typical changes of
are severe bilateral hallux valgus deformities and clawing of advanced rheumatoid arthritis: There are walking aids and
several lesser toes and a hammer toe deformity of the third left toe. orthotic shoes beneath her chair. The skin on her lower limbs
There are callosities over the dorsal surfaces of the PIP joints of
is atrophic, her lower limbs are thin and the calf muscle mass is
the lesser toes. The lesser toes are dislocated/inflamed/ulcerated.
There is swelling over the MTP joints with the appearance of
similarly atrophic.
possible subluxation of these joints.’ CANDIDATE: On examination I note that this patient has evidence of
‘The skin appears papery, thin and fragile with a possible severe arthropathy affecting her left foot, and that her right foot appears to
vasculitis. There are no obvious rheumatoid nodules or ulcers have undergone some surgical correction.
present. There is normal sensation of the foot and ankle. Similarly, I also notice evidence of arthropathy affecting her upper limbs and
the dorsalis pedis and posterior tibia pulses are present and
evidence of possible knee arthroplasty, suggesting a systemic arthritides
capillary refill is <2 seconds.’
such as rheumatoid arthritis.
‘The patient was not able to perform a double heel raise test
because of pain. On double heel raise test, the heel failed to invert EXAMINER: Just focus on the feet for now.
and the medial longitudinal arch remained collapsed. This CANDIDATE: Examining the feet sequentially, the left forefoot shows
suggests tibialis posterior insufficiency. The patient demonstrates severe clawing and dorsal subluxation of all the lesser toes: The toes
016
effectively sit upon the dorsum of the distal forefoot and are severely Palpating the talar neck, and manipulating the ankle by
clawed, there is a callosity on the dorsum of all the PIP joints and there is holding the heel, assess ankle movement. These are also
healing ulceration on the dorsum of the first toe PIP joint. It does not reduced, though at rest the ankle sits in neutral alignment and
clinically appear to be infected. there is both dorsiflexion and plantarflexion through the ankle.
The great toe is severely mal-aligned, in a hallux valgus deformity, there ‘I would now like to test the patient’s power in the major
is a large bunion and the MTP joint appears swollen and with possible muscle groups.’
prominent osteophytes distorting the skin. EXAMINER: Go on.
The great toe is also markedly pronated and there are dystrophic
changes affecting the great toe toenail.
It is important to place the patient’s foot into the position in
which you want to test mucle power; asking them to ‘invert’,
The skin of this lady’s lower leg and foot is atrophic and pigmented and
‘evert’ or push up or down will confuse the patient and make
I notice some swelling around her ankle and evidence of muscle atrophy
you look like an amateur. Rehearse the following for a generic
in her lower legs.
test of foot motor function, but exercise caution in the
‘Would you mind if I look at the sole of your foot, madam?’
rheumatoid foot as you may hurt the patient.
(Extending the patient’s leg very gently, being aware of the knee
arthroplasty)
‘Extensors: Tibialis anterior, extensor digitorum longus,
extensor hallucis longus’
The fat pad has subluxed forward as the lesser toes have subluxed and
the metatarsal heads of all rays, but in particular the second and third rays
Ankle dorsiflexion – Place the ankle and foot into maximum
are very prominent. There is callus on the skin under all the lesser toe
dorsiflexion, place your hand on the dorsum of their foot
metatarsal heads, though relative sparing of the great toe.
and say to the patient, ‘Hold your foot in this position’, ‘Resist
me when I push against you’.
The metatarsal heads are subcutaneous and are immediately palpable.
(Watching the patient for signs of discomfort.) Notice the tibialis anterior fire up, and also notice the
(Replacing the patient’s foot on the ground.) The lesser toes are all active contraction of the toe extensors.
subluxed or dislocated; 2 and 3 are not passively correctable although Toe extension – Maintain the dorsiflexed posture, but this
4 and 5 are slightly more so. I note that the IP joints of the second and time place hand on dorsum of toes, and say to the patient,
third toes are stiff and possibly ankylosed, and the fourth and fifth toes are ‘Hold your foot in this position’, ‘Resist me when I push
similarly stiff at the level of the IP joints. against you’.
The great toe hallux valgus deformity is not passively correctable, and Plantiflexors – Gastrosoleus
I notice that movements within the great toe, and in particular extension, Place the foot and ankle into extreme plantarflexion, place
are markedly reduced. There is palpable osteophytosis associated with the your hand under the sole of the foot and say to the
great toe MTP joint. patient, ‘Hold your foot in this position’, ‘Resist me when
‘Do you feel me touch you here and here, madam?’ The patient’s I push against you’.
sensation is grossly intact, and I can palpate the dorsalis pedis pulse . . . Toe flexors: Flexor digitorum and hallucis
but not the posterior tibial pulse.
Maintain the plantarflexed position, but this time place
‘I would now like to continue to examine this patient’s midfoot, your fingers beneath the lesser toes and then the hallux,
hindfoot and ankle’ . . . and say to the patient, ‘Hold your foot in this position’,
EXAMINER: Go on. ‘Resist me when I push against you’.
CANDIDATE: If you don’t mind, madam, I would like to test the movement Evertors: Peroneus longus and brevis
of your foot and ankle. I will try not to hurt you, but please let me know if
Place the foot into extreme eversion, place your hand
I cause you any discomfort.
against the lateral border of the foot, and say to the
PATIENT: Fine.
patient, ‘Hold your foot in this position’, ‘Resist me when
(With due diligence in avoiding hurting the patient:) I push against you’
CANDIDATE: I notice that this lady has preservation of her medial Inversion: Tibialis posterior
longitudinal arch, albeit at the moment without weight-bearing. Place the foot into maximal inversion (ideally in slight
I note that there appears to be neutral alignment of the hind-mid- plantar-flexion to neutralize tibialis anterior), and place
and forefoot, though I will assess this better when I ask the patient your hand against the medial border of the foot. Say to
to stand. the patient, ‘Hold your foot in this position’, ‘Resist me
Gently controlling subtalar joint and hindfoot movement with when I push against you’.
one hand, passively abduct and adduct and invert and evert the
mid/forefoot. The movements are generally reduced. CANDIDATE: Accepting that this patient has globally reduced movement
Gently controlling the talar neck with one hand, and throughout the hindfoot and midfoot, and some painful inhibition as a
grasping the heel with the other, attempt to rock the heel from consequence, there does not seem to be any overt weakness of any
side to side. The movements are markedly reduced. muscle group.
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EXAMINER: What would you like to do now? should be stopped one half-life prior to surgery and suspended
CANDIDATE: I would like to examine the patient weight-bearing and then until 2 weeks following surgery.
walk the patient. The principles of management for the severely arthritic
rheumatoid foot are to realign, stabilise and refunction the
first ray by performing either a first MTP joint arthrodesis or
On examination the patient’s lesser toes maintain their sub- a Keller’s arthroplasty, though the evidence in the literature
luxed position, the plantar fat pad remains subluxed forward suggests that first MTP joint arthrodesis provides greater sta-
and the lesser toes remain subluxed on the dorsum of the
bility and a more predictable outcome, accepting the risks of
forefoot, not contacting the ground, and the hallux remains
non-union in arthrodesis.
in valgus and pronation and does not seem to be loaded
With respect to the lesser toes in end-stage rheumatoid
effectively.
disease, the options are to perform a Hoffman-type excision
The height of the medial longitudinal arch is preserved in
arthroplasty, with excision of all the metatarsal heads, through
the weight-bearing stance. Beware, as the rheumatoid foot may either a plantar or a dorsal approach, sectioning the metatarsal
be accompanied by midfoot collapse due to arthrosis or to necks to create an even parabola of gradually decreasing length
tibialis posterior insufficiency. from the second to the fifth metatarsals. The alternative is to
The hindfoot is normally aligned in slight valgus, relative to
perform an excision arthroplasty of either a Stainsby type,
the forefoot.
removing the bases of the proximal phalanges, or of a Fowler
CANDIDATE: Would you mind walking, please? type, excising both the metatarsal head and the base of the
(The patient advises that she can only take a few steps, because proximal phalanx. However, the principle in all cases is to try
of pain walking barefoot.) She walks with a normal foot pro- to relocate and refunction the plantar plate by passing an
gression angle and a shortened step length, there is reduced elevator under the metatarsal head to relocate and reposition
ankle movement with reduction of all three rockers, there is no the plate.
heel strike as such, initial contact is flat-footed and there is no EXAMINER: Are you aware of any publications supporting the principles
toe-off in terminal stance. that you have described?
EXAMINER: OK to the patient, thank you. Now have a look at the patient’s Bell. (Pass.)
x-rays.
CANDIDATE: This is an AP and a lateral of the patient’s left foot. The AP
shows erosive arthropathic changes of the lesser toe metatarsal heads, with Short case 1
frank dorsal dislocation of the MTP joints. There is also erosive change of Examine the feet.
the articular surfaces of the proximal phalanges. The clawing is apparent Hallux valgus with pronated great toe
on the AP. Clawed toes
EXAMINER: OK, we won’t discuss the contralateral foot, which you have Callosities under metatarsal heads
correctly observed has been operated upon, but talk me through the
Varicose eczema
general principles for the management of this lady’s forefoot.
CANDIDATE: The principles are to offer initially conservative and, if
unsuccessful, operative management. Pes planus
Conservative management is centred around providing Look (Figure 13.7)

accommodative and supportive footwear, with custom-made Stand – Incl. single leg tiptoe, ROM (heel valgus > varus)
shoes with a wide-toe box to accommodate the toes, and Walk – Failure of restoration of arch
insoles which are made of an appropriate material which Sit – Inc. shoes, etc
protects the metatarsal heads. Scoops can be applied to the Feel
insole to accommodate individual prominent heads. Bony landmarks
If the patient’s symptoms are intolerable and are signifi- Tendons – Tibialis posterior
cantly affecting their quality of life, then the operative options Sensation
include the management of rheumatoid disease in general Pulses
during surgery and then specific to the foot.
Move
The patient must be appropriately prepared for surgery,
Passive ROM (reduced subtalar and midtarsal movements)
with specific attention in rheumatoid patients to the safety of
Proximal to distal
intubation with respect to the stability of the C-spine and
Special tests –
management of disease modifying anti-rheumatoid drugs Beighton’s criteria (flexible flatfoot) (young/adolescent)
(DMARDs). Steroids and non-biological agents can be con- Marfan’s/Ehler–Danlos
tinued in the perioperative period, and biological agents
016
the rest of the examination should be directed towards

confirming this clinical diagnosis.)
CANDIDATE: The medial longitudinal arch of the left foot is not
visible.
EXAMINER: What do you think the diagnosis is?
CANDIDATE: I think the diagnosis may be tarsal coalition.
EXAMINER: You have one test only to confirm this – Which one will
you use?
CANDIDATE: Can you stand on your tiptoes for me? On double heel
raise stance the left heel fails to invert and go into varus. The
medial longitudinal arch of the foot remains flat. Jack’s test fails to
correct the pes planus deformity.
(Jack’s test: The patient is asked to stand weight-bearing

with the foot flat on the ground, the candidate then
dorsiflexes the big toe, and watches for the re-creation of
the medial arch: This is suggestive of a flexible flat foot.)
EXAMINER: Good.
I carried on examining the patient.

CANDIDATE: The patient walks with an antalgic gait. Palpation
revealed tenderness at the anterolateral aspect of the foot –
The sinus tarsi (location of the coalition). There is no peroneal
spasm/protective spasm of the peroneal muscles. There are
normal ankle movements of both feet but no passive movement
present in the left subtalar joint compared to the opposite side.
EXAMINER: Why don’t you go on to test motor function of the feet?
Figure 13.7 Pes planus Plantarflexion, dorsiflexion, inversion and eversion were tested
whilst the patient was sitting in the chair. There was grade
Tarsal coalition 5 MRC power compared to the opposite side. This was done very
This is not an uncommon lower limb short case, with usually slickly as I had practised it before with somebody sitting in a chair
at least one patient in the examination hall with the condition. EXAMINER: What are you going to do for this patient?
CANDIDATE: Resection of the coalition.
EXAMINER: What about conservative management?
Short case 1: Young boy (approximately 11 years old) sitting on CANDIDATE: The patient is markedly symptomatic and I do not
a chair think conservative management will work although it may have a
Examiner looks around and spots the young boy. role in less severe cases.
EXAMINER: Why don’t you start by examining this young man’s left Discussion
foot and tell me what you find. He has been complaining of some The subtalar joint may be rigid and any attempt to bring the
vague pain in this foot for several months. foot into inversion aggravates pain and causes peroneal
CANDIDATE: (After a brief introduction and handshake with patient.) muscles to go into spasm.
May I examine your foot? Would you stand up for us so that we Calcaneal navicular accounts for two-thirds of cases; pain
can have at look at your feet? in the anterolateral aspect of the foot in the region of the
sinus tarsi
Examination started with inspection from behind (the rules were Talocalcaneal coalition (one-third of cases) presents with
immediately broken!). pain under the medial malleolus and reduced subtalar
CANDIDATE: On inspection there is a marked pes planus deformity movement
of the left foot with a valgus heel compared to a normal looking Talonavicular – Very rare
right foot.
Depending on the nature of tissue involved the coalition can
be a synchondrosis (cartilage), syndesmosis (fibrous tissue) or
synostosis (bone).
(A spot clinical diagnosis – Even at this early stage I picked
Fifty per cent of the cases have bilateral affection, and
up that it was a probable tarsal coalition. However, one
multiple coalitions are present in 20% of the cases.
cannot assume anything and has to carry on examining, but
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016
eversion is painful. The midfoot can be stabilised and the

The natural history is unclear; it is not uncommon to find tarsometatarsal joint moved in a combined fashion and then
relatives with the condition who are entirely symptom free. individually. The metatarsophalangeal joint movements and the
Presentation features are generally either recurrent ankle interphalangeal joint movements are full and pain-free. We will
sprains or else a vague ache in the foot. Management depends now look at the active movements of the foot and ankle. With the
on the severity of symptoms. Mild cases may initially be man- hindfoot held in neutral, active dorsiflexion is limited to neutral. If
aged conservatively; observe with shoe modification and the hindfoot is allowed to go into pronation, dorsiflexion is
change in activity. Established symptomatic cases with pain markedly increased. There is a good range of plantarflexion and
would be an indication for surgery, usually excision of the bar. this can quite clearly be seen to be a combined movement of all the
If symptomatic degeneration is present one could consider a joints of the foot and ankle. There is a good range of inversion and
triple arthrodesis; however, this should not be done until late eversion, but there is weakness of resisted inversion and the
adolescence/adulthood. A talocalcaneal coalition is more likely activity of tibialis posterior is substantially reduced.’
to require arthrodesis owing to disturbance of the weight-
bearing relationship of the foot (especially so if the coalition
extends over >50% of the posterior facet). Memorandum 2
‘On inspection there is a planovalgus deformity of the right/left
foot. There is hindfoot valgus, forefoot varus, external rotation of
the foot and forefoot supination. In addition, there is splaying of
Tibialis posterior tendon dysfunction/rupture the forefoot. Medially, there is a swelling over the posterior tibial
Memorandum 1 tendon, posterior and distal to the medial malleolus. From behind,
the patient demonstrates the sign of too many toes.’
‘In the standing position from the front, we notice that the ‘There is a rigid/flexible flat foot and heel inversion is not/is
patient’s feet are externally rotated, that her hindfeet are in valgus occurring. The patient is unable to perform a single limb heel raise
and that her forefeet are abducted. When seen from behind, these test (supported on wall).’
deformities are even more obvious. She demonstrates the sign of ‘I am feeling for any areas of tenderness or crepitus; there is
‘too many toes’ and requires assistance to rise up on to tiptoes. The anterolateral ankle and sinus tarsus pain. There is loss of power
hindfoot remains in valgus and the medial longitudinal arch and weakness of inversion from an everted position. Passive range
remains flattened. She has even more difficulty in the single foot of motion of the hindfoot and midfoot is reduced to about half
stance.’ normal.’
‘As she walks in bare feet one notices the heel strikes briefly and
collapses into valgus before the forefoot goes into marked
pronation during the stance phase. Toe-off is markedly reduced Classification (Johnson and Strom, 19896)
and the feet are in an attitude of external rotation with the forefeet Johnson and Strom devised three classification stages, with
abducted, which produces a roll-over gait.’ Myerson7 adding a fourth:
‘I would like now to examine the patient’s shoes. There is
increased wear on the medial aspect of the sole, with roll-over onto Stage 1 (tendinopathy)
the medial side of the toe. The uppers are not broken but there are
orthoses in the shoes, which show some evidence of wear on the Tenosynovitis, mild symptoms
medial side.’ Medial ankle and foot pain
‘We are now going to examine the patient in the seated Swelling without deformity
position.’ Still able to perform a single limb heel rise test
‘The lesser toes are held in a somewhat flexed position and there Normal tendon excursion
are small pressure lesions on the dorsal surfaces of the proximal
Radiographs normal, MRI shows oedema around the
interphalangeal joints. The great toe is slightly extended at the
tendon ± intrasubstance degeneration of the tendon
interphalangeal joint and there is dystrophy of the toenail.’
‘There is some swelling around the tarsometatarsal region of the
Stage 2 (flexible deformity)
first ray. There is also some swelling around the outside of the left
ankle. On examining the plantar aspect of her feet, there is obvious Deformity still remains flexible
swelling on the medial aspect of the midfoot with overlying Pain and tenderness over the tendon; palpable
callosity formation. With the thumb on the neck of the talus, the enlargement/defect
hindfoot is put into the neutral position and when it is held there it Too many toes sign; single heel raise test abnormal
is quite obvious that the forefoot is supinated.’
Radiographs show increase in the lateral talocalcaneal
‘When we examine her for tenderness, we find marked localized
angle; MRI shows tendon degeneration ± discontinuity
tenderness just below the tip of the left lateral malleolus.’
‘Once more palpating the neck of the talus we can assess
Stage 3 (fixed deformity)
tibiotalar dorsiflexion and plantarflexion followed by talocalcaneal
inversion and eversion. My hand now slides down to stabilise the Rigid flat foot deformity associated with hindfoot valgus
hindfoot so that we can assess midfoot inversion and eversion. and loss of subtalar joint motion
I am moving my hand down to stabilise the hindfoot so that we Forefoot varus, absent single heel rise test, secondary
can invert and evert the midtarsal joint. In this case, midtarsal degeneration
016
Predominantly anterolateral ankle pain secondary to Equinus

impingement of the calcaneus on the fibula and not
The majority of weight is borne by the forefoot, the hindfoot
anteromedial ankle or foot pain as seen in the earlier stages
remaining off the ground. The equinus deformity may be
of the disease
compensatory for either quadriceps or gluteus maximus weak-
ness, or because of shortening of the limb. The equinus
Stage 4 (fixed deformity with generalized arthritic changes of
deformity may also be caused by contracture of gastrocnemius,
the foot) ankle contracture or post-traumatic deformity.
Significant soft-tissue attenuation and loss of the deltoid
ligament
Valgus angulation of the talus Calcaneus
Subtalar joint degeneration Here the weight is borne mainly by the hindfoot. The forefoot
Fixed forefoot supination may have varying degrees of weight-bearing, but definitely
below normal.
Management
Stage 1 Varus
NSAIDs, physiotherapy, insoles, immobilization in a short The weight is borne mainly on the outer side of the foot. This
leg walking cast, tendon decompression and debridement deformity is mainly at the hindfoot with associated forefoot
pronation.
Stage 2
Non-operative, orthotic arch supports, etc Valgus
FDL tendon transfer with medial displacement calcaneal Weight-bearing is borne mainly on the inner side of the foot.
osteotomy, which redirects the strong pull of This deformity is of the hindfoot or of both the forefoot and
gastrocnemius muscle; lateral column lengthening. hindfoot with associated forefoot supination.
Cobb repair involves a split anterior tibial tendon transfer
often combined with a medial displacement calcaneal
osteotomy Inverted foot
When the hindfoot and forefoot are both in a varus position,
Stage 3 the deformity is termed an inverted foot. The accentuation of
Subtalar or triple arthrodesis depending on the degree of this position will gradually turn the sole towards the sky –
joint arthrosis and age of the patient Supination of the foot. In these positions, i.e. in inverted and
supinated foot, adduction of the forefoot and plantar flexion of
Stage 4 the ankle will coexist.
Tibiotalocalcaneal arthrodesis may be required if the
tibiotalocalcaneal joints are incongruent and arthritic Everted foot
Rarely The hindfoot and forefoot are both in a valgus position. The
outer part of the sole increasingly bears less weight. In this
Triple fusion and ankle arthroplasty with ligament position, abduction of the forefoot and dorsiflexion at the
reconstruction and tendon transfer
ankle will coexist.
Pan talar fusion
Deformities of the foot Forefoot position

Part of the problem with examination of the foot and ankle is Pes cavus
that various terminologies are used in a very loose fashion and A normal foot has a medial longitudinal arch that is higher
this can confuse even the best prepared of candidates. Despite than the lateral one. When this normal proportion is exagger-
efforts towards standardisation of terms there can still be ated, the medial side of the foot tends to assume the shape of a
considerable confusion. high arch. It rarely occurs as a single deformity. It is a common
In addition, the foot is a complex structure which has accompaniment of equinovarus, equinus and clawing of
multiple joints and is, therefore, much more difficult to exam- the toes.
ine than single joint systems. This means that various parts of A forefoot cavus describes cavus owing to excessive plantar
the foot interact with each other and create complex deform- flexion of the first metatarsal, and results from the action of
ities that require discrete and definite descriptions and makes peroneus longus, when its action is preserved and its normal
sequential sensible examination difficult to complete. antagonists are weak, i.e. tibialis anterior in CMT disease.
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Hindfoot cavus describes cavus which is caused primarily

by increased calcaneal pitch, which may be seen in idiopathic
The relationship of the forefoot to the hindfoot
cavus, but is also seen in polio where gastrosoleus is weak. Forefoot neutral: With the heel in neutral, the plane of the
metatarsals and the plane of the heel are colinear
Forefoot varus: Forefoot supination: With the heel neutral,
Pes planus the lateral border of the forefoot is lower than the medial
Collapse of the medial longitudinal arch. The normal concav- border of the forefoot
ity caused by the medial longitudinal arch is absent and instead Forefoot valgus: Forefoot pronation: With the heel neutral,
the medial side of the foot may bulge as a medial convexity, the medial border of the forefoot is lower than the lateral
particularly on weight-bearing. border of the foot
References 3. Jude EB, Selby PL, Lilleystone P, et al.

Bisphosphonates in the treatment of
5. Alexander IJ, Fleissner PR. Pes
cavus. Foot and Ankle Clin.
1. Schon LC. Radiographic and clinical Charcot neuroarthropathy: A double- 1998;3:723–35.
classification of acquired midtarsus blind randomised controlled trial.
deformities. Foot Ankle Int. 6. Johnson KA, Strom DE. Tibialis
Diabetologia. 2001;44:2032–7. posterior tendon dysfunction. Clin
1998;19:394–404.
4. Guyton GP. Current concepts review: Orthop. 1989;239:196–206.
2. Brodsky J. Patterns of breakdown, Orthopaedic aspects of Charcot–
natural history, and treatment of the 7. Myerson MS. Adult acquired flat foot
Marie–Tooth Disease. Foot Ankle Int. deformity. J Bone Joint Surg Am.
diabetic Charcot tarsus. Orthop Trans. 2006;27:1003–10.
1987;11:484. 1996;78A:780–92.
016
Paediatric clinical cases

Chapter
14 Sattar Alshryda and Philip Henman
Introduction In intermediate cases, a thorough but relevant history is essential

to reach a diagnosis (and pass the exam!). In short cases
Preparation for the FRCS paediatric orthopaedic section is
the diagnosis is usually obvious (listen to the examiner carefully.
confusing not only for the candidates but for the examiners
The answer is in the question!). Do not let the stress of the exam
as well. The GMC has outlined and approved the depth and
prevent you interacting with the child. (A candidate reported
breadth of knowledge required for specialty training in trauma
that a child told him the diagnosis ‘I have Perthes’ disease’!).
and orthopaedic surgery including paediatric orthopaedic. The
The duration of symptoms, mode of onset, history of any
expected levels of knowledge are indicated on the following
injury, frequency and timing of symptoms, aggravating/reliev-
four-point scale:
ing factors, any functional impairment, previous investigations
1. knows of or treatment received should be noted.
2. knows basic concepts In children with cerebral palsy (CP), a thorough prenatal
3. knows generally and perinatal history is expected. A history of bleeding during
4. knows specifically and broadly. pregnancy, maternal diabetes and reduced fetal movements
Figure 14.1 is a snapshoot from the GMC documents for during late pregnancy, breech presentation, difficult labour,
specialty training in trauma and orthopaedic surgery. It is premature birth, and jaundice at birth are significant factors
evident that candidate should achieve level 4 in common topics to be enquired about.
such as developmental dysplasia of the hip (DDH), slipped Enquire about developmental milestones (Table 14.2); e.g.
upper femoral epiphysis, leg length discrepancy, clubfoot and when did the child first sit and walk?
scoliosis. It is useful to enquire if other members of the family have
Having helped hundreds of candidates to pass their exams, similar problems. A number of orthopaedic clinical conditions
we rarely come across candidates who attained the above levels; run in families; e.g. DDH, clubfeet, pes cavus, etc. Finally, a
nevertheless, most succeed to pass the exam! Based on previous history of past illnesses and hospitalisations completes the history.
candidates experience collected over the years, we have rewritten
the two paediatric orthopaedic chapters of this book to cover Examination of a child
most topics that featured in these exams. Both chapters are Start examination whilst taking the history; observe the child
complementary to each other. Some repetition is unavoidable activities, interaction with people and environment. Notice if
and may be advantageous. We have added clinical photographs there is any walking aids, wheelchairs, braces or SOS bracelets.
to create a mental association to these clinical scenarios. School uniforms may indicate whether the child goes to main-
Table 14.1 summarizes cases that have been featured in the stream schools or schools for children with special needs.
clinical section of the exam. The wide range of these cases can Like any other examination, it usually involves:
be disconcerting and we will try in this chapter to guide you on General assessment
how to tackle these or similar cases successfully even if you
Specific muscular-skeletal examination related to the main
know little about the condition. Some of these topics are
complaint
covered in other section of the book such as scoliosis, congeni-
The examiner usually guide you on what is required to assess
tal hand deformities and trigger thumb.
(so listen to the question carefully and do not hesitate to ask
for clarification if the instruction was not clear).
Approach
Children come to clinic (and exam) because of one or more of General assessment
three complaints: This serves two purposes:
1. Deformity Support the primary diagnosis; for example, finding
2. Altered function (commonest is gait abnormality) plagiocephaly and congenital torticollis will support the
3. Pain diagnosis of a dislocated hip
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Figure 14.1 GMC documents for specialty

training in trauma and orthopaedic surgery
Find other orthopedic problems that may or may not be With some training and experience, these three aspects can be
related to the presenting problem but requires attention. covered simultaneously rather than sequentially.
For example, finding torticollis may require specific Eliciting general physical signs and correctly relating
treatment. I am often referred patients with benign feet them to an underlying condition can be very impressive in
deformities but examination uncovers a dislocated hip. the exam. The following list suammrizes common physical
This can be simulated in the exam signs:
General assessment usually involves three aspects: Plagiocephaly (DDH)
General physical signs (Figures 14.2–14.5) Dysmorphic features (dysplasia and genetic syndromes)
Posture Eyes (slanted with epicanthal fold in Down’s syndrome,
Gait blue sclera in osteogenesis imperfecta)
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Chapter 14: Paediatric clinical cases
Table 14.1 Common, frequent and rare paediatric cases that featured in
previous FRCS exams
Common Frequent Rare

Cerebral palsy Long bone Leg deformity
deformity (congenital)
(traumatic)
Knee deformity Achondroplasia Multiple epiphyseal
dysplasia
Limb length Tarsal coalition Sprengel’s shoulder
discrepancy
Toes deformity Radioulnar Trigger thumb
synostosis
Clubfoot Madelungs Patellar dislocation
deformity (congenital)
Scoliosis Patellar Congenital absent
dislocation limb
(traumatic)
Bony exostosis Proximal femoral Perthes’ disease Figure 14.2 General signs associated with DDH. Top left: Congenital torticollis,
focal deficiency top right plagiocephaly, and bottom pictures calcaneo-valgus feet
Neurofibromatosis Arthrogryposis popliteal cyst
Osteogenesis Congenital
imperfecta dislocation of the
radial head
Table 14.2 Normal developmental milestones
Age Motor skills Social skills

3 months Lifts head up when Smiles when spoken to
prone
6 months Sit with support, head Laughs and smiles
steady when sitting spontaneously
9 months Sit without support Waves ‘bye-bye’, vocalize
Crawl ‘ma-ma or ‘da-da’ Figure 14.3 Hemi-hypertrophy. Right hemi-hypertrophy (including the
tongue) in a child with Beckwith–Wiedermann syndrome. Do not forget to
1 year Walks with one hand Starts cooperating with examine for internal malignancy (or its treatment)
support dressing
2 years Runs forward Use 3-word sentences,
Hypertrophied calves (Duchenne and Baker muscular
match colours
dystrophy)
3 years Jumps in place Dresses oneself, put shoes Long slender fingers (arachnodactyly) may be a sign of
own Marfan’s syndrome
5 years Hops names four colours; Café-au-lait spots, axillary freckling in neurofibromatosis
counts 10 objects Haemangiomas may suggest Klippel–Trenaunay–Weber
correctly syndrome
6 years Skips Does small buttons on Hairy patches, skin tags or sacral dimples may indicate
shirt; ties bows on shoes underlying spinal pathology
Thickening of the ankles, wrists and knees, rachitic rosary
in Rickets
Large (may be asymmetrical) tongue Feet deformity can be a sign of packing disorder (DDH).
(Beckwith–Wiedermann syndrome) A cavus foot deformity is a common feature of
Height (short in dysplasia; tall in Marfan’s syndrome) diastematomyelia
Weight (overweight in Prader–Willi syndrome) Nail abnormalities in nail–patella syndrome
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Figure 14.5 Rickets. Thickening of the wrists and rachitic rosary in a child with
rickets
feel, move and special tests) with some differences which we

will explain in the relevant sections below.
As with taking history, examination should be focused on
aspects relevant to the main complaint. Although it is good to
follow a system of examination, it is impossible (and not
advisable) to do every test on a child.
Figure 14.4 Pseudo-hypertrophy in a child with Becker’s disease
Cerebral palsy
Generalized joint laxity is valuable in assessing a flatfoot or May come up as an intermediate case, it is unusual as a short
patellar dislocation (see Beighton’s score, Table 4.1) case. It is possible you will be shown a gait analysis video at the
Posture end of the case and asked to describe it. Don’t panic, simply
describe what you see. If the patient is just walking up and
:The standing posture
down, say so and try and describe the gait (see below). If the
:The curvature of the spine patient appears to have ping-pong balls or some other marker
:The level and contour of the shoulders stuck to their joints this is motion analysis or a kinematic study.
:The level of the anterior superior iliac spine (ASIS) If the patient seems to be made to walk over a marked panel
:Limb symmetry (carrying angle, geno-varum and of the floor and virtual lines shoot up as they step on it, this is
valgum, muscle girth) a force plate to measure kinetics. If they have trailing wires the
: For hindfoot alignment – Valgus or varus chances are they are having electromyography.
: For evidence of tiptoeing, flat foot or cavus deformity When examining the patient make a conscious effort to
Gait talk directly to the patient and not through a carer. Minimize
: Any characteristic abnormal gait (toe-walking, antalgic patient movement to avoid undue distress. Ask how well the
gait, waddling gait, etc) patient can walk before asking them to move. Examine in
: Foot and ankle movements and positions order:
: The knee movements and positions General examination
: Hips and pelvis movements and positions :
General physical signs
: Head and shoulder movements and positions :
Posture
: Upper limb swings :
Walk
A classic example of the importance of general assessment Specific musculo-skeletal
in exams and real life is finding features suggestive of Down’s : Examine relevant aspects of every joint/segment by
syndrome in a child who is referred with a dislocated hip. This look, feel, move and special tests
will impact on preoperative work up (heart and cervical spine)
consenting (high recurrence rate) and surgical technique
(femoral varus osteotomy). General examination
General physical signs
Specific musculo-skeletal examination Comment on presence of wheelchair, walking aids,
This refers to examinations of individual regions or joints communication devices and orthosis, e.g. ankle–foot
(such as neck, shoulders, elbows, wrists, hands, spine, hips, orthosis (AFO), knee–ankle–foot orthosis (KAFO), wrist
knees, ankles and foot). These are essentially as in adults (look, splints, spinal brace, etc
017
Look at trunk for gastrostomy or a subcutaneous reservoir Head: Is it steady, does it move from side to side or up
for a baclofen pump and down?
Pattern of involvement Easy!
Anatomical Specific muscular-skeletal

Monoplegia: affecting one limb only – Rare Examine the patient on the couch (first supine then prone –
Hemiplegia: affecting one side. Upper limb classically more If patient is able to do so).
affected than lower
Diplegia: predominantly lower limbs Couch
Quadriplegia or total body involvement: May well be in Look, feel, move and special tests– Nothing clever needed.
wheelchair
Hip joint examination
Movement disorder Although hip examination in children is similar to that of an
Spastic: increased reflex reaction adult, children pelvis is small and can be easily tilted causing
inaccuracy when assessing the hip’s range of movement
Athetoid: linked writhing movements
(ROM). This is particularly true in children with CP; hence,
Ataxic two people are recommended to conduct the examination.
Hypotonic In the exam, do not hesitate to mention this and if one of the
Mixed examiners offers help, try to utilize him or her (in our clinic we
Dystonia is another form of movement disorder which is get help from a nurse or one of the parents).
described where the pattern of abnormal posture changes Look for any visible deformity, discoloration and scars. Look
seemingly at random and feel for dislocated femoral heads in buttock. Dislocated
hips are more frequent in children with total body involvement,
Posture (standing/sitting) significantly less frequent in diplegics and rare in hemiplegics.
Note posture, any obvious deformities, the position of the Feel for temperature and tenderness.
upper limbs, trunk alignment, leg length discrepancy and Move (if the child age and condition allow, check active
foot position before passive ROM). Ask the child to flex the right hip (record
Comment on spine alignment. Scoliosis is more common the active flexion), if it is not full, try to flex it fully (record the
the more severe the movement disorder. There are two main passive flexion). Do the same for other ROM. to stabilise
patterns of scoliosis in cerebral palsy, an ‘idiopathic scoliosis’ the pelvis with one hand whilst assessing the ROM particularly
type curve with vertebral rotation (rib hump) and possible abduction/adduction.
compensatory curve – And a ‘long C’ or neuromuscular Clinicians often talk about R1 and R2 and it is useful to
curve which classically describes a single curve from neck to know of (and even more impressive to demonstrate) them.
lumbosacral junction R1 and R2 stand for range of motion 1 and 2 respectively.
Depending on the speed you use to check the range of motion
Walking of a limb, you may feel a catch where the limb stops moving
but with gentle and slow force it moves again to its final range
Observational gait analysis need not be as scary as it
of motion. R1 refers to range of motion of the limb up to the
sounds – Just describe what you see but in a logical order.
catch whereas R2 refers to the final range of motions achieved.
Practice on your friends and neighbors
The difference between R1 and R2 helps differentiate between
Start with big obvious things – Need for walking aids,
spasticity and contractures. The higher the difference the more
orthoses, speed, symmetry. Then describe what happens
spastic the muscle is and the more likely it responds to Botox.
from the bottom up as the patient walks
Feet: Foot progression angle, initial contact, foot shape and Special tests
comment on the three rockers of the foot 1. Thomas’ test to assess the hip flexion contracture. Flex both
Lower limbs: Describe the joint positions and movement hips maximally with the knees flexed. Put a hand under
during gait cycle, ankles, knees and hips the lumbar region to ensure flatting the lumbar lordosis,
Pelvis: Level or tilted? Lateral movements when walking? but also ensure no pelvic tilting. Allow the side being
Trendelenberg? assessed to extend fully. The angle between the couch and
Trunk: Posture and movements. Flexion, lordosis, the thigh is the degree of flexion contracture
lateral tilt? 2. Staheli’s (prone extension) test is an alternative for
Upper limbs: Posture, swinging or held stiffly. The flexed Thomas’ test with an advantage of being able to measure
posture of the arm in hemiplegia may not be evident until the actual extension. Patient is placed prone and the legs
the patient walks or performs more complex tasks allowed to dangle over the edge. With the contralateral hip
Shoulders and upper body: Posture, excessive movement? flexed, extend the ipsilateral side to the degree that causes
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Figure 14.7 Popliteal angle. Foot and ankle examination
Figure 14.6 Staheli’s (prone extension) test. Child is placed prone position,
flatten spine by adjusting the pelvis position and assess hip extension. In this
child there is 30° of fixed flexion deformity Feel for temperature and tenderness. Find the point of
maximum tenderness and relate it to a possible pathology.
Check for the patellar position (alta or Baja) and for
mal-tracking
the pelvis to elevate. The degrees short of full extension
equal the degrees of fixed flexion deformity (Figure 14.6)
3. Adductors contractures and Phelp’s test. Child is supine, Move
stabilise the pelvis as above. the degree of hip abduction is Knee joint is a sloppy hinged joint allowing mainly with
measured with the hip and knee in extension (normal = 45°). flexion–extension motion (slight rotation and translation is
Adductor contracture <30° is a risk for progressive hip possible but very limited). The normal knee’s ROM is
subluxation. Repeating the test with the knee flexed to exclude 0–150°. The knee extension should be measure with the hip
the medial hamstring (MH) which crosses both joints. If there is extended (which relaxes the hamstring muscles) gives the
is no MH tightness, the values should be similar (Phelb’s test) fixed flexion deformity of the knee, which is usually caused by
4. Ober’s test (iliotibial band (ITB) contracture) Child is on the capsule (or bony deformity).
the side with the spine straight. The hip to be tested (the
upper most) is then flexed to 90° (with the knee flexed to a Special tests
right angle through the test), fully abducted, and brought The popliteal angle is performed with the child supine and the
into full hyperextension and allowed to adduct maximally. hip is flexed at 90° with the contralateral hip is extended
The angle of the thigh and a horizontal line parallel to the (Figure 14.7). The knee is then extended. The angle between
examination table represents the degree of abduction the vertical line and the tibia is the popliteal angle (normal
contracture. A normal limb will drop well below this <20°). Some authors measure the angle between the femur and
horizontal line. If there is abduction contracture, the hip tibia as the popliteal angle. Other authors flex the hip to 45°
cannot be adducted to neutral position rather than 90° (mimicking the hip flexion in normal gait)
Then help patient to turn and lie on his belly (prone position) and measure the angle. The latter is called the modified or
to continue assessment: the functional popliteal angle and probably more relevant
5. Duncan–Ely test to assess rectus femoris contractures). clinically.
Child is in prone and the knee is gradually flexed. The Anterior pelvic tilt may increase popliteal angle by
examiner feels the spasticity and resistance of the rectus tightening the hamstring muscle, so measuring the difference
muscle and observes the elevation of the ipsilateral hemi- between the measurements with the contralateral hip extended
pelvis.. The elevation of hemi-pelvis is usually subjectively and those with the hip flexed is the Hamstring shift test.
graded into (+, ++ and +++) Flexing the hip beyond the hip fixed flexion deformity ensures
6. Assess the lower limb rotational profile (See in-toeing and the pelvis is not anteriorly tilted and gives a more representa-
out-toeing) tive measure of hamstring tightness.
SLR is another way to measure the degree of hamstring
Knee joint examination contracture by raising the limb keeping the knee in full exten-
Look for any visible swelling, deformity, discoloration, sion (as in spine examination). The angle between the extrem-
callosities and scars ity and the table is measured (normal <70°).
017
Figure 14.9 Salenius curve
Figure 14.8 Bowed legs and knocked knees

Look for midfoot break which is common in children with
tight gastrosoleus muscle.
Look
Gait Knee deformity (genu varus/genu valgus)
: A normal heel strike/toe-off gait? The unusual natural history of coronal lower limb alignment is
: Is it of normal height? (High stepping gait indicates a popular topic in the exam. It could face you in a clinical or
foot drop viva station. The candidate is expected to know the natural
: Is the gait smooth and symmetrical? history of coronal leg alignment and signs of deviation from
Any scars, swellings? physiological (Figure 14.8).
Deformities (flat feet, high arched feet, hallux valgus or Salenius and Vankka1 studied the coronal alignment (tibio-
varus, toe clawing)? femoral angle) of lower limb in children and found that chil-
Examine the patients shoes – Evidence of asymmetrical dren are born with genu varum (bowed leg) of about 15°,
wearing may indicate abnormal gait which decreases through infancy. The legs become straight
Foot/ankle symmetry – Heel alignment – Valgus or varus around 18 months of age, then progress to valgus (knocked
deformity? knees) reaching maximum valgus of average 10° at around 3–4
Achilles tendon – Any obvious swelling, discontinuity/ years of age. Valgus then gradually decreases reaching the
erythema? adult value of 5° around age 8 (Figure 14.9). With a standard
Feel for temperature and tenderness. Find the point of max- deviation of 8°, meant that 95% of newborn children could
imum tenderness and relate it to a possible pathology. have a tibio-femoral angle of –1° (i.e. valgus) to as high as 31°
and still within normal. Therefore, the trend is more important
Move than a single reading.
It is useful to remember that genu varus is more likely to
Ankle plantar flexion (30–40°)
be pathological if:
Ankle dorsiflexion (15°)
1. Present after 2 years
Subtalar joint motion – Grasp the talar head between thumb
and index finger of one hand and heel with the other – Turn 2. Unilateral or asymmetry of >5°
sole towards midline (to assess inversion) and outward to assess 3. Associated with shortening of the limb (or stature)
eversion. No movement is tarsal coalition or joint fusion. 4. Severe (beyond 2 SD of the mean as per Selenius chart)
First MTP joint dorsiflexion (65–75°) to allow adequate 5. In child with obesity.
third rocker. And genu valgus is more likely to be pathological if:
1. Severe (intermalleolar distance >10 cm at 10 years or
Special tests >15 cm at 5 years)
Silverskiold test: Child is supine, the heel inverted to lock the 2. Unilateral
subtalar joint (prevent any dorsiflexion through midfoot). The Always consider pathological causes of genu varus and valgus
degree of dorsiflexion is measured with the knee flexed and when encountered in clinics or exams (Table 14.3).
extended. Flexing and extending the knee relaxes and tightens
the gastrocnemius muscles only and not the soleus. This allows Examination
finding which muscles are tight. If the tightness involves the Overall inspection: ask the child to stand. Look for facial
gastrocnemius only it can be released selectively. dysmorphism, the height and weight of the child and plot
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Table 14.3 Causes of genu varus (bowed legs) and genu valgus (knocked
knees)
Bowed leg Knocked knees

1. Physiological 1. Physiological
2. Tumours such as 2. Tumours such as
osteochondorma osteochondromas
3. Skeletal dysplasia 3. Skeletal dysplasia
4. Blount’s disease 4. Primary tibia valga
5. Infection 5. Infection
6. Trauma 6. Trauma
7. Metabolic (vitamin D deficiency, 7. Renal osteodystrophy
fluoride poisoning, osteogensis
imperfecta) Figure 14.10 Asymmetrical knee deformities. The left picture shows a girl
with valgus deformity coming from the femur following hemiepiphysiodesis
8. Focal fibrocartilaginous dysplasia 8. Neuromuscular while the right is Blount’s disease with the deformity in the tibia. To ascertain
disorders (Polio) and the site bending the knee will correct the tibias alignment on the left but not on
tight ITB the right
Do not forget to look at parents’ legs (and actually ask if

them on an appropriate height–weight chart (most centres there is a similar problem in the family). If this is the case,
now use electronic charts). suspect autosomal dominant diseases such as hypophosohate-
Children with bone dysplasia or metabolic disease are mic rickets, multiple exostosis and bone dysplasia).
frequently of short stature. Don’t be pushed to offer a surgical plan without radio-
Examine lower limb alignment quickly from front, side and logical assessment. You should ask, if prompted, for standing
back. While at the back, quickly check spinal alignment – Tell leg alignment x-rays taken. Radiographs are also useful in
patient and carer what you are doing. Carefully inspect the limbs documenting the site and size of the deformity and enable
for scars, cutaneous markings, dimples, etc. Check leg length. the aetiology to be diagnosed in some cases.
Assess alignment when patient supine on examination
couch. Square the pelvis on the couch. Rotate the legs so that Investigations
patella points straight upwards. Now look at the leg – Is it in Radiological assessment
varus or valgus? Is it correctable?
1. Tibio-femoral angle as per the Selenius curve
If there is a noticeable deformity, where is it? Is it in the
2. Metaphyseal–diaphyseal angle of Levine and Drennan
femur, tibia or in the joint? For instance in Blount’s disease it
(normal <11° but abnormal >16°)
is often clear that there is an angulation below the knee,
whereas in physiological bowing, the whole leg describes a 3. Metaphyseal–epiphyseal angle (normal <20°)
gentle curve (Figure 14.10). If in doubt, bend the knee, this Biochemical if metabolic diseases are suspected
will dissociate these three places and make the site of deformity
clearer. Assess the knee for ligament laxity. Treatment
If asked to measure the angulation across the knee, try not Treat any underlying pathology if they exist.
to emit any audible signs of distress. Examiners hate that. Observation: Usually the correct first line until a trend has
Palpate the ASIS and offer to mark the site with a pen. (It been established
would be unwise to actually do so.) Place the goniometer Bracing: although debated it is still practiced, particularly for
centre on the centre of the patella. Line one limb up on the juvenile tibia vara; may be successful in mild deformity.
ASIS and the other on the line of the tibial crest or midpoint of
‘Guided growth’: this is the modern and expensive reincarnation of
the ankle. This is of course terribly inaccurate.
physeal stapling. Hugely popular at the moment and it works.
Intermalleolar distance can be helpful and reproducible Learn to recognise an eight-plate when you see one (Figure 14.11).
when performed by the same clinician and in bilateral sym- The advantage of the eight-plate is the reversible breaking effect on
metrical genu valgus. It may not be accurate if it is unilateral or the physis.
the patient is obese.
Assess the lower limb rotational profiles (see below) as Osteotomy: when all else has failed. Choice is between single
rotational deformities are often associated with genu varum stage correction with internal fixation or gradual correction
or valgum. Moreover, they should be considered in any surgi- using a ring fixator. It is for this reason that Charles Taylor
cal correction plans. and his Spatial Frame deserve beatification.
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Table 14.4 Causes of leg length discrepancy

way she walks. He commented on the weight of the child and
Causes Examples the clear valgus of both knees. He also noted bilateral large
carrying angles. He asked the patient to walk and noted that
Congenital 1. Longitudinal limb deficiency (hemimelia)
she has flat feet on both side.
2. Hemihypotrophy or hemihypertrophy
He examined the knees with the patient standing from the
( do not forget association with internal
front, side and behind. He could not see any scar. He asked the
malignancy)
patient to lie on the couch and started measuring the angles
3. Dysplasia
by identifying the ASIS, the patella and mid of the ankle. He
4. Metabolic diseases
initially forgot to measure the intermalleolar distance, but
Acquired 1. Trauma he admitted that he should have checked it when she was
2. Infective (osteomyelitis involving the physis, standing. The examiner asked ‘How would that help you?’
gonococcal septicemia) The candidate answered that all signs showed that this girl
3. Neoplasia has a physiological genu valgus and the intermalleolar dis-
4. Inflammatory diseases (juvenile rheumatoid tance would help me to quantify this. The examiner asked
arthritis) ‘Show me how you would measure the distance’. The candidate
5. (In adult, joint replacement) asked the patient to stand with both knee caps pointing
Neuromuscular 1. Cerebral palsy forward and the knees touching each other, identified both
disease 2. Poliomyelitis malleoli and measured the distance between them which was
(NB. In these conditions, limb equalisation 7.5 cm.
including shoe raises may be harmful) The examiner asked ‘How would you manage this
patient?’ The candidate said that he would like to obtain a
Apparent 1. Joint dislocation (DDH) radiograph. The examiner was not impressed, ‘You just said
2. Joint contractures everything was within normal limit, so do you think the x-ray is
justified’?
The candidate replied that he was not sure, but he felt that
he would discharge this patient to GP care with advice to be
re-referred if the situation worsens. Hence, he felt that radio-
graph would provide extra assurance for him as a clinician and
to the child and her family that there is nothing serious. He
probably would not x-ray her knee if he arranged to bring her
back to his clinic.
Leg length discrepancy

This is a very common referral to children’s orthopaedics;
it can present as an intermediate or short case in a child or
adult. History should be directed to find the cause (Table 14.4),
the trend (worsening or improving) and any prior treatment
and outcomes.
Five objectives of clinical assessment:
1. Size of discrepancy
2. Site of discrepancy
3. Status of the joints
4. Is the discrepancy real?
5. The cause of the discrepancy if not yet available.
General assessment
Figure 14.11 The eight-plate General physical signs
Look at the patient in general, any dysmorphism, facial and
tongue asymmetry (Beckwith–Wiedemann syndrome), skin
Examination corner markings, and signs of previous surgery. Look briefly at the
Short case 1 upper limbs for deformity or obvious shortening. Leg length
A candidate was to examine the knees of a 9-year-old over- discrepancy is common in spastic hemiplegia. Upper limb
weight school girl who was teased at school because of the length difference may not be easy to evaluate so don’t waste
time if not obvious.
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Posture Table 14.5 Management options for leg length discrepancy

Standing: equinus of the ankle on short side or flexed knee on Leg length Options
the long side. Look for pelvis obliquity. discrepancy
Gait 0–20 mm Conservative: Nothing, insole or shoe raises
Short leg gait, comment on rhythm and trunk position. Look 20–50 mm Consider epiphysiodesis of the opposite
at the shoes for adjustments and wear pattern. side at appropriate age, unless the child is
already very short, when you may consider
Specific muscular-skeletal lengthening of the short limb after
Leg length evaluation appropriate consultation
After skeletal maturity, acute shortening of
Patient standing in socks. Sit or crouch in front of the patient – the long limb is an option
Use a chair if available, it makes it look as if you’re used
to doing this, is more comfortable and avoids the appalling >50 mm Offer lengthening of the short limb ±
epiphysiodesis of the long limb
possibility of losing your balance and toppling into the
patients lap.
Ask patient to stand straight with both knees straight.
Place thumbs firmly but not painfully on anterior superior
iliac spines. Don’t tickle. This will tell you which is the long
leg and a surprisingly good idea of the discrepancy. Ask for
standing blocks, they will be marked in mm. Place your best
guess height in blocks under the foot of the short leg and check
ASIS again. Adjust block height until the pelvis is level with
knees straight. This is the functional leg length difference.
With the pelvis level, step back and assess leg alignment. Figure 14.12 Galeazzi’s test
Beware of fixed hip flexion and/or adduction (see next step).
Turn patient with back to you, or walk round them. Still with Place thumbs on ASIS and middle finger tips on the greater
pelvis level and knees straight, inspect from the back and take trochanter (GT) simultaneously to assess hip position. The
a quick look at the spine. Patients with hemihypertrophy difference in distance between ASIS and GT suggests discrep-
and other conditions may have leg length discrepancy and ancy proximal to GT. This can be measured more precisely
scoliosis. by drawing Bryant’s triangle and measure the perpendicular
distance between the tip of greater trochanter and another line
Couch evaluation dropped from ASIS perpendicular onto the bed. This is often
If more is expected of you, direct patient to initially sit on the called Bryant’s test.
couch, look whether scoliosis corrects. Comment on knees and Flex hips to 90° and look at heights of the knees (Galeazzi’s
feet position when the patient is sitting, sometimes it is very sign; Figure 14.12) to assess femoral length, place heels
clear that one side is shorter. Lie patient supine on the couch. together and look at knee height to assess tibial length. Inspect
Square the patient’s pelvis to the couch and comment on any the feet, a dysplastic or traumatized hindfoot may lose you a
obvious deformity. centimetre or more in height. Offer to use a tape measure to
Swiftly assess joints (hips, knee and ankles) range of document the various segment lengths using the usual bony
motion to exclude joint contractures as a cause of leg length landmarks. This is pretty dreary stuff and of little practical use,
discrepancy. but your examiner might like watching you do it.
True and apparent shortenings are terms are often used in If you suspect congenital femoral dysplasia and/or fibular
the contest of leg length discrepancy. True shortening is hemimelia, examine the knee for ligament insufficiency, par-
referred to the affected limb is physically shorter than the other ticularly cruciates.
leg. It is measured using a tape the ASIS to the medial mal-
leolar tip while both lower limbs are in identical positions and Management (Table 14.5)
the pelvis is square. It depends on current leg length discrepancy, predicted leg
The apparent shortening refers to the sum of the true length discrepancy at skeletal maturity and patient’s perception
shortening plus the shortening due to fixed deformities. It is of discrepancy.
the apparent shortening that matters to the patient. This Current leg length discrepancy
measurement helps in assessing the extent of natural compen-
sation developed for concealing the actual disparity.
: Clinical
By now, the size of discrepancy is appreciated and would
: Radiological
be confirmed by radiograph. The next step is to determine the – Teleoroentgenography: single exposure hips to
site(s) of the discrepancy ankles over radio-opaque ruler
017
– Orthoroentgenography: Separate exposures

centred on hip, knee, ankle over a single film with EXAMINER: Very good. I can tell you he has already had
a ruler epiphyseodesis of the right distal femur and proximal tibia and is
– Parallel beam scanogram: Separate exposures 16 years old on Tuesday. How would you manage this now?
centred on the hip, knee and ankle over a radio- CANDIDATE: I would discuss the options with the patient. He could
opaque ruler on separate films be managed with a shoe raise if he has had enough surgery.
– CT scanogram ( becoming most popular) Alternatively the options are to lengthen the left femur again or
Predicted leg length discrepancy at maturity to shorten the right femur by, say, 25 mm, which would give him
a more acceptable discrepancy.
: Menelaus rule of thumbs
EXAMINER: If he were to opt for lengthening, how would that be
: Moseley straight line method
done? Are there any particular risks in this patient?
: Eastwood and Cole method
CANDIDATE: The standard method is by using an external fixator,
: Paley’s multiplier method
either circular frame or monolateral. I know there are lengthening
Patient’s perception of discrepancy intramedullary nails available but I understand they are both
: How tall the child is? Is he taller or shorter than extremely expensive and essentially experimental. A particular
average? concern in this patient is his cruciate deficiency, one would have
: How tall are the parent or family members? to take great care to avoid posterior subluxation of the knee
during lengthening, and I would like an x-ray of the hip too
before making any further decisions.
Examination corner
Short case 2
Short case 1
In his first short case, a candidate was asked to examine a
Patient is an adolescent male in shorts. Be friendly and polite.
5-year-old girl with right leg shortening. She was sitting on the
Please don’t try to be down/in with the kids – The children hate
couch with significant shortening of the right leg, mainly the
that.
thigh.
EXAMINER: Would you please evaluate this gentleman’s leg length
I could see her shoes underneath the couch fitted with a
discrepancy? Talk me through your findings as you go.
massive shoe raise (probably 8 cm). Quick evaluation of
CANDIDATE: On inspection the patient looks generally fit and well. upper limbs revealed no obvious abnormality. After
He has a visible shortening of the left leg and tends to stand with I mentioned these finding, I was asked about the possible
the right knee flexed. I can see surgical scars on the left thigh and diagnosis, I answered proximal focal femoral
what appear to be pin-site scars consistent with previous external deficiency (PFFD)
fixator treatment. I see that his left trainer has what looks like a Discussed the associated conditions, when I mentioned
2 cm build up on the sole. fibular hemimelia, I was asked to assess the patient’s fibula.
I mentioned I could see five toes and could feel reasonable
Would you mind walking to the wall and back? He has a short
size and site of the fibular head and lateral malleolus, but it
leg gait, but no obvious discomfort. The left knee is in a little
was difficult to assess the shaft, but x-ray may be more
valgus compared to the right and the entire leg seems slimmer.
accurate to confirm this
Could you stand with your feet level and your knees straight Classification and treatment: We discussed the Aiken
please? (Assess pelvic tilt by palpating ASIS) There is a significant classification and the bell rang before starting discussing
leg length discrepancy; could you pass those blocks please? treatment
(Adjust standing blocks to level pelvis) On block standing there
seems to be a 4 cm leg length discrepancy, short on the left.
Examining the patient from behind, with his pelvis level the spine
is straight. Would you please lie down on the couch on your back?
Toe deformity
His hip movements are good. The majority of the shortening is in
Various toe deformities are common in clinics and exams
the femur on the left though the tibia is a few millimeters short
(Figure 14.13 and Table 14.6). Children with hallux valgus,
too. Foot and ankle are good. Knee examination demonstrates an
hallux varus, mallet and curly toes have been commonly
exaggerated anterior draw and Lachmann’s test on the left
featured in the FRCS exam. The usual presentation is cos-
consistent with cruciate ligament deficiency.
moses, although pain or pressure over deformed toes are
not uncommon. Some children are asymptomatic, but
EXAMINER: Good. Can you guess the clinical background to these
parents are concerned they may get trouble in the future.
findings?
Although less common in children, possible underlying
CANDIDATE: These findings would be consistent with a patient
causes such as trauma, neuromuscular problems, inflamma-
with congenital femoral deficiency who has had an episode
tory arthritis and diabetes mellitus should be enquired about
of femoral lengthening during childhood and is now
and noted.
approaching skeletal maturity with further relative shortening
Unless you are specifically asked to examine the feet,
of the left leg.
start with general examination (general signs, posture and gait)
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Table 14.6 Definition of toe deformities
Deformity MTPJ PIPJ DIPJ

Hammer Dorsiflexed or Plantar Neutral,
toe neutral flexed hyperextended,
Claw toe Dorsiflexed Plantar Plantar flexed
flexed
Mallet toe Neutral Neutral Plantar flexed
Curly toe Neutral or plantar Plantar Plantar flexed
flexed flexed
Figure 14.14 Residual (undertreated) clubfoot
osteotomies and fusion. If you do well and time permits,

you may get asked about your indications for your
procedures of choice and to describe how you do them
Clubfoot
Figure 14.13 Toe deformities. 1: Hallux valgus, 2 and 4: Curly (under lapping)
toes, 3: Overlapping toes and 5: Hallux varus Treated clubfoot is a common short or intermediate exam
case, particularly when there is suboptimal outcome such as
under correction (Figure 14.14) or over correction. This
but do not waste a lot of time on them particularly if it should be easy viva even for candidates who did not do
was short case. paediatric orthopaedic training. It is unlikely you would face
Look at the shape of the feet (pes cavus, pes planus), a newborn child with clubfoot (although you may in the viva
describe any deformity. Feel for tenderness and try to be section).
precise about the site of tenderness. There may be two very Enquire about:
close but clinically distinctive areas of tenderness.
Age at initial presentation ( the earlier the better outcome)
Assess the flexibility of toe joint. Normally joints are flex-
ible, note any contractures. Do not forget to examine the shoes. Treatment before relapse
: Number of casts (normally around 4–6)
Management : Tenotomise (90% needs tendoachillis tenotomy)
Manage conservatively if at all possible; strapping, : Length of brace wear. Boot and bar braces such as
stretching, interdigital spacers, guards, footwear Denise Browne boots should be worn continuously for
adjustment, orthotics, etc 3 months, after which they will be used at nap and
Several surgical options are available to deal with toes night-time for 4 years. Compliance (or tolerance) has
deformities ranged from tenotomies, capsular release and been shown to be the most significant risk factor for
pinning; tendon transfer, Butler’s procedure, various bony relapses)
017
: Tendon transfer (about 20% needs tibialis anterior joint. They usually continue to grow until the growth plate
tendon transfer) closes at puberty. There are four common variants of bony
Start with the general examination unless you are clearly exostosis that you may encounter in the exam:
directed by the examiner, e.g. ‘Examine this young boy’s left 1. Solitary osteochondromas
foot.’ Describe the deformity to the examiner and in particular They usually present as a painless, slow-growing swelling
look for residual metatarsus adductus, heel varus and equinus. in children or adolescents, mostly around the knee.
You can use Pirani’s score to structure your description. Look They may cause mechanical symptoms depending
for secondary deformities (equinus can cause knee recurva- on the location. There may be a history of trauma,
tum). Are these deformities correctable? but this is often coincidental. The patient is otherwise
Assess the range of motion of joints and tendons’ strength healthy.
particularly peroneal and tibialis anterior tendons. If the tibia- 2. Hereditary multiple exostoses (Diaphyseal aclasia)
lis anterior tendon pulls the foot into dorsiflexion and supin- An autosomal dominant (ask for family history when you
ation, it may need to be transferred to the midfoot. Assess the suspect the diagnosis) condition. Patient is usually short
shoes for size, modification and wear patterns. with multiple bony exostosis and asymmetrical growth at
the knees or/and ankles. There may be a leg length
Investigations discrepancy. There may be scars from previous surgeries.
Weight-bearing AP, lateral and Saltzman’s views of the foot. 3. Multiple epiphyseal dysplasia
Mostly autosomal dominant condition characterized by the
Management
presence of epiphyseal (periarticular) chondromas of the
Serial casting can be repeated but the older the child the less knees and ankles. Patients with this condition usually
likely it would be successful on its own. Surgical intervention present in late childhood. The spine is usually normal.
often involves combinations of soft-tissue releases, bony pro- Recessive multiple epiphyseal dysplasia is distinguished
cedures and tendon transfers tailored to that individual foot to from the dominant type by malformations of the hands,
achieve supple, pain-free plantigrade foot. feet, and knees and scoliosis.
Medial release (almost every medial structure can be 4. Dysplasia epiphysealis hemimelica (Trevor’s disease)
released or lengthened but avoid damaging the deltoid It is an epiphyseal dysplasia, thus, involving the joint. The
ligament) lesions are usually restricted to one side of the body, either
Posterior release (tendoachilles and ankle posterior left or right; hence, the name hemimelica. It usually occurs
capsule) in infants or young children. The medial side is affected
Tendon transfer such as whole or split tibialis anterior twice as often as the lateral side.
tendon transfer The approach to patients with solitary or multiple bony
Bony procedures to correct alignment: Lateral calcaneum exostoses include:
slide to correct varus, closing wedge cuboid osteotomy to Recognition of the condition and optimum description
swing the forefoot around the talo-navicular joint and
correct forefoot adduction. Dorsal closing wedge of the
:
The nature of swelling (Bony hard, pedunculated or
sessile, attached to the underlying structure–bone, does
first metatarsal to elevate the first ray
not move with tendon or muscle, non-pulsatile, etc)
Rarely arthrodesis is needed for severe and uncorrectable
deformity.
: Is it single or multiple (actively search for other lesions)
Fortunately, over-corrected clubfoot has become rare since
: Is it localized to one limb or side
Ponseti’s treatment was introduced. It was common after
: Any family history
surgical treatment. The heel is usually in valgus and forefoot Assess (or predict) the effect of the bony exostosis
is abducted. These require medial calcaneum slide to correct :
Pressure affects on muscle, nerve-including spinal cord,
valgus, opening wedge Cuboid osteotomy or calcaneum vessels, etc
lengthening to swing the forefoot around the talo-navicular : Interference with growth-shortening, mal-alignment,
joint and correct forefoot abduction and dorsal openning arthritis or joint pain (ask for long leg alignment views)
wedge of the first metatarsal to create the medial longitudinal : Cosmetic appearance
arch (basically the opposite of what you do for under-corrected Be aware of neoplastic potential (mostly to
clubfoot). chondrosarcoma)
: Solitary (1%) versus multiple (probably higher as there
Bony exostosis (osteochondromas) are many – controversial).
The most common bone tumours in children may be solitary : Growth of the swelling after maturity (or cartilage cap.
or multiple. They usually rise from tubular bones metaphysis >1 cm in adult)
due to aberrant cortical overgrowth adjacent to the growth : Family history of malignant transformation
plate leading to eccentric bony growth usually away from the : Neurological compression.
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Investigation Table 14.7 Diagnostic criteria for Nf-1 from the National Institute for
Health
1. X-ray: The radiographic appearances are usually characteristic
2. CT scan: Useful in the assessment of osteochondromas in Signs Requirement
the pelvis, shoulder, or spine Café-au-lait spots 6 or more, >5 mm in children,
3. MRI is useful for assessing continuity of the parent bone (Figure 14.15) >15 mm in adults
with the cortical and medullary bone in an Cutaneous 2 or more
osteochondroma, cartilage cap size, impingement neurofibromas
syndromes, and arterial and venous compromise
Plexiform 1 or more
4. Angiogram is rarely needed; however, it may give useful
neurofibroma
information when assessing vascular occlusion, aneurysm
and pseudoaneurysm formation Axillary or inguinal Any
freckling (Figure 14.15)
Treatment Optic glioma 1 or more
1. Solitary osteochondromas; resects if symptomatic or very
Lisch nodules 2 or more
large (avoid in skeletally immature because severe growth
deformity may result) Distinctive bone Sphenoid dysplasia, cortical thinning
2. Multiple osteochondromas: It is risky and not feasible to lesions of long bone with or without
remove multiple bony exostoses. However, excision of the pseudarthrosis
symptomatic ones may be beneficial. Treatment of First-degree relative Must have documented Nf-1 as per
osteochondroma sequel is often needed these criteria
a. LLD (as above) If two or more of these signs are present then a diagnosis can confidently
be made.
b. Angular deformity
i. Timed hemiepiphyseal stapling
ii. Corrective osteotomy
c. Surgical decompression of neurovascular compression.
Examination corner
I was asked to assess a child with a swelling in the popliteal
area. I think this was my lowest point – Struggled to feel it,
examiner seemed to be getting a bit impatient by my ability to
decide if it was a bony swelling. Finally gave osteochondroma
as potential diagnosis and was relieved to be handed an x-ray Figure 14.15 Neurofibromatosis. Axillary or inguinal freckling and café-au-lait
showing the very same. spots
Neurofibromatosis
Neurofibromatosis (Nf ) is the most common hereditary,
hamartomatous condition affecting the peripheral and central
nervous systems; hence, it is commonly features in the exam.
Most candidates are able to pick the diagnosis of Nf because of
distinctive features (Table 14.7).
Elbow gunstock deformity (Figure 14.16) Figure 14.16 Elbow gunstock deformity
A common spot diagnosis short case. The candidate is usually
asked to assess a child with an elbow deformity. Most candidates 90° with thumbs up. Measure the carrying angle in the ana-
do not have difficulty in reaching the diagnosis, but they do not tomical position comparing both sides. Demonstrate the range
provide optimum anatomical and functional assessment. of movement and functional movement (can he reach his face,
Inspect both sides for scars and palpable lumps (can be mouth and buttock). Check for signs (and symptoms) of elbow
caused by hereditary multiple osteochondromatosis). You can instability. Do not forget neurological assessment. Ask the
ask the patient about history of trauma whilst examining. The patient and parent about the real concern and their
deformity is clearer when the patient abducts both shoulders to expectations.
017
Management Achondroplasia
Bilateral varus or valgus elbow deformity in child with If you are examined on a patient with achondroplasia, it is time
chromosomal anomalies usually does not require surgical to score high. Clinical features are characteristics and potential
intervention orthopaedic problems are well recognised. Patients have a
Unilateral, mild with no risk of progression (no growth normal IQ and areusually very cooperative. The features
plate damage), manage conservatively. The parent and include:
child need to be reminded the operation would be
Head and face
associated with scarring and this can be ugly
Unilateral, severe with no risk of progression, offer closed :
Large head with frontal bossing
wedge osteotomy with displacement of distal fragment (to :
Midface hypoplasia
prevent medial or lateral translation associated with simple :
Dental malocclusion and crowding
wedge osteotomy Skeletal features
Unilateral, severe with risk of progression, delay treatment :
Disproportionate short stature: Normal trunk length
until skeletal maturity unless the deformity becomes severe with rhizomelic shortening of the proximal limbs with
or the joint becomes unstable. redundant skin folds
: Brachydactyly and trident hand configuration
Examination corner : Lumbar lordosis
: Hyperextensibility of most joints, especially the
Short case 2
knees
EXAMINER: This 9-year-old boy was referred by his GP because his : Limited elbow extension and rotation
elbow did not look right, would you like to assess his elbow please? : Bowed legs
CANDIDATE: He is a slim and healthy looking boy with obvious Radiographic findings
deformity of his left elbow. I think he has a gunstock deformity
following a supracondylar fracture.
: Small skull base
(There was a silence for a few seconds – the examiner probably
: Progressive interpedicular narrowing in the lumbar
spine region
wanted more information.)
EXAMINER: So what is a gunstock deformity?
: Short pedicles which can cause spinal stenosis
: Short femoral neck and metaphyseal flaring with
CANDIDATE: It is a varus deformity of the elbow caused by growth
inverted V shape distal physis
arrest of the medial physis.*
: Small sacrosciatic notch, flat-roofed acetabulum
EXAMINER: How would you manage this boy?
CANDIDATE: The deformity does not limit elbow function and most Two sets of orthopaedic problems that are associated with
patients seek advice for cosmetic reasons. So if it is mild, I would achondroplasia:
reassure the child and parents and I offer them a review in
1. Spine
6 months to a year. If it is severe and the child is distressed by it,
I offer them corrective surgery.
Craniocervical junction abnormalities with subsequent
cord compression may cause death in infancy. High risk
EXAMINER: What type of surgery?
with contact sport, car accident and intubation in general
CANDIDATE: Supracondylar osteotomy.
anesthetics
EXAMINER: What type of supraconylar osteotomy?
Lumbar stenosis with neurological claudication in early
CANDIDATE: Lateral closing wedge osteotomy?
adulthood. This responds to decompression
EXAMINER: Would you do epiphysiodesis at the same time to prevent
Kyphosis
recurrence?
2. Limb lengthening
CANDIDATE: He is 9 years old and still growing, so I would not do
epiphysiodesis.
Very controversial particularly for if it is for cosmetic
reasons. It may be justified in very short patients who for
(Fail)
* example cannot drive nor do their jobs because of very
Although, gunstock deformity can be caused by
short limbs
growth arrest, the commonest cause is usually mal-union.
It is a combined varus and internal rotation of the distal
fragment. Few candidates were asked to demonstrate the Growth hormone treatment is still being evaluated.
internal rotation component of the gunstock deformity
(Yamomoto’s test). The candidate should have assessed Tarsal coalition (rigid flat feet) (Figure 14.17)
the deformity further and he should not have jumped into This condition has been featured in the clinical exam fre-
the diagnosis. quently as a short case, but also a common viva question.
The classical scenario is a teenager (10–14 years old) with
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017
Figure 14.17 Tarsal coalition. Left rigid flat due to tarsal coalition. Note the
left heel remains in valgus on tiptoeing
recurrent ankle sprains or fractures or both and the examination

revealed rigid flat foot (unmissable!). Another scenario is to
assess this child who was referred by his GP because he has
flat feet?
Ask the patient to stand up with the feet slightly apart and
observe the posture. The heel is usually in valgus and the
forefoot is abducted (if adducted, think of skew foot). Inspect
the bottom of the feet; you should be able to pass two fingers
under the medial arch. If the planter aspect of the foot is Figure 14.18 Left radioulnar synostosis
convex, consider vertical talus.
Observe the patient walking. Observe him standing on
toes while supported to a wall. In flexible (physiological) Radioulnar synostosis (Figure 14.18)
flat feet, the heels normally move to varus and the medial An extremely common short case. Can be congenital or
arch becomes more prominent. In tarsal coalition, the heel acquired; partial or complete; fibrous or bony. Congenital
remains in valgus (well, not always true) and the arch does bilateral in 60% of cases.
not reconstitute. Ask the patient to sit on the couch dangling Traumatic radioulnar synostosis is more common and can
his feet down. While doing so, ask permission to look at his happen in adult as well as children. It has been classified by
shoes for wear pattern. If the shoes are new and there is no Vince and Miller2 into three types:
wear pattern, try to score extra marks by asking how long Type 1: Distal, located in the distal intra-articular portion of
s/he has had the shoes for. There is more wear over the the forearm
medial side of the heel. Type 2: Diaphyseal, located in the middle and non-articular
Ask the patient where the pain is (if there is any). Calca- distal one-third of the forearm, most common
neonavicular coalition usually causes lateral side pain while Type 3: Located in the proximal third of the forearm
talocalcaneal coalition causes medial side pain. Assess for
Predisposing factors for traumatic radial ulnar synostosis:
tendoachillis tightness as this may cause stiff flat feet. Then
assess the ROM of the ankle and subtalar joint. There is Badly displaced and comminuted fractures
significant stiffness in the subtalar joint movement. It can be Both fractures at the same level
difficult to elicit as these patients have compensatory ball and Crushing injuries of the forearm
socket ankle joint (by remodeling) and this can be deceptive. Open fractures
Try to use the thumb and index finger to stabilise or at least to Single-incision exposure of both bones
check for talus body movement when assessing subtalar joint Fractures with concomitant head injury
movement. Delayed surgical fixation
017
Symptoms: In children osteotomy through the fusion mass with

Difficulty turning doorknobs K-wire or Steimann pin fixation has been described but is
Difficulty buttoning shirts generally not recommended.
Difficulty using eating utensils or writing devices When the deformity is congenital the soft tissues have been
contracted from in-utero and the neurovascular structures are,
Difficulty using or grasping small objects
therefore, sensitive to large rotational corrections. Complica-
The traumatic radioulnar synostosis will be covered in more
tions of surgery include nerve palsies, vascular compromise,
details in the upper limb section.
compartment syndrome and mal-union.
Congenital radioulnar synostosis may present:
Resection of the bony bridge with interposition of fascia
In isolation (by itself) lata, plus resection of the radial head and division of the
In association with other skeletal abnormalities (about one- interosseous membrane have been described in the textbooks
third of the time) but they are technically demanding, results are often unpre-
In association with problems of the heart, kidneys, nervous dictable and are generally not recommended although this may
system or gastrointestinal system change in the future.
In association with certain genetic syndromes, such as
Holt–Oram syndrome (also called hand–heart syndrome)
and fetal alcohol syndrome Examination corner
It has been classified into four types by Cleary and Omer3 Short case 1
Type 1: Fused clinically but not radiologically, small but A candidate in her first short case was asked to examine the
normally developed radial head left forearm of a middle-aged male patient. She commented
Type 2: Similar but with clear bony synostosis on several well-healed surgical scars present over both
Type 3: Hypoplastic, posteriorly dislocated radial head the volar and dorsal surfaces of the wrist, which she was
told to ignore and to just concentrate on the forearm. There
Type 4: Hyperplastic, anteriorly dislocated radial head
was muscle wasting present over the flexor muscles of the
Th parents usually notice that the child holds his upper limb forearm.
in funny angles and is not able to rotate his hand. There is The candidate was a little confused as what to do next and
usually no pain. Sometime, a trauma brings attention to the was told to examine forearm rotation. The patient demon-
problem when a child falls on elbow and was found unable strated restricted forearm pronation. Asked what the diagnosis
to rotate the forearm and the x-ray confirmed the was she mentioned radioulnar synostosis. She was then asked
abnormality. the likely cause, to which she replied, ‘trauma’. The candidate
was then asked to check the patient’s forearm rotation on the
Management right side, which was similarly restricted.
The examiner then asked whether she still felt trauma was
With the congenital variety there is usually little functional the cause and would it not be more likely to be congenital. In
deficit. The forearm is in fixed pronation (30°), neutral or in retrospect the candidate felt that being asked to examine the
slight supination. This is generally less disabling than fixed forearm had unnerved her and she would have made a better
supination. Children may compensate with increased rotatory account of the condition if she had been asked to examine the
movements at the wrist, carpus and shoulder. Patients with patient’s elbow.
unilateral synostosis usually do not require surgery unless ‘Would you care to examine this gentleman’s forearm?’
there is marked fixed pronation.
There is no universal agreement on the best treatment. The Short case 2
current opinions are to rotate the forearm to the optimal A candidate was asked to examine the elbow of a young girl
position. The optimal position is controversial as well. aged about 5. The lack of forearm rotation was immediately
In unilateral synostosis, forearm position ranges from 15° spotted when the patient was asked ‘show me your arms’.
of pronation to 35° of supination. Patients with bilateral syn- A slight loss of full extension was also noted after which the
ostosis may request surgical correction with the dominant candidate was asked what the probable diagnosis was. The
limb fixed in 30–45° of pronation whilst the other side is fixed candidate was then shown radiographs, which confirmed a
in 10–30° of supination. Other authors suggest the dominant proximal radioulnar synostosis. There followed a brief discus-
sion about management options.
hand is left in 20° of pronation and non-dominant hand in
(Pass)
neutral.
Surgery
Rotational osteotomy refers to the realignment of the forearm
by distal osteotomy with slight shortening to reduce the ten- Madelung’s deformity (Figure 14.19)
sion on soft-tissue structures. In adults both bones are More common in exam than in real life. It can be a spot
realigned and fixed with compression plating. In children diagnosis when the deformity is moderate or severe, but it can
realignment of the radius is the preferred option. be very subtle and needs a high level of suspicion. The clues are
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‘Now, turn your hand up?’ ‘Let’s measure this.’ ‘Active supin-
ation is 20°.’ ‘Let me see whether I can increase it further
by turning your wrist gently.’ ‘No I cannot without causing
you pain’ . . . etc.’
Assess the functional profile such as picking up objects,
washing face, writing, doing buttons up, and putting trousers
on, . . . etc.
There are two rare variants you may need to be aware
of them. Reverse Madelung’s deformity in which the physeal
growth arrest is ulnar and dorsal (rather than ulnar and volar);
hence, the radial articular surface tilt is dorsal and the ulnar
head prominence is volar. The second is the Chevron carpus in
which the physeal growth arrest is ulnar and central. This can
be quite difficult to diagnose as there is little or no deformity
of the wrist and no instability of the distal radioulnar joint.
Madelung’s deformity could be:
1. Post-traumatic (growth disturbance of distal radial ulnar
volar physis secondary to trauma-usually repetitive)
2. Dysplastic (multiple hereditary osteochondromatosis,
Ollier’s disease, achondroplasia, multiple epiphysial
Figure 14.19 Madelung’s deformity dysplasias, and mucopolysaccharidoses
3. Chromosomal or genetic (Turner’s syndrome)
4. Idiopathic or primary
that the patient is usually female, with bilateral prominent ulnar
styloid and restricted supination, dorsiflexion and radial devi- Management
ation. Flexion and pronation are usually normal.
Conservative
There are different ways how the examiners may pose the
initial question; commonly they are guided by the patient’s In mature patients with mild deformity, symptomatic treat-
initial symptoms or current problem. The prominence of the ment using pain killers, splints and job modification.
distal end of the ulna is what draws the attention of most
patients initially; later pain and loss of function may become Surgery
an issue. Do not rush to give a diagnosis. Assess the patient, the There are four important considerations:
limb and function fully first, then provide a diagnosis, ideally 1. Patient age and the growth remaining in the distal radius
with a list of differential diagnosis. Usually a patient is a young 2. Severity of the deformity
female. Ask her to expose her upper limbs to the elbows paying 3. Severity of the symptoms
attention on how easy or difficult she finds this and comment 4. Clinical and radiographic findings
on this. Describe what you see:
Operative treatments are divided into:
‘There is a prominence of ulnar head toward the dorsum with the
whole wrist deviated ulnar and volar ward. I cannot see any scar,
Operation to prevent or correct primary deformity
swelling or deformity over the back of hand, wrist or forearm. In
(Vickers’ physiolysis, osteotomy, epiphysiodesis, radius
particular I cannot see ulnar (or radial) drift of fingers or thumb lengthening)
deformity. “May I ask you to turn your hand over please?” She has Operation to decrease pain and improve range of
difficulty in supination and trying to use her shoulder to movement (Sauve–Kapandji operation) – Some authors
compensate for lack of supination, I will assess this fully when advocate a Darrach procedure (excision of the distal ulnar);
I come to ROM assessment, . . . etc.’ however, there is a risk of carpal instability
Ask the patient about any tender areas and palpate the hand Both (wrist fusion, osteotomy).
for tenderness. If you are not sure about the diagnosis at this
stage . . . start from the fingers and proceed proximally, keep
looking at the patient’s face to sense any pain or discomfort.
Arthrogryposis
There is usually tenderness over the distal radioulnar joint. Literally means curved joints. Arthrogryposis is a descriptive
Gently check how mobile it is. term and not an exact diagnosis, because there at least 150 pos-
Assess movement: ‘Can you straighten your elbow fully sible underlying diagnosis. Hall et al. 1985 considered three
please? And can you bend them fully please?’ If there is any main groups:
restriction in active ROM, try to improve it passively. ‘Can you 1. Classical arthrogryposis multiplex congenita; in which the
tuck your elbows to your waist and stick your thumbs up?’ limbs are involved and the muscles are absent or deficient
017
2. Arthrogryposis associated with neurogenic (brain, spinal The shoulder is usually internally rotated and adducted,
cord or peripheral nerve) or myopathic (congenital elbow in extension, wrist and finger in flexion. Ask the patient
muscular dystrophy or myopathy) to show you what s/he can do, ‘Can you reach your face
3. Arthrogryposis associated with other syndromes or (for washing and feeding)?’ ‘Can you reach your buttock (for
anomalies such as diastrophic dysplasia or toileting)?’ ‘Can you do your buttons?’ ‘Can you pick up this
craniocarpotarsal dystrophy coin?’ ‘Can you hold a pen?’ ‘And can you write?’ ‘If you
Arthrogryposis multiplex congenital has a sporadic occurrence. imagine my hand as door knob, can you turn around?’ ‘Can
Aetiology is still unknown with several theories advocated. you use computer keyboard?’ . . . etc.
Fetal akinesia (decreased fetal movement) seems to be a If s/he cannot do certain task, assess why and what stop
common pathway for these theories. Other recognisable pat- the patient doing so. Is it the shoulder’s internal rotation, is it
terns of arthrogryposis have an established heritability, the most the elbow stiffness or is it the wrist? Do not hesitate to say,
commonly encountered are the distal arthrogryposes and I would refer the patient for full OT assessment (this is what
Freeman–Sheldon syndrome. we do in clinic). If a problem is identified, suggest a solution
Several candidates have been tested on patients with arthro- or solutions and involve the patient and carer with the solution
gryposis. Recognition is not particularly difficult. There are you suggest (‘So if we improve the elbow bending, do you
classical features that you can rattle off quickly to the examiner: think that would help?’). Start with the safest and most suc-
1. Involved limbs are tubular in shape, with thin and cessful solution and proceed to the others. For example, if the
subcutaneous tissue and absent skin creases, particularly elbow extension deformity was the problem, consider physio-
over joints therapy before operation, manipulation before tendon transfer
2. Deformities are usually symmetric, and severity increases and so forth.
distally, with the hands and feet typically the most Pay attention to the details, particularly signs of previous
deformed (I call them the Kangaroo upper limbs). surgical interventions. It is not a good idea to offer them a
surgery that they had already had it.
3. The patient may have joint dislocation, especially the hips
Deformities of the wrist and elbow and the foot and knee
and, occasionally, the knees.
can be addressed in the first weeks of life with a combination of
4. The trunk is rarely affected (occasionally scoliosis).
passive stretches and resting splints. In the lower limb this is
5. Atrophy may be present, and muscles or muscle groups
effectively a modification of the Ponseti regime, with variations
may be absent.
depending on the severity of the deformity and the position
6. Sensation is usually intact of the knee joint.
7. Patients have normal IQ in most cases. Hip dislocations are common and usually have occurred
A multidisciplinary team approach (paediatrician, ortho- in utero well before birth, these joints are rarely amenable
paedic, geneticist, neurologist, psycholist, physiotherapist and to closed treatment with a brace and are, therefore, treated
occupational therapist) is essential for successful outcome in either by open reduction in the first year of life, or are best left
these patients. The basis of orthopaedic assessment and man- dislocated.
agement is to optimize function and to keep these children as Orthopaedic interventions can be useful in most joints
independent as possible (and they do). and regions of the arthrogrypotic child (rarely the shoulder),
In the exam situation, you are more likely to be directed to but this should be carefully planned, staged and timed.
a particular problem to assess. ‘This child was born with Aim to correct most major deformities within the first
bilateral clubfeet. He had two courses of Ponseti serial casting 12–18 months of life then concentrate on function.
but it has not been successful. Would you like to examine him In later life, surgical interventions are limited to maintain-
and tell us what you think?’ Or ‘This 5-year-old child is known ing mobility and optimizing function. Tendon transfer may
to have arthrogryposis. He had bilateral dislocated hip which bring motor power to a joint that has been optimised. The
was reduced when he was 1 years old. He is here for routine elbow joint is well suited for tendon transfers with good results
follow up appointment. We want you to assess his hips please’. in selected cases.
I simulate arthrogryposis assessment to that of patient with
severe rheumatoid arthritis. Although, we are interested in the
state and function of individual joint, but the function of the
Klippel–Feil syndrome
whole limb is far more important. Adult or child: Short webbed neck or no neck appearance
When you are asked to assess a patient with arthrogryposis with low hairline.
in exam, do not panic. Listen to the examiner carefully (often Spot diagnosis: Head on top of the shoulders with restricted
the answer is in the question). Introduce yourself, and then range of movement. Full spinal and neurological
undress them reasonably. examination are required.
Inspect the upper limb comparing both sides at the same Associated features:
time. Comment briefly on the general signs of arthrogryposis Sprengel’s shoulder
but do not dwell on them. Describe the posture of the limbs. Torticollis
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Congenital scoliosis/kyphosis of the cervical spine (high

risk of instability)
Congenital heart disease – Echocardiogram is indicated
Renal anomalies – Ultrasound is indicated
Feil classified the syndrome into three types:
Type I – A massive fusion of the cervical spine
Type II – The fusion of 1 or 2 vertebrae
Type III – The presence of thoracic and lumbar spine
anomalies in association with type I or type II Klippel–
Feil syndrome
There is a high risk of instability, especially if the malforma-
tion limits mobility at one level; these include atlanto-occipital
fusion with C2–C3 block vertebrae, abnormal atlanto-occipital
junction with several distal block vertebrae; and a single open
interspace between two block segments. Subluxation of the
cervical spine can occur with minor injury. Warn patients
against contact sport (diving, gymnastics and rugby) and
review annually with flexion/extension plain radiographs.
Arthrodesis of unstable segments may be required if excessive
instability and neurological abnormalities are present.
Klippel–Feil syndrome is a classic spot photograph diagno-
sis in the paediatric orthopaedic oral examination but it rarely
comes up in the clinical section presumably there is more
important clinical scenario to cover in a limited amount of
time available.
Sprengel’s deformity of the shoulder (Figure 14.20)

A complex anomaly that is associated with malposition and Figure 14.20 Sprengel’s deformity
dysplasia of the scapula. Although, it is commonly associated
with the Klippel–Feil syndrome, it can be a feature of other Congenital pseudoarthrosis of the clavicle
syndromes such as Poland syndrome and VATER syndrome. The patient will be a child and it will almost always be the right
Embryologically, the scapula is derived from the neck and clavicle. If it occurs on the left side it is associated with
normally descends to the thorax by the end of the third month dextrocardia. There will be a non-tender swelling/lump over
of intrauterine life; any interruption in its descent can result the middle third of the clavicle and possibly a gap across the
in a hypoplastic, elevated scapula, known as the Sprengel’s clavicle. The shoulder may hang lower than on the opposite
deformity. normal side. The clavicle is also effectively shortened.
The trapezius, rhomboid, or elevator scapulae muscle may The pseudoarthrosis is caused by failure of fusion of the
be absent. The Sprengel’s deformity usually presents with medial and lateral ossification centres. Possible aetiology is an
shoulder asymmetry and restriction of shoulder abduction. abnormally high subclavian artery. Differential diagnosis
The scapula is elevated by 2–10 cm and its inferior pole is includes post-traumatic pseudoarthrosis, neurofibromatosis
rotated medially. and cleidocranial dysostosis of the clavicle (skull abnormality).
This is a painless condition and produces little functional
Management abnormality. There are parental concerns about the unsightly
Conservative lump. The opposite ends of the clavicle fragments are enlarged
Physiotherapy to maintain the range of movement and strength just lateral to the midpoint of the clavicle. The larger sternal
of shoulder girdle. fragment is pulled upwards by the sternocleidomastoid and lies
slightly superior and in front of the shorter acromial fragment.
Surgery The shoulder droops and is rotated forwards.
Several surgical procedures have been recommended to
improve the cosmetic appearance and the shoulder function Management
when it is severely impaired. These include but not limited Conservative
to Mears, Konig, Green and Woodward scapuloplasty. For Observe; leave it alone, especially if the patient is asymptomatic,
optimum outcome, experts recommend surgery before 8 years. because of the risk of possible complications from surgery.
017
Surgery Congenital radial head dislocation

Excision of the pseudoarthrosis, curettage of the bone ends and A classic short case. Possibly a radiographic spot diagnosis in
fixation with plate and screws. A bone graft (tri-cortical iliac the paediatric oral with discussion about its differentiation
crest) is sometimes required to reconstruct the length and from a traumatic or paralytic dislocation. May occur as an
shape of the clavicle. A recon plate is then contoured and fixed isolated entity or associated with several generalized skeletal
with screws. Surgery can be carried out by the age of about malformation syndromes.
4 years although opinion varies as to the appropriate age for Developmental dislocations of the radial head may occur
surgery. Brachial plexus neurapraxia has been reported with diaphyseal aclasia or hereditary multiple osteochondro-
following resection and fixation of the pseudoarthrosis. With matosis as a result of retarded ulnar growth. In paralytic
skeletal growth the lump and instability at the pseudoarthrosis disorders the muscle imbalance between the supinators and
site increase. The overlying skin becomes atrophic and the pronators can result in radial head dislocation.
deformity can become cosmetically unsightly. The affected Be familiar with the various management options available
shoulder droops. The patient may complain of mild pain and and their indications.
weakness in the shoulder. Surgery is generally advised, ‘My
preferred option would be to fix it’. Memorandum
‘On examination of the left/right elbow there is a suggestion of
a mass present posteriorly around the lateral epicondyle. The
Examination corner attitude of the left/right elbow suggests there is a loss of full
Short case 1 supination.’
Classic short case: spot diagnosis – the candidate should recog- ‘I would like to confirm this clinically. There is both a restriction of
nise the diagnosis immediately on inspection. full supination and loss of full extension of the elbow. Flexion and
EXAMINER: Would you like to examine this young girl’s shoulder and pronation appear full. The swelling itself is non-tender and
describe what you are doing as you go along? bony hard.’
She is a young girl about 5 years old and, therefore, it is vital to
Background
smile at the child to put her at ease no matter how stressed you may
The radial head may be dislocated anteriorly, laterally or poster-
feel. Introduce yourself to both mother and child. Crouch down so
iorly. Posterior dislocations are nearly always congenital. Con-
you are at her eye level.
genital anterior dislocations are nearly always associated with
CANDIDATE: On inspection from the front there is an obvious
other congenital conditions. The primary defect is thought to be
swelling over the middle of the right clavicle. Is it painful? Can
capitellum dysplasia. The anteriorly dislocated radial head is
I touch it? On palpation the swelling is bony, hard, non-tender,
rounded, often with a deficient capitellum and a long radius.
not attached to skin, its surface is uneven, its edge is distinct and
The posterior border of the ulna is concave instead of convex.
it is non-pulsatile. There is a suggestion of a small amount of
The posteriorly dislocated radial head is thin and elongated, and
painless mobility between the two ends. The swelling is probably
the posterior border of the ulna is markedly convex.
bony in origin and very suggestive of pseudoarthrosis of the
Relocation is usually not successful. The condition predis-
clavicle. Can you swing your arm outwards (demonstrated whilst
poses to osteoarthritis of the ulnohumoral joint in later life.
talking)? She has a good range of shoulder abduction, which is
It can be bilateral.
not painful.
EXAMINER: Good, let us look at her x-rays. Clinical features
CANDIDATE: This confirms a pseudoarthrosis of the right clavicle with A completely dislocated radial head is usually pain free with
smooth sclerotic enlarged deformed bone margins characteristic little loss of function. Pain may develop in adolescence or adult
of the condition. life if the radial head is subluxed. An anterior dislocation will
EXAMINER: How are you going to manage it? usually have restricted flexion and supination due to a mech-
CANDIDATE: My preferred option would be to fix it. It’s an unsightly anical block. Posterior dislocation usually causes limitation of
deformity that tends to worsen when the child grows. It can also extension and rotation of the forearm. Lateral dislocation of
be painful and the shoulder tends to droop down. the radial head tends to cause cubitus valgus. The radial head
EXAMINER: Is there any place for conservative treatment? can usually be easily palpated and may produce an ugly prom-
CANDIDATE: That’s certainly an option if it’s painless and causing no inence on the lateral side of the elbow. Associated conditions
undue problems and the parents are not concerned about its include arthrogryposis, Ehlers–Danlos syndrome, diaphyseal
appearance. aclasis and nail–patella syndrome.
EXAMINER: Why are they always right sided?
Management
CANDIDATE: That is because it is thought that the subclavian artery
interferes with fusion of the medial and lateral ossification Conservative
centres. They can occur on the left side with dextrocardia. If there are no symptoms and if the limb function is
satisfactory then leave it alone
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017
In childhood, it is best to leave alone; surgery should

preferably not be carried out because it may cause
longitudinal growth disturbances
In adulthood again preferably to manage conservatively
especially if detected co-incidentally
Surgery
Open reduction of the radial head with shortening of the
radius. This is difficult and recurrent dislocation is
common. The flat or convex radial head and flat capitellum
make relocation very difficult
If necessary, excision of the radial head in the adult can be
done to relieve pain and improve appearance; however, the
ROM is not significantly altered. This is not recommended Figure 14.21 Trigger thumb
in children as proximal migration of the radius and inferior
radioulnar subluxation can develop as normal growth of
the ulna continues
In some conditions a short ulna predisposes to radial head Examination corner
dislocation, e.g. multiple osteochondromatosis. The radial Short case 1
head will fall back into position if the ulna is lengthened to A candidate was asked to examine the thumb of a 3-year-old
restore the normal relative lengths of the radius and ulna. child who was sitting in his mum’s lap. He hoped it was a
trigger thumb, so he did not jump in to examine the child’s
hand but he started talking to the parent (and the child) and
Examination corner
observing the deformity. He commented that the child looked
Short case 1 healthy and active; both thumbs IPJ seemed to be flexed. He
Young boy about 9 years old with mother could not see any other abnormal features such as scars or
congenital abnormalities.
EXAMINER: Would you like to examine this young girl’s elbow for me?
CANDIDATE: (I immediately thought about congenital radial head CANDIDATE: My initial thought is that this child has trigger thumbs
dislocation or radioulnar synostosis. I began with a simple and I would like to confirm my initial impression.
description of how the elbow appeared) EXAMINER: How would you do this?
On general inspection the elbow is held in about 20° of flexion CANDIDATE: In trigger thumb, it is usually bilateral, the IPJ can be
and almost full pronation. There is an obvious swelling on the flexed further but the extension is limited and there is usually a
posterolateral aspect of the elbow mobile, palpable lump at the mouth of A1 poly which moves as
The ulna appears more prominent at the wrist. I would like to I flex and extend the IPJ.
go on and palpate the swelling. On palpation the swelling is non- EXAMINER: How would you treat him?
tender, 2 cm by 2 cm, bony hard consistency non-pulsatile, non- CANDIDATE: My preferred option in this age group is surgical release
mobile, not attached to skin. of the A1 poly, but in infants, I would advise on regular gentle
Examining elbow movements there is normal flexion but loss of stretching as this can be successful. Failing this, surgery would be
the final 20° of extension. Pronation and supination are both mildly advocated.
restricted with loss of about the final 20° of each movement. EXAMINER: This child is 3 years old now, would you wait till he is
EXAMINER: So what do you think the diagnosis is? older and stronger?
CANDIDATE: Congenital dislocated radial head. CANDIDATE: I usually recommend surgery when the child is between
EXAMINER: What are the other causes of a dislocated radial head? 2 and 4 years of age. Before 2, there is a higher risk from
anesthetic and surgery; after 4 years, the child may develop
CANDIDATE: Trauma, diaphyseal aclasia, radioulnar synostosis
permanent structural changes leading to fixed flexion deformity.
EXAMINER: How do you treat it?
(Pass)
CANDIDATE: If it is not painful and causing minimal functional
difficulties I would treat the condition conservatively, advice with
reassurance. Surgery can be difficult.
Other paediatric upper limb conditions

Trigger thumb (Figure 14.21) Clinodactyly, camptodactyly, Kirner’s deformity, thumb
Rarely shown in the clinical exam because most patients duplication, radial club and ulnar club hands have been
are operated on by the age of 4. It is usually asymptomatic featured in the clinical exam as short cases of spot diagnosis
and the patient is brought in by parents after noticing a fixed and further management. These have been covered in the
posture of the thumb’s IPJ. hand core topic.
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Figure 14.22 Congenital limb deficiencies
Congenital absence of limbs or part of a limb 2. Longitudinal arrest

Preaxial – varying degrees of hypoplasia of the thumb
(Figure 14.22) or radius
You may encounter a patient with congenital anomalies of the
Central – divided into typical and atypical types of
extremity as a short case and the examiners want to see a cleft hand
reasonable understanding of the classification and potential
Postaxial – varying degrees of ulnar hypoplasia to
treatment options.
hypothenar hypoplasia
Three important issues are to be explored in these types of
scenarios: The functional limitation; the cosmetic appearance; Intercalated longitudinal arrest – various types of
phocomelia
and the psychological impact on child and parent.
International Federation of the Hand Classification4:
1. Failure of formation Failure of differentiation
2. Failure of differentiation 1. Soft tissue – syndactyly, trigger thumb, Poland syndrome,
3. Duplication: May apply to whole limb, mirror hand, camptodactyly
polydactyly 2. Skeletal – various synostoses and carpal coalitions
4. Overgrowth: Includes conditions such as hemi- 3. Tumorous conditions – include all vascular and
hypertrophy and macrodactyly neurological malformities
5. Congenital constriction band syndrome
6. Miscellaneous
7. Generalized skeletal abnormalities such as arthrogryposis, Child with a popliteal cyst (Figure 14.23)
congenital dislocation of the radial head and Madelung’s
deformity
EXAMINER: This 7-year-old boy was brought by his parent as they
Failure of formation noticed a swelling at the back of his knee. Would you like to
1. Transverse arrest – It can be at any level, shoulder to examine him and tell us what you think?
phalanx (congenital amputation)
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017
CANDIDATE: (Introduces himself and asks permission to examine the

child knees) . . . The child looks healthy and active and I could see
he is not in discomfort when he moves his knee. Is this the
swelling that’s concerned you?
MOTHER : Yes.
CANDIDATE: Is it painful? Or has it caused any symptoms?
EXAMINER: (Interrupting) We just want you to examine the swelling
and describe your findings as you go along.
CANDIDATE: There is ill-defined swelling at the posteromedial aspect
of the knee, it measures about 2 × 3 cm. ‘Can I feel it please?’ It is
not particularly warm and has ill-defined margin. It is not tender
even when I press hard on it.
The knee is not swollen or hot and I can bend it fully without
any discomfort. I would like to check for transillumination, but
I am sorry I do not have a torch.
EXAMINER: Here is a torch.
Candidate demonstrated positive transillumination of the cyst. Figure 14.23 Popliteal cyst
He offered to examine the groin for any swelling and the foot for
any unexpected pathology.
radial head. Forty per cent of patient developed immune
EXAMINER: What would you tell this boy and his parent?
related nephropathy which is the most serious complication.
CANDIDATE: This is likely to be a popliteal cyst and it is a benign
Most patients do not need any surgical intervention; however,
condition that rarely causes symptoms and usually disappears as
patients with recurrent or permanent patellar dislocation
the child gets older.
should be treated with surgical stabilisation.
EXAMINER: The parent wanted to know how quickly the swelling will
disappear.
CANDIDATE: I am not sure but it could take several years. As long as it
does not cause symptoms or gradually gets bigger, I would not Examination corner
worry about it. Short case 1
EXAMINER: How would you investigate?
EXAMINER: Would you like to examine this young lady who
CANDIDATE: The diagnosis is clinical and further tests are just to
complains of gradually increasing pain in her knees?
rule out unexpected pathology, so if the swelling is associated
CANDIDATE: ‘Can I ask you to stand up please?’ There is bilateral knee
with pain, increasing size, I would consider MRI scan or
swellings and puffiness; I cannot see any scar or deformity. ‘Can
ultrasound.
I see you walking please?’ She walks normally and the knees bend
(Pass) appropriately with walking. ‘Can I ask you to lie on the couch
please?’ I cannot feel any hotness. She seems to have tenderness
around her knee cap on both sides. ‘Can you straighten your knee
In straightforward cases like the above two, most candidate out please?’ ‘And can you bend it fully?’ Now, I am checking the
pass easily, but we advise to aim more than just a pass by knee stability. I think this girl has patellofemoral chondromalacia
quoting supporting evidence. For example, the candidate and early arthritis.
would have scored higher if he mentioned ‘This is likely to
EXAMINER: Why do you think so?
be a popliteal cyst and it is a benign condition that rarely
CANDIDATE: She is young, female with bilateral anterior knee pain
causes symptoms and usually disappears as the child gets older.
and tenderness. This is a classical presentation.
Dinham in his classical paper5 reviewed the natural history of
EXAMINER: Then would you like to examine her elbows as well?
over 100 popliteal cysts and found most popliteal cyst disap-
peared spontaneously within 5 years. CANDIDATE: ‘Can I ask you to stand up please?’ ‘And if you turn your
hands forward please.’ There are no visible scars, or swelling. ‘Can
you straighten your elbow any further please?’ OK, there is a loss of
Nail–patella syndrome about 15° of full extension. ‘Can you bend it fully please?’ They are
Uncommon autosomal dominant disease usually presented in almost symmetrical with a loss of 15°. ‘Please, tuck your elbows to
late childhood or early adulthood with knee pain or recurrent your waist with the thumbs pointing up.’ I can see she cannot
dislocation of the patella. Four features are very characteristic supinate her hands fully. ‘Can you turn them down please?’ Again,
for this syndrome: Fingernail dysplasia, absent or hypoplastic she has restricted pronation.
patellae, the presence of conical iliac horns and hypoplasia of
017
EXAMINER: Do you still think it is classical patellofemoral

chondromalacia?
CANDIDATE: No, may be juvenile rheumatoid arthritis affecting her
knees and her elbows.
EXAMINER: Do you want to examine her dad’s elbows?
CANDIDATE: (more puzzled) ‘Can I ask you to straighten your elbows
with hands facing forward?’ I cannot see any scar and the elbows
lost at least 30° of full extension and I cannot straighten them any
further. There is significant restriction of pronation and
supination.
EXAMINER: Can you guess the underlying pathology?
(Pass)
In retrospect, the candidate feels that he had failed that par-
ticular short case but he did well in other stations and man-
aged to obtain the pass mark. He’d never seen or read about
the nail–patella syndrome, but the scenario was of classical
nail–patella syndrome.
Pes cavus Figure 14.24 Tripod theory to explain pes cavus. Pes cavus is a spectrum of
Pes cavus is a deformity in which the longitudinal arch of high arched foot deformities including cavo-varus foot, plantaris, calcaneus and
the foot is high and does not reduce on weight-bearing. It is calcaneo-cavus foot deformities
a spectrum including cavo-varus foot, Plantaris, calcaneus
and calcaneo-cavus foot deformities. A child with pes cavus
can be the subject of intermediate or short case. It is not
surprising that many candidates do not like this topic. This weak while tibialis posterior is normal leading to varus hind-
is partly because there is a wide spectrum of clinical prob- foot. Because the weakness of the tibialis anterior, patient tries
lems and presentations, which may need different types of to compensate by using toes extensors to provide enough
treatments. Moreover, there are various underlying condi- dorsiflexion to clear the floor causing hyperextension at the
tions in cavus foot and these conditions merit special atten- MTPJs and subsequent clawing. It also tightens the planter
tion and assessment. Here we try to provide a simple and fascia (windless mechanism) and the arch of the foot is accen-
logical approach to a patient with pes cavus. We strongly tuated further.
recommend reading the topic in more depth in one of the In spina bifida and poliomyelitis, there is a weakness of the
textbooks as well. triceps surae leading to calcaneus deformity due to unopposed
Rang’s tripod theory depicts the foot as a balanced tripod action of ankle dorsiflexors and reciprocally plantarflexed
(the calcaneum, the first and the fifth rays); with all three forefoot.
points resting on the ground (Figure 14.24). Muscle imbalance Varus heel (subtalar inversion) locks the midtarsal joints
causes one or more of these structures to assume abnormal causing a rigid foot. Excessive pressure may fall under the head
posture around their joints increasing the height of medial of metatarsals leading to painful callosities.
arch. For example, cavo-varus is usually caused by the calca- When faced with a patient with pes cavus, the clinical
neum moved into varus (stronger tibialis posterior) pushing picture is usually clear, but there are key questions to answer:
the foot into supination. To compensate and balance the 1. What actual problems does the patient have now?
tripod, the first ray has to flex more. This increases the height 2. What might happen in the future?
of the medial arch. The same could happen when there is an (a) Is it progressive?
excessive planter flexion of the first ray (strong peroneus (b) Risk of ulceration or infection
longus).
3. Is there an identifiable neurological cause?
The pattern of muscle imbalance varies according to the
4. What are the patient (and parent) expectations?
underlying condition, hence, the type of pes cavus. In
Charcot–Marie–Tooth disease (HSMN), for example, the
tibialis anterior is weak or paralysed while peroneus longus is What is the problem?
normal. The head of first metatarsal is depressed owing to Pes cavus can produce a wide spectrum of symptoms.
unopposed action of peroneus longus. The peroneus brevis is It can cause infective ulceration threatening limb or life; on
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017
the other hand, many patients have quite limited problems and As in history, the clinical assessment has two objectives
little or no disability requiring no treatment. Common prob- 1. Describe the deformity and the effect of the deformity
lems in cavus foot: 2. Search for any underlying condition. This includes full
1. Toe deformity rubbing on shoes neurological assessment
2. painful calluses under the metatarsal heads caused by
Inspection (patient is standing – If able)
forefoot plantar flexion and fixed toe deformity
3. Lateral foot pain and painful calluses on the lateral foot Are the leg muscles wasted?– Quick glimpse on the hands
border due to hindfoot varus Is there a high medial arch (can you pass two fingers
underneath)? Is it bilateral? And symmetrical?
4. Walking difficulty due to foot deformity or foot drop
5. Foot wear problems due to deformity Is the heel in varus, neutral, valgus (coronal plane)? Is it in
equinus or calcaneus (in the sagittal plane)?
6. Ankle instability due to hindfoot varus and peroneus brevis
weakness Is the whole forefoot plantarflexed (plantaris) or is the first
ray most plantarflexed?
7. Worries about progression.
Is there toes clawing? Callosities, ulceration?
It is valuable to assess the impact of these individual problems
on patients. How does it affect you? Does it interfere with your Shoes and walking aids
work? Sport? Walking, etc.? Children may not complain of Watch the patient walking
pain, but they fatigue easily.
Palpation
Is it progressive? Are the deformities correctable or fixed? How easy
correctable?
1. The length of history (When did you notice the deformity?
Patient may be born with it. Is it getting worse? Is the other : Hindfoot
foot normal? Do you have problem with bowel or bladder? Varus – Coleman’s test (Figure 14.25)
Any weakness in your hands or shoulder?)
Equinus – Can be brought down. Check for TA
2. Any previous history of ulceration or infection? How was it tightness (Silverskjőld’s test)
treated? Is it getting more frequent? Or more difficult to
treat? :First ray – Can be brought level with the other rays?
Parents or carer may provide valuable information. Secure the hindfoot with left hand in neutral position
and look at the rays from front. Are they level? If not,
Is there an identifiable neurological cause? can they be brought level?
Are there any problems with your hands, back, vision, etc? Has : Is the toe deformity correctable? (Blackburn grading)
anybody else in the family had a similar problem? Is there any Assess for tenderness at the callosities
family history of neurological diseases? Assess the sensation – Usually gloves and stocking type in
HSMN and dermatomal in spinal disorders
Causes of pes cavus Assess foot circulation as it may have impact on surgical
1. Congenital intervention.
(a) Idiopathic Movement
(b) CTEV Assess active movement of each joint, paying particular
(c) Arthrogryposis attention on the powering muscle. Common pattern is the
2. Acquired foot dorsiflexion powered by the toes flexor rather than
(a) Trauma tibialis anterior
(b) Neuromuscular If the active movement is not full, try passive movement to
achieve the full range
(i)Muscular dystrophy
Full neurological assessment to identify the cause.
(ii)HSMN
(iii)Polio Investigation
(iv) Spinal cord disorders (spina bifida, spinal Radiology
dysraphism)
(v) Friedrich’s ataxia
: X-rays
(vi) Cerebral palsy 1. Weight-bearing lateral (calcaneal pitch – Normal
<30° and lateral Meary’s angle – Normal 0–5°)
What are the patient (and parent) expectations? 2. PA (Meary’s angle – normal 0°)
‘How can I help you? What do you expect from your visit? Is it the 3. Coby’s view (calcaneotibial angle <5°)
pain or the ulcer that really bothers you?’ : MRI (spine and brain when indicated)
017
feet become stiff. The aim of surgery is to achieve pain-free,

plantigrade, supple but stable foot. There are various types
of operations that may be beneficial depending on the condition
of that particular cavus foot. It is recommended to know the
basic principle of these operations. These can be summarized:
1. Release of the plantar fascia.
2. Closing-wedge dorsiflexion osteotomy of the first (±
second) metatarsal
3. Calcaneum sliding and closing-wedge osteotomy
4. Transfer of the peroneus longus into the peroneus brevis at
the level of the distal fibula
5. Achilles tendon lengthening
6. Clawing of the toes is improved by flexor-to-extensor
transfers and extensor tendon lengthening or tenotomy
7. Jones’ procedure
8. Triple arthrodesis
In-toeing/out-toeing
Another standard in children’s clinics and something you
should be able to rattle through quite swiftly.
General points
There is a wide range of normal values for rotational align-
ment in children and adults. Pathology should be suspected
when there is:
Pain
Limp
Length discrepancy
Asymmetry
Rapid change in rotational profile
Examination (Table 14.8 and Figures 14.26 and 14.27)

Ask about height and weight, think metabolic bone disease/
bone dysplasia.
Stand patient in front of you, assess leg lengths and Tren-
Figure 14.25 Pes cavus and Coleman’s test. Coleman’s test shows the heel delenburg’s. In an adolescent, think slipped upper femoral
varus fully corrects indicating the primary deformity is the hyperflexion of the epiphysis (SUFE)! Quick look at back – Never hurts.
first ray. Surgery to elevate the first ray will improve the apparent heel varus and
there is no need for calcaneum osteotomy
Ask the patient to walk the longest distance you have
available. Assess the foot progression angle (FPA)
Bloods such as muscle enzymes and genetic screening (Figure 14.26). This is the angle subtended between the straight
Neurophysiology may be indicated in assessing underlying line along which the patient is walking, and lines drawn
neurology through the long axes of the footprints. This can be measured
with some accuracy if the patient is made to step in chalk
Treatment powder before walking or with video gait analysis. In the clinic
Conservative the foot progression angle is usually eyeballed. Normal FPA
Physiotherapy: Tendoachilles stretching or strengthening ranges from –5° to 20°. In-toeing of –5° to –10° is mild, –10°
exercises, muscle strengthening may improve muscle to –15° moderate and more than –15° is severe.
imbalance Direct the patient to the examination couch and ask them
Orthotics and accommodative to lie prone. Put a pillow under the chest with arms flexed and
hands under the chin – This is comfortable and avoids
Operative squirming. Flex the knees and start assessing the rotational
Operative intervention may be indicated when the child becomes profile from feet upward or from hip downward. My prefer-
symptomatic, and when orthotics is ineffective, but before the ence form: Feet upward!
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Table 14.8 Summary evaluation of rotational profile of the lower limb
Measurement Normal (°) Significance

Foot progression 5 to +20 < –5 in-toeing; > 20 out-
angle toeing
Foot lateral Straight Curved inward, metatarsus
border adductus
(Some use heel
bisector line)
Transmalleolar 0–40 Outside the range
thigh angle indicates tibial torsion
Thigh foot angle 0–20 Outside the range
indicates tibial torsion
Prone hip 20–60 Outside the range
internal rotation indicates femoral torsion
Prone hip 30–60 Outside the range Figure 14.27 Assessment of rotational profile of the lower limb. 1: Foot
external rotation indicates femoral torsion progression angle; 2 and 3 lateral border of the foot and heel bisector line;
4: Foot thing angle; 5 and 6 prone hip internal and external rotations
Femoral 40 at birth Higher values indicates respectively; 7 and 8 femoral anteversion
anteversion 20 at 5 years persistent femoral
16 at 16 years anteversion
Describe the shape of the foot in general terms. Someone

with significant metatarsus adductus or a skew-foot may
appear to have in- or out-toeing simply due to the position
of the foot itself.
With the knee flexed at 90°, kneel up on the couch and peer
down the axis of the tibia in order to assess the foot–thigh
angle (FTA). This is the angle subtended between the line
of the thigh and that good old imaginary line through the
middle of the foot. An unscrupulous clinician can of course
twist the foot to give just about any angle desired and the
interobserver error in this measurement is alarming. If one
earnestly wishes to take a reproducible measurement, the trick
is to gently hold the foot in neutral dorsiflexion and try and do
the same each time. Normal FTA ranges between 0° and 20°.
This angle measures the tibial and hindfoot rotational status.
The transmalleolar thigh angle (TMA) is a measure for tibial
torsion only and with practice, you can assess it relatively
easily. Normal value of TMA is 0–40° and a value <0° suggests
internal tibial torsion.
Hip rotation: Flex the knees to 90° and use the tibias as
goniometers to measure hip internal rotation (<70°) and
external rotation (<30°) on each side.
Measure the femoral anteversion (Gage’s test): find the
greater trochanter and palpate gently with one hand while
rotating the femur as above with the other. Judge when the
lateral prominence of the trochanter is at its greatest and
record the degree of hip rotation that corresponds with that.
This measurement appears rather improbable when written
down; in practice it is surprisingly convincing. Practice on a
friend in advance and don’t waste time over it in the exam.
Normal femoral anteversion is about 40° at birth, 20° by the
age of 9 and reaches the adult value of 16° by the age of
Figure 14.26 Foot progression angle and relationship to femoral anteversion 16 years.
017
Try to use the correct terms. Version when the rotational

profile is within normal and torsion if it is abnormal. So if the
References
1. Salenius P, Vankka E. The development of the tibiofemoral angle
version of the femur is >40° at 9 years, this is called internal in children. J Bone Joint Surg Am. 1975;57:259–61.
femoral torsion.
2. Vince KG, Miller JE. Cross-union complicating fracture of the
Do not overlook the fact that muscle tone/pull in patient forearm. Part I: adults. J Bone Joint Surg Am. 1987;69:640–53.
with cerebral palsy (CP) may cause in-toeing or out-toeing.
3. Cleary JE, Omer GE, Jr. Congenital proximal radio-ulnar
The written description above seems rather complex, but synostosis. Natural history and functional assessment. J Bone
in reality and with some practice the whole procedure can be Joint Surg Am. 1985;67:539–45.
done in well under a minute. If you don’t have a compliant
4. Swanson AB. A classification for congenital limb malformations.
friend or partner to practice on, the sequence of examin- J Hand Surg Am. 1976;1:8–22.
ations can be usefully rehearsed using a doll or large soft
5. Dinham JM. Popliteal cysts in children. The case against surgery.
toy. Really. J Bone Joint Surg Br. 1975;57:69–71.
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Section 4 The general orthopaedics and pathology oral
General viva guidance

Chapter
15 Abhijit Bhosale and Stan Jones
Having passed the part 1 every candidate should have a rea- Many examiners also use these books. Knowledge gained is then
sonable knowledge of orthopaedics but further refined prepar- reinforced by viva practice.
ation is essential for the part 2. Practice can be gained by having mock viva sessions:
The part 2 section of the examination is clinically oriented. With registrar colleagues who may also be preparing for or
The first day involves examination of patients: have just passed the examination
Intermediate cases (an upper and lower limb) each lasting With consultant colleagues (who may be examiners) in
15 minutes and candidates are expected to take an their offices or clinics
appropriate history, examine in a structured and friendly At the local teaching programme
manner, discuss the relevant investigations and formulate a During local trauma meetings
treatment plan for the respective patients/cases It is better to make mistakes at these sessions and learn from
Three short upper limb cases lasting 15 minutes in total them than to do so at the main examination as that can lead to
Three short lower limb cases also lasting 15 minutes failure. In addition, further knowledge can be gained at these
The short cases involves examination of patients to demon- sessions.
strate relevant clinical signs and, thus, make a diagnosis. We suggest candidates do not prepare for the viva examin-
Candidates may be required to discuss management of the ation in isolation. It is good to be part of a revision group. Some
respective patients. candidates may find it beneficial to revise with others of similar
The second day is dedicated to viva examinations. Candi- knowledge while others may find it stimulating to work with
dates will be examined across four viva stations, i.e. paediatric/ others who have more knowledge and, thus, stimulate them.
hands, adult pathology, trauma and basic science. In each of
the stations, the candidates will be examined for 15 minutes by
each of the 2 examiners and are marked by each examiner
Courses
separately. During each 15 minutes section each candidate will Examination revision courses are a useful preparation tool, but
be examined on 3 separate clinical scenarios each lasting 5 these courses can be expensive and not all are really worth the
minutes. At the end of the 15 minutes a bell is rang and the expense, time off work, traveling to the venue and hotel costs.
candidate will then be examined by the second examiner. Each Courses come in different formats, i.e. clinical, viva or lecture or
examiner scores the candidates for each of the respective a combination of these. A clinical-oriented course is a must.
5 minutes sections. It is advisable to go on at least one course, but we recom-
mend that you inquire from colleagues who have just passed
the examination which courses they found most beneficial.
How to prepare for the viva Courses are also a good forum to gather some useful tips from
The key to success in the viva examination is to have a broad other colleagues or the lecturers who may also be examiners.
knowledge of the curriculum, listen to the examiner, answer Be careful however that any info is accurate and bonafide and
the questions asked and do so in a structured and confident hasn’t been exaggerated third or fourth hand by candidates. Be
manner. also careful with candidates downplaying the exam. Misleading
Many candidates prepare seriously for the clinical section information can seriously damage your well being!
of the examination only after passing part I. This is not
advisable as there may not be adequate time between the two
parts of the examination to enable one to cover the breadth of Structured questions
the curriculum and, hence, be fully prepared. Remember fail- As of November 2014 viva questions have been pre-set by the
ure is costly financially, mentally and physically. examination board. Examiners meet the evening before the
Preparation for the viva examination involves assimilation of clinicals and for each session of the viva (morning/afternoon)
further knowledge by reading standard textbooks such as Post- chose from a set list of questions. The examiners conducting
graduate orthopaedics and Miller’s textbook of orthopaedics. the viva examination will choose six questions from a total of
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Section 4: The general orthopaedics and pathology oral
nine questions. Some questions may be ambiguous and, there- the candidate is aware of what viva they are involved with.
fore, need to be clarified or discarded. Other questions may Examiners are not allowed to discuss any candidate’s perform-
include laminated clinical photos that are unclear or of poor ance or marks with any other team of examiners at any time of
quality such that they are amended or discarded. Examiners the exam. Examiners should give neutral feedback and avoid
will generally avoid questions that fail to differentiate between negative or positive comments. They should allow the oppor-
good and badly performing candidates. Sometimes the bio- tunity for candidates to answer the question and remain fairly
mechanics or statistics question that no one expects to be quiet during the viva, at maximum contributing 20% of the
chosen is snapped up by examiners who may actually enjoy discussion. Examiners are there to assess candidates not to
vivaing on the topic. Some questions may be ambiguous and, teach. The viva exam is a summative exam and enough infor-
therefore, need to be clarified or discarded. Other questions mation needs to be gleaned by the examiners to confidently
may include laminated clinical photos that are unclear or of give the candidate an appropriate mark. If a candidate is failed
poor quality such that they are amended or discarded. Each in general more copious notes are made by the examiners to
question has a model answer and the subsection examiners provide available evidence to justify their decision.
around a table discuss and agree on a minimum level of The co-examiner should make notes whilst the other exam-
knowledge required to safely pass a viva question with a score iner is asking questions. They should not interrupt, leave the
6. They reach a consensus opinion usually fairly quickly. examination table to answer their phone, appear bored or
disinterested or fall asleep.
Scoring
Score 8. Generally a candidate will keep on talking and the Candidates’ etiquette
examiners may occasionally run out of scripted questions
A small number of candidates perhaps through intense ‘nerves’
to ask. Can quote the literature to support an answer
or ‘stress’ may behave in a bizarre dysfunctional manner. This
Score 7. Doing well for most of the oral but some gaps in
may involve invading an examiners personal space, appearing
places. Occasional prompts
odd with strange visual expressions or just being all over the
Score 6. Score 6 covers a large difference in performance. place. This behaviour should have been spotted and dealt with
This will be from a well-polished answer which has been by intensive professional coaching and feedback before a candi-
generally very good except for a couple of silly mistakes that date even had a chance to sit the exam. Just as serious is
has dragged the mark down to a scrapped through score arguing, being rude, disrespectful or arrogant. Examiners are
6 where the candidate was a whisker away from failing and advised to ignore this type of behaviour but we live in the real
scoring a 5. Sometimes a candidate is absolutely fine with world and think it is likely to subconsciously affect a candidate’s
basic questions but just can’t raise their game when more mark. Viva courses that mimic the real exam are important as
difficult questions are asked. With each topic the examiner they allow a candidate the chance to dry run their performance.
usually gives a candidate a couple of opportunities to go Good courses should involve experienced exam-focused con-
further with their answer and score a higher mark. sultants who can provide appropriate feedback. Poor body
Score 5. Big gaps in knowledge. Large chunks of the topic language and eye contact can be addressed at this stage before
unanswered. it becomes too late. A hesitant and anxious performance can be
Score 4. The candidate has said something unsafe or practiced and honed in on until a candidate comes across as
dangerous. Does not understand the question or where it is articulate and confident in their viva approach. This is one of
going. Unfamiliar with topic. Can’t keep the question the main advantages of joining a group to revise for the exam.
moving forward. Like pulling teeth out for the examiners
Examiners’ etiquette Tips about the viva examination

Examiners have been encourage to make full use of the Listen to the question being asked and answer
marking system from 4 to 8. Each pair of examiners marks appropriately.
independently and are not allowed to discuss their score with Maintain eye contact with your examiners and smile.
each other until after awarding their marks. Any major dis- If asked how you would manage a condition start by saying
crepancy in marks (2 marks or more) needs to be fully justified 'I would'. Always refer to yourself
and investigated. They have to remain attentive, be articulate When asked about a topic, it is legitimate to keep talking
and encourage candidates to perform to the best of their until you are stopped and it is advisable not to invite any
ability. They should be objective, open minded, unbiased and leading questions that you do not have answers for.
be able to move a question forward appropriately. An exam- Do not argue with examiner, even if you know you’re right!
iner should not keep hammering on a point especially if a In case of controversy, quickly move on as smoothly as
candidate doesn’t know the answer. you can.
Examiners should put the candidate at ease at the begin- If an examiner says, ‘Are you sure?’ It suggests your answer
ning of the viva and introducing themselves and making sure is not correct. Take the hint
018
Chapter 15: General viva guidance
If you do not know the answer to a question do not stay may have been difficult. Give your balanced opinion on it.
mute but let the examiner know you have no idea so he/she It creates a bad impression if you are very critical or
can move on to another question. condescending of a poor fixation as it suggests you may
If you do not understand the question being asked you are end up being an unsupportive colleague in the future.
justified in asking the examiner to repeat it. Don’t keep Practice drawing figures such as the Selenius graph and
asking each question to be repeated however. brachial plexus, etc. and be sleek.
Do not keep thinking about previous poorly answered It is not necessary to know a long list of references to pass
questions but move on. the viva. At the same time candidates are unlikely to score
Do not start an answer quoting references, unless it is very an 8 with no idea at all about the literature.
obvious (e.g. Baumgartner’s paper on tip apex distance) In between vivas do not discuss your questions with your
If asked to comment on a fixation, don’t criticise the colleagues
fixation straightaway, always start by saying that the case Good luck!
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Hip oral core topics

Chapter
16 Sammy A. Hanna and Paul A. Banaszkiewicz
Anatomy of the hip candidates would be expected to identify the vast majority of
anatomical structures correctly. That said some of these ana-
Surgical approaches tomical pictures can be quite detailed and complicated.
These are common and important surgical approaches.
A thorough knowledge and understanding of the five main Blood supply of femoral head
approaches to the hip joint (medial, anterior, anterolateral, This is a favourite question in either the trauma, basic science
lateral and posterior) is required. Do not just stick to just the or adult pathology oral. This may lead into a discussion about
posterior or Hardinge approach as the medial approach (in the avascular necrosis (AVN) of the femoral head. The blood
paeds viva) and anterior approach (recent renewed interest) supply has three sources:
may sneak into a viva discussion. That said the posterior 1. The medial circumflex femoral artery (MCFA) is the most
approach to the hip joint is probably the most commonly important supply; it is a branch of the profunda femoris
asked surgical approach in the whole FRCS (Tr & Orth) exam artery
so you would be absolutely crazy not to learn this approach
2. The lateral circumflex femoral artery (LCFA) supplies the
inside out and back to fronta.
inferior portion; it is a branch of the profunda femoris
When asked about an approach, we suggest you structure
artery
your answer as follows:
3. The artery of the ligamentum teres, a branch of the
Indications for the approach obturator artery or occasionally the MCFA. Forms the
How to set up the patient medial epiphyseal vessels. Usually unimportant with only
Anatomical landmarks and location of incision small amount of the femoral head supplied from this artery
Internervous planes (if any) The main contribution stems from the MCFA deep branch,
Extensile measures (if any) the lateral epiphyseal artery. This supplies the majority of the
Structures at risk head and neck. The LCFA supplies the anterior inferior head.
Limitations of the approach At the base of the neck the ascending branches of the medial
and lateral circumflex arteries form an extracapsular arterial
Colour atlas pictures ring with minor contributions from the superior and inferior
gluteal arteries. The extracapsular arterial ring gives off
Candidates may be asked to identify structures labelled in a
ascending cervical arteries that travel upwards under the hip
blank manner on a colour atlas picture. Make sure that you
capsule and along the femoral neck deep to synovial mem-
practice identifying relevant anatomical structures around a
brane continuing toward the femoral head as retinacular
hip joint in a colour atlas textbook before the exam. The
arteries1. The retinacular arteries are divided into three groups
examiners tend to lift these pictures from the more popular
colour atlas textbooks or CDs on the market. Hardcore candi- Posterior inferior and posterior superior (from medial
dates should consider using these particular atlas books for femoral circumflex artery)
revision to enhance chances of success in the FRCS (Tr & Anterior (from lateral femoral circumflex artery)
Orth) exam, although this may be taking things just a little
At the margin of articular cartilage on the surface of the neck of
too far. These are quite straightforward viva questions and
femur the retinacular arteries form a subsynovial intracapsular
arterial ring, that supplies the head through multiple ascending
a
epiphyseal arterial branches that go on to enter the head of the
The surgical approach part of a viva topic can sometimes be the
femur (lateral epipyseal most important) (Figure 16.1)b.
differentiating section of a viva, where if you answer it reasonably
well you can scrap through an otherwise ordinary viva
b
performance, but if you are unconvincing and lack confidence you Have a mental picture of Figure 16.1 in your mind to revise
may end up with a disappointing marginal fail. from – It’s much easier.
019
Chapter 16: Hip oral core topics
Identification and surface anatomy of the sciatic nerve

Popliteal fossa: Anatomy, approaches and the
neurovascular structure arrangement
Posterior approach to the hip: Structures going above and
below the piriformis muscle, anatomy of the superior and
inferior gluteal nerves and arteries. Identification of
pudendal nerve and nerve to obturatus internus beneath
the piriformis muscle
Safe zones for acetabular screws
Femoral head blood supply
Basic science oral 3: Anatomy of posterior hip and thigh

Surface markings of the sciatic nerve
Causes of superior gluteal artery injury
Hamstring origin
Figure 16.1 Blood supply of the femoral head Approaches to the hip joint
Basic science oral 4: Hemipelvis anatomy

Laminated picture of a hemipelvis with outline of muscle
Epiphyseal blood supply: tenuous supply from: origins. Candidates were asked to identify five or six
Branches of the subsynovial intra-articular ring that muscle origins
enter the head posterosuperiorly (lateral epiphyseal
Basic science oral 4: Anatomy posterior aspect hip
arteries) Name the structures on the posterior aspect of the hip.
Vessels from medial epiphyseal artery entering through the A colour figure was provided with bare labels
ligamentum teres
Basic science oral 5: Gluteal muscles
Anastomoses with metaphyseal arteries Anatomy of the gluteal muscles and pelvis
Metaphyseal blood supply: excellent supply from: Surgical approaches to the hip joint; complications of the
Extracapsular arterial ring direct lateral approach
Branches of ascending cervical arteries Trauma oral 1: Surgical approaches
Branches of the subsynovial intra-articular ring Neck of femur fracture in a 45-year-old patient. How to
Intramedullary branches of the superior nutrient artery reduce closed – Essentially asked to describe the Ledbetter’s
technique – Flexion/Traction/IR/Ext/ABD:
The hip is fully FLEXED
Examination corner and slightly ADDUCTED as TRACTION is applied
Full INTERNAL ROTATION is then applied
Basic science oral 1: Blood supply femoral head Leg is then CIRCUMDUCTED into slight abduction while the
Second question after initial discussion on the position a leg assumes rotation is maintained
after a traumatic posterior and anterior dislocation of the hip. then brought into EXTENSION
EXAMINER: What is the blood supply of the femoral head?
Trauma oral 2: Surgical approaches
CANDIDATE: The blood supply to the femoral head is derived from
Anteriorly or posteriorly dislocated hip. Failed closed
the medial and lateral femoral circumflex arteries; these are reduction Describe open reduction and approach used
branches of the profunda femoris artery. They form an
extracapsular arterial ring around the base of the trochanter.
Ascending cervical arteries are given off this ring, which then Osteonecrosis of the femoral headc
branch into retinacular arteries, which form a subsynovial
intracapsular arterial ring. Definition
The candidate was stopped in mid sentence by the examiner, who Osteonecrosis (ON) is the death or necrosis of bone secondary
was satisfied with the answer and wanted to move on to another to loss of its vascular supply or more simply ‘death of bone from
question. This led on to a discussion of AVN of the hip and types of ischaemia’.
total hip arthroplasty (THA) to use in a young patient.
Causative factors
Basic science oral 2: Anatomy of the posterior thigh
The examiner had a colour-laminated photocopy of the whole of
A variety of aetiological associations with ON have been
the posterior thigh from an atlas. demonstrated (Table 16.1).
Identification of bare labels on it. All muscles had to be
identified with attachments and nerve supply c
The term osteonecrosis is preferred to ‘avascular necrosis’ or
‘aseptic necrosis’ because it does not imply a specific aetiology.
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019
Table 16.1 Causative factors of AVN fat embolisation or air embolisation from dysbaric
• Idiopathic phenomena
3. Intraosseous venous factors affect the femoral head by
• Trauma reducing venous blood flow and causing stasis. Obstruction
• Steroid therapy of venous drainage. Conditions such as Caisson’s disease or
• Alcohol SCD
• Caisson’s disease
Extravascular
• Sickle cell disease and other haemaglobinopathies 4. Intraosseous extravascular factors affect the hip by the
• Post irradiation increasing the pressure, resulting in a femoral head
• Gaucher’s diseased compartment syndrome. Fat cell hypertrophy after steroid
administration, lipid deposits in marrow extravascular
• Hyperlipidaemia space or within osteophytes can create an elevation of
• Systemic lupus erythematosus (SLE) intraosseous extravascular pressure. There is encroachment
• Renal transplantation on intraosseous capillaries resulting in decreased
intramedullary circulation
• Burns 5. Extraosseus extravascular (capsular) factors involve the
• Endotoxin reactions tamponade of the lateral epiphyseal vessels located within
• Pancreatitis the synovial membrane. This can occur after trauma,
infection or arthritis causing a hip effusion
• Nephritic syndrome
• Inflammatory bowel disease
Pathophysiology
The pathophysiology is still controversial and uncertain. Sev-
Vascular disturbance of the femoral head eral theories have been put forward2.
Aetiological factors in AVN are usually related to underlying Intraosseous hypertension theory (compartment
pathological conditions that alter blood flow, leading to cellular syndrome bone) Increased pressure in a closed rigid
necrosis and ultimately femoral head collapse. This damage can osseous compartment of bone increases intraosseous
occur in one of five vascular areas around the femoral head: pressure. Blood flow through the intraosseous
compartment is inversely proportional to the bone marrow
Intravascular pressure; thereby, any condition that causes an increase in
1. Extraosseous arterial factors are the most important. The this pressure will produce a decreased blood flow to bone
femoral head is at increased risk because the blood supply is in that area resulting in secondary ischaemia and AVN
an end-organ system with poor collateral development. Abnormality of extraosseous blood flow. There may be
Blood supply can be interrupted by trauma, vasculitis significant differences in the regional vascular anatomy
(Raynaud’s disease), or vasospasm (decompression sickness) between individuals that predispose them to AVN
2. Intraosseous arterial factors may block the A fat emboli phenomenon in subchondral arterioles. This
microcirculation of the femoral head through circulating results in intraosseous coagulation, which leads to generalized
microemboli. These can occur in sickle cell disease (SCD), venous thrombosis and retrograde arterial occlusion
One hypothesis considers AVN is caused by fat cell
hypertrophy in which fatty marrow overload leads
d
When mentioning causes of ON stick to the most common ones to increased bone marrow pressure inside the femoral head
first. If you start with Gaucher’s disease you are inviting trouble. It resulting in sinusoidal vascular collapse and AVN
isn’t the most obvious cause of ON and may irritate the examiners Other authors believe the condition is caused by a direct
enough for them to switch the topic. Gaucher’s disease is a cause of cytotoxic effect on osteocytes (alcohol)
ON but it is small print and should be mentioned near the end of
Several studies have demonstrated clotting
your list after the more obvious causes have been discussed
(trauma, alcohol, steroid use, etc).
abnormalities such as deficiencies in protein S, protein
C and antithrombin III in patients with ON. A few
EXAMINER: How common is Gaucher’s disease as a cause of ON? studies have shown the presence of both
CANDIDATE: Not very common hypofibrinolysis and thrombophilia in patients with
EXAMINER: But since you’ve mentioned it, tell me you all you know about ON. Both hypofibrinolysis and thrombophilia are
Gaucher’s disease. associated with an increased incidence of thrombotic
The examiners will think your reasoning is poor, you have no sense of order of events that may contribute to the pathogenesis of
priority in your answer and you have not demonstrated higher order thinking. osteonecrosis
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Table 16.2 Ficat classification of AVN
0 Silent Preclinical and pre-radiographic

Diagnosis suspected in one hip when the other hip has definite disease
Bone marrow pressure studies abnormal and core biopsy would reveal characteristic
histological patterns. This stage was not described in original classification. No clinical
symptoms. Normal radiographs. MRI non-diagnostic
1 Preradiographic Radiographs usually normal or at most minor changes such as subtle loss clarity with poor
definition or blurring of trabeculae pattern. Diagnosed with a positive MRI or bone scan.
Earliest clinical manifestation of the syndrome. Usually presents with sudden onset of
ischaemic hip pain in the groin with or without radiation down the front of the thigh
2A Precollapse (Before flattening of head or This extends over several months with clinical symptoms and signs persisting or
sequestrum formation worsening. Radiographs demonstrate osteopenia/sclerosis femoral head
2B Crescent sign Curvilinear subchondral radiolucent line due to subchondral fracture
3 Collapse Segmental flattening and collapsed femoral head. Worsening pain, limp, limited range of
Bone sequestrum broken off motion in all planes
4 Osteoarthritis Terminal phase, secondary degenerative change superimposed on a deformed
femoral head
Jones has suggested that a combination of three factors Acetabular labral tear: Patient describes snapping and
result in microcirculatory thrombus leading to ON: Stasis, ‘clicking’ in the groin. Symptoms also mainly mechanical
hypercoagulability and endothelial damage3. Many Sports hernia: Can be associated with a lump or ‘fullness’
mechanisms are overlapping and mutually supportive and not seen in AVN
all eventually lead to a final common pathway of vascular
occlusion and ischaemia leading to both marrow cell and
osteocyte necrosis
Classification systems
Ficat
Clinical features The original classification in 1964 did not include stage 0.
Usually non-specific with insidious-onset hip pain, which is Stages 0–II are described as early stages and Stages III and IV
worse with weight-bearing, often present at rest and eventually are classified as late stages. Stages II and III represent the
at night. It is associated with a decreased or painful range of distinction between precollapse and collapse. This classifica-
hip movement, limp, muscle weakness and antalgic gait. tion system established the premise of staging osteonecrosis
and subsequent classification systems4 (Table 16.2).
Radiology
Steinberg (University of Pennsylvania)
Radiographs. AP and frog-leg lateral radiographs. Normal
in the early stages of the disease Seven-stage system (0–6)e. It is considered more useful than
Bone scan. Poor sensitivity especially with early disease Ficat because it grades the severity and extent of the involve-
MRI scan. Generally accepted as the gold standard for ment, both of which affect prognosis (Table 16.3).
confirming a suspected clinical diagnosis of ON and
asymptomatic contralateral disease Mitchell MRI staging classification of AVN5
ON is diagnosed when a peripheral band of low signal intensity The Mitchell classification may be useful in grading lesion
is present on all imaging sequences, typically in the superior acuity, as infarcted bone will tend to progress through the
portion of the femoral head, outlining a central area of marrow. classes of signal intensity over time. However, this progression
This peripheral band is most apparent on T1-weighted is not always consistent, and more than one class of signal
sequences. On T2 sequences, the inner border of the peripheral abnormality may be found in a single lesion (Table 16.4).
band shows a high signal in 80% of cases. This is called the The prognostic value of MRI is more dependent upon the
‘double line’ sign and is pathognomonic for ON. size and location of the lesion. Small lesions confined to the
medial anterosuperior portion of the femoral head tend not to
Differential diagnosis collapse. AVN that does not contact the subchondral margins
Transient osteoporosis of the hip: A self-limiting tends to have a good prognosis regardless of lesion size.
condition, MRI demonstrates oedema into the femoral
neck and metaphysis, which is not common with ON
e
Femoroacetabular impingement: Symptoms tend to be Easy to mix up and say that the Steinberg classification is a six-stage
more mechanical and do not usually occur at night. system because you remember the number 6. It’s not, as there are
seven stages, from zero to six. Some clever examiner will pick you
Positive impingement test
up on this.
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Table 16.3 Steinberg classification of osteonecrosis adult hip Table 16.4 Mitchell MRI staging classification of AVN
0 Normal x-ray, bone scan and MRI, diagnosed on histology • Class A Bright on T1 Intermediate on T2 (fat)
I Normal x-ray, abnormal bone scan or MRI findings (minimal • Class B Bright on T1 and T2
pain) (blood)
II Sclerosis and/or cyst formation in the femoral head • Class C Intermediate on T1 Bright on T2 (fluid and/
or oedema)
III Subchondral collapse (crescent sign) without flattening
IV Flattening of the femoral head without joint narrowing or
• Class D Dark on T1 and T2
(fibrous tissue)
acetabular involvement
V Flattening of the femoral head with joint narrowing and/or
acetabular involvement
histological examination of the hip (biopsy) is no longer required for a
VI Advanced degenerative change
diagnosis of AVN. MRI is the most sensitive and specific diagnostic
Notes: method.
Volume head involvement (VHI): Minimal (<15%), moderate (15–30%),
extensive (>30%).
Surface collapse and dome depression: 2 mm, 2–4 mm, >4 mm.
Location: Medial, central, lateral. Prevention
Identification and elimination of risk factors. Applicable to
Table 16.5 Management of ON alcohol intake and steroid administration
Adherence to established safety guidelines for divers and
• Pre-collapse those working under hyperbaric conditions
Prevention Alcohol
Non-operative Protective weight-bearing Management (Table 16.5)
Pharmacological: bisphosphonates,
Goals of management are to relieve pain, improve function,
iloprost, statins
minimize morbidity and maintain options for secondary pro-
Hyperbaric oxygen
Pulsed electromagnetic field cedures. Four radiographic finding are routinely used when
formulating a management plan: (1) Is the lesion precollapse
Joint-sparing Core decompression or post-collapse; (2) size of necrotic segment; (3) amount of
procedures Vascular fibular graft
femoral head depression; (4) acetabular involvement with
• Post collapse signs of osteoarthritis.
Osteotomy Varus/valgus
Rotational Non-operative
Joint arthroplasty Bipolar hemiarthroplasty
Observation (protective weight-bearing)
Cemented THA Not a good option as most patients do poorly. Collapse of the
Uncemented THA femoral head was noted by Ohzono et al.6 to occur in 80% of
Arthrodesis
patients within 4 years of onset of hip pain (success rates for
Ficat stage 1, 35%; stage 2, 31%; stage 3, 13%). Observation may
be indicated in those with very limited disease or if the patient is
not fit enough for surgery. Start with non-weight-bearing with
Classic reference
progression to full weight-bearing when clinical symptoms and
Ficat RP. Idiopathic bone necrosis of the femoral head. signs demonstrate that the hip is less irritable. Radiographic and
Early diagnosis and treatment. J Bone Joint Surg Br. clinical follow-up is essential until the hip pain subsides.
1985;67:3–9.
Toulouse Non-operative pharmacological management
Ficat and Arlet proposed the original classification of avascular necrosis Lipid-lowering agents, statins, anticoagulants and bisphospho-
in 1964 before the advent of MRI. It consisted of stage I through to nates have all shown promising results but require further
stage IV and did not include stage 0 previously identified by research and clinical reports regarding their efficacy. Agarwala
Hungerford in 1979.
et al.7 reported on the efficacy of alendronate in the medical
In 1985 the Ficat classification added a stage 0, also known as ‘silent hip’.
Stage 0 is both preclinical and preclinical with the diagnosis suspected in management of ON. They demonstrated improvement in
one hip when the other hip has AVN. This was diagnosed on a positive symptoms (walking time, standing time, pain and disability),
functional exploration of bone. retarded progression of the disease and reduced rate of collapse
Despite Mont et al. identifying at least 16 classification systems in use of the femoral head. Mode of action is inhibition of osteoclas-
to grade and describe avascular necrosis , the Ficat system continues
tic activity, which reduces oedema, and the rate of remodeling
to be the most widely used system. One significant change is that
in the femoral head. This then increases bone mineral density
019
and as such delays the progression of bone collapse. At a mean Core decompression
follow-up of 4 years, 364 hips (92.2%) had a satisfactory The principle is to relieve pressure, increase vascularity and
clinical result and had not required any surgery. Failure requir- stimulate a healing response. This in turn is believed to reduce
ing THA occurred in 4 of 215(2%) Ficat stage 1 hips, 10 of 129 pain and halt the progression of the disease. Modern percutan-
(8%) Ficat stage 2 and in 17 of 51 (33%) Ficat stage 3 hips. eous techniques are simple, safe and particularly effective in
Iloprost is a vasoactive compound used in the treatment of the treatment of small lesions at an early stage of disease. There
vascular occlusion, vasculitis and pulmonary hypertension. It is minimal morbidity and recovery time.
acts on the terminal vascular bed by inducing vasodilatation, There is some controversy as to the effectiveness of the
reduction of capillary permeability and inhibits platelet aggre- procedure but a reasonable body of evidence supports its use.
gation8. Promising early clinical and radiographic improve- Mont et al.12 published a meta-analysis of patients treated with
ments at 1 year have been reported9. core decompression covering 1206 hips. Survival rates
Animal studies have shown that statins reduce bone reported for Ficat stage 1 were 84%; stage 2 65%; and stage 3
marrow adipocyte size and, therefore, potentially reduce 47%. Approximately two-thirds do well (half if you exclude
intraosseous pressure within the femoral head. They have centres of excellence with the most experience). Selection of
pro-osteoblastic and anti-adipogenic effects on bone marrow patients is important as if the head is too severely involved the
stromal cells. These effects protect against corticosteroid- procedure is unlikely to be successful (Figure 16.2).
induced osteonecrosis.
Core decompression and porous tantalum rod implant
Electrical stimulation This functions as a structural graft to provide mechanical
Only a few short-term studies have been published in peer- support and possibly allows bone growth into the avascular
reviewed journals and, whilst they report encouraging early femoral head. The operative technique is much simpler than
results, most orthopaedic surgeons remain skeptical and this a vascularized free graft. It avoids the morbidity associated
management option has not proved widely acceptable. More with autogenous bone harvesting and the risks of disease
long-term studies are required and, therefore, it remains transmission with allograft bone. There is some concern
experimental and requires further evaluation as part of a RCTf. about ease of removal and large amounts of metallic debris
if there is conversion to THA. One series13 reported a 15%
Hyperbaric oxygen (HBO) therapy failure rate, with retrieval analysis demonstrating limited
One small study10 reported beneficial effects for stage-1 AVN. ingrowth response and insufficient mechanical support of
Daily HBO therapy was given for 100 days. Overall, 81% subchondral bone.
showed a return to normal on MRI as compared with 17% in
an untreated group. A recently published randomised trial by Non-vascularized bone grafting
Camporesi et al.11 has also shown encouraging results. More Non-vascularized cortical strut grafting using either the fibula
detailed studies are needed to evaluate this treatment modality. or tibia placed into a core tract into the femoral neck combines
Mode of action is reversal of cellular ischaemia by increasing the effectiveness of core decompression with that of providing
the oxygen concentration of extracellular fluid and by reducing mechanical support to the femoral head, thus, retarding its
oedema by inducing vasoconstriction. Drawback is the pro- tendency to collapse. The graft provides a source of mechanical
longed course of treatment required.
Joint-preserving methods
The Kerboull necrotic angle is calculated by adding the area of
necrosis on the AP and frog-leg lateral views. Patients with a
Kerboull angle >200° more commonly have poor results with
certain joint-preserving procedures.
Mesenchymal stem cells

Cultured stem cells are injected under fluoroscopic guidance
into the necrotic lesion following percutaneous core decom-
pression. A K-wire (diameter 2.7 mm) is used to perforate the
interface between the necrotic bone and healthy tissue. The
stem cells stimulate neogenesis and new bone formation using
the necrotic tissue as a scaffold. This is experimental, and needs
further research.
f
Play it safe. This is what the examiners want to hear. Figure 16.2 Failed core decompression for AVN
233
019
support for the articular surface of the femoral head during the et al.15 reported good to excellent results in 229 of 295 hips (78%)
healing phase and stimulates neovascularization. at a mean of 11 years (range 3–16 years), postoperatively these
results have not been matched in Europe and the USA.
Vascularized bone grafting In summary, a PFO is a reasonable joint-preserving pro-
Results suggest superior clinical results than non-vascularized cedure when done by an experienced hip surgeon with osteot-
grafts. The procedure is technically difficult, time-consuming omy training in a patient younger than 45 years who has a
and requires special equipment and microvascular surgical Kerboull angle <200°.
techniques. Possible option in young patient (<50 years) with
precollapse lesion. Consider the diagnosis, patient’s age and Joint replacement
extent of disease progression. Bipolar hemiarthroplasty
Possibly best indicated in an elderly patient whose ON resulted
Trapdoor procedure from chronic alcohol abuse and who would be non-compliant
Indicated for precollapse (Ficat stage 2). The break in the with THA precautions postoperatively. Protrusio and erosion
articular cartilage is exposed following hip dislocation and is of the acetabulum may occur. It is not popular as a high failure
opened like a trapdoor. Necrotic bone under the flap is excav- and complication rate. Long-term results are not encouraging.
ated and then removed with a power burr to expose bleeding Better options in this situation such as dual motion
bone. The defect is then filled with cancellous bone graft. Mont
et al.14 reported encouraging results with Ficat grade 3 (24) and Hybrid THA
4 (6), with 73% good to excellent results at 5 years, but hips with Studies of patients undergoing cemented THA for advanced
Kerboull angles >200° did poorly. Further studies with longer ON have indicated a high incidence of loosening of the
follow-up are needed to assess the usefulness of this procedure. acetabular component. The combination of an uncemented
acetabular component and cemented femoral stem offers a
Muscle pedicle bone grafting different alternative for this difficult problem, with at least
This attempts to preserve the viability of bone graft. Donor one study reporting good medium-term results.
sites include the insertion of quadriceps femoris (posterior)
tensor fascia lata muscle (anterior) and sartorius. Core decom- Limited femoral head resurfacing arthroplasty16
pression performed along with muscle pedicle bone grafting. Main candidates would be Ficat stage III disease, a combined
necrotic angle of >200° or >30% involvement, femoral head
collapse of >2 mm, and no evidence of damage to the acet-
Proximal femoral osteotomies abular cartilage. Mixed results reported and initial enthusiasm
This attempts to shift most of the involved portion of the head for use has diminished.
medially. There are two general types of osteotomies: Angular
intertrochanteric (varus and valgus) and rotational transtro- Hip resurfacing arthroplasty (HRA)
chanteric. They are usually indicated for Ficat stage 2 or 3. The With advanced ON it is relatively contraindicated as failure
results are best with age 45 or younger, unilateral disease, rates may be high. Although early results for AVN in young
idiopathic or traumatic aetiology, small to medium area of active patients have been encouraging great concern has arisen
infarction, no joint narrowing, a combined necrotic angle for the complications of metal-wear debris and adverse reac-
<200° and a 20° arc of intact lateral femoral head to act as a tion to metal debris (ARDIS). One recent long term study
weight-bearing support. Only applicable to a small number of by Amstutz et al17 (FU 10.8 years, 99 hips) reported excellent
carefully selected patients and it is difficult to convert failed results.
cases to THA. Avoid if steroid- or alcohol-induced AVN.
Reported success rate of 70–80% in stage II–III hips. Uncemented THA
Valgus flexion osteotomy indicated for small anterolateral Although the optimal method of fixation of hip implants in
lesions with or without collapse. Corrects adduction deformity ‘dead’ bone remains open to debate, some recent studies have
common with anterolateral segment collapse with valgus reported excellent results using uncemented implants. Cheung
realignment and with the addition of flexion transfers the load et al.18 reported the outcome of 182 total hip arthroplasties (in
to the posterior articular surface. In a small number of patients 144 patients, 117 AVN hips and 65 non-AVN hips) performed
the necrotic lesion occurs in the medial aspect of the femoral using hydroxyapatite-coated femoral stems. Mean age was
head in which case a varus intertrochanteric osteotomy is 51 years and mean follow-up 14.7 years (range 9.7–19.1 years).
indicated. Precise location of the necrotic segment, either Four stems were revised because of aseptic loosening, three in
anterior or posterior, determines whether flexion or extension the AVN group and one in the non-AVN group. The 19.1 year
is added to the osteotomy. survival using revision for aseptic loosening as an endpoint for
The Sugioka transtrochanteric rotational osteotomy shifts the AVN and non-AVN patients were 97.1% and 96.2% respect-
diseased portion of the head medially, inferiorly and posteriorly. ively. Stable boney ingrowth was present in 99.5% hips.
This is a technically demanding procedure and, although Sugioka Johannson et al.19 in a systematic review found that patients
019
with sickle cell disease, renal failure and/or transplant, and

Gaucher disease have significantly higher revision rates. There
was a positive influence on survivorship with the newer
designs of cementless THA in ON.
Cemented THA
Historically poor results have been reported for cemented
THA in ON. Chandler et al.20 reported their experience with
THA in patients <30 years. They found that 61% of their
‘problem hips’ were in patients with ON. Stauffer, in 1982,
found aseptic loosening of the femoral component in 50% of
patients with ON21. These results are historic and are based on
using first-generation cementing techniques, dated implants
and young age of the patient.
In 2002 Fyda et al.22 reported their results with 53 cemented
THA done between 1970 and 1984 in patients with ON. They
Figure 16.3 AP pelvis showing AVN left femoral head
noted a 28.6% prevalence of femoral loosening and a 29.2%
prevalence of acetabular loosening in patients surviving
of progression of <10%. The natural history of asymptomatic
10 years since the surgery.
medium-sized, and especially large, osteonecrotic lesions was
Garino and Steinberg23 reported a 96% survivorship in
progression in a substantial number of patients. For this
123 hips for ON. All femoral components were cemented with
reason they recommended joint-preserving surgical treatment
second-generation techniques. Seventy-one acetabular com-
in asymptomatic patients with a medium-sized or large, and/or
ponents were cemented, and the rest were press-fit and
laterally located, lesion.
porous-coated. Kim et al.24,g analyzed the survival of hybrid
Nam and Kim26 demonstrated that the rate of disease
and cementless metal on polyethylene (MoP) THAs in young
progression was related to the extent of necrotic lesion, being
patients <50 years average follow up 9.3 years. They found no
5% for small lesions (<30% femoral head), 46% for medium-
significant difference in Harris Hip Score (HHS) and both
sized lesions (30–50%) and 83% for large necrotic lesions. The
groups had an overall revision rate of 2%. Although there
development of pain is related to the occurrence of femoral
was no aseptic loosening of the components both groups had
head collapse.
high rates of polyethylene (PE) wear and osteolysis.
Cemented THA for ON is an excellent choice in an older
patient with low functional demands. With modern cementing Classic reference
techniques it is reasonable option in a younger patients but an Mont MA, Hungerford DS. Non-traumatic avascular necrosis of
uncemented THA may be the better choice and there is more the femoral head. J Bone Joint Surg Am. 1995;77:459.
evidence to support uncemented implant use in ON particu-
Review article of published studies of AVN. Meta-analysis of 21 studies
larly from North America. (818 hips) with average follow up of 34 months. Methods of treatment
were often based on small numbers of patients with different
Arthrodesis aetiologies and stages of the disease.
Arthrodesis may be indicated in young patients with unilateral
disease, e.g. trauma. Many cases are bilateral. It is more of a
theoretical option for advanced disease than a practical one.
Examination corner
Asymptomatic ON Adult elective orthopaedics oral 1: ON hip

Typical GP lead-in letter is a middle-aged male with a short
This is becoming more topical as MRI scans are detecting history (4–6 weeks) of severe unilateral or bilateral (less likely)
more asymptomatic early lesions. Mont et al.25, in a systematic hip pain. Candidates may be given a further clue with the
review of untreated asymptomatic ON, found a high (84%) aetiology such as ‘has been taking steroids for asthma’ or,
risk of progression of large lesions and a substantial (25%) risk ‘has a history of sickle cell disease’, although this makes the
of progression of medium-sized lesions. However, small medi- diagnosis perhaps too easy. ‘There is no history of trauma’ may
ally located lesions had a more benign course, with a low risk also be included in the introduction.
Candidates will then be shown a radiograph of N and
asked to comment (Figure 16.3). ON of the hip is not always
obvious on a plain AP radiograph. It is important that candi-
g
There are very few direct comparisons of cemented THA vs dates do not miss the diagnosis as it is very difficult to recover
uncemented THA for ON. This study is slightly confusing as hydrid the viva afterwards and you put yourself on the back foot. The
(uncemented cup/cemented stem) vs uncemented.
235
019
Exeter stem) and a cemented second generation highly cross-

linked PE cup with a ceramic on polyethylene bearing surface
(Figure 16.4). Another option especially if the patient is <50
years is an uncemented THA with either a ceramic on ceramic
(CoC)- or MCP-bearing surface. Recent UK NJR data at 10 years
for males <55 yrs (all diagnoses) reports a 6.35% revision rate
with an uncemented THA MoP-bearing surface, 4.50% revision
rate with an uncemented THA CoP-bearing surface and a
3.47% revision rate for uncemented THA CoC-bearing surface.
Some examiners may prefer to avoid using an uncemented
option in ON because of concerns of a higher failure rate.
Therefore candidates will need to justify an uncemented THA
choice with some published clinical results specific for ON.
A metal on metal (MoM) hip resurfacing procedure is
something candidates should avoid mentioning nowadays.
It is a controversial option that could end up with you digging
a big hole for yourself and dragging yourself down rather than
Figure 16.4 Postoperative cemented THA for ON hip scoring any extra points.
EXAMINER: What are the published results of hip arthroplasty in
patients with AVN?
viva question becomes a bare 6 pass needing a nearly flawless
CANDIDATE: There are conflicting reports regarding the outcome of
performance thereafter.h
This is pattern recognition so just keep looking in the ortho- THA for AVN. Historically, THA had poorer results in AVN
paedic books or on various web links to familiarize yourself with compared to osteoarthritis. Other studies have refuted this and
the radiographic appearance of early ON. Learn and practice report an equally successful outcome after THA. Suggested
how to describe the radiographic and MRI appearance of ON reasons to explain this observed discrepancy include pooling
The next couple of minutes should be fairly predictable. together of patients with different associated risk factors for
With aetiology a list of causes should be generated starting AVN and that many reported studies used either first-generation
with common conditions first. cementing techniques or first-generation uncemented prosthetic
Pathophysiology is slightly more difficult as you could designs. This contrasts with more current studies using
either discuss the five potential areas of vascular disturbance contemporary prosthetic designs and modern cementing
in ON or go straight to the various theories of ON put forward.
techniques. Patient age may also be an issue, with AVN typically
A 7 or 8 candidate would be able to answer in greater detail
affecting a young age, which means that the outcome of AVN can
the specific pathological feature of perhaps steroid induced
AVN, alcohol, Caisson’s disease and sickle cell disease if probedi. be expected to be suboptimal. Patients with sickle cell disease,
Classification should be relatively straightforwardi. Candi- renal failure and/or transplant and Gaucher disease have
dates should really know this in detail – It is reckless not to do so. significantly higher revision rates.
Although Ficat et al. is the classic paper the examiners may Michael Mont has extensively studied AVN. In one paper he
go for the more detailed Steinberg classification as it is more reviewed various studies and reported wide differences in failure
detailed, has more prognostic value and stretches you a bit rates of THA of between 10% and 50% at 5 years27. Furthermore,
further. in his systematic review of 27 published series, all except two
With management briefly mention prevention before studies reported a higher rate of failure in patients with AVN than
structuring your answer into conservative, joint-preserving
in age-matched patients with other disorders28.
and joint-replacement surgery management.
Recent UK NJR data at 10 years for males <55 yrs (all EXAMINER: Yes, you are forcing cement into dead bone. This
diagnoses) reports a 7.54% revision rate with a cemented THA gentleman is young, at 40 years of age. How will you manage him?
MoP bearing surface compared to a 3.57% revision rate with a CANDIDATE: I would perform an uncemented THA on this patient
cemented THA CoP bearing surface. Therefore an acceptable with a ceramic on ceramic bearing surface telling him it will last
non-controversial answer would be a cemented THA (cemented between 15 and 20 years before requiring revision.
Although there has been a recent trend in performing more
cemented THA as NJR data suggests across all ages better early
h
Whilst we hesitate to say it is a pass/fail issue the examiners may survival rates at 11 years he is still only 40 years old and I would
think you may miss this diagnosis in the clinic and be unsafe in have concerns with long-term risks of loosening in a young active
your practice. male and prefer to use an uncemented hip arthroplasty. Despite
i
If you had to chose or bet on one causative agent being probed go slightly better results from NJR data using an uncemented CoC
for steroids.
j bearing surface at 10 years for males under 55 yrs I have concerns
We come across a number of candidates near to the exam in practice
vivas who apart from knowing the name ‘Ficat’ do not know any regarding sqeaking, catastrophic ceramic fracture and cost and
classification systems used for ON.
019
therefore would opt to use a CoP bearing surface. I would want to deposited throughout the network of dead trabecular bone.
make sure the polyethylene is a second generation highly cross The nonviable trabecular bone is slowly resorbed by the pro-
linked variety. Newer manufacturing techniques involve either cess of creeping substitution. Newly deposited bone does not
sequential irradiation and annealing (X3) or infusing Vitamin E into attain the previous mechanical strength and structural integ-
rity of the femoral head leading to subchondral collapse with
irradiated PE to stabilise free radicals and prevent oxidative
weight-bearing.
degradation
Adult elective orthopaedics oral 4: ON
Adult elective orthopaedics oral 2 Femoral head with ON resected at surgery for THA
A cut section of a femoral head showing subchondral collapse (Figure 16.6).
was presented (Figure 16.5). This is another popular lead pic- AVN (Ficat classification and management)
ture into AVN hip. Principles of classification.
The following were discussed: The lack of a universally accepted classification system for
Radiographic findings in AVN – Differentiating features AVN makes it difficult to compare and analyze data pub-
between precollapse and collapse lished from different centres. The Ficat classification system
The grading of AVN – ‘YOUR’ management for this grade has a low interobserver reliability and only modest intraob-
The role of fibula grafts, decompression server reliability. The validity of a classification system
There was a very superficial discussion throughout reveals the accuracy with which it describes the true patho-
logical process. Validity has not been formally assessed for
Adult and pathology oral 3 any of the classification systems for osteonecrosis of the
Osteonecrosis: femoral head.
Classification
Causes Adult and pathology oral 5
Management Clinical and MRI differences between AVN and bone marrow
oedema syndrome (BMES):
Basic science oral 1
BMES presents with similar symptoms to ON with disabling
Causes of ON hip pain without any history of trauma
Classification With BMES standard radiographs are normal or
Pathophysiology of ON, specifically steroid-induced AVN demonstrated non-specific osteopenia
Discussion of some new theories and treatments proposed With MRI a heterogenous bone marrow oedema
Management of ON pattern would be seen in the affected femoral head,
neck and trochanteric region. There is decreased signal
Basic science oral 3: AVN following fractured neck of femur: blood intensity on T1-weighted images and increased signal on
supply femoral head
T2-weighted sequences
What happens to the bone in AVN? Histological changes? The main differentiating feature from ON is the lack of focal
defects or subchondral changes on T2 MRI images
How does repair occur? All patients with BMES recover completely over a
Inflammatory cascade. Fibrous vascular in growth in the period of 6–12 months without the need for surgical
regions of cell death. Primitive mesenchymal cells differentiate intervention. Treatment is usually symptomatic including
into osteoblasts and osteoclasts. Immature woven bone is
Figure 16.5 Cut section femoral head demonstrating ON with subchondral

collapse Figure 16.6 ON femoral head resected at surgery for THA
237
019
Table 16.6 Grading of protrusio acetabuli according to distance between the acetabular line and ilioischial line
Grade Men Women

I: Mild 3–8 mm 6–11 mm 5–10 mm protrusion
II: Moderate 9–13 mm 12–17 mm 10–15 mm
III: Severe >13 mm with fragmentation >17 mm with fragmentation >15 mm protrusion
femoral stem sinkage, LLD and dislocation. A cemented THA is

a safer choice.
Protrusio acetabuli
Definition
Acetabular protrusio is the proximal and medial migration of the
femoral head through the medial acetabular wall into the
pelvis29. It is defined radiographically as migration of the femoral
head medial to Kohler's linek (a line from the lateral border of the
obturator foramen to the medial border of the sciatic notch).
Classification Hirst grade I–III

Radiological classification based on plain radiographs of the
pelvis. Armbuster et al.30 found that in adult men the acetab-
ular line is on average 2 mm lateral to the ilioischial line, but in
women it is 1 mm medial. They considered protrusio to be
present if the medial wall of the acetabulum is >3 mm or more
medial to the ilioischial line in a male or >6 mm medial to it in
Figure 16.7 Radiographic view of the pelvis showing normal appearances on a female (Figure 16.7 and Table 16.6).
the left and those of protrusio acetabuli on the right. X–X, acetabular line, Y–Y, Some authors use the centre-edge angle measurement to
ilioischial line, Z–Z, iliopectineal line diagnose protrusion. An angle >40° is considered diagnostic.
Others consider violation of the teardrop as a diagnostic cri-
terion. The teardrop is the most consistent landmark and is a
analgesia and NSAIDs, physiotherapy and protected weight-
useful way to assess and track progression of protrusion. The
bearing to maintain strength and mobility of the hip
acetabular roof angle is negative.
COMMENT: This viva question is more challenging than the
usual ON hip viva question. It is similar to the 2 for 1 supermar-
ket offer in that the examiners can switch between the two Aetiologyl
topics. Although BMES is a rare disorder compared to ON, both The primary idiopathic form of protrusio is termed Otto’s
conditions may not be completely distinct and separate entities pelvis or disease (arthrokatadysis). It is more common in
but related to a common cause which remains unclear. females (10 : 1), develops after puberty, involves both hips
Trauma oral 1
Post-traumatic AVN (fractured neck of femur, managed with k
Also known as the ilioischial line.
AO cannulated screws) l
This is classic adult elective orthopaedic oral material. An AP
Stage using ARCO (Association Research Circulation radiograph of the pelvis demonstrating obvious bilateral protrusio is
Osseous), Ficat shown. After preliminary discussions concerning the grading/
Management options – Cemented or hybrid THA, classification of protrusio the examiners follow on to ask about
possible role for arthrodesis if very young or at least the possible aetiological causes of protrusio. This generally leads on to
option discussed technical difficulties of performing a THA. As soon as ‘bone
Uncemented THA for AVN post-fractured neck of femur is grafting’ is mentioned, the oral will turn 90° and the examiner will
perhaps not the best option as bone quality is likely to be start to discuss the principles of bone grafts. Some examiners
osteoporotic, there may be issues with osseointegration, consider protrusio as only the prop to lead into a discussion about
bone grafting.
019
and progresses to osteoarthritis in mid-adult life. Clinical pre- especially abduction as the trochanter starts impinging on
sentation includes pain and limitation of leg abduction, loss of the superior acetabular margin
hip extension (flexion contracture) and a hyperlordotic posture. 3. Symptoms due to causative disease: rheumatoid arthritis,
Varus deformity of the femoral neck and arthritic changes osteomalacia, etc
are common. A degree of protrusio is present in approximately
5% of all cases coming to THA surgery, with 50% cases occur-
ring in patients aged between 61 and 70 years. It has been
Investigations
Standard AP and lateral radiographs of the pelvis will confirm
reported as being present in approximately 22% of rheumatoid
the diagnosis and will permit staging. Judet views or a CT scan
patients requiring arthroplasty. The deformity may progress
will evaluate defects in the posterior and medial wall and help
until the femoral neck impinges on the side of the pelvis.
in planning placement of the acetabular cup. MR arthrogram
to access the status of the articular cartilage if joint preserva-
Associationsm tion surgery complicated. Exclude metabolic and rheumato-
Decreased bone density logical causes of the condition
Osteoporosis
Osteogenesis imperfecta Management
Osteomalacia Surgical triradiate cartilage closure combined with valgus
Rickets intertrochanteric osteotomy (VITO) for skeletally
Rheumatoid disease (19%) immature patients
Marfan’s disease Protrusio joint preservation surgery for adolescent and
Ankylosing spondylitis young adult patients31. In cases without cartilage
degeneration, open surgical dislocation with
Normal density osteochondroplasty of the acetabular rim and femoral
Osteoarthritis neck. With early cartilage degeneration VITO, reverse
Otto’s disease (idiopathic, 75%) periacetabular osteotomy (PAO) or combined reverse
PAO and VITO. The latter leads to more cranial directed
Increased density forces at the hip, reducing pressure on the floor of the
Hypophosphatasia acetabulum. In addition, it reduces impingement at the
Paget’s disease (4%) superior acetabular margin
Management of symptomatic protrusio is THA with non-
operative measures reserved for patients unfit or unwilling
Aetiology of secondary protrusio acetabuli to undergo surgery. There is merit in delaying THA
Infective: Staphylococcus, streptococcus, Mycobacterium
surgery in young individuals with minimal symptoms
tuberculosis
Inflammatory: Rheumatoid arthritis, ankylosing spondylitis, Principles of THA reconstruction
psoriatic arthritis, Reiter’s syndrome
THA may be technically demanding due to associated
Metabolic: Paget’s disease, osteogenesis imperfecta,
significant medial and proximal migration of the joint
osteomalacia hyperparathyroidism
Genetic: Sickle cell disease, Marfan’s syndrome Ehler–Danlos
centre, deficient bone medially and reduced bony support
syndrome to the acetabular component peripherally
Neoplastic: Neurofibromatosis, metastasis (breast, prostrate Template preoperatively to avoid offset and leg length
most common) radiation-induced osteonecrosis acetabulum discrepancies. Placing the hip centre back into the correct
Trauma: Iatrogenic fracture during surgery acetabular, anatomical position is essential to restore proper joint
fractures, osteolysis following THA biomechanics and to lower reactive forces
The medial wall of the acetabulum is typically thin, and
does not usually need reaming. The general principle is to
Symptoms bone graft the floor and lateralize the cup
Clinical features fall into three categories: Because of medial migration of the femur, the sciatic nerve
1. Symptoms due to the anatomical abnormality (deeping is often nearer the joint than normal and should be
socket): stiffness identified early and protected
2. Symptoms due to secondary osteoarthritis: pain, limp, all Hip dislocation can be difficult due to the excessive depth
movement becomes progressively painful and limited of the acetabulum and medial displacement of the femoral
head. Perform a controlled hip dislocation avoiding
excessive force as this may result in fracture of the
m
Remember O5R2MAP. posterior wall of the acetabulum or proximal femur.
239
019
Perform an extensive capsular incision. Consider in situ cement alone is uncertain. Cancellous bone grafting can pro-
neck ostotomy. In severe cases a trochanteric osteotomy vide a biological buttress after incorporation and also reduce
may be required for adequate exposure the effect of thermal necrosis and osteolysis that may follow the
When the femoral head has protruded into the pelvis, an exothermic curing of cement. One study reported better results
hourglass constriction is created, and the walls of the in hips with moderate and severe protrusio reconstructed with
periphery of the acetabulum diverge. Peripheral reaming bone graft than in mildly affected hips in which cement alone
will create a new rim with convergent walls wide enough to was used32. Reconstruction with bone graft enables a better
support the acetabular component. It is important to anatomical positioning cup, and its use has been suggested in
achieve a good rim press fit (if using a cementless shell) as hips with only a minor protrusion.
the thin or deficient medial wall is not relied on to prevent The adequacy of correction deformity correlates with long-
recurrent deformity. Femoral head bone autograft should term prosthetic survivorship. Bayley et al.33. found loosening
be placed on the medial wall, especially if there are of 50% of acetabular components at long-term follow-up when
significant cavitatory and central segmental bony defects. the centre of rotation of the hip was not corrected to within
Sections of femoral head can be used 10 mm of the anatomical location. Loosening occurred in only
Current trend is to use cementless fixation. The shell is 8% of acetabular components in which the hip centre was
1–2 mm larger in diameter than the last reamer and restored to within 10 mm of the anatomical.
because of the presence of bone graft should have an
excellent fit and is quite stable. The use of additional screws Examination corner
fixation is recommended
Adult elective orthopaedics oral 1: Idiopathic protrusio
If cementing, avoid excessive cement medially as it may be (Otto’s pelvis)
difficult to pressurize into the acetabulum. When a cup is Indications for surgery
inserted too medially and too high in moderate and severe Approach
protrusio, the neck will impinge against the acetabular rim, Use of bone graft
reducing the primary arc of motion, thus, causing Cementing technique
instability and predisposing to loosening
In cases with a severe deformity, a reconstruction cage may Adult elective orthopaedics oral 2: Bilateral protrusio
be required Radiograph shown of bilateral protrusio (Figure 16.8).
If coxa vara is present, standard femoral component EXAMINER: These are the radiographs of a 58-year-old woman
position (approx. 1 cm above lesser trochanter) may result who presented to the orthopaedic clinic complaining of
in limb length discrepancy (LLD). Careful preoperative bilateral hip pain (Figure 16.8). Would you like to comment
templating and more distal femoral component placement on them?
is required to avoid limb lengthening CANDIDATE: This is an AP radiograph of the pelvis, which
The standard treatment of mild protrusio with cement alone demonstrates a bilateral grade III Hirst protrusio.
has been called into question. The thin medial wall protruded EXAMINER: What is protrusio?
acetabulum is often osteoporotic so that adequate fixation by CANDIDATE: If the femoral head is medial to Kohler’s line or the
centre-edge angle is >40°, then protrusio is present.
EXAMINER: How do you grade protrusio?
CANDIDATE: Mild, moderate and severe based on the distance
of the medial wall of the acetabulum to Kohler’s line. Mild is
5–10 mm, 10–15 mm is moderate and >15 mm is severe.
EXAMINER: What are the causes of protrusio?
CANDIDATE: Protrusio can be classified as primary, attributed to
incomplete or delayed triradiated cartilage ossification
(chondrodystrophy), or secondary, attributed to diseases which
weaken the medial acetabular wall, such as rheumatoid arthritis,
ankylosing spondylitis, osteoarthritis, chronic renal
osteodystrophy, osteoporosis, etc. The principle joint reaction
force vector is directed more medially than normal with resultant
medial migration of the hip centre.
EXAMINER: What are you going to do for the patient?
CANDIDATE: I would initially attempt conservative management but
the deformity is quite marked and if symptoms of stiffness and
pain were severe enough I would offer her an uncemented THA
Figure 16.8 Radiograph of bilateral protrusio
019
with a ceramic-bearing surface and bone grafting to the

medial wall.
EXAMINER: Any difficulties you may encounter at surgery?
CANDIDATE: The neck may need to be cut in situ as it may be
difficult to dislocate and you could end up with a fracture if you
are not careful. The medial wall of the acetabulum is usually thin
or may be partially membranous, and should not be penetrated.
I would use supplementary acetabular screws as the acetabular
shell is not well supported by host bone medially. Failure to
restore normal lateral offset may cause the greater trochanter to
impinge off the anterior edge of the acetabulum, which may lead
to posterior instability. A femoral stem design with increased
offset reduces the risk of femoral-pelvic impingement especially if
a short neck length is used to equalize leg length.
EXAMINER: What complications can occur?
CANDIDATE: Intraoperative complications include acetabular
fracture, neurovascular injury, and visceral injury. Penetration of Figure 16.9 Postoperative (AP pelvic) radiograph following right uncemented
the medial wall may place intrapelvic structures such as the THA
bladder, ureter, bowel and external iliac artery at risk. Sometimes
the posterior soft tissue envelope of the capsule and external
rotators will not reach the posterolateral trochanter for repair. The Imaging
most common postoperative complications include loosening A number of hip angles should be measured36:
and medial migration of the acetabular component. Others 1. Lateral centre-edge angle of Wiberg (LCEA). This
include dislocation, infection and LLD. assess the superolateral coverage of the femoral head or more
EXAMINER: This is her postoperative (AP pelvic) radiograph simply femoral head lateralisation on an AP pelvis radiograph.
following right THA (Figure 16.9). What are the results reported It is obtained by measuring the angle between two lines:
for THA in protrusio? (a) a vertical line through the centre of the femoral head;
CANDIDATE: Baghdadi et al.34 from the Mayo clinic in 2013 in CORR and (b) a line from the centre of the femoral head to the
retrospectively reviewed 162 hips undergoing THA for acetabular superolateral aspect of the acetabular sourcil. An angle
protrusio. They reported survival from aseptic cup revision at <20° is diagnostic of dysplasia whereas values above 40° may
15 years of 89% for uncemented compared to 85% for cemented indicate pincer femoroacetabular impingement (FAI).
cups. The risk of aseptic cup revision significantly increased by 2. Anterior centre edge angle of Lequesne (ACEA). This
24% for every 1 mm medial or lateral distance away from the measures anterior dysplasia on the false profile radiographic
native hip center of rotation to the prosthetic head center. view that provides a true lateral view of the acetabulum. It
is the angle between two lines: (a) a vertical line through
the centre of the femoral head; and (b) a line from the centre
of the femoral head to the most anterior point of the acet-
Acetabular dysplasia in adultsn abulum. It is a measure of anterior coverage of the femoral
Acetabular dysplasia describes an underdeveloped or shallow, head. An angle <20° is suggestive of anterior subluxation or
upwardly sloping acetabulum, which may occur with varying deficiency.
degrees of deformity of the proximal femur such as excessive 3. Tönnis angle (acetabular inclination). This measures
femoral neck anteversion, coxa valga or femoral neck cam the angle of the weight-bearing surface or sourcil. It is the
deformity35. It is an important cause of hip pain, often angle between two lines: (a) a line from the most inferior point
affecting young women. Symptoms may be experienced for of the acetabular sourcil to the lateral margin of the acetabular
many years before osteoarthritis develops. Patients describe a sourcil; and (b) a horizontal line running through the most
sharp activity related groin pain that increasingly affects their inferior part of the sourcil.
lifestyle. Symptoms may be exacerbated by rising from a seated A normal Tönnis angle is between 0° and 10°. A decreased Tönnis
position, climbing in or out of a car, going downstairs or angle can lead to a pincer form of FAI whilst an increased
sudden rotational movements. Tönnis angle may indicate structural instability.
4. Acetabular angle (of Sharp). This measures acetabular
n
inclination or opening. It measures the intersection between
This is a different viva question to DDH. Interest in acetabular
the following two lines: (a) a horizontal line from the inferior
dysplasia in adults has increased as its surgical treatment has
advanced and the understanding of young adult hip disorders aspect of one teardrop to the other; and (b) a line from the
has grown. inferior aspect of the teardrop to the superolateral margin of
241
019
the acetabulum. A normal angle is between 33° and 38°. Higher Soft tissues
angles imply dysplasia in adults. Hamstrings, adductors and rectus femoris muscles are
usually shortened and contracted. Abductor
Investigations muscles horizontal and the hip capsule is elongated
CT scan. This will identify early degenerative changes, cysts and redundant. Psoas tendon hypertrophied.
and acetabular/femoral version. Three-dimensional CT recon- Sciatic nerve shortened susceptible to stretching.
structions can be useful in identifying cam on the anterior The femoral nerve and artery are forced laterally
femoral neck. by a high riding femur and are more vulnerable
MRI arthrogram. To detect chondral/labral pathology and to injury
extracapsular abnormalities such as avascular necrosis.
Management Classification
Diagnostic local anaesthetic hip injection with examination under Crowe I–IV
anaesthesia (EUA) to confirm the intra-articular origin of pain Crowe classified dysplasia radiographically into four categories
Hip arthroscopy for management of chondro/labral path- based on the proximal migration of the femoral head
ology and excision of a cam impingement lesion. Occasionally (Table 16.7 and Figure 16.10). This classification system is
when hip arthroscopy is used to treat labral pathology this may simple to use, reliable, reproducible and relates to the outcome
lead to a worsening of symptoms, as the stabilising effect of the of THA in patients with dysplasia. Although no measure of
labrum may be lost. reliability was included in the original article later studies have
The mainstay of surgical management is the Ganz periace- documented high levels of interobserver and intraobserver
tabular osteotomy (PAO). The acetabulum is reoriented to reliability.
enhance coverage of the femoral head. The aim of surgery is
to achieve congruity, stabilise the hip joint, medialize the hip Hartofilakidis 1–3
joint center and to reduce contact pressures. This will relieve Some surgeons prefer the Hartofilakidis’ classification
pain, improve function and prevent further overload of the (Table 16.8 and Figure 16.11) system, as they believe it is more
labrum, cartilage and soft tissues, thereby delaying the onset of practical and simpler to use and may predict the clinical
osteoarthritis. outcome of THA more accurately, since it yields a more
Advantages include posterior column remains intact leaving precise description of the acetabular pathology.
the pelvis stable and allowing immediate partial weight-bearing,
minimal internal fixation, extensive mobilization of the acetab-
ular fragment is possible, the blood supply of the acetabulum is Management
unaffected and the dimensions of the true pelvis are maintained. Conservative
Indications include: There is certainly a role for conservative treatment of the
Symptomatic acetabular dysplasia with persistent pain older patient with neglected bilateral developmental dysplasia
A centre edge angle of <25° of the hip (DDH) who has minimum hip pain. Many patients
A congruent hip joint
Maintained range of motion with hip flexion>110°
Preoperative osteoarthritis corresponding to Tonnis Table 16.7 Crowe classification of acetabular dysplasia
grades 0–1
Grade I <50% subluxation or proximal dislocation <10% or
0.1 of pelvic height
Congenital hip dislocation/subluxation Grade II Subluxation between 50% and 75% or proximal
The hallmark of the dysplastic hip is lack of coverage of the dislocation of 10–15% or 0.1–0.15 of pelvic height
femoral head, whether it is subluxed or dislocated. Usually do not have leg length inequality or loss of
bone stock
Anatomical features Grade III Subluxation between 75% and 100% or proximal
Acetabulum dislocation of 15–20% or 0.2 of pelvic height
Complete loss of superior acetabular roof
Shallow, anteverted, deficient anteromedial wall, small and
Possibly thin medial wall
poor bone quality
Anterior and posterior columns are intact
Femur Grade IV Dislocated or proximal dislocation of >20% or 0.2 of
pelvic height
Small deformed head, short anteverted valgus neck, small
True acetabulum is deficient but remains
and posteriorly displaced greater trochanter and narrow,
recognisable
straight tapered femoral canal. Decreased neck/shaft angle
019
Table 16.8 Hartofilakidis’ classification
Type 1 Dysplasia in which the femoral head is still contained

within the true acetabulum
Type 2 Low dislocation in which the femoral head articulates
with a false acetabulum, the inferior lip of which is in
contact with or overlaps the true acetabulum
Type 3 High dislocation. The false acetabulum has no contact
with the true acetabulum. The femoral head is
completely out of the true acetabulum and migrated
superiorly and posteriorly to a varying degree
Figure 16.11 Hartofilakidis’ classification. Diagram of the three main types of

congenital hip disease in adults showing (a) dysplasia, (b) low dislocation and
(c) high dislocation
Arthroplasty
Figure 16.10 Radiograph showing measurements for the Crowe End-stage arthritis is generally treated with THA.
classification system (A, vertical distance between the reference interteardrop
line (line 1) and the head-neck junction (line 2); B, vertical distance between
the line connecting the ischial tuberosities (line 3) and the line connecting the Arthrodesis
iliac crests (line 4)
If unilateral disease is present, arthrodesis for end-stage arth-
ritis is certainly an option worth considering in a young
with this deformity function well until later life. Unilateral patient with high activity levels. However, it is difficult to
disease particularly in a young patient is more problematic to convince these patients to undergo arthrodesis with the known
treat conservatively even with minimal hip pain. Difficulties excellent early results of THA.
with LLD and low back pain (LBP) can tip the balance
towards surgery.
Consider shoe-raises, simple analgesics and steroid
injections.
Total hip arthroplasty for DDH
Surgical approach
The surgical approach must allow for exposure and identifica-
Arthroscopic hip debridement
tion of the true and false acetabulum, identification of the
Especially if labral tears are present. However, it is important sciatic nerve and lengthening of the leg. A conventional pos-
to point out that this may cause secondary instability due to terior or lateral approach may be adequate for mild dysplasia
the lack of bony coverage. whilst in more severe cases a trochanteric osteotomy may be
needed (there is a risk of postoperative trochanteric migration
Realignment osteotomy or non-union). Whatever surgical approach is used, the sciatic
This is possibly indicated for a young adult in their early 20s. nerve should be identified, particularly where previous surgery
A periacetabular osteotomy is usually performed. This offers a has been carried out as the nerve may be densely adherent to
three-dimensional correction and improves acetabular depth, the site of a previous femoral osteotomy. Some surgeons would
which would make a future THA technically easier, unlike a debate this point, particularly if the degree of lengthening were
proximal femoral osteotomy. <2 cm.
243
019
Leg length discrepancy preserve adequate PE thickness but increased dislocation risk.
If the leg has been lengthened too much, the femur is usually Consider an alternative bearing surface such as highly cross-
shortened by a subtrochanteric osteotomy. Shortening by linked PE, CoC.
resecting more proximal femoral bone avoids the problems The use of an oblong socket has been suggested to restore
associated with an osteotomy but involves resection of meta- the hip centre without the use of structural graft. The oblong
physeal bone that is needed for stabilisation of the uncemented part of the cup fills in the deficient segment and allows further
implant and osseous ingrowth. stabilisation with screws. There is concern regarding the failure
to restore bone stock with this device.
Insertion of the cup at the correct level with cement to
Placement and coverage of the cup fill the superior defect and without bone grafting has been
Anatomical position (low hip centre of rotation) associated with poor long-term results.15 Bone grafting
Advantages: Facilitates lengthening, better hip function, allows the cup to be placed in the correct anatomical pos-
best available bone stock, diminishes joint reaction forces ition, provides bone stock for future revision surgery and
Disadvantages: Difficult surgery, a femoral shortening restores leg length.
procedure may be necessary Linde et al.16 found that the incidence of loosening with
the cup in the true acetabular position was 13% at 15 years
compared to 42% loosening at 15 years if placed more
Non-anatomical position (high hip centre of rotation) proximally.
A hip centre located at least 35 mm proximal to the intertear-
drop line.
Advantages: Technically easier than the anatomical Technical considerations of the femur in DDH
position; allows the component to be more completely A narrow femoral canal may make femoral reaming difficult.
covered by native bone and so may avoid the need for bone Marked anteversion of the femoral neck may be misleading
grafting and also decreases the need for a concomitant and make component positioning difficult (there is a tendency
shortening femoral osteotomy for anteversion).
Disadvantages: Increased shearing forces may lead to Derotation with subtrochanteric osteotomy may be neces-
early loosening, a higher rate of dislocation than the sary to place the component in the proper orientation (con-
anatomical location, further revision surgery is difficult as sider if anteversion >40°). Another option would be to use
bone stock is not restored, affords a limited amount of leg modular femoral stem systems that allow to dial-in the desired
lengthening, can only use a very small acetabular version (S-ROM®) or the use of custom-made femoral stems,
component with a thin polyethylene cup as the ceramic which are also able to address the excessive anatomical
bearing surface is often not possible because a bigger anteversion.
acetabular shell would be needed If the greater trochanter impinges, it may require osteot-
omy and lateral displacement. There is a possibility of iatro-
genic deformity of the proximal femoral shape from
Acetabular coverage previous osteotomies. Retained metalwork can be extremely
When there is a large segmental defect in the superior wall of difficult to find and remove, and removal creates stress
the acetabulum, consider using a bulk femoral head autograft risers. Uncemented fixation with optimal fit and fill of
held with screws to restore superior coverage of the acetabular the canal, initial stability and adequate bone ingrowth are
component. The main long-term concern with bulk femoral not easily achieved in a narrow femoral canal with a thin
head allografts is loosening of the socket, with variable rates cortex.
from 0% to 25% reported in the literature. Another option
would be to use tantalum augments.
Adequate acetabular cup coverage is required (at least Subtrochanteric shortening
70%, medialize if necessary down to the inner table) to pre- This is indicated when there are several centimetres of
vent early loosening. Avoid reaming any more of the superior shortening or if derotation osteotomy is required. It is per-
roof than necessary and lateralisation of the acetabular formed as an oblique or step cut osteotomy. A CT of the pelvis
component. and lower limbs is essential to measure the femora accurately
Intentional controlled fracture of the medial wall (cotylo- and, thus, the true LLD. Advantages include preservation of
plasty) to allow for medial advancement of the socket is not the metaphyseal femoral region (provides most rotational sta-
universally accepted. There is concern regarding long-term bility of the implant) and allowing concomitant correction of
problems of protrusio, cup loosening and failure to restore angular and anteversion deformities. It is technically difficult
bone stock making revision surgery difficult. and there is a risk of non-union. Osteotomy can be secured
A shallow dysplastic acetabulum may only accept a small with vascularized onlay autograft fixed with one or two cerc-
size acetabular component. Small head size is needed to lage cables or locking plate fixation.
019
Complications--Increased risk of complications including

nerve injury, vascular injury, deep infection, dislocation
and LLD.
Results--Krych37 reported on a series of 28 Crowe IV hips
managed with uncemented THA with subtrochanteric
shortening. There was an improved HHS from 43 points to
89 points. Twelve (43%) of 28 hips had an early or late compli-
cation or re-operation: 2 subtrochanteric non-unions, 1 fem-
oral component loosening, 1 acetabular component loosening,
1 liner disengagement and 4 hip dislocations.
Examination cornero
This can be either an intermediate case or an elective adult
orthopaedic oral topicp. Once the preliminaries of the radio-
graphic description of the condition and Crowe’s classification
are out of the way, discussion will turn to management. A large Figure 16.12 AP pelvis radiograph left Crowe 3 hip
part of the discussion will probably centre on the technical
issues in performing a THA in this type of hip. Preoperative planning would also include an estimation
of the acetabular component size, the preferred method of
Adult elective orthopaedics oral 1: Young arthritic patient with DDH fixation (cement/uncemented) and need for bone graft.
Radiograph of a 23-year-old woman complaining of severe arth- Cemented acetabular reconstruction has fallen out of
ritic left hip pain secondary to DDH. favour because of reported revision rates up to 37%. Unce-
Discuss management options including the role of pelvic mented cups are generally preferred as they are more
osteotomy? versatile
On the femoral side the size of the femoral canal and the
Adult elective orthopaedics oral 2: Painful THA need for special or custom implants should be assessed.
Patient who had a right THA at 30 years of age for DDH. THA has The need for femoral shortening should be made pre-
now failed. operatively. If there is any doubt subtrochanteric shortening
Discuss the management. should be performed but it increases the surgical complexity
and potential for complications. Up to a maximum of 4 cm
This question is a double take of both the principles of lengthening without shortening can be performed in THA
revision hip surgery and difficulties with DDH surgery. The but this involves complicated soft-tissue releases. More
patient is only 30 and so may require repeated revisions in experienced surgeons are likely to go to subtrochanteric
the future. shortening earlier.
Adult elective orthopaedics oral 3: Unilateral DDH The method and amount of femoral shortening needs to
Radiograph shown of a 43-year-old woman with a deformed be worked out beforehand. Ideally leg lengths should be
arthritic left hip secondary to DDH (Figure 16.12). equalized postoperatively unless there is a bilateral deformity
Outline your management of this hip? and future surgery is planned for the opposite side.
How do you preoperatively plan for DDH surgery? Preoperative planning should also include the surgical
approach to be used, solutions to deal with the hypoplastic
Preop work up would include a full history and clinical acetabulum and femur, management of LLD and restoration
examination. Investigations would include AP pelvis AP and of abductor function.
lateral radiographs left hip and CT scan. Radiograph shown post-THA surgery (Figure 16.13). Sub-
On the acetabulum side the position of the true acetabu- trochanteric shortening had been performed for Crowe 3 dys-
lum should be identified and a decision made whether to plasia. Preferable to avoid subtrochanteric shortening if
restore the acetabulum to its true position or not. The degree possible but facilitates reduction, helps equalize limb length
of anteversion of the acetabulum should be defined as well as and protects the sciatic nerve. This is usually required with
the adequacy of bone stock for satisfactory cup fixation and Crowe 3 and definitely with Crowe 4 hips.
coverage. In depth discussion of how to calculate the amount of LLD
and how much shortening needed.
Although the femur is shortened during the operation, the
distalisation of the femoral head to sit in the true acetabulum
o
Additional information on the website often results in an overall leg lengthening. The transverse
www.postgraduateorthopaedics.com. subtrochanteric osteotomy allows shortening and derotation
p
This is quite a popular viva topic. There is a lot to talk about and the to be performed. When required, osteotomies can be re-cut
viva can progress in many different directions depending on how which compares favourably to Chevron and step cut
well a candidate is answering the questions.
245
019
osteotomies which require careful preoperative templating Primary THA

and planning since they are less amenable to alteration.
Indications
Adult elective orthopaedics oral 4: Bilateral Crowe 4 DDH Disabling hip pain refractory to conservative management,
Radiographs shown of bilateral Crowe 4 DDH (Figure 16.14). severely affecting the patient’s quality of life.
Outline your management of this patient?
Discussion of the technical details of performing THA Contraindications

Adult elective orthopaedics oral 4: Bilateral Crowe 4 DDH
With figure 16.14b there was a long discussion on how you Absolute
would know the sex of the patient. Female as intrauterine Active infection (local or distant)
contraceptive device seen on AP radiograph. Not quite a
pass/fail question but not far away from this. We are unsure
why this much importance was placed on this particular point Relative
Neuropathic hip
Progressive neurological disease
Systemic co-morbidity factors
Inadequate vascularity
Psychiatric illness
Non-ambulators
Severe abductor muscle loss
Obesity may also be a relative contraindication to THA
although this is controversial. Several studies have shown a
higher anaesthetic risk and operative complications,
including serious cardiovascular and respiratory events,
venous thromboembolic disease, infection, component
mal-alignment, longer hospital stay and poorer functional
outcomes and poorer 5-year survival. Additionally, obese
patients tend to have more co-morbidity factors such as
diabetes, hypertension, etc. Other studies have supported
THA in obese patients.
The best exam answer would be to say that obesity itself is
not a contraindication to surgery:
Figure 16.13 Postoperative AP pelvis radiograph left Crowe 3 hip with
uncemented THA and subtrochanteric shortening
Figure 16.14 AP pelvis radiographs bilateral Crowe 4 hips
019
‘I would ask the patient to attempt to lose weight, make them

aware of the increased risks, associated complications and poorer
Surgical approach
outcomes and let theatre know so that they can arrange for a large Trochanteric osteotomy (Charnley approach)
orthopaedic table to be in place as well as deep Charnley retractors NJR data (10th Annual report) confirms used much less these
and a strong assistant. If the patient was morbidly obese I would days for primary THA (1% 2012)r
ask one of my hip surgeon colleagues to review the case, as it might
not be a case I would want to take on myself.’ Advantages
Hip easy to dislocate
Technical goals THA surgery Excellent acetabular and proximal femur exposure
Obtain correct offset Cement easy to insert
Equalize leg length Better femoral component alignment
Restore the centre of hip rotation Useful in revision hip surgery
Correct positioning of implants in the patients primary arc
range Disadvantages
Increased blood loss
q
Complications Increased operating time
Technically difficult to reattach trochanter
Local risks
Possibility of trochanteric non-union or wire breakage
Dislocation (2–3%)
Trochanteric bursitis and non-specific trochanteric
Infection (0.5% osteoarthritis, 1% rheumatoid arthritis) hip pain
LLD (15%)
Technically challenging approach for inexperienced
Nerve injury 1–2% primary THA, 3–4% revision THA, surgeon
5–6% THA for DDH. Possible causes include
overlengthening, compression from haematoma, extruded
cement or acetabular screw laceration Hardinge direct lateral approach
Vascular injury NJR data 2012 reports use in 40% cases for primary THA.
Aseptic loosening (10% at 15 years)
Periprosthetic fracture Advantages
Compared with the posterior approach; decreased rates of
Systemic risks dislocation and sciatic nerve injury with preservation of
Death (<0.5%) posterior soft tissues
Deep vein thrombosis (2%) Familiarity as trainees mainly use this approach for hip
Non-fatal pulmonary embolism hemi-arthroplasty for fractured NOF
Fatal pulmonary embolism
Cerebrovascular accident (CVA) (0.2%). Perioperative Disadvantages
CVA greatly increases the risk of in-hospital mortality or Possible superior gluteal nerve injury if the gluteus medius
discharge to a medical or chronic-care facility (as opposed division is extended >5 cm above the greater trochanter
to home) and increases the duration of hospital stay. Risk Damage to abductor musculature leading to a
factors include advanced age, history of CVA, coronary Trendelenburg limp post surgery
artery disease, atherosclerotic disease and atrial fibrillation Increased risk of heterotopic ossification
Myocardial infarction Limited acetabular exposure
Urinary tract and chest infection Unsuitable if a large amount of femoral lengthening
necessary
Informed consent Inability to adjust trochanteric tension
Discuss in terms of the Some concern regarding the security of the reattachment of
Goals of surgery the abductor muscles
Reported success rate of THA Tendency to insert femoral component within the femoral
Alternatives to surgery canal angled from anteriorly to posteriorly
The buzz sentence is that “It is a shared care decision to
procedure to surgery with the patient” r
Opponents of the Charnley approach regard it as old fashioned, too
invasive and there are better approaches to use. It is still used in
q
Discuss in terms of local and systemic risks and also common, less Wrightington and other some specialist hip units but less and less
common and rare complications. these days.
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019
Posterior approach Avoids cutting the abductor muscles

2012 NJR data confirms increase in use for primary THA, Good exposure of the acetabulum
54% cases. Lower incidence of heterotopic ossification
Faster rehabilitation and decreased hospital stay
Advantages
Disadvantages
Preservation of abductor muscles/function
Avoids the complications of trochanteric osteotomy May be difficult to access the femur especially in obese
patients and those with wide pelvises
Lower incidence of heterotopic ossification
Easy exposure, faster rehabilitation, diminished Risk of injury of the cutaneous nerve of the thigh
operating time compared to the Hardinge approach
for primary THA Technical tips for primary THA
Ability to deal with associated pathology, e.g. posterior Acetabular preparation
column acetabular plating. Failure to ream up to the true acetabular floor will have three
negative effects:
Disadvantages
Lateralisation of the acetabular cup (increasing joint
Increased risk of posterior dislocation
reaction forces)
Increased risk of sciatic nerve injury
Uncoverage of the superior acetabular cup or inappropriate
Increased risk of infection abduction of the cup to achieve coverage
Positioning of the cup in an area of suboptimal vascularity
Anterolateral (Watson Jones) approach Avoid excessive cup medialisation. Decreasing the offset by >1
This was originally described for open reduction with internal cm will weaken the abductors, increase joint reaction forces
fixation (ORIF) of femoral neck fractures. It exposes the inter- and may lead to THA instability. Consider using extended
val between gluteus medius and tensor fascia lata (both of offset stems and lateralized liners when appropriate.
which are supplied by the superior gluteal nerve). Rarely used
for THA as often requires additional division of gluteus med-
Cup orientation
ius and minimus that lie over the anterior capsule for adequate Generally accepted values are 30–50° acetabular abduction and
exposure which may lead to a Trendelenburg gait. acetabular anteversion of between 0° and 30°. Charnley recom-
mended 45° abduction and 0° anteversion. Lewinnek et al..38
Disadvantages recommended a safe zone of 40 ± 10° abduction and 15 ± 10°
anteversion. Implants outside this range are four times more
Exposure of the acetabulum depends on heavy retraction of
likely to dislocate.
the soft tissues and can be associated with damage to the
femoral vein, artery and nerve
Exposure is difficult in obese or very muscular patients Classic reference
Access to the femur is restricted and possible only Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR.
with strong lateral rotation, adduction and flexion Dislocations after total hip-replacement arthroplasties J Bone
so that orientation of the femoral component may be Joint Surg Am. 1978;60:217–220.
difficult Lewinnek et al. report a 3% dislocation rate in a series of 300 THAs.
Anterior dislocations were associated with increased acetabular
Anterior (Smith–Peterson) approach component anteversion. The authors describe a safe range (5–25°
anteversion and 30–50° abduction) to position the cup. The
Exploits the plane between between sartorius (femoral nerve) dislocation rate for implants outside this range was four times
and tensor fascia lata (superior gluteal nerve) superficially and higher than for those within the range (6.0% vs 1.5%). Significant
factors affecting dislocation included acetabular component
gluteus medius (superior gluteal nerve) and rectus femoris
orientation, surgeon experience and a history of previous surgery.
(femoral nerve) deeply. Despite being a highly cited article the study is significantly limited
Mainly used in paediatric cases for open reduction DDH by flawed methodology that weakens the study’s conclusions.
and washout of septic joint.
Modified approach can be used for THA
MIS variation of this exposure for use in THA has gained Femoral offset
popularity in recent years but technically difficult and steep This is the perpendicular distance between the long axis of the
learning curve. femur and the centre of rotation of the femoral head. Increased
offset:
Advantages Increases the range of motion
True internervous plane Decreases the incidence of impingement
019
Increases stability by improving soft-tissue tension

Too small an offset will reduce the movement arm of the hip Discussion of metal-backed cups:
abductors and cause a limp. Too large an offset will result in Wear
an increased bending movement arm during weight- Creep
bearing, which produces increased stresses within the stem Osteolysis
that may lead to stem fracture or femoral loosening Fatigue failure
Examination corner Adult and pathology oral 1

History of THA
Judet hip – Manufacture and mode of failure
Several femoral prostheses were set out on the table:
Bone cement
Discussion of uncemented femoral stems
Methods of porous coating of the stem
What is stress shielding in the context of THA?
Cementless femoral stems: Bone ingrowth, surface
Loss of proximal femoral bone density as a result of the load patterning, coatings, etc
bypassing the area. According to Wolff’s law, bone remodels There are two basic methods of biological fixation either a
according to the load it’s subjected to; hence, the loss of porous coated metallic surface or a grit-blasted surface
density. A fundamental principle of solid mechanics is when Ingrowth occurs when bone grows inside a porous surface.
two materials are joined; the stiffer material or structure bears On-growth occurs when bone grows onto a roughened
the majority of the load. surface. The surface characteristics of an implant
What type of uncemented stems are associated with this? determine which occurs
Fully porous coated stems as most of the load goes through EXAMINER: What type of THA would you use?
the stem. Distal bone loading as more of the mechanical load CANDIDATE: I would use a __________ cemented femoral stem
bypasses the proximal femur because:
What factors affect stem stiffness?
Good long-term, peer-reviewed follow-up results have
Stem stiffness approximates to radius4, Co–Cr alloy is stiffer been published (probably the most important reason for
than titanium, solid and round stems are stiffer. Hollow, slots, using it and should be stated first)
flutes and a taper design reduce stiffness I am familiar with the instruments and find them easy
What is Hoek’s law? to use
Most of my training has been with the __________ hip
When two adjacent springs are loaded, load passes through
the stiffer spring (the stem) bypassing the spring that is less Evidence from the National Joint Registry (NJR) of England and
stiff (femur). Wales supports the use of an all cemented THA with a metal on
polyethylene (MoP) bearing surface. An overall revision rate of
Basic science oral 2 3.51 (3.31–3.72) at 11 years was reported with the 12th annual
Comparison of the biomechanics of the Charnley and report.
Exeter THA Then go on and talk about the design features of you first-
Loaded taper vs composite beam biomechanics choice hip.
Laminated clinical photograph shown of an Exeter and Charn-
ley femoral stem
EXAMINER: What are these components?
Complications of THA
CANDIDATE: This is an Exeter and a Charnley femoral stem. Both are
Infection
cemented stems but have a different design philosophy. (Model
answer is given in the applied basic science chapter, Chapter 31) Overall in UK ~1%
EXAMINER: What are the controversies surrounding the choice of
Dislocation
cemented and uncemented implants with NJR and NICE
guidelines?
Incidence ~2–3%
CANDIDATE: The NICE-issued guidance suggesting minimum Limb length discrepancy
follow up of 10 years, just 7% of uncemented acetabular
Incidence 1–27%(~15%). Mean LLD ranges reported in litera-
components in the NJR had the top ODEP rating of 10A,
ture from 2.8–11.6mm. LLD discrepancy perceived in >1/3rd
meaning strong 10-year data to support its use. This compared
patients with a 1cm difference following THA. Possible effects:
with 44% of the cemented acetabular components that had the
top rating. The difference was less marked for cemented and Patient dissatisfaction with potential for litigation
uncemented femoral components with a 10A rating being used in Short leg limp
83% of cemented and 76% of uncemented femoral components. Vaulting type gait pattern
Low back pain
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Groin pain Vascular injury may occur with extraction of intrapelvic

Need for shoe raise cement and medially migrated sockets. CT arteriography is
helpful in identifying proximity of vascular structures to
Nerve injuries implant and intrapelvic control of vessels prior to component
Incidence of sciatic nerve injury: removal is occasionally required. With difficult cases get the
0.7–3% in primary THA vascular surgeons to scrub in on the case.
2.9–7.5% in revision THA
Urinary tract complications
Risk factors include:
Bladder infection is the most common complication,
Revision procedures (3–8%) with ~7–14% after THA
Female gender (less soft-tissue mass) Urinary obstruction should be treated before THA
THA for DDH (5.8%)
Post-traumatic osteoarthritis Trochanteric non-union and migration
Posterior approach to the hip This is a concern with the Charnley approach
Cementless femoral fixation (mechanism unclear)
>4 cm lengthening of the extremity Heterotopic ossification
Femoral nerve injury: Incidence is variable (3–50%)
0.04%–0.4% in primary THA Only 2–7% have significant symptoms
Consider MRI to look for gluteal haematoma. Haematoma can Candidates may be asked risk factors, classification,
damage the nerve either directly (increased pressure on the prevention and management of HO in the oral or clinical
nerve) or indirectly (ischaemia as a result of vasa vasorum exam (discussed later in this chapter)
compression). Get urgent post op radiographs to look for
excessive leg lengthening or component mal-alignment. With Gastrointestinal
an uncemented cup if significant acetabular screw penetration Bleeding gastric ulcer, acute cholecystitis and postoperative
assess with an urgent CT scan or Judet view and consider ileus (usually neurogenic)
urgent re-exploration of the hip. Check coagulation.
Re-explore a hip if there is sciatic nerve palsy, especially if it
Myocardial infarction and/or congestive heart failure
is progressive, painful (ongoing compression) and there is
evidence of haematoma or a strong suspicion of direct injury Preoperative cardiac opinion is advisable if the patient has
(transected or ligated with a poorly placed suture). If there is a significant history of ischaemic heart disease
documented leg lengthening then re-explore and carry out
limb shortening by modular prosthetic head replacement. Fat embolism syndrome
More than 90% of clinically evident nerve injuries involve the In fat embolism syndrome fat particles and bone marrow
sciatic nerve, with approximately 50% of these involving the are forced into the circulation at the time of femoral
peroneal division only. Nearly 80% of all injuries will have an preparation and stem insertion
incomplete recovery. EMG studies may be used to assess the
level of the lesion and monitor recovery but do not show any Death39
immediate abnormality. The 11th NJR report in 2014 performed an in-depth analysis of
factors associated with 90-day mortality after THA. Severe
Aseptic loosening liver disease was associated with a 10-fold and metastatic
This is the most serious long-term problem with THA. cancer a 7-fold increase, congestive cardiac failure and myo-
cardial infarction with a 3-fold increase and renal disease a 2-
Haemorrhage and haematomas fold increase in relative risk of death within 90 days of surgery.
Common urgent sources of venous and arterial bleeding With adjustment for age and gender the mortality risk had
include branches of obturator and femoral vessels, medial halved over an 8 year period. Four treatment variables were
circumflex vessels, and inferior and superior gluteal vessels. associated with decreased mortality: (1) Spinal anaesthetic or a
combination of spinal and another anaesthetic, (2) posterior
Vascular injuries approach, (3) the use of mechanical thromboprophylaxis and
These are extremely rare (0.2–0.3%). Most vascular injuries (4) the use of chemical thromboprophylaxis, but multivariable
occur during revision surgery because of distorted anatomy analysis showed adjusting for these factors does not fully
and scarring. The femoral vessels are primarily at risk from account for the decreased mortality over time. Type of pros-
retraction and dissection over the front of the acetabulum. thesis was unrelated to mortality. Being overweight was asso-
Penetration of the medial wall of the of acetabulum may injure ciated with lower mortality, but a lot of data entries were
the common iliac artery or the superficial iliac vein. missing (59.5%).
019
Examination corner Dislocation of THAs

Adult and pathology oral 1 Introduction
Describe your preferred approach to the hip for THA Early dislocation occurs in the early postoperative period
Can you quote a dislocation rate for your approach?
(within 6 months) after THA and is usually caused by non-
compliance with postoperative instructions before full muscu-
What prostheses would you choose for the femur and acet- lar strength is attained or a technical error during surgery.
abulum and why? Dislocation occurring between 6 months and 5 years is
Can you quote survival rates from the Swedish Hip Registrar for categorized as intermediate and is usually the result of older
your implant? age, female gender (decreased muscle mass) and predisposing
factors (AVN, inflammatory arthritis, etc).
Adult elective orthopaedics oral 2
Late dislocation occurs after 5 years and generally requires
EXAMINER: What are the complications following THA? surgical treatment. It has a multifactorial etiology polyethylene
The candidate went through the various complications that can (bearing surface) wear, deterioration in muscle mass, neuro-
occur and their incidence. logical impairment, and fractures such as trochanteric avulsion
EXAMINER: What is the overall complication rate? as a result of wear and osteolysis. Additional predisposing
CANDIDATE: Overall 10% of patients are not happy with their THA factors for late dislocation include younger age (greater wear),
EXAMINER: Are you going to tell patient that? female gender (muscle laxity), unrecognised component mal-
CANDIDATE: I would warn the patient that 1 in 10 of patients who positioning, and prosthesis–bone impingement as a result of a
get a THA either have a significant complication or are not change in body habitus (weight loss).
entirely happy with the outcome of surgery.
Incidence
Adult elective orthopaedics oral 3: Radiograph of an arthritic right hip
The reported incidence varies widely, from 0.3% to >10% in
different series, with 2–3% a generally accepted figure for
Describe the radiographic features
primary THA. This figure increases dramatically after each
What are the radiographic differences between an
osteoarthritic and a rheumatoid hip? revision operation and can be as high as 25% after multiple
What are the indications for THA? operations.
Give a detailed preoperative assessment of the patient
Patient-related factorst
History previous hip surgery (osteotomy, conversion
of prior arthodesis). Factors such as poor abductor
Go through obtaining informed consent for a THA
function, bone loss and deformity increase the
General discussion about the Swedish arthroplasty hip
register. Voluntary basis, collect and analysis of outcome dislocation risk
data about primary THA and re-operations, revisions, etc. Revision hip arthroplasty. The main reasons are
Allows identification of predictors for both good and poor compromised abductor function and bone loss that
results, sets revision THA as the endpoint for survival leads to compromises in implant orientation and
analysis and concerns with completeness of reporting location
Pre-existing neurological disease. Weakness in muscles
Registries should comply with local, federal and state around the hip or hip contractures
legislation regarding privacy
Muscular weakness
Registries in general require skilled statistical analysis,
interpretation by skilled orthopaedic surgeons and Diagnosis, i.e. fractured neck of femur (advanced age,
outcomes to be peer-reviewed poorer or damaged muscles, greater propensity for falls
They enhance the professional development of surgeons and altered proximal femoral anatomy), AVN, DDH
and improve patient safety and outcome. Funding comes (poorer muscle strength, bone deformity and alterations
from government funds, surgeons’ fees, implant company from normal implant position)
fees, donations, etc Age >80 years (relative risk 1.3) Reasons may include a
Adult elective orthopaedics oral 5 greater risk of falls, poorer soft tissues and greater
How would you plan if you were to start using a different

type of THA?
Survival analysis – Details, methods, Kaplan–Meier curve, etc s
See website additional information
Draw survival analysis curve and describe it www.postgraduateorthopaedics.com.
t
Confidence intervals ‘Several patient risk factors for dislocation after THA have been
identified and these include . . .’ Practice the talk. The FRCS (Tr &
Orth) is not just about reading facts in a book.
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019
incidence of confusion and non-compliance with

dislocation precautions
Surgeon factors
Surgeon volume: Surgeons who perform <30 THA per
Female gender (relative risk 2.1). The literature is unclear.
year have about 3 times the dislocation risk. A review of
Hypothesis is an increased tissue laxity. Duration of follow
Medicare patients in the USA described varying rates of
up may influence absolute rates as women live longer
dislocation according to surgeon volume (1–5/year, 4.2%;
Inflammatory arthritis. Poor soft-tissue quality 6–10, 3.4%; 11–25, 2.6%; 26–50, 2.4%; >50, 1.5%)41.
Higher ASA score A systemic review of the literature published in 2006 by
Cognitive dysfunction (confusion, dementia, substance Battaglia et al.42 (from Charlottesville, Virginia, USAv)
abuse). Poor compliance with hip dislocation precautions demonstrated a substantial positive association between
Stroke, Parkinson’s disease and grand mal epilepsy: despite surgical volumes and improvement in most THA
a general belief that there is a higher rate of dislocation in outcomes, including dislocation. Lower dislocation rates
such patients, there is very little evidence to support this were associated with increasing surgical volume and this
correlation appears to be stronger for surgeon volumes
Implant-related factors than for hospital volumes.
Head size. The distance a head must travel to dislocation
is defined as excursion. The greater the excision distance Hip stability
the more stable the hip. Excursion distance is usually Dislocation is frequently a multifactorial issue. Assessment
one-half the diameter of the femoral head. Large femoral should focus on the following four variables:
head sizes increase volumetric PE wear that can lead to 1. Component design: range of motion of a hip pros-
increased periprosthetic osteolysis thesis consists of two parts; the primary arc and the lever
Femoral offset range. The primary arc is the arc of motion allowed between
Head–neck ratio the two ends of impingement and is controlled mainly by
Acetabular component design (hooded or the head/neck ratio. By maximizing this ratio, best stability
constrained cups) is achieved. The head/neck ratio is defined as the diameter of
the head divided by the diameter of the neck. Using a large
Surgical factors head with a narrow neck will maximize this and increase
stability. Addition of a skirt (femoral neck collar) or an
Surgical approach: Multiple previous studies have acetabular lip will decrease the ratio and thus decrease the
shown a higher dislocation rate with the posterior primary arc before impingement.
approachu. However, recent studies suggest that with The second part of the range of motion is called the lever
careful posterior soft tissue and capsular repair along with range. This is primarily controlled by the head radius. The
reattachment of the external rotator muscles, rates are lever range is essentially the range of motion allowed between
now equivalent to the anterolateral approach40. head/neck impingement and dislocation of the head. This is
Posterior approach also predisposes to retroversion of closely related to the excursion or jump distance, which is the
the cup distance the femoral head has to travel after primary impinge-
Acetabular position and orientation: Anteversion should ment to dislocate. This distance is equal to the radius of the
be 10 ± 10° (>25° increased risk of dislocation). The theta femoral head. Maximizing the femoral head size diameter will
angle or angle of inclination (i.e. coronal tilt) should be increase both the lever range and the excursion distance, which
40 ± 10° in theory increases hip stability.
Femoral position and orientation: Anteversion
2. Component alignment: The optimal acetabular com-
should be 5–10° (if >15° there is an increased risk of
ponent position is in 15–20° anteversion and 40–45° inclin-
dislocation)
ation. The socket must be placed as medial and as inferior as
Impingement: Femur against the pelvis or residue
possible to place the hip centre of rotation in an anatomical
osteophytes, femoral prosthetic neck on the acetabular
position. This will reduce the reactive forces the THA is sub-
cup
jected to. The femoral stem is best placed in 0–15° anteversion.
Soft-tissue tension: Preoperative templating should assess Placement of the acetabular of femoral components in
head offset and neck length such that when the prosthetic
increased anteversion increases the risk of anterior dislocation,
stem is inserted the appropriate neck length and offset are
restored
v
In the viva or clinical discussion most fair minded examiners would
be suitably impressed if you quickly throw in the origin of a paper
and this moves up the examination process onto a different
u
Be careful with this topic. Most hip surgeons consider the higher platform. The occasional examiner may however think you are
dislocation rate historical and that today it is much less of a being too smart or smug. Still other examiners will say you don’t
problem, especially if using larger femoral head sizes. really need to know papers to pass the exam!
019
whereas increased retroversion increases the risk of posterior Options include increasing the head size and/or neck
dislocation. An open cup (>50° inclination) increases the risk length and changing the acetabular liner. Large femoral
of posterior-superior dislocation, whereas a closed cup (<40° head sizes increase the head-to-neck ratio and jump
inclination) increases the risk of inferior dislocation. distance required for dislocation. Increasing the neck
3. Soft-tissue tension: this refers to the abductor complex length increases femoral offset and lessens the risk of
tension primarily. The abductor complex is made of the gluteus impingement
medius and gluteus minimus muscles. Factors affecting tension Removal of sources of impingement: Cement,
of the complex include the position of the hip centre of rotation osteophytes, etc. Usually in the postoperative period
(COR), the hip offset and the neck length. Decreasing the hip Posterior lip augmentation device (PLAD): Possible
offset will result in a reduced abductor moment arm (d). This option for a recurrent dislocating Charnley in an elderly
results in a reduced moment of force from the abductors (Mab) woman with a small head implanted using a posterior
as Mab = Fabxd. This will increase the joint reaction force approach. Unlikely to be successful in other situations.
generated by the hip. Clinically, this will present as a Trende- Concerns with impingement, wear and limited hip
lenburg gait with a gluteus medius lurch when walking. The movements. Advantages include reduced operating time,
risk of dislocation is also increased. A low neck cut will result in lower intraoperative blood loss and shorter hospital stay.
a short THA neck. This will also have a negative effect on the Advancement of the greater trochanter: Increases
abductor complex tension and reduce the offset. Impingement abductor tension and stability. This operation is somewhat
of the greater trochanter with the ilium can also occur further historic as the advent of modular implants allows an
reducing stability. Compensating for a low neck cut by using a increased femoral neck length to accomplish the same goals
neck collar will reduce the primary arc by reducing the head/ without the possibility of greater trochanteric non-union.
neck ratio, which can cause further instability. Therefore, it is best suited for proximal migration of an un-
4. Soft-tissue function: This is affected by a wide range of united trochanter after a trochanteric osteotomy
neuromuscular disorders and local hip soft-tissue problems. Soft-tissue augmentation: Reinforcement of the hip
The neuromuscular disorders can be classified into central abductor muscles or the posterior aspect of the
(cerebral palsy, stroke, seizures, etc) and peripheral (spinal hip joint using Achilles tendon allograft, fascia lata or
stenosis, neuropathy . . . etc). Local soft-tissue factors include synthetic ligament in patients who are poor candidates
trauma, ageing, infection, malignancy . . . etc). for other options such as constrained liners. These
procedures can be technically demanding and are likely
Management to fail in patients with any component malpositioning
As a general rule, if the hip dislocates more than twice, recur- Bipolar hip arthroplasty: May have a role in the
rent dislocation is likely, and the hip should be revised to salvage management of complex recurrent instability in
enhance stability. Remember to rule out infection and look which other stabilisation procedures have failed. This
for an obvious cause such as component malposition, retained procedure has a high failure rate in this situation, and
osteophytes or cement. Although in many circumstances the offers only modest improvement in function. It increases
cause of recurrent dislocation is multifactorial, there is usually the overall range of motion (ROM) with articulation at two
one main area that stands out. bearing surfaces. This provides a greater safe arc of motion,
Beware though of finding ‘the cause’ as even the ‘obvious increased stability, improved head: neck ratio and a larger
causes’ such as component mal-alignment may have a disap- jump distance. The main disadvantage is that the mobile
pointing outcome despite surgical correction. head articulates directly with acetabular bone and can
Conservative: May very occasionally be indicated in cause pain and medial bone erosion
elderly, non-mobile, medically unfit patients not in pain Constrained acetabular socket design: Not a good choice
Closed reduction under GA/spinal and EUA: It is for a young patient as there is a high failure rate after
important to screen the hip under image intensification to 5 years owing to significant shear forces transmitted to the
assess for stability and determine the positions that the hip bone–prosthesis interface leading to accelerated wear and
dislocates. A period of bed rest (Charnley wedge) followed loosening. There is a restricted ROM and residual hip pain
by mobilization with a hip brace worn for usually 6 weeks. can be very problematic. Consider as a last chance bail-out
Good success rate in first-time dislocations without a option when other procedures have failed. This can be
clearcut mechanical problem. Less successful in recurrent technically difficult surgery, and is usually successful in
dislocations preventing dislocation but patients may not tolerate the
Revision of the arthroplasty components to improve implant very well. Complications include liner
position: Applicable if there is significant component displacement from the acetabular shell or an acetabular cup
malpositioning dislodging from the acetabulum. When dislocations occur
Modular component exchange (dry exchange): Only with a constrained device they are difficult to manage.
indicated if the components are reasonably well positioned. There may be the possibility of converting an uncemented
253
019
cup to a constrained option. In general try to use an

uncemented constrained socket in preference to a EXAMINER: Would you do anything else at the time of opened
cemented socket as this increases implant longevity reduction?
Tripolar arthroplasty (dual mobility): dual-mobility hip CANDIDATE: In the form of any type of major revision – No.
components provide for an additional articular surface, with She probably wouldn’t have been worked up for this.
the goal of improving hip range of motion until I would attempt to get the hip back into the joint and look for
impingement occurs. A large polyethylene liner articulates any obvious cause for the dislocation. I would manage the
with a polished metal acetabular component, and an patient with bed rest for 3 weeks and then cautiously with a
additional smaller metal head is snap-fit within the hip brace.
polyethylene liner. In the first articulation the head is EXAMINER: She dislocates again whilst in bed and has developed a
“engaged” but mobile within the polyethylene (PE) liner. If sacral pressure sore.
the femoral neck and the rim of the PE liner come into CANDIDATE: This is a difficult situation. Further attempts at closed
contact, a second articulation begins to function and consists or open reduction are unlikely to be successful. I would refer on to
of the back of the PE liner and the metallic acetabular shell. an experienced hip surgeon.
These components have been used for primary total hip EXAMINER: You are the experienced hip surgeon.
arthroplasty in patients at high risk for dislocation, total hip CANDIDATE: The choice lies with either a Girdlestone procedure or
arthroplasty in the setting of femoral neck fracture, revision revision surgery. A Girdlestone procedure isn’t a particularly good
for hip instability, and revision for large MoM hip option, as she will find it very difficult to walk again. How fit is she
Resection arthroplasty: Usually used in the multiply for revision surgery?
revised patient with significant soft-tissue and bone EXAMINER: She wants surgery so she can walk normally again. She
deficiency. Not a good option as it leaves the patient with a has a number of co morbidity factors and it would be very risky to
shortened leg and significant limp perform major revision surgery.
CANDIDATE: After a full discussion with the patient and her
relatives, and if the risks of surgery were acceptable I would revise
Examination corner
the stem to a 44 Exeter DDH stem and perform a cement in
Adult elective orthopaedics oral 1: Radiograph of a dislocated right cement revision. For the acetabulum I would use a cemented
Thompson’s prosthesis (Figure 16.15) constrained liner.
EXAMINER: This is a radiograph of a 78-year-old woman who had a EXAMINER: Why would you want to use a cemented constrained
cemented Thompson’s hemiarthroplasty performed for a acetabular cup – Why not just cement a straightforward
fractured neck of femur 5 days previously. She was mobilizing acetabular cup into the socket and use a large head?
well until she developed pain and had this radiograph taken. CANDIDATE: I think that there would be a risk of a further
CANDIDATE: This shows a dislocated prosthesis. dislocation if the cup wasn’t constrained. Even with a large
EXAMINER: What are the causes of dislocation? femoral head there would still be a significant risk of dislocation.
CANDIDATE: Causes of dislocation could include the A constrained cup is a safer option in someone who is elderly and
Thompson’s prosthesis inserted incorrectly usually too much has significant co-morbidity factors.
anteversion, residue osteophytes causing impingement, EXAMINER: Good. What are the indications for a constrained
retained cement, weak abductor function, faulty repair of the implant?
surrounding soft tissues, non-compliance with postoperative CANDIDATE: I would consider a constrained implant in the
instructions. following circumstances: Multiple dislocations with
EXAMINER: How are you going to manage this patient? previous failed attempts of management, patients with
She mobilized well round the house prior to the cognitive issues, patients with very poor abductor function
fracture and occasionally went out with her daughter to and where there is no obvious cause for instability. The
the shops. failure rate using other management options in these
CANDIDATE: She needs to be taken to theatre and a closed situations is high.
manipulation and screening performed of this hip to access for Ideally they are best suited for elderly low-activity patients and
stability. I would try to avoid using them in younger patients because of
EXAMINER: What are the chances of obtaining a closed the worry of impingement and PE-induced osteolysis with early
reduction? loosening and failure.
CANDIDATE: In most cases I have been involved with the hip has EXAMINER: We used a cemented constrained cup with a cement in
relocated without any difficulties encountered. cement femoral stem revision. This is her postoperative
EXAMINER: Closed reduction failed. What are you going to do? radiograph (Figure 16.16). At surgery the prosthesis had been
inserted in about 40° anteversion, the neck cut too low and the
CANDIDATE: I would perform an opened reduction of the hip.
femoral head size was too large.
019
Closed reduction in A&E under sedation if safe or closed

reduction in theatres under GA with assessment of the range
of motion and stability. Hip brace for 6 weeks.
● If closed reduction fails?
Open reduction and assessment of soft-tissue interposition in
the acetabulum, soft-tissue tension or an impingement prob-
lem. If a simple cause is identified, one must be prepared to
address this (liner/head exchange, excision of acetabular
osteophyte . . . etc).
● The hip dislocates again 2 weeks later?
Closed/open reduction. CT scan to assess component orienta-
tion (anteversion femoral stem, acetabular component version.
Rule out infection (history-has the patient shown any signs of
infection since the operation, blood tests-inflammatory markers)
Discuss findings with patient and counsel regarding non-
operative vs revision if a cause is identified.
Figure 16.15 Dislocated right Thompson prosthesis With a viva question on hip dislocation there are three possible
answer options:
Option 1
Candidates can immediately start discussing patient related
factors continuing on with implant, surgical and surgeon
factors as they settle into the question
Patient-related factors
Implant-related factors
Surgical factors
Surgeon factors
Option 2
The second option is to discuss THA factors relating to hip
stability. This is more difficult as you may get side tracked by
the examiners probing you in further detail about femoral
offset or head/neck ratio (component design). In addition,
there is some overlap of headings for example component
design (e.g. offset) will also affects soft-tissue tensioning.
Component alignment
Component design
Soft-tissue tensioning
Soft-tissue functioning
Figure 16.16 Radiograph following revision to constrained THA
This answer option is good to use if a candidate is shown a
radiograph of a dislocated THA
Adult elective orthopaedics oral 2 Option 3

Radiographs of a posteriorly dislocated hip – Uncemented The third option is to randomly mention any factor associated
components. Examiner said this THA was performed 2 weeks with hip dislocation that comes into your head. This is an
ago. First dislocation. unstructured method and doesn’t impress the examiners. This
● Describe the findings approach is usually seen from candidates who haven’t thought
through the topic beforehand. Option 3 may lead you up a
Dislocated THA. There were no other abnormal findings. Satis- cornered blind alley discussing obscure factors related to hip
factory component orientation. dislocation. The thread of the question can get lost. Avoid.
● What might have caused this? There are several clinical scenarios that the examiners can
The candidate explained that, as it was the first episode of present:
dislocation, it could be due to patient non-compliance (taking Dislocation in the immediate postoperative period. Either a
into account the radiographic parameters). Infection should be discussion of conservative management and factors to
ruled out through a careful history and blood tests. prevent re-dislocation or a grossly mal-aligned implant
● Treatment? requiring revision
255
019
II. 6–24 months

A dislocated MoM hip. This is a curved ball that can go
anywhere Smaller inoculum or lower virulence at the time of surgery,
A dislocated hip with avulsed greater trochanter. The Woo chronic indolent infection
and Murray paper43 reported a 6-fold increase in III. >2 years
dislocation rate to 17.6% with trochanteric avulsion. Re- Least common, usually haematogenous spread
attachment generally advised. Methods (Dall-Miles cable although bacteria implanted at the time of the original
grip system), success rate etc surgery may have remained dormant until a change in the
A dislocated revised hip. Discussion may focus on host’s immunity occurs (onset of diabetes,
a constrained acetabular socket design or conversion to malignancy, etc)
dual mobility
A dislocated revised hip following a previous MoM Tsukayama et al.44
complicated with ALVAL (again constrained cup or dual
mobility option) 1. Early postoperative infection
A dislocated Thompson ultimately leading to a constrained Presents <1 month after surgery with a febrile patient and
cup option a red swollen discharging wound
Loose total hip that has dislocated. The hip will need to be 2. Late chronic postoperative infection
revised. The viva would discuss how to plan and perform The patient is well, the wound has healed well, there is a
revision of that particular hip worsening of hip pain and a never pain-free interval
Late dislocated hip first time no obvious cause. How to 3. Acute haematogenous infection
manage
This can occur several years after surgery with a history of
Although there are a large number of potential management
options for a dislocated hip the actual choice is likely to be
bacteraemia (UTI or other source of infection) and severe
limited to three or four obvious preferences. This would be in hip pain in a previously well-functioning hip
keeping with realistic clinical situations that examiners are now 4. Positive intraoperative culture
encouraged to ask candidates in the exam. At least three samples from different locations taken with
You still, however, would need to know and be able to clean instruments. This occurs when a preoperative
discuss all the options available in the viva exam. presumptive diagnosis of aseptic loosening was made
Basic science 1 AAOS

You may be presented a clinical condition such as dementia or AAOS make a clear distinction between early and late PJIs: an
Parkinson’s disease that increases the risk of THA dislocation and early infection occurs within three weeks of the procedure,
asked to comment on factors you can alter to minimize this risk
whereas PJI that develops thereafter is considered late
Anterolateral approach, large head size and maximizing
head/neck ratio. Consider using dual motion hip prosthesis. Organisms
Take care with analgesia avoiding strong opiates to minimise
potential for confusion post op, consider nerve blocks peri- Numerous studies have shown that Gram-positive organisms
operatively etc. Consider ITU bed initially for close medical are the most common bacteria causing joint infections, with
management of patient, careful fluid balance etc. Staphylococcus aureus and Staphylococcus epidermidis account-
ing for the majority of infections. Enterococci, streptococci
and Gram-negative organisms such as Escherichia coli, Pseu-
Infection complicating THA domonas species and Klebsiella species are less common but
not infrequently reported.
Incidence
Approximately 1% after primary and 3–4% after revision The glycocalyx
hip surgery This is the polysaccharide biofilm that permits increased
adherence and survival of bacteria on biosynthetic surfaces.
Classification Numerous factors, including restricted penetration of antimi-
crobials into the biofilm, decreased bacterial growth rates and
Fitzgerald expression of biofilm-specific resistance genes, all contribute to
Acute postoperative period (up to 3 months) bacterial and biofilm resistance.
Delayed deep infection (3–24 months)
Late haematogenous >24 months
Approximately one-third of the infections fall into each group. Oral questions
Coventry What factors are involved in reducing the infection rate in

I. First 30 days THA surgery?
Immediate postoperative period – The infected
This is a classic FRCS (Tr & Orth) oral question. Dividing your
haematoma or superficial infection that progresses to a answer into preoperative, perioperative and postoperative
deep infection
019
factors greatly simplifies your answer and, more importantly, Diagnosis

demonstrates to the examiners a more structured approach in This can be difficult, especially if a low-grade infection is
your viva technique. That said, most candidates, even if they present. The surgeon’s clinical diagnostic skills and judgement
mention factors in a random haphazard manner, should still be are more important than any specific test.
able to obtain a pass mark for this question.
Investigations
History
Prevention of infection in THA
Type 1
Prophylactic measures to reduce hip arthroplasty infection are
given in Table 16.9. Continuous pain, usually fever, erythema, swollen and tender
fluctuant wound; either an infected haematoma or deep spread
Preoperative factors from a superficial wound.
Same-day admission
Type 2
Separation of elective from trauma cases
Gradual reduction in function of the hip with increasing pain.
All septic lesions should be examined and treated (feet,
Hip never ‘feeling right’ from the time of original operation.
urinary, dental)
Prolonged period of wound discharge postoperatively.
Shave in the anaesthetic room (not night before)
Type 3
Perioperative factors
History of sepsis. Dental extraction, chest or urine infection.
Antibiotic prophylaxis: Systemic antibiotics, antibiotic-
loaded cement Blood tests
Surgical technique: Gentle handling of tissues, careful White blood cell count
haemostasis, limitation of haematoma formation, avoid Usually normal and not helpful unless the infection is acute.
cremation of tissues/necrosis, length of surgery, wound
lavage, etc Erythrocyte sedimentation rate (ESR)
Movement: Avoid unnecessary theatre personnel An ESR >35 mm/h 1 year after THA in the absence of any
movement during surgery other systemic illness suggests hip infection until proven
Ace masks: BOA guidelines otherwise. However, the ESR may not always rise in the pres-
Gowns: Modern, weaved patterns ence of deep sepsis. It has low specificity and sensitivity as a
Gloves and hands: Two pairs of gloves, changing the outer marker of prosthetic joint infection
ones frequently
C-reactive protein (CRP)
Head gear: No hair exposed
Body exhaust systems This acute-phase reactant peaks 48 hours postoperatively
and returns to normal in 2–3 weeks. Based on multiple
Sterile drapes: Disposable non-woven drapes
studies >10 mg/L is significant. Sensitivity is 96%; specifi-
Drainage wound: Arguments for and against
city, 92%.
Ventilation system: Laminar flow, ultra-clean-air system
Ultraviolet light: Bactericidal Interleukin-6 (IL-6)
IL-6 is produced by stimulated monocytes and macrophages,
Postoperative factors and it induces the production of several acute phase proteins
Antibiotic cover for urethral catheterisation including CRP. IL-6 peaks at 2 days following uncomplicated
The risk of infection is increased in rheumatoid arthritis, arthroplasty and rapidly returns to a normal value. Recent
diabetes, those with immunosuppression and those with a studies suggest that IL-6 is a more accurate marker for peri-
history of previous joint infection prosthetic infection than ESR or CRP.
Radiographs
Table 16.9 Prophylactic measures for hip arthroplasty infection These are of limited value with respect to the infected hip.
MRC trial 45
Factor Both infected and aseptic hips can have similar appearances.
However, some radiographic signs suggestive of infection
Antibiotic-loaded cement 11 include:
Systemic antibiotics 4.8 Localized or irregular, scalloped pattern of endosteal bone
Ultraclean air 2.6 erosion
Rapidly progressive radiolucent lines
Plastic isolators 2.2
Periosteal new bone formation (considered by some to be
Body exhaust suit 2.2 pathognomonic of deep infection)
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019
Evidence of early loosening Debridement, antibiotics and retention of prosthesis

Lacy pattern of new bone formation This is carried out for either early postoperative infection or
Area of bone erosion >2 mm about the entire cement mass acute haematogenous infection if the duration of clinical signs
of stem or cup and symptoms is <3 weeks (before formation of the glycolax),
Radiographic signs of loosening are seen in two-thirds of late the components are stable at the time of debridement, the
infections, but <50% of early infections. organism sensitivity is known and the overlying soft tissues
and skin are of good quality.
Radionuclide imaging Debridement involves removal of fibrous membranes,
sinus tracts and devitalized bone and soft tissue, and
Technetium-99m scan
exchange of the polyethylene liner and femoral head. If
This is very sensitive but is non-specific. Increased uptake can one or both components are loose, both components, all
be found in stress fractures, tumours, loosening, heterotopic cement and all infected and necrotic tissue should be
bone formation and other inflammatory and metabolic dis- removed. The success rate is very variable, from 16% to
orders. A technetium scan can remain positive for up to 2 years 89% depending on how strictly treatment criteria are
following an uncomplicated THA. The technetium scan is followed49. Following debridement antibiotics are continued
most useful if negative, as infection is unlikely, and it allows for a minimum of 6 weeks.
elimination of many of the component-related causes of pain
at the site of a THA.
Single-stage procedure
111 Advantages
Indium-labelled white cell scan (leukocyte scan)
In theory in a labelled leukocyte scan, indium-111 should not Only one major operation
accumulate at sites of increased bone turnover in the absence Improved postoperative mobility and pain
of infection. The usefulness of this scan remains controversial. Avoids disuse atrophy, limb shortening and soft-tissue
It has a limited role because of its sensitivity of 44%, its scarring associated with a second procedure
specificity of 100% and accuracy of 82%46. Reduced cost
Avoids the complications of cement spacer use (spacer frac-
ture, abraded particles from the spacer, bone resorption)
Hip aspiration, arthrogram and needle biopsy
Aspiration should not be performed routinely for all patients Disadvantages
with pain at the site of a THA because the false-positive rate is
unacceptably high. It is most useful where there is clinical or Demanding prolonged procedure
radiographic evidence of infection or elevation of either the Antibiotic sensitivities must be known preoperatively
CRP or ESR. If aspiration is to be performed, all antibiotics Use of antibiotic-loaded cement for femoral fixation is
should be stopped for at least 4 weeks to improve sensitivity. considered essential, which limits the choice of prosthesis
Transport should be rapid to allow immediate incubation
and to minimize the risk of a false-negative aspiration. Samples Contraindicated
require extended culture. A spectrum of sensitivity (67–92%) If antibiotic sensitivities are not known preoperatively
and specificity (94–97%) is reported in the literature47. Doubt about the adequacy of debridement
Follow the standard protocol. The accumulation of dye in Massive bone loss requiring grafting (owing to increased
pockets with an arthrogram may suggest abscess formation risk of sepsis)
(pseudobursa). Presence of multiresistant bacteria
Biopsy at operation, frozen section and Gram stain Results

Intraoperative cultures are not always positive and frozen One-stage exchange arthroplasty has been popularized by
section is not available in all centres but can be a valuable Buchholz et al.50, whose group reported a 77% success rate in
diagnostic adjunct in equivocal cases. 583 patients. Wroblewski51 reported a 91% success rate, and a
Infection is defined if >10 neutrophil polymorphs per very recent study by Zeller et al. reported a 94% success rate52.
high-powered field are seen48.
Two-stage revision
Management The first stage consists of excision of the sinuses, the drainage
Suppression treatment of all abscesses and the meticulous removal of all foreign
Long-term oral antibiotic suppressant treatment alone will not material: Membranes, cement, plugs and any potentially
eradicate deep infection but may control the sepsis and may infected soft tissue. The timing of the second stage depends
have its place in an elderly patient who is medically unfit for on the response to antibiotics, the patient’s general well-being,
major surgery. wound healing and bone stock.
019
Advantages weight-bearing, but there is an associated risk of dislocation.

Adequacy of debridement – Can be repeated at the time of Non-articulating spacers are preferable in patients with exten-
reimplantation sive bone loss, or with deficient abductors secondary to a high
Infected organism known and appropriate antibiotic given risk of dislocation if an articulating spacer is selected.
Persisting foci of infection can be identified Salvage
Allows clinical assessment of treatment prior to If definitive treatment fails the following salvage operations
reimplantation may be required.
Allows uncemented reconstruction
Augmentation with allograft may be carried out with Resection arthroplasty
greater confidence This is an occasionally necessary salvage procedure. It often
provides marked relief of pain but results in the use of ambu-
Disadvantages latory aids, patients fatigue easily and have a Trendelenburg
Two operations and their associated morbidities gait. Patients may experience hip joint pain and have a large
Prolonged period of bed rest and hospital stay between the leg length discrepancy.
two stages resulting in a limited functional outcome
Arthrodesis
Increased cost
This is a technically demanding procedure and is rarely
The second stage of a two-stage revision is further
complicated by altered anatomy and loss of planes of performed.
dissection Amputation
Most reported protocols advise a 6-week gap between the two
This is occasionally performed on patients with a life-
stages but this can be increased if necessary. Recently it has
threatening or limb-threatening infection or who have massive
been suggested that shortening the interval period to 3 weeks
soft-tissue and bone loss or vascular injury. The presence of
does not increase the rate of infection.
systemic co-morbidities is strongly associated with the rate of
A delayed exchange (two-stage procedure) is indicated for:
amputation.
Resistant organisms
Gram-negative organisms (Pseudomonas, E. coli) Antibiotics in cement
Draining sinus This is a controversial issue. The use of antibiotic-impregnated
Unhealthy or oedematous soft tissue cement in primary THA may lead to the emergence of resist-
Well-established osteomyelitis with loss of bone stock ant organisms.
Results The prophylactic use of antibiotics with dental treatment

A recent review of the Norwegian Arthroplasty Register53 In 1997 a panel of experts adopted by the American Academy of
comprising of 784 infected THAs reported a success rate of Orthopaedic Surgeons (AAOS) and the American Dental Asso-
94%. Two-stage revision is probably safer and more successful ciation decided that antibiotic prophylaxis was not routinely
than a single stage revision and the majority of surgeons would indicated for dental patients with total joint arthroplasties, but
perform a two-stage revision. Both methods in experienced should be considered in a small number of patients undergoing
hands give similar results and both methods have advantages procedures with a high incidence of bacteraemia.
and disadvantages. As yet, no randomised clinical trial exists to
compare the two methods of treatment. The complexity of the
operative procedure and the many factors involved has dis- Examination corner
couraged investigators from evaluating the timing of surgery. Adult elective orthopaedics oral 1: Infected THA
Risk factors
Antibiotic spacer
Investigations
A cement spacer, the most common being PROSTALAC (pros- Management
thesis of antibiotic-loaded acrylic cement), can be inserted Risk factors include presence of co-morbidities (morbid
between first and second stage revisions to maintain soft-tissue obesity, rheumatoid arthritis, myocardial infarction, atrial fibril-
balance and leg lengths. This allows local delivery of a high lation), higher ASA scores (>2), bilateral procedures, allogenic
concentration of antibiotics. A custom-made spacer in the oper- blood transfusion, postoperative surgical site infection and
ating room can be used, which consists of coating a small, inex- longer hospital stay54.
pensive sterile femoral component with antibiotic-laden cement.
Adult elective orthopaedics oral 2: infected THA
The choice between an articulating and non-articulating
Most of this oral seemed to be spent on discussing the
spacer remains controversial; however, most surgeons prefer
investigations and various management options of the
articulating spacers when feasible in order to maintain leg infected THA.
length and soft-tissue tension. These permit partial to full
259
019
Table 16.10 Vancouver classification
Type Location Subtype Management options

A Trochanteric AG: Greater trochanter Treat conservatively with protected weight-bearing.
Indications for ORIF: Displaced >2.5 cm, abductor weakness due to non-union and
chronic pain
AL: Lesser trochanter Treat conservatively with protected weight-bearing unless a large portion of the
medial cortex is involved
B Around or just distal B1: Stable prosthesis ORIF with cerclage
to stem wires alone if long oblique or plate osteosynthesis.
Cortical strut grafts and cerclage fixation can be used separately or utilized in
combination with a plate
B2: Unstable The fracture need to be bypassed with a longer (revision) stem with plate
prosthesis reinforcement, with or without cortical strut
B3: B2 + inadequate A combination of a revision stem and bone grafting
bone stock (impaction or strut grafting). In severe osteolysis revision
stems with distal screw fixation are preferred
C Well below the Ignore implant and manage fracture with locking plate
stem
Adult elective orthopaedics oral 3 Discussion of laminar flow. Score 8 candidates should be
How would you manage the infected THA? aware of the recent controversies suggesting no benefit
from laminar flow use in reducing early deep infection
A major part of this oral answer is to be able to discuss the
advantages and disadvantages of one-stage vs two-stage revi-
sion hip surgery for infection:
Conservatively on long-term antibiotic suppression: Low Periprosthetic femoral fractures and
virulence organisms, patient unfit for surgery
Incision and drainage and washout: Only applicable in the
failure modes
early postoperative stage or within 3 weeks of an acute Cemented implants tend to fracture late (5 years or so). They
haematogenous infection occur most commonly at the stem tip or distal to the pros-
One-stage or two-stage procedure thesis. This is due to the modulus mismatch in the area
Resection arthroplasty resulting in rising stresses.
Arthrodesis (controversial) In revision cases, fractures tend to occur at the site of
Amputation: For uncontrollable life-threatening sepsis cortical defects from previous operations. Fractures also occur
if the new stem does not bypass a cortical defect by >2 cortical
Adult elective orthopaedics oral 4 diameters.
Comment on a THA radiograph. Uncemented implants tend to fracture within the first
• Painful. 6 months after implantation.
Why?
• Infection
• Investigations and management. Incidence
1% primary THA
Adult elective orthopaedics oral 5 4.2% revision THA
Infection control in theatres, including MRC trial on the effects
of laminar flow, antibiotics and exhaust suits.
History
Adult elective orthopaedics oral 6 Important points in the history include:
Prevention of sepsis following THA: Preoperative and
intraoperative measures
Loosening of the prosthesis may proceed many
Management of wound haematoma following THA periprosthetic fracture and, therefore, symptoms suggestive
of loosening such as constant thigh pain or start-up pain
Basic science oral 1 after getting up from sitting should be documented
General discussion about the prevention of infection Onset of pain: differentiate between a traumatic event (with
in THA emphasis on the mechanism of injury) or whether the pain
had a non-traumatic spontaneous onset
019
Any stigmata of perioperative infection should be very Type C (well distal to stem)
carefully investigated in the history. Any history of Fractures well distal to a solidly fixed stem. Type
prolonged wound healing, draining sinuses, or repetitive C fractures are best managed with ORIF using a non
antibiotic use should alert the surgeon to previous infection contact bridging (NCB) periprosthetic locking plate
Complications
Classification
Mal-union (5–30%)
Many classifications are descriptive and give information
Non-union (10–30%)
about the site of the fracture but are of little value in formulat-
ing a strategy for management. Periprosthetic refracture
Infection (10%)
Duncan and Masri (Vancouver; Table 16.10) Reduced function (one-third)
This takes into account three key factors: The fracture site, the Plate failure (15%)
stability of the femoral component and the quality of the Instability/dislocation (10%)
proximal femoral bone. Although the classification system Death
has proved to be reliable, reproducible and valid one concern
is that plain radiographs may fail to distinguish between B1
and B2 fractures adequately. This can become problematic Examination corner
intraoperatively as a more extensive procedure may be Trauma oral 1: Radiograph of a supracondylar fracture in an 80-year-
required without the necessary equipment or implants being old woman distal to a THA
on hand or scheduled operating time availablew. For management of this case, ORIF was suggested to avoid
problems with a stress riser above the supracondylar nail and
Type AG and AL (around trochanteric region) difficulty with proximal locking so close to the fracture.
Usually stable and minimally displaced. Displaced fractures are I was then shown a radiograph of a retrograde nail with
commonly related to osteopenia, and can usually be fixed substandard fixation. I was asked how I would manage this if
adequately by circlage wires supplemented by screws or hook the patient was still on the operating table – Would I remove
plates if required. the fixation? I answered that I would not but that I would
consider supplementary fixation and/or a cast brace.
Type B (around femoral stem)
Adult elective orthopaedics oral 1: AP radiograph demonstrating a
B1 – Prosthesis well fixed: This occurs in the region of the periprosthetic fracture at the tip of a cemented THA with well-fixed
tip of a well-fixed stem. Spiral and long oblique fractures cemented cup
can be fixed by circlage wires or cables and crimpsleeves.
CANDIDATE: This is an AP radiograph of the pelvis, which
Supplementary fixation can be obtained by using either an
demonstrates a cemented THA with a periprosthetic fracture just
onlay cortical strut graft or plate. Short, oblique or
proximal the tip of the prosthesis. The cup appears well fixed,
transverse fractures can be slow to heal, and are treated with
there are no lucencies seen in any of the three Dee Lee and
biplanar fixation on the anterior and lateral aspects with any
Charnley zones. I would like to see an immediate postoperative
combination of plates and cortical onlay grafts. Bone graft
film for comparison, to see whether these changes are
may also be used to enhance fracture healing
progressive or were present immediately postoperatively.
B2 – Prosthesis loose and good bone stock: The best
A lateral radiograph would also be useful.
method of management is to use a revision stem, which
EXAMINER: How would you manage this patient?
bypasses the site of the fracture by at least 5 cm or twice
the outer diameter of the diaphysis. In most cases a CANDIDATE: I would take a good history, clinical examination and
long uncemented stem, which achieves good diaphyseal radiological work up of this patient. The type of fracture, and
fixation with or without diaphyseal locking screws, systemic and local host factors should all be considered.
provides the most effective contemporary method for I would request routine blood tests including FBC, U&Es, blood
managing these fractures. Occasionally, a cemented long glucose, LFTs and clotting screen. I would cross-match the patient
stem prosthesis is used in elderly patients with osteoporotic 4 units and order an ECG and chest x-ray. I would attempt to involve
bone to allow immediate weight bearing my anaesthetic colleagues for early review of the patient in case any
B3 – Prosthesis loose and poor bone stock: A challenging further investigations needed to be performed prior to surgery such
fracture to manage with a high rate of complications. Best as ECHO cardiogram or pulmonary function tests. I would apply
managed surgically, if medically fit, with proximal femoral temporary Thomas Splint traction while I plan definite surgeryx.
replacement or so called mega-prosthesis for low demand
and elderly. In a young patient, an allograft–prosthesis
x
composite is an attractive option Or you could cut to the chase and say ‘assuming the patient has
been fully worked up for surgery including relevant blood tests,
investigations and anaesthetic review, I would treat the fracture
w
A nasty surprise to keep you on your toes. according to the Vancouver classification’.
261
019
scratch fit distally. If this could not be achieved I would use a long

EXAMINER: What classification of periprosthetic hip fractures do
stem uncemented implant with a distal interlocking screw option.
you know?
I would hesitate to use cement as long-term results can be poor.
CANDIDATE: I am familiar with the Vancouver classification system.
The femoral bone surface in revisions is often sclerotic, hard and
This periprosthetic fracture is a B2.
resistant to cement interdigitation. Using cement after an
EXAMINER: What do you mean by a B2 fracturey?
osteotomy may compromise osteotomy healing.
CANDIATE: There are three key features to the Vancouver
classification (fracture location, stability of the implant, and
surrounding bone stock) and three anatomical fracture locations
described (trochanteric, around the stem and distal to stem).
EXAMINER: What are the surgical options?
Aseptic loosening of THA
How would you plan for surgery?
Wear debris
CANDIDATE: I would manage the periprosthetic fracture according
The generation of particulate debris after THA occurs as a
to the Vancouver classification and perform a revision hip
result of two processes:
replacement using a long stem uncemented prosthesis. Prior to Wear
surgery I would attempt to obtain the original operative notes Corrosion
with implant labelsz. I would want to know the bearing surfaces The fundamental mechanisms of wear include adhesion, abra-
and types of implant. I would have all the revision equipment and sion and fatigue. Wear debris sources include PE, cement and
prostheses available to enable me to deal with any intraoperative metal particles. PE-bearing surfaces are thought to be the
eventuality. My preference would be to schedule the surgery on major factor responsible for periprosthetic osteolysis and
an urgent extra half-day elective list rather than a busy trauma list aseptic loosening in THA.
with theatre staff unfamiliar with complex revision hip systems. Studies have shown there is a critical size of particle. Small
I would make sure the company rep. was also available. I would phagocytosible particles 0.5–10.0 μm in size are more active
make sure the cell saver was available, order one femoral head than large (>10 μm) or very small particles (<0.5 μm). Par-
frozen allograft and have freezed dried allograft available if ticles >10 μm stimulate a giant cell response with the forma-
necessary. I would make sure OSCAR cement removal system was tion of multinucleated giant cell but no osteolysis. Below
available I would liaise with my anaesthetic colleagues in case a 0.5 μm the particle size is too small to significantly activate a
HDU bed is needed postoperativelyaa. response. Irregularly shaped particles are more active than
The acetabular component appears to be well fixed and in a spherical particles.
good position. There is no obvious wear of the cup. Taking these
points into account I would attempt to retain the acetabular
component, providing it was not loose or obviously worn,
Modes of wear
damaged or mal-positioned upon intraoperative inspection. The mechanical conditions under which the prosthesis was
I would have equipment and prostheses ready ‘on the shelf’ to functioning when the wear occurred has been termed the wear
perform a revision of the acetabulum if required. modes.
I would approach the hip through a posterior approach Mode 1 The generation of wear debris that occurs with
incorporating the old incision into this if possible. I would open motion between the two bearing surfaces as intended by the
up the fracture site and expose the cement mantle and this may designers
allow for adequate cement removal but I would have a Mode 2 Refers to a primary bearing surface rubbing against
contingency plan of performing an extended trochanteric a secondary surface in a manner not intended by the
osteotomy (ETO) if needed. I would initially use osteotomes to designers. Usually this mode of wear occurs after excessive
remove as much cement as possible proximally and then OSCAR wear in mode 1. An example would be a femoral head
to remove the distal cement and bone plug. I would then use articulating with a metal acetabular backing following
cerclage cables to reconstruct the femur and sequentially ream wearing through of the polyethylene
up the femoral canal until the reamer bites and chatters with the Mode 3 Refers to two primary surfaces with interposed third
femoral cortex. I would plan to use a long stem uncemented body particles. This is known as third body abrasion or third
modular tapered fluted revision prosthesis aiming for a good body wear
Mode 4 Refers to two non-bearing surfaces (non-primary)
rubbing together. Includes the back-sided wear of an
y
The examiner wasn't happy with the candidate just saying ‘B2’ he acetabulum liner, fretting and corrosion of modular taper
wanted a more comprehensive account. connections, and fretting between a metallic substance and a
z
Not always possible to obtain old medical records.
aa fixation screw. Particles produced by mode 4 wear can
There are a lot of facts to cover in a short space of time but the
score 8 candidate will manage it (usually without coming across migrate to the primary bearing surfaces and induce third
too rushed for time) – they just keep talking. body wear (mode 3)
019
Table 16.11 Modes of femoral stem failure
Mode Mechanism Cause Findings

Ia Pistoning Subsidence of stem within cement mantle Radiolucent line (RLL) between stem and cement
in zones I and II. Distal cement fracture
Ib Pistoning Subsidence of stem and cement within bone RLL all seven zones
II Medial stem pivot Centre rotation of middle stem Medial migration of proximal stem
III Calcar pivot Centre of rotation at calcar; distal toggle Sclerosis and thickening of bone at stem tip
IV Bending cantilever fatigue Proximal resorption leaving distal stem fixed Stem crack or fracture
RLLs zones I and II, VI and VII
Osteolysisbb
PE particles (0.10–10.0 μm) generated from MoP articulations
are the main culprit in the phenomenon of osteolysis. These
particles activate phagocytes releasing numerous cytokines such
as IL-1 and IL-6. These in turn activate the osteoblasts, which
produce the receptor activator of nuclear factor kB ligand
(RANKL). This attaches to the RANK receptor on osteoclasts
promoting bone resorption and osteolysis. RANKL is blocked
by osteoprotegerin (OPG). The RANKL : OPG ratio in the
bone microenvironment determines overall bone homeostasis.
Modes of cemented femoral stem

looseningcc
With cemented femoral implants Gruen described four
modes of failure55.
Mode 1: Pistoning behaviour

1a. A radiolucent line is seen between the stem and cement at
the superolateral part of the stem. The stem is displaced Figure 16.17 Four modes of cemented femoral stem failure according to
distally, producing the radiolucent zone and a punched out Gruen et al.54
fracture of the cement near the tip of the cement mass
1b. A radiolucent zone can be seen about the entire cement
mass, often with a halo or thin line of reactive sclerotic
bone about the radiolucent zone
inadequate superomedial and inferolateral cement support.
Mode 2: Medial stem pivot This may produce a fracture of the cement at the midstem
This is caused by medial migration of the proximal portion of and a fracture of the sclerotic bone lateral to the tip of the stem.
the stem. Lateral migration of the distal tip results from
bb
Mode 3: Calcar pivot
This is a large basic science topic which can easily be asked as a This is caused by medial and lateral toggle of the distal end of the
viva question. Please see www.postgraduateorthopaedics.com for
stem. The distal stem lacks support and a bone reaction develops.
additional information including classic references to know.
cc
You may be shown a radiograph of a loose THA as a lead in into Adequate proximal support produces a windscreen wiper type of
modes of cemented stem failure. The question can be chalenging reaction at the distal stem, with sclerosis and thickening of the
for even the best prepared candidate.Two out of every cortex medially and laterally at the level of the tip of the stem.
10 candidates in practice vivas are absolutely spot on anwering this
question, whilst the remaining candidates tend to get the modes of
failure mixed up in places. The second part of the viva question will
Mode 4: Cantilever bending
deal with the priniples of how you would revise the THA (rehearse This is caused by proximal loss of support of the stem while
your answer). distally the stem is securely fixed. Radiolucent zones may
263
019
Table 16.12 Definitions of radiographic loosening of cemented femoral Figure 16.18 Gruen
stems according to the criteria of Harris et al.55 zones
Definite loosening:
● Subsidence of the component
● Fracture of the stem
● Cement mantle fracture
● Radiolucent line between the stem and cement mantle not
present on the immediate postoperative radiograph
Probable loosening:
● Radiolucent line at the bone/cement interface that is either
continuous or >2 mm wide at some point
Possible loosening:
● Radiolucent line at the cement/bone interface between
50% and 100% of the total bone/cement interface not present
on the immediate postoperative radiograph
develop proximally, medially and laterally to the stem, and

may progress to stem failure.
Radiographic features of cemented femoral stem

loosening
There are various radiological indicators suggestive of femoral
loosening including:
Stem migration or subsidence SCOIR
Cement or component fracture
Osteolysis (non-linear radiolucency of >5 mm)
Increased cement–bone interface >2 mm
Radiolucent line between stem and cement at superolateral Failure to prevent cement motion while the cement is
part of stem of >2 mm (subsidence) hardening
Radiolucent line between stem and cement in all Gruen Failure to position the component in a neutral or mildly
zones >1 mm valgus position
Inadequate cementation(Grade C or D according to
Barrack et al.) or cement thickness (<2 mm in any
Gruen zone) Radiographic features of cemented acetabulum
In 1982 Harris et al.56 defined criteria for the radiographic
loosening
identification of loosening of cemented femoral stems into Bone–cement lucency >2 mm and/or progressive
definite, probable and possible (Table 16.12). The presence Medial migration (and protrusion) of cement and cup (into
of ‘probably loose’ and ‘possible loose’ were both based on the the pelvis)
presence and extent of bone–cement radiolucencies By Change in inclination of the cup (indicating component
1993 Harris felt that these radiographic findings were no longer migration) >5°
valid or useful. A previous autopsy study by Harris had shown Eccentric polyethylene wear of the cup
most of the radiolucent lines were secondary to adaptive Fracture of the cup and/or cement (rare) BMCEF
remodelling rather than to disruption of bone continuity57.
Technical problems that contribute to stem Classic reference
loosening Harris WH, McCarthy JC Jr, O’Neill DA. Femoral component

loosening using contemporary techniques of femoral
Failure to remove adequate cancellous bone medially so cement fixation. J Bone Joint Surg Am. 1982;64:1063–7.
that the column of cement does not rest on dense
Institution: Massachusetts General Hospital Boston
cancellous or cortical bone
Harris et al. reported on the results of 171 THAs following the
Inadequate quantity of cement
introduction of second generation cementing techniques.
Cement laminations and voids
019
A 1.1% incidence of definite loosening of the femoral compon- There were three hips with initially a mode Ia failure with a
ent at a mean duration of 3.3 years follow up was noted. None subsequent distal cement fracture with poor proximal–medial
of the femoral components were probably loose and 7 (4%) support. This progressed into mode II.
were possibly loose. In addition, Harris et al. proposed a radio-
logical classification system for femoral stem loosening. Three
categories were defined: Definite loosening, probably loosening DeLee and Charnley zones (acetabulum; Figure 16.19)
and possible loosening. Second generation cementing tech-
The acetabulum is divided into three zones: Superior (1),
niques were developed in the mid 1970s to provide more
middle (2) and inferior (3). Zone 3 is the most common area
reproducible interdigitation of cement into bone. This was
one of the first published series of the early results following for osteolysis.
its introduction. Lower rates of loosening and increased rates of
survival of the femoral component were reported compared to Incidence of loosening
first generation cementing techniques With current cementing techniques there is a rate of femoral
loosening of ~3% at 11 years.
Acetabular component loosening tends to be a late finding.
Zones of loosening It increases dramatically after 10 years to between 11% and 41%
Gruen zones (femur; Figure 16.18) at 10–15-year follow-up. Cement is strongest in compression,
Evaluation of radiographic stability is graded using the zonal has poor tensile strength and only moderate shear stress. Acet-
analysis described by Gruen et al.55. The femur is divided into abular cup inclination means that mainly shear and tension
seven zones on the anteroposterior radiograph. One is the forces are placed on the acetabular component
greater trochanter (first site of osteolysis), while seven is the
lesser trochanterdd. Grading of cement technique
Age-related expansion of the femoral canal and cortical Barrack et al.58 have classified the quality of cement mantle
thinning may give the appearance of a progressively widening radiographically into four grades (Table 16.13).
radiolucency at the bone–cement interface. These radiolucen- Grade C and D mantles have been shown to have greater
cies do not typically have an associated sclerotic line seen in rates of aseptic loosening but there is high interobserver vari-
loose femoral stems. ability in cement mantle grading. This grading system has been
Osteolysis typically has more irregularity with variable criticized since it is somewhat influenced by the amount of
areas of cortical thinning and ectasia. cancellous bone removed during reaming and broaching.
When the entire cancellous bed is removed, there will often
Classic reference be ‘whiteout’ (indicating good cementing technique), and yet
there will be no cancellous foothold for the cement.
Gruen TA, McNeice GM, Amstutz HC. Modes of failure of It is suggested that a minimum of 2 mm of cement thick-
cemented stem-type femoral components: A radiographic
ness be allowed between prosthesis and bone. The two-thirds
analysis of loosening Clin Orthop. 1979;141:17–27.
rule states that two-thirds of the canal is displaced by the
Institution: University of California Los Angles femoral stem and the other third by cement.
Gruen et al. developed a widely used system in which the
femoral component interface is considered in seven zones. Figure 16.19 DeLee
and Charnley zones
These allow the location of cement fractures or lucent lines
either at the cement–bone or the cement–prosthesis interface.
They also comprehensively review the four Gruen mech-
anical modes of cemented femoral stem failure.
The study involved a retrospective sequential radiographic
evaluation of 301 patients with 389 THA with a follow up of
6 months to 6 years (mean follow up 3 years). There was
radiographic evidence of loosening in 76 of the 389 hips (19.5%).
Serial radiographic examination of these 76 hips demon-
strated that 56 (14.4%) had progressive femoral loosening and
were classified into the 4 modes of failure. Mode Ib was the
most common cause of failure in 5.1% of cases. Modes Ia, II and
IV were each seen in 3% of cases. Mode III (calcar pivot) was
rarely seen only in three hips (0.7%).
dd
Try not to get them the wrong way round! The examiners will be
happy to point this mistake out to you.
265
019
Table 16.13 Barrack et al.55 cement grading

Examination corner
Grade A Medullary canal completely filled with cement
(white out) with no distinguishable border between
the cement and the bone The candidate was shown a radiograph demonstrating gross
aseptic loosening of a THA.
Grade B Near complete filling. Slight radiolucency exists
CANDIDATE: This is a difficult and challenging situation.
bone–cement interface
Postoperative film would be useful for comparison, to see whether
Grade C1 Radiolucency >50% at the bone cement interface these changes are progressive or were present immediately
Grade C2 Cement mantles have areas in which the cement postoperatively. A lateral radiograph would also be useful. I would
thickness is <1 mm, or the prosthesis is up against be very concerned about catastrophic failure occurring in the near
bone future and regard the case as urgent. Looking at the acetabular
Grade D Radiolucency >100% bone cement interface side there are AAOS grade 3 bone loss changes present (brief
including absence cement distal to the cement tip. pause). The cup has rotated and is obviously loose.
Cement mantles have gross deficiencies or multiple The candidate briefly mentioned the “AAOS classification of
large voids bony acetabular defects” to the examiners. He was hoping they
would ask him about this classification system. The candidate
thought this wasn’t too obvious but some examiners are much
Mulroy et al. report a thin (<1 mm) femoral cement
cleverer than they appear. They simply ignored it and let him
mantle and defects in the cement mantle are associated with
continue talking.Classification systems aren’t essential to know for
early loosening59. Jasty et al. found that cement voids and stem
the exam and examiners generally don't ask you about them but
abutment against the femur (indicating an inadequate cement
by the same token they are helpful to know.
mantle) were associated with loosening60. A mantle defect
where the prosthesis touches bone creates an area of concen- Adult elective orthopaedics oral 2
trated stress and is associated with higher wear rates. Small 5 × 7 inch postoperative photograph shown of an
In the early 1970s, a contradictory cementing technique was AP radiograph pelvis.
introduced that involved implantation of a canal-filling femoral EXAMINER: This patient had revision surgery to his right hip
component in a line-to-line manner associated with a thin performed with impaction bone grafting of the femur 3 months
cement mantle This principle has given excellent long-term previously. What do you think of the radiograph?
clinical and radiological results and has been named the ‘French CANDIDATE: My mind went blank. There was nothing very obvious
paradox’. An explanation of this phenomenon has been recently to say about the radiograph. I mumbled something nonsensical.
provided by in vitro studies which showed that a thin cement EXAMINER: The femoral stem has subsided and sunk into the femur.
mantle in conjunction with a canal-filling stem was supported This is one of the worries of impaction grafting along with the
mainly by cortical bone and was subjected to low stresses. increased risk of infection.
EXAMINER: What type and size of bone graft would you use for
Classic reference impaction grafting?
CANDIDATE: Small particles.
Barrack RL, Mulroy RD Jr, Harris WH. Improved cementing
EXAMINER: The term you are looking for is ‘crouton size’ particles.
techniques and femoral component loosening in young
patients with hip arthroplasty: A 12-year radiographic review Let us move on and talk about types of bone graft. Can you name
J Bone Joint Surg Am. 1992;74:385–9. the various types of bone graft that exist?
CANDIDATE: Autograft is from the same person, allograft from
Institution: Massachusetts General Hospital Boston
another person, xenograft from a different species and isograft
Barrack and colleagues report a series of 50 THAs in 44 patients from identical twins. Or they can be described in terms of tissue
<50 years at mean follow up of 12 years. They attributed a
composition, either cortical, cancellous, corticocancellous and
diminished incidence of femoral aseptic loosening (2%) to
osteochondral, etc.
improved second-generation cementing techniques.
Adequate femoral cement grades (Barrack grade A or B) were EXAMINER: Which graft is best in terms of incorporation?
achieved in 100% of cases. CANDIDATE: Cancellous autograft
Barrack et al. proposed a four-scale femoral cement mantle EXAMINER: Why?
grading system to assess femoral cementation on immediate CANDIDATE: It is the best in terms of osteoconductive,
postoperative films. This classification was subsequently modi- osteoinduction and osteogenesis potential.
fied by Mulroy with C being divided into C1 and C2. Harris et al
EXAMINER: What do you mean by these terms that you have
have shown the strongest predictive factor for mechanical
failure is excessively thin mantles or mantles with defects (C2 just used?
grade) as opposed to mantles with single or multiple voids (C1 CANDIDATE: I went on to describe fairly well osteoconductive,
grade). osteoinduction and osteogenesis.
019
Impaction grafting using fresh–frozen morsellized allograft is COMMENT: The diagnosis is obvious but candidate 1 has given
effective for both acetabular and femoral reconstruction. There a more complete and comprehensive answer. Answering this
are problems with cost, supply and potential infection. There type of oral question is rather like passing your driving test,
are worries about the biomechanical variability of donated demonstrating to the examiner that you are looking in
bone owing to its mode of preparation and its biological the mirror before you pull out. Rather than the examiners
variability. Concerns with transmission of infection from donor ‘assuming’ that candidate 2 ‘knows their stuff’, candidate
to recipient have led to irradiation of bone allograft as a means 1 has put them at ease by demonstrating that ‘they do indeed
of sterilisation. The typical gamma radiation dose for bone know what they are talking about’.
used in impaction grafting is 25 kGy. There are worries that
irradiation may affect the mechanical properties of the graft Adult elective orthopaedics oral 4: Radiograph of broken femoral
and its long-term incorporation. A dose of 25 kGy does not prosthesis
greatly affect the mechanical properties of bone, but increas-
CANDIDATE: This is an AP radiograph of the pelvis. It shows a
ing the dose has a detrimental non-linear effect on bone
broken femoral prosthesis. This is Gruen mode IV failure, a
strength and bone incorporation. Irradiation has been shown
to impair osteoconductive capacity of bone graft. It is postu- bending cantilever failure. It is the most common form of
lated that oxidation of lipids present in the marrow renders failureee. The other modes of failure are pistoning, either the stem
them cytotoxic to osteoblasts. Washing of irradiated graft within cement or the stem within bone, medial stem pivot and
removes fat, which may diminish the properties related to calcar pivot.
oxidized lipids. EXAMINER: What do you think is happening at the neck of the
Tight packing of allograft chips into the proximal part of prosthesis? (It was obvious osteolysis).
the femur to obtain initial implant stability is crucial for long- CANDIDATE: Bone resorption is taking place here and this has led to
term survival of the reconstruction. Risks include subsidence
cantilever failure. Bone resorption is also present superolaterally.
(50%), high postoperative fracture risk, perforation (14%,
The acetabular component is loose also. There are lucencies in
manage with either cable, mesh or strut graft) and it is tech-
nically difficult, with cost issues. DeLee and Charnley zones 1, 2 and 3.
EXAMINER: What do you think of this area here? (Large lucency in
Adult elective orthopaedics oral 2: X-ray of massive subsidence after acetabular bone superiorly.)
impaction grafting CANDIDATE: There is probably a segmental and possibly also rim
What is impaction grafting? defect in the acetabulun caused by osteolysis. Bone graft will be
Complications? needed when revising the cup.
Adult elective orthopaedics 3: Aseptic loosening of THA

CANDIDATE 1: This is an AP radiograph of the pelvis. It shows a
CANDIDATE: This is an AP radiograph of the pelvis, which
THA in situ but I am not familiar with the type of prosthesis used.
demonstrates Gruen mode IV failure, bending cantilever fatigue
Turning towards the femoral component what we can see is a
with complete stem fracture of the femoral prosthesis. This mode
straight stem prosthesis with a modular head. The head size
of failure is caused by proximal loss of support of the stem while
would appear to be large, possibly 28 mm. The tip is blunt and
distally the stem is securely fixed.
there is no cement plug, suggesting first-generation cementing
Distally the stem appears to be well fixed, proximally it is
techniques. There are trochanteric wires present, which would be
loose within the cement mantle with lucent lines particularly in
in keeping with a trochanteric approach.
Gruen zones I, II, VI and VII. progressing to stem failure.
We can see lucencies in Gruen zones I, II, IV and VII. There is
Other modes of failure include mode IA subsidence of the stem
bony sclerosis around the tip of the prosthesis and the tip is in
in the cement mantle, and IB subsidence of cement mantle
contact with the lateral cortex of the bone. This is suggestive of
and stemff.
Gruen mode II failure of the medial stem pivot.
Mode II failure is medial stem pivot and mode III failure is
A lateral radiograph of the hip would be helpful at this stage.
calcar pivot.
Turning towards the acetabular component there are lucencies
Looking at the acetabulum there appears to be lucencies in
present in all three DeLee and Charnley zones. A postoperative
DeLee and Charnley zones 1–3, suggesting that the acetabular
radiograph would be helpful to decide whether these changes
component is also loose.
were present postoperatively or are progressive. There is obvious
wear of the acetabular cup as shown by superior migration of the
femoral head. There are also significant acetabular bony defects
present, probably AAOS type III, a combination of segmental
ee
and cavitatory defects. This was actually incorrect but we don’t think the examiners
CANDIDATE 2: This radiograph demonstrates gross aseptic loosening realized this. Mode Ib is the most common cause of failure in 5.1%
of a THA of both the acetabular and femoral components. of cases.
ff
Not asked for but the examiners seemed pleased I had continued on.
267
019
I would remove the acetabular component and cement using

EXAMINER: You need to look a little bit more closely on the
osteotomes. I would assess the remaining bone stock and decide
acetabular side, especially superiorly.
upon either a further cemented or uncemented acetabular
CANDIDATE: There is a large lytic defect superiorly.
component. My preference would be for an uncemented tantulum
EXAMINER: There is obviously a large amount of bone loss
multihole revision component using multiple screws for additional
superiorly and one would also have to revise the acetabular
fixation and femoral head allograft to restore bone stock. I would
component at the time of surgery using bone graft.
attempt to upsize the femoral head size if possible. If I was
Tell me what you know about types of bone graft? significantly concerned about the risk of dislocation but the cup
The other fork in the road with this viva involves the examiner was solidly fixed I would perform a cement in cement acetabular
asking how you would manage this condition. Your answer would revision to allow for upsizing the femoral head.
involve reciting a standard (ideally rehearsed) answer for how you
would a perform revision hip arthroplasty along with a tailored Adult elective orthopaedics oral 6
response to the specific clinical situation presentedgg
How would you investigate and manage a patient with
CANDIDATE: I would take a full history and clinical examination. early loosening of a THA?
I would counsel the patient regarding the natural history of the
condition and recommend revision is undertaken on an urgent The question is essentially about excluding infection as a cause
of early loosening.
basis as the situation is likely to deteriorate and may lead to
catastrophic periprostatic fracture.
Basic science oral 1: Retrieval of THA – Discussion on reason
I would order blood tests to check for inflammatory markers – for failure
FBC, CRP and ESR to exclude prosthetic infection. Osteolysis
I would obtain a lateral radiograph of the hip/prosthesis. The Why would you not have a complete cement mantle?
femoral bone stock appears satisfactory, but if there was any Canal too small, prosthesis too big, mal-alignment and
doubt I would order a CT scan. poor surgical technique
I would obtain the original operative notes to check what surgical
approach was used and which implants were inserted. The
Candidate was given a worn plastic acetabular cup and asked to
acetabular cup is loose, and there is evidence of excessive
comment.
polyethylene wear on the preop radiographs and so needs to be
Methods to reduce oxidation of highly cross-linked
revised PE. Discussed post-irradiation remelting to quench residue
I would position the patient laterally; give prophylactic free radicals and addition of antioxidants such as vitamin E
antibiotics and approach the hip via a posterior approach. to PE powder prior to consolidation into a solid state to
After dislocating the THA I would attempt to remove the proximal improve the resistance to oxidation
stem and cement knocking it out with a mallet after using a flexible Highly cross-linked PE has a susceptibility to crack
osteotome to disturb the cement implant interface. propagation and failure. Inferior mechanical properties:
Reduced Young’s modulus, yield strength, fracture
I would plan an extended trochanteric osteotomy as access to
toughness, fatigue crack resistance
the distal stem and cement mantle may be difficult. I would
Discussion on aseptic loosening of THA, wear particles,
remove the remainder of the cement, the distal stem and the sources, etc. then followed
cement restrictor with a combination of osteotomes, reamers and
EXAMINER: How do you assess wear of a THA at follow-up clinic?
the OSCAR system.
CANDIDATE: My mind went blank and I waffled on about nothing in
I would repair the ETO using a cerclage cable system.
particular. I thought the examiners were looking for a
I would then plan to implant a long-stem modular,
complicated answer. Keep things simple, all they were looking for
uncemented, tapered, fluted revision prosthesis, aiming for a
was comparison of the degree of migration of the femoral head
good distal press-fit after reaming the femoral canal.
into the acetabular component on serial radiographs. We
If this cannot be achieved further options would be either a
eventually got there but I didn’t do too well with it. This is basic
distally locking THA stem or a long cemented femoral stem
stuff that can catch you out if you are not careful.
although I would be concerned about introducing cement into
the osteotomy site which would compromise
osteotomy healing. In addition, the results of cemented I was shown an x-ray of a THA with severe loosening of the
femoral revision stems have traditionally been femoral compartment in all Gruen zones. The examiners
disappointing. asked me what the mechanism of loosening was. I told
them it was pistoning of the prosthesis and the cement
mantle affecting all seven zones. They asked me to
enumerate all the Gruen zones and describe the different
gg
Don't forget to look at the acetabulum – Is it loose and requires modes of loosening one can get.’
revision or well fixed and can be left alone.
019
Anatomically shaped components are designed to fit the

‘The examiners then asked me what I would do with
the THA. I said I would plan for revision surgery. They overall shape of the femur in a better way allowing for better
asked me how I would go about this. I started off with centralisation of the stem and a more even thickness of the
history, examination and investigations. I mentioned cement mantle. Compared with symmetrical stems, anatom-
performing a full blood count, CRP and ESR. The examiner ical stems generate different strains within the cement mantle
asked me whether I would do a bone scan. I said I would because of their specific shape. They are of the composite-
prefer a white cell scan as a bone scan itself was of beam type since their shape limits the subsidence required to
doubtful value. I then mentioned that I would like to achieve a stable position.
perform an aspiration of the hip to rule out infection, All stems are now straight distally but excessive proximal
which the examiners were happy with. They asked what curve with cemented stems should be avoided to prevent
the management would be if the aspirate is negative.
cement overhanging proximally and laterally which may be
I said I would offer revision THA. They asked what
problematic if revision is required
information I would give the theatre staff. I said
I would get the old notes to find out what type of Surface finish (matt or polished): Polished stems are pre-
prosthesis was used and also inform the theatre staff ferred with loaded-taper design since they allow stepwise
about bone grafting and also the different types of cabling subsidence to a stable position, with the associated micro-
devices and osteotomy plates available in case we have to movement producing less metal and cement debris at the
do an extended trochanteric osteotomy. I told them cement–stem interface. In the composite–beam prostheses,
I would then proceed with an uncemented long femoral roughening the surface to increase the cement–stem bonding
stem. The examiners seemed satisfied with the answer.’ enhances stability. Changing the Exeter stem from a polished
to a matt finish resulted in a much higher failure rate.
Collar or collarless: May promote direct transfer of load
Design features of THA components from the implant to the medial cement mantle and/or the bone
of the medial femoral neck. Direct collar-bone contact can
Femoral component design unload the vulnerable proximal cement mantle. A collar may
Femoral stems can be cemented or uncemented. Some design reduce tensile stresses in the stem and reduce overall migra-
features are common to both tion. A collar may control insertion, especially when the stem
Medial offset or femoral offset: Perpendicular distance is undersized compared with the broach. May be useful as an
between the centre of the femoral head and the long axis of aiming device for determining version and as a stop point
the distal part of the stem. Primarily a function of stem design. while inserting the stem. It may prevent the stem from ‘set-
Inadequate restoration leads to increased joint reaction force, tling’ during cyclic loading, and does not avoid micromove-
bony impingement and dislocation while excessive offset can ment of the stem. Additionally in the long term it does not
lead to stem fracture or loosening. prevent absorption of the calcar.
Neck length: Measured from the centre of head to base of Shape of the tip: Tapered or blunt.
collar. Modularity (non-modular, modular): Modular heads
Neck shaft angle: Typically about 135°. allow for adjustment in neck lengths.
Longitudinal slots/grooves: Improves rotational stability of
the stem within the cement mantle. Decreases stress shielding, Head size
and increases the interlock between the stem and the cement. This influences the range of motion, wear and dislocation.
Cement centralizer: Provides a more uniform cement
mantle. 22.25 mm head
Ratio of femoral head diameter to the femoral neck
diameter: If increased there is a greater primary arc of motion. Low frictional torque
Stem cross-section (oval or square): The cross-sectional Higher rate of dislocation
shape influences the distribution of cement within the femoral Greater linear wear and creep
canal, the rotational stability of the implant and the stress
distribution within the cement mantle. 32 mm head
Stems with an oval cross-section have a better fit within the Greater stability and range of movement but increased
medullary canal and can occupy more of the cavity, leaving less volumetric wear
room for cement and cancellous bone. More rectangular cross- Less space is left for the acetabular component, resulting in
sections such as the Exeter (Stryker) are limited in size by their a thinner layer of polyethylene
contact against the inner cortex of the oval cross-section of the
medullary canal. 28 mm head
Overall shape: Straight (curved only in the frontal and not The 28-mm head is a reasonable compromise as it produces
sagittal plane) or anatomical (designed to fit the sagittal intra- the least linear wear and volumetric wear rates similar to the
medullary anatomy). 22-mm head.
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Table 16.14 Classification system of cementless femoral stem designs
General Category Type Geometry Description Location of fixation

Straight stems
Tapered proximal 1 Single wedge Narrows medially-laterally. Proximally coated. Flat stem, Metaphyseal
fixation thin in anterior–posterior plane
Tapered proximal 2 Double wedge, Narrows distally in both medial–lateral and anterior– Metaphyseal
fixation metaphyseal posterior planes. Wider than type 1. Fills metaphyseal
filling region
Tapered proximal 3A Tapered, round Rounded tapered conical stem with porous coating at Metaphyseal–diaphyseal
fixation proximal two-thirds junction
Tapered distal 3B Tapered, splined Conical taper with longitudinal raised splines Metaphyseal–diaphyseal
fixation junction and proximal
diaphyseal
Tapered distal 3C Tapered, Rectangular cross-section with four-point rotational Metaphyseal–diaphyseal
fixation rectangular support in metaphyseal–diaphyseal region junction and proximal
diaphyseal
Distally fixed 4 Cylindrical, fully Extensive porous coating. Proximal collar to enhance Primarily diaphyseal
coated proximal bone loading and axial stability
Modular 5 Metaphyseal and diaphyseal components prepared Metaphyseal and
independently diaphyseal
Curved, anatomic 6 Proximal portion is wide in both lateral and posterior Metaphyseal
stem planes. Posterior bow in metaphysis, anterior bow in
diaphysis
36 mm head
Increases impingement free ROM
Reduced dislocation risk
Increased torsional forces at the head–neck junction
Increased trunion wear and corrosion
Cementless femoral component

Uncemented stems rely on biological fixation and are mainly
two types; bone ingrowth and bone ongrowth designs.
Ingrowth is the formation of bone inside a porous surface
whereas ongrowth refers to bone growth over a roughened
surface. Ingrowth requires a pore size between 50 μm and 400
μm and the percentage of voids within the coating should be
between 30% and 40% to maintain mechanical strength.
Ingrowth surfaces include sintered beads, fiber mesh, and
porous metals. Sintered beads are microspheres of either cobalt
chromium or titanium alloy attached by the use of high tem-
peratures. Fiber mesh coatings are metal pads attached by
diffusion bonding. Porous metals have a uniform three- Figure 16.20 Classification of the cementless femoral stem designs
dimensional network, with high interconnectivity of the voids
and high porosity (75–85%) compared with that of sintered valley) is referred to as the surface roughness of the stem. Bone
beads and fibre metal coatings (30–50%). grows into the divots achieving biological fixation. Plasma
Ongrowth surfaces are created by grit blasting or plasma spraying involves mixing metal powders with an inert gas
spraying. An abrasive grit blasted surface creates microdivots that is pressurized and ionized, forming a high-energy flame.
on the surface, which are of similar size to pores in porous- The molten material is sprayed onto the implant, creating a
coated designs. The depth of the divot (distance from peak to textured surface.
019
It is important in both designs to achieve early stable press

fit or frictional fit fixation to allow for bony osseointegration.
Press fit fixation is achieved by under-reaming of the bone.
When the prosthesis is wedged in, compression hoop stresses
stabilise the implant to achieve a rigid fixation. On the other
hand, frictional fit is achieved by line-to-line reaming of the
bone. The rough surface of the prosthesis provides enough
resistance to motion, which achieves implant stability when it
is impacted into its final position. This is also called scratch fit
or interference fit. Stems can be either proximally porous
coated or fully porous coated. Advocates of the use of proximal
coated stems argue that this decreases the incidence of stress
shielding and loss of proximal femoral bone density as a result
of proximal femoral loading (Hoek’s law).
Berry et al.61 classified cementless stems into four categor-
ies based on geometry and fixation: (1) wedged-shaped
metaphyseal filling implant; (2) single wedge shaped implants
that are relatively thin in an anterior to posterior direction;
(3) tapered stems that are designed to get most fixation at
the metaphyseal-diaphyseal junction; (4) distally cylindrical
or fluted stems designed to obtain initial fixation in the
diaphysis.
Khanuja et al.62 further modified these categories into six
types based on shape, amount of osseous contact and progres-
sion of stem fixation from proximal to distal (Table 16.14 and
Figure 16.20).
Type 1 stems also called single wedge are designed to
engage metaphyseal cortical bone in one plane: Medial to
lateral . They are flat and thin in the anterior-posterior plane. Figure 16.21 Corail Standard Offset 135° neck angle, collarless uncemented
The component narrows proximally, primarily in the med- femoral stem. The 155 μm hydroxyapatite coating on the grit-blasted surface of
iallateral plane, and tapers distally. Initial stability is by wedge the corail stem induces rapid osteointegration.
fixation in the medial-lateral plane or three-point fixation
along the stem length. The broad flat shape achieves rotational
stability.
Type 2 (double wedge) stems obtain proximal cortical Type 4 is cylindrical and fully coated along the entire
contact in two planes: Anterior–posterior and medial-lateral. prosthesis. A proximal collar enhances axial stability and
Diaphyseal engagement is necessary to enhance rotational transmits forces to the calcar.
stability. Type 5 is modular which allows independent preparation
Type 3 stems achieve fixation in the metaphyseal- and separate components for the metaphysis and diaphysis.
diaphyseal junction and proximal diaphysis. They have a long Type 6 prostheses are curved anatomic stems that match
consistent taper in both the medial-lateral and anterior poster- the proximal femoral endosteal geometry. Stability is achieved
ior plane. They are divided into three subgroups on the basis of through metaphyseal fill and the distal curve.
their shape and means of fixation. Some implants combine ingrowth and ongrowth technol-
Type 3A is tapered and round. Most have porous coating ogy. An example of an ongrowth coating material is hydro-
on the proximal two-thirds and obtain three-point fixation. xyapatite (HA); Ca10 (Po4) 6(OH) 2. It is plasma sprayed either
Proximal fins or ribs may be added for rotational stability. directly on the implant or onto a porous coating.
Preparation requires reamers distally and broaches NJR data from England and Wales show that the Corail®
proximally. stem (Figure 16.21) is the most common uncemented stem used
Type 3B stems have a conical taper with longitudinal raised in primary THA. It is made of forged titanium alloy (TiAl6V4).
splines to provide rotational stability and fixation. The profile It is a straight implant, with a quadrangular cross-section. The
of these stems is very narrow providing the ability to change trapezoidal-like proximal cross-section provides rotational sta-
version in difficult cases. The preparation for these stems is bility and self locking in the metaphyseal area. The distal por-
done by conical reamers. tion has a tapered design, to produce a stiffness gradient and to
Type 3C stems are tapered, rectangular and conical, grit- avoid medullary canal blocking. Macro-textural features (hori-
blasted across its entire length. zontal and vertical grooves) enhance primary mechanical
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019
stability, which may be further augmented by the use of an

mechanically loose stem. The bony pedestral attempts to stop
optional collar. The HA coating is applied to the entire stem in the stem from sinking further down the medullary canal.
order to prevent the release of metal ions, to provide for max- The authors also proposed radiographic features of unce-
imum osseointegration at the interface and to prevent the mented femoral component stability.
interposition of a fibrous membrane around the distal portion A stable implant demonstrated no migration and spot
of the stem. HA coating is applied using an atmospheric plasma welds. A spot weld indicates stable osteointegration
spray process. The thickness of the ceramic layer is 150 μm. Stable fibrous ingrowth occurred when an implant
HA is osteoconductive and enhances growth of mineralised showed no progressive migration, sclerotic lines around
bone onto the implant essentially by providing bone with its the porous surface and less atrophy of the medial femoral
mineral phase substrate. Theoretically, its osteoconductive neck than observed when bone growth occurs
properties lead to bi-directional gap closure (from bone to An unstable implant was defined as one with definite
evidence of progressive subsidence or migration of the
prosthesis and from prosthesis to bone), giving more rapid
implant. Increased cortical density and thickening typically
closure. Studies have demonstrated no difference in the clinical occur beneath the collar and at the end of the stem
and radiographic outcomes when stems with hydroxyapatite
were compared with the same stems without hydroxyapatite.
There have been cases of HA coatings delaminating from the Cemented femoral component
prosthesis – Usually if it is applied too thickly.
Cement fixation relies on microinterlock with endosteal bone.
Other concerns include excessive third body abrasion wear
It is important to point out that cement fatigues with cyclic
if coating fragments are present within the joint space. How-
loading and this starts in areas of stress points in the mantle
ever, this theoretical risk has never been proven. Fragments
(such as defects where the prosthesis touches bone). To achieve
released after coating degradation remain in the immediate
optimal cement fixation, the following strategies are employed:
environment of the intramedullary part of the stem and do not
migrate into the surrounding soft tissues or in the joint cavity. Decreasing porosity of cement by vacuum mixing
There have been concerns that HA may induce osteolysis Pulsatile lavage of bone prior to cementing to produce
but this is attributable to migration of other particles. Com- clean dry trabeculae, which improves interdigitation
plete coating resorption is a recognised occurrence with HA. Pressurisation to improve microinterlock
Extraction of a well-osseointegrated implant can be a challen- Use of a stem centralizer to achieve a uniform mantle
ging procedure. However, a specific strategy and technique thickness and eliminate defects
using dedicated instrumentation will considerably lessen the Two main femoral stem designs philosophies are used in
risks and complications associated with prosthesis removal. cemented THA:
Taper slip, ‘force-closed’ fixation
Composite beam or ‘shaped-closed’ fixation
Classic reference A loaded taper design stem (double or triple taper) is polished
Engh CA, Bobyn JD, Glassman AH. Porous-coated hip replacement. and collarless. This allows some subsidence within the mantle
The factors governing bone ingrowth, stress shielding, and when axial load is applied. The viscoelastic properties of poly-
clinical results J Bone Joint Surg Br. 1987;69-B:45–55. methylmethacrylate (PMMA) will result in radial forces being
Engh et al. presented a comprehensive review of factors con- generated as a result of axial loading and wedging of the stem
trolling bone ingrowth and biological fixation of uncemented within the mantle. These are transferred to bone as hoop
femoral stems. stresses, which enhance fixation and stability of the stem.
The authors defined the criteria for reporting definite fem- A distal centralizer is used to facilitate subsidence of the stem
oral stem loosening when reporting survivorship analysis of to a stable position without creating excessive stresses in the
uncemented THA. distal cement mantle. Examples of taper loaded stems include
The paper also presented the first classification system for the Exeter stem (Stryker, Kalamazoo, Michigan, USA), CPT
reporting stress shielding which has stood the test of time and
stem (Zimmer, Warsaw, Indiana, USA) and C stem (DePuy,
is still widely used
1. First degree – A slight rounding off of the proximal medial
Warsaw, Indiana, USA).
edge of the cut femoral neck The second design is referred to as composite beam. This
2. Second degree – A rounding off of the proximal medial has a matt finish with a roughened surface. This allows for
femoral neck combined with loss of medial cortical density rigid bonding between the stem and cement. Most of these
at level 1 on the AP radiographs stem designs have a collar to enhance stability and to eliminate
3. Third degree – More extensive resorption of the cortical subsidence within the mantle. An example is the Stanmore
bone extending from level 1 into level 2 stem (Biomet, Bridgend, UK).
4. Fourth degree – Severe resorption of cortical bone Radiostereometric analysis (RSA) has shown that loaded-
extending below levels 1 and 2 into the diaphysis taper and composite-beam stems migrate differently over time.
Radiographs were also evaluated for cortical hypertrophy, In the first year of implantation, loaded-taper stems show an
pedestal formation, and spot welds. A bony pedestral is bone initial subsidence between 0.9 mm and 1.4 mm and retrover-
accumulation within the medullary canal below the tip of a sion between 0.4 mm and 0.5 mm. After the initial year, stems
019
tend to stabilise. Initial migration seems to be independent of sized slightly smaller in diameter than the actual component.
the type of cement, its viscosity and the thickness of the cement A line-to-line fit involves preparing bone to the same size as
mantle. The cement mantle surrounding these stems migrates the implant and securing with screws.
only slightly within the femur, which does not appear to Surgical tip: If an intraoperative fracture occurs during
compromise long-term results. placing an uncemented shell in the acetabulum, assess stability
Stems relying on the composite-beam principle have more of the shell. If this is stable, add screws. If unstable, remove
initial stability (especially longitudinal) with migration the shell, stabilise/fix the fracture then reinsert the shell with
between 0.1 mm and 0.5 mm during the first year. Migration screws.
into retroversion during the first year is usually between
0.28 mm and 0.8 mm, but is sometimes 1.0 mm and can Hybrid THA
even be as much as 2.0 mm. In some instances migration at the Hybrid THA combining a cemented stem and a cementless
cement–bone interface has also been seen. Both factors are socket was introduced because of the high rates of failure of
worrying since excessive and continuous migration is predict- cemented THA in young patients, particularly on the
ive of failure. acetabular side.
Data from the Swedish hip registry have reported 4–11%
Acetabular component aseptic loosening rates for hybrid THA. This is a less popular
Metal-backed cemented acetabular sockets have higher failure option today as initial enthusiasm from a few years ago has
rates compared to all PE cups. Elevated posterior lip designs died down. There are fewer complications when using an
are thought to reduce the risk of dislocation. Flanges on the cemented femoral stem in osteoporotic bone.
acetabular components are designed to improve pressurisation
of cement.
Examination corner
Cementless design Basic science oral 1: Design features of THA

The cemented femoral stem can be either polished, collarless
The initial stability of an implant is achieved by mechanical and tapered (loaded taper) or non-polished (matt finish),
interlock with the host bone. This is then converted to a long- collared and rectangular (composite-beam). Stem subsidence
term secondary stability by the ingrowth/on growth of a stable occurs with loaded taper stem designs, the initial subsidence
biological interface. occurring because of cement creep allowing ongoing radial
Attempts to improve bone ingrowth into metal implants compression of the cement, sealing the stem–cement interface.
have centred on either porous coating and/or coating with
hydroxyapatite. The optimum thickness of hydroxyapatite Basic science oral 2: Materials properties of ceramic on ceramic
for coating is approximately 50 μm. A pore size of 50 μm bearing surfaces
is accepted as the minimum for bony ingrowth with an Bioinert and minimal inflammatory response. Excellent
abrasive resistance, low coefficient friction, high impact
ideal pore size of between 50 μm and 400 μm to enhance
strength, chemical resistant, high Young’s modulus
bone ingrowth. Hydroxyapatite stimulates bone growth onto
elasticity, excellent wetability properties and absence of
a prosthesis, achieving osseointegration and facilitating a metal ion release
biological bone between implant and bone. This biological Superior wear resistance provides an excellent choice for
bone can provide mineralized continuity around the pros- young and active patients
thesis, with a sealing effect and a reduction in large early The 6 Vs
migration. 1. Very strong
2. Very stiff
Threaded designs 3. Very hard
Threaded cups can be either non-porous or porous coated. 4. Very biocompatible
Non-porous coated threaded cups rely on a mechanical 5. Very reduced volumetric wear debris (compared with
interlock between the acetabular bone and the implant threads other bearings)
for both initial stability and long-term fixation. They have 6. Very brittle
fallen out of favour in recent years as a number of studies have
shown unacceptable high early revision rates. Ceramic-bearing surfaces are associated with audible
squeaking. The incidence of squeaking has been reported to
Hemispheric designs vary widely, from 1% to 20%, with 3% being a generally
accepted figure.
The majority of acetabular components are hemispherical and A definite aetiology for squeaking in ceramic on ceramic
are available in incremental sizes. bearing hips remains elusive and controversial.
Initial fixation of the acetabular component is usually The cause is both complicated and multifactorial, with
accomplished by either a press-fit technique or a line-to-line studies reporting mixed findings with factors such as cup
fit. The press-fit technique involves the bone prepared being
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position, patient age, height and weight. Recent work has particular debris along relevant interfaces and retard
implicated stem alloys, stem geometries and neck geometries periprosthetic bone loss.
as causative factors. The V-40 neck and titanium-molybdenum-
zirconium-iron stem are particularly prone to cause squeaking.
The current explanation for squeaking is based on the
visible wear stripe concept. Retrieval analysis suggests a heavy
wear pattern during activities at the extremes of motion such Metal on metal (MoM) hip articulations
as rising from a seated position or other high flexion activities.
On these occasions, edge loading between the ceramic head
Introduction
and the posterior rim of the ceramic cup occurs. Squeaking can This is still a controversial topic ideal for the FRCS (Tr &
also occur with metal on metal articulations. Orth) exam.
Chip fractures and cracks can occur at the rim of the acet- There is recent ongoing debate concerning unexplained hip
abular liners, particularly when components are malpositioned. pain, early failure and formation of pseudotumours. NJR data
have shown an unexplained high early rate of failure for all
Adult elective orthopaedics oral 1 designs of MoM hip resurfacings and total hip replacements.
I was shown an AP radiograph of an uncemented THA and The 11th annual report in 2013 detailed that only 1.1%
asked to comment. The hip was uncemented which caught of hip resurfacing and 0.9% of hip arthroplasty involved a
me off guard initially. MoM-bearing surface. General recommendations are that
I used the zones described by Gruen and DeLee and MoM THA give poor implant survival compared with other
Charnley to assess the location and extent of radiolucent options and should not be implanted. Whilst not contraindi-
lines and osteolysis. I mentioned that I would like to assess
cated at best there is a limited role for MoM hip resurfacing
serial radiographs of the hip. Periprosthetic cystic or
procedure.
scalloped lesions with a diameter exceeding 2 mm not
present on immediate postoperative films would be highly
suggestive of osteolysis Resurfacing arthroplasty
I mentioned that there were radiolucent lines in Gruen The ideal candidate for an MoM hip resurfacing arthroplasty is
zones III, IV and V only. There was no evidence of endosteal a relatively young man with normal anatomy and primary
bone formation (spot welds) at the bone interface. The
osteoarthritis. For the exam be very careful about suggesting a
examiner pointed out pedestal formation at the stem tip
MoM hip resurfacing procedure. This surgery should ideally
suggestive of implant loosening which i had missed but in
retrospect was quite obvious. only be performed in a small number of highly selective patients
I pointed out that serial radiographs should be reviewed by a hip surgeon with extensive resurfacing experience per-
for femoral neck fretting, which would be suggestive of forming a minium number of procedures per year and having
impingement of the metal neck on the acetabular shell. The peer reviewed resurfacing results published in the literature.
radiograph showed a rounding off of the medial edge of
the resected femoral neck Contraindications to resurfacing
There was no evidence of calcar resorption of the
femoral neck which, if present, suggests significant stress Femoral head too deformed, e.g. SUFE
shielding. I mentioned checking for femoral stem migration Acetabular morphology unsuitable, e.g. severe DDH
on serial radiographs (measured as the difference between Narrow femoral neck (risk of notching and fracture)
the shoulder of the implant and the greater trochanter). Chronic renal failure (absolute)
Effective joint space was then discussed. History of metal hypersensitivity (e.g. jewellery)(absolute)
‘The effective joint space has been defined as all
Large femoral head cysts
periprosthetic regions that are accessible to joint fluid and,
thus, particulate debris. An inflammatory response Large areas of AVN
generated by osteolysis produces an increased hydrostatic Inflammatory arthropathy
pressure that allows for dissemination of particulate debris Being female and wanting to have children
within the effective joint space. Once wear particles are Small femoral head size (<46 mm)
generated they will follow the path of least resistance and Large BMI (BMI>35 kg/m2)
will, thus, find their way between the cement–bone
Large leg length discrepancy
interface or implant–bone interface in the case of
uncemented designs. Severe osteoporosis (inadequate femoral head bone stock)
It is important to achieve an adequate seal to prevent (absolute)
this path for particulate debris. This can be achieved by
either a complete cement mantle or a circumferentially Complications
proximally coated cementless implant.’
AVN/collapse of the femoral head
With uncemented designs, an intact mechanical barrier
at the prosthesis–bone interface may reduce the ingress of This can present as postnecrotic fractures as late as 2–3 years
after implantation.
019
Femoral neck fracture (1–3%) necrosis/metallosis. There is no clear consensus defining the
This is the most common mode of failure. Most occur in the boundaries between metallosis, ALVAL and pseudotumours
first 9 months.
The Australian joint registry found a significant gender Risk of neoplasm
difference between men (0.96%) and women (1.98%). This At present the primary concern of long-term induction of
was attributed to postmenopausal women having a reduced neoplasm is unfounded. There is no documented increased
bone density or the increased risk of overpenetration of risk of neoplasm. Chromosomal abnormalities in peripheral
cement into osteoporotic bone. Carrothers et al. (Oswestry) blood are more common with MoM bearing articulations.
found no significant gender difference between men (1.0%,
33 of 3346) and women (1.3%, 21 of 1654)63. Revision
Predisposing factors for femoral neck fracture are (1) tech- Patients are more likely statistically to require revision surgery
nical issues (notching of the superior neck, varus component for pain if they have a high abduction angle, are female, have a
positioning, undersizing of the femoral component, inad- small femoral component or a high BMI. All of these variables
equate pin centering technique, incomplete seating of the are associated with higher rates of wear.
femoral component, cement overpenetration with thermal There is a large disparity in the revision rates of different
necrosis, uncovered reamed bone), (2) head perfusion issues resurfacing implants. The Birmingham Hip Resurfacing (BHR)
(posterior approach, cylindrical reaming), (3) host issues (age, (Smith & Nephew, Warwick, UK) had the lowest revision rate
female, bone quality, anatomy) and (4) surgeon issues (experi- (8.85% at 10 years) in comparison to an overall revision rate of
ence, learning curve). A smaller head size is particularly prone 12.63 at 10 years for resurfacing prostheses. A higher revision
to femoral neck fracture. rate (28.28% at 10 years) in the ASR® (DePuy, Warsaw, Indi-
Femoral head loosening (0.4%) ana) due to excess metal debris and component loosening led to
its withdrawal64. Female gender has been found to be associated
Cement mantle, depth of cement penetration within the resur-
with a higher incidence of pseudotumours; however, this may
faced head, bone density and clearance between the reamed
be due to the smaller head sizes used in females.62 This study
head and femoral component are all associated with implant
found a revision rate at 6 years of 6% in those over 40 years and
survival. 13% in females below 40 years of age.
Acetabular component loosening (0.6%)
The relative risk is much higher for women vs men (4.9). Large diameter MoM THA
These were introduced in 2003 to treat failure of the femoral
Metallosis
component of MoM resurfacing when the acetabular compon-
Metallosis is the macroscopic staining of the soft tissues and is ent was well fixed. They began to be used in large numbers
associated with abnormal wear usually of the bearing surface instead of MoM hip resurfacing in patients with a poor quality
or taper junction. femoral head. Perceived advantages included a low dislocation
rate, a greater range of movement, lower wear rates and a
ALVAL (aseptic lymphocyte-dominated vasculitis-associated lesions) potential for greater longevity compared to MoP THA.
This is a delayed hypersensitivity-like reaction. Histological The most common presenting symptom of a failed MoM
analysis of soft tissues retrieved at revision surgery or biopsy THA is pain, located predominantly in the groin and occasion-
demonstrates an immunological response, which leads to peri- ally radiating to the greater trochanter and down the thigh, and
prosthetic osteolysis. frequently associated with clicking and clunking sensations.
Over the past few years concerns have been raised in relation
Pseudotumour (massive granuloma, neocapsule tissue reaction) to reports of catastrophic soft-tissue reactions resulting in
A pseudotumour can cause extensive collateral damage. Often implant failure and associated complications. Periprosthetic
there is formation of a synovial-like biomembrane which can tissue sampling during revision surgery of MoM articulations
produce collagenase, IL-1 and TNF which may lead to bone has shown the presence of ARMD and ALVAL, which includes
resorption and osteolysis. These are best diagnosed using a type IV hypersensitivity reactions and immunological response
metal artifact reduction sequence (MARS) MRI scan. Ultra- to metal wear debris. It remains to be shown whether these
sound still has a role as it is cheaper, more available has no adverse reactions are dose-dependent and whether they are
radiation risk and allows for hip aspiration in certain situations. mediated primarily by an immune response to, or a direct
The detection of small or deep lesions is, however, difficult. toxic effect of the metal debris.
A pseudotumour has been defined as ‘a soft-tissue mass
Adverse reactions to metal debris (ARMD) associated with the implant which is neither malignant nor
This is an umbrella term to describe joint failures associated infective in nature’65. ALVAL is a histological diagnosis, which
with pain, a large sterile effusion of the hip and/or macroscopic has also been used to describe the clinical appearance of tissue
275
019
necrosis and abnormal joint fluid at revision surgery. Metallosis

is defined as aseptic fibrosis, local necrosis, or loosening of a
device secondary to metallic corrosion and release of wear debris.
MoM failures seem to relate to poor technique including
component malposition, use in unsuitable patients whose
anatomy dictated malposition/edge bearing, and the wide
introduction of some unsatisfactory implants with insufficient
in vivo evaluation. The evidence from the literature is clear
that all medical devices depend on appropriate surgical tech-
nique and patient selection. It appears that these simple rules
affect the success of MoM hips more than other hip types.
It has been shown that steeply inclined acetabular compon-
ents with inclination angles of >55° combined with smaller
size of component were likely to give rise to higher serum
levels of cobalt and chromium66. Malpositioning of the com-
ponents can lead to earlier failure and revision. A study pub-
lished in the Lancet in 2012,67 based on data from the NJR of
England and Wales, analysed 402 051 hip arthroplasty and
showed that 6.2% of MoM implants had failed within 5 years, Figure 16.22 Radiograph of femoral neck fracture hip resurfacing
compared to 1.7% of MoP and 2.3% of CoC hip implants. The
same study concluded that each 1 mm increase in head size of
MoM implants was associated with a 2% increase of failure.
The viva could now lead onto the ASR® implant, design
Another important source of wear in MoM (THA) bearings
characteristics and mode of failure, although it would be
is the head-neck taper. The use of large femoral heads on taking on a basic science slanthh. This could lead on to discus-
narrow-stem tapers increases the risk of corrosive wear at the sion of joint registries, how to set one up, etc.
trunnion as a result of increased frictional torque, which is The ASR® was less forgiving of component malorientation,
associated with large diameter heads(trunnionosis). This may both because the cup was subhemispherical-designed to
contribute to any elevated metal ions and adverse tissue reac- reduce impingement, and because of the internal groove
tions. It has been shown that the failure rate of the ASR® (DePuy, designed to accommodate the cup inserter. The effective arc
Warsaw, Indiana) MoM THA is higher than that of the resur- of cover was essentially reduced, rim loading occurred earlier
facing version, which supports the trunnion wear theory68,69. and there was a higher than expected failure of this device. In
addition there was suboptimal manufacturing of the cobalt
chromium material. It has been recalled from the market.
Examination corner
Adult elective orthopaedic oral 2: Radiograph of a femoral neck
Adult elective orthopaedic oral 1 fracture following MoM resurfacing
The examiner handed me a MoM prosthesis.
EXAMINER: This is a radiograph of a 51-year-old man who presented
EXAMINER: What is this prosthesis?
to casualty with right hip pain (Figure 16.22). He had an MoM hip
EXAMINER: What are its design characteristics?
resurfacing procedure 1 week previously.
EXAMINER: What is the advantage of MoM articulation?
CANDIDATE: The radiograph demonstrates a fairly obvious femoral
CANDIDATE: Less wear debris, a lower risk of osteolysis and less neck component fracture.
aseptic loosening compared with metal on PE articulations.
EXAMINER: What are the potential causes for this?
EXAMINER: Do you know any literature evidence?
CANDIDATE: The fracture occurred in the early postoperative period
EXAMINER: What are the problems of metal debris? so the most obvious causes would be notching of the femoral
CANDIDATE: There are local and systemic effects of metal ions. neck at surgery. Notching increases the risk of fracture.
ALVAL, pseudotumours and ARMD are causes for concern. EXAMINER: How can you prevent this?
EXAMINER: What does the BHS guideline say about this? CANDIDATE:
CANDIDATE: A recent document giving information and advice to Accurate templating prior to surgery
surgeons on metal on metal bearings was published jointly by the Accurate central pin placement using a reliable jig system. Some
BHS and BOA. They recommend that worsening or severe pain, jigs are more user-friendly than others and are designed to
rising metal ions or increasing size of cystic or solid mass are minimize this risk
concerning and may require revision surgery. There is increasing
evidence that solid masses are more concerning than cystic ones.
There is also evidence that cystic masses are found adjacent to
well functioning hips. hh
The adult and pathology can go towards basic science and vice
versa. The boundaries aren’t always clear cut.
019
Upsizing the head when performing the initial femoral head Adult elective orthopaedic oral 3: radiograph of an opened MoM
reaming and only downsizing if there is no chance of notching acetabular cup
Experienced surgeon past the learning curve
EXAMINER: This is a postoperative check radiograph of a hip
resurfacing arthroplasty (Figure 16.23). Would you like to
EXAMINER: Any other risk factors?
comment on the x-ray?
CANDIDATE: A smaller femoral component size is prone to this
CANDIDATE: The cup is opened and the cup angle is steep and
mode of failure. Accurate component placement without
more than the 40° currently recommended.
notching is more difficult when the femoral head size decreases.
EXAMINER: This is the postoperative radiograph. Would you go back
Also, following head preparation, the ratio of femoral bone to
in and reposition the cup into a more closed vertical position?
metal component decreases disproportionately with decreasing
head size. Other risk factors include varus alignment of the CANDIDATE: This is a difficult dilemma in the postoperative period.
femoral component and a thick cement mantle at the dome of If the cup is in a reasonable position albeit opened more than
the femoral head. ideal I would leave it. If it was markedly opened I would revise it.
I would probably want to discuss it with my colleagues and take
EXAMINER: So how can we minimize these risks at surgery?
their advice.
CANDIDATE: I can’t think of anything else.
EXAMINER: What angle of cup inclination is recommended?
EXAMINER: Computer navigation.
CANDIDATE: With conventional hips cups were inserted at 45° of
EXAMINER: How well do patients do if they require revision of an
abduction and 20° of anteversion. It is now recommended to
MoM hip?
insert the cup in 40° of abduction.
CANDIDATE: Patients with femoral loosening have significantly
EXAMINER: OK, you don’t do anything but he presents to your clinic
lower hip scores after revision surgery than did those with
2 years after surgery with progressively increasing hip pain. What
femoral neck fracture and those with femoral head collapse or
are you going to do?
AVN. If the revision is performed for pseudotumours then results
CANDIDATE: I would investigate him for a painful MoM hip
tend to be much poorer because of the associated soft-tissue
resurfacing as per BHS guidelines. I would first want to exclude
damage.
infection – I would go through the history and examination
EXAMINER: You mentioned a learning curve for MoM resurfacing. Is
findings looking for pointers towards infection such as a
there any literature that has looked into this?
postoperative wound haematoma or washout. I would measure
CANDIDATE: De Smet et al. published an annotation in the Journal
ESR/CRP, IL-6, perform a bone scan and aspirate the hip.
of Bone and Joint Surgery summarizing the Ghent advanced hip
EXAMINER: You have excluded infection.
resurfacing course70. They stated that an orthopaedic surgeon
CANDIDATE: There are many causes for a painful resurfacing hip
should have a minimum experience of 200 conventional THAs
implant. I would want to consider soft-tissue issues such as psoas/
before starting hip resurfacing. Opinion varied on the number of
adductor tendonitis – I would request a lateral radiograph looking
resurfacings needed to overcome the learning curve, ranging
for excessive retroversion of the acetabular component that leads to
from 20 (36% of voters) to 50 (28% of voters) and >50 (30% of
the cup uncovering anteriorly which may be the reason. I would
voters).
exclude referred pain from elsewhere such as the spine, sacrum or
femoral hernia. Other causes of failure could include impingement,
aseptic loosening of components, femoral neck fracture or
resorption/AVN. The radiographs perhaps suggest an element of HO.
EXAMINER: HO has been excluded as a significant factor. All these
other factors have also been excluded.
CANDIDATE: I would examine for any groin swellings, as well as the
hip range of movement, pain and limping. I would want to
measure serum cobalt/chromium levels.
EXAMINER: There are marginally elevated.
CANDIDATE: I would request an MARS MRI scan specifically looking
for any evidence of soft-tissue masses such as pseudotumours.
I would obtain the old operating notes to ascertain the particular
model of the prosthesis and head size
EXAMINER: The MRI is normal. There is no evidence of fluid
collections or pseudotumours.
CANDIDATE: Then I wouldn’t do anything at the moment. I would
leave alone and follow up in clinic regularly.
EXAMINER: You wouldn’t revise the hip.
CANDIDATE: No.
Figure 16.23 Radiograph of MoM hip resurfacing with opened cup
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019
EXAMINER: The patient returns 6 months later, still in pain, in fact

getting worse.
CANDIDATE: I would re-measure his serum cobalt/chromium levels.
EXAMINER: Why?
CANDIDATE: If levels are raised and climbing compared to previous
results and the hip is becoming progressively more painful and
with the high cup component inclination angle I would need to
consider revision.
EXAMINER: The MRI was normal.
CANDIDATE: I might want to repeat the hip MRI as things may have
changed. If any fluid is present around the hip MRI I would
perform a hip aspiration looking for brown-stained fluid typical of
pseudotumours.
EXAMINER: You can also get a milky fluid with pseudotumours.
CANDIDATE: I would discuss his case with an experienced revision
hip surgeon as per BHS/BOA guidelines.
EXAMINER: Blood metal ion levels were static, repeat MRI again
showed no evidence of pseudotumours and we are observing the
patient at present. If there is any change we will need to revise.
A fluid collection by itself around the joint in an asymptomatic
patient, unless very large can be safely observed with interval
scanning. The MARS MRI scan is more important in the decision-
making process to revise the MoM hip replacement than elevated
cobalt/chromium levels. A significant worry would be patients
with muscle or bone damage on MARS MRI.
COMMENT: This was a good candidate answer; they were

familiar with the workup of the painful MoM hip resurfacing.
Figure 16.24 Aspirated fluid from a painful MoM hip
Everything was covered, including BHS/BOA national guide-
lines. Sensible practical answers were given not just reading
facts from the book and ticking boxes. EXAMINER: What are the advantages of an MoM hip resurfacing?
CANDIDATE: The advantages of hip resurfacing arthroplasty
Adult elective orthopaedic oral 4: photograph of aspirated fluid
include improved range of movement, improved gait parameters,
from a painful MoM hip
ease and decreased morbidity of revision arthroplasty, reduced
EXAMINER: This is a photograph of joint aspirate fluid from a patient dislocation rates, normal femoral loading and reduced stress-
being investigated for a painful MoM hip resurfacing shielding, simpler management of a degenerated hip with a
(Figure 16.24). What does it show? deformity in the proximal femoral metaphysis (after trauma or
CANDIDATE: Brown coffee-like fluid. osteotomy), less risk of infection, and a reduced risk of DVT/PE
EXAMINER: Why aspirate the hip? secondary to not using instruments in the femur.
CANDIDATE: If you suspect infection.
The procedure preserves the femoral neck and part of the head and
EXAMINER: What do you think of the aspirate?
does not invade the femoral canal, thus, preserving bone stock.
CANDIDATE: The aspirate is more suggestive of a pseudotumour Recent studies have shown preservation of bone mineral density
fluid collection. (BMD) in the femoral neck after resurfacing arthroplasty, and a signifi-
EXAMINER: What would you find at surgery? cant increase in BMD in Gruen zone VII educ.
CANDIDATE: Either a cystic or solid mass with extensive soft-tissue
destruction and necrosis. Revision total hip arthroplasty (THA)
EXAMINER: What would the serum cobalt and chromium levels show?
CANDIDATE: They are generally raised in cases of pseudotumours Surgical goals in revision hip surgery
and ALVAL, although a very small number of patients who 1. Removal of loose components without significant
develop pseudotumours have normal metal ion levels. destruction of host bone and tissue
EXAMINER: That’s the point – You don’t need raised serum cobalt/ 2. Reconstruction of bone defects with bone graft with or
chromium levels to develop pseudotumours, although if they are without metal augmentation
raised it is more likely. 3. Stable revision implants
4. Restoration of normal hip centre of rotation
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Table 16.15 AAOS classification system for acetabular deficiencies in THA

Indications
Type Lesion
Indications for revision hip surgery include:
Painful aseptic loosening of one or both components Type I Segmental deficiency Loss of part of the
Catastrophic implant failure • Peripheral (rim) acetabular rim or medial
• Central (medial wall wall
Recurrent dislocation or instability absent)
Infection
Type II Cavitary deficiency Volumetric loss in the
Periprosthetic fracture
• Peripheral (superior, bony substance of the
Progressive osteolysis anterior, posterior) acetabular cavity
Excessive wear of components • Medial (medial wall
Adverse Soft Tissue Reaction to Particulate Debris intact)
Type III Combined deficiencies Combination of segmental
Contraindications bone loss and cavitary
Contraindications for surgery would include: deficiency
Referred pain from elsewhere Type IV Pelvic discontinuity Complete separation
Medically unfit patient between the superior and
inferior acetabulum
Caution with painless LLD
Rarely indicated for painless loss of motion Type V Arthrodesis
Be very careful about operating for hip pain when no
obvious cause is found. Preferable to obtain a second
opinion and leave to experienced revision hip surgeon Osteolysis of ischium. Indicates bone loss from the
When the pain present prior to the index procedure inferior aspect of the posterior column
persists postoperatively the pain was probably not from the Osteolysis of the teardrop. Severe involvement means
hip originally complete obliteration of the teardrop
Kohler’s line. Position of the implant relative to Kohler’s line
Acetabular reconstruction Defects are classified by type, indicating whether the remaining
Acetabular defect classification systems are used to predict the acetabular structures are completely supportive (type 1), par-
extent of intraoperative bone loss and guide reconstructive tially supportive (type 2), or non-supportive (type 3).
options. Several classification exist;the two most commonly Type 1: Supportive rim with no bone lysis or component
cited are those by D’Antonio (AAOS classification) migration
(Table 16.15) and Paprosky (Table 16.16). Type 2: Anterior and posterior columns are intact. Some
The AAOS classification is descriptive and does not provide destruction of the dome and medial wall of the acetabulum. In
the surgeon with a guide for reconstructive options. Poor reli- type 2A there is superior bone loss from component migration
ability has been reported. The Paprosky classification system is or osteolysis but an intact acetabular rim (contained cavitary).
based on the status of the acetabular rim, dome, columns and In type 2B, the superolateral rim is absent so the defect is
contact area available for ingrowth at the time of revision. It considered segmental (uncontained). Type 2C demonstrate
assesses the severity of bone stock loss and the ability of the more localised medial wall destruction
acetabulum to contribute to implant stability. It is preferred by Type 3: Defects demonstrate extensive superior migration of
some surgeons because it is simple, useful for operative planning the acetabular component with >2 cm of superior bone loss
and allows critical evaluation of various management options and loss of the superolateral rim. Type 3A defects
and their outcomes. The intra- and interobserver reliability have demonstrate moderate, but not complete, destruction of the
been found to be moderate to poor by some authors. teardrop (medial wall of the teardrop is still present) and
moderate lysis of the ischium. Because the medial wall is
AAOS classification system (Table 16.15) present, the component usually migrates superolaterally.
This has special categories for pelvic dissociation and Type 3B defects show complete obliteration of the teardrop
arthrodesis. and severe lysis of the ischium, usually resulting in
superomedial component migration.
Paprosky classification system (Table 16.16)
Talk the radiograph talk
Four radiographic criteria are assessed:
‘The AP pelvic radiograph shows a type 1 AAOS segmental defect
Acetabular component migration. Superior migration to the superior peripheral acetabular rim following THA.’
involves acetabular dome loss, superior/medial greater ‘The radiograph demonstrates a Paprosky type 2C acetabular
involvement of the anterior column, superior/lateral defect. The teardrop is obliterated with generalized rim
greater involvement of the posterior column enlargement and severe medial wall destruction.’
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Table 16.16 Paprosky classification of acetabular defects
Type Radiographic finding Intraoperative finding Trial

stability
I No cup migration Intact rim and no distortion. No major osteolysis. Bone loss Full
minimal
No substantial bone loss Small focal areas contained bone loss
Columns intact
IIA Superior(or superomedial) migration of Superomedial bone loss Full
<3 cm
No substantial ischial lysis Columns supportive and rim intact
No substantial teardrop lysis Migration into defect under thin superior rim
Host-bone contact of >50%

IIB Superior (or superolateral) migration of Uncontained superior rim defect <1/3 Full
<3 cm
Columns supportive
Host-bone contact of >50%
IIC Medial wall defect Uncontained medial wall defect Full
Cup medial to Kohler line Rim intact and rim columns supportive
IIIA Superolateral cup migration Unsupportive dome Partial
Moderate ischial lysis Columns intact
Partial teardrop destruction Host–bone contact of 40–60%
Kohler line intact
IIIB Superomedial migration Risk of pelvic discontinuity None
Severe ischial destruction Bone contact of <40%
Teardrop loss Rim defect of >50%
Migration medial to Kohler line
Acetabular reconstruction options second generation porous acetabular components such as tan-
The ideal revision socket should be simply to insert, have good talum or titanium metal. These make a major difference in the
long-term survival results, be reliable, be able to accommodate setting of difficult acetabular revisions involving massive bone
unusual defects, should give initial stability and facilitate bone loss.
stock preservation It should allow the option of using a large
head and the choice of various bearing surfaces Structured bulk allograft
Acetabular reconstruction options include: In hips with substantial segmental acetabular bone loss, the
structural support necessary for hemispherical component sta-
Isolated acetabular liner exchange bility is lost. Structural allograft can be used in this situation.
Indicated for a well-fixed and well-oriented acetabular com- Potential for restoration of normal hip center and bone
ponent with progressive acetabular osteolysis. Patients stock for future revisions but technical difficulty so needs
are often asymptomatic. Goals of surgery are to prevent careful planning. Complications include unsuccessful osseoin-
full-thickness liner wear with associated catastrophic failure. tegration of graft into host leading to implant failure, increased
Bone-grafting of the osteolytic lesion is often required. Post- risk of infection, increased operating time and increased
operative dislocation is a concern. Use of a modified Hardinge blood loss.
approach and largest possible femoral head component(opti-
mizes head : Neck ratio) reduces this risk. Metal augments(tantalum)
An alternative for structural support involves use of special
Uncemented hemispherical cup with or without bone graft modular porous metal augments. There are several choices of
In most patients, bone loss encountered at acetabular revision augments that can be sized, oriented, and positioned to closely
can be managed with a standard cementless hemispherical match the dimensions of segmental acetabular defects.
component if initial stability and sufficient component-bone
contact is achieved. Fixation is usually supplemented with Cemented cup
transacetabular screws, and contained bony defects are filled Less favoured over last 2 decades, disappointing results in the
with cancellous bone allograft. A major advance is the use of revision setting.
019
Impaction grafting ± mesh Table 16.17 AAOS classification of femoral abnormalities in THA
Initially described with cemented acetabular cup, this tech- Type Lesion
nique can be used with cementless components. Potential for
Type I Segmental (loss of bone supporting shell of femur)
restoration of lost bone stock and versatility in managing both
a. Proximal
contained and segmental patterns of bone loss. Technically i. Partial
difficult and time consuming. ii. Complete
b. Intercalary
Cage
c. Greater trochanter
Usually reserved with the most difficult acetabular revisions with
massive bone loss and pelvic discontinuity. Historically, these Type II Cavitory (loss of endosteal and cancellous bone but
intact cortical shell)
constructs lack the potential for biological fixation and were
doomed to fatigue failure. To address this limitation, cages and Type III Combined segmental and cavitary
custom triflange components have recently been designed and Type IV Mal-alignment (loss of normal femoral geometry)
manufactured with ingrowth surfaces. owing to previous surgery (osteotomy), trauma
Acetabular cages provide short-term stabilisation. In this a. Rotational
setting, the device provides fixation and stability during the b. Angular
period of time that another device (such as a hemispherical Type V Stenosis (occlusion of canal from trauma, fixation
cup) achieves long-term biological osseous ingrowth. devices or bony hypertrophy)
Failure of graft incorporation with resorption leads to
Type VI Femoral discontinuity (loss of femoral integrity from
eventual cage fatigue and construct failure.
fracture/non-union)
Contemporary reference Type 3: There is a proximal femur, which is both ballooned

and deficient in its cortical integrity
Deirmengian GK, Zmistowski B, O'Neil JT, Hozack WJ.
Type 4: These defects are characterized by mal-alignment
Management of acetabular bone loss in revision total hip
arthroplasty. J Bone Joint Surg Am. 2011;93:1842–1852. involving either rotatory or angular deformity
Type 5: These features are often the sequel to previous
Current concepts review
periprosthetic fractures
Current concepts overview of acetabular reconstructive
options. Type 6: Characterized by periprosthetic discontinuity
between the upper and lower halves of the femoral shaft
Weeden and Paprosky classification system for femoral defects

Contemporary reference (Table 16.18)
Reid C, Grobler GP, Dower BJ, Nortje MB, Walters J. Revision The Weeden and Paprosky classification depends on the quan-
total hip arthroplasty: Addressing acetabular bone loss. SA tity of metaphyseal and diaphyseal bone stock. It is based on
Orthop J. 2012;11:34–46. the principle that as proximal bone becomes weak and unsup-
Provides a useful management framework(history, clinical portive, the relatively spared diaphyseal bone can be success-
examination and investigations) that can be utilized in the fully used to provide reliable, long-term fixation. The system
isolated loose acetabular cup needing revision viva scenario. assigns the femur to one of four categories on the basis of the
extent and location of bone loss.
Femoral reconstruction Implant optionsii

Several classification systems exist for describing femoral bone Proximally loading modular porous coated stems
loss in revision hip surgery. Cylindrical extensively porous coated ingrowth stems
Modular revision stems
AAOS Classification system for femoral defects (Table 16.17) Impaction bone grafting
Whilst the AAOS classification system is well established and Distally locked prosthesis
highly descriptive in detailing osseous abnormalities, it does Megaprosthesis
not provide a guide for reconstruction. Allograft–prosthesis composites(proximal femoral
replacement)
Type 1: These defects are segmental in nature, typically
involving the proximal part of the femur
Type 2: These defects typically involve ballooning of the
cortex to create an ecstatic canal. There is an intact proximal ii
See website www.postgraduateorthopaedics.com for additional
femoral tube with irregular endosteal loss and cavitation information.
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Table 16.18 Weeden and Paprosky classification system for femoral defects results in a Trendelenburg’s gait, a feeling of instability of the
Type I: Minimal metaphyseal cancellous bone loss/normal hip, the probable need for a walking aid and the inability to
intact diaphysis stand on one leg. The strength of the abductor muscles post-
Type I defects are seen after removal of uncemented component operatively is related to preoperative muscle mass as well as to
without biological ingrowth on its surface. The diaphysis and the placement of hip center. Exposure of the hip is difficult
metaphysis are intact and there is partial loss of the calcar and AP because of the distorted anatomy and soft tissue contractures.
bone stock. Uncommon in the revision setting
Type II: Extensive metaphyseal cancellous bone loss/normal Results
intact diaphysis The complication rate for conversion can be high. One study
Often seen after removal of cemented prosthesis. Calcar reported a 33% failure at 10 years with a previous history of
deficiency and major AP bone loss. Common finding in the early surgical fusion because of loosening, infection or recurrent
stages of aseptic loosening dislocation. Nerve palsy has been reported to be as high as
Type IIIA: Metaphysis severely damaged >4 cm diaphyseal 7% in some series.
bone for distal fixation
Grossly loose femoral component Hip arthrodesis
First-generation cementing techniques A hip arthrodesis, when performed correctly, preserves bone
Extensive metaphyseal bone loss, leaving it unsupported. stock, provides indefinite pain relief, allows a reasonably active
Most frequent encountered defect in femoral revision surgery lifestyle albeit with some restriction of physical activity and
Type IIIB: Metaphysis severely damaged/ <4 cm diaphyseal allows conversion to a THA at a later date. The patient must
bone for distal fixation understand and accept before surgery the disabilities associ-
These defects extend slightly further than type IIIA, although ated with the procedure.
reliable fixation can be achieved just past the isthmus of the femur
Seen with the use of longer cementless stems Indications
Type IV: Extensive metaphyseal and diaphyseal bone loss/ This is indicated in a young patient with unilateral OA hip. It
isthmus non-supportive is especially suited in the young man with OA secondary to
Extensive defect with severe metaphyseal and diaphyseal bone trauma and involved in heavy manual work. The long-term
loss and a widened canal that cannot provide adequate fixation results of THA in this patient population are disappointing.
for a long stem
Prerequisites
Postoperative complications The patient must have a normal contralateral hip, ipsilateral
Failure rates of revision THA are three times that of primary knee and spine, as a fused hip increases the stresses on these
surgery. joints and the clinical results of hip fusion can be compromised.
Infection (12–17%)
Dislocation (5–10%)
Vascular injury
Nerve palsy
Cortical perforation
Fracture
Heterotopic ossification
LLD
DVT/PE rate similar to those for a primary operation
Conversion of hip arthrodesis to THA

This is indicated if a fused hip causes severe persistent low
back pain, pain in the ipsilateral knee, or the pseudarthrosis is
painful (rule out infection).
Contralateral hip pain is rarely an isolated problem. The
contralateral joints are especially vulnerable if the hip has been
fused in a poor position (flexed >30°, adducted >10° or
abducted to any extent). In this situation osteotomy should
be considered first to correct the position.
One needs to try assess the function of the abductors
preoperatively. Inadequate strength of the abductor muscles Figure 16.25 Fused left hip
019
Contraindications Failure of internal fixation

Active infection, obesity, poor bone stock. Non-union (pseudoarthrosis rate of 15–25%)
OA hip, knee, spine
Instability ipsilateral knee
Advantages LLD (common)
Painless and stable joint for many years. Hip fusion and contralateral THA
THA has 40% more mechanical failure and loosening. Con-
Disadvantages sider an anterior approach to reduce the risk of dislocation
Immobile joint (particularly when sitting) if there is a contralateral arthrodesis.
Pain in adjacent joints with long-term follow up Informed consent
Warn about variable amounts of leg length discrepancy and a
Techniques possible need for a shoe lift postoperatively.
Fusion of the hip may be obtained by extra-articular, intra-
articular or combined intra-articular and extra-articular
methods. Examination corner
Adult elective orthopaedics oral 1: Radiograph of pelvis showing
AO Cobra head plate technique ankylosed right hip possibly caused by old tuberculosis
Fixation spanning the pelvis and proximal femur. Stable but EXAMINER: What is the position of the hip for fusion?
disrupts hip abductors and requires bone graft (Figure16.25). CANDIDATE: 30° flexion, neutral to 5° external rotation and neutral
or slight adduction.
Trans-articular sliding hip screw EXAMINER: What are the various techniques that can be used for hip
The lag screw is inserted just superior to the dome of the fusion?
acetabulum. Poor fixation achieved owing to a large lever EXAMINER: What effect does arthrodesis have on a contralateral
arm and increased torque and, therefore, hip spica casting total hip replacement?
may be required postoperatively. CANDIDATE: Mechanical loosening occurs at a higher rate when the
opposite hip has been arthrodesed.
Anterior plating technique
An extended Smith–Petersen approach is used and, although
the femoral head and acetabulum can be prepared for hip
arthrodesis, the abductor mechanism is not violated. The
Heterotopic ossification following THA
fusion plate is taken across the anterior column of the pelvis Definition
superiorly into the sacroiliac joint.
Heterotopic ossification is the abnormal formation of mature
Combined intra-articular and extra-articular fusion lamellar bone outside the skeleton usually in soft tissue.
Combination of plating and lag screw fixation.
Incidence
Position The radiographic incidence of HO following primary THA has
been reported to vary between 5% and 90% (21% in Brooker et
Avoid abduction and internal rotation
al.’s original paper71), but only 3–7% have significant symptoms.
20–30° flexion
Neutral – 5° external rotation
Neutral – 5° adduction Predisposing risk factors
Arthrodesis in an abducted position produces pelvic obliquity and Male (2× >F)
a limp. More flexion produces a greater leg length discrepancy and Hypertrophic OA
lumbar lordosis, whilst less flexion creates sitting difficulties. Ankylosing spondylitis
Diffuse idiopathic skeletal hyperostosis (DISH)
Complications Post-traumatic OA
Most patients will have complications from this surgery, which Prior hip fusion
may be either major or minor. Paget’s disease
Malposition (most common) Rheumatoid arthritis
Neurovascular injury History of previous HO in ipsilateral or contralateral hip
Femoral fracture in the first year following surgery Advanced age
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Surgical risk factors Determination of ectopic bone formation was made on AP

Intraoperative muscle ischaemia radiographs at a minimum of 6 months following THA in
Direct lateral approach72 100 consecutive patients. Significant HO was found in 21 hips
following THA rated as Class I (7), Class II (5), Class III (7) and
Extent of soft-tissue dissection
Class IV (2).
Bone trauma HO rated Class I, II or III did not affect the Harris Hip Score
Persistence of bone debris (reamings, marrow within the (HHS) whilst the two patients with Brooker class IV had lower
surgical field) than anticipated HHS.
Typically HO is asymptomatic, but higher Brooker grades
Pathology can result in impairment of hip arthroplasty function due to
pain, impingement, instability, decreased range of movement
Inappropriate differentiation of pluripotent mesenchymal or ankyloses, trochanteric bursitis and nerve irritation.
stem cells into osteoblastic cells. A definite causal factor has In the early days of THA, HO was considered a minor
not been identified. Research suggests overexpression of BMP- problem that had little effect on the clinical outcome. In
4 and PGE2. 1973, Brooker et al.68 introduced a method of classifying HO
and reported an incidence of 21%. In this article, HO influenced
Clinical features the functional outcome of the surgery only in cases with a
complete bony bridge.
HO following THA is usually painless and noted as an inci-
dental finding on radiographs. When symptomatic it presents
with limited hip motion and leads to a poor functional out- One main concern is that bone that appears to be bridging in
come. Pain is rare but can occur. Occasionally, localized an AP radiograph, may actually be located either anterior or
warmth, mild oedema and erythema may occur similar to posterior to the hip and will, therefore, not cause a significant
infection. Surgical excision is rarely indicated owing to the loss of hip range of motion. The overall incidence of HO
high incidence of recurrence. originally reported in Brooker’s paper (21%) is substantially
Surgery may be indicated in the rare cases of: lower than that accepted these days.69 A recent systematic review
A severe restriction of hip range of motion has reported an incidence of 43% and that of severe HO (Broo-
Severe pain from impingement ker grades III/IV) of 9%73. The reproducibility of the Brooker
Allow the process to mature (sharp cortical and trabecular classification and its use for clinical and research purposes is still
markings) before operative resection. Some authors recom- controversial. A number of authors have questioned the low
mend waiting 12 months before operative resection. interobserver and intraobserver reliability achieved when using
this classification system. Several studies have reported poorer
clinical outcomes with Brooker grade III HO than what was
Radiology reported in the original paper by Brooker74,75.
Calcification of soft tissues can occur as early as 2 weeks post-
operatively, maturing fully by 1 year. Bone scans are positive
after 3 weeks, with increased uptake in the soft tissues. Prevention
External beam radiation therapy 700–800 rads single dose
Classification: Brooker 1–4 (<4 h preop or 72 h postop)
Brooker et al.68 described four stages based on an AP radio- Indomethacin 75 mg for 6 weeks. Acts by inhibiting the
graph of the pelvis: production of prostaglandins. Potential side effects include
GI bleeding, renal impairment, severe allergic reactions,
Islands of bone within the soft tissues about the hip
headaches, etc. A worry if uncemented components are
Bone spurs from the proximal femur or pelvis with at least
used, as bony in growth may be affected
1 cm between opposing bone surfaces
Combination therapy. Radiotherapy and NSAIDs
Bone spurs with <1 cm gap
suggested for patients at highest risk for HO
Apparent bony ankylosis of the hip
Grade 1 or 2 does not influence the outcome of THA, but
grades 3 or 4 have a less favourable result. Examination corner
Adult and pathology oral 1
Classic reference The candidate was shown an AP radiograph of a primary THA
performed several months previously. There were severe Broo-
Brooker AF, Bowerman JW, Robinson RA, Riley LH Jr. Ectopic ker grade 4 changes on the radiograph.
ossification following total hip replacement: Incidence and a The candidate was asked about predisposing causes,
method of classification J Bone Joint Surg Am. Brooker classification and about which symptoms the
1973;55:1629–32. patient was likely to complain.
019
Causes are different to risk factors and include trauma, Indications for pelvic osteotomy
spinal cord injury, severe burns and genetic conditions such DDH rarely involves a primary femoral deformity; hence, it is
as fibrodysplasia ossificans progressiva (AD, stone man usually treated with a pelvic osteotomy rather than isolated
syndrome). femoral osteotomy. Acetabular osteotomies in the adult patient
CANDIDATE: Pain is an uncommon feature of the condition. have been classified into two groups: Reconstructive and sal-
Stiffness may be present but it would need to lead to a significant vage osteotomies. Periacetabular osteotomy has recently
disability before one would consider surgery. With Brooker grade emerged as the method of choice for young adults with signifi-
4 changes the patient may complain of difficulty with sitting, cant hip dysplasia and minimal arthritic changes.
ascending stairs, or putting on shoes and socks.
Adult and pathology oral 2 Clinical
‘I was shown an AP pelvic radiograph with a THA in situ With osteotomy motion is neither lost nor gained but its range
that had evidence of severe heterotopic ossification. is altered. The patient must have sufficient preoperative
I was asked about predisposing causes and the Brooker motion so that correction leaves a functional range of move-
classification.’
ment. Mechanical hip pain commonly occurs with weight-
Basic science oral 1 bearing and may be associated with a subjective feeling of
Discussion of the management and prophylaxis of heterotopic instability or weakness and clicking or locking. Exclude painful
ossification after a pelvic fracture. hip conditions other than mechanically induced pain. Chon-
Possible role for postoperative irradiation after fixation of com-
dral defects and loose bodies may also mimic symptoms of
plicated acetabular fractures. Risk factors include iliofemoral
surgical approach; T type fractures; and presence of associated
mechanical hip pain. In the assessment of the patient’s active
abdomen and chest injuries. If symptoms severe consider and passive range of motion, the presence of flexion, abduction
surgical excision. and external rotation contractures should be noted along with
any leg length discrepancy.
Osteotomy Radiographs
AP and lateral radiographs of the pelvis and the proximal
Introduction femur. On the femoral side assess for:
Osteotomy aims to improve congruency and reduce point
Poor bone quality
loading by restoring proper biomechanics. This is achieved
An abnormal femoral neck shaft angle
by increasing the surface area available to transfer loads,
Incongruity of the femoral head
decreasing muscle forces across the joint and reorientating
the weight-bearing surfaces of the joint to allow normal areas Unusual trochanteric anatomy
to articulate, moving away the diseased areas from the weight- Whilst with the acetabulum evaluate for:
bearing axis. Proximal femoral osteotomy, pelvic osteotomy or Poor bone stock
both can achieve these goals. Proximal femoral osteotomy Presence of cysts and osteophytes
should be considered when the predominant deformity is in Degree of dysplasia
the proximal femur. Patients with inflammatory arthritis are Functional radiographs (maximum abduction and adduction)
not suitable candidates for osteotomy. Timely intervention is are helpful in establishing which position of the proximal
required as the prognosis is adversely affected by the presence femur will improve the congruency of the hip joint and cover-
of advanced arthrosis. age of the femoral head. Other studies include a three-
dimensional CT scan, CT arthrogram or MRI scan.
Indications for proximal femoral osteotomy
Young patient with advanced OA hip to avoid THA
Contraindications
Post-Perthes’ hinged abduction disease (valgus extension Stiffness
osteotomy) Obesity
SUFE (flexion osteotomy) Inflammatory joint disease
DDH (varus derotational osteotomy to address the Presence of significant arthrosis
anteverted valgus neck) Stiff hip (minimum 90° flexion, 15° abduction/adduction)
Avascular necrosis
Idiopathic protrusio (valgus extension osteotomy) Technical considerations
Mal-union of trochanteric fractures The aims of surgery are:
Congenital coxa vara Elimination of impingement
285
019
Correction of deformity Flexion osteotomy

Restoration of a pain-free range of movement Indications include hip extension contracture, AVN with
Maintenance of the mechanical axis of the femur in both anterior involvement in the sagittal plane and posterior
coronal and sagittal planes sparing of the femoral head. The apex of the osteotomy is
Maintain or restore equal leg lengths located posteriorly and so a wedge of bone is removed anteri-
Restoration of proper rotational alignment orly. The shaft of the femur is flexed and the proximal femur is
extended. A posterior closing wedge may be better, less likely
to compromise future stem insertions.
Types of osteotomies
The major types of femoral osteotomy are: Extension osteotomy
Flexion Indications for extension osteotomy include hip flexion con-
Extension tracture and deficient anterior acetabular coverage (seen fre-
Varus quently with DDH). The apex of the osteotomy is located
Valgus anteriorly so that the shaft of the femur is extended and the
Rotational proximal femur is flexed.
Combinations of the above THA after previous osteotomy
A previous femoral osteotomy may render subsequent conver-
Varus osteotomy
sion to THA technically difficult because of distortion of the
A prerequiste for surgery is congruency of the joint in the proximal femoral anatomy. Varus and valgus osteotomies may
realigned position. This is confirmed with improved femoral alter neck shaft angle and be rotationally mal-aligned. Rota-
head coverage seen on the functional abduction view radio- tional mal-alignment can affect the estimation of anteversion
graphs. Some surgeons perform hip arthrograms to assess this of the femoral component. A custom-made femoral prosthesis
prior to the osteotomy. The patient should have a minimum or intraoperative femoral osteotomy may be necessary for
of 15° abduction preoperatively. The osteotomy works by success.
shifting the greater and lesser trochanters upwards, reducing
the tension of the abductors and iliopsoas and, therefore, the
vertical compression forces. This improves a Trendelenburg
Femoral acetabular impingement
gait pattern. A disadvantage is that this osteotomy usually Femoral acetabular impingement encompasses a spectrum of
shortens the leg by at least 1 cm. The most common tech- disease patterns and severity. It is a cause of hip pain, restricted
nique is to excise a medially based wedge of predetermined hip motion, labral disease, articular cartilage degeneration and
size and fixation of the osteotomy with a blade plate device. secondary osteoarthritis.
Varus osteotomy displaces the centre of hip rotation medially It is recognised as a sequela of common paediatric hip
and should be combined with medial displacement of the conditions such as Perthes’ disease and SUFE.
femoral shaft to maintain the lower extremity mechanical axis
passing through the centre of the knee. This avoids overload- Cam impingement
ing the medial compartment of the ipsilateral knee but results The cam type of impingement is caused by an overgrowth of
in a laterally prominent proximal femur, which may cause the anterior and anterosuperior femoral head-neck junction,
cosmetic concerns. leading to an increased peripheral radius of the head entering
the acetabulum throughout the range of movement of the
Valgus osteotomy hip. The chondral rim of the acetabulum is vulnerable to
This is usually indicated as a salvage procedure in a young damage. Predisposing factors include SUFE, mal-union of a
patient for an OA hip or post-Perthes’ disease deformity with femoral neck or head fracture and femoral retroversion.
coxa magna, hinged abduction and a large medial osteophyte.
An acceptable passive range of motion is required, with a
minimum flexion of 90° and adduction of 15° preoperatively. Pincer impingement
An adduction functional film should show improved congru- Pincer type impingement occurs because of acetabular over-
ency of the joint. Valgus osteotomy generally lengthens the coverage of the femoral head caused by a deep or retroverted
limb. If lengthening is undesirable, a closing wedge can be used acetabulum. A centre-edge angle of >40° is considered diagnos-
but this may shorten the leg by as much as 2 cm. tic of pincer impingement. This results in degeneration, ossifi-
A valgus osteotomy displaces the centre of hip rotation cation and tears of the anterosuperior portion of the labrum as
laterally and should be combined with lateral displacement of well as a posteroinferior contrecoup pattern of cartilage loss
the femoral shaft to align the mechanical axis of the limb from the femoral head and corresponding acetabulum. Predis-
through the centre of the knee and avoid overloading the posing factors include acetabular protrusio, acetabular retro-
lateral compartment. version and mal-union of an acetabular fracture.
019
Clinical findings There are two subtypes:

Patients present with hip pain that is located in the anterior Diffuse form
part of the groin and sometimes the lateral aspect of the hip
The disease may be active or inactive
but without greater trochanter tenderness. The pain can be
Look for periarticular erosions on radiographs
sharp and catching, worse with sitting and deep flexion. If the
pain involves substantial catching or popping, suspect labral A diffuse mass may be present on examination
pathology. On clinical examination patients demonstrate a Nodular form
painful range of hip movement, particularly internal rotation
and positive impingement test. Less common than the diffuse form of PVNS
The impingement test is performed by placing the patient Does not show the same destructive changes as the
in the supine position with the hip in 90° flexion and then diffuse form
adducting and internally rotating the hip. May cause recurrent haemarthrosis and aspirate may be of
normal colour (instead of the classic brown colour)
Investigations
AP and cross-table lateral (groin lateral) radiographs of
Radiology
the hip Radiographs show cysts on both sides of the joint and are not
Three-dimensional CT scan to confirm the diagnosis and confined to the weight-bearing areas. MRI will demonstrate
define the bony lesion hyperplastic synovium.
MRI to evaluate abnormal (bump) head-neck junction and
possible labral and chondral pathology Management
Ultrasound-guided biopsy is recommended for histological diag-
Joint preservation surgery nosis. Conservative treatment of symptomatic PVNS of the hip in
the young patient has included external beam radiation and open
The objectives are to eliminate abnormal contact between
synovectomy, with THA reserved for aggressive end-stage dis-
the proximal part of the femur and the acetabulum and to
ease. Arthroscopic synovectomy or open synovectomy is viewed
address intra-articular labral and articular cartilage abnormal-
as the treatment of choice for the active form of diffuse disease.
ities. Surgical options include open dislocation, arthroscopy and
Radiation may control PVNS in extensive recurrent disease.
limited open approaches and arthroscopic techniques alone.
Combined arthroscopy and limited femoral head-neck
osteochondroplasty allows evaluation and treatment of intra- Examination corner
articular labral and cartilage injuries whilst offering direct
visualisation for osteochondroplasty. Long case 1: PVNS right hip
Many surgeons prefer an all-arthroscopic technique of Radiographs of pelvis
femoral osteochondroplasty, citing better function and patient
outcomes. It should be performed fairly cautiously to reduce
The candidate was shown an AP radiograph of the hip of a
the risk of femoral neck fracture. Insufficient bony resection is
young woman with rapid deterioration in hip function
a common cause for revision arthroscopy.
Radiographic features included joint space narrowing and
lytic defects in the bone on both sides of the joint
Pigmented villonodular synovitis (PVNS) What findings at surgery would you expect?
of the hip
Introduction Tuberculosis of the hip
PVNS is a proliferative disease of synovial tissue, which affects
the knee, hip, ankle and elbow. A slow-growing benign locally
Introduction
invasive tumour of the synovium, the disease usually presents The hip is the most commonly affected joint and accounts
as a monoarticular haemarthrosis, and may exist in a nodular for 15% of all cases of osteoarticular tuberculosis. The initial
or a diffuse form. The hip is involved in 15% of cases. lesion usually starts as an osteomyelitis in one of the bones
adjacent to the joint (osseous tuberculosis). In some cases
the disease may begin in the synovium (synovial tuberculosis)
Clinical features but spreads quickly to involve the articular cartilage and
Acute episodic attacks of hip pain and swelling bone (articular tuberculosis). A progressive pattern of
Groin pain and restriction of movement destruction of the hip occurs in patients who are not treated.
Always consider PVNS in a younger patient with Treatment must be instituted early with the aim of salvaging
unexplained hip pain the hip.
287
019
Clinical features Joint arthroplasty:

The timing of total hip replacement (THA) in patients with
There is an insidious onset with aching in the groin and thigh
active tuberculosis (TB) of the hip is controversial, because of
and limp. Later the pain becomes more severe and causes sleep
the potential risk of reactivation of infection. Hardinge and Sir
disturbance. A child may complain of night cries’, the so-called
John Charnley76 recommended in 1977 postponing THA until
‘starting pain’.
any sinuses had not discharged for 20 years, or until the
All movements of the hip are grossly limited by pain and
affected hip had been ankylosed for more than 10 years.
spasm. The leg is scarred and thin, and shortening is often
Another study from the 80s77 recommended that joint arthro-
severe because many factors can contribute (adduction deform-
plasty is not performed in the active stage and should only be
ity, bone destruction, damage to the upper femoral epiphysis).
considered after a safe period of absolute disease quiescence.
Ankylosis of the hip/knee may occur spontaneously, and it
Radiology may be unnecessary to perform arthrodesis. Conversion of
Radiology is often non-specific. The earliest change is diffuse ankylosis or arthrodesis should be covered by antituberculosis
osteoporosis but with a normal joint space. There maybe a lytic treatment for 3 months before surgery and 9 months post-
lesion involving either the head of the femur or the acetabu- operatively. The authors of both studies concluded that there
lum. The outline of the articular ends of the bone becomes was a low probability of reactivation if:
irregular because of destruction by the disease process. >10 years since infection
Solid arthrodesis
Management Previous medical treatment
Chemotherapy is the main basis of management. However, a recent systematic review78 has suggested that THA
Skin traction in a Thomas splint: in patients with active TB of the hip is a safe procedure, provid-
Provides rest of the affected part ing symptomatic relief and functional improvement if under-
Relieves muscle spasm taken in association with extensive debridement and appropriate
antituberculosis treatment. They reached this conclusion after
Prevents and corrects deformity
reviewing multiple databases referenced articles published
Maintains joint space between 1950 and 2012. A total of 6 articles were identified,
Minimizes chances of developing a wandering acetabulum comprising 65 patients. TB was confirmed histologically in all
patients. The mean follow-up was 53.2 months (24–108
months). Antituberculosis treatment continued postoperatively
for between 6 and 15 months, after debridement and THA. One
non-compliant patient had reactivation of infection. At the final
follow-up the mean HHS was 91.7 (56–98).
The surgical challenges encountered include scarring and
adhesions in the hip area, shortening, anatomical distortion of
the acetabulum and femur, LLD and bony defects.
Examination corner
Adult elective orthopaedic oral: Radiograph demonstrating a
Brittain ischiofemoral arthrodesis (Figure 16.26)
This is a classic and distinct spot diagnosis of the adult and
pathology oral. It is an extra-articular hip arthrodesis used to
treat tuberculosis infection. This concept was first popularized
by Brittain of Norwich in 1941. Subtrochanteric osteotomy and
medial displacement of the femoral shaft with a tibial graft
bridging the femur and ischium are carried out. It is a clever
concept based on the principle that compression provided by
the adduction forces will induce hypertrophy of the tibial graft
(as opposed to iliofemoral grafts, which are under distraction).
The graft was also extracapsular, i.e. could be performed away
from the tuberculous infection. The structure that is particu-
larly at risk when performing an ischiofemoral arthrodesis is
the sciatic nerve. This is put at even more risk if there is a
severe fixed flexion deformity of the hip as this effectively
drags the nerve forward into the plane of the strut graft
between the femur and the ischium.
Figure 16.26 Brittain ischiofemoral arthrodesis
019
General orthopaedic and adult oral Types of patient-based measures outcome

This was actually a spot MRI diagnosis of spinal tuberculosis
Disease-specific questionnaires
with a discussion of the differential diagnosis.
Most traditional hip outcome measures (e.g. Harris, D’Aubigne,
EXAMINER: What are the current recommendations for
Mayo and Iowa Hip Scores) are disease-specific. Most disease-
antituberculosis treatment?
specific outcome measures have not been validated. The
CANDIDATE: Either a triple or four-phase drug treatment. This is WOMAC hip assessment is a newer, validated, disease-specific
the initial intensive phase, which is for a period of 2 months. outcome measure. It consists of 24 items, assessing three dimen-
This is followed by a continuation phase with rifampicin and sions: Pain, stiffness and physical function.
isoniazid, which is usually continued for a period of 6–9 months.
EXAMINER: What about long-term therapy of 12–18 months. Patient-specific outcome measures
CANDIDATE: Orthopaedic surgeons initially favoured long-term An example of a patient-specific outcome measure would be
therapy but the short course therapy of 6–9 months used the MACTAR scale, in which the patient is asked to list the
successfully for pulmonary tuberculosis has been shown to be primary reasons why he or she is undergoing THA.
equally successful with osteoarticular tuberculosis. It is now
thought that extending chemotherapy beyond a year is required Region-specific questionnaires
in only rare circumstances. The Oxford Hip Score is a questionnaire designed to assess the
EXAMINER: What are the side effects of treatment? patient’s perceptions in relation to outcomes of THA.
CANDIDATE: Rifampicin: Rashes, hepatitis, orange discoloration of
Functional capacity outcome
urine, sweat and saliva. Isoniazid: Hepatitis, peripheral
neuropathy. Pyrazinamide: Anaemia, arthralgia, hepatitis, gout.
This measures functional capacity before and after a medical
Ethambutol: Optic neuritis (red–green colour blindness).
treatment. The 6-minute walk utilizing the same course and
prompts has proven useful in assessing THA patients.
‘There were much more interesting things to discuss
about this topic: The characteristic MRI differences Global outcome measures (generic health status questionnaires)
between secondary metastatic disease, infection and
The SF-36 is a typical global outcome measure.
tuberculosis, the indications for surgery with tuberculosis
of the spine, etc. The examiners were having none of this
and more or less just concentrated on drug treatment of Examination corner
the disease. I must admit I did struggle a bit and the
examiners would not let go of it and move on to Basic science oral 1
something else.’ EXAMINER: Do you know any outcome measurements that can be
used to assess the success of primary THA?
Management of tuberculosis (including drugs). CANDIDATE: No.
EXAMINER: Have you heard of the SF-36 or the Nottingham Health
Profile or the Oxford Hip Score?
Outcome measurements CANDIDATE: I have heard of the Oxford Hip Score.
A number of questionnaires have been developed to evaluate EXAMINER: What type of outcome measurement is it?
outcomes of interventions for OA hip. Six broad dimensions CANDIDATE: Sorry, I am not sure of your question.
are important: Pain, ability to walk, level of activity, walking EXAMINER: Let’s move on. How does heparin work?
capacity, patient satisfaction and clinical examination. (Fail)
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Knowledge Update: Hip and Knee approaches to total hip
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Knee oral core topics

Chapter
17 Khaled M. Sarraf and Deiary F. Kader
Menisci Mensical tissue is considered biomechanically as a biphasic

tissue. As the mensiscus is loaded,water is forced from the
Anatomy matrix and when the load is released, the negatively charged
Menisci are crescent-shaped fibrocartilaginous structures that are GAGs attract water back into the matrix, rehydrating the tissue.
triangular in cross-section. The lateral meniscus is more circular During flexion the posterior excursion of the lateral menis-
and covers 70% of the lateral tibial plateau, while the medial cus is 11.2 mm, which is nearly twice that of the medial
meniscus is C-shaped and covers 50% of the medial tibial plateau. meniscus1. Therefore, medial meniscal tears are three times
The menisci are composed primarily of type I collagen more common than that of the lateral meniscus (Figure 17.2).
(90%). The fibres are arranged radially and longitudinally (cir-
cumferential). Longitudinal fibres help dissipate hoop stresses in Blood supply
the meniscus. The hoop tension is lost when a single radial cut or
Branches of the lateral, middle and medial genicular
tear extends to the capsular margin. The extracellular matrix arteries from the popliteal artery provide the major
(ECM) consists of proteoglycans, glycoproteins and elastin. vascularization to the inferior and superior aspects of
By virtue of their specialized structure, high fixed-charge each meniscus
density, and charge-charge repulsion forces, proteoglycans in
The meniscus is vascularized by the perimeniscal
the ECM are responsible for hydration and provide the tissue
capillary plexus (PCP), which is formed by branches of the
with a high capacity to resist compressive loads (Figure 17.1).
lateral, middle and medial genicular arteries
At birth the whole meniscus is vascular
In adults only the outer 10–30% of the meniscus is
vascular2. Hence, the outer 30% is called the red zone
(PCP is present in the red zone)
The white zone is the inner avascular portion of the
meniscus
The intermediate portion is called the red–white zone
The red zone can heal via fibrovascular scar formation
Innervation
Peripheral two-thirds of the meniscus is innervated by
type I and II nerve endings
The posterior horn has the highest concentration of
mechanoreceptors
Functions of menisci
Load bearing
At least 50% of the compressive load of the knee joint is
transmitted through the meniscus in extension, and
around 85% is transmitted in 90° flexion. In the
meniscectomized knee the contact area is reduced to
Figure 17.1 Proteoglycans. Aggrecan is the major large proteoglycan of
approximately 50%. Partial meniscectomy also increases
the meniscus.Its main function is to enable the meniscus to absorb water, the contact pressures
whose confinement supports the tissue under compression
020
Chapter 17: Knee oral core topics
Figure 17.2 Axial anatomical view of the knee
Shock absorption are attached peripherally by the coronary ligaments and are
Menisci attenuate the intermittent shock waves connected anteriorly by the transverse (intrameniscal) liga-
generated by impulse loading during gait.The ment (Figure 17.2). They move anteriorly in extension and
shock-absorbing capacity of normal knees is ~20% posteriorly in flexion. The lateral meniscus is more mobile as it
higher than in meniscectomized knees. The meniscal has less soft-tissue attachments.
tissue has shock-absorption capacity because it has
nearly half of the stiffness of articular cartilage (more
elastic) Examination corner
Articular conformity Basic science
The meniscus displaces in an anteroposterior (AP) EXAMINER: What is the main constituent of the meniscus?
direction as the knee passes through its range of
movement. In addition, the menisci deform to remain in The meniscus is a fibrocartilaginous structure consisting of
extracellular matrix (primarily water, collagen, proteoglycans,
constant congruity to the tibial and femoral articular
elastin and glycoproteins) as well as cells which are mainly
cartilage. Deformable properties of the meniscus aids load fibrochondrocytes.
transmission and shock absorption
Knee joint stability EXAMINER: What type of collagen is found in the meniscus?
The medial meniscus in particular controls AP The main collagen found is type I. There are small amounts of
translation. Meniscectomy alone may not seriously type II, III and V.
affect stability. However, in association with anterior EXAMINER: Draw the shape of the meniscus including the
cruciate ligament (ACL) tears, meniscectomy significantly orientation of the collagen fibres and describe how they aid
increases the anterior knee laxity with its function.
Lubrication
The menisci is microscopically arranged into three distinct
The menisci distribute synovial fluid and promotes a viscous layers: Superficial, lamellar and deep. The superficial layer
hydrodynamic action needed for fluid-film lubrication exists on both the tibial and femoral surfaces.In the superior
Proprioception region there is an unorganized random arrangement of col-
lagen fibrils, which contrasts with the inferior region in which
This has been inferred from the finding of type 1 and
the fibers are more radially orientated. The lamellar layer that
type 2 nerve endings in the anterior and posterior
also exists on both the femoral and tibial sides has fibers that
horns of the menisci are randomly orientated. The main part of the meniscal tissue
Prevention of soft-tissue impingement during joint motion is located between the two lamellar layers. A dense frame-
work of circumferential coarse type I collagen fibres lie in this
Biomechanics layer, cross-linked with radial fibers from the periphery. The
The peripheral one-third of the meniscus plays a crucial part in radial fibres may act as a “tie” holding the circumferential
joint stability and load transmission. The inner two-thirds of fibres together, providing structural rigidity against compres-
the meniscus plays an important role in maximizing joint sive forces and resisting longitudinal splitting of the menisci
contact area and increasing shock absorption. The menisci (Figure 17.3).
293
020
In contrast, the medial meniscus is more C-shaped. The pos-

terior horn is attached to the posterior intercondylar fossa of
the tibia, while the anterior horn attaches anterior to the ACL
insertion and the medial tibial spine. The medial meniscus is
firmly attached to the joint capsule throughout its periphery,
including the deep medial collateral ligament which is a
condensation within the capsule.
Meniscal tears
There are two main types of tears. Traumatic tears usually
Figure 17.3 Diagram demonstrating the collagen fiber ultrastructure and
occur in younger patients owing to sporting injuries. Degen-
orientation within the meniscus: Collagen orientations are of three main types: erative tears occur in the older age group – In 60% of the
(1) circumferential, (2) radial and (3) random. Circumferential are mainly found in population over 65 years. The majority are asymptomatic and
the deep zone, Radial fibers are spread throughout the deep zone and are also
present on the periphery and horns of the meniscus in the lamellar zone.
occur in degenerative joint disease and can have an insidious
Despite the presence of radial fibers, random fiber orientation dominates the onset.
lamellar zone. In the superficial zone fiber orientation is random in the superior Medial meniscal tears are three times more common than
region and more radially orientated in the inferior region.
lateral meniscal tears, however, lateral meniscal tears are more
prevalent in acute ACL injuries.
During weight-bearing, the compressive forces exerted are Partial meniscectomy (50% excision) increases the peak
resisted by the hoop stresses in the circumferential fibres contact stress by 43% and reduces the contact area by 20%
within the meniscus. The hoop tension is lost when a single while total meniscectomy increases the peak contact stress by
radial cut or tear extends to the capsular margin. In contrast, 130% and reduces the contact area by 50%3.
shear forces within the meniscus are resisted by the radial This will ultimately reduce the joint’s shock absorbing cap-
collagen fibres of the meniscus. acity and load sharing ability. The effect of performing
The combination of the fibres allow the meniscal structure to such procedures is more profound on the lateral side in com-
expand under compressive forces and, hence, increase the parison with the medial due to the morphology of the tibial
contact area within the knee joint.
plateau. The medial tibial plateau is concave while the lateral is
Biomechanical studies have shown that 85% of the compressive
load is taken by the meniscus during flexion, while around 50%
convex, and, hence, the significant increase in contact stress in
of the compressive load is transmitted in extension. the latter.
Meniscal root tear is a complete disruption of the circum-
EXAMINER: What do you mean by hoop stress?
ferential fibres posteriorly. Usually presents with a history of
The development of ‘hoop stress’ within the meniscus snapping knee in deep flexion and can be diagnosed by MRI
depends on intact anterior and posterior attachments. Hoop scan, which usually shows root avulsion and meniscal extru-
stress also relies on the conversion of axial load into tensile sion. Posterior root tear and total meniscectomy have biome-
strain through intact longitudinally oriented collagen fibers. chanical similarities and both can cause significant change in
The compression of the menisci by the tibia and femur contact pressure4.
generates outward forces that push the meniscus out from
between the bones. The circumferential tension in the Tear orientation and appearance (Figure 17.4)
menisci counteracts this radial force. Hoop stress is the stress
Incomplete/complete longitudinal, bucket handle
in a direction perpendicular to the axis of an item. As the
thickness of the item decreases the hoop stress increases. Displaced bucket handle
Horizontal cleavage tear
EXAMINER: What you have described above also relies on the
Oblique or parrot beak
meniscal attachments being intact. Could you please discuss the
Flap, displaced flap and double flap
various attachments of both menisci?
Radial tear
The lateral meniscus which is more circular in its morphology Complex tear is a combination of the above.
covers a wider area of the tibial plateau it lies on in comparison Degenerative tears are usually complex in nature
to the medial meniscus. It is attached to the tibial plateau via
the coronary ligament. The posterior horn is attached to the
Zip tear meniscofemoral ligament tearing through the
medial femoral condyle by two menisco-femoral ligaments. posterior horn of the lateral meniscus
Ligament of Humphry which lies anterior to the PCL and
ligament of Wrisberg which lies posterior to the PCL (see
Examination corner
Figure 17.2). The lateral meniscus, unlike the medial, has no
attachment to its adjacent lateral collateral ligament (LCL) and Basic science oral 1
only has loose peripheral attachments to the joint capsule. The examiner shows a photograph of torn meniscus and asks:
020
meniscal repairs who are undergoing an anterior cruciate

ligament reconstruction compared to 50% in meniscal repair
alone8. This is speculated to be due to the local growth and
clotting factors including stem cells and platelet-derived
growth factors that are released during injury and from the
femoral and tibial bone drilling5. Generally only 30% of tears
in patients younger than 20 years old are repairable8. Tears in
the peripheral third have the highest potential for healing due
to the presence of the blood supply.
Consider the following:
Patient’s age: Better results when patients are below
30 years of age
Activity level and occupation
Figure 17.4 Different types of common meniscal tears Chronicity: Better results if carried out <8 weeks
Blood supply, location, quality of meniscal tissue, type
and length of tear (this is a primary determinant of
healing)
Tell us about different types of tears that can occur in the meniscus?
(See Figure 17.4) Associated ligamentous injury
Which one would you repair? Leg axial alignment
There are various factors that I would consider before decid- Relative contraindications to repair
ing whether to repair a meniscal tear. There are patient
factors as well as local factors. Patient factors include young
Stable tear (partial-thickness tear)
ages as patients under 30 do better than older the 30. Peripheral tear <10 mm long that cannot be displaced
I would also want to know the level of activity of the patient Complex, degenerative and central/radial tears are best
including their occupation; this is in order to counsel the excised partially
patient appropriately. Some tears are more amenable to
repair than others and this depends on the time since the Types of meniscal repair
tear – Early repair is better than late; the type of tear – Red Inside-out technique with vertical mattress suture is still
on red as opposed to red on white or white on white; and the gold-standard technique
whether or not there is a concurrent ligamentous injury –
Outside-in: Versatile access, less expensive instruments
Ligament injuries need to be addressed to ensure stability
and safe
and restoration of normal load onto the meniscus.
There is also studies showing that meniscal tears are more All-inside: Becoming very popular with the developments
favourable when performed with an ACL reconstruction due of new devices and reports of >80% success rate.
to the presence of platelet-derived growth factors (PGDF)5. They allow the sutures to be tensioned once inserted
Open repair. Rarely performed
How does an ACL rupture affects the medial meniscus?
An ACL rupture usually leads to abnormal strain exerted onto Vertical mattress sutures are more reliable than horizontal
the menisci upon weight-bearing and throughout the range of mattress, as they are perpendicular to the circumferential fibres
motion of the knee. This strain particularly affects the posterior and have a less chance of cutting out.
horn of the medial meniscus . 40% of tears in ACL injuries are To optimize healing one could use:
of the peripheral posterior horn of the medial meniscus6. Fibrin clot
Around 50% of ACL injuries have a concurrent meniscal
Rasps and shavers are used to freshen both sides
injury or articular cartilage. Repeated episodes of instability
of the tear prior to repair (most common in regular
secondary to an ACL injury predisposes to meniscal tears. In
chronic ACL instability, up to 90% of patients will have menis-
practice)
cal injury after 10 or more years. Similarly, the prevalence of Trephination of the meniscus with a spinal needle
articular cartilage lesions can be as high as 70% in ACL- Vascularized synovial flaps
deficient patients after 10 years. Studies of meniscectomy Autologous blood clot
confirm the importance of meniscal function and subsequent Parameniscal synovial abrasion
loss as a risk factor for the development of knee osteoarthritis7.
Endothelial cell growth factor
Fibrin sealants
Meniscal repair Notch (non-articulating) microfracture to produce bleeding
These biological factors are an important part of the
The majority of repairable menisci are associated with ACL
surgical intervention
rupture. It is reported that there is a 93% healing rate in
295
020
Complications This is a landmark paper, which was one of the first to report the
9
Excluding failure to heal which is usually quoted at 15–20% deleterious effect of meniscal excision. At the time it was a
and re-tearing, neurovascular injury is the commonest common belief among surgeons that the meniscus could be totally
excised without long-term harm to the patient. In fact some
Medially: Injury to the saphenous nerve and its surgeons predicted that degenerative arthritis and disability
infrapatellar branch 1–2.5% were inevitable if a torn meniscus was not completely removed.
Laterally: Popliteal artery and peroneal nerve injury 1% This article stimulated many subsequent basic science and
clinical studies that determined the many important functions
Meniscal allograft transplantation of the menisci and the natural history of the post meniscectomy
knee
This is still regarded as an experimental procedure. It is carried
out to prevent joint deterioration following total meniscect-
omy and to help improve knee stability in patients with liga-
mentous instability. It is more commonly performed on the Classic reference
young and on the lateral meniscus due to its biomechanical
Johnson RJ, Kettelkamp DB, Clark W, Leaverton P. Factors effecting late
importance. results after meniscectomy J Bone Joint Surg Am. 1974;56:719–29.
Indications Total meniscectomy is associated with instability and rapid severe
articular degeneration.
Consider: The long-term outcomes after meniscectomy are unsatisfactory for the
Patient’s age (best results in those <20 years old) majority of patients according to a range of measures including activity
Symptoms (in the future may be done prophylactically) and pain ratings, knee joint instability, knee joint structure and knee
biomechanics during level walking.
Knee stability, ACL competency and alignment The findings of this study concur with Tapper et al. and reports on the
Compartment wear (Outerbridge I and II better outcome). consequences of meniscectomy. The authors used stringent criteria in
Diffuse grade III or the presence of grade IV lesions, their clinical assessment and compared the two legs using the
with joint space narrowing, are considered relative unaffected side as a control. This work reinforced the importance of
the meniscus in keeping the knee healthy and strongly recommended
contraindications
that the meniscus should be removed only when it is definitely
abnormal.
Graft
Fresh-frozen
Freeze-dried grafts
Collagen or synthetic grafts Examination corner
The meniscus is immunologically privileged owing to dense
matrix isolating the cells. These grafts need to be appropriately What is the composition and structure of the menisci?
sized to match the patients’ native meniscus as much as Describe collagen fibres arrangement.
possible. What is the role of menisci in load distribution?
When do you consider repairing a meniscal tear?
Technique How does meniscal root tear affect joint contact
pressure?
Open
Arthroscopically assisted The meniscal root has a major role in the properties of the
meniscus within the knee. A meniscal root tear completely
Classic reference disrupts the circumferential fibres of the meniscus leading to
extrusion of the meniscus. This behaves in a similar manner in
Fairbank TJ. Knee joint changes after meniscectomy J Bone Joint Surg regards to the load patterns on the knee to a complete menis-
Br. 1948;30:664–70. cetomy. This is more pertinent in a posterior root tear. Total
This was the first detailed article to characterize the radiographic meniscectomies increase the peak contact stresses in the knee
changes in the knee post meniscectomy. Fairbank also offered an by 235%, reduce the joint’s shock absorbing capacity and its
explanation for the changes to the articular surface. He deduced that load sharing ability.
the changes in the articular surface are caused by overload due to loss
of the meniscal tissue. He was the first to suggest that the meniscus
may have a load bearing function.
Meniscal cyst
Aetiology
Classic reference Cause unknown
Myxoid degeneration of stressed fibrocartilage
Tapper EM, Hoover NW. Late results after meniscectomy J Bone Joint
Probably traumatic in origin
Surg Am. 1969;51:517–26
020
Meniscal tear may create a one-way valve allowing for cysts Aetiology
to form 1. Possibly failure of resorption of the central portion of the
meniscus during development
Pathology 2. Secondary to instability of the meniscus during
Contain gelatinous fluid, surrounded by thick fibrous development, subsequent to failure of attachment of the
tissue meniscotibial (coronary) ligament to the posterior horn
Nearly always associated with a small, horizontal cleavage (type III)
tear in the meniscus
Isolated cysts without meniscal pathology have been Classification (Watanabe 1974)
reported Type I – Complete
More likely to occur laterally The meniscus covers the whole tibial plateau, causing
inadequate visualisation on arthroscopy
Clinical features
Insidious onset of discomfort Type II – Incomplete
Point tender cyst on palpation The central portion extends further across the tibial plateau
Symptoms are intermittent or related to activity than normal
Lump is situated at or slightly below the joint line
Usually anterior to collateral ligament Type III – Wrisberg variant
Seen most easily with the knee slightly flexed (<45°) Involves deficiency of attachment to the posterior horn
Lateral cysts are firm, medial cysts are usually larger and meniscotibial ligaments, so the posterior horn is only
softer secured by the meniscofemoral ligaments
Pisani’s sign (cyst size decreases with knee flexion)
Clinical features
Differential diagnosis The discoid lateral meniscus is usually asymptomatic. Snap-
Ganglia: Superficial, not as hard and unconnected to ping knee syndrome (popping knee syndrome) in children
the joint <10 years old is usually associated with type III. The knee
Calcified deposits in the collateral ligament: Show on snaps spontaneously, causing momentary pain and apprehen-
radiographs sion. A characteristic clunk may be felt at 110° as the knee is
Prolapsed torn meniscus (pseudocyst) bent, or at 10° as the knee is straightened.
Sebaceous cyst A McMurray test may cause an obvious pop (referred to as
popping knee syndrome), with temporary subluxation of the
Bursitis
posterior horn and occasional locking.
Various tumours: Sarcoma, lipoma, fibroma and
In older children, the discoid meniscus usually presents
histiocytoma
with the symptoms of a meniscal tear. Types I and II com-
PVNS monly have longitudinal or horizontal tears. Type III usually
have no tears, but may exhibit degenerative changes. All types
Management may have radial, bucket-handle or complex tears.
Depends on symptoms, size, location and relation to
meniscal tear Typical radiographic findings
If contiguous with the meniscal tear the meniscus is Widened joint space
debrided and the cyst is decompressed arthroscopically or Squaring of the condyle
with needle aspiration Ridging
If the cyst is distinct or very large, an open excision is more Cupping of the lateral tibial plateau
successful
Hypoplastic lateral intercondylar spine
Congenital discoid menisci MRI appearance

Abnormal development of the meniscus can lead to a hyper- Visualisation of the meniscus across the entire
trophic and discoid shaped meniscus. In children, most menis- compartment in three consecutive cuts (usually in the
cal tears are caused by congenitally discoid menisci. The lateral compartment)
incidence of discoid meniscus is 5% in Anglo-Americans, but
can go up to 20% in Asians. It is most commonly lateral (rarely Management
medial: Incidence of 4–15% vs 0.06–0.03%) and 25% of If asymptomatic or there is only a clunk (not associated
patients have bilateral discoid menisci. with a tear) leave it alone
297
020
Figure 17.5 Less Medial:lateral condyle ratio is 80 : 20 – Most common on the

common discoid medial
meniscus revealing the
non-weight-bearing lateral aspect of the medial femoral
classic radiological condyle. When found on the lateral femoral condyle it is
features more commonly located on the central portion of the condyle
Patella lesion in 10%
Aetiology
Aetiology is unknown. It may be:
Traumatic: lesion is thought to be due to macrotrauma or
repeated microtrauma
Vascular: possibly AVN (adult form more associated with
vascular cause)
Hereditary/congenital: abnormal epiphyseal ossification
The condition tends to occur in children during increased
physeal activity
Clinical presentation
Non-specific, poorly localized pain
Activity-related pain
Stiffness
Swelling
Mechanical symptoms with locking
Antalgic gait
Effusion in unstable lesion
Localized tenderness
Wilson’s sign (induction of pain as the knee is passively
extended while the tibia is held in internal rotation: Tibial
Symptomatic patients with a type I or II discoid spine contacts OCD on the lateral aspect of the medial
meniscus may be treated with arthroscopic debridement
femoral condyle at 30° of flexion). Not very sensitive nor
and contouring of the central portion, leaving a rim of
specific to osteochondritis dessicans
6–8 mm (saucerisation). Peripheral tears in the
vascularized zone should be repaired. Often the
remaining rim is degenerate and may necessitate total Pappas classification (according to age at detection)
meniscectomy Category I: Below age 12 (excellent prognosis)
Type III menisci, traditionally treated with total Category II: Between 12 and 20 years
meniscectomy, are now usually managed with meniscal Category III: Above 20 years
repair and reattachment of the posterior horn to the tibial
plateau Prognosis
Further surgery is often required for recurrent tears Healing potential is high in juvenile (75%)
OA is common following meniscectomy Adolescent prognosis is unpredictable (50% heal)
There is no increase in the risk of OA in asymptomatic Healing is markedly reduced in those with a mature
patients skeleton with possible premature OA especially if left
untreated. It is usually symptomatic in adults
Osteochondritis dissecans (OCD) Other than age, location of the lesion such as the lateral
Definition femoral condyle or the patella have poorer prognosis.
Similarly, the appearance of synovial fluid behind the
A lesion of subchondral bone that results in subchondral lesion on MRI correlates to a worse prognosis
delamination and sequestration with or without articular 10
A systematic review by Harris JD et al. to determine
mantle involvement (Stanitski)
which surgical technique has improved outcomes and
Subgroups: Juvenile, adolescent and adult types enabled athletes to return to their preinjury level of sports
Peaks in preteen years revealed there is little high-level evidence to support one
Male : Female ratio is 5 : 3 form of treatment over another. However, cartilage repair
Bilateral 20% and restoration appeared to fair better when compared to
020
microfracture when measured against speed of return to

I would look at T2-weighted MRI sequences in order to highlight
sport. The overall rate of return to pre-injury level of sports evidence of linear high-intensity signals between the lesion and parent
was 66% bone which would indicate the degree of stability of the lesion. If the
articular cartilage over the osteochondritis dissecans fragment is intact
Diagnostic imaging then no high signal (fluid) will be observed posterior to the fragment.
However, if the fragment is separated from the underlying subchon-
Preferred radiographic view is the tunnel view. The lateral
dral bone or the cartilage is fractured, then the synovial fluid would
radiograph typically demonstrates that the affected track around the perimeter of the fragment and indicate instability.
segment of the medial femoral condyle is contained within Management is controversial as per the last recommendations from
a region defined by the intersection of the Blumensaat line the ROCK group (Research on OsteoChondritis of the Knee)11. Gener-
and the continuation of the line along the posterior femoral ally treatment is determined on the age of the patient and the charac-
cortex (referred to as Harding area) teristics of the OCD in terms of its stability. In this case the T1- and T2-
MRI helps in staging the lesion weighted sagittal MRI scans reveal a large articular defect on the lateral
femoral condyle, I cannot visualize the fragment that is apparent on
the lateral x-ray. Given the patient is 11 years old and this is an acute
Examination corner injury I would attempt to fix this loose fragment as it appears to be
fairly large. I would perform this with a headless screw. If the fragment
is completely detached and well rounded (chronic) then I would
• An 11-year-old football player complains of ongoing vague left
remove it and perform microfracture to the bed. I would consent the
knee pain associated with activity. She denies any swelling, locking,
patient for all options and take an intraoperative decision depending
clicking or giving way. She sustained a further acute mild injury
on my findings.
while playing football that exacerbated her pain and brought her to
the ED. On examination, you find anterolateral focal tenderness, • What are the other options of fixation in an unstable OCD?
mild effusion but no signs of instability. This is her x-ray (Figure 17.6),
what do you see? There are other fixation devices such as absorbable headless pins
or darts, bone grafting, fixation with autograft osteochondral
This is a horizontal beam lateral knee radiograph of a skeletally imma- plugs, and salvage procedures such as autologous or matrix-induced
ture patient revealing a effusion, more specifically a lipohaemarthrosis chondrocyte implantation (ACI or MACI) and fresh osteochondral
with a bone fleck present just distal to the articular surface of the allografts.
condyle. I am unable to determine whether this is from the more
common medial condyle or lateral as per the patients focal tenderness. • You mentioned age as a risk factor. Please explain.
I would need an AP radiograph in the first instance to help me Patients younger than 12 years of age have an excellent prognosis as
establish that this is indeed a bone fragment and also where it is per the Pappa’s classification. There is a high healing potential in the
coming from. juvenile with an open physis. Healing becomes less predictable in the
• What other investigation would you like to perform to obtain more adolescent age of 12–20 and markedly reduced beyond skeletal
information? maturity. Many OCD lesions in the juveniles heal spontaneously with
activity modification11.
An MRI scan
• Here it is (Figure 17.7). Explain what you are looking for on an MRI
scan in this condition in general, and then tell me how would you
proceed in treating this child?
Figure 17.7 Sagittal knee MRI scan in T1 and T2 revealing and effusion with
Figure 17.6 Lateral knee radiograph with OCD an OCD of the lateral femoral condyle
299
020
extracted from the matrix and are cultured. At 6 weeks

Guhl arthroscopic classification the chondrocytes are reimplanted in the defect. The
Intact lesion 1–3 cm (in situ, soft area covered by intact main difference between the two procedures is that with
cartilage) ACI the cells are injected under a prepared periosteal
Early separation (stable flap) patch over the defect while in MACI the cells are
Partially detached (flap attached by hinge) embedded with a matrix or scafold. MACI evolved out
Complete detachment (full-thickness loss within bed or of ACI and is not available in countries such as the USA
displaced) yet
Stage the lesion by radiographs, MRI and arthroscopy.
Articular cartilage injury
Management This is a separate entity from OCD. It is usually related to
rotational force and direct trauma
In young patients (open physis, category I, juvenile OCD),
Which also includes asymptomatic lesions in adults ! It is located in weight-bearing areas such as the medial
activity modification with restricted weight-bearing. femoral condyle
50–75% will heal without fragmentation Aritcular cartilage decreases the friction within the joint
by fluid film formation, the presence of synovial fluid and
OCD in young adults is usually symptomatic and almost
invariably leads to early-onset OA if large enough, unless the fact that is has elastic deformation properties. It also
treated distributes the load within the knee
In situ lesions ! retrograde or anterograde drilling (where It is avascular, aneural and has no lymph drainage
indicated) Articular cartilage injury is classified as linear, satellite,
Early separation stage ! secure with headless screws, flap, crater, fibrillation and degenerate lesions
cannulated screws, bone pegs or equivalent. 85% healing Any injury above the tidemark has a poor potential for
rate in juvenile OCD. Metal work removal might be healing due to the avascularity of this region
necessary (ensure head of device is buried within cartilage) Any injury extending below the tidemark that penetrates
Incompletely detached ! remove underlying fibrous the subchondral bone has a better potential for healing as it
tissue, perform some form of chondroplasty and then fix causes an inflammatory response and may heal with
the flap as above fibrocartilage
Completely detached ! removal of the loose body (often Not all defects are symptomatic
too damaged to replace) possibly followed by: Articular cartilage defects have no pathognomonic
symptoms or signs and they frequently coexist
: Abrasion chondroplasty (microfracture): This usually
with meniscal tears, patellofemoral dysfunction and
leads to formation of fibrocartilagenous tissue covering
early OA
the defect. There has been improved outcomes in
Femoral condyle lesions cause pain at or close to the
skeletally immature patients
joint line aggravated by running and descending stairs
: Osteochondral graft in the form of allograft plugs or
autografts (OATS): This can be done either
arthroscopically (lesions under 30 mm) or via an Table 17.2 Classification of chondral lesions according to the ICRS system
arthrotomy (lesions larger than 30 mm)
Normal Grade 0
: Autologous chondrocyte implantation (ACI) or
matrix-induced chondrocyte implantation (MACI): Almost normal Grade 1a – Superficial lesions/softening
Grade 1b – As 1a and/or superficial fissures
This involves a two stage procedure, starting with
and cracks
articular cartilage harvest. This harvested cartilage is
sent to a laboratory, where the chondrocytes are Abnormal Grade 2 – Extent < 0% of thickness
Severe lesion Grade 3a – Extent >50% of thickness
Grade 3b – Down to the calcified layer
Table 17.1 Outerbridge arthroscopic grading system Grade 3c – Down to subchondral bone
(without penetrating)
Grade 0 Normal cartilage Grade 3d – Includes bulging of the cartilage
Grade I Softening and swelling around the lesion
Grade II Partial thickness defect, fissures 1.5 cm diameter Very severe lesion Grade 4a – Penetration of subchondral
bone but not across the entire diameter of
Grade III Fissures down to subchondral bone, diameter
the defect
> 1.5 cm
Grade 4b – Penetration across the full
Grade IV Exposed subchondral bone diameter of the defect
020
Surgical treatment The principle is transplanting living viable cells that are
Multiple complementary procedures are available and capable of synthesizing and maintaining a cartilaginous
still evolving implant. The end result is similar to hyaline cartilage.
The biomechanical environment needs to be corrected This procedure can only be performed on a stable joint
with no mal-alignment.
Autologous matrix induced chondrogenesis (AMIC)
Treatment options :
A one-step procedure combining microfracture with
Debridement: Removing loose flaps only the application of a collagen I/III membrane to protect
Microfracture: Usually the first line of treatment for the without initial blood clot in order to serve as a
full-thickness or near full-thickness articular cartilage scaffold for the developing chondrocytes. This clot is
injuries that measure 2 cm or less. It involves the often descriped as a super clot that is rich in the
creation of multiple subchondral perforations in the essential factors (e.g. progenitor cells, mesenchymal
cartilage deficient areas to allow (in theory) sustained stem cells (MSCs), cytokines and growth factors)
reparative response and allow healing with necessary to form new cartilage
fibrocartilage from the mesenchymal stem cells (MSCs) : Described indications are symptomatic full-thickness
that are sourced from the subchondral bone/blood chondral/subchondral defects in the major joints, post-
vessels traumatic or osteochondrosis dissecans, located in
Mainly type 1 cartilage – Low stiffness and poor wear weight-bearing areas
characteristics over time : This procedure should not be performed on kissing
Technique: Obtain vertical borders, remove calcific lesions, inflammatory disease, associated fracture, or on
bone bed and make multiple holes 3–4 mm apart generalized OA
with chondral pick. The defect and site of microfracture Autologous osteochondral transfer
are not covered. This procedure was popularised by :
Also called mosaicplasty or osteochondral autograft
Steadman transfer (OAT)
This should not be performed in uncontained defects and : Involves transferring osteochondral plugs from
in the presence of axial mal-alignment. relatively non-load bearing site to weight-bearing defect
sites in the knee. Most common harvest sites include
Poor outcomes the superior trochlear ridge and the intercondylar notch
Obesity area in the knee. The plug site should also have
Smoking relatively thick hyaline cartilage, and easily accessible in
Inflammatory conditions an open or arthroscopic technique
Mal-alignment : Usually for small lesions <2 cm2
Ligamentous laxity : Plugs should be cylindrical, at least 8 mm long and
Rehabilitation: NWB/Toe-touch weight-bearing for 6–8 4–12 mm diameter
weeks with full passive ROM (unless PF joint : The procedure is technique-sensitive and operator-
microfracture). No sports for 6 months dependent
Better outcomes in patients under 40 years of age : Requires mini-open approach
Best results are in the femoral condylar lesions : Donor site morbidity remains an issue
Recently microfracture has been supplemented with Osteochondral allograft
barrier implantation to minimize leakage of the : Transplanting fresh osteochondral allograft containing
marrow elements living chondrocyte into the defect
Autologous chondrocyte implantation (ACI) continues to : There is no size limitation
be under evaluation and has promising early results13. : Used in post-traumatic reconstruction, OCD and
There is no size limitation and it produces hyaline-like osteonecrosis
cartilage : Disease transmission is a potential hazard
High cost : Problems with graft availably and high cost
Requires two procedures: Arthroscopic biopsy and
open implantation
Synthetic osteochondral grafts (e.g. biomatrix, trufit plug)
Recently collagen membranes have been used instead of
periosteum Remains controversial
Matrix induced autologous chondrocyte implantation No long-term studies with good clinical outcomes
(MACI) Less morbidity to the patient
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020
Some older types negatively affected adjacent healthy • Draw a cross-section of articular cartilage? (Mention
articular cartilage arcades of Benninghoff) (Figure 17.8)
Focal resurfacing implants (HemiCAP)
The three-dimensional structure of articular cartilage shows
: Indicated in middle-aged patients with symptomatic arcades of collagen that give rise to the appearance of the
weight-bearing full-thickness defects fibres in the three zones described above (tangential/horizon-
: Flushed implants do not increase peak contact tal; transitional/oblique; radial/perpendicular) all in relation to
pressure.14 Variable results reported the joint surface and the tidemark.
• Where does the nutrition of the cartilage come from?
Examination corner Nutrition of the articular cartilage comes from the synovial
fluid that it bathes in. As the joint is loaded, the flux of water
Basic science oral 1 in and out of the cartilage allows the nutrients to diffuse
You are likely to be asked by the examiner to draw the structure through its matrix. This is supported by the viscoelastic prop-
of articular cartilage and explain its function as you go along erties of cartilage.
(Figure 17.8).
• Talk me through what happens if you injure the articular
• What is the function of articular cartilage? cartilage with a scalpel while performing the arthro-
scopic portals?
Its primary function is to provide a very low friction surface to
allow smooth articulation of the joint. The coefficient of friction This type of acute trauma to articular cartilage is classified as
of articular cartilage is as low as 0.002. The biomedical industry either superficial or deep laceration, and this is in relation to
has not been able to replicate this property to improve arthro- whether the laceration is deep enough to cross the tidemark
plasty function. It also serves as a shock absorber. or not. If it is a superficial laceration, no adequate cellular
response takes place macroscopically and, therefore, no cartil-
• What are its main components?
age repair occurs. This is due to the fact that the chondrocytes
Water (65–80% wet weight), collagen (10–20% wet weight, die and given that the cartilage is avascular no migration of
>50% dry weight), proteoglycans (10–15% wet weight) and chondrocytes occur and the defect remains. On the other hand
chondrocytes (5% wet weight). if the laceration is deep and crosses the tidemark it penetrates
the subchondral surface leading to fibrin clot formation and an
• What is the primary collagen type found in articular
inflammatory process which includes the release of growth
cartilage?
factors and fibroblasts. This allows for fibrocartilage scar
The collagen gives the articular cartilage its tensile stiffness. Type II formation which is unorganized and has poor loadbearing
constitutes 90% of the collagen present. Other types present properties. This is the theory behind abrasion chondroplasty.
include VI, XI and X (type X being only found in the calcified zone).
• Describe zones of articular cartilage (you may use a
diagram). Spontaneous osteonecrosis of the knee (SONK)
Articular cartilage is divided into four zones: 1. Superficial(tan- Osteonecrosis of the knee with no identified cause
gential): 10–20% thickness 2. Middle(transitional): 40–60% More common among females who are middle-aged or
thickness 3. Deep(radial): 30% thickness then we have the elderly
Tidemark followed by 4. zone of calcified cartilage.
• How do each zone differ in regards to their structure Arcades of benninghoff
and content?
- The superficial zone has relatively low proteoglycan content
Superficial zone
and contains no cells. It is, however, rich in collagen which is Horizontal fibres
arranged in parallel to the joint surface and allows good
resistance to shear forces. As the water concentration is
high, it is squeezed out to provide lubrication. Oblique fibres
Middle zone
- In the middle zone, the collagen fibres increase in their
diameter and become less organized and more oblique in
their arrangement. The middle zone has a high concentra-
tion of proteoglycans Radial fibres
- Collagen fibres in the deep zone are perpendicular to the Deep zone
tidemark. The highest concentration of proteoglycans are
found in the deep zone. This is consistent with its main ne
function which is to resist axial compression. Calcified zo
- Hydroxyapatite composes most of the calcified zone. This
allows the cartilage to anchor itself into subchondral bone. Figure 17.8 Schematic diagram of the cross-section of articular cartilage
showing the Archades of Benninghoff
020
Most commonly found in the distal aspect of the medial :

Targeted physiotherapy focusing in range of motion
femoral condyle, and is almost always involving one joint and quadriceps strengthening
Associated with meniscal root tear Operative: Only considered after an extensive attempt of all
May represent a subchondral insufficiency/stress fracture non-operative measures as success is variable
: Retrograde drilling
Clinical presentation : Arthroplasty (in larger lesions and bone collapse)
Sudden onset of severe knee pain (usually non-specific). : High tibial osteotomy (if mal-alignment present, a trial
Can be focused over the medial femoral condyle with an off-loader brace is recommended
Decreased range of motion with no mechanical block preoperatively)
Effusion present in the acute stages
Pain worse on activity Anterior cruciate ligament (ACL) injury
Diagnostic imaging Anatomy
ACL is a primary resister to internal rotation of the tibia at
Weight-bearing AP and lateral x-ray of knee (include hip <35° of flexion while the anterolateral ligament is a stabiliser
and ankle if indicated) of internal rotation >35° of flexion.
MRI can confirm the diagnosis and delineate the extent of
Intra-articular ligament
the lesion
Originates just anterior to and between the tibial
Extensive bone marrow oedema seen on T2 images
intercondylar eminences
(Figure 17.9)
The ACL femoral attachment lies posteroinferior to the
Differential diagnosis include: OCD, transient
lateral intercondylar ridge (‘resident’s ridge’) which runs at
osteoporosis, occult fracture
approximately a 30–35° angle with respect to the long axis
of the femoral on the posteromedial aspect of the lateral
Treatment femoral condyle
Non-operative: Most are treated successful in this manner It is 33 mm long and 11 mm in diameter
: Activity modification The names of the two bundles of the ACL describe their
: Rest and nonepartial weight-bearing tibial origins: The anteromedial bundle tightens in flexion
: Analgesia including NSAIDs (an anterior restraint); the posterolateral bundle tightens in
extension (a rotary restraint)
Supplied by the middle geniculate artery
90% type I and 10% type III collagen
Prevents anterior translation and primary resister to
internal rotation of the tibia at flexion angle <35° while the
antrolateral ligament is a stabiliser of internal rotation in
>35° of flexion15
Has a proprioceptive role with the presence of
mechanoreceptors within the ligament. ACL innervation
come from the posterior articular nerve which is a branch
off the tibial nerve
Tensile strength of the native ACL is 2200 Newtons
Clinical features
Mechanism of injury
:
low velocity, deceleration and pivotal injury, usually
non-contact
: valgus external rotation or hyperextension force in
contact injury
: high-energy RTA
Audible or feeling of ‘popping’
Acute haemarthrosis in young within 1–2 hours; less
dramatic in older patients
Figure 17.9 Spontaneous osteonecrosis of the medial femoral condyle
revealing extensive bone marrow oedema within the condyle Inability to continue playing sport
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020
Females more susceptible than males 4 : 1 Noyes also tested for the tensile strength and stiffness of patella,
20% of ACL injury is associated with MCL injury semitendinosus, gracilus and quadriceps tendon as well as fascia lata
Meniscal damage occurs in 15–40% of acute ACL tears and and iliotibial band grafts. A 14 mm bone patella tendon graft measured
becomes much more common with chronic ACL 168% of the tensile strength and almost 4 times the stiffness of a
normal ACL. The semitendinosus and gracilis tendons were measured
deficiency16 individually and were found to have 70% and 40% of the normal ACL
There is an 80% incidence of lateral meniscal injury with strength. The patella graft was the only construct found to be stronger
combined ACL–MCL injury than the native ACL. These values represent the graft strength at
In chronic ACL deficiency, medial meniscal injury is more implementation and do not account for the in vivo incorporation
process.
common The choice of harvesting site for grafts used in ACL reconstruction
Osteochondral lesions (bone bruising) are present in 80% influences both the strength and stiffness of a graft. Bone-patellar
of ACL ruptures.17 This includes damage to the articular tendon-bone grafts provide the greatest strength and stiffness
cartilage from the crush effect of the tibial plateau and the compared to other sites. However, surgeons must consider that a
femoral condyles range of factors will influence appropriate graft choice. Thigh
stiffness could lead to limitations in a patient’s ability to extend
Chronic ACL deficiency causes posterior femoral the knee.
subluxation and posterior tibiofemoral contact, leading Performing biomechanical testing on various ACL grafts and
to erosion of the posteromedial tibial plateau and understanding graft strength and stiffness was an essential step
subsequent fixed varus deformity. However, intact ACL in developing ACL surgical techniques and rehabilitation
protocols. The results of this work are still quoted in the literature.
has been associated with anteromedial arthritis
The study, however, did not include quadrupled semitendinosus
pattern and correctable varus deformity (see also section tendon.
on UKA)
Classic reference
Examination corner
Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KR.
Fate of the ACL-injured patient: A prospective outcome study Am
J Sports Med. 1994;22:632–644
• Are ACL injuries more common in female or male
athletes?
Daniel et al. showed that ACL reconstruction does not always yield
improved outcomes compared to the natural history and pointed out ACL rupture are most common in female athletes in compari-
that patients who were able to ‘cope’ with ACL deficiency may have son to male athletes playing the same support. It is increased
better outcomes is some respects than do patients who have by a ratio of 4–5 : 1 in comparison with male athletes.
reconstruction. • Why is that? What is the suggested explanation?
In ACL injured patients, sports participation reduced following
rehabilitation both with surgical reconstruction and conservative This is multifactorial, and includes intrinsic factors such as
treatment. increased valgus mal-alignment, a smaller intercondylar notch,
Joint arthrosis was more severe in patients undergoing surgical reduced ligament diameter. There has been theories in regards
intervention. Pre-injury volume of sport participation, age, and amount to the hormone levels and many studies have looked into the
of joint displacement measured by the KT-1000 arthrometer correlated relationship between menstruation and ACL rupture with no
with the need for late surgery.
conclusive evidence. Landing biomechanics where females
This was one of the first papers that prospectively documented
more commonly land with more extension and valgus plays
the outcome of conservative treatment in ACL injured patients and
the factors that correlate with a greater risk of functional impairment a large part in the increased rate of rupture. Neuromuscular
and joint arthrosis. Daniel described a population of individuals conditioning has been shown to reduce this rate18.
who coped satisfactory with ACL deficiency over an extended period
of time.
Examination corner
Classic reference How do you do the Lachman’s test?

• Check PCL sag and medial tibial step-off before the test
Noyes FR, Butler DL, Grood ES, Zernicke RF, Hefzy MS. Biomechanical
• Maintain the knee in neutral rotation during the test.
analysis of human ligament grafts used in knee-ligament repairs and
• The most sensitive test for detection of an ACL tear. Knee is
reconstructions J Bone Joint Surg Am. 1984;66:344–52.
placed in 20–30° of flexion. The femur is stabilised with the
This is a landmark article published by Noyes et al. on the structural non-dominant hand. An anteriorly placed forced is applied
and mechanical properties of both native ACL and the various tendon to the proximal tibia with the dominant hand. The amount
grafts used in reconstruction. The authors found that the ACL had a
of transaltion of the tibia on the femur, and the firmness of
mean ultimate tensile strength of 1725 N and a stiffness of 182 N/mm.
the ‘endpoint’ should be compared to the contralateral knee
020
How do you do the pivot shift for a non-functioning ACL?

Lateral x-ray of the knee may reveal and haemarthrosis or
• Place a valgus stress, axial load and internal rotation on the lipo-haemarthrosis. It may also reveal tibial subluxation on
tibia as the knee is slowly flexed. In full extension, gravity the femur
pulls the femur posteriorly, resulting in anterior subluxation Sagittal MRI (T2) of the knee usually demonstrates
of the tibia. With further flexion, posterior pull by the ilioti- disruption of the oblique ACL fibres, and bone bruising
bial tract reduces the tibia at about 20–30° (shift). (bone marrow oedema with increased signal) of the middle
• Partial ACL tear and lax MCL lead to positive Lachman’s and third of the lateral femoral condyle and posterior third of
negative pivot. Complete tear leads to positive Lachman’s the lateral tibial plateau (Figure 17.11)17
and pivot. The knee cannot be pivoted if there is complete
Coronal MRI (T2) images show an empty lateral wall of the
disruption of the iliotibial tract or MCL giving a false nega-
intercondylar notch
tive pivot shift test (see pivot shift analysis in Chapter 9).
Outcome of injury
McDaniel – Rule of thirds
Differential diagnosis of acute haemarthrosis Patients with ACL-deficient knee
ACL rupture One-third are able to compensate and can pursue normal
Intra-articular fracture recreational sports
Patella dislocation One-third are able to compensate but will have to reduce
Capsular tear their sporting activities
Peripheral meniscal tear One-third do poorly and develop instability with simple
Beware of patient on warfarin with haemarthrosis activities of daily living
secondary to minor trauma However, a few are able to compensate and pursue normal
recreational sports and most patients try to keep their
Imaging activities within ‘the envelope of stability’ to avoid
AP x-ray of the knee may reveal a Segond fracture recurrent giveaways21,22
(now thought to possibly be an avulsion of the anterolateral
ligament – ALL) – Pathognomonic for an ACL injury. Management
The ALL passes anterodistally from an attachment
Management should be individualized based on age, activity
proximal and posterior to the lateral femoral epicondyle to
level, laxity, instability, associated injuries and other factors.
the margin of the lateral tibial plateau, approximately
midway between Gerdy's tubercle and the head of the fibula
(Figure 17.10)19
Figure 17.10 A Segond

fracture seen occasionally
on plain AP radiographs
of the knee in ACL
ruptures
Figure 17.11 Sagittal MRI T2-weighted demonstrating the bone bruising in

an ACL injury (ligament rupture not visible on this sequence)
305
020
Non-operative Anterior knee pain 30–50%

Commonly requires restriction or modification of Patellar tendonitis 3–5%
activity level Fracture patella, rare
Extensive physiotherapy to rehabilitate and strengthen the Patella tendon rupture, rare
quadriceps and hamstrings Patella baja (shortening of patellar tendon – Seen
Proprioception training when the remaining tendon after harvest is sutured
ACL brace together)
Associated with high incidence of instability in younger Development of late OA
patients
Potentially may lead to meniscal tear, articular injury and BPTB allograft
subsequent degenerative changes Slower incorporation
Fallen out of favour as advances in surgical technique and Biologically inactive
physical therapy have reduced operative morbidity and Less stability at 6 months
improved outcome Risk of disease transmission
Surgical Essential role in revision surgery
Weaker after having been irradiated and not biologically
1. Primary repair of bony avulsion lesion in young patients
active
2. Primary repair ± augmentation. Obsolete
Radiation affect the structural and mechanical properties of
3. Extra-articular reconstruction (MacIntosh, Ellison) the graft
Involves tenodesis of the iliotibial tract
Pass a mobilized strip made up of the posterior third of Hamstring graft autograft
the iliotibial band to the PLC of the knee through a This graft is usually quadrupled.
tunnel deep to the LCL Advantages:
Reduces or eliminates pivot shift but there is concern
Patient’s own tissue
regarding its effectiveness in addressing anterior
translation Small incision
Large cross-sectional area of tendon
Has been used recently to augment intra-articular
reconstruction especially in patients with severe Relatively easy passage of graft
ligamentous laxity or failed primary surgery Less donor site morbidity
4. Intra-articular reconstruction: This is current best practice Disadvantages:
Arthroscopic ACL reconstruction (open reconstruction Slow tendon-to-bone healing in the tunnel in 8–12 weeks
is now in decline) No bone graft in the tunnels – ‘windshield wiper’ effect
(can occur with the use of suspensory fixation which can
Graft types
lead to tunnel abrasion and expansion when the knee is in
Autografts: bone–patella–tendon–bone (BPTB), hamstring motion)
(semitendonosis and gracillis), quadriceps. Ipsilateral
Deep flexion weakness after surgery
hamstring autografts are the most commonly used graft in
Possibility of injury to saphenous nerve (poor technique)
the UK
Allograft: BPTB, achilles tendon, hamstring, tibialis
anterior Synthetic grafts (LARS/Gore-Tex®/Dacron®)
® ® ®
Synthetic: LARS , Gore-Tex , Dacron or polyester Higher failure rate
Xenograft Expensive
Osteolysis
BPTB autograft Risk of infection
Advantages: Atraumatic effusions
Patient’s own tissue No disease transmission
Easy to harvest No harvest site morbidity
Bone-to-bone healing
Direct rigid fixation Quadriceps graft
Faster biological integration in 6 weeks Thick tendon but short, with good biomechanical properties.
The graft is taken with a patella bone plug. It is associated with
Disadvantages: decreased anterior knee pain. However, graft harvest weakens
Donor site morbidity from graft harvest the quadriceps and can be technically difficult. In most centres,
020
it is rarely used as a primary graft but more commonly used in

bundle reconstruction in relation to anterior and rotational
revision surgery. stability during a mid to long-term follow-up (3–12 years).
However, there were no differences in the subjective find-
Graft fixation ings22. A 2013 Cochrane review concluded that there was
Aperture fixation: Interference screw at the level of the insufficient evidence to determine the efficacy of double-
joint (metal or bioabsorbable). Note that these screws bundle vs single-bundle ACL reconstruction in adults. There
interfere with the 360° circumferential healing of the graft was limited evidence in the 17 trials included, that double-
in the tunnel bundle reconstruction had some superior results in objective
Suspensory fixation measurements of knee stability and increased protection in
preventing re-rupture and further meniscal injury23. Double
Cortical: EndoButton®, tightrope, screw posts, staples bundle reconstruction is technically more demanding, thus,
Cancellous: transfixion pin/cross-pin leading to a higher risk of complication with tunnel placement.
WasherLoc™ (tibia)
• What is the ideal ACL tunnel placement in the femur and
None (Press-fit) the tibia?
Ideal fixation is strong enough to avoid failure, stiff enough to This is controversial and no consensus is present in regards to
restore knee stability by resisting displacement under load, and the gold standard for femoral tunnel placement. Again the
secure enough to avoid slippage of the graft from its initial advocates of the so called anatomic, more anterior, femoral
position. It is preferable for the fixation to be biocompatible, tunnel placement have now reverting back to the posterior
MRI safe and allow for easy revision. placement of femoral tunnels. The femoral tunnel should not
be placed too anterior (as that would limit flexion and exten-
sion) or too posterior (as that would make the knee lax in both
flexion and extension). The projection of the femoral tunnel
Examination corner
can also lead to problems: If the tunnel is too vertical you risk
Adult and pathology 1 oral rotatory instability or even blow out of the posterior femoral
The examiner shows a radiograph of Segond fracture of the cortex. Tibial tunnel placement is less controversial, and should
knee and asks (Figure 17.10): be placed midway between the anterior horn of the lateral
meniscus and anterior aspect of the medial tibial spine. If tibial
• Describe the radiograph
tunnel is placed too anterior there is a risk of notch impinge-
This is an AP radiograph of a knee which appears to be non- ment which leads to a fixed flexion deformity.
weight-bearing. The most obvious abnormality is an avulsion
• Which graft would you use? And why?
fracture from the lateral aspect of the tibial plateau. This
represents a Segond fracture. I would use autologous ipsilateral hamstrings graft using gracilis
and semitendinosus. I would use this as this is the graft that I am
• What does the fracture suggest?
most familiar with harvesting and using. The results are consist-
A Segond fracture is pathognomonic for an ACL injury. It was ent and the graft itself has good tensile strength and has low
previously thought to be an avulsion off the lateral capsule of donor site morbidity. The incision is small and cosmetically
the knee but recent studies have indicated that this is actually acceptable, and the risk of anterior knee pain, patella tendonitis
a rupture of the anterolateral ligament (ALL) from its tibial and patella fracture that you can get with patella tendon (BTB)
insertion19. grafts is avoided. I would not use any of the synthetic grafts until
there are more robust research and data in regards to their long-
• How many bundles does the ACL have? term risks including the possibility of osteolysis which occurred
The ACL is made up of two bundles. Then anteromedial (AM) in previous generations of synthetic grafts.
and the posterolateral (PL) bundles. The name of bundle • How would your management differ with an ipsilateral
describes its femoral origin. MCL sprain?
• When does the anteromedial bundle get tight? With an MCL injury, I would delay the ACL reconstruction to
The anteromedial bundle is tight in flexion. It is primarily an allow the MCL to heal. I would place the patient in a hinge
anterior restraint and is tested using anterior drawer or the brace until that date especially if the patient has signs and
Lachman’s tests. While the posterolateral bundle is tight in symptoms of instability.
extension, and its primary role is a rotary restraint. This bundle • If your MRI revels a PLC injury, what would you recon-
is evaluated with a pivot shift test. struct first the ACL or PLC?
• Is double bundle reconstruction clinically superior to A PLC injury is commonly a missed injury in ACL reconstruction
single bundle? failure. If it is a grade III PLC injury then this will require
A recent prospective randomised controlled trial revealed that reconstruction. This should occur either at the same time as
ACL reconstruction using the transtibial approach, double the ACL reconstruction or performed as a first stage of a two-
bundle reconstruction was significantly better than single stage procedure.
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020
Principles of ACL reconstruction Table 17.3 The effect of tunnel malpostioning on graft strain and knee
range of motion. Malpostioning the femoral tunnel is less forgiving as it lies
Graft: Best to use a biologically active graft closer to the knee center of rotation. The effect of femoral tunnel
malpostioning on graft strain is also dependent on the knee flexion angle at
Tunnels: ‘anatomically’ and isometrically placed tunnels. the time of graft tensioning
Exact tunnel position is controversial with no consensus
yet in the orthopaedic literature or the knee community Femoral tunnel Graft tensioning angle
placement
Fixation: The graft should be adequately tensioned
Rehabilitation should respect fixation choice Tensioning the graft Tensioning the
in extension graft in flexion
Surgical technique Anterior The knee is tight in The knee is lax in
Femoral tunnel placement: the optimum tunnel position in flexion extension
anatomic single bundle ACL reconstruction remains Posterior Lax in flexion Tight in full
controversial: Recent evidence suggests that placing the extension
femoral tunnel through the anatomic centre of the femoral
origin of ACL may further improve the rotatory stability Tibial tunnel Extension Flexion
placement
compared to antromedial bundle femoral tunnel position24
Tibial tunnel: the tibial tunnel aperture should be anterior Anterior Notch impingement Tight knee (graft
to the PCL and within the footprint of the ACL. It is strain)
usually between the medial tibial spine and the anterior Posterior Tight knee (graft Loose knee (lax
horn of the lateral meniscus. The trajectory of the tunnel strain) graft)
should be less the 75°
Care should be taken in calculating the length of the tibial
and femoral tunnels taking into account the length of the Cyclops lesion from the residual tissue anterior to the ACL
graft available as well as the method of graft fixation which blocks extension. Some surgeons prefer tunnelling
Notchplasty is usually unnecessary if the graft is correctly the graft into the native ACL stump at its tibial attachment
placed. Remove osteophytes if present as they may cause Infection
impingement of graft DVT and PE
To tension the graft appropriately, it is common practice to Secondary osteoarthritis
apply 40 N or 10 lb of tension on the graft while it is
secured in 20–30° of flexion Considerations for ACL injuries in the paediatric population
Techniques are intended to avoid violating or minimizing
Complications (Table 17.3) injury to the physis which could lead to growth
Tunnel placement technical errors (please see Figure 17.11 disturbance. This is more relevant in an open physis and
and ACL Examination corner) patients under 14
: Anterior placement of the femoral tunnel limits flexion Reconstruction could be performed in a physeal sparing
manner or transphyseal technique. No significant
: Anterior placement of the tibial tunnel limits extension
difference in growth disturbance has been found in either
Tunnel widening – Secondary to graft motion within the technique25
tunnel (both biological and mechanical factors) and found
Certain considerations need to be taken during
more with non-aperture fixation methods. More than
reconstruction to minimize the risk of physeal injury. This
3 mm of motion interferes with graft incorporation within
includes limiting the tunnel diameter to <8 mm (which
the tunnel
means graft diameter not >8 mm), drill tunnels at a lower
Three types of graft motion speed, avoid oblique tunnels (i.e. more vertical tunnel
1. Bungee cord effect – Longitudinal motion placement need to be considered) and avoid interference
2. Wind-wiper effect – Horizontal motion screw fixation within the tunnels
3. Creep of the graft – This leads to tissue elongation All inside technique using Arthrex Flipcutter is an
Graft rupture from notch impingement alternative way
Graft failure from mal-aligned limb (coronal and sagittal
mal-alignment need to be corrected either prior or during KT 2000 Arthrometer
ACL reconstruction commonly with a high tibial This instrument is used to quantify anteroposterior knee
osteotomy) displacement. It measures AP translation of the tibia in
Flexion contracture and arthrofibrosis relation to the femur
Failure of fixation – Fixation is the weakest link in the early Manual maximum anterior displacement of 30 lb can be used,
20,21
postoperative period Side-to-side difference of >3 mm is significant
020
Examination corner Unlike organ transplantation, allografts aren’t usually at risk

Adult orthopaedics and pathology oral 1 for tissue rejection by the host. This is due to the minimal
Shown sagittal MRI of Ruptured ACL (Figure 17.11) presence of protein antigen in these washed grafts (the bone
ends are completely cleansed of any marrow elements).
• What are the indications for ACL reconstruction? A number of studies have found measurable but not stat-
istically or clinically significant in the longevity of allografts.
The indications for ACL reconstruction are patients that
A study by Noyes et al.26 looked at 4 and 7 year follow-up of
present with symptoms and signs of instability following an
70 allograft patients and found no significant deterioration of
ACL rupture. Reconstruction is more pertinent for the
the allografts over the measured time period.
younger and active patient as that reduces the incidence of
A further disadvantage in allografts is cost which can be
further injury to the knee leading to the possibility of
anything between 1000 and 5000. Given the current economic
early OA. Meniscal and chondral injuries are not uncommon
climate and the state of the NHS this would be difficult to justify.
in an ACL deficient knee. Children with ACL ruptures should
also be strongly considered for reconstruction to avoid
further knee injuries as their compliance to activity limitation
and modification will be poor. High demand middle-ages Tibial eminence fracture
patients who are symptomatic also do warrant reconstruc- These are most commonly seen in skeletally immature children
tion (age is not a contraindication unless osteoarthritis is and adolescents aged 8–14 years. The tibial eminence is the non-
present). articular portion of the tibia between the tibial plateaus and is in
• What are the principles of ACL reconstruction? close proximity to the anterior cruciate ligament insertion. The
The principles are to reconstruct tibial and femoral bone tun- mechanism of injury is similar to ACL injury in adults. This
nels in an anatomic and isometric manner, with the use of a fracture frequently occurs as a result of a fall off a bicycle.
biologically active graft that is adequately tensioned and fixed
to allow early rehabilitation and provide stability. Meyers and McKeever classification (1959)
• Tell me what are the types of grafts and which would Type I: Non-displaced
you use?. Type II: Partially displaced or hinged
Grafts can be autologous, allogenic, synthetic or xeno- Type III: Completely displaced
grafts. Autografts can be: 1. Hamstrings 2. Patella tendon Type IIIA (Zifko) involves the ACL insertion only
(BTB) 3. Quadriceps tendon. Allografts include hamstrings, Type IIIB (Zifko) includes the entire intercondylar
patella tendon, quadriceps tendon as well as Achilles
eminence
tendon. There are various synthetic grafts on the market
which previously failed but new generation grafts have Type IV (Zaricznyj 1977): Comminution of the fracture
shown promising results (they are mostly being used for fragment
extra-articular ligament reconstructions such as MCL, LCL,
MPFL). Xenografts are undergoing clinical trials and have Treatment
potential in the future but are not currently used in clinical
Casting in extension for type I
practice.
I would use a hamstrings autograft from the ipsilateral leg Open reduction and internal fixation
as I am familiar with this procedure. This graft type has good Arthroscopic reduction and fixation
and reliable long-term results. It also involves a relatively small Rarely, ACL reconstruction is necessary (ACL laxity is
incision with low donor site morbidity. It also offers a relatively found in 10% of surgically treated and 20% of non-
easy passage of the graft in the tunnel. surgically treated injuries)
• If a patient asks you about other options of grafts
Type I fractures can almost always be treated by closed means,
and wants more information about allografts, what
would you tell them about their advantages and
whereas types II, III and IV fractures frequently require surgi-
disadvantages? cal intervention. Arthroscopic reduction and fixation has
become popular because of its lower morbidity. The fracture
Allografts have their advantage; no risks, pain, or scars from fragment can be fixed by using screws, bent K-wires or sutures.
the harvest site. Operation time is less as no harvesting is Beware of ACL laxity secondary to stretching in Type I injuries.
involved and patient has less postoperative discomfort with
lower incidence of joint stiffness and quadriceps wasting. They
are also useful in multi-ligament reconstruction when there is a
Examination corner
need for several grafts. Their disadvantages include the risk of
infection from the cadaveric tissue. The dilemma occurs in Trauma oral 1
ascertaining the balance of sterility and radiation vs the alter- The examiner shows a lateral x-ray of a type II fracture of the
ation of the collagen tissue within the graft reducing its tensile tibial eminence in a skeletally immature knee (Figure 17.12 a
strength. and b) and asks:
309
020
(a) (b)
is the more likely a screw fixation would be performed. Screw
fixation is stronger and more reliable. There is debate in
regards to the degree of screw projection (whether to should
remain within the epiphysis or cross into the metaphysis). If it
does cross into the metaphysis then the risk damage to the
physis and possibility of growth disturbance. Screw fixation is
technically less demanding and allows earlier mobilization.
Suture fixation is technically more demanding but does avoid
phsyeal injury. It is important to ensure that the meniscus is
disengaged from the fracture at the time of fixation.
Posterior cruciate ligament (PCL) injury

Anatomy
This is the strongest ligament in the knee
It is regarded as ‘a central stabiliser’. It is the primary
restraint to posterior tibial translation
Figure 17.12 (a, b) AP and lateral knee radiograph revealing a tibial
eminence injury Posteromedial bundle (PM): tight in extension
Antrolateral (AL): long and thick part, twice the size of PM
bundle tightens in flexion
• Describe what you see? Originates from a broad crescent-shaped area in the
AP and lateral radiographs of a skeletally immature knee, posterolateral medial femoral condyle
probably over the age of 10, with a tibial eminence fracture. It inserts centrally posteriorly 1.0–1.5 cm below the
The fracture has a hinge to it and is displaced slightly. articular surface of the tibia
• How do you classify this fracture? It has an average length of 38 mm and a diameter of 13 mm
PCL and quadriceps are dynamic partners in stabilising the
According to the Meyer Mckeever classification and this would knee in the sagittal plane.
be a type II. Type I is an undisplaced fracture and the a type III
is completely displaced. Type IV which was an addition and not There are three components
in the original description is a comminuted fracture. Anterolateral: Long and thick part, twice the size of the
posteromedial bundle; tightens in flexion
• What other radiological investigations would you ask for?
Posteromedial: Tight in extension
I would request an MRI scan f this child’s knee to delineate Meniscofemoral ligaments: Mechanically very strong
any associated intra-articular injury to the soft tissues of the
knee. A CT scan would aid preoperative planning but given we Anterior: Humphrey’s ligament
are dealing with a child an MRI scan would be more Posterior: Wrisberg’s ligament
appropriate.
Vascular supply from the middle geniculate artery
• What other structures could be damaged in the knee?
These fractures especially the types III and IV are associated
with 30–40% risk of injuries to the menisci, chondral cartilage
Mechanism of injury
and collateral ligaments within the knee. 3% of all knee injuries
Direct injury against the proximal tibia when
• How do you manage this type of fracture? the knee is flexed 90° is the most common
After having taken a full history from the patient and any (dashboard injury)
witnesses of the injury, assessed the patient and obtained all Falling on a flexed knee with foot in plantar flexion
appropriate investigations and I would proceed into counsel- Forced hyperextension (>30°) is associated with multi-
ling the patient and his family in regards to open reduction ligament injury. Most instability is experienced with the
internal fixation of this fracture.
knee in 90° of flexion
• What are the options of fixation and which fixation High association with periarticular fractures around the
method is stronger and has less risk of causing growth knee. It is recommended that the PCL is examined after
disturbance? fracture fixation as there is 7.8% incidence of PCL
This fracture can be fixed with a screw, K-wires or sutures. This injuries27. This is also a 2–5% rate of PCL injury with
can be done open or arthroscopic-assisted. The older the child femoral shaft fractures28
020
Also associated with posterolateral corner (PLC) injury and Performed at 30° and 90°. Considered positive if there is a
knee dislocations difference >10° of external rotation of the foot. If positive
at 30° but not at 90° then it is an isolated PLC injury.
Diagnosis If positive at both 30° and 90° then this indicates a PCL
and PLC injury
Injury is often missed in the acute knee
External rotation recurvatum test
Clinical examination is more reliable than MRI scan
The PCL may be dysfunctional despite normal MRI
MRI scan is a confirmatory study for a PCL injury in acute Grading of PCL instability
injury (Figure 17.13 a and b). However, it is only 50% of Normal tibial step-off is 10 mm at 90° flexion
the time diagnostic in chronic cases; therefore, it should be Instability could be mild, moderate or severe
used with caution Grade I laxity is when there is a 5-mm step-off
Lateral stress view radiographs reveal increased posterior Grade II laxity is when there is no step-off (flush)
sag on posterior drawer in comparison with the Grade III laxity is when there is –5-mm step-off
contralateral knee (becoming gold standard) There is a high association between grade III PCL
Kneeling stress x-ray shows the degree of posterior translation injury and PLC injury. This highlights the importance
of the dial test
Tibial step-off sign/posterior sag sign (medial tibial Management
plateau is anterior to the femoral condyle at 90° flexion in a In isolation, PCL injury often causes little long-term instabil-
normal knee) ity. However, it may lead to medial or PF joint pain at a later
Posterior drawer test at 90° date. It is more troublesome in soccer players owing to diffi-
Quadriceps active drawer test. Flex the knee to 60° and culty in deceleration.
control the foot by applying downward force onto bed, Acute isolated PCL injury is commonly missed as it may
then ask the patient to contract the quads. The test is present with very little pain in the knee without haemarthrosis.
positive when the tibia reduces There may be only bruising at the popliteal fossa. Chronic PCL
Posterolateral rotatory instability (dial test prone – injury on the other hand may present with pain in the medial
Requires two people to perform test accurately): compartment or anterior knee pain.
(a) (b)
Figure 17.13 (a, b) Sagittal and coronal T2 MRI scan revealing a ruptured PCL
311
020
It is acceptable to treat an acute, isolated PCL injury con- an arthroscopic transtibial technique of an open tibial inlay
servatively. The knee is kept in extension in a brace with calf technique. This can be either a single or double-bundle
support (posterior tibial support, PTS brace) until the pain reconstruction
subsides (4–6 weeks) with quadriceps rehabilitation. Start early
passive motion only in the prone position to maintain anterior Knee dislocation
tibia translation.
ACL, PCL, MCL, LCL and PLC are the main stabilisers of the
Outcome is poor after meniscectomy, or with patellar
knee. Any triple-ligament knee injury constitutes a frank dis-
chondrosis, gross laxity and weak quadriceps. If associated
location. This is relatively rare but is a severe and potentially
with posterolateral or posteromedial injuries, knee stability is
limb-threatening injury.
dramatically reduced.
There is 3.3–18.0%30,31 incidence of vascular compromise
and a 20–30% incidence of nerve injury. The incidence of any
Surgical reconstruction fracture may be as high as 60%. It usually happens as a result of
a high-energy injury such as an RTA. It may occur following
PCL (open/arthroscopic) reconstruction is recommended:
lesser injuries, such as sporting accidents. It may be missed on
Acute combined ligamentous injuries initial assessment.
Acute isolated injury with bony avulsion Recent CORR papers in 2014 revealed lower incidence of
Symptomatic chronic PCL injuries that failed vascular injury compared to the previously quoted figure of
rehabilitation 50%. The largest study of knee dislocations to date (including
Arthroscopic reconstruction, although technically demanding, 8050 dislocations) from the USA revealed an overall rate of
is safe and commonly performed nowadays. Single bundle concomitant vascular injury of 3.3–13.0% requiring surgical
and double bundle PCL reconstruction can be performed. intervention.30 Furthermore, a systematic review31 revealed an
Double-bundle reconstruction is technically more demanding. overall frequency of 18% for vascular injury – With 80%
Although both techniques resulted in similar patient satisfac- requiring surgical intervention – And 25% for nerve injury
tion in a level II RCT as measured by outcome assessment, the following knee dislocation. Knee dislocations with injury to the
double bundle procedure significantly improved knee ACL, PCL and MCL (Schenck and Kennedy KDIIIL) had the
stability29. highest rate of vascular injury (32%) followed by posterior
dislocations (25%).
Complications Classification
Immediate
Knee dislocation is classified on the basis of direction of tibial
Vascular injury to popliteal vessels: Posterior to PCL displacement (displacement of the tibia with respect to the
insertion on tibia (close to tunnels) with only the posterior femur):
capsule separating it
Anterior (most common: 30–50% of dislocations, and
Infection associated with intimal tears) and posterior; also medial,
Technical error ! imprecise tunnel placement, graft lateral (highest rate of peroneal nerve injury) and rotatory
tensioning, insecure fixation (usually irreducible) or combined
Alternatively the Schenck classification is based on the
Delayed pattern of ligament injury of knee dislocation (KD)
Loss of motion Key factors also include whether it is:
Avascular necrosis (medial femoral condyle) Closed or open
Recurrent or persistent laxity (common) when a combined High or low energy
injury is not adequately addressed Dislocation or subluxation
Neurovascular involvement
Outcome (Figure 17.14 a and b)
Good clinical outcome seen in acute primary PCL repair Mechanism of injury
with bony avulsions Hyperextension leads to anterior dislocation. Dashboard
Mid-substance ligament repair are not advised as they are injury leads to posterior dislocation.
typically not successful
PCL reconstructions are less successful than ACL
reconstructions
Examination
The knee must be examined carefully, looking for:
Key is to identify and address all other concomitant
ligament injuries. Surgical technique is upon surgeon’s Valgus and varus laxity
preference. Surgical reconstruction can be performed using Anteroposterior translation
020
(a) (b)
Figure 17.14 (a, b) Postop PCL reconstruction. Old MCL injury (Pellegrini–Stieda)
Recurvatum Involve the vascular surgeon with a view to arteriography/

:>10° hyperextension suggests ACL injury CT angiogram
:>30° hyperextension indicates PCL injury Radiography before manipulation (assess direction and
Rotation indicates MCL and LCL injury associated fracture)
Reduction as soon as possible in the emergency/
Pulses need to be palpated: Popliteal, posterior tibial and operating room
dorsalis paedis
Check for the dimple sign medially, indicating
Both sensory and motor nerves to the lower limb need to posterolateral dislocation and medial condyle
be assessed buttonholing, which preclude close manipulation
Clear and accurate documentation is paramount
Increased external rotation suggests popliteofibular
ligament and popliteus tendon injury while increased
external rotation and varus laxity suggest LCL injury
Management as well
Surgical emergency Gross varus laxity and external rotation indicate extensive
Deal with life-threatening injuries first damage to the PLC, including the articular capsule
Assess circulation by physical examination and/or Doppler Immobilization in an extension knee splint
in the emergency department Check radiograph to confirm congruity; if not, consider
Serial physical examination for at least 48 hours is external fixator
sufficient to detect most of the clinically significant vascular Conservative management is going out of favour as it leads
injuries to gross instability
Ankle : Brachial Pressure Index (ABPI) can be used to Early surgical reconstruction and/or repair is currently
assess the need for arteriogaphy/CT angiography. Arterial recommended by the Knee Dislocation Study Group
intimal tears are more common and easily missed, and Timing of intervention is critical
pulses are commonly intact During the first week there is a likelihood of late vascular
ABPI <0.9 is suggestive of significant arterial injury compromise
313
020
Surgical dissection after 3 weeks becomes very difficult Table 17.4 Structures of the PLC of the knee
Ligament surgery is best performed as soon as the vascular Layer I ITB and biceps femoris
surgeon allows
Common peroneal nerve lies between layer I and II
Early motion is allowed to prevent arthrofibrosis if the
integrity of the ligament and vascular reconstruction Layer II Patellofemoral ligament and patellar retinaculum
permit Layer III Superficial: LCL and fabellofibular ligament
Most ACL/PCL/MCL can be treated with bracing the MCL Deep: popliteus tendon, popliteofibular ligament,
followed by combined ACL/PCL reconstruction once range arcuate ligament, coronary ligament, lateral joint
of movement is regained, usually after 6 weeks capsule
Alternatively, repair the capsule and repair or augment the
Lateral geniculate artery lies between the superficial and
MCL early and reconstruct the ACL 6–8 weeks later
deep layers of layer III
ACL/PCL/PLC can be treated by repairing or
reconstructing the PLC acutely (within 3 weeks) and
delayed ACL/PCL reconstruction 8 weeks later. PLC
The LCL of the knee is a cord-like structure 5–7 cm in
repair/reconstruction should be performed either prior to
length. It is the primary static restraint to varus opening of the
or in the same sitting (single-stage vs two-stage)
knee and secondary restraint to posterolateral rotation.
reconstruction of ACL or PCL, otherwise the graft is likely
It extends from an area proximal and posterior to the lateral
to fail
epicondyle to the anterior aspect of the fibula head deep to the
Open dislocation, fracture dislocation and vascular biceps femoris tendon. The LCL femoral attachment is
compromise require staged procedures 18.5 mm superiodorsal to the popliteus insertion. The popli-
teofibular ligament acts as a primary restraint to external
Indications for applying an external fixator rotation of the tibia on the femur at 30° of flexion. Similarly,
If the tibiofemoral joint is incongruent after reduction the popliteus is a static and dynamic external rotation
Vascular injury (plus fasciotomy) stabiliser.
Massive soft-tissue injury The structures of the PLC function are to resist posterior
translation as well as external and varus rotation of the tibia.
Method of Ex-Fix application in a dislocated knee with an They are the primary stabilisers of external tibial rotation at all
arterial injury: knee flexion angles and the secondary restraints to anterior
Position the patient supine for the ease of initial pin and posterior translation. Isolated PLC sectioning produces a
placement (lateral femoral pins and anteromedial maximal average increase of 13° of external rotation at 30° of
tibial pins) knee flexion and only an average increase of 5.3° at 90°.
Turn the patient prone for the popliteal shunt by the Although isolated sectioning of the PCL has no effect on
vascular surgeons (more recently many vascular and external tibial rotation, combined injury to the PCL and pos-
trauma surgeons have promoted vascular exploration and terolateral structures leads to the highest increase in external
repair from a posteromedial incision which can be an rotation of 20.9°, especially at 90° of knee flexion32,33. Hence,
extension of the fasciotomy incision which allows good the dial test is performed in the prone position at 30° of flexion
visualisation and access to the popliteal artery as well as the to diagnose PLC injury and at 90° to diagnose combined PCL
femoral artery more proximally) and PLC injuries.
Apply bars to the pins to achieve a solid construct with Varus opening at 30° of flexion suggests LCL injury while
the knee joint reduced and the limb perfused (patient varus opening at 0° is indicative of combined severe injury to
supine) the PLC and the cruciate.
Vascular anastomosis can be performed safely with the
patient back in prone position Principles of surgical intervention
Concurrent fasciotomies should be considered in these Early repair (within 3 weeks) of torn and detached
situations to avoid compartment syndrome secondary to ligaments, tendons and capsule in acute injuries.
reperfusion injury A combination of early repair and reconstruction has been
shown to provide better results
Posterolateral corner (PLC) of the knee Late reconstruction of two or three of the main stabilisers
The main stabilisers of the lateral and posterolateral aspect of of the PLC of the knee, i.e. the LCL, popliteus tendon and
the knee are popliteus, LCL, popliteofibular ligament, biceps popliteofibular ligament in chronic cases
femoris, iliotibial band, arcuate complex and capsular The reconstruction can be fibula-based, such as the
ligaments (Table 17.4). modified Larson technique, or combined tibia- and fibula-
based, such as the LaPrade anatomical reconstruction
020
Combined ACL/PCL and PLC injury must be treated by The Schenk classification describes the dislocation
reconstruction of all injured ligaments. Isolated ACL or according to the ligaments injured.
PCL reconstruction without addressing the PLC will
ultimately fail • What is your initial management of a knee dislocation?
This is a high-energy injury and should be approached using an
ATLS® protocol. There is a considerable incidence of vascular
Examination corner and/or neurological injury. This is described in the literature at a
rate of 20–50%. Compartment syndrome is also a risk factor in
Trauma oral 1
these injuries. Once the primary survey has been completed
The examiner shows a clinical photograph of a dislocated knee
and the neurological and vascular status of the affected leg has
(Figure 17.15) and asks:
been documented, I would administer sedation and attempt to
• Describe what you see. reduce the knee. Once reduced, I would reassess the limb
(neurological and vascular status) and document my findings.
This is a lateral radiograph showing a dislocation of the right
knee. I would like to see a AP radiograph to determine whether • Examiner interrupts: The knee was successfully reduced
this is a posteromedial or posterolateral dislocation. There is and remains so, but you are unable to feel a pulse. The
also evidence of a bone fragment just anterior to the tibia foot remains warm and pink. What are your thoughts?
which indicates an associated fracture. Associated fractures
Suspicion of a vascular injury warrants immediate intervention.
are seen in 60% of knee dislocations.
I would discuss this with the vascular, plastic or if neither are
• How do you classify this injury? available then the general surgeons (depending on what ser-
vices are available in my hospital). I would alert theatres and
This injury is usually classified on the basis of tibial displace-
prepare the patient for a spanning external fixation to stabilise
ment – This is only applicable if the knee is dislocated at the
the knee and popliteal fossa arterial exploration ± repair. An on
time of imaging. Anterior dislocation is the most common,
table angiogram can be performed in theatre.
followed by posterior dislocation as in this case. There can be
medial and lateral as well as rotary (combination of the above • And what if there is a pulse?
A/P with M/L).
As this is a high-energy injury, I would discuss this with the
radiologist and arrange a CT angiogram. If there is any diffi-
culty in obtain the CT, I would perform an ankle-brachial
pressure index. An index <0.9 in the context of this injury
warrant surgical exploration. The benefit of the CT in such
injuries is that it can detect intimal tears in the popliteal artery
which might be masked by a normal pulse. The risk on an
unidentified intimal tear is that it progresses or the artery
forms a thrombus leading to ischaemia. If the foot had any
signs of ischaemia, prompt vascular intervention is required.
• Which types of dislocations are vascular injuries most
commonly seen in?
Around 20% of all dislocations have a vascular insult, with 50%
being in the anterior or posterior knee dislocations. Anterior
dislocations generally have an intimal tear from the traction
applied on the artery, while posterior dislocations more com-
monly lead to complete tear of the popliteal artery. This is associ-
ation of vascular injury with anterior and posterior dislocations are
due to the anatomical trifurcation of the popliteal artery and its
anchorage within proximal and distal soft tissues. Anterior and
posterior dislocations lead to the artery tethering at the popliteal
fossa. The artery proximally is within a fibrous tunnel at the
adductor hiatus and then continues in the fibrous tunnel at soleus.
• What is your order of ligament reconstruction in a multi-
ligament knee injury?
It all depends on the ligamentous injuries found on the MRI
scan. If I decide to perform early reconstruction which has been
shown to provide improved outcomes, I would reconstruct the
PLC and PCL primarily (and perform a delayed ACL reconstruc-
tion). Neglecting to identify a PLC injury or not reconstructing/
Figure 17.15 Lateral knee radiograph of a dislocation repairing it adequately leads to failure of knee stability.
315
020
• How else can this injury be treated? Q angle leads to increased lateral forces on the patella femoral
articulation which could lead to anterior knee pain, mechanical
If the dislocation has been reduced and is relatively stable, it can
symptoms, accelerated polyethylene wear (in resurfaced patel-
be braced with early rehabilitation. Once the scaring has occurred
lae) and in extreme case patella dislocation.
clinical as well as radiological assessment can be performed and
at that point, any areas of instability that haven’t resolved can be • What are the technical errors that need to be avoided in
addressed. The commonest complication of knee dislocations order not to increase the Q angle?
(pre or post reconstruction) is arthrofibrosis leading to stiffness.
One should avoid:
In fact a large proportion of multi-ligament knee reconstruction
require an MUA to improve the range of motion. Medialisation of the femoral component
Internal rotation of the femoral component
Internal rotation of the tibial plate
Lateralizing the patella button on the patella (in resurfaced
Patellofemoral (PF) joint disorders cases)
This is regarded as the ‘black hole of orthopaedics’. The inter-
• What is the best way of assessing component malrota-
national patellofemoral group explanation is that: tion leading to patella maltracking after a total knee
The aetiology is complex and multifactorial in origin replacement?
There is poor correlation between clinical symptoms, signs
CT scan
and radiological findings
There is a lack of clinical interest
Widespread terminological confusion
Myths about anterior knee pain (AKP)
Anatomy and biomechanics
Patellar articular cartilage is the thickest in the body. It has two
AKP is self-limiting
main facets separated by a ridge. The medial facet is convex
AKP is related to growth
and the lateral facet is concave. The femoral trochlea has a
It is an expression of a psychological problem higher and longer lateral facet compared with the medial side.
Vastus medialis obliquus (VMO) is responsible for patellar The patella increases the efficiency of the extensor mechanism
instability by 1.5 times and the muscles about the knee absorb more than
High Q angle indicates surgical realignment three times the energy generated. Fifty per cent of the quadri-
Lateral release improves AKP/instability ceps tendon inserts into the upper pole of the patella and the
Tissue homeostasis theory34 rest blends into its anterior surface.
PF joint pain can be caused by supraphysiological loading
of the anatomically normal knee Ground Reaction Forces (GRF)
Walking on level ground causes GRF of 0.5–3.0 times body
weight (BW)
Examination corner
Cycling: 1.2 times BW
Adult pathology oral 1
Stairs (up or down): 3.3 times BW
The examiner shows a clinical photograph of valgus knees
Jogging and squat: Rise 6 times BW at 140°
and asks:
Squat: Descent 7.6 times BW at 140°
• What is the Q angle and how do you measure it?
The Q angle is an angle between (1) a line drawn from the anterior Typical anterior knee pain
superior iliac spine to the midpoint of the patella (axis of the Pain (mostly dull/occasionally sharp) during: stair
extensor mechanism) and (2) a line drawn from the midpoint of
climbing – squatting – prolonged sitting – rising from a chair
the patella to the tibial tuberosity (axis of the patella tendon).
The normal Q angle for males is 10–13° while is it 15–18° in Giving way (quads inhibition)
females (i.e. females are more genu valgum than males). Catching or pseudo-locking
Mild swelling caused by synovial irritation
• What is its significance?
It is very important in understanding patella bony mal-
alignment. An increased Q angle leads to patella instability
Sources of anterior knee pain
and this can be caused by femoral anteversion, genu valgum The articular cartilage is avascular and aneural; therefore, the
and external tibial torsion or pronated feet. Tight ligamentous possible theories are:
structures can contribute to an increased Q angle. Synovial irritation
In terms of arthroplasty, abnormal patella tracking is the Subchondral bone deformation
most common complication of TKA and the key to normal Intramedullary pressure changes
patella tracking is to restore the Q angle. An increased
Ischaemia-induced neural proliferation and pain
020
Lateral neuroma formation Patellar shape

Tissue homeostasis theory Patella alta
2. Mal-alignment
Causes of anterior knee pain Patellar mal-alignment is an abnormal rotational or
Local translational deviation of the patella along any axis
Muscle imbalance External tibial torsion/foot pronation
Soft-tissue imbalance Increased femoral anteversion
Tightness: Quads, hamstrings, ITB or lateral retinaculum Genu valgum
Laxity: Hypermobility syndrome Increased Q angle or abnormal tibial tuberosity–
Retinacular pain from overload or neuroma trochlea groove (TT–TG) distance
Patellar or quadriceps tendinopathy 1. Soft tissue (dynamic)
Synovial – Synovitis – Plica – Tumour (PVNS, Ligamentous laxity (medial patellofemoral ligament
chondromatosis) rupture)
Articular damage – Patella/trochlea 2. Abnormal gait
Traumatic Walking with valgus thrust
Degenerate
Inflammatory Medial patellofemoral ligament (MPFL)
Fat pad syndrome
This is the primary static soft-tissue restraint to lateral patellar
Stressed bone, Osgood–Schlatter’s disease/Sinding– displacement. It provides 60% of the total medial restraining
Larsen–Johansson syndrome force35. The MPFL is most effective between 0° and 30° of
Distant flexion, as the trochlea, which is a primary restraint, provides
stability with further flexion. MPFL sectioning can lead to
Mal-alignment (high Q angle)
substantial changes in patellar tracking. It originates from an
Core pelvic muscles
Femoral anteversion ‘leaning forward’
Tibial torsion
Foot hyperpronation
Referred: Spine or hip (SUFE!) via the obturator nerve.
Examination
Standing: Valgus/varus alignment, gait, leg length
inequality, Q angle
Sitting: VMO/quads atrophy, lateral patellar tilt, patellar
tracking, J sign
Supine: Patellar glide test, patellar tilt test, Clarke’s test
(commonly painful – Examiner likely to stop you from
performing it), apprehension test, compression test and
trochlear depth in hyperflexion
A patella that deviates laterally in terminal extension (J sign)
suggests significant mal-alignment that may benefit from a distal
realignment. Patellar tilt associated with lateral patellar compres-
sion, if severe, can be treated with lateral retinacular release.
Patellar instability
Recurrent patellar subluxation or dislocation can be very
disabling.
Risk factors
1. Bony factors (static) Figure 17.16 Medial structures of the knee. AMT, adductor magnus tendon;
AT, adductor tubercle; GT, gastrocneumius tubercle; ME, medial epicondyle;
Trochlear dysplasia MGT; medial gastrocnemius tendon; MPFL, medial patellofemoral ligament;
Hypoplastic femoral condyle POL, posterior oblique ligament; sMCL, superficial medial collateral ligament
317
020
area between the medial epicondyle and the adductor tubercle Femoral attachment should be identified using
and inserts onto the proximal two-thirds of the patella. fluoroscopy. The tunnel is classically placed midway
The average length of the ligament is 5.5 cm. During acute between the medial epicondyle and the adductor
patellar dislocation there is a 90–95% incidence of damage tubercle, and just posterior37 to a line extending from
to the MPFL. Nomura et al. reported almost every acute knee the posterior cortex of the femur contrary to what is
dislocation has resulted in an MPFL rupture36. Femoral called (Schottle’s point) which is more anterior and
attachment is commonly affected. In the past 10 years, MPFL lies anterior to the line extending from the
reconstruction has become a popular procedure for treatment posterior cortex of the femur . The graft should be
of recurrent patellar dislocation. fixed at 60° of knee flexion applying only 2 Newton
of force38
Investigations This procedure offers very good outcomes if performed
A lateral radiograph is the most helpful view for assessment with the appropriate indications and can be combined with
of patellar tilt and trochlear depth bony alignment procedures39
Axial radiographs (merchant’s view) to assess patellar tilt
angle (normal <10°), congruence, sulcus angle (normal Proximal realignment procedure
138°) and trochlear dysplasia Lateral release (open/arthroscopic) is rarely performed
MRI for articular lesion. This also confirms the site of nowadays in isolation. It is only indicated when there is
avulsion. Rupture is most commonly at the femoral origin pain and lateral retinacular tightness or when the patella is
but occasionally can be at the patella insertion chronically dislocated
CT scan to assess Medial imbrication (open/arthroscopic). Indicated in mild
to moderate maltracking, especially in the skeletally
: Femoral anteversion (normal 5–15°)
immature
: Tibial torsion
Quadricepsplasty
: TT–TG distance >15–20 mm is significant
: Patellar tilt
Combined proximal and distal realignment procedures
: Trochlear depth
These procedures are indicated for tubercle mal-alignment and
Isotope bone scan to measure bony activity and
traumatic incompetency of the medial restraints.
homeostasis within the knee can sometimes be useful
Distal realignment procedures
Management Direction of tibial tubercle (TT) transfer:
Non-operative Medial transfer to treat mal-alignment
The first line of treatment should always be non-operative meas- Anteromedial transfer for mal-alignment and PF joint
ures. The patient’s education and intensive rehabilitation under chondrosis
the supervision of a skilled physiotherapist plays a major role in Anterior when there is distal PF joint chondrosis
the success of non-surgical treatment. Acute first-time patellar
dislocation is treated conservatively in an extension splint for Elmslie–Trillat: medialisation without posteriorisation of
2–4 weeks. Occasionally, surgical intervention is necessary to fix the tibial tubercle
or remove an osteochondral fracture. Rarely, the medial patello- Fulkerson: medialisation with anteriorisation of the tibial
femoral ligament is repaired or reconstructed acutely. Despite tubercle in the arthritic patella. The obliquity of the cut
intensive rehabilitation there is a 20% risk of recurrent disloca- depends on the degree of mal-alignment and arthrosis.
tion. This figure increases to 50% after the second dislocation. A steep cut up to a 60° angle maximizes anteriorisation and
is useful in patients who have more arthrosis than mal-
Surgical alignment
This is only carried out when intensive rehabilitation fails to Historical/abandoned procedures (these are still relevant
prevent further dislocation. for clinical practice as patients might have had them done or
require revision procedures, and an understanding of what has
MPFL reconstruction been done is essential for any surgical planning):
Indications: Recurrent patella instability (lateral) with no Hauser: transfer of the TT to a medial, distal and posterior
underlying structural mal-alignment or minor malposition. It increases the PF joint reaction force and causes
alignment patellofemoral degenerative joint disease
Gracilis hamstrings autograft are most commonly used in Goldthwait 1899–Roux 1888: medial transposition of the
this procedure. Harvest technique as per ACL medial half of the patellar tendon, lateral release/medial
reconstruction. Some have also used synthetic grafts as this reefing. Now the lateral half is placed under the medial half
procedure and medially
020
Maquet: anterior transportation of TT, which decreases Medial patellofemoral ligament reconstruction is
patellofemoral contact forces. Not performed nowadays as it indicated in recurrent dislocation when other parameters
has a high incidence of skin necrosis, compartment are within normal or near normal
syndrome and no effect on the Q angle Manage trochlear dysplasia (true lateral x-ray and CT scan
proven) by trochleoplasty
Summary
Identify the cause of instability and take the following actions Patellofemoral joint arthroplasty
accordingly: This is effective in isolated PF joint arthritis (Figure 17.19a
Lateral release when there is lateral patellar compression and b), post-traumatic arthrosis and severe chondrosis
syndrome after an extended period of supervised and non-operative
Tibial tubercle medialisation when there is abnormal TT : measures.
TG distance
Tibial tubercle distalisation when Caton–Deschamps or Contraindications
Insall–Salvati patella index ratios >1.3 (Figure 17.17) Inflammatory arthritis
Tibial tubercle elevation when there is patellar chondrosis Chondrocalcinosis of menisci or tibiofemoral surface
Manage the immature knee by soft-tissue realignment Patients with inappropriate expectations
procedures Considerable patellar mal-tracking or mal-alignment
Patellar tendonitis, synovitis and patellar instability
Outcome
Some studies reveal up to 90–95% good and excellent
results in isolated PF joint arthrosis at mid-term
follow-up: This includes the Avon patellofemoral
arthroplasty40,41
NJR reports revision rates of PF joint implants of 14.7% at
8 years
Obesity and ACL deficiency do not seem to increase the
failure rate
It is an excellent alternative to patellectomy and accepted
alternative to TKR in patients younger than 55 (in centres
that do them regularly)
Examination corner
EXAMINER: A 44-year-old female presents to the knee clinic with

knee pain that has been going on for some years, getting
progressively worse. Her GP has tried multiple therapies but she is
no longer coping with her symptoms.
Describe the radiographs (Figure 17.19).

These are skyline views of both knees.
In a skyline or merchant’s view what would you
comment on?
Figure 17.17 PL: Maximum patella length. TL: patella tendon length. PA:
patella articular surface. TP: tibial plateau line. D: Shortest distance between
I would look at the patella position and comment on whether
the patella articular surface and the tangential line of the tibial plateau. there is evidence of a tilting patella, joint space within the
The Insall–Salvati ratio is PL/TL, the traditional number used is <1.2 (0.8–1.2) patellofemoral joint, the trochlear morphology and the pattern
with patella baja being <0.8 and patella alta is >1.2. The Blackburne–Peel of OA or compression of the patella onto the torchlea.
ratio is measured on a lateral radiograph with 30° of flexion. It is a measure of
patella height taking the patella articular surface (PA) divided by the distance • If the rest of the knee joint was normal what would be
between the horizontal line at the level of the tibial plateau and the inferior your diagnosis?
aspect of the patellar articular surface (D): (D/PA). A ratio of 0.8 is considered
normal, with patella alta being a ratio of >1.0. Caton–Deschamps index is Isolated patellofemoral joint osteoarthritis.
measured by X/PA. A ratio >1.3 is highly suggestive of patella alta
319
020
(a) (b)
Figure 17.18 Sagittal and axial T2-weighted MRI of an isolated PF joint OA

affected knee in 43-year-old man
Dynamic (soft tissue): Tight lateral structures

(lateral retinaculum) or incompetent medial
structures (VMO/MPFL) both contribute to PF joint OA
especially in chronic cases that have progressed beyond
instability
Other factors include trauma – 28% of patients with isolated PF

joint OA report previous patella instability compared with
Figure 17.19 Knee radiograph with PF joint OA none in the tricompartmental knee OA42. Obesity is also asso-
ciated with PF joint OA.
What do radiological findings determine?
• What is the aetiology of this condition?
Radiological findings correlate poorly with clinical symptoms
Aetiology is complex and multifactorial and relates to any and signs.
factor that increases PF joint pressure. It can be divided into
What are the management options for a patient with PF
three main factors:
joint OA?
Alignment: This can affect the position of the patella in
either rotational or translational plane leading to an I would initially investigate what treatment the patient has had
increased Q angle or abnormal tibial tuberosity–trochlea already.
groove (TT–TG) distance. This can also be affected by genu Non-operative measures:
valgum, increased femoral anteversion or external tibial Weight loss
torsion. Valgus mal-alignment is associated with increased Activity modification
risk of disease progression Physiotherapy (VMO strengthening might improve
Static (bony): Abnormalities within the trochlear groove symptoms)
depth or patella abnormality (lateral tilt) Analgesia
020
Intra-articular injections (corticosteroid – NICE does not Patellofemoral arthritis in young patients
recommend hyaluronic acid)
Surgical measures: these need to be tailored to the patient Non-surgical
and the clinical/radiological findings. Patient education, physiotherapy, activity modification
Arthroscopic debridement/microfracture/chondroplasty/ Optimize body weight
osteochondral graft
Lateral patella facetectomy
Distal ateriorizing procedures (Fulkerson or Maquet
Surgical
procedures) Arthroscopic cartilage debridement (gentle), lateral release
Patellofemoral arthroplasty (PFA) (tilt and arthritis), Fulkerson tibial tubercle elevation for distal
Total knee arthroplasty (TKA) focal lesion, patellar resurfacing, patellofemoral joint
When would you decide to perform a PFA? And what are arthroplasty, TKR (older patients) and patellectomy (rarely)45
the contraindications?
PFA is indicated for isolated PF joint OA with correlated severe Knee osteoarthritis
knee symptoms. Unlike hip arthritis, knee osteoarthritis does not always pre-
Contraindications to this procedure include inflammatory arth- sent with night pain. Women have a higher overall prevalence
ritis, medial/lateral tibiofemoral OA, chondrocalcinosis, patella of OA and have more severe OA of the knee than men. Despite
instability or patella mal-tracking. that they are three times less likely to undergo TKR. Women
What type of arthroplasty would you offer this patient if have thinner distal femur articular cartilage. They also have a
you had to choose and why? thinner patellar articular cartilage and are more susceptible to
isolated PF joint arthritis46,47.
With careful patient selection I would offer this patient a PFA –
Avon implant. I would refer it to a centre that does this
procedure on a routine basis. Differential diagnosis of painful swollen knee
NJR results reveal that the median age for the patients under- Mechanical pain occurs when the joint is stressed/loaded
going PFA is lower than TKA. (e.g. degenerative arthritis)
Eight-year survival of PFA is 14.7%, which is considerably Inflammatory: Occurs mainly at rest such as:
higher than TKA (2.82%), but the Avon patellofemoral implant
has an improved revision rate of 10.4% at 8 years. Inflammatory polyarthropathy (e.g. rheumatoid arthritis)
PFA vs TKA: a systematic review by Van Jonbergen43 showed that Crystal-induced
the clinical results reported on PFA outcome studies are related Spondyloarthropathy (e.g. ankylosing spondylitis and
to prosthetic design, surgical technique, patient selection and psoriasis
length of follow-up. Two-thirds of patients have shown good to Infectious (e.g. staphylococcal, gonococcal and Lyme
excellent results in their 3- to 17-year follow up.
arthritis)
Van Jonergen in another study revealed that patellofemoral
arthroplasty does not have a negative effect on the outcome
Neuropathic: Related to nerve distribution
of later TKA44. Psychosomatic: Poorly defined pain that is
disproportionate to clinical signs
What are the most common reasons for the failure of the
Benign synovial disorders
PFA implant?
Pigmented villonodular synovitis
Most common reason for revision is pain and aseptic loosening Synovial chondromatosis
and progression of femorotibial OA. Progression of OA will Synovial haemangioma
require conversion to a primary non-constrained TKA.
Lipoma arborescens
Non-surgical management of arthritis

Patellectomy Exercise, muscle strengthening and aerobic exercises
This is salvage last-resort surgery – It may not eliminate pain. Weight loss – Reduce the progress of arthritis and
It reduces extension power by 30–50%. The tibiofemoral joint reduce pain
reaction force may increase by 250%, causing OA. Although NSAIDs – GI side effects with chronic use (consider
rarely performed, there are satisfactory results in 77%45. addition of PPI or COX-2 inhibitors)
Bracing and orthotics – Bracing and orthosis for passively
Lateral patellar compression syndrome correctable unicompartmental disease, <10° angulations
There is pain caused by a tight lateral retinaculum. Usually the (off-loader valgising brace for isolated medial OA)
patella has normal alignment and mobility. Imaging shows an Steroid injection, corticosteroid and lignocaine are
abnormal patellar tilt without subluxation. Arthroscopic lat- considered toxic to chondrocytes as shown in some studies,
eral release is generally very effective. and, hence, should be used with caution in early OA48,49
321
020
Surgical management of arthritis in young patients Severe osteoporosis

Extra-articular deformity
Arthroscopy: This is controversial, and is only used for
debriding chondral flaps and symptomatic meniscal tears, Crystal arthropathy
as arthroscopic surgery for OA of the knee has been shown Near total lateral meniscectomy
provides no additional benefit to optimised physical and Obesity (BMI >40): Valgus knee is poorly tolerated
medical therapy50 because of medial thigh contact
High tibial osteotomy was popularized by Coventry and Large varus thrust
Insall in the 1970s If >20° correction is needed
Unicompartmental knee replacement Patellofemoral OA is a relative contraindication
Total knee replacement Li et al.51 revealed that among the 11 studies they looked at in
their systematic review, the clinical outcome of simultaneous
Proximal or high tibial osteotomy (HTO)
HTO and ACL reconstruction for medial compartment OA in
This is an excellent operation for relatively young or highly the young patient with an ACL-deficient knee provides a satis-
active individuals, with isolated medial compartment OA and factory restoration of the knee stability, improvement in pain,
varus alignment of the knee. more predictable return to sport, and alleviation of medial OA.
The principle is to realign the weight-bearing axis from
varus to slight valgus i.e. offloading the medial compartment. Planning
Realignment can be achieved either by closing wedge lat-
Standing, long leg radiographs in neutral rotation
eral HTO (commonly used), opening wedge medial HTO or
dome osteotomy, which is more technically demanding. Measure the mechanical axis (normal = 1.2° varus)
Anatomical axis (6–7° valgus)
Prerequisites for HTO Measure the degree of deformity and plan the size of wedge
The place of osteotomies in the management of osteoarthritis necessary
of the knee was formulated by the International Society of Change the overall alignment to transfer the load to the
Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine unaffected side
(ISAKOS) in 2004. Sixty-four per cent across the tibial plateau from the medial
The ideal patient and the not suitable patients for HTO side (Fujisawa point)52
according to ISAKOS Varus arthritis can be treated with laterally based closing
wedge osteotomy above the level of the tibial tubercle or
Ideal candidate medial opening wedge HTO
Age 40–60 years Final alignment should create 10–13° valgus in medial OA.
<15° varus mal-alignment of the limb Overcorrection of 3–5° above the 6–7° normal valgus angle
>100° flexion in knee The medial tibial cortex represents the apex of the bony
None smoker wedge in lateral osteotomies and should be left intact
BMI <30
No PF joint arthrosis Methods of osteotomy fixation
Stable knee Cast immobilization
Normal lateral compartment and arthrosis grades I–III in Staples
the medial compartment Osteotomy specific plate and screws (most common method)
No meniscectomy External fixator
No cupula: dished-type defect in the posteriomedial tibia. Distraction osteogenesis: Correction can be adjusted after
Leading to a fixed anterior subluxation of the tibia. This surgery. However, pin tracts create a potential problem for
defect is associated with ACL deficient knee and act as a subsequent TKA
resting place for the femur
Patients should be able to use crutches and have no major
Closed wedge HTO
varicose veins or peripheral vascular disease Surgical technique
Computer-aided measurement of the wedge size can
Contraindications (unsuitable patients) be used
Severe OA changes in the lateral compartment or PF joint A 10-mm wedge excision leads to 10° corrections in a
Severe medial compartment arthritis 57-mm-wide tibia
Incompetent MCL An angular jig is more accurate
Coronal knee subluxation (tibial subluxation >1 cm) Curved incision from the head of the fibula to 2 cm below
Inflammatory arthritis the tibial tubercle
020
The tibia is dissected subperiosteally anteriorly and The outcome of the various high tibial osteotomies strongly
posteriorly depend on the amount of correction achieved. Under-
The proximal fibular head is excised at the superior correction leads to recurrence of the varus deformity. On the
tibiofibular joint or the proximal tibiofibular joint is other hand over-correction leads to valgus overload and sub-
separated using a Cobb elevator protecting the sequent lateral compartment degeneration54.
peroneal nerve
Identify the bare area of the fibular head (safe landmark)
Open wedge HTO
A calibrated osteotomy guide must be used for the Surgical technique
bone cut Medial longitudinal incision or an oblique incision
Leave 15–20 mm of tibial plateau to avoid fracture The MCL is mobilized posteriorly
Fix with a plate or staples Use two 2.5-mm Kirschner wires to mark the oblique
Rigid fixation and early mobilization eliminates patellar osteotomy
ligament contracture (leading to patella baja) Starting proximal to the pes anserinus 4–5 cm distal to the
DVT prophylaxis is similar to that after TKR medial joint line
Drive the wires to the tip of the fibula 10–15 mm below the
Complications lateral joint line
Inadequate valgus correction: Aim for tibiofemoral angle The osteotomy of the posterior two-thirds of the tibia should
of 11–13° valgus hinge on the lateral (not posterolateral) side of the tibia
Overcorrection: PF joint derangement Leave a 10-mm lateral bone bridge intact laterally
Recurrence of deformity The second osteotomy begins in the anterior one-third of
Alteration in patellar height (patella baja) the tibia at an angle of 135° while leaving the tibial
Intra-articular fracture tuberosity intact
Osteonecrosis of the tibial plateau To compensate for an ACL-deficient knee one can
Vascular injuries: Anterior tibial artery, popliteal artery decrease the posterior tibial slope, i.e. open a bigger gab
Peroneal nerve palsy posteriorly
Delayed or non-union To compensate for PCL-deficient knee the slope should be
increased, i.e. creating a bigger opening anteriorly
Compartment syndrome
A more challenging TKR procedure when needed in the Distal femur osteotomy
future
Varus-producing HTO can be used to correct lateral compart-
Varus laxity (loose LCL)
ment arthritis and valgus deformity <12°; however, a deformity
Open wedge HTO of 12° or more needs distal femoral varus-producing osteotomy
to address a lateral femoral condyle deficiency and to prevent
The open wedge HTO gained recognition after the
joint line obliquity and gradual lateral tibial subluxation.
encouraging reports by Professor Hernigou in 198753
Either lateral distal femur opening wedge osteotomy using
Advantages a Puddu plate/Tomofix or a medial distal femur-closing wedge
osteotomy are undertaken.
Preserves bone stock (subsequent TKR is technically easier) Coventry et al.55 reported a 5-year survival of 87% and a 10-
Makes tightening of the MCL easier year survival of 66%. However, the 5-year survival was reduced
Preserves the lateral side for LCL or posterolateral down to 38% when valgus angulation at 1 year was <8° in a
reconstruction if insufficient patient whose weight was >1.32 times the ideal weight.
No risk to peroneal nerve
Less dissection
Easier to achieve precise angular correction Examination corner
Better control over the posterior tibial slope The examiner showed a radiograph of PCL avulsion and asked:
Describe the injury
Disadvantages How do you attach the avulsed fracture?
Requires a bone graft (substitute, autograft, allograft) Describe the posterior approach to the knee
Increased incidence of non-union and delayed union
Large correction may affect leg lengthening
Loss of fixation and recurrence of varus deformity Knee arthritis and arthroplasty
Worsens patella baja by raising knee joint line The primary aim of total knee replacement (TKR) is to achieve:
Slow rehabilitation Pain relief which would lead to improved mobility and
Plate fixation makes TKA harder increased range of motion. This is achieved by obtaining
323
020
A weight-bearing line through the centre of the knee or Preserve bone stock on the distal femoral cut
a postoperative mechanical axis of 0 ± 3° Better kinematics but relatively less predictable (controversial)
A joint line perpendicular to the weight-bearing line Avoids the tibial post-cam impingement
Soft-tissue balance Ease of management of supracondylar fracture (plate/nail)
Restoring normal Q angle and joint alignment
Disadvantages
Anatomical and mechanical axes Less conforming surfaces to allow roll-back
The valgus cut angle is the angle between the femoral anatom- Slide: Increases contact stresses and polyethylene
ical and mechanical axes. The normal anatomical axis or delamination
tibiofemoral angle measures 5–6° of valgus. Technically more difficult to balance
The mechanical axis, or weight-bearing line, is the line Loose or ruptured PCL can lead to flexion instability
from the centre of the hip to the centre of the tibiotalar joint;
it typically measures 1.2° of varus. Hence, 60% of the weight
PCL substitution/sacrificing
goes through the medial compartment. Indications
Previous patellectomy
Femoral roll-back Rheumatoid arthritis
Femoral roll-back is the posterior shift in the femoral–tibial Stiff knee in post-traumatic arthritis
contact point in the sagittal plane as the knee flexes. Previous HTO
Large deformity requiring the release of PCL
Aetiology of arthritis Deficient or absent PCL
Idiopathic
Advantages
Post-traumatic
Avascular necrosis Conforming surfaces allowing roll-back
Inflammatory arthritis No component slide
Provides a degree of VVC
Cam-post mechanism improves anterior-posterior stability
Contraindications to TKA Uses more congruent joint surfaces than CR, which
Infection reduces wear
Neurogenic genu recurvatum Facilitates any deformity correction
Deficient quadriceps mechanism (polio) Better range of motion
Technically easier (to balance) than CR and reproducible
Constraint ladder within knee implant design Higher degree of flexion
PCL retaining (cruciate retaining or CR)
Rotating platform more constrained due to conformity Disadvantages
PCL substituting (posterior stabilised or PS) Increased constraint associated with high stresses at
Unlinked (non-hinged) constrained condylar implant fixation interface leading to increased loosening
(varus–valgus constrained or VVC) Femoral bone loss
Linked (hinged), constrained condylar implant (rotating- Tibial post increases wear
hinge knee or RHK) Tibial post dislocation (Cam jump)
Three times greater joint line alteration compared to CR
PCL retaining (CR) Patella clunk/crunch syndrome
The PCL is a major stabilising ligament in the normal and
pathological knee. It tightens the flexion space and act as a Mobile-bearing tibial components
secondary mediolateral stabiliser in flexion. Clinical trials have shown that the mobile bearing design does
not provide any functional or radiological advantage over
Advantages (compared to PCL-substituting design) fixed-bearing prostheses56,57.
Provides least constraint
Lowered shear forces at the tibial component–host Theoretical advantages
interface Maximum conformity without an increase in component
Preserves proprioceptive fibres (intact PCL) loosening
Greater stability during stair climbing (quadriceps Increased contact area in both sagittal and coronal planes
strength) Minimal constraint
Fewer patella complications Reduced component sliding during flexion
020
Reduced shear stresses on the polyethylene insert Knee arthroplasty surgical technique
Allows self-correction of tibial component in rotational Skin incision
mal-alignment
Anterior longitudinal midline skin incision
Facilitates patellar tracking
Skin blood supply is in the subcutaneous fat so avoid
Better kinematics in gait
undermining
Low polyethylene wear
Medial vessels are relatively large so in cases where there
Theoretical disadvantages are multiple scars use the most lateral
Bearing dislocation and spin out if the soft tissues are Deep dissection
imbalanced
Medial parapatellar in most cases
Underside bearing wear creating small debris; hence, more
osteolysis Subvastus, midvastus
Lateral parapatellar (very valgus knee, laterally subluxed
Technically difficult, less forgiving soft-tissue imbalance
patella)
Constrained unlinked (non-hinged) condylar implant (VVC) Tibial tubercle osteotomy (Whiteside)
Constrained prosthesis with a long tibial post without a link Rectus snip
connecting the tibial and femoral components, e.g. constrained Quadriceps turn-down
condylar knee (Legion by Smith and Nephew and TC3 by DePuy).
Soft-tissue balancing
Indications Collateral ligaments are no longer isometric but act as a
LCL or MCL minor deficiency sleeve
Excessive bone lose Sleeve release affects both flexion and extension gaps
Weak bone at the epiphysial interface Medially, posteromedial release affects extension only
Laterally, iliotibial tract and posterolateral release affect
Advantage extension only
Provides anteroposterior and varus-valgus as well as some In FFD release the tight posteromedial corner first
rotational stability (substitute for deficient collaterals or
bone loss) Equal flexion/extension gap (Table 17.5)
If the flexion and extension gap is symmetrical, adjust
Disadvantages the tibia
Increased femoral bone resection If the gap is asymmetrical, adjust the femur (majority
Aseptic loosening due to the large forces acting on the of cases)
prosthesis (these are stemmed implants) Downsize the femur, cut more off the posterior femoral
condyle
Constrained-linked (hinged) condylar implant (RHK)
Resect the distal femur to increase the extension gap
Rarely indicated
Increasing the tibial slope increases the flexion gap
Indications PCL excision increases the flexion gap by roughly 5 mm
Used for global instability (total collateral ligament Tibia cut
disruption/recurvatum)
Posterior slope 3–5° generally, but depends on knee
Severe bone loss ± neuropathic arthropathy
design
(Charcot joint)
PS knee performs better with no slope
Tumour resection
CR knee performs better with a 3–5° slope
Hyperextension instability, e.g. in polio
Advantage Distal femoral cut

Provides stability in cases of large bone loss and significant Valgus angle 5–7° from anatomical axis
instability Perpendicular to mechanical axis
Intramedullary alignment jig
Disadvantages Cut less femur in CR knee
Large bone resection Cut 1–2 mm more femur in PS knee
High level of constraint leading to increased rate of aseptic
loosening due to the large forces acting on the prosthesis To make flexion gap rectangular
(these are stemmed implants) Externally rotate the femoral cutting block 3° or align it
Periprosthetic fractures for the stress risers created parallel to the femoral epicondylar axis
325
020
Table 17.5 Balancing the flexion and extension gaps
Flexion gap loose Flexion gap OK Flexion gap tight

Extension gap loose Thicker insert Augment femur/downsize Convert to PS design/downsize femur
femur and use thicker insert
Extension gap OK Resect more distal femur and Perfect Downsize femur/increase tibial slope
use thicker insert
Oversize femoral component
Extension gap tight Resect distal femur Resect distal femur/release Thinner plastic insert/cut more tibia
posterior capsule
Release capsule posteriorly
Flexion/extension gaps should be rectangular and equal Fixed flexion deformity

Never internally rotate the tibial component <10° can be corrected by cutting bone
May need to resect more bone from the femur
Mal-alignment
Remove posterior osteophytes
Coronal mal-alignment causes a 24% failure rate at a Severe FFD needs posterior capsular cutting (with great
median period of 8 years58. The best implant survival has care) with the knee in extension and the capsule under
been in knees with overall alignment between 2.4° and 7.2° tension (lamina spreader)
of valgus tibiofemoral angle59. Computer navigation has
For very severe FFD, use a Cobb to lift the posterior
been advocated to decrease variability in surgical technique capsule of the femur while sticking to bone
and improve implant durability, and ultimately hoping to
lead to improved patient outcomes
Patellofemoral maltracking
Recent evidence, however, has challenged this concept by
showing that a postoperative mechanical axis of 0 ± 3° did This is potentially a major problem after TKA. If the patella is
not improve 15-year implant survival60 mal-tracking, it is advised to release the tourniquet and re-
assess prior to taking any action. To prevent mal-tracking the
The optimum AP position of the femoral component is in
line with the anterior cortex of the femur surgeon should:
A forward femoral implant leads to overstuffing of the Externally rotate the femoral component
patella and instability in flexion Lateralise the femoral component
A medialized femoral component leads to patellar mal- Avoid anterior placement or oversizing of the femoral
tracking component
A posterior tibial slope of >10° leads to premature failure Avoid internal rotation of the tibial component (increases
Tibial medial overhang causes impingement and pain the Q angle)
(minor lateral overhang is acceptable) Avoid an excessive valgus angle
A slight posterior overhang is acceptable Avoid raising the joint line
A posterolateral overhang may cause popliteus muscle Medialize the patellar button
impingement Avoid inferior placement of the patellar component
The following cause increased anterior displacement of the
Medial release for varus knee patella:
1. Osteophyte excision Oversized femoral component
2. Deep MCL to posteromedial corner (pie crusting) Overstuffing the patella
3. Semimembranosus aponeurosis
4. Superficial MCL Patella resurfacing debate
5. Pes anserinus insertion This issue is still contentious in the field of arthroplasty. Recent
6. PCL long-term follow-up of 78 knees showed no difference in
outcome between resurfaced and non-resurfaced knees61. For
Mostly 1 and 2, but if still tight proceed to 3–6. Check stability
resurfacing:
at each stage.
Reduces anterior knee pain
Lateral release for valgus knee Improves knee strength in flexion (stair descent)
See ‘Valgus knee’, below. Less likely to revise the knee for anterior knee pain
020
Against resurfacing:
COMMENT: There is no right answer here, it is a personal
No difference in outcome preference – as long as you can back up your argument with
Increase wear particles evidence. Describing what you would do reveals to the examiner
Long-term problems with patellar fracture that you have thought about it and have formed an educated
Historically, extensor mechanism problems occurred in up to opinion. The examiner might not agree with you, but you have
10% of patients and accounted for up to 50% of the long-term stated in the outset that it is controversial.
problems of TKA. Reported problems include:
Patellar tendon avulsion Patella baja
Patella fracture and AVN Shortened patellar tendon, which is hard to evert
Patellofemoral instability Knee flexion is limited by patellar impingement on
Component loosening the tibia
Indications for selective patella replacement: Seen most often following previous HTO, fracture of the
Advanced osteoarthritic patella proximal tibia, or tibial tubercle osteotomy
Rheumatoid arthritis Avoid cuts that raise the joint line
Preoperative patellofemoral pain Increases the difficulty of TKR
Obese patients
Overweight females Managing patella baja
Chondrocalcinosis Use a small patellar dome superiorly
Trim anterior tibial and patellar polyethylene at the
impingement points
Examination corner Lowering the joint line by cutting more off the proximal
Adult orthopaedic and pathology oral 1 tibia and using distal femoral augmentation (rarely
necessary)
EXAMINER: While performing a total knee arthroplasty, what
are the options in regards to the patella? Raising the joint line affects:
CANDIDATE: What to do with the patella during total knee
PCL function
arthroplasty is a controversial topic with no consensus in the
Collateral ligaments tension
orthopaedic literature. The options are to leave the patella as it is 64–66
regardless of the amount of degenerate changes present, remove
Patellofemoral joint mechanics
all patella osteophytes, circumpatellar electorcautery or perform
patella resurfacing.
Valgus knee
There has been a recent RCT published in the BJJ in 2014 of 300 The normal tibiofemoral angle is 5–6°
knees revealed that the improved clinical outcome with The normal knee mechanical axis is 1.2° varus
electrocautery denervation compared with no electrocautery of The valgus knee can be defined as a tibiofemoral angle
the patella is not maintained at a mean of 3.7 years' follow-up62. >10°
Another prospective, randomised, double-blinded study of Valgus knee is associated with bony and soft-tissue
350 primary total knee arthroplasty with selective patellar abnormality
resurfacing with a mean follow up of 7.8 years demonstrated that There are acquired or pre-existing bony deficiencies
satisfaction was higher in patients with a resurfaced patella. In There is lateral subluxation of the patella
patients followed for at least 10 years, no significant difference There is lateral capsule and ligament contracture
was found. No difference was found in KSS scores, survivorship Elongated PCL may become dysfunctional in severe
and no complications of resurfacing were identified. The vast valgus
majority of patients with remaining patellar articular cartilage There is distal femoral rotational deformity with externally
do very well with TKA regardless of patellar resurfacing. Knees rotated epicondylar axis up to 10°
with exposed bone on the patellar articular surface were
excluded63. Aetiology
In view of the above, I would selectively resurface. If there is Mainly primary arthritis
evidence of Grade III–IV osteoarthritic changes involving the
Inflammatory arthritis and osteonecrosis (small
patella then I would resurface it. Otherwise, I would perform proportion)
circumferential electrocautery for the potential improved pain in
Post-traumatic arthritis (loss of lateral meniscus)
the short term, accepting that it is temporary.
Over-correction after HTO
Childhood metabolic disorder (rickets)
327
020
Alignment
No more than 5° femoral cut Examination corner
Component rotation is best achieved using the AP axis Adult orthopaedic and pathology oral 1
(Whiteside)
Do not use additional 3° of external rotation, as the distal EXAMINER: Describe what you see (Figure 17.20).
femur is externally rotated already CANDIDATE: This is an AP weight-bearing radiograph of bilateral
Be careful not to internally rotate the femoral component lateral compartment degenerative change which are more
by posterior referencing off a deficient lateral condyle significant on the left side. There are valgus deformities with loss
of joint space in the lateral compartments. There are osteophytes
Approach and soft-tissue release in the lateral compartment, evidence of subchonrdal cysts and
The medial parapatellar approach gives good access to the sclerotic margins all which are consistent with osteoarthritis of
whole knee and better soft-tissue cover (preferred the lateral compartment of both knees, with severe changes on
approach) the left side.
The lateral parapatellar is a direct approach. EXAMINER: The patient is 76 years old with a history of
Theoretically it preserves the neurovascular supply to the hypertension and hypercholesterolaemia, which are
extensor mechanism and enhances postoperative controlled with medication. She is otherwise independent but
rehabilitation her mobility has significantly been reduced due to continued
pain in the left knee, which disrupts her sleep and affect her
Make preoperative and intraoperative assessments of the
activities of daily living. What are you going to offer this lady?
deformity. If the deformity is passively correctable and the
flexion–extension gaps are equal, then a lateral release is CANDIDATE: I would take a detailed history.
unnecessary EXAMINER: (Interrupts) done. What I told you is the history you
There is no consensus regarding the sequence of soft-tissue will get from her. What are you going to do next?
release CANDIDATE: I would like to examine her gait, do a full knee
examination, including measuring the valgus angle with a
Soft-tissue release in the valgus knee goniometer as well as noting any evidence of fixed flexion
Osteophyte excision deformity in the knee which is not uncommon in severe valgus
Lateral patellofemoral ligament release OA. I will assess the integrity of the collateral ligaments to
establish if she has an intact MCL and whether any of her valgus
Release posterolateral capsule off the tibia
deformity is correctable. I would also examine her hip and ankle
Sacrifice PCL in moderate-severe valgus
Flexion and extension tightness

Release (or pie-crust) lateral collateral ligament (LCL) from
the femur
Extension tightness
1. Release (or pie-crust) the iliotibial band. A release would be
performed at Gerdy’s tubercle
2. Release popliteus (has a flexion component to it)
Flexion tightness
Release posterolateral capsule off the tibia
Cut PCL and recess posterior capsule
If it remains tight, you rarely need to proceed to
: Biceps femoris tendon – Z-lengthening
: Detachment of lateral head of gastrocnemius
Complications
Same as for varus knee
There is a high risk of peroneal nerve stretching after severe
valgus correction
It is best to use a loose bandage postoperatively and to keep
the knee in slight flexion Figure 17.20 AP radiograph bilateral valgus knees
020
to check for any deformities or stiffness. I would then obtain a If the MCL is too lax or the LCL had to be recessed/released
lateral and skyline radiograph of the knees and pelvis and hip during the procedure to achieve the necessary correction, then
x-ray if indicated. Long leg view would be very helpful to I would proceed to a more constrained knee prosthesis. This
determine the mechanical axis and degree of valgus. Routine would be a non-hinged constrained prosthesis that provides AP
bloods including CRP, ESR, Hb and group and save as well as a and varus-valgus stability with the high central post as well as
CXR and ECG would be required if any surgical intervention is to some rotary stability. This will compensate for the lack of
be taken. collateral integrity. If the collaterals are completely deficient
EXAMINER: Well she has tried all non-operative measures with global instability or bone deficiency (rarely the case), then
with her primary care physician and musculoskeletal I would consider a hinged prosthesis such as a rotating hinge.
physiotherapist and has come to you asking for an operation. This has the disadvantage of increased rate of aseptic loosening
What are you going to offer her? She has 10° of fixed flexion secondary to the high level of constraint and the large forces
and 20° of valgus deformity. acting on the prosthesis. The stems that used in both femoral
CANDIDATE: I will offer her a total knee replacement. and tibial side are present to increase stability and reduce the
EXAMINER: What approach would you use? stress at the bone/cement interface. These implants also have a
CANDIDATE: I would perform a medial parapatellar approach as higher risk of periprosthetic fractures from stress risers below
this is the approach that I am most familiar with when the stems.
performing at TKR. I am aware that some people would advocate
the lateral parapatellar approach in cases of severe valgus
deformity. Unicompartmental knee replacement (UKR)
EXAMINER: Talk me through the approach and releases. It is important to understand that UKR is not ‘half a total
CANDIDATE: After the midline incision, medial parapatellar knee’67. It is a ligament-balancing procedure more than a
approach, excision of Hoffa’s fat pad and everting the patella realignment procedure and is not intended to correct an
I would excise the osteophytes on both femur and tibia. extra-articular deformity. The pattern of arthritis is usually
I would then release the lateral patellofemoral ligament. anteromedial owing to ACL preservation. The intact ACL
I would perform a lateral and posterolateral capsular release from and the preserved posterior tibial plateau cartilage lead to
the tibia, while protecting the LCL and popliteus. I would stretching of the MCL every time the femur rolls back in
routinely sacrifice PCL in moderate to severe valgus deformities. flexion, preventing fixed varus deformity68.
If the knee remains tight laterally in extension the I would
pie crust the iliotibial band (ITB) or release it subperiosteally
off Gerdy’s tubercle. The next structure to release would be
Advantages
the popliteus (although it acts both in flexion and
Avoids patellofemoral overload
extension. However, if the knee remains tight the LCL will need Retains knee kinematics
to be released, usually subperiosteally off the tibia. I would Restores function and range of movement
also routinely recess the posterior capsule with extreme care if Rapid recovery: Three times faster than after TKR
any fixed flexion remains. Rarely, which I have no experience Less blood loss and, hence, transfusion
with, one can perform a Z-lengthening to the biceps femoris Cost less than TKR (all factors considered)
or detach the lateral head of gastrocnemius in extreme Quicker operation than TKR
case when the deformity is not corrected by conventional Quicker return to work than after TKR
releases. Lower infection rate (halved) compared with TKR
EXAMINER: Good. What are your thoughts preoperatively Allows minimally invasive approach
and what would you ask the theatre staff to prepare? Easier to revise than HTO
CANDIDATE: Given that this is a valgus knee with fixed flexion No patellar fractures or dislocations
deformity, it will require soft-tissue releases to correct the Maximizes the longevity of total knee arthroplasty
alignment. As mentioned in my examination, I would want to Reduced incidence of DVT
assess the collaterals, specifically the integrity of the MCL. I would
Reduced mortality from pulmonary embolism
also want to assess whether these deformities are correctable or
High flexion lifestyle
fixed. This will dictate the type of knee prosthesis required for this
patient.
If the collaterals remain competent following both bone cuts
Prerequisites
and soft-tissue release to correct the deformity, then I would Intact ligaments (especially ACL and PCL)
proceed with an unconstrained TKR. Given this is a valgus knee Correctable varus deformity
I would expect that there might be attenuation of the PCL and, <10° FFD
therefore, a PCL-sacrificing prosthesis would be my preference. Flexion beyond 100°
329
020
Preservation of the articular cartilage lateral

more concerning as this can dictate the level constrain needed.
compartment, as demonstrated on a valgus stress
Although in most occasions a CR or PS TKR can be implanted, a
radiograph
studies have shown that the revision of UKA to TKA is a more
Clinically asymptomatic PF joint and contralateral complex procedure compared to primary TKA, with a higher
compartment
incidence of using constrained implants (twice as likely in a revision
vs primary TKA) and the use of thicker polyethylene inserts70.
Contraindications I would ensure that the theatre staff have constrained implants
Inflammatory arthritis (non-hinged and hinged) as well as stems and augments
Sepsis available at the time of revision. I will also warn the patient of the
Young age slim possibility of converting to a two-stage revision, if
High level of activity unexpected intraoperative findings are faced.
Relative contraindications Painful knee arthroplasty

ACL degeneration
Painful knee arthroplasty presents a major diagnostic chal-
Chondrocalcinosis69 lenge. In certain cases even a careful history-taking, meticulous
Lateral meniscectomy clinical examination and numerous investigations may not
Osteonecrosis help in reaching a diagnosis. Infection is particularly difficult
Combined obesity and small bone size in some women to diagnose. To date there is no single preoperative investi-
gation that can reliably diagnose an infection. Our inability to
Principles diagnose subclinical infection before revision surgery is still a
major concern.
Appropriate for 25% of osteoarthritic knees requiring
arthroplasty
Never release the MCL Possible causes of painful knee arthroplasty
Polyethylene-bearing dislocation rate is 1/200 after medial Infection
compartment mobile bearing UKR Aseptic loosening
Polyethylene bearing dislocation rate is up to 6% after Instability
lateral compartment mobile bearing UKR Stiffness
Dislocation rate can be reduced by using a fixed bearing Mal-rotation
UKR Mal-alignment
Patellar pain or dislocation
Management options for medial compartment OA Extensor mechanism rupture
HTO suitable for high-demand, young patients Incompetent medial collateral ligament
UKA (better functional results, much better 10-year Periprosthetic fracture
survival – 98% vs 66%) Implant breakage
TKA Complex regional pain syndrome
Hip or spine pathology (referred pain)
Unexplained pain (1/300)
Examination corner
Adult and pathology 1 oral Management
EXAMINER: If you had a patient who has a UKA implanted in his History
knee 12 years ago with symptoms of gradual onset of pain, Date of index operation, postoperative pain relief/problems,
serial radiographs over the years with evidence of loosening wound leak, wound infection (and need for antibiotics), pain
which has been fully investigated and is aseptic, what at rest, mechanical pain, stair climbing and descent, any injuries,
implant would you chose to revise him to? medical problems, especially diabetes and rheumatoid arthritis.
CANDIDATE: As long as the patient is fit and able to withstand a
further procedure, and I am happy with the evidence that this is
Examination
aseptic loosening, I would discuss the option of performing a single Limp, walking aid, leg alignment, patellar alignment/tracking/
stage revision to a primary unconstrained total knee replacement. tenderness, inflammation, effusion, quadriceps tone, CRPS
I would assess the potential bone loss preoperatively and (RSD) signs, joint tenderness localized/generalized, ROM
intraoperatively. The tibial bone loss is usually more prominent and active/passive, laxity in sagittal/coronal plane and finally assess
the hip, spine and foot.
020
Investigations
Plain weight-bearing x-ray, bloods (including WCC, ESR and CANDIDATE: It is made of ultra-high-molecular-weight polyethylene
CRP – IL-6 (expensive) in specialist units), bone scan (not (UHMWPE). It is a subset of thermoplastic polyethylene and has
helpful until at least year after the index procedure), white long hydrocarbon chains. These chains are bonded together by
cell-labelled bone scan, knee aspiration, fluoroscopic align- covalent bonds. The longer chain allows more effective load
ment check, CT scan to check rotation and long leg films to transfer to the polymer by strengthening intermolecular
assess the overall alignment. SPECT bone scan and SPECT–CT interactions. This leads to a very tough material with a high
has also been a novel imaging option to detect loosening/ impact strength.
infection and highlight areas of maximal activity. UHMWPE is highly resistant to corrosive chemicals, has a very
low coefficient of friction and is highly resistant to abrasion.
It was first used clinically by John Charnley in 1962.
AAOS clinical guideline practice summary for diagnosis of
EXAMINER: How has the properties of the polyethylene been
periprosthetic joint infections of the knee71
manipulated to improve its characteristics?
In patients with suspected periprosthetic infection, the AAOS
CANDIDATE: We now have highly cross-linked UHMWPE or XLPE. It
working group strongly recommended:
is cross-linked by using gamma or electron beam radiation, which
Testing ESR and CRP is then thermally processed to improve the material’s oxidation
Joint aspiration resistance. This process is performed in an inert environment of
The use of intraoperative frozen sections vacuum or inert gas, to prevent oxidation. Antioxidants, such as
Obtaining multiple intraoperative cultures ( at least three vitamin E, have been infused into the XLPE in order to abolish the
but no more than six using different instrument for each free radicals that are introduced during the irradiation process.
sample and from different areas) The cross-linking of UHMWPE has reduced the rate of wear both
Against initiating antibiotic treatment until after cultures in vivo and in vitro.
Against the use of intraoperative Gram stain (as it is not EXAMINER: Is highly cross-linked polyethylene currently used in
helpful in ruling out infection) clinical practice?
Nuclear imaging was weakly recommended as an option CANDIDATE: Yes, it is now commonly used as a bearing surface in
in patients in whom diagnosis of periprosthetic joint total hip arthroplasty with positive results regarding less wear in
infection has not been established and who are not comparison to conventional polyethylene, although showing
scheduled for re-operation similar amount of surface damage in retrieved acetabular liners72.
However, this is not yet the case in knee arthroplasty although
What is the definition of periprosthetic joint infection? many studies are looking into that.
It has been defined by the workgroup on the Diagnosis of EXAMINER: What are the disadvantages of XLPE?
Periprosthetic Joint Infection at the Proceedings of the CANDIDATE: It is more brittle than conventional poly and, therefore,
International Consensus Meeting on Periprosthetic Joint has a higher risk of fracture. It is also two to four times more
Infection in 2013 as: expensive. A study from HSS showed that although material
Two positive periprosthetic cultures with identical properties of XLPE reduce adhesive and abrasive wear, it does not
organisms reduce the risk of crack propagation, deformation, pitting and
OR delamination found in TKR. Given that wear-induced osteolysis in
TKR has not been found to be a major cause of failure at long-term
A sinus tract communicating with the joint
follow-up and that mid-term follow-up studies show no difference
OR
in outcome measures between conventional PE and XLPE in
Three of the following minor criteria knees, they currently cannot recommend the use. Conventional
: Elevated CRP and ESR compression-molded polyethylene with its outstanding long-term
: Elevated synovial fluid WCC OR ++ change on results should remain the material of choice in TKR73.
leukocyte esterase test strip
: Elevated synovial fluid PMN%
: Positive histological analysis of periprosthetic tissue
Polyethylene wear
: Single positive culture
The rate of polyethylene wear and osteolysis is determined by
several factors:
Patient factors: Age, size and activity level
Examination corner
Surgical factors: Alignment, rotation, cementing, balancing
Basic science oral 1 Implant factors
EXAMINER: What is the material of the insert between the : Polyethylene thickness
femoral and tibial component made of? : Material, property and polymerisation
331
020
: Manufacturing method: Compression moulding

preferred to machined component EXAMINER: How would you go about confirming your diagnosis
: Sterilisation method: Avoiding gamma radiation in air prior to any surgical intervention?
: Cross-linking: Moderately/highly cross-linked CANDIDATE: I would perform a joint aspiration in a sterile
polyethylene – May offer improved resistance in environment. I prefer doing this in theatre. The technique that
the knee I use is aspiration of the joint through a 3 mm stab incision of the
: And whether the implant vacuum pack is still in date dermis with a scalpel under local anaesthetic, so avoid any skin
and not expired which would increase the presence of commensals appearing in my sample. I would obtain as much
free radicals fluid as possible with a large bore needle and insert them directly
into blood culture bottles as well as sending it in a microbiology
specimen pot for urgent gram stain as well as well microbiology
Examination corner and culture including sensitivity and synovial white blood cell
Adult and pathology oral 1 count and differential (synovial PMN > 90% is positive for acute
infection and >80% for chronic as per the Consensus Meeting on
EXAMINER: A patient comes in to your elective clinic as an add-
Periprosthetic Joint Infections).
on, as he was feeling generally unwell, and coming to see you
C-reactive protein concentration, leukocyte esterase
because his knee has become suddenly more painful, swollen
concentration in the joint fluid aspirate, and other molecular markers
and red. He is an 84-year-old man with no significant medical
of periprosthetic joint infection are currently under investigation.
history except a total knee replacement 3 years ago. What
EXAMINER: If you were to embark into operative treatment
would you like to ask this patient?
what are your options and what is your preferred method?
CANDIDATE: I would initially like to establish the reason for total
CANDIDATE: The main principles are to eradicate infection and
knee replacement and if possible find out where it was performed
eventually implant a new prosthesis in a clean environment to
and obtain the operative details. I would ask him if there were any
restore knee function that is pain free. The two-stage exchange
wound problems or evidence of infection during the
arthroplasty is currently the most accepted procedure for the
postoperative period, such as a superficial wound infection that
treatment of periprosthetic joint infection. Two-stage revision
required antibiotics, or any more serious infections that required
involves resection of the infected implants, thorough
admission to hospital and IV antibiotic therapy. I would then want
debridement and irrigation, placement of a temporary antibiotic-
to establish more about his current state and medical
impregnated cement spacer (static or articulating), and delayed
background, if he is on any immunosuppressive therapy, or if he
component reimplantation once the infection is eradicated after a
has had any trauma or recent infective processes that he is aware
period of intravenous antibiotic. One-stage revisions are
of. I would then move on to investigate if there has been any
increasing in popularity in certain specialist centres. Its
changes in regards to how the knee feels to him, and if there is
proponents focus on its advantages over two-stage procedures in
any restriction in its movement.
it being a single operation for the patient, with decreased
EXAMINER: Good. What are you concerned about?
morbidity, lower cost and some argue that it provides improved
CANDIDATE: A prosthetic joint infection.
functional results75. Strict criteria are usually applied in centres
EXAMINER: What are your initial investigations, specifically who perform single-stage revisions including: A healthy patient,
your blood markers? infection being acute and postoperative, known organism and
CANDIDATE: I would request an AP, lateral and skyline radiograph of adequate soft-tissue coverage.
the knee, looking for any signs of loosening, fracture, and compare I would personally offer the patient a two-stage revision.
it with the last postoperative radiograph available. In regards to I would support my decision with a recent systematic review that
blood tests, I would request a FBC – Looking at the WCC and demonstrated an average success rate of 90% for two-stage
differential as well as signs of anaemia for the possibility of revision in infected total knee replacements76. The study also
anaemia of chronic infection. I would request a CRP, an ESR and, if reported that two-stage revision provided better outcomes than
I am in a specialist unit, IL-6, which is very sensitive and specific. one-stage revision.
EXAMINER INTERRUPTS: So you mention sensitivity and
specificity. Please tell me what are the sensitivity and
specificity of the blood test that you requested, as you will
need to know how much you can rely on the results of the Knee arthrodesis (Figure 17.21 a and b)
tests that you have requested?
CANDIDATE: CRP has a sensitivity of 88% and a specificity of 74%,
Indications
ESR has a sensitivity of 75% and a specificity of 70% and IL-6 has a
Failed knee replacement
sensitivity of 97% and a specificity of 91% according to a study by
Uncontrollable sepsis
Berbari in JBJS(AM) in 201074. These tests are not diagnostic Neuropathic joint
independently. Young patient with severe articular joint disease and
ligamentous damage
020
(b)
(a)
Figure 17.21 Knee arthrodesis (a, b: AP and lateral radiographs) secondary to loss of extensor mechanism following a severe 3% full thickness burn over her
knee joint with concurrent infection and partial neuropathy in a diabetic 79-year-old woman. This was done using a Whichita Fusion Nail® and the patient achieved
full union with very good function and resumed independence77
Disruption of extensor mechanism 10–20° of flexion

Poor soft-tissue envelope The above may be easier to achieve with external fixator
Systemically immunocompromised rather than IM nail
Resistant microorganisms
Post-traumatic arthrosis in a heavy manual labourer
Techniques
1. Intramedullary arthrodesis
Contraindications Long custom-made nail through piriform fossa
Bilateral knee disease
Intramedullary fixation with modular and
Ipsilateral ankle or hip disease
non-modular nails
Ipsilateral hip arthrodesis
Linked nail through the knee is easier to apply
Severe segmental bone loss
More reliable in achieving union than external fixation
Contralateral limb amputation
Technically difficult
Forty per cent complication rate (nail breakage and
Optimal position for knee fusion migration)
7–10° of external rotation May cause widespread osteomyelitis in the tibia and
Slight valgus femoral shaft
333
020
The nail has to be inserted after removing implants and

infection treatment
2. External fixation
Conventional or circular frames
Allows for arthrodesis in the presence of infection
Can be applied at the time of implant removal
A 20–60% complication rate (neurovascular
injury, pin site infection and fracture through
pin site)
3. Plate fixation
Main drawback is recurrent or new infection
Single anterior or dual plating
Complications
Non-union
Mal-union
Delayed union
Recurrent infection
Benign synovial disorders

Pigmented villonodular synovitis
Synovial chondromatosis
Synovial haemangioma
Lipoma arborescens
Examination corner
Adult orthopaedic and pathology oral
EXAMINER: What is the diagnosis? (Figure 17.22) Figure 17.22 Lateral knee radiograph with synovial chondromatosis
CANDIDATE: This is a weight-bearing lateral knee radiograph that
reveals multiple small, well-defined, juxta-articular mineralized
nodules of similar size. This is likely to be synovial Pigmented villonodular synovitis (PVNS)
chondromatosis. PVNS is a benign proliferative condition of the synovial mem-
EXAMINER: So what is synovial chondromatosis? brane and tendon sheath. Knee PVNS is usually monoarticular
CANDIDATE: It is a benign mono-articular disorder of unknown and affects young adults. It is characterized by synovial inflam-
origin that is characterized by multiple intra-articular cartilaginous mation and haemosiderin deposits.
metaplasia forming loose bodies, not all of which are ossified. Aetiology: Unknown, possible trauma, neoplastic process,
Seventy per cent of cases are found in the knee followed by chronic inflammation
twenty per cent in the hip. It most commonly affects patients in Incidence <1/500 000
the fourth and fifth decade and men are more commonly Usually painless knee swelling, but it may present with
affected than women. catching, multiple nodules, locking or instability
EXAMINER: Agreed, arthroscopy may not be appropriate here. Two main types: Diffuse and localized
Any other risks that you would like to mention to the patient Diagnosis is mainly by MRI scan (Figure 17.23) and
in regards to this condition? biopsy. Joint aspirate colour and cytology can be helpful
CANDIDATE: This is a benign condition, but I will be sending The diffuse type is commoner and harder to eradicate
the samples for histological confirmation of the radiological Bone erosion, subchondral cysts and joint space narrowing
and macroscopic diagnosis. There is a very small chance of may be seen in PVNS
malignant degeneration into synovial chonrdosarcoma but this is
Treatment aims to eradicate all abnormal synovial tissue
rare.
A combination of non-surgical and surgical intervention
may be necessary
020
: Secondary arthritis is best treated with knee

arthroplasty
Synovial chondromatosis (osteochondromatosis)

This is a benign metaplastic disorder of synovial membrane,
characterized by the formation of multiple cartilaginous
nodules or osseous loose bodies inside the articular space.
It typically affects adult men twice as often as women
Patients present with pain, swelling, effusion, locking and
limited motion
Clinical examination reveals diffuse tenderness, crepitus,
palpable nodules or loose bodies
Can be localized or generalized
X-ray shows calcified intra-articular loose bodies
MRI shows synovial proliferation and calcified nodule or a
large intra-articular soft tissue
Synovial chondromatosis is generally a primary condition,
but it may occur secondary to osteoarthritis
In primary synovial chondromatosis the loose bodies
are typically numerous, small, round and uniform in size
In secondary synovial chondromatosis the loose bodies are
few and variable in size
Treatment is by arthroscopic removal of loose bodies alone
or with synovectomy
Recurrence after open/arthroscopic treatment ranges from
3% to 30%
Figure 17.23 Multiple PVNS lesions shown on the T2-weighted MRI with Recurrence can occur even after synovectomy
low signal intensity in the posterior and anterior aspect of the knee with an
effusion present
Knee disarticulation (through knee amputation)
Radiation therapy: External beam therapy is now less popular Any indication such as infection, ischemia or traumatic
than intra-articular radioisotope yttrium-90 injection, which An alternative to ultrashort transtibial stump
has beta emission only, causing less body irradiation Important alternative to transfemoral amputation
Surgical treatment New indications is infected and loose knee arthroplasty
:Arthroscopic synovectomy has better functional results Advantages
than open surgery, but higher recurrence rates. However, Superior compared to a transfemoral stump
it can offer good access to the posterior compartment if Thigh muscles are all preserved
performed by experienced arthroscopists. Multiple
Preservation of adductor muscle insertion
portals can be useful in these cases including a
Hip motion is not limited
posteromedial and suprapatellar portal. It is best reserved
Bilateral knee disarticulation can walk ‘barefoot’
for well-assessed patients (MRI/biopsy), less extensive
disease with only intra-articular involvement Enhanced proprioception
: Open synovectomy is usually through combined anterior A long lever arm when sitting
and posterior approaches. It is associated with a high rate Decreased metabolic cost of ambulation
of postoperative stiffness and slow rehabilitation
Treatment plan Nail–patella syndrome
: Localized PVNS and less extensive disease: Autosomal dominant genetic disorder Chromosome 9
Arthroscopic synovectomy alone can be sufficient Lean body build
: Diffuse PVNS involving the popliteal compartment: Patella affected in 90% of patients, patellar aplasia in 20%
Arthroscopic synovectomy through anterior and (Figure 17.24)
posteromedial portals followed by yttrium-90 (6 weeks Elbows: Limited pronation, supination, extension
post-operation) Subluxation of the radial head may occur
: Recurrence (20–50%) can be treated by open radical General hyperextension of the joints can be present
synovectomy Exostoses (‘iliac horns’) 80% of patients
335
020
Knee outcome measures

SF36 is the most popular general health outcome measure
WOMAC – Western and Ontario McMaster University
Osteoarthritis Index: Most commonly used condition-
specific outcome measure for osteoarthritis owing to its
efficacy and sensitivity to change
KOOS: Developed to evaluate sports-related injuries such
as ACLs and meniscal injuries
IKDC – International Knee Documentation Committee,
1993: Joint-specific tool to evaluate symptoms, function
and sporting activity
Lysholm Score, 1982: Developed to evaluate knee ligament
surgery
Cincinnati Knee Rating Scale, 1983: Assesses subjective
symptoms and functional activity level
Tegner activity level, 1985: Designed to lend numeric
scores to patient activity level. It is sport-specific; hence, it
may limit its applicability cross cultures
MARX Activity Level Scale: This is a functional activity
questionnaire rather than a sport-specific questionnaire. Its
strength lies in its measure of function rather than sport
activity
Oxford Knee Score: Designed specifically for patients
undergoing knee replacements. It is joint-specific with
Figure 17.24 Lateral knee radiograph demonstrating patellar hypoplasia good evidence of reliability of content and validity of
construct78. It has also been shown that the Oxford Knee
Kidney failure and teeth weakness Score at 6 months is a useful predictor of early revision
The treatment of nail patella syndrome is mainly supportive after TKRs. Scores <27 are associated with a risk of
with the majority of patients being asymptomatic. revision within 2 years79
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020
Foot and ankle oral core topics

Chapter
18 Kailash Devalia and Jane Madeley
Introduction Ankle arthroscopy1

There is a large recommended syllabus from the British Arthroscopes (1.9, 2.3 and 2.7 mm diameters, 30 and 70°
Orthopaedic Foot and Ankle Society for the FRCS (Tr & Orth) scopes).
examination. This syllabus is very detailed and comprehensive. Non-invasive distraction technique.
Whilst a candidate may not be expected to know all the details
of every condition, he or she should at least be prepared to
answer questions on most conditions and in particular on the Contraindications
more common foot and ankle disorders. Absolute: localized soft-tissue or systemic infection, severe
Most foot/ankle conditions are likely to be encountered in rigid end-stage degenerative joint disease
the short cases, although an intermediate case should not come Relative: moderate degenerative joint disease, severe
as surprise. As with all cases, appropriate history and slick, oedema, RSD and suspect vascular supply.
targeted examination, go a long way to securing a pass even if
you only know a little on managements available.
The BOFAS Educational Comittess hold courses aimed Indications
for trainees nearing the FRCS (Tr & Orth) exam. The Diagnostic
emphasis is on clinical examination cases and day to day When MRI findings are in doubt
clinical scenarios. The content is taught to the standard of
the FRCS (Tr & Orth) exam. The course has grown in
Therapeutic
complexity and can be up to 3 days in length even involving
cadaveric workshops. The course has had excellent feedback Anterior and anterolateral ankle impingement
and comes highly recommended. Anterolateral synovitis lesion following plantar flexion
and inversion injury
Anterior ankle impingement with mild degenerative changes
Common cases Effective outcome with both open and arthroscopic
Several foot and ankle cases are known as to be surgery (86% satisfaction rate)
examiner favourites as they are relatively common conditions With arthroscopy: quicker recovery, reduced length of
and are easily available to recruit for the exam. These cases stay and smaller incisions
include:
1. Hallux valgus Osteochondral lesions
2. Hallux rigidus Arthroscopic debridement associated with any technique of
3. Rheumatoid foot subchondral bone penetration (curettage, drilling or
4. Pes cavus microfracture) in lesions <15 mm in diameter has fair
5. Residual CTEV evidence (level II and III studies) recommending intervention
6. Pes planus Evidence regarding lesions >15 mm is insufficient to make
7. Tarsal coalitions recommendations
These conditions are also relatively common oral topics for the
adult pathology or paediatric orals. Good knowledge, stepwise Ankle arthrodesis
examination technique, going through set answers for particu- Equivalent fusion rates to open arthrodesis
lar topics and being aware of where you can end up digging a Significantly quicker times to union, decreased pain,
hole for yourself, can compensate for a practical weakness in shorter hospital stay, faster rehabilitation and mobilization
the subject. and a lower complication rate
339
021
Arthroscopic ankle arthrodesis in ankles with coronal Anterolateral

plane deformity <15° has fair evidence to support this Lateral to peroneus tertius tendon and extensors
mode of intervention (level II and III studies) Working port. Created once arthroscopy is introduced
Insufficient evidence for arthroscopic fusion in ankles with Risks: Damage to superficial peroneal nerve
>15° of varus/valgus deformity Preoperative mark the SPN branch by plantar flexion of
Risk of non-union forth toe. Most commonly injured nerve in ankle
arthroscopy
Septic arthritis
Effective intervention with cure rates over 90%, conversion Anterocentral
to open washout if failure to improve within 2 days of Rarely used as considered dangerous
arthroscopic irrigation Medial or lateral to EDL tendon
Risks: Damage to anterior tibial artery and deep peroneal
Arthroscopic landmarks nerve; to EHL and EDL; to terminal branches of the
A thorough knowledge of ankle anatomy is needed to avoid superficial peroneal nerve
potential complications
Before performing ankle arthroscopy it is important to Posterior scope
mark out in pen on the surface of the ankle potential Patient is prone.
structures at risk: Dorsalis pedis artery, deep peroneal For posterior impingements, Os trigonum, Haglund’s excision
nerve, great saphenous nerve, anterior tibial tendon, and, rarely, osteochondral lesions
peroneus tertius tendon and superficial peroneal nerve and
branches Posterolateral
The joint line is identified by inverting and plantarflexing Just lateral to the edge of the Achilles tendon, at the level of
the ankle the tip of the lateral malleolus. The portal is usually at or
slightly below the joint line
Joint Distraction Most commonly used and safest portal
Good distraction of the joint is necessary for adequate Risks: Damage to short saphenous vein and sural nerve
visualisation
Skin traction with heel and foot strap. Avoid superficial Posteromedial
midfoot placement of the foot strap, less soft tissue Rarely used
protection underlying nerves. Medial to Achilles tendon at the level of the tip of the
Body traction: Lopped around surgeon. The surgeon lateral malleolus
applies more or less traction by leaning forwards or Enter joint capsule under direct vision from the
backwards. Simple, cheap and effective posterolateral port
Risks: FHL, posterior tibial vessels and nerve
Joint distension
Usually with 30 mm of normal saline Complications
Portals Studies have reported variable complication rates, ranging
from 7.6–17% including:
Five portals have been developed for use
Nerve injury (SPN most common)
Anterior scope Infection
Patient is supine Painful scars
For anterolateral impingements, most osteochondral Synovial fistula
lesions and arthroscopic ankle arthrodesis Articular cartilage damage
Complex regional pain syndrome
Anteromedial
Prolonged portal drainage
Primary viewing port. Least dangerous port.
Established first
Just medial to the tibialis anterior tendon and lateral Rheumatoid foot
to the saphenous nerve and vein directly at level of joint Introduction
line. Incise skin, bluntly dissect soft tissues and joint The two predominant symptoms of the rheumatoid foot are
capsule pain and deformity. Approximately 15% of rheumatoid
Risks: Damage to tibialis anterior tendon, saphenous nerve patients present initially with foot symptoms. Eventually
and vein 70–90% of those with long-standing rheumatoid arthritis have
021
Chapter 18: Foot and ankle oral core topics
foot involvement. The disease starts in the forefoot and, with Assess the skin condition for risk of infection and wound
time, advances to involve the hindfoot. healing
Practice describing the typical rheumatoid deformities Assess the vascular status of the foot
using clinical photographs as props – You have 30 seconds to Make a careful neurological assessment as there may be a
1 minute maximum real time for this in the exam. This is more neuropathic component
helpful for a viva question but is also useful for a clinical case. Look for tendinopathy or ruptured tendons
Assess whether the primary deformity is in the hindfoot or
forefoot
Deformities Determine which joint is causing pain; this is not always
A. Forefoot – very commonly involved easy and may need a diagnostic injection
1. Hallux valgus is often present but rarely problematic Take a drug history, in particular steroid therapy and
2. First MTP joint erosive arthritis, sometimes associated methotrexate, anti-TNF-α agents
with IP joint arthritis
3. MTP joints develop dorsal subluxations/dislocations
(synovitis of the MTP joints, weakening and stretching
Management
of the capsule and collateral ligaments, planar plate Multidisciplinary approach. Optimisation of medical treat-
laxity/rupture) with the cushioning fat pads pulled ment with involvement rheumatologists.
forwards with atrophy (metatarsalgia and forming
keratosis) Conservative
4. The MT heads become prominent around the sole of the Special shoes/footwear
foot predisposing to pain, callosities and skin breakdown Accommodating orthoses
5. Hammer toe and claw toe deformities of the lesser toes Steroid injections
(intrinsic muscle contracture) Immune-mediating drugs (TNF inhibitors)
B. Hindfoot – less commonly involved and less severe
1. Valgus ankle, which often presents late with pain and Surgery (see Examination corner)
instability Goals of surgery are a stable pain-free plantar grade foot.
2. Valgus hindfoot with synovitis and arthritis in the There is a move towards joint preservation surgery.
subtalar joint If both the forefoot and hindfoot are involved, care is needed
3. Talonavicular joint subluxation/dislocation causing to decide which to operate on first. If the hindfoot is correctable,
flattening of medial arch and forefoot pronation go for forefoot surgery first. If the hindfoot is severely deformed
4. Subfibular impingement and rigid, it is often necessary to correct this first.
C. Soft tissues
Forefoot
1. Tenosynovitis of the tibialis posterior and peroneal
tendons presents mainly with swelling of tendons both Standard technique for forefoot correction in rheumatoid
medially and laterally around the ankle foot: MTPJ1 arthrodesis(10° dorsiflexion/10° valgus) with
2. Collapse of the medial longitudinal arch of the foot MT2–4 head resections (Fowler’s procedure) and
occurs due to rupture or weakening of the tibialis realignment of lesser toes deformities
posterior tendon and gradual disruption of the Synovectomy useful when severe synovitis present but no
talocalcaneal interosseous ligament MTPJ subluxation/dislocation and no metatarsalgia
3. Distal migration and atrophy of the forefoot fat pad Weil’s shortening osteotomy of MT heads is an alternative
4. Prominent plantar metatarsal heads leading to plantar to MT heads resection if no severe arthritic changes present
callosities in joint. This allows reduction of the MTP joints and return
5. Painful bursitis between the metatarsal heads of the fat pad to the sole of the foot
6. Tarsal tunnel syndrome (valgus hindfoot) Stainsby procedure is where proximal phalanx base is
resected with release of plantar plate and extensor tenodesis
7. Morton’s neuroma
to flexors. This is an alternative to MT heads resection or
8. Retrocalcaneal bursitis
shortening
Mechanical offloading of MTPJ reduces synovits (through
MT heads resection/MT shortening)
Clinical examination If associated hallux valgus is present with lesser toes
Proximal to distal deformities, then MT head resections would accentuate the
Assess the hip and knee before foot surgery. This might hallux valgus and MT-shortening osteotomies may be a
need addressing first prior to foot surgery better option
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Hallux valgus with no arthritic changes: better to perform involving the MTP joints, subchondral cysts whilst with advanced
modified Lapidus rather than standard MT osteotomy and disease subluxation, dislocation, deformity and ankylosis are
soft-tissue correction seen.
If hallux valgus present with MTPJ1 arthritis, MTPJ
Adult and pathology oral 2: radiographs of a rheumatoid foot with
arthrodesis is a better alternative
dislocated MTP joints
Main complications with forefoot reconstruction is
metatarsalgia and recurrence of deformity Discussion about surgical management.
Althogh silastic joint arthroplasty could be a good Pobble amputation. This operation involves amputation of all
option for the hallux, in rheumatoids results are not the lesser toes at the MTP joints. It is used for severe pain and
promising because of the risk of erosive synovitis and deformity. ‘I have been shown an old radiograph of a rheuma-
implant failure toid foot with the lesser toes missing and asked to comment
Lesser toe amputation could be an alternative with a severe on what operation was performed.’
isolated toe deformity
Adult and pathology oral 3: a strange question
Associated osteopenia justifies the use of stronger fixation
with locking plates for arthrodesis EXAMINER: A 53-year-old lady attends your orthopaedic clinic
complaining of a painful and swollen second left MTP joint. The
Hindfoot GP has mentioned a possibility of rheumatoid arthritis. How will
Arthrodesis is the main stay for correction of rheumatoid you confirm the diagnosis?
hindfoot and ankle deformity CANDIDATE: I would take a history from the patient, find out how
Try to avoid a single-joint arthrodesis (e.g. triple long she has had symptoms in the toe.
arthrodesis better than isolated talo-navicular arthrodesis) EXAMINER: Several months.
The most important aspects of hindfoot correction are CANDIDATE: I would measure ESR, CRP and rheumatoid factor.
alignment and stability EXAMINER: All normal.
Tibiotalocalcaneal arthrodesis is preferred over pantalar CANDIDATE: I am not sure I would do anything at this stage.
arthrodesis Possibly I would send her for an x-ray of the foot.
Total ankle replacement is successful; however, it is EXAMINER: The point here is that you may want to refer her on to a
associated with increased incidence of subsidence, fracture rheumatology colleague for a second opinion. Reviewing her in
and mal-alignment 6 months is also a reasonable option – She won’t come to any
harm. The radiograph shows proximal resorption of the proximal
Examination corner phalanx of this second toe.
Adult pathology oral 1 CANDIDATE: This can occur in rheumatoid disease.
Radiograph of rheumatoid foot shown (Figure 18.1) EXAMINER: Are you just going to accept this?
CANDIDATE: There are other causes for this resorption such as gout
Describe how rheumatoid arthritis affects the foot?
and I would measure her serum urate level.
Early radiographic features are soft-tissue swelling, widening EXAMINER: Would you not want to biopsy the toe?
of joint spaces and osteopenia. Later on marginal erosions
CANDIDATE: I would not want to jump in at this stage and biopsy
without further information. (I was struggling a bit here and wasn’t
sure what he was getting at.)
EXAMINER: The point here is that other rare conditions can cause
this appearance, e.g. PVNS. Let’s move on to something else.
Adult and pathology oral 4: Clinical photograph of rheumatoid

forefoot
Splayed foot
Hallux valgus with pronation and underriding, lesser toe
hammering. Vasculitic lesions on shin. We discussed orthotic
shoes, then Fowler’s excision arthroplasty

Clinical picture shown of severe rheumatoid disease
EXAMINER: How would you treat the patient?
CANDIDATE: I would take a full history and enquire about mobility
and functional limitations. It is important to use a
Figure 18.1 AP radiograph of rheumatoid foot
021
multidisciplinary approach involving rheumatologists, physicians, performed a systematic review of the literature up until
occupational therapists and orthopaedic surgeons. 2005 comparing outcomes following second-generation TAR and
A pyramid treatment approach is used starting with non- AA. They concluded that both techniques gave comparable
steroidal anti-inflammatory agents, progressing to steroids and intermediate and long-term outcomes, reporting good or
may include cytotoxic drugs, e.g. methotrexate, or ‘biologicals’ excellent outcomes in 68.5% of TAR and 67% of AA patients and
(drugs which modify the immune system by blocking cytokines or mean AOFAS scores of 78.2 following TAR and 75.6 following AA.
their receptors, such as IL-1 or TNF-α). There may be a role for However, the majority of the 49 studies reviewed were single-
conservative management such as custom-made orthosis to centre case series and none directly compared the two
accommodate the deformity, padded heels or foot/ankle treatments. A systematic review by Jordan et al.4 identified four
orthotics. A patient may have considerable deformity in their feet studies comparing TAR with AA in which two studies reported a
but manage well with conservative treatment. Attempts significant improvement in functional outcome in favour of TAR
should be made to minimize the doses of steroids used but also a higher complication rate. All of these studies, however,
preoperatively. It is advisable to temporarily discontinue demonstrated a lack of high quality evidence with
biological drugs before surgery, but continuation of methotrexate methodological flaws and weaknesses.
is thought to be safe.
Grennan et al.2 showed no increased risk of infection or wound
complications if taking methotrexate, but stopping the Ankle arthritis
medication prior to surgery did lead to a flare up in rheumatoid
disease in about 5% of patients. Symptoms
I would offer her ankle arthrodesis as this has been shown to be Pain
the gold standard management option for ankle involvement in Stiffness
rheumatoid arthritis. Coronal and sagittal plane deformities can Deformity
be corrected. The ankle is fused in neutral flexion, with 5° of Perceived or actual instability
hindfoot valgus and external rotation to match the contra- Limitation of ADL
lateral leg.
EXAMINER: What are the complications of ankle arthrodesis? Causes
CANDIDATE: Complications include infection, delayed or non-union Primary osteoarthritis of the ankle is rare. It is usually second-
(10%), neurovascular injury, wound healing problems and mal- ary to another predisposing cause. Look for features of a
alignment. Longer term there is the potential to develop secondary cause on any radiograph studieda.
degenerative changes in adjacent joints, reported as between 1% Post-traumatic arthritis: rising incidence especially in
and 60%. younger age group. Displaced ankle fractures, distal tibial
EXAMINER: What technique would you use? pilon fractures, talar neck and body fractures with AVN,
CANDIDATE: Various techniques have been used including chronic ankle ligamentous instability
cannulated screws, plate fixation, retrograde nail, and external Osteochondritis dissecans of the talus
fixation. I would prefer arthroscopic arthrodesis using screws Inflammatory arthritis: Rheumatoid arthritis
unless the deformity was very severe with poor bone stock. Others: Charcot joint, previous septic arthritis,
EXAMINER: What about ankle arthroplasty? haemophilia, pyrophosphate arthropathy, etc
CANDIDATE: Ankle arthroplasy is a good choice in rheumatoid
patients as they have low functional demands and have other Conservative management
joints affected. There are a number of complications that can occur
Modification of footwear, e.g. cushioned heel inserts with a
with ankle arthroplasty. stiff rocker bottom sole
EXAMINER: Such as?
Splints and orthosis, e.g. moulded ankle-foot orthosis
CANDIDATE: Infection, wound breakdown, aseptic loosening, mal- Intra-articular steroid injections or viscosupplements
alignment, stiffness and impingement. There are worries about rates
Non-steroidal anti-inflammatory medication, painkillers
of osteolysis and revision for TAR although movement is allowed
which allows walking with reduced stresses on adjacent joints.
EXAMINER: What are the results like for ankle arthroplasty?
Limited surgical approaches
CANDIDATE: The STAR prosthesis has a 10-year survival of 80.3% Can be used to improve symptoms in the short term and buy time.
and is one of the most widely used prostheses.
EXAMINER: You seem mixed up. What are you going to offer this patient?
CANDIDATE: There is not enough evidence in the literature to give
firm guidance as to the preferred option. Haddad et al.3. a
Attempt to mention this subtly to the examiners when describing
radiographs to them.
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Arthroscopic ankle debridement Whilst ankle arthrodesis, for many surgeons, remains the
Can be technically difficult to get into the joint gold standard treatment for end-stage ankle arthritis, there
May be useful if there is an obvious cause that could be is enough survivorship data around to make a case for an
corrected, e.g. anterior impingement osteophytes ankle replacement
Resection of osteophytes, synovectomy, areas of Challenges of revision: Poor soft-tissue coverage, loss of
impingement, loose osteochondral fragments bone stock, poor choice of off-the-shelf revision
Expectations must be reasonable components. Fall-back position is arthrodesis
1
Buys time, 90% good/excellent results reported at 2 years Meta-analysis by Haddad et al. in 2007 gave equivalent
outcome at 5 and 10 years for both groups
Poor outcomes in advanced arthritis
Open ankle debridement Indications for total ankle arthroplasty

Use anterior/lateral approach based on future definitive Low physical demand patient
procedures Age >55 yearsc
More invasive Coronal mal-alignment <10° of varus and valgusd
Can be complicated with cutaneous nerve entrapment, Competent (or reconstructable) deltoid ligament and
extensor tendon damage, wound dehiscence and formation lateral ligament
of hypertrophic scar tissue Degeneration secondary to inflammatory, osteoarthritis or
post-traumatic arthritis
Joint distraction using Ilizarov fixator
Improves symptoms of post-traumatic OA Relative contraindications
The fixator is applied for a period of 3 months. The Age <55 years
articular surfaces do not come into contact with one Diabetes mellitus
another during this time. The patient is allowed to weight Poor bone stock or bone loss
bear. At 6 weeks hinges are applied to the construct to Avascular necrosis of the talus
allow movement whilst maintaining distraction
High BMI
The increased hydrostatic pressure within the joint is History of ankle sepsis (consider if >1 year post infection,
thought to stimulate proteoglycan production if inflammatory markers are normal and if preoperative
Improvements in range of movement and pain as well as biopsy and aspirate are negative)
increased radiological joint space are seen at 2 years
Motion distraction better than static fixed distraction Absolute contraindications
No improvement in range of motion High physical demand (e.g. construction worker)
Effect temporary rather than long lasting Peripheral vascular disease
Common side effects: Pin site infection Peripheral neuropathy (including Charcot)
Paralysis/neuromuscular disease
Definitive surgical proceduresb Coronal mal-alignment >20° varus or valgus
Total ankle arthroplasty for ankle arthritis Previous infection
Early designs of ankle arthroplasty relied upon a cemented Soft-tissue compromise (multiple previous incisions,
and constrained configuration and were subject to flaps)
loosening, up to 85% in 1 series at 5 years
Second-generation implants (cementless, semi-constrained,
either fixed bearing or mobile bearing) have a reduced rate
of revision c
Many surgeons are extending the age indication for total ankle
Renewed interest with improved jigs providing
arthroplasty, performing surgery in young low-demand patients
reproducible results and mobile bearings improving with inflammatory arthritis.
mobility and reducing loosening. Appreciation that d
For example, the original operating technique for mobility total
realigning the hindfoot and restoring ligament integrity ankle replacement recommends implantation where coronal plane
improves survivorship, resulting in better intermediate- tibial-talar tilt does not exceed 20°. However, many surgeons are
term outcomes extending the indications with respect to mal-alignment, balancing
the hindfoot with appropriate calcaneal osteotomy and stabilising
the ankle with deltoid ligament or lateral ligament complex
b
Talking the talk: The options for management of ankle arthrosis reconstruction as required, either as a staged procedure or at the
would include conservative management, a limited surgical time of arthroplasty. In the exam it is wise to be safe and therefore
approach such as arthroscopic ankle debridement or a more conservative, but having an awareness of the evolution in practice
definitive surgical procedure such as ankle arthrodesis. will not hurt.
021
Design features TAR The most important surgical principle is to achieve the
A successful and well-executed TAR provides the patient soft-tissue balance and congruent alignment of the
with a near normal gait pattern in relation to the component for long-term survival of the prosthesis
kinematics of the knee, ankle and midtarsal joint
Benefits and complications of ankle arthroplasty
First-generation ankle arthroplasty: All polyethylene tibia,
metal talar component with cement fixation. High Benefits
constraint led to loosening. In some cases surface Maintains mobility
incongruity led to poly wear Prolongs/prevents progression of arthritis in adjacent joints
Second-generation ankle arthroplasty: Two-component Recent advances have made short- and intermediate-term
and three-component designs results of second-generation implants more positive (78–80%
In the two-component design the tibial element is a survival at 5 and 10 years1).
metal-backed polyethylene prosthesis with a metal talar
component; hence, a fixed-bearing component, e.g. the Complications
AgilityTM. The AgilityTM is the most commonly used TAR A recent meta-analysis has characterized complications and
in the USA. It relies upon a syndesmotic fusion at the distal the prevalence in total ankle replacement and their likelihood
tib–fib joint for tibial component stability. The design of causing failure.8 The study reviewed 2386 implants with a
allows slight side-to-side and rotational movement as the mean failure rate of 12.4% at a mean follow-up of 64 months.
talus component moves within the tibial component, Nine main complications are reported at the rates below:
dissipating rotational forces 1. Subsidence (10.7%)
In the three-component design both talar and tibial 2. Aseptic loosening (8.7%)
elements are metal with a mobile polyethylene bearing. 3. Intraoperative fracture (8.1%)
These may be press-fit or cemented components (e.g. BP, 4. Wound healing problems (6.6%)
STAR and MobilityTM) 5. Technical error (6%)
The LCS (low contact stress) ankle arthroplasty developed 6. Implant failure (5%)
in the 1970s, evolved into the Buechel–Pappas (BP) 7. Non-union (4.4%)
arthroplasty, named after the designers, being the first
8. Postoperative fracture (2%)
three-component design
9. Deep infection (1.7%)
The mobile-bearing implants, with their highly congruent
By grouping the non-union and aseptic loosening groups, eight
bearing surfaces, overcome the problem of high contact
reasons for TAR failure have been identified. Three of these
stress and the resultant poly wear. At the same time they
complications (deep infection, aseptic loosening and implant
are not as constrained as the first-generation designs, which
failure) resulted in >50% of failures. Conversely, two of the
reduce shear at the bone/implant interface and, thus,
more common complications (intraoperative fracture and
reduce loosening
wound healing delay) did not lead to failure in any case. Deep
The Buechels and Pappas5 themselves reported 2–12 infection was an uncommon complication (occurring in only
(mean 5) year follow-up with 88% good–excellent, 5% fair
1.7% of arthroplasties) and resulted in failure in 80.6% of the
and 7% poor outcomes in a series of 75 BP ankle
arthroplasties in which it occurred. Complications have, thus,
replacements with deep sulcus talar component design.
been graded in terms of their likelihood of causing failure:
Wood et al.6 reported 79% survivorship at 6 years in
100 BP ankle replacements Low-grade complication – Very unlikely to cause failure
The STAR ankle has evolved from a cemented fixed Intraoperative fracture
bearing ankle to an uncemented mobile bearing Wound healing problems
three-component arthroplasty. It features two anchor Medium-grade complications – Failure occurs <50% of the time
bars to improve tibial fixation and a concave talar Technical error
component which is reciprocally shaped to the poly
Subsidence
meniscus. The designer reported 95% 5-year
Postoperative fracture
survivorship and these results have been reproduced by
High-grade complication – Failure occurs >50% of the time
other authors
Mobility ankle arthroplasty is a three-component mobile Deep infection
bearing press-fit ankle arthroplasty7. This has now been Aseptic loosening
withdrawn from the market due to a high incidence of Implant failure
medial pain
The rate of intraoperative and postoperative malleolar Ankle arthrodesis for ankle arthritis
fractures is high especially during the learning curve but There is plenty of evidence that ankle arthrodesis yields good
does not adversely affect the final outcome results in the alleviation of pain from ankle arthritis, but there
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are important critical long-term adverse outcomes to consider, Posterior talofibular ligament (PTFL): strongest, last to
including the late onset of arthritis in contiguous joints9. fail
Ankle arthrodesis Medial ligaments
This is historically the gold standard Deltoid: Superficial fan-shaped from tip of medial malleolus
A fusion rate between 80% and 90% has variously been to talus, navicular and calcaneus. Deep part is more
reported important for stability and is attached to talus
Relief of pain is usually excellent but most have limited
hindfoot motion that makes walking on uneven ground Other important ligaments
difficult and few are able to run effectively Syndesmotic ligaments
Gait analysis shows that walking speed is decreased, as are AITFL: Anterior-inferior tibiofibular ligament
step length and single stance duration PITFL: Posterior-inferior tibiofibular ligament
Types of ankle fusion IOTFL: Interosseous tibiofibular ligament, which extends
into interosseous membrane
Compression arthrodesis using rigid internal fixation,
e.g. cross screw or parallel screw compression, anterior Peroneal stabilisers
tension plate
SPR: Superior peroneal retinaculum
Arthroscopically assisted ankle fusion (only in the absence
IPR: Inferior peroneal retinaculum
of gross deformity)
Compression arthrodesis with external clamp (Charnley). Mechanism of injury
High incidence of pin tract and superficial infections
A forced inversion injury leads first to damage to the ATFL. In
Ilizarov technique: Allows tibial lengthening at the same time more severe injuries this is followed by damage to the CFL. It
Intramedullary nail for tibio–talar–calcaneal fusion is almost impossible to injure the CFL in isolation. Disruption
of the PTFL is rare.
Position of fusion
Acute inversion injuries can be graded as either unstable or
Neutral position: Dorsiflexion/plantarflexion (10° equinus stable.
if patient cannot stabilise the knee) (CP) Unstable injuries are further subdivided according to the
5° valgus degree of talar tilt and anterior drawer present under stress.
5° external rotation – Similar to contralateral limb A partial or complete tear of the ligament complex heals in a
Traditional teaching recommends slight posterior lengthened position, causing lateral joint laxity. If only the
translation of the tibia ATFL is involved, anterior subluxation of the talus in the ankle
mortise will occur. When both the ATFL and CFL are injured,
Complications
talar tilt will also be present.
Non-union, mal-union, infection, poor wound healing, pin
tract infection, tibial fractures, amputation, painful History and examination
neuroma, posterior tibia nerve injury, vascular injury Giving way: usually painless and mechanical
Wound infection and breakdown with a reported incidence Painless/painful: most instabilities are painless. If painful
of up to 40% in some series. Non-union occurs in one- must exclude internal impingement, osteochondral fractures,
third of cases in some series peroneal injuries and arthritis
Acute/chronic: acute instabilities need conservative approach
at least for 4–6 weeks
Chronic ankle instability Functional/mechanical: functional instabilities are not true
Introduction instabilities and are mainly due to internal impingement. This
This is a must-learn key topic for the oral part of the examination. requires EUA and arthroscopy
Ankle sprains are very common and the vast majority can Locking/clicking: arthritis, osteochondral fragments
be managed conservatively without any functional instability. Hyperlaxity (Beighton’s score): may lead to recurrence
and, hence, needs more robust non-anatomical repairs
Anatomy Key points
Lateral ligaments
Exclude hindfoot varus, forefoot overpronation and
Anterior talofibular ligament (ATFL): Primary restraint subtle cavus deformity: most important predisposing
to anterior translation of talus factor to recurrent lateral instability. This may lead to
Calcaneofibular ligament (CFL): primary restraint to failure of surgical repairs if not corrected simultaneously.
varus forces to talus Hindfoot varus/first ray overpronation can be addressed
021
with lateral displacement calcaneal osteotomy and ATFL and CFL ligaments remnants are identified
dorsiflexion osteotomy of the first metatarsal The ATFL is divided mid substance
Most chronic lateral instabilities are painless. If painful, The anterior cortex of the distal fibula is freshened with a
exclude associated occult pathology (OCLs, synovitis, OA, burr, suture anchors are deployed into the anterior fibula
peroneal tendon pathology) and into the junction between the talus neck and body
Anatomical repairs restore joint biomechanics, but weak as and then the ATFL halves are double-breasted over one
scarred tissues used for repair another
Non-anatomical repairs are potentially more robust, but do The Gould component of the repair involves gathering the
not restore normal joint kinematics and stiffen the free edge of the extensor retinaculum and, by means of the
subtalar joint suture anchors, suturing it to the freshened surface of the
Recurrence is associated with generalized ligament laxity, fibula and the adjacent periosteum
high functional demand and missed hindfoot varus. Robust
non-anatomical repairs may be preferred at the expense of Non-anatomical repairs
a stiff subtalar joint Non-anatomical repair uses tenodesis to restrict joint motion
and restore stability without repair of the native ligaments.
Management Naturally such repairs do not accurately restore the joint
Acute injuries and instabilties kinematics and have a tendency to stiffen both ankle and
subtalar joint.
Most sprains improve with conservative management
The Evans repair harvests the entire peroneus brevis
including rest, ice, analgesia and early rigorous rehabilitation
tendon, suturing its muscle belly onto peroneus longus, then
Indications for surgical reconstruction routes the tendon up through the fibula from the tip of the
fibula emerging posteriorly, 3 cm proximally. The tendon is
Failure of conservative management (>4–6 weeks). MRI
scan is useful to confirm the presence of chronically ruptured sutured under tension to the periosteum, to create a
or chronically attenuated ankle ligaments, and is useful to ligament.
exclude occult ankle osteochondral lesion or ankle synovitis The Chrisman–Snook repair routes the anterior half of
peroneus brevis tendon through the fibula, while maintaining
Chronic instability with positive clinical examination and
its distal attachment to the base of fifth metatarsal
positive stress radiographs
and attempts to recreate the ATFL and the CFL by routing
Anterior drawer sign: Absolute drawer >10 mm or >5 mm
the tendon graft from anterior to posterior through the
on contralateral side., positive varus tilt test: Absolute talar
fibula, securing the free proximal end in the body of the os
tilt of >10° or >5° on contralateral side
calcis.
Surgical approaches The non-anatomical repairs have been proven to provide
Surgical reconstructions are grouped broadly into anatomical reproducible, effective and longlasting stabilisation of the
repairs of the ligaments and non-anatomical repairs using ankle, accepting that they do restrict subtalar joint motion,
tenodesis, and, more recently, anatomical reconstruction with produce symptomatic stiffness and do not reproduce normal
tenodesis. ankle kinematics.
Anatomical repairs Complications of surgery

Anatomical repair (e.g. Brostrom–Gould) utilizes the local tissue Ankle and subtalar stiffness
to restore normal anatomy and joint kinematics, and maintains Recurrence
ankle and subtalar joint movement. Within this principle lies its Scar tenderness
weakness in the respect that the native tissue may be scarred or Superficial peroneal/sural nerve injury
attenuated by recurrent sprain and, therefore, suboptimal for
purpose. It has a very good, long-term reproducible result and Flowchart for ankle sprains/instability (Figure 18.2)
is the first line of surgical treatment. Oral question
Brostrum Describe a surgical technique for chronic ankle instability
Direct repair of ATFL and CFL (anchors/fibre-wires/
EthibondTM)
Gould Examination corner
Augment the repair with inferior retinaculum AP radiograph of the ankle demonstrating talar tilt (Figure 18.3)
This topic always begins with a clinical radiograph of the
Steps
ankle showing talar tilt. There may also be a lateral radiograph
‘J ‘shaped incision over the distal fibula, protecting the demonstrating anterior talar shift.
superficial peroneal nerve branches and peroneii
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021
these are her stress views. Are you really going to manage her
with physiotherapy, which she has had on two previous
occasions?!
CANDIDATE: In this case I would consider surgical reconstruction.
EXAMINER: Can you name any surgical procedures performed for
chronic ankle instability?
CANDIDATE: Brostrom–Gould lateral ligament reconstruction.
EXAMINER: Why a Brostrom–Gould?
CANDIDATE: I’m not sure.
EXAMINER: . . .
(Fail)
The first point would be to say that just mentioning physio-
therapy as an initial management for the condition without
qualifying the answer further is inviting trouble. A much better
Figure 18.2 Flowchart for ankle instability reply would have gone along the lines of ‘The stress views show
significant tibiotalar tilt and, if taken in conjunction with an
appropriate history and clinical examination, are suggestive of
chronic ankle instability, this may be an indication to consider
surgical management.’ Even better to continue on with ‘Surgi-
cal options can be either an anatomical repair such as a modified
Brostrom repair or a non-anatomical repair such as Chrisman–
Snook repair.’
This examiner seemed to give the impression that a positive
stress view equated with a surgical reconstruction. It is import-
ant to be quite clear that a positive stress view in itself is not an
indication for surgery. Stress radiographs may show significant
talar tilt and anterior subluxation but the patient may have
minimal symptoms of ankle instability and may not require a
reconstructive procedure. This point should have been men-
tioned in the general discussion in retort to the examiner’s
comments.
Trauma oral 1: clinical radiograph showing tibiotalar tilt

Figure 18.3 Radiograph of the ankle demonstrating talar tilt
CANDIDATE: This is a radiograph, which is a stress view
demonstrating significant tibiotalar tilt suggestive of chronic
ankle instability.
EXAMINER: This is a radiograph of an ankle. What does it EXAMINER: You are seeing this patient in the fracture clinic
demonstrate? 6 months after an ankle sprain with this x-ray. What are you going
CANDIDATE: This is a lateral stress radiograph of the ankle, which to do?
shows tibiotalar shift indicating injury to the lateral ankle CANDIDATE: If he has symptomatic, disabling ankle instability then
ligament complex. I would offer him surgery. It is important to emphasize the need
EXAMINER: How are you going to manage this patient? to identify hindfoot varus, forefoot pronation and subtle
CANDIDATE: I would initially manage this patient with cavovarus deformity as a correctable underlying cause of
physiotherapy. instability.
EXAMINER: Come on, is physiotherapy going to help in this situation EXAMINER: Is he likely to have anything else but symptomatic
with this amount of talar tilt? instability with this radiograph? (Not a question but a
CANDIDATE: A patient may have significant talar tilt on stress somewhat sarcastic comment.) What types of repair are you
views but not require surgery. The literature suggests that familiar with?
up to 80% of grade 3 injuries can be treated conservatively with CANDIDATE: A repair of the lateral ligament can be either
good results. augmented or non-augmented. (A slightly mixed up answer, not
EXAMINER: This patient is being seen in your fracture clinic entirely accurate.)
6 months following a lateral ligament injury which is not getting EXAMINER: (Not entirely happy with answer.) What is the
any better. She has severe symptoms of pain and instability and recommended type of repair to perform?
021
CANDIDATE: It would probably be a modified Brostrom repair.

Diabetic foot
EXAMINER: An anatomical repair. What would you tell the patient Introduction
the outcome is likely to be? Approximately 10% of diabetic admissions to hospital are with
CANDIDATE: In fact, most ankle reconstructions do very well, with a foot problems. The severity of diabetic foot disease is directly
90% success rate. It’s one of these operations that tends to do well. related to the adequacy of blood sugar control.
EXAMINER: Yes, you are quite right about this. When would you
allow a patient to return to playing football? Pathology
CANDIDATE: Three months. (Complete guess)
Diabetic ulcers : one-third neuropathic; one-third
EXAMINER: Would you allow them to play unsupported or would ischaemic; one-third mixed
you make them wear a support brace?
CANDIDATE: I would allow them to play without any support.
Neuropathy
COMMENT: Complete guess and wrong answer. Most athletes Symmetrical distal polyneuropathy involving motor, sensory
should continue to use a tape or brace indefinitely during
and autonomic nerves.
sports activities, but a brace is not routine after 3 months for
most work-related activities or activities of daily living. Autonomic dysfunction
Adult and pathology oral 2: clinical radiograph showing tibiotalar tilt Reduced sweating causes dry plantar skin. Prone to fissure
CANDIDATE: This is a radiograph, a stress view demonstrating Alters nail growth
significant tibiotalar tilt suggestive of chronic ankle instability. Reduced local vascular response to injury
EXAMINER: How do you manage this patient? (Saved by bell.) We will
Sensory disturbance
leave it at that.
Painless sensory neuropathy causes a stocking-distribution
Adult and pathology oral 3: clinical radiographs, AP stress view sensory loss
showing tibiotalar tilt and lateral stress view showing anterior Reduced pinprick sensation, light touch and vibration.
subluxation talus on the tibia
CANDIDATE: This is a radiograph, a stress view demonstrating

Semmes–Weinstein monofilament test
significant tibiotalar tilt suggestive of chronic ankle instability. This simple test can identify persons at an increased risk for
EXAMINER: How much of a tilt is significant? foot ulceration:
CANDIDATE: A tibiotalar tilt of >15°. A 10-g (5.07) nylon monofilament is applied to the sole of
EXAMINER: You haven’t commented on the lateral x-ray. What do the foot
you think about the talus? If the patient perceives the touch of the monofilament at the
CANDIDATE: It’s moved forward. point it buckles, they have protective sensation; if they fail to
EXAMINER: Yes, the radiograph demonstrates an anterior perceive it, they do not
subluxation of the talus. What value of subluxation is significant? Loss of vibration sense with a 128-Hz tuning fork is a
CANDIDATE: 3 mm.
sensitive predictor of early neuropathy
EXAMINER: 3 mm compared to what?
CANDIDATE: Compared to the normal contralateral side. Motor involvement
EXAMINER: What surgical operations do you know that can be used Intrinsic muscles weakness and imbalance between the long
to manage this condition? flexors and extensors leads to cavus foot and claw toes.
CANDIDATE: You can either perform an anatomical repair or a non- Tibialis anterior weakness results in equinus contractures.
anatomical repair. An anatomical repair is usually preferred and The metatarsal heads are pulled forwards, decreasing cushion-
this can be either augmented or non-augmented. The classic ing and increasing vertical and shear forces.
operation was a Brostrom repair in which there was a
midsubstance repair of the ligament but this tended to stretch Peripheral vascular disease
out in time. Gould modified the Brostrom repair, by reinforcing Is common, has bilateral involvement.
with suturing of the lateral extensor retinaculum. This
modification is important in patients who have excessive Clinical assessment
inversion and laxity of the subtalar joint. However, there is very A. Assess diabetic control (type, duration, severity,
little to choose between the last two methods. There was a medications, HbA1C level)
randomised controlled trial performed by Karlsson, which showed
HbA1C level indicates blood glucose level control over the
that the Gould repair had more complications and slightly lower
preceding 3 months
functional scores than the modified Brostrom repair.
Normal: 6.5%
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021
B. Assess ulcers ± infection: neuropathic/vascular/ vascular team)

mechanical, duration, previous ulcers and treatments, For nerve function
bloods, x-rays, MRI, WBC scan, bone scan or labelled
Biothesiometer: Measures vibration perception threshold.
white cell scan. Wagner stage documentation
The calculated standard deviation score evaluates the risk
Risk factors for ulceration of ulceration
Semmes–Weinstein hairs
Dry skin leading to fissures
Nerve conduction studies
Loss of protective sensation causing micro-trauma
Autonomous vascular ischaemia For vascular status
Deformities causing high pressure areas especially MT Doppler ultrasound
heads and plantar midfoot area
ABPI: Normal value is 1 (0.8–1.2); a value <1 indicates
Neuropathic ulcers peripheral vascular disease: >0.45 required for any surgical
intervention
Location: typically under metatarsal heads
Transcutaneous oxygen saturation: Correlates highly with
Painless
risk of wound breakdown. Normal: 40; <25 – high risk of
Punched out margins wound dehiscence
Healthy granulation tissue at base which bleeds on touch Angiography
Surrounding thick hyperkeratosis
Palpable pulses and distended veins Assess deformities (stable/unstable, pain, functional loss)
Evidence of loss of protective sensation Deformities
Clawed toes
Ischaemic ulcers
Plantar callosities: metatarsalgia with increased pressure
Location: anywhere in foot or leg under the metatarsal heads
Painful The claw toes expose the metatarsal heads to further
Dull fibrotic base, poor granulation tissue, doesn’t bleed mechanical insult with plantar ulceration
easily
Equinus contractures: increased risk of plantar ulcerations
No hyperkeratosis Other deformities: due to chronic Charcot foot – Cavus,
Surrounding hair loss hallux valgus, rocker bottom
Pulses: less palpable, ABPI <0.8
Management
Classification: Wagner (Table 18.1) Mainstay of treatment is effective control of blood glucose level
Assess neurovascular status (ABPI Index, monofilament testing, Prevention is better than cure
Patient education
Accomodative footwear with padding in high-risk areas
Table 18.1 Wagner classification foot ulceration
Ulcer management –– Superficial, non-infected ulcers and
Grade Description Management neuropathic ulcers:
0 No ulcer, but foot Educate the patient and Total contact cast with areas cut to offload the ulcers
deformity present, advise them to modify their Correct mechanical deformities or equines contractures
at risk foot for ulcers footwear
Ischaemic ulcers:
1 Clean, uninfected, Broad-spectrum antibiotics
superficial ulcer Optimize vascularity: vascular team involvement for
angioplasty or bypass surgery
2 Deep ulcer with Debridement
Total contact casting (TCC)
necrotic tissue
3 Deep ulcer with Debridement + local Ulcers with infection:
abscess/osteomyelitis antibiotic/sequestrectomy Stepladder approach from antibiotics to amputation
If bone palpable/
probed: 67% risk of Risk factors for failure of TCC
osteomyelitis Large ulcers ( >2 cm)
4 Forefoot gangrene Partial amputation Long duration ( >2 months)
5 Gangrene of the entire Below knee amputation Wagner grade III or above
foot Associated deformities (clawing/equinus/midfoot–
hindfoot instability/rocker bottom)
021
Deformities management (see Charcot foot) –– Pathophysiology: Two acute deformities that frequently develop in the midfoot
Neurotraumatic: loss of protective sensation – Medial dislocation of the navicular and cuneiforms
Microtrauma – Deformity with forefoot in abduction causing medial skin
Neurovascular: Autonomous hyperaemia causes increased necrosis (apex medial): usually treated with
bone resorption osteoectomy
Inflammatory: injury – inflammation – Osteoclast Dorsal dislocation of navicular and cuneiforms with
stimulation – Bone resorption and remodelling medial column shortening causing lateral rocker
bottom deformity (apex lateral): Usually needs
Classification: Eichenholz: arthrodesis
Stage 0 (prefragmentation)
Three main stays of surgical treatments
Acute inflammation
1. Osteoectomy: to offload the non-healing ulcers. Avoid
Regional demineralisation
incisions on weight-bearing surfaces. Limited bone
Difficult to differentiate from infection
resection not to jeopardize the midfoot stability as will lead
Stage I (fragmentation) to recurrence
Painful 2. Hindfoot stability: Commonly through tibiotalocalcaneal
Periarticular demineralisation and fragmentation, leading arthrodesis through hindfoot nail
to dislocations/fractures 3. Amputations: for recurrent, intractable deformities or
Stage II (coalescence) ulcerations/COM
Painless/dull ache
Sclerosis Oral questions
Stage III (remodelling) Discuss the role of amputation in the diabetic foot
Painless Describe how to salvage ‘the foot at risk’
Deformities (mal-united ankylosed joints)
Interdigital neuroma
Goals of treatment
Reduce deformities to prevent subsequent complications of
Definition
A neuroma consists of degeneration and fibrotic changes in
ulceration, infection and amputation
the common digital nerve near its bifurcation.
Provide stability mainly to hindfoot and ankle
Prevent ulcerations through protective braces/footwear
Aetiology
Principles Unknown. There may be similar changes in unaffected nerves.
Mainstay is diabetic control and patient education Several causative factors have been suggested, although none is
Accomodative footwear universally accepted.
Prevent ulcerations; when present: Aggressive treatment Anastomosis between the medial and lateral plantar nerves
with TCC in third webspace
Avoid operating in acute (fragmentation/demineralisation) High heeled shoes with narrow toebox: Forced toe
stage as difficult fixation dorsiflexion
Arthrodesis preferred over ORIF Compression by the transverse intermetatarsal ligament
Treat equinus contractures Bursal hypertrophy
Long-term non-weight-bearing: 2–4 months followed by
protective weight-bearing in cast/brace for 6 months to
2 years Symptoms
Acute deformities/dislocations (esp. midfoot) Can be non specific
need surgery for correction even during Women > men
fragmentation stage Neuralgic sharp pain in a toe and/or interdigital space
Chronic deformities and dislocations should be managed Burning, tingling pain over the involved toes
with modified footwears/orthotics/braces. Indication for Numbness
surgery in chronic stable arthropathies is uncontrolled Pain worse on walking, sometimes at night
progression of deformity not responding to conservative Most common third webspace, followed by second and
measures fourth webspaces
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021
Diagnosis Nerve supply to the foot and ankle

Examination This is a predictable question about foot anatomy. There are
Local plantar pain and tenderness of the involved nerve in many ways for the examiner to lead into the subject.
the intermetatarsal space
Posterior tibial nerve
Mulder’s click on metatarsal compression: Reproduces the
patient’s symptoms A branch of the sciatic nerve
A local anaesthetic injection into the affected space that Enters the deep posterior compartment of the leg between
relieves symptoms two heads of the gastrocnemeii
Travels deep to soleus, between it and tibialis posterior
Special investigations Branches into medial and lateral plantar nerves, and
Standing AP and lateral weight-bearing films to exclude calcaneal sensory branches
other forefoot pathology It supplies the plantar aspect of the foot
MRI (preferred over ultrasound scan but has false
positive rate) Medial plantar nerve
Ultrasound scan: Can be combined with steroid injection Motor to
Abductor hallucis
FHB and FDB
First lumbrical
Synovitis Sensory to
Bursitis 3½ digits, like the median nerve in the hand
Metatarsalgia
Tarsal tunnel syndrome suggested by discomfort around
the ankle Lateral plantar nerve
Peripheral neuropathy, diabetes Motor to
Spinal disorder: HNP, history of nerve root entrapment Adductor hallucis
Dorsal and plantar interossei
Second–fifth lumbricals
Management Abductor digiti minimi
Conservative Sensory to
Advice and education of the patient
1½ digits
Sensible accomodative shoewears. Wider toe box. Avoid
Calcaneal sensory branches provide sensation to the heel pad
high heels
Metatarsal bar: Offload forefoot Saphenous nerve
Corticosteroid injection can be successful, especially if the A terminal branch of the femoral nerve
history is short and size is small
Supplies the anteromedial side of the leg down to the
dorsomedial ankle and midfoot
Surgery
Dorsal/plantar incision: Revision mainly through plantar Deep peroneal nerve
approach A branch of the common peroneal nerve
Nerve plantar to deep transverse ligament and, hence, Supplies only a small area of skin on the first web space
easier exposure with plantar exposure Passes beneath the extensor retinaculum at the front of the
Recurrence mainly due to left over plantar branches ankle joint between EHL and EDL
Planar incision may give painful scar
Divide transverse inter meta-tarsal ligament Superficial peroneal nerve
Excise nerve 2–3 cm proximal to the bifurcation A branch of the common peroneal nerve
Can bury the nerve in interosseous muscle Exits the deep fascia anterolaterally about 8–12 cm above
the tip of the fibula
Consent Supplies the dorsum of the foot except the first web space
(deep peroneal nerve) and the lateral part of the foot
Warn patients of the 80% success rate supplied by the sural nerve
Patients may develop a painful scar
It descends in peroneus longus until it reaches the peroneus
Recurrence brevis, and passes over the anterior border of peroneus
Warn about the area of numbness in the web space brevis and descends between it and EDL
021
Sural nerve Investigations

A branch of the tibial nerve X-rays: exostosis/fractures
Pierces the superficial aponeurosis halfway down the leg Nerve conduction studies: 90% accurate; sensory changes
between the two bellies of the gastrocnemius and is joined more pronounced
by the peroneal communicating nerve MRI: SOL
Supplies the lateral aspect of the heel, the fifth metatarsal
and small toe Management
Steroid injection
Tarsal tunnel syndrome Insoles
Entrapment neuropathy of posterior tibial nerve and/or its Surgical decompression
branches due to compression in the tarsal tunnel. Patients
can have both proximal (whole nerve) and distal (terminal
Surgery
branches, especially the lateral plantar nerve 1½ digits) 80% successful
syndromes. Curved incision posterior to medial malleolus, extending
distally upto abductor hallucis muscle
Boundaries Divide flexor retinaculum
Medial: medial malleolus proximally, medial aspect talus Divide both the superficial and deep fascia over abductor
and calcaneus distally hallucis
Flexor retinaculum Release medial and lateral plantar nerve completely
Abductor hallucis Release plantar fascia if necessary
Complications
Aetiology
Recurrence: incomplete release, revision surgery; poor
Above medial mallelous
results
Space occupying lesions (SOLs)
Bowstringing
Ganglion in the tendon sheaths
Varicosities Anterior tarsal tunnel syndrome
Neurilemma tibial nerve
Entrapment neuropathy deep peroneal nerve beneath inferior
Lipomas
part of extensor retinaculum.
Diabetics
Rheumatoid synovitis/tenosynovitis Aetiology
Tight-laced shoes
At/below the level of medial mallelous Anterior ankle osteophytes
Calcaneal fractures: susttentaculum tali/medial process of TMT joint osteophytes
calcaneus Tibialis anterior/EHL/EDL tenosynovitis
Heel valgus: Pes planus, tib post insufficiency, talocalcaneal SOL
tarsal coalitions
Accessory FDL muscle Examination
Paraesthesia first webspace
History Positive Tinnel’s sign
Intractable, diffuse and poorly localized nerve pain Positive provocation test: ankle forced plantarflexion
Burning, tingling, numbness and cramping sensation that
radiates onto the plantar and medial aspect of the foot Management
Hard- or soft-tissue mass Non-operative
Surgical: decompression of nerve with release of extensor
Examination retinaculum
Heel valgus with hyperpronation of foot Cheilectomy ankle and TMT joints
SOL
Pain/paraesthesia in typical distribution Hallux rigidus
Positive Tinel’s sign behind the medial malleolus
Hallux rigidus is a degenerative arthritis of the first metatar-
Positive provocation test: direct manual compression or sophalangeal (MTP) joint of the big toe. There is painful
dorsiflexion and eversion
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021
limitation of first MTP joint movement, particularly dorsiflex- Limited surgical procedure
ion. Later on, osteophytes appear on the dorsal and/or lateral MUA and intra-articular steroid injection may provide relief
articular margin and block extension. of symptoms in mild/moderate cases. Not proven to be effect-
ive if severe changes are present.
Epidemiology
Twice more common in females Joint preserving
Usually bilateral 1. Cheilectomy: removal of the dorsal osteophyte first MT
Active patient, stage I disease,
Aetiology
Motion preserving, relieves pain while maintaining
Idiopathic stability and allowing for a secondary procedure in the
Post-traumatic future
First-ray hypermobility Oblique resection of 30–50% of joint (up to
Metatarsus elevatus (definite correlation; however, the MT one-third of the dorsal MT head) and resection PP
elevation may be secondary due to intrinsic contracture osteophyte
and planar plate retraction) Simultaneous proximal phalanx or MT osteotomy
Osteochondritis dissecans If degenerative changes present, then increased ROM
Inflammatory: gout/pseudogout/rheumatoid can lead to more symptoms
Preop mid range of motion pain or crepitus is a
History warning sign for a poor result after cheilectomy
Activity-related pain with dorsiflexion Cheilectomy des not work when hallux rigidus is severe,
Stiffness, block to dorsiflexion (mechanical) coexistant sesamoid disease or long first MT: Shorten
Painful plantar flexion due to capsular stretch MT1 to offload sesamoid joint
(functional) 2. Closing wedge osteotomy of the proximal phalanx
Difficult shoe wear: Especially high heels (Moberg)
Difficulty in the push-off phase of running Dorsiflexion osteotomy (~10°)
Dorsal prominence, swelling with ulceration Changes the arc of motion from flexion to extension:
End result is increased dorsiflexion (useful in runners/
Examination athletes)
Assess the presence of marginal osteophytes, which are Reduced pressure on dorsum of first MTP joint
typically dorsally and laterally Useful for adolescent with early degenerative change,
Painful first MTP ROM can be combined with cheilectomy
Pain during tiptoeing 3. Metatarsal osteotomy
Check motion at IP joint (it should be mobile) Plantar flexion osteotomy
Dorsal medial cutaneous nerve is often sensitive Reduces dorsal impingement
Assess for presence of other foot pathology, e.g. lesser toe No better than cheilectomy
deformities, metatarsalgia
Joint sacrificing
Investigations
1. Keller’s procedure: excision arthroplasty
Weight-bearing AP and lateral radiographs.
Old patients with limited activities
Stage I: mild osteophytosis, joint space preserved
Low demand, home ambulators
Stage II: moderate osteophytosis, narrow joint space
Complications: transfer metatarsalgia, cock up
Stage III: severe osteophytosis, joint space obliteration
deformity (persistent MTP joint dorsiflexion), weak
Assess IP joint status, lesser toes deformities flexor strength, hallux varus/valgus, hallux instability
Revision to fusion can be difficult and require bone
Management block
Conservative treatment 2. Interposition arthroplasty
Reassurance: The radiological stage not always related to
Proximal phalanx base resection and interposition
clinical symptoms, which may progress slowly
material either dorsal capsule, gracilis tendon, extensor
NSAIDs hood with extensor hallucis brevis
Footwear modification: Rigid, moulded and stiff insoles or Weakens plantar flexion, transfer metatarsalgia
rocker bottom insoles
021
Maintains MTP joint motion, whereas arthrodesis Aetiology

doesn’t, good short term results reported Multifactorial, more common in women (8 : 1), less common
Contraindications: Short MT1/adjacent metatarsalgia in non-shoe wearing population.
3. Silastic (Swanson) implant arthroplasty 1. Intrinsic
Earlier used for low-demand, elderly patients but now Idiopathic
also used for younger patients Familial
Many modifications of implants and cuts (primus- Hyperlaxity: Generalized hypermobility, tarso-
tornier) available metatarsal joint instability
Complications: Silicon synovitis, implant wear, implant Inflammatory: RA, gout
breakage, dislocation, bone lysis and loss, cock-up
Neuromuscular: CP, Down’s syndrome, Marfan’s, stroke
deformity
2. Extrinsic (acquired)
Limited evidence for use
4. MTP joint replacement (hemi/total) Related to footwear( tight-fitting shoes, pointed toe
shoes, high-heeled shoes)
Hemi (HemicapTM)
Total (MojeTM) Pathogenesis
Ceramic on ceramic/metal on polyethylene Multiple theories
Complications: Implant loosening, implant fracture, Increased GRF: GRF acts on medial aspect of first MTPJ,
osteolysis, bone overproduction, cyst formation and pushes PP into valgus. This is currently most favoured
transfer metatarsalgia Primary metatarsus varus: this is the primary deformity
Limited long-term evidence to support use with hallux valgus as secondary deformity
5. Arthrodesis First TMTJ hypermobility
Gold standard
Stage II and III Pain may be extrinsic or intrinsic
Optimum position of fusion: 10–15° valgus and 25° Extrinsic pain
dorsiflexion Due to deformity
The IP joint should be mobile (accelerates IP joint Extrinsic pain may be managed non-operative
arthritis) management by
Motion sacrificing: Loss of pivoting movement during Shoes with a wider deeper toe box
sports; inability to wear high heels Padding the bunion
Osteotomy saw cuts/cone reamers Pressure from the next adjacent toe can be managed with
Fixation with screws, plates or pins a silastic toe spacer
Complications: delayed union/non-union, under/ Intrinsic pain relates to
overcorrection of deformity, screw loosing/breakage, Joint incongruence
transfer metatarsalgia, sesmoiditis, degenerative Degeneration
arthritis IP joint Synovitis: MTP joint/sesamoid joint
Non-union: inadequate joint surface preparation, Intrinsic pain is more readily treated by surgical restoration of
instability of the fusion site, thermal necrosis joint congruence although orthotics (sole stiffner, Morton’s
bone, poor patient compliance postoperatively, extension, forefoot rocker) may have a role.
smokers
Important assessments
Painless/painful: must identify the source of pain (bunion/
Hallux valgus arthritis/inflammatory synovitis/transfer metatarsalgia).
Inflammatory and degenerative conditions better treated
Introduction with first MTPJ arthrodesis
Common short case or adult and pathology oral topic. Age: extreme age preference for non-operative
High-yield orthopaedics, go through a viva dry run to management
polish your answers.
Is deformity passively correctable? Need for Akin osteotomy
Definition or with severe deformity more proximal procedures
Unstable first TMT/hyperlaxity/recurrence from previous
Hallux valgus is a lateral deviation of the great toe with medial
surgeries: Role of Lapidus procedure to stabilise first
deviation of the first metatarsal.
TMT joint
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Tendo Achilles tightness Hallux valgus surgery should be designed to ‘refunction’

Associated lesser toe deformities the first ray, and in particular the maintenance of length. The
Previous interventions limitations of some of the osteotomies performed in ortho-
Radiological assessment: joint congruency (DMAA), joint paedics today can be easily identified when checking down this
degeneration, sesamoid stations, lesser toe deformities, first list. Thus, for example, the Mitchell’s osteotomy inevitably
TMTJ hypermobility with plantar gapping/subluxation shortens and defunctions the metatarsal; the distal chevron
(Table 18.2) does not correct DMAA and is, therefore, not applicable where
this is a goal of surgery (also associated with a risk of metatar-
Surgical principles sal head instability and AVN).
Remove the bunion None of the metatarsal osteotomies address the problem of
Correct the hallux valgus angle tarso-metatarsal joint instability, albeit a none-too-common
phenomenon.
Correct the intermetatarsal angle
A lapidus fusion, first tarso-metarsal joint arthrodesis,
Correct hallux interphalangeus
may be applicable, though attention must be paid to MTP
Correct or maintain the distal metatarsal articular
joint congruence, and the need for an attendant distal meta-
angle (DMAA)
tarsal osteotomy to correct the DMAA must be recognised.
Restore joint congruence: Most deformities are Lapidus fusion has some notoriety in being prone to delayed
incongruent and, hence, do not need DMAA correction.
and non-union.
(Congruent HV: no joint subluxation and DMAA >10°;
Problems of great toe deformity and posture are addressed
incongruent HV: Joint subluxation but DMAA is normal.)
with lateral release and, where necessary, Akin osteotomy to
Avoid first MT shortening (defunctions first ray) correct hallux interphalangeus and great toe pronation.
Avoid first MT elevation (defunctions first ray) The lateral release primarily allows correction of the ses-
Stabilise and debulk the medial MTP joint capsule with amoid station, and includes release of the metatarso–sesamoid
capsulorhaphy suspensory ligament and the phalangeal insertion band.
Avoid plantar dissection to prevent AVN first MT head For severe hallux valgus, with widely divergent intermeta-
Relocate sesamoids under first MT head : Normally located tarsal angle, many authors recommend proximal metatarsal
under MT1 head over cristae, within FHB tendons. osteotomy with distal soft-tissue balancing, such as the prox-
Sesamoids remain in their position but with first MT going imal chevron osteotomy, proximal crescentic osteotomy or the
into varus, lateral and upward rotation of sesamoid takes Ludloff osteotomy (critics of which cite instability, loss of
place. This leads to adductor and FHB contractures leading fixation and dorsal mal-union, shortening and metatarsal head
to pronation and progression of deformity elevation as significant risks).
The more proximal the osteotomy, the better the As with the lapidus fusion, the proximal osteotomy may
correction render the MTP joint incongruent, by dramatically altering the
Double osteotomies for severe deformities with DMAA. In these circumstances the need for a double osteot-
altered DMAA omy must be identified.
Pressure studies demonstrate that hallux valgus deformity Where the MTP joint is mildly arthritic, the patient might
effectively defunctions the first ray; that is to say, the patient be counselled with respect to corrective osteotomy, accepting
does not load the first ray optimally. The consequence of this is the possible need for an arthrodesis at a later date. Where the
load transfer to the lesser rays, resulting in transfer metatar- MTP joint is frankly arthritic, the patient may be counselled
salgia, plantar plate rupture and clawing of the lesser toes. The with respect to the need for an arthrodesis.
radiological correlation would be hyperostosis of the second Other indicators of a potential need for MTP joint fusion
ray and all the features of lesser toe clawing. in managing hallux valgus include: Severe deformity with
Table 18.2 Angle values in hallux valgus
Angles Description Normal Mild Moderate Severe

Hallux Between the proximal and distal articular <10
interphalangeus surfaces of PP1
Hallux valgus Between MT1 and PP1 axes <15 20–30 30–40 >40
Intermetatarsal Between MT1 and MT2 axes <9 11–15 15–20 >20
Distal MT articular Between the articular surface of MT head and <10
angle (DMAA) axis of MT1
021
osteoporosis, severe MTP joint incongruence or frank disloca- Figure 18.4 Hallux
tion associated with severe hallux valgus, salvage after failed valgus angles. A,
Intermetatarsal angle
bunion surgery or failed arthroplasty, hallux valgus associated (MT1–MT2); B, hallux
with neuromuscular disease/spasticity, inflammatory arthritis valgus angle; C, DMMA.
and salvage after severe infection.
For the purposes of the exam, make your mind up as to
which osteotomy you prefer, and justify it in the context of the
deformity correction goals described above.
If, the night before the exam, you still can’t make up your
mind, go for a Scarf and Akin osteotomy with lateral release,
accepting the main criticism that the surgical exposure is
overlong and that ‘troughing’ is a potential problem. The Scarf
and Akin osteotomy with lateral release can be manipulated to
achieve every surgical goal, and is applicable to the most severe
deformity. Where tarso–metatarsal joint instability may be
considered a potential problem, the Scarf osteotomy does not
preclude a later lapidus fusion.
Radiographic parameters
Standing AP and lateral radiographs forefoot:
Hallux valgus angle (HVA), the angle between the
diaphyseal axis of the first metatarsal and that of the
proximal phalanx of the great toe: Upper limit of
normal 15°
Intermetatarsal angle (IMA), the angle between the
diaphyseal axis of M1 and M2: Upper limit of normal 9°
Interphalangeal angle, the determinant of hallux valgus
interphalangeus, reflects the angle of joint line convergence
between the proximal and distal articular surfaces of the
proximal phalanx, and is measured as the angle between
the long axis of the phalanx, and the axis of the distal
metaphyseal/joint segment of the phalanx, normally <10°
The distal metatarsal articular angle (DMAA), describes
the angular relationship between the articular surface of the
head and the axis of the diaphysis of the first metatarsal:
Normally <10°
Assess also for:
Management
Congruity of first MTP joint
Main clinical concerns are pain, difficulty with footwear and
Degenerative changes cosmesis.
Sesamoid position
Overall foot shape Hallux valgus correction – The goals of treatment
Alleviate pain
Degree of severity (Figures 18.4 and 18.5) Correct the deformity
Mann and Coughlin classified deformities by HVA: Refunction the first ray
Reduce transfer metatarsalgia
Mild, <20°
Moderate, 20–40° Conservative management
Severe, >40° Activity modification
By IMA (some overlap and inconsistency in the literature):
Footwear modification (wide toe box, padding to the
Mild, <11° bunion, Silastic spacer)
Moderate, between 14° and 20° Orthotics (sole stiffener and a forefoot rocker to offload the
Severe, > 20° forefoot)
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021
Complications
Poor satisfaction
High recurrence (70%)
Hallux varus
Medial cutaneous nerve injury or entrapment,
hypoaesthesia, neuroma
Mitchell’s osteotomy
Excision medial eminence, step cut osteotomy at the
metaphyseal-diaphyseal junction and medial
capsulorrhaphy
For mild deformity with HVA >30° and IMA >13°
Defunctions the first ray as shortens the first MT (transfer
metatarsalgia, plantar plate rupture, clawing lesser toes,
reoccurrence)
Chevron osteotomy
Figure 18.5 AP radiograph of left hallux valgus. There is an incongruent first
V-shaped, extracapsular, distal metatarsal osteotomy
MTP joint, lateral sesamoid dislocation and bunion exostosis. The For mild to moderate deformity but IMT angle <12°
metarsophalangeal angle is 44° and intermetatarsal angle is 17° 70° cuts with more longer and horizontal plantar limb
(perpendicular to GRF)
Head displaced up to 50% width of metaphysis (>50% –
Operative management Destabilisation)
Mild deformities: lateral release and distal osteotomy Can correct DMMA if medial wedge resection combined
Moderate to severe deformity: lateral release and Scarf/ with osteotomy
proximal osteotomy Intrinsically stable but fixation with single screw is
Severe deformity with altered DMAA: lateral release and preferred to avoid mal-union
Scarf/double osteotomy
HV with first TMTJ hypermobility: Lapidus procedure Complications
Hallux interphalangeus: add Akin procedure Loss of position
Osteonecrosis (damage to plantar and lateral blood supply:
2–20%)
Mild disease
Lateral release
Allows correction of the sesamoid station Moderate to severe disease
Includes release of the adductor hallucis, the metatarso– Wilson
sesamoid suspensory ligament and the phalangeal Oblique osteotomy made through the distal diaphysis from
insertion band distal medial to proximal lateral
The distal fragment is slid laterally to correct the
Silver intermetatarsal angle
Simple bunionectomy and capsular reefing Redundant medial capsule plicated
The geometry of the osteotomy requires significant
Complications
shortening of the 1MT to correct the intermetatarsal angle
Poor satisfaction rates Concern with transfer metatarsalgia means it is out of
High recurrence favour at the moment and not one to volunteer in the exam
McBride Scarf osteotomy
For HV with no contracture Most versatile Z-osteotomy allowing multiplanar
Simple bunionectomy correction
Transfer of released adductor tendon from PP to lateral Has advantage of both proximal and distal osteotomy due
MT1 neck to the Z-cut
Lateral release, plus medial capsulorhaphy Has larger surface area and, hence, high union rate
021
Longitudinal cut of Z is parallel to ground ,and not MT Ludloff

shaft axis, perpendicular to GRF, and therefore stable
Long oblique osteotomy
Transverse cuts of Z perpendicular to MT2 shaft but
Cut: dorsal proximal to plantar distal
divergent to avoid ‘troughing’
Osteotomy rotates around a screw to get desired correction
Lateral transfer of dorsal fragment corrects IMT angle
and then locked with another screw
Rotation of distal fragment can correct the DMAA
Less risk of shortening and dorsal mal-union
Plantar orientation of cut prevents MT elevation
Controlled shortening possible to reduce the MTP joint Modified Lapidus procedure
without tension or decompress an arthritic joint but avoid
First TMT joint arhrodesis (original lapidus: MT1–MT2
defunctioning the first ray with excessive shortening
base arthrodesis)
Long-term results very good although no RCT comparing
For young patients with hypermobile joint
Scarf osteotomy to any other technique
For HV with first tarso–metatarsal joint instability or
Minimal risks of transfer metatarsalgia
arthritis
Complications Severe deformities with large Inter metatarsal angle (>25°)
Troughing: Impaction of the two osteotomy fragments, Recurrent hallux valgus
resulting in loss of metatarsal height, fracture and
Complications
malrotation, resulting in loss of correction
Dorsal mal-union Non-union 10–20% (inadequate joint preparation,
apposition or fixation, premature weight-bearing): Requires
Stress fracture related to the proximal end of the cut
bone grafting as otherwise leads to too much shortening
Steep learning curve, can be difficult to salvage if it goes wrong
Doesn’t correct DMAA
May lead to MT elevation (dorsal mal-union) and
Proximal osteotomies shortening
Allows larger correction with same degree of displacement
because osteotomy closer to CORA (centre of rotational Akin osteotomy
angular deformity which is first TMT joint) PP base osteotomy: Adjunct to MT corrective osteotomy
This exerts a longer lever arm allowing correct of very For residual HV or fixed pronation deformity after MT
severe deformities that may be beyond distal or diaphyseal osteotomy
procedures Hallux valgus interphalangeus
Complications Crossover deformity with second toe
Shortens PP1 and, hence, releases soft-tissue tension on
Osteotomy is away from the first MTP joint through which
flexors and extensors
the GRF passes this may lead to dorsal mal-union due to
the vertical cut in lateral views Keller’s arthroplasty
Often causes first MT shortening and, hence, risk of
Resection of the base (one-third) of the proximal phalanx
defunctioning first ray and transfer metatarsalgia
of the great toe
Reoccurrence, hallux varus,first MTP joint stiffness,
Low-demand patients
mal-union and non-union and stiffness
Mann crescentic osteotomy Complications

Crescentic nature of proximal osteotomy avoids shortening Transfer metatarsalgia
and, hence, the Gold Standard Cock-up deformity (hallux extensus due to PP shortening
and EHL contracture)
Combine with distal osteotomy if DMAA needs correction
The stability of primary fixation (screw/plate) is pivotal
Dorsiflexion mal-union common complication
Good clinical results (level 2 evidence) with improved First MTP joint arthrodesis in HV
AOFAS scores Severe HV with first MTPJ arthritis, joint incongruence or
frank dislocation
Proximal Chevron osteotomy Severe deformity with osteoporosis
Less correction than Mann Salvage after failed previous surgery
Osteotomy cuts similar to distal chevron; however, joint HV associated with neuromuscular disease/spasticity,
penetration is a risk inflammatory arthritis
Needs stable fixation(screw and K-wire, two screws or a plate) Salvage after severe infection
359
021
Other complications Surgical indications

Recurrence: 5–20% Failure of conservative strapping
Hallux varus: 1–5% Painful MTPJ
AVN: 1–2% Shoe wear problems
Obvious cause of deformity: valgus mal-union
Hallux varus
Aetiology Surgical options
Congenital: (1) primary (uncommon), varus-only 1. Soft-tissue corrections
deformity; (2) related to metatarsus adductus, clubfoot, Medial release and lateral stabilisation
equinovarus Abductor hallucis lengthening/release/transfer from
Acquired – Neuromuscular, trauma, rheumatoid medial PP1 base attachment to lateral PP1 base under
arthritis MT1 head
Over-correction of hallux valgus (common): typically EHL split transfer/EHB tendon transfer/tenodesis:
valgus mal-union of MT1 The harvested tendon is passed under the deep transverse
Described as varus deformity but triplanar involving MT ligament from distal to proximal. For dynamic
supination first MT joint, hyperextension first MT joint transfer, tendon is stitched back to itself. For static
and hyperflexion hallux IP joint transfer (tenodesis), tendon is passed through MT head
Hallux deviated or subluxed medially with a non- 2. Bony correction
purchasing digit in varus rotation and usually negative MT1 osteotomy: If mal-union present
inter metatarsal angle (MT1–MT2) PP1 osteotomy
Excessive lateral release or tight medial capsulorrhaphy 3. Joint procedures
Abductor hallucis tightness
Arthrodesis IP joint: Especially if there is fixed varus
Excessive resection of medial eminence
and flexion deformity of IP joint
Historically, fibular sesamoidectomy as part of McBride
MTPJ arthrodesis: For rigid deformity with fixed varus
procedure thought to be primary aetiology. However, a
and extension. Most idiopathic hallux varus would
sesamoidectomy done as an isolated procedure will not
require MTPJ arthrodesis
produce the varus. Though due to a combination surgical
errors Resection MTPJ arthroplasty: For coexisting IP joint
arthritis Combine with IPJ arthrodesis
Clinical features
Usually deformity well tolerated
Treatment if painful Bunionette deformity
Assess for ligamentous laxity, neuromuscular disorders Idiopathic
RA
Important assessments (to be done as patient weight bears) Hallux valgus and primus metatarsus varus – ‘splayfoot’
Flexibility IP1 joint (deformity correctable or not)(static or Women
dynamic)
Flexibility MTP1 joint Classification: Coughlin
Associated contractures/ joint degeneration (arthritis/ Type I: Large/bowed fifth MT head
rigidity will contraindicate tendon transfer/tenodesis) Type II: Bowed fifth MT shaft
Associated MT1 deformities (Contraindicates tendon Type III: increased intermetatarsal angle MT4–MT5 >8°.
transfer/tenodesis unless deformity is corrected first)
Gait Important assessments
Radiographs Cosmetic/symptomatic
All hallux valgus angles are used, hallux abductus IP angle, Painful: Plantar condyles
degree of spray between first and second MT, any elevates Painful callosities
MTP joint stability
Management Shoe-wear problems
Reassurance if asymptomatic
Strapping in valgus: if seen in early postoperative period; Management
for 3 months Non-operative: advice, shoe wear modification, padding,
Shoe wear modifications callus management
021
Surgical: failure of conservative treatment

EXAMINER: I think you are a bit confused and have got them mixed
Type I: Osteotectomy – Bunnionette excision
up. Never mind, let’s move on to another topic you may know
Type II: Chevron or diaphyseal osteotomy (reverse Scarf )
more about.
Type III: Proximal oblique MT5 osteotomy
Fixation with twist-off screws/ K-wire (Candidate failed oral)
Risks Discussion
The oral topic was lost at this stage because the candidate’s
MTP joint instability
reply was not particularly well thought out. The candidate first
Worsening of deformity if excessive bony resection failed to mention the need for standing weight-bearing AP and
Delayed-union lateral radiographs and what he/she would look for with them.
The examiner alluded to this later on.
The second point concerns mentioning conservative
Examination corner management for a severe hallux valgus deformity. Standard
examination protocol dictates that when discussing manage-
ment options we are always told to mention conservative
Discuss the conservative management and appropriate surgery
treatment first. Generally speaking, to jump in and start discuss-
indicated for a given clinical example of hallux valgus. A number
ing surgery without first referring to it can be an invitation for
of different severities could be shown in a viva and candidates
trouble. Equally, you can dig a hole for yourself if you mention
ideally should prepare set answers for different degrees of HV.
conservative management for a severe hallux valgus deformity
Typically a very severe deformity ± other associated deformities
and do not quantify your answer, as with this candidate.
of the foot requiring surgery will be shown but any thing is
A better reply would be, ‘This lady has a severe hallux
game and several photographs may be shown. Make sure you
valgus deformity and I would offer her a basal metatarsal osteot-
know how to confidently talk around the radiology.
omy for the condition if she is willing to accept the risks of surgery.’
Or, covering all bases, ‘This lady has a severe hallux valgus
Adult and pathology oral 2: clinical photograph of a woman with a
deformity. Conservative management is unlikely to be successful in
severe hallux valgus deformity
this case and I would offer her surgery. Conservative management
EXAMINER: This 48-year-old lady presents to your clinic complaining certainly has a place in a less severe deformity and is a perfectly
about this foot deformity. acceptable form of management for mild deformities.’
CANDIDATE: This is a clinical photograph which demonstrates
a severe left hallux valgus deformity. There is no obvious ulceration Adult and pathology oral 2: clinical photograph of a middle-aged
woman with severe hallux valgus deformity
of her bunion but the skin over it appears atrophic, shiny and red.
EXAMINER: How are you going to manage this patient? CANDIDATE: This is a clinical photograph, which demonstrates a
CANDIDATE: I would take a full history and perform a clinical severe hallux valgus deformity of her left big toe.
examination of the patient. I would want to know if she has any EXAMINER: She is complaining of severe pain in her bunion. How
pain in the big toe . . . (at this point the candidate was cut short by are you going to manage her?
the examiner) CANDIDATE: Even though it is a severe hallux valgus deformity and
EXAMINER: She has pain and she cannot wear normal shoes. conservative management is unlikely to be helpful I still think we
CANDIDATE: Although she has a severe deformity I would still like to should initially consider ite.
try conservative management. (See Discussion, below.) EXAMINER: It is not likely to be successful though, surely.
EXAMINER: Come on now, is conservative management likely to be CANDIDATE: No, it is not, but before I would consider surgery I would
successful in this lady? like to find out a little bit more about her pain, whether the MTP
CANDIDATE: Not really, no. joint has arthrosis, how old she was . . . f (Candidate was interrupted)
EXAMINER: These are her radiographs. EXAMINER: She is 52; she has pain only in the bunion.
CANDIDATE: I would need to calculate the hallux valgus angle and CANDIDATE: I would like to examine the foot, paying particular
intermetatarsal angle. attention to the neurovascular status because if it is compromised
EXAMINER: What are the normal values for these angles? I will not be performing any surgery on her.
CANDIDATE: The normal hallux valgus angle is 9° and the normal EXAMINER: Good.
intermetatarsal angle is 15°.
e f
This candidate has an unfortunate turn of phrase with this answer. The candidate’s answer jumps about too much. The candidate
Be careful when mentioning conservative management for a severe mentioned conservative management and then backtracked and he
hallux valgus deformity. The candidate has not explained clearly then started to discuss history and examination findings. No
enough the role of conservative management, either generally or in mention at all about the role of radiographs in the management of
this patient’s specific case. the procedure although they were right in front of him on the table.
361
021
CANDIDATE: She’s 52, so a Keller’s procedure would not be a good choice

EXAMINER: What would you do for this patient?
for her as she is too young. If there is arthritis at the MTP joint then my
CANDIDATE: A distal osteotomy.
preference would be to perform a distal osteotomy such as a Wilson’s
procedure or Mitchell’s osteotomy. I realize that a basal osteotomy is Discussion about consent for the procedure then took place and the
used by some surgeons to a treat severe hallux valgus, but I am not candidate was asked to draw a diagram showing the distal
familiar with this procedure. I have read about it but I have never seen osteotomy.
one performedg.
Adult and pathology oral 5: surgical options for a severe hallux valgus
EXAMINER: How do you do a Mitchell’s osteotomy? Why don’t you draw
deformity
it out for us. Here is a pen and paper.
Scarfe and Akin oral
CANDIDATE: This is the metatarsal and I would perform a double
osteotomy here. EXAMINER: Describe how you would perform a lateral release and a Scarf
EXAMINER: Where? and Akin osteotomy.
CANDIDATE: At the neck. CANDIDATE: A lateral release is performed to enable the sesamoid
EXAMINER: That’s fine; it is not quite clear on your diagram. bones which are often subluxed to relocate to their normal station
CANDIDATE: I would then displace the metatarsal laterally and secure the beneath the metatarsal head. It is performed through a dorsal
displacement with a screw through the two fragmentsh. incision in the first web space at the level of the first MTP joint. The
release varies from surgeon to surgeon, but the elements released
(Candidate failed)
can include:
Adult orthopaedics and pathology oral 3: hallux valgus in a young patient The metatarso–sesamoid suspensory ligament which
Diagnosis, including radiographs in reality is the condensation of the capsule of the MTP joint
Various angles to consider where it descends to the sesamoids. This incison is
Management longitudinal rather than vertical, as a vertical incision will
divide the collateral ligament and predispose to hallux
Adult and pathology oral 4: hallux valgus varus. This allows the head to move laterally over the
Detailed questioning sesamoids
Things to look for in history and examination The phalangeal insertion band, a condensation between the
Angles fibular sesamoid and the lateral base of the proximal
Scenarios for treatment phalanx, is released
Metatarsal cuneiform fusion The tendons of the adductor hallucis muscle may be
released in severe cases
Adult and pathology oral 4: clinical picture of mild hallux valgus Finally, if necessary, the deep transverse metatarsal ligament
deformity may be released
Full discussion on hallux valgus
Pathogenesis EXAMINER: OK. How do you perform a Scarf and Akin osteotomy?
Angles CANDIDATE: A medial longitudinal inscison is made along the midline
of the medial border of the foot. Caution is exercised to avoid the
g medial dorsal cutaneous branch of the saphenous nerve. The capsule
You should be aware of basal metatarsal osteotomies and be able to
is divided in the midline and reflected dorsally but not plantarly as
describe how to perform one if asked. I presume the examiners were
wanting to discuss this for the management of a severe hallux valgus this is the point of entry of the vascular pedicle to the metatarsal
deformity. The candidate’s answer was more of an excuse than head. The shaft is exposed proximally, identifying but not exposing
anything else and certainly not good enough for the examiners. the tarso–metatarsal joint. The capsular reflection is continued onto
Most foot and ankle surgeons prefer to perform either a basal the base of the proximal phalanx, but protecting the insertion of EHL
osteotomy or a Scarf procedure for a severe deformity. and the insertion of the plantar plate at the base of the proximal
h
The candidate was not detailed enough in his description of how to phalanx.
perform a Mitchell’s osteotomy. A few extra details were needed to
The bunion is excised, protecting and preserving the sesamoid
safely satisfy the examiners. The examiners wanted the candidate
to discuss more fully the various surgical procedures available ridge, again to avoid a hallux varus, and then the Scarf cut is
to manage a severe hallux valgus and how to perform them. They performed.
were not particularly interested in the history or examination EXAMINER: What are the principles?
findings and wanted to hurry the candidate along so that they could CANDIDATE: A Z-cut osteotomy, with a short distal limb perpendicular to
discuss the technical details of the operation. It is much safer to go
the second ray, sloping back at 60° and commencing at the shoulder of
through the history, examination and investigations regime if they
allow you to do so if only to avoid getting caught out in the more the metatarsal. A short proximal limb, again sloping back at 60°, but
difficult technical details of an operation. this limb may be perpendicular to the second metatarsal or sloping
slightly proximally to facilitate rotation.
EXAMINERS: The candidate was not confident in the management of hallux
valgus.
021
The third longitudinal cut joins the apices of the first two cuts, and associated with Keller’s excisional arthroplasty including
the saw blade is directed in the plane of the sole of the foot, or, if recurrent deformity. Although the Keller’s procedure has
necessary, slightly plantarward, to depress an elevated metatarsal. been used for decades for thetreatment of advanced
symptomatic hallux valgus, it fails to maintain the proper
EXAMINER: What are the concerns?
alignment and biomechanical functionality of the hallux and
CANDIDATE: In displacing the osteotomy the metatarsal halves may so has fallen out of favour in recent years. Occasionally it may
trough, elevating the head. The displaced osteotomy preserves or even be used in elderly low-demand patients with painful hallux
restores length and can, if necessary, be rotated to correct the DMAA. valgus associated with arthritis of the MTP joint.
EXAMINER: How is it fixed? Complications include recurrence of the deformity,
CANDIDATE: Two variable pitch screws are used, usually Barouk screws. transfer metatarsalgia, excessive shortening of the toe and
EXAMINER: Are there any concerns with this fixation?
‘cock up’ deformity. Salvage of the procedure can be
difficult with techniques including arthrodesis, re-excision
CANDIDATE: The metatarsal is fragile and may split, so the surgeon must
and reconstruction of soft tissue, and placement of hemi-
introduce the screw slowly, to allow stress relaxation to prevent a split. implants or total implants.’
EXAMINER: What are the principles of an Akin osteotomy?
EXAMINER: What are ‘YOU’ going to offer the patient?
CANDIDATE: The Akin is a medial closing wedge osteotomy of the
CANDIDATE : I would need to get much more information from the
proximal phalanx of the great toe, used to correct hallux
patient before offering surgery. I would want to know how much
interphalangeus.
pain the patient was experiencing and whether it was globally
EXAMINER: What are the concerns?
around the foot or more localized from transfer metatarsalgia,
CANDIDATE: The plane of the cut must be perpendicular to the axis of
beneath the sesaoids, along the cutaneous nerves or from any
the phalanx, to avoid a ‘cock-up’ deformity, and the great toe tendons
lesser toe deformity. I would additionally enquire about any
must be protected as division of these in performing the osteotomy is
difficulty wearing certain shoes, limitation of activities of daily
reported.
living and the cosmetic appearance of the big toe.
EXAMINER: How would you fix the osteotomy?
I would also enquire about the previous surgery, any general
CANDIDATE: With either a screw or a staple; my own preference is for
conditions such as rheumatoid arthritis and any medical
a screw.
problems such as diabetes or peripheral vascular disease. I would
Bell goes. (Pass) additional want to know her occupation and any sporting
activities she does. It is also very important to explore her
expectations from surgery as any revision surgery is likely to
Examination corner interfere with high performance sports such as running or pivot
Radiograph shown of a failed Keller procedure done 15 years type sports, plus the toe may still be sore after spending a long
previously in a 62-year-old female (Figure 18.6). Discuss your time on her feet during the day or going up and down stairs and
treatment options. shoe wear may still be an issue.
‘I went down the route of getting a full history and performing Operation-wise I would consider arthrodesis of the MTP joint
a detailed clinical examination of the foot to define the with interpositional bone graft as it has reasonably good results
current problems. There are numerous complications reported in the literature and is recognised as a good procedure
in the difficult situation of excessive shortening of the hallux.
EXAMINER: What would you warn the patient of postoperatively?
CANDIDATE: I would warn them it would be a complicated surgical
procedure with no guarantee of success, and in particular there
would be the increased risks of infection, delayed union, non-
union, implant breakage, ankylosis of the hallux IP joint breakage
of metalwork, reoccurrence of deformity and general
dissatisfaction with the procedure.
Pes planus
Two common presentations of flat foot in the exam are tarsal
coalitions (covered in the paediatric section) and adult
acquired flat foot.
Arches of foot
Longitudinal and transverse arches which are maintained by:
Figure 18.6 AP radiograph demonstrating excessive bone removal following
Keller’s excision arthroplasty Static stabilisers: The shape of the foot bones
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021
Dynamic stabilisers; the activity of muscles

A wide variety of intrinsic muscles and ligaments
Longitudinal arches: medial and lateral (Figure 18.7)
Medial longitudinal arch (MLA)

Tall, concave arch
Resilient due to many bony components
Consists of apex (trochlea surface of the talus) and 2 pillars
(MT 1–3 heads, medial tubercle of the calcaneus)
Strong dynamic component: tibialis posterior
Lateral longitudinal arch (LLA)

Arch is flat and contains few bones
The pillars are MT 4–5 heads and lateral tubercle of calcaneum
Difficult to define the apex of the LLA because although
body weight is transmitted into it via the talus, the talus is
not part of the arch
Dynamic component: peroneus brevis
Figure 18.8 Medial longitudinal arch of the foot
The longitudinal arches are supported and stabilised by:
3. Tendons which run a longitudinal course in the foot. They
1. Bony support: The shape of the bones which allows them to
prevent the extremities separating (peroneus longus and
interlock
small foot intrinsics)
2. Tendons which attach at the apex of the arches and
4. A variety of longitudinally arranged ligaments that prevent
increase the arch height (tibialis anterior)
the extremities separating. (The long and short plantar
ligaments, plantar calcaneonavicular (‘spring’) ligament.)
5. The plantar aponeurosis links the extremities of the arches,
and acts as the equivalent of a tie beam in an architectural arch
Transverse arch
Not a true arch
Provides mainly bony support: cuneiforms intrlinked with
each other, supported by ligaments
Tibialis posterior insufficiency

More likely a clinical case rather than viva topic but would not
discount either (Figure 18.9).
Hypovascular zone: Within 14 mm of its insertion on the
navicular tuberosity
Female gender
Inflammatory arthritis
The decision to operate is based on

Mobility of the hindfoot (fixed/correctable heel valgus and
ST joint)
Mobility of the forefoot (can the heel valgus be corrected
without forefoot supination?)
Tibilalis posterior muscle(tear/defunctioned)
Functionality of ligaments (spring and deltoid ligaments)
Presence of arthritis
Surgery
Figure 18.7 Medial and lateral longitudinal arches of the foot Conservative
021
Figure 18.9 Clinical photograph of tibialis posterior insufficiency.Too many toes sign with heel valgus
Joint preservation(soft-tissue reconstruction of tendons Associated deformities

and ligaments, bony osteotomies Forefoot fixed supination: add medial cuneiform dorsal
Joint sacrificing(arthrodesis) open wedge osteotomy
Heel equinus: add Gastroc release /TA lengthening
Classification: Johnson and Hattrup Forefoot abduction: add lateral column lengthening
Three clinical stages of posterior tibial tendon dysfunction.
Myerson added a Stage IV, where there is a fixed foot deform- FDL transfer
ity and tilting of the talus in the ankle mortice. The natural
history is believed to be a progression from tendonopathy Harvested at Master knot of Henry where it crosses
over FHL
without deformity, through a mobile deformity to a fixed
deformity. Tenodesis of distal stump with FHL unnecessary
Always excise diseased tibialis posterior tendon
Stage I: Tenosynovitis tibialis posterior, no deformity Can perform tenodesis with proximal tib post tendon if
Tib post is functional and intact but inflamed. muscle healthy
Patient can do a single heel raise test but with mild weakness.
Symptoms are mild to moderate with posteromedial pain, Cobb procedure
swelling but minimal deformity.
Split transfer tibialis anterior to tibialis posterior proximal
Absent “too many toes sign”. stump. Transfer part of tibialis anterior through a tunnel in
Treatment: Tenosynovitis: Tenosynovectomy of the tibialis the medial cuneiform and back through the sheath of
posterior tendon. tibialis posterior, attaching it proximally
Partial tear but normal hindfoot: Conservative treatment Distal tibialis posterior excised or used to reconstruct
with medial heel wedge-brace. spring ligament
If deformity appears: Consider tenosynovectomy and medial Tibialis posterior muscle has to be healthy and functional
translational CO. for transfer to work
Stage II: Ruptured or dysfunctional tib post tendon with flexible deformity Combined with medial translational or Rose calcaneal
Tib post is elongated or torn and, therefore, weak and osteotomy
dysfunctional. Not synergistic as FDL
Inability to maintain resisted inversion.
Inability to perform single heel raise test. Medial displacement calcaneal osteotomy
Heel valgus present but flexible; flatfoot present. Medial translational (~1 cm) or step cut Rose osteotomy
Subtalar joint still mobile. Shifts Achilles pull axis medially
Deformity is still passively correctable. Re-aligns the hindfoot biomechanics reducing ankle and
Treatment: FDL transfer to tib post and medial calcaneal subtalar joint reaction forces
translational osteotomy. Brings axis of ST joint to neutral
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021
Lateral column lengthening: Modified Evans Pes cavus

Calcaneal lengthening when flexible flatfoot abduction Epidemiology
present with first TMT joint instability CMT is most common inherited motor neuropathy
1-cm opening wedge with iliac crest autograft Can be neurological in nature
Osteotomy performed 1.5 cm proximal to Calcaneo Often no underlying neurological cause found
cuboid joint Usually symmetrical
Weakness mainly affects: Peroneus brevis, tibialis anterior,
Stage III: Fixed hindfoot valgus intrinsics
Hindfoot valgus rigid. Men > women but women more severe
Forefoot supination and abduction rigid. Patients present in second or third decade
Represents advanced disease. If unilateral it is due to a spinal cord tumour until proven
Treatment: Triple arthrodesis. otherwise
Occasionally, triple arthrodesis alone may not fully
Inheritance pattern
correct the deformity; adjunctive procedures may be neces-
sary to correct residual forefoot varus, forefoot abduction, Autosomal dominant (AD) is most common – Defect on
or hindfoot valgus deformities10. Adjunctive procedures chromosome 17
include medial displacement calcaneal osteotomy to Affects peripheral nerve myelination (peripheral myelin
address residual hindfoot valgus; medial column procedures protein 22 – PMP22)
such as a plantar flexion osteotomy of the medial Sex-linked recessive and autosomal recessive (AR) forms
cuneiform, fusion of the first tarsometatarsal joint or navi- present earlier
culocuneiform fusion to address residual forefoot varus Are more severe
deformity; and lateral column lengthening to address fore-
foot abduction. Predictors of severity
Early presentation (under 10 years)
Stage IV: Ankle valgus Autosomal or sex-linked recessive
Stage added later Females
Chronic disease Associated sensory deficit (causes ulcers as in diabetes)
Medial strain at ankle causes deltoid insufficiency and
rupture Hereditary motor sensory neuropathies
Could be flexible or rigid (more common)
AD
Treatment: Ankle arthrodesis/tibiotalocalcaneal
Distal motor and sensory deficits
arthrodesis/ankle replacement
Family history
Table 18.3 Main hereditary motor sensory neuropathies
Types HSMN I (CMT hypertrophic) HSMN II (CMT neuropathic) HSMN III Dejerine–
Stotta disease
Incidence More common (AD) Less common (AD) AR
Onset 10–20 years 20–30 years Infancy
Pathology Demyelination Wallerian degeneration
Reflexes Absent Present
NC/EMG Prolonged latency EMG normal
Reduced velocity
Features Motor > sensory Motor > sensory Foot drop
Peroneii Tib Ant most affected Peroneii/Tib Ant most affected Scoliosis
Cavus/cavovarus Cavus/cavovarus Difficult mbulation
Hammer toes Hammer toes
Hip dislocation rare Hip dislocation rare
Scoliosis rare Scoliosis rare
Intrinsic hand muscles weakness Intrinsic hand muscles weakness
021
Types Less pronounced

There are seven in total; the most common are shown in : Proprioception, two-point discrimination and vibration
Table 18.3. may be affected
Muscle power
Cavus Test appropriate muscles for power (PL, PB, TA, TP, etc)
Plantar flexion of the first ray: Peroneus longus overpowers Screen for other neurological problems – Spine, skin, gait
tibialis anterior (broad-based ataxic gait)
Exacerbated by intact plantar fascia windlass mechanism In advanced severe cases patients develop upper limb signs
Intrinsic minus hand
Varus
Plantar flexion of first ray also causes forefoot pronation.
The compensatory tripod effect causes hindfoot varus Investigations
Weak peroneus brevis overpowered by TP Radiographs
Standing AP and lateral
Equinus Lateral shows high arch with cuboid visible in profile
Weak TA overpowered by gastrosoleus complex Increased calcaneal pitch angle (>30° = abnormal)
Positive Meary’s angle (0–5° = normal)
Claw toes AP shows fibula more posterior due to external rotation of
Tib ant weakness causes EHL/EDL recruitment for ankle tibia
dorsiflexion
Intrinsic minus foot MRIs
Both causes MTPJ hyperextension and PIP/DIPJ flexion – Be selective
Clawing Asymmetric cases
Other neurological features in foot
Clinical features Systemic signs of neurological disease
History Genetic testing
Deformity and stiffness are the chief complaints – Not pain Screening for affected families
or parasthesia
Difficulty with uneven ground and sports Nerve conduction studies and EMGs
Family history common EMG more useful as motor nerves primarily affected
Plantar pain from metatarsalgia Demyelination means conduction velocities are slowed
Repeated ankle sprains and painful callosities(secondary to
clawing) Management
Examination Non-operative
Typical foot deformities Footwear modifications and moulded AFOs, stretching
Are deformities correctable? physiotherapy
Toe clawing Non-operative treatment does not alter course of disease
Hindfoot varus with a high medial arch or pes cavus These patients are often young. Treatment of choice is
deformity? operative
Can be used to delay surgery until deformities become
: Is the hindfoot deformity correctable with the Coleman
symptomatic
block test. If so this shows that the subtalar joint is
mobile and the varus hindfoot is driven by excessive Surgical treatment
plantar flexion of the first ray Aims of treatment are to achieve a plantargrade, stable foot
Silverskold test: Improved ankle dorsiflexion with knee flexed that moves and is pain free
= gastrocnemius tightness. Equivalent ankle dorsiflexion with Key to treatment is deciding how to correct the deformities
knee flexion and extension = Achilles tightness depending upon their flexibility and degree of arthrosis
Are joints painful? Soft tissue or bony or both
: Indicates arthrosis
Thighs normal girth, calves thin – Stork legs First ray plantarflexion
: Sensory changes Dorsal closing wedge osteotomy
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Peroneus longus to peroneus brevis transfer Big toe clawing

Also corrects inverted forefoot Jones’ procedure
Big toe IPJ fusion and EHL transfer to first MT dorsum
Cavus
Plantar fascia release Arthrodesis
TP transfer to dorsum of foot through the IOM Triple arthrodesis is required to correct all deformities if
fixed and painful
Hindfoot varus Try to avoid as long as possible as patients are young
Peroneus longus to Brevis transfer Last resort
Lateral closing wedge calcaneal osteotomy (Dwyer)
Lateral calcaneal slide osteotomy In reality
Not all deformities are fully flexible or stiff
Equinus A combination of corrective osteotomies and tendon
Usually corrects after other deformities corrected transfers are used
TA lengthening left till all other corrections done to prevent After all corrections patients often still need an orthosis to
over lengthening combat a weak tibialis anterior
TP IOM transfer does help but may not be enough to
Clawing
combat drop foot deformity
Toes treated with Girdlestone Taylor split FDL to EDL transfer
Combine with Weil’s osteotomy if incomplete correction
PIPJ fusions and Weil’ osteotomies
MTPJ release and PIPJ excision arthroplasty
References 4. Jordan RW, Chahal GS, Chapman A. Is

end-stage ankle arthrosis best managed
8. Glazebrook MA, Arsenault K,
Dunbar M. Evidence-based
1. Glazebrook MA Evidence-based with total ankle replacement or classification of complications
indications for ankle arthroscopy. arthrodesis? A systematic review. Adv in total ankle arthroplasty.
Arthroscopy. 2009;25:1478–90. Orthop. 2014;2014:986285. Foot Ankle Int. 2009;30:
2. Grennan DM, Gray J, Loudon J, et al. 945–9.
5. Buechel FF Sr, Buechel FF Jr,
Methotrexate and early postoperative Pappas MJ. Twenty-year evaluation 9. Coester LM, Saltzman CL, Leupold J,
complications in patients with of cementless mobile-bearing total Pontarelli W. Long-term results
rheumatoid arthritis undergoing ankle replacement. Clin Orthop following ankle arthrodesis for
elective orthopaedic surgery. Relat Res. 2004;424:19–26. post-traumatic arthritis. J Bone
Ann Rheum Dis. 2001;60: Joint Surg Am. 2001;83–A:
214–17. 6. Wood PL, Sutton C, Mishra V, Suneja R.
219–28.
A randomised, controlled trial of two
3. Haddad SL, Coetzee JC, Estok R, et al.
mobile bearing total ankle replacements. 10. Johnson JE, James RY. Arthrodesis
Intermediate and long-termoutcomes
J Bone Joint Surg Br. 2010;91:69–74. techniques in the management of
of total ankle arthroplasty and ankle
stage-II and III acquired adult
arthrodesis: A systematic review of the 7. Gougoulias NE, Khanna A, Maffuli N.
flatfoot deformity. J Bone Joint Surg
literature. J Bone Joint Surg Am. Total ankle arthroplasty. Br Med Bull.
Am. 2005;87:1865–76.
2007;89:1899–905. 2009;89:111–51.
021
Spine oral core topics

Chapter
19 Joseph S. Butler and Alexander D. L. Baker
Introduction In adults, nutrition is via diffusion though the vertebral end

plate. In children, vessels cross the endplate to the disc.
Spinal surgery is a diverse and rapidly evolving subspecialty
within orthopaedic surgery, making it an exciting and
rewarding career choice, yet a challenging area to review Age-related changes in the spine
for the FRCS (Tr & Orth). It is a mandatory topic for The degenerative process that affects the spine is complex, it
assessment making it very difficult for exam candidates to begins at an early age and is almost ubiquitous. It is often
be successful without a solid understanding of the core topics stated that the spine is the first part of the skeleton to age, with
in this area. However, most examiners are not full-time spine early degenerative change visible on cervical radiographs as
surgeons and accept that most candidates are not going to early as the second decade of life. Men are affected more
become full-time spine surgeons either. The questions asked frequently than women and at an earlier age. The progression
tend to be of one of two types: Either they are ‘core topics’ of the age-related change is relentless and affects all anatomical
that any consultant orthopaedic surgeon should know about structures. The process begins within the intervertebral disc.
(and be able to manage appropriately or know when to refer Increasing age is associated with dehydration of the inter-
on) or they are general orthopaedic questions that are being vertebral disc. This dehydration is associated with progressive
applied to the spine (e.g. the principles of bone grafting). In histological, biochemical and biomechanical change. Histolo-
order to cover the breadth of material required, this chapter gically the boundary between nucleus pulposus and annulus
will aim to be succinct, cover core topics in sufficient depth fibrosus becomes less distinct and the organisation of collagen
to ensure a pass and provide the candidate with a framework fibres less ordered. Biochemical changes include the loss of
with which to tackle spine questions. Areas that will be aggrecan and water from the extracellular matrix and an
covered include: increase in the proteases responsible for enzymatic degrad-
General knowledge ation. There is an increased keratin sulphate to chondroitin
Degenerative conditions (including the prolapsed sulphate ratio. Fissuring and tears appear in the annulus fibro-
intervertebral disc) sis with degeneration and loss of orientation of collagen fibres.
Spinal trauma These histological and biochemical changes lead to mech-
Tumours affecting the spine anical changes in the function of the intervertebral disc. Loss of
Infection and inflammation disc height leads to instability within the motion segment,
The paediatric spine which in turn leads to compensatory calcification, osteophyte
formation, hypertrophy and buckling of the ligamentum fla-
Surgical approaches
vum. Facet joint arthrosis develops. Annular tears and disc
Other miscellaneous conditions
herniation may occur. Progressive loss of disc height in com-
Current areas of debate
bination with these changes leads to narrowing of the neural
exit foramen, increased loading of the arthritic facet joints and
General knowledge narrowing of the spinal canal. This narrowing (stenosis) can be
either central, involve the lateral recesses, or the neural exit
Structure of the intervertebral disc foramen.
There are two main components of the intervertebral disc, the Within the spinal column altered biomechanics affect dif-
annulus fibrosus and nucleus pulposus (Figure 19.1). The ferent regions in different ways. The support and relative
annulus fibrosus consists of concentric rings of type stability provided by the thoracic rib cage cause the thoracic
I collagen. Sequential layers of oblique fibres resist hoop region to be relatively spared. In the more mobile cervical and
stresses and prevent excessive movement. The nucleus pulpo- lumbar regions degenerative change is more common. In the
sus forms the gelatinous core, which allows elastic deform- cervical spine the lower levels (C5/C6 and C6/C7) are most
ation. Type II collagen predominates in the nucleus pulpous. frequently affected. Likewise the lower lumbar motion
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Figure 19.1 Structure injury and to prevent devastating sequelae. Previously the
of the intervertebral disc Stagnara wake-up test was used to check spinal cord function.
Intraoperative neurophysiological studies such as somatosen-
sory evoked potentials (SSEPs) or motor-evoked potentials
(MEPs) are used to monitor the spinal cord and detect early
changes in spinal cord function that might be correctible such
as early positional vascular or traction injuries. Stimulating a
peripheral nerve using an overlying electrode produces SSEPs
which test the posterior (dorsal) sensory columns by creating
an afferent impulse that can be detected by recording elec-
trodes over the sensory cortex. Motor tract status may be
inferred from intact sensory tracts, but MEPs provide a better
gauge of motor function. These are created by transcranial
segments are more frequently affected. Instability can progress electrical stimulation of the motor cortex and recorded from
and degenerative spondylolisthesis may occur. Degenerative a peripheral muscle.
spondylolisthesis is most common between the fourth and fifth
lumbar vertebra.
The pathogenesis of these age-related changes is unclear, Degenerative conditions
but a decrease in the nutrient supply to the disc is likely to be a
key factor. The main pathway for nutrition to reach the inter-
The lumbar spine – neurogenic claudication
vertebral disc is via the vertebral body endplate. Permeability and radiculopathy
of the endplate to nutrients decreases with increasing age, thus, Neurogenic claudication and radiculopathy are the most
decreasing nutrient supply to the disc. common indications for spine surgery in older people.
Neurogenic claudication is a symptom complex that is
Biomechanics caused by central lumbar spinal stenosis. It typically includes
The primary motion segment of the spinal column consists of a reduction in walking distance due to bilateral leg pain (clau-
two vertebral bodies and the intervening intervertebral disc. dication), a feeling of heaviness, fatigue, aching, numbness and
The combinations of flexion, extension and rotation in three loss of function affecting the lower limbs. Symptoms are typ-
planes produce six degrees of freedom. The most common ically reduced by rest and bending forward. Bending forward
biomechanical model used compares the spine to a crane with flexes the lumbar spine reducing the lumbar lordosis increas-
the vertebral bodies acting like the upright of the crane, the ing the space available for the cauda equina within the spinal
posterior spinal muscles acting as a posterior tension-band and canal. Activities that involve flexion of the lumbar spine (e.g.
the upper limbs acting like the arm of the crane suspending a walking uphill, upstairs, pushing a shopping trolley and
load at a distance. cycling) are frequently found to be easier than less arduous
tasks that extend the lumbar spine (walking downhill, stand-
Bone graft ing) which increase the lumbar lordosis.
One of the challenges for the clinician is to effectively
Any arthrodesis (fusion) procedure will require bone graft (e.g. distinguish a neurological cause for the claudication from a
posterior spinal fusion in scoliosis or spondylolisthesis). Auto- vascular one (Table 19.1). The characteristics of the symp-
graft (the patient’s own bone) and allograft (donated bone) are toms described above will help, and clinical examination
the two main types used, possibly supplemented by synthetic with palpation of peripheral pulses as well as ankle-brachial
materials such as tri-calcium phosphate. Iliac crest autograft is pressure recording is also useful. Standing relieves vascular
considered the gold standard and has the best fusion rates but claudication whereas neurogenic claudication may be
is associated with donor site morbidity. Allograft available as exacerbated.
demineralized bone matrix avoids donor site morbidity, but is Neurogenic claudication is caused by central spinal
theoretically only osteoconductive rather than osteoinductive. canal stenosis. Facet joint hypertrophy, posterior bulging
Bone morphogenic protein is being increasingly used and may of the dehydrated intervertebral disc and thickening of the
stimulate bone healing; however, it may be associated with ligamentum flavum combine to reduce the space available
increased rates of wound inflammation and its cost is prohibi- for the nerves of the cauda equina within the canal. This
tive in some centres. Hydroxyapatite and demineralized bone degenerative process may or may not be associated with a
matrix may also be used. degenerative spondylolisthesis that further narrows the
central canal.
Spinal cord monitoring Degenerative spondylolisthesis, most commonly occurs
Spinal cord monitoring is used in complex spinal surgery, such at the L4/5 level. It may cause the symptoms described
as deformity correction to detect early signs of neurological above as a result of central stenosis, it may also cause
022
Chapter 19: Spine oral core topics
Table 19.1 Neurogenic vs vascular claudication the annulous fibrosus. This typically affects those of
Type of claudication working age (between 20 and 50 years). Disc herniation is
the result of the degeneration of an intervertebral disc but
Symptom Neurogenic Vascular its occurrence may be precipitated by a bending, lifting or
Pain Worse on standing Relieved by standing jarring movement (coughing/sneezing). The natural history
of most lumbar disc herniations is that of spontaneous
Numbness Present Absent
resolution over time. A herniated disc is a localized dis-
Site of pain Leg/buttock/thigh Calf (rarely anterior) placement of nucleus pulposus beyond the normal limits of
Relieving factors Bending forward Standing the disc. The clinical features and treatment options for disc
prolapse vary depending on age and the location of the
Walking distance Variable Fixed
prolapsed disc.
Worse going Downstairs Upstairs
Nomenclature
A disc prolapse can be broad based (involving between 25%
symptoms by compressing nerve roots within the neural and 50% of the disc circumference), focal (involves <25%)
exit foramen or within the lateral recess. Exit foraminal or symmetrical (involves 50–100% of the circumference of
stenosis will cause unilateral or bilateral radiculopathy. Dif- the disc). A focal disc herniation may be described as a
ferent degrees of loss of disc height, osteophytosis, exit protrusion or extrusion. An extruded disc has a narrow
foramenal dimensions and central stenosis will determine ‘neck’ at its base. Extruded disc material is ‘sequestrated’ if
the neurological structure compressed and, therefore, the it is no longer in continuity with the disc2. A ‘central’ disc
symptoms experienced. herniation is one that is located posteriorly, in the midline.
Radiculopathy is characterized by pain, paraesthesia, Other locations include para-central, foraminal and far-
numbness and muscle weakness caused by injury to a spe- lateral disc herniations.
cific spinal nerve or nerve root. Causes include lumbar disc In children the symptoms and signs of disc prolapse are
herniations, lateral recess stenosis, foraminal stenosis, spon- less well defined and back pain is a more prominent feature.
dylolisthesis and other compressive pathology such as facet Nerve root tension signs are also less likely to be positive and
joint cysts. More rarely the pathology may originate within spontaneous resolution is less likely.
the nerve root itself (e.g. neurofibromas). Symptoms affect Radiculopathy usually predominates over back pain and is
the dermatome and myotome of the injured nerve root. often described as burning or electrical in nature, and is
Thus, the pain felt on the outer aspect of the leg (L5 derma- associated with paraesthesia and numbness. It is important to
tome) originating from an L4/5 disc prolapse (‘referred’ exclude non-spinal causes for back pain and exclude ‘red flags’
pain) can be described as an L5 radiculopathy. The term indicative of serious spinal pathology:
‘sciatica’ is frequently misused by patients and clinicians and History of trauma
it is perhaps best thought of as more general term. Sciatica Age <20 or >55 years old
describes pain in the distribution of the sciatic nerve and,
Thoracic or abdominal pain
therefore, encompasses the various different lumbar radicu-
Nocturnal pain
lopathies below the knee (L3, L4, L5 and S1). This is impre-
cise as the medial malleolus is innervated by the saphenous Pain that is constant, progressive or non-mechanical in
nature
nerve which is a sensory branch of the femoral nerve (L4)1.
The even older term ‘lumbago’ describes a severe low back Constitutional symptoms (fever, night sweats, weight loss)
pain that radiates round via the buttocks to the hips to the History of malignancy, steroid use, drug abuse or HIV
top of the thighs. Persisting severe restriction of lumbar spine flexion
Structural spinal deformity
Investigations Widespread neurological abnormality
MRI has become the gold standard for investigating these Investigation is with MRI but is not normally required in
symptoms. Detailed images of the spinal canal in sagittal and the acute setting unless there are features of cauda equina
transverse section can be used to assess the space available for syndrome (bilateral lower limb radiculopathy, saddle anaes-
neural structures. Its main disadvantage is that the investiga- thesia, urinary and bowel symptoms). Initial treatment is
tion is performed supine which may cause a spondylolisthesis non-operative with the provision of analgesia, including
or other deformities to reduce or appear less severe. Standing NSAIDs if not contraindicated. Consideration should be
x-rays may be helpful in this regard. Alternatives include CT given to the short-term use of antispasmodics (a benzodi-
myelography. azepine). Neuropathic analgesics may be used. If conserva-
Lumbar disc herniation. The most common cause of tive treatment has not been successful microdiscectomy
lumbar radiculopathy is a herniation of the nucleous pul- may be considered and produces significant improvements
posus of an intervertebral disc beyond the normal limits of in leg pain in >80% of patients.
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Cauda equina syndrome validated patient reported outcome measures (SF-36 and
Cauda equina syndrome caused by compression of the cauda Oswestry Disability Index).
equina (usually by a large central low lumbar disc hernia-
tion) and is characterized by urinary retention, faecal incon- Controversies and novel treatments
tinence, saddle area numbness and loss of anal tone. One of the main dilemmas that the spine surgeon faces
Bilateral radiculopathy, which is pathognomonic of cauda when treating a degenerative spondylolisthesis is whether
equina syndrome occurs when a central disc herniation is to fuse the spine in order to stabilise and prevent progres-
sufficiently large to compress nerve roots on both sides of sion of the spondylolisthesis. Following the Cochrane
the spinal canal. review4 demonstrating higher fusion rates with instrumen-
The importance of detecting cauda equina syndrome early tation this is usually undertaken using posterior screw and
is that early intervention (<48 h) has been suggested to rod instrumentation with or without an anterior cage. In
improve outcome. More recently the extent of the compression younger patients with higher demands fusion surgery
rather than the timing of surgery has also been linked to may help prevent progression of the spondylolisthesis and
outcome. the need for further surgery. However, in an older age
Cauda equina syndrome can progress at a variable rate group the spondylolisthesis rarely progresses and decom-
(hours, days or weeks), and patients present at various points pression without instrumentation avoids the complications
along that process. A distinction may be made between cauda associated with instrumented or non-instrumented fusion
equina syndrome with symptoms of urinary disturbance surgery.
(altered sensation or incontinence) but not retention (CES- Novel technologies including interspinous spacer
I), and CES with retention (CES-R). CES-Incomplete patients devices are currently being evaluated but have not found
may have subtle urinary difficulties including altered sensa- wide acceptance. Typically they attempt to treat symptoms
tion, loss of the desire to void, poor urinary stream, stress by flexing the spine at the symptomatic level, relieving
incontinence or difficulty in initiating micturition. Saddle symptoms in a similar but exaggerated way to bending
area sensory change may be subtle, unilateral or partial. forward. Although there have been some encouraging early
Trigone (catheter-tug) sensation is be present. CES-Retention results, the exact indications for such surgery have yet to be
is characterized by complete loss of bladder sensation. Pain- established.
less urinary retention results with overflow incontinence.
There is extensive loss of sensation in the saddle area with Degenerative conditions affecting the cervical
absent trigone sensation.
The outcome of surgery for patients with CES-I is generally
spine – Radiculopathy and myelopathy
more favourable. Surgery aims to prevent progression to Cervical spondylosis is a widely used but non-specific term
CES-R. referring to the generalized degeneration of the cervical spine
frequently seen in older people although it can begin at an
Outcomes of surgery for spinal stenosis and spondylolisthesis early age. Characteristic x-ray changes can be identified.
There are many different surgical techniques that have been Patients may present complaining of neck pain, radiculopathy
described for treating compressive lesions including inter- or myelopathy. Neck pain caused by cervical spondylosis
lamina decompression (most common), laminectomy, typically presents as episodic bouts of pain that resolve over
undercutting facetectomy, laminotomy, selective nerve root days or weeks. Symptoms may be exacerbated by increased
decompression and many others. All are aimed at relieving activity and may be associated with occipital headache. Treat-
symptoms by relieving neural compression. In addition, ment is largely conservative with rest and analgesia. Assess-
where there is instability (spondylolisthesis), decompres- ment is aimed at identifying and excluding surgically treatable
sion may be supplemented with fusion. Whichever tech- conditions.
nique is undertaken treatment, it is aimed at removing the Cervical radiculopathy is typically caused by a compres-
mechanical compression and the subsequent recovery of sive lesion affecting a single nerve root in the cervical spine.
symptoms relies on recovery of the compressed neural Compression can be caused by osteophytes, herniated disc
structure. The outcome of surgery of this type is relatively fragments, facet joint hypertrophy and loss of disc height. It
predictable and significant improvements in leg pain, presents with unilateral neck pain, and pain radiating into the
walking distance (and associated disability), and quality of upper limbs in the distribution of the affected nerve root.
life can be expected following surgery. Recent high quality These symptoms are associated with decreased or altered sen-
data from prospective studies in a large number of patients sation and lower motor neurone signs in a similar distribution.
have shown the clinically significant benefits of spine sur- The most commonly affected levels are the C6 and C7 nerve
gery over conservative treatment and the maintenance of roots. The natural history of radiculopathy is benign with a
these improvements in the medium term3. Patients under- significant proportion of cases resolving spontaneously or with
going surgery have shown significant improvements in conservative treatment. Its peak incidence is in middle age and
pain, physical function and disability as assessed using this decreases with increasing age.
022
Radiculopathy affecting the C6 nerve root (exiting arms of forces acting at adjacent levels which may cause adja-
above the sixth cervical vertebra) will produce pain radiat- cent level degeneration.
ing to the radial side of the forearm and hand affecting the
thumb and index fingers, decreased or altered sensation in Cervical disc replacement
a similar distribution with weakness of biceps (supination) Cervical disc replacement is an emerging surgical technique
and wrist extension. The brachioradialis reflex may be offering an alternative to ACDF. It is aimed at treating the
decreased. same pathologies through the same anterior approach but
Radiculopathy affecting the C7 nerve root will produce attempts to preserve segmental motion potentially reducing
pain radiating to the long (middle) finger, decreased sensation rates of adjacent segment degeneration. Initial results are
in the same area, weakness of wrist flexion, elbow extension encouraging and appear to be at least comparable to
and a decreased triceps reflex. ACDF5. However, this surgery does not prevent movement
Cervical myelopathy can be defined as spinal cord dys- of the posterior facet joints as ACDF does. Posterior facet
function due to compression of the cervical cord within the joint arthropathy is commonly associated with anterior
cervical spine. It is the most common type of spinal cord lesion degeneration. Although cervical disc replacement may
in older people. The compression is commonly caused by improve pain from a cervical radiculopathy in the same
osteophytes, ligamentum flavum hypertrophy and bulging or what that an ACDF does it will not address pain from facet
prolapse of the intervertebral disc. joint arthropathy which and ACDF might by preventing
Cervical myelopathy presents with upper motor neuron motion.
signs and symptoms in both upper and lower limbs. Initial
presentations may be subtle but detection and treatment is Posterior surgery – foraminotomy/laminoplasty
essential before irreparable cord damage occurs. Typically Posterior surgery may also be used in the cervical spine
cervical myelopathy follows a progressive stepwise deterior- either to decompress a single nerve root (foraminotomy)
ation with relatively stable periods and periods of rapid deteri- or to decompress multiple levels. It has the advantage of
oration. It rarely resolves spontaneously. Symptoms include being motion preserving and when surgery is required at
decreased coordination, loss of fine dexterity (e.g. buttoning a more than two levels it is the treatment of choice. However,
shirt, handwriting, manipulating small objects), balance and its disadvantage is that the surgery can potentially destabilise
gait problems, and problems with bowel and bladder function. the spine posteriorly leading to a tendency to drift into
Balance and walking problems may lead to frequent trips, falls kyphosis. Furthermore, as cervical spondylosis advances pro-
or bumping into things. There may be diffuse altered sensation gressive loss of disc height anteriorly leads to a progressive
and occasionally the sensation of shooting pains or ‘electric loss of the normal cervical lordosis and may itself produce
shocks’ radiating down the arms when moving the head in cervical kyphosis. To avoid this combination of risk factors
particular position. kyphosis is a relative contraindication to posterior surgery in
Associated (upper motor neuron) signs include: A wide spondylotic patients.
based unsteady gait, upper and lower limb weakness, hyper-
reflexia, intrinsic muscle waiting in the hand, positive Babinski
and Hoffman signs and an inverted radial reflex. Spinal trauma
Spinal fractures occur in 10% of all adult major trauma
Anterior cervical discectomy and fusion (ACDF) patients, although the incidence is probably higher as many
ACDF is a key procedure in cervical spine surgery, providing minor or osteoporotic fractures presumably go unrecognised
excellent outcomes with a low complication rate. The anterior and untreated. Careful assessment and subsequent manage-
approach allows access to the cervical disc that can be removed ment of patients with potential spine injuries is essential to
along with osteophytes at the posterior aspect of the vertebral prevent spinal cord injury and maximise the potential for
body. It allows removal of most lesions causing myelopathy or recovery. Patients suspected of having a spinal cord injury or
radiculopathy. Placement of anterior bone graft between the unstable spinal fracture should arrive at their destination
vertebral bodies in the excised disc space indirectly assists already immobilized on a spinal board, if this is not the case
decompression of the exit foramen indirectly and facilitates these measures should be put in place as soon as a spinal injury
bony fusion. is suspected. Patients are kept immobile until a definitive
Complications that may occur include pseudarthrosis opinion regarding spinal stability can be obtained. Standard
(increased in smokers), hoarseness and dysphagia as a result spine trauma assessment should always proceed as per ATLS®
of retraction or injury to the recurrent laryngeal nerve (2–5%). principles.
This may also be caused by placement of the ET tube (more
common). Graft complications also include the graft loosening Assessment
and migration. Progression of the underlying disease process Airway (with cervical spine control), Breathing, Circulation,
may cause degeneration of adjacent levels. Alternatively, fusion Disabilty (including neurological examination) and Exposure
alters the mechanics of the cervical spine increasing the lever (including inspection of the back).
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022
Life-threatening conditions take priority. An initial 5- sacral segment. Different patterns of incomplete injury have
second assessment for airway obstruction, massive haemor- been identified. Sacral sensory sparing is important as it indi-
rhage or cardiac arrest is followed by a handover from pre- cates an incomplete injury and the potential for improvement.
hospital personnel and then assessment of ABCD&E. The Brown–Séquard syndrome is an injury that affects one side
cervical spine needs to be controlled and protected until of the spinal cord. It results in loss of ipsilateral motor func-
cleared clinically and radiologically. Sandbags, tape and hard tion, conscious proprioception and contralateral pain and
collar immobilization on spinal board are typically used ini- temperature sensation with decreased sensation to light touch.
tially with the patient transferred off the spinal board as soon The prognosis is relatively good with 90% of people regaining
as is feasible due to the risk of development of pressure sores. bowel and bladder function and independent mobility.
A high index of suspicion is mandatory with high-energy Anterior cord syndrome has light touch and joint position
injuries, head or facial injuries or an altered level of sense proprioception preserved in dorsal columns with loss
consciousness. of motor function (movement), pain and temperature sensa-
Hypovolaemic shock should be distinguished from neuro- tion from the anterior injury. The prognosis is more
genic shock. Neurogenic shock is defined as vascular hypoten- guarded with recovery only if it resolves within a short period
sion that occurs as the result of spinal cord injury. The cell (24 h).
bodies of the autonomic nervous system are located in the Central cord syndrome is the most common incomplete
spinal cord grey matter. Injuries to the spinal cord above the spinal cord injury and frequently results from an extension
mid thoracic level may affect the function of the autonomic injury in a spine with pre-existing degenerative change. The
nervous system, which results in loss of ‘sympathetic tone’. upper limbs are more affected than the lower limbs. Upper
This leads to peripheral vasodilation resulting in hypotension limb flaccid paralysis with hypertonic paralysis or preservation
and if the lesion is above T2 there will also be bradycardia. of function in the lower limbs is seen. Fifty-to-sixty per cent of
Furthermore patients are unable to respond in a normal way to patients regain lower limb function, but damage to the central
the hypovolaemia caused by other injuries. Neurogenic shock synapses and cell bodies (in the grey matter) frequently result
may be the only indication of spinal cord injury in an uncon- in poor hand function.
scious patient. Resuscitation should aim to restore cord perfu-
sion without causing oedema. Neurological symptoms can be ASIA/Frankel grading system
transient (fluctuating GCS) and if present suggest more serious A. Complete paralysis
underlying injury. Repeated neurological assessment is B. Sensory incomplete – Sensory function but no motor
required to establish trends of improvement or deterioration. function below the level of the injury
Bradycardia is suggestive of neurogenic shock and diaphrag- C. Motor incomplete – Motor function (MRC) grade 2 or less
matic breathing suggests cervical cord injury. below level of injury
Spinal shock is defined as spinal cord dysfunction as a D. Motor incomplete – Motor function (MRC) grade 3 or
result of physiological rather than anatomical disruption. It is above below the level of the injury
the result of swelling, oedema and inflammation and it usually E. Normal function
settles in the first few days following spinal cord injury. The
neurological dysfunction below the level of injury (e.g. absent MRC scale for muscle power
reflexes) subsequently recovers with the resolution of spinal
0. No muscle contraction is visible
shock. The bulbocavernosus reflex recovers first. If a complete
1. Muscle contraction is visible but there is no movement of
neurological deficit persists for >24 hours after spinal shock
the joint
resolves the potential for recovery is limited. Incomplete def-
icits are more likely to recover. 2. Joint movement is possible with gravity eliminated
3. Movement overcomes gravity but not resistance
Neurological examination 4. The muscle can overcome gravity and move against
Assessment and onward communication can be greatly facili- resistance but is weak
tated by the use of an ASIA chart. Structured scoring systems 5. Full and normal power against resistance
provide a reproducible template for serial evaluation. If a
cranial nerve deficit is detected consider vertebral artery injury Clearing the spine
or high cervical fractures/dislocations. Neck or back tender- Local protocols will usually be in place. In order to clear the
ness is not always present. A palapable ‘step’ in the spinous spine clinically (without radiological assessment) in a con-
processes may suggest a fracture or dislocation. scious patient the patient must be fully alert and orientated
A ‘complete cord’ injury is defined as complete loss of and not complaining of neck pain. There should be no associ-
motor and sensory function below the level of a spinal cord ated head injury. There should be no involvement of sedative
injury. An incomplete cord injury is defined as partial preser- drugs or alcohol. There should be no other ‘distracting’ injury
vation of sensory or motor function below the level of spinal a (long bone fracture). A complete neurological examination
spinal cord injury with sensory or motor function in the lowest should be normal and be documented.
022
Under these circumstances the cervical collar can be Neurological injury

removed and the neck examined carefully looking for signs This can be classified as ‘complete’ or ‘incomplete’ as described
of bruising, deformity, bony tenderness, reduced range of and graded above. Incomplete injuries include nerve root
movement or pain on movement. injuries or the syndromes described. Complete injuries have
If none of these are present the cervical spine can be cleared no function below a certain level. The ‘level’ of the injury is
and radiographic studies are unlikely to be required. If the determined by the distal most level with intact sensory and
patient complains of pain, radiographs in two planes of the C- motor function. Patients with spinal cord injuries are at risk of
spine from the skull to T1 are required. If radiographs fail to deterioration not only from progressive cord injury, but also
show a fracture and the patient continues to have moderate to from the dysfunction of other organ systems.
severe cervical spine pain or tenderness, then the collar is left Positioning – Patients with spinal cord injuries should be
in place until voluntary flexion and extension radiographs or nursed flat. The site of spinal cord injury is as a zone of critical
further imaging CT/MRI is undertaken. ischemia. Loss of vasomotor tone means severe hypotension
Clearing the spine in unconscious patients remains contro- can result from sitting up a patient with spinal cord injury even
versial with recommendations ranging from removal of the after resuscitation. The hypotension that results from sitting a
cervical collar after 24 hours in patients with normal radio- patient up can result in worsening ischemia to the injured
graphs, to indefinite immobilization. spinal cord and brain and can adversely affect recovery.
Gastrointestinal system – Stress ulceration is common and
Radiological investigation
consideration should be given to the prophylactic use of
CT scanning is more sensitive than radiographs in two planes proton pump inhibitors. Paralytic ileus is common following
at detecting fractures and is becoming more frequently under- all forms of major trauma. Bowel function is frequently
taken as part of the assessment of trauma patients. Head affected by spinal cord injury. All patients should be kept nil
injuries and cervical spine injuries commonly occur together. by mouth initially. Once spinal shock has resolved, the use of
Multiply injured patients will usually undergo a full trauma regular suppositories and manual evacuation should be initi-
scan, but when thinking of ordering an isolated CT head in a ated early and monitored regularly.
patient with head injuries, a cervical spine CT scan should be Genitourinary system – Bladder function is commonly
requested as a routine. The remaining thoracic and lumbar affected and prolonged retention with associated distension
spine may be adequately imaged either by AP and lateral plain can lead to further injury to the bladder which is prevented
radiographs or by sagittal and coronal reformatting of CT by catheterisation. A catheter can also be used to assess trigone
scans of the chest, abdomen and pelvis undertaken as part of (‘catheter-tug’) sensation as part of neurological assessment.
a CT trauma series. Autonomic dysreflexia is a potentially life-threatening con-
Oblique cervical spine radiographs (with the x-ray beam at dition that can occur in patients with spinal cord injuries. The
45°, patient supine, cassette on far side) show the pedicles and most common cause is an undetected blocked urinary catheter
facet joints well. Dynamic imaging, including flexion/exten- or bowel obstruction. Severe (paradoxical) hypertension and
sion radiographs may be used to assess stability in the subacute bradycardia result. Treatment is with removal of the initiating
setting but not initially. Other spinal x-rays are indicated when stimulus and pharmacological treatment with antihyperten-
examination reveals a soft-tissue injury (e.g. a step in spinous sives and vasopressors.
processes, swelling or bruising), the patient complains of pain, Skin – Pressure sores can develop rapidly owing to loss of
or neurological deficit is detected. If one fracture is identified protective sensation and the capacity for movement. Pressure
the whole spine should be imaged (10% have a second frac- area care should begin as soon as the patient arrives in hos-
ture). Other associated injuries (e.g. calcaneal fractures) may pital, with removal of the spinal board as soon as practicable.
indicate a spine x-ray is required. Regular turns from side to side (40°) with adequate support
CT scans show laminar fractures, and retropulsed should be undertaken regularly and recorded.
fragments better than x-rays. When viewing a CT canal size Deep vein thrombosis – Thromboembolic disease is a sub-
(and compromise) can be assessed by looking at the intact stantial risk in immobile patients. This is now one of the most
vertebral body. The canal is usually 0.8 times body diameter commonly reported causes of mortality in spinal cord injury.
or more. Physiotherapy – Joint contracture as a result of loss of
MRI also has its advantages. MRI is the urgent investiga- voluntary movement or spasticity can occur rapidly following
tion of choice for spinal cord injury. Neural structures and soft injury. Regular passive range of movement exercises of all
tissues (including discs) are seen more clearly. Soft-tissue affected joints should be undertaken regularly. Resting splints
injuries can be identified form the high signal on T2 scans. should be provided overnight.
Classification of injury
After a severe trauma there are usually two aspects of the Osteoligamentous injury
injury that require assessment the neurological and the The classification of the bony or osteoligamentous injury
osteoligamentous. depends on the location of the fracture and will be discussed
375
022
below. The terms unstable and stable are often used. Denis the conscious patient occipital headache may be present
classified the ‘stable’ fracture is one that will not deteriorate although neurological examination may be normal. Dysfunc-
neurologically or structurally under normal physiological tion of cranial nerves IX–XII may be present but is hard to
loads. detect. This injury has been classified by Anderson and
Montesano:
Management Type I comminuted undisplaced axial impact fracture
The aim of management of a spinal injury is to minimize pain Type II continuous with base of skull fracture
and maximise function. The risk of further neurological injury Type III avulsion at the attachment of the alar ligament
may be reduced by providing mechanical stability whilst at the Treatment for types I and II is conservative (cervical collar).
same time facilitating other aspects of patient care. Type III injuries are unstable and treated with halo vest or with
The use of steroids has been widely debated, the theoretical occipito-cervical fusion.
concept being that a reduction in inflammation may reduce
further injury to the spinal cord. Steroids are widely used in Atlanto-occipital joint
the context of brain and spinal cord tumours with good effect
Traumatic dislocations at this level are usually fatal. If a cord
on symptoms and motor function. However, there is only
injury exists at this level most patients will die before reaching
limited evidence that they provide any benefit for fractures
hospital as a result of respiratory compromise. More minor
and treatment is not without morbidity. Several large studies
traumatic atlanto-occipital subluxations may reduce spontan-
(NASCIS 1, 2 and 3) have looked at the use of steroids in the
eously. Rare survivors may have injuries to cranial nerves VII–X.
early post-injury period. Unfortunately their methodology has
Powers’ ratio is the distance from the basion to the posterior
been criticised, as has the interpretation of their results.
arch of C1 divided by distance from the opisthion to the
NASICS 1 – 1984. No difference in outcome was identified anterior arch of C1. Normal is 1, >1 suggests anterior disloca-
in the group that received steroids but subsequent animal tion, <1 posterior dislocation. Treatment is with Halo-vest
studies suggested the dose of methylprednisolone was immobilization. Traction is avoided as there is a risk of over
insufficient to see a benefit distraction. Occiput-C1 fusion can prevent late displacement.
NASICS 2 – 1990. An increased dose (30 mg/kg bolus then
5.4 mg/kg per hour for 23 h). No difference in initial
analysis. A subgroup analysis showed a benefit in motor
Atlas (C1) fractures
function at 6 months in those given the steroids within Injury to C1 is associated with other injuries in 50% of cases.
8 hours of injury Neurological injury is less common as there is a relatively large
canal diameter at this level. Diagnosis is usually made on the
NASICS 3 – 1997. Similarly required a subgroup analysis of
trauma CT although it may also be detected on an ‘open
those receiving the higher dose of prednisolone for a
mouth’ radiograph. Four types of C1 fracture are recognised:
prolonged period (48 h) initiated between 3 and 8 hours to
find a benefit Burst fractures involving the anterior and posterior arches
In a joint statement in 2013 The Congress of Neurological (the ‘Jefferson’ fracture)
Surgeons (CNS) and The American Association of Neuro- Isolated posterior arch fractures
logical Surgeons (AANS) concluded ‘Methylprednisolone Isolated anterior arch fractures
should not be used for the treatment of acute spinal cord injury’. Unilateral lateral mass fractures
Specific injuries will be discussed below but in general The lateral masses of C1 and C2 should be in line on imaging.
terms decompressing, realigning and stabilising the spine will If the combined displacement of the C1 lateral masses is 7 mm
allow the best potential for early mobilization, prevention of or more relative to C2 the transverse ligament is likely to be
complications and recovery of function. On the other hand, disrupted and the injury unstable. Stable fractures can be
surgery is not without risk either and carries with it the risk of managed in a cervical collar for 12 weeks. Unstable fractures
creating further injury including vascular injury. Management require an initial period of traction for 3 weeks or until
can be operative or non-operative and depends on the injury. reduction of the lateral masses is achieved and then a halo vest
for a total time of 12 weeks. Occipito-cervical fusion may be
required for unstable injuries.
Upper cervical – occiput to C2
Occipital condyle fractures Atlanto-axial instability
These are rare injuries usually caused by axial compression on Atlanto-axial stability relies on the transverse ligament, which
a laterally flexed neck or represent an avulsion injury. They are passes between the lateral masses of C1 behind the odontoid
rarely detected in x-ray but are being identified more fre- peg, and the alar ligaments, which connect the odontoid peg
quently with the increasing use of CT scanning for trauma. and the occipital condyles. Instability may be in AP translation
They are associated with potentially lethal trauma and are or in rotation. Instability may result from a fracture of C1, an
associated with other spinal fractures in 30% of patients. In odontoid peg fracture, or rupture of the transverse and alar
022
ligaments. Radiological investigation will reveal an abnormally

large atlanto-dens interval (5 mm or greater). MRI scan may
Bilateral C2 pars fractures/C2 traumatic
reveal the ligamentous injury. Also, dynamic CT scans have spondylolisthesis/Hangman’s fracture
been used to assess bony stability. Acquired instability may These are relatively common injuries usually caused by hyper-
also arise in Down’s syndrome or rheumatoid arthritis. extension in motor vehicle collisions. Hanging is now a rare
Rotational instability is more commonly seen in children cause! Thirty per cent are associated with other spinal frac-
and typically presents with neck pain, torticollis and a tures. Dysphagia and dyspnoea are recognised complications
decreased range of movement. It has been classified by Fielding of a retropharyngeal haematoma. They have been classified by
and Hawkins into 4 types based on the amount and direction Effendi and modified by Levine and Edwards:
of displacement. Type I–III C1 rotates anterior to C2 (<3 mm, Type I – Minimally displaced (<3 mm no angulation).
3–5 mm, >5 mm respectively) and type IV C1 rotates Caused by axial compression treatment is symptomatic with
posteriorly. cervical collar
Treatment is aimed at preventing further displacement in Type II – Significant angulation and >3 mm displacement.
unstable injuries and symptom control in stable injuries. Stable Caused by hyperextension with axial load treatment is
injuries with intact transverse and alar ligaments are suitable traction or halo-vest immobilization
for non-operative management in a rigid cervical collar or Type IIA – Angulation at the fracture sight without
halo-vest for 6–12 weeks. In an adult with a transverse liga- displacement. Resulting from a flexion–distraction injury
ment injury that involves a large bony fragment, reduction these can displace further with traction which should be
may be achieved with traction and immobilization with a halo avoided. Treat with a halo vest
vest for 12 weeks. In the elderly, life-long conservative treat- Type III – Anterior translation with uni or bi-lateral facet
ment may be an option for those in whom surgery is joint dislocations at C2/3. Attempted closed reduction or
contraindicated. open reduction and stabilisation
In children with rotatory instability treatment is usually
conservative. Many of these injuries in children reduce spon-
taneously and initial immobilization is relatively contraindi- ‘Subaxial’ C3 to C7 injuries
cated as it may hold the subluxation in the displaced position. These injuries have been classified by Allen and Ferguson and
Rarely, if the injury does not reduce spontaneously gentle are based on the mechanism of injury. There are six mechan-
halter traction may be required. isms which are then subdivided into stages based the severity
A mid-substance tear of the stabilising ligaments will not of the injury and the appearance of radiographs. The classifi-
usually heal and C1–2 fusion (with resultant loss in cervical cation guides treatment. The three most common types are
rotation) is indicated. flexion–compression, flexion–distraction and compression in
When atlanto-axial instability exists care must be taken extension.
during intubation and the preoperative investigation of Flexion–compression injuries. This mechanism causes fail-
patients with rheumatoid arthritis with flexion and extension ure of the anterior column in flexion and the posterior column
x-rays is routine. Advanced techniques such as fibre optic in distraction. There are five stages. Blunting of the anterior
intubation are routinely employed. superior vertebral body (stage I), vertebral body beaking (stage
II), beak fracture (stage III), retrolisthesis <3 mm (stage IV)
Atlas (C2) fractures and retrolisthesis >3 mm (stage V). Stages I and II may be
managed conservatively in cervical collar or halo vest, other
Odontoid peg (Dens) fractures have been classified by Ander- stages may require surgery and type V may require anterior
son and D’Alonzo into three types based on the location of the and posterior surgery. Teardrop fractures of the anteroinferior
fracture: endplate as it is driven into flexion by a compressive flexion
Type I – Fracture of the tip caused by avulsion of alar injury should be distinguished from a benign osteophyte or
ligaments (which connect the dens to occiput). These are avulsion fractures. Teardrop fractures are relatively unstable
treated symptomatically and may require stabilisation.
Type II – Fracture of the base of the odontoid peg. This is the Flexion–distraction injuries (facet joint dislocations). This
most common and most problematic type with a high rate of mechanism of injury causes failure of the posterior tension-
non-union. Typically these fractures displace with the C1 band and progressive subluxation and dislocation of the facet
dens ligaments intact. Management is reduction and either joints. These are frequently missed injuries, oblique radio-
posterior arthrodesis of C1–C2, or anterior (odontoid screw) graphs visualise the facet joints more clearly. Lateral radio-
stabilisation. Halo vest immobilization for 3 months may be graphs may show anterior subluxation of the vertebra, soft-
used if displacement <5 mm and the patient is <50 years old tissue swelling and the articular processes may overlap more.
Type III – Fracture through vertebral body. Management is On an AP radiograph the spinous process may be deviated to
usually with a halo vest. A cervical collar may be used in affected side. The diagnosis is confirmed on CT. Stage 1 <25%
elderly patients with stable fractures subluxation of the facets, stage II unilateral facet joint
377
022
dislocation, stage III bilateral facet joint dislocation, stage IV occupant of a stationary car that has been stuck from behind
is bilateral facet joint dislocation with displacement of the by another car. There is considerable controversy regarding
vertebral body the full vertebral width. All stages require the pathophysiology and natural history of this condition. At
reduction with traction (up to one-third body weight) and the moment of collision the head is thrown back causing
subsequent instrumented fusion. The general consensus is abnormal extension of the cervical spine. The recoil of the seat
that awake reduction regardless of neurological deficit should then throws the individual forward and as the torso is
be undertaken to monitor neurological function. With reduc- restrained by their seatbelt, and the cervical spine flexes. Many
tion there is a risk that an associated disc extrusion may cause report persistent symptoms. Most patients who settle do so in
cord compression and, therefore, a post-reduction MRI first 3 months. Treat as for sprains elsewhere – Rest, NSAIDs
should be undertaken and a surgical team available on and mobilization. Many cases result from RTAs and involve
standby in case urgent ACDF is required. Anterior decom- medico-legal claims.
pression and fusion is required when a discectomy has to be
undertaken otherwise posterior fusion may be chosen. In type Thoracolumbar spine trauma
IV injuries both may be required (anterior to decompress and
This is the most common site of spinal injury (40–60% of all
posterior to facilitate reduction with facetectomies and
spinal fractures involve T12, L1 and L2). Amongst young
stabilisation).
patients, thoracolumbar fractures are usually the result of
Extension–compression injuries. These injuries cause failure
high-energy trauma, whilst fractures in the elderly may be
of the posterior column in compression. There are five stages.
caused by osteoporosis. Thoracolumbar fractures are often
Stage I is a unilateral vertebral arch fracture, stage II bilateral
associated with abdominal trauma and 10–15% of thoracolum-
lamina fractures, stage III bilateral vertebral arch fractures
bar spinal injuries have significant visceral injuries.
with minor anterior displacement of the vertebral body, stage
IV is further displacement of the vertebral body and stage Nomenclature
V severely (complete). Types I–III can be treated with immo- The title of this section points to a difficulty that currently
bilization in a cervical collar or halo vest. Types IV and V are exists with respect to nomenclature. Both the AO group and
displaced fractures that are treated with posterior cervical the Scoliosis Research Society define the term ‘thoracolum-
fusion. bar’ as referring to the region of the spine that is the junction
Vertical compression injuries. These injuries are divided between the thoracic and lumbar spine including T12, L1 and
into three stages. Compression of the vertebral endplate (stage the intervening disc. However, most fracture classification
I), compression and fracture of the vertebral endplate with systems use the term to refer to the whole thoracic and
minimal displacement (stage II) and displacement or fragmen- lumbar spine extending from T1 to L5 the majority of which
tation (stage III). Stage I and II are usually managed conserva- involve T12, L1 and L2. The biomechanical environment
tively with a cervical collar or halo vest for 6–12 weeks. Stage from T1 to L5 changes considerably so the applicability of
III ‘burst’ fractures are caused by severe compressive load and one classification system for all regions of the spine is per-
are commonly associated with spinal cord injury and may haps doubtful.
require surgery. Surgical treatment may aim to decompress
the canal and stabilise the spine. Decompression is most com- Background
monly achieved anteriorly as compression is frequently caused In 1931 shortly after the development of medically diagnos-
‘retropulsed fragments’. Stabilisation with fusion may be tic x-ray, Watson Jones published the results of the system
achieved anteriorly posteriorly or both. of treatment he had inherited from his mentor Sir Robert
Extension–distraction injuries. There are two stages. Stage Jones in Oswestry. In the majority of cases flexion was
I is failure of the anterior longitudinal ligament with vertebral thought to be the deforming force and extension (in a cast)
body fracture treated with halo vest immobilization and stage was thought to reverse the force of injury, and reduce the
II there is further displacement leading to injury of the poster- fracture. Extension casting was proposed as the preferred
ior column which requires surgical stabilisation. method of treatment. Extension casting was used to try and
Lateral flexion injuries. There are two stages. Stage I is an correct the kyphosis and put tension on the anterior longi-
undisplaced unilateral fracture, stage II is displaced with a tudinal ligament to help reduce anteriorly displaced
contralateral ligamentous injury. Stage I can be treated with fragments.
immobilization in a cervical collar, stage II required surgical In 1948 Chance (a radiologist) described the appearances
stabilisation. of a more unstable fracture in which the posterior bony elem-
ents were disrupted (separated/distracted).
Soft-tissue injury (whiplash) In 1962 Holdsworth produced the first widely used classifi-
This area is controversial and not well understood. Patients cation system that incorporated the importance of the poster-
may complain of a plethora of symptoms including pain and ior ligamentous complex in the stability of fractures.
stiffness. Classically the patient presents following a low-speed Holdsworth’s two-column theory of spinal stability divided
motor vehicle collision, in which they have been the restrained the spine into the anterior column and the posterior
022
osteoligamentous complex. He suggested that the extension fractures (A2) are fractures in which both end plates fail but
brace was not required for single-column anterior fractures, both the posterior and anterior walls of the vertebral body
but also that it was ineffective at controlling posterior two- remain intact. Incomplete burst fractures (A3) are fractures
column injuries. involving the posterior bony wall but only one endplate. Burst
fractures (A4) occur when the entire vertebral body fails under
Classification systems compression. The radiological features of burst fractures
Three common classification systems are commonly in use. include widened pedicles on the AP view and loss of vertebral
The Denis three-column theory of spinal stability is widely height/cortical integrity of the posterior vertebral body on the
known and its terminology frequently used, but the usefulness lateral radiograph.
of this classification system has been questioned. The AO/ B – Distraction injuries. In these injuries the posterior or
Magerl classification system is a detailed comprehensive clas- anterior tension-band fails in tension. As previously described
sification following the usual AO ABC 1,2,3 system but its Chance fractures (B1) are characterized by failure of the pos-
complexity limits its practicality. This classification has terior bony elements in tension. Soft-tissue disruption of the
recently been updated. The Thoraco-Lumbar Injury Classifica- posterior ligamentous complex (B2) is important because it
tion and Severity Score (TLICS) system is perhaps the most results in instability that is not easily visible on plain radio-
useful as it guides treatment. graphs. Hyperextension injuries may result in failure of the
In 1983, following the advent of CT, Denis produced a anterior tension-band.
three-column theory of spinal stability. Denis defined the C – Displacement or dislocation injuries. These severe
middle column as lying between the posterior ligamentous injuries are rare and represent dissociation between the cranial
complex and the anterior longitudinal ligament, comprising and caudal sections of the spine. They are commonly associ-
of the posterior wall of the vertebral body, the posterior longi- ated with spinal cord injuries.
tudinal ligament and posterior annulus fibrosus. He concluded The score is completed by recording the patient’s neuro-
that the mode of failure of the third column correlated with logical status:
both the type of fracture and neurological injury. Burst frac- N0 – Neurologically intact
tures were reported as resulting from failure of the vertebral N1 – Transient neurological deficit, which is no longer
body under axial load. The key concept of the classification is present
that burst fractures in which the middle column is disrupted N2 – Radicular symptoms
have failed in axial load and, therefore, cannot be stabilised
N3 – Incomplete spinal cord injury or any degree of cauda
with an external support (extension brace), and are, thus,
equina injury
thought of as being unstable under axial load. The radiological
N4 – Complete spinal cord injury
features of widened pedicles, loss of height and cortical integ-
NX – Neurological status is unknown due to sedation or
rity of the posterior vertebral body on the lateral x-ray, and
head injury
retropulsed fragments seen on CT scan are described. The
usefulness of this classification has been brought into question In 2005 Vaccaro et al. published the TLICS score emphasizing
as many burst fractures are mechanically stable and are well- the importance of the integrity of the posterior ligamentous
managed non-operatively. complex and neurological status (Table 19.2). This scoring
In 1994 following the advent of MRI, Magerl et al. pro- system aids surgical decision making by indicating the likeli-
posed a ‘comprehensive’ classification of thoracolumbar frac- hood of instability and the requirement for surgery. In the
tures. The authors proposed a classification system based on absence of strong outcome data it is based on the expect
the familiar AO system of A, B and C types with 1, 2 and 3 opinion of a panel of authors/contributors. The classification
subgroups further divided by 1, 2 and 3 sub-subgroups. The is based on injury morphology, the integrity of the posterior
system is based on fracture morphology and the severity of the ligamentous complex and the neurological status of the patient
injury increases from A1 to C3. This AO classification has producing a score out of 10. Injuries that score 5 or more are
recently been simplified and updated by Vaccaro and adopted treated surgically and 3 or less conservatively.
by AO6 with the inclusion of a neurological score and slight As the fracture becomes more unstable and the potential
changes to the classification of both A and C type injuries. benefit of neurological decompression increases the score
A – Compression injuries. In these injuries the anterior increases.
structures fail under compression. Minor non-structural (A0)
fractures are fractures that are not associated with instability Imaging
(e.g. transverse process). Wedge compression fractures (A1) Radiographs – AP and lateral radiographs of the spine reveal
are the most commonly encountered spinal fractures. The most information pertinent for planning treatment and are
posterior elements are intact, but the anterior vertebral body mandatory. CT is best for assessing fracture patterns and
fails in flexion and compression. Spinal cord injury is uncom- spinal canal dimensions. MRI is excellent for assessing the
mon. These are usually stable injuries when there is a kyphosis posterior ligamentous complex, neural structures and cord
of <30° or loss of vertebral body height <50%. Pincer injury.
379
022
Table 19.2 Thoraco-Lumbar Injury Classification and Severity Score (TLICS)
Morphology Neurological status Integrity of PLC

Compression – 1 Intact – 0 Intact – 0
Burst – 2 Nerve root – 2 Indeterminate – 2
Translation/rotation – 3 Complete cord injury – 2 Injured – 3
Distraction – 4 Incomplete cord injury – 3
Cauda equina injury – 3
Treatment dural tears and other visceral injuries. Surgical treatment is

AO type A1 to realign and stabilise the vertebral column. Careful attention
to basic patient care (pressure area care, nutrition, etc) is
These ‘wedge compression’ injuries affect the anterior vertebral
required to prevent subsequent injury. Early mobilization
body (anterior column). Most follow minor trauma and are
(either independent or assisted) helps prevent complications
associated with osteoporosis. These injuries are stable and
of recumbency.
rarely require surgical stabilisation or involve neurological
injury. Traditional treatment is symptomatic with bed rest, Timing of surgery
analgesia and subsequent mobilization. More recently NICE
Emergency decompression is indicated for progressive neuro-
has recommended vertebroplasty and kyphoplasty as possible
logical deficit or when a cauda equina syndrome is present. In
treatment options for some people with spinal compression
the neurologically intact unstable injury operate once other
fractures caused by osteoporosis7. Kyphoplasty and vertebro-
conditions allow. Where there is a complete cord injury delay
plasty are both associated with a reduction in pain in the short
surgery until oedema settles (48 h) as early decompression
term. The long-term outcome remains unclear and these pro-
does not improve results and may be associated with a risk
cedures may be associated with an increased adjacent level
of hypovolaemia causing further ischemia to the already
fracture risk (possibly as a result of increased vertebral stiff-
injured cord.
ness, possibly as a result of disease progression).
AO type A3 & A4 ‘burst fractures’ Sacral fractures

With burst fractures there is disruption of the anterior and These injuries are often overlooked but may represent severe
middle columns and frequently retropulsion of fragments into injuries. Twenty-five per cent are associated with distressing
the spinal canal. If the posterior elements are involved, 50% neurological complications including incontinence or sexual
have neurological injury. No studies have found a direct cor- dysfunction. Sacral fractures may be associated with pelvic
relation between the percentage of canal occlusion and neuro- fractures and spino-pelvic dissociation.
logical injury. Management depends on mechanical stability They have been classified vertical into three types (Denis)
and neurological injury (as assessed using the TLICS score). affecting three zones. Zone 1 injuries are lateral to the sacral
Conservative management has been advocated in neurologic- foramina. These fractures may be associated with L5 nerve
ally intact, mechanically stable patients. With conservative root injury. Zone 2 injuries run thought the sacral foramina
treatment long-term back pain is usually mild and there is and 15% have sacral nerve root injuries. And Zone 3 injuries
unlikely to be any neurological deterioration. Retropulsed are medial to the foramen and 30–50% are associated with
bone may reabsorb or remodel. Alternatively posterior fixation nerve root injury. Transverse fracture lines produce H-type
may improve mechanical stability, restore alignment and and U-type fracture patterns, which are highly unstable injur-
indirectly reduce retropulsed bone by distraction on the pos- ies spino-pelvic dissociations. The strong sacrospinous and
terior longitudinal ligament. Complications with surgery sacrotuberous ligaments hold the distal part of the sacrum
include recurrence of kyphosis, a (low) risk of neurological fixed to the pelvic ring, while the superior part of the sacrum
injury with pedicle penetration or over distraction. Some and spine rotates out of the pelvic ring, resulting in the frac-
authors advocate anterior decompression as a more complete ture. A subclassification (Roy Camille) divides these injuries
clearance of the canal can be achieved at the same time as further into type 1 angulated fractures, type 2 angulated and
reconstructing the anterior column and avoiding further displaced, type 3 complete (100%) translational displacement
injury to the posterior tension-band. and type 4 comminuted. Indications for surgical treatment
include displacement of >1 cm or fractures associated with
Dislocations (AO type C) neurological injury (decompression and stabilisation). Surgical
These are unstable injuries with all three columns involved. requires fixation of the lumbar spine to the pelvis with sacro-
They are often associated with severe neurological deficit, iliac screws.
022
Tumours The scoring system proposed by Tokuhashi8 is useful in

establishing indications for treatment and subsequent surgical
Extradural tumours approach. A poorer prognosis is correlated with a lower score.
Introduction Six parameters are given a score (0–2). A score of <5 indicates
Metastatic disease is the most common form of skeletal a life expectancy under 1 year and a palliative approach is
tumour, and the spine is the most common site for skeletal suggested. A score of over 9 indicated a longer life expectancy
metastasis with the most common primary tumours being and suggests excision should be considered.
breast, lung, prostate, renal, thyroid, the GI tract, and Mye- General condition (poor 0, moderate 1, good 2)
loma. Primary spinal tumours occur but are much less
Number of extra-spinal metastases (3 or more scores 0, 1 or
common. The role of spine surgery is dependent on the aeti-
2 scores 1, 0 scores 2)
ology, stage and grade of the lesion. Curative resection is
possible in a few cases but is the least common indication for Number of spinal bony metastases (3 or more scores 0,
spinal surgery. Palliative resection for the prevention of (or 2 scores 1, 1 scores 2)
prevention of progression of ) neurological impairment is a Number of metastases to major internal organs
common reason for surgical intervention. Pain from bony (unremovable 0, removable 1, no mets 2)
destruction and resultant mechanical instability may respond Tissue of origin (lung, stomach 0, kidney liver uterus 1,
to surgical stabilisation. The most common presenting com- other, breast, thyroid, prostate, rectum 2)
plaint is pain, which can either be bony (mechanical) or occur Spinal cord palsy (complete 0, incomplete 1, none 2)
as the result of neural compression. Muscle weakness may If a malignant lesion is suspected the next step in assessment
occur as a result of neural compression and can be detected will be to biopsy the lesion to obtain a tissue diagnosis and
in up to 50% of cases of metastatic disease. histological grading. This biopsy should be done within the
unit that will treat the tumour and also sent for culture.
Assessment
The assessment of a patient with a spinal tumour follows the Surgical treatment
general pattern of staging, grading, (multidisciplinary) assess- Surgical resection of tumour may be aimed at improving
ment and treatment. Investigation will begin with history survival (resection) or palliating symptoms by decompressing
(paying particular attention to ‘red flags’), examination and neural structures and stabilising the spine. This may be under-
imaging studies. Examination should include breast, thyroid, taken anteriorly or posteriorly or both depending on the size
respiratory, abdominal and rectal examinations and a test for and location of the lesion and the goal of surgery. In general
faecal occult blood. Blood should be sent for inflammatory terms if a curative resection is hoped for or survival is likely to
markers and tumour markers such as serum plasma electro- extend beyond 6 months, intervertebral bony fusion should be
phoresis and PSA. undertaken to avoid instrumentation failure. If life expectancy
Radiological investigations should include local and dis- is short and a palliative procedure is being considered, fusion
tant imaging. Local imaging should include plain radio- may not be required and posterior surgery is more commonly
graphs and a whole spine MRI (looking for neural undertaken.
compression and the extent of spinal involvement). A CT Following surgery patients can often expect functional
may be required for detailed bony anatomy if resection is improvement, pain relief, and in a few cases, cure. Surgery
being considered. Distant imaging depends on the likely path- is increasing being performed. NICE have issued clinical
ology and may include a bone scan (looking for evidence of guidelines on the treatment of metastatic cord compression8.
other skeletal metastases), a chest x-ray, or a CT scan of chest, Most large centres now have metastatic spinal cord compres-
abdomen and pelvis to search for a primary tumour or vis- sion services and multidisciplinary teams with surgeons,
ceral metastasis. oncologists, haematologists and radiologists to decide the best
Histological grading requires a biopsy. As tumours and treatment for each individual case. Decompression (with stabil-
infection are occasionally difficult to distinguish, ensure that isation) of compressed neural structures may lead to functional
samples are also sent for culture: ‘Biopsy all infections and improvement even with prolonged paraplegia. If posterior sur-
culture all tumours’. gery is being performed, a simple laminectomy to ‘decompress’
Some basic facts about the epidemiology of spine tumours the tumour is contraindicated as progression of the tumour
help significantly when staging the tumour. With increasing (most frequently in the vertebral body), will lead to mechanical
age metastatic disease becomes more common. Vertebral body instability and kyphosis. Decompression and stabilisation is
lesions are more likely to be malignant and posterior lesions frequently undertaken.
benign. Under the age of 21 most spinal tumours are benign,
over 21 most are malignant. Under the age of 3 metastatic Radiotherapy
malignant tumours become more common again. The thoracic Although surgery has an increasing part to play in the treat-
spine is the most commonly affected region and the cervical ment of spinal tumours, many malignant tumours respond to
spine the least. radiotherapy. Radiotherapy may be used to reduce tumour
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bulk and treat pain in situations where there is neurological

compromise without significant vertebral collapse. Tumour
Intradural tumours
In contrast to extradural tumours most intradural tumours are
type, neurological status and radiosensitivity determine out-
not metastatic. It is useful to divide intra dural tumours into
come. Prostate and lymphoreticular tumours respond best.
‘extramedullary’ and ‘intramedullary’ groups.
Approximately 70% of breast tumours are radiosensitive. GI
and renal tumours are often resistant to radiotherapy. Extramedullary tumours
Minimally invasive surgery and vertebroplasty Extramedullary tumours occur inside the dura but outside the
Some patients with malignant disease and associated co- spinal cord. They are usually benign. They cause symptoms by
morbidities are too unwell or are unwilling to consider resec- compressing neural structures, which can lead to pain or loss
tion or major surgery. Surgery may also interrupt chemother- of motor function. Examples include neurofibromas, schwa-
apy or radiotherapy regimens. When there is pain caused by noma (of dorsal sensory roots) and meningioma.
instability minimally invasive surgery may allow the surgeon
Intramedullary tumours
to stabilise the spine whilst minimizing soft-tissue trauma
facilitating a faster postoperative recovery in patients with Intramedullary tumours occur within the spinal cord. Most
limited life expectancy. Fusion may not be required as the are malignant. Examples include astrocytomas (affecting
strength of the implants is likely to outlast the demands of children), ependymomas (affecting adults) and, rarely,
the patient. haemangiomas.
Vertebral body augmentation with high viscosity cement
(PMMA) may be considered at the same time as skeletal biopsy Infection and Inflammation
and may improve pain in patients where decompression and
instrumentation is not required. Infection
Spinal infections are relatively common and can affect the disc
Specific tumours (discitis), the vertebrae (osteomyelitis), the spinal canal (epidural
Benign lesions include: abscess), or affect the soft tissues surrounding the spine (psoas
Haemangioma are slow growing, commonly asymptomatic abscess). Symptoms can be severe and prolonged and there is the
and often detected as an incidental finding on imaging. They risk of severe neurological injury with epidural abscess or
appear lytic on x-ray and may cause pain from loss of mech- kyphosis. Diagnosis is often delayed. Pain may be vague and
anical support. poorly localized and often other infections coexist. There is a
Osteoid osteoma/osteoblastoma are usually found in the change in the pattern of infection with age (50% occur in the
posterior neural arch. Most present with the typical (NSAID over 50s). The intervertebral disc (like the meniscus of the knee)
sensitive) pain. Excision is curative but treatment with an is vascular in younger children. In the neonate intraosseous,
NSAID may be all that is required. vertebral arteries anastomose with the adjoining disc through
Osteochondroma are most commonly found on the spinous the vertebral end plate. With increasing age these arterioles
process (related to apophysis). Excision is for symptomatic within the end plate involute and the disc loses its vascularity.
treatment. Sarcomatous change has been described and exci- Discitis is, therefore, more common in younger children and
sion is indicated if a large (>10 mm) cartilage cap is seen on vertebral osteomyelitis more common in adults. Risk factors
MRI. include surgery, intravenous drug use, diabetes, steroid use,
Aneurismal bone cysts typically affecting the posterior chronic infection and other immunocompromised states. Most
elements and Giant cell tumours (affecting vertebral the body) infections are caused by Staphylococcus aureus or Streptococcus.
are also seen. Tuberculosis (TB) varies in incidence geographically and
with socio-economic factors and is increasing in incidence. TB
Malignant lesions include mimics other infections and affects the disc late. Vertebral col-
Most commonly malignant disease is metastatic. lapse and spinal deformity is more common than in other forms
Solitary plasmacytoma/multiple myeloma typically presents of infection. The anterior longitudinal ligament may be lifted off
with pain and can be treated with radiotherapy (highly sensi- adjacent vertebrae. Extensive debridement and reconstruction is
tive), surgical excision (solitary) or stabilisation. often required especially when there are neurological abnormal-
Chordoma is locally aggressive and may present with com- ities. Antituberculous therapy should be given at the same time
pression of pelvic contents. as surgery. Antituberculous therapy may be given alone when
Lymphoma most commonly occurs in the elderly (mean there is no deformity or neurological compromise. Neurological
age 85) and more frequently in men than women. injury can recover as late as 9–12 months post-decompression.
Chondrosarcoma typically presents with pain and x-rays
may show typical matrix calcification. Investigations
Osteosarcoma presents in the young (<20) it is rare and MRI with gadolinium contrast is the investigation of choice. It
survival is poor (median survival 6–10 months). is non-invasive and both sensitive and specific (96% sensitive,
022
93% specific). Technetium bone scans are 90% sensitive. Plain Management
radiographs do not usually show changes for several weeks. Management is initially conservative management with med-
Discitis has a low signal on T1-weighted images and increased ical therapy and supportive bracing. Surgery is reserved for
(high) signal within the disc is seen in T2-weighted images. cases of intractable pain, progressive instability or neurological
There may be loss of endplate definition. Blood cultures may deterioration. The goal is to prevent further neurological
help obtain an organism (especially if pyrexial). Tissue for deterioration. The atlanto-dens interval (ADI) and space avail-
culture can be obtained with a needle biopsy (pathology speci- able for the cord (SAC) are assessed on lateral flexion and
mens can be sent at the same time). Treatment can be moni- extension lateral radiographs. Instability can be defined as a
tored with ESR CRP and WBC. change of >3.5 mm in the ADI between flexion and extension
views but in itself is not necessarily an indication for surgery. If
Management the change is >10 mm difference in ADI there is an increased
Treatment of osteomyelitis and discitis is initially conservative risk of neurological injury and, therefore, an indication for
with rest and targeted intravenous antibiotics (high dose intra- surgery.
venous antibiotics for 6 weeks or until CRP normalizes and The SAC measures the distance between the posterior
then oral antibiotics for 6 weeks or until there are no signs of neural arch and the posterior aspect of the dens. An SAC of
infection). Bracing may provide pain relief. Surgical debride- <14 mm associated with increased risk of neurological injury
ment may be required if there is no improvement on antibiot- and is an indication for surgery.
ics, progressive vertebral collapse and deformity or the Usually a posterior approach is used. Subaxial disease is
presence of neurological injury. Perhaps counter intuitively, mainly treated with posterior instrumented fusion at the
spinal stabilisation can have a role to play as it has a beneficial affected level(s). Subluxation should be stabilised before sur-
effect on infection. Non-operative management does not usu- gery with the patient awake. Posterior C1–C2 fusion is indi-
ally improve neurology. Decompression is indicated for the cated is the change in ADI is >10 mm the SAC is <14 mm or
treatment of an abscess. Radiological decompression may be there is progressive myelopathy. Adding transarticular screws
an option for a soft-tissue abscess. Most epidural abscesses may reduce the need for postop halo immobilization. Posterior
should be decompressed surgically, particularly if associated occipitocervical fusion with resection of the C1 posterior arch
with abnormal neurology as neurology may improve dramat- is indicated if there is basilar invagination. Fixation may allow
ically after decompression. pannus to shrink. Complications include problems with
wound healing and pseudarthrosis.
Rheumatoid arthritis
The cervical spine is frequently affected in rheumatoid arth- Ankylosing spondylitis
ritis. However, since the advent of DMARDs and anti-TNFs, Ankylosing spondylitis is a chronic autoimmune seronegative
there has been a significant reduction in the amount of spondyloarthropathy affecting the spine and sacroiliac joints.
rheumatoid spinal disease encountered. Orthopaedic manifestations include bilateral sacroiliitis, pro-
Disease progression causing erosion of bone and soft tissue gressive spinal kyphotic deformity, cervical spine fractures,
with subsequently instability may lead to symptoms of neck large-joint arthritis (hip and shoulder) and spinal deformity.
pain, stiffness occipital headaches and the gradual onset of a It typically begins in the second decade of life. It affects men
cervical myelopathy. Neurological symptoms may be caused more severely than women and has a prevalence of approxi-
by bony compression of neural structures and compounded by mately 1 in 1000. Serum HLA-B27 is positive in 80–90% of
pannus. Three main forms of instability are observed. Atlanto- patients Rheumatoid factor is typically negative. A definite
axial instability is the most common and may lead to myelo- diagnosis of ankylosing spondylitis is made using the ‘New
pathy. Later cranial settling (basilar invagination) may occur York’ Criteria. This requires the presence of sacroiliitis visible
compressing the upper cord and brainstem. Subaxial instabil- on imaging and two of three clinical criteria:
ity is also observed. It has been classified by Ranwat: Low back pain and stiffness for >3 months that improves
I. Pain, without neurological deficit with exercise but is not relieved by rest
II. Altered sensation, subjective weakness, hyperreflexia Limitation of motion of the lumbar spine in both the sagittal
IIIA. Objective weakness, early myelopathy and frontal planes
IIIB. Objective weakness, advanced myelopathy Limitation of chest expansion
non-ambulatory On radiographs the sacroiliac joints are affected first, followed
by the progressive appearance of syndesmophytes (vertically
Assessment orientated) and eventually fusion with the bamboo spine.
Initial assessment is with plain radiographs including flexion/ Squaring of the vertebral bodies is seen. Other systemic mani-
extension views to assess stability. festations include anterior uveitis & iritis, heart disease, pul-
MRI is required to assess the soft tissues and spinal cord. monary fibrosis, renal amyloidosis, aortitis, aortic stenosis,
Most patients have pannus visible around the odontoid peg. regurgitation as well as Klebsilella pneumonia. Classically the
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whole spine may be affected with the ‘question mark’ posture. Infection
The cervical spine may be fixed in flexion (chin on chest Tumour
deformity if severe). Flexion (kyphosis) is also seen in the When investigating the cause of back pain in a paediatric
thoracic and lumbar spine as well as the hips. If this is severe population the age of the patient can help narrow the diagno-
patients cannot see ahead whilst walking. sis. Children under the age of 10 are more likely to suffer from
infections or tumours whilst in older children disc herniation,
Treatment
spondylolysis and Scheuermann’s disease are more common.
Anti-inflammatory analgesics are the first choice of treatment Also lower back pain becomes more common with
combined with physiotherapy. The role of physiotherapy (in increasing age.
particular posture education) is essential as it helps prevent Investigation depends on the suspected pathology. Inflam-
deformity as the disease progresses and fusion occurs reducing matory markers provide a serological assessment for infection.
the requirement for osteotomy. Standing plain radiographs may detect spondylolysis or spon-
Spinal osteotomy may be considered using sagittal balance dylolisthesis. An MRI scan is likely to detect a disc herniation,
and in particular the ‘chin-brow angle’ to determine the infection, but may miss spondylolysis or early spondylolisthesis
amount of correction required. Address hip and lumbar as it is performed supine. MRI may also detect intra-spinal
deformities first. Cervico-thoracic osteotomy may also help anomalies such as spinal dysraphism or spinal tumours. CT
but carries the highest risk. scanning provides greater bony detail. A bone scan may be used
Fractures of the ankylosed spine are common and may be when other investigations have failed to confirm a diagnosis.
missed on plain radiographs. Most fractures occur at the mid-
cervical level or at the cervicothoracic junction. Frequently
fractures are unstable involving ‘all three columns’. Long lever Spondylolysis and spondylolisthesis
arms mean the risks of subsequent (late) neurological deterior- Spondylolysis is a defect in the pars interarticularis. Bilateral
ation are high. Likewise surgery is associated with increased defects may allow an anterior slip of one vertebral body on
risk of complications including instrumentation failure and the next most caudal level (spondylolisthesis). It most fre-
deformity progression. Fusion should be undertaken in the quently affects the L5 vertebra at the L5/S1 level and is most
pre-fracture position as the fracture may result in deformity frequently detected in adolescents and different aetiologies
correction (in a similar way to osteotomy) but is not controlled have been suggested including repetitive micro trauma. It is
and is likely to result in neurological consequences. Strong more common in gymnasts and other athletes in which spinal
constructs with multiple fixation points are required. Sudden extension is repetitive (cricket, bowling). There are also racial
onset new pain (especially if associated with correction of differences in incidence (Inuits 25%, Whites 6%, African
deformity) requires investigation to rule out a fracture. Long 2–3%). Patients typically present with back pain made worse
lever arms mean injuries are likely to be unstable and pseudar- by extension. A palpable step may be present. There may be leg
throsis more likely. CT and MRI are very useful imaging pain and neurological signs if a spondylolisthesis is present.
modalities to detect a fracture if one is clinically suspected. Hamstring tightness may also be present. In adolescents a
Large joint arthropathy can be treated with arthroplasty spondylolytic spondylolisthesis is most commonly seen. The
but if this is to be the case this should be undertaken after any types of spondylolisthesis have been classified by Wiltse et al.
spinal osteotomies as the sagittal realignment may change the (1976)9:
relative orientation of stem and acetabular component. I. Dysplastic
II. Isthmic
The paediatric spine A. Spondylolytic (pars fracture)
The spectrum of spinal disease seen in the paediatric popula- B. Pars elongated/attenuated
tion differs from that seen in adults. Spinal deformity and back C. Acute fracture (other than pars)
pain are the most common presenting complaints. The investi- III. Traumatic
gation of back pain in children requires a different approach IV. Degenerative
from that in adults as the number and frequency of significant V. Pathologic
pathologies demands a higher index of suspicion and more VI. Iatrogenic
detailed investigation.
Treatment initially is with analgesia and activity modification.
Bracing and physiotherapy (hamstring stretches) may also be
Back pain considered. Follow up until skeletal maturity is required to
Common causes for back pain in children and adolescents ensure spondylolisthesis doesn’t occur. Surgery may be con-
include: sidered after 6 months if pain persists or there is evidence of
Disc herniation progression to spondylolisthesis. Different surgical treatments
Spondylolysis and spondylolisthesis have been described including decompression and posterolat-
Scheuermann's disease eral fusion, repair with Scott wiring or Buck screw fixation.
022
If a spondylolisthesis is present management depends on between the T12 and L1 vertebrae and a lumbar scoliosis has
pain and the grade of the slip. The Meyerding classification its apex between the L1–2 disc space and L4. The apex of the
divides spondylolisthesis into grades I–IV with each represent- curve is located by the most laterally deviated vertebra.
ing a slip of 25% of vertebral body diameter and grade Scoliosis occurs in different groups of patients and is classi-
V spondyloptosis. fied according to pathogenesis. Scoliosis may be idiopathic
Grade I or II spondylolisthesis is treated initially with (70%), congenital (15%), neuromuscular (10%) or due to
analgesia and activity modification in a similar way to a spon- miscellaneous other causes such as Marfan’s syndrome or
dylolysis. Pain, slip progression and neurological symptoms neurofibromatosis (5%). Congenital scoliosis is a scoliosis that
are indications for surgery (decompression and in situ poster- arises as the result of the growth of abnormal vertebrae
olateral fusion). An acute presentation of a high-grade slip present at birth. Neuromuscular scoliosis is a scoliosis that
(spondylolytic crisis) is an indication for urgent surgical sta- arises as the result of a neuromuscular condition such as
bilisation. The most common complication of surgery is L5 cerebral palsy or Duchenne muscular dystrophy. Scoliosis
nerve root injury associated with attempted reduction. can also be classified according to its age of onset. Early-onset
scoliosis has its onset before the age of 7. Late-onset scoliosis
Disc herniation has its onset after the age of 7.
The presentation of disc herniation in children is somewhat Late-onset (adolescent idiopathic) scoliosis
different to that in adults. Back pain is typically the dominant Late-onset (adolescent) idiopathic scoliosis is the most
symptom and radiating neurological symptoms are less common form of scoliosis. The prevalence of curves over 10°
common. A coronal imbalance or ‘list’ may be present on in an at-risk population (children aged 10–16) is approxi-
examination together with positive nerve root tension signs. mately 2% with the same number of males as females affected.
Focal neurological signs may also be absent. An MRI scan is As curve magnitude increases there is a decrease in incidence,
the investigation of choice. Treatment is initially non-surgical and an increase in the proportion of girls affected. For curves
but symptoms may persist requiring surgical treatment. over 20° the female to male ratio is 5.4 : 1 and for curves over
30% the female to male ratio is 10 : 1 and a prevalence of 0.2%.
Scheuermann’s disease and kyphosis Aetiology is largely unknown and is probably multifactorial.
Scheuermann's disease was first described using lateral radio- There is a genetic tendency to develop scoliosis with 20% of
graphs and defined as anterior wedging of >5° in three con- affected individuals having at least one affected family
secutive vertebrae. The cause in unknown but deformity member. Of curves measuring 20° or more, 20% will not
results from abnormality of the ring apophysis of the vertebral progress (or progress very slowly) and do not require treat-
end plate. Patients typically present with pain and (if severe) ment. Others will progress significantly and cause major spinal
deformity. The normal thoracic kyphosis is approximately deformity.
20–45°. Treatment depends on the severity of symptoms and The development and progression of scoliosis is related to
degree of the deformity. Non-surgical treatment includes anal- skeletal growth. Scoliosis typically deteriorates (progresses)
gesia, physiotherapy and activity modification and pain may during growth and once skeletal maturity is reached it stabil-
settle as growth slows towards skeletal maturity. With severe ises. Scoliosis tends to progress most rapidly during periods of
curves (>75°) surgery may be required to correct the deform- increased growth velocity, in particular the adolescent ‘growth
ity. Bracing may be effective at controlling progression of a spurt’. Features of immaturity and increased growth potential
kyphosis until skeletal maturity but compliance is poor. indicate curves that are likely to progress.
The majority of individuals (80%) affected by scoliosis will
go on to develop back pain but this is not disabling in the
Scoliosis majority of cases. If the curve is particularly severe >90° it may
Scoliosis (derived from the Greek Skolios meaning crooked) is affect cardio-respiratory function but the majority of patients
a term that describes a deformity of the spine in coronal go on to lead normal lives with minimal functional deficit.
plane. It is defined as a lateral curvature that measures >10° Indications for consideration of treatment in idiopathic scoli-
using the Cobb method. When present it usually forms part osis are unacceptable deformity and evidence of curve progres-
of a three-dimensional spinal deformity. The ‘side’ of a scoli- sion. Surgery is usually reserved for severe curves measuring
osis is the side to which the spine deviates away from the over 50°.
midline, it is the side of the convexity of the curve. The Cobb The two main forms of treatment for scoliosis are surgery
angle defines the magnitude of the curve with minor (small) and brace treatment.
curves measuring between 10° and 25°, moderate curves
between 25° and 50° and severe (large) curves measuring Bracing
over 50°. Scoliosis is also described by the region of the spine Bracing is used to try and maximize growth by delaying the
that it affects. A ‘thoracic’ scoliosis has its apex between T2 need for surgery and possibly reducing the number of patients
and the T11–T12 disc, a ‘thoracolumbar’ curve has its apex that require surgery. Bracing is not a corrective treatment. Its
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goal is to halt curve progression. The best that can be expected Neuromuscular scoliosis
of brace treatment is that when the brace is removed, the curve Neuromuscular scoliosis is a scoliosis that occurs in associ-
is the same size as when it was applied. Bracing is not without ation with a neuromuscular condition. The pathogenesis of
morbidity. In order for a brace to be effective it must be worn neuromuscular scoliosis is different from that of congenital
almost all if not full time (23 h a day). Generally, bracing is and idiopathic scoliosis in that the scoliosis occurs as a result
poorly tolerated by patients (particularly in hot climates) and it of muscular weakness which in turn leads to a lack of support
may set up an adversarial relationship between parent and for the spine and the resultant ‘collapsing curve’. The shape of
child. It can cause deformity of the thoracic cage and may the scoliosis may be a long ‘C’ shaped curve, although other
have a deleterious effect on pain and outcome following sur- curve patterns have been described.
gery. Typically if bracing is to be used it is applied when there The Scoliosis Research Society (SRS) has classified neuro-
is evidence of curve progression and the scoliosis is moderate muscular scoliosis into upper motor neurone, lower motor
in size (25–45°) whilst there is still the significant potential for neurone and myopathic types according to the anatomical
growth. It is then maintained until skeletal maturity or if there location of the neuromuscular lesion. Upper motor neurone
is evidence of progression despite the brace another mode of causes include cerebral palsy, Friedreich’s ataxia, syringomye-
treatment is employed. lia, tumour, trauma. Lower motor neurone causes include
myelodysplasia, spinal muscular atrophy, poliomyelitis,
Surgery tumour and trauma. Myopathic causes include Duchenne
The aim of surgery is to (partially) correct and stabilise the muscular dystrophy, arthrogryposis and congenital hypotonia.
curve, reducing the deformity and the risk of further progres- The two most frequently encountered neuromuscular con-
sion. Different techniques have been employed including pos- ditions causing scoliosis are cerebral palsy and Duchenne
terior and anterior approaches. During surgery the different muscular dystrophy. In 90% of individuals with Duchenne
instrumentation constructs are inserted in order to apply a muscular dystrophy a scoliosis will develop and this frequently
controlled force to the spine to correct the three dimensional develops 1–2 years after progressive muscular weakness has
deformity. The spine is then fused using bone graft that can be lead to loss of ambulatory function.
autogenous (typically local bone from spinous processes), or Cerebral palsy on the other hand is a condition in which
donated allograft bone (typically fresh frozen femoral heads). there is a wide variety of function and the likelihood of
The bone graft forms a scaffold along which the remodelling developing a curvature is related to its severity. Overall
process of osteoclasts and osteoblasts can take place. Recently 25–30% of patients with cerebral palsy develop a scoliosis but
bone substitutes have also been used to supplement bone graft in 4-limb cerebral palsy the incidence of scoliosis increases to
and encourage bone healing. These can be calcium phosphate 75%. In cerebral palsy the average age of onset of a scoliosis is
preparations, bone morphogenic protein, or demineralised approximately 10 years.
bone matrix. Eventually a solid mass of bone is formed stabil- In these patients scoliosis can lead to problems with sitting
ising the spine and instrumentation. This process can take balance, causing patients to become hand-dependant sitters,
6 months or even up to a year to complete and it is, therefore, which in turn limits upper limb function. Other complications
usually recommended that patients avoid contact sports include pressure sores, back pain, pain from costo-pelvic
throughout this period. impingement and an overall poorer quality of life. Other
problems such as reflux and the ability to swallow (together
Early-onset scoliosis with associated chest complications) may be affected by patient
The term early-onset scoliosis applies to patients under the age positioning and the presence of a scoliosis.
of 7 with an idiopathic scoliosis. It is significant because at this Treatment options for neuromuscular scoliosis include
young age the development of the lungs is not complete and conservative management with braces, wheelchair modifica-
cardiorespiratory compromise may result from a progressive tions, total contact orthoses or surgery in form of posterior
curve and decreased life expectancy. spinal fusion. A brace will only be effective whilst it is worn
Patients that present with an idiopathic scoliosis below the and does not have a ‘corrective’ effect.
age of 3 years (infantile scoliosis) have the most heterogeneous The goals of treatment in neuromuscular scoliosis are aimed
prognosis. A significant number (80–90% of curves) will at maximising quality of life, maintenance of function, main-
resolve before the age of 2 years. However, those that do not tenance of respiratory function and sitting balance. Surgery in
resolve go on to develop extremely severe curves that cause the form of posterior spinal fusion corrects deformity and may
major deformity and associated affects on cardiac and respira- help to preserve function and preserve quality of life. In cerebral
tory function resulting in limited life expectancy and death in palsy a high level of carer satisfaction following surgery has been
early adult life. Treatment is problematic and prolonged. The reported. Similar benefits are seen in Duchenne muscular dys-
most common forms of treatment are serial plaster jackets trophy and surgery may also allow patients to live for longer
(localizer casts) and subsequently bracing and eventually grow- having an additive effect with nocturnal ventilation in delaying
ing rods. the deterioration of respiratory function.
022
Congenital scoliosis Osteogenesis imperfecta is a connective tissue disorder

Congenital scoliosis is a scoliosis that develops as a result of the caused by a defect in type 1 collagen. Different types of osteo-
growth of various congenital vertebral anomalies that are genesis imperfecta and inheritance patterns have been
present at birth, as a result of either a failure of formation or described, but it is now generally believed to be inherited in
segmentation or both. In congenital scoliosis multiple verte- an autosomal dominant manner with variable penetrance.
bral anomalies are often hereditary but isolated anomalies are Features of the condition vary with type but include: Brittle
mostly sporadic. No single genetic or environmental cause has bones, blue sclerae, absent or poor dentinogenesis, scoliosis,
been identified. poor muscular tone, short stature, respiratory and hearing
The bony structure of the spine is determined at the problems.
mesenchymal stage of embryonic development in the first Neurofibromatosis is a condition that affects neural crest
6 weeks of intrauterine life. Somites form and then undergo cells and is inherited in an autosomal dominant manner. There
a process of segmentation and recombination to give rise to are two types. Type 1 neurofibromatosis is caused by a muta-
the cartilaginous mould that will subsequently ossify to form tion in the neurofibromatin gene on chromosome 17 and
the bony spine. Errors in this process can lead to formation presents with: neurofibromas, groin and axillary freckling,
defects or segmentation defects or a combination. Commonly café-au-lait spots, tibial bowing, lisch nodules and optic nerve
seen congenital vertebral anomalies include the unilateral tumours. Type 2 is characterized by tumours affecting the
unsegmented bar, the hemivertebra (either fully segmented, eighth (vesibulocochlear) cranial nerve causing hearing loss,
semi-segmented or incarcerated), wedge vertebra and block balance problems and headache.
vertebra. Other syndromes associated with scoliosis include but are
The prognosis and progression of congenital curves not limited to: Angleman syndrome, Di George syndrome,
depends on their growth potential and whether that growth cleidocranial dysplasia, Goldenhar syndrome, Klippel Feil syn-
is balanced. Thus, a fully segmented hemivertebra in connec- drome, Sprengel’s shoulder, Noonan syndrome, Retts’ syn-
tion with a contralateral unsegmented bar has the least bal- drome and spondyloepiphyseal dysplasia.
anced growth and the worst prognosis. A block vertebra on the
other hand has benign prognosis rarely leading to a curve Assessment
beyond 20°. History
Congenital scoliosis may be associated with other congeni- A history of pain should be investigated to rule out another
tal malformations as part of the VATER (Vertebral, Anorectal, cause (prolapsed disc, osteoid osteoma, spondylolisthesis
Tracheal, Oesophageal, Renal) or VACTERL (Vertebral, Anor- intraspinal anomaly). An assessment of the patient’s skeletal
ectal, Cardiac, Tracheal, Oesophageal, Renal and Limb) associ- maturity (age, menarche, parental height), to estimate the risk
ations as well as many others. Detection of a congenital of curve progression and an assessment of the general health of
scoliosis should, therefore, prompt further investigation, the individual (fitness for anaesthesia). In the neuromuscular
including an echocardiogram and renal ultrasound as a group the assessment of general fitness is likely to require
baseline. input from multiple different specialties and a multidisciplin-
Congenital vertebral anomalies may generate a congenital ary team approach.
kyphosis or kyphoscoliosis. Congenital kyphosis and kyphos-
coliosis are much less common than either idiopathic or con- Examination
genital scoliosis. When present it is potentially a more serious Assessment of the curve includes: Site, size and location of the
diagnosis as progression can be rapid and may lead to spinal curvature. Common associated problems such as rib promin-
cord compression and paralysis. ence, shoulder height and waist asymmetry. Features of under-
lying spinal dysraphism (hairy patches). Abnormal abdominal
Syndromic/miscellaneous causes of scoliosis reflexes are most commonly associated with intraspinal anom-
Many different syndromes with different aetiologies are asso- alies. Neurological examination of the lower limbs. Features of
ciated with scoliosis. The following are just a few of the more recognisable syndromes present (café-au-lait spots, axillary
common examples: freckling, blue sclerae, long arms, etc).
Marfan’s syndrome is a connective tissue disorder with The Adam’s forward bend test performed by examining the
manifestations in many organ systems. Caused by a domin- patient from the back and asking the patient to bend forward
antly inherited defect in the chromosome 15 gene FBN1, which accentuates the deformity particularly rotational deformity
encodes the glycoprotein fibrillin-1. Patients appear tall with and the rib prominence.
elongated limbs. Skeletal manifestations include: Hammar The most common type of curve seen in late-onset idio-
toes, pes planus, elongated limbs, ligamentous laxity, scoliosis, pathic scoliosis is a ‘right thoracic’ curve presenting in a girl
chest wall anomalies, arachnodactyly and a high-arched palate. just after menarche. Atypical features indicate possible under-
Other problems include ocular (lens) problems and cardiac lying pathology. Atypical features include a left-sided curve,
anomalies (dilated aortic root). severe pain, rapid progression and short angular deformities.
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022
Investigations the midline. The anterior longitudinal ligament is divided in

Full-length standing plane radiographs that show the iliac midline, retracted laterally with periosteum and retractors
crests and hip joints. inserted deep to longus colli. The level is checked with a clip
Risser’s sign which examines the progression of develop- on the anterior portion of the cervical disc to prevent disc
ment and fusion of the iliac apophysis is visible on plain x-rays injury.
and is a useful indication of maturity. Complications include a hoarse voice, most commonly
MRI scanning of the spine can be used to detect underlying associated with endotracheal tube placement but also by injury
neuroaxial anomalies, such as diastomatomyelia, syringomye- to recurrent laryngeal nerve by retraction or dissection. Dys-
lia and Arnold–Chiari malformations. phagia due to swelling. Vascular or visceral injuries are pos-
Surface topography is also frequently used to assess scoli- sible. Neck swelling with airway compromise caused by
osis. This can produce an objective assessment of the results haematoma requires urgent decompression closure is usually
of surgery but in some circumstances can also be used instead with clips to allow ward staff to decompress haematoma.
of frequent x-ray when following up the progression of
curves. Thoracic spine
Treatment Anterior approach
Idiopathic – Curves under 20° or non-progressive curves do This approach may be used for an anterior release in scoliosis
not require treatment. Curves between 20° and 50° can be surgery, the treatment of fractures, tumours or for thoracic
treated in a brace or if not tolerated observed. For severe disc excision.
curves over 50°, surgery. For thoracic curves and double major
curves, posterior spinal fusion. Anterior surgery for thoraco- Technique
lumbar curves. Anterior release for stiff curves >80°. The patient is positioned in lateral decubitus position with the
Neuromuscular – bracing or posterior spinal fusion table flexed. The side of approach depends on pathology. For
scoliosis surgery approach the spine from the side of the
Surgical approaches convexity. The incision is made one to two levels above the
affected level along the level of the rib, extending from para-
Cervical spine spinal muscles to midclavicular line. Trapezius and latissimus
Anterolateral approach (Smith–Robinson) dorsi dissected superficially. Rib dissected subperiosteally and
Commonly used for ACDF this is one of the most common removed preserving the intercostal bundles. Parietal pleura
approaches to the neck. It allows access to all levels. incised. Lung retracted (gently) to expose vertebra and discs.
Segmental vessels are ligated and divided.
Technique
Patient placed in supine position with their neck and head Thoracolumbar (Hodgson)
slightly extended (roll under shoulders). Head may be stabilised Typically used for thoracolumbar scoliosis correction or for
in a Mayfield clamp or head ring and the shoulders may be access to thoracolumbar vertebrae for tumour or fracture.
taped holding them inferiorly and posteriorly to facilitate
intraoperative x-ray. Right-sided approaches may be more Technique
commonly used (easier for right-handed surgeons). Recent Patient in lateral decubitus position with their limbs and trunk
anatomical studies have demonstrated that in terms of the supported. Flex the table with apex at thoracolumbar junction.
relative courses of the recurrent laryngeal nerve, there is no Usually left-sided approach to avoid the IVC and liver. Make a
difference in the side of the approach10. Differences in the skin incision over the rib, curved distally and longitudinally.
course of the nerves with the nerve on the right side looping Dissect serratus anterior, external oblique and latissimus dorsi.
round subclavian artery and the left the aorta only occur below Remove the rib. Incise the pleura, open the chest and site rib
the level of T1. The skin incision is made along a transverse spreaders. Split the costal cartilage to enter the retroperito-
skin crease and is guided by surface anatomy. The Hyoid bone neum. Sweep away Gerota’s fascia and peritoneum with swabs.
corresponds to C3. The thyroid cartilage corresponds to the Divide the abdominal muscle layers. Divide the diaphragm
C4–C5 level. The cricoid cartilage corresponds to the C6–C7 2 cm from its origin down to the vertebrae using marking
level. Platysma is incised in line with the skin incision or split stitches. Ligate segmental vessels.
along the length of its fibres to allow extension of the approach Closure – Close the diaphragm using marker sutures to
superiorly and inferiorly. The anterior (medial) border of SCM help. Suture the costal cartilage anteriorly ± retroperitoneal
is identified and the fascia is divided anteriorly. Blunt dissection drain. Close abdominal muscles separately. Place a chest drain
continues in the avascular plane between the carotid sheath before rib approximation. Close pleura, periosteum and inter-
(palpated laterally) and the trachea (medially) to expose deep costal muscles. Suture serratus anterior and latissimus dorsi
fascia. The deep (pretracheal) fascia is divided longitudinally in separately.
022
Lumbar spine exaggerated osteoclastic bone resorbtion followed by exagger-

ated bone formation. It typically follows three phases, lytic,
Anterior approach to the lower lumbar spine
active, and burnt-out phases. Bone formation may cause spinal
This approach may be used for anterior discectomy and fusion stenosis or foraminal stenosis with neurological compression
or disc replacement, corpectomy and cages for tumour, trauma as well as facet joint arthropathy. Back pain, symptoms of
and infection. spinal stenosis or radiculopathy may develop. Also increased
Technique blood supply to the bone may cause a relative ischemia of the
neural tissue (steal syndrome). Plain radiographs reveal
Pararectal retroperitoneal approach. Patient supine with their expanded bones with thickened cortices. Serum alkaline phos-
hips/knees slightly flexed. Make a skin incision in the midline. phatase is elevated with a normal calcium level. Urinary hydro-
Incise the linea alba, lift the left rectus and retract it laterally xyproline levels are elevated. Bone scans show increased
(preserve segmental nerve supply). Incise the posterior rectus uptake. The mainstay of treatment is non-operative with
sheath laterally above the arcuate line. Find the peritoneal NSAIDs and bisphosphonates. Symptoms from spinal stenosis
edge. Extend the sheath incision proximally/distally. Avoid and radiculopathy commonly resolve with medical treatment
entering the peritoneum. Enter the retroperitoneal space and and surgery is rarely indicated. If surgery is contemplated for
sweep away the peritoneum with a swab; expose psoas (nerves resistant cases, increased intraoperative bleeding should be
on surface), ureter and iliac vessels. For L5/S1 dissect the expected.
lumbosacral plexus with a pledget to avoid injury (risk of
retrograde ejaculation in males). Ligate the median sacral
vessels and expose the disc. For L4/5 retract the aorta/IVC to Current controversies
the right. Ligate and divide segmental vessels at L5 and the
iliolumbar vein/ascending lumbar vein. Closure: Close the Vertebroplasty
rectus sheath, being careful to prevent hernias. Vertebral body cement augmentation has been used to treat
pain from the mechanical instability of tumours (NICE Guide-
Other miscellaneous conditions line CG758): ‘Vertebroplasty or kyphoplasty should be con-
sidered for patients who have vertebral metastases and no
Thoracic disc prolapse evidence of MSCC or spinal instability if they have either,
Thoracic disc prolapses are rare and make up <1% of all disc mechanical pain resistant to analgesia, or vertebral body
surgery. Asymptomatic prolapse probably more common. collapse.’
Diagnosis is often delayed. An MRI scan is the investigation Its role in treating osteoporotic spine fractures is becom-
of choice. Patients present with pain and sign and symptoms of ing increasingly accepted. NICE technology appraisal
cord compression, lower limb weakness, ataxia, numbness and (TA2797): ‘NICE recommends vertebroplasty and kypho-
bowel/bladder dysfunction. plasty (without stenting) as possible treatment options for
Treatment is surgical via anterior (thoracotomy) or poster- some people with spinal compression fractures caused by
ior (costotransversectomy). Neurological recovery often very osteoporosis.’ Prospective randomised trials show conflicting
good. results11,12.
Mild complications of the procedure include transient
Diffuse idiopathic skeletal hyperostosis arterial hypotension; cement leakage into the intervertebral
disc space (little or no clinical consequence), or paravertebral
(DISH – Forestier’s disease) soft tissues. A substantial number of patients with osteoporosis
First described by Forestier in 1950 as a ‘senile ankylosing develop new fractures after the procedure; two-thirds of these
hyperostosis’. It is a systemic condition in which ligaments, new fractures occur in a vertebra adjacent to those previously
tendons and joint capsules ossify. It can occur anywhere in the treated. Moderate complications include infection (discitis,
spine and may also affect other joints and ligaments. It is more osteomyelitis; or epidural infection-can be difficult to treat),
common in men and uncommon under the age of 50 years. pulmonary cement embolism and cement leak into the epi-
The cause is unknown. There are three types described. Type dural/foraminal space. Severe complications include cement
1 ossification of the anterior longitudinal ligament (Forest- leakage into the paravertebral veins leading to pulmonary
ier’s), type 2 diffuse changes (DISH) and type 3 ossification embolism, cardiac perforation, cerebral embolism and even
of the posterior longitudinal ligament. It is often asymptomatic death.
and diagnosed incidentally (ossification continuous along at
least four adjacent vertebrae). Management is symptomatic. Disc replacement
Proposed for the treatment of degenerative disc disease not
Paget’s disease affecting the spine resolving with conservative measures. Benefits include main-
Paget’s disease is a disorder of bone remodelling and one-third tenance of mobility delaying the onset of adjacent level degen-
of patients affected will have spinal involvement. There is an erative change.
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022
Procedure is performed via an anterior approach in the older population. The aim of these devices is to unload
(retroperitoneal). A Cochrane review (2012)13 on the use of the spine, restoring foraminal height, and stabilize the spine
TDR in LBP however could not find any evidence of better by distracting the spinous processes. Marketed as a safe,
outcomes in terms of LBP and patient function between TDR effective, and minimally invasive surgical alternative for relief
and spinal fusion, and advised caution on adopting TDR. of neurological symptoms in patients with low back degen-
erative diseases, recent studies suggest less impressive clinical
results and higher rate of failure than initially reported.
Spinal spacer devices Current evidence is not sufficient to know of their real
An alternative to conventional decompressive surgery in outcome and the evidence of their effectiveness is open to
managing symptomatic lumbar spinal pathology, especially discussion.
References 5. Murrey D, Janssen M, Delamarter R,

et al. Results of the prospective,
9. Wiltse LL, Newman PH, MacNab I.
Classification of spondylolysis and
1. Medical Research Council. Aids to the randomised, controlled multicenter spondylolisthesis. Clin Orthop Rel Res.
Examination of the Peripheral Nervous Food and Drug Administration 1976;117:23–9.
System. London: Elsevier, 2000. investigational device exemption 10. Haller JM, Iwanik M, Shen FH.
2. Fardon D, Milette P. Nomeclature and study of the ProDisc-C total disc Clinically relevant anatomy of
classification of lumar disc pathology. replacement versus anterior recurrent laryngeal nerve. Spine.
Recommendations of the combined discectomy and fusion for the 2012;37:97–100.
task forces of the North American treatment of 1-level symptomatic
Spine Society, American Society of cervical disc disease. Spine J. 2009 11. Klazen CA, Lohle PN, de Vries J, et al.
Radiology and American Society of 9:275–86. Vertebroplasty versus conservative
Neurology. Spine. 2001;26:5. treatment in acute osteoporotic
6. Spine 2013 Volume 38 – Issue 23. vertebral compression fractures (Vertos
3. Weinstein JN, Lurie D, Tosteson TD, (A useful online video presentation II): An open-label randomised trial.
et al. Surgical compared with available on the AO Spine website.) Lancet. 2010;376:1085–92.
nonoperative treatment for lumbar
7. NICE Technology Appraisal 12. Buchbinder R, Osborne RH, Ebeling
degenerative spondylolisthesis. Four-
Guidance (TA279). Percutaneous PR, et al. A randomised trial of
year results in the Spine Patient
vertebroplasty and percutaneous vertebroplasty for painful osteoporotic
Outcomes Research Trial (SPORT).
balloon kyphoplasty for treating vertebral fractures. N Engl J Med.
J Bone Joint Surg Am.
osteoporotic vertebral compression 2009;361:557–68.
2009;91:1295–304.
fractures. April 2013. 13. Jacobs, W.C.H., et al., Total Disc
4. Gibson JA, Waddell G. Surgery for
8. NICE Clinical Guideline 75. Metastatic Replacement for Chronic Discogenic
degenerative lumbar spondylosis.
spinal cord compression. November Low Back Pain: A Cochrane Review.
Cochrane Database Syst Rev. 2005;4:
2008. Spine, 2013;38(1):24–36.
CD001352.
022
Tumour oral core topics

Chapter
20 Thomas Beckingsale and Craig H. Gerrand
Patients with suspected cancer MUST be referred without

delay!
A high index of suspicion!
Delays in diagnosis are common for sarcoma patients and
1 may lead to poorer outcomes
NICE guidelines and referral pathways Failure to suspect a sarcoma can lead to mismanagement
In the UK, patients with suspected cancer must be offered an In the UK there are fewer than 600 bone sarcomas, and
appointment with a specialist within 2 weeks of GP referral. 3300 soft-tissue sarcomas diagnosed each year, <1% of all
Treatment must be started within 62 days from the date of cancers. (Based on figures for 2013.)
referral, or within 31 days of a definitive diagnosis of cancer.
Those affected are often teenagers or young adults.
Children must receive treatment within 31 days of referral for
Clinicians, therefore, need to be vigilant to ensure timely
suspected cancer.
diagnosis and treatment, and avoid mismanagement
Examiners have recently been instructed by the Intercollegi-
ate Board not to ask candidates about NICE guidelines. These Unexplained bone pain in children should never be
dismissed as ‘growing pains’, especially if unilateral
are national UK guidelines and the exam is international there-
fore international candidates would not be familiar with them. X-ray investigation is mandatory to exclude bony
malignancy, avoid delay in diagnosis, and prevent incorrect
treatment, such as arthroscopy or steroid injection when
Suspected sarcoma there is an underlying tumour
As per NICE guidelines, patients with a palpable lump that Patients with suspicious lesions should be referred
meets any of the following criteria: urgently to a specialist Sarcoma Service (see above) for
>5 cm biopsy and treatment
Increasing in size
Painful X-rays are mandatory!
Deep to fascia Patients with increasing, unexplained or persistent bone
Recurrent after a previous excision pain or tenderness, particularly pain at rest, an unexplained
Should be referred to a local sarcoma service under the limp, or a suspected spontaneous fracture should be
2-week rule. investigated urgently
Patients with x-rays suspicious of a malignant or aggressive X-rays can look normal, even in the presence of a primary
process should also be referred under the 2-week rule. bone tumour, so consider safety-netting through early
Sarcoma treatment is delivered by specialist multidisciplin- review if there is concern
ary teams (MDT), comprising diagnostic and treatment
expertise to cover the range of diagnoses and presentations of Tumour biology/basic concepts
sarcoma as well as complex benign tumours. In England and
Wales, there are five specialist bone tumour units in Newcas- What is a sarcoma?
tle-upon-Tyne, Birmingham, London, Oxford and Oswestry. Sarcomas are a rare and diverse group of malignant tumours
In addition, Liverpool, Leeds, Sheffield, Manchester, Notting- arising from connective tissue (the embryonic mesodermal
ham, Bristol, Plymouth, and Exeter are home to soft-tissue layer) and also, by convention, nerve tissues.
sarcoma units, and referrals can also be made through the A tumour is an abnormal growth which:
South Wales MDT, and the London Sarcoma Service. enlarges by cellular proliferation more rapidly than
Northern Ireland has its own Sarcoma MDT for bone and surrounding normal tissue
soft-tissue sarcomas centred in Belfast, while in Scotland, referrals Continues to enlarge after the initiating stimulus ceases
are made through the Scottish Sarcoma Network with patients Usually lacks structural organisation and functional
treated in Aberdeen, Glasgow, Edinburgh, Dundee and Inverness. coordination with normal tissues
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023
Serves no useful purpose to the host organism :Advances in molecular/genetic diagnosis have shown
A malignant tumour is one with a predisposition to invasive and that MFH can usually be more correctly categorized
destructive local growth, and also to distant metastatic spread. under other tumour categories
Benign tumours, while in some instances still locally : Tumours that, despite extensive testing, do no fall
aggressive, do NOT metastasise. under other headings, are now termed undifferentiated
pleomorphic sarcomas
How are tumours classified? : There are over 100 specific soft-tissue tumour subtypes
The World Health Organisation (WHO) publishes classifica- See Table 20.1 for common genetic translocations seen in
tion systems for all types of cancer as part of the International sarcomas.
Classification of Diseases (ICD). The WHO Classification of
Tumours of Soft Tissue and Bone, covering mesenchymal Tumour biology
tumours, was revised in 2013 (fourth edition). Concepts of tumour growth2
The WHO classification system provides a universal The compression zone/pseudocapsule – Tumours grow in
nomenclature a centrifugal fashion leading to compression and then
It ensures comparability of translational research and atrophy of the normal surrounding tissue
international clinical trials Reactive zone – Surrounding the pseudocapsule is an area of
Changes from the third edition have been driven by advances oedema and neovascularity characterized by the presence of
in molecular biology and include more cytogenetic data inflammatory cells and micronodules of tumour. Resection
: Malignant fibrous histiocytoma (MFH), previously one should, therefore, pass outside the reactive zone to ensure
of the most common diagnoses, has been removed complete removal of the tumour and minimize local recurrence
Table 20.1
Diagnosis Chromosomal abnormality Genes involved

Alveolar rhabdomyosarcoma t(2;13)(q35;q14) PAX3-FKHR
t(1;13)(p36;q14) PAX7-FKHR
Alveolar soft part sarcoma t(X;17)(p11.2;q25) TFE3-ASPL
Angiomatoid fibrous histiocytoma t(12;16)(q13;p11) FUS-ATF1
Clear cell sarcoma t(12;22)(q13;q12) EWS-ATF1
Congenital fibrosarcoma/ t(12;15)(p13;q25) ETV6-NTRK3
Congenital mesoblasticnephroma
Dermatofibrosarcomaprotuberans t(17;22)(q22;q13) PDFGB-COL1A1
Desmoplastic small round cell tumor t(11;22)(p13;q12) EWS-WT1
Endometrial stromal sarcoma t(7;17)(p15;q21) JAZF1-JJAZ1
Ewing’s sarcoma/ t(11;22)(q24;q12) EWS-FLI1
Peripheral primitive neuroectodermal tumor t(21;22)(q22;q12) EWS-ERG
t(7;22)(p22;q12) EWS-ETV1
t(17;22)(q12;q12) EWS-FEV
t(2;22)(q33;q12) EWS-E1AF
t(16;21)(p11;q22) FUS-ERG
Inflammatory myofibroblastic tumor t(1;2)(q22;p23) TPM3-ALK
t(2;19)(p23;p13) TPM4-ALK
t(2;17)(p23;q23) CLTC-ALK
Low-grade fibromyxoid sarcoma t(7;16)((q33;p11) FUS-CREB3l2
Myxoidchondrosarcoma t(9;22)(q22;q12) EWS-CHN
t(9;15)(q22;q21) TFC12-CHN
t(9;17)q22;q11) TAF2N-CHN
Myxoidliposarcoma t(12;16)(q13;p11) TLS-CHOP
t(12;22)(q13;q12) EWS-CHOP
Synovial sarcoma t(X;18)(p11;q11) SSX1-SYT
SSX2-SYT
SSX4-SYT
023
Chapter 20: Tumour oral core topics
In High-grade tumours, micronodules and extension of the Pain history: site, character, severity, radiation, modifying
tumour into and through the reactive zone can lead to factors, onset, periodicity. Night pain is classically
satellite and skip lesions associated with malignant disease. Pain from tumours may
fluctuate
Local behaviour of soft-tissue tumours If patient presents after a fracture, was there pain
Soft-tissue tumours tend to respect anatomical boundaries, beforehand (prodromal) or only minimal trauma?
i.e. fascia and bone resist invasion by tumour A personal or family history of malignancy or a
Thus, tumours tend to remain within the osteofascial predisposing condition (e.g. Li–Fraumeni syndrome,
compartment in which they arise. For example, the thigh multiple osteochondromas ollier disease, Maffucci
has three compartments: Anterior, posterior and medial syndrome, neurofibromatosis type 1 (Nf-1))
Anatomical compartments with less well-defined Previous radiotherapy is a risk factor for the formation of
boundaries are termed extra-compartmental, e.g. popliteal secondary malignancies, commonly sarcomas such as
fossa. Extra-compartmental tumours can extend further angiosarcoma. It is also associated with pathological
than those contained within compartments and are, thus, fractures of bones within the treated field, the treatment of
more difficult to remove with a wide margin (see below) which is complicated by frequent non-union
Extension of tumour through the boundaries of a
compartment does occur but tends to be late in the disease Key features on examination include:
process, and can follow defects in the osteofascial envelope, Swelling: site, size, depth (above or below fascia) shape,
for example where there are perforating vessels surfaces, edges, consistency, fluctuance, pulsatility,
tethering, overlying skin, draining lymph nodes
Margin3 Involvement of adjacent joint and neurovascular
Based on this understanding of tumour growth and anatomical structures
compartments, Enneking et al. described resection margins as Signs of previous treatment, e.g. scars, radiotherapy
intra-lesional, marginal, wide, or radical as follows: tattoos, mastectomy
Intra-lesional nargin – The resection passes through the Abdominal examination for masses, organomegaly.
tumour and macroscopic tumour deposits are left in the wound Consider rectal examination
Marginal margin (sic) – The tumour is excised with an intact If metastatic bone disease a possibility, consider
pseudocapsule but the reactive zone is violated possibly leaving examination of other sites, e.g. breast and thyroid
microscopic satellites within the wound
Wide margin – The tumour is excised with a cuff of normal
surrounding tissue. In high-grade lesions there is a risk that
microscopic skip lesions will remain within the normal tissue
An abnormal x-ray: seven questions
Radical margin – The entire compartment in which the tumour 1. Where is the lesion? (Figure 20.8)
resides is excised en bloc in theory removing the entire tumour The particular bone involved, the part thereof
NB. The risk of local recurrence is directly related to the (epiphysis, metaphysis, diaphysis), and the relationship
surgical margins. to the medullary cavity (central or eccentric) give
valuable diagnostic information; e.g. unicameral bone
How to approach a patient with a cysts are central, metaphyseal lesions and 50% arise in
the proximal humerus (Figure 20.1)
suspected tumour 2. How extensive is the lesion?
Clinical history and examination How large is the lesion? Is it solitary or multiple? e.g.
A careful and thorough history and examination can help skip lesions of primary bone tumours or multiple
point to a likely diagnosis. Key points include: metastatic deposits (Figure 20.2)
Patient age. For example, Ewing’s sarcoma is most common 3. What is the lesion doing to the bone?
in adolescence but is exceptionally rare after 40, whereas Look at the zone of transition between the lesion and
giant cell tumour (GCT) of bone is almost never seen in the bone
children but increases in incidence in the fourth decade A narrow zone of transition is well-defined and
Duration of symptoms geographical (like the edge of a land mass on a map). It
Rapid growth of a new lesion or change in a pre-existing is usually possible to draw round the edge with an
lesion, which might signify malignant transformation; for imaginary pencil. This is seen in lesions that grow
example, growth of an osteochondroma after skeletal slowly enough to be walled off at the margins. There
maturity may also be bony expansion and a neo-cortex. This
Red flags for cancer including a history of lethargy or usually indicates a benign lesion (Figure 20.1)
weight loss. This may be more common in patients with A wide zone of transition is one that is ill-defined and
metastatic bone disease permeative, with a poorly demarcated border. This is
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023
Figure 20.2 Metastatic disease affecting the pelvis and right proximal femur.
There are multiple lesions affecting more than one bone. The lesions have a
wide zone of transition, are producing no specific matrix, are eroding the cortex
and are extending into the soft tissues (all comments especially true of the
lesion in the right superior pubic ramus)
Figure 20.1 Pathalogical fracture through a unicameral bone cyst of the

proximal humerus in a 9-year-old girl. 50% of unicameral bone cysts arise in
the proximal humerus. The lesion has occurred in the metaphyseal region of
a skeletally immature patient. It has a geographical border with a narrow zone of
transition. There is no periosteal reaction and no obvious matrix production
seen in rapidly growing, aggressive lesions and usually

indicates a malignant lesion (Figure 20.2)
4. What is the bone doing in response?
The bone can respond by ‘walling off’ a slowly growing
lesion leading to a narrow zone of transition
The periosteum can react to the tumour, producing
– A Codman’s triangle. A triangle of reactive bone at
the edge of the tumour where the periosteum is
elevated (Figure 20.3)
– Sunray spiculation. A spiculated periosteal reaction Figure 20.3 Osteosarcoma of the left distal femur. There is a metaphyseal
lesion in a skeletally immature patient, with a wide zone of transition.
reflects rapid underlying growth preventing normal A widespread periosteal reaction is seen with classic Codman’s triangle (A). The
new bone formation under the raised periosteum lesion is producing an osseous matrix, which is extending through the cortices
(Figure 20.4) and into the surrounding soft tissues
023
Figure 20.5 Ewing’s sarcoma of the right proximal tibia. There is a lesion in
the metaphyseal, diaphyseal region in a skeletally immature patient. It has a
wide zone of transition and there is an onion-skin type periosteal reaction
laterally (A). There is no particular matrix. Medially there is cortical destruction
with a soft-tissue mass (B)
– Onion-skinning. Multiple layers of new periosteal

bone formation, possibly reflecting phases of
Figure 20.4 Osteosarcoma of the right distal femur. There is a growth of the tumour (classically seen in Ewing’s
metaphyseal lesion in a skeletally mature patient extending into the epiphyseal sarcoma) (Figure 20.5)
region. It has a wide zone of transition, there is a corresponding sunray
periosteal reaction, and it is producing a bony matrix that is extending
through the cortex into the soft tissues
5. Is the lesion making matrix?
Ground glass. This is classically used to describe
fibrous lesions within bone, e.g. fibrous dysplasia,
although the appearances of fibrous dysplasia can be
diverse (It looks like the medullary trabeculae have been
smudged out by the viewer’s thumb) (Figure 20.6).
Fluid-filled lesions (e.g. simple bone cyst) may also look
like this
Popcorn calcification. Punctate, ring and arc
calcifications are seen in cartilage forming tumours, e.g.
enchondroma or chondrosarcoma, where calcification
occurs at the margins of tumour lobules (Figure 20.7)
Bone forming. This is characteristic of osteogenic
tumours (i.e. osteosarcomas). New bone can be mixed
with lytic areas within the bone, and is often seen within
the associated soft-tissue mass (Figures 20.3 or 20.4)
No specific matrix. This is seen in rapidly growing
tumours that cause bony destruction and lytic lesions,
e.g. metastatic/myelomatous deposits
6. Is the cortex eroded?
Figure 20.6 Fibrous dysplasia of the right hip. There is a metaphyseal lesion in
a skeletally immature patient. It has a narrow zone of transition, which is walled
Medullary lesions may cause endosteal scalloping or
off proximally, and there is no periosteal reaction. There is a ground glass matrix cortical resorption, the presence of which is indicative
and no cortical destruction or extension into the soft tissues of more aggressive behaviour
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023
Figure 20.7
Enchondroma right distal
femur. There is a
metaphyseal lesion in
this skeletally mature
patient. It has a relatively
narrow zone of transition
and there is no periosteal
reaction. It is producing
rings and arcs of
calcification, consistent
with a cartilaginous
matrix. There is no
cortical erosion or soft-
tissue mass
Figure 20.8 Characteristic sites of tumours within bone
(a) Full length x-rays (Figure 20.9) of the affected bone

including the joint above and below the lesion may
show multiple lesions
(b) MRI and CT give better three-dimensional information
about the extent of the tumour in the bone and possible
soft-tissue involvement, and can help to plan any
7. Is there a soft-tissue mass? surgical intervention once the diagnosis is made
Soft-tissue extension is also indicative of more (c) Isotope bone scan may show lesions in multiple bones
aggressive behaviour, be that secondary to cortical 2. Screen for potential primary tumours
destruction in metastatic disease or due to permeative
(a) History and examination
growth through the cortex in bone sarcomas, e.g.
osteosarcoma or Ewing’s sarcoma. (Figures 20.3, 20.4 – History may give useful clues to guide further
or 20.5) investigation, e.g. previously unreported haematuria
– Examination may identify a suspicious lump, e.g.
in breast or thyroid
How to investigate a patient with suspected (b) Blood tests
metastatic bone disease – Serum electrophoresis may diagnose myeloma
Patients with a clear diagnosis of metastatic bone disease – Tumour markers including prostate specific
(MBD) (i.e. multiple characteristic lesions and a clear history antigen (PSA) carcinoembryonic antigen (CEA) and
of cancer) should be discussed in a local cancer MDT. Every carcinoma antigen 125 (CA125) may suggest
orthopaedic department should have a clinical lead for MBD. potential primary tumours
If there is dubiety or a lesion meets the referral guidelines then
– Blood biochemistry including liver and thyroid
urgent referral to the local sarcoma service is needed. The BOA
function tests may help to identify other organs
publishes guidelines on orthopaedic standards of care for
affected. Bone biochemistry for hypercalcaemia is
MBD. Care should be taken when a patient appears to have a
mandatory. Patients with hypercalcaemia may
solitary metastasis that a sarcoma is not missed.
appear moribund but may make a rapid recovery
Where a radiograph has shown destructive, usually lytic,
when this is treatment
possibly multiple bony lesions, and metastatic disease without
– Full blood count. May be helpful as part of the
a known primary is suspected, then investigation should
workup
include the following:
1. Get more information about the lesion itself. Local site c. CT chest/abdo/pelvis is used as a screening tool to pick
imaging up tumours in the main body cavities (Figure 20.10)
023
Figure 20.9 Metastatic

lung cancer in the right
humerus. There is a
diaphyseal lesion which
appears aggressive,
particularly in its effect
on the cortex, which
appears hazy, and,
therefore, has a wide
zone of transition. There
is no specific matrix, the
cortex is eroded and it
appears to extent out to
the soft tissues. There is
also a suspicion of a
pathological fracture
Figure 20.10 CT showing an incidental lesion on the right kidney, likely the
source of the metastatic deposit
NB.
Never assume that a solitary lesion is a metastasis
Do not rush to fix a pathological fracture, even if open, if
the underlying diagnosis is unknown – Wound care with
traction or splintage will suffice while investigations are
performed
If in doubt discuss the case with a bone tumour unit
How to investigate a suspected primary bone

or soft-tissue tumour in a sarcoma unit
Patients referred to a sarcoma service under suspected
cancer guidelines may have a biopsy earlier in the care
d. Other investigations pathway. This prevents unnecessary staging investigations
for initially suspicious lesions that turn out to be benign.
– These may be indicated according to the clinical After initial history and examination, investigation should
picture and the results of other investigations, e.g. include the following.
mammography for suspected breast primary;
1. Image the lesion itself – ‘local staging’
thyroid ultrasound for suspected thyroid
cancer, etc Soft-tissue lesions can initially be investigated with an
– If a patient has metastatic disease and a primary ultrasound scan. This can give useful information about
tumour cannot be identified, many hospitals now the lesion, in particular size and depth, and is helpful
have a ‘carcinoma of unknown primary’ team with for rapidly excluding benign soft-tissue masses such as
whom the patient can be discussed. They may advise ganglions and lipomas. Experienced musculoskeletal
further investigations such as a PET scan radiologists, working within a sarcoma MDT, may
perform image guided biopsy during this initial
3. Biopsy if a primary source can not be identified investigation as part of ‘one-stop clinics’, thus,
(a) If doubt remains after investigation, or a lesion is significantly shortening the time to diagnosis
solitary, discussion with a bone tumour unit is Further ‘local staging’ is best performed by MRI scan
recommended which shows the local extent of the tumour. CT can be
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023
used to gain further information about primary bone

tumours, and may also be helpful if there is
calcification in the tumour or if the tumour is located
in the pelvis
2. Biopsy
The ‘principles of biopsy’ are discussed later but this
can be performed in clinic by Tru-cut needle, with or
without ultrasound guidance as above, or in an open
manner in theatre
3. Systemic staging
CT chest/abdo/pelvis is used after a diagnosis of
sarcoma has been made to look for metastases in lung,
and less often lymph nodes, liver and other bones,
Other investigations are guided by tumour type.
Patients with primary bone tumours routinely have an
isotope bone scan to rule out multifocal or metastatic
disease in bones. Ewing’s sarcoma patients should also
have bone marrow aspirate as part of staging. PET
scans are being used more frequently, particularly when
Figure 20.11 PET–CT scan showing increased uptake in a leiomyosarcoma
the presence of otherwise undetected metastatic disease of the right thigh
might influence treatment
scanning device. The scan is usually performed in

Imaging modalities – when to use which? conjunction with a CT scan and the active areas on the PET
scan are then correlated with the anatomy on the CT scan
Magnetic resonance imaging (MRI) (Figure 20.11)
Shows the local extent and anatomical relationships of the PET scanning in orthopaedic oncology is unusual as a
tumour, including critical neurovascular structures, primary investigation but can be useful to detect recurrent
compartments and local joints or metastatic disease and is becoming more widely used
Shows further pathological detail, the extent of local
oedema, and the presence or absence of skip/satellite How to perform a biopsy
lesions and local lymphadenopathy
A biopsy is performed to obtain a histological diagnosis
Is critical for planning surgical procedures and margins and is critical to guide management
Is excellent for viewing soft tissues but less good at Biopsy planning is important as all tissue contaminated by
delineating bony architecture the biopsy and its track must be removed during the
definitive resection. As such, it should be performed by, or
Computerized tomography (CT) after discussion with, the specialist MDT
Is better than MRI at imaging bone where its use can add Biopsy can be excisional, incisional or, most often,
further important information, e.g. showing the nidus of percutaneous, but must adhere to the following principles
an osteoid osteoma, or endosteal scalloping and matrix 1. Incisions should be placed longitudinally on limbs and
formation in cartilaginous tumours positioned such that they can be removed en bloc
during the definitive resection
Positron emission tomography (PET) 2. The biopsy track must only pass through a single
PET scanning gives metabolic information. It involves muscle compartment
injecting a positron-emitting radionuclide tracer attached 3. The biopsy track must not contaminate critical
to biologically active molecule (usually fluorodeoxyglucose neurovascular structures
(FDG)). The biological molecule is taken up by active 4. For open biopsy, close attention must be paid to
tissues, including the tumour, and the radionuclide then haemostasis and tissue dissection should be kept to a
undergoes beta decay, emitting a positron. The positron minimum to reduce local tissue seeding
travels a short distance through the tissues losing kinetic 5. A drain, if sited, must be placed in the line of the
energy until it decelerates enough to interact with an incision
electron, releasing a pair of gamma photons in opposite 6. Biopsies for sarcoma should be discussed with the
directions. These photons are then detected by the pathologist to ensure tissue is sent fresh if appropriate
023
Percutaneous biopsy, e.g. by Tru-cut needle, is the most metastases (defined as any skip lesions, regional lymph
popular method of biopsy in the UK. It reliably provides nodes or distant metastasis)
enough tissue for diagnosis and has a low complication :
Low-grade tumours are defined as stage I
rate. Assessment of necrosis and mitotic rate is less reliable :
High-grade tumours are defined as stage II
on core needle than incision biopsy, but this seldom :
Metastatic tumours are defined as stage III
influences management
:
Intracompartmental tumours are further classified
Incision biopsy is generally only performed if as “A”
percutaneous biopsy is non-diagnostic, further
information is required, or to obtain material for research
: Extracompartmental tumours are further classified
as “B”
Excision biopsy, where the entire lesion is removed, is
reserved for benign lesions where imaging has been
: The MSTS staging system is equally applicable to bone
and soft-tissue tumours (Table 20.2)
diagnostic or for small superficial tumours for which an
The American Joint Committee on Cancer (AJCC, now
excision biopsy would not compromise later re-excision.
version 7) staging systems are also widely used. They are
If there is any dubiety then an incision or percutaneous
more complicated and probably beyond the scope of the
biopsy must be performed prior to excision
FRCS examination but are included here for completeness
and to enhance understanding
How to ‘stage’ a lesion : The AJCC system for bone tumours classifies tumours
Staging of benign bone tumours3 as stage I–IV using the size, the presence or absence of
Benign bony tumours were described, by Enneking et al., regional lymph node involvement, the presence or
as latent, active, or aggressive3 absence of distant metastasis, and the histologic grade
of the tumour4 (Table 20.3)
: Latent lesions are asymptomatic and are often
incidental findings. They are often treated with – The size of tumour is designated T1 if it is ≤8 cm in
observation only, e.g. bone island, osteoma of skull, maximum diameter, T2 if it is >8 cm, and T3 if
non-ossifying fibroma there are multiple or discontinuous tumours
: Active lesions cause symptoms including pain and – Lymph node involvement is designated N0 if there is
swelling, and are often treated by curettage and no nodal involvement, and N1 if there is regional
grafting, e.g. osteoblastoma or chondroblastoma lymphatic spread
: Aggressive lesions are symptomatic and are locally – Metastasis is similarly designated M0 if there is no
destructive. Treatment usually involves curettage and evidence of metastasis, and M1 if there is evidence of
grafting, but may require en bloc resection and metastatic disease
reconstruction, e.g. giant cell tumour of bone – Grade is designated G1 for well-differentiated
tumours, G2 for moderately differentiated tumours,
Staging of sarcomas G3 for poorly differentiated tumours, and G4 for
undifferentiated tumours
The simplest staging system is that described by Enneking
et al.3 : The AJCC system for soft-tissue tumours classifies
The Enneking/Musculoskeletal Tumor Society (MSTS) tumours as stage I–IV using the size, site, the
system uses grade (low or high), site (intra-compartmental presence or absence of regional lymph node
or extra-compartmental) and presence or absence of involvement, the presence or absence of distant
Table 20.2 MSTS staging system3

Table 20.3 AJCC staging system for bone tumours4
Stage Description Grade Site Metastases
Stage Grade Size Nodes Metastasis
IA Low-grade, G1 T1 M0
intracompartmental IA G1 or G2 T1 N0 M0
IB Low-grade, G1 T2 M0 IB G1 or G2 T2 N0 M0
extracompartmental
IIA G3 or G4 T1 N0 M0
IIA High-grade, G2 T1 M0
IIB G3 or G4 T2 N0 M0
intracompartmental
III Any G T3 N0 M0
IIB High-grade, G2 T2 M0
extracompartmental IVA Any G Any T N0 M1 (lung only)
III Any grade, metastatic G1–2 T1–2 M1 IVB Any G Any T Any N Any M
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023
metastasis, and the histologic grade of the tumour5 Primary bone tumours
(Table 20.4)
Introduction6
– The size of tumour is designated T1 if it is ≤5 cm in Epidemiology
maximum diameter and T2 if it is >5 cm. Further Primary malignant bone tumours are rare
description classifies superficial lesions as T1a or T2a
and deep lesions as T1b or T2b : <600 per year in the UK
– Lymph node involvement is designated N0 if there is : 0.2% of all malignancies, but 4% of malignancies in
no nodal involvement, and N1 if there is regional children under 14 years of age
lymphatic spread : More common in males. Males (58%): female
– Metastasis is similarly labelled M0 if there are no (42%) = 13 : 10
metastases, and M1 if there is evidence of metastatic : Incidence is about 8/1 000 000 per year
disease : Overall, 38% occur in the long bones of the lower limb,
– Grade is described as G1 for well-differentiated 16% in the bones of the pelvis, sacrum and coccyx and
tumours, G2 for moderately differentiated tumours, 14% in the scapula and long bones of the upper limb.
G3 for poorly differentiated tumours – The pattern changes with age; however, such that in
patients under the age of 20, 70% of bone tumours
Lymphatic spread? occur in the extremities, compared with 40% in
NB. Soft-tissue sarcomas normally metastasise via haemato- patients over 40 (Figure 20.12)
genous routes to the lungs. Lymphatic metastases are rare but
are more often seen in the following five histological types: : The four most common tumours are osteosarcoma,
chondrosarcoma, Ewing’s sarcoma and chordoma
Angiosarcoma (Figure 20.13)
Synovial sarcoma
Rhabdomyosarcoma – Incidence of osteosarcoma peaks in childhood with
Epithelioid sarcoma a second peak in late adult life.
Clear-cell sarcoma – Ewing’s sarcoma has a peak incidence in
adolescence and early adult life but is extremely rare
after the age of 30.
– The incidence of chondrosarcoma and chordoma
Table 20.4 AJCC staging system for soft-tissue tumours5
increases with age.
Stage Grade Size Nodes Metastasis : Overall, cumulative 5-year survival is 58% for men and
59% for women for all bone sarcomas.
IA G1 T1a, 1b. N0 M0
IB G1 T2a, 2b. N0 M0 How do bone tumours present?
IIA G2 or G3 T1a, 1b. N0 M0 Swelling. Initially soft-tissue oedema. Later bony
IIB G2 T2a, N0 M0
enlargement and soft-tissue extension
2b.
Pain, typically worse at night. Often mistaken for
III G3 T2a, T2b N0 M0 growing pains
III Any G Any T N1 M0 Occasionally cachexia and weight-loss
IV Any G Any T N0 M1 Coincidental injury. Not causative but may bring attention
to swelling
Figure 20.12 Proportion of bone sarcomas

diagnosed by age group and anatomical site
(England: 1985–2009). Reproduced with
permission of Public Health England
023
Figure 20.13 Age-specific incidence of the most

common bone sarcoma variants (England:
1985–2009). Reproduced with permission of Public
Health England
Follows an EXT gene mutation that leads to aberrant

growth of a fragment of epiphyseal plate
Persistent growth of the fragment by enchondral
ossification leads to a cartilage-capped, subperiosteal, bony
projection
Manifests clinically during second decade of life,
usually because of local irritation, trauma or fracture
The cartilage cap grows under the same hormonal control
as physeal plates and, therefore, ceases growing after
skeletal maturity
Most commonly affect the ends of long bones, especially
around the knee. (Distal femur most common ≈25%)
X-ray appearance is of a flattened (sessile) or
pedunculated (on a stalk), juxta-articular protuberance,
growing away from the adjacent joint. The cortex of the
lesion is continuous with the cortex of the bone, as is the
medullary cavity (Figure 20.14)
If symptomatic, treatment is by surgical excision through
the base of the lesion. Recurrence is more likely if the
Figure 20.14 Osteochondroma left proximal humerus cartilage cap is incompletely excised and the patient has not
reached skeletal maturity
Pathological fracture (5–10%)
Malignant transformation to chondrosarcoma is
Rarely, symptoms of metastasis to lung. Shortness of
exceptionally rare in solitary osteochondromas,
breath, chest pain, haemoptysis
but persistent growth after skeletal maturity or a
Occasionally neuralgia or paraesthesia from nerve thick cartilage cap (1.5–2.0 cm) are suspicious
compression features which should prompt referral to a bone tumour
centre
Types of bone tumours
The WHO classification is extremely detailed but bone tumours Multiple osteochondromas/hereditary multiple exostoses (Figure 20.15)
can more easily be classified in to four main categories:
Autosomal dominant trait of multiple osteocartilaginous
Cartilage-forming tumours exostoses
Bone forming tumours Majority are familial but up to 20% occur due to
Fibrous tumours sporadic mutations
Non-matrix producing tumours HME is caused by a mutation to one of three genes,
EXT1 (8q), EXT2 (11p) and EXT3 (19q)
Cartilage-forming tumours7 The most common skeletal dysplasia (and, therefore,
Developmental or hamartomatous tumours likely to come up in clinical exams)
Solitary osteochondroma Short stature with bony deformity and disfigurement
Osteocartilaginous exostosis (often a short ulna)
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023
Figure 20.15
Hereditary multiple
exostoses. Multiple
ostoechondromas are
seen around the left knee
Figure 20.16 Hand x-ray of a patient with Ollier’s disease showing multiple
Grossly and radiographically similar to solitary enchondromas of the small bones of the right hand
osteochondromas but histologically are often more
disorganized in structure with bosselated caps
Treatment for symptomatic lesions is surgical excision as Benign cartilaginous tumours
for solitary osteochondromas Enchondroma
Lesions that continue to grow after physeal closure raise Common, solitary, asymptomatic, intramedullary,
the suspicion of malignant transformation. Whilst still cartilaginous tumours
rare, this occurs more frequently than in solitary
50% occur in the hands
osteochondromas, arising in 1–5% of patients
When present in long bones, difficult to distinguish from
Enchondromatosis low-grade chondrosarcoma
Non-familial, sporadic, multiple cartilaginous tumours Malignant transformation is rare, usually in large lesions in
Often unilateral, confined to one limb. Usually peripheral long bones
affecting the small bones of the hands or feet Often present after pathological fracture, particularly in the
small bones of the hands and feet
Histologically more cellular and myxoid than solitary
enchondromas (see benign tumours) and consequently the X-ray shows a well-defined lucent lesion (short zone of
rate of malignant transformation is higher transition) with stippled calcification (see Figure 20.7)
Enchondromatosis = Ollier’s disease (Figure 20.16) Lesions found incidentally with no concerning features
on MRI (oedema, cortical erosion) can be observed
: Incidence 1:100 000
Biopsy is indicated if there is any doubt about the
: Risk of bone malignancy is 10–15% behavior of the lesion or it is symptomatic
: Also increased risk of visceral and CNS malignancies
Surgical treatment is by curettage with or without grafting
: Overall risk of malignancy is 25%
Enchondromatosis + haemangiomas = Maffuccis Chondroblastoma
syndrome Relatively rare entity, accounting for 1% of all primary
: Risk of bony malignancy is 25–30% bone tumours presenting in the second decade
: Overall risk of malignancy, including CNS and visceral, Most common around the hip, shoulder, or knee joint
approaches 100% (Figure 20.17)
023
Figure 20.18 Chondrosarcoma of the right inferior pubic ramus
Figure 20.17 CT scan showing a well-circumscribed lesion in the epiphysis of

a skeletally immature patient. There are flecks of calcification within the lesion
which is classic in position and appearance of a chondroblastoma
Well-defined lytic lesion with stippled calcification

confined to epiphysis of a long bone
Biopsy shows scattered giant cells in a field of mononuclear
cell described as ‘chicken wire calcification’
Treatment by curettage with or without grafting
Malignant cartilaginous tumours7

Chondrosarcoma8 (Figures 20.18–20.20)
Malignant tumour producing a cartilaginous matrix
(Figure 20.18)
Most common in fifth and sixth decades
Most common in pelvis, femur and humerus
Present with persistent pain and swelling
Lucent metaphyseal/diaphseal defect with endosteal
scalloping and stippled calcification
Bright on T2 MRI imaging because cartilaginous
component has a high water content (like articular cartilage)
Diagnosis critically depends on discussion of clinical,
radiological and histological features. Can be difficult to
distinguish enchondroma from chondrosarcoma on
histological grounds alone
Grade I
Low-grade chondrosarcoma
Distinguished from enchondromas by location (long
bones/pelvis/scapula and ribs), and microscopic evidence
of haversian invasion
Rarely metastatic Figure 20.19 Dedifferentiated chondrosarcoma. An area of lucency with
5-year survival >90% overlying cortical destruction is seen within a pre-existing enchondroma
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023
Other rare variants include

: Mesenchymal chondrosarcoma
: Clear-cell chondrosarcoma
Bone-forming tumours7
Reactive or post-traumatic lesions
Subungual exostosis
Osteocartilaginous lesion of the distal phalanx
Treatment is by excision and recurrence is common if
incomplete
Developmental or hamartomatous lesions

Bone islands
Solitary enostosis. Small area of increased density within an
area of cancellous bone
Usually only 1–2 mm diameter
Osteopoikilosis = multiple bone islands
: Rare, autosomal dominant, asymptomatic condition
Figure 20.20 T2 sagittal MRI showing a lesion on the anterior surface of the : Sometimes seen with cutaneous nodules suggesting a
sacrum which appears destructive with a wide zone of transition generalized mesenchymal defect
Benign tumours
Grade II Osteoid osteoma
Definite increased cellularity and nuclear size. Focal Benign, painful, solitary diaphyseal lesions, usually of the
myxoid change is also seen femur or tibia (>50%) and located in the cortex
Metastatic in 10–33% Usually present in the third decade
5-year survival 80% Pain is classically worse at night and often entirely relieved
by non-steroidal anti-inflammatory drugs, reflecting the
Grade III role of prostaglandins in the pain response
X-rays and CT scan show a central lucent nidus within
Marked hypercellularity, cellular atypia, and high
thickened sclerotic cortex (<1 cm). Isotope bone scan
mitotic activity
shows increased uptake
Aggressive, rapidly enlarging
These lesions usually ‘burn-out’ over time and, thus,
Metastatic in 70% conservative treatment with NSAIDs is an option.
5-year survival 30% However, given the level of symptomatology experienced
Grade 1 tumours rarely metastasise and are often treated by by patients, treatment is often required
intralesional curettage Treatment is by CT-guided radioablation or by surgical
Higher grade tumours are treated by wide surgical excision, often using a ‘burr-down’ technique
excision. Chondrosarcomas are poorly sensitive to
radiotherapy and there is no active chemotherapy Osteoblastoma
treatments Benign, painful, osteoid-forming neoplasm, usually of the
Ten per cent undergo de-differentiation in one area, spine (40%) or long bones (Figure 20.21)
becoming highly malignant sarcomas with spindle Spinal lesions originate in the vertebral arch, rarely affect
cells and bizarre giant cells (similar to fibrosarcoma the vertebral body, and can lead to radicular or
or malignant fibrous histiocytoma), x-ray myelopathic symptoms
showing an area of lucency within classic stippled X-ray and CT show a lucent lesion with a central
calcification. Dedifferentiated chondrosarcoma density, similar to osteoid osteoma, but larger in size
characteristically presents as a pathological (i.e. >1 cm)
fracture in the elderly (Figure 20.19). Prognosis is Treatment is by curettage and grafting or en
dismal bloc excision
023
Associated with retinoblastoma and pro-geroid/pro-

cancerous syndromes: Li–Fraumeni, Rothmund-
Thompson, Bloom’s
X-ray of ‘classic’ intramedullary osteogenic sarcoma shows
a sclerotic, destructive lesion in the metaphysis of a long
bone invading the cortex and extending into the soft tissues
(‘sunburst’ pattern)
Increased alkaline phosphatase levels are associated with a
poorer prognosis as are elevated lactate dehydrogenase levels
Treament is with neo-adjuvant chemotherapy (involving
an anthracycline (doxorubicin), a platinum (cisplatin) and
high dose methotrexate), surgery and adjuvant
chemotherapy. Other chemotherapeutic agents (e.g.
etoposide and ifosfamide) are sometimes added to the
regime for poor responders during adjuvant chemotherapy
Local treatment involves complete excision of the primary
tumour. Limb sparing is usually feasible
A good response to chemotherapy is >90% necrosis and is
associated with a better prognosis than poor response
Metastatic disease is treated by resection where possible
Mifamurtide, muramyl tripeptide
phosphatidylethanolamine (MTP-PE), is a synthetic
analogue of a component of mycobacterial cell wall
: It simulates a bacterial infection, stimulating the
immune system, particularly white cells and causing the
Figure 20.21 Osteoblastoma of the right tibia. Note the cortical sclerosis release of TNF-α and numerous interleukins
with a central lytic nidus. Very similar in appearance to an osteoid osteoma : Activated white cells then attack cancer cells
but with a bigger nidus
: Use granted by NICE in 2011 for non-metastatic
disease, treated with complete excision and
chemotherapy
Malignant tumours : Controversy around the clinical trial, which did show
Osteosarcoma an absolute risk reduction of death of 8%
Second most common primary bone tumour (myeloma : Infection post-resection, which MTP-PE simulates, has
is first) been shown in both human and veterinary literature to
improve survival
Twenty per cent of all primary bone tumours (all ages), but
55% of all bone tumours in children and adolescents. The most
common malignant bone tumour between ages 10 and 19
Distal femur (35%) > prox. tibia (20%) > prox. humerus
Fibrous tumours7
(10%) Developmental or hamartomatous tumours
Bimodal distribution: first large peak during rapid growth Non-ossifying fibroma
in adolescence. Second smaller peak in sixth decade Very common (up to 35% incidence in normal children)
because of Paget’s sarcoma and radiation sarcoma Asymptomatic (but can present after pathological
Seventy per cent do not have radiologically detectable fracture), well-demarcated, solitary, eccentrically placed
metastases at presentation metaphyseal lesion
Ninety-five per cent intramedullary X-rays show a lucency with a sclerotic margin
: of which 90% are high grade Treatment is by observation, unless risk of pathological
fracture, as lesions usually resolve by adulthood
– Of these, 50% are osteoblastic, and the remainder
are chondroblastic, fibroblastic, small-cell or Fibrous dysplasia
telangiectatic/giant-cell. Common, usually monostotic, fibro-osseous lesion,
affecting long-bones of the lower limb (50%)
Five per cent surface
Often an incidental finding but can present with swelling or
: of which 90% are low grade pathological fracture usually in adolescence
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023
Figure 20.23 McCune–Albright syndrome. Polyostotic fibrous dysplasia is

Figure 20.22 Fibrous dysplasia of the right proximal femur showing seen in the femurs and pelvis with widespread bony changes and deformity
characteristic pathological fracture and developing shepherds crook deformity
X-ray shows a well-demarcated, fusiform expansion, with Malignant tumours

ground-glass calcification and cortical thinning Fibrosarcoma
Histology reveals abnormal, thin bony trabeculae described Rare, malignant spindle-cell tumour affecting the ends of
as ‘Chinese letters’ long bones (50% around the knee), in the third to sixth
The classic ‘shepherd’s crook’, deformity of the upper decades
femur, resulting in coxa vara, is caused by multiple, X-rays show lucent lesions with cortical destruction and
sequential pathological fractures (Figure 20.22) extension into the soft-tissues, a mottled appearance of the
Polyostotic involvement is seen in McCune–Albright bone and indistinct margins
syndrome (Figure 20.23) Treatment is by wide excision and reconstruction
: non-familial, resulting from a post-zygotic mutation to
GNAS1 (20q) Malignant fibrous histiocytoma
: Syndrome characterized by polyostotic fibrous dyplasia, Rare, pleomorphic spindle-cell tumour (storiform or
hormonal disturbances including precocious puberty, ‘starry-night’ pattern) affecting the metaphysis of long
and café-au-lait spots, which have a jagged edge (‘coast bones around the knee in adults (any age)
of Maine’), are unilateral, and do not cross the midline X-ray shows a poorly defined lucent lesion with
: Fibrous dysplasia most commonly affects the lower cortical destruction, but minimal periosteal new bone
limbs and pelvis but can also frequently affect the skull formation
and facial bones Treatment is as for osteosarcoma with chemotherapy, wide
excision and reconstruction
Benign tumours Adamantinoma
Osteofibrous dysplasia Rare, slow-growing (pain developing over many years),
Painless swelling of the tibia (>85%)/fibula of young low-grade spindle-cell neoplasm affecting the tibia in
children affecting the metaphysis/diaphysis but not the >90% of cases (Figure 20.24)
epiphysis X-ray shows a multicystic (‘soap-bubble’) lucency with
X-ray shows intracortical, multiloculated lesion with cortical thinning and expansion (this is different to the
osteolysis and thinning often with anterior bowing central, metaphyseal soap bubble appearance of unicameral
Can undergo malignant transformation to adamantinoma bone cysts)
Treatment is with curettage (± grafting) but there is Locally aggressive but can metastasise in 20% of cases late
significant risk of local recurrence, particularly if this is in its course
performed before skeletal maturity Treatment is with wide excision and reconstruction
023
Figure 20.25 ABC of the proximal tibia in a skeletally immature patient.

The lesion is metaphyseal, eccentric and has multiple fluid–fluid levels
and grafting, surgical fixation through the cyst with an

intramedullary nail or corticosteroid injection
Figure 20.24 Adamantinoma of the left tibia, arising in an area of
osteofibrous-dysplasia showing the characteristic anterior bow. With the ‘eye of
faith’, the proximal extent appears like soap bubbles Aneurysmal bone cyst
Solitary, expansile, multiloculated, eccentrically placed,
cystic lesion, usually of the long bones or spine (15%)
(Figure 20.25)
Presents with pain and swelling usually before the third
Non-matrix-producing tumours7 decade
X-rays show an expansile lesion with a trabeculated
Reactive or post-traumatic lesions appearance. MRI shows loculations with fluid levels
Unicameral bone cyst In many cases the lesion is secondary and reactive to
Solitary, cystic bone lesions found in the metaphyses of another benign lesion (e.g. osteoblastoma,
long bones in childhood and adolescence. Not seen in chondroblastoma, fibrous dysplasia, giant cell tumour)
adults Must distinguish from telangiectatic osteosarcoma which
Classic site is prox. humerus (50%). Other common site is can have aneurysmal change within it
prox. femur (25%), fractures of which can be difficult to Treatment is by curettage and grafting but recurrence rate
manage can be as high as 50%
Usual presentation is with pain (usually indicates
impending fracture), actual fracture or as an incidental Developmental or hamartomatous tumours
finding Haemangioma of bone
Fractures usually heal, but the cyst usually only partly Solitary, asymptomatic lesions, usually affecting the
resolves vertebral bodies or skull (lower thoracic most common)
X-ray shows well-defined lucent area with a geographical, comprising thin-walled cavernous blood vessels
sclerotic margin, sometimes with a ‘fallen leaf’ sign X-rays show accentuated, thickened vertical trabeculae =
Treatment is by observation for the majority. Surgical ‘Jail Bar’ on coronal/sagittal imaging and ‘salt and pepper’
intervention is indicated for those at risk of fracture. on axial imaging
Options described include minimally invasive No treatment is usually required but pathological fracture
decompression and curettage (preferred option), curettage can occur
407
023
Widespread disease can occur (skeletal distal femur 25%, proximal tibia 25% and distal radius
haemangiomatosis/lymphangiomatosis), but has no 10%) in the third decade
known familial tendency and is self-limiting X-ray shows an aggressive lytic lesion in the metaphyseal/
epiphyseal part of the bone, usually juxtaarticular. There is
Benign tumours often complete cortical destruction with an associated neo-
Eosinophilic granuloma cortex (Figure 20.26)
Solitary (80%) bony lesions of unknown etiology (possibly Histologically, the tumour comprises spindle-shaped
reactive or inflammatory) classically seen in males in the tumour cells and multinucleated giant cells, which are
first decade usually in the proximal femur, spine, skull indistinguishable from osteoclasts. These are recruited
or ribs from the monocyte–macrophage population. Agents which
Can be multi-focal and include soft-tissues including skin, interfere with osteoclast recruitment (e.g. bisphosphonates
lymph nodes and lung and RANKL inhibitors) may be helpful in difficult cases
X-rays show one, or more, well-defined lucencies. In the Must distinguish from giant-cell rich osteosarcoma
spine, secondary vertebral collapse is often seen (vertebra Denosumab is a human monoclonal antibody designed to
plana). There may be an associated periosteal reaction inhibit RANKL. It blocks the osteoclastic action of the
Microscopically contains histiocytes and multinucleated multinucleated giant cells within the tumour, thus, leading
giant cells (Langerhan’s) to reossification of the defect. Relapse occurs when the
Unifocal lesions usually regress spontaneously, particularly drug is stopped
after biopsy, but curettage and grafting may be required Treatment is by curettage and grafting and the use of a
surgical adjuvant (e.g. high-speed burr, liquid nitrogen,
Giant cell tumour of bone cement). Local recurrence rates can be high, particularly in
Rare (1–2 per million per year) solitary, locally aggressive difficult sites such as the pelvis, spine and distal radius
lesion seen at the epiphyseal ends of long bones (typically Malignant transformation and metastasis is a rare (<5%) but
well-recognised complication. Locally recurrent tumours are
associated with a higher risk of metastatic disease
Malignant tumours
Ewing’s sarcoma/PNET
Malignant, small round blue cell neoplasm of bone (rarely
of soft tissue) presenting most commonly in the
metaphyses/diaphyses of the femur (25%), tibia (10%),
humerus (10%) and in the pelvis (10%). Most common
malignant bone tumour under the age of 10. Second most
common tumour between the ages of 10–19
(Osteosarcoma No. 1)
Presentation is with pain and swelling, but anaemia, fever,
a raised ESR and a leukocytosis may also be present
incorrectly suggesting infection as the diagnosis
X-ray shows a lytic, moth-eaten appearance with
laminated periosteal bone reaction (‘onion peel’).
MRI shows the local extent of the tumour and depth of
soft-tissue involvement
Investigation for Ewing’s also includes whole body isotope
bone scan and a bone marrow biopsy to rule out metastatic
disease. Bone marrow involvement is associated with a
poorer prognosis
Reciprocal translation between chromosomes is seen
: t(11;22)(q24;q12) = EWS-FLI1*
: t(21;22)(q22;q12) = EWS-ERG
: t(7;22)(p22;q12) = EWS-ETV1
Figure 20.26 GCT of the proximal tibia showing locally aggressive behaviour
: t(17;22)(q12;q12) = EWS-FEV
but a narrow zone of transition. There is a pathological fracture but no obvious : t(2;22)(q33;q12) = EWS-E1AF
periosteal reaction or soft-tissue extension : t(16;21)(p11;q22) = FUS-ERG
023
* Know this one for MCQ/EMQs

Treatment of primary bone sarcomas
Chemotherapy is with vincristine, doxorubicin, Reconstructive/ limb-salvage surgery9,10
cyclofosfamide, ifosfamide and etoposide Safe margins must not be compromised for a preferred
Local treatment is with wide surgical excision. Additional functional or reconstructive outcome
radiotherapy is added if margins are close. Radiotherapy is Limb-salvage rates 90% in most centres
sometimes used as the primary local treatment modality
Amputation is reserved for tumours that extensively
where surgical excision is not possible involve neurovascular structures, or where safe margins
Overall 5-year survival is 66% (75% with a good response cannot be achieved. In osteosarcoma, assessment of a safe
to chemotherapy and 20% in those with a poor response) margin depends on the response of the tumour to
neoadjuvant chemotherapy as well as the thickness of the
Chordoma
margin histologically
Arises from remnants of the notochord, so almost Greatest experience of megaprosthesis use is in long bones
exclusively arise in the midline/axial skeleton esp. femur, tibia and humerus (Figure 20.27)
(50% sacrococcygeal, 35% cranial) (see Figure 20.20)
Extendable prostheses are available to accommodate
Slow-growing neoplasm, presenting in fifth decade growth in children
Lytic lesion with bony destruction and focal calcification Ten-year implant survival around 75%, depending on
Systemic metastases in 50% to lymph nodes, lung, liver anatomical site and length of resection. BUT: With revision
and bone procedures, durability of limb-salvage can be as high as
Chordomas are generally considered radio-insensitive and 90% at 20 years. Survival of implants has been improved by
radiation dose is limited due to adjacent neurological the use of hydroxyapatite collars. Silver-coated implants
structures. However, proton beam therapy has shown early may be more resistant to infection
promise in this tumour type and there are good results Secondary amputation, when required, usually follows
using carbon ion radiotherapy deep periprosthetic infection or local recurrence
Surgical excision is the only curative treatment, but needs
to be balanced with the morbidity, given the proximity of Adjuvant treatment
vital neurological structures Radiotherapy
Malignant bone-forming tumours (e.g. osteosarcoma) and
malignant cartilage-forming tumours are poorly
Figure 20.27 Right radiosensitive
distal femoral
replacement performed
Ewing’s sarcoma is classically radio and chemosensitive
after resection of the and radiotherapy can occasionally form the mainstay of
osteosarcoma seen in treatment in areas where surgery is difficult (e.g. pelvis)
Figure 20.4
Chemotherapy11
For osteosarcoma, randomised trials have demonstrated
increased disease-free and overall survival in localized
disease with the use of multiagent chemotherapy
: It is recognised, however, that although most patients
do not have radiologically detectable disease at
presentation, many have occult micrometastatic
disease. In the pre-chemotherapy era, survival was poor
(20%)
: Neo-adjuvant (pre-surgical) chemotherapy allows early
and effective treatment of micrometastases and usually
leads to a reduction in inflammation around the
tumour, and sometimes in the size of the tumour,
which helps the surgical resection
: Standard treatment is with combination doxorubicin,
cisplatin and high dose methotrexate, but where
possible, patients are recruited into clinical trials
: The response of the tumour to neo-adjuvant
chemotherapy (measured as percentage necrosis on
histology of the resected specimen) is prognostically
409
023
significant. Patients with >90% necrosis do better than actually very rare), weight loss, night sweats,
those without lymphadenopathy, hepatosplenomegaly and ‘cyclical’ fever
: Good responders are treated with the same agents after X-ray shows variable lesions (lytic, sclerotic or mixed), but
surgery but non-or poor responders may benefit from the classic is a dense ‘ivory’ vertebra
the addition of ifosfamide and etoposide Pathognomic histopathological finding is the Reed–
Sternberg cell (large with a ‘mirror image’ double nucleus.
Looks like an owl!)
Immunohaematopoietic tumours Treatment is with radio- and chemotherapy
Plasmacytoma and multiple myeloma
Most common primary bone tumour Leukaemia
Multiple myeloma invariably presents in the spine, but may Haematopoietic disease widely affecting the bone marrow
also present in the sternum, ribs, pelvis and skull and limbs Bone pain is presents in 25% of children and 5% of
Generally presents in or after sixth decade. Male 2 : 1 adults with the disease but radiographic changes are
female present in up to 90%
Present with pain, anaemia, increased ESR and X-rays show
hypercalcaemia 1. Transverse lucent metaphyseal line in children
Serum electrophoresis identifies a monoclonal 2. Osteolytic destruction
proteinaemia. Bence–Jones proteins (light-chain subunits
3. Generalized osteopaenia
of immunoglobulins) are found in the urine
4. Periosteal elevation
X-ray shows multiple round, lytic defects with no
5. Focal sclerosis
surrounding sclerosis or reactive bone. Classically do
not show up on isotope bone scans so skeletal survey is Treatment varies with subtype but includes chemotherapy,
needed radiotherapy and, in some cases, bone marrow transplant
Treatment is with steroids and chemotherapy ± bone Treatment of immunohaematopoietic tumours
marrow transplant. This generally improves survival only Treatment of immunohaematopoietic tumours
rather than effecting a cure (e.g. myeloma, lymphoma and leukaemia) is usually with
A diagnosis of plasmacytoma depends on chemo- and radiotherapy, but rarely involves surgery
1. No other radiographic lesions Surgery is reserved for stabilisation of completed or
2. A negative bone marrow biopsy from a separate site impending pathological fractures
3. No significant protein or immunoglobulin abnormality
on urine or serum assays Vascular neoplasms
Angiosarcoma
– X-rays show a solitary, expansile, lytic lesion
Usually present with a rapidly enlarging mass in the lower
– Treatment is with radiotherapy or en bloc excision
limb in males. Usually after radiotherapy/
– The diagnosis of solitary myeloma is debated as 70% lymphadenectomy (Stewart–Treves syndrome)
develop disease at multiple sites (i.e. multiple
X-rays show extensive bony destruction with erosion of the
myeloma) and die within 5 years. Others can
cortices and MRI shows extension into the soft tissues
develop multifocal disease years after the index
Aggressive tumours which metastasise early
plasmacytoma
Treatment is with radical excision
Primary non-Hodgkin’s lymphoma Metastatic bone disease

Usually large B-cell lymphomas of the axial skeleton Best managed by an MDT in conjunction with the
although 25% can occur in the femur departmental lead for MBD12
X-rays show moth-eaten osteolysis and destruction with no
periosteal reaction Epidemiology
Local evaluation is by MRI and staging is by CT scan and ‘Big 5’: Lung, breast, prostate, kidney and thyroid
isotope bone scan to look for multifocal disease >20 000 patients develop bony metastases per annum in
Treatment is by radiotherapy ± chemotherapy the UK
Prognosis depends on histological subtype, grade and stage 11 500 deaths from breast cancer per year of which 70%
have MBD
Hodgkin’s disease
A specific type of lymphoma often presenting with pain Preoperative assessment
(classically after alcohol consumption although this is As for any suspicious lesion as described earlier
023
Do not assume a solitary lesion is a metastasis

Bone profile blood test important to look for
hypercalcaemia
Investigations to find primary cancer (see earlier section)
Assess general fitness for surgery
a. biological, as opposed to chronological, age
b. functional ability or performance status
c. medical co-morbidities or ASA grade
d. patient motivation
: Correct reversible conditions, e.g. anaemia
Renal, thyroid and melanoma metastases can be extremely
vascular. Preoperative angiography and embolisation can
reduce blood loss during surgery
Biopsy
Where diagnosis is in doubt or the metastasis is a solitary
lesion
Must follow principles as above and should be discussed
with/performed by the bone tumour MDT
Metachronous, solitary renal metastasis, after successful
urological treatment of the primary, may be best managed
by wide excision with curative intent
Prophylactic fixation
13
Assess fracture risk using Mirels score
: Site: Upper limb (1 pt), lower limb (2 pts), inter/
subtrochanteric (3 pts)
: Pain: Mild (1 pt), moderate (2 pts), limits function Figure 20.28 IM nail right femur for MBD as seen in Figure 20.2. The lesion
(3 pts) in the femur would score 12/12 according to Mirel’s criteria. It is in the
: Matrix: Blastic (1 pt), mixed (2 pts), lytic (3 pts) subtrochanteric region of the femur (3 pts), the patient experiences pain at
rest (3 pts), the matrix is lytic (3 pts) and more than two-thirds of the
: Size: (maximal cortical destruction) <1/3 (1 pt), cortex is destroyed (3 pts). It has been treated with local curettage,
1/3–2/3 (2 pts), >2/3 (3 pts) cementation and nailing of the entire femur. The reamer, irrigator, aspirator
: Scores are added together: 8 are at high fracture risk (RIA, Synthes) system was used to minimize distal tumour seeding within
the bone
(>30%) and should undergo surgery before
radiotherapy (Figures 20.2 and 20.28) complications of tumour progression postoperatively
: Other considerations include prognosis, mobility and (Figure 20.28)
likelihood that lesion may respond to non-surgical : Adjuvant radiotherapy may reduce the risk of local
treatment recurrence
: The Mirel score is a guide only and a clinical decision : There is a high rate of failure with fixation of proximal
taking all factors into account is essential femoral lesions; therefore, consider cemented hip
Radiotherapy is usually palliative, is given in a single replacement/tumour prosthesis
fraction, but may prevent fracture if the lesion heals : Pelvic and acetabular lesions should be treated by an
experienced orthopaedic oncology surgeon
Stabilisation of pathological fractures
Other treatments:
Assume that fractures will not heal.
Chemotherapy, bisphosphonates and hormonal
Aim for manipulation may all have a role and, hence, a
: Immediate stability contemporaneous oncology input is mandatory with MDT
: Immediate weight-bearing discussion
: A durable reconstruction that will outlive the patient
and will remain stable if there is local recurrence Spinal metastases
: Stabilise all lesions in any given bone if possible Commonest site for MBD
: If practical, local tumour debulking with PMMA Present with pain/neurological deficit
cement packing, may increase stability and reduce Always look for signs or symptoms of cord compression
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023
Consider possibility of unstable spine NOT to be confused with giant cell tumour of bone
MRI to assess extent of involvement – Whole spine A locally aggressive synovial tumour affecting mainly large
Biopsy only on advice of spinal centre joints (diffuse type) and tendon sheaths (nodular type)
Radiotherapy as definitive treatment if Knee most commonly affected but is also seen in the hip,
:No instability ankle, foot and wrist
:It is a radiosensitive tumour X-rays generally show only soft-tissue swelling, but juxta-
articular erosions can sometimes be seen particularly in the
:Multi-level disease
hip. MRI may show small voids within the tumour caused by
:Stable neurology
iron deposits, and ‘blooming’ on a gradient echo sequence
:General condition precludes surgery
Lesions are seen as tan coloured nodules with
:Poor prognosis
haemosiderin deposition (pigmented) and a dramatic
:Or as adjuvant treatment postoperatively hyperplastic villous response is seen in the adjacent
Surgery if synovium, particularly in large joints
:Unstable Treatment is by excision of the lesions ± total
:Progressive neurological deficit synovectomy. In diffuse disease, recurrence is 50%.
:Intractable pain, unresponsive to non-operative Radiotherapy is sometimes used for recalcitrant disease
management and recent use of chromic phosphate (p32) has shown
: Spinal cord tolerance reached after prior radiotherapy some encouraging results
Objectives of surgery
: Prevention of further neurological deficit. Recovery of Benign fibrous lesions
neurological deficit can occur, but is uncommon Fibroma of tendon sheath
: Restoration of spinal stability Small, well-circumscribed lesions affecting tendons in the
: Decompression of spinal cord and spinal nerves hands and feet
: Restoration of structural integrity and stability of the Treatment is by excision if symptomatic
vertebral column
: Tumour eradication if feasible Fibromatosis
: Surgery should ideally be undertaken before the patient A generic term for a group of diseases characterized by a
loses the ability to walk and should be done to cellular, infiltrative growth of fibroblastic tissue.
maximize useful function (Dupuytren’s, Peyronie’s, etc)
: The magnitude of the procedure should not exceed the Palmar fibromatosis/Dupuytren’s disease is common
patient’s ability to survive it or the surgeon’s level of (10% incidence), affects men 4 : 1 women, may be familial,
competence and is associated with diabetes, epilepsy and alcoholic liver
: Decompression AND stabilisation is usually required disease. Treatment is often by surgical excision. For more
detailed summary of Dupuytren’s disease, see the section in
Soft-tissue tumours7 the hand oral topics
Plantar fibromatosis is rare compared to Dupuytren’s
Benign synovial lesions disease. It presents with large nodules but contracture is
Synovial chondromatosis not a feature. Unlike Dupuytren’s, surgery should be
Multiple islands of metaplastic cartilage in the synovium discouraged as recurrence is common and florid
of a major joint, which calcify (or even ossify) to a varying Fibromatosis can occur as a soft-tissue tumour (extra-
degree abdominal desmoids tumour) in adolescents and young
Patients complain of pain, swelling and decreased ROM or adults, typically around the shoulder or pelvic girdles. It is
mechanical symptoms locally invasive and resection has a high rate of local
X-rays show numerous partially calcified loose bodies recurrence. The natural history is unpredictable in that
within the joint recurrent nodules can remain dormant for many years, or
Treatment is by surgical excision and synovectomy, grow rapidly for some time and then plateau
arthroscopically if possible, but recurrence is common The pathologist will need clinical information when
Malignant transformation is very rare examining a surgical specimen of fibromatosis as
differentiating it from low-grade fibrosarcoma can be
Teno-synovial giant cell tumour difficult
Previously known as pigmented villonodular synovitis Radiotherapy may be helpful for recurrent disease
(PVNS) but renamed in the fourth edition of the WHO Chemotherapy (methotrexate and vinorelbine) has shown
classification good response in reducing tumour volume
023
Nodular fasciitis Neurofibromatosis

A proliferation of fibroblasts most commonly seen on the Genetic disorders of nerve development and growth
volar aspect of the forearm from the second to fifth decades Nf-1 (von Recklinghausen’s disease) and Nf-2
It can be mistaken for a malignant condition because of the
hypercellularity, atypia and mitotic rate seen within the Nf-1
rapidly growing lesion
1 in 4000 incidence of which up to 50% are new mutations
Despite the aggressive microscopic features, the affecting gene on Ch 17.
condition is self-limiting and can be treated with local
Diagnosed by two or more of the following
excision
:Five or more cafe-au-lait spots
Elastofibroma :Two or more neurofibromas or one plexiform
A firm, rubbery tumour, which occurs almost exclusively neurofibroma
in the fascia between the ribs and the inferior portion of the : Tumour of the optic nerve (optic glioma)
scapula : Benign growth on the iris (Lisch nodule)
Patients present with pain as the lesion ‘flicks’ over the : Scoliosis
border of the scapula on shoulder elevation : Deformity of other bone (esp. tibial bowing)
Microscopic examination reveals a collagenous, fatty lump, : Freckling of groin or armpit
with numerous elastin fibres throughout : Parent sibling or child with Nf-1
Treatment is conservative or by surgical excision for Patients are kept under observation and treatment aims at
symptomatic lesions symptomatic control. Surgical excision can be performed
for large or unsightly lesions. Malignant transformation
Peripheral nerve lesions occurs in up to 5% and should be treated as per
sarcomatous lesions
Traumatic neuroma
An exuberant, non-neoplastic growth of nerve tissue, which
Nf-2
occurs at the proximal end of a severed or injured nerve
Treatment includes conservative measures (cortisone 1 in 40 000 incidence
injection, physiotherapy) or surgery Bilateral acoustic neurofibromas (CN VIII) which lead to
tinnitus and progressive deafness, ± other gliomas,
Morton’s neuroma menigiomas, neurofibromas, schwannomas or early
Thickening and degeneration of an interdigital nerve in cataract formation
the foot Treatment is aimed at surgical debulking of the acoustic
Clinical diagnosis by pain on web-space pressure with neuromas to relieve compression but avoid complete
metatarsal approximation, Mulder’s click and digital nerve deafness
stretch
Treatment is by steroid injection or surgical excision Miscellaneous lesions
Benign Schwannoma Lipoma
Encapsulated nerve sheath tumour with a highly ordered Tumours of mature adipocytes, identical to the
cellular component (Antoni A area) and a loose myxoid surrounding adipose tissue, with minimal variation in cell
component (Antoni B area) size and shape
Usually solitary, fusiform lesions on flexor surfaces Usually seen in the fifth decade as superficial lesions
of limbs MRIs demonstrate circumscribed, bland lesions, identical
in signal to the surrounding fat
Treatment by marginal excision to spare nerve fibres,
which are usually splayed over the surface of the lesion. Treatment is by marginal excision
Even with intralesional excision (to spare nerve function), Lesions showing variation of adipocyte size, nuclear atypia,
local control is usually good fibrous septal stroma and lipoblasts are now termed
atypical lipomatous tumours when they occur in the limbs
Neurofibroma or well-differentiated liposarcomas when they occur in the
Most occur as solitary lesions in the third decade visceral cavities of the trunk. Unlike simple lipomas they
carry a risk of local recurrence but have almost no
Non-encapsulated lesions although usually well
malignant potential unless dedifferentiation occurs
circumscribed
(Figure 20.29)
Treatment is by marginal excision
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023
Figure 20.29 T1 MRI (fat is bright) showing a large, deep, intramuscular

lipoma of the left thigh. It is made of largely bland fatty tissue. Although there is
some streaking, there are no dark nodules to suggest an area of de-
differentiation. (Contrast with Figure 20.30)
Haemangioma
Commonest soft-tissue tumour of infancy Figure 20.30 T1 MRI of a left thigh showing a large fatty lesion. However,
Multiple (usually small) lesions in Maffucci’s syndrome within this lesion is a large dark nodule, which is bright on T2 (see Figure 20.31).
This represents an area of dedifferentiation into a liposarcoma
Capillary and cavernous forms, most usually present on
head or neck, consisting of a mass of ‘knotted’ blood vessels
Diagnosed by ultrasound ± MRI No effective treatment is available but bisphosphonates and
Plain x-ray may show calcification within vessels, steroids can be beneficial during flares
Treatment of peripheral lesions is usually by observation
whilst the child grows, but can include laser treatment (for Ganglion
flat superficial lesions), embolisation or surgical resection Fibrous-walled cysts containing mucinous fluid,
commonly seen on the extensor surfaces of hands, wrist
Myositis ossificans circumscripta and feet, originating from the underlying joint
Solitary, non-progessive, benign ossification of the soft Treatment (if large or symptomatic) is by aspiration and
tissues needling of the cyst, injection of a sclerosant (recurrence up
Usually presents as a painful lump within a muscle often to 70%) or surgical excision (recurrence up to 40%)
following trauma
X-ray shows calcification within the lesion after maturation Soft-tissue sarcomas (STS)14
but may be negative in early presentation STS are a heterogenous group of tumours of mesenchymal or
Treatment is by surgical excision connective tissue origin. They are rare, with an incidence of
around 45 per million per year, and comprise <1% of all adult
Myositis ossificans progressiva cancers. The median age at presentation is around 55 years.
Very rare genetic (autosomal dominant), progressive Histological types include:
disease affecting groups of muscles, tendons and ligaments
usually in the spine and upper limb, leading to progressive Undifferentiated pleomorphic sarcoma
fibrosis, calcification and ossification, resulting in The term Malignant Fibrous Histiocytoma has been
deformity. Biopsy leads to muscle trauma and should be removed from the most recent WHO classification
avoided. Associated with infantile hallux valgus Pleomorphic, high-grade tumour presenting in the fifth to
Often fatal secondary to pulmonary impairment seventh decades more commonly in men
023
Rhabdomyosarcoma
Malignant tumour of skeletal muscle. Histologically small
round blue cell tumours
Most common malignant soft-tissue tumour in children
(87% <15 years), rare after the age of 40
Three major subtypes
1. Embryonal (55%): Generally seen from birth to 15 years,
usually in the head, neck and truck. Cytogenetically
show a loss of heterozygosity at chromosome 11p15.5
2. Alveolar (20%): Generally seen between ages 10 and
25 years, usually in the extremities. Reciprocal
translocation is seen between chromosomes 2 and 13
(t(2;13)(q35:14))
3. Undifferentiated (20%): Generally seen in older patients
(fourth decade and above). Poor prognosis
Treatment includes neo-adjuvant chemotherapy and wide
excision. Radiotherapy is given for close margins or
otherwise unresectable tumours
Synovial sarcoma
Classically spindle-cell tumours with an epithelial
component seen between the ages of 15 and 40 years in
the soft-tissues of the lower limb, usually adjacent to
Figure 20.31 T2 MRI of the same lesion as Figure 30. Note that the fatty
areas are dark and supress, while the area of dedifferentiation is bright the knee
NOT of synovial origin
Can present with a long history of pain
Reciprocal translocation t(x:18) is present in 90%
A diagnosis of exclusion after other tumour types have Irregular calcification is seen in 20%
been excluded by immunohistochemical staining and Chemotherapy can cytoreduce some tumours improving
genetic testing resectability but does not affect overall survival
Treatment is by wide surgical excision. Use of
chemotherapy is controversial Fibrosarcoma
Rare malignant tumour of fibroblasts generally seen in the
Liposarcoma fourth to sixth decades
Malignant tumours of fat seen predominantly deep to the Well- and poorly differentiated types
fascia of the lower limbs and in the retroperitoneal space Well-differentiated tumours display the classic ‘herring-
Three major subtypes bone’ cell pattern histologically and have a 60% 5-year
survival
1. Atypical lipomatous tumours with dedifferentiation
(40%). They are characteristically seen in fifth to Poorly differentiated tumours have a much poorer
seventh decades. Local recurrence is more common in prognosis
retroperitoneal tumours and the risk increases if there
are areas of dedifferentiation. Metastasis is generally Malignant peripheral nerve sheath tumour
only seen in tumours with dedifferentiation Malignant spindle-cell tumour of nerve or
(Figures 20.30 and 20.31) neurofibromatous origin, presenting in the third and
2. Myxoid and round cell liposarcomas (50%). Generally fourth decades
present in the third and fourth decades. Ten per cent of all soft-tissue sarcomas
Cytogenetically, reciprocal translocation is seen Fifty per cent arise in patients with neurofibromatosis
between chromosomes 12 and 16. Metastasis occurs in type 1
25% of myxoid and 50% of round cell tumours Can be difficult to differentiate histologically from
3. Pleomorphic liposarcomas (10% liposarcomas). Present leiomyosarcoma or fibrosarcoma
in the fifth to seventh decades and have a poor Local recurrence and metastasis are common (both
prognosis with early metastasis around 50%)
415
023
Pervaiz et al. Cancer, 2008. Updated SMAC using later studies

Epithelioid sarcoma which used higher doses of doxorubicin and ifosfamide and
Malignant soft-tissue tumour usually seen in the showed a benefit in local, distant and overall recurrence-free
superficial subcutis or tendon sheaths of the hand and survival as well as an increase in overall survival equivalent to
wrist in the second and third decades, most commonly an absolute risk reduction in death of 11%20
in men BUT: Side effects are significant (e.g. cardiotoxicity with
Can be mistaken for squamous cell carcinoma or synovial doxorubicin) so use is limited, particularly in the elderly
sarcoma population at risk of soft-tissue sarcoma
Probably of synovial origin Some specific tumour types are chemo-sensitive and,
Aggressive tumours which metastasise early either hence, chemotherapy does form part of the treatment
haematogenously or through the lymphatics regime for these, e.g. rhabdomyosarcoma, soft-tissue
Poor prognosis Ewing’s and primitive neurectodermal tumours (PNETs)
Treatment of soft-tissue tumours14

Reconstructive/limb-salvage surgery Examination corner
Safe margins must not be compromised for a preferred Basic science oral 1
functional or reconstructive outcome Candidate shown a picture of a diseased and necrotic hand.
Randomised controlled trial showed increased rates of local CANDIDATE: Due to the manginess of the hand I initially failed to
recurrence in limb-salvage surgery compared to spot that there was a digit missing. I started by discussing
amputation but no significant difference in 5-year infection and osteomyelitis before realizing that it was a
disease-free survival or overall survival. Hence, malignancy. I went for epithelioid sarcoma and ended up in a
limb-salvage surgery has become the norm15 difficult discussion until the bell went.
Amputation is reserved for tumours that bridge several EXAMINER: The candidate offered epithelioid sarcoma as the
compartments, or extensively involve neurovascular diagnosis. Although this should form part of the differential as the
structures, or those for which an amputation would be most common soft-tissue sarcoma of the hand, squamous cell
more functional than the salvaged limb (e.g. following carcinoma is much more common and was in fact the diagnosis.
complex resection of the foot)
Adjuvant treatment Candidate shown an x-ray of a pathological neck of femur
fracture.
Radiotherapy16
CANDIDATE: I was quickly moved on past history and examination
Radiotherapy reduces the rate of local recurrence but has
to discuss investigations and management. I discussed the
no effect on survival
likelihood of primary verses metastatic and explained that there
Preoperative or postoperative radiotherapy?
was no urgency to fix at the expense of diagnosis. This was the
: Preop radiotherapy can be given at a lower dose (50 Gy correct decision as the diagnosis turned out to be a renal cell
vs 65 Gy) and with a smaller treatment volume, but is metastasis. We then discussed further management including
associated with a higher rate of wound complications, embolisation.
particularly in the proximal thigh17
: Postop radiotherapy has higher rate of long-term Basic science oral 3
fibrosis and lymphoedema because of the higher doses ‘Describe this tumour.’
and field sizes used potentially leading to a worse Common prop-based question usually using a plain radio-
functional outcome18 graph and occasionally another imaging modality, e.g. MRI.
In UK, usually given postop to reduce rate of local
recurrence except for radiosensitive tumours (e.g. myxoid
Candidate shown a radiograph of an osteosarcoma of
liposarcoma) when preop treatment may shrink the tumour
the femur.
Asked to describe the x-ray appearance.
Chemotherapy Asked about principles of tumour staging and biopsy.
Sarcoma Meta-Analysis Collaboration (SMAC): Asked about the surgical options available in the treatment
Cochrane review, 2000. Included data from 14 randomised of bone tumours.
trials and showed a small but significant reduction in both EXAMINER: You are the tumour surgeon. How are you going to
local and distant recurrence-free survival but only a trend stage and manage this tumour?
towards increased survival for patients treated with
chemotherapy in soft-tissue sarcoma19
023
Basic science oral 5 1. Urgent discussion with a bone tumour MDT. Urgent
Candidate shown a radiograph of a lucent lesion of the referral must not be delayed by local arrangement of
proximal femur. further investigations
Asked to describe management, investigation and likely
2. Local imaging of the bony lesion
diagnosis.
Discussed scoring system of Mirel. (a) X-rays have usually been performed prior to
referral, and often have alerted the referring unit to
Basic science oral 6 the possibility of a primary bone lesion, triggering
Candidate shown a radiograph of a lytic lesion of the midshaft the referral. X-rays should include the whole bone
of the humerus in an elderly woman. and include the joint above and below to screen for
Asked to describe the x-ray and offer a differential diagnosis. skip/satellite lesions
The diagnosis was myeloma.
(b) MRI gives good information about soft tissues. It
EXAMINER: Where else do you get myeloma deposits? How do you is used to delineate the extent of the tumour, to
confirm the diagnosis? seek out extracompartmental extension and/or
skip lesions, and assess any involvement of critical
Basic science oral 7 neurovascular structures. Images can give
Candidate shown a radiograph of a pathological fracture diagnostic information in certain circumstances,
through a fibrous cortical defect in the distal tibia. but are generally used for biopsy planning and
Asked to present a differential diagnosis.
later to plan the definitive resection
EXAMINER: How do you manage the fracture? How do you confirm (c) CT scans can give more detailed information about
the diagnosis? the bony involvement and anatomy. Can be useful
for diagnosis, e.g. osteoid osteoma
Adult and pathology oral 1 3. Biopsy
Candidates may be asked to describe how they would (a) Biopsy is performed to obtain a definitive
perform a biopsy of a suspicious bone lesion. histological diagnosis. (For principles of biopsy see
Answers should include the following principles: earlier question)
1. A biopsy should only be performed after detailed 4. Staging
history, examination, investigation and planning (a) The lung is the most common site for metastasis
2. A biopsy should only be performed by, or after and, hence, CT chest is the most important staging
discussion with, a surgeon working as part of a bone investigation, but often the abdomen and pelvis are
tumour MDT included. Whole body bone scan is also helpful to
3. Careful planning of the biopsy track is essential such look for other bone lesions
that all contaminated tissue and the track itself can be (b) Certain tumours (as diagnosed from the biopsy)
excised en bloc during the definitive resection require specific staging procedures, e.g. bone
4. Biopsies can be taken using a core needle marrow biopsy in Ewing’s sarcoma
percutaneously or by open incision 5. Treatment planning in the MDT
5. Biopsies can be taken with or without image guidance
including CT, US or II Metastatic lesions If the history, examination and radio-
6. Where open biopsies are performed, the incision graphs point towards this being a metastatic lesion, further
should be placed along the longitudinal axis of the limb investigations can be undertaken locally. Malignant lesions
7. Close attention to haemostasis and minimal tissue in bone are more likely to be metastases in patients over
dissection are important during incisional biopsy to 40 years of age. If there is any dubiety urgent discussion
minimize tissue seeding should be undertaken with a bone tumour MDT. Where
there is a fracture, the candidate should not rush in to
Adult and pathology oral 2 recommending surgical fixation when the diagnosis is
Candidates are commonly asked to give an account of the not known.
typical workup for patients with a bony lesion? Metastatic lesions should be investigated with a
In answering these types of question, start by saying global aim of finding the primary cancer (if not already
that one would: obvious) and a local aim of delineating the metastatic
lesion and determining if orthopaedic intervention is
1. Take a history and perform a detailed examination
required:
2. Take plain radiographs of the affected part
1. Laboratory studies
Primary bone lesion/tumour (a) FBC, U&E, LFTs, bone profile
417
023
(b) Serum electrophoresis (myeloma screen) The radiological features should be diagnostic. X-rays
(c) Tumour markers as appropriate to history, should show cortical continuity between the bone and the
e.g. PSA prominent lesion. Lesions can be sessile (broad-based) or
2. Imaging to ‘hunt’ the primary pedunculated (stalked). MRI scan should confirm the
contiguous nature of the cortex with the lesion but will
(a) Chest x-ray (looking for lung primary or
also delineate the cartilage cap. Bland cartilage <1 cm in
lung mets)
depth indicates a benign lesion and excision biopsy is
(b) Bone scan (looking for other metastases)
appropriate treatment if the lesion is symptomatic.
(c) CT chest and abdomen (looking for primary
Red-flags include lesions which continue to enlarge after
tumour ± other mets, e.g. liver). CT pelvis may be
the cessation of skeletal growth and the closure of the
included at this stage if surgical treatment of a
physes, and a thickened cartilage cap. Malignant
lesion around the hip is being considered
transformation is very rare in isolated lesions but is reported
(d) Other imaging may be indicated by the original at between 1% and 5% in multiple hereditary exostoses.
history and examination, e.g. mammogram, Biopsy of suspicious lesions, by or after discussion with a
thyroid USS, etc. bone tumour MDT, must preceed surgical excision, as wide
If all the investigations aimed at finding the primary cancer
margins, including excision of the biopsy track, will be
are negative a biopsy of the bone lesion will be required to
necessary if malignant change is diagnosed.
obtain a definitive diagnosis. This must then be treated as
a possible primary bone lesion and discussed with a bone Staging?
tumour MDT.
Osteochondromas are benign lesions. If asymptomatic,
3. Local imaging of the metastatic lesion
they are labelled as latent, but, if they become
a. Plain radiographs of the whole bone including the symptomatic, they are then labelled as active. This is
joint above and below to screen for other lesions in according to the system described by Enneking,
the same bone classifying benign lesions as latent, active, or aggressive.
b. A CT scan shows calcified tissue better and can (If asked to give an example of a lesion that would be
delineate the amount of bone erosion labelled as aggressive, the classic is a GCT.)
c. An MRI scan shows soft-tissue detail better and can
delineate the size and extent of the metastatic Adult and pathology oral 4
lesion, in particular whether there is a soft-
X-ray osteoid osteoma in the femoral neck
tissue mass
How to investigate?
Discussions on fixation of metastatic lesions should
● X-ray will show thickening of the cortex. A lucent
include:
nidus may be identified, but may be obscured by the
1. The Mirel score by the cortical thickening.
2. The general condition of the patient and conservative ● CT scan shows the classic lucent nidus (<1 cm) with a
measures, including reference to team working with central point of sclerosis and is diagnostic.
other specialists ● Bone scan is usually unnecessary, but will show
3. Principles of fixation increased uptake.
(a) Assume that any pathological fracture will not heal To fix or not to fix?
(b) Fix all lesions in a bone if possible Treatment is either conservative or operative.
(c) Aim for immediate stability, immediate weight- Conservative treatment is with NSAID medication which
bearing and a durable reconstruction that will classically absolves the pain associated with this lesion.
outlive the patient Operative treatment of oseoid osteoma is with CT-guided
(d) In general, arthroplasty is preferred to fixation radioablation, ‘burr-down’, or surgical excision.
around joints Depending on the position of the lesion within the
Again, if there is any dubiety then discussion with a bone femoral neck, mechanical stabilisation with internal
tumour MDT is mandatory. Remember too, that solitary fixation may be required if an open procedure is
metastases may, in certain circumstances be best treated as
performed.
primary tumours and should be discussed with a bone
tumour MDT. Basic science oral 1
Candidates may be asked to differentiate between infection
and neoplasm on radiographs.
Osteochondroma proximal femur
It may not be possible to distinguish between infection
Differential diagnosis/management?
and tumour on the basis of radiograph
023
Both may show diffuse changes, patches of lucency and : Sclerotic, bone-forming lesion typically in the
sclerosis, and periosteal reaction metaphysis of a long bone around the knee or
The clinical picture may not be helpful either as fever, shoulder with a wide zone of transition, invading
raised ESR, and swelling with localized dolor, rubor the cortex and extending into the soft-tissues
and calor may also be features of Ewing’s sarcoma : Periosteal reaction
Definitive diagnosis often requires biopsy for histology
– Codman’s triangle (periosteal elevation)
and culture to distinguish between infection and
– ‘Sunray’ spiculation (indicative of extension
tumour
into the soft-tissues)
Basic science oral 2 Paget’s disease
Candidates may be asked to describe the radiological differ- : In the earliest stages of the disease, osteoclastic
ences between benign and malignant bone lesions. The resorption predominates and significant
differences are really between locally aggressive lesions and radiolucency may be seen
others. : As the disease progresses overall density increases
Key features
Zone of transition – Trabeculae become coarser and thicker
: Wide/diffuse in malignant lesions – Cortical bone becomes less compact
: Narrow in benign lesions – Corticomedullary demarcation becomes less
obvious
Periosteal reaction seen in malignant lesions
Candidates may be shown various x-rays and asked to – Diameter of the bone increases
describe the salient feature and offer a differential diagnosis,
e.g.
: Vetebral bodies may show uniformly increased
density mimicking possible metastatic tumour
Ewings sarcoma : Pelvic lesions may show areas of sclerosis or lysis as
: Bony lucency with a wide zone of transition – well as areas of ‘honeycomb’ or striation
Classically spreads through cortex without : In long-bones, disease usually starts at one end and
destroying it extends along the bone. The junction between
: Periosteal reaction diseased and normal bone is often seen as a ‘flame-
like’ wedge of advancing rarefaction
– ‘Onion peel’
: Bone of the skull show areas of patchy sclerosis in
: Differential diagnosis the latter stages of the disease and the bone may
appear significantly thicker than normal
– Osteomyelitis
Osteosarcoma
Bibliography/further reading soft parts sarcoma of the thigh. Cancer.

1981;47:1005–22.
National Cancer Intelligence Network;
2010.
Bullough’s Orthopaedic Pathology provides
an extensive overview of bony and soft-tissue 3. Enneking WF, Spanier SS, Goodman 7. Bullough PG. Orthopaedic Pathology,
lesions and includes numerous x-rays and MA. Current concepts review. The Fourth Edition. Edinburgh: Mosby; 2007.
histology slides. The clarity and order of his surgical staging of musculoskeletal 8. Aigner T. Towards a new understanding
book has given much inspiration for the sarcoma. J Bone Joint Surg Am. and classification of chondrogenic
layout of this chapter7. 1980;62:1027–30. neoplasias of the skeleton –
Papp et al.’s immersion orthopaedic 4. NCCN. NCCN Clinical Practice Biochemistry and cell biology of
pathology article in J Bone Joint Surg Am is Guidelines in Oncology. Bone Cancer. chondrosarcoma and its variants.
also very useful as further reading for the V.1.2009. London: National Virchows Archiv. 2002;441:219–30.
exam21. Comprehensive Cancer Network; 2009. 9. Jeys L, Grimer R. The long-term risks of
1. NICE. Guidance on Improving Cancer infection and amputation with limb
Services: Improving Outcomes for People 5. NCCN. National Comprehensive Cancer
Network Clinical Practice Guidelines in salvage surgery using endoprostheses.
with Sarcoma. The Manual. London: Recent Results Cancer Res.
National Institute for Health and Oncology: Soft Tissue Sarcoma.
V.2.2008. London: National 2009;179:75–84.
Clinical Excellence; 2006.
Comprehensive Cancer Network; 2008. 10. Jeys LM, Kulkarni A, Grimer RJ, et al.
2. Enneking WF, Spanier SS, Malawer endoprosthetic reconstruction for the
6. NCIN. Bone Sarcomas: Incidence and
MM. The effect of the anatomic setting treatment of musculoskeletal tumors of
Survival Rates in England. London:
on the results of surgical procedures for
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the appendicular skeleton and pelvis. sarcomas of the extremities – postoperative radiotherapy in exrtemity
J Bone Joint Surg Am. 2008;90:1265–71. Prospective randomised evaluations of soft tissue sarcoma. Radiother Oncol.
11. Schuetze SM, Arbor A. Chemotherapy (1) limb-sparing surgery plus radiation 2005;75:48–53.
in the management of osteosarcoma therapy compared with amputation and
19. SMAC. Adjuvant chemotherapy for
and Ewing's sarcoma. J Nat Comp (2) the role of adjuvant chemotherapy.
localised resectable soft tissue sarcoma
Cancer Net. 2007;5:449–55. Ann Surg. 1982;196:305–15.
in adults. Cochrane Database Syst Rev.
12. BOA. Metastatic Bone Disease: A Guide 16. Yang JC, Chang AE, Baker AR, et al. 2000;Issue 4.
to Good Practice. London: British Randomised prospective study of the
20. Pervaiz N, Colterjohn N, Farrokhyar F,
Orthopaedic Association; 2001. benefit of adjuvant radiation therapy in
et al. A systematic meta-analysis of
the treatment of soft tissue sarcomas of
13. Mirels H. Metastatic disease in long randomised controlled trials of
the extremity. J Clinic Oncol.
bones. A proposed scoring system for adjuvant chemotherapy for
1998;16:197–203.
diagnosing impending pathological localized resectable soft-tissue
fractures. Clin Orthop Relat Res. 17. O’Sullivan B, Davis AM, Trucotte R, sarcoma. Cancer. 2008;113:573–81.
1989;249:256–64. et al. Preoperative verses postoperative
radiotherapy in soft-tissue sarcoma 21. Papp DF, Johnston JC, Carrino JA, et al.
14. Beckingsale TB, Gerrand CH. The Immersion education for orthopaedic
of the limbs: A randomised trial.
management of soft-tissue sarcomas. pathology: A review of the orthopaedic
Lancet. 2002;359:2235–41.
Orthop Trauma. 2009;23:240–47. in-training examination and American
15. Rosenberg SA, Tepper J, Glatstein E, 18. Davis AM, O’Sullivan B, Turcotte R, Board of Orthopaedic Surgery
et al. The treatment of soft-tissue et al. Late radiation morbidity following Certification. J Bone Joint Surg Am.
randomisation to preoperative verses 2010;92:152–60.
023
Section 5 The hand and upper limb oral
Hand oral core topics

Chapter
21 David R. Dickson and John W. K. Harrison
Hand surgery syllabus for the FRCS (Tr & Orth) Basal thumb osteoarthritis
Hand swellings
examination Carpal tunnel syndrome
‘The hand’ covers the hand and forearm and the structures Kienböck’s disease
anatomically contained within. Knowledge of the structural Median nerve injury
anatomy and the biomechanics of joint and tendon function
Perilunate dislocation
is required.
Radial nerve palsy
Ulnar collateral ligament injuries
Pathology
A working knowledge of the acute conditions and trauma of
the hand is required, i.e. injury to the bones, joints, tendons,
Basic science
nerves, skin and vessels of the hand, and infective processes. Brachial plexus
Knowledge of the non-acute congenital, degenerative,
Nerve conduction studies
inflammatory (rheumatoid) and neoplastic conditions as well
Extensor compartments of the wrist
as benign tumours, e.g. ganglions, is also required.
Flexor tendon sheath/vinculae/radial and ulnar bursae
Name muscles in deep flexor compartment of forearm
Training in operative hand surgery Ulnar nerve anatomy at wrist
For the purpose of the examination, the trainee should have
Seddon’s classification of nerve injury
gained experience in the operative management of:
Factors influencing outcome in nerve repair
The acutely injured hand
Fractures and dislocations, including scaphoid non-union
Nerve injuries
Children
Syndactyly
Tendon injuries and common tendon transfers
Camptodactyly
Skin grafts
Clinodactyly
Infections
In elective surgery, the candidate must have sound knowledge Congenital bands
of the procedures appropriate for carpal tunnel syndrome, Delta phalanx
trigger finger, Dupuytren’s contracture, benign tumours, Radial club hand
degenerative conditions of the thumb carpometacarpal joint Congenital absence of thumb
and wrist joints, and surgery of the rheumatoid hand.
Trauma
Intermediate cases Distal radius fractures
Brachial plexus injuries Scaphoid fracture/non-union/perilunate injuries
Peripheral nerve injuries Bennett’s fractures (name deforming forces)
Rheumatoid shoulder/hand and wrist Carpal instability
Compartment syndrome
Short cases Digital nerve injury
Fingertip injuries
Rheumatoid hand and wrist Finger amputations
Dupuytren’s disease Flexor tendon injuries: Repair, rehabilitation and late
Ulnar nerve injury (high vs low lesion) reconstruction
421
024
Section 5: The hand and upper limb oral
‘Mangled hand’ Physes

Pathoanatomy of MCP joint dislocation In the hand these are located distally in the second to fifth
UCL injuries – Stener lesion metacarpals, and proximally in the thumb metacarpal and all
phalanges.
Rheumatoid
Dropped fingers Flexor pulleys
Boutonnière/swan-neck Fingers
Elbow replacement
Facilitate sheath collapse and expansion during digital motion.
MCP joint replacements There are five annular pulleys: A2 and A4 pulleys originate
Rheumatoid thumb from bone and it is critical to preserve them to prevent bow-
stringing of the flexor tendons; A1, A3 and A5 originate from
Others the volar plates. A1 pulley is released in trigger finger.
Dupuytren’s disease: Associations, management of PIP The three cruciate pulleys are not critical for flexor func-
joint contracture, treatment options tion. C1 is distal to the A2 pulley over the proximal phalanx;
Drainage infection C2 and C3 are either side of the A4 pulley over the middle
Kienböck’s phalanx.
Thumb
Enchondromata
In the thumb there are two annular pulleys and one oblique
Tumours
pulley. The oblique pulley is most important. A1 overlies the
Tourniquets
MCP joint, attached to the volar plate. A2 overlies the IP joint,
attached to the head of PP. The oblique pulley overlies the
MCQ paper shaft of PP. The tendon of adductor pollicis attaches to the A1
Ganglions and oblique pulleys.
Trigger finger
Management principles for the rheumatoid hand Flexor sheaths
Causes of loss of extension in the rheumatoid finger The ulnar bursa can connect to the radial bursa through the
space of Parona – The space between the flexor tendons and
General guidance the pronator quadratus muscle – Causing a ‘horseshoe’
Generally the oral is very straightforward and consists of a abscess.
series of clinical photographs and radiographs of common
hand conditions that the average trainee would have no diffi- Vinculae
culty in recognising. There is a large amount of material but,
The vinculae are folds of mesotendon carrying the blood
again, a working knowledge of all subjects is sufficient. It is a
supply to both tendons from transverse branches of the digital
case of describing what you see, the diagnosis, differential
arteries. There is a short vinculum (vinculum brevis) and a
diagnosis and management options. Do not expect any
long vinculum (vinculum longus) to each FDP and FDS
encouragement or any clues as to how you are doing through-
tendon. Nutrition of the tendons is also derived from diffusion
out the oral.
through the synovial fluid.
It is a combined oral with paediatrics, with both orals last
15 minutes each. There are usually one or two paediatric hand
trauma questions thrown in at some stage from either the Anatomy of the intrinsic muscles
hands or paeds examiner. The intrinsic muscles have their origins and insertions within
Most trainees will not have done a hand job even for 6 the hand. These are the thenar muscle group, hypothenar
months. A practical, safe knowledge of hand surgery is muscle group, adductor pollicis, lumbricals and interossei.
required rather than textbook minutiae. Practising orals
before the exam with an experienced hand surgeon will help Lumbrical muscles (four)
greatly. The lumbrical muscles are the workhorse of the hand. They are
the only muscles to originate on a tendon (FDP) and insert on
Anatomy a tendon (radial lateral band of the extensor expansion). The
radial two lumbricals are innervated by the median nerve and
Bones the ulnar two lumbricals by the ulnar nerve. Action is MCP
There are 19 in the hand (plus 2 sesamoids), and 8 in the joint flexion and IP joint extension. Laceration of FDP distal to
wrist. the lumbrical origin leads to a ‘lumbrical plus’ finger.
024
Chapter 21: Hand oral core topics
Interosseous muscles (seven) Oblique retinacular ligament (ORL)

Four dorsal interossei abduct the index, middle and ring Passive extension of the DIP joint (tenodesis effect) – Bilateral
fingers away from the axis of the middle finger (Dorsal strong narrow bands that originate from the periosteum of the
ABducts, or DAB). Three palmar interossei adduct the index, PP and A2 pulley and insert into the extensor tendon at
ring and little fingers towards the axis of the middle finger the base of the DP. Active extension of the PIP joint tightens
(Palmar ADducts or PAD). The interossei flex the MCP joint the volarly placed ORL, leading to DIP joint extension.
and extend the PIP joint through the lateral bands. They arise
from the metacarpal bones. The dorsal interossei insert into Sagittal band
the lateral sides of the index and middle fingers and to the Connects the extensor tendon to the volar plate of the MCP
medial sides of the middle and ring fingers. The palmar inter- joint to extend the MCP joint. In hyperextension of the
ossei insert into the medial side of the index finger and to the MCP joint the IP joints fall into flexion because the extensor
lateral sides of the ring and little fingers. All are supplied by the tendon distal to the sagittal band becomes lax. In this position
ulnar nerve. An occasional variant is for the first dorsal inter- the IP joints can only be extended by the intrinsics.
osseous muscle to be supplied by the median nerve.
Boundaries of the anatomical snuffbox
Anatomy of the extrinsic muscles The ‘snuffbox’ is a hollow area distal to the radial styloid on the
The extrinsic extensor muscle bellies of the hand overlie the dorsal–radial aspect of the wrist.
dorsum of the forearm and their tendons pass over the dorsum Floor: Scaphoid
of the wrist to insert in the hand. Radial border: Extensor pollicis brevis (and abductor
pollicis longus)
Dorsal extensor compartments of the wrist (six) Ulnar border: Extensor pollicis longus
There are fibro-osseous tunnels through which the extensor Proximally: Radial styloid
tendons pass and are numbered from radial to ulnar. Distally: Base of thumb metacarpal
1. APL/EPB: Located on the radial surface of the radial The radial artery courses through the snuffbox on its way to
styloid. Chronic tenosynovitis here is known as de the dorsal first web space. The cephalic vein originates over the
Quervain’s disease. Both tendons are in separate synovial ASB.
sheaths
Cleland’s ligament (dorsal – Ceiling)
2. ECRL/ECRB: ECRL inserts on to the base of the second
metacarpal, and ECRB onto the base of the third. A fibrous ligament between the phalanges and the dermis
Intersection syndrome (skin) that is dorsal (posterior) to the neurovascular bundle.
3. EPL: Lister’s tubercle separates the second from the third These fibrous bands are located between the middle of the PP
compartment. Delayed rupture following distal radius and the DIP joint.
fractures Grayson’s ligament (volar – Ground)
4. EIP/EDC: Extensor tenosynovitis and ruptures. Contains A very fine membrane, which lies in front of the neurovascular
the posterior interosseous nerve
bundle. Originates from the anterior layer of the fibrous flexor
5. EDM: Double tendon. Floor is dorsal capsule of DRUJ. tendon sheath and inserts into the skin.
Vaughan–Jackson syndrome – Rupture in rheumatoid
arthritis FDS of the small finger
6. ECU: Lies over the head of the ulna. Tendonitis or Absent in 30% so remember that it may be absent in flexor
instability of ECU tendon injury of the little finger. Comparison with the oppos-
ite side is essential when evaluating for an FDS laceration in
Extensor tendons and hood the small finger.
The extensor tendon broadens before dividing into three slips
EDC of the small finger
over the dorsal surface of the proximal phalanx. The central
slip inserts into the base of the middle phalanx. The two lateral EDC may be absent in half of people in whom extension is
bands receive attachments from the lumbrical and interossei achieved by the EDM.
tendons to form a broad extensor expansion or hood, which
overlies the metacarpal head and the proximal part of the PP. Nail anatomy
Over the middle phalanx the lateral slips are held dorsally by The nail plate is supported by the nail bed. This consists of the
the triangular ligament and volarly by the transverse retina- germinal matrix (lunula is the visible portion) that produces
cular ligaments. Imbalance of the lateral bands results in a the nail, and the sterile matrix that produces keratin to thicken
swan-neck or boutonnière deformity. The transverse retinacu- the nail. The eponychium is the proximal nail fold and the
lar ligaments attach to the volar plate. paronychium is the lateral nail fold.
423
024
Blood supply of the hand up the contents of the carpal tunnel, which may lead
The hand has a generous blood supply. Eighty per cent is from into the boundaries of the tunnel
the ulnar artery.
Hand oral 2
Superficial palmar arch Similar to oral 1 with an interactive photograph of the back
Lies 2 cm distal to the deep arch. Surface anatomy is the distal of the wrist – Asked to identify labels to various anatomical
palmar crease. The superficial arch is the curved continuation structures
of the ulnar artery and is incomplete in 80% as there is no : State the relevant aspect of the wrist shown
anastomosis with the superficial palmar branch of the radial : Be systematic – E.g. if shown all the extensors state
artery. there are six compartments and then start to name
From its convexity a palmar digital artery passes to the them from one side to the other
ulnar side of the little finger and three common palmar digital
: Can conclude that this anatomy is important for a
dorsal approach to the wrist, which can lead the
arteries run distally to the web spaces between the fingers, examiner to the next question such as approach for
where each vessel divides into proper palmar digital arteries wrist arthrodesis
that supply adjacent fingers. The arteries lie superficial to the
nerves in the palm and deep to the nerves in the digits.
Hand oral 3
Deep palmar arch Shown a radiograph of a distal radius fracture that you’ve
been asked to plate on the volar surface
Surface anatomy is Kaplan’s line (from the hook of hamate to
Describe the technique, landmarks and structures at risk
the base of the first web space). The deep palmar arch is an : FCR approach
arterial arcade formed by the terminal branch (deep branch) of : Tendon is usually palpable and incision placed over it.
the radial artery anastomosing with the deep branch of the If not palpable the line is between the scaphoid
ulnar artery and is complete in 98%. Lies deep to the long tubercle and distal biceps tendon
flexor tendons and superficial to the interosseous muscles. : Care should be taken with the radial artery on the
From its concavity three palmar metacarpal arteries pass radial side and the median nerve ulnarwards
distally and join with the common palmar digital branches of : FPL retracted
the superficial arch. : Pronator quadratus elevated
: Brachioradialis can be released as it is a
deforming force
Radial artery What is the innervation of pronator quadratus?
The radial artery passes into the hand between the two heads of : Anterior interosseous nerve
the first dorsal interosseous muscle. Lying between the first Do you repair this muscle at the end?
dorsal interosseous and adductor pollicis muscle, it gives off : Benefit is to cover the plate and, thus, protect the
two branches. flexor tendons
The radialis indicis artery passes distally between the first
: Often the suture pulls through but worth a try. Just
beware the radial artery when trying to repair the
dorsal interosseous and adductor pollicis muscles to supply muscle
the radial side of the index finger What is the watershed line and what is the relevance of it?
The princeps pollicis artery passes distally along the : This is the ridge just distal to the pronator quadratus to
metacarpal bone of the thumb and divides into the two which the volar wrist capsule attaches
palmar digital branches of the thumb at the metacarpal : It is thought that using this as the distal limit to plate
head application will reduce the risk of flexor tendon
The main trunk of the radial artery passes into the palm attrition form the plate
between the oblique and transverse heads of adductor pollicis What is the shape of the dorsal surface of the radius and
what is the relevance when placing screws and checking
to form the deep palmar arch.
screw placement on a lateral radiograph?
: The dorsal surface of the radius is not flat, it is peaked
with Lister’s tubercle being the summit. This three-
Examination corner
dimensional structure is not appreciated on a lateral
Hand oral 1 radiograph and dorsal penetration can occur but,
Intraoperative photograph of the volar aspect of the wrist – unless the screw is longer than the peak of the distal
Asked to identify various anatomical structures radius, it can ‘appear’ OK
: State the relevant part of the wrist shown : The risk can be reduced by measuring for screw length
: Be systematic. If the carpal tunnel contents are shown without penetrating the dorsal surface, taking oblique
state the structures you see and state that these make views and also an axial view
024
If the patient also had carpal tunnel syndrome – How

In the forearm (anterior interosseous branch1)
would you decompress this – Separate incision or just FPL
extend the approach to the distal radius? What structure Radial half of FDP
do you need to take care of? PQ
: Safer to use two incisions – FCR approach for the distal
radius and standard approach for the carpal tunnel In the hand
: One incision risks damage to the palmar Motor – The ‘LOAF’ muscles of the thenar eminence
cutaneous branch which can result in painful neuroma
: Lateral two lumbricals
: Opponens pollicis
Anatomy of the median nerve : Abductor pollicis
: Flexor pollicis brevis
Nerve roots
Formed by the joining of the lateral and medial cords Sensory
of the brachial plexus in the axilla (C6, C7, C8, T1) Flexor surfaces and nails of the radial 3½ digits
The median nerve receives its sensory Skin thenar eminence supplied by the palmar
contribution predominantly from the lateral cord and the cutaneous branch, which is given off 5 cm above the
motor contribution predominantly from the medial cord wrist
Abnormal connections
Course Martin–Gruber (17%) – Median to ulnar nerve in
Lies lateral to the brachial artery in the arm, then crosses forearm
anteriorly to lie medial to the artery in the antecubital Riche–Cannieu (77%) – Deep branch ulnar to median
fossa, passing beneath the bicipital aponeurosis in hand
There are no branches before the elbow Clinically may present as ulnar nerve lesion but no intrinsic
It descends between the two heads of pronator teres and is deformity, or as severe carpal tunnel syndrome but with no
separated from the ulnar artery by the deep head of muscle weakness
pronator teres
Then passes beneath the fibrous arch of FDS in the
proximal third of the forearm
Carpal tunnel anatomy
Fibro-osseous tunnel formed by the concavity of the
About 5–6 cm distal to the elbow it gives off the anterior
anterior surface of the carpus and roofed over by the flexor
interosseous branch (motor to FPL, FDP index finger and
retinaculum
pronator quadratus)
Knowledge of the anatomy of the carpal tunnel is essential
In the forearm it descends between FDS and FDP roughly
to undertake carpal tunnel decompression
in the midline
It becomes superficial just above the wrist where it lies
between the tendons of FDS and FCR Boundaries of the carpal tunnel
Palmar cutaneous branch (sensory to thenar skin) arises Radial wall: Tubercle scaphoid, ridge of trapezium
5 cm proximal to the wrist joint, ulnar to FCR and passes Ulnar wall: Pisiform, hook of hamate
over the flexor retinaculum Floor: Carpus, proximal metacarpals
Main nerve passes deep to the flexor retinaculum, to the Roof: Flexor retinaculum
radial side of the tendons of FDS
The recurrent motor branch to thenar muscles arises at the
distal end of the carpal tunnel (see below)
Contents
The nerve median nerve finally ends by dividing FPL – The most radial structure
into medial and lateral branches to supply the radial Median nerve (just deep to the flexor retinaculum and
3½ digits lateral to FDS)
FDS – Lies on the profundus tendons arranged 2-by-2
(middle and ring lie superficial to index and little).
Branches Remember, 34 (third and fourth) is more than 25 (second
Near the elbow and fifth)
PT FDP – All together on a deeper plane (lie side-by-side on
FCR the floor of the carpal tunnel)
PL The FCR tendon lies in a separate fibro-osseous tunnel
FDS deep to the flexor retinaculum
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024
Flexor retinaculum 4. Nerve may be replaced by a branch from the radial or

ulnar nerve
Attachments
Pisiform and hamate on the ulnar side
Trapezium and the tuberosity of the scaphoid on the
Kaplan’s cardinal line
radial side A line drawn from the distal border of the abducted thumb
to the hook of hamate
There is also a deep slip, which is attached to the medial lip
of a groove on the trapezium The recurrent motor branch of the median nerve is
estimated by the point where the middle finger tip flexes
Functions onto Kaplan’s line
Prevents bowstringing of the long flexor tendons The deep palmar arch lies deep to Kaplan’s cardinal line
It gives partial insertion to some muscles (PL, FCU) The superficial palmar arch lies 2 cm distally, deep to the
It gives partial origin to some muscles (thenar and distal transverse palmar crease
hypothenar muscles)
Examination corner
Variations of the motor (recurrent) branch
Hand oral
of the median nerve Clinical photograph of a typical carpal tunnel scar with
A key surgical landmark and major surgical danger in wasting of the thenar eminence
carpal tunnel release This woman has had recent surgery to her hand. What do
Surface landmark is the intersection of the flexed middle you think she has had done? (settler question)
finger tip with Kaplan’s line Demonstrate the lines on the examiner’s hand that you
would make when deciding where to make your incision
There are several variations to the motor branch in the
palm, the three most common are • What are the contents of the carpal tunnel?
• As described in the text
1. Extraligamentous branch (50%) arises distal to the
• What is the distal extent of the incision?
transverse carpal ligament and recurrent to the thenar • In line with Kaplan’s line. The carpal tunnel is release
muscles. The nerve hooks radially and upwards to enter when I see the fat pad at the distal end of the retinacu-
the thenar muscle mass between the FPB and APB lum. I may need to enlarge the skin incision as necessary
muscles to ensure I have achieved this.
2. Subligamentous branch (30%) arises within the carpal • What is the proximal extent of the wound?
tunnel, emerging distal to the flexor retinaculum and • The flexor retinaculum should be released. Using a
recurrent to the thenar muscles McDonald I assess for any residual proximal to my
release and if need be continue the release more prox-
3. Transligamentous branch (20%) arises from the nerve
imally until the McDonald can easily be rotated.
within the carpal tunnel and pierces the flexor retinaculum
• If you need to extend the incision proximally across the
More rarely the motor branch can either originate from the wrist crease how would you do this?
ulnar side of the median nerve or lie on top of the flexor • Do not cross the wrist crease at 90° to it – This can cause
retinaculum a scar contracture which can affect function
NB. Patients with rare variations usually have a large • What are the variations in the path of the motor branch?
palmaris brevis muscle • As described in the text
• What would you tell the patient would happen with the
thenar wasting? How would you manage this?
Variants of the palmar cutaneous branch • Very unlikely to recover.
of the median nerve • Would not routinely address this at the same surgery. Most
people function well from a combination of other function-
The course of the palmar cutaneous branch of the median ing muscles. Can be addressed down the line with a transfer
nerve may vary in four important ways: • When would you get nerve conduction studies?
1. Normally the nerve is given off 5 cm proximal to the wrist • In cases where there is doubt about the diagnosis
and runs along the ulnar side of FCR before crossing the • Recurrence
flexor retinaculum. The nerve divides into two major • Failure to improve following decompression
branches, medial and lateral, whilst crossing the flexor • Negative carpal tunnel provocation test
retinaculum • Diabetic patient
• Neck symptoms
2. There are two distinct branches, which travel separately
• Interpret a set of nerve conduction studies (NCS)?
across the wrist • latency = demyelination
3. Within the carpal tunnel and penetrates flexor • amplitude = axonal loss
retinaculum
024
• What complications would you warn the patient of? Diagnosis

• Infection, bleeding, nerve damage, stiffness, swelling and No agreement on the gold standard for establishing the
CRPS diagnosis
• Scar sensitivity
• Pillar pain Relative importance of history, examination and NCS is
• If they have altered sensibility present all the time before unclear. Investigating studies have defined carpal
surgery this may not improve with surgery but the tunnel syndrome on either one or a combination of these
periods of increased tingling should settle. criteria
• When can the patient expect to return to work? Concern on relying on NCS is due to:
• Depends on the job
• Most office based jobs can return at about 2 weeks
:Test only being abnormal when the nerve compression
has caused structural damage to the nerve
• More manual workers may take 4 weeks
• When will pinch and grip strength return? : A number of patients having abnormal NCS but being
• Thumb pinch returns on average at 6 weeks. asymptomatic
• Grip strength returns on average at 12 weeks. In practice most clinicians rely on a combination of history
• How long can the scar sensitivity take to settle? and examination findings. NCS are not routinely
• Vast majority settle within 6 months. performed by most clinicians but reserved for:
• How would you investigate and manage a patient who
still had symptoms following surgery?
:
Good history but negative provocation tests
• Need to reassess :
Consideration of ‘double crush’ phenomenon
• Was the diagnosis correct? :
Failed carpal tunnel surgery
• Possible double-crush phenomenon :
Recurrent carpal tunnel syndrome following previous
• Incomplete release at the time of surgery. successful decompression,
Symptoms
:
Carpal tunnel syndrome2 Paraesthesia in radial 3½ digits
:
Worse at night
Incidence :
Weakness in the hand, dropping things
One per cent in the general population (14% in diabetics) :
Pain
:
40% bilateral involvement
Pathophysiology :
Male : Female ratio: 1 : 6
:
Not always classical
Believed to be related to pressure applied to the median
Examination
nerve within the carpal tunnel
Normal nerve conduction is disrupted by pressure on the :
Examine neck movements
myelin sheath of the nerve :
Swelling over volar aspect of the wrist
Severe compression may result in Wallerian degeneration :
Wasting of thenar muscles
of axonal fibres :
Sensation (light touch, two-point discrimination)
Visual inspection at the time of surgery often reveals :
Power (APB)
deformity of the nerve (‘hour-glass’ appearance) and evidence Provocative tests
of an inflammatory reaction woth oedema and hyperaemia :
Median nerve compression test (Durkin’s) – Apply
Any condition that decrease the space and, thus, increase direct pressure with your thumb over the nerve, with
pressure within the tunnel can result in carpal tunnel the patient’s elbow extended and wrist flexed 60° (86%
syndrome such as inflammatory arthropathies, flexor sensitivity, 83% specificity)
tenosynovitis, generalized oedema of pregnancy or : Tinel’s sign (74% sensitivity, 90% specificity)
haematoma from trauma : Phalen’s test (positive if signs <60 s) (61% sensitivity,
The vast majority of cases are idiopathic 83% specificity)
The acronym ICRAMPS helps you to remember the causes Nerve conduction studies (NCS):
of carpal tunnel syndrome
: Abnormal if:
: I – Idiopathic
: C – Colles’, Cushing’s – Sensory conduction is prolonged >3.5 ms
: R – Rheumatoid (demyelination)
: A – Acromegaly, amyloid – Increased distal motor latency >4.0 ms
: M – Myxoedema, mass, (diabetes) mellitus – Decreased amplitude (axonal loss)
: P – Pregnancy – Accurate 85–90%
: S – Sarcoidosis, systemic lupus erythematosus – False-negative rate 10–15%
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024
Differential diagnosis the ring finger, and distally to Kaplan’s line. It is not
: Cervical disc disease routinely recommended to cross proximal to the wrist crease
: Peripheral neuropathy – Alcohol, diabetes Some recommend extending your incision proximal to the
: Pronator syndrome (discussed below) distal wrist crease to make sure the fascia of the distal forearm
is released as this can cause compression of the nerve. Most
: Spinal cord lesions – Tumour, syrinx, MS
feel that this structure can be adequately decompressed with a
: Thoracic outlet syndrome
smaller incision using scissors and retractors to protect the
: Collagen vascular disorders median nerve. Still others feel that decompressing the
: Raynaud’s disease transverse carpal ligament is sufficient. However, you should
: CRPS not cross perpendicular to a flexion crease
Adjunctive surgical procedures – No demonstrable benefit of
Management additional synovectomy or internal neurolysis following
Non-operative carpal tunnel release and may lead to adhesions
Indicated in those with mild intermittent symptoms without
Endoscopic carpal tunnel release
neurological impairment, who have had symptoms <1 year,
and who have no muscle wasting. The classic indication is a Introduced to reduce the incidence of pillar pain but this
temporary, reversible carpal tunnel syndrome (pregnancy). has not been demonstrated
Patients with pure nocturnal symptoms may also benefit from Use either the Agee (one-incision) or Chow (two-incision)
a trial of non-operative treatment. technique. Steep learning curve with increased early
complication rate, including actual injury to the
Splintage in neutral (extension increases tunnel pressure)
median nerve
: Evidence it is more effective than no treatment for Pain less at 3 months compared to open release, but no
symptom relief and function for at least 3 months difference at 1 year3
: No evidence that full time splinting is better than
nocturnal splinting
NSAIDs have no clear evidence of benefit
Steroid injections
: 80% transient relief
: 20% symptom-free at 12 months
Ultrasound
: Evidence of benefit compared to placebo in 2 studies for
at least 6 months
Physiotherapy
:Not proven
Combination therapy
: A study comparing NSAIDs, splinting and hand
therapy vs surgery revealed better outcome at both
6 and 12 months
Surgical
Indicated in those with progressive persistent symptoms with
neurological defects.
Open carpal tunnel decompression

Ninety-five per cent of patients have good or excellent
results
Allows good visualisation of the median nerve and the
contents of the tunnel
The physiological state of the nerve can be assessed
Incision – A safe incision is offered (Figure 21.1):
Longitudinal from the distal wrist crease and just ulnar to Figure 21.1 Landmarks for open carpal tunnel decompression. I, Incision; H,
palmaris longus (found by opposing the thumb to the little hook of hamate; K, Kaplan’s line; black spot, motor branch; PI, palmaris longus;
finger and flexing the wrist), in line with the radial border of FCR, flexor carpi radialis
024
Complications of carpal tunnel release Positive NCS after 3–6 months

?Relief of symptoms after steroid injection into carpal tunnel
Infection: <1%
Tender scar: Owing to division of very fine terminal
branches of the palmar cutaneous nerve Pronator syndrome1
Haematoma: Major bleeding is rare if safe anatomical
landmarks are observed
Background
Compression of the median nerve in the elbow or forerarm
Dehiscence: Sutures removed too early
Results in altered sensation in the median nerve
Damage to nerves: Recurrent motor branch of the median
distribution and thenar eminence
nerve, palmar cutaneous branch median nerve, ulnar nerve
Much less common than carpal tunnel syndrome
Pillar pain: Pain felt when pushing down on the base of the
Reported in individuals who do repetitive upper extremity
hand following carpal tunnel release. Aetiology uncertain,
activity
possible because of gradual stretching of intercarpal
ligaments, which are no longer de-tensioned by the flexor
retinaculum. Others suggest that division of the flexor Sites of entrapment
retinaculum disturbs the alignment of the pisotriquetral Ligament of Struthers – 1% of population (supracondylar
joint, which is the source of pillar pain process)
Complex regional pain syndrome: Rare but always Bicipital aponeurosis (lacertus fibrosus)
mention in consent Origin of the pronator teres (abnormal anatomy, tight
Weakness of pinch: Returns to preoperative levels in a fibrous bands)
mean of 6 weeks Proximal arch of FDS
Weakness of grip: Returns to preoperative levels in mean
of 3 months Clinical
Bowstringing of flexor tendons: More a theoretical
Pain or ache in the volar proximal forearm and tender to
complication than a practical one
palpation
Paraesthesia of the median nerve-innervated digits and
Failed carpal tunnel release thenar eminence (palmar cutaneous branch – Not involved
Recurrent or persistent symptoms in up to 20% in carpal tunnel syndrome)
Need to consider whether the persistence of symptoms os Usually no night symptoms of paraesthesiae or tingling
due to inadequate release, wrong diagnosis, ‘double crush’ Weakness of the forearm or clumsiness of the hand.
phenomenon or due to the severity of the nerve Phalen’s test generally negative as the site of compression is
compression prior to surgery proximal to the transverse carpal ligament. Tinel’s test is
Patients that had altered sensibility all the time before negative at the wrist but may be positive at the proximal
surgery should be aware that this may not imrpove anterior aspect of the forearm
following surgery or may take several months to do so
Persistence of night-time symptoms should raise the Provocative tests
suspicion of incomplete release Resisted elbow flexion with forearm supination (bicipital
Consider other differential diagnoses including cervical aponeurosis)
radiculopathy at C5/6, compression of the upper trunk Resisted forearm pronation with elbow extended (two
brachial plexus and proximal median nerve compression, heads of pronator teres)
double crush phenomenon relates to more than one site of Isolated long finger PIP joint flexion (FDS origin)
compression that, if in isolation, would not cause
symptoms, but together cause symptoms. Perform NCS
after at least 3 months Investigations
Symptoms unchanged: Wrong diagnosis, inadequate NCS/EMGs usually negative
decompression, postoperative fibrosis, double crush Radiographs of the distal humerus may show the (rare)
phenomenon supracondylar process
New symptoms: Normal structures damaged at surgery,
new diagnosis Management
Re-exploration is indicated if: Usually responds to non-operative treatment –
Marked symptoms Modification of activities, NSAIDs, heat and massage
Other causes of symptoms ruled out If not settled after 6–12 months, surgical decompression of
Positive provocative tests all potential sites of compression
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024
Decompression Management
: 10 cm lazy ‘S’ incsion from the antecubital fossa Non-operative management
heading distally (extended proximally if a ligament of
Elbow splinting in 90° of flexion, NSAIDs, etc
Struthers is found)
Many symptoms and signs will gradually resolve in time
: Divide bicipital aponeurosis
: Identify the superficial head of pronator teres which Surgical decompression
should be ‘step cut’ to lenghten the tendon and, thus, This is indicated following the failure of conservative
relieve any compression treatment for 6 months
: Deep head of pronator teres is released as it arches Surgery involves complete exposure of the AIN from its
around the median nerve origin from the median nerve – Approach as for pronator
: The tendinous portion of the FDS arch is divided syndrome
Results are unpredictable
Anterior interosseous syndrome4

Examination corner
Background
Hand oral: clinical photograph of the OK sign – Patient making a
A pure motor entrapment. There is no sensory disturbance square instead of a circle
AIN supplies FDP to index and middle fingers, FPL and PQ Spot diagnosis (Kiloh–Nevin sign)
• How would you exclude an FPL rupture?
Tests • Tenodsis test
Direct pressure over the nerve may elicit symptoms (Tinel’s • USS
sign negative) AIN-innervated muscles
Symptoms occur acutely with sudden onset of dull non- : FPL, FDP index ± middle and pronator quadratus
specific pain in the proximal third of the volar forearm
• What are the sites of compression?
Weakness of flexion at the DIP joint of the index finger and • Deep head of the pronator teres muscle (most common
IP joint of the thumb (OK sign) site of compression)
The middle finger profundus may have some weakness but • FDS arcade
usually has some function because of cross-over • Enlarged bicipital bursa
innervation from the ulnar nerve • Gantzer’s muscle (accessory head FPL).
Mild weakness of pronation • Management?
• Splints and non-operative for 6 months
‘OK’ sign – Tip-to-tip pinch. Tests FDP to the index finger
• Consider decompression at 6 months.
and FPL. If patient makes a square instead of a circle this is
called the Kiloh–Nevin sign
To isolate PQ – Test resisted pronation with the elbow
maximally flexed (elbow flexion eliminates pronator teres) Anatomy of the ulnar nerve
Nerve roots
Differential diagnosis The nerve arises from the medial cord of the brachial plexus
Parsonage–Turner syndrome (bilateral AIN syndrome – (C8, T1).
Viral brachial neuritis, motor loss preceded by intense pain
in the shoulder region) Course
Mannerfelt–Norman syndrome (FPL rupture) Travels medial to the brachial artery in the upper arm
Passes through the medial intermuscular septum at
Sites of constriction the midpoint of the arm to enter the posterior
compartment
Deep head of the pronator teres muscle (most common site
Through the arcade of Struthers (band of fascia from
of compression)
the medial head of triceps to the medial intermuscular
FDS arcade septum) approximately 8 cm proximal to the medial
Enlarged bicipital bursa epicondyle
Gantzer’s muscle (accessory head FPL) Passes posterior to the axis of the elbow joint between the
medial epocondyle and olecranon in the cubital tunnel
Investigations Enters the forearm between the humeral and ulna heads
NCS usually unhelpful of FCU
024
Passes distally on the medial side of the forearm on FDP • What structure do you need to look out for and protect
and deep to FCU during the approach to the cubital tunnel?
Gives off the dorsal cutaneous branch 5 cm proximal to • Antebrachial cutaneous nerve.
the wrist • How would you address the nerve if it subluxed?
At the wrist lies between FCU tendon and ulnar artery • Transpose.
(ANT – Artery–nerve–tendon) • What functional problems do the patients have and
Passes through Guyon’s canal between the pisiform and the what tendon transfers could you use to address these?
hook of hamate and divides into superficial and deep • Depends on the level of compression.
• Discuss with the patient on the functional problems.
branches at the distal end
• See the tendon transfers section later.
Superficial branch supplies palmaris brevis and is sensory
to the ulnar 1½ digits
Deep (motor) branch passes ulnar to the hook of hamate
and then deep between the heads of origin of flexor and
Ulnar nerve compression
abductor digiti minimi Aim to diagnose whether the patient has a high or a low lesion.
Cubital tunnel syndrome is far more common (95%).
Branches Symptoms
Motor
Paraesthesia of the ulnar 1½ digits ( and ulnar
FCU dorsal aspect of the hand if the lesion is proximal to
FDP to little and ring fingers the wrist)
All small muscles of the hand except LOAF (see Anatomy Difficulty in fine motor activities
of the median nerve above)
Weakness of pinch grip (adductor pollicis)
Sensory
Ulnar 1½ digits Signs
Medial skin palm Little finger escape (Wartenberg’s sign) – Abduction of the
extended little finger in the line of pull of EDM owing to
weakness of the third palmar interosseous muscle
Examination corner Ulnar claw hand
Hand oral Wasting of the small muscles of the hand (hypothenar
eminence, metacarpal guttering, first dorsal interosseous)
• Describe the course of the ulnar nerve?
• As described above. Wasting of the ulnar border of the forearm (FDP and FCU)
• Explain the ulnar paradox? Decreased sensation in the ulnar 1½ digits ± dorso-
• Normally you would expect a higher nerve lesion to ulnar hand
create greater deformity. The opposite is true with the Positive Tinel’s test behind the medial epicondyle of
ulna nerve. In both a high and low ulnar nerve lesion the the elbow
intrinsics are lost. In the low ulnar nerve lesion the long Weakness of the interossei and ulnar two lumbrical
flexors and extensors are not adjusted by the intrinsics muscles
and so a claw appears. In a high ulnar nerve the long
flexors are also lost so the fingers are less clawed. Positive Froment’s test – FPL (anterior interosseous nerve)
• How would you differentiate between an ulna or T1 compensating for weakness of adductor pollicis; see
lesion? Figure 21.2)
• Sensory loss in T1 distribution Jeanne’s sign – Hyperextension of the thumb MP joint
• Motor loss will affect the thenar eminence too. (involvement of FPB)
• What are the sites of compression at the elbow? Weakness of FDP of little and ring fingers (Pollock’s test)
• See text. Positive elbow flexion test – Maximally flexing the elbow
• What technique you will use and why, i.e. simple decom-
produces pain and paraesthesiae in the ulnar nerve
pression, medial epiconylectomy or transposition?
distribution within 60 seconds
• There is currently no conclusive evidence for one treat-
ment over another.
• Proponents of the transposition site the traction elem-
ent of injury to the nerve on elbow flexion.
Ulnar paradox
• Certainly if the nerve is unstable (i.e. it flicks over the The expectation with a nerve lesion is that a more proximal
epicondyle on elbow flexion) the nerve should be lesion would result in a greater deformity. However, there
transposed. is less clawing of the hand with the more proximal the
nerve lesion
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024
Other causes of compression

Bony abnormalities: Osteophytes, cubitus valgus
Anconeus epitrochlearis muscle (accessory muscle):
Vestigial muscle originating from the medial border of the
olecranon and inserting into the medial epicondyle, and
crossing over the cubital tunnel. It is an uncommon cause of
ulnar nerve compression at the elbow, which may be bilateral
Constricting fascial bands
Tumours, ganglions
Scarring
Recurrent subluxation of nerve around medial
epicondyle
Figure 21.2 Froment’s test. The patient is on the left. Notice how on he can Suspected cubital tunnel syndrome may be mimicked by other
hold the paper with thumb adduction on the right hand (ulna nerve) but needs
to use thumb IPJ flexion (AIN) on the left hand. (Picture Courtesy of
disorders, including:
©DonaldSammut 2014) Cervical disc disease
Spinal tumours
Thoracic outlet syndrome
In a distal lesion only the intrinsics are weak and so the
stronger pull of the flexors overpowers the extensors Apical lung tumour
resulting in a claw hand Post-radiotherapy brachial plexopathy
In a more proximal lesion the flexors are also weakened,
thus, reducing the amount of flexion at the IP joints of the Oral question
little and ring fingers by leaving the extensors unopposed • How do you differentiate a T1 nerve root lesion from an
and so the hand appears less clawed ulnar nerve palsy?
• A patient with a T1 root lesion may have a Horner’s
Cubital tunnel syndrome5 syndrome, paraesthesia over the medial aspect of the
forearm and weakness of all small muscles of the hand with
Second most common compression neuropathy after clawing of all four fingers.
carpal tunnel syndrome
Chronic compression of the ulnar nerve may occur as a
result of ischaemia or mechanical compression by repeated Management
elbow flexion, direct compression or post-traumatic Conservative management
scarring This should be the first step in treating patients in the
Subluxation of the nerve may also add to the direct trauma absence of severe continuous symptoms with clinical signs
to the nerve of sensory loss or muscle weakness
The size of the cubital tunnel decreases with elbow Patients with mild, intermittent symptoms should be
flexion educated to avoid direct pressure to the nerve, use elbow
Both tunnel and intraneural pressure increases with elbow pads and modify activities to prevent prolonged periods of
flexion elbow flexion
Night splints to hold the elbow in 40–50° of flexion (studies
have shown this position to thave the lowest intraneural
Sites of entrapment pressures)
1. Medial intermuscular septum Conservative treatment may relieve symptoms of ulnar
2. Arcade of Struthers – A thick fascial structure arising nerve dysfunction at the elbow in as many as 50% of
from the medial head of triceps to the medial patients
intermuscular septum. It arises 8–10 cm prixmal to the Corticosteroid injections at the elbow are best avoided
medial epicondyle because of the high incidence of fat necrosis
3. Osborne’s ligament – A fibrous aponeurotic arch
(Osborne’s ligament/cubital tunnel retinaculum) Surgery
4. Fibrous arch connecting the two heads of FCU Indicated following failure of non-operative measures or clin-
5. Between the two heads of FCU (flexor carpi ulnaris ical evidence of sensory and/or motor loss or severe neur-
aponeurosis) opathy on NCS.
024
Operations used include: of anterior transposition, most commonly utilizing a submus-

1. Simple decompression (release of the cubital tunnel cular or intramuscular technique. Success in improving symp-
retinaculum) toms and function is reported in as many as three out of four
2. Decompression with medial epicondylectomy: patients.
Theoretical advantage of a more extensive decompression
than simple release without the disturbance in blood Ulnar tunnel syndrome
supply of the nerve. It is also thought to help negate the This is caused by ulnar nerve compression in Guyon’s canal. It
traction forces with elbow flexion. Concerns with this is much less common than entrapment of the nerve at the
technique are medail elbow tenderness (up to 70%) and elbow. Pain is usually less significant when compared to ulnar
valgus instability (due to damage to the MCL origin). These nerve compression at the elbow or carpal tunnel syndrome.
concerns have been reduced by using a partial
epicondylectomy (5–7 mm only)
3. Anterior transposition of the ulnar nerve, which may be to
Signs
Local tenderness, Tinel’s test, Phalen’s sign, severe ulnar
the subcutaneous, submuscular or intramuscular positions.
clawing, weakness, atrophy, paraesthesia of the ulnar
Anterior transposition risks devascularization of the nerve.
1½ digits (Figure 21.3)
It is best indicated when either:
Dorso-ulnar sensory branch spared
A bony deformity is present in the groove behind the
medial epicondyle, or
The nerve exhibits a tendency to sublux or dislocate
Anatomy of Guyon’s canal
with elbow flexion and extension Roof: Volar carpal ligament
Transposition of the ulnar nerve can be to: Ulnar wall: Pisiform
Radial distal wall: Hook of hamate and ADM
The subcutaneous tissues above the fascia of the flexor
pronator group Floor: Transverse carpal ligament and pisohamate ligament
The ulnar nerve and artery lie beneath the volar carpal liga-
Within the musculature of the flexor pronator group itself
with the fascia repaired ment on top of the transverse carpal ligament in Guyon’s
canal.
Beneath the flexor pronator group with the origin repaired
to the medial epicondyle
There is currently no evidence that one surgical technique is Causes of compression
superior to any other regardless of the subjective clinical or The causes of compression are numerous and include:
objective nerve conduction assessments preoperatively. In Typically ganglion or lipoma
most straightforward cases there is very little difference in Tumours
outcome whether the nerve is treated by simple decompres- Thrombosis/pseudoaneurysm of the ulnar artery
sion, medial epicondylectomy, subcutaneous transposition or Pisiform instability
submuscular transposition. A satisfactory outcome is achieved Pisotriquetral arthritis
in approximately 80% of patients using any of these techniques
and function generally returns within 6 months.
‘There are several surgical options available to treat this condition,
my preference would be . . . because . . .’
The nerve is safely found proximal to the cubital tunnel and
decompressed distally into FCU.
Complications from surgery

Infection
Scar tenderness
Neuromas (medial antebrachial cutaneous nerve)
Failure to relieve symptoms following decompression
owing to either the presence of severe intraneural fibrosis
or inadequate decompression
Disruption of blood supply to the nerve
Irritation of superficially placed nerve
Following the failure of a previous decompression of the ulnar
nerve at the elbow, treatment generally consists of some form Figure 21.3 Ulnar nerve palsy
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Fractures distal to the radius/ulnar, hook of hamate, Radial nerve compression

pisiform
Palmaris brevis hypertrophy Anatomy
Muscle anomalies Arises from the posterior cord of the brachial plexus
(C5, 6, 7, 8)
Symptoms Passes through the triangular space to enter the spiral
Symptoms may be pure motor, sensory or mixed based on the groove where it lies on the medial head of triceps
location of compression within the tunnel. The tunnel is Pierces lateral intermuscular septum ~7 cm proximal to
divided into three zones. lateral epicondyle
Passes deep to the mobile wad in the radial tunnel, giving
Zone 1 off a superficial branch
Area proximal to the bifurcation of the nerve. Combined Becomes the posterior interosseous nerve (PIN) as it passes
motor and sensory symptoms. deep to the superficial head of supinator
Zone 2
Surrounds the deep motor branch and has pure motor symp-
Sites of entrapment
toms only. Ganglions and hook of hamate fracture are the Axilla (Saturday night palsy)
most likely aetiology in zones 1 and 2. Humeral shaft fracture – It was thought that a radial
nerve palsy has a higher incidence with a Holstein–Lewis
Zone 3 fracture (junction of middle and distal third humerus),
Surrounds the superficial sensory branch of the ulnar nerve but a meta-analysis6 has shown that it is more likely with
and has sensory symptoms only. Thrombosis or aneurysm of a midshaft fracture. This paper showed an overall incidence
the ulnar artery is the most likely aetiology in zone 3. Allen’s of radial nerve palsy of 11.8% with a humeral fracture,
test and Doppler studies are useful in making the diagnosis. and 88% recover
Examination corner
Cubital tunnel syndrome
Cervical disc disease Hand oral
Thoracic outlet syndrome A patient demonstrates a wrist and finger drop following a
Motor neurone disease (motor signs only) humeral shaft ORIF
• How will you manage this patient intially?
Management • If a posterior approach was used and the nerve has been
clearly seen at surgery and is known to be intact, this is
The key to management is identifying the aetiology: most likely to be a neuropraxia. In this case I would
NCS manage the patient non-operatively with a wrist exten-
MRI for ganglions sion splint.
CT for hook of hamate fractures • When would you re-explore the nerve?
Doppler US for ulnar artery thrombosis • If the nerve had not been clearly seen or any evidence of
a haematoma.
Conservative • If so, what would you do if the plate was sat on top of
the nerve?
Wrist splinting • I would remove the plate to release the nerve, re-fix the
Avoidance of repetitive trauma fracture and discuss the patient with a peripheral nerve
surgeon. This section of the nerve will probably need
Surgical excision and then repair, probably by grafting.
Decompression of both motor and sensory branches ± • If not, at what stage will you get nerve conduction
excision of the pisiform/hook of hamate studies and EMGs?
• Four to six weeks should show evidence of
Release of the volar carpal ligament, isolating the ulnar
reinnervation.
nerve proximal to the wrist initially with a longitudinal
• What test can you perform in the clinic to check for
incision radial to FCU
reinnervation?
Occasionally patients are seen who have carpal tunnel and • Advancing Tinel’s.
Guyon’s canal compression syndrome simultaneously. The • What muscle will be the first to re-innervate?
volume of Guyon’s canal increases after carpal tunnel • What are the tendon transfers for this patient?
release, and ulnar compressive symptoms improve in • Pronator teres for wrist extension
approximately one-third of patients following carpal tunnel • Palmaris Longus for thumb extension
release alone • FCR for finger extension.
024
Posterior interosseous nerve compression Because of the close proximity of the nerve to the lateral
epicondyle, the condition can be difficult to differentiate
Introduction from a ‘resistant’ tennis elbow (coexists in 5% of patients)
Pain at the lateral elbow
Weakness of wrist extension with radial drift (ECRL Anatomy of the radial tunnel
innervated higher than PIN take-off) Medial: Biceps tendon and brachialis
No sensory loss Lateral: Brachioradialis, ECRL and ECRB
Roof: Brachioradialis
Clinical features Floor: Radiocapitellar joint capsule and supinator muscle
Onset often insidious
Dull aching of the proximal forearm Clinical features
Difficulty extending fingers and thumb History
Wrist extension is still possible (ECRL not affected) but it is Deep-seated dull aching/pain in the extensor muscle mass,
weak plus there is an element of radial deviation (ERCB) often radiating to the wrist
Able to extend the IP joints due to interossei
Examination
PIN innervates nine muscles 1. Localized tenderness directly over the PIN distal to the
ECRB, supinator, EIP, ECU, EDC, EDM, APL, EPB, EPL lateral epicondyle
2. Middle finger extension test – Each finger is tested under
Sites of compression/entrapment resisted extension. Testing the middle finger (firm pressure
over the dorsum of the PP) increases the pain because the
Thickened fascia at radiocapitellar joint ECRB inserts into the base of the third metacarpal. The test is
Radial artery recurrent leash of Henry positive if it produces pain at the edge of the ECRB in the
Edge of ECRB proximal forearm. It is performed with the elbow and middle
Arcade of Frohse (tendinous proximal border of supinator) finger completely extended and the wrist in neutral position
Distal edge of Supinator 3. Resisted active supination test – The radial tunnel begins
at the radiocapitellar joint and extends to the end of the
Unusual causes supinator muscle. In radial tunnel syndrome the maximal
Parsonage–Turner syndrome tenderness is distal to the radial head in a line from the
Chronic radial head dislocation lateral epicondyle through the radial head to a point 2–3
cm more distal over the radial tunnel
Fracture of the radial head or neck
Synovitis of the radiocapitellar joint
Mass lesion (lipoma, ganglion) at the elbow Causes
As for PIN syndrome but not usually any mass lesions:
Differential diagnosis 1. Fibrous bands tether nerve to the radial humeral capsule
C7 radiculopathy 2. Radial Recurrent leash of vessels (the leash of Henry)
Lateral epicondylitis 3. Fibrous medial edge along ECRB
4. Fibrous Arcade of Frohse (proximal superficial edge of
Management supinator)
5. Supinator (distal border)
Conservative initially as many patients will spontaneously
improve
Avoidance of aggravating activities Investigations
NSAIDs Diagnostic injection of local anaesthetic into the radial
Full surgical decompression of all potential compression tunnel
sites if no improvement after prolonged non-operative NCS not particularly helpful, as they are usually normal,
management which is in contrast to the PIN compression syndrome
Radial tunnel syndrome Management

Introduction Non-operative
This is a pain syndrome and a clinical diagosis Long non-operative approach warranted
There is no motor or sensory dysfunction Activity modification
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024
Temporary splinting Surgery

NSAIDs Should only considered in patients with continual
troubling symptoms following a prolonged period of
Surgical non-operative management
Operative release is often disappointing, with only 50% Involves exploration and release of constricting tissue
satisfactory results The nerve is susceptible to damage and neuroma formation
Coincidental undiagnosed tennis elbow can lead to failure and a very careful release with a ‘no touch technique’ is
of radial tunnel decompression required
Results of surgical exploration are unpredictable
Wartenberg’s syndrome (cheiralgia
paraesthetica) Examination corner
Uncommon condition
Short case 1
Originally described in 5 patients by Wartenberg in 1932
Lipoma in the forearm causing pressure neuritis of the
Radial sensory nerve is superficial in the distal superficial radial nerve
forearm which renders it suscpetible to external Clinical findings: Numb over the dorsum of index finger
compression and first web space
Neuritis/compression neuropathy of the superficial sensory
branch of the radial nerve
Dupuytren’s disease7–14
Causes This is an absolutely must-learn topic for both the clinical
Typically it is due to external compression from watches or short cases and hands oral.
jewellery
In pronation the nerve can be compressed between the Epidemiology
tendinous insertions of brachioradialis and ECRL A benign fibromatosis of the palmar and digital fascia
The nerve undergoes traction when the wrist is moved It is thought to be inherited through an autosomal
from radial extension to ulnar flexion dominant pattern with variable penetrance, though this is
Anomalous fascial bands unproven
Thrombosis of the radial recurrent vessels Greater than 25% of men of Celtic origin over 60 years of
Haemorrhage in the proximal forearm age have evidence of Dupuytren’s disease
The male : female reported ratios vary from between 4 : 1
Clinical features and 10 : 1.
Burning, numbness or pain in the distribution of the Those of oriental origin and diabetics tend to have palmar
superficial radial nerve (outer aspect of the distal forearm) disease but not joint contracture.
Tenderness along the course of the nerve proximal to There is no reported predilection for side or dominance.
the wrist Unilateral disease is more commonly a sporadic
The most useful sign is a positive Tinel’s test directly over finding without a family history and is usually less
the nerve as it exits from beneath brachioradialis severe.
Dellon’s sign – Active forceful pronation of the forearm In women, Dupuytren’s disease is typically seen later and is
and ulnar deviation of the wrist with the elbow extended by usually less severe.
the side for 60 seconds may provoke symptoms of
numbness or tingling in the territory of the sensory branch Cellular pathology and pathophysiology
Classically described in two forms: Nodules and cords
Management Nodules
Conservative :
Palpable subcutaneous lumps that may be fixed to the
Remove watches, jewellery or any garment compressing the skin and/or palmar fascia
region : Dense hypercellular and hypervascular
NSAIDs Cords
Wrist splint : Highly organized parallel collagen fibre structures
Steroid injection : Relatively hypocellular
Approximately 50% of patients respond to conservative : Increased cellularity is associated with higher
treatment recurrence rates
024
:Predominantly type III collagen (in contrast to the type – Abductor digiti minimi confluence
I in normal fascia)
Nodules are commonly found throughout cords
: Central palmar aponeurosis (the most affected part in
Dupuytren’s disease) is subdivided into three layers:
Trauma, ischaemia and microvascular angiopathy are
Longitudinal, vertical and transverse
thought to play key roles in the development of the disease
There are two main theories on the mechanism of – Longitudinally this appears as a triangular structure
pathological change that fans out distally into the pretendinous bands.
1. Intrinsic theory – Metaplasia of the existing fascia The pretendinous bands bifurcate and have three
2. Extrinsic theory – A subdermal origin for the diseased distinct layers of insertion
tissue that attaches itself to and grows on underlying Superficially – Into the dermis

fascial bands
Middle layer – Wraps around the metacarpal
The myofibroblast is the key cell and contains actin, head by twisting and travelling adjacent to the
allowing active contraction. These cells produce MCP joint capsule to form the spiral band. This
fibronectin, to link to other myofibroblasts, and increased continues deep to the NV bundle and emerges
amounts of type III collagen distally as the lateral digital sheet
Oxygen free radicals that occur in hypoxic tissue are Deep – Into the flexor mechanism
thought to play a role via fibroblast stimulation
– Vertical layer consists of Grapow fibres and the
Cytokines (TGF-β, platelet-derived growth factor, septa of Legueu and Juvara
fibroblast growth factor) are also probably involved,
and stimulate transformation of fibroblasts into Grapow fibres anchor the dermis to the palmar
myofibroblasts, resulting in fibrous hyperplasia of the aponeurosis
palmar fascia Eight vertical septa of Legueu and Juvara create
There are three stages described by Luck seven fibro-osseous compartments deep to the
1. Proliferative: Large myofibroblasts, very vascular, palmar fascia
minimal extracellular matrix, random cell proliferation Four compartments each containing the paired
2. Involutional: Dense myofibroblast network, increased tendons to each finger
amounts of type III collagen fibres compared to type I Three compartments containing the NV bundles
3. Residual: Myofibroblasts disappear and are replaced by and associated lumbrical
fibrocytes – Transverse fibres consist of the superficial
transverse ligament (Skoog’s ligament) and the
more distal natatory ligament
Anatomy11 : Digital
Dorsal skin is loosely attached where as the palmar skin is
firmly attached to the underlying fascial tissue and – Neurovascular bundles are surrounded by four
skeleton. An understanding of the normal fascia is crucial structures
to managing this disease Lateral digital sheet located on both radial and
Palmar fascia consists of radial, ulnar and central palmar ulnar sides of the digit is a continuation of the
aponeuroses spiral band and natatory ligament
: Radial aponeurosis (least commonly affected in Grayson ligament volarwards
Dupuytren’s disease) is subdivided Cleland ligament dorsally
Retrovascular fascia medially
– Thenar fascia
– Pretendinous band of the thumb The bands are normal facial structures but are referred to
– Proximal commissural ligament (thenar extension as cords when they become diseased
of the transverse ligament of the palmar A spiral cord (Figure 21.4) is one which entwines the
aponeurosis) neurovascular bundle pulling it towards the midline where
– Distal commissural ligaemtn (thenar extension of it can be easily injured by the ill-prepared surgeon. It
the natatory ligament) occurs when several structures are involved including
: Ulnar aponeurosis is subdivided

: Pretendinous band
: Spiral band
– Pretendinous band to the little finger : Lateral digital sheet
– Hypothenar fascia : Grayson’s ligament
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024
however, describe pain in some nodules which are thought

to be in the proliferative phase
A progressive digital deformity as a result of cord
formation
Difficulty in undertaking activities of daily living
Decreased manual dexterity
History
Hand dominance
Family history
Rate of progression
Diabetes
Epilepsy
Alcohol
Foot/penis involvement
Smoking
Trauma
Previous treatment
Assessing the impact of functional difficulty
Ascertain the expectations of treatment
Figure 21.4 Spiral cord
Examination
Risk factors for Dupuytren’s disease Previous scars
Positive family history Skin pits
Northern European heritage Digits involved and cord type
Male MCP angle (measure with PIP joint fully flexed as cord can
Alcohol excess cross both joints)
Diabetes PIP angle (measure with MCP joint fully flexed)
Chronic lung disease Garrod’s pads over the dorsal PIP joint
Smoking Sensation
AIDS Digital Allen’s test
Epilepsy (this is disputed and may be related to the Mention Ledderhose’s and Peyronie’s
medication) The combination of PIP joint in a fixed flexion deformity
Trauma (in a genetically suscpetible individual) with the MCP joint in flexion signifies a severe deformity
and a poor prognosis
Dupuytren’s diathesis Indications for treatment
This is an aggressive form of the disease and should be
considered in patients presenting with Classically the Hueston’s tabletop test
Early onset disease :
Involves placing the hand and fingers prone on a tabletop
Involvement of the radial side of the hand :
The test is positive when the hand will not go flat
Both hands :
Rarely alters management decisions, but is of value as a
screening test for general practitioners to identify those
Ectopic disease
patients requiring referral
– Ledderhose’s disease – Plantar fibromatosis Consideration of treatment should be given when
– Peyronie’s disease – Penis :
MCP joint contracture >30°
– Garrod’s pads – Nodules over the dorsal surface of the :
PIP joint contracture >15°
PIP joints :
First web space contracture
Remember
Symptoms : A severe MCP joint contracture will correct with
This is not a painful condition and other pathology should excision of the cord as the collateral ligaments are not
be considered if pain is a signifcant feature. Patients can, in a shortened position
024
: However, a PIP joint contracture leads to a stiff joint as Limited fasciectomy

the collateral ligaments and volar plate tighten This is the most widely performed surgical technique. The
Excision of an early nodule may cause a flare-type reaction, digital neurovascular bundles are identified proximally and
leading to an early return of the disease traced distally
Only the longitudinal contractile cords and nodules that
Informed consent are responsible for a joint contracture are excised
Aims – Excision of the diseased tissue to restore full Moerman’s described a segmental fasciectomy9
movement. The operation is not curative
Complete fasciectomy
General/regional anaesthetic
McIndoe popularized this technique using a transverse
Complications
palmar incision to excise the entire palmar fascia
: Recurrence rate 30–50% at 10 years8. Not all require The procedure has now been abandoned as it is impossible
further surgery in practical terms to excise the entire palmar fascia, and
: Incomplete correction of PIP joint contracture attempting to do so does not necessarily prevent recurrence
: Wound healing delay Secondly, the extensive dissection is a major assault on the
: Temporary or permanent digital nerve impairment hand, resulting in swelling, joint stiffness, haematoma
(1.5%) formation and, possibly, skin necrosis
: Splinting regimen postoperative (night splints up to
6 months) Dermofasciectomy
: Cold intolerance This is indicated for recurrent disease with skin
: Amputation involvement and occasionally in the primary management
of a digit in a young diathesis patients
Involves excision of overlying skin and diseased tissue
Treatment options Proponents argue that diseased tissue is not isolated to the
cord but involves the skin, which if left behind may cause
Collagenase injections13,14 recurrence
Currently licensed for use in Dupuytren’s disease with a The defect is replaced with a full-thickness skin graft from
palpable cord the forearm or groin (hair-free)
Consists of two different collagenase enzymes (AUX-1 and The skin graft acts as a ‘firebreak’ to reduce recurrence
AUX-II) taken from Clostridium histolyticum 10
Recurrence rate is 8% at 5.8 years follow-up
These enzymes primarily have action on collagen types
I and III Staged distraction and fasciotomy followed by fasciectomy
Injections are placed in the cord through a single puncture First described by Messina, this is usually reserved for
site with the enzymes working synergistically to cleave the severe PIP joint involvement
collagen chains at the injection site It is a two-stage procedure, which involves applying an
The injection should be performed optimally where the external fixator to provide tension along the cord
cord is easily palpable and furthest away from the tendon. The DD regresses under stretch and then a planned
Only one cord should be treated at any one time. The MCP fasciectomy is performed after a few weeks
joint should be corrected beforing attempting correction of
Not commonly undertaken in the UK
a PIP joint contracture
The patient returns the next day for manipulation which is Amputation
usually undertaken under LA for patients comfort Consider for severe recurrent disease
Greater efficacy in MCP joint than PIP joint contractures
Fasciotomy Incisions
A good incision should provide well-vascularized skin flaps,
Fasciotomy is indicated only for a well-defined
pretendinous palmar cord causing an MCP joint extensile exposure and access for identification and preserva-
contracture tion of the digital nerves and arteries.
It is quick and can be performed under LA Brunner
It may also be used in severe multiple digital contractures if Zigzag with apex made at the midaxial point of each finger
the palmar skin is macerated to allow the fingers to be flexor crease
opened away from the palm Allows excellent exposure laterally
There is a risk of digital nerve injury and recurrence Raised skin flaps should be full-thickness and flap apex
This can be undertaken percutaneous with a needle >60° angle to prevent tip necrosis
439
024
• What complications would you warn patients of before a

limited fasciectomy?
• Scar tenderness, infection, bleeding, neuro-vascular
damage, stiffness, CRPS, incomplete correction and
recurrence
• What would you do if you cut the digital nerve? How
would you repair this? What suture would you use?
• Nerve should be repaired under magnification to pre-
vent neuroma formation, and try and restore protective
sensation. Requires a fine suture e.g. 9–0.
• Describe the postoperative rehabilitation programme.
• Volar POP splint for 72 hours
• Seen by the hand therapists for a wound check and
apply a removable thermoplastic splint
• Start ROM exercises
• ROS at 10 days
• Begin scar therapy at 2–3 weeks
• Night splintage for 6 months.
Figure 21.5 How to draw a Z-plasty. 1. Draw perpendicular (white dotted

line) to longitudinal incision. 2. Mark flaps (white and black angles are at 60°).
PIP joint release (sequential)
3. Cross over flaps as shown Prior to surgery it should be discussed with the patient
about what degree of residual PIP joint contracture would
be acceptable following removal of the disease
Take care at the apex to avoid damage to the underlying
neurovascular bundle A joint release can be undertaken which can intially obtain
a straight finger. However, it requires more dissection and
Straight longitudinal incision closed with Z-plasties confers greater morbidity in terms of swelling, pain and
stiffness. The patient typically takes longer to recover and
Midline incision with Z-plasty of the flaps at closure
the final result is often not the straight finger that was
(Figure 21.5). Be prepared to draw the Z-plasties if you
intially achieved
mention this in the exam
The sequential approach involves releasing the following
It has the advantage of lengthening the wound by up to
structures until an acceptable contracture is achieved
75%, which can help with skin coverage following
correction of a large contracture :
Release the check rein ligaments (proximal attachment
of the volar plate that normally prevents
McCash open technique hyperextension)
Transverse palmar incision with digital extension, either : Release of accessory collateral ligament
Brunner or Z-plasty, along the digit : Incise fibrous flexor sheath
The wound provides excellent access to the diseased tissue : Volar plate release (contentious)
and is left open at the end of the procedure : Full collateral ligament release is not recommended
This is a good technique in elderly patients, as it causes less : + transarticular K wire (4 weeks)
oedema and haematoma formation, it is useful if you are A full release of the volar plate may cause excessive scarring
short of skin, and it causes less pain and stiffness and result in loss of flexion, which is more disabling than a
postoperatively; however, it takes a relatively long time to flexion contracture
heal (6–8 weeks)
Postoperative management
Oral question Apply volar splint with digits extended for 2–4 days. Then
actively mobilize and apply a night splint for up to 6 months.
• Show me (on the examiner’s hand) the incision you
would make for a fasciectomy from the palm to middle Complications
phalanx? Intraoperative
• Brunner with apices out to the midaxial line.
• Have you seen a Z-plasty? Why do we use them? Show Digital nerve injury (1.5%)
me where you would make the flaps. Digital artery injury (actual incidence not known as there are
good anastomoses to compensate if one artery is damaged)
024
Overstretching of the finger and spasm in the digital

arteries may lead to digital ischaemia. Positioning in
flexion, patience and application of warm saline usually
return the perfusion
Early postoperative
Haematoma (release tourniquet before closure)
Skin flap necrosis
Small areas of skin loss will heal spontaneously, but healing
of larger areas is slow and may result in scar contracture
Finger loss – More common in revision surgery with prior
damage to a unilateral digital vessel; hence, the need to
assess sensation and perform a digital Allen’s test
preoperatively to identify potential hazards
Infection
Late postoperative
Stiff hand
Loss of grip strength 6/52
Figure 21.6 Clinical picture of Dupuytren’s disease with a pretendinous cord
Complex regional pain syndrome type 1 (4% males, 8% to the ring finger causing an MCP joint contracture
females) – Rare but serious complication. Cardinal features
are excessive pain, stiffness and vasomotor instability
Inadequate release • What is the diagnosis?
Scar-related problems • Dupuytren’s disease.
Recurrence disease • How would you manage this patient?
Flare reaction (combination of tenderness, shiny redness of • This would be based upon the patient’s functional prob-
the wound, swelling) lems, expectations and medical well-being.
• A pretendinous cord affecting solely the MCP joint will
fully correct with surgery and so I will perform surgery
Examination corner when the patient has significant functional problems.
This usually occurs with MCP joint contractures >30°.
Hand oral 1: Clinical picture of severe DD affecting the little and ring
• Where would you start?
finger
• In the palm where the nerve and vessels can be more
• Who gets Dupuytren’s disease? easily and reliably found under Skoog’s ligament. The
• It occurs predominantly in males of northern European nerve and vessels are then traced distally to allow safe
origin. It is associated with excessive alcohol intake, dia- excision of the disease.
betes, chronic lung disease, chronic pulmonary tubercu- Hand oral 3: Clinical picture severe DD affecting the PIP joint of the
losis and trauma most have a positive family history. little and ring finger
• So what will you tell the patient about a limited fasciect-
omy procedure? • What do you see here?
• I would tell the patient that surgery is under general • This is a clinical picture, which shows a severe contrac-
anaesthetic or an axillary nerve block as a day case. tion of the PIP joint of the little and ring fingers. There
Postoperatively their hand wrapped in a heavy dressing. appear to be cords present in the palm extending into
This will be reduced at 48 hours and a smaller dressing the digits.
applied. Sutures will be removed at 10 days and they will • Is there anything that may guide you clinically as to how
then be referred for physio. The surgery is not curative, much correction can be obtained at surgery?
and the disease can recur. I would mention that he has • It is important to access the PIP joint with the MCP
severe contractures of his PIP joint and we may not be joint fully extended as well as flexed. The PIP joint
able to get the deformity fully corrected. There is a small deformity often improves with MCP joint flexion by
risk of a skin graft to cover any defect and this would be relaxing the MCP joint deformity and the intrinsic
taken from the inner forearm. I would mention the risk muscles. In addition, there is a high likelihood of midline
of digital nerve injury and vascular injury that, in the displacement of the neurovascular bundle (spiral cord).
worst-case scenario, may result in amputation. I would estimate 1–1½ hours for the surgery when
planning my list
Hand oral 2: clinical picture of a hand (Figure 21.6) • What incision would you use?
A pretendinous cord to the ring finger causing an MCP joint • Brunner with the apices extending right out to the mid-
contracture. axial line
441
024
There is no strong evidence to support any theory and it is,

Hand oral 4: Clinical picture of DD
therefore, probably multifactorial. Many patients present with
• Details on aetiology and presentation. a history of trauma but over half of patients in one study could
• Most are male of north European origin not recall any injury15. Others have suggested an occupational
• Associated with several medical conditions ‘recurrent micro-trauma’ but the evidence for this is poor.
• Most have a family history but as yet no clear gene has Whilst the aetiology is unclear there are several well-
been identified
established risk factors:
• What tissue is involved?
• Skin and palmar fascia. Ulnar-negative variance (i.e. the ulna is shorter than the
• The palmar fascia is divided into three layers (talk into distal radius). It is thought that this leads to an abnormal
the detail given above). loading of the lunate and has lead to the development of
• What are the named cords? the surgical options
• Pretendinous NB. Ulnar variance can only be measured on a standard PA
• Spiral view of the wrist (shoulder flexed/internally rotated 90°,
• Natatory elbow flexed 90°, neutral forearm rotation)
• Lateral
• Abductor digiti minimi
Shape of the lunate. There are three shapes and it is more
• Commissural (thumb web space). common in type 1
• Surgical indications? :Type 1 – Trapezoid
• Functional problems :Type 2 – Rectangular
• Generally MCP joint <30° and even less in PIP joint as :Type 3 – Square
less easy to achieve full correction.
• When might you perform a dermofasciectomy? Blood supply (Gelberman). There are three patterns of
• Extensive skin invovlement supply. There is no definite association with a particular
• Revision surgery pattern, but it is thought that the I pattern have the
• Some would consider this in a primary surgery for diath- greatest risk
esis patients. :
Y pattern
• Revision options? :
X pattern
• Revision fasciectomy
• Dermofasciectomy
:
I pattern
• Joint release Male sex
• Arthrodesis
• Amputation. Classification (Lichtman)
Stage I
15,16 :
Kienböck’s disease Plain radiographs are typically normal though a linear
or compression fracture may be noted
Most surgeons have radiographs showing Kienböck’s disease
and they often show them during the hand oral for the FRCS
: MRI demonstartes diffuse T1 signal decrease
(Tr & Orth). This leads on to the usual questions about
: Positive bone scan
classification and treatment. Stage II
:
Sclerosis with or without multiple fracture lines
Introduction :
No collapse of the lunate
There is an agreement that the histological and radiographic Stage IIIA
appearances are consistent with avascular necrosis of the :
Lunate collapse
lunate. First descibed in 1910 Kienböck felt ‘this condition is :
Normal carpal height
due to a disturbance in the nutrition of the lunate caused by
Stage IIIB
ruputre of the ligaments and blood vessels during contusion,
sprain or subluxation’. It is typically unilateral although bilat- :
Lunate collapse
eral cases have been reported. :
Capitate migrates proximally causing a reduction in
carpal height
Aetiology : Scaphoid in a flexed position
The aetiology of Kienböck’s disease is unknown. There are Stage IV
several theories have been put forward: : Radiocarpal and/or midcarpal arthritis
Trauma
Mechanical overloading Clinical presentation
Metabolic abnormality Can be an incidental finding with the patient being
Haematological disorder asymptomatic
024
Typically males aged between 20 and 40 load on the lunate by 66% but increases the
Insidious onset of central wrist pain with stiffness and scaphotrapezial load by 150%
weakness of grip strength Direct can be achieved through vascularized bone grafts
Tenderness over the lunate and there maybe evidence of a : 2,3 – Intercompartmental supraretinacular artery
radiocarpal effusion (ICSRA), or 4,5 – Extensor compartment artery (ECA)
are used
Management : Technically demanding but studies have suggested
The surgical options are based on the aforementioned theories satisfactory pain relief and improved range of
and none are proven to prevent progression of disease. Conse- movement
quently surgical management is and indicated for patients who
fail to respond to non-operative management in the form of Stage IIIB
rest, analgesia and splintage. The carpal instability resulting from the collapse is the
The severity of symptoms and radiological appearances do focus of treatment
not correlate well. In planning treatment one needs to assess This is managed by either a limited intercarpal arthrodesis
the patient’s pain and disability thoroughly. The surgical or proximal row carpectomy
options vary according to the stage of the disease. A wrist Scaphocapitate or scaphotrapeziotrapezoid (STT) or
denervation incorporating both the anterior and posterior fusion repositions the scaphoid into a neutral posture and
interosseous nerves just proximal to the wrist joint (as re-establish carpal height. Load transfer subsequently occurs
described by Berger) can be a useful adjunct in the surgical predominantly through the scpahoid rather than lunate fossa
management regardless of the stage of the disease. Proximal row carpectomy has shown no benefit to an STT
fusion for stage IIIB disease, possibly because of pre-
Stage I existing damage to the lunate fossa, which will articulate
Simple immobilization to ‘unload’ the lunate and allow any with the head of the capitate
revascularization to occur unimpeded
Usually by use of a cast which is required for 3 months Stage IV
Progress can be followed on MRI A salvage procedure in the form of a total wrist fusion is
If symptoms fail to respond can consider treatment indicated
outlined in stages II and IIIA
Examination corner
Stage II and IIIA
Hand oral: Radiographs demonstrating Kienböck’s disease
Surgery aimed at trying to enourage direct or indirect
revascularization • A 42-year-old businessman comes to your clinic com-
plaining of mild left wrist pain. These are his wrist
Indirect is achieved by ‘unloading’ the lunate by shielding it
x-rays. What do you see?
from excessively high sheer stresses
• This has the appearances of Kienböck's disease as
: In an ulna minus deformity, this is achieved by a radial shown by the marked sclerosis of the lunate. There are
shortening osteotomy to ‘level’ the joint (Figure 21.7) no osteophytes present and the lunate is not collapsed.
: In a neutral or ulna positive variance treatment is The architecture of the wrist is well preserved. I note he
controversial. A capitate shortening can be undertaken is ulnar minus.
to ‘unload’ the lunate. It has been shown to reduce the • What do you think of his MRI scan?
• The MRI scans show decreased signal intensity consist-
ent with the avascular necrosis of Kienböck’s disease.
• How do you classify Kienböck’s disease?
• Kienböck’s disease is usually diagnosed and staged on
plain radiographs. Lichtman graded the disease into four
stages radiographically.
• Stage I has a normal lunate. Stage II sclerosis. Stage III
shows collapse and fragmentation. It is subdivided into
IIIA with no carpal collapse, and IIIB with carpal collapse
(carpal index <0.54) and fixed scaphoid rotation. Stage
IV is generalized arthritis of the wrist.
• How do you manage Kienböck’s disease?
• There is no correlation between staging and symptoms,
and no conclusive evidence that surgery prevents pro-
Figure 21.7 AP and lateral radiographs showing sclerotic and fragmented gression of the disease.
lunate (type IIIA), and ulnar minus. Treated by a joint levelling procedure • I would treat this patient based on the level of symptoms.
(a radial shortening)
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024
• I would initially treat the patient non-operatviely Most common sites

• If he did not settle I would offer him a joint levellling Dorsal wrist ganglion (from scapholunate ligament)
procedure with a radial shortening and plate fixation Volar radial ganglion (radioscaphoid or
through a volar approach.
trapeziometacarpal joints)
Hand oral 2: Radiograph of Kienböck’s disease
• What condition do you see here? Flexor sheath ganglion (appears in the A1 or A2 pulleys)
• Keinbocks
• As evidenced by . . . Clinical presentation
• What is the natural history of this disease?
Concern over the presence of a lump
• Unclear
• No conclusive evidence that people will progress Cosmesis
through the stages Pain
• Pain does not correlate with the radiographic severity Variation in size, especially a reduction in size
• Why is the aetiology? Wrist weakness
• Unproven Extrinsic compression of adjacent nerves (ulnar nerve
• Several theories (as listed above) Guyon’s canal, median nerve in the carpal tunnel)
• What is the classification and what stage is this (in the
initial radiograph)?
• Lichtmann classification Management
• What is the indication for surgery? It is very important to tailor the management to the patient
• Failure of non-operative management and discover whether the problem to be addessed is concern,
• What are the surgical options in this patient (clear ulna pain or cosmetic.
negative variance)?
• Joint levelling procedure Non-operative management
• Revascularization
• What if the joint was already level? Reassurance – Whilst many patients know they have
• Unload the lunate with a capitate shortening a ganglion a surprising number of patients have
• Lunate revascularization concern over the presence of a lump. Spend time
reassuring the patient this is not and will not become a
cancer. It is a harmless swelling which may resolve
Ganglion17 spontaneously in time. Useful to mention the Bible
was used as an old-fashioned treatment method and
Introduction that surgery would be exchanging a swelling for a
Ganglion cysts are the commonest soft-tissue swelling of the scar, etc
hand. It is not a true cyst as it is does not have an epithelial
lining. It is a fibrous swelling usually attached to an underlying Aspiration ± steroid injection
synovial cavity of a joint or tendon. It contains clear mucinous May be effective in upto 30% of wrist ganglions
fluid, which is a mixture of glucosamine, albumin, globulin Useful in confirming the diagnosis of a ganglion
and hyaluronic acid. It is unclear if ganglion fluid is simply Can be helpful in the ‘painful ganglion’ because if the pain
synovial fluid which has escaped from the joint, or if it is resolves on aspiration then excision should similarly relieve
formed by cells in the synovium at the origin of the ganglion. pain if the ganglion recurs
They are most common in women and most occur between
the second and fourth decades of life. Surgical excision
Excise for cosmesis, pain or functional disability.
Recurrence rate 5%
Pathology Reports of arthroscopic ganglion excision as yet have failed
Remains unclear to prove superior results
Theories of mucoid capsular degeneration
and joint capsule synovial herniation have been Dorsal wrist ganglion
proposed Accounts for up to 70% of all ganglions
Consist of compressed collagen fibres with no true Arises from the scapholunate ligament
epithelial or synovial lining membrane
Occult ganglions may only be visible/palpable with wrist
Whilst some present following a history of trauma – There flexion though patient may only complain of pain in
is no good evidence to support a traumatic or extension when the ganglion ‘impinges’ on the dorsal rim
inflammatory aetiology of the distal radius
024
Transverse skin incisions are preferrable for cosmesis A horseshoe ganglion may grow on either side of the
Success depends on identification of the pedicle connecting extensor tendon
the ganglion to the joint and excision of the surrounding The ganglion is mobilized and traced back to the joint
capsule with trimming of any dorsal osteophytes present
The joint capsule should not be closed after surgical Skin closure is either primary, a local rotation flap or a
excision full-thickness skin graft
Volar radial wrist ganglion Examination corner

Second most common ganglion accounting for
up to 20% Short answers/notes
Two-thirds arise from the radiocarpal joint at the Write short notes on the management of a 21-year-old
woman who presents with wrist ganglia
scapholunate interval
Confirm the diagnosis of a ganglion
One-third from the scaphotrapezial joint
Ganglion lies under the volar crease between the FCR History
and APL Usually painless swelling
An Allen’s test before surgery is mandatory as the Examination
ganglion is often intimately adherent to the radial artery Exclude worrisome features
and requires careful dissection from it Transillumination
Inadequate collateral circulation from the ulnar artery may
Management options
contravene surgery
Reassurance
The recurrence rate is higher than for dorsal wrist Especially if asymptomatic
ganglia ‘You haven’t got cancer’
Aspiration (±steroid injection) – High chance of recurrence
Flexor sheath ganglion Can be performed as an outpatient procedure and
repeated if necessary
Also known as a volar retinacular or seedling ganglia Excision
Third most common ganglion in the hand (~10%) Indications would include a persistent, painful or enlarging
Firm swelling felt at the base of the finger in the ganglion
web space that can cause discomfort when gripping Inform the patient that they would be substituting
objects a scar for a swelling, that the scar may be painful,
Small, firm, hard and tender mass ~2–5 mm in and that there may be an area of numbness around
diameter the scar
Can be performed under either local or general
Arises through the A1 or A2 pulleys and does not move
anaesthetic
with finger flexion, unlike the flexor tendon nodule seen
Recurrence can occur in ~5%
with trigger finger Trace the pedicle down to the joint capsule and excise part
Excise through a small Brunner’s type incision with a of the joint capsule
margin of tendon sheath. Protect the neurovascular Do not close the defect in the joint capsule
bundle
Recurrence after excision is very uncommon Hand oral: clinical photograph of either a dorsal and palmar wrist
ganglion
Spot diagnosis
Mucous cyst Usual questions about management
A mucous cyst is a dorsal digital ganglion arising from an
osteoarthritic DIP joint Hand oral: clinical photograph of a mucous cyst
The cyst tends to lie to one side of the extensor tendon • What is the diagnosis?
A dorsal osteophyte is commonly present and must be • Mucous cyst
excised • How would you treat this?
May present as ridging of the nail plate or recurrent • Reassurance if that is all that is needed
• Can attempt aspiration but high recurrence rate
infection with discharge
• Excision
Generally occurs between the fifth and seventh decade • You excise the cyst. How would you close the defect.
A transverse incision should be used to protect the Draw the rotation flap you would use to close.
germinal matrix of the nail bed
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024
Osteoarthritis of the base of the thumb18–25

Background
Peritrapezial osteoarthritis commonly affects postmenopausal
women, with 80% having radiographic changes although many
have few symptoms.
Anatomy
The thumb carpometacarpal (or trapeziometacarpal) joint
is saddle-shaped and has little inherent stability but allows
for a wide range of flexion–extension, abduction–
adduction and rotation
Opposition is a composite movement involving flexion and
pronation
Stability is predominantly provided by the three main
ligaments stabilise the joint
: Lateral ligament
: Dorsal ligament
: Volar-ulnar or beak ligament
The beak ligament is the most important
: It is extremely strong and is the primary static stabiliser
of the joint
: It is thought that degeneration of this ligament leads to
joint instability and early disease
History Figure 21.8 Typical basal thumb osteoarthritis. Note the shouldering of the
Pain CMC joint with a compensatory hyperextension of the MCP joint
: Constant dull pain around the base of thumb and radial
side of the wrist Special tests
: Worse with use : Painful and unlikely to be performed in the exam
: Particularly aggravated with pinch or strong grip : Grind test – Pain with axial loading of the thumb
activities such as removing a tight jar lid metacarpal and rotation of the CMC joint; positive if
: May affect MCP joint from compensatory pain disappears with repeat test with distraction of the
hyperextension joint. May feel crepitus
: Night pain is unusual : Crank test – Axial loading of the thumb with passive
Difficulties with ADLs (undoing screw top jars, doing up flexion and extension of the metacarpal
buttons, writing) : A further test consists of longitudinal traction and
Carpal tunnel symptoms pressure over the base of the thumb metacarpal to
reduce the subluxed joint. Reproduction of pain
Examination strongly suggests disease at the thumb CMC joint
Look
: Squaring-off of the base of the thumb (shoulder sign – Radiographs
Dorsal subluxation of the thumb’s metacarpal base) AP hand and Robert’s view (Figure 21.9 – True AP view of
: Adduction contracture of the first web space the thumb. Taken with the thumb fully abducted and the
: Thenar muscle wasting forearm fully pronated)
: Compensatory hyperextension of the MCP joint to Consideration of other diagnoses
increase span owing to the adduction contracture : Thumb CMC joint laxity
(Figure 21.8) : De Quervain’s
: Look for trigger fingers and carpal tunnel syndrome : Trigger Thumb
(43% association) : Scaphoid non-union
024
Figure 21.9 Robert’s

view of thumb CMC joint Stage 4
Pantrapezial arthritis
Severe subluxation
Joint space is narrow, cystic and sclerotic subchondral bone
changes
Management
Thumb CMCJ OA is extremely common and a significant
proportion of patients can be managed without surgery.
Non-operative
A trial of non-operative treatment should be tried in all
patients regardless of the severity of the radiographic
changes
Options
: Activity modification
: NSAIDs
: Intra-articular steroid/local anaesthetic injections
– One RCT found no benefit of steroid over saline23
– A different study showed 59% were satisfied
and only 28% had required surgery at
3 years24
:
Thumb splinting – Can offload degenerate parts of
the joint
: Physiotherapy
In reality a combination of these options should
be tried
One prospective study showed 70% of patients listed for
: SNAC/SLAC wrist surgery no longer required this following 7 months of
: Kienböck’s therapy, splints and analgesia
No evidence for the use
Classification (Eaton and Littler) Surgery
Radiological classification for staging thumb CMC joint OA
The indications for surgery are disabling symptoms unrespon-
Corresponds poorly to clinical symptoms sive to conservative treatment.
Poor interobsevor corroboration
Early stages of the disease (stage 1)
Stage 1
If instability is present an Eaton–Littler procedure is
Radiographs demonstrate widening of the joint space performed (soft-tissue reconstruction of the beak
Synovitis and joint effusion ligament using half of FCR passed through a
Pre-arthritis stage hole drilled across the base of the thumb
metacarpal). Contraindicated if degenerative changes are
Stage 2 present
Slight narrowing of the joint space More recently an extra-articular 30° extension osteotomy
Mild subluxation of the thumb has been described as an alternative method
STT joint normal of management
In reality few patients will present at this stage
Stage 3
Joint space markedly narrowed Late stages of the disease
Often sclerotic and cystic change There are numerous surgical treatment options for OA of the
Moderate subluxation base of the thumb (Table 21.1).
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024
Table 21.1 Surgical treatment options for osteoarthritis of the The arthrodesis can be stabilised with an AO 2.4 mm
trapeziometacarpal joint
compact hand set T-plate, K-wires or a tension-band
Trapeziometacarpal arthroplasty without excision of the wire
trapezium 4. Joint replacement arthroplasty: Both cemented and
Trapeziectomy uncemented designs
± Ligament reconstruction and tendon interposition
± Soft-tissue interposition Total joint replacements generally have a constrained
Osteotomy ball and socket design with the stemmed ball inserted
Arthrodesis into the metacarpal and the socket anchored to the
Joint replacement arthroplasty trapezium
This is gaining in popularity despite only short-term
results to date in a small series
The choice depends on three main factors: Currently no evidence that it is superior to
Whether there is isolated CMC joint disease or trapeziectomy and it is not in common usage
pantrapezial disease 5. Osteotomy: A number of osteotomies have been described
Patient’s activity level at the base of the first metacarpal
Surgeon’s experience Good results have been reported with an abduction–
Procedures that preserve the trapezium or aim to maintain extension osteotomy for stage II and early stage III
thumb length will theoretically preserve function. However, disease
loss of trapezial height has not been shown to correlate with
It is suggested as a more durable procedure than
thumb strength postoperatively18. an arthroplasty and restricts motion less than
1. Trapeziectomy an arthroplasty, but has not gained widespread
Generally provides reliable pain relief but may be popularity
accompanied by thumb weakness Despite the wide variety of surgical options exist and none
It is not a technically demanding procedure but there is is clearly superior. Overall, expect 80–90% good results
protracted rehabilitation time (6 months) whatever procedure is used
Requires 4–6 weeks in a thumb splint postoperatively Therefore, length of surgery and rehabilitation time are
Instability of the base of the thumb metacarpal is a important. Patients should be warned that several
possible complication months might be needed to gain the full benefit from the
Numerous modifications to simple excision have been procedure
devised to try to prevent this (haematoma distraction, A recent publication by Gangopadhyay showed the
APL sling) results at 5–18 years for simple trapeziectomy,
2. Excision plus ligament reconstruction and tendon trapeziecotmy with tendon interposition and
interposition (LRTI) trapeziecotmy with LRTI19. There was no difference in
terms of pain relief, grip or pinch strength, range of motion
More popular in USA than Europe or complication
Time-consuming and there is no proven benefit over A Cochrane review in 200922 found marginally better pain

simple trapeziectomy20
relief with LRTI but an amount that could have happened
Ligament reconstruction using FCR is done to support by chance. They did report a significantly greater number
the base of the first metacarpal and to prevent thumb of complications with LRTI
shortening, and the remaining tendon is rolled up to act
as a spacer Approach
3. Arthrodesis Dorsal
Possibly indicated for younger, manual workers with : Longitudinal incision over the anatomical snuffbox
isolated trapezometacarpal disease to maintain better : Take care not to damage the branches of the superficial
grip strength radial nerve
This is a technically more difficult procedure, with a : The dissection is taken down on to the capsule between
higher incidence of serious complications22 EPB and EPL
It places increased demands on the triscaphe joint, : The radial artery crosses the floor of the
which may become painful anatomical snuffbox and has to be carefully mobilized
The joint is fused in a clenched fist position (10–20° dorsally
radial and 30–40° palmar abduction). In reality this is : A longitudinal capsular incision is then made before
where the thumb tip lines up with the index fingetip for subperiosteal dissection of the trapezium, which can be
a pinch removed whole or piecemeal
024
Modified Wagner • What are the structures at risk?

: Curved incision between glabrous and non- • Superficial radial nerve
glabrous skin • Radial artery
: Elevate the thenar muscles of the trapezium • FCR
: Less likely to encounter bracnhes of the radial nerve or • How do you know the bone you are about to excise the
trapezium and not the scaphoid?
the radial artery
• Saddle shape trapezium but get an x-ray if any doubt
before you excise
MCP joint hyperextension25
• Patient returns to your clinic 1 year later and an x-ray
This may disappear with correction of the adduction shows the thumb metacarpal is now articulating with
contracture at the thumb metacarpal the scaphoid
Some advocate treatment with hyperextension of >30° • What would you do now?
• Depends on symptoms.
: Either a volar capsulodesis if the joint surfaces are intact
• Migration of the thumb proximally does not always
: Or a fusion if there are painful degenerative changes denote pain and functional problems
Others choose to treat the CMC joint and evaluate the • What if they have symptoms?
MCP joint following rehabilitation • Assess the cause of the pain – Remaining osteophytes,
ST arthrosis or arthrosis between the thumb metacarpal
and the scaphoid
Examination corner • No proven treatment – Consider steroid injections,
splints, stabilisation procedure or even a silastic implant
Hand oral 1: Clinical photograph of hand demonstrating
shoulder sign
• What do you see here? What is the diagnosis? Small joint arthritis
• Thumb held in an adducted position
• Shouldering of the base of thumb in keeping with OA
History for this should cover any skin, eye or bowel problems.
• What problems do the patients usually have?
• Common joint to get arthritis Osteoarthritis
• Not always symptomatic Involves base of thumb and DIP joints mainly
• Symptoms are worse on pinch and twisting activites of
Heberden’s (DIPJ) and Bouchard’s (PIPJ) nodes are painful
the thumb such as lifting a kettle or twisting a door knob
dorsal osteophytes
or using a knife
• How would you manage the patient intially?
• Activity modification Systemic lupus erythematosus (SLE)
• Splints Chronic inflammatory disorder with joint involvement
• Steroid injection
in 75%. Malar rash, fever, pericarditis. In the hand
• How would you manage this patient surgically?
there is a similar deformity to rheumatoid deformity
• Trapeziectomy
• (For you the candiate to decide but need to justify why – with joint subluxations and dislocations but normal
Probably easier to do a simple trapeziectomy) joint spaces and no erosions. Soft-tissue procedures
• Would you perform LRTI? are unsuccessful, and require arthrodesis (or
• (Your decision as the candidate) arthroplasty)
• No I would not. There is no clear evidence that it is
beneficial, is time consuming and can lead to increased
complications
Gout
• What literature can you quote to support your surgical Urate crystal deposition from various causes (idiopathic,
approach? thiazide diuretics, renal failure, malignancy). Causes
• Cochrane review acutely inflamed joints and characteristic punched-out
lesions. Gouty tophi and kidney stones may occur. Crystals
Hand oral 2: a patient is listed for a trapeziectomy are negatively birefringent (yellow) on polarized light
• Which approach would you use
microscopy
• Dorsal or modified Wagner
• (Increased rate of superficial radial nerve irritation with Psoriasis
dorsal approach)
Arthritis present in 20% of those with psoriasis. HLA-B27
• Show on the examiner where you would make your
in 50%. Other manifestations include extensor and scalp
surgical incision
• Clearly demonstrate landmarks and the incision line
plaques, and nail pitting. In the hand, there is asymmetric
arthritis with marked deformity (‘pencil in cup’)
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024
Haemochromatosis History
With osteoarthritic changes to the metacarpal heads this Pain
should be considered as a rare cause and a full blood count Weakness
performed Loss of function (it should be noted that, despite advanced
disease, patients maintain an excellent level of function)24
Rheumatoid arthritis of the wrist and Swelling
hand26–32 Cosmetic deformity
Difficulty in activities of daily living and hobbies
Introduction
The most common inflammatory arthritis affecting Clinical
0.5–1.0% of the population Pancarpal disease
Women are three times more often affected than men Synovial proliferation and inflammation involves the
A chronic progressive symmetrical polyarthropathy and whole wrist joint, causing pain, stiffness and swelling
systemic disease of unknown aetiology The inflammatory synovitis causes ligament laxity and
Rheumatoid factor (IgM autoantibody to IgG) is present destruction of articular cartilage, and invades bone, causing
in 80% cyst formation and bone destruction
The main structures requiring treatment are painful, The end stage is either spontaneous fusion of the wrist joint
arthritic joints, tendon rupture and subluxation, and nerve or palmar dislocation and ulnar translocation of the
compression radiocarpal articulation
The continuing improvement in the medical management
of this disease has markedly reduced the number of Periscaphoid disease
patients requiring surgery Synovitis disrupts the radiocarpal and intercarpal
Management of these patients should be with a multi- ligaments, leading to rotatory instability of the scaphoid
disciplinary approach involving rheumatologists, hand and carpal instability (DISI pattern)
therapists, hand surgeons and the patient The intercarpal ligaments and wrist capsule become
stretched and weakened
Pathophysiology The scaphoid assumes a flexed position, leading to
Chronic inflammatory autoimmune process that causes loss of carpal height, the carpus drifts into radial
joint inflammation, cartilage destruction and ligament deviation and there is volar subluxation of the
wekaness radiocarpal joint
The formation of pannus, caused by synovial The carpus ultimately dislocates in a volar and
inflammation, in areas or increased vascularity. The ulnar direction. Power grip is weak; the wrist is no longer
pannus invades into terminal vessels resulting in soft-tissue stable
ischaemia and stretching of tissues
Activated neutrophils from the pannus release
Distal radioulnar joint instability
lysosomal enzymes and free radicals that destroy the The ulnar subluxates dorsally (caput ulnae syndrome)
articular surfaces Prominence of the ulna gives rise to the piano key sign
Volar subluxation and supination of the carpus occurs due owing to destruction of the TFCC
to laxity of the strong extrinsic volar carpal ligaments. This,
with distal radioulnar joint disease and ulnar subluxation MCP joint
of ECU, leads to prominence of the ulnar head Volar–ulnar subluxation
(caput ulnae) Synovitis causes capsular laxity
There is radial deviation of the metacarpals, altering the Compensatory ulnar deviation at MCP joints from
line of pull of the EDC tendons. This, combined with longitudinal pull of extensor tendons with radial deviation
capsular laxity from synovitis, leads to volar–ulnar of metacarpals
subluxation at the MCP joints Ulnar intrinsics then shorten
Tightness of the ulnar intrinsics causes imbalance of
the digits, leading to swan-neck and boutonnière Extensor tenosynovitis
deformities Attrition over the prominent ulnar head causes extensor
Rheumatoid nodules are present in 25% and consist tendon ruptures initially affecting the little finger
of a collagen capsule, and fibrous and central necrosis (Vaughan–Jackson syndrome)
if large The EPL can rupture around Lister’s tubercle
024
Flexor tenosynovitis Early diagnosis of rheumatoid arthritis is vital as DMARDs

Pain and volar swelling have the greatest effect when started early in the disease
The FPL can rupture in the carpal tunnel from synovitis of Traditional DMARDs consist of methotrexate,
osteophytes over the scaphotrapezial joint hydroxychloroquine, sulfasalazine and azathioprine
An anterior interosseous nerve syndrome is the differential These can be used individually or in combination and can
often require up to 6 months to have full effect
Carpal tunnel syndrome Newer DMARDS include TNF-α (e.g. Etanercept,
Secondary effect of swelling at the wrist .joint Infliximab) and recombinant monoclonal antibodies such
as Rituximab. These newer drugs are generally well
tolerated and can prove efficacious as early as 2 weeks
Assessment Side effects such as infeciton, hepato-toxicity, vision loss
Looking is the most important part as these patients and pancytopenia have all been reported
commonly have marked pain
Medication and surgery
Quickly screen neck, shoulder and elbow movements.
Place hands on a pillow : Methotrexate was previously thought to increase the
Swellings – Nodules, MC heads, caput ulnae risk of postoperative infections and surgical
complications during elective surgery
Obvious deformity – Subluxed ulnar head/carpus,
deviation metacarpals, Z-deformity of the thumb, : Suddenly stopping the drug often results in a flare-up of
swan-neck/boutonnière, dropped fingers the disease, making movement painful and
rehabilitation difficult
Scars (three most common rheumatoid patient scars:
Dorsal midline from wrist arthrodesis, transverse over MC : The continuation of methotrexate treatment does not
heads from MCP joint arthroplasty, and longitudinal over increase the risk either of infections or early surgical
thumb from MCP joint fusion) complications in rheumatoid patients and so it should
be continued28
Muscle wasting
Feel any obvious swellings over joints for synovitis and
: TNF medications such as etanercept that should be
stopped prior to elective surgery
along subcutaneous border of ulna for nodules
Active movement – Forearm rotation for DRUJ (loss of
: Rituximab may be stopped prior to surgery but speak to
your rheumatologist
supination as the ulnar head is subluxed dorsally), prayer
position for wrist extension, back of hands together for Planning treatment
wrist flexion, global screening finger movements – ‘can you
make a fist then straighten out your fingers?’ Surgery is indicated for pain, deformity and loss of
function
Functional assessment – Different grips
Treatment should be individualized based on the type and
: Power – ‘squeeze my fingers’ severity of the local destructive process, the involvement of
: Tripod – ‘hold a pen’ other joints in the upper and lower extremities, the overall
: Key – Pulp to pulp status of the patient’s disease and the patient’s background
: Precision – Tip to tip, ‘pick up a coin’ and expectations from surgery
In the rheumatoid patient, lower limb problems should
Radiographs in general be treated before upper limbs. Retention of
walking ability is of overriding importance and periods
PA and lateral wrist radiographs plus PA of the
whole hand to assess the severity of arthritis throughout of crutch walking following lower limb surgery are best
the hand avoided after reconstructive procedures on the upper limbs
Rheumatoid wrist disease can be staged using either the More proximal joints (shoulder and elbow) should
Larsen (stages 0–5) or Wrightington classification be treated before distal joints (wrist and hand) – The hand
(grades 1–4) has to be positioned to carry out appropriate tasks that
require good function at the shoulder and elbow
Urgent procedures – In the hand there are some
Management procedures that should be carried out urgently. These
Medical26,27 include tenosynovectomy to prevent tendon ruptures or to
release nerve compression
In addition to anti-inflammatories and steroids, there are
disease-modifying anti-rheumatioid drugs (DMARDs)
DMARDs can reduce the extent to which rheumatoid Operative management
arthritis damage bones and cartilage, decreasing disease The most common rheumatoid hand operations – Wrist fusion,
impact and disability finger MCP joint replacements, fusion thumb MCP joint.
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024
The wrist Can be achieved with a wrist fusion plate, intramedullary

Commonly affected – Up to 90% of patients at 10 years pin (from third MCP joint through carpus and into distal
May manifest itself at the radiocarpal, midcarpal, DRUJ or radius) or K-wires
any combination of these The position of fusion is debatable but most surgeons
prefer slight extension and ulnar deviation
DRUJ It is performed through a straight longitudinal dorsal skin
Commonly affected early in the disease process with one- incision and the dorsal halves of the carpal bones and the
third developing caput ulnae distal radius are fragmented with bone nibblers. The bone
The extensor tendons can, thus, be threatened along with fragments are then packed into the wrist joint, which is
the pain and loss of function from the arthritic DRUJ stabilised with a Steinmann or Stanley intramedullary pin.
A synovectomy can be performed (rarely) in the presence This is normally inserted through the head of the third
of synovitis without arthritis metacarpal and passed down the metacarpal shaft across
Most surgeons would look rely on bony procedures to deal the wrist joint and into the distal radius. Alternatively,
with a symptomatic DRUJ damage to the MCP joint can be avoided by introducing
The options include – distal ulna resection, Suave– the pin through the bases of the second and third
Kapandji and ulna head arthroplasty metacarpals, but this gives less secure fixation
Distal ulna resection In general, plate fixation is avoided in the rheumatoid
patient. The porotic bone does not take screws well and
: Popularized by Darrach
there are concerns about wound healing
: Generally indicated for older sedentary patients
Wrist arthrodesis is a good surgical procedure and remains
: Dorsal approach through the floor of the fifth extensor the gold standard for salvage of the advanced RA wrist
compartment leaving a cuff of capsule on the radius for
There is a high rate of fusion, with few operative or
the repair
postoperative complications
: Osteotomy through the metaphysis conserving as much If a pseudoarthrosis develops it is rarely symptomatic
length as possible
If bilateral wrist fusion is performed, the dominant wrist
: Main complaint is painful impingement of the ulnar should be fused in slight flexion to facilitate perineal care
stump on the radius
Ideally, both wrists should not be fused; if possible, one
: Any pre-existing ulnar carpal translation is a should be replaced to allow retention of some movement
contraindication as this may progress
Suave–Kapandji Wrist arthroplasty
: Fuses the DRUJ with excision of a section of ulna The potential advantage over arthrodesis is preservation of
proximal to the DRUJ motion
: Has the advantage of stabilising the ulnar side of the The aim is for active wrist motion with an arc of movement
carpus and so preventing ulnar translocation that can ~30–40°
occur with resection Prerequisites for a wrist arthroplasty include good bone
: However, stump instability remains a complication stock; the deformity must not be too severe
along with DRUJ non-union (contraindicated if the wrist joint is subluxed or dislocated)
Arthroplasty – ulnar head replacement or DRUJ and extensor tendons must be functional. A relative
arthroplasty contraindication is previous sepsis
: Not commonly used A retrospective review by Murphy demonstrated similar
: Typically used as a salvage procedure for failed complication rates between arthrodesis and arthroplasty
resection or Suave–Kapandji but improved ability to undertake ADLs in the arthroplasty
: The ulnar head replacement requires good soft tissue group32
for stability and so is not suitable in a significant Patients who have had an arthrodesis on one side and an
proportion of RA patients arthoplasty on the other side typically prefer the
arthoplasty side
Partial arthrodesis Prostheses are inserted through a dorsal approach. It is
Not rarely undertaken generally only appropriate in the very low demand patient
Useful in patients with isolated radiocarpal, midcarpal or to with a well-balanced wrist
stabilise the wrist in ulnar translocation Salvage of failed arthroplasties remains difficult because of
loss of bone stock. It typically requires conversion to an
Wrist arthrodesis arthrodesis with a plate and bone grafting. The conversion
A safe and reliable option that provides predictable pain arthrodesis confers significantly greater complications than
relief (NB. Rule out DRUJ pain) primary fusion
024
MCP joint replacement advanced to preclude any useful benefit from

This is the most commonly affected joint in RA synovectomy but, if the wrist was less severely
Classic deformity of volar subluxation, flexion and ulnar affected, synovectomy may be useful
deviation : Discussion on the relative merits of arthrodesis vs
Synovitis weakens the radial collateral ligament and radial arthroplasty
sagittal band leading to the ulnar extensor tendon
Hand oral 2
subluxation and ulnar deviation of the digit
Rheumatoid hand with caput ulnae
Replacement aims to relieve pain and realign the joint
Silastic replacements (Swanson® and NeuFlex®) are most • How would you manage this patient?
commonly used • All RA management is about managing the patient’s
pain and function not the appearance
Approach
• The only exception is in cases where there may be a risk
:
Transverse or longitudinal skin incisions in leaving the condition such as persistent synovitis and
:
Protect dorsal veins caput ulnae can lead to tendon rupture
:
Longitudinal capsulotomies to radial side of extensor Picture showing Vaughan–Jackson syndrome
tendons • What is the differential diagnosis and how would elicit
: Capsule and ulnar intrinsics released which the diagnosis is?
• Drop fingers can be a result of PIN palsy, tendon rupture
: Cut metacarpal heads just distal to the collateral ligaments and extensor tendon subluxation ulnarwards
: Ream and insert the implants • PIN palsy should affect all four fingers and thumb, and
: At closure, suture lax radial capsular flap under the the tenodesis test will be intact. In tendon rupture, the
extensor tendon to the ulnar capsule, to correct radial tenodesis test will be positive. In sagittal band rupture,
deviation finger extension can be maintained the finger is
: This can be carried out with or without intrinsic transfer extended passively (this relocated the extensor tendon
over the metacarpal head)
Unconstrained pyrolytic implants are in use – But it is
• How would you manage the drop fingers – If 2 affected?
difficult to get good soft-tissue control in RA patients
if 3? if 4?
• Firstly prevent further tendon rupture. Carry out a Dar-
PIPJ
roch’s procedure.
This can be treated with arthrodesis or arthroplasty (with a • Tendons
Silastic implant)
Just little – Buddy onto the ring finger
Index finger is often more suited to arthrodesis as its role is
Ring and little – Either buddy both to the middle or
primarily for pinching activities with the thumb
transfer EI to little and buddy ring to middle
(conferring a sideways force), whereas the ring and little Middle, ring and little –EI to ring and little, with middle
fingers have a greater role in grip strength and so buddied to index
preservation of PIPJ motion as preferrable when possible FCR or FDS transfer if all digits affected
Fusion is undertaken usually through a dorsal approach
with the joint fused in flexion. The degree of flexion should Adult and pathology oral 2: clinical photograph (Figure 21.10)
reflect patient occupation, hobbies, normal cascade and Clinical picture of rheumatoid hands.
cosmetic appearance. The fusion can be achieved with
K-wires, cerclage wire or a headless compression screw
Arthroplasty is mainly reserved for the older, less active
patients though some surgeons are using the implant in
younger patients to maintain function (accepting the risks of
implant failure)
Patients with pre-existing boutonnière or swan-neck
deformities are associated with poorer results with
arthroplasty and so arthrodesis may be preferrable
Examination corner
Hand oral 1: AP radiograph of a severely deformed rheumatoid wrist
Description of radiographs
Principles of management
: Be careful when mentioning synovectomy in this
particular instance – The bony changes are too
Figure 21.10 Clinical picture of rheumatoid hands
453
024
not neglect also to examine the flexor side of the hand and
wrist for its presence
Symptoms
If flexor tenosynovitis is present in the carpal tunnel it
can cause
: Carpal tunnel syndrome
: Tendon rupture
Palm and fingers

Triggering
Loss of active finger flexion or passive finger extension
The consequences of flexor tenosynovitis are pain, stiffness
(restricted active motion) and tendon rupture. Inevitably, flexor
tenosynovitis can coexist with any related joint problems in
Figure 21.11 Clinical picture of hands of a rheumatoid patient the hand.
• Describe these hands Examination

• Always be systematic when describing any picture.
Examination for flexor tenosynovitis can be difficult as swelling
• Start with deformity at wrist then digits.
• Discussion on treatment of painful hands.
is sometimes minimal, but restriction of active movement and
• Stepwise approach like any pain. crepitus as bulky tendons move beneath pulleys are common.
• Analgesics
• Splints Look
• Steroid injections Overall posture of the hand
• Then surgically into arthrodesis or arthroplasty
For evidence of tendon ruptures, isolated swan-neck
Hand oral 3: clinical picture (Figure 21.11) deformities (isolated rupture of FDS)
Clinical picture of hands of a rheumatoid patient. Swelling is seldom visible (or palpable) beneath the flexor
retinaculum, but appears in the palm, distal forearm and
• Describe what you see.
• How do you do this operation (MCP joint replacements)? digits
• Either a single longitudinal incision to each digit or a single
transverse incision over the MCP joints if doing multiple Feel
digits.
Puffy thick feel to the rheumatoid hand
• Separate the extensor from underlying capsule
• Divide junctura if they are adding to the deformity Pinch test
• Release the ulna intrinsics and sagittal bands :
Normally you can pinch between your finger and thumb
• Capsulotomy on the radial side (can be reefed on the two thicknesses of skin in front of the proximal phalanx.
way out to tighten the radial side) Thickened tenosynovium bulges out through defects in
• Release of the ulnar collateral origin (unless minimal the fibrous sheath and creates a wedge of tissue instead
deformity)
• Assess for bone loss
: A thickened sensation around the distal palmar crease
• Metacarpal head resection
area at the entrance to the A1 pulley may indicate the
• Thin layer of proximal phalanx resection presence of synovitis
• Preparation with awl and then broaches each side. Palpation of the fingers may indicate the presence of
• Trial (aim for ability to slightly hyperextend the MCP joint) nodules or diffuse synovitis
• Closure 2–0 PDS.
• Realign the extensor.
• What is the chance of recurrence of the deformity?
Move
• Most will gradually redevelop an ulnar drift but not to Examination of tendon function for both FDS/FDP
the extent of preop. Crepitus over the tendons
Inability to flex the DIP joint

Flexor and extensor tendons Tendon rupture
Tenosynovitis in the rheumatoid hand is more obvious on Adherence of FDP to FDS
the extensor surface of the wrist and hand but one should Triggering caused by nodules
024
Tendon rupture results from invasive synovitis, infarction Table 21.2 Options for reconstruction
secondary to vasculitis, attrition from bony prominences and Tendon ruptured Salvage procedure
pressure under the unyielding extensor or flexor retinaculum.
FDS None
Management FDP – Wrist Suture to adjacent FDP tendon or
Acute synovitis tendon graft
Conservative FDP – Finger DIP joint fusion

Splintage and drugs FDP + FDS finger Tendon graft or FDS transfer from
Steroid injections into the carpal tunnel or tendon sheath another finger
(explain small risk of tendon rupture) FPL Synovectomy and fusion IPJ
Surgery
Full synovectomy should be performed simultaneously with
Surgery is indicated for any tendon reconstruction (Table 21.2), as re-ruptures are not
: Failure of conservative treatment at 4 months and the uncommon.
presence of persistent and painful tenosynovitis Loss of both tendons within the digital sheath is disabling but
: Median nerve compression in the carpal tunnel reconstruction is difficult. Transfer of the FDS from another
: Triggering finger can be used if a healthy distal FDP stump is present,
: Tendon rupture otherwise tendon grafting may be necessary despite its unpre-
Timely tenosynovectomy is vital in preventing tendon rupture dictable outcome.
and preserving the function of the hand. When there is doubt it
is better to perform a tenosynovectomy to prevent tendon rup- Vaughan–Jackson syndrome
ture than to persist with medical treatment. The surgeon should Rupture of EDC of ring and little fingers caused by
adopt an aggressive approach towards rheumatoid tenosynovitis attrition from prominent ulna head (caput ulnae) and DRUJ
and be prepared to intervene surgically on a prophylactic basis. synovitis.
Chronic synovitis Differential diagnosis of dropped fingers
Synovectomy Ulnar subluxation of extensor tendons
There are three sites Volar subluxation of MCP joints
Carpal tunnel (floor of the carpal tunnel is inspected for PIN palsy
bony spicules, which are excised if present) Locked trigger finger
The palm at the level of the mouth of the A1 pulley
Fingers at the level of the PIP joint just distal to the A2 pulley Management
Synovectomy ± Darrach’s for pre-rupture
Make a Brunner’s incision. Remove diseased synovium and
Tendon transfer
intertendinous nodules, and repair any tendon defects. Release
of the A1 pulley in rheumatoid arthritis is controversial as it : Little finger – EI to EDM transfer
may allow ulnar migration of the flexor tendons and aggravate : Ring finger – Buddy ring EDC to middle EDC
ulnar drift deformity at the MCP joint. The annular pulleys
should be preserved (including the A1 pulley) and the tendon Mannerfelt–Norman syndrome
sheath is opened between the annular pulleys. Postoperative The most common flexor tendon to rupture in rheumatoid
stiffness can be a problem and early mobility is essential. arthritis is FPL rupture, caused by scaphotrapezial synovitis.
Tendon rupture Management

Primary tendon repair – Primary repair is generally not Prompt exploration of the carpal canal and removal
possible owing to poor tissue at the tendon ends of diseased synovium and osteophytes
Primary tendon graft – Fraught with difficulties and results (scaphotrapezial joint)
are usually poor; in a young patient this should at least be IPJ arthrodesis preferred option – Gives a stable thumb
considered with good power transmitted from the short muscles
Tendon transfer – Limited availability on flexor side (FDS Soft-tissue reconstruction
ring finger, palmaris longus, brachioradialis) : Transfer FDS of the ring finger – A possible option but
Side-to-side suture – Good in older patients, should be the range of motion gained is small. It is difficult to get
considered for ruptures at the wrist level the tension right
Arthrodesis (DIPJ – Ruptured FDP but intact FDS) : A free tendon graft can be used to bridge the gap
455
024
Oral question Mobility is needed at the basal thumb joint so that the
thumb can be positioned appropriately and, therefore, this
Describe the typical manifestations of rheumatoid disease at
precludes fusion
the hand and wrist.
Management
Rheumatoid thumb : CMCJ – trapeziectomy
: MCP joint
Introduction
– Mild deformity – Temporary pinning and
More than two-thirds of rheumatoid patients have some
capsulodesis
involvement of the thumb. All three joints can be affected.
Thumb deformities caused by RA can markedly impair func- – Severe deformoty – MCP joint fusion
tion by limiting pinch, grip and motion.
Type 4 – Gamekeeper’s thumb at the UCL
Classification (Nalebuff)29 Disease is confined to the MCP joint and is similar to a
This classification is not sequential and only describes different UCL rupture
patterns of deformity. The ligament is stretched rather than ruptured and this
often results in a secondary adduction contracture of the
Type 1 – Boutonnière-like deformity web space
MCP joint flexion and IP joint hyperextension The CMC joint and IP joint are usually normal
Importantly the basal joint is not affected Surgical treatment is aimed at stabilising the MCP joint
This is the most common pattern of deformity in the Management
rheumatoid thumb
The primary disease is at the MCP joint where synovitis
: In the early stages this is achieved by synovectomy and
repair or reconstruction of the UCL
bulging dorsally causes attrition of the EPB insertion and
extensor hood damage with loss of MCP joint extension. : In more advanced cases, where joint destruction is
The EPL subluxes ulnarly and in time starts to act as a present, arthrodesis of the MCP joint with or without a
flexor of the MCP joint. The IP joint gradually web space release is indicated
hyperextends because all the muscles are now extending it
In the early stages both the MCP joint flexion and IP joint Type 5 – Hyperextension of the MCP joint
hyperextension are passively correctable
This is rare
However, relatively rapid fixed deformities develop,
initially of the MCP joint and later of the IP joint as well The deformity is caused by isolated hyperextension of the
MCP joint owing to slackening and lengthening of the
Treatment
volar plate
: Synovectomy with EPL rerouting There is no adduction of the metacarpal, which
: MCP joint fusion distinguishes it from the type 3 deformity
As this hyperextension increases there is compensatory
flexion of the IP joint caused by FPL tightness
Type 2 – Boutonnière with CMC joint subluxation
Treatment aim is to provide stability to the MCP joint in
This is rare extension
A combination of the type 1 boutonnière deformity with
subluxation or dislocation of the CMC joint
: Capsulodesis
The treatment is similar to that for type 1 deformity, with
: Tenodesis
the addition of trapeziectomy : Arthrodesis
Type 3 – Swan-neck deformity Arthritis mutilans

The reverse of the boutonnière type deformity Severe destruction of all joints with gross instability and
This is the second most common rheumatoid thumb shortening of the thumb
deformity This is difficult to manage and treatment usually involves
The disease starts at the CMC joint and leads to fusion to maintain or gain length
subluxation of that joint
General rules
Deformity is CMC joint subluxation/dislocation leading to
an adduction contracture Primary joint indicates the deformity and other joint
collapses into a particular instability pattern
It is impossible to move the thumb out of the palm without
hyperextending the MCP joint, which in turn causes IP Second joint deformity can become fixed and require
joint flexion treatment
024
It is impossible to consider the primary joint in isolation • How would you manage the patient if the had associ-
and the effect of treatment on one joint must be considered ated CMCJ disease
in relation to its effect on other joints • Consider steroid injections for pain
Is the joint deformity flexible or fixed? • If deformity then trapeziectomy
The thumb collapses into a zigzag pattern in both the
flexion/extension and abduction/adduction planes
Instability in the thumb, particularly at the MCP and Boutonnière deformity of the finger
IP joints, is more disabling than loss of flexion and
extension Introduction
PIP joint flexion and DIP joint hyperextension
It can be further classified as to whether the deformity is
Examination corner fixed or flexible
Hand oral 1: Clinical photograph of a rheumatoid hand Boutonnière is the French word for buttonhole, and is used
in this context because the head of the PP buttonholes
• Describe the deformities present through the extensor hood secondary to rupture of the
• Best to say boutonnière or swan-neck and then describe
central slip
the deformity – It allows the examiner to know you
recognise it.
• What classification systems are used for the deformities Pathology
seen? The pathology starts in the PIPJ
• Nalebuff
The central slip attenuates or ruptures due to synovitis
• Describe the management of the boutonnière thumb.
• In the early stages synovectomy and possible soft-tissue Volar subluxation of the lateral bands occurs because of
but most patients will require fusion disruption of the triangular ligament
The lateral bands become converted from an extensor to a
Hand Oral 2: clinical photograph of a rheumatoid thumb flexor of the PIP joint
• Describe the deformities seen
The functional loss with a boutonnière deformity is a lot
• As above – Be systematic less than with the swan-neck deformity, especially if some
• Discussion about the management options of the flexion is possible at the distal joint
MCP joint
• Synovectomy in early cases Acute injury
• Most will be beyond this and require a bony procedure –
This is usually traumatic and can be difficult to diagnose as
Fusion
• How would you fuse the joint – Approach, technique
the finger does not immediately adopt a Boutonnière
and position of fusion position (not until the lateral bands have subluxed
• Dorsal approach volarwards)
• Care with the extensors Treatment is conservative, using a ‘Capener splint’ which
• Multiple options – Decide which you will use allows active DIP joint flexion/extension
Bony options –
: Chevron is more stable but fiddly
: Ball and socket gives more opportunity to adjust the Elson’s test for acute central slip disruption32
fusion position The PIP joint of the finger is bent 90° over the edge of a
: Straight cut is easiest but the fusion angle is the fixed table. With resisted middle phalanx extension, the DIP
with the cut joint either
Fixation options : Goes into rigid extension (positive test – Disruption of
: K-wires – Cheap but can irriatate the skin, tendons and the central slip) because all the forces in the finger are
create a passage for infection, but are easily removed if
infection occurs distributed to the terminal tendon through the intact
: Cerclage wire – Fiddly but good compression, the wires lateral bands, or
can irritate : Remains floppy (negative test)
: Headless compression screws – Good compression,
more costly, can be difficult in getting sufficient bone
in the head of the metacarpal for the screw to purchase
Classification (Nalebuff and Millender)
(given the angle of fixation) Based on the degree of deformity, the presence of passive
Angle of fixation best judged by resting the tip of the correctability and the state of the joint surfaces:
thumb on the radial aspect of the index fingertip – Know Mild
you can get good pinch
: Dynamic imbalance
457
024
:
Passively correctable PIP and DIP joints Arthrodesis
:
PIP joint lag of 10–15° in extension A predictable form of relieving pain
Moderate Function is best preserved by considering the role of the
:Established contracture (i.e. not passively correctable) digit involved as varying degrees of flexion are required
:PIP joint lag of 30–40° in extension depending on which finger involved
:Joint preserved
Arthroplasty
Severe
Not routinely used for grade 3
: PIP joint in fixed flexed position with joint involvement
The results of arthroplasty in pre-existing boutonnière
: Volar plate and collaterals also contracted fingers are poorer and less predictable
Classification-based approach
Management options for chronic deformity Type 1
Many operations have been described for the management :
Trial of splinting
of this deformity but often the results from surgery can be :
Terminal extensor release
highly variable and unpredictable Type 2
A word of caution – Great care is needed when deciding to
operate on the PIP joint as, although extension may be
:
Central slip reconstruction followed by static then
dynamic splints
regained, one can easily lose flexion and end up either no
better off or worse than before surgery Type 3
Moreover, correction of a mild boutonnière deformity is : Arthrodesis
often associated with minimal functional improvement and
the recurrence rate is high
The results of soft-tissue reconstruction of rheumatoid
boutonnière deformity can be unsatisfactory and, if surgery Examination corner
is required, fusion of the PIP joint in a functional position Hand oral 1: Clinical photograph of a rheumatoid boutonnière finger
may be a safer option deformity
Spot diagnosis
Terminal tendon release
• What is a boutonnière deformity?
Release of the extensor mechanism at the junction of the • Describe the deformity at each joint
middle and proximal thirds of the middle phalanx, which • How are boutonnière deformities classified?
leaves the ORL intact • Nalebuff
The lateral bands slide proximally, increasing extensor tone • Outline the classification
at the PIP joint and the intact ORL provides extensor tone • What are the management options for a boutonnière
to the DIP joint deformity?
More simply, there is less hyperextension stress on the DIP • Depends on the pain and functional problems to the
joint and the flexion of the PIP joint is lessened patient – It may require nothing
• A classification-based approach:
If a resultant mallet occurs in the DIPJ this is usually mild
and better tolerated than the bouttoniere Type 1
: Trial of splinting
Secondary tendon reconstruction : Terminal extensor release
Excision of scar tissue and direct repair of central slip Type 2
Free tendon graft (central slip reconstruction)
: Central slip reconstruction followed by static then
dynamic splints
Lateral band transfer procedure Type 3
This is only carried out after passive joint motion has been : Arthrodesis
restored, using one lateral band as a form of reconstruction
of the central slip Hand oral 2: candidate handed a Capener splint
: Littler – Ulnar lateral band through radial lateral band • What is this?
to P2 • Capener splint
: Matev – The ulnar lateral band is transferred to a distal • Fit it to the examiner’s hand
stump of the radial lateral band. The proximal stump of • Really simple – The key is to know which way round to
the radial lateral band is brought through the central place it!
slip and anchored at the dorsal base P2 • Find one from a hand therapist and practice applying it
024
• How does the splint work? Management (based on the classification)

• Will maintain the PIPJ in extension at rest 1. PIPJ correctable
• When might you use it?
• Predominantly in acute central slip injuries. Extension restriction splint, e.g. Murphy splint(if the
• Describe Elson’s test PIP joint is the problem)
• The PIP joint of the finger is bent 90° over the edge of a Fusion DIP joint (if the DIP joint is the problem)
table. With resisted middle phalanx extension, the DIP 2. Intrinsic release plus some form of tenodesis on the volar
joint either aspect of the PIP joint
Goes into rigid extension (positive test – Disruption of the
central slip) because all the forces in the finger are Oblique retinacular ligament reconstruction
distributed to the terminal tendon through the intact FDS tenodesis
lateral bands, or 3. Either a soft-tissue procedure or arthrodesis
Remains floppy (negative test) Prerequisites for a soft-tissue procedure are full flexion
• Management of a chronic boutonnière. of the PIP joint before soft-tissue reconstruction,
• As above oral
which may require MUA, sometimes the release of the
dorsally contracted skin and then intrinsic release,
if appropriate, and some form of tenodesis
Swan-neck deformity 4. Arthrodesis is probably the procedure of choice in this
Introduction advanced stage
PIP joint hyperextension and DIP joint flexion
It is a common, progressive and disabling deformity that FDS tenodesis
severely affects hand function due to loss of flexion at the Through a volar incision one limb of the FDS tendon is
PIP joint divided proximally and passed dorsally through the middle
phalanx to provide a volar tether to hyperextension. K-wires
Pathology are placed across the joint for 4 weeks.
The deformity is caused by an imbalance of forces at the
PIP joint and a lax volar plate
The deformity can only occur if hyperextension is Examination corner
possible at the PIP joint Hand oral 1: Clinical photograph of rheumatoid swan-neck finger
Unlike the boutonnière deformity the condition can be deformity
secondary to problems at either the MCP joint or • What is the swan-neck deformity?
DIP joint • Decribe the deformity at each joint
The condition most commonly occurs in rheumatoid • What is it caused by?
disease although there are other rarer causes (mallet finger, • Unlike boutonnière this is more complicated and can be
laceration or transfer of FDS) caused by problems at MCP, PIP or DIP joints
Other causes • The outline the problems that can be caused at each joint
• How do you classify them?
: Intrinsic tightness secondary to MCP joint disease • Nalebuff
: Intrinsic contracture • Then outline the different classes
: FDS rupture • How do you manage them?
: Volar plate insufficiency • Patient-centred treatment – May not require anything
: Mallet deformity • Then talk through the management based on the clas-
sification (as above in the text)
: Extrinsic spasticity
Hand oral 2: Candidate handed a Murphy splint
Classification (Nalebuff types 1–4) • What is this?

• Murphy ring
1. Flexible hyperextension deformity of the PIP joint • What is the classification of swan-neck deformity?
2. PIP joint flexion is limited when the MCP joint is • Nalebuff then go through the stages
maintained in extension. i.e. Intrinsic muscle tightness is • Which type/types would this be suitable for?
present • Supple correctable swan-necks to prevent the hyperex-
3. Limited PIP joint flexion in all MCP joint positions, but the tension in the PIPJ
PIP joint surface is still preserved • Asked to fit to the examiner’s hand.
• Ensure you have seen one and fitted it – The important
4. PIP joint is stiff and there is destruction of the articular
thing is to put it on the correct way around
surface of the joint
459
024
Scaphoid fractures33–39 Changes present on MR scan after 12 hours

MRI proven to have a greater diagnostic performance over
The scaphoid is the most commonly fractured bone in the
other modalities and when can be undertaken offer cost-
carpus
savings in terms of reduced use of immobilization and
Knowledge is required of the diagnosis and management of
reduced time off work
acute fractures and the complications of non-union and
avascular necrosis (AVN)
Displacement
Blood supply This is important as displacement increase the risk of non-
union
The blood supply of the waist and proximal pole of
the scaphoid (70%) is derived from the dorsal branch Defined as
of the radial artery entering distally on the dorsal ridge : Displacement >1 mm
through ligamentous and capsular attachments : Angulation >10°
The proximal pole is the region with the most tenuous : SL angle >45°
blood supply, owing to the distal to proximal (retrograde) : CL angle >15°
intraosseous supply
The distal scaphoid and tuberosity (30%) are supplied by
branches of the superficial palmar branch of the radial artery Fracture location
Proximal pole (25%)
Mechanism of injury Waist (65%)
Fall onto an outstretched hand resulting in forced Distal pole and tuberosity (10%)
dorsiflexion of the wrist
Classification (Herbert 1990)
Examination Interobserver reproducibility is fair
Fullness in the ASB (effusion in wrist) Type A: Stable fractures
Tenderness in the ASB and scaphoid tubercle :
A1 Tuberosity fracture
Reduced range of motion (but not dramatically) :
A2 Incomplete waist fracture
Pain at extremes of motion Type B: Unstable fractures
Pronation followed by ulnar deviation will cause pain
:
B1 Unstable oblique fracture
:
B2 Complete or displaced waist fracture
Investigation :
B3 Proximal pole fracture
Radiographs (scaphoid series) :
B4 Transscaphoid perilunate dislocation
Four standard radiographs :
B5 Comminuted fracture
PA in ulnar deviation (extends scaphoid) Type C: Delayed union
Lateral Type D: Established non-union
Two oblique views : D1 – Fibrous union
Sensitivity is only approximatley 70% at detecting acute scaph- : D2 – Pseudarthrosis (sclerotic)
oid fractures. If radiographs are normal patients should be
immobilized and re-examined and investigated approximately
2 weeks later. Management
Bone scanning Undisplaced
Sensitivity 97% (93–99%) but specificity 89% (83–94%) Below elbow cast for 8 weeks
May be positive in ST osteoarthritis Re-examine and x-ray at 8 weeks after removal of plaster
: If still tender, then treat in cast for a further 4 weeks
CT At 12 weeks leave free regardless of whether there is
Sensitivity 93% (83–98%) and specificity 99% (96–100%) tenderness or not
However, usually more accessible than MRI Percutaneous fixation
Also has a role in assessing displacement in :
No current evidence for improving union rates over a
radiographically proven fractures cast assuming the fracture is truly undisplaced
MRI : However, an earlier return to work34 (9.3 vs 13.2 weeks)
Sensitivity 96% (91–99%) and specificity 99% (96–100%)
: Suggested as over-treatment if used for all fractures35
Fracture line will be visible on T2-weighted sequence as a Cast choice – There is no proven benefit of plastering
line of high signal, which represents marrow oedema above or below the elbow, or of including the thumb or not
024
Displaced Incidence
These require reduction and internal fixation with either : Distal pole <10%
: Headless compression screws (differential pitch on : Waist 10–20%
screw to provide compression), e.g. Herbert, Herbert– : Proximal third 30%
Whipple (cannulated), Acutrak (cannulated) : Proximal fifth 100%
: K-wires – Good ease of insertion but they do not
provide compression. Use if there is marked Management
comminution Aims
:
Correct deformity
:
Restore alignment
Surgical technique :
Prevent development of a SNAC wrist
Volar Preoperative assessment
Indicated for waist fractures as it does not damage the dorsal :
Position of non-union (proximal poles less likely to be
blood supply and can correct a humpback deformity successful than waist – 67% vs 85% respectively)
Surface landmarks are the scaphoid tubercle and FCR : Time since original injury (The longer the time the less
tendon. Skin incision is longitudinal along the radial likely bone grafting will succeed)
border of FCR, curving radially to the scaphoid tubercle at : Exclude evidence of degenerative changes
the distal wrist crease : Vascularity of the proximal pole
Divide the superficial branch of the radial artery and dissect : Consider graft options and approach
through the bed of the FCR tendon sheath Graft options
Incise and reflect the capsule and the radioscaphoid and : Inlay (Russe) graft
radioscapholunate ligaments
Screws are placed distal to proximal, 45° to the horizontal – Corticocancellous inlay graft set in a cavity made in
and 45° to the long axis of the forearm the proximal and distal fragments of the scaphoid
A piece of trapezium may need to be excised to gain access through a volar approach
to the distal pole of the scaphoid – The graft is slightly longer than the defect
– The graft does not need internal fixation as the
Dorsal natural shape of the scaphoid clamps down on this
graft and keeps it stable
Use for proximal pole fractures as it provides the best
access when the wrist is hyperflexed : Interposition (Fisk) graft
Care is needed to avoid damage to the dorsal blood supply
– Corticocancellous opening wedge graft placed
The incision is centred on Lister’s tubercle. The approach through a volar approach and designed to restore
is between the third and fourth extensor compartments
scaphoid length and correct angulation
(EPL and EDC). Transverse capsulotomy. Flex the
– This is the preferred option for a humpback
wrist 90° to expose the proximal pole and to reduce the
deformity and carpal instability (DISI)
fracture
The entry point for the wire for the screw is just radial to : Vascularized bone graft
the scapholunate ligament and aim along the thumb
metacarpal – Reportedly higher union rates in displaced non-
unions and non-unions with AVN
– Huge number of grafts described but can be
Scaphoid non-union divided into
Defined as fractures that have not united within 6 months of
Pedicled
injury. The non-union is not necessarily painful to the patient
but if left the patient will develop degenerative changes 1,2-intercompartmental supraretinacular artery
(SNAC – See later). (1,2-ISCRA) (aka Zaidemberg)
Pronator quadratus bone graft (aka Mathoulin)
Risk factors for the development of non-union include
Index finger metacarpal
: Delay in diagnosis Free vascularized bone grafts (NB.
: Delay in treatment Microvascular skills and very time-consuming)
: Angulation (intrascaphoid angle >45°) Iliac crest
: Displacement (>1 mm) Medial femoral condyle
: Location – The more proximal the greater risk Use of these free grafts is currently unclear and
: Smoking controversial
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024
: Which graft?
• Careful history – Does the mechanism fit with a possible
– Large systematic review36 carpal injury
• Examination – Presence of effusion, where are they
Non-vascularized graft without internal
tender, may have only minor limitation of movement.
fixation – Union rate 80% • Radiographs
• Four views – May be negative
Non-vascularized graft with internal fixation –
• What treatment would you give this patient now?
Union rate 84%
• If clinically could be a scaphoid fracture treat as such
Vascularized bone grafts – Union rate 91% • Cast for 2 weeks
This study, however, failed to separate confounding • Reasonable to state you would follow your hospital
variables such as fracture location and age protocol (if you have one)
– Meta-analysis37 • When would you review? How would you reassess?
• Two weeks clinically and radiologically
AVN of the proximal pole on MRI
• What would you do if repeat radiographs were normal?
Vascularized graft – Union 88%
• Need further imaging – Either CT, bone scan or MRI
Non-vascularized graft – Union 47% depending on local resources or protocol. Be aware of
specificity and sensitivty rates (in above text)
– A suggested treatment algorithm by Gray and Shin38
• What cast would you use? Why?
• Below elbow cast with the thumb not included
If AVN or displaced, use a vascularized graft

• No evidence that above elbow or thumb inclusion
If non-displaced and no evidence of AVN, use a

makes any difference
non-vascularized graft • Wrist position also makes no difference but most people
– The choice of graft predominantly remains down to use slight extension as this is a more useful position for
surgeons experience and preference the wrist
• When would you get further radiographs?
Assessing for AVN • You can not diagnose union on one set of x-rays (Just as it
: AVN of the proximal pole is an important predictive can be difficult to ascertain the fracture on radiographs,
factor in the success of surgery to treat non-unions union can be the same). It is a combination of clinical
examination and radiographs that allow union to be stated
: The incidence varies widely, from 9% to 40%, following • What would you do if the patient still had pain at 8
waist fractures weeks? (If cast again – Then what at 12 weeks?) i.e. at
: Radiographs may show increased density of the proximal what time would you mobilize?
scaphoid fragment (owing to decreased bone turnover) • Get further x-rays.
: Gadolinium-enhanced MRI may correlate with outcome, • Treat for upto 12 weeks.
but the gold standard is punctate bleeding at surgery • No evidence that continued cast treatment beyond
Fixation 12 weeks makes any difference to union rates
• When do you discharge the patient from clinic?
:None – Relies completely on the support from the graft • When clinically and radiologically united
wedged inside the bone • Usually need at least one set of radiographs at least
: K-wires – Usually used in very proximal non-unions 6 months form injury to ensure the fracture united (or at
where there is insufficient bone proximally to take a screw. least shows no evidence of non-union on the radiographs)
However, requires removal before wrist can be mobilized
: Headless compression screw – Preferred option by Hand oral 2: radiographs showing an obvious scaphoid fracture
most surgeons as provides compression, stabilises the • What is going on here?
graft and does not require routine removal • Is it displaced? How else could you assess this?
Approach • Displacement is difficult to adequately asssess on radio-
graphs – Anything other than a simple hairline fracture
: Waist – Can be dorsal or volar though easier to correct
may be displaced
a ‘humpback’ deformity through a volar approach
• Get a CT if in doubt
: Proximal pole – Dorsal approach • How would you treat this patient?
• CT to assess displacement
• Closed reduction and percutaneous fixation with a
Oral question headless compression screw
Hand oral
• When would you let this patient return to work?
A set of scaphoid views radiographs – No obvious fracture. • Depends on the job
Patient present with acute pain following a fall. • Desk based jobs can be returned to within 2 weeks if
comfortable but must avoid heavy lifting
• How would you assess this patient? • Heavy manual work may require 2–3 months
024
Hand oral 3: radiographs showing an established non-union Classification

• Why treat a scaphoid non-union? 1. Arthritic changes between the radial styloid and distal
• To decrease pain, reduce the risk of secondary OA, scaphoid
correct carpal kinematics and increase function 2. Degenerative process affecting the whole scaphoid fossa of
• How would you treat the non-union? the distal radius
• Preop work up with CT to assess size of the defect 3. Capitolunate arthritis (radiolunate joint spared)
• MRI can be used to assess vascularity of the proximal pole 4. Whole carpus involved
• What type of bone graft would you use?
• Need a discussion of different forms of autograft available
• Distal radius is within the operative field and avoid the Management
co-morbidity of other donor sites Stage 1
• Vascularized ‘vs’ non-vascularized
Radial styloidectomy and limited carpal fusion
• Iliac crest – Morbidity associated with it.
(scaphocapitate or scaphoid–lunate–capitate)
If the scaphoid proximal pole is necrotic it may be removed
after performing a limited arthrodesis between the distal
scaphoid and capitate and styloidectomy
Examination corner
Stage 2
Hand oral 1: Radiograph of a waist of scaphoid non-union
Approaches to the scaphoid – Both dorsal and volar Scaphoid excision and four-corner fusion
Proximal row carpectomy (not in younger patients due to
Hand oral 2: Radiograph of a scaphoid non-union post screw fixation risk arthritis)
• Discuss your management now? Stage 3
• Management based on patient symptoms and need
• If the screw is loose this would need to be removed to Scaphoid excision plus four-corner fusion is probably the
prevent further damage to joint surfaces procedure of choice as the head of the capitate is involved
• Need to assess size of the defect and presence of arthritis
• Discussion with the patient about possibly attempting Stage 4
bone grafting and further screw fixation Wrist arthrodesis
Hand oral 3: Radiograph of a complete waist of scaphoid fracture Four-corner fusion (FCF) vs proximal row carpectomy (PRC)39
(Herbert B2) Decreased need for immobilization and earlier recovery
• How would you manage this fracture? with a PRC
• This is a Herbert B2 fracture. Its management is contro- No concern with metalwork or risk of non-union with PRC
versial. Some surgeons would fix it and others would Tendency towards greater grip strength with FCF
manage it conservatively. The advantage of percutan- No difference in ROM
eous fixation is a faster return to work as suggested in
PRC produces an incongruent joint (capitate head has a
the paper by McQueen et al. in the JBJS 200834 and
smaller radius of curvature than the lunate fossa), and
I would discuss this with the patient
studies have shown degenerative change may occur.
Therefore, not recommended for younger patients
The present management for AVN is a vascularized bone
graft.
Examination corner
Oral question Hand oral 1: SNAC wrist in a 35-year-old manual worker
Discuss the nature and treatment of non-union and AVN. • What is the diagnosis?
• SNAC wrist
SNAC wrist • How do you classify this condition?
• Go through how the arthritis develops sequentially
With a non-union of the scaphoid, arthritis is likely to through each stage
develop at 5–10 years • What options could allow him to keep his manual job?
Patients commonly present after minor trauma with • Don’t forget simple things – Analgesics, splints and
wrist pain, having been previously asymptomatic. steroid injections.
Radiographs show a non-union with longstanding • Can try a wrist denervation
degenerative changes
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024
no direct muscle attachments and is linked by strong intrinsic

• Limited arthrodesis such as a FCF
• Alternatively can consider a PRC ligaments. It moves as a result of the forces applied to the distal
• How would you perform a four-corner fusion? carpal row causing relative movement at the midcarpal and
• Dorsal approach to the wrist radiocarpal joints.
• Berger capsulotomy
• Inspect the radiolunate joint surfaces to ensure a FCF is Intrinsic ligaments
reasonable The intrinsic ligaments have their origin and insertion
• Prepare the joint surfaces with osteotomes, curettage within the same carpal row
and rongeurs They are short stout structures, which are not amenable to
• Reduce the lunate angulation (usually extended in a DISI surgical repair
deformity) before fixation as this will affect the postop ROM
• Fixation
The distal row firmly binds all the distal carpal bones
together so that they move as one
Headless compression screws – Main difficulty can be The most important proximal row ligaments are the
getting the correct angle scapholunate ligament (SLL) and the lunotriquetral
Hubcap plate – Main difficulty is positioning the plate so it ligament (LTL)
does not impinge on the dorsal surface of the radius
Both these ligaments allow some (but not excessive)
Hand oral 2: SNAC wrist grade I in an asymptomatic 25-year old man
movement between the proximal carpal bones and
transmit forces along the row to ensure adaptive motion
• How would you manage this patient? Both these ligaments have three parts – Volar, proximal
• Advise this is a difficult problem and discuss carefully and dorsal portions. This leaves the distal portion of the
with the patient
articulation between the scaphoid and lunate, and between
• As surgery can make him symptomatic and risk of com-
plications advise non-operative management
the lunate and triquetrum free
• It is likely his arthritis will progress on radiographs but he Scapholunate ligament
may remain asymptomatic :
The dorsal portion provides the greatest yield strength
• Expalin part of the joint is already damaged and surgery and constraint to rotation, translation and distraction
at this stage has not been proven to prevent progression : The volar portion provides additional rotational stability
• What if this man was 65?
• Most would agree to leave this until he became
: Secondary stabilisers include the dorsal intercarpal
symptomatic (DIC), dorsal radiocarpal (DRC) and scaphotrapezial
(ST) ligaments
Lunotriquetral ligament
Carpal instability40–44 : In contrast to the SLL, the volar portion is the strongest
and thickest part of the ligament providing the greatest
Definition resitance to rotation, translation and distraction
Carpal instability is a term used to describe abnormal carpal : Secondary stabilisers include the ulnar segment of the
biomechanics under physiological loading owing to disruption ulnar arcuate, radiotriquetral and DIC ligaments
of the complex ligament system that controls the relative
motion of the bones that form the carpus. Extrinsic ligaments
The extrinsic ligaments connect the carpal bones to the radius
Carpal anatomy or metacarpals. They are stronger volarly. The dorsal aspect
ligaments are weaker and consist of radiolunotriquetral (RLT)
The biomechanics of the wrist joint are difficult to understand
and transverse ligaments (basis for the Berger flap42).
without first understanding some anatomy. The carpus is
composed of two rows of bones: The proximal row and the Space of Poirier
distal row. There are four joints at the wrist: DRUJ, radio-
There are no ligaments running from the centre of the distal
carpal, midcarpal and carpometacarpal.
end of the radius to the capitate and this leaves an area of
weakness over the front of the lunocapitate joint. A lunate
Distal row
dislocation or perilunate fracture dislocation is associated with
The bones in the distal row are: Trapezium, trapezoid, capitate a transverse capsular rent through this inherently weak region.
and hamate. They are bound together by strong interosseous
(intrinsic) ligaments and move together as a single unit.
Kinematics
Proximal row Kinematics involves the study of movements of a body
The bones in the proximal row are: Scaphoid, lunate and trique- without reference to the forces that are acting to cause that
trum. The proximal row moves as an intercalated segment. It has movement
024
Terminology
Elements of the official terminology for instability are complex
but it is critical to grasp them. They include:
Static – Constant
Dynamic – Intermittent
Dissociative – Between bones of the same carpal row
(e.g. DISI/VISI)
DISI Normal VISI
Non-dissociative – Between the proximal and distal rows
or between the proximal row and distal radius (e.g.
midcarpal)
Figure 21.12 Dorsal intercalated segment instability (DISI) deformity – Dorsal No universally accepted system exists for classifying carpal
angulation scaphoid with scapholunate angle >60° instabilities. Generally speaking, five patterns of instability
are described.
The wrist is a composite joint which requires movement in
both the midcarpal and radiocarpal joints to achieve a full Carpal instability dissociative (CID)
range of flexion and extension, with approximately half
Relates to instability between (or through) carpal bones of the
occuring in each of these joints
same row (either proximal or distal).
The proximal carpal row flexes in radial deviation and
extends in ulnar deviation Carpal instability non-dissociative (CIND)
The scaphoid has a naturally tendency to flex in contrast to Relates to instability between carpal rows or transverse osseous
the triquetrum which extends
segments and can be caused by ligament injury or bony frac-
This leaves the lunate as the link between these two bones ture (or both).
and so it essentially acts as a torque convertor
If the LTL is disrupted the lunate would tend to flex with Carpal instability complex (CIC)
the scaphoid and create a VISI deformity (Figure 21.12)
Combination of CID and CIND lesions or defying other clas-
If the SLL is disrupted the lunate would tend to extend with sifications that are called complex.
the triqetrum and create a DISI deformity Most frequently represented by the perilunate fracture
Isolated midcarpal joint motion occurs through a dart- dislocation and the volar lunate dislocation. Mayfield et al.
throwing motion plane – Radial devation with extension to classified this injury into four stages, progressing from radial
ulnar deviation with flexion. This may have a role in to ulnar43. They can be lesser arc (ligamentous) or greater arc
rehabilitation (e.g. following SLL reconstruction – Dart- (radial styloid, scaphoid or capitate fracture):
throwing exercises will move the midcarpal joint without
Stage I – Rupture of the scapholunate and
stressing the proximal row and, thus, the repair)
radioscaphocapitate ligaments
In contrast, isolated radiocarpal motion occurs with a
Stage II – Dislocation of the capitolunate joint
reverse dart-throwers action along the plane of extension
with ulnar deviation to flexion with radial deviation Stage III – Rupture of the lunotriquetral interosseous
ligament
Row theory Stage IV – Dislocation of the lunate
The proximal carpal row is interlinked by the interosseous In 95% of cases the capitate dislocates dorsally off the lunate.
ligaments and moves independently of the distal carpal row. In a volar lunate dislocation it passes through a weakness
between the volar extrinsic ligaments – The space of Poirier.
Column theory
The wrist consists of three longitudinal columns: The lateral Carpal injury adaptive (CIA)
column (scaphoid), which is mobile; a central column (capi- Another type of carpal instability is called adaptive and is the
tate, lunate), which provides flexion/extension; and a medial consequence of deformity in the distal radius from a fracture.
column (hamate, triquetrum), which allows carpal rotation. Therefore, it should correct with anatomical reduction of the
Each column provides a different type of wrist stability. fracture.
Oval ring theory
Compromise between the two above theories, in which the
Clinical features
carpus is considered as a ring. History
There has been disagreement between the various support- Mechanism of any injury (e.g. history of a sprained wrist
ers of each theory but it would appear that some wrists func- which fails to resolve)
tion more like rows and others more like columns. Aim to localize symptoms
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024
Pain with loading activities and weakness

Click or clunk on wrist movement
Swelling
Loss of function
Examination
Swelling
Localized tenderness (scapholunate ligament found just
distal to Lister’s tubercle)
Active and passive range of motion
Special tests
Specific provocative manoeuvres should be performed based
on the patient’s symptoms:
Pseudostability test – For midcarpal instability
Kirk–Watson’s test – Assesses scapholunate ligament
competence
Reagan’s ballottement test – For lunotriquetral instability.
Trap the lunate between the thumb and index finger of one
hand and the triquetrum in the other as the bones are moved
independently and in opposite directions to each other
Kleinman’s shear test – The examiner’s thumbs are placed
on the dorsal aspect of the pisiform and lunate, and the
bones are translated in an opposite direction with respect
to each other
Investigations
X-rays Figure 21.13 Radiograph showing marked scapholunate dissociation with
flexed scaphoid (ring sign), loss of carpal height and loss of the radioscaphoid
Carpal instability series: joint space (SLAC wrist)
PA/lateral view of the wrist (wrist in neutral)
Clenched fist PA view Cartilage surfaces
Scapholunate instability (Figure 21.13): Synovium
Scapholunate angle >60° Intrinsic and extrinsic ligaments
Scapholunate gap >3 mm (Terry Thomas sign) Relative stability/motion of the carpal bones to each other
Ring sign (end-on view of distal pole of flexed scaphoid) Presence of anomalous structures, entrapped or mechanically
Step in Gilula’s lines interfering tissues, scar and/or other blocking tissue
Static instability: The acronyms DISI and VISI refer to the static posture of the
lunate seen on a true lateral radiograph of the wrist.
If present will show up on the x-ray
A comparison of radiographic views of the contralateral wrist
Dynamic instability:
are essential because these findings may be noted in an asymp-
May not be seen even on the clenched fist view tomatic wrist and may represent a normal variant.
If you clinically suspect a ligament injury but the Kirk–
Dorsal intercalated segment instability (DISI)
Watson’s test and/or radiographs are negative, book the
patient for either an MR arthrogram or an arthroscopy When the lunate is extended or rotated dorsally in relation to
depending on your level of suspicion. the long axis of the radius and capitate the situation is called
DISI. The scapholunate angle is >60° (normal 30–60°,
Arthroscopy average 47°).
Causes include:
Allows direct visualisation of the radiocarpal and midcarpal
joints, and intrinsic ligaments (Geissler classification for SLL injury
scapholunate instability). Dynamic stress tests can also be Scaphoid fracture
performed (although not with physiological loading). Arthro- Kienböck’s
scopy allows the assessment of: Perilunate injury
024
Volar intercalated segment instability (VISI)

When the lunate is flexed and the scapholunate angle is <30° Examination corner
the situation is called VISI. It is much less common than DISI
Hand oral: Radiographs demonstrating perilunate and lunate
and is most commonly caused by lunotriquetral ligament injury. dislocations
NB. These are really quite common in either the hand or
Management trauma oral. This is a spot diagnosis that you really must be
Scapholunate ligament injury able to recognise without any prompting from the examiners.
Mention that you need to see two views – AP and lateral – And
Acute be prepared to discuss surgical approaches and treatment
Early open repair through a dorsal approach by direct suture, options.
pull-through sutures or suture anchors. Supplemented by You are called down to the A&E department because a
K-wire stabilisation of the scapholunate and scaphocapitate motorcyclist has come off his motorbike at high speed and
articulations. Delayed open repair can be performed up to landed on his right wrist. The casualty officer has asked you
6 months after acute injury. to look at this x-ray to see if there is a fracture present
: This is a PA radiograph of the right wrist. The most
Chronic obvious feature is a break in Gilula’s lines about the
wrist; the carpus is foreshortened with overlapping of
Surgical procedures are classified as either bony or soft tissue
the proximal capitate and distal lunate margins. There
Soft tissue: Excellent results have been reported for a is radial displacement of the fractured scaphoid with
modified Brunelli procedure (FCR tenodesis)44. Dorsal the distal carpal row. I would want to get a lateral
capsulodesis (Blatt capsulodesis) has fallen out of favour radiograph to confirm my suspicion
Bony procedures: Limited wrist fusion, such as the This is his lateral x-ray
scaphotrapeziotrapezoid fusion (STT), to correct DISI. : The lateral radiograph confirms a dorsal trans-scaphoid
These procedures can be technically difficult and perilunate fracture dislocation of the carpus. The lunate
demanding lies in a neutral position within the lunate fossa, in line
with the radius. The distal poles of the scaphoid and
Lunotriquetral ligament injury triquetrum have displaced dorsally. The longitudinal
axis of the capitate lies dorsal to the longitudinal axis of
Rarely recognised acutely but, if so, then perform acute open the radius
repair of the ligament. The scaphoid and lunate are both : (if the lunate is displaced there is a ‘spilled teacup’
flexed, leaving the triquetrum extended. VISI due to CID. sign – The lunate is volarly rotated and displaced
Chronic symptomatic lunotriquetral instability should be resembling a spilled teacup.)
treated by either lunotriquetral fusion (high rate non-union),
FCU tenodesis or an ulnar shortening.
• How will you manage this injury?
• After a thorough neurological examination the patient
Acute perilunate dislocation
needs to be taken urgently to theatre for reduction of
Emergency treatment is closed reduction with open repair of this injury. Internal fixation can be performed at a later
the ligaments possibly when the swelling has settled. stage when swelling has settled, using a dorsal approach
to visualize the scapholunate ligament, but a volar inci-
Closed reduction sion may also be required. Plaster immobilization is
Dorsal perilunate dislocation – Hyperdorsiflex the wrist, necessary for 6 weeks while the ligaments heal. In the
apply traction and try to hinge the capitate head on to the long term, I would be concerned about avascular necro-
lunate before flexing the wrist. Likely to reduce because of sis of the proximal pole of the scaphoid.
extensive soft-tissue injury
Volar lunate dislocation – Hyperdorsiflex the wrist, apply
pressure on the lunate to reduce and flex the wrist. May not Scapholunate advanced collapse (SLAC wrist)
reduce in a closed procedure. If open reduction is required
for volar lunate dislocation use an extended carpal tunnel
Background
incision Progressive arthritis caused by scapholunate interval disrup-
tion with a flexion deformity of the scaphoid.
ORIF
All injured structures (radial styloid/scaphoid fracture, Pathology
scapholunate ligament injury) can be repaired through a SL ligament disruption allows the lunate to extend and the
dorsal approach, although a carpal tunnel release may be scaphoid to flex (a DISI deformity), thus, reducing carpal
required height. Arthritis develops initially at the radial styloid due to
K-wires are used for bony stabilisation flexion of the distal scaphoid (see Figure 21.11). The proximal
467
024
pole behaves like a ball and socket joint and only develops Proximal row carpectomy
degenerative change at a later stage. The capitate migrates : Best motion (60% normal), worst grip strength and
proximally through the widened scapholunate interval (loss pain relief. Technically less demanding
of carpal height), leading to capitolunate arthritis. The radi-
olunate joint is spared as it is a ball and socket joint, and lunate Stage 3
extension still allows concentric loading of the lunate fossa of Scaphoid excision and FCF
the distal radius.
Scapholunate interval – >2 mm Stage 4
Carpal height ratio – Used to assess carpal collapse. Ratio of Wrist fusion
carpal height to the length of the third metacarpal
determined on a PA radiograph. The normal value for carpal
: Best pain relief, good grip strength but loss of motion.
Immobilize the wrist for a couple of weeks in plaster
height is >0.54 (0.46–0.61)
beforehand to see how the patient gets on. Position of
Ring sign – Cortical silhouette of the flexed scaphoid
wrist fusion is slight )extension (20°)
tuberosity seen on PA view
Scapholunate angle – Long axis of the scaphoid in relation
to the long axis of the lunate. Average 47°
Examination corner
Capitolunate angle – 0–15°
Hand oral: PA and lateral radiographs demonstrating scapholunate
Classification of SLAC wrist dissociation with obvious Terry Thomas sign
Watson has classified SLAC wrist into four stages: • What are the various radiographic features of carpal
instability?
Stage 1: Arthritis between the scaphoid and radial styloid
• Widening of the scapholunate interval (>3 mm Terry
Stage 2: Arthritis between the scaphoid and entire scaphoid Thomas sign is so-called because of the comedy actor
facet of the radius who had a large gap between his two front teeth).
Stage 3: Stage 2 plus arthritis between the capitate and lunate Increased scapholunate angle (>45°) in the lateral view.
Stage 4: Generalized arthritis Cortical ring sign of the scaphoid in the PA view –
Caused by a volarflexed scaphoid. V-sign of Taleisnik –
Management of SLAC wrist Refers to the volar silhouette of the palmar flexed scaph-
oid and radius seen on the lateral view. Discussion on
Non-operative management followed.
Indicated if symptoms are minor/minimal. Advice, • Which ligaments give secondary support to the SLL?
analgesia, wrist support, etc • Dorsal intercarpal
• Dorsal radiocarpal
Surgical • ST ligament
Options for surgical treatment are based on the stage of the • How would you treat this if this was 4 weeks post injury?
disease • This is at a stage when repair may still be possible.
• May arthroscope wrist first to assess
Stage 1 • Open repair through a dorsal approach
• How would you treat this if the patient was 6 months
Radial styloidectomy ± scaphoid stabilisation (STT fusion)
post injury?
± capitolunate fusion
• Likely beyond repair stage – Now a question of recon-
: Technically demanding; must adhere to strict surgical struction – Depending on patient’s symptoms.
details (Kirk–Watson); results can be unpredictable; • Still do wrist arthroscopy first to assess and look for any
excessive resection can result in wrist instability and degenerate changes.
ulnar translocation
Stage 2 Wrist arthroscopy

Scaphoid excision and four-corner fusion This is primarily a diagnostic modality that can help
: If it unites (non-union 7%) a good result is maintained locate sources of wrist pain when other modalities have
in the long term and some wrist movement is preserved failed to do so. It can also be used for a range of therapeutic
(50% normal). Performed through a midline dorsal procedures such as debridement, washout for sepsis, TFCC
incision and scaphoid used as the bone graft. repairs, arthroscopically assisted distal radius fracture fix-
Incomplete reduction of the dorsiflexed lunate may ation, ganglion excision, as well as carpal bone excision and
result in limitation of wrist extension. A spider plate is ligament repairs. Most of the therapeutic treatments are still
introduced to improve results seen with K-wires/ in the developmental stages and are not currently
staples. However, studies have not yet shown this mainstream.
024
Setup Fibroblastic (collagen) 5–28 days

Patient supine :
Fibrobasts begin to rapidly proliferate and produce
Hand suspended from finger traps (two to four fingers collagen type 3, proteoglycans and components of the
included) extracellular matrix
Elbow flexed at 90° with an inflated tourniquet : Random alignment
traction Remodelling (cross-linking) >28 days
Portals
: Cellularity begins to decrease
: Decrease in collagen type 3 production
Access is predominantly from the dorsal surfaces with the : Collagen fibres begin to orientate along the tendon
portals named after the relationship to the extensor
parallel to the direction of stress
compartments
3–4 portal is the main access point to the radiocarpal joint
: Connections between collagen fibres to increase
strength
and can be found by palpating the ‘soft spot’ just distal to
Lister’s tubercle
A 4–5 or 6R portal is often secondarily introduced for Contraindications to repair
instruments. This is best done initially with a needle and Wounds liable to infection
checking with the camera from the 3–4 portal that the Uncooperative patient
access point and angel are correct
There are two 6 portals – 6R (radial) and 6U (ulnar) named Zones
in relation to the ECU tendon Kleinert and Verdan classified flexor tendon injuries according
Midcarpal portal is usually a less well defined soft spot to the anatomical zone of injury:
approximately 1 cm distal to the 3–4 portal. This is the
Zone 1: Distal to FDS insertion
midcarpal radial portal – A more ulnar portal can be
Zone 2: Bunnell’s ‘no man’s land’. From A1 pulley to FDS
created again initially with a needle
insertion. FDS and FDP tendons are enclosed in a flexor
A 2.7 mm 30°angled arthroscope is usually used for
sheath
arthroscopic purposes
Zone 3: Distal edge of flexor retinaculum to A1 pulley
Zone 4: Within the carpal tunnel
Flexor tendon injuries45–47 Zone 5: Proximal to the carpal tunnel
Types of injury There are similar but less specifically described zones for the
It is important to know whether the finger was flexed or thumb, prefixed by T:
extended at the time of injury as this the position of the hand Thumb T1: FPL insertion to A2 pulley
at the time of injury determines tendon retraction40. Thumb T2: Zone 1 to distal part of the A1 pulley
Flexed fingers – Distal tendon retracts Thumb T3: Zone 2 to carpal tunnel
Extended fingers – Proximal tendon retracts
Management
Biology of healing The optimal suture material, number of strands and repair
technique are still debated amongst hand surgeons
Intrinsic healing is the formation of collagen bundles directly
The aim is to provide a repair that provides sufficient
across the injury site. Extrinsic healing involves the formation
strength to allow early postoperative mobilization and
of a layer of scar tissue surrounding the injury site and can lead
minimize gap formation whilst trying to prevent further
to adhesions. Aim for ‘no-touch’ technique to prevent damage
damage to the tendon and adhesion formation
to tendons and adhesion formation.
Technical aspects
The repair is weakest at 6–12 days.
: Number of strands
Stages of healing – Increasing the number of strands across the repair
Inflammatory (cellular) 0–5 days site increases the strength of the repair
: Haematoma formation at the site of injury – The more strands means a bulkier repair which can
: Platelets release vasodilatory chemokines and inhibit gliding
chemotactic factors – The more strands means potential further tendon
: Migration of inflammatory cells particularly damage from increased handling
neutrophils and macrophages – Currently most repairs provides a minimum of four
: Phagocytosis of necrotic tissue and clot strands
469
024
: Position of core suture Aim to mobilize early (48 h postoperatively) to prevent

adhesions
– Position dorsally within the tendon increases
As little as 1.6 mm of tendon excursion can prevent
strength possibly as this is the tension surface of the
clinically important adhesion formation
tendon when the finger is flexed
Most patients will be put into and active ‘place and hold’
– The core suture should pass 1 cm from the repair
regimen rather than a traditional passive ROM regimen
site. This has shown increased strength in contrast
to shorter distances. This is probably due to the A randomised control trial by Trumble in 2010 found that
increased risk of suture pull-through form shorter patients that underwent active motion had significantly
distances fewer flexion contractures, better satisfaction scores and
improved ROM than passively rehabilitated patients.
: Epitendinous suture Importantly there was no difference in the tendon
re-rupture rate47
– Helps to tidy the repair site and improve gliding
– Improves the overall strangth of the repair
Complications
: Locking loops rather than grasping loops have Re-rupture
increased breaking strength, reduced gapping and fewer Infection
incidents of suture pullout Adhesions
: Minimal handling Joint contractures – Too tight a repair or from prolonged
splintage
– The less the tendon is handled and further damaged
the less risk there is of adhesion formation Bowstringing – From damaged pulleys
: Actual repair techniques Reconstruction

– There are multiple ones described (make a decision Defined as a delayed primary repair performed >3 weeks after
as to the one you will use, why and be able to injury. Contracture of the muscle–tendon unit has usually
draw it) occurred and a tendon graft is often required. It can be carried
– Examples are Kessler, modified Kessler, Strickland, out as a one-stage or two-stage procedure.
Bunnell and Adelaide Prerequisites for tendon reconstruction:
Motivated patient
Technique Adequate skin and soft-tissue cover
: The repair should be carried out as early as possible Full passive range of movement of joints
after the injury Adequate sensation and circulation of finger
: Apply a tourniquet and regional anaesthesia or a
general anaesthetic Methods
: Make a Brunner or midaxial approach and use windows Delayed direct repair
between pulleys Single-stage flexor tendon grafting
: For retracted tendons try to milk the tendon with the Two-stage grafting
wrist/digits flexed Tenodesis or arthrodesis
: If this fails, make a small transverse incision at the level Amputation
of the distal palmar crease just proximal to the A1
pulley. Pass a Silastic cannula from the distal wound Two-stage flexor tendon reconstruction
through the sheath to the proximal wound. Attach a First stage
catheter to the proximal end of the tendon and pull Aims:
through to the distal wound
Tenolysis and release of joint contractures
: Use 3/0 non-absorbable sutures for core suture and a 6/
Digital nerve repair or grafting
0 monofilament for a circumferential epitenon suture
: Close the sheath, if possible Provide healthy skin (may require a flap)
: For zone 2 injuries it is recommended that both Full flexion on traction of the Silastic rod at the wrist
tendons are repaired Preserve A1, A2 and A4 pulleys
Second stage
Rehabilitation Carried out 2–3 months after first stage. Tendon graft options
There are many variations on the rehabilitation and it is include:
worth spending a couple of hours with a therapist to see Palmaris longus
what regimen they use Plantaris – Medial to tendo-Achilles
024
Long toe extensors – second, third or fourth toes • Tension free repair
EIP • Repair under magnification/microsope
Fascia lata • Fine suture, e.g. 9–0
• What are the clinical signs of re-innervation of a nerve?
Flexor pulley reconstruction • Tinel’s sign
• Improving sensation
Indicated if bowstringing of flexor tendons causes a • Sweating
functional problem with loss of flexion of digit
This is required after rupture or iatrogenic damage to A2 Hand oral 2: flexor tendon injuries
or A4 pulleys
• Show me how you examine a injured hand?
Can use a free tendon graft of FDS passed under extensor • What are the results of flexor tendon repairs?
tendon and neurovascular bundles at the level of the • Discuss the rehabilitation regimes: Kleinert, Duran and
proximal and middle phalanges Belfast
• Are there any particular problems with Kleinert rehabili-
FDP avulsion injuries tation (PIP joint stiffness)?
Caused by forced extension of a flexed DIPJ
Hand oral 3: clinical picture of a hand with all fingers in resting
Classification (Leddy) posture except the middle finger in full extension
I – Tendon end in palm. Rupture of vinculae
• What is the diagnosis?
II – Tendon held at level of PIPJ by long vinculus • FDP rupture
III – Held at A4 pulley by avulsed bony fragment • What other structures would you check?
IV – Profundus avulsed off bony fragment • FDS
• Digital nerve and artery
Management • Check the digital artery supply on the examiner’s
In types I and II, extensive trauma and complications of fingers.
adhesions and the quadriga effect are seen. DIP joint fusion • Perform an Allen’s type test on the digit
should be considered. Type III requires ORIF and the frag- • Also be prepared to demonstrate assessing for the
ment can be held with sutures that are passed through the digital nerve
distal phalanx and then tied on to a button on the nail. Pin-prick/2-point discrimination are fine
Slide a pen down the side of the digit (absence of
sweating in a cut nerve)
Examination corner • What repair would you use?
• Decide beforehand and be able to justify (see
Hand oral 1: Clinical photograph of a hand with a 3- to 4-cm above text)
horizontal laceration over the ulnar side of the distal palm • Draw the repair on a piece of paper.
• What structures could be damaged? • This is a must - amazing how many candidates can’t
• Be systematic. State this is a laceration over the volar draw it
aspect of the distal palm • What evidence have you for that repair?
• You would be concerned about the flexor tendons (both • See above notes
FDS and FDP at this level), the ulnar digital nerve and the • How would you rehabilitate the patient afterwards?
radial digital/common digital nerve, the radial and ulnar • There are so many regimens – The key is to whether you
digital arteries. are going for early active mobilization. That relies on a
• How would you extend the wound? co-operative patient. Otherwise can do delayed mobil-
• The wound needs to be extended in a way that allows ization but early active yield better results. Best to know
assessment of all these structures AND the potential what your therapists do and go through that – Most are
need for repair as such they will require longituinal variations on the Belfast
extensions probably in a Brunner type fashion
Hand oral 4: oatient presents with an inability to flex the thumb
• What are the principles of tendon repair?
several months following volar plating for a distal radius fracture
• Minimal further damage to the tendon or sheath
• Need to create windows within the sheath for repair (as • What is the diagnosis?
needed) without risking bowstringing • FPL rupture
• Grasp the tendon in one spot only. • Why has this happened?
• The need for both core and epitendinous sutures (have • Usually attritional rupture over the plate or screw
decided which and why you will use the one you do) • What are the treatment options?
• What are principles of nerve repair? • Removal of the plate
• Debride devitalized tissue • Tendon reconstruction/transfer (using FDS ring finger)
• Mobilize each end of the nerve • or IPJ fusion
471
024
Thumb amputation Background

Underestimated injury
Examination corner
Hand oral: Clinical photograph of thumb amputation Urbaniak classification
A patient arrives in casualty with this injury. What is your Class 1
management?
Circulation adequate, circumferential laceration
History Standard bone and soft-tissue management
Age, occupation, hand dominance
Mechanism of injury Class 2
Pre-existing hand problems Circulation inadequate
Ischaemia time (warm – 6-h hand/12-h digit, cold – 12-h
hand/24-h digit)
:
A – No additional bone, tendon or nerve injury
Current medication :
B – There are additional injuries present
Previous medical history :
Vessel repair (microvascular) is required
Hobbies In general, class 2B injuries may be better treated with
Smoking amputation
Tetanus status
Class 3
Examination
Complete degloving of skin ± amputation through the
Level of injury
DIPJ. These injuries are unlikely to gain adequate function,
Amputated part
Degree of crush/avulsion and amputation is usually required
Quality of skin and soft tissues The most common complication following surgical
Degree of contamination reconstruction is cold intolerance
Investigations
Radiographs of the hand and injured part Examination corner
Hand oral 1: Clinical photograph of ring finger ring avulsion injury
Management
Absolute contraindication for reimplantation include: • Classification?
Life-threatening concomitant trauma • Urbaniak and then outline the different classes
Severe premorbid disease • When would you consider an amputation?
Severe injury to the digit – Extensive degloving, gross • Class 2B and 3
contamination • What is the prognosis?
Relative contraindications: • Depends on the severity
Lengthy warm ischaemia time • Worsens in the greater classes
Elderly with microvascular disease • Cold intolerance, stiffness and swelling are not
Uncooperative patient uncommon
Surgical options
Refer to experienced hand surgeon or the plastic surgeons if
not experienced in dealing with this type of injury41,42
Mallet finger49,50
Primary closure This is another favourite FRCS (Tr & Orth) question in either
Reimplantation the hand or trauma oral.
Thumb reconstruction
: Wrap around procedure Definition
: Great toe transfer
: Second toe transfer procedure A mallet finger deformity is characterized by loss of
extension at the DIPJ
They are typically closed injuries but can be caused by a
Ring avulsion injuries48 laceration
The mallet can be either a tendon tear or bony from an
This is a topic that under normal circumstances one would
avulsion fracture
briefly skip over during the course of preparation for the FRCS
(Tr & Orth) exam. You need to be reasonably familiar with Mechanism of injury is thought to be forced flexion
this one as it tends to be asked more often than you would of the DIPJ (e.g. a ball striking the tip of an extended
normally expect. finger)
024
Management High-pressure injection injuries52

Tendinous mallets These are rare but severe injuries that should be treated as a
: treat non-operatively in an extension splint surgical emergency
: A wide variety of splints are available – Stack splints, The non-dominant hand is more commonly affected
aluminium and thermoplastic splints. A randomized They occur when equipment, capable of reaching pressures
control trial50 found no difference in final extension lag greater than the skin can withstand, injects its contents into
following treatment. However, care has to be taken over the human body
skin maceration from sweating and often a custom- The skin can withstand 7 bar whereas some of the
made splint may help to reduce this equipment causing these problems can exceed 2500 bar
: Treat in the splint for 6–8 weeks Paint is thought to be more toxic than grease. Extensive
: If there are soft-tissue complications from the splint soft-tissue necrosis occurs despite an often small entry
or non-compliance is a problem then a percutaneous wound. The extent of spread depends on the site of entry,
K-wire can be put across the DIPJ anatomical barriers and the volume and pressure of the
Bony mallet substance injected. Material readily passes along tendon
: most can be managed non-operatively unless the joint sheaths as these offer the pathway of least resistance
is subluxed or possibly a displaced fragment involving Clinical evaluation
>1/3 of the joint : History
: For those with joint subluxation attempt a closed – Presure of the gun
reduction and percutaneous K-wire. If that fails, be
prepared to perform an ORIF with either dorsal – Material injected
blocking wire and K-wire across the DIPJ or a suture – Volume injected
anchor – Distance from gun to extremity
The results of both non-operative and operative treatment – Pain may not be present intially
are not always satisfactory, with only 30–40% of patients : Physical examination
regaining full extension the DIPJ
However, the residual extansion lag in most patients is a – The whole extremity
cosmetic rather than a functional problem – Look for entry and, if present, exit wounds
– Careful N/V assessment of the digits and hand
Chronic mallet finger – Tendon involvement
Initially treat with mallet splint for 6 weeks – Presence and location of crepitus
If this produces no benefit and the patient is requesting : Radiological assessment
treatment, book for DIPJ fusion
– Radiodense materials can easily be seen and the
51 extent located on plain radiographs
Fingertip injuries
Either soft tissue or bony Management
The principle is to achieve a well-healed fingertip and to :Broad spectrum antibiotics
preserve length :Tetanus
If there is no exposed bone, treat non-operatively with :Urgent surgical exploration, debridement and
Tegaderm dressings, especially in children fasciotomy
If there is exposed bone this needs soft-tissue coverage. : The wound is excised and extended proximally and
Options distally until the full extent of spread is revealed and as
: Shorten the bone end and Tegaderm dressings or much material and non-viable tissue as possible is
primary closure removed
: Local flap coverage (Atasoy, Cutler, cross-finger) : Repeat debridement at 48 hours should be done
: Terminalisation – Indicated for a severely crushed distal : The hand is splinted and elevated in the position of
phalanx, and is made through the DIPJ with trimming safety
of the condyles of the head of the middle phalanx Aggressive treatment has reduced the amputation rate,
The nail plate lies beneath the nail and is responsible for its with most patients returning to their original work
growth. If there is a crush injury possibly involving the nail Digital injections are, however, followed by high rates of
bed, the nail should be removed and the nail bed explored necrosis and amputation, and there is long-term morbidity
and repaired as appropriate in surviving digits
473
024
Examination corner Function – Sacrificing existing function should be kept to a

minimum or the function to be gained must be
Hand oral 1: Clinical slide of a pressure injection
significantly more desirable than that lost
• How would you assess this injury? Sufficient amplitude – The transferred muscle–tendon unit
• History and physical assessment as detailed above needs amplitude (i.e. excursion) to produce the movement
• What are the principles of management? required. Tendon excursion is propotional to the muscle
• Emphasize surgical emergency fibre length. It can determined by the amount a muscle can
• Broad spectrum antibitoics and tetanus be stretched from its resting position, plus the amount it
• Exploration and debridement contracts. The amplitude is typically 33 mm for wrist
flexors/extensors; 50 mm for finger extensors and 70 mm
for finger flexors
Compartment syndrome Adequate strength – The muscle-tendon unit must be able to
Decreased tissue perfusion in a myofascial compartment generate sufficient strength to undertake its action. The force
leading to muscle necrosis and contractures is proportional to the cross-sectional area of the muscle.
This condition presents with severe pain and can be caused Power is force × distance. The power of a donor muscle will
by any injury that either decreases compartment volume or reduce by one MRC grade after transfer and, if a weak donor
increases compartment content such as: is chosen, it may be too weak for useful function after
:Tight casts and dressings transfer. Therefore, only grade 4 or 5 muscles should be used
:Burns Synergistic action – The transferred tendon works best if
:Trauma the preoperative function is synergistic with its desired
:Reperfusion after replantation action after the transfer, as it will be more readily
integrated into normal hand use and easier to rehabilitate
Hand – Treat by prompt decompression through two
dorsal incisions (over the second and fourth metacarpals Direction – Best if the tendon runs in a straight line, which
for interossei), carpal tunnel release ± midlateral incisions permits it to exert its maximal effect. This is not always
over the hypothenar and thenar eminences, and midlateral possible and some transfers need to go through a pulley or
release to digits through the interosseous membrane in the forearm. This,
however, will weaken the action of a tendon transfer
Only one transfer for one function per motor unit
Tendon transfers53
In the oral just relax, take a deep breath in and answer the
question.
Operative technique
Multiple short transverse incisions
Careful tendon handling
Definition Correct tension
A tendon transfer is the use of a functioning muscle–
tendon unit to restore function in a non-functioning
muscle or tendon Joining the tendons
There are a number of options – Any can be used
Indications End-to-end anastomosis (allows for a good line of pull for
the donor)
Permanent nerve injury
End-to-side (allows for recovery of the recipient muscle-
Ruptured or avulsed tendon or muscle
tendon unit – When this may be anticipated)
Neuromuscular disease
Side-to-side
The options of nerve reconstruction, tenodesis and
arthrodesis have been considered Tendon weave procedures
: Pulvertaft weave (concerns over propogation of slits
Principles of tendon transfers :
and adjusting tension)
Spiral linking
Surgeons planning tendon transfers need to adhere to the
following principles whilst tailoring the surgery to the needs
: Lasso
and requirements of the indiviudal patient. : Loop-tendon suture
Motivated patient
Full passive range of movement of joints Transfers for specific lesions
Adequate tissue bed – The soft tissues must be adequate to There are numerous transfers described in the literature. It is
allow tendon gliding, ideally on a fascial plane. Tendons do unnecessary to know them all. We present classic transfers for
not glide well through scar tissue or under skin grafts median, ulna and radial nerve palsies
024
Median nerve – Low lesion (wrist) : An alternative option is the FDS from middle
A low median nerve palsy results in loss of thumb and ring fingers using a slip of each tendon to a
abduction and opposition single digit
Many patients may have a function thumb with residual
function provided by the dual innervation of FPB and
continued function of adductor pollicis and flexor pollicis Examination corner
longus Hand oral 1
Each patient should be assessed on an individual basis to
• What are the indications for a tendon transfer?
see if transfer is of benefit • Permanent nerve injury
To get appropriate line of pull for the transferred tendon a • Ruptured or avulsed tendon or muscle
pulley is often required on the ulna side of the wrist • Neuromuscular disease.
:Extensor indicis to APB which is divided at the MCP • The options of nerve reconstruction, tenodesis and
joint, passed proximal to the extensor retinaculum and arthrodesis have been considered
• What are the prerequisites for a tendon transfer?
rerouted around the ulnar side of the wrist and then
• Motivated patient
subcutaneously onto the APB
• Scar free bed
: Ring finger FDS is transferred to APB via pulley in the • No infection
FCU tendon • Function to be gained is more useful than that lost
: Abductor digiti minimi to APB insertion (Huber • Full joint ROM preop
transfer). Care must be taken not to damage the • Amplitude
tenuous blood supply and innervation during this • Strength
transfer • Synergistic tendon where possible
: Transfer palmaris longus and a strip of palmar • Minimal change in direction
• One transfer for one function
aponeurosis to APB (Camitz)
• Are there any tendon transfers you are familiar with?
± MCP or IP fusion • Start simple
These tendon transfers allow the thumb to be placed in a • EI to EPL
more functional position with some dynamic control • Radial nerve palsy – Easier in terms of loss of function
and the transfers done
Median nerve – High lesion (elbow)
The deficit is as for low lesion plus loss of flexion of the Hand oral 2
index and middle fingers • A picture of a patient unable to give a ‘thumb’s up’
Thumb flexion • What is happening here?
:Brachioradialis is the transfer of choice • EPL rupture
• How does the EPL rupture?
:ECRL and ECU are alternative options
• Most common following distal radius fractures
Index ± middle finger DIPJ flexion • Why is it more common in undisplaced distal radius
:Most common is to suture all four FDP tendons fractures?
together in the forearm (this does not increase grip • Increased pressure within the intact third extensor
strength) compartment which causes ischaemia to the tendon.
: An alternative is to transfer ECRL around the radial Classically ruptures several weeks after injury.
• Displaced fractures are thought to cause damage to the
side of the forearm onto the index FDP and possibly
third compartment reducing pressure on the tendon so
also onto the middle finger FDP ischaemia does not occur.
: The ECRB more centrally based than ECRL so • What are the treatment options?
produces wrist extension without radial deviation • Leave it alone
Thumb extension • EI to EPL tendon transfer
:Palmaris longus to EPL • Arthrodesis.
• How can you tell preoperatively the patient has an EI to
:If palmaris longus is absent then use FDS from middle transfer
or ring finger • Pointing with the index finger and the other three digits
Finger extension flexed means EDC is not working and has isolated EI
: FCR/FCU (through interosseous membrane) to EDC • Describe EI to EPL indicating on the examiner’s hand
: Avoid using FCU when ECRL is still functional (as in a where you would make your incisions?
• Transverse over neck of index metacarpal and fourth
PIN palsy) as this can cause excessive radial deviation in
extensor compartment at the wrist crease and then a
the wrist
475
024
longitudinal incision over the EPL tendon along the Aetiology

thumb metacarpal. Exact aetiology is unclear
• How would you joint the two tendons together? Whether tightness of the fibrous tendon sheath results in
• Pulvertaft weave using a 4–0 PDS to hold the two ends
inflammation and narrowing of the sheath, or
together once correctly tensioned.
degeneration of the tendon results in tendon enlargement
• How would you rehabilitate the patient?
• 3–4 weeks in a splint preventing tension on the repair and nodule formation remains unclear
then gradual ROM and then strengthing Indeed, both may occur in response to inflammation
Often follows trauma or unaccustomed activity
Hand oral 3
• What deformities and patient difficulties are seen with a Management

high radial nerve palsy? Steroid injection
• Wrist drop and inability to extend fingers or thumb
• What are the typical causes of a high radial nerve palsy? :
Place the needle into the tendon and then withdraw
• Humeral shaft fracture slowly until the injection can be easily placed as this will
• Saturday night palsy be within the sheath and not the tendon
• What are management options for this palsy? : Multiple injections into the same digit are a risk factor
• Splints for tendon rupture
• Nerve repair ± grafting (where indicated) : Success rate is about 80% in idiopathic cases and 60% in
• Tendon transfers diabetics
• What tendon transfers are you aware of for this palsy?
• Pronator teres for wrist extension
: Less likely to be effective if symptoms have been present
for >6 months
• Palmaris longus to EPL
• FCR to Finger extensors : Patients should be warned about flare reaction, fat
atrophy and skin depigmentation
: Diabetics may observe a transient rise in serum glucose
Trigger finger54 levels
Open surgical release
Background : Indications
Also known as digital tenovaginitis or stenosing
tenosynovitis – Locked digit
Swelling of the superficial and deep flexor tendons at the – Failure to respond to two injections
entrance to the A1 pulley : Performed as a day case under LA and tourniquet
The ring finger is most commonly affected followed by the : Warn about digital nerve injury (particularly the thumb
thumb, middle, index and then little finger radial digital nerve) and recurrence
It is associated with underlying conditions such as diabetes, : Technique
rheumatoid arthritis and gout
Idiopathic trigger finger is up to 6 times more common in – Oblique or longitudinal (over the metacarpal head)
women than men, and is most prevalent between ages 40 or transverse incision over the distal palmar flexor
and 60 crease
– Blunt dissection
Clinical features – Identify the proximal edge of the A1 pulley and
release the proximal 1 cm of the pulley
Clicking
– If the A2 pulley is released this can result in
Pain can be on both active and passive movement
bowstringing
May demonstrate triggering
A tender nodule may be palpable at the level of the A1 pulley : The most common complication of open release is
May have a secondary PIPJ contracture digital nerve injury
: Diabetes is a poor prognostic indicator, they typically
Classification have multiple digitis involved and are especially prone
to develop stiffness following surgical release
1. Mild crepitus
2. Abnormal movement
3. Clicking/triggering but not locking Oral question
4. Locked but passively correctable How does the management of a trigger finger differ in a
5. Locked and not passively correctable rheumatoid patient?
024
Causes of a flexion contracture :

Most occur sporadically although multiple
enchondromas are seen with Ollier’s disease and in
Congenital – Camptodactyly
Maffucci’s syndrome occur with haemangiomata
Skin – Scar contracture
Lipoma
Fascia – Dupuytren’s disease
Neurilemmoma
Flexor tendon sheath – Fibrous contracture
Tendon – Subluxation from sagittal band rupture, extensor :
Schwann cell origin and encapsulated so can be shelled
tendon rupture, locked trigger finger out of nerve
Capsular structures – Volar plate shortening Glomus
Block to extension – Arthritis, osteophytes :Pain, tender and cold intolerance
If the finger is locked in flexion exclude: :Tumour of perivascular temperature-regulating
Infection – Kanavel’s signs bodies
Arthritis : Fifty per cent subungual. MR can be useful. Treat by
excision
Sarcoma
Examination corner Acrometastasis – Metastasis to a digit. Very rare.
When metastases are seen below the elbow they are
Hand oral 1: Clinical photograph of a hand with one of the fingers
flexed into the palm (ring or middle)
mainly lung with renal and breast accounting for most of
Spot diagnosis the rest
• What is the diagnosis?

• Most likely to be trigger finger
• What is the differential diagnosis?
Squamous cell carcinoma of the skin
• Consider Dupuytren’s, PIPJ contracture, trauma over a finger digit
• Also scar contracture, congenital, arthritic This is one of those esoteric questions that may appear in the
• What conditions are associated with trigger finger?
FRCS (Tr & Orth) hand oral. They always seem so straightfor-
• Diabetes, RA, gout
ward afterwards (when discussing them with colleagues) but,
• What is the management?
• Many respond to steroid injections though this is lower for the unprepared candidate in the heat of the exam, you can
in diabetics certainly struggle with them.
• When would you perform open release? A clinical photograph in the hand oral is essentially a spot
• Failure to respond to injection diagnosis. You may be asked a list of likely causes, investi-
gations and management.
Risk factors for SCC
Tumours of the hand :
UV
Differential :
Ionizing radiation
Ganglion (see earlier)
:
Genetic predisposition (e.g. Xeroderma pigmentation)
Giant cell tumour of tendon sheath (pigmented
:
HPV infection
villonodular synovitis, xanthoma) :
Chronic inflammatory disorders
:
Second commonest soft-tissue tumour of the hand
:
Chronic scarring or ulcers
Diagnosis
:
Firm swelling on volar aspect of the digits
:
20% arise from joints, and bony erosions are seen in 10% :
An erythematous scaly plaque or nodule that may be
ulcerated or exophytic
:
Treat by excision, with a recurrence rate of 10%
: Usually itchy and bleeds easily
Epidermal inclusion cyst
: Usually on the dorsal surface of the hand (rare on
:
Generally seen on the volar aspect with a small wound the palm)
on close inspection : Subungual SCCs are uncommon but a paronychia
: Painless failing to respond should be biopsied
Enchondroma Management
: Benign hyaline cartilage tumour found in : MDT with a dermatologist
medullary bone : Cryotherapy
: Forty per cent of enchondromas occur in the hand
: Cause of pathological fracture and bone graft once – Can be used on small (<1 cm) superficial lesions
fracture is united – 94% 5-year cure rate
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: Wide surgical excision 2. Failure of differentiation

– Mainstay of management a. Soft-tissue involvement
– 95% cure rate b. Skeletal involvement
3. Duplication (polydactyly)
4. Overgrowth (macrodactyly)
Examination corner 5. Undergrowth
Hand oral: Clinical photograph of squamous cell carcinoma 6. Congenital constriction hand
at the tip of a finger with ulceration, necrosis and skin 7. Generalized skeletal anomalies – Madelung’s deformity
breakdown
• An elderly gentleman is seen in your clinic with the Radial longitudinal deficiency
lesion on his finger. How will you manage it? Represents a spectrum of developmental deformities on the
• Ulcerating lesion with skin breakdown and necrosis over radial side of the arm
the DP of the ring finger. Bilateral in up to 75% of cases
• History and clinical examination looking for involvement
In unilateral cases the opposite thumb is hypoplastic
of structures and presence of lymph adenopathy
• Further imaging such as radiograph The classification focuses mainly on the radiological
• The bone is not involved. The radiograph is normal. appearance of the radius; however, the abnormalities can
What do you think the diagnosis is? extend well beyond the radius
• Main concern is malignancy, with benign lesions . :Shortening and bowing of the ulna
• Probably SCC :Absence or hypoplasia of scaphoid and other
• How are you going to manage it?
carpal bones
• This needs to be staged
• Involvement of skin cancer MDT : Thumb hypoplasia/absence
• Role of incisional biopsy to gain histological diagnosis – : Thenar muscle hypoplasia/absence
Don’t forget to send a sample for microbiology. The abnormalities result in significant functional
• Once staged and have the biopsy result may require difficulties
amputation of the part or all the digit The forearm is frequently shortened with loss of elbow
extension
Congenital hand deformities Classification (Bayne and Klug with additions from
The examining board is very conscious of its responsibility to
provide a fair examination as well as a rigorous one.
James and Goldfarb)
Type 0
Introduction :
Radius normal length with proximal and distal physes
In the FRCS (Tr & Orth) examination hand oral any :
Hypoplasia or absence of scaphoid and other
congenital abnormality is fair game for the examiners carpal bones
to show : Can result in radial angulation of the hand and carpus
There is an opportunity to discuss Swanson’s classification : May not require surgery
of congenital deformities : Some require release of radial wrist extensors and
If you are very unlucky there will be an release of tight dorsal, volar and radial capsule
opportunity to discuss the development and function of Type 1
the hand :
Distal radius physis is deficient
Likewise, any congenital abnormality may also appear in :
Normal proximal radius
the short cases (cleft hand, syndactyly, polydactyly) :
Radioulnar synostosis or congenital dislocation of the
radial head
Background : Lengthening with a frame
About 1 in 600 children is born with a congenital upper limb Type 2
deformity. :
‘Radius in minature’
:
Entire radius is hypoplastic but both physes are present
Swanson’s classification :
Bowing of the ulna
1. Failure of formation :
Distraction lengthening
a. Transverse arrest – Amelia Type 3
b. Longitudinal arrest – Radial club hand, cleft hand : Distal portion including the physis is absent
024
: Usually treated with centralisation or microvascular Ulnocarpal arthrodesis

metatarsophalangeal free tissue transfer :
Prevents the problems of gradual recurrence of
Type 4 deformity with the centralisation procedure
: Absent radius : A number of surgeons perform this for a failed
: Usually treated with centralisation or microvascular centralisation
metatarsophalangeal free tissue transfer Vasularized second MTP joint transfer
Type 5 :
Designed to reconstruct the osseous support on the
: Abnormal glenoid radial side of the wrist
: Absence of proximal humerus Address the thumb – May require pollicisation
Radiographs Contraindications for surgery

Severe neurovascular anomalies
Important to assess the whole limb from shoulder to
fingertip Stiff elbow
Look for short humerus Good function
Radius hypoplasia or absence Surgery can be dangerous if there are other congenital
conditions
Ulna bowing
Absence of carpal bones
Ulnar club hand
Associated conditions with radial club hand Less common than radial club hand
No associated cardiac or haematological problems
Fanconi’s syndrome
Wrist is stable but the elbow is a problem
:Autosomal recessive Ulnar digits are often absent and, if present, syndactylized
:Aplastic anaemia
:Need bone marrow transplant
Swanson’s classification of ulnar club hand
TAR
1. Hypoplastic ulna
: Autosomal recessive
2. Total absence of the ulna
: Thrombocytopenia and absent radius 3. Humeroradial synostosis (congenital fusion of the
: Thumb usually present elbow joint)
Holt–Oram 4. Deficient ulna and absent wrist
:Autosomal dominant
:Cardiac abnormalities Thumb duplication
VATER Occurs in 1 per 3000 live births
: Vertebral anomalies Approximately 50% are Wassel type 4
: Imperforate Anus Usually sporadic and unilateral and not associated with
: Tracheo-oEsophageal aplasia syndromes
: Renal anomalies Unless Wassel 7 which is associated with
: Holt–Oram
Management : Fanconi’s syndrome
Counselling : Blackfan–Diamond syndrome
Search for associated congenital abnormalities
: FBC Classification (Wassel)
: Renal USS Based on the complete or incomplete duplication of each
: Echo phalanx
Surgery usually undertaken at 6–9months Uneven numbers are incomplete duplications (bifid) and
Centralisation procedure even numbers are compete bony duplications
: Most popular treatment for types 3 and 4 Numbers rise with sequential number of bones involved,
: Requires pre-centralisation stretching with a cast or starting distally and working proximally
with an external fixator
: Align carpus on ulna 1. Bifid DP
: Soft-tissue balancing 2. Duplicate DP
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3. Bifid PP Hypoplasia of the thumb

4. Duplicate PP (most common)
Commonly requires pollicisation of the index finger in the first
5. Bifid metacarpal year of life.
6. Duplicate metacarpal
7. Triphalangism Blauth’s classification of thumb hypoplasia
Principles of management (five types)
Thumb hypoplasia has also been classified by Blauth
Forming one thumb out of two
Type I: Short thumb, hypoplastic thenar muscle
1. Preserving the skeleton of one thumb and augmenting
Type II: Adduction contracture, UCL instability, normal
this with soft tissue from the second thumb. Nearly all skeleton with respect to articulations
of one digit is retained and augmented with tissues
Type IIIA: Extensive intrinsic and extrinsic
from the other digit. Duplicate tissues from the ‘spare part’,
musculotendinous deficiencies, intact CMC join
which are not used, are excised. This allows for
obtaining a good size match and tendon and ligament Type IIIB: CMC joint not intact
balance. This is the favoured option. For Wassel 4–6 – Type IV: Floating thumb
Retain ulnar thumb so that integrity of the UCL is Type V: Complete absence of thumb
maintained
Management
2. The other option is removing the central composite tissue
segments from each thumb and combining the two into Type I requires no treatment
one (Bilhaut–Cloquet procedure). There are significant Types IIIB–V are treated with pollicisation
problems with stiffness, size, angular deformities, nail Types II and IIIA are treated with reconstruction,
scarring and function. This procedure is generally avoided addressing the following issues
unless there is no other way to obtain a thumb of : Stabilisation of the MCP joint
sufficient size : Ulnar collateral ligament
3. Segmental digital transfer. This is occasionally performed : Web deepening
when there is a clearly superior proximal segment on one : Opponens transfer if opposition is insufficient
digit and a clearly superior distal segment on the other : Extrinsic flexor and extensor exploration with
digit. Bring the best distal segment of one duplicate on to correction of any anomalies
the best proximal segment of the other
4. Excision. Appropriate where duplication is rudimentary Principles of thumb reconstruction
without skeletal elements or the accessory thumb is widely
Allow opposition
separated from a normal thumb
Must be sensate
Must have good circumduction at the CMC joint
Examination corner Joints must be stable to allow pinch grip
Hand oral: Picture of a Wassel IV thumb

Syndactyly
• What is this?
Congenital fusion of digits
• How do you classify thumb duplication?
• Wassel classification Most common congenital malformation of the upper limb
• What type is this? Affects 1 in 2000
• IV 50% bilateral
• Is this associated with any syndromes? More common in males
• Wassel IV is usually sporadic Third web most common
• Wassel VII are associated with conditions
Classification
• What are the principles of surgical management?
• Preserve the ulnar thumb but use parts of the radial : Simple
thumb for reconstruction.
– Only soft tissue – No bony connections
: Complex
Post-axial polydactyly – Side to side fusion of adjacent phalanges
This is 10 times more common in African Americans. If it
occurs in Caucasians there may be serious associated : Complicated
abnormalities.
– Accessory phalanges
024
: Complete or incomplete : Release skin, fascia, tendon sheaths, intrinsics, collateral

ligaments and volar plate
– Complete extend to the fingertips
: Lengthen the FDS tendon
Timing of surgery
: Usually left until 1 year of age Clinodactyly (lateral plane deformity)a
: Deal with digits that have biggest length disparity first
Radioulnar curvature of the little finger
: If multiple digits do a staged approach to avoid
More common in males
compromising vasculature
Usually bilateral
There are three types
Cleft hand
Central deficiency
: I – Minor angulation, normal length (very common)
At least one digit absent
: II – Minor angulation, short phalanx, associated with
Down’s syndrome
Sporadic are usually unilateral, U-shaped and affect the
ulnar side : III – Marked deformity, associated with delta phalanx.
A delta phalanx is a wedge-shaped phalanx with a
Familial tend to get worse with each generation and are V-
C-shaped physis
shaped with radial side involvement
Surgery is usually only required when there is first
webspace involvement
Management
If a delta phalanx replaces a normal bone, manage by an
Camptodactyly opening reverse osteotomy
If delta phalanx is an extra bone, then excise it
Congenital digital flexion deformity
(Figure 21.14).
Usually occurs at the PIP joint of the little finger
Affects <1% of the population
Can be familial
No functional significance in the majority
Can be static or progressive
There are two types
: Type 1 infantile type
– Seen in infancy
– M=F
: Type 2 adolescent type
– F>M
– Frequently bilateral but not symmetrical
– Familial deformity
– Increases during adolescent growth spurt
Aetiology
The deformity has been attributed to the following
abnormalities
: General absence of development of all tissues of
the digit
: Abnormal lumbrical origin
: Contracture of the collateral ligaments of the digits
: Flexor and extensor tendon imbalance
: Abnormal FDS origin or insertion
Figure 21.14 Delta phalanx

Management
Reassurance and stretching
Avoid surgery if at all possible a
Clino has ‘C’ and ‘L’ = lateral plane; Campto has ‘C’ and ‘A’ = AP
Surgery may be indicated for a flexion contracture of >60° deformity.
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024
Kirner’s deformity Work through an answer of the management options

May be mistaken for clinodactyly. Volar and radial curvature beforehand rather than jumping about with this one as I did:
at the distal phalanx of the little finger. Usually autosomal I first mentioned that it will be very upsetting to the parents
dominant. Frequently bilateral. and one would need to spend time with them.
I did not mention a search for associated congenital abnor-
malities, which the examiners pressed me about. I suggested
Management observing the condition initially.
Surgery is generally for cosmetic reasons only. Avoid when the For mild cases manipulation and control with strapping may
growth plate is open – Corrective osteotomy. be all that is required.
I mentioned the words ‘centralisation of the wrist/forearm
deformity’ and ‘thumb reconstruction’ and the examiners were
Examination corner happy with this and were not interested in any further details
whatsoever.
Hand oral 1: Clinical photograph of duplicated thumb When discussing management options try to avoid
jumping straight in with surgery.
• Diagnosis
(Candidate pass.)
• How do you classify duplicated thumb (Wassel)?
• Principles of treatment and treatment of type shown
Hand oral 7: Clinical photograph of radial club hand
Hand oral 2: Clinical photograph of syndactyly • What is the diagnosis and how do you manage it?
• Asked for a classification system for congenital hand • Spot diagnosis and very quick. The examiners were not
deformities (Swanson’s) looking for a detailed answer. The whole thing took <30
seconds maximum before we moved on to another
Hand oral 3: Clinical photograph of camptodactyly (usual questions)
clinical photograph.
• What is this deformity? Hand oral 8: Radiograph of obvious radial club hand
• What causes the deformity? Spot diagnosis.
• How is it managed?
Hand oral 4: Clinical photograph of syndactyly

Constriction bands
• Asked for classification of congenital hand deformities. Streeter’s dysplasia. More common in fingers and toes. May
be deep with distal oedema. Congenital amputation. Treat by
Hand oral 5: Clinical photograph of a radial club hand Z-plasties.
EXAMINER: You are called to the paediatric ward because a newborn
baby has the above condition. What is this deformity? (Spot
diagnosis.)
Miscellaneous
EXAMINER: OK – How do you manage it?
Arthrogryposis – Stiff joints. Absence of skin
creases
CANDIDATE: I thought I answered the questions fairly well but the
discussion seemed to be going around in a bit of a circle. The
Symphalangism – Stiffness of PIP joints ± ankylosis
examiner seemed a bit unhappy and eventually came out with Congenital trigger thumb – Common, palpable swelling –
what they really wanted. Somewhere along the way I should have
Notta node. Most resolve by 1 year – Surgical release if
mentioned that there was a high incidence of other congenital
continues
deformities with this condition and I might want to consider Madelung’s deformity – Growth arrest of the volar-ulnar
arranging a renal and cardiac ultrasound! distal radius
(Candidate pass.)
Hand infections55–57
Hand oral 6: Clinical photograph of radial club hand
Recognition and prompt intiation of appropriate treatment is
EXAMINER: What is the diagnosis and how do you manage it? required to prevent permenant impairment.
CANDIDATE: This is a clinical picture, which is suggestive of bilateral
radial hemimelia. Both forearms are short; there is radial and volar Aetiology
deviation at the wrist and hypoplastic thumbs. The fingers also
Most commonly occur following trauma
appear poorly developed.
Human bites
There is no point in beating around the bush as the diagnosis is Animal bites
obvious. However, after you have given the diagnosis continue
to describe the clinical features on the photo.
Illicit drug use
Post surgery
024
Pathogens Felon
The history is useful in helping to elicit the most likely organ-
ism and, thus, the most appropriate antibiotic treatment. The This is a localized compartment syndrome contained by
the fibrous septae connecting the pulp to the distal phalanx
vast majority of hand infections are bacterial in origin with
Staphylococcus aureus the most common pathogen. Contamin- Usually occurs following penetrating trauma
ated wounds from agriculture injuries often are affected by Present as a tense, tender, swollen and erthythematous pulp
multiple organsisms including anaerobic and gram negative Urgent decompression through a vertical midline incision
bacteria. Children can also present with unusual pathogens distal to the skin crease, taking care to break down all
including oral flora, Haemophilus influenzae and Pseudomonas containing septa is required to stop the vicious cycle of
sp. Bites by human often involve Eikenella corrodens. inflammation, veous congestion, venous compromise, pulp
Immunocompromised patients are predisoposed to opportun- necrosis and abscess formation
istic infections from mycobacteria, fungi and viruses.
Deep space infection
History There are several deep anatomical spaces within the hand and
Penetrating injury, fight bite – Note where wrist that can contain infection following trauma: Webspaces,
When thenar, mid palmar, hypothenar, radial and ulnar bursae,
Pain space of Parona and dorsal subcutaneous and subaponeurotic
Loss of function spaces.
Medical history – Diabetes Thenar space
Tetanus status
Thumb typically held abducted away from the palm with
Consider HIV and hepatitis status pain over the adductors on extension or opposition
Examination Drainage requires incisions to volar thenar crease and
drosal webspace to drain both the retro-adductor and
Temperature, pulse and respiration
thenar spaces
Examine for puncture wounds
Swelling Mid palmar space infections
Posture of the hand Space lies between the metacarpals and palmar aponeurosis
Warmth Seperated form the thenar space by an oblique septum that
Tenderness connects the third metacarpal with the palmar aponeurosis
Test motor and sensory function Clinically this presents with tense and painful
Examine the arm for spreading lymphangitis erythematous swellings on both palmar and dorsal surfaces
Epitrochlear lymph nodes drain the ring and little finger, of the hand
axillary nodes drain the radial digits Loss of active motion of the middle and ring fingers
Cellulitis resolves with antibiotics only and elevation Drain through a curved incision beginning at the distal
palmar crease, extending ulnar-ward to just inside the
Investigations hypothenar eminence
FBC, ESR, CRP
Blood cultures Hypothenar space
Wound swab/pus sample Infection confined to the hypothenar eminence muscles
Radiographs Contained in the space by the septum connecting the
palmar aponeurosis to the fifth metacarpal
Specific infections Little finger typically held in maximal abduction
Paronychia/eponychia Drainage is by a longitudinal incision down the ulnar
Infection of the nail fold bordering the nail plate border between glabrous and non-glabrous skin
Usually occurs followig disruption of the seal between the
nail fold and nail plate folowing trauma such as nail biting Radial and ulnar bursae including space of Parona
or manicure. This allows entry of bacteria, usually S. The radial and ulnar bursae are proximal continuations
aureus, though mixed flora can be seen with nail biters of the flexor sheaths to the thumb and little finger
Early presentation before the onset of fluctuance may be respectively
managable by elevation and oral antibiotics These two bursae can communicate with each other
The presence of fluctuance necessitates incision and through the space of Parona which lies between pronator
drainage which may require temporary nail removal quadratus and FPL
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024
Classically present with a ‘horseshoe abscess’ be considered in young patients without a history of penetrat-
Requires drainage of both digits flexor sheaths and ing trauma.
Parona’s space Kanavel’s four cardinal signs:
To drain the radial bursa, make a lateral incision over the Finger held in a flexed position
proximal phalanx of the thumb and enter the sheath. Sausage digit (symmetrical swelling)
Introduce a probe and push it towards the wrist Severe tenderness along the tendon sheath
Make a second incision where the probe is palpable just Pain on passive extension of the finger
proximal to the wrist. Irrigate with a cannula
To drain the ulnar bursa, open it distally on the ulnar side Management
of the little finger, and through a transverse incision just Intravenous antibiotics and prompt surgical drainage
proximal to the wrist and lateral to FCU Make a transverse incision over the distal finger crease or a
midlateral incision at the level of the middle phalanx, and
Web space infection
open the tendon sheath and pass a catheter
The subfascial web space is a fat-filled space situated on the
Make a second transverse incision at the level of the distal
palmar surface of the hand and interdigital area
palmar crease and the sheath just proximal to the A1 pulley
The limits of the web space are the natatory ligaments and flush through until clear
distally, the deep attachment of the palmar fascia
Some advocate continuous catheter irrigation on the ward
proximally and its attachment to the tendon sheath laterally
following surgery. The evidence that is beneficial is
The infection usually arises from a wound to the skin inconclusive and there are reports that the catheter blocks
between the fingers though can occur from contiguous and/or the skin becomes macerated from the continual
spread from a pulp infection or via the lumbrical from a irrigation
deep palmar space infection
Severe cass with associated necrosis require an open
Web space infections may lead to a collar stud abscess exploration to debride devitalized tissue. This can be done
Drainage is via two longitudinal incisions, one dorsally and either through a midaxial or Brunner incision. The
one ventrally, but the web should not be incised Brunner incision is more straightforward with lower risk to
Dorsal subcutaneous and subaponeurotic spaces the neurovascular bundles though the midaxial gives a
more reliable flap for later closure
Dorsal swelling from infection can occur either primarily
from infection in the dorsal space (superficial or deep to Osteomyelitis
the extensors) or from a palmar infection This is an infrequent complication if hand infections are
The strong fascial components on the palmar side in treated appropriately
comparison with the loose mobile dorsal skin favour the More common from direct innoculation or spread from
palmar infection to balloon dorsally and so careful local infection, particularly in diabetics
examination of the palmar surface should be undertaken
Typically it is only suspected after failure of antibiotic
when assessing any dorsal infection therapy or repeat infections
Dorsal spaces are best drained via longitudinal incisions Requires surgical debridement of all affected bone and
centred over second and fourth metacarpals sequestra and prolonged antibiotic therapy
Subaponeurotic space collections require incision of the If amputation is necessary, it should be done at the joint
dorsal fascia between the extensor tendons down to the proximal to the infected bone or the infection will not clear
interosseous fascia
NB. Infection of the finger pulp may erode the distal phalanx,
Flexor sheath infection but may improve when the overlying abscess is drained
Suspicion of this infection mandates immediate surgical drain-
Human bite (‘fight bite’) injuries
age as infection within this space destroys the synovial gliding
surface resulting in adhesions or tendon rupture. These are common with the patient presenting with a
history of punching someone and a wound over the
Anatomy MCP joint
The flexor sheaths of the index to the ring fingers start from Radiographs should be taken to exclude fracture or the
the proximal edge of the A1 pulley. The little finger flexor presence of a fragment of tooth
sheath connects to the ulnar bursa (contains flexor tendons Patients may deny the mechanism of injury but wound
2–5 deep to the flexor retinaculum). over the MCP joint should be assumed to have penetrated
the joint and mandate a formal arthrotomy and washout
Clinical features under general anaesthetic
Typically occurs following penetrating trauma though haema- Pathogens include the normal flora of the mouth,
togenous spread can occur and gonococcal infections should which includes 42–190 different organisms. The most
024
common infecting organism is still S. aureus; other appears smooth and shiny. With further progress the skin may
common organisms include streptococci, Eikenella become red, tender and frequently an abscess forms.
corrodens, Enterobacter, Proteus and Serratia spp In syphilitic dactylitis the swelling is painless. Sickle cell
disease causes dactylitis because of infarction of bone second-
Septic arthritis ary to thrombosis of the nutrient artery.
As with any other joint this is a surgical emergency, as
untreated the cartilage is destroyed by the lysosomal Radiographs in tuberculous dactylitis
activity of the bacteria Soft-tissue swelling
It can occur from direct innoculation, contiguous or Cortical thinning
haematogenous spread Medullary destruction
Most valuable sign if pain on passive or active motion of Periosteal reaction
the affected joint from its position of maximal volume
(MCP joint extension, IP joint 30° flexion) Management
Any suspicion is better managed with surgical exploration Curettage for culture material followed by antituberculous
rather than expectantly chemotherapy and splinting.
MCP joint should be approached with a dorsal longitudinal
incision over the joint and a longitudinal split between the
extensor tendon and saggital band Pyogenic infection
PIP joint can be approached via a dorsolateral incision with Syphilis
the joint entered between the central slip and lateral bands Enchondroma
Mycetoma (Madura hand)
Multiple xanthomatosis
Examination corner Sickle cell disease
Hand oral 1: Clinical photograph of paronychia? Diagnosis can be confirmed by biopsy. In spina ventosa there
is grossly swollen, spindle-shaped bone.
• What are the common causative organisms?
• Often S. aureus though mixed flora in nail biters is not
uncommon Triangular fibrocartilage complex (TFCC) lesions
• How would you manage this patient? There are several topics that you are extremely unlikely to be
• If there is pus – Let it out asked about in the FRCS (Tr & Orth) exam. It is always risky
• Antibiotic therapy saying ‘never’ and that’s why one learns these topics on the off
• If no pus warm soaks may help witht the antibiotics. chance that they in fact turn up. Although I doubt very much that
you will be asked about TFCC lesions, one should know about the
Hand oral 2: Clinical photograph of fight bite injury to the MCP joint
of the index finger
anatomy of the TFCC, the two subgroups of TFCC lesions
(Table 21.3) and the various management options available.
• How would you assess this injury?
• History. Wounds over the MCP joint should raise the
suspicion of a fight bite until proven otherwise. Must Table 21.3 Classification of TFCC lesions
specifically ask the patient.
Class 1: Traumatic injuries
• Wounds – Depth and exact location, tendon function
• What organsisms so you need to cover? 1A Central perforation or tear
• The most common infecting organism is still S. aureus
1B Ulnar avulsion with or without ulnar styloid fracture
• Other common organisms include streptococci, Eikenella
corrodens, Enterobacter, Proteus and Serratia spp. 1C Distal avulsion (origins of ulnolunate and ulnotriquetral
• What is the role or surgery? ligaments)
• Hard to disagree with stating you would explore, deb- 1D Radial avulsion (involving the dorsal and/or volar
ride and washout all these wounds in theatre – Not radioulnar ligaments)
infrequently can see bits of tooth in the joint that are
not visible on radiographs. Class 2: Degenerate TFCC tears
2A TFCC wear (thinning)
2B 2A plus lunate and/or ulnar chondromalacia
Tuberculous dactylitis
2C TFCC perforation plus lunate and/or ulnar chondromalacia
Inflammation of the phalanges or the metacarpals. The bone
becomes enlarged, spindle-shaped and, in the case of tubercu- 2D 2C plus lunotriquetral ligament disruption
lous dactylitis, is painful. The skin overlying the affected bone 2E 2D plus ulnocarpal and DRUJ arthritis
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Introduction Degenerative tears

TFCC is important in loading and stabilising the DRUJ. Tears The abnormalities involve a pathological progression of dis-
are a cause of ulnar-sided wrist pain and are classified ease associated with ulnar-positive variance and impaction
according to their location. between the ulnar head and the proximal pole of the lunate.
Non-operative treatment is tried first with rest, immobilization
Anatomy of TFCC and steroid injections.
Surgical treatment is aimed at decompressing the ulnocar-
Dorsal and volar radioulnar ligament
pal articulation. Traditionally, surgery involved diaphyseal
Articular disc ulnar shortening with the added advantage of tightening the
Meniscus homologue ulnocarpal ligaments and is particularly recommended when
Ulnar collateral ligament concomitant LT instability is present.
ECU subsheath Other options include the wafer (2A–2C) or arthroscopic
Origins of the ulnolunate and lunotriquetral ligaments wafer (2C) resection of the ulnar head. Positive ulnar
The periphery is well vascularized, whereas the radial central variance >2 mm is a contraindication to wafer resection
portion is relatively avascular, thin and prone to degenerative and is best managed with diaphyseal shortening. Class (2E)
changes. Peripheral tears are usually traumatic, whilst central lesions are managed with either a limited ulnar head resection
tears are generally degenerative and are often found in associ- such as a Sauve–Kapandji procedure (arthrodesis of the
ation with ulnar-positive variance. DRUJ and creation of a pseudoarthrosis at the level of the
ulnar neck).
Clinical presentation Darrach’s resection of the distal ulna is considered a salvage
Ulnar wrist pain and restriction of forearm rotation procedure because of the concerns regarding impingement and
instability of the residual ulnar stump.
Tenderness over TFCC
Pain with ulnar deviation of carpus and compression Examination corner
Hand oral 1: Management of TFCC lesions
Investigations Most TFCC tears respond to conservative management – Splin-
Radiographs tage, steroid injections and restriction of activities.
TFCC is not visualized on plain radiographs Peripheral tears may be repaired arthroscopically or at
open operation, although this procedure is not easy as the
May show ulnar-positive variance
TFCC is small and exposure is limited.
Localized subchondral defect of the lunate caused by Large central flap tears will not heal; they may be deb-
impaction on the distal ulna rided arthroscopically but this is ineffective if there is ulnar
impaction as the ulna will still abut on the lunate.
Arthrography Ulnar impaction is treated with ulnar shortening, either a
shaft osteotomy or trimming of the distal end of the ulna
Leakage of dye distally
beneath the TFCC (wafer procedure of Feldon). The ulna needs
only to be shortened by 1–2 mm and it is not necessary to
MRI repair or resect the TFCC tear.
Offers improved accuracy in the diagnosis of TFCC tears
Hand oral 2: arthroscopic picture of a central TFCC tear
Diagnostic arthroscopy • What is the diagnosis?

• How are these tears classified?
Gold standard • Traumatic and Degenerative
• Then detail then actual parts of each
Management • Which tears would you repair?
• Peripheral tears that lead to an unstable DRUJ
Traumatic injuries
• How would you repair a tear?
All acute traumatic lesions of the TFCC are initially managed • Arthroscopic or open
non-operatively with immobilization and NSAIDs. • Open allows the knot to be placed whilst ensuring the
In general: dorsal sensory branch of the ulnar nerve is not going to
1A – Arthroscopic resection of the torn portion be injured
(Figure 21.15 a–c) • How would you treat this patient?
• Debridement to of the central flap to a stable rim
1B – Arthroscopic repair
• Assess the distal ulna – Consider either a wafer resection
1C – Arthroscopically assisted limited open repair or an ulnar shortening
1D – Partial excision or direct repair with ulnar shortening
024
(a) (b)
(c)
Figure 21.15 (a–c)Type 1a (central) TFC tear – This is not repairable and has
been debrided to a stable margin using vapour
Wrist arthrodesis This procedure is more beneficial for young, active patients or
middle-aged patients but is not for elderly patients.
Indications
A painful or unstable wrist joint with advanced destruction Preoperative considerations
caused by: In the rheumatoid wrist the application of a dorsal plate
Osteoarthritis increases the chances of a dorsal wound dehiscence.
Rheumatoid disease Range of movement of other joints
SNAC/SLAC wrist
Remember that the elbow and shoulder joints will have to
Salvage of failed wrist arthroplasty
compensate for loss of wrist motion.
Salvage in Kienböck’s disease
Surgical details
Contraindications Dorsal approach in the wrist
Infection With a severe deformity, consider a wider exposure to the first
Lack of soft-tissue coverage dorsal compartment to allow excision of the radial styloid. The
487
024
individual carpal bones and distal radius are exposed with the Skin necrosis
wrist in hyperflexion. Articular cartilage is removed with a Infection
Rongeurs. It is important to treat the long finger CMC joint Transient nerve palsy
in the arthrodesis or a painful non-union may occur, whereas Persistent pain (exclude non-union)
most surgeons usually prefer to spare the index CMC joint to
allow its participation in power grip.
Complex regional pain syndrome (CRPS)58
Ulnar head Definition
In RA consider resection of the ulnar head, and then using it CRPS is not a disease, but a collection of symptoms without a
for a bone graft. known cause, without a clear pathophysiology and without a
cure. The condition comprises of four cardinal features: Pain
Position of arthrodesis out of proportion to the degree of injury, swelling, stiffness and
With the non-RA wrist vasomotor instability. It is divided into two types: type 1 where
there is no obvious nerve damage and type II where there is
Place in 20° of dorsiflexion because this position allows for
identifiable nerve damage.
power gripping. Maximum grip is generated in 35° of dorsi-
flexion but this interferes with ADLs. Diagnostic criteria
In the rheumatoid wrist The following ‘Budapest Criteria’ should be present at the time
of evaluation to make the diagnosis:
A neutral or a flexed position is more desirable. In the frontal
plane a position of 5–10° of ulnar deviation is preferred to 1. Continuing pain disproportionate to the inciting event
counterbalance the zig-zag collapse and ulnar drift. Despite the 2. Symptoms (at least 1 in 3 of the following 4 categories)
usual recommendations, some patients will prefer slightly I. Sensory (hyperaesthesia/allodynia)
more flexion or extension in the wrist. If possible, consider II. Vasomotor (temperature/colour changes –
casting the wrist before surgery in extension and the neutral Asymmetrical)
position to determine which position is more comfortable for III. Sudomotor (oedema/sweating – Asymmetrical)
the patient. IV. Motor/trophic (Decreased ROM, weakness tremor/
dystonia, trophic changes in skin, hair or nails
Methods of fixation
3. Signs (at least 1 in 2 of the following categories)
Steinmann pin fixation
I. Sensory (hyperaesthesia to pin prink, allodynia to
Through the third metacarpal into the radius or via the second
light touch)
or third web space of the hand. Plaster for 8 weeks to prevent
II. Vasomotor (evidence of temperature or colour
rotation.
asymmetry)
AO wrist fusion plate III. Sudomotor (evidence of oedema/sweating asymmetry)
This is an 8-hole titanium plate with 2.7-mm screws inserted IV. Motor/trophic (evidence of decreased ROM,
into the distal four holes and 3.5-mm screws in the proximal weakness, tremor, dystonia, trophic changes to skin,
four holes. To have the wrist in 20° of dorsiflexion, a con- hair or nails)
toured plate is necessary. Lister’s tubercle will have to be 4. No other diagnosis explaining the signs or symptoms
removed to achieve a flat bed for plate application and use
as a bone graft. Excise all cartilage and insert bone graft (do Investigations
not forget the third carpometacarpal joint). Most often the Primarily this is a clinical diagnosis.
plate is applied to the long metacarpal so that three cortical Radiographs can show diffuse osteopenia but this is not a
screws can be inserted into the metacarpal and four screws sensitive test and, thus, along with other imaging modalities
into the radius (often a screw will also be inserted into the play no role in the diagnostic criteria.
capitate). A bone scan may show increased uptake of isotope in early
CRPS but later on the bone scan returns to normal.
Postoperative routine Diagnostic sympathetic block (stellate ganglion)
Volar splint for 6 weeks
Union is usually achieved by 3 months Aetiology
Plate is not removed unless it causes symptoms Trauma is the most common, particularly wrist fractures
Iatrogenic such as carpal tunnel decomrpession and
Complications dupuytens surgery
Extensor tenosynovitis is the most common complication Ischaemic heart disease and myocardial infarction
and is related to a prominent dorsal plate and screws Cervical spine or spinal cord disorders
024
Cerebral lesions Uses

Infections Immobilize, protect, controlled mobilization, prevent
In some patients a definite precipitating event cannot be deformity
identified
Types
Theories Static
The true cause of CRPS is controversial but the evidence Dynamic
revolves around two theories or what the intiating event
causes. Materials
1. Inflammatory. The early phase of the condition is that of Plaster/synthetic
an inflammatory response and some believe that CRPS is Thermoplastic – Become malleable with heating
an exaggerated local inflammatory response to trauma (water, bath)
2. Neurological. Neuralgic pain associated with CRPS may be Examples:
explained by damage to small fibre neurons. A-delta and C- : Capener – Provides passive extension force (three-point
fibres transmit information from mechanical, thermal and loading) to PIPJ for boutonnière, but allows active
chemical stiumli. They release vasoactive substances such flexion against resistance
as substance P which is found in CRPS : Murphy rings – Statically limit PIPJ hyperextension
and allow flexion for swan-neck deformities
Natural history
: Stack – Static extension to DIPJ for mallet finger
90% of CRPS following distal radius fractures resolved : Dynamic outrigger – For extensor tendon repair/MCP
within 2 years
joint replacements; allows passive extension/active flexion
Some, however, do have persistent signs and symptoms
It is believed to be reactivated or recur following further
trauma or surgery. This remains unproven Miscellaneous oral questions
It is impossible to cover every possible hand oral topic that could
Prevention be asked in the FRCS (Tr & Orth) exam in detail. Below, however,
Two RCTs that have found a decrease in CRPS of 8–15% are some less known questions that candidates may be asked.
with distal radius fractures by administration of 500 mg of
vitamin C per day
Examination corner
Some studies have suggested a decreased risk with regional
rather than general anaesthesia but this is not proven Hand oral 1
Clinical photograph of a large, well-circumscribed, lobulated,
Management firm mass situated over the volar surface of the long finger
Good analgesia including centrally acting medication such (Figure 21.16). Painless but slowly enlarging. Radiographs
as gabapentin show no bony abnormality.
Physiotherapy • What is the diagnosis and management?
: Hand therapy is the mainstay of treatment • Spot diagnosis of pigmented villonodular synovitis
(giant cell tumour of tendon sheath).
: Should continue until symptoms have resolved
: Aim is to prevent late contractures, secondary weakness After a ganglion, this is the second most common tumour
and reduce cortical remodelling found in the hand and a classic favourite with examiners.
Mirror visual therapy A benign lesion, radiographs are usually normal but may
show soft-tissue swelling or may show local pressure effects
: Patient exercises than normal and affected hand along on bone.
but sees the affected hand moving normally due to the Localized form PVNS that arises from a tendon sheath or
mirror image of the normal one adjacent joint. A diffuse form of giant cell tumour not seen in
Regional blocks with sympathetic blockade are often used the hand that occurs in areas adjacent to large weight-bearing
but no strong evidence that they work joints. This is synonymous with the extra-articular form of
PVNS. Local complete excision is recommended but the condi-
tion has capacity for local reoccurrence (10–20%).
Splinting of the hand and wrist Must discuss differential diagnosis of a soft-tissue swelling
A splint may appear in the clinicals or be used as a prop in the of the digit.
orals. Therefore, a basic understanding of principles of use,
Hand oral 2: clinical photograph of subungual exostosis
materials and indications is needed.
A spot diagnosis – Move on to it if you know it; if not, a safe
approach is to describe what you see and then go through a
Definition differential diagnosis.
Type of orthosis (external device to support a body part)
489
024
Figure 21.17 Stener lesion – Clinically the displaced proximal end of the UCL
can be felt over the metacarpal head
Figure 21.16 Clinical photograph of hand swelling What clinical tests can be undertaken?
What are the other causes of radial-sided wrist pain?
This is a bony diverticulum from the terminal phalanx and What are the treatment options?
has the typical cartilaginous cap seen with exostosis elsewhere Which tendons are involved?
in the body. This elevates the nail plate, with subsequent
ridging if the germinal matrix is involved. It is thought the Hand oral 6: Bennett’s fracture
aetiology is probably traumatic but this is in dispute. The Why is it unstable (i.e. what is the deforming tendon)?
treatment is surgical excision. It is necessary to first remove Management
the nail, then the nail bed is split and elevated, the exostosis What size of K-wire is used for fixation?
removed and the nail bed can be sutured back into place.
Differential diagnosis includes: Trauma oral 1: UCL injury of the thumb
Glomus tumour (Masson’s tumour) – Tumour of glomus Stener lesion (Figures 21.17, 21.18)
body which regulates blood flow and temperature; 50% Approach
subungual. Triad of pain, exquisite tenderness and cold Complications
intolerance
Enchondroma Trauma oral 2: rugger jersey finger (Figure 21.19)
Subungual inclusion dermoid cyst following an old Classification
penetrating injury (look for an overlying scar, which may Discussion of Brunner incisions
be very small) Pull-out suture
Amelanotic melanoma, which usually presents as a
granulation in the centre of the nail, but this diagnosis Trauma oral 3: clinical photograph of a hand after a crush injury
must be considered if there is swelling beneath the nail. (Figure 21.20)
The diagnosis may be delayed as it may mimic infection. Differential diagnosis
Nodal involvement is present in 40% of patients at first
presentation. A biopsy should be taken, including This includes compartment syndrome and infection
sampling of the lymph nodes and then the tumour can be • How assess?
staged before definitive treatment, which usually consists • Look for any breaks in the skin or discharge. Check if hand is
of ray amputation and chemotherapy. A clinical picture of perfused – Skin colour/warmth, radial pulse, capillary refill
subungual melanoma is sometimes shown in the hand oral time. Feel if swelling soft and fluctuant, or hard. Ask patient
to move their fingers. Check passive stretch of digits.
Hand oral 3: Pigmented lesion under nail bed Request urgent radiographs to look for any fractures
Differential diagnosis: Melanoma, subungual haematoma, glo- • Management?
mus tumour. • If compartment syndrome of the hand is suspected
urgent fasciotomies are required. This is performed under
Hand oral 4: Fingertip injury a general anaesthetic. An arterial pressure transducer can
Fingertip injuries of the distal phalanx be set up in theatre and compartment pressures in the
Management in a young, female non-smoker, dominant interosseii, thenar and hypothenar muscles recorded.
hand, tip available A pressure >30 mmHg confirms the diagnosis but you
will proceed to fasciotomies based on the clinical suspi-
Hand oral 5: De Quervain’s disease. Clinical photo of swelling over radial cion. A full release can be achieved using dorsal incisions
styloid over the second and fourth metacarpals, a lateral incision
What is the diagnosis? to the thenar eminence and a medial incision to the
024
Figure 21.19
Radiograph of little finger
of patient following a fall
onto her hand
Figure 21.18 Testing the integrity of the UCL. (Picture Courtesy of

©DonaldSammut 2014)
Figure 21.21 Radiograph of a motor cyclist’s wrist after an accident
Figure 21.20 Clinical photograph of a hand after a crush injury These show a lunate dislocation. This can occur with hyperex-
tension of the wrist leading to tearing of the perilunate intrinsic
hypothenar eminence. If the digits are grossly swollen carpal ligaments starting on the radial side. The most severe
these can be released through midlateral incisions. injury can lead to extrusion of the lunate through the Space of
Poirier – A weak area in the volar extrinsic carpal ligaments. This
Trauma oral 4: Radiograph of a motor cyclist’s wrist after an accident
is a Mayfield grade IV injury, the most severe degree of injury59.
(Figure 21.21)
Mayfield described the pathomechanics of perilunate injuries
with grade I is disruption of the scapholunate ligamentous
Pathogenesis
491
024
complex, grade II disruption of the lunocapitate connection In addition, fractures of the scaphoid and capitate can be
and grade III the lunotriquetral connection is violated. secured with antegrade fixation devices.
The combined dorsal-volar approach offers the advantages
• How manage?
of both approaches, but increases surgical time and dissection.
Check for and document any median nerve symptoms. This
injury requires prompt reduction in theatre. This can be Dorsal approach
achieved closed by hyperextension of the wrist and pres-
sure over the lunate. The patient can be referred to a hand Incision
surgeon for repair of the intercarpal ligaments through a A standard straight midline longitudinal incision in line
dorsal approach and temporary K-wire fixation in the next with the third metacarpal extending into the distal forearm
few days. The incision is made though the third compartment
Extensor retinaculum
Further questions
The extensor retinaculum between the third and fourth
• Q. Presentation? extensor compartments is reflected off of the wrist capsule
• A. with care to avoid any damage to the capsule itself
Significant wrist pain The EPL is mobilized out of its sheath and is reflected
Swelling hand radially
Limited hand and wrist movement Subperiosteally elevate the fourth compartment, without
Tingling and numbness of the fingers (acute onset carpal disrupting the tendon sheath
tunnel syndrome) Homan retractors are placed on either side of the radius
Digits are often held in a semiflexed position and passive
extension causes pain Capsular incision
There is abnormal carpal alignment and crepitus may be Longitudinally incise through the dorsal capsule in line
felt is there is an associated fracture with Lister's tubercle, and then elevate the wrist capsule off
of the dorsal rim of the distal radius including the dorsal
• Q. Timing of intervention? radiotriquetral ligament
• A. The scenario would be the injury occurring in the Preserve the radiotriquetral ligament
middle of the night and you on call as the orthopaedic The dorsal capsule is usually opened along its origins from
consultant and what to do with the injury. dorsal rim and longitudinally in space between second and
The dilemma is do you take the patient to theatre and fourth extensor compartments
perform emergency reduction or wait until the morning and
get the hand surgeons involved for more definitive manage- • Q. Operative repair?
ment (repair of carpal ligaments)? • A.
A closed reduction should generally be performed to re- K-wire fixation
establish overall alignment followed by delayed surgery. The Temporary lunate fixation to the radius
majority of time you will get a closed reduction although the : Scapholunate fixation
injury itself may be unstable. : Before the scapho-lunate joint is pinned, pass the
A worry is that the injury may be irreducible as ligamentous repair sutures, but do not tie them
interposed capsule may prevent reduction and you are stuck together until all of the pins have been inserted and
with a patient in theatre with an unreduced lunate dislocation the reduction is optimal
at 4 am. : Once k-wire fixation has been performed, repair the
It is unlikely you will be experienced enough to perform an scapholunate interosseous ligament and augment this
open reduction, emergency repair of intercarpal ligamants and with bone anchors placed in the scaphoid. Reinforce
K-wire stabilisation. You may or may not be familiar with the the repair with a dorsal capsulodesis
technique for open reduction of this injury. Scapho-capitate fixation
If you can’t get a reduction and are unfamiliar with the surgery : An additional K-wire is often across the
for open procedure discuss with your hand colleague(recom- scapholunate joint
mended you pre-warn him/her before taking the patient to : With optimal reduction, the lunate should cover the
theatre) who will then need to perform an open reduction with head of the capitate
removal of the obstructing factor, usually interposed capsule. Lunotriquetral fixation
• Q. Specifics of operative management (scoring 7 or 8)60? • Q. Complications?
• A. Volar, dorsal and combined dorsal–volar approaches • A.
The volar approach is required to repair the tear in the
palmer capsule ligament at the lunocapitate joint as well as Chondrolysis
carpal tunnel release. Persistent wrist pain
The dorsal approach gives the best exposure of the carpus Traumatic osteoarthritis
for restoration of alignment and interosseous ligament repair. Carpal instability
024
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024
Elbow oral core topics

Chapter
22 Matthew Jones and Asir Aster
Anatomy of the elbow crosses the brachial artery lateral to medial in the arm and
enters the cubital fossa, which is formed by the distal humerus
The elbow is a complex joint consisting of ulnohumeral,
proximally, the pronator teres medially and the brachioradialis
radiocapitellar and proximal radioulnar joints. The distal
laterally.
articular part of the humerus is angled anteriorly by 30° to
the axis of the humeral shaft. As the medial ridge of the
trochlea is larger than the lateral ridge and the capitellum, Surgical approach
the distal humerus has a valgus angle of 6° compared to the Posterior: Various modifications (the method of triceps
epicondylar axis. The coronoid and olecranon fossae are split/olecranon osteotomy)
separated by a thin section of bone accommodating the cor- Anterolateral (Henry’s): Brachialis splitting (dual
onoid and olecranon in extreme flexion and extension innervated muscle: Between radial and musculocutaneous
respectively. The radial fossa accommodates the radial head nerves) followed by dissecting between pronator teres
in full flexion. The medial epicondyle gives the origin to the (median nerve) and brachioradialis (radial nerve)
common flexors/pronator muscles and the medial collateral Posterolateral (Kocher): Between anconeus (radial
ligament (MCL). The lateral epicondyle gives the origin to nerve) and extensor carpi ulnaris (posterior
the common extensors/supinator muscles and the lateral interosseus nerve)
collateral ligament (LCL). The greater sigmoid notch, the Lateral column approach: Lateral supracondylar ridge
articulating part of the proximal ulna, is not covered with proximally into ‘Y’-shaped distal extension. The first limb
articular cartilage centrally. The lesser sigmoid notch, articu- of the ‘Y’ is between anconeus and the extensor carpi
lating with the radial head, is on the lateral aspect of the ulnaris to expose the posterior joint. The second limb of ‘Y’
coronoid process. is between extensor carpi radialis longus and brevis to
The elbow capsule allows a maximum distension between expose the anterior joint
70° and 80° of flexion. This is the position of relative comfort Medial column approach: Medial incision. Free the ulnar
for patients with a tense effusion. nerve. Expose the medial intermuscular septum and
The MCL has three bundles: Anterior, posterior and trans- flexor/pronator muscle group. Detach the intermuscular
verse bands. The anterior is the strongest of the three and is septum and reflect triceps posteriorly to expose the
taut from full extension to 60° of flexion. It resists valgus stress posterior joint. Split the flexor/pronator distally to expose
in pronation. The radiocapitellar articulation is the secondary the anterior joint
constraint to valgus stress. The posterior band is taut between
60° and full flexion.
The LCL has the lateral ulnar collateral ligament (LUCL), Arthroscopic portals
the annular ligament, the radial collateral ligament and the Direct lateral portal: At the centre of a triangle defined by
accessory collateral ligament. The LCL complex is taut the lateral epicondyle, the radial head and the olecranon.
throughout the elbow motion owing to its isometric position, This is frequently used as the initial entry portal to inflate
with the exception of the LUCL, which is taut in flexion the joint with saline
beyond 110°. Anterolateral portal: 1 cm distal and 1 cm anterior to the
The radial nerve spirals medial to lateral posteriorly (13 cm lateral epicondyle, between the radial head and the
from the trochlea) and then pierces the lateral intermuscular capitellum. This gives good access to the anterior aspect of
septum (7.5 cm from the trochlea) to lie between brachialis the joint
and brachioradialis, and passes distally anterior to the lateral Anteromedial portal: 2 cm distal and 2 cm anterior to the
epicondyle. The ulnar nerve is medial to the brachial artery in medial epicondyle. This is often created using an ‘inside
the arm prior to piercing the medial intermuscular septum to out’ technique by cutting down onto the tip of the
pass posterior to the medial epicondyle. The median nerve arthroscope inserted using the anterolateral portal
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025
Proximal medial portal: 2 cm proximal to the medial Treatment

epicondyle along the anterior surface of the humerus Non-operative management
towards the radial head
The aim is to decrease the stress applied to the injured
Direct posterior portal: 2 cm proximal to the tip of the tendons/increase the stress tolerance. Approximately 75% of
olecranon. Access to olecranon fossae patients improve.
Posterolateral portal: 2–3 cm proximal to tip of Rest, NSAIDs and steroid injections (injected under the
olecranon, lateral border triceps. Access to the muscle – Not subcutaneously – To prevent depigmentation
radiocapitellar joint of skin and fat atrophy and not into the tendon to avoid
tendon weakening and rupture) may reduce the pain tempor-
Examination corner arily but do not necessarily improve healing. Counterforce
bracing reduces the force transmitted to the tendon origin/
Basic science oral prevents full expansion of the muscle; therefore, preventing
Identification of different bands of the medial and lateral
maximal contraction. There are six key forearm exercises:
collateral ligaments and their function
Wrist flexion/extension, forearm supination/pronation and
Identification of neurovascular bundles around the elbow
Surgical approaches, internervous and intermuscular planes finger extension/flexion with gradual increase in the resistance,
repetitions and gradual decrease in forearm support during the
exercises.
Tendinopathies Operative management
Repetitive tensile overload which exceeds tissue stress tolerance ECRB/EDC release by arthroscopy, percutaneous or open
causes tissue damage. If it occurs at a rate that exceeds a procedure, when non-operative treatment has made no
tissue’s ability to heal, tissue degeneration is caused. Histolo- improvement. Good results have been reported in up to
gically, there are no acute inflammatory cells. There is 85%. This may be secondary to tendon lengthening/defunc-
granulation-like tissue which consists of immature fibroblasts tioning/denervation or the introduction of an acute inflam-
and disorganized non-functional vascular elements termed matory response.
angiofibroblastic hyperplasia1. It is thought to result from
an aborted healing response to microtrauma. Pain arises pos- Differential diagnosis
sibly from tissue ischaemia. Electron microscopy has shown Radiocapitellar degeneration (tender 2 cm distal to the lateral
that these vascular elements do not have lumen2. epicondyle) and radial tunnel syndrome (tender 4 cm distal to
A ‘mesenchymal syndrome’ is described, whereby patients the lateral epicondyle).
appear to develop multiple, related conditions including lateral
and medial epicondylitis, achilles tendinopathy, rotator cuff
pathology and carpal tunnel syndrome.
Golfer’s elbow
Tendinopathies around the elbow are tennis elbow, golfer’s This is degenerative tendinosis of pronator teres (PT) and
elbow and posterior tennis elbow. flexor carpi radialis (FCR).
The point of maximum tenderness for PT is proximal to
Tennis elbow the medial epicondyle and for FCR is just distal to the medial
epicondyle.
This is degenerative tendinosis of extensor carpi radialis brevis
(ECRB) and extensor digitorum communis (EDC). Provocative test
The point of maximum tenderness is just anterior and
FCR – Elbow flexion/forearm supination/resisted wrist
distal to the lateral epicondyle. flexion and forearm pronation
Provocative test PT – Resisted forearm pronation
ECRB – Elbow extension/forearm pronation/fingers in Surgical release is not as satisfactory as for tennis elbow.
flexion/wrist extended against resistance
EDC – Elbow extension/forearm pronation/wrist Differential diagnosis
neutral/fingers in extension/long finger extended Injury to MCL, ulnar neuritis/cubital tunnel syndrome and
against resistance. (Pain over EDC origin – ulnohumeral arthritis.
Tendinosis. Pain over radial tunnel – Radial tunnel
syndrome.)
Posterior tennis elbow
Investigation This is degenerative tendinosis of the triceps tendon insertion.
MRI in acute post-traumatic conditions, where avulsion of Maximum tenderness is at the insertion. It is provoked by
the extensor origin may be diagnosed, which may need resisted elbow extension. Surgically treatment is by debride-
reattachment ment (not >50% tendon excision) and direct side-to-side repair.
025
Chapter 22: Elbow oral core topics
Differential diagnosis Apart from swelling, ecchymosis and tenderness (in both
Posterior impingement, olecranon periostitis/bursitis and partial and complete ruptures) it is vital to examine for prox-
ulnohumeral arthritis. imal migration of the muscle belly and loss of proximal to
distal tracking of the tendon on passive forearm rotation
(complete rupture). Do not be deceived by palpating the intact
Examination corner
bicipital aponeurosis.
Upper limb short case MRI or USS will be useful in doubtful cases and in partial
EXAMINER: This gentleman is complaining of numbness in the ulnar ruptures.
nerve distribution of his hand. What is the cutaneous distribution
of the ulnar nerve in the hand?
Treatment
CANDIDATE: There is some anatomical variation, but in most people Non-operative
it is the little finger and ulnar border of the ring finger. There is Analgesia and early range of motion exercise, when able. Leads
also a dorsal branch which supplies the dorsum of the hand on to 30% loss of forearm flexion power and 40% loss of supin-
the ulnar side. ation power3.
EXAMINER: The symptoms have been present for 4 weeks since a
Operative management
posterior decompression and instrumented fusion of his lumbar
spine. Why do you think he has developed these symptoms? Acute rupture: Best done within the first 2 weeks prior to the
CANDIDATE: The procedure will have taken place under general
obliteration of the tunnel of the tendon. A single-incision
anaesthetic and he would have been positioned prone with his
technique using anchors or a two-incision technique using
arms resting on boards. He would have been in that position for
bone trough can be used. The two-incision technique reduces
some time and the nerve may have been compressed during this
the risk of injury to the radial nerve. The dominant arm
period.
usually achieves a better result than the non-dominant arm
EXAMINER: Why is it only unilateral?
Chronic rupture: Needs allograft or autograft to regain the
length. Results are not as good as acute repair
CANDIDATE: It could be the way that the arm was positioned on
that side, or he had some subclinical compression on that side
Partial tear: Splinting and decreased activity. Failing this
preoperatively which was exacerbated.
management, surgical completion of tear, debridement and
repair may be necessary
EXAMINER: After clinical examination, what test would you request?
CANDIDATE: Nerve conduction studies.
EXAMINER: And if these confirmed severe slowing of conduction at
Distal triceps rupture
the cubital tunnel, what would you recommend? This is the rarest of all tendon ruptures. Risk factors are renal
CANDIDATE: If symptoms were persisting and significant enough
insufficiency with secondary hyperparathyroidism, systemic or
for surgery, I would offer surgical decompression. I would be
local steroid use and previous surgery using a posterior
more likely to offer surgery if there were loss of motor function or
approach.
constant sensory dysfunction.
The mechanism of rupture is similar to olecranon frac-
ture – Sudden forced flexion of the extended elbow (eccentric
EXAMINER: He has no weakness or wasting and in fact his
tensile loading). A common site is at the insertion enthesis.
symptoms are slowly resolving.
Modified Thompson test4: Forearm hanging free from
CANDIDATE: In that case I would treat non-operatively with night
bed – Elbow 90° flexed. Triceps muscle belly is squeezed.
splintage and review in a few weeks to re-examine him and
Absence of elbow extension suggests complete triceps rupture.
confirm resolution of symptoms.
If elbow extension is present but painful, suspect a partial tear.
Partial tear should be further investigated with MRI as
>50% tear needs surgical repair. Repair is done through a
Tendon ruptures posterior approach and gives good results.
Distal biceps rupture
A predisposing factor for rupture is degeneration in the hypo- Olecranon bursitis
vascular zone close to the radial tuberosity insertion. Risk The olecranon bursa is the most commonly affected bursa
factors are smoking (7.5 times) and anabolic steroid use. around the elbow. The bursa is a discrete structure, which
Mechanical irritation also plays a role – There is 50% reduc- does not usually communicate with the elbow joint, although
tion in the interosseous space in pronation. This is common in in rheumatoid arthritis it may do so.
the dominant arm, in males of 40–60 years and in
weightlifters. Causes
The tendon ruptures with a painful pop following the arm Infection: 25% of bursitis is due to infection.
being forced from a flexed position into extension – Eccentric Staphylococcus aureus is responsible for 90% of these
tensile overload. infections
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025
Inflammatory Varus/valgus – Common extensor and flexor/pronator

Traumatic: Acute or repetitive trauma (‘student’s elbow’) muscles
Haemodialysis Anteroposterior – Brachialis, biceps and triceps
Idiopathic
Assessment of systemic signs, haematological and biochem- Instability – Types
ical markers help to identify infection. Aspiration may be Acute – Following fracture dislocation or dislocation
beneficial. Organisms may not always be seen on Gram Chronic – Repetitive microtrauma, usually affecting MCL
staining. A high WCC of >1000/mm3 in the aspirate suggests Longitudinal – Injury to radial head, central band of
infection. interosseous membrane and ligamentous injury to
radioulnar joints (Essex–Lopresti fracture/dislocation)
Treatment
Rotatory – Posterolateral rotatory instability (lateral ulnar
Infected bursitis collateral ligament)7
Stage of initial cellulitis with no collection – Rest and
antibiotics Acute instability
Presence of collection of pus – Aspiration and maybe Acute instability presents as fracture dislocation or pure liga-
drainage (may cause chronic sinus formation) mentous injury. The terrible triad comprises:
Posterolateral dislocation or LCL injury
Non-infected bursitis Coronoid fracture involving >50% of its height
NSAIDs and compressive bandages Radial head fracture
Steroid injections have been used, but may lead to dermal After reduction of the dislocation, assess the congruity of
atrophy reduction. If the reduction is incongruent, a bony fragment
Excision or soft tissue is interposed. If no clear bony fragment on plain
x-ray, consider a CT and/or MRI. Check the stability of the
joint. If there is loss of stability when extending beyond 45° of
Examination corner flexion, immobilize at 90° of flexion and pronation. If it is not
Adult pathology oral possible to maintain stability between 45° and 60° of flexion in
pronation, surgical exploration and repair/reconstruction of
EXAMINER: A 45-year-old patient in the ED with a painful, swollen
the ligaments is indicated. Postoperatively the elbow is immo-
left elbow and evidence of cellulitis covering most of the skin,
bilized in flexion with an extension block; the extension is
worse on the posterior aspect. His temperature is 38.4°C and he
increased by 30° every week for 3 weeks to allow a full arc of
keeps the elbow in 30° of flexion and does not like any further
movement. In fracture dislocations anatomical reconstruction
flexion. What is your differential diagnosis, please?
of the fractures is essential with or without ligament repair
CANDIDATE: Septic arthritis of the elbow or infected olecranon
(depending on assessment of stability after fracture fixation).
bursitis.
EXAMINER: Which do you think is more likely based on what you Chronic instability
have heard so far? Chronic valgus instability results from repetitive microtrauma
CANDIDATE: Infected olecranon bursitis. I would expect the elbow to the anterior bundle of MCL in athletes involved in over head
to be held nearer to 80° of flexion if there were a painful joint throwing. It presents with pain at the ulnar attachment of
effusion. MCL. Valgus laxity allows abutment of the olecranon against
EXAMINER: What will you do clinically to confirm your diagnosis? the medial aspect of the humerus, resulting in the formation of
CANDIDATE: I will test passive supination and pronation. In septic an osteophyte. This posteromedial osteophyte gives rise to
arthritis the patient will not allow any rotation of the elbow. posterior impingement and loss of full extension. Direct liga-
ment repair is less successful than reconstruction. Reconstruc-
tion is performed using autograft (eg palmaris longus tendon).
Elbow instability Success depends on correct tensioning of graft (the ulnohum-
eral joint medial opening should be closed) and placement of
Instability of the elbow may follow bony or ligamentous injur- the graft in the position that allows isometric tension during
ies. The outcome of ligamentous injuries is worse than bony the full arc of motion.
injuries5.
Longitudinal instability
Elbow stabilisers Longitudinal instability arises from an Essex–Lopresti frac-
MCL (anterior bundle) and LCL complex (especially lateral ture/dislocation owing to fracture of the radial head, rupture
ulnar collateral ligament) of the interosseous membrane and the radioulnar
6
Coronoid (50% loss of height – Instability) and joint ligaments. If excising the radial head is an option,
radiocapitellar joint (secondary valgus restraint) the longitudinal stability must be tested under fluoroscopy by
025
proximally pulling the radius and assessing the distal radio-

ulnar joint (DRUJ). If proximal migration of the radius is >6 EXAMINER: There fracture does not extend beyond what you can
mm at the DRUJ, the radial head must be replaced. see. It is now midnight. Are you going to take him to theatre
Failure to replace the radial head causes proximal migra- tonight?
tion of the radius, giving symptoms from lateral elbow CANDIDATE: Unless the wound is grossly contaminated I will not
instability as well as DRUJ/triangular fibrocartilage complex operate on him tonight. I will ensure he has had antibiotics, a
(TFCC) symptoms. Treatment options are ulnar shortening, photograph of the wound, a sterile dressing and a splint. I will plan
interosseous membrane reconstruction with patellar tendon to operate on him in the morning with a full complement of staff.
graft (as the modulus of elasticity and ultimate tensile strength EXAMINER: You are in theatre with him the next morning. How will
are closer to the patellar tendon), radial head reconstruction you position him and what kind of anaesthetic will he require?
and, lastly, in patients with limited forearm rotation and pain- CANDIDATE: This operation may take >2 hours and ,therefore, he is
ful forearm, creation of a one-bone forearm. probably better with a general anaesthetic, but I will liaise with
the anaesthetist regarding this. I will position him laterally with
Rotatory instability
the arm over a bar. I will use a tourniquet as the fracture is low
Posterolateral rotatory instability arises from damage to the
enough to accommodate this.
lateral ulnar collateral ligament (LUCL), which normally pro-
EXAMINER: What approach will you use?
vides a sling support to the radial head posterolaterally. In the
CANDIDATE: A posterior approach with olecranon osteotomy. I will
absence of an intact LUCL, the radial head subluxes laterally
make a chevron osteotomy using an oscillating saw followed by
and the ulna pivots on the MCL and rotates off the trochlea in
an osteotome to crack through to the joint. I will pre-drill the
a valgus/externally rotated position during flexion. Acute avul-
olecranon for later repair.
sion injuries are treated with reattachment to bone. Acute
intrasubstance injury and chronic injury are treated with EXAMINER: Where will you put your plates?
reconstruction using tendon graft. CANDIDATE: (Discussion regarding 90/90 vs parallel plating)
Examination corner Elbow arthritis

Trauma viva The elbow helps to position the hand in the spherical space for
EXAMINER: You are called to see a 30-year-old man in Resus who which the shoulder is the centre of rotation. Its functional
has come off his motorbike at high speed and collided with a tree. range of movement is a 100° arc of flexion (30–130°) and pro-
What are your priorities? supination (50°/50°). The symptoms of elbow arthritis include
CANDIDATE: ABC. I would initially manage the patient according to pain, stiffness, swelling (effusion and synovitis), neurological
ATLS® principles. symptoms (mostly ulnar nerve) and instability.
EXAMINER: OK. We’ll assume that has been done and he is
Causes
cardiovascularly stable with an isolated injury to the left elbow.
What can you see from this photograph?
Inflammatory
CANDIDATE: This is a clinical photograph of this gentleman’s left
Post-traumatic
elbow, forearm and hand. The elbow is grossly swollen, bruised
Primary osteoarthritis
and deformed. I cannot see any wounds on this picture but would Neuropathic
examine him closely for evidence of an open injury.
EXAMINER: It is open. There is a wound on the medial side of
Inflammatory
the elbow. Rheumatoid arthritis is a common inflammatory arthritis
CANDIDATE: I would also check his neurological and vascular status affecting the elbow. Up to 50% of patients with rheumatoid
and for evidence of compartment syndrome. arthritis have elbow involvement. Women are affected three
EXAMINER: The injury is neurovascularly intact and he is comfortable
times more commonly than men. Medical anti-rheumatoid
when the limb is splinted. What investigation will you do?
therapy has reduced the need for surgery, but this is still
required in selected cases.
CANDIDATE: He should have had a chest and pelvis x-ray as part
of his ATLS® management. I would also request plain radiographs
Clinical findings
of the elbow.
EXAMINER: Here they are.
Joint contractures (especially juvenile idiopathic arthritis)
Ligamentous instability secondary to attenuation
CANDIDATE: These are AP and lateral radiographs of the left elbow
of this gentleman. There is an intra-articular, comminuted fracture MCL – Valgus ulnohumeral instability
of the distal humerus. The upper humerus is not visible, I would LUCL – Posterolateral rotatory instability
want x-rays of this too. Annular ligament – Radial head subluxation
Combined – Multidirectional instability
499
025
Neurological symptoms Osteophytes at the tip of the olecranon and coronoid

Ulnar nerve – Secondary to valgus instability It is not common to have mal-alignment or subluxation of
Posterior interosseous nerve – Synovitis/pannus around radiocapitellar joint
the radiocapitellar joint
Neuropathic
Subarticular fractures
The neuropathic joint is painless with severe loss of bone and
Subchondral cyst – Pannus induced joint architecture and loss of joint stability.
Periarticular osteopenia The causes include surgical denervation, diabetes, syringo-
myelia and syphilis.
Radiological findings
Panarticular (ulnohumeral and radiocapitellar) loss of Treatment of elbow arthritis
joint space Non-operative
Subchondral cysts Activity modification/splinting/intra-articular steroid
Periarticular osteopenia injection/analgesia
Absence of subchondral sclerosis and osteophytes, except Disease modifying agents for inflammatory arthritis
when secondary osteoarthritis present
Subluxed/dislocated radiocapitellar joint Operative
Debridement – Arthroscopic/open. The Outerbridge–
Post-traumatic Kashiwagi (OK) procedure involves opening the olecranon
The elbow is most intolerant to trauma. Immobilization pre- fossa, drilling through the floor of the olecranon fossa to
disposes it to stiffness. Intra-articular injuries predispose to the coronoid fossa and debriding osteophytes and
post-traumatic arthritis. It affects all age groups, mainly removing loose bodies from both fossae
young/middle-aged individuals. Synovectomy with or without radial head excision –
Arthroscopic/open
Clinical findings
Ulnohumeral interposition arthroplasty – For non-
Pain at the end range of movements inflammatory conditions. Resurfacing materials used
Stiffness include fascia lata and Achilles tendon. Rarely done
Locking or clicking – Loose bodies Resurfacing – Radiocapitellar joint (metaphyseal fixation
Ulnar nerve dysfunction – Medial osteophytes from the by pegs). Lateral resurfacing of the elbow – In the early
ulnohumeral joint stages of osteoarthritis involving the radiocapitellar joint
prior to the progression into valgus tilt. Advantages
Radiological findings
are – Minimal bone loss during bone preparation (3 mm
Joint space irregularity/narrowing of the affected loss from either surface), maintains normal anatomy and
compartment alignment and the ability to regain full rotational arc
Subchondral sclerosis (as replaced radiocapitellar joint) as well as flexion/
Subchondral cysts extension arc (as resurfacing gives ideal surface and room
Osteophytes for radial head). As the lost cartilage in the lateral elbow is
being replaced, theoretically the forces are redistributed
Primary osteoarthritis anatomically and, therefore, it could prevent the usual
This type of arthritis is common in middle- to old-age males progression of the arthritis to the medial joint
performing repetitive manual labour. Replacement – Unlinked. Greater risk of instability
especially in rheumatoid patients as the unlinked prosthesis
Clinical findings
relies on ligamentous stability
Pain at the end range of motion Replacement – Linked/semi-constrained. ‘Sloppy hinge’
Mechanical block to flexion and extension such as the Coonrad-Morrey and Discovery prostheses.
Pain on carrying weight in extension Ideal for unstable rheumatoid elbow
Locking and clicking – Loose bodies Replacement – Linked/constrained. It is historical.
There is excessive load transfer to stem/cement/bone
Radiological findings interfaces and high (25% in 4 years) evidence of
Subchondral sclerosis of the radiocapitellar joint with loosening
preserved joint space Arthrodesis – unilateral arthrodesis is at 110° of flexion to
Progressing to radiocapitellar narrowing producing valgus help reaching the face. If bilateral arthrodesis is needed, the
tilt, with involvement of the lateral facets of the second elbow should be at a greater degree of extension to
ulnohumeral joint reach perineum for personal hygiene
025
Examination corner
EXAMINER: Yes.
Adult pathology viva
CANDIDATE: The problem is that a total elbow arthroplasty would
EXAMINER: This 40-year-old delivery driver with rheumatoid arthritis not be strong enough for him to use the arm for heavy physical
is sent by his rheumatologist. He has failed conservative activity. He is only 40 and has a physical job. The alternative of
management and the rheumatologist is asking whether surgery is elbow arthrodesis would obliterate elbow movement and may
an option. What do you think of his x-rays? also prevent him from doing his job.
CANDIDATE: These are AP and lateral plain radiographs of this EXAMINER: So what will you do?
gentleman’s left elbow. There is a marked loss of joint space in CANDIDATE: I would discuss the options with the patient so that he
the ulnohumeral joint and radiocapitellar joint. There are is fully informed about the advantages and disadvantages of each
extensive osteophytes implying secondary osteoarthritis. option. My recommendation would be to try and persist with
There are some cysts in the distal humerus. non-operative treatment for as long as possible.
EXAMINER: What are the surgical options? EXAMINER: He has exhausted all non-surgical therapy and is
CANDIDATE: This is a difficult problem as this is a young patient. The interested in the arthrodesis. What position would you fuse
options are debridement, partial replacement, total replacement him at?
and arthrodesis. Based on his x-rays, I would not expect him to CANDIDATE: I would tailor the angle to the patient. Essentially he
benefit much from debridement or partial replacement. Does he needs to get his hand to his mouth, and this would usually
need to lift for his work? involve fusion at about 110° of flexion.
References 3. Morrey BF, Askew LJ, An KN,

Dobnys JH. Rupture of the distal
fractures of the radial head and
coronoid. J Bone Joint Surg Am.
1. Nirschl RP. The etiology and treatment tendon of biceps brachii. 2002;84:547–51.
of tennis elbow. Am J Sports Med. A biomechanical study. J Bone Joint
1974;2:308–19. 6. Closkey RF, Goode JR,
Surg Am. 1985;67:418–21.
2. Kraushaar BS, Nirschl RP. Tendinosis Krischenbaum D, Cody RP. The role
of the elbow. Clinical features and 4. Strauch RJ. Biceps and triceps injuries of the coronoid process in elbow
findings of histological, of the elbow. Orthop Clin N Am. stability. J Bone Joint Surg Am.
immunohistochemical and electron 1999;30:95–107. 2000;82:1749–53.
microscopy studies. J Bone Joint Surg 5. Ring D, Jupiter JB, Zilberfarb J. 7. O’Driscoll SW. Elbow instability.
Am. 1999;81:259–78. Posterior dislocation of the elbow with Hand Clin. 1994;10:405–10.
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Shoulder oral core topics

Chapter
23 Matthew Jones and Asir Aster
Anatomy of shoulder anterior pillar and the infraspinatus and teres minor form
the posterior pillar. Even if there is a tear in the supraspinatus
The shoulder comprises three joints: The glenohumeral,
tendon, as long as the pillars of the suspension bridge or the
sternoclavicular and acromioclavicular. The scapula in turn
cable are intact the cuff function is maintained. When there is
articulates with the chest wall to confer additional range of
discontinuity of either end of the pillar or cable, there will be
movement. Two-thirds of shoulder abduction occurs at the
anterior or posterior translation and elevation will be com-
glenohumeral joint and one third at the scapulothoracic
promised. The rotator interval (triangular) is formed super-
articulation.
iorly by the anterior border of supraspinatus, inferiorly by the
The glenohumeral joint is extremely mobile, but this
superior border of subscapularis and medially by the base of
mobility comes at a cost to stability. The joint has both static
the coracoid. The apex is formed by the transverse humeral
and dynamic stabilisers to prevent dislocation. The static sta-
ligament. It contains the coracohumeral ligament.
bilisers are:
The sternoclavicular (SC) joint and acromioclavicular (AC)
Bony congruity between the humeral head and glenoid joint are gliding joints. In the SC joint, the anterior and
The glenoid labrum posterior SC ligaments prevent superoinferior translation and
Negative pressure the interclavicular and costoclavicular ligaments prevent ante-
Ligaments (Table 23.1) roposterior translation. In the AC joint, the superior and
The dynamic stabilisers are the rotator cuff and extrinsic inferior acromioclavicular (AC) ligaments prevent anteropos-
muscles of the shoulder including the pectotalis major, latissi- terior translations and the coracoclavicular ligaments (CC;
mus dorsi, deltoid, coracobrachialis, pec minor, biceps and trapezoid and conoid) prevent superior translation of the
triceps. clavicle. The clavicle is the first bone to ossify (5 weeks of fetal
In functional ranges of movement, the dynamic stabilisers development) and it is the last one to fuse (25 years – Medial
are the principle stabilisers. They centre the humeral head in epiphysis), and although it is a long bone it ossifies by intra-
the glenoid by concavity compression. The capsular ligaments membranous ossification.
act as check reins at extremes of range. The scapula spans ribs 2 to 7. It has three processes: The
Cuff function is compared to a suspension bridge model spine, coracoid and acromion. Glenoid orientation ranges from
and cable/crescent. The subscapularis tendon forms the 7° of retroversion to 10° of anteversion and has 5° of superior
tilt. The humeral head is in 20–30° of retroversion and has a
Table 23.1 Shoulder ligaments and action 130° superior inclination relative to the shaft. The coracoid
Ligament Action process provides attachment to three ligaments (coracohum-
eral, coracoacromial and coracoclavicular) and three muscles
Superior glenohumeral Opposes inferior translation (pectoralis minor, coracobrachialis and short head of biceps).
in adduction The suprascapular artery is superior to the superior transverse
Middle glenohumeral Opposes anteroinferior ligament and inferior to the inferior transverse ligament. The
translation in the midrange suprascapular nerve is inferior to both ligaments.
Inferior glenohumeral Opposes anterior translation The scapula can wing medially or laterally. In medial
abduction winging, trapezius is unopposed by the weak serratus anterior
and the medial border of the scapula becomes prominent. In
Anterior ligaments collectively Oppose anterior humeral
lateral winging, the trapezius is weak and, therefore, it is the
(superior, middle and inferior) translation in external
rotation lateral border that protrudes.
Pectoralis minor divides the axillary artery into three parts.
Posterior glenohumeral Oppose posterior translation The first part has one branch, the second has two branches and
in internal rotation
the third has three branches.
026
Chapter 23: Shoulder oral core topics
Parts of the axillary artery (Table 23.2) Arthroscopic portals

Posterior: (viewing) 2 cm medial and inferior to the
Spaces of the shoulder (Table 23.3 and Figure 23.1) posterolateral corner of the acromion
Surgical approaches Anterior: Lateral and inferior to the coracoid process. This
portal should be made under direct vision using a needle as
Deltopectoral approach: Between deltoid (axillary nerve)
a guide. Aim for the rotator interval between supraspinatus
and pectoralis major (medial and lateral pectoral nerves).
and subscapularis
The cephalic vein lies between them: Retract it either
way, usually laterally due to multiple deltoid branches. Lateral: Junction of anterior one-third and posterior
Place stay sutures in subscapularis and incise tendon two-thirds of the lateral border of the acromion and 2 cm
leaving a cuff to repair. Incise capsule. Beware of brachial inferior. Provides a view of/access to the subacromial
plexus and particularly the musculocutaneous nerve medial space for cuff inspection/repair
to the coracoid, at risk from excessive retraction. Lateral to Additional arthroscopic portals – Nevasier, anterolateral,
the coracoid is the ‘safe side’, medial is the ‘suicide’! posterolateral, anteroinferior and posteroinferior
Lateral approach: Deltoid splitting (axillary nerve). When
split extends beyond 5 cm inferior to acromion; axillary
nerve is at risk. Rotator cuff tendons are beneath deltoid so Examination corner
one can use this approach for access to the cuff. Can also be Basic science oral
used to nail the humerus, but if doing this, split the muscle, Identification of structures from pictures, especially axial CT
not the tendon, and repair it afterwards images or cross-sectional cadaveric photographs –
Posterior approach: Between infraspinatus (suprascapular Muscles, tendons, ligaments, intermuscular spaces and
nerve) and teres minor (axillary nerve). Inferior retraction intervals, nerves and blood vessels
Explain – Static and dynamic stabilisers of the shoulder
of teres minor risks damaging the axillary nerve and the
Surgical approaches – Surface markings, internervous
posterior humeral circumflex artery (quadrilateral space). planes, intermuscular planes and structures at risk
Medial retraction of infraspinatus can injure the Mark the standard arthroscopic portals on the picture and
suprascapular nerve mention the use of these portals
Cuff – Identification of individual muscles, innervation,
Table 23.2 Axillary artery anatomy function and rotator interval
Part Location Branches
First Medial to pectoralis
minor
Supreme thoracic
Impingement syndrome
Types of impingement
Second Posterior to pectoralis Thoracoacromial
minor Lateral thoracic Subacromial impingement
Third Lateral to pectoralis Subscapular Primary – Intrinsic (degenerative tendonopathy) or
minor Anterior humeral extrinsic (coracoacromial arch)
circumflex
Posterior humeral
circumflex
Quadrilateral
space
Table 23.3 Anatomical spaces of the shoulder
Space Borders Contents Teres

mino
ps
r
ice
Quadrilateral Four borders: Teres minor, Four words:

f tr
space teres major, long head of Posterior

rus
do
(rule of fours) triceps, humerus humeral

Hume
hea
circumflex artery
Teres
g
Four syllable majo

Lon
Triangular r
nerve: Axillary interval
Triangular Teres minor, teres major, Circumflex
space long head triceps scapular artery
Triangular Long head of triceps, Profunda brachii Triangular
interval humerus (plus lateral head Radial nerve space
of triceps), teres major
Figure 23.1 Shoulder spaces and intervals
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Secondary – Owing to glenohumeral instability Treatment

Subcoracoid impingement Non-operative management
Internal impingement Anti-inflammatory medications and steroid injections for
symptom control. Physiotherapy aiming at stretching for full
Subacromial impingement shoulder motion and strengthening the rotator cuff, deltoid
Subacromial impingement relates to the symptoms of pain and and scapulothoracic muscles.
dysfunction from either a reduction in the volume of the Operative management
subacromial space, or an increase in the contents. Rotator cuff
Subacromial decompression: Arthroscopic or open release of
damage occurs with excess stress, repetitive tensile loading, or
the coracoacromial ligament and removal of the anterolateral
inadequate healing. Subacromial impingement is an overuse
lip and undersurface of the acromion. Failure to respond to
phenomenon, which lacks acute inflammatory cells and should
conservative therapy is an indication for operative intervention.
appropriately be called tendinosis. The affected swollen tendon
has less space under the acromion and causes intrinsic
impingement.
Subcoracoid impingement
Extrinsic impingement occurs when the space available for This presents with pain in the anterior shoulder caused by
the rotator cuff is diminished because of: contact between the subscapularis and the coracoid process,
and is caused by a prominent coracoid in forward flexion and
subacromial spurring
internal rotation of shoulder.
acromial fracture or os acromiale
osteophytes from the under-surface of the Provocative tests
acromioclavicular joint Coracoid impingement sign: This is performed in a similar
exostoses at the greater tuberosity way to Hawkins’ sign, apart from the arm being adducted
The subacromial spurring is caused by enthesophyte forma- 10–20° to bring the lesser tuberosity in contact with the
tion at the coracoacromial ligament’s acromial insertion, coracoid
secondary to dynamic loading. In 1986, Bigliani introduced a Coracoid impingement test: Pain relief with local
morphological classification of the acromion1 anaesthetic in the subcoracoid region
Type I: Flat acromion
Treatment
Type II: Curved acromion (parallel to the
humeral head) Open or arthroscopic coracoplasty.
Type III: Hooked (converging on the humeral head) –
Commonest association with subacromial impingement Internal impingement
Chronic degeneration of the cuff affects its optimum function This is caused by internal contact of the posterior rotator cuff
and allows the deltoid to overcome the cuff’s concavity com- with the posterosuperior aspect of the glenoid when the arm is
pression and pulls the humeral head upwards. The deltoid’s abducted, extended and externally rotated. It often occurs in
upward pull causes the cuff to impinge on the coracoacromial throwers and they demonstrate lost internal rotation of the
arch, causing secondary subacromial impingement. affected shoulder in comparison to the unaffected side3.
Treatment
Stages of impingement2
Physiotherapy is used to regain internal rotation and rotator
Stage 1: Oedema and haemorrhage <25 years old
cuff strengthening. Surgical treatment is by removal of poster-
Stage 2: Fibrosis and tendonitis 25–40 years old osuperior glenoid osteophytes and posterior release.
Stage 3: Bone spurs and tendon rupture >40 years old
The symptoms include anterolateral shoulder pain over the
shoulder with aggravation by overhead activities. Examination
Rotator cuff tears
Rotator cuff tears range from partial tears to complete irrepar-
reveals a painful mid-abduction arc from 60° to 120°.
able tears. The cuff fails because of a repetitive tensile load
Provocative tests which exceeds its ability to heal. Greater than 90% of partial
tears occur on the articular side away from the acromion
Neer’s impingement sign: Pain on forward elevation of
secondary to poor blood supply4. The natural history of rota-
the arm
tor cuff tears cannot reliably be predicted.
Neer’s impingement test: Temporary relief of pain with
subacromial injection of lidocaine
Hawkins’ sign: Pain on internal rotation of the arm in 90°
Classifications
of forward elevation, as this brings the greater tuberosity Partial-thickness tears based on location
under the acromion and further exacerbates any Bursal side tear
compression of the supraspinatus tendon Intratendonous tear
026
Articular side tear (includes PASTA lesion: Partial articular :

Subscapularis: Gerber’s lift-off test if sufficient range of
supraspinatus tendon avulsion) internal rotation to get the hand to the lumbar spine.
Partial-thickness tears based on depth of involvement: Beware of triceps recruitment giving a false negative
Ellman’s classification test. Alternatively, the belly press (Napoleon) test
: Grade I: Tears with a depth of <3 mm Lag tests for each cuff muscle
: Grade II: Depth of 3–6 mm, but always less than half : Supraspinatus: passively place the limb in the position
tendon thickness for Jobe’s test and see if the patient can maintain it
: Grade III: Depth >6 mm or more than half thickness of : Infraspinatus: passively place the limb in external
the tendon rotation and see if the patient can maintain it
Full-thickness tears: Cofield’s classification : Teres minor: passively place the shoulder in abduction,
Small (<1 cm) forward elevation and external rotation. If the patient
Moderate (1–3 cm) cannot maintain this actively, the hand will drop in
front of the face (hornblower’s sign)
Large (3–5 cm)
Massive (>5 cm)
: Subscapularis: if sufficient range of internal rotation,
passively place the patient’s hand off their lumbar spine
Goutallier staging of fatty degeneration of the rotator cuff
and see if they can maintain it
muscle5
:Stage 0: Normal muscle without any fatty streak
Investigations
:Stage 1: Muscle contains some fatty streaks
Plain radiographs
:Stage 2: There is still more muscle than fat
:Stage 3: There is as much fat as muscle :
Sclerosis of undersurface of the acromion
:Stage 4: More fat than muscle :
Traction spurs in the coracoacromial ligament
Anatomical classification :
Upward displacement of the humeral head
: Longitudinal tear: Longitudinal split
:
Acetabularized coracoid, acromion and glenoid
: Crescent shaped: Minimally retracted
:
Acromioclavicular joint arthritis – Inferior osteophytes
: U-shaped: Medially retracted
:
Degenerative calcification of the cuff
Cuff tendon imaging
: L-shaped: A combination of a longitudinal tear with a
transverse limb : Ultrasonography: Dynamic evaluation of cuff
: MR arthrogram: Detects cuff tears and also assesses cuff
musculature
Clinical features
Referred pain at deltoid insertion site Treatment
Loss of range of motion: Initially affecting active Partial-thickness rotator cuff tears
movements, but later passive movements are restricted due
Non-operative management includes activity modification,
to progressive capsular contracture
stretching followed by strengthening exercises and anti-
Weakness and wasting of the involved cuff muscle
inflammatory medication. Surgery is indicated for failure of
Instability – Especially when the cuff tear was secondary to conservative treatment. If the shoulder demonstrates stiffness, a
dislocation
shoulder mobilization programme is instituted before surgery.
Mechanical – Snapping or catching during movements Principles of partial cuff tear surgery include:
owing to lack of concentric concavity compression
Assessment of the cuff tear – Mainly the thickness of the
tear and its quality
Assessment Release of capsular contractures
Wasting – Mainly seen in the supraspinous and Reintroduce healing biology – By debridement of the
infraspinous fossae degenerated cuff and by performing simultaneous
Range of motion: Active followed by passive movements. subacromial decompression
Examine from the front and from the back with your hands Reattach the tendon to its anatomical footprint
on the scapulae to differentiate glenohumeral from Protect the repair until it heals
scapulothoracic movement Regain movement and its control postoperatively by a
Power physiotherapy programme
: Supraspinatus: Jobe’s test (empty can test) Tears involving <50% are treated with debridement with or
: Infraspinatus and teres minor: External rotation without acromioplasty. A tear depth of >50% is an indication
strength for completion of tear and repair of the cuff with acromioplasty.
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Full-thickness rotator cuff tears Table 23.4 Walsh classification of glenoid wear
Non-operative management consists of physiotherapy, A1 Minor concentric wear, no subluxation

NSAIDs, rest, avoidance of aggravating factors and judicious A2 Major concentric wear, no subluxation
steroid injections.
The principles of physiotherapy include four-quadrant B1 Posterior eccentric wear, posterior subluxation
stretching, strengthening exercises of the rotator cuff, deltoid B2 Biconcave glenoid, posterior subluxation
and surrounding musculature. C Retroverted glenoid >25°
Operative management is by open, mini-open or arthro-
scopic approaches
Longitudinal tear: Side-to-side repair ligament leads to anterosuperior escape of the humeral
Crescent-shaped: Repaired back to greater tuberosity head. The glenoid and coracoacromial arch becomes
U-shaped: Margin convergence to create crescent-shaped ‘acetabularised’
tear and repaired back to bone Capsulorrhaphy arthropathy: The posterior glenoid is
L-shaped: Mobile torn leaf to other leaf by side-to-side eroded with anterior capsular tightening, and anterior
repair and repair back to bone erosion of the glenoid with anterior translation of humerus
occurs with posterior capsulorrhaphy
Irreparable rotator cuff tears Neuropathic arthritis
Non-operative treatment includes NSAIDs, steroid injections
and local therapeutic modalities to relieve pain. Early restor- Investigations
ation of the passive range of motion and activity modification Standard radiographs include AP views in the plane of the
is followed by muscle strengthening exercises. glenoid and axillary views
Surgical options in this difficult scenario include CT scan to assess glenoid bone stock, zone of wear and
Subscapularis tendon transposition is used to fill large gap orientation
in the supraspinatus insertion US scan or MRI is used to evaluate the quality of the
Latissimus dorsi muscle transfer for posterosuperior rotator cuff for preoperative planning
defects Table 23.4 shows Walsh classification of glenoid wear6.
Pectoralis and teres major transfer for anterosuperior
defects Treatment
Glenohumeral arthrodesis when the deltoid and rotator Non-operative treatment: range of movement and
cuff muscles are not functional strengthening exercises with NSAIDs, analgesics and
Human-derived allograft (e.g. Graft Jacket) steroid injections
Porcine xenograft Operative management: Arthroplasty for pain relief and
improved function
Arthritis Types of shoulder arthroplasty

Anatomic total shoulder replacement
Glenohumeral arthritis Hemi-arthroplasty
This is the end result of loss of articular cartilage in the
Reverse total shoulder replacement
shoulder. Clinical features include muscle wasting, painful
limitation of range of movement and palpable crepitus. Radio- : Indicated when the cuff is deficient
graphically, the usual findings of loss of joint space, osteo- : Not recommended in younger, higher demand patients
phytes, subchondral sclerosis and bone cysts can be seen. due to loosening of glenoid component
: Relies on a functional deltoid
Types : Medialises the centre of rotation of the shoulder and
Primary degenerative: Triad of anterior capsular contracture, thereby increases the length of the lever arm for the
posterior glenoid wear with posterior humeral subluxation deltoid
Secondary degenerative: Secondary to trauma, infection or
avascular necrosis
Examination corner
Inflammatory arthritis: Glenoid erosion is predominantly
medial with frequent bilateral symmetrical involvement Upper limb intermediate case
Cuff tear arthropathy: A deficient cuff leads to a lack of EXAMINER: This 70-year-old gentleman has been referred by his GP
centralisation of the humeral head in the glenoid. Deltoid with swelling and reduced function of the right shoulder. What
and other extrinsic muscles pull the humeral head can you see on inspection?
upwards. Progressive incompetence of the coraco-acromial
026
Clinical features
CANDIDATE: This gentleman’s right shoulder is grossly swollen over
Discomfort over the anterior and superior aspects of the
the AC joint and anterior glenohumeral joint. There are no scars shoulder
or erythema present.
Radiating pain aggravated with physical activity, especially
EXAMINER: OK. Here are his x-rays. above the head activities
CANDIDATE: These are AP and axillary radiographs of Feeling of popping, catching or grinding
this gentleman’s right shoulder demonstrating cuff
Tenderness over AC joint
arthropathy. The humeral head is superiorly displaced and
Provocative test: Cross-body adduction (Scarf ) test causes
there is acetabularisation of the glenoid and coracoacromial
pain in AC joint region
arch. There is secondary osteoarthritis as evidenced by loss
of joint space, subchondral sclerosis and cysts, and Investigations
osteophytes. Radiograph: Zanca view to visualize the AC joint
EXAMINER: What do you expect to find when you examine his (10° cephalic tilt)
rotator cuff? Symptom relief from injection of local anaesthetic is
CANDIDATE: I expect to find weakness in abduction and external diagnostic
rotation.
EXAMINER: This gentleman has exhausted non-operative Treatment
management. What surgery would you propose? Non-operative
CANDIDATE: In view of his deficient rotator cuff, I would suggest a Activity modification, moist heat, NSAIDs, corticosteroid
reverse total shoulder replacement. injections and physiotherapy. Ultrasound guidance can help
EXAMINER: What would you want to know from your examination to confirm intra-articular injection.
before proceeding to surgery?
Surgical treatment
CANDIDATE: I would check that he has a good passive range of
movement and if not I would refer to physiotherapy to see if this Excision of AC joint by an open or arthroscopic technique (do
could be optimised. I would also check that deltoid is functioning not excise >0.5–1.0 cm of the lateral end of clavicle to protect
well. the coracoclavicular ligaments and prevent superior migration
EXAMINER: How does a reverse shoulder prosthesis work
of the clavicle). Most surgeons prefer arthroscopic to open
biomechanically?
excision.
CANDIDATE: The centre of rotation of the shoulder is moved
medially which increases the lever arm for the deltoid. AC joint injury
This enables the deltoid to function more effectively through a Traumatic injuries to the AC joint are classified by Rockwood7
greater range of movement and to compensate for a deficient as shown in Table 23.5.
rotator cuff.
Examination corner
Acromioclavicular joint arthritis Trauma viva
Primary arthritis of the ACJ is much more common than the EXAMINER: This 45-year-old lady fell off a horse. You see her in the
glenohumeral joint. Asymptomatic AC joint degeneration is A&E and ATLS® principles have been followed. She has an
frequent and, therefore, symptoms do not correlate well with isolated injury to the left shoulder. What do you seen on this
x-ray findings. Post-traumatic arthritis is more common than photograph?
primary arthritis.
Table 23.5 AC joint injury
Type Ligaments Radiographs Management

I AC ligaments sprained Normal x-ray Non-operative
II AC ligaments torn, CC ligaments sprained Superior displacement of clavicle <25% Non-operative
III AC and CC ligaments torn Superior displacement of clavicle 25–100% Depends on symptoms/demand
IV AC and CC ligaments torn Clavicle displaced posteriorly through trapezius Surgical repair/stabilisation
V AC and CC ligaments torn Clavicle displaced superiorly by >100% Surgical repair/stabilisation
VI AC and CC ligaments torn Clavicle displaced inferiorly (rare) Surgical repair/stabilisation
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Type I
CANDIDATE: This is a clinical photograph of this lady’s left shoulder Traumatic
from the anterior aspect. There is bruising and swelling of the structural
shoulder with prominence of the distal clavicle.
EXAMINER: What is your diagnosis?
CANDIDATE: This could be a clavicle fracture or AC joint
Less muscle
dislocation. patterning
EXAMINER: How will you make the diagnosis?
CANDIDATE: I would like to see plain x-rays: An AP and a Zanca view
with 10–15° of cephalic tilt.
EXAMINER: Here they are.
CANDIDATE: There is dislocation of the AC joint with gross superior Type III Type II
Atraumatic A traumatic
displacement of the distal clavicle. This implies complete tear of
muscle patterning structural
the AC and CC ligaments. This is classified according to
Rockwood as type V. Less trauma
EXAMINER: What treatment would you recommend?
Figure 23.2 Stanmore classification(Bayley triangle)
CANDIDATE: I would recommend surgical stabilisation to restore
and maintain the AC joint anatomy.
EXAMINER: What would be the sequel of non-operative Thomas and Matsen
management? TUBS: Traumatic Unidirectional with a Bankart lesion.
CANDIDATE: The AC joint would remain dislocated and would likely Treat with Surgery
remain unstable. This would result in pain, clicking and AMBRI: Atraumatic Multidirectional Bilateral. Treated
dysfunction of the shoulder. with Rehabilitation and, if surgery is required, an Inferior
capsular shift and closure of the rotator interval
Osteolysis of the distal clavicle Bayley (Stanmore) (Figure 23.2)

This is seen predominantly in weight lifters and is thought to History
represent repetitive microfracture of the distal clavicle. Patients There is a definite history of trauma elicited in acute disloca-
present with pain in the AC joint region and x-rays show a tions. Electrical shocks and seizures are usually associated with
lytic area in the distal clavicle. Treatment is non-operative with posterior dislocations because the combined strength of the
NSAIDs, activity modification and sometimes steroid injec- internal rotators overwhelms the external rotators. Atraumatic
tion. If symptoms persist, excision of the distal clavicle may be instability causes discomfort in activities of daily living with
considered. discomfort even at rest.
Assessment
Shoulder instability An acutely dislocated joint is very painful with muscles in
Joint instability is an abnormal symptomatic motion in the spasm. The humeral head may be palpable depending on the
joint resulting in pain, subluxation or dislocation. Joint direction of dislocation along with asymmetry of shoulder
laxity is a clinically detectable degree of translation in the contour. Neurovascular status of the extremity should be
joint, which falls within a physiological range and is assessed before and after any intervention. Stability tests useful
asymptomatic. for demonstration of instability include the fulcrum test,
Factors affecting the stability of the shoulder are described apprehension test, Jobe’s relocation test and the jerk test. The
at the beginning of this chapter. laxity tests include the drawer test and sulcus test, and are used
Classifications for instability to compare with the laxity of the normal contralateral shoul-
der. Testing of the strength of muscles around the shoulder
Degree – Subluxation or dislocation should complement the examination.
Chronicity – Acute or chronic
Direction – Unidirectional or multidirectional Investigations
Volition – Voluntary or involuntary Radiographs: In the acute setting, an AP view, scapular
Historically, Thomas and Matsen’s ‘TUBS and AMBRI’ classi- lateral view and/or axillary view are taken to attain
fication8 has been used, but this has been largely replaced by information with regard to direction of dislocation,
the Bayley triangle from Stanmore9. This recognises three associated fractures and possible blocks for relocation. The
‘polar groups’ but also that patients can lie on a spectrum Stryker notch view demonstrates humeral head defects.
between groups. The West Point axillary view demonstrates glenoid defects
026
CT scan is useful for greater detail of anatomy Non-structural instability – Muscle patterning: Non-
MR arthrogram can reveal associated rotator cuff and operative management
labral tears Mixed structural and muscle patterning: Non-operative
Arthroscopy is invasive but is useful to assess structural management is the first line treatment. Surgery is indicated
damage in the shoulder accurately and is a dynamic if the muscle patterning component can be corrected and
investigation the underlying structural instability remains a problem
Electromyography (EMG) is useful in muscle patterning
Surgical interventions for structural anterior instability
instability
Anatomical repairs
Treatment Bankart repair: Reattachment of the Bankart lesion to the
Acute dislocations margin of the glenoid either by open or arthroscopic
Acute dislocations should be reduced as gently and exped- technique
itiously as possible after a complete set of radiographs. Various Large Hill–Sachs lesion: Transfer of infraspinatus to fill the
techniques of reduction used are defect to help prevent redislocation
Hippocratic method – Foot in the axilla (historical) Non-anatomical repairs
Traction–countertraction method
Latarjet procedure: Transfer of the coracoid and conjoint
Stimson method: Prone with application of downward tendon to the anterior glenoid rim
traction
Magnuson–Stack procedure: Advancement of the
Kocher method: Redislocation rates are slightly higher with subscapularis
this technique. Considered dangerous by some surgeons
Putti–Platt procedure: Imbrication and shortening of the
due to risk of iatrogenic injury, particularly humeral
subscapularis
fracture
Glenoid or humeral osteotomies: Particularly if there is
Spaso technique: Supine with longitudinal traction and excessive anteversion of the glenohumeral joint
external rotation
Posterior dislocation is reduced with longitudinal lateral traction Surgical interventions for structural posterior instability
followed by external rotation. Unreduced and chronic disloca- Reverse Bankart procedure and capsular shift
tions need open reduction. Chronic dislocation with minimal Reverse Putti–Platt procedure
discomfort and good functional range can be managed with
Boyd–Sisk procedure: Transfer of long head of biceps to
supervised neglect. Dislocation associated with greater tuberosity posterior glenoid
fracture has a lower rate of recurrence. The age of the patient at
A reverse Hill–Sachs defect is managed by transfer of
the time of initial dislocation is the major determinant of recur-
subscapularis or the lesser tuberosity
rent instability, with rates as high as 90% in patients <20 years.
The dislocation rate decreases as the age of the patient increases. Treatment for non-structural instability and muscle patterning
Dislocation in those of advanced age is commonly associated Needs a multidisciplinary approach. The initial step is to assess
with rotator cuff tear. The important elements in post-reduction the muscle patterning/function and the direction of instability.
management are protection and rehabilitation to prevent recur- EMG studies are useful for evaluation. Patients with a muscle
rent instability. Immobilization in external rotation rather than patterning disorder have a muscle coordination problem that
the standard internal rotation position has been shown to have forms the basis of the biofeedback exercises concentrating on
good results in a study by Itoi et al.10 improving joint position sense and relearning correct muscle
When there is a dislocation – Reduce it, check if it is movement patterns. The aim is to strengthen the shoulder
congruent (incongruent = bony or soft-tissue interposition), musculature to achieve concavity compression.
immobilize for 3–4 weeks to allow soft-tissue healing to com- After correction of muscle patterning, if the patient fails to
mence, then assess clinically for stability. If stable, rehab with respond to vigorous strengthening exercises, endurance and
physiotherapy. If unstable, assess with MR arthroscopy for coordination, the surgical option is an inferior capsular shift
lesions that may require surgical intervention such as HAGL procedure either by open or arthroscopic method. The principle
(humeral avulsion of inferior glenohumeral ligament, Hill– is to tighten the anterior, inferior and posterior aspects of the
Sachs or Bankart). If the dislocation caused an axillary nerve capsule symmetrically by advancing its humeral attachment.
palsy, check this at 3–4 weeks and, if no signs of recovery,
request nerve conduction studies and refer to a nerve surgeon. Neurological problems around the shoulder
Recurrent instability Suprascapular nerve (C5, C6)
Principles of treatment This comes off the upper trunk (C5, C6) of the brachial
Structural instability – Traumatic or atraumatic: Surgical plexus and runs through the suprascapular notch to supply
stabilisation supraspinatus and then via the spinoglenoid notch to supply
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026
infraspinatus. Specifically at the spinoglenoid notch the Surgical options include neurolysis, direct repair or nerve
suprascapular nerve may be compressed by a ganglion associ- grafting, dynamic muscle transfer techniques and
ated with a labral tear11. scapulothoracic fusion when reconstruction is not possible
Compression at suprascapular notch: Affects both
suprascapular and infrascapular muscles Thoracic outlet syndrome
Compression at spinoglenoid notch: Affects infraspinatus This is a diagnosis of exclusion and is based on history and
symptoms. Common causes are cervical rib and anomalies of
Clinical features scalenus muscle.
Posterior and lateral shoulder pain Neurogenic type
Wasting of supraspinatus and weakness of abduction
Upper plexus type
Wasting of infraspinatus and weakness of external rotation
Lower plexus type
Management Vascular type
EMG and NCS are useful for diagnosis. A direct superior
Sites of compression
trapezius muscle splitting approach is used to decompress
the suprascapular notch. Arthroscopic debridement is used As the plexus passes over the first rib
for ganglia at the spinoglenoid notch. Under the clavicle by the subclavius tendon
Underneath the conjoint tendon inserting into the coracoid
Long thoracic nerve (C5, C6, C7) process
This runs in close relation with the first rib and supplies the Clinical features
serratus anterior muscle. The serratus anterior pulls the scap- Pain in the shoulder and neck region radiating to the
ula inferolaterally and rotates the inferior angle laterally. forearm and hand
Clinical features Paraesthesia radiating along the arm
Serratus anterior weakness results in medial winging of the Loss of sensation of little and ring fingers
scapula where there is superomedial elevation and the inferior Change in colour of hands or chronically reduced pulse
angle is rotated medially. This is different from spinal acces- Provocative tests include Adson’s test, Wright’s test,
sory nerve involvement resulting in trapezius weakness and Roo’s test
lateral winging where there is scapular translation inferolater- : Adson’s test: head extended and rotated towards
ally and the inferior angle is rotated laterally. affected side. Ipsilateral arm extended and abducted 30°
and palpate the radial pulse. The test is positive if the
Management pulse disappears when the patient takes a deep breath
Observation is the standard treatment for idiopathic and non- and holds it
penetrating trauma. : Wright’s test: Shoulder abducted and externally rotated,
Surgical options include neurolysis in the early stages, and head rotated away from the affected side and palpate
neurotisation and reconstructive procedures, including tendon the radial pulse. The test is positive if this position
transfers (pectoralis major). diminishes the radial pulse
: Roo’s test: shoulders braced back, elbows flexed 90°,
Spinal accessory nerve fingers rapidly flexed and extended overhead for 1
This passes through the sternocleidomastoid muscle and travels minute. The test is positive if this reproduces the
through the posterior triangle onto the medial border of the symptoms
scapula. It supplies the sternocleidomastoid and trapezius muscles.
Common causes of injury are penetrating or blunt trauma and Investigations
injury during surgical dissection in the posterior triangle of neck. Plain radiographs of chest and cervical spine
CT for suspected bony anomaly not visible on x-ray
Clinical features MRI for suspected cervical pathology, tumour or radiation
Wasting of sternocleidomastoid and trapezius plexitis
Lateral scapular winging Doppler, arteriography/venography if vascular symptoms
Secondary impingement predominate
EMG/NCS if neurological symptoms predominate
Management
Non-operative treatment if injury is >12 months old with Treatment
good compensation Non-operative treatment is with physiotherapy to correct
Surgical exploration within the first 6 months of injury postural imbalances
026
Surgical treatment involves resection of the first rib

(cervical rib if present) with release or excision of the CANDIDATE: There is wasting of deltoid and pectoralis major and
anterior and middle scalene muscles and excision of any medial winging of the scapula.
anomalous structures. This can be done through EXAMINER: What do you mean by medial winging?
transaxillary or supraclavicular approaches CANDIDATE: It is caused by serratus anterior weakness. The
Venous thrombolysis or arterial thrombectomy and functioning trapezius pulls the scapula superomedially and
vascular reconstruction are urgently indicated in acute rotates the inferior angle medially.
presentations EXAMINER: This patient has pain around the shoulder and this
problem started spontaneously 7 years ago and motor symptoms
Quadrilateral space syndrome remain non-progressive. What do you think is going on?
This is caused by compression of the axillary nerve and pos- CANDIDATE: It could be brachial plexus neuritis.
terior humeral circumflex artery in the quadrilateral space, EXAMINER: How could you help this patient?
which is bounded by the teres major and minor muscles, the CANDIDATE: I would examine the patient’s shoulder to assess the
humeral shaft and the long head of the triceps12. functional restrictions and would like to know the patient’s
expectations.
Clinical features EXAMINER: He has full range of movements and full cuff function.
Affects the dominant arm in young adults He wants to improve the appearance of the shoulder.
Poorly localized anterior and lateral shoulder pain CANDIDATE: As he has no functional restriction, I would not offer
Tenderness in the quadrilateral space near teres minor any surgical treatment. I would advise against any surgery to
insertion improve the appearance. If he needs it I would refer him to a pain
management team to control his chronic neuropathic pain.
Investigations EXAMINER: Do you think this muscle wasting will improve?
MRI scan: Selective atrophy of teres minor muscle/ CANDIDATE: Unlikely, as it has remained the same for the last
posterior paralabral cyst 7 years.
Arteriogram: Occlusion of posterior circumflex humeral EXAMINER: (Showing clinical photograph of the left shoulder of a
artery with the arm in abduction and external rotation 20-year-old male.) What do you see?
caused by oblique fibrous bands
CANDIDATE: I can see a scar measuring 4 cm in the posterior
Treatment triangle of the neck with marked wasting of the trapezius.
EXAMINER: Would you expect to see winging of this patient’s scapula?
Decompression of posterior paralabral cyst
CANDIDATE: Yes, but this time I would expect lateral winging
Release of oblique fibrous bands through posterior
secondary to weakness of trapezius and unopposed action
approach
serratus anterior.
Brachial neuritis (Parsonage–Turner syndrome) EXAMINER: Is it a brachial plexus injury?

CANDIDATE: No. I suspect an injury to the spinal accessory nerve.
This is a non-traumatic condition which is immune-mediated
The scar in his neck suggests either penetrating trauma or
or inflammatory in nature.
previous neck surgery.
Clinical features EXAMINER: How do you manage this patient?
Severe, acute onset of periscapular pain CANDIDATE: That depends on the onset of symptoms. How and
Motor weakness in shoulder and arm with sensory loss when did the problem start?
EXAMINER: It started after he had a lymph node biopsy last month.
Investigations CANDIDATE: In that case I would recommend urgent exploration
EMG/NCS: Patchy, multifocal neurological process and direct repair or nerve grafting as soon as possible.
MRI: High signal intensity in affected muscles
Treatment is supportive and is directed towards reducing pain.
It has a favourable prognosis, though some residual defects
may remain.
Miscellaneous conditions
Long head of biceps (LHB)
The LHB originates from the supraglenoid tubercle and the
Examination corner
glenoid labrum. It helps in glenohumeral compression in
Adult pathology viva abduction–external rotation. It also helps to prevent proximal
EXAMINER: (Showing photographs of right shoulder.) This is a humeral migration, especially in cuff dysfunction. LHB tendino-
45-year-old patient. Describe the findings. sis is mostly associated with other shoulder pathology. Primary
tendinosis is rare and is associated with trauma in young adults.
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Clinical features pain felt on testing. Pain in the AC joint region is AC joint
Pain in the anterior aspect of the shoulder aggravated by related. Deeper shoulder pain implies labral pathology
overhead activity
Treatment
Palpable snap or click with internal to external rotation in
overhead position is associated with biceps instability Type I: Simple debridement
Tenderness in bicipital groove, moving laterally with Type II: Arthroscopic repair
external rotation and medially with internal rotation Type III: Excised with biceps anchor securely fixed
Rupture causes acute pain and audible pop, accompanied Type IV: If more than one-third of biceps tendon is
by balling up of the biceps known as ‘Popeye sign’ involved, suture and repair; debridement if less
Provocative tests include Speed’s test, Yergason’s test and Complex tears: Repair of type II lesion and resection of
biceps instability test other lesions
Investigations Frozen shoulder

Plain radiography Frozen shoulder, also known as adhesive capsulitis, is a gleno-
Ultrasound scan humeral joint contracture that occurs after minimal or no trauma
MR arthrogram to identify associated SLAP lesions and arises as a fibrotic process intrinsic to the capsule. The histo-
Arthroscopy can diagnose and treat most of the lesions logical is similar to that of Dupuytren’s disease, with proliferation
of fibroblasts, transformation to myofibroblasts and increased
Treatment collagen deposition. However, the clinical picture in both these
Non-operative treatment for tendinosis includes use of conditions is different, with Dupuytren’s being a progressive and
NSAIDs, steroids and physiotherapy for strengthening pain-free deformity of the fingers and frozen shoulder being a
rotator cuff muscles painful and self-limiting condition. It is much more common in
diabetic patients and is also associated with thyroid dysfunction.
Intra-articular tendinosis
Debridement: <50% tendon involved Criteria for diagnosis of frozen shoulder
Tenotomy or tenodesis: >50% involved History of restricted shoulder range of motion without an
Subluxation/dislocation: Tenotomy or tenodesis inciting factor
Global stiffness – Markedly affecting external rotation
SLAP lesions Plain radiographs with normal joint space and no focal
Superior labrum from anterior to posterior (SLAP) tears are periarticular abnormality. Osteoarthritis is an important
usually associated with glenohumeral instability (inferior to differential diagnosis to exclude
the equator of glenoid) and rotator cuff tears (superior to the
Natural history
equator of glenoid). MR arthrogram is useful for diagnosis.
Phase 1 – Painful ‘freezing’ phase: Aching pain begins at
13 night and persists during the day. Ache is unrelated to
Snyder classification
Type I: Fraying of superior labrum but not completely activity, it is worse at rest and disturbs sleep. The shoulder
detached is held in adduction and internal rotation for comfort
Type II: Detachment of labrum and biceps anchor Phase 2 – Progressive stiffness: ‘frozen’ phase: Lasts 3–12
months. There is global restriction with restricted activities
Type III: Torn labrum turned down into the joint (bucket-
handle tear) of daily living. With time pain diminishes with a narrow
comfort zone
Type IV: Bucket-handle type tears that extend up into the
biceps tendon Phase 3 – Resolution: ‘thawing’ phase: Slow gain in motion
and comfort over 12–42 months. Complete recovery may
Complex types involve combination of two or more types
not occur
Clinical features Shoulder examination will reveal diffuse tenderness. Active
and passive range of motion is tested in six standard motion
History of trauma
arcs and compared with the opposite normal shoulder. Post-
Transient episodes of weakness and numbness (‘dead arm’)
traumatic stiffness has asymmetrical restriction of shoulder
Biceps tenderness range of movements depending on the site of injury.
Provocative tests include O’Brien test, anterior slide test
and crank test Investigations
: O’Brien test: Shoulder elevated to 90°, adducted 10–15° Radiographs: To differentiate primary and secondary
across the body, internally rotated. Patient resists frozen shoulder
downward pressure on the forearm by examiner. The test MRI: If required to differentiate from cuff/labral/bony
is repeated in external rotation, which should relieve any pathology
026
Arthroscopy: Demonstrates a tight anterior capsule which Examination corner

can be released to improve range of movement
Adult pathology viva
Management EXAMINER: A 70-year-old gentleman is seen in fracture clinic with
Supportive treatment includes use of analgesics, topical severe pain in the right arm. What do you seen on his x-rays?
treatment with ultrasound, TENS and intra-articular CANDIDATE: These are AP and lateral plain radiographs of this
steroid injections gentleman’s right humerus including the shoulder and elbow.
Gentle stretching exercises with or without strengthening There is a lytic lesion in the humeral diaphysis with a wide zone of
Manipulative therapy to release adhesions. A safe sequence transition and extensive cortical involvement.
for shoulder manipulation – Flexion, extension, abduction EXAMINER: What do you think it could be?
and adduction, external and internal rotation (FEAR) CANDIDATE: This could be a bone tumour, either primary or
under GA or regional block secondary, infection or myeloma.
Surgical release of adhesions arthroscopically, releasing the EXAMINER: How will you make the diagnosis?
rotator interval, middle glenohumeral ligament and
CANDIDATE: After a full history and examination I would request
coracohumeral ligament to improve the range of movement
a bone scan to determine whether this is an isolated lesion.
Rehabilitation after intervention is crucial in preventing I would request a myeloma screen, an MRI scan of the lesion
recurrence of stiffness and a CT scan of the chest, abdomen and pelvis to look for
a primary.
Calcific tendonitis EXAMINER: This is an isolated, painful secondary bone tumour.
Calcific tendonitis is a condition of unknown aetiology character- There are multiple metastases elsewhere from what looks like a
ized by the build up of calcium hydroxyapatite crystals within the renal primary. How are you going to manage this lesion?
tendons, which undergoes spontaneous resorption with subse- CANDIDATE: I would discuss with the multidisciplinary team
quent healing of the tendon. The most common site of occurrence including the oncologists to see whether radiotherapy is an option.
is within the supraspinatus tendon and at a location 1.5–2.0 cm EXAMINER: Would you consider prophylactically nailing this
away from the tendon insertion on the greater tuberosity. humerus?
14 CANDIDATE: That would depend upon the Mirel’s score which is
Stages
based on four factors: Pain, location, involvement of cortex and
Pre-calcific stage: Fibrocartilaginous transformation occurs
whether the lesion is lytic or blastic.
at the site of predilection triggered by hypoxia
EXAMINER: What is his Mirel’s score?
Calcific stage: Subdivided into formative and resorptive
CANDIDATE: His pain is severe so that’s 3. It is the upper limb so
phases
that’s 1. It is lytic so that’s 3 and based on these plain x-rays it
Formative phase: Calcium crystals are deposited in matrix
involves more than two thirds of the cortex so that would be 3.
vesicles
Overall his score is 10. The threshold for intervention would be a
Resorptive phase: Characterized by appearance of thin-
score of 8 or more.
walled vascular channels at the deposit
EXAMINER: How would you technically go about nailing this
Post-calcific stage: Granulation tissue with young
humerus?
fibroblasts remodels the space
CANDIDATE: I would position the patient in the beach chair position
Clinical features include pain which is most pronounced
and use a deltoid splitting approach onto the rotator cuff. I would
during the resorptive phase, a reduced range of motion and
carefully split the cuff muscle longitudinally and protect it during
in long-standing cases, atrophy of the supraspinatus muscle.
the procedure. I would use a long nail to stabilise the whole bone
It is not associated with any abnormalities in calcium and
and I would repair the cuff split at the end.
phosphorus metabolism.
EXAMINER: OK, let’s say this is a different patient now and they
Investigations have a similar lesion but you have confimed that this is an
isolated metastasis from a renal primary. How does this change
Radiographs for diagnosis, initial assessment and follow-up
things?
Ultrasound is more sensitive and is used for diagnosis and
treatment CANDIDATE: With an isolated metastasis it may be possible to treat
curatively. I would liase with the renal and oncology teams to
Treatment determine whether the renal tumour was curatively resectable
and I would liaise with the local bone tumour centre for
The first line of treatment is conservative, with emphasis
on pain control followed by range of motion leading to management of the metastasis.
strengthening exercises EXAMINER: Are there any particular concerns when operating on
renal mets?
Needling and lavage under ultrasound or arthroscopic
guidance CANDIDATE: They can be highly vascular and may benefit from
embolisation preoperatively.
Extracorporeal shock wave lithotripsy (ESWL)
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Glenohumeral arthrodesis Patients undergoing shoulder arthrodesis require preopera-

tive counselling for a full understanding of their postopera-
Shoulder arthrodesis is an end-stage salvage option for the failing,
tive limitations and functional capacities. The optimal
painful joint that cannot undergo or has failed reconstruction.
position for arthrodesis is ‘30–30–30’: 30° of forward flexion,
Indications 30° of abduction and 30° of internal rotation, with modifica-
Paralysis of deltoid and rotator cuff tions based on patient body size or other patient-specific
Infection with loss of glenohumeral cartilage factors. The aim is for the patient to be able to get their hand
to their mouth.\
Refractory instability
Failed reconstructive procedures
Techniques
Contraindications Techniques of shoulder arthrodesis are broadly divided into:
Patients who lack functional scapulothoracic motion Extra-articular
Paralysis of periscapular muscles Intra-articular offers the simplest and most direct
High risk of pseudarthrosis – Charcot arthropathy method
Advanced bilateral shoulder disease Combination of both
References evaluation by CT scan. Clin Orthop

Relat Res. 1994;304:78.
10. Itoi E, Hatakeyama Y, Urayama M,
et al. Position of immobilization
1. Bigliani LU, Morrison DS, April EW. after dislocation of the
The morphology of the acromion and 6. Walch G, Badet R, Doulahia A, et al.
Morphologic study of the glenoid in shoulder. A cadaveric study.
its relationship to rotator cuff tears. J Bone Joint Surg Am.
Orthop Trans. 1986;10:228. preimary glenohumeral osteoarthritis.
J Arthroplasty. 1999;14:756–60. 1999;81:385–90.
2. Neer CS second. Impingement lesions. 11. Neviaser TJ, Ain BR, Neviaser RJ.
Clin Ortho Relat Res. 1983;173:70–7. 7. Rockwood CA, Williams GR, Young D.
Disorders of the acromioclavicular Suprascapular nerve denervation
3. Walch G, Boileau P, Noel E, et al. joint. In CA Rockwood, FA Matsen secondary to attenuation by a
Impingement of the deep surface of the (eds). The Shoulder, Second Edition. ganglionic cyst. J Bone Joint Surg Am.
supraspinatus tendon on the Philadelphia, PA: WB Saunders; 1998, 1986;68:627–8.
posterosuperior glenoid rim: pp. 483–553. 12. Cahill BR, Palmer RE. Quadrilateral
An arthroscopic study. J Shoulder Elbow space syndrome. J Hand Surg.
8. Thomas SC, Matsen FA, 3rd.
Surg. 1992;1:238. 1983;8:65.
An approach to the repair of avulsion of
4. Payne LZ, Altchek DW, Craig EV, et al. the glenohumeral ligaments in the 13. Snyder SJ, Karzel RP, Del Pizzo W,
Arthroscopic treatment of partial management of traumatic anterior Ferkel RD, Friedman MJ. SLAP
rotator cuff tears in young athletes: glenohumeral instability. J Bone Joint lesions of the shoulder. Arthroscopy.
A preliminary report. Am J Sports Med. Surg Am. 1989;71:506–13. 1990;6:274–9.
1997;25:299.
9. Lewis A, Kitamura T, Bayley JIL. 14. Sarkar K, Uhthoff HK. Ultrastructure
5. Goutallier D, Postel JM, Bernageau J, The classification of shoulder of the subacromial bursa in painful
et al. Fatty muscle degeneration in cuff instability: New light through old shoulder syndromes. Virchows Arch.
ruptures: Pre- and postoperative windows! Curr Orthop. 2004;18:97–108. 1983;400:107.
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Brachial plexus core topics

Chapter
24 David R. Dickson and Chye Yew Ng
Introduction Aetiology
World-wide, motorcycle accidents are the leading cause of Arm in upward traction (hanging onto a branch) – Lower
adult traumatic brachial plexus injury (BPI), which root avulsion/traction
typically occurs in young males Arm in downward traction (weight falling onto shoulder) –
They are relatively uncommon injuries and have been Upper root avulsion/traction
estimated to occur in only 1.2% of polytrauma patients2 Mechanisms
There are two basic clinical presentations: Partial palsy : RTA (particularly motor cyclists)
involving the upper roots (C5, 6 or C5, 6, 7) and total palsy
(C5–T1)
: Birth trauma (shoulder dystonia, large infants,
maternal obesity, diabetes, cephalopelvic disproportion
Infraclavicular BPI to the terminal branches may occur and forceps delivery)
secondary to shoulder trauma1
: Shoulder girdle trauma (dislocation, proximal humeral
The incidence of obstetric BPI (OBPI) in the Western World fractures, hyperextension injury)
is thankfully low (while not impossible, you are unlikely to
come across children with OBPI in the examination)
: Gunshots
Narakas’ Rules of Seven 70s

3 : Iatrogenous (e.g. clavicle plating)
Candidates should be aware of the classification but it is not
: 70% of brachial plexus injuries are due to road traffic necessary to memorise the specific numbers.
accidents (RTAs)
– 70% of these involved motorbikes
Leffert classification
: 70% have multiple injuries
: 70% are supraclavicular injuries I Open
II Closed
– 70% of these have at least 1 root avulsion IIA Supraclavicular
Pre-ganglionic
: 70% of root avulsion involve the lower plexus
Post-ganglionic
: 70% of root avulsions will leave the patient with chronic IIB Infraclavicular
pain III Radiotherapy
Brachial plexus
IV Obstetric
injuries IVA Erb’s (upper root)
IVB Klumpke’s (lower root)
Supraclavicular Infraclavicular IVC Mixed
(70 – 75%) (25 – 33%)
Complete 5 level Single / Combined

Upper trunk C6 – C8 Avulsion C8/T1 isolated
injury cord
35% 8% 3%
50% 30%
Proximal rupture
distal avulsion
Pathoanatomy
Isolated peripheral
60%
nerve Traction can result in three main injury patterns
25%
C4 – T1 Avulsion
10%
:
Root avulsion (pre-ganglionic injury)
:
Stretch
Five level avulsion
Whole Limb 45%
:
Rupture (post-ganglionic injury)
Any combination of these injuries can occur within the
30%
Figure 24.1 Distribution and location of BPI same patient
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Table 24.1 Classifications of Nerve Injuries
Myelinated peripheral nerve fibres are surrounded by A pragmatic distinction is between a non-degenerative
Schwann cells and a loose vascular tissue called the (Sunderland I) or a degenerative (Sunderland II–V) lesion
endoneurium (Table 24.1)
Individual nerve fibres are collected into bundles called
fascicles which are covered by the perineurium Anatomy of the brachial plexus
Each nerve has a number of fascicles which are surrounded The brachial plexus is formed from the ventral primary rami
by the epineurium of C5–T1 spinal nerves. A small number of patients can have
Lundborg introduced the concept of physiological variable contributions from C4 (‘pre-fixed’ plexus) and T2
conduction block*: (‘post-fixed’ plexus).
Type A It is organised into five components: Roots, trunks,
:Intraneural circulatory arrest divisions, cords and branches. (Remember the mnemonic
Rob Taylor Drinks Cold Beer)
:Metabolic block with no nerve fibre pathology
:Immediately reversible : Five roots
Type B : Three trunks (upper, middle, lower)
: Intraneural oedema : Six divisions (two from each trunk)
: Increased endoneurial fluid pressure : Three cords (posterior, lateral, medial)
: Reversible within days or weeks : Multiple branches
Important to appreciate that any nerve injury is often The cervical roots are composed of ventral (motor) and
mixed and there could be a spectrum of severity in any dorsal (sensory) roots from the spinal cord
lesion (Sunderland ‘VI’) The motor nerve cell bodies lie within the spinal cord
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Chapter 24: Brachial plexus core topics
The dorsal root ganglion holds the cell bodies of the : Medial cutaneous nerve of the forearm
sensory neurons, an injury proximal to this is described as : Medial head of median nerve
pre-ganglionic : Ulnar nerve
The two roots combine to form the spinal nerve (The ulnar nerve is the most important branch and the rest of
proper which then exits through the spinal the branches begin with the word medial.)
foramen
Five branches of the posterior cord are:
The rootlets have no protective layer as they originate from
the spinal cord which contributes to their vulnerability to : Subscapular nerve – Upper
avulsion injury : Subscapular nerve – Lower
The roots, however, have a protective layer formed : Thoracodorsal nerve
by the dura and are able to move freely within the : Axillary nerve
foramen : Radial nerve
The upper roots of C5, C6 and C7 are tethered to their (Acronym: 2 STAR – Two Subscapular nerves, Thoracodorsal
respective transverse processes, whilst C8 and T1 are not. nerve, Axillary nerve and Radial nerve)
It is thought that this may explain the greater degree of
avulsion injuries seen at C8 and T1 Tips on approaching clinical examination
The roots (ventral rami) then pass between the scalenus
anterior and medius muscles
for FRCS
The roots then merge to form the trunks in the posterior The challenge lies in localisation of the lesion. This can
triangle of the neck only be achieved by having a thorough understanding of
the anatomy of the brachial plexus. The extent, level,
: C5 and C6 form the upper trunk. Erb’s point where C5 severity and chronicity of a brachial plexus injury will
and C6 become confluent determine the physical signs that are manifested
: C7 continues as the middle trunk While there are over 50 named muscles to be tested, it is
: C8 and T1 form the lower trunk not practical (and there is not enough time in FRCS exam)
The trunks then divide into anterior and posterior to allow you to examine every single muscle in the upper
divisions (behind the clavicle), which in turn form three limb. You then have to rely on pattern recognition
cords (named in relation to the axillary artery) – Useful to have a glance at the hand which would give you
: Anterior divisions of the upper and middle trunks form clues as to whether this is partial palsy (good hand) or total
the lateral cord palsy (poor hand)
: Posterior divisions of all the trunks form the A totally flail arm and hand represent total palsy
posterior cord Patients who have had reconstructive surgery (i.e. have
: Anterior division of the lower trunk forms the scars) may present greater challenges during examination
medial cord as they may have variable degree of recovery
: The cords give rise to the terminal branches
Pre-ganglionic vs post-ganglionic lesion
Branches A potential pitfall in candidates is the desire to arrive at a
The three branches from the roots are: narrow and specific diagnosis right at the start. However, it
is more important to demonstrate your logical thinking
Long thoracic nerve
and deduction during the examination
Dorsal scapular nerve
While it is tempting to establish whether this is a pre-
Nerve to subclavius ganglionic or post-ganglionic lesion, remember that no
There is one branch from the trunks: clinical, radiological or neurophysiological evidence is
Suprascapular nerve absolutely accurate. Often this can only be established at
None from divisions surgery
(‘3–5–5 rule’ – Describes branches from cords). The following are clues that you may identify and mention
There are three branches from the lateral cord: to the examiners in order to demonstrate your higher order
: Lateral pectoral nerve thinking
: Lateral head of median nerve : Horner’s syndrome
: Musculocutaneous nerve – Partial ptosis of the upper eyelid
There are five branches from the medial cord: – Miosis (constricted pupil)
: Medial pectoral nerve – Anhidrosis (loss of sweating on one half of the face)
: Medial cutaneous nerve of the arm – Enophthalmos (eye appears sunken)
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: The T1 root lies close to the T1 sympathetic ganglion. :The classic test is wall-press test
Evidence of injury to the T1 sympathetic chain as :In BPI, the patient may be unable to lift the arm
evidenced by a Horner’s syndrome would infer that the :The arm should be supported by the examiner with one
T1 root has probably been injured hand and the patient asked to push forward as if trying
: If rhomboids or serratus anterior are weak then a pre- to open a door. At the same time the examiner should
ganglionic injury should be suspected hold the lower pole of the scapula with another hand
: If chest x-ray is shown, look for elevated (paralysed) Latissimus dorsi (thoracodorsal nerve – C6, C7, C8)
hemi-diaphragm (phrenic nerve palsy C3, C4, C5) :
While the arm is supported in a flexed position, ask the
: Fractures of the transverse processes of the cervical patient to push down (while the examiner palpates for
vertebrae or a fractured first rib indicate a high-energy musle contraction)
injury with likely intradural injury of the lower two roots
Deltoids (axillary nerve – C5, C6)
: Scapulothoracic dissociation is often associated with
: Extend, abduct and flex the shoulder to test the
root avulsion and major vascular injury
posterior, middle and anterior parts respectively (unless
the muscle is clearly wasted)
Clinical examination : Demonstrate specific signs (if isolated nerve palsy
Inspection suspected)
: Best to start with the patient stood with both arms and
– Swallow-tail sign
torso exposed
: Look at the face for Horner’s syndrome The patient is asked to extend the shoulder while

: Look for surgical scars bending the trunk forward. A result of 20° or
: Muscle wasting – Shoulder girdle, arm, forearm greater of extension lag relative to the normal
and hand side indicates a positive sign
: Posture of the limb – Abduction internal rotation
: Scapula winging
Exclude fixed contractures by gentle passive movements Actively and maximally abduct the shoulder in
internal rotation with the elbow flexed.
Motor testing
Abduction lag relative to the normal side
: Requires knowledge of the Medical Research Council indicates a positive sign
(MRC) grading
Standing from the front
– 0 – No contraction
– 1 – Flicker Pectoralis major (lateral and medial pectoral nerves)
– 2 – Active motion (gravity eliminated) : Clavicular head (C5, C6)
– 3 – Active motion (against gravity only) – Atrophy would imply lateral cord injury
– 4 – Active motion (against resistance) – Ask the patient to touch their contralateral shoulder
– 5 – Normal power (and the examiner palpates for evidence of
: If a muscle is weak, repeat testing in the horizontal contraction)
plane in order to eliminate gravity, e.g. abducting : Sternocostal head (C7, C8, T1)
the shoulder to test elbow flexion/extension power
: Muscle testing is an active process involving – Atrophy would imply medial cord injury
– Ask the patient to push against the hip (and the
– Look (for contraction and movement of the limb) examiner palpates the axillary fold)
– Feel (for contracted muscle/tendon)
– Move (to test resistance) Rotator cuffs
: Be systematic. Start proximally and work distally

: Supraspinatus (suprascapular nerve – C5, C6)
– Test shoulder abduction in the scapular plane with
Standing from the back the thumb pointing downwards
Trapezius (spinal accessory – XI, C3, C4)
: Infraspinatus (suprascapular nerve – C5, C6)
: Can you shrug your shoulders?
Rhomboids (dorsal scapular nerve – C4, C5) – Test external rotation with the shoulder in
adduction and the elbow flexed
: Push your shoulder blades together?
Serratus anterior (long thoracic nerve – C5, C6, C7) : Teres minor (axillary nerve – C5, C6)
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Chapter 24: Brachial plexus core topics
– Test external rotation with the shoulder in Histamine is placed on the skin. The skin is then scratched.
abduction and the elbow flexed A normal reaction with an area of skin served with an intact nerve
is the triple repsonse
: Subscapularis (upper and lower subscapular nerves – The triple response is vasodilatation, wheal formation and flare
C5, C6, C7) response
When the nerve is damaged proximal to the dorsal root ganglion
– Belly-press sign. Ask the patient to bring the elbows there is also a normal response but the skin is anaesthetic
forward while pressing the belly. A flexed wrist
If the nerve damage is distal to the dorsal root ganglion then there
relative to the normal side indicates a positive sign is vasodilatation and wheal formation but no flare response. This
Next, proceed with the following composite testings to is because a flare response requires an intact axon in continuity
demonstrate the myotomes (levels) involved (accept some with its cell body (located within the dorsal root ganglion)
degree of variability in the books you have read – As not all
humans are born the same!)
Elbow flexion (C5, C6)
Neurophysiology
Elbow extension (C7, C8) Remember this is an aid to the overall diagnostic (and prognostic)
process
Forearm supination (C6)
Perform at least 2–3 weeks after the injury (earlier studies may be
Forearm pronation (C7, C8)
falsely reassuring)
Wrist flexion/extension (C6, C7)
Communication between the surgeon and the neurophysiologist
MCP joint flexion/extension (C7, C8)
is crucial to the correct interpretation of the results
Grip (C8)
Nerve conduction studies (NCS)
Fingers abduction (T1)
: Can evaluate both sensory and motor components
Sensory testing
: Diagnose root avulsions – SNAPs will be normal despite loss
: Establish normal sensation in an uninjured area (such as of sensation. In a post-ganglionic injury the SNAPs will also
forehead or sternum) be absent
: First, assess the dermatomes and then if felt necessary, Electromyography (EMG)
examine according to the terminal branch distribution
: After a few days the denervated muscle shows decreased
Check radial pulse and offer to test the reflexes
motor unit potentials (MUPs) which fire at a higher rate
: After 4–6 weeks the muscles begin firing at their own inherent
Investigations ‘pacemaker’ which appears as fibrillations on the EMG
Radiology : Afer 8–12 weeks no MUPs will appear if the nerve injury is
complete
Key radiographs are cervical spine, chest and shoulder
: Can show evidence of muscle recovery long before there is
: Avulsion fractures of the tranverse processes are associated any clinical activity
with root avulsions
: Chest radiographs
Management
– Rib fractures (important if considering intercostal nerve Three key questions
transfers)
– Look for apical pleural cap which may be associated with 1. Who needs surgery
first rib fracture 2. When surgery should be done
– Paralysis of the hemidiaphragm (phrenic nerve palsy) 3. What surgery – Prioritizing the restoration of which motor
functions
CT myelography - invasive Who requires surgery?
: The gold standard in diagnosing root avulsions : Those who have no hope of spontaneous recovery – Such as
MRI – Non-invasive root avulsions
: Findings consistent with a severe injury include : Those in whom there is no clinical and/or neurophysiological
evidence of improvement after serial examinations
– pseudomeningocele (T1-weighting) When should you proceed to surgery?
– empty root sleeves (T2-weighting)
: Following nerve avulsion/rupture, apart from end-organ
– cord shift away from the midline degeneration (motor end-plate), there is also central neuronal
: May show subtle denervation changes in muscles death by apoptosis (‘A race against time’)
: There is, thus, a trend towards early exploration for diagnostic
and prognostic purposes
Histamine test : Some would still allow a period of time for spontaneous
Of historical interest only recovery to occur. Opinions vary but 3-months post injury is
Used as a diagnostic tool to differentiate between pre-ganglionic generally accepted as the key timepoint to decide on
and post-ganglionic lesions intervention
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027
Surgical priorities : Some commonly performed nerve transfers

: Restore elbow flexion – Restoration of elbow flexion
: Restore shoulder abduction (stability)
: Restore hand function Ulnar nerve fascicle (FCU) to musculocutaneous

nerve branch (biceps)
Median nerve fascicle (FCR) to
Range of nerve surgery
musculocutaneous nerve branch (brachialis)
Neurolysis – Restoration of shoulder function and stability
:
Involves release of scar tissue around a nerve in
continuity Spinal accessory nerve to suprascapular nerve
: Scar may form outwith or inside the epineurium, Radial nerve branch (triceps) to axillary nerve
preventing recovery or causing pain (deltoid)
Nerve repair
:
Primary end-to-end repair is rarely possible, except in Salvage/late reconstructions
those with an acute laceration and a narrow zone of In delayed presentations (>1 year) or when the outcome of
injury nerve surgery is likely to be poor, consider the following
Nerve graft reconstructive options
:
Prerequisites for successful nerve grafting include : Arthrodesis
healthy proximal stump, tension-free neurorrhaphy, – Shoulder
good tissue bed and reconstruction performed in a – Wrist
suitable time frame – Thumb base
: Autograft (sural) remains the gold standard although
decellularised allograft is also available : Tendon transfers
Nerve transfer (or neurotisation) – Shoulder
: Involves the transfer of a functioning fascicle or
nerve branch (expendable donor) to a denervated Trapezius to deltoid
muscle – Elbow
: Principles of motor nerve transfer
Steindler flexorplasty is designed to mobilize
– Donor nerve near target motor end plates the flexor/pronator mass from the medial
– Expendable donor nerve epicondyle to a more proximal point on the
– Pure motor donor nerve humerus (tenodesis effect)
– Donor-recipient size match
– Donor function synergy with recipient function
: Free functioning muscle transfer
– Motor re-education improves function – Gracilis to restore elbow flexion
References
1. Hems TEJ, Mahmood F. Injuries of
the terminal branches of the
infraclavicular plexus. J Bone
Joint Surg Br. 2012;94:
799–804.
2. Midha R. Epidemiology of brachial
plexus injuries in a multitrauma
population. Neurosurgery.
1997;40:1182–8.
3. Narakas AO. The treatment of brachial
plexus injuries. Int Orthop. 1985;9:29–36.
027
Section 6 The paediatric oral
Paediatric oral core topics

Chapter
25 Kathryn Price and Antoine de Gheldere
Introduction everything about CTEV is commendable but of no use if

you know nothing about DDH
This section is an overview of important paediatric topics that
Similar principles apply with your reading material. Some
tend to appear regularly in the examination. It should point
paediatric books are a little flimsy, while others are highly
you towards the more important areas of the paediatric sylla-
subspecialized textbooks that are difficult to use for
bus. Topics are included for two primary reasons:
revision
1. They have been repeatedly asked in previous exams
Go on a well-recommended and established paediatric
2. They are often the subject of confusion, and textbooks are course. There has been some feedback suggesting that
sometimes the source of it! several courses may be a little too detailed for the exam but
The paediatric oral can be awkward as the examiners expect it is unlikely that you will emerge with too much
you to have both a comprehensive range and depth of paediat- knowledge from such a course! Towards the end of your
ric knowledge. Candidates may struggle unless they have had a preparation for the exam, ask your local paediatric FRCS
reasonable working exposure to paediatrics, ideally 6 months (Tr & Orth) examiner to viva you at least once, but
as part of a higher surgical training rotation. Some topics are preferably on a couple of occasions
very predictable – In the oral candidates will invariably get one Try to set up a study group of trainees about to sit the
of the ‘big three’ (developmental dysplasia of the hip (DDH), examination and regularly meet up to go through different
Perthes’ and slipped upper femoral epiphysis (SUFE)). areas/topics of revision
The paediatric oral for the most part consists of clinical
photographs and radiographs acting as prompts to lead you Principles of paediatric orthopaedic history
into a particular topic. With the introduction of standardized
questions for the oral examinations, it is unlikely that the
and examination
dreaded video of gait analysis in a cerebral palsy (CP) patient Whilst each region of the body demands specific attention
will be shown. there are some important features of examination in the paedi-
The paediatric oral component of the exam now involves atric population that set it apart from adult practice:
three questions, each lasting 5 minutes. A typical example Many children are too young to volunteer an accurate
might involve: history – There is an increased reliance on examination
1 A paediatric trauma question – Perhaps involving growth and investigation in this situation
plate injury Children are growing and developing. There is a
2 One of the ‘big three’ (Perthes, SUFE or DDH) moving baseline which can make for diagnostic difficulty
3 A further topic such as congenital talipes equinovarus but it also makes for a forgiving skeleton when it comes to
(CTEV), Brodie’s abscess, CP or in-toeing healing
The key elements for success in the oral are: Injury must always be interpreted in the context of
developmental stage – And be alert to non-accidental
To have worked for 6 months in a paediatric orthopaedics
injury (3 month olds do not ‘fall off the bed’)
higher surgical training job. Knowledge is important but if
you have not been near a paediatric orthopaedic clinic it Where knee pain think hip and where hip pain think knee
will be obvious to your examiner Where night pain think neoplasm until proven otherwise
Correctly gauging the depth of paediatrics knowledge History
required for the oral. Aiming too high can be a disaster and : Should include a note of family history which may raise
can swallow precious time needed for other areas; too low the likelihood of an inherited condition
and you will certainly fail. Remember the exam is to test : Must include attention to the pregnancy and birth
you at the level of a Day 1 Consultant in the generality of history. Prematurity, birth trauma, etc. can have
orthopaedic and trauma surgery. Knowing absolutely ongoing implications
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028
Section 6: The paediatric oral
: Should evaluate motor development and take note of

milestones reached – Always ask age at which the child EXAMINER: What are you looking for on a rotational profile and how
walked would you do this?
: Should carefully consider related symptoms from other CANDIDATE: With the child prone you can assess for femoral
systems rotation, tibial torsion and foot deformities. The femoral rotation
is assessed by allowing the legs to rotate outwards and then
inwards. Movement away from the midline represents internal
Milestones: Mean age (95th centile) rotation of the hip, movement towards the midline represents
Head control – 3 months (6 months) external rotation. You can also perform Gage’s test, feeling for the
point where the greater trochanter is the most prominent during
Sitting – 6 months (9 months)
movements to assess the version of the hip.
Stand – 8 months (12 months)
After this, the thigh-foot angle gives you an idea of tibial
Walk – 12 months (18 months) – Remember 1 year is a
torsion, be it internal or external. The foot itself can then be
mean ‘normal’ walking age so 50% of children will walk later,
examined to see if there is any deformity there or if the border is
but 18 months to 2 years is generally taken as the upper limit
straight.
of normal
This assessment lets you assess how many limb segments are
Examination (whilst tailored to a given problem) for lower involved in the rotational problem and to what extent.
limbs in general: EXAMINER: OK, when you do this assessment you find that there is
: Should include an assessment of gait by observation 35° of femoral anteversion, with no other obvious problems
: Should include inspection of the spine, hips, knees identified?
and feet CANDIDATE: Well, I would reassure the parents that this is part of
: Should include a clinical check of lower limb torsional the normal spectrum of what we see. Persistent femoral
alignment and length anteversion is extremely common and will remodel without
intervention in >90% of cases by the age of 9 years. I would
Follow-up of children with significant musculoskeletal
explain that the only way to correct this would be with bilateral
pathology is often carried through to skeletal maturity
derotational femoral osteotomies, which would be a potentially
life-threatening procedure in a child this age. The vast majority
Examination corner never need any intervention, however, if it is still a clinical
problem by the age of 9 then we will gladly review back
Normal variants
The candidate is shown a picture of a 3-year-old girl standing. in clinic to discuss intervention. I would reassure them that
The feet and patellae are both in turned. we will not have missed the opportunity to intervene, and
that the surgery is possible even in to adult life if deemed
EXAMINER: This 3-year-old girl has been referred to you by her GP
necessary.
due to parental concerns regarding her in-toeing. How would you
EXAMINER: They ask if there is anything else that they can do to try
assess her?
to avoid this?
CANDIDATE: I would take a history from the family to establish how
CANDIDATE: I would explain that it is the normal muscle pull that
long they have been concerned, if there was any history of
causes the bone to remodel. I would not limit them in any way or
problems such as CTEV. I would also like to establish a
do anything differently. The only thing I would advise would be to
developmental history, and family history of limb problems and
avoid them sitting with their legs in the W position, and advise
the trend as to whether things are improving, staying the same or
crossed legs if possible.
getting worse. After this I would examine the child.
EXAMINER: OK, they are happy to accept that.
EXAMINER: So, the family state that she is normally fit and well, no
The candidate is shown a clinical photograph of a 2-year-old boy
other concerns from birth. She is reaching milestones normally.
with planovalgus feet.
They have noticed her feet turning in since she started to walk
and are unsure if it is still the same. They feel that she is very EXAMINER: This young man has been referred to your clinic
clumsy and trips over her feet on a regular basis. What following parental concerns regarding his foot position. How
examination would you like to do? would you assess him?
CANDIDATE: I would like to see her walk, run, walk on her heels and CANDIDATE: I would take a history first regarding pregnancy, birth,
on tiptoes. Then I would examine her on the couch for any leg development and family history. I would enquire as to how long
length discrepancy, range of movements of all the joints, the feet have been noted to hold this position. I would also want
particularly hips and check for any tight tendons. Most to know if he complains of any discomfort.
importantly I would turn her prone to do a rotational profile. EXAMINER: He is otherwise fit and well with no concerns. The
Lastly, I would check the spine to ensure there was no parents say that his feet have always rolled over since he has
pathology there. been walking.
028
Chapter 25: Paediatric oral core topics
for the range of movement of all joints; any increased

CANDIDATE: OK, I would examine the child. I would want to see him
tone, any contractures and then assess rotational profile and
walk and run. I would try to get him to stand on tiptoes. If this is
his spine.
not possible then I would assess Jack’s test and feel for hindfoot
EXAMINER: OK, you find that this is just an isolated genu varum with
movement passively to establish if it flexible or fixed. After this
no concerns about anything else. What would you do from here?
I would assess him on the couch to check all of the lower limbs for
joint movements, tendon contractures (particularly CANDIDATE: I would explain to the parents that all children at this
gastrocnemius) and assess rotational profile and the spine. age have bowlegs. The Salenius curve showed that we would
expect them to be varus until the age of 2, then become overly
EXAMINER: From what you can see it seems that he has flexible
valgus by 3 and return to a normal adult alignment by the age of
planovalgus feet with no other concerns. What would you advise
7. Having said this, only time will tell if he will follow the normal
the family?
pattern. At this point I would carefully document the degree of
CANDIDATE: I would explain that flexible flat feet are extremely
varus and do no further test unless there were concerns about
common in children this age. It is due to ligamentous laxity
vitamin D deficiency or trauma. I would reassure the parents that
allowing the foot to sag down on weight-bearing. However, when
the likelihood is that the leg alignment would correct itself over
the soft tissues are tensioned the arch restores normally. Unless
the next few years without intervention. I would suggest that they
this is symptomatic then it requires no treatment. The vast
take photographs of his legs today and then keep an eye on
majority will have an arch reconstitute by the age of 7, for those
things over the next year. I would review back once more in a
that don’t it is rarely a problem. It only becomes an issue if the
year’s time to ensure that things are improving. If there are
gastrocnemius complex is tight.
concerns at that stage then I would do blood tests and a
EXAMINER: If he was a bit older and was complaining that his feet
mechanical axis x-ray.
hurt when he walked what would you advise?
EXAMINER: What would be in your differential diagnosis?
CANDIDATE: If there were any tightness of the gastrocnemius
CANDIDATE: Physiological varus, trauma, infections, blounts
complex then I would send them for stretches. They can also try
disease, tumours, metabolic bone disease.
medial arch supports, however, I would warn them that some
EXAMINER: OK, let’s move on.
children find these helpful and some find them more painful.
I would only see them back again if there were further concerns. The candidate is shown a clinical photograph of a 3-year-old girl
EXAMINER: If the planovalgus foot was fixed and not flexible, what walking on tiptoes.
would you be thinking? EXAMINER: This young lady has been referred to you with persistent
CANDIDATE: The main cause for a rigid flat foot in a child would be tiptoe walking. How would you assess her?
tarsal coalition. In small children it can be extremely difficult to CANDIDATE: I would take a history regarding pregnancy, birth, any
see on x-rays due to the high proportion of cartilage in the tarsus. perinatal concerns, developmental milestones and general
In an older child I would try to see it with x-rays, CT or MRI health. I would then ask specifically about the tiptoe walking.
depending on results and symptoms. When it began, if it all the time, if it is worse when she runs, etc,
EXAMINER: OK, let’s move on. then I would examine her.

EXAMINER: Parents tell you that everything has been normal with
The candidate is shown a clinical photograph of an 18-month-old
no concerns. She has always seemed to walk on tiptoes and they
child with bilateral symmetrical genu varum.
don’t really notice a difference between walking or running. What
EXAMINER: This child has been referred to your clinic due to
would you look for on examination?
parental concerns over bowlegs. They feel that things have got
CANDIDATE: I would want to see her walk and run. I would want
progressively worse since he started walking and want him
to see her walk on her toes and try to walk on her heels.
assessed.
I would do an assessment of her tone on the couch looking for
CANDIDATE: OK, I would start with taking a history relating to
clonus and brisk reflexes. After this I would do all of the
pregnancy, birth, development, and family history. After this
normal checks for joint movements. I would test for contractures
I would find out what concerns the parents have got, when they
of the adductors, hamstrings, rectus femoris and the
first noticed the bowlegs and whether they think things are
gastrocnemius complex. I would also want to check her spine.
progressing, improving or staying the same. After this I would
EXAMINER: What are you trying to exclude?
examine the child.
CANDIDATE: Any underlying problem really, but primarily
EXAMINER: He is a normal, fit and healthy little boy. They have
cerebral palsy. Mild cerebral palsy can present in early childhood
always noticed him being bow legged but definitely think that
with persistent tiptoe walking due to increased tone. They would
things are getting worse at this stage. What examination would
typically have rate-related symptoms and have signs of an upper
you do?
motor neurone lesion on examination.
CANDIDATE: I would assess him standing for any leg length
EXAMINER: Assuming all of those things are normal and this is just
discrepancy, his posture and the leg position. I would
idiopathic toe walking what would you advise?
watch him walk and then assess him on the couch to look
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028
missing physis (where part of the physis has been lost, usually
CANDIDATE: I would explain to the family that this is quite common in a road-drag injury).
in young children. In the first instance I would send them to This has prognostic value, with progressively more chance
physiotherapy to learn some stretching exercises and advise of growth arrest as you move up through the classification.
them to encourage her to walk flat footed as much as possible.
The majority of cases will resolve by school age. The elbow
EXAMINER: What would you advise if she were 6?
This is a testing area clinically and requires your attention.
CANDIDATE: For older children I would still suggest stretches in the Inability to discuss a supracondylar fracture and its manage-
first instance. If this is not successful then we can try serial casting ment would certainly be a pass/fail issue in the eyes of an
to correct the problem with or without splintage afterwards. examiner.
Tendon lengthening is the last resort after all else has failed and In part the topic is complicated by the many ossification
there is a clear functional problem. centres:
EXAMINER: And what kind of tendon lengthening would you do?
Capitellum (6 months)
CANDIDATE: Usually a HOKE percutaneous lengthening in
Radial head and medial epicondyle (5 years)
these cases.
Trochlea (7 years)
Lateral epicondyle (9 years)
Olecranon (11 years)
This gives rise to confusion regarding the normal appear-
Paediatric trauma ances – You should critically assess the following when viewing
It may be tempting to skip over this area and hope your adult plain radiographs of a paediatric elbow:
trauma knowledge will be adequate, but there are important Carrying angle 7°
aspects to paediatric trauma that are not appropriately covered
Baumann angle. A line perpendicular to the axis of the
by adult trauma knowledge. A comprehensive treatment of
humerus, and a line that goes through the physis of the
this topic is not appropriate to this text; however, there are
capitellum. Normal value is 70–75°
some important features of paediatric trauma that will be
The teardrop or hour glass is formed by the anterior
highlighted. Important principles underlie paediatric fracture
margin of the olecranon fossa and the posterior margin of
treatment:
the coranoid fossa with the capitellum forming the inferior
Periosteum is thicker, more vascular and more active than portion. The capitellum and trochlea should be
in adults – Healing is fast and the periosteal hinge is often superimposed. These lines indicate that a correctly
an effective aid to maintaining reduction (and can block positioned lateral radiograph has been obtained
reduction if not understood!)
Medial epicondylar epiphyseal line angle. This is formed by
Children’s bones remodel well in the plane of joint motion the intersection of the long axis of the humeral shaft and
Fractures involving physes can result in progressive the line formed by the medial epicondylar growth plate.
deformity – We must ‘respect the physis’ Normally 25–45°
Increased vascularity and porosity of paediatric bones (cf. Humerotrochlear angle. This angle is formed by the shaft
adult) give rise to increased plasticity manifested as incomplete of the humerus and the axis of the condyles on the lateral
fractures: x-ray 40°
Failure in compression – Buckle/torus fracture Lateral capitellar angle is measured by the intersection of a
Failure in tension – Greenstick fracture line parallel to the midpoint of the distal humeral shaft and
Healing bones can overgrow (increased blood supply and one drawn through the midpoint of the capitellum.
stimulation to physes of injured limb), so overlapping of Normally 30°
(femoral) fractures of 1.5 cm is often accepted. Anterior humeral line is drawn along the anterior margin
You must understand and be able to describe the physeal of the humerus and passes through centre of capitellum
injury classification of Salter and Harris1 (Figure 25.1). Anterior coronoid line is drawn on a lateral radiograph
To Salter’s original classification, two further classes have along the coronoid and continued proximally. It should
been added – Injury to the perichondrial ring of LaCroix and just touch the capitellum anteriorly in a normal elbow. If
the capitellum is angled or displaced anteriorly, this line
intersects or lies posterior to the capitellum
Supracondylar fracture
The supracondylar fracture is the most frequent injury to this
area:
Figure 25.1 Salter–Harris fracture types 95% are hyperextension injury
028
Olecranon in fossa as fulcrum Lateral condylar fracture

Assessment – Clinical (deformity, distal neurovascular Varus force on supinated forearm
deficit), 15% neurological injury (usually neurapraxia of Salter–Harris type IV
anterior interosseous nerve (AIN) – Look for IPJ index and Milch classification – Poor reliability
thumb flexion), radiographs (orthogonal views, note Jakob classification
posterior fat pad)
Gartland classification
:Stage 1 – Intact cartilage hinge
:Stage 2 – Complete fracture, minimal displacement
:
Type I: Minimally displaced = simple immobilization/
:Stage 3 – Rotational displacement
splintage
Pin stage 2 and 3 via lateral approach
: Type II: Hinged = stabilised on posterior hinge at 120° Complications include
flexion or fix as for type III
: Type III: Off-ended = closed/open K-wiringa Late presentation (>6/52)
Formally opening the joint is reserved for cases that do not :
Anatomical correction difficult due to remodelling
reduce closed. An anterior approach is considered when :
Consider subtotal coronoid osteotomy or intra-articular
vascular compromise is suspected osteotomy
Vascular compromise should lead to swift surgical Non-union
reduction. Thereafter: : May present with ulnar neuritis, cubitus valgus
:Pink and pulse = splint : Fix in best functional position ± bone graft
:Pink, no pulse = splint and monitor (collateral
circulation is usually sufficient) Medial condylar fracture
: White, cool, no pulse = explore Rare
Active motion should be commenced at 3 weeks (stiffness Open reduction with internal fixation (ORIF) if >2 mm
is the enemy thereafter) displacement
Cubitus varus is the commonest iatrogenic complication
with a poorly reduced/stabilised distal fragment pulled into Epicondylar fractures
varus and rotated. This is best avoided but can be addressed Lateral
by a late valgus osteotomy of the distal humerus
Immobilize then early active range of movement (ROM)
Remember tardy ulnar nerve palsy with cubitus valgus
Where displaced >5 mm, consider excision
T-condylar fracture
The t-condylar fracture is less common Medial
Axial impaction results in trochlear–capitellar separation Valgus load to extended elbow
Aim for anatomical joint reduction 50% occur with posterolateral elbow dislocation
Fix condylar fragments first (closed or via posterior approach) Note that there is a risk of ulnar nerve entrapment with
closed reduction
Fix condylar fragment to shaft with K-wires or plate
Closed vs open reduction debatable – ~ORIF >5 mm
Physeal separation displacement
Physeal separation can occur and poses diagnostic difficulties
owing to the cartilaginous nature of the young elbow Radial neck fractures
Rotatory force – NB. Consider non-accidental injury 50% isolated, 50% with proximal ulnar fracture
Salter–Harris I or II in infants and toddlers Usually Salter–Harris I or II
Confused with ‘dislocation’ Valgus stress injury
Consider arthrogram Functional limitation greater in:
MUA and K-wire (only attempt up to 1 week) :
>10 years
:
>30°
:
>3 mm
a
The issue of how to K-wire a supracondylar fracture has generated Closed reduction/flexible intramedullary nail/ORIF
disproportionate attention. What matters is achieving a stable hold. Removal of K-wire and ROM at 3/52
This can either be with divergent laterally based K-wires or crossed
K-wires. There is nothing in the literature to favour one technique Olecranon fractures
significantly over the other. For crossed wires many practitioners
choose to visualize and thereby protect the ulnar nerve from the Uncommon
medial K-wire through a small incision. Minimal displacement – plaster of Paris (POP) 3/52
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028
>5 mm displacement – Closed reduction . . . ORIF = injuries in up to 40% of cases – Complete bilateral epiphyseod-
tension-band wiring (TBW) or screw(s) esis may be desirable to avoid angular or length deformity.
Tillaux
Pulled elbow
A toddler’s injury with classic presentation
:
External rotation mechanism
Axial traction by a pull on the hand or wrist. The forearm

:
Anterior tibiofibular ligament avulsion
is usually held in incomplete extension, and partially
:
Salter–Harris III
pronated.
:
Managed with closed or open reduction
Triplane
X-ray is not necessary but if obtained exclude fractures
(including plastic deformation of ulna). : External rotation mechanism
Treatment with closed reduction using either forearm : Salter–Harris III on AP + Salter–Harris II on lateral =
hyper-pronation or supination-flexion methods Salter–Harris IV
: 2–3– Or 4 part
The ankle : CT is desirable to plan surgical approach
: Require ORIF
5% of all children’s fractures
17% of physeal injuries
Note 6 mm growth per annum at distal tibia and fibula; Polytrauma
hence, potential for angular and limb length growth Paediatric major trauma requires attention to advanced paedi-
disturbance atric life support principles. These are parallel to the more
Poland (1898)2 highlighted three characteristics of paediatric familiar territory of ATLS® but there are crucial differences.
ankle fractures: Not every orthopaedic trainee undertakes ATLS® training, but
1. Physis as plane of fracture it would be a good idea to familiarize yourself with the course
2. Physis weaker than ligaments book (although you might wish to avoid spending time on the
3. Growth arrest risk detailed analysis of arrhythmias!).
Classification of fractures can be: Injury patterns are different in children. Remember the
Mechanistic bumper of a car strikes the tibia of an adult but the head/
torso of a toddler. Energy imparted per unit area will be
: Lauge–Hansen, Dias–Tachdjian3
greater the smaller the child
– Helpful with reduction Physiological reserve is greater in a child, which is good
– Poor interobserver reliability news, but the benefit is tempered by its capacity to
obscure underlying impending cardiovascular collapse (a
Anatomical child can lose 30% of circulating volume and remain
normotensive). Therefore, when a child arrests it is usually
: Salter–Harris
very bad news indeed (that is not to say it is great news in
– Good reproducibility anyone)
– Prognostic value It is important not to be phased by the fact that resuscitation
involves a child – Airway (with cervical spine control),
: Vahvanen and Aalto4 breathing and circulation remain the top priorities in paediat-
There are three pitfalls to be avoided: ric resuscitation:
1. False-negatives (missed fractures) – Consider The airway in a child is narrower and shorter and more
supplementary mortise and oblique views prone to blockage
2. False-positives (normal variants) – There can be many Breathing should be maintained by jaw thrust – Chin lift is
secondary ossific nuclei at the foot and ankle, e.g. os not appropriate in trauma and in infants (where it
subtibiale beneath the medial malleolus exacerbates obstruction)
3. Persistent displacement – Consider periosteal interposition Circulation is primarily assessed by colour, capillary refill,
in the fracture site skin temperature, pulse and blood pressure
Transitional fractures at the ankle occur whilst the growth Disability assessment should actively look for the
plate is closing, at the age of 13–14 years. In order, this greater incidence of head injury in paediatric
progresses from centre medially and, finally, laterally. In these trauma cases
injuries the ‘golden rule’ of respecting the physis becomes
secondary to the need to achieve articular congruity since Cervical spine
50% are said to go on to degenerative change if there is >2 In a compliant child the principles of assessment are similar to
mm articular step. Growth arrest is said to complicate these those in an adult – The NEXUS study showed 100% sensitivity,
028
20% specificity and 100% negative predictive value of 5 clinical Spinal cord injury without radiological abnormality
features in determining the need for radiographs: (SCIWORA) is more common in those under 8 years
1 Midline tenderness Lordosis is less apparent in young children
2 Altered alertness Growth plates can mimic fractures – Look for smooth
3 Intoxication edges and corners suggestive of the former
4 Neurological compromise C1 posterior arch ossifies at 3 years
5 Distracting injury and tenderness Dens ossifies at 3–8 years
Where indicated, assessment of radiographs needs to be sys- C1 anterior arch ossifies at 6–9 years
tematic – Alignment, Bones, Cartilages, Soft tissues (ABCS). Prevertebral (retropharyngeal) soft tissues at C3 should be
There are some specific issues to be aware of in children’s <2/3 AP diameter of vertebral body. From C4 down
C-spine radiographs: (glottis and below) the prevertebral tissues are doubled
The upper C-spine is most vulnerable (owing to the Widened (distraction) or narrowed (extrusion) disc
relatively large cranial mass and, therefore, a high injuries should be sought
fulcrum) CT is reserved for inadequate plain imaging and where plain
Pseudosubluxation – Of C2 on C3, and C3 on C4, up to imaging raises concern (Figure 25.2).
16 years of age is caused by relative ligament laxity and flat
facet joints permitting AP movement; this is a normal
Examination corner
variant
The anterior atlanto-dens interval (AADI) up to 5 mm – Paediatric trauma
AADI is greater than in adults (up to 3 mm) The candidate is shown an x-ray of an off-ended Gartland III
supracondylar fracture of the elbow in a 4-year-old child.
EXAMINER: A 4-year-old child is taken to the ED by his mother
following a fall from a climbing frame after school. This is
the x-ray which was taken, have a look and tell me what
you see.
CANDIDATE: This is an AP and a lateral x-ray of the right elbow of a
4-year-old boy. There is a widely displaced, off-ended
supracondylar fracture which would be a Gartland type III. The
proximal bone spike is extremely prominent and close to the skin
suggesting it has button-holed through the soft tissues. I would
be concerned about the possibility of an open injury and the
viability of the skin overlying that spike. I would like to know if it is
closed and neurovascularly in tact.
EXAMINER: There is no cut in the skin overlying the spike of bone
but the skin is tethered and looks white over that point. With
regards to the neurovascular status, there is no palpable radial
pulse and the capillary refill is prolonged to 5 seconds. He refuses
to voluntarily move his fingers and states that he has tingling in
his whole hand.
CANDIDATE: OK. We know that there is very significant
displacement and the vascularity and nerves are being
compromised by the pressure. We also know that the skin is
compromised by that spike of bone. This is a surgical emergency
and so we will need to get him to theatre ASAP. I would inform
my consultant, the theatre team and the anaesthetist about the
child’s condition and prep him for theatre.
EXAMINER: What would you do to prepare for theatre?
CANDIDATE: I would splint the arm for comfort. I would mark and
consent for closed or open reduction with K-wire fixation of the
fracture. I would also consent them for exploration ± vascular
exploration and repair and fasciotomies to leave all options open.
Figure 25.2 Normally (and in pseudosubluxation) a line through the anterior
aspect of the spinal process of C1 and C3 should also pass through the anterior I would tell them to remain nil by mouth (NBM); however, under
aspect of the spinal process of C2 these circumstances we would not wait for adequate starvation
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028
times anyway. I would inform the vascular/plastics team about

CANDIDATE: I know that it was published in JBJS that the presence
the possibility of requiring vascular repair if it fails to re-perfuse
of a preoperative anterior interosseous nerve (AIN) palsy made it
when we straighten the arm and get them up to theatre.
more likely that the brachial artery was damaged. There has been
EXAMINER: Assuming that you are the consultant and you now have
plenty of literature stating that you do not need to explore the
the child asleep in theatre, what will you do?
artery unless the perfusion is compromised and the editorial
CANDIDATE: I would attempt to reduce the fracture closed in the following that paper suggested that the reader should explore
first instance and stabilise it with crossed K-wires. After this with caution! Certainly in out unit, the policy is that as long as the
I would reassess the arm for perfusion. hand is well-perfused and the fracture is reduced that you do not
EXAMINER: What would you do if you could not reduce it closed? need to explore. I think that it can be extremely difficult to get
CANDIDATE: In this circumstance, I would perform an open small children to show good AIN function without an injury,
reduction via an anterior approach to the elbow. This would allow let alone under these circumstances! Also, the majority of brachial
me to visualize and reduce the fracture and allow free access to artery injuries are intimal tears which will tend to clot off even
the vessels to inspect them and repair if necessary. after repair. So, my only indication for exploration would be
EXAMINER: OK, let’s assume that you have managed to reduce it inadequate perfusion after the surgery.
closed. After reduction the hand becomes pink and well-perfused EXAMINER: OK, let’s move on.
and the pulse returns. What would you do? The candidate is shown an x-ray of a supracondylar fracture
CANDIDATE: I would place them in an above elbow backslab with which is off-ended (Gartland III)
the elbow slightly extended to reduce any pressure on the vessels EXAMINER: This is the x-ray of a 3-year-old girl brought to the ED by
and observe them extremely closely for 24–48 hours for any signs her father after falling off a friend’s trampoline. Tell me what
of compromise. you see.
EXAMINER: OK, what about if the arm remains pale with poor CANDIDATE: This is an AP and a lateral x-ray of the left elbow of a
capillary refill? small child showing a completely displaced supracondylar
CANDIDATE: The first thing to do is assess the reduction. If the fracture (Gartland III).
fracture is perfectly reduced then the vessels will not be trapped EXAMINER: Just run through the Gartland classification for me.
in the fracture and we should assume that the vessel has been CANDIDATE: The Gartland classification for supracondylar fractures
injured. We would then call our colleagues in either vascular or of the elbow has types I–III. Type I is completely undisplaced, type
plastic surgery depending on local protocol to explore and repair II has pure extension with the posterior hinge remaining in tact,
the vessel. and a type III is where the fracture is completely displaced or has
If the fracture is not properly reduced then I would attempt a rotation/varus/valgus.
further reduction and stabilisation. Sometimes it has not fully EXAMINER: OK, so how would you manage this young girl?
reduced because some soft tissue is stuck in the fracture kinking
CANDIDATE: I would check that the injury was closed and
the vessel. If after this repeat manoeuvre the vascularity improves
neurovascularly intact.
I would treat it like the first patient. If this made no difference
EXAMINER: It is.
then I would continue on with exploration of the vessel.
CANDIDATE: Good, then I would splint it in an above elbow back
EXAMINER: What would you do if the perfusion improved but the
slab and mark and consent her for theatre for an manipulation
pulse did not return?
under anaesthetic (MUA) and K-wiring. I would speak to my
CANDIDATE: Again this depends slightly on the reduction. If the
consultant and the anaesthetist/theatre team to try to get the
fracture is fully reduced then it is extremely unlikely that the
surgery done as soon as possible.
vessels are being kinked or trapped in the fracture. As long as
EXAMINER: Would you take her to theatre in the middle of
perfusion is good in the hand then I would observe and wait in
the night?
the same manner we did with the first child. It is well-established
CANDIDATE: Assuming it was closed and neurovascularly intact,
that the brachial artery goes in to spasm after these kinds of
then I would not take her at 3 in the morning! I would push to get
injuries.
the case done late in the evening to reduce the risk of her
CANDIDATE: If the fracture was not fully reduced then I would
developing neurovascular issues and reducing the chances of
repeat the reduction again to ensure that this was not a
needing an open reduction.
problem. Again, if the pulse was definitely absent
EXAMINER: If you leave these injuries overnight does it increase the
preoperatively and the perfusion was good with a warm
chances of needing to perform an open reduction?
hand at the end of the procedure I would observe. If there
CANDIDATE: There has been work from the USA stating that
was any concern over the vascularity of the hand then I would
it does not increase the risk of needing an open reduction.
explore the vessel.
What you need to bear in mind when you are quoting that
EXAMINER: Is there anything else that you base your decision on
paper is that they manipulated all of the fractures under ketamine
regarding exploration of the vessel?
in the ED before admission! That means that there is not an
028
increased risk of open reduction if you reduce the fracture and transcervical, type III is basicervical and type IV is
then leave them over night. Not relevant if you are leaving them intertrochanteric. Type I is further subclassified as to whether the
off-ended, which would be the standard practice in the UK. epiphysis stays with the metaphysis or whether there is
EXAMINER: OK, so now you are the consultant in theatre and the significant displacement between the two.
child is asleep and ready to go. You manipulate it back in place EXAMINER: That’s right, so what would you tell the family regarding
without too much difficulty. How are you going to fix it? the risk of avascular necrosis (AVN) based on that classification
CANDIDATE: Well, the two options are to do two lateral wires or system?
crossed K-wires. The benefit of doing two lateral K-wires is that CANDIDATE: I would inform them that with this injury pattern the
you avoid placing a wire next to the ulnar nerve as it rounds the risk of AVN is between 90% and 100%.
medial epicondyle. If you use 2 mm K-wires it has been shown EXAMINER: OK, so how would you manage this child?
to be as stable as crossed 1.6 mm wires. The problem is that CANDIDATE: I would inform my consultant and theatres/anaesthetist
it is much more technically difficult to do. In a little elbow it about the child. I would make sure that he had a group and save
can be tricky to get the wires across, you need to get good spread and any other relevant investigations based on his past medical
of the wires at the fracture site and good bicortical hold. Also, history. I would mark and consent him for theatre for ORIF of the
some fracture types are not suitable for this technique. It right hip fracture and get him to theatre ASAP.
should also be noted that you can still damage the ulnar nerve EXAMINER: What would you do surgically assuming you were
as the K-wire protrudes through the opposite cortex. adequately trained?
The other option is to use 1.6 mm crossed K-wires. This is CANDIDATE: I would attempt a closed reduction of the fracture in
technically less demanding but gives a greater risk of damaging the first instance to see if I could reduce it. If I was lucky enough
the ulnar nerve. I would use this technique as it is the one that to reduce it anatomically closed then I would fix it in situ using
I am most familiar with. To minimize the risk of damage to the cannulated screws. If I could not reduce it closed then I would
ulnar nerve I would fix the lateral side first, and then gently perform an open reduction through an anterolateral approach.
extend the elbow to reduce the tension on the nerve. I would I would visually reduce the fracture and fix it with cannulated
perform a mini-open approach on the medial side so that I could screws. In both instances I would evacuate the haematoma, by
be clear that the ulnar nerve was free and then fix the medial side. aspiration if I managed a closed reduction.
EXAMINER: OK, let’s move on. EXAMINER: What would you say regarding risks when consenting
The candidate is shown an x-ray of a displaced hip fracture in a them for the surgery?
9-year-old child which has fractured through the physis leaving the CANDIDATE: Bleeding, infection, neurovascular damage, avascular
epiphysis in the acetabulum. necrosis, mal-union, non-union, leg length discrepancy,
EXAMINER: This is the x-ray of a 9-year-old boy brought in progression to osteoarthritis, need for future procedures.
by ambulance having been hit by a car as he walked across the EXAMINER: OK, let’s move on.
road. It was estimated by witnesses that the car was travelling The candidate is shown an ankle x-ray of a 14-year-old boy with a
approximately 25 MPH. What can you see on the x-ray? minimally displaced Salter–Harris II fracture seen on the lateral
CANDIDATE: This is an AP pelvic x-ray of a 9-year-old boy. The most projection.
obvious abnormality on it is a fracture to the right hip. There EXAMINER: This young man is 14 years old and attended ED
appears to be a fracture running through the physis with the following a footballing injury to this ankle. What do you see on
head in place in the acetabulum and the metaphysis displaced the x-ray?
posteriorly. I cannot identify any additional fractures in the pelvis
CANDIDATE: This is an AP and lateral x-ray of the right ankle. The
but considering the mechanism I would be concerned regarding
most obvious abnormality is a minimally displaced Salter–Harris
any missed fractures.
type II fracture of the distal tibia seen on the lateral projection.
EXAMINER: What would your management be for this child? I cannot see any other fracture lines on this x-ray but I would be
CANDIDATE: Well, in the first instance he would need to have a concerned about the possibility of a triplane injury in this
trauma call and be dealt with as per ATLS® protocols. This was a age group.
high-energy mechanism and so we would have to exclude
EXAMINER: If you wanted to determine if this was a triplane injury
additional injuries. As much as he has a hip fracture, the leading
then what further tests would you do?
cause of death in children is head injury followed by occult
CANDIDATE: I would do a CT scan of the ankle to fully define the
visceral injury.
fracture pattern.
EXAMINER: OK, let’s assume that there has been a full ATLS®
EXAMINER: OK, so you get a CT scan and it confirms your suspicions
assessment and this is an isolated injury. Do you know any
that this is a triplane injury with an intra-articular extension with a
classification systems for this injury?
2 mm gap. What would you do now?
CANDIDATE: I know of the Delbet classification for hip fractures in
CANDIDATE: Well, this is a displaced intra-articular fracture which
children, types I–IV. Type I is through the physis, type II is
needs reduction and fixation. I would plan to take him to theatre
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028
to fix this – Probably with two screws, one in the epiphysis and occur by chance. We would need to check whether or not there
one in the metaphysis. Commonly you can reduce the joint have been any previous concerns regarding the child or any
surface by just placing a large reduction clamp across it, but if siblings.
there was any concern then I would open it to ensure reduction. The child will need to be examined by a consultant to look for
EXAMINER: Would you be concerned about damage to the physis any further evidence of harm. The most common feature seen is
during the surgery? skin lesions. We would also need to feel all of the limbs to look for
CANDIDATE: No. Commonly you can fix this with screws running signs of healing fractures and look in the eyes for any retinal
parallel to the physis without damaging it. If there was some haemorrhages.
reason that this would not be possible then accurate reduction If after this assessment, the team feels that NAI cannot be
and stable fixation of the fracture is definitely the priority. By excluded then we would have to perform a skeletal survey to look
definition of the injury being a triplane, the physis is closing for associated injuries ± CT head depending on hospital protocol.
anyway and is not a priority. We would also need to perform blood tests looking for any
EXAMINER: OK, let’s move on. underlying cause for the injuries such as osteogenesis imperfecta
or vitamin D deficiency.
EXAMINER: What would you be looking for on a skeletal survey?
CANDIDATE: Essentially anything abnormal! The skeletal survey can
give you some indication of bone quality and any deformity
Examination corner
associated with conditions like rickets suggesting an underlying
Non-accidental injury metabolic bone problem as opposed to NAI. If the child is being
The candidate is shown an x-ray of a 9-month-old boy with a abused then we may see multiple injuries, healing fractures of
spiral femoral shaft fracture. different ages. Rib fractures, humeral fractures and metaphyseal
EXAMINER: This x-ray was taken after a 9-month-old boy was corner fractures are very specific to NAI, but they are only seen in
brought to the ED by his mother following an unwitnessed fall. the minority of cases of abuse. Unfortunately, the vast majority of
Tell me what you think it shows. NAI-related injuries are exactly the same as accidental injuries
CANDIDATE: Well this is an AP and lateral x-ray of the right femur in sustained by children every day.
a 9-month-old boy. The most obvious abnormality is a displaced EXAMINER: What factors would make you think an injury was not
spiral fracture of the diaphysis. I would be very interested to know accidental in these cases?
the ambulatory status of this child and the history so that I could CANDIDATE: You will always be more suspicious in cases where
assess the risk of non-accidental injury (NAI). abuse has been questioned before. With regards to the history:
EXAMINER: Well, the child is not walking yet, he is freely
crawling and starting to reach for furniture but not coasting. Delayed presentation after an obvious injury
Mum says that she was out of the room when she heard a History of injury does not match the injury pattern
crash, then she found him crying on the floor unable to Changing story from the parent, or differing accounts
weight bear. from interested parties
Recurrent unexplained injuries
CANDIDATE: Did she say that his leg was trapped in anything?
Ambulatory status – Those who are not walking rarely
EXAMINER: No, she just found him in the middle of the floor. sustain diaphyseal spiral fractures whereas it is extremely
CANDIDATE: OK, well on that history I would be extremely common in toddlers
concerned for this child’s safety due to the risk of NAI. I would Unusual family dynamics – Sometimes you can see very
admit him for gallow’s traction to treat his femoral fracture and odd dynamics between parents and children suggesting
inform the consultant on-call, my paediatric colleagues and the there is more going on than meets the eye
safeguarding team.
EXAMINER: What would you say to the mother? EXAMINER: Okay, so let’s assume that it was NAI and that all of the
appropriate action has been taken. How would you treat this child
CANDIDATE: I would tell Mum that this is a very unusual injury to
with regards to the femoral fracture?
have occurred in a child of this age who is not ambulatory. If it did
occur from him just stumbling in the middle of the floor, then we CANDIDATE: Personally I would treat them on Gallow’s traction until
would be concerned about his bone quality as this would there was good callus formation and then let them go home non-
normally not result in a femoral fracture. We would need to admit weight-bearing, if that is the designated discharge plan.
him to do some further investigations to see if we can find the EXAMINER: OK.
cause of this injury. The candidate is shown an x-ray of a midshaft off-ended radius
EXAMINER: What further tests would you arrange? and ulna fracture with 40° of angulation and early callus formation
CANDIDATE: Well in the first instance we would need to do in a 9-year-old girl.
a formal assessment of the chance of this being NAI. In this EXAMINER: This child was brought to the ED after the child was sent
age group a femoral shaft fracture is extremely unusual but can home from school. It was the first day back after the summer
028
holiday; teachers were concerned about the shape of her arm. it straight but off-ended and hoping that it remodels or accepting
Mum is unaware of any injury. that you will have to do an open reduction and internal fixation.
CANDIDATE: Well this is an AP and lateral x-ray of the right forearm. EXAMINER: What would you do if it remained off-ended?
It shows an off-ended midshaft fracture of both the radius and CANDIDATE: I think that in a 9 year old I would open it and plate it.
ulna. There is translation of the radius and there is approximately EXAMINER: Why not elastic nails?
40° of dorsal angulation associated with it. There is a periosteal CANDIDATE: I think that you will have to do a proper open
reaction and what would appear to be early callus formation. reduction with a decent sized wound due to the callus formation.
EXAMINER: What are your thoughts? At this stage, your wound would be big enough to plate it.
CANDIDATE: I would be extremely concerned about NAI in this I appreciate that nails would be less invasive to remove down the
situation. The fact that there are signs of healing on the x-ray line than a plate, but this could be an extremely challenging
indicates that this injury is at least a week to 10 days old. It was an nailing due to callus and remodelling in the canal. All in all I think
unstable fracture and so must have been extremely painful and that I would plate it and if needed remove the plate.
unlikely to be missed by the child or the parents. The angulation EXAMINER: OK, let’s move on.
on the x-ray is significant and it was sufficiently deformed that the
school picked it up on observation on the first day.
The fact that there has been a significant delay to presentation, Developmental dysplasia of the hip (DDH)
the fact that Mum claims there is no injury history, and the fact
There is a very good chance that you will be asked about DDH
that no-one has noticed this girl having an extremely angulated
in your children’s orthopaedics oral. It is an ‘A listed’ topic.
and unstable injury is extremely concerning.
This in itself is not particularly helpful as it is a big, complex
EXAMINER: Is this the kind of injury that you would expect to see
and controversial subject to learn. For starters it is very
in NAI?
important to be able to recognise it on a clinical photograph
CANDIDATE: Yes and no! We know that there are injuries which are or radiograph. Quite where the discussion will then go is
very specific for NAI, such as rib fractures, humeral shaft fractures anybody’s guess.
in <18/12 and metaphyseal corner fractures. Although these
injuries are unlikely to have occurred without NAI, they form the
significant minority. The bulk of NAI related injuries are exactly
the same as occur through accidents.
Background
DDH encompasses a large spectrum of conditions from mild
Although this injury is by no means classical of NAI, I have a
dysplasia through to frank irreducible dislocation of the hip. It
very high index of suspicion due to the delayed presentation, the
is the most common paediatric hip condition presenting to
neglect of its treatment for the first 10 days, and the claims from
orthopaedic services in the UK.
Mum that she was completely unaware of a problem until she
The incidence depends on the definition used. Early
was sent home from school.
instability is extremely common, but >90% of cases will
EXAMINER: What would your management be if you saw this child
resolve by the age of 6– 8 weeks without intervention. Those
in ED?
using universal ultrasound screening quote the incidence as
CANDIDATE: I would check and document the neurovascular status
being 1/400 live births. The actual treatment rates are more in
before and after splinting the arm with a plaster. I would examine
the region of 4–6/1000 live births. The left hip is affected
the child from head to toe to look for any other injuries, including
3 times more commonly than the right, and the process is
bruises and bite marks. I would admit the child from ED so that
bilateral in 20% of children.b
they were in a place of safety and make enquiries regarding any
other children that may be in the home. I would inform the Aetiology
consultant on call, the paediatric team and the safeguarding team There are multiple theories regarding the aetiology of DDH.
of my concerns. Then most likely she would require a skeletal Its development is likely to be multifactorial rather than being
survey. attributable to any one cause. Common theories include:
EXAMINER: Okay, so that was done and a diagnosis of NAI was made
Mechanical factors – This theory states that intrauterine
following multiple fractures being seen on the skeletal survey. If
crowding leads to DDH through forcible adduction of the
we assume that the proper authorities are managing the social
legs. This is supported by the predominance of DDH in
side of things, how would you manage the fracture?
first pregnancies (due to increased abdominal and uterine
CANDIDATE: Well, I don’t think that it is acceptable to leave in its
current position! At the very least it would require a trip to theatre
b
for an MUA to correct the angulation and attempt to reduce it. The examiners may ask you why the left hip is significantly more
I think that it is unlikely that you would be able to fully reduce the affected than the right. The left hip is adducted against the mother’s
fracture at this stage leaving you with the decision about leaving lumbosacral spine in the most common intrauterine position (left
occiput anterior). In this position less capital cartilage is covered by
the bony acetabulum and dysplasia is favoured.
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Table 25.1 Advantages and disadvantages of universal and selective ultrasound screening programmes for DDH.
Type of programme Advantages Disadvantages

Universal ultrasound Minimizes late presentation Costly
screening Allows early treatment for the majority of cases May lead to overtreatment through early
Does not rely on clinical examination by junior assessment
doctors
Selective ultrasound More cost effective More likely to lead to late presentation
screening Prevents overtreatment Most cases of DDH do not have risk factors
tone), multiple pregnancies and oligohydramnios. It femoral head on the superior lip of the acetabulum causes
similarly supports the association with packaging disorders segmental depression of the femoral head and anteverts
such as torticollis, plagiocephaly and foot deformitiesc. The the neck
left hip is more frequently affected, and this is believed to 3. As the hip dislocates it inverts the limbus (labrum, capsule
be because the most common intrauterine position leaves and rim of acetabular cartilage) and allows interposition of
the left leg adducted against the lumbar spine. Similarly, the psoas tendon between the head and the cup. The psoas
breech positioning in utero is associated with an increased tendon pressing on the capsule causes the classic hourglass
incidence of DDH constriction. Pressure from the femoral head on the ilium
Genetic factors – There is an association with family leads to formation of a false acetabulum superior to the
history for DDH although there is no clear pattern of true socket
inheritance. Having a first degree relative with DDH 4. The presence of the femoral head within the acetabulum is
increases the child’s risk to 12%. If the relative is an required for its normal development. After dislocation the
identical twin then this risk increases to 36%. Rates also socket becomes very shallow with overgrowth of cartilage
vary considerably between populations, with there being in the floor. The anterosuperior aspect of the acetabulum
very high rates of DDH in Japan, but virtually no incidence fails to develop leaving the hip uncovered anteriorly and
in Black Africans laterally. There is hypertrophy of the ligamentum teres and
Hormonal factors – Hormonal imbalances in the mother the transverse acetabular ligament further blocking
can be a risk factor for DDH. It is thought that the high reduction
circulating levels of progesterone and relaxin leading up to 5. After dislocation has been prolonged, the musculature
birth result in excessive laxity of the hip joint capsule around the hip becomes contracted preventing reduction
allowing instability. This theory explains the very high rates This is why abduction bracing is commonly successful in early
of instability during the first 6 weeks of life that resolves infancy, but usually fails as the child becomes older.
spontaneously. It also explains the increased incidence in
females who have their own hormonal production
Oral questions
External factors – Communities that advise swaddling of
babies (wrapping them tightly in a blanket), have high What is developmental dysplasia of the hip?
levels of DDH due to the forcible adduction of the hips. What are the risk factors for DDH?
Communities that carry children on their hip with the legs What other conditions are associated with DDH?
abducted have negligible rates. This may partially explain What is Ortolani’s test?*
the difference in incidence between races What is Barlow’s test?*
*An ability to describe these tests clearly will demonstrate
Pathoanatomy that your theoretical knowledge extends into the clinic – Make
certain you can do this. Their sensitivity decreases as the child
Early treatment in DDH is important as there is a clear pro-
gets bigger.
gression of bony remodelling and contractures, which prevent
reduction without major surgery. This process is as follows:
1. Laxity of the hip joint capsule allows reducible subluxation Screening programmes for DDH
of the femoral head Screening for DDH has been commonplace for decades. It is
2. As the hip subluxes the head everts the acetabular labrum well-established that earlier identification and treatment of
with a small rim of acetabular cartilage. Pressure from the DDH can reduce the magnitude and duration of treatment.
A recent study has shown that the risk of open reduction
c
In the exam, you may be asked about associated hip abnormalities surgery increases progressively with late presentation, with
in a child with one of these abnormalities. Uncertainty has now 86% of cases requiring major surgery when presentation is
been cast on the association with CTEV (clubfoot). later than 10 months of age5.
028
(a) (b)
α °
Figure 25.3 (a) Ultrasound image of the infant hip showing the Graf α angle calculation. The femoral head is >50% covered by the bony acetabulum. (b) Picture
showing the features of an infant hip ultrasound. A – Bony ilium, B – Acetabular labrum, C – Femoral head, α – Graf α angle, β – Graf β angle
Clinical examination of all newborns for DDH is routine, : Breech presentation

assessing leg length, range of movement and the Ortolani and : If resources allow – congenital talipes equinovarus
Barlow tests. The effectiveness of clinical examination is ques- (CTEV), metatarsus adductus, torticollis,
tionable, with the sensitivity being as low as 36% in inexperienced oligohydramnios, high female birthweight
hands. Therefore, ultrasound screening for DDH has been estab-
lished as the gold standard to assess hip morphology and stability. Radiological assessment
Two types of screening programmes exist: Universal and Ultrasound
selective ultrasound screening. In universal programmes all Ultrasound is used in children younger than 4 months as the
newborns are assessed by ultrasound, whereas in selective proximal femur is largely cartilaginous at that age. The con-
programmes only those with clinical concerns on examination sensus method for screening assesses the Graf angles, the
or those with risk factors for DDH will be scanned6. The pros femoral head coverage and tests dynamic stability. The Graf
and cons of both systems are shown in Table 25.1 method uses the α angle and the β angle. The α angle lies
In the UK, most centres operate a selective ultrasound- between the ilium and the bony acetabulum, and the β angle is
screening programme based on the Newborn Infant Physical formed between the ilium and the acetabular labrum. An
Examination (NIPE) programmed. This advocates clinical exam- example ultrasound is shown in Figure 25.3a and 25.3b.
ination of the hips at birth and then again at 6–10 weeks of age. It The Graf α angle should be 60° or more. If the value is less
has removed the 6–9 month, and 1-year hip check that was than this then the acetabulum is shallow. The Graf β angle
previously advised by the Standing Medical Advisory Committee should be <55°. If the hip is well located in the socket it should
(SMAC). The NIPE recommends ultrasound assessment for: be easily covered by the labrum. As the hip starts to dislocate,
Any child with clinical concerns regarding DDH the labrum is pushed out increasing this angle.
Any child with a risk factor X-ray
: Family history The AP pelvis x-ray is used for the assessment of children over
the age of 4 months. An example x-ray is shown in
d
Newborn Infant Physical Examination website: Figure 25.4a with an example of the lines used for assessment
www.newbornphysical.screening.nhs.uk/ in Figure 25.4b.
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(b)
(a)
B
C
A
Figure 25.4 (a) AP pelvic radiograph of an 18-month-old girl presenting with left sided DDH. (b) Picture showing the lines used for assessment of DDH.
A – Hilgenreiner’s line, B – Perkins line, C – Acetabular index, D – Shenton’s line, E – Medial clear space between ischium and medial femur
The x-ray shown in Figure 25.4a shows the classic features hip capsule and ascends with the synovial reflection, tightly
of DDH. The metaphysis of the left hip lies in the upper outer tethered to the back of the femoral neck. This artery gives off
quadrant of a grid formed by Hilgenreiner’s and Perkins lines metaphyseal and epiphyseal branches to supply the bulk of the
(should normally be in the inferior medial quadrant). Shen- proximal femur. The physis acts as a complete barrier to
ton’s line is disrupted, there is increased medial clear space diffusion making these vessels end-arterial.
(should be no >5 mm) and the acetabular index is increased. The main blood supply for the femoral epiphysis in a child
The proximal femoral ossific nucleus is smaller in the left hip comes from the posterosuperior ascending branch of the
than in the right. medial circumflex femoral artery. Because it is tethered tightly
to the posterior aspect of the femoral neck, if the leg is placed
Treatment in extreme flexion and abduction it can be compressed on the
The principles of treatment for DDH are to obtain concentric rim of the acetabulum. Similarly, extreme adduction and
stable reduction of the hip as early as possible whilst limiting internal rotation stretch the vessel and compromise the blood
the risk of complications. The development of the hip is supply. This is why extreme positioning in a hip spica is
dependent on the femoral head being stable within the acet- contraindicated.
abulum, and remodelling potential decreases with age. The
vast majority of remodelling for the acetabulum occurs before Treatment methods
the age of 4 years, but will continue to a degree until 6 years of Observation
age. Early reduction of the hip reduces the need for pelvic Many hips assessed in a child during the first few weeks of life
osteotomy by maximising remodeling potential. are seen to be physiologically immature or display instability.
Ninety per cent of these children will stabilise without any
Blood supply to the femoral head intervention by the age of 6 weeks7. These children should be
The major risk of DDH treatment is avascular necrosis. treated with double nappies or just observation, with a repeat
Although the proximal femur has a plentiful blood supply, ultrasound assessment after 6 weeks of age. The vast majority
the physis acts as a complete barrier to flow. This means that will not require any further intervention.
any damage to the supply for the epiphysis will result in an
avascular insult. Abduction bracing
The profunda femoris artery supplies the medial and lateral In the first 6 months of life, abduction bracing is the first line
circumflex femoral arteries. The lateral circumflex femoral treatment. In the UK this is most commonly in the form of a
artery supplies the majority of the anterolateral portion of Pavlik harness. The harness holds the hip in mild flexion and
the chondroepiphysis and the greater trochanter. The medial abduction to provide the optimum conditions for hip reduc-
circumflex femoral artery gives off the posterosuperior tion. This allows the child to kick their legs and actively push the
ascending branch which pierces the posterior aspect of the femoral head in to the acetabulum encouraging development.
028
Table 25.2 Features of the anterolateral and medial approach for open reduction of the hip.
Medial approach Anterolateral approach

Age of child <1 year of age Any age
Advantages – Mechanical blocks to reduction are easily seen and accessible – Can address all blocks to reduction and perform
– Avoid splitting the apophysis capsulorrhaphy
– Can address pelvis and false acetabulum through
same incision
– Away from the MCFA
Disadvantages – Cannot address the false acetabulum, inverted limbus or – Split the apophysis
perform capsulorrhaphy – The acetabulum is very deep making it difficult
– Risk damage to the medial circumflex femoral artery (MCFA) – Risk damage to the lateral femoral cutaneous nerve of
causing AVN the thigh
reduction is the next logical step. This involves examination

under anaesthesia (EUA), arthrogram and, possibly, tenoto-
mies. An example of an arthrogram is shown in Figure 25.5.
There are three possible outcomes following an attempted
closed reduction:
1. The hip reduces well and is stable throughout a good range
of movement
2. The hip will reduce but needs to be held in an extreme
position to keep the head reduced
3. The hip is irreducible due to obstructions
The child in scenario 1 has had a successful closed reduction.
They should be treated in a hip spica for 6 weeks, then changed
to another spica for a further 6 weeks.
The child in scenario 2 needs careful assessment. The ‘safe
zone of Ramsey’ is the range of abduction through which the
hip remains reduced in the acetabulum. If the hip requires
wide abduction to keep the hip reduced, adductor tenotomies
can sometimes improve the stability and increase the safe zone.
If the hip can be held reduced in >45° of abduction, then this
will typically be accepted. If extreme positioning is required to
hold the reduction then the procedure should be abandoned to
prevent development of AVN and plans made for an open
reduction.
Figure 25.5 Picture of a hip arthrogram in DDH showing the left hip to be In scenario 3 the child clearly requires an open reduction.
dislocated. The acetabulum is shallow with pulvinar in the floor. The psoas The arthrogram can be helpful to plan the need for any
tendon is interposed between the head and the socket with an hourglass associated procedures that may be required. If the acetabulum
constriction of the capsule
is extremely shallow, then a pelvic osteotomy may be required.
If the head is very high and cannot be easily brought down to
In order for a Pavlik harness to be used the hip must be the level of the acetabulum, then it is likely that a femoral
reducible on abduction and flexion. For irreducible hips, shortening osteotomy will be needed.
a maximum of 1–2 weeks can be allowed in a harness to see Structures which may prevent reduction of the femoral
if it will reduce. If the hip remains dislocated then the harness head into the acetabulum are:
must be removed or it can cause avascular necrosis, deform- Bulky ligamentum teres
ation of the femoral head and development of a false Hypertrophied transverse acetabular ligament
acetabulum. Inverted limbus (acetabular labrum, capsule and rim of
acetabular cartilage)
Closed reduction of the hip Psoas tendon
For those children who have failed Pavlik harness treatment, or Hour glass constriction to capsule
those presenting too late to implement it, an attempt at closed Pulvinar (fibrofatty material in the acetabulum)
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028
Open reduction surgery

For those children where a closed reduction has failed, an open
reduction is required. This can be performed through an ante-
rolateral or medial approach, the former being more commonly
used. Table 25.2 lists the features of these two techniques.
The goals of open reduction surgery are to remove all
blocks to reduction, take down the false acetabulum and per-
form a capsulorraphy to stabilise the hip. At the end of
the procedure the child is placed in a hip spica, typically in
the human position to reduce the risk of AVN for 6–10 weeks.
Associated procedures
At the time of performing an open reduction it may become
necessary to address the femur or acetabulum in order to
attain and sustain reduction. These are as follows.
Proximal femoral osteotomy can be required for either
shortening or derotation purposes. For older children with
high-riding dislocations, there has commonly been contraction
of the musculature preventing reduction. In these circumstances
a pure shortening osteotomy is required to allow reduction of the
hip without excessive pressure on the head causing AVN.
In those children with extreme femoral anteversion,
Figure 25.6 Treatment algorithm for children with DDH
whereby extreme internal rotation of the leg is required in order
to keep the hip reduced, derotation is advised. This should be There is a clear body of support in the paediatric orthopaedic
back to the normal level of anteversion for age, not 15°. community for each of these treatment plans. Earlier reduction
Pelvic osteotomy may be required in order to provide a gives the best chance of remodelling and reduces the need for
congruent hip joint. If the acetabulum is so shallow or defi- further procedures such as pelvic osteotomies. We know that
cient anteriorly that the hip cannot be maintained in the delaying surgery past 10 months of age significantly increases
socket, then this procedure may be required at the time of the need for open reduction surgery8. On the other hand,
open reduction. Many surgeons defer this procedure to allow avascular necrosis is the worst of complications and the only
time for remodeling. If the acetabulum is still shallow by the problem we really don’t have a good answer for. As long as you
age of 4, then consideration should be given to performing a understand the reasoning behind your decision, you can safely
redirectional osteotomy such as a Salter. give any of these answers in the exam.
Figure 25.6 Treatment algorithm for children with DDH
Outcome
Timing of surgery For those treated early with a Pavlik harness, the risk of
There is significant controversy regarding the timing of sur- requiring hip arthoplasty is not significantly greater than that
gery for DDH with regards to the risk of avascular necrosis. of the normal population. It has been stated that 50% of
There are three schools of thought regarding management: children requiring open reduction surgery will go on to require
The first group believe that the hip should be reduced at the hip arthroplasty in their 50s. Certainly outcome is related to
earliest possible time to allow the maximal remodelling the morphology of the hip at skeletal maturity, making femoral
potential. These surgeons will progress through Pavlik and acetabular osteotomy to correct residual dysplasia
harness, closed reduction and then straight on to open desirable8.
reduction as needed without delay, feeling that with
modern techniques the risk of AVN is acceptable Examination corner
The second group will treat babies with a Pavlik harness
Paeds oral 1
and then attempt a closed reduction after this fails.
DDH – Late presentation and role of arthrogram
However, they will postpone open reduction surgery until
Economics of preoperative traction before open reduction
the age of 13 months or until the proximal femoral ossific
nucleus appears as this is felt to be protective against AVN Paeds oral 2: DDH in an 18-month-old child
The third group feel that the risk of AVN is too great for History and examination
any treatment other than a Pavlik harness. If this fails, they Arthrogram findings
will wait until 13 months before attempting a closed or Management options
open reduction
028
Paeds oral 3
Clinical finding in a neonate with suspected DDH
Paeds oral 4
DDH management
Open reduction indications and approaches
Which soft tissues should be released or excised to ensure
reduction
Complications
Paeds oral 5
An ultrasound image of DDH
Anatomical structures and features on the ultrasound scan
Paeds oral 6
EXAMINER: What radiographic features are present in DDH?

CANDIDATE: The characteristic features include: Break in Shenton’s
line, increased acetabular index, delayed ossific nucleus,
Figure 25.7 AP radiograph pelvis
development of a false acetabulum, proximal and lateral
migration of femoral neck and centre edge angle <20°. EXAMINER: Tell me what you can see in this x-ray?
EXAMINER: What would you find by examining the child? CANDIDATE: This is an AP pelvic x-ray of a 18-month-old child. The most
CANDIDATE: On inspection, the child would have asymmetrical obvious abnormality is a high dislocation of the left hip. There is
groin folds. They would have limited abduction and a leg length disruption of Shenton’s line, the metaphysis is lying in the superolateral
discrepancy. Galeazzi’s sign demonstrates this, where the affected quadrant of the squares made by Hilgenreiner’s and Perkin’s lines. The
side appears shorter when the knees and hips are flexed. If the acetabulum is shallow with an acetabular index of approximately 35° and
hip is unstable but congruent, Barlow’s test would be positive. the proximal femoral epiphysis of the left femur is much smaller than the
Ortolani’s test would be positive if the head is dislocated. one on the right. The most likely diagnosis would be a late presenting
EXAMINER: The child is 8 months old. What would your DDH, but I would need to examine the patient to exclude other causes
management be? such as neuromuscular conditions.
CANDIDATE: I would investigate this child’s hip by ultrasound EXAMINER: Yes, this was a late presentation for DDH. What would your
screening and an x-ray. To confirm the diagnosis I would perform management plan be for this child?
an arthrogram under general anaesthesia. On confirming the CANDIDATE: The principles of treatment are to get a stable concentric
diagnosis I would manage this with close reduction and spica cast. reduction as soon as possible whilst minimizing the risk of complications – In
EXAMINER: particular avascular necrosis. My plan would be to take this child to theatre to
How do you do an arthrogram? perform and EUA and arthrogram and attempt a closed reduction.
What can you see on the arthrogram? EXAMINER: Do you think that is likely to be successful at this stage?
How do you check the adequacy of reduction? CANDIDATE: No, I would tell the parents that I thought it would be unlikely
What are the complications of treatment? to work but every now and then we are pleasantly surprised! I would tell
How do you reduce the incidence of AVN? them that if the hip went in closed then we would treat them in a hip spica.
If the hip would not reduce we can get the information needed to plan
Paeds oral 7 which procedures may be required in association with an open reduction.
Management of DDH presenting at 2 years EXAMINER: Which procedures do you think may be necessary?
Smith–Peterson approach to the hip CANDIDATE: With a high-riding dislocation it is common to need to
perform a shortening proximal femoral osteotomy to reduce the pressure on
Paeds oral 8: Clinical photograph of Ortolani’s test the femoral head and reduce the risk of AVN and re-dislocation. At the age of
How is it performed? 18 months it is possible to perform a Salter pelvic osteotomy. If the
Sensitivity acetabulum is extremely shallow and the hip is unstable after reduction of the
Management at 8 months
hip, I would do this at the same sitting. If the hip was in joint and stable
General discussion about screening
I would probably allow the child time to remodel, but warn the parents that it
may be necessary to perform the procedure at a later date.
Paeds oral 7 EXAMINER: What sort of age would you plan to do a Salter pelvic
osteotomy if required?
The candidate is presented with an AP x-ray of the pelvis for CANDIDATE: Most acetabular remodelling occurs by the age of 4, so
an 18-month old child with an established unilateral high- I would not do it before this stage. If the cup was still very shallow by
riding dislocation of the left hip (Figure 25.7) 4 and not progressing well then I would list them at that stage. If it
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028
was not too far off and still improving, then I would give them up protecting the lateral femoral cutaneous nerve. I would split the apophysis
until 6 years. of the crest stripping the outer table subperiosteally. I would then divide
EXAMINER: What is the latest that you would do a Salter osteotomy? the straight head of rectus femoris after placing a stay suture in the
CANDIDATE: The Salter relies on the elasticity of the pubic symphysis. It is tendon. Clearing the tissue from the hip capsule over the acetabular brim
recommended to perform the procedure between 18 months and 6 years. medially, the psoas tendon is divided at this level. I would then perform a
People have done this procedure later than 6 but personally I would not t-shaped capsulotomy to open the hip.
like to try it! EXAMINER: If you needed to perform any additional procedures, which
The candidate is shown an ultrasound picture of a dislocated hip. approach would you use?
EXAMINER: This is an ultrasound picture of a hip in a child with DDH. CANDIDATE: The pelvic osteotomy can be performed through the same
They are currently 3 months of age and the hip has failed to reduce in the incision by stripping the inner table subperiosteally following the
Pavlik harness. It is now dislocated and irreducible. What would be your apophysial split. If you needed to perform a femoral osteotomy then
management plan from this point? I would do a separate incision for a direct lateral approach.
This question relates to the timing of interventions in DDH with
respect to the risk of avascular necrosis. For children presenting in the first Pelvic osteotomies
few months of life the established treatment sequence is to try abduction Principles
bracing, then a closed reduction if this fails, proceeding to open reduction There are three categories of pelvic osteotomies:
as a last resort. There are three schools of thought regarding management Re-directional – Where the acetabulum is deficient in one area, e.g.
of these children where an open reduction is required: anterior deficiency in DDH
The hip should be reduced as soon as possible and, therefore, you
Volume-reducing – Where the acetabulum is shallow, being deficient
should offer a closed reduction, and then proceed immediately to superiorly, e.g. in neuromuscular conditions such as cerebral palsy
open reduction if that fails. Although there is a risk of avascular
Salvage – Where the femoral head is not contained or the joint in
necrosis, they do not believe that this is sufficient to warrant delaying
incongruent, e.g. in avascular necrosis or Perthes’ disease
hip reduction and losing the best remodelling potential for the
acetabulum Redirectional osteotomies
The second group will proceed to attempt a closed reduction as the
Redirectional osteotomies address a deficiency in one region of
risk of AVN is low. However, if this fails they will abandon treatment
the acetabulum. In order to provide cover to this area, the
until the child is 13 months or the ossific nucleus develops in the hip.
acetabulum needs to be reoriented. This requires both columns
This is felt to be protective for the blood supply reducing the risk of
to be cut proximally and the acetabulum to be rotated around
AVN during open reduction surgery
a distal point. The procedure performed depends upon the age
The last group will only try a Pavlik harness. If this fails, they believe of the child.
that the risk of AVN with any other intervention is unacceptably high
18 months to 6 years of age – Salter osteotomy. This osteotomy hinges on
until the ossific nucleus develops. They would wait for this or until
the pubic symphysis, which is elastic in young children. The inferior
the age of 13 months before trying a closed reduction, proceeding to
fragment is then brought anteriorly and laterally to improve coverage of
open reduction as needed
the hip before a bone block is placed to hold position. The bone graft is
At this time, there is insufficient evidence to make a clear judgment
typically secured using two wires. (Figure 25.8a and b)
as to which theory is correct. There is currently a UK wide multicentre
6 years to teenage – Triple pelvic osteotomy (Tonnis). After the age of 6 the
trial running which will hopefully answer this question in years to
pubic symphysis loses its elasticity. The ischium and pubis must be cut to
come. At this point I believe that I would offer a closed reduction, as we
allow the rotation to occur. Once position has been achieved, the fragment
know that delaying the time to surgery makes it significantly more likely
is secured using screws. (Figure 25.8c)
that open reduction surgery will be required. The risk of avascular
Teenage to adulthood – Periacetabular osteotomy (PAO). Once the
necrosis is low at this stage, and early reduction reduces the need for
triradiate cartilage has fused, it is possible to perform a PAO. This keeps
pelvic osteotomy in the future. Also, the risk of AVN following open
the posterior wall intact and keeps the point of rotation close to the
reduction surgery is higher at 13 months than closed reduction at
acetabulum allowing greater correction. Once position has been achieved,
4 months. I would not however, proceed to an open reduction until the age
the fragment is secured using screws. (Figure 25.8d)
of 13 months or the development of the ossific nucleus to protect the
blood supply. The prerequisites for performing a redirectional osteotomy
EXAMINER: How would do the approach for an open reduction? are that there is good movement of the joint, the deficiency can
CANDIDATE: With a fully consented patient under general anaesthesia, be addressed with the osteotomy and that the joint is congru-
I would position them supine on a radiolucent table with a sandbag under ent. Caution is advised to the surgeon performing femoral
the pelvis. Routine prep and drape with chlorhexidine. I would perform osteotomy at the same time as a re-directional osteotomy. By
an open adductor tenotomy primarily, dividing the tendons close to the covering an area of deficiency, the surgeon uncovers another
bone to reduce bleeding. Then I would perform a bikini line incision over aspect of the hip. For example, during open reduction surgery
the anterior superior iliac spine. I would dissect down to fascia and for DDH, excessive derotation of the femur with a Salter
carefully identify the interval between Sartorius and tensor fascia lata osteotomy may result in posterior dislocation of the hip.
028
(a) (b)
(d)
(c)
Figure 25.8 (a) Picture showing the cut required for a Salter pelvic osteotomy. (b) Picture showing the end position following a Salter osteotomy with bone graft
interposed. (c) Picture showing the location of the cuts for a triple pelvic osteotomy. (d) Picture showing the location of the cuts for a periacetabular osteotomy
Volume-reducing osteotomies neuromuscular conditions such as cerebral palsy, where

The volume-reducing osteotomies are also referred to as muscle imbalance causes the femoral head to gradually erode
posterior-hinging osteotomies. They are typically used in the superior acetabulum as the hip migrates. In order to
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028
(a) (b)
Figure 25.9 (a) Picture showing the location of the cut for a volume-reducing osteotomy. (b) Picture showing the position of the osteotomy following correction
with bone block in situ
does not require metal fixation, and rotation rather than

translation is more likely. Pemberton changes direction more
than volume.
Prerequisites for this type of osteotomy are that there is
good hip movement and the joint will be congruent. It must be
noted that the acetabulum is commonly still deficient laterally
due to erosion. These procedures commonly need to be asso-
ciated with a proximal femoral osteotomy to seat the hip
deeply in the acetabulum.
Salvage osteotomies
The salvage pelvic osteotomies are used when all else has
failed! These can be used in any condition at any age. These
osteotomies can be used when the femoral head is no longer
Figure 25.10 Picture of a Shelf pelvic osteotomy. Creates a bony shelf to cover contained fully in the acetabulum, or where the head is
the extruded part of the epiphysis misshapen leading to incongruency. The most common pro-
cedure is the Shelf osteotomy, where corticocancellous bone
graft forms a shelf over the lateral extent of the acetabulum
restore hip congruency, osteotomes are used to lever down to augment its surface. This allows a greater contact area and
the superior lip of the acetabulum and bone graft is used to so decreases contact pressures for the hip, and stabilises the
hold the position. Dega osteotomy changes volume by cut- hip by preventing any further subluxation or hinge
ting the outer cortex of the pelvis above the acetabulum abduction.
down to the triradiate cartilage and deflected downwards. The graft must be placed as close to the joint surface as
Pemberton osteotomy is similar to Salter's osteotomy but a possible. The hip capsule lies on the undersurface of the graft
small arc of the posterior column at the triradiate cartilage is and undergoes metaplasia to form fibrocartilage in relation to
left uncut and the acetabular roof is hinged on this arc to the forces put through it on weight-bearing. Unless the shelf is
allow anterior or anterolateral coverage. The obvious advan- placed just above the hip capsule then it will not allow the
tages include that it is more stable than a Salter osteotomy, weight-bearing surface to be extended.
028
(a) (b)
Figure 25.11 (a,b) Example AP and frog-leg lateral x-rays of a child with a right chronic mild SUFE demonstrating the features described above
Slipped upper femoral epiphysis (SUFE) :

Retroversion of the femoral neck is extremely common
in SUFE. This positioning of the neck increases sheer
Background forces across the physis
SUFE is one of the most significant pathologies affecting the : The physis is more vertically aligned in children
developing hip. There is a relative weakening of the perichon- sustaining SUFE, again increasing the sheer force
dral ring of the physis making it more susceptible to sheer : Obesity is a common risk factor as 5–6 times body
stress. This allows the metaphysis to slip superiorly, anteriorly weight affects the femoral head and neck during
and laterally. This deformity of the proximal femur can lead to jumping and running, causing repeated trauma to the
decreased range of motion, pain and is likely to be one of the already weakened physis
leading causes of cam-type impingement and development of Endocrine anomalies
early osteoarthitis1. : Children presenting with SUFE as a result of endocrine
The incidence is quoted as being 2–3/100 000 children; anomalies typically present much earlier and have a
however, this appears to be on the increase. This may be due greater incidence of bilateral slips
to our increased awareness of the condition or the increase in : Extremes of stature and hypogonadism may predispose
adolescent obesity. Boys are more commonly affected than to SUFE
girls (2 : 1), and the condition is thought to be bilateral in
25% to 60% of cases if you include pre-slips.
: Increased incidence with growth hormone
deficiency, GH therapy, hypothyroidism and
hyperparathyroidism
Aetiology : Chronic renal failure and Turner’s syndrome have an
There are two main groups of children that develop SUFE: association with SUFE
Teenagers and younger children with underlying endocrine : Deficiencies in sex hormones lead to an
abnormalities. For those presenting in teenage years, the increased incidence of SUFE as they improve the
underlying cause appears to be mechanical. For the younger integrity of the physis. After menarche girls are
children, the endocrine imbalance leads to weakening of the protected by their circulating oestrogen levels,
physis allowing the slip. Some of the main theories are dis- making slips very rare
cussed below:
Mechanical factors Diagnosis
: The perichondral ring of the proximal femoral physis SUFE classically affects children in and around adolescence
provides resistance to shearing stress. During the (girls: 11–13, boys: 14–16). The child commonly presents with
adolescent growth spurt it becomes stretched and loses groin or knee pain, or even with a painless limp on an exter-
its integrity nally rotated leg.
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028
Table 25.3 Management plan for acute treatment of SUFE
Acute Acute on chronic Chronic

Mild slip PIS Gentle reduction of acute portion, then PIS PIS
Moderate slip PIS Gentle reduction of acute portion, then PIS PIS
Severe slip ORIF – Timing controversial Gentle reduction of acute portion, if moderate PIS + corrective osteotomy
or mild PIS, is still severe then ORIF
There is a wide range of clinical findings depending

on the severity of the slip. For those with a mild slip, there
will probably be a mild limitation of internal rotation in
flexion in comparison to the other side. For severe slips,
there will be a leg length discrepancy with the affected leg
lying adducted and externally rotated. Movements will be
restricted with obligate external rotation with flexion of
the hip.
AP and frog-leg lateral x-rays should be obtained to
Figure 25.12 Picture showing the calculation of Southwick’s angle in a mild
identify and classify a SUFE. It should be noted that SUFE (left) and a moderate SUFE (right)
the positioning for the lateral view should be extremely
careful to prevent any further displacement of the slip. In
severe slips it will not be possible to get a lateral view; Children with stable slips are mobile and weight-bearing to
however, the diagnosis is clear on the AP x-ray in this some degree.
circumstance. The relevance of the stability of the slip is with regards to
Features seen on the AP pelvic x-ray in SUFEe (Figure AVN. Loder described 96% good results in those with stable
25.11a): slips, but reported 47% AVN occurring in those with unstable
Klein’s line (the line extending along the superior aspect of slips. More recent studies have confirmed that AVN is more
the femoral neck) should intersect the lateral portion of the common in unstable cases9.
epiphysis, but this intersection is reduced or absent in
SUFE Duration of symptoms
Shenton’s line is disrupted as the neck migrates superiorly SUFE may also be classified according to the duration of
Loss of the normal overlap of the femoral neck metaphysis symptoms:
and the ischium (Scham’s sign) Acute slips – <3 weeks duration of symptoms
Steel’s metaphyseal blanch sign is the density in the Acute on chronic – Acute exacerbation of symptoms
femoral neck caused by the overlap with the slipped following chronic slip
epiphysis Chronic slips – >3 weeks duration
Reduced epiphyseal height The relevance of the timeframe of the slip is with regards
The frog-leg lateral film is extremely helpful for diagnosis in to surgical management. Those with chronic slips will have
minor slips and for grading the severity of the slip. An example remodelling changes on the posterior and inferior border of
is shown in Figure 25.11b the femoral neck in an attempt to stabilise the head. As the
blood supply to the epiphysis travels along the posterior
Classification aspect of the neck, if the surgeon attempts to reduce a
SUFE can be classified according to stability (ability to chronic slip they can stretch the vessel over the callus leading
weight-bear), duration of symptoms and the severity of to AVN.
the slip.
Severity of slip
Loder classification SUFE is classified according to the severity of the slip using
The Loder classification divided slips into stable or unstable. Southwick’s angle. This is the angle between a line perpendicu-
A child with an unstable slip is said to be in so much pain lar to the epiphysis and the femoral neck line on a frog-leg
that they are unable to mobilize even with crutches. lateral view (Figure 25.12). Slips are defined as:
0
Mild – <30 difference from the other side
0 0
e
Moderate – 30 to 60 difference from the other side
Classic oral question: ‘What are the six radiographic features of 0
Severe – >60 difference from the other side
a SUFE?’
028
It is important to realize that the angle stated is in compari- Table 25.4 Reasons for and against prophylactic pinning of the normal hip
in unilateral SUFE
son to the contralateral side. In a normally aligned hip South-
wick’s angle should be 0°. However, it has been recognised in Reasons for prophylactic Reasons against
recent years that the majority of children sustaining a SUFE pinning prophylactic pinning
have got retroversion of the hips affecting this value. If both Slips are bilateral in 25–60% of Slips are unilateral in 40–75%
hips have sustained a SUFE, then it should be assumed that the cases of cases
normal hip angle would be 0°.
A contralateral slip may be an Risks of surgery include
Management unstable severe slip leading to infection, fracture, and
AVN chondrolysis
The goals of operative management in SUFE are to prevent
any further progression of the slip, avoid avascular necrosis The child is definitely
and provide the best long-term outcome possible for the child. pre-disposed to SUFE
If hip function is to be affected
Pinning-in-situ (PIS)
by a unilateral slip, preserving
For all minor or moderate slips, the general consensus is PIS function on the other side is
is the best treatment. We know from past experience that even more important
manipulation of the slip to provide an anatomical reduction Current complication rates
commonly resulted in AVN, particularly true in chronic following percutaneous screw
slips. This is because the posterior blood supply for the fixation are very low
epiphysis becomes tented over the remodeling changes from
Helps to minimize leg length
the SUFE and the vessels contract to accommodate their new
discrepancy
position. By forcing the epiphysis back to an anatomical
position the vessel is overstretched compromising the blood
supply. The exception to this rule is the acute on chronic slip.
Chronic severe slips
It is acceptable in this circumstance, with very gentle pos-
itioning, to reduce the head to the chronic slip position prior For the chronic severe slip the two options for fixation are
to PIS. PIS in association with a corrective osteotomy to improve
The modern technique for PIS is to use a single cannulated alignment, or open reduction and fixation. The majority of
screw placed as centrally as possible within the head on both surgeons prefer to perform PIS and then correct the align-
AP and lateral views. The surgeon must be extremely careful to ment through an osteotomy as this is felt to be the best
avoid penetration of the joint with the screw as this will lead compromise in terms of minimizing future complications
to chondrolysis. This complication has been substantially without causing AVN. There are, however, surgeons who
reduced since the technique of single screw fixation has been feel that open reduction is indicated in this group as they
adopted as opposed to multiple wires. will definitely progress to osteoarthritis without correction.
The screw typically requires an anterior entry point on This open reduction may either be performed through an
the femoral neck to allow a clear shot at the centre of the anterolateral approach with a trochanteric flip or by fully
epiphysis. This also provides protection to the vessels located dislocating the hip depending on the training and preference
at the inferoposterior aspect of the neck. Once adequate of the surgeon. If the surgeon chooses to perform an open
position of the guide wire has been achieved, a screw should reduction then it is imperative to shorten the neck and
be passed. The goal is to place five threads into the epiphysis remove any remodelling changes from the posterior surface
and maintain good hold on the metaphyseal fragment with of the neck. If this step is neglected then AVN is almost
multiple threads as well. This gives the lowest risk of implant certain to develop.
failure. Acute severe slips
Hips treated with PIS are protected against further
The acute severe slip is a different scenario entirely. In this
slippage with the minimum risk of developing AVN. They
circumstance there is no remodelling posteriorly to endanger
may still have problems long-term with femoroacetabular
the vasculature. There is general consensus that open reduc-
impingement, but this may be dealt with later as described
tion of these slips is advisable. The timing of surgery is contro-
below.
versial. Work from Southampton, amongst others, has
Reduction of severe slips suggested that the risk of AVN in acute severe slips is related
to the timing of surgery10. They found that the risk of AVN
The severe slip presents a management dilemma. With this
increased substantially past 24 hours of presentation. After this
level of displacement the patient will definitely go on to
stage they advised placing the child on traction for a few weeks
develop problems with impingement without intervention.
to convert the situation to a chronic severe slip and then
Unfortunately, the risk of AVN is also at its highest within
manage appropriately. This has obvious implications for the
this patient group.
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028
timing of tertiary referrals. The technique for open reduction correction vs the risk of AVN. With the advent of arthroscopic
is very similar to that for the chronic slip. osteoplasty, it seems to be more reasonable to perform an
intertrochanteric osteotomy to reduce the risk of AVN. This
Acute treatment of SUFE summary can reduce the deformity to the equivalent of a mild slip that
For all children with SUFE, the acute management is aimed at can be easily dealt with by osteoplasty.
reducing the risk of AVN and preventing further slippage.
Assessment must subsequently be made as to whether late Prognosis
procedures such as corrective osteotomies or osteoplasty will The risk of development of osteoarthritis of the hip is depend-
be required. ent on the shape and congruency of the joint at skeletal
maturity. Those developing AVN have got the worst prognosis
Management of the contralateral hip for obvious reasons. Recent publications have suggested the
There is controversy regarding the management of the con- residual changes from SUFE are one of the most common
tralateral hip in a unilateral SUFE. In young children or those causes of cam-type impingement leading to early osteoarth-
with endocrine disorders the answer is simple. The rate of ritis12. Therefore, management of SUFE should first and
bilaterality in these cases is very high and so the other hip foremost attempt to minimize deformity and prevent AVN.
should be prophylactically stabilised. Long-term management should attempt to prevent femoroa-
For older children without an underlying condition the cetabular impingement to improve the longevity of the hip.
decision is harder. The reasons for and against prophylactic
pinning are shown in Table 25.4.
There is increasing evidence that prophylactic fixation is Examination corner
worthwhile. Maclean and Reddy published their results of Paeds oral 1: Severe unstable SUFE
unilateral SUFE management in JBJS in 200611. For those Outline your management, including AVN rates and types
undergoing prophylactic pinning of the contralateral hip of corrective osteotomy
there were no complications. For those left unstabilised, 25% Paeds oral 2: SUFE: Radiographic spot diagnosis
went on to develop another slip despite careful monitoring in Predisposition
clinic. Some slips were unstable and one child went on to Management of severe grade III slip
develop AVN. Fish and Dunn osteotomies: Examiner wanted to hear the
The author’s viewpoint is that you have already identified a word ‘shortening’. Subcapital osteotomy without
shortening carries an unacceptably high risk of AVN owing
child who is predisposed to SUFE. Prophylactic single screw
to stretching of the contracted posterior vessels as the
fixation at the time of surgery for the other hip is quick, safe
head is reduced on the femoral neck
and effective with very few complications. If that child pro-
gressed to develop an acute severe slip of their other hip with Paeds oral 3: Radiograph of severe SUFE
subsequent AVN then that situation was avoidable. Classification of slips, particularly the Loder classification
system
Late procedures Incidence
The two main late treatment plans to consider for SUFE are Management of severe slips: Pin in situ vs osteotomy
osteoplasty and corrective proximal femoral osteotomy. Discussion about various osteotomies and complications
Osteoplasty can be performed either open or arthrosco- of each (higher incidence of AVN in more proximal
pically. Shaving the extra bone of the metaphyseal hump osteotomies such as Dunn compared to the Southwick
prevents cam-type impingement as the hip is flexed and biplanar osteotomy)
abducted. This procedure can improve the range of motion, EXAMINER: Do you know any papers in the last year about
reduce pain and potentially slow the progression to osteo- management of severe SUFE?
arthritis. This is particularly helpful for mild and moderate CANDIDATE: I mentioned a review paper about management of
slips. SUFE13. This led on to discussion of another paper from
Corrective proximal femoral osteotomy can be used to Southampton concerning the timing of reduction and
minimize residual deformity following SUFE. The aim is to stabilisation of an acute, unstable SUFE14. The examiner knew
realign the proximal femur to improve the range of movement both papers very well and we discussed the second paper in a fair
and prevent impingement and progression to osteoarthritis. amount of detail.
Multiple osteotomies have been described for correction of
the deformity. The location of the osteotomy ranges from the Paeds oral 4: Lateral radiograph of SUFE with history of sudden
intertrochanteric region to the physis itself. The closer the onset of knee pain
osteotomy comes to the physis the greater the possible correc- EXAMINER:
tion that can be achieved. Unfortunately, the closer that the
What is the diagnosis?
surgery is performed to the physis the greater is the risk of What will you find on clinical examination?
AVN. Again the surgeon is forced to balance the power of
028
Figure 25.13 Radiograph mild SUFE Figure 25.14 Frog-leg lateral x-ray of both hips
What radiographic changes are present to indicate this as being

comparison to the other side. If we draw Klein’s line along the
an acute on chronic slip?
superior border of the neck we can see that it runs through the
What will you do?
epiphysis on the left hip, but just misses it on the right side. This is
What complications can occur?
highly suggestive of a SUFE, I would like to see a frog-leg lateral to
What is the incidence of chondrolysis?
be sure.
EXAMINER: Would you pin this boy’s other hip? (It looked normal on The candidate is shown a frog leg lateral x-ray of both hips from
the radiograph.) the same child showing displacement of the right epiphysis
CANDIDATE: No. But I will follow up with serial radiographs into (Figure 25.14).
maturity with advice to come back if there is knee or hip pain. EXAMINER: OK, here is the frog-leg lateral view.
EXAMINER: What does the recent literature say on this? CANDIDATE: Well it appears that there is displacement of the
CANDIDATE: There are papers that advocate fixing the normal side epiphysis on the right in comparison to the left. It is somewhat
prophylactically. I would refrain except in situations of clinical difficult to appreciate clearly because there has already been
need and (as he seemed to like the idea of prophylactic pinning, remodelling changes. I would say that this is a chronic mild SUFE.
I added) in predisposed individuals. EXAMINER: How would you classify a SUFE?
EXAMINER: What are the predisposing conditions? CANDIDATE: There are a number of classification systems available.
Paeds oral 5: SUFE: Aetiology, clinical presentation and management The classification based on timing divides slips in to acute, acute
on chronic and chronic. Acute injuries having occurred within a
Complications few weeks without any remodelling having occurred.
Outline the principles of single AO screw fixation and how
Another classification is based on the severity of the slip.
you would do it
This is based on the Southwick angle. That is the line
Would you reduce the slip or fix in situ?
Would you take out the screw – What does the literature say? perpendicular to the physis in relation to the line of the neck on
the frog-leg lateral. The classification is based on the difference in
Paeds oral 5 comparison to the other side assuming that hip is unaffected. If
The candidate is shown an x-ray of a very mild SUFE of the right the difference is <30° then the slip is mild, 30–50° is moderate
hip (Figure 25.13). and >50° is severe.
EXAMINER: This is the x-ray of an 11-year-old girl who presented to The Loder classification has also been devised referring to the
your colleagues in the sports medicine clinic with an 8-month stability of the slip. If they are able to weight bear then the slip is
history of groin pain. They were concerned that there may be deemed stable and has a much better prognosis. If they are in so
something more going on and so took this pelvic x-ray. What do much pain that they are unable to mobilize even with crutches,
you see? then it is unstable carrying a significant risk of AVN.
CANDIDATE: Well, this is an AP pelvic x-ray of an 11-year-old girl. The overall classification of SUFE is based on a combination of
There is slight asymmetry of the hips, the right side is not these systems. This would make this slip a chronic, mild, stable
completely aligned and appears to have lost some height in SUFE.
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028
Figure 25.16 Frog-leg lateral radiograph pelvis bilateral screws in situ
predisposed. If she develops another mild, chronic SUFE then she

will likely do very well with a PIS as she had on this side. If,
Figure 25.15 AP radiograph pelvis however, she gets an acute severe SUFE then we know that her
risk of AVN is going to be in the region of 50% regardless of what
we do. With modern techniques of percutaneous single screw
placement complication rates are extremely low. They published
results of prophylactic pinning for SUFE from Nottingham and
showed no serious complications.
As such, I would discuss this with the family and advise
on prophylactic pinning. If they had very strong feelings
against it, then I would just pin the right hip, otherwise I would
pin both.
The candidate is shown an AP and frog-leg lateral of the

same child with screws in both hips (Figures 25.15 and 25.16).
EXAMINER: Well, it seems that the surgeon treating this child agreed
with you. Here are the postoperative x-rays. What do you think
about the quality of fixation?
CANDIDATE: Both screws are located centrally on both the AP and
lateral and are contained within the head. The right-sided screw is
closer to the joint than the left, but is clearly within the head.
Figure 25.17 Radiograph severe acute SUFE EXAMINER: Why do you think that is?
CANDIDATE: In terms of fixation, you ideally want to have five
threads across the physis to get a good fix. This can sometimes be
more challenging on the slipped side.
EXAMINER: What would be your management of this child?
EXAMINER: So, what would you do postoperatively?
CANDIDATE: I would take a full history and examine the patient.
CANDIDATE: Well the x-rays are very good. I would allow them to
I would want to exclude underlying causes such as hormonal
mobilize full weight-bearing on the left and partial weight-
imbalances; however, at this age it would be relatively unlikely.
bearing on the right for 6 weeks to allow the physis to fuse and
I would explain the diagnosis to the family and the child and
then place no further restrictions on her.
advise on pinning-in-situ for the right hip and I would advise
pinning the left hip prophylactically.
EXAMINER: What would be your reasoning for pinning the The candidate is shown an x-ray of a severe acute SUFE in a
other hip? 12 year old (Figure 25.17).
CANDIDATE: We don’t know exactly why children get SUFE, but we EXAMINER: This young man is 12 years old. He was playing rugby
do know that retroversion of the hip is a risk factor. It is thought when he felt something snap in his leg. He was brought
to be bilateral in up to 40% of cases. By the fact that this child has immediately to ED and this x-ray was taken. Tell me what you
presented with a right sided SUFE then you know she is think it shows (Figure 25.17).
028
but stretched, and reducing it at this stage may avoid AVN. If it is

CANDIDATE: This is an AP pelvic x-ray of a 12-year-old boy. There is
longer than this, then the healing reaction has started and you
a severe SUFE on the left hip with the epiphysis lying posterior
will be causing a second hit which could kill the blood supply.
and inferior to the metaphysis. The right hip looks to be OK on
Those ones I would put on traction and operate when it was
this film. Is there any further imaging?
chronic.
EXAMINER: No, he was in too much pain to allow repositioning of
EXAMINER: And what would your management of a chronic severe
the limb.
SUFE be?
CANDIDATE: Were there any preceding symptoms from the hip?
CANDIDATE: I believe that I would pin-in-situ and do a corrective
EXAMINER: Not that he has reported. What would you like to do
osteotomy in the intertrochanteric region. If there were any
with this young man?
further issues with impingement then we could arrange
CANDIDATE: Well, this is an extremely rare and serious injury. As
arthroscopic cheilectomy in the future.
I am not a paediatric orthopaedic surgeon I would refer him on to
EXAMINER: OK.
one of my colleagues with more experience. If there was no-one
appropriate in house then I would refer to the regional paediatric
centre.
EXAMINER: OK, let’s assume that you are now the paeds consultant Legg-Calvé-Perthes’ disease
in the regional centre – What are you going to do? Background
CANDIDATE: I would want him transferring in a blue light Legg–Calvé–Perthes’ disease was first recognised in 1909 by
ambulance as a matter of urgency. Once he has arrived I would Waldenstrom, who wrongly ascribed its cause to tuberculosis
assess him clinically and get an urgent CT of the hip to clarify if it of the hip. In 1910 it was independently recognised as being
is definitely acute, or whether there is a chronic component. Then caused by avascular necrosis by Legg (USA), Calvé (France)
I would operate as soon as possible. and Perthes (Germany). It is commonly referred to as Perthes’
EXAMINER: What procedure would you do? disease for brevity and we will use this term throughout this
CANDIDATE: I think that I would advise an open reduction, chapter.
shortening through the physis and screw fixation. I would not The incidence of Perthes’ disease has been falling over
dislocate the hip as I have no experience in doing this and know recent years both within the UK and globally. Currently we
that it can cause significant problems unless you have been believe the incidence to be 1.5–4.0/100 000 live births, with a
trained to do so. If there were any signs of chronic change then prevalence of 6–12/100 000 children. This level has decreased
I would carefully remove the posterior bone to prevent kinking of in the UK by 50% from 1990 to 200815.
the vessels during reduction. I would also advise on prophylactic The male : female ratio is 6 : 1, and the most common age
pinning of the other hip. of presentation is 3–7 years. The disease is bilateral in 15% of
EXAMINER: What would you tell the family regarding prognosis cases; however, it is never completely synchronous or symmet-
from this injury? rical. If both hips are identically involved then the surgeon
CANDIDATE: I would say that it is a very significant injury. From the should seek an alternative diagnosis such as multiple epiphy-
injury itself, the risk of avascular necrosis is anything up to 50% seal dysplasia.
regardless of treatment. Reducing it quickly and effectively is the There is wide variation in incidence geographically, higher
best chance of avoiding this. In terms of AVN, we will have to levels being associated with social deprivation. There is also a
watch closely as it can take anything up to 18 months to present racial component with white children being most commonly
and we will only know the outcome after it has healed. affected16. The occurrence of Perthes’ is affected by latitude,
EXAMINER: Would your management be altered in any way if the with an increase in incidence of 1.44/100 000 births for each
injury was 3 days old when it was referred to you? 10° separation from the equator16. The lowest levels are
CANDIDATE: I know that there has been a paper published from reported in equatorial regions with the highest incidence being
Southampton suggesting that we should delay surgery if seen in Northern Europe15.
presentation is after 24 hours. They suggest that surgery should There is a significantly increased incidence of genitourinary
be performed within the first 24 hours or the child should be and inguinal anomalies in children with Perthes’ disease. In
placed on traction for a few weeks to convert the injury to a particular hypospadias, undescended testes and inguinal hernia
chronic severe SUFE. They suggest that this reduces your were frequently seen. Asthma is an independent risk factor for
incidence of AVN. Perthes’ disease even when steroid use has been accounted for.
EXAMINER: Is that something that you believe? Generalized behavioural disorders have an association, although
CANDIDATE: I think that the numbers of these children are so small
attention deficit disorder has not been shown to be linked17.
that it is difficult to really know. My inclination is that if they
presented to me within the first 2–3 days then I would operate.
Aetiology
This is on the basis that the blood supply may be just hanging on Perthes’ is an idiopathic avascular necrosis of the femoral head
in childhood. Many risk factors have been identified over the
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028
years; however, none of these account for the occurrence of Synovial inflammation – Leading to widened joint space on
disease in its entirety. The main theories are highlighted below: x-ray
Genetic inheritance – It has been suggested that there is a Articular cartilage overgrowth – As cartilage continues to
genetic inheritance for Perthes’ disease. This is difficult to get nutrition from the synovial fluid even though the bone
establish due to confounding factors, such as social has lost its blood supply
deprivation, smoking and diet. Also, there are a number of Physeal disorganisation – Columns of cells become
conditions that mimic Perthes’ disease such as multiple disorganized and do not undergo normal calcification
epiphyseal dysplasia (MED). All of these conditions have a Epiphysis – There is initial necrosis and subchondral
clear genetic inheritance potentially biasing results fracture formation. Sclerosis is followed by fragmentation
Thrombophilia – Thrombophilia has been suggested as a as the head revascularizes and bone is resorbed. There is
contributory factor. Multiple studies have shown an delayed ossification with bone healing occurring months
association, whereas many other papers have not after fragmentation
demonstrated any link. This area remains controversial18 Metaphyseal cysts – These are actually disorganized groups
Vascular deficiency – Recurrent infarction as opposed to of cells extending from the physis into the metaphysis
one thrombotic event appears to be the underlying cause of
Perthes’ as seen in animal studies. Abnormalities of the Staging
hip vasculature both in vessel calibre and function have
Perthes’ disease runs its course over a 2–3-year period. Wal-
been identified in recent work adding further evidence
denstrom described the stages of disease as follows:
to this theory19
Evolutionary period
Environmental factors – There is a clear link to low social
class and passive smoking15. This can partially account for : A – Initial stage – Dense epiphysis, irregular margin
the urban clustering seen in epidemiological studies. There : B – Fragmentation stage – Epiphysis is flattened and
are also links to dietary deficiencies, particularly vitamin divided
D deficiency Healing period – Epiphysis becomes homogenous,
Endocrine anomalies – Children with Perthes’ have a evidence of recalcification
delayed bone age, and studies have shown reduced levels of Growing period – Normal growth and ossification of
somatomedins and abnormalities of the insulin-like growth deformed head
factor-1 pathway18 Definitive period – Permanent residual features at skeletal
Other factors – There have been suggestions that Perthes’ is maturity
caused by repeated microtrauma, inflammatory processes This was modified and simplified by the Elizabethtown classi-
and subtle type II collagen deficiencies18 fication in to four stages:
The prevailing opinion is that Perthes’ is a multifactorial Stage I – Initial stage
disease with genetic and environmental factors playing a Stage II – Fragmentation stage
role18. The model is that of the susceptible child undergoing Stage III – Healing phase
a particular insult at a key stage of development.
Stage IV – Definitive stage
Clinical presentation Classification

The child may present with ongoing or recurrent pain in the Salter and Thompson Classification20
groin or the knee. Frequently they are brought with a persist-
The Salter and Thompson classification is used in the initial
ent painless limp.
phase of Perthes’ disease. This system is based on the extent of
On examination, the child is usually short for their age and
the subchondral fracture line on the frog-leg lateral film:
very active. In early stages there may be nothing to see clinic-
ally, or there may be a slight limitation of internal rotation in Group A – <50% head involvement
flexion. As the disease progresses, there may be a fixed flexion Group B – >50% head involvement
deformity, restricted abduction and internal rotation. You may This classification gives the clinician an indication as to the
see obligate abduction and external rotation as the hip is flexed. severity of the disease. Unfortunately it only applies to the
Although 15% of cases are bilateral, it is rare to present with initial stage, and the subchondral fracture line is seen in fewer
both hips being acutely affected at the same time. than 50% of cases (Figure 25.18).
Pathology Catterall classification21

Several pathological findings have been shown in the hip in The Catterall classification is more complicated and divides
Perthes’ disease related to the avascular insult and disordered patients in to four groups based on severity of head involve-
growth: ment as seen on the AP and lateral x-ray of the hip:
028
not been shown to have a good inter-rater reliability23 and

adds little to the prognostic benefit of the system.
Determining prognosis in childhood

‘Head at risk’ signs
Catterall described both clinical and radiological ‘head at risk’
signs to warn the clinician of children likely to have a poor
outcome.
Clinical signs
:
Obesity
:
Decreased range of motion or recurrent admissions
for pain
: Adduction contracture in extension
: Flexion with abduction
Figure 25.18 Frog-leg lateral x-ray showing a subchondral fracture line in Radiological signs
early Perthes’ disease
: Calcification lateral to the epiphysis
: Metaphyseal cysts
Group 1 – Anterior epiphyseal involvement, no collapse, : Increased medial clear space (signalling lateral
no physeal or metaphyseal involvement subluxation)
Group 2 – More extensive anterior involvement with some : Horizontal physis
collapse centrally, pillars intact medially and laterally
: Gage sign (lucent v-shaped defect in the lateral aspect of
Group 3 – Near whole head involvement, ‘head within a the physis)
head’ appearance. Central collapse with very small pillars
medially and laterally intact. Metaphyseal involvement
extensive with broad neck Age and severity
Group 4 – Whole head involvement and collapse. Physeal The age of the child is extremely important in Perthes’ disease,
and metaphyseal involvement possibly due to the remodelling potential of the hip. Catterall
With this classification system, the greater the proportion of identified three age groups:
head involved the worse the prognosis. It also makes reference
<6 years – Will typically do well unless there is severe
to the fact that metaphyseal and physeal involvement indicate a
involvement of the head
more severe disease process and impact on the outcome.
6 – 8 years – Will typically benefit from containment
surgery unless very mild head involvement
Herring Lateral Pillar Classification22
>8 years – Will typically do badly without surgery unless
The Herring Lateral Pillar classification is used during the late very minimal head involvement. Those with Herring
fragmentation phase of the disease. It is based on the level of C hips are thought to do so badly that it is questioned
collapse of the lateral pillar of the femoral epiphysis. This is whether surgery is of benefit at all in this age group
defined as the lateral 15–30% of the head as seen on a true AP
x-ray of the hip. They described three groups: Which children benefit from early surgery?
Group A – No involvement There are three main areas to consider when deciding whether
Group B – >50% height maintained in comparison to the or not a child would benefit from surgical containment: The
other side clinical picture, the age of the child and the degree of head
Group C – <50% height maintained in comparison to the involvement.
other side The clinical picture is extremely important. In a child with
The relevance of the lateral pillar is in relation to the likeli- multiple head at risk signs, recurrent pain and restricted range
hood of containment of the hip. If it remains intact the of motion, the surgeon should be concerned even if the child is
lateral pillar acts as a buttress preventing subluxation of young. This is the first factor to be considered.
the head. Therefore, extensive lateral pillar involvement After the clinical severity, the next important factor will be
makes it much more likely that containment procedures will the age of the child. Those under the age of 6 will only do badly
be required. if the clinical course is very severe or if there is extensive head
The classification was modified to include a B/C border involvement. Those over the age of 8 will do poorly with much
group comprising a very narrow, poorly ossified lateral pillar milder disease. Therefore, with increasing age the threshold for
or those with exactly 50% loss of height. This modification has intervention should drop.
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028
It is vital to maintain the range of motion to keep the

sphericity and congruency of the joint. Physiotherapy can be
helpful where there is some limitation of movement. In extreme
cases, children have been admitted for periods of abduction
traction to try to reduce contractures. If a child presents with
decreased range of motion and needs repeated physiotherapy
then that is a warning that the disease course is severe and
consideration should be given to surgical intervention.
In previous years abduction bracing has been used to try to
provide external containment of the hip. These braces have
been shown to be ineffective, not actually preventing adduction
of the hip. Studies comparing the outcome of bracing vs
surgical containment have shown that in those children with
Figure 25.19 Determining prognosis in Perthes’ disease a Herring Grade C hip, surgery achieved better results.
Medical intervention
In Perthes’ disease there is a significant mismatch between bone
The last factor to consider is the level of head involvement.
resorption and formation. When revascularization occurs there
Even if the child is older, if there is only minor involvement of
is florid osteoclastic activity leading to weakening and fragmen-
the head then they should do well. For those with total head
tation of the head. There is a notable delay before the osteoblas-
involvement, particularly with greater involvement of the lat-
tic activity occurs to heal and recalcify the head. This has led to
eral pillar, the risk of future arthritis is significant.
significant interest in medical interventions which can decrease
It is extremely difficult in Perthes’ disease to decide on the
osteoclastic activity and increase osteoblastic function15,18.
value of surgical intervention. For containment surgery, this
In recent years, the use of bisphosphonates has increased
should be performed before the head collapses and so the
for many orthopaedic conditions including Osteogenesis
surgeon is really making an educated guess as to the likely
Imperfecta. These drugs reduce osteoclastic resorption of bone
outcome. Each patient is unique and so the decision for sur-
and theoretically could prevent collapse of the femoral head.
gery must be considered individually for each case. The author
Early animal studies show very promising results in preventing
uses the system below as a guide. Each of the three factors
femoral head collapse. There are concerns relating to the
would be rated from good on the left to bad on the right.
systemic use of bisphosphonates on the growing skeleton,
Greatest importance is given to the clinical presentation, how-
intra-articular injection provides good results whilst limiting
ever, if any factor is ranked on the right hand side of the
the systemic effect. Further work is needed before clinical
diagram then surgery should be considered.
recommendations can be made18.
Other areas of promise are with the use of osteoprotegrin,
Management BMP-2 and BMP-7. Osteoprotegrin works in a similar manner
The goal of treatment in Perthes’ disease is to obtain and maintain to bisphosphonates except that it reduces osteoclast formation
a good range of movement of the hip, and to maintain contain- as well as function. This appears to make it an even more
ment of the femoral head in the acetabulum18. Due to the healing effective drug than bisphosphonates in the early testing stages18.
capacity and the remodelling potential of the juvenile hip, even if BMP-2 and BMP-7 are bone growth factors which have
the head undergoes collapse it can still retain congruency if the been commonly employed in the adult situation in order to try
head is contained and mobile. There are non-operative, medical to stimulate bone healing. This strategy is aimed at increasing
and surgical means to try to achieve these goals. the osteoblastic function to get earlier healing and reduce the
risk of femoral head collapse. Early results suggests that this
Non-operative management may be effective, but there is a definite risk of heterotopic
Non-operative measures include activity modification and ossification with use around the hip18.
physiotherapy to maintain range of motion. Surgeons differ in
their opinion regarding the effect of physical activity in the Surgical intervention
outcome for Perthes’ disease. Some feel that all impact activities Surgical intervention in Perthes’ disease can be divided into
should be restricted to prevent any unnecessary collapse of the preventive, remedial and salvage procedures15. These proced-
head, whereas others feel that this is unlikely to make a difference. ures are discussed below.
Bearing in mind that this process spans years in highly active
small children, even if you advise no impact it is extremely Preventive (containment) procedures
unlikely that this will be achieved! There is no evidence that Preventive, or containment surgery, must be performed early
activity restriction prevents femoral head collapse15,18, and it is in the course of the disease if it is to be effective15. These
worth noting that head collapse has been seen in children under- procedures are aimed at preventing subluxation of the femoral
going arthrodiastasis without any weight-bearing. head to maintain a congruent joint. The most commonly used
028
Table 25.5 Advantages and disadvantages of commonly used containment techniques
Procedure Advantages Disadvantages

Proximal femoral varus Internal fixation Limits abduction reducing range of movement
osteotomy Avoids any pelvic surgery Shortens the leg
Effective procedure for containment of Alters proximal femoral anatomy for future
the head arthroplasty
Acetabular augmentation Internal fixation Pelvic surgery where acetabulum is largely
procedures Avoids alteration of femoral anatomy unaffected
Maintains leg length Does not attempt to maintain femoral head
Does not limit abduction sphericity
Arthrodiastasis Minimally invasive External fixation
Does not affect leg length Pin site infections
Does not affect anatomy of hip Stiffness
Potentially avoid collapse completely Psychological issues
procedures are proximal femoral osteotomy, shelf osteotomy

and arthrodiastasis. The advantages and disadvantages of these
techniques are shown in Table 25.5.
Proximal femoral varus osteotomy is the most commonly
performed containment procedure for Perthes’ disease.
Approximately 10–15° of varus is required to seat the femoral
head more deeply in the socket and contain the lateral pillar18.
In these circumstances, even if the head partially collapses it is
likely that the joint will remain largely congruent improving
outcome.
Some surgeons prefer to perform a Shelf procedure to
augment the acetabulum. This achieves surgical containment
by preventing subluxation and hinge abduction. The increased
surface area reduces contact pressures by distributing load.
More recently arthrodiastasis has gained popularity. This is
the placement of a hinged external fixator across the hip joint
providing a small amount of distraction. This system will allow
the hip to flex and the child to weight bear, but it prevents
abduction of the hip. The concept of this system is to com-
pletely off-load the hip to prevent collapse of the femoral head.
Early results have shown this to be effective; however, in
extreme cases the head can collapse regardless of weight- Figure 25.20 Treatment algorithm for surgical intervention in children with
bearing due to structural instability. Perthes’ disease
Remedial procedures An alternative solution in these cases is to perform an

Remedial procedures are those attempting to limit the impact abduction extension proximal femoral osteotomy. The infer-
of the disease after the opportunity for containment has oposterior aspect of the femoral head is commonly spared in
passed15. The goal of these procedures is to increase range of Perthes’ and usually maintains its sphericity. By performing an
motion, limit pain, restore congruency as much as possible abduction and extension osteotomy the surgeon brings this
and slow the progression to osteoarthritis. portion of the head in to the weight-bearing region and clears
For those children with femoral head collapse, lateral sub- the extruded fragment. This improves range of motion and
luxation and hinge abduction, cheilectomy can be very helpful. prevents hinge abduction, and may be augmented with chei-
The subluxed fragment of head prevents full hip movement lectomy if desired.
and makes containment surgery impossible. By removing this For children who develop a mushroom-shaped femoral
fragment (open or arthroscopically) the sphericity of the head head, acetabular augmentation is a good option. This allows
can be restored allowing improved movement. This can be the hip to be contained, prevents hinge abduction and
followed by containment procedures if desired. increases contact area reducing contact pressures.
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Salvage procedures EXAMINER: How do you manage Perthes’ disease?

For those children who have had Perthes’ disease and the head
CANDIDATE: My initial management of Perthes’ disease would be
has healed in a non-spherical shape, salvage procedures may be
conservative – Analgesia and NSAIDs for pain relief. Regular
considered. These are hip preservation techniques aimed at
review in clinic. Admission to hospital for bed rest and traction.
improving range of motion, preventing femoroacetabular
Physiotherapy. Avoidance of activities that provoke pain.
impingement and subsequent progression to osteoarthritis.
EXAMINER: If the condition is not settling down, what else would
These procedures include osteoplasty, femoral neck recon-
you do if pain is severe and movement is grossly restricted?
struction and redirectional pelvic osteotomies.
Recent papers suggest that arthroscopic osteoplasty for CANDIDATE: I would perform an arthrogram.
Perthes’ disease is a useful procedure with good results24. It EXAMINER: This is what we did; what can you see?
is worth noting that 39% of patients needed total hip arthro- CANDIDATE: This shows that there has been some lateral
plasty (THA) 8 years following hip preservation procedures, subluxation of the femoral head with pooling of the dye medially.
and one third of patients requiring THA for Perthes’ have had EXAMINER: So how will you proceed?
one of these techniques in the past15. Modern techniques may CANDIDATE: If the patient is still having a lot of flare-ups and pain
improve these statistics and we will have to await long-term I would consider either a femoral derotation varising osteotomy or
outcome studies to confirm this. pelvic osteotomy. But it is very rare to need to do this. Most children
with Perthes’ disease can be managed with supervised neglect.
Prognosis EXAMINER: How many hospital admissions would it take before you
The long-term prognosis for these children is based on the would proceed towards surgery?
morphology of the hip at skeletal maturity. The Stulberg clas- CANDIDATE: About three.
sification looked at the shape of the hip at maturity and EXAMINER: Humph, I would probably have a lower threshold for
described five groups25: surgery.
Group I and II – Spherical congruent hips (normal or near
normal) Paeds oral 2: Similar AP radiograph of the pelvis demonstrating
severe Perthes’ disease at the left hip
Group III – Aspherical congruent hips (flattened head but
still round enough to allow good movement) EXAMINER: Yes, this patient has severe Perthes’ disease with gross
Group IV and V – Aspherical non-congruent hips (flat flattening of the femoral head. You mentioned Gage’s sign being
head with or without abnormalities of the acetabulum) a radiolucency of the lateral edge of the epiphysis, growth plate
For those children where the hip remained spherical and con- and metaphysis. What are the other Catterall’s head-at-risk signs?
gruent (groups I and II), they did not develop early arthritis. CANDIDATE: We can see also see metaphyseal cysts, lateral
For those with aspherical congruent joints (group III), they subluxation of the femoral head, a horizontal growth plate and
developed mild to moderate arthritis in late adulthood. For calcification of the lateral epiphysis on this radiograph, indicating
patients with aspherical non-congruent hips (groups IV and that the patient has severe Perthes’ disease.
V), they typically developed severe arthritis before the age of 50. EXAMINER: What clinical features are associated with a poor
This is why the management of Perthes’ disease is aimed at prognosis?
maintaining a congruent joint. By containing the hip it has the CANDIDATE: A patient older than 6, who is female and has a marked
best chance of remodelling to become spherical. Even if this is restriction of hip movements with recurrent episodes of stiffness.
not achieved, we know that as long as the hip remains congru- EXAMINER: So how do you treat Perthes’ disease?
ent then the survival of the hip is not severely impaired. It is CANDIDATE: I would manage Perthes’ disease initially
only in those hips where the joint has lost congruency that conservatively, with so-called supervised neglect. Analgesia,
degeneration is rapid and inevitable. regular follow-up in clinic, physiotherapy and hospital admission
for severe exacerbations. In only very severe cases would
Examination corner I consider surgery, such as a femoral derotation osteotomy or
pelvic osteotomy.
Paeds oral 1: AP radiograph of the pelvis with severe (obvious)
Perthes’ disease
A spot diagnosis oral (learn to recognise pattern radiographs of The management of Perthes’ disease is somewhat con-
particular conditions). Testing a candidate’s ability to articulate troversial. The literature is rather confusing as different
the radiographic features of Perthes’ disease. authors have different indications for surgical treatment.
In fact, some surgeons are sceptical about whether sur-
CANDIDATE: This is an AP radiograph of a pelvis in a child. The most
gical containment works at all. Other surgeons are much
obvious features are at the right hip. There is fragmentation and
more aggressive. Walk the middle ground and stay away
lateral displacement of the femoral head, concentric widening of
from controversy unless you know the subject very well.
the joint space, areas of increased sclerosis and metaphyseal
You are there to pass the examination, not get the gold
cysts. The appearances are very suggestive of Perthes’ disease.
028
disease and the likely prognosis dependent on the extent of involvement

medal. Remember 50% of patients do well without
of the lateral pillar of the femoral head.
treatment and the majority of the remaining 50% will
do well into their fifth decade without treatment. A: No involvement of the lateral pillar
B: <50% loss of height in comparison to the other hip
Paeds oral 3
C: >50% loss of height in comparison to the other hip
Perthes’ disease: Aetiology, classification and prognosis.
EXAMINER: How would you grade this child’s x-ray?
Paeds oral 4: Radiograph of advanced Perthes’ disease of the hip CANDIDATE: I believe that this would be a group C hip with >50% loss of
Diagnosis height. It is worth noting that this child also shows some of the ‘head at
Classifications: Catterall, Salter–Thompson, Herring risk’ signs. The physis looks horizontal, there are clearly metaphyseal cysts
Prognostic factors and there is a suggestion that there may be some calcification appearing
How would ‘you’ manage this patient? lateral to the physis.
EXAMINER: What would you tell the family regarding the prognosis and
your management from here on?
Paeds oral 4 CANDIDATE: I would tell the family that younger patients with Perthes’
The examiner shows the candidate a pelvic x-ray of a 4-year-old have a better prognosis than older children. Being 4, he would fit in to the
child with fragmentation of the whole of the right femoral best outcome group. However, even at this young age, some children do
epiphysis. go on to get bad results. Bearing in mind that he has full head
involvement, is a C on the lateral pillar classification and also has some
EXAMINER: This is the x-ray of a 4-year-old boy who presented with a
head at risk signs, I would be concerned about this young man. In the first
limp. What can you tell me about the x-ray?
instance I would get him in as soon as possible to perform and EUA and
CANDIDATE: This is an AP projection of the pelvis, on which the most
arthrogram to establish the shape of the femoral head and whether or not
obvious abnormality is fragmentation of the right hip. The hip itself
it could be easily contained. If this showed that the head was containable
appears to be well located and the acetabulum appears normal. I would
and there was a good range of movement, then I would suggest a varising
want to exclude an infective process, but I think that the most likely
proximal femoral osteotomy.
diagnosis would be Perthes’ disease.
EXAMINER: Why do you think containment surgery would be necessary
EXAMINER: That is right, it is Perthes’. What can you tell me about the
for this child?
aetiology of Perthes’ disease?
CANDIDATE: As I said, the fact that he is young goes in his favour, but
CANDIDATE: By definition it is an idiopathic avascular necrosis, so we
does not mean that he cannot get a bad result. He has extensive head
don’t really know! It is clearly a multifactorial process, with links to the
involvement and collapse of the lateral pillar. That is prognostic that the
following risk factors:
head will likely collapse and sublux out of the joint because it has lost its
Gender – Boys are affected about six times more frequently than girls lateral buttress. He is still in the early stages of the disease and so
Low socioeconomic class – There is a clear link to living in more containment surgery makes it more likely that the head will reform to be
deprived areas, being urban rather than rural, but particularly social congruent within the acetabulum, giving him the best possible chance of
class 4 and 5. It is not clear if this is due to other factors such as dietary avoiding THR in the future. If you wait until the head collapses further
deficiency, passive smoking, etc. or is an independent risk factor and subluxes then you have missed that window.
Passive smoking – This is thought to increase risk by anything up to EXAMINER: OK, that sounds reasonable. Let’s move on.
five times
The candidate is shown a pelvic x-ray with bilateral symmetrical
Coagulation defects – Although these children do not have an
established thrombotic tendency, there have been many studies
hip pathology. Both femoral heads are flattened with a slightly
showing them to have traits, or borderline deficiencies. Other studies
widened metaphysis.
have failed to show this link. It is likely that there is some kind of EXAMINER: Take a look at this x-ray and tell me what you see.
intermittent thrombotic tendency in relation to external triggers CANDIDATE: This is an AP pelvic x-ray of a child of approximately 6 years
which gives repetitive ischaemia. Very controversial!! of age. The most obvious abnormality is in the shape of both proximal
Vascularity of the femoral head – There has been work showing that femurs. The acetabulum looks relatively normal for both hips, but there is
there may be different vascular supply in these children making them symmetrical femoral head deformity with flattening. The physis appears
more prone to ischaemia. Recent work from Liverpool has suggested to be slightly irregular with a wide metaphysis bilaterally.
that the vessels have a reduced response to vasodilators, making them EXAMINER: The family were told that this was Perthes’ disease, but have
less able to regulate femoral head blood flow come to you for a second opinion. What do you think?
In reality, it is most likely a combination of several of these factors CANDIDATE: I think that it is extremely unlikely to be Perthes’ disease. As
which combine to cause critical ischaemia for a brief period. much as 15% of cases are thought to be bilateral, they are never
EXAMINER: And once you have made the diagnosis of Perthes’ disease, synchronous and absolutely symmetrical. If you add to that the slightly
how would you classify it? irregular appearance of the physis and metaphysis, I think it much more
CANDIDATE: Well this child is in the fragmentation stage, and so I would likely that this represents a skeletal dysplasia. The most likely candidates
use the Herring lateral pillar classification. That grades the severity of the would be multiple epiphyseal dysplasia or spondyloepiphyseal dysplasia.
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028
EXAMINER: How would you make that diagnosis? EXAMINER: How would you assess the hip at maturity?
CANDIDATE: I would examine the child looking for any other signs or CANDIDATE: The Stuhlberg classification gives prognostic information at
features of skeletal dysplasia (short stature, short limb segments, etc) and skeletal maturity. It divides hips into five categories:
would get x-rays of other joints as indicated to show changes in other Types 1 and 2 are largely spherical and congruent
areas. After this I would tell the parents a small amount about skeletal Type 3 is aspherical but congruent
dysplasia and then refer on to my colleagues in the skeletal dysplasia clinic
Types 4 and 5 have misshapen femoral heads and the joint in non-
for them to make a formal diagnosis and counsel the parents accordingly. congruent
The candidate is shown an x-ray of the pelvis showing Perthes’ For types 1 and 2, the prognosis is not that much worse than for the
disease of the left hip in the fragmentation stage. The femoral general population. Type 3 hips may require a total hip replacement
head has extensive involvement, has already started to collapse approximately 10 years earlier than controls. Those with type 4 and 5 hips
and has subluxed partially out of the acetabulum. degenerate quickly and will likely need a hip replacement before 50.
EXAMINER: This is the x-ray of a 7-year-old boy with Perthes’ disease. Can
you tell me what it shows? Coxa vara
CANDIDATE: This is an AP x-ray of the pelvis. The most obvious
abnormality is fragmentation and partial collapse of the proximal femoral Definition
epiphysis of the left hip. There appears to be total hip involvement and Localized bone dysplasia characterized by decreased neck-shaft
this would be a Herring C on the lateral pillar classification as there has angle (<110°) owing to a defect in ossification of the infer-
been >50% loss of height in comparison to the other side. The head has omedial femoral neck (Fairbank’s triangle).
started to sublux laterally and is no longer fully contained within the
acetabulum. He also displays several of the ‘head at risk’ signs with a Epidemiology
horizontal physis, gage sign, metaphyseal cysts and calcification lateral to Incidence 1 : 25 000
the physis. Bilateral in one-third to one-half of cases
EXAMINER: What would be your plan of management for this young man? No clear pattern of inheritance has been established, but there are reports
CANDIDATE: Well, I think that given the degree of involvement and of positive family histories and of identical twins being affected
collapse in combination with him being 7, the outlook for this hip is poor.
Surgical intervention will likely improve his chance of developing a Aetiology
congruent hip joint for skeletal maturity. I would take him for an EUA Congenital (noted at birth). Often associated with a short femur or skeletal
and arthrogram to plan any further management. I would assess at this dysplasia. Nearly always unilateral
stage whether there would be any chance of containing the head or Developmental (AD, progressive). Historically has been called infantile,
whether we would have to consider salvage procedures. develops over time
EXAMINER: What salvage procedures would you be considering? Acquired (trauma, rickets, Perthes’, SUFE). A defect of enchondral
CANDIDATE: If the hip was largely round but there was a bump preventing ossification in a metaphyseal triangular fragment of the inferior femoral
containment, the first option would be cheilectomy to allow you to perform neck, where physiological shearing stresses cause fatigue of the local
routine containment surgery. This cheilectomy could be performed either dystrophic bone, resulting in a progressive varus deformity
open or arthroscopically with containment performed after that.
If it was felt that this would not be possible or ill-advised, then you Weinstein classification
could perform an abduction/extension osteotomy. What this does is bring
Coxa vara associated with hypoplastic femur or proximal focal femoral
the round portion of the femoral head up in to the weight-bearing region,
deficiency (PFFD)
and distalises the bump to prevent lateral impringement.
Coxa vara associated with congenital skeletal dysplasia
Alternatively you could perform a pelvic osteotomy such as a Shelf.
Acquired coxa vara (trauma, metabolic diseases such as rickets and
This recovers the hip, spreads your contact pressures and reduces load,
Perthes)
and stabilises the hip preventing hinge abduction. This is accepting that
Adolescent coxa vara associated with SUFE
the hip will remain aspherical, but the hope is that it remains congruent
Idiopathic infantile coxa vara
giving the next best outcome.
A newer possibility would be to place a hinged hip distractor on to
prevent any further collapse. This would not change the shape of the head, Clinical features
but would hopefully prevent any further degeneration. Then after the In unilateral cases children present with a painless progressive
disease has resolved you could do a cheilectomy to try and restore the limp. The limp is not antalgic, it is painless and the weight-bearing phase is
shape of the head. not shortened. In bilateral cases a waddling gait is noted
EXAMINER: What would you tell the family regarding the prognosis for the Examination reveals a prominent greater trochanter on the affected side
future? and weakness of hip abductors
CANDIDATE: I would tell them that the prognosis is based on the shape of Positive Trendelenburg’s test and gait
the hip at skeletal maturity and many things can happen between now and In unilateral cases there will be a leg length discrepancy (2–3 cm) and the
then to change the outcome. thigh and popliteal creases are uneven
028
<35–40°. Pauwel’s Y-shape and Langenskiöld intertrochan-

teric corrective valgus osteotomies are used for a neck-shaft
angle <90°.

Definition
Leg length discrepancy is a measurable difference in the overall
length of the two legs, which can be true, apparent or
functional:
True – An absolute difference in leg lengths, clinically
measured from ASIS to medial malleolus
Apparent – Where there is a measurable difference owing to
positioning but the actual limb lengths may be the same.
Clinically measured from xiphisternum or umbilicus to the
medial malleolus
Functional – The difference the patient perceives (corrected
clinically by blocks under the short limb)
Causes of leg length inequality (eight surgical sieves)

Congenital (small number but major difference in leg length
Figure 25.21 Measurement of Hilgenreiner’s epiphyseal angle (HEA) discrepancy)
PFFD (inequality remains proportional to the length of the
Decreased internal rotation of the hip is often present opposite limb)
owing to decreased femoral anteversion or true Congenital short femur
retroversion Tibia/fibula hemimelia
DDH
Differential diagnosis Vascular malformations (including Klippel–Trenaunay–
Congenital Weber syndrome)
Proximal focal femoral deficiency AV fistula
DDH Diffuse haemangioma
Achondroplasia Seldom mentioned, but CTEV can be associated with a
Associated with fibula hemimelia short limb as well as a short foot
Hemihypertrophy
Acquired
Rickets Trauma
SUFE Diaphyseal fractures may lead to overlap and mal-union.
This is usually a static, non-progressive, small leg length
discrepancy
Radiographic assessment Epiphyseal injuries can damage the growth plate. This may
Hilgenreiner’s epiphyseal angle (HEA): The angle between lead to partial (particularly Salter–Harris type III and IV)
Hilgenreiner’s line and a line drawn along the femoral capital or complete growth plate arrest. If partial and the arrest is
physis. The normal angle is <25° (Figure 25.21). peripheral, it can cause a progressive angular deformity in
Weinstein26 found that if the HEA was: addition to leg length discrepancy
<45°, deformity corrects spontaneously
45–60°, outcome uncertain – Observe Infection
>60°, all patients will progress and, therefore, require Growth plate arrest in septic dislocation (Tom Smith’s dis-
corrective surgery ease). Diaphyseal osteomyelitis can cause overgrowth owing to
bone hyperaemia.
Management
The aim of surgery is to correct the deformity such that Neurological
the neck-shaft angle is restored to 140° and the HEA to Cerebral palsy, polio and spinal dysraphism
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028
Neoplasms Moseley straight-line method

Neurofibromatosis, haemangioma, Wilm’s tumour Moseley converted the Green–Anderson tables into a
straight-line graph
Skeletal dysplasia syndromes A logarithmic scale of predicting remaining limb growth
Hemihypertrophy and hemiatrophy syndromes (and along with expected discrepancy at maturity
knowing which it is can be a challenge) It assumes growth inhibition is constant and requires at
Russell–Silver syndrome (shorter lower limb) least three scanogram measurements
Klippel–Trenaunay–Weber syndrome (asymmetrical limb
hypertrophy) White–Menelaus rule of thumb
Used in the last few years of remaining growth (>10 years).
Inflammatory conditions This method assumes that
Juvenile chronic arthritis (overgrowth) :Distal femoral physis grows 9 mm/year (3/8 inch)
(contributes 70% of femoral growth)
Radiotherapy : Proximal tibia physis grows 6 mm/year (1/4 inch)
Causes physeal damage and may lead to premature fusion of (contributes 60% of tibial growth)
the growth plate. : Proximal femur grows 3 mm/year (1/8 inch)
It further assumes that these physes fuse at the age of 16 in
Clinical evaluation boys and 14 in girls
Standing Allows calculation of the discrepancy at maturity and the
effect of epiphysiodesis. Reliable method as long as skeletal
Look for scoliosis, pelvic obliquity and joint contractures age is the same as chronological age
Stand on pre-measured blocks and reassess any scoliosis or
pelvic obliquity Eastwood and Cole method
Gait – Short-leg gait. On the short side, stance stride is Leg length discrepancy measured using blocks or
shorter and push off reduced tape measure and the total discrepancy is plotted
against chronological age. The points on the
Sitting graph represent directly the pattern of increase in
Does the scoliosis correct? (If yes, then it is functional.) discrepancy
Epiphysiodesis reference slopes are placed on the same
Supine graph
Get a tape measure. True leg length discrepancy measures
the overall difference between the ASIS and the medial Bone age determinants (Greulich and Pyle atlas27)
malleolus. Apparent leg length discrepancy is measured AP films of the left wrist and hand are compared to
between the umbilicus and xiphisternum to medial radiographs in Greulich and Pyle atlas to determine skeletal
malleolus age
Galeazzi’s test – Look for flexed knee height with heels
together
Thomas’ test to rule out flexion deformity of the hip
Radiographic evaluation
Ankle – Rule out equinus deformity Teleroentgenogram (grid films)
Knee – Flexion or hyperextension deformity A single 3-ft radiograph of the entire lower limbs. Magnifica-
Skin – Previous operative scars, café-au-lait spots tion distortion is minimal in small children, but it increases as
Temperature variation in the limb may indicate a the child grows bigger. Used in infants and young children.
haemangioma
Orthoroentgenogram
Also a 3-ft radiograph, but the radiographs are taken in 3 sep-
Prediction of leg length discrepancy arate exposures centred exactly over the hip, knee and ankle to
It is not unheard of to be presented with a growth reduce magnification distortion.
chart in the oral. You should take time to familiarize
yourself with them so that you can interpret them with Scanograms
confidence. Designed to avoid inaccuracies owing to projectional errors.
A series of radiographs of the hips, knees and ankles exposed
Green–Anderson tables separately to avoid magnification errors is taken with the child
Predict the remaining growth for the distal femur and in the supine position with a metal ruler in between the
proximal tibia according to skeletal age extremities.
028
CT scanogram initial lengthening is often followed by growth plate fusion.

This is the preferred method in patients with angular deform- This has limited application and unpredictable results. Occa-
ities or joint contractures. It measures the distance from the sionally it is indicated for the correction of deformity sited at
top of the femoral head to the medial malleolus. Allows a more the level of the physis.
accurate measurement of the whole limb length, and involves
Diaphyseal lengthening
less exposure to radiation.
The diaphysis is divided and acutely lengthened by up to 3–5 cm.
The lengthened bone is stabilised with a locked intramedullary
Management nail. Supplementary bone graft is needed. The procedure
It is generally accepted that leg length discrepancy: remains unpopular because of a significant complication rate.
<2 cm: Managed conservatively (shoe lifts up to 2 cm can
be accommodated inside a shoe but thereafter must be Diaphyseal osteotomy
attached to the sole) The diaphysis is divided and followed by progressive distrac-
2–4 cm: Epiphysiodesis is indicated in the longer limb tion of 1.5 mm/day through an external skeletal fixation frame.
>5 cm: Lengthening ± epiphysiodesis is indicated Little new bone is formed within the gap and, once the desired
length is achieved, the bone is fixed with a large plate with
Epiphysiodesis (surgical growth arrest) bone grafting across the callous bridge.
Parents (particularly of children who are predicted to have a
relatively short adult height) may struggle to accept a proced- Ilizarov frame (circular)
ure that will limit the height of their child. This needs to be The frame is formed by a series of full or half ring distractors
explained in the context of the greater investment required by and multiple small-diameter pins. The frame allows simultan-
everyone in the alternative – Limb lengthening on the eous correction of rotational and angular deformities as well as
shorter side. leg length discrepancy. Corticotomy is performed at the lower
Open growth plate arrest (Phemister technique 1933) has metaphyseal level. Internal fixation and bone grafting are
been replaced by percutaneous epiphysiodesis. Under radio- rarely required. The disadvantages of this frame are the learn-
graphic control, a small window is cut in the peripheral part of ing curve, a long initial operating time and tethering of
the bone and the physis is curetted. This is usually performed muscles.
2–3 years prior to maturity on the distal femur or proximal
tibial physis. De Bastiani orthofix
Staple epiphysiodesis is achieved by using medial and lat- A unilateral frame, which allows only distraction. Once
eral staples. It is potentially reversible by removing the staples. attached it does not allow angular or rotational correction.
It is less reliable than percutaneous epiphysiodesis, growth
may not be retarded immediately and uneven inhibition may Complications
lead to condylar deformity. Attempts to correct a discrepancy Serious complications can occur with leg lengthening:
of >5 cm may lead to miscalculation of limb growth potential
Pin tract infection, loosening of pins
or development of deformity owing to uneven retardation of
growth. ‘8’ plates have made this technically less demanding. Osteomyelitis
In addition to their use for angular growth correction, they can Deformity of adjacent joints
be inserted medially and laterally to cause temporary physeal Nerve palsies
arrest. They must be removed by 2 years after insertion or Vascular injuries
permanent physeal arrest may occur. Muscle contractures and weakness
Premature consolidation
Lengthening procedures Mal-union, delayed union and non-union
Periosteal release Re-fracture after fixation removal
This is a useful adjuvant procedure, particularly if a large limb Angular and rotational deformity
length discrepancy (LLD) is anticipated. It can be repeated 4–5 The safe limit of lengthening is 15% of the original bone
years later although it is less effective. The procedure is per- length, although more has been attempted successfully.
formed by elevating and stripping the periosteal attachment
adjacent to the growth plate.
Examination corner
Chondrodiastasis (physeal distraction)
Paeds oral 1: Clinical picture of a child standing with one leg on a
Distraction force is applied progressively across the epiphyseal wooden block
plate. The growth plate fractures, following which the bone is Causes of leg length discrepancy
lengthened gradually and the distracted segment heals spon- Causes of undergrowth
taneously. The operation is no longer widely used because
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028
Causes of overgrowth
:
Rigid – Resist passive movement
Pathology of osteomyelitis :
Dystonic – Intermittent posturing
Ataxia (cerebellum and brainstem) lack balance
Picture of CT scanogram Mixed (combination of spasticity and athetosis)
Discuss the potential pitfalls with this technique.
Anatomical classification
Monoplegia (one limb involved)
Cerebral palsy (CP) Hemiplegia (one side of the body)
Definition Diplegia (lower limbs) with mild upper limb involvement –
A permanent and non-progressive motor disorder owing to May be asymmetrical
brain damage before birth or during the first 2 years of life. Triplegia – Three-limb involvement
The lesion is static but (because a child is growing) the clinical Quadriplegia or total body involvement
picture is not. It is important to remember that epilepsy is coincident in one-
third of cases, visual problems in 50% and mental retardation
Incidence in 50%, with these complications being more common in more
severely involved children.
Two per 1000. This is increased by resource-poor prenatal
and postnatal care. It is also inadvertently increased where
excellent care enables profoundly disabled children to
survive where otherwise they would have died Orthopaedic evaluation
The persistence of two or more primitive reflexes (Moro
Aetiology startle reflex, parachute reflex, tonic neck reflex, neck righting
reflex and extensor thrust) usually means the child will be
This is not known in up to one-third of cases. The following
non-ambulatory.
risk factors have been identified:
Main problems with the musculoskeletal system are:
Prenatal: Placental insufficiency, toxaemia, smoking,
Spasticity
alcohol, drugs, infection such as toxoplasmosis, rubella,
Lack of voluntary control
CMV and herpes type II (TORCH), epilepsy, third
trimester bleeding Weakness
Perinatal: Prematurity (most common), anoxic injuries, Poor coordination
infections, kernicterus, erythroblastosis fetalis, multiple Sensory impairment
births, trauma, placental abruption Spasticity causes deformities that follow a staged pattern:
Postnatal: Infection (CMV, rubella), head trauma 1. Dynamic contractures
In a discussion about aetiology it is important to recognise Increased muscle tone and hyperreflexia
that, whilst low birth weight (often manifested in prematurity) No fixed deformity of joints
is a strong risk factor for cerebral palsy, up to two-thirds of Deformity is overcome during examination
cases are born at term. 2. Fixed muscle contractures
The influence of perinatal hypoxia is easily overplayed – It
has only been demonstrated in 1 in 10 cases. Persistent spasticity and contracture
It is often impossible to give a definite cause in a given case; Shortened muscle tendon units
often the diagnosis is not apparent until several months and Fixed deformity of joints: Cannot be overcome
sometimes years after birth. 3. Fixed contractures with joint subluxation/dislocation and
secondary bone changes
Classification Gait disorders are the most common problem. The use of
three-dimensional computerized gait analysis and force plate
There is no universally accepted and satisfactory classification
studies assists in the development of and subsequent evalu-
system for CP. It is best considered in terms of either physi-
ation of an individualized management plan.
ology or anatomy.
Physiological classification Hoffer classification of ambulation potential

Spastic (pyramidal system, motor cortex) – By far the most Ambulation is classified to four grades:
common Grade 1: Community ambulator
Athetoid (extrapyramidal system, basal ganglia) Grade 2: Household ambulator
: Ballismus – Uncontrolled proximal movements Grade 3: Therapeutic ambulator
: Chorea – Uncontrolled distal (e.g. finger) movements Grade 4: Non-ambulators
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Gross Motor Function Classification System (GMFCS) and remains somewhat controversial. NICE published
This is predictive for hip subluxation: equivocal guidance in 2006 (reviewed in 2010),
intramuscular botulinum injection and intrathecal
Level I: Walks without restrictions; limitations in more
baclofen
advanced gross motor skills
Level II: Walks without devices; limitations in walking Fixed deformity. Tendon release or lengthening, muscle
transfer, split tendon transfers
outdoors and in the community
Level III: Walks with mobility devices; limitations in walking Bony abnormalities. Derotation osteotomy or joint
arthrodesis
outdoors and in the community
Level IV: Self-mobility with limitations; children are
transported or use power mobility outdoors and in the
community
Clinical features
Spine
Level V: Self-mobility is severely limited even with the use of
supporting technology Scoliosis is the most common presentation. Surgical correction
is usually considered when curves progress beyond 40° or there
is worsening pelvic tilt. Custom-moulded seat inserts allow
General management better positioning but do not prevent curve progression.
A comprehensive assessment of a child with CP is essential Bracing is controversial and does not stop curve progression
to plan appropriate management. Because of the but may be able to delay it.
multiplicity of problems, a multidisciplinary team is Scoliosis curves are divided into groups I (ambulators) and
required II (non-ambulators):
Evaluation and management plans should be organized for Group I (double small curves with thoracic and lumbar
motor, sensory and cognitive problems such as: Epilepsy, involvement): Managed with posterior fusion
speech and hearing difficulties, visual defects, feeding
Group II (large lumbar or thoracolumbar curves):
difficulties, learning and behavioural problems Requires anterior and posterior fusion. If there is a
Orthopaedics can only address spasticity problems and the significant pre-existing pelvic obliquity, then fusion to
deformity caused by the spasticity the pelvis is also needed to achieve adequate curve
The common sites of involvement are: correction
Spine deformity
Hip joint subluxation/dislocation Hip subluxation/dislocation
Flexion deformity of the knee If hips dislocate they can be painful and make sitting and
Foot and ankle abnormalities nursing difficult. Dislocation can contribute to pelvic obliquity
Flexion deformity of the hand and scoliosis.
There are several schools of thought in respect of timing of
Hip at risk
orthopaedic interventions.
Traditionally, soft-tissue releases were undertaken succes- Abduction <45°. Femoral head uncovered >30% (using
sively with bony surgery reserved for difficult cases – The Reimer’s index on AP radiographs to give the migration
common practice of a surgery every year after a clinic visit percentage; Figure 25.22)
led to the term ‘birthday surgery’. Managed with abductor tenotomy. Iliopsoas tenotomy can
More recently, the advent of botulinum toxin has enabled be performed at the same time, but avoid in patients who
some surgeries to be postponed so that single event multiple can walk
level surgery (SEMLS, also known as ‘shark attack’) can take
place in the hope of delivering improved musculoskeletal Hip subluxation
function on a one-off basis. The risks (to ambulation) are high Head uncovered >>50%
but so are the potential benefits. Femoral varus osteotomy (derotation and shortening)
Work in Sweden28 has convincingly demonstrated that a Additional pelvic (Dega’s in a growing child and Chiari
surveillance programme with early intervention can deliver a post-maturity) osteotomy is occasionally necessary
much improved clinical picture for these children, with hip
dislocation effectively eradicated. Hip dislocation
Early: Open reduction, femoral shortening and varus
Management options derotation osteotomy
Dynamic contractures. Physiotherapy (stretching and Late: Proximal femoral resection (not ‘Girdlestone’),
casting), orthotic use, selective dorsal rhizotomy (this excision with interposition where symptomatic. Bone
involves division of afferent sensory neurons to reduce spikes at the resected proximal femoral end are a common
spasticity. It is highly dependent on good patient selection complication
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Foot and ankle

Ankle equinus
Caused by triceps surae contracture. A Silfverskiöld’s test
differentiates between tight gastrocnemeii alone and accom-
panying tightness of the soleus by assessing dorsiflexion with a
flexed and extended knee, respectively. Various surgical pro-
cedures are described for the correction of the equinus
deformity.
1. Baker’s procedure
An inverted U incision of the gastrocnemius
aponeurosis is performed through a vertical midline
incision in the middle one-third of the leg
Aponeurosis slides apart in a controlled and stable
fashion
There is a high recurrence rate that makes
relengthening virtually impossible
2. Strayer’s procedure
Via a mid posteromedial calf incision the
Figure 25.22 Hip migration index. The percentage of the femoral head that gastrocnemius is ‘peeled’ from the underlying soleus,
falls outside the acetabulum
which is not damaged
3. Percutaneous Achilles tendon lengthening
Windswept hips A triple hemisection technique, taking care to dorsiflex
Characterized by abduction of one hip and adduction of the foot only to the plantigrade position
the contralateral hip Minimal scarring: The incisions are two lateral and one
Adductor release medial
Fixed deformity in an older child may need to be managed The most unpredictable procedure, especially in young
by a combination of varus osteotomy on the abducted side children, as it does not respect soleus
and valgus osteotomy with shortening on the adducted side 4. Slide technique (White) of Achilles tendon lengthening
to create symmetry about the pelvis DAMP: Distal anterior two-thirds, medial two-thirds
proximal
Flexion contracture knee Small risk of over-lengthening
Knee flexion contracture with decreased range of 5. Open Z-lengthening of Achilles tendon
movement may develop secondary to hamstring spasticity
Neglected cases, severe deformity
Spasticity of the quadriceps (cospasticity) is often
Risk of over-lengthening and calcaneus deformity
associated with this deformity
Those procedures which preserve soleus are generally pre-
If hamstrings alone are lengthened, a stiff, flexed knee gait ferred as the soleus is the primary ‘antigravity’ muscle of
becomes a stiff, extended knee gait
the ankle and its function cannot be easily recovered. If
Indications for hamstring lengthening vary, but guidelines Achilles tendon lengthening is performed with tight ham-
are a popliteal angle of 90–100° in non-ambulators and of strings, then a crouch gait occurs, and the child walks with
135° in ambulators their ankles maximally dorsiflexed and their knees flexed. In
Distal lengthening is preferred in ambulatory patients this situation a GRAFO (ground reaction ankle foot orthosis)
is required to try to maintain ambulation. Hamstring tight-
Spastic crouch contracture
ness should be corrected at the same time as Achilles tendon
Gait with flexed knees and hips, ankle dorsiflexion which lengthening.
commonly develops in spastic diplegia (weight of the child
increases in a cubic fashion whilst the muscle strength only
increases in proportion to cross-sectional area of the muscle) Equinovarus
Either psoas or hamstrings or both are responsible Most often caused by tibialis posterior spasticity,
May be iatrogenically precipitated by lengthening the although occasionally the tibialis anterior tendon is
Achilles tendon at fault
Is often progressive – With knee pain often leading to a late Split tibialis posterior transfer involves rerouting half of the
presentation to orthopaedic services tendon dorsally to the peroneus brevis
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Split tibialis anterior tendon transfer to the cuboid is often

combined with Achilles tendon and tibialis posterior Paeds oral 4
lengthening to manage a fixed equinovarus EXAMINER: What is cerebral palsy?
CANDIDATE: CP is a permanent and non-progressive motor disorder
Equinovalgus
caused by brain damage before birth or during the first 2 years of
Spastic peroneal muscles pull the forefoot laterally life. The lesion is static but the clinical picture is not.
Excessive valgus, external rotation and dorsiflexion of the EXAMINER: How do you classify CP?
calcaneus in relationship to the talus
CANDIDATE: CP can be classified either anatomically or
Management physiologically. Physiological categories include spastic, athetoid,
Ankle foot orthoses. Grice arthrodesis. Subtalar extra- ataxia and rigid or mixed varieties. The anatomical types include
articular arthrodesis performed through a lateral approach monoplegia, hemiplegia, diplegia and quadriplegia.
using a corticocancellous bone graft. Especially indicated in EXAMINER: What part of the brain is affected with athetoid CP?
a growing child as it allows for full growth of the hindfoot CANDIDATE: The extrapyramidal system, basal ganglia.
Subtalar fusion
Paeds oral 5
Triple arthrodesis Exactly the same questions as oral 4 (I think it was the same
examiner). However, the examiner did not like the definition of
Upper limb cerebral palsy CP, the sticking point being ‘non-progressive’. The examiner
Surgery can achieve good cosmetic results but functional considered the disorder a progressive one. The candidate
gains may be small (or non-existent) stuck to their guns and mentioned that although the lesion
Thumb in palm deformity is common but difficult to is static the clinical picture is not. There was a bit of to-ing and
manage. Correction entails release of the adductor pollicis fro-ing between the candidate and examiner about this point.
and first dorsal interosseous muscle, fusion of the MCP (Pass)
joint and rerouting of EPL CANDIDATE: The examiner did not know the definition of CP
Finger flexion contractures can be released by selective particularly well and we spent a while arguing about whether the
myotendinous lengthening in the forearm condition was progressive or non-progressive. It was a bit off-
putting and was not the best way to start the oral.
Key advice here is stick to what you know but don’t be

Examination corner argumentative!
Paeds oral 1: CP clinical photograph
Describe the diagnosis, classification, definition and manage- Paeds oral 6: Clinical photograph of child with total body
ment for hip problems in CP. involvement CP
Define CP
Paeds oral 2: Video clip of gait analysis in a child with scissors gait Classify CP
The prerequisites of normal gait (gage) are:
1. Stability in stance phase Paeds oral 6
2. Foot clearance in swing The candidate is shown an x-ray of a 10-year-old girl with a left
hip subluxation, shallow acetabular index and pelvic tilt. At the
3. Normal initial contact
top of the x-ray you can see the start of a scoliosis.
4. Step length
5. Energy conservation EXAMINER: A 10-year-old girl is transferred to your care after
moving in to the area. She has got cerebral palsy and she is
Paeds oral 3: Video clip of scissors gait wheelchair bound. This is the x-ray taken of her pelvis on your
first consultation.
Describe the gait.
CANDIDATE: Well, this is an AP pelvis x-ray of a 10-year-old girl. Both
Scissoring during gait is caused by adductor spasticity. Legs of the legs appear to be in adduction, however, the left leg is more
are flexed slightly at the hips and knees, giving the appearance adducted than the right. There is an obvious pelvic tilt, with the left
of crouching, with the knees and thighs hitting or crossing in a side tilted up and there appears to be a scoliosis although we
scissors-like movement. The typical features include:
would need full spinal x-rays to ascertain this. With regards to the
Rigidity and excessive adduction of the leg in swing phase
hips, the right hip looks to fairly well centered and covered. The left
Plantarflexion of the ankle
hip is starting to sublux. I would estimate the migration percentage
Flexion at the knee
Adduction and internal rotation at the hip to be 50% on this x-ray although I would need to formally measure
Contractures of all spastic muscles it to be sure. The acetabulum also appears shallow on this side,
Complicated assisting movements of the upper limbs with an acetabular index of approximately 35° following erosion of
when walking the superior lip of the acetabulum as the head has migrated out.
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asymmetrical tone issues making one leg worse than the other. In
EXAMINER: How would you measure the acetabular index and the
this situation, the more affected leg (left) is acting as an abduction
migration percentage?
splint for the right leg keeping it in joint. If you effectively treat
CANDIDATE: I would draw Hilgenreiner’s line through the triradiate
the left leg you remove the splint and then the other hip migrates
cartilages and then Perkin’s line, perpendicular to this at the
as the first side did. Also for children with scoliosis, if you only
lateral extent of the acetabulum. The acetabular index is
address one side, then one hip is varus, the other is valgus giving
calculated by drawing the angle between Hilgenreiner’s line and
pelvic tilt and driving the scoliosis to progress.
the line from this line to the superolateral aspect of the
I appreciate that this is very controversial. However, the
acetabulum at Perkin’s line.
birthday syndrome is well-known CP and we try very hard to
The migration percentage is calculated by measuring what
avoid this. This was the basis for the multilevel CP surgery in
proportion of the femoral epiphysis lies lateral to Perkin’s line in
walkers. If you only do one bit at a time, the disease process
comparison to the entire diameter, ie, what percentage lies
invariably leads to a new problem. This means that traditionally
outside of the acetabulum.
these children ended up coming in for surgery on an annual basis
EXAMINER: How would you use the migration percentage to guide
throughout their entire childhood, never really getting the full
your management?
benefit of any of your interventions. It is much better for them to
CANDIDATE: The natural history of hip subluxation in cerebral palsy get the surgery all done in one go.
is well known. A migration percentage (MP) of <15% is normal.
EXAMINER: How much varus would you put the hip in to?
Anything <40% can be monitored for progression as per NICE
CANDIDATE: In this child I would take it down to 100° as there is no
guidance. Once the MP exceeds 40% then the hip is likely to
walking potential and she is still relatively young. We know that the
proceed to complete dislocation if left unattended. Once the MP
bone continues to remodel as long as they grow and so the best
hits 60%, then urgent intervention is required to keep the hip
chance of avoiding a revision procedure is to deeply seat the hips.
in joint.
For a child who was walking then I would bring the hip to 120°.
EXAMINER: So you would plan to intervene for any child with a MP
of 40%?
CANDIDATE: No, every child is different and cerebral palsy can be an
The candidate is shown a picture of a child in a pushchair
extremely complex condition to treat. Assuming that the child is
with legs adducted and internally rotated, hips and knees
fit enough for surgery and there are no contraindications, then
flexed in AFOs.
I would discuss hip reconstruction at that point. If they were very
opposed to surgery, then we could wait, monitoring the situation EXAMINER: This child is 3 years old and has been brought to your
closely and intervene when the hip shows further signs of clinic for an initial assessment. He was originally diagnosed with
subluxation. I would, however, point out to the family, that the CP after a traumatic birth and resulting brain injury. How would
longer that we leave the hip to displace it is likely to undergo you assess him?
femoral head deformation and erode the acetabulum. I would CANDIDATE: I would want to establish his level of function and
also consider hip reconstruction earlier than 40% if there were potential, any learning difficulties or associated medical
other factors such as seating concerns, perineal hygiene, etc. conditions from his family. I would do a thorough assessment to
EXAMINER: For this child what would you recommend? establish the pattern of involvement, type of CP and walking
CANDIDATE: I would just like to clarify the GMFCS of the child, and potential. I would also carefully assess his tone and the presence
know if there were any confounding factors which may affect the of any contractures.
decision. EXAMINER: What patterns of involvement are you aware of for this
EXAMINER: She is GMFCS IV and there is nothing else that would condition?
affect your decision. CANDIDATE: The main patterns include hemiplegia (just one side of
CANDIDATE: In that case, my treatment of choice would be bilateral the body affected), diplegia (legs more affected than arms) and
hip reconstructions to level the pelvis. I would perform a quadriplegia (where there is total body involvement).
shortening, varising, derotational osteotomy of the left femur EXAMINER: And what types are there?
using a proximal femoral locking plate. After this I would assess CANDIDATE: The main types would be spastic and choreoathetotic.
the congruency of the joint and proceed to a Dega The spastic type just has constant increased tone, whereas the
acetabuloplasty as necessary. Assuming that the child was other type is much more difficult to treat. Patients experience
managing well after the first side, then I would go on to do a great fluctuations in condition and it is more about writhing
similar femoral osteotomy on the other leg to level the pelvis. movements as opposed to contractures.
EXAMINER: You would operate on the right hip even though it is EXAMINER: And how would you assess walking potential?
well contained? CANDIDATE: I would use the GMFCS, which scores them I to V based
CANDIDATE: Yes, if the parents consent. For children with GMFCS IV on ambulatory capacity. I is virtually normal; II would probably
or V cerebral palsy the entire body is affected. They typically have require a walking aid for longer distances; III can walk short
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distances with aids but would require a wheelchair for long amount of pain from his hips, and when you examine him he
distances; IV is wheelchair bound but has got head control; and grimaces on hip movement.
V is wheelchair-bound requiring head support. CANDIDATE: Well in this case it is a discussion regarding
EXAMINER: What would you tell the family about his likely outcome reconstruction vs salvage procedures. I think that this looks like it
and management if he was felt to be GMFCS IV spastic is a long-standing dislocation with significant deformation of the
quadriplegia? femoral head. If we were to do a reconstruction it would likely
CANDIDATE: For a child who is GMFCS IV then he would not really lead to a painful joint. I believe that I would advise a salvage
walk unassisted and would be wheelchair bound life-long. These procedure. My preference would be a pelvic support
children can usually have some sort of walking in a special frame osteotomy (PSO).
system with assistance and splintage as required. EXAMINER: Why would you choose a PSO over a proximal femoral
As long as he grows then his musculoskeletal system will be excision?
constantly changing and we will have to monitor him and CANDIDATE: The problem with a proximal femoral excision is that
address problems as they arise. With regards to his hips we know no matter how much you excise it tends to rise up afterwards and
that the majority of children with a GMFCS of IV will develop hip can cause pain. If we are doing a salvage then I would just like to
subluxation. The NICE guidance for these kids is that we should do the operation once and be fairly sure that it will do the job.
be performing an initial pelvic x-ray by the age of 3 and then EXAMINER: OK, let’s move on.
screening the hips annually for any signs of subluxation.
EXAMINER: What categories of hip surgery are you aware of in CP?
CANDIDATE: The three main categories are: Preventive,
reconstructive and salvage. Preventive surgery is largely soft- Neurofibromatosis (Nf)
tissue work such as adductor and psoas tendon releases to
attempt to slow the progression of hip subluxation. These are Definition
typically reserved for younger children or older children who are This is an autosomal dominant (AD) disorder of neural crest
very mildly affected. Reconstruction is in the form of proximal origin, which is often associated with neoplastic and skeletal
femoral ± acetabular osteotomy to restore congruency of the hip abnormalities. There are two major types:
joint. Salvage procedures are those when the hip is fully out and it Peripheral (Nf-1)
is decided that a reconstruction cannot be performed. These Central (Nf-2) – Rare, 1/100 000. Eighth cranial nerve
would typically involve a pelvic support osteotomy or a proximal schwannomas are pathognomonic
femoral excision.
OK.
Neurofibromatosis type 1 (peripheral
The candidate is shown an AP x-ray of the pelvis of a 14-year-old
child with both hips dislocated.
neurofibromatosis or von Recklinghausen’s
EXAMINER: This child is 14, has CP with a GMFCS of V. He has just disease)
moved in to your area and you are seeing him for the first time. Incidence 1 : 4500
This is the x-ray that you take on that initial consultation. AD gene mutation at chromosome 17: One in two are new
CANDIDATE: OK, this is an AP pelvis x-ray of a 14-year-old boy. Both mutations
hips appear to be completely dislocated with shallow acetabulae The manifestations vary but all carriers will have some
bilaterally. The femoral heads appear to be deformed bilaterally. clinical features (100% penetrance)
There does not appear to be significant pelvic tilt or an obvious Neurofibromas are Schwann cell tumours
scoliosis.
EXAMINER: What do you think the appropriate management for this Diagnosis
child would be?
Two or more of the following criteria are diagnostic:
CANDIDATE: It depends very much on his symptoms and medical
1. At least 6 café-au-lait spots (5 mm in children, 15 mm
condition. If he is wheelchair bound, his walking potential is
in adults)
irrelevant. If he has a bilateral symmetrical hip dislocation this
2. More than two neurofibromas or one plexiform
rarely goes on to cause problems with scoliosis or other posture
neurofibroma
related issues. The fact that he is older as well means that his
remodelling potential is not good. If he was completely pain free
3. Axillary, groin and base of neck freckles
or only marginally affected then I would not suggest surgical 4. Optic gliomaz
intervention. 5. Two or more Lisch nodules (benign iris hamartomas)
EXAMINER: It appears on discussion with the family that he is 6. Osseous lesions: Long bone cortex thinning
medically quite good. They feel that he is getting a significant with or without pseudoarthrosis, dystrophic scoliosis
7. Positive family history: First-degree relative with Nf-1
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Musculoskeletal manifestations Examination corner

Scoliosis
Paeds oral 1: Clinical photographs
Extremity hypertrophy Severe scoliosis with cafè-au-lait spots (distinguishing
Pseudoarthrosis of long bones (tibia, ulna, humerus) feature)
Peripheral or spinal nerve tumour Thoracolumbar radiograph demonstrating short
dystrophic curve
Radiology Paeds oral 2

Neurofibromatosis diagnostic criteria
Cortical bone defects: Usually caused by neurofibromatosis
Inheritance and chromosome defect
tissue irritating the periosteum
Bone cyst formation: Caused by proliferation of tissue
within the medullary canal Paeds oral 2
Bowing of long bones A child who is 10 years old attends your fracture clinic with a
Pseudoarthrosis of long bones displaced olecranon fracture after a very minor fall. Mum is
extremely concerned sue to the fact that she has had four previous
fractures, all of which occurred after minimal trauma. What would
Tibial bowing be your differential diagnosis?
This occurs in 2% of Nf-1 and is always anterolateral. It is In any child who attends with repeated injuries there must be
usually unilateral and the foot is spared. Fracture is common a thought regarding the possibility of non-accidental injury.
by age 3. Treatment is extremely challenging – Bracing, exci- This would need to be excluded first and foremost. I would
sion and bone grafting, Ilizarov callotasis and amputation all then consider underlying causes for recurrent fractures such
have their advocates. In contrast, posteromedial bowing is as osteogenesis imperfect, metabolic bone problems such as
usually benign ±LLD. vitamin D deficiency or just bad luck! We all know that
injuries can occur with very minimal trauma if the mechan-
ism is correct and we do see many children who have
Scoliosis multiple injuries throughout childhood because they are very
The spine is the most common site of skeletal involvement. active.
There are two types: Dystrophic and non-dystrophic. However, the recurrent injuries with minimal trauma and
Features of non-dystrophic scoliosis are similar to those of particularly the olecranon fracture would make me suspicious
idiopathic scoliosis. of osteogenesis imperfecta (OI). That injury is particularly
Features of dystrophic scoliosis include: common in OI.
Posterior vertebral body scalloping (saccular dilatation of EXAMINER: What would you do to confirm a diagnosis of OI?
the dura)
CANDIDATE: In the first instance I would take a history, including family
Enlarged neural foramina (dumb-bell tumour)
history to establish any inheritance. Then I would examine the patient
Rib or transverse process pencilling looking particularly for blue sclerae or dentinogenesis imperfecta.
Short, tight, sharply angulated curves that involve only a Ultimately, however, the diagnosis will come from genetic testing usually
few vertebrae with severe apical rotation and wedging from a skin sample looking for the COL1A1 and COL1A2 genes.
Soft-tissue masses Mutations in these genes are responsible for the vast majority of cases of
Defective pedicles OI. I would also take some blood tests to exclude other causes such as
vitamin D deficiency.
Management EXAMINER: How would you classify this child?

CANDIDATE: The Sillence classification is the most commonly used
Non-dystrophic scoliosis is managed as idiopathic scoliosis.
classification:
A dystrophic curve is relentlessly progressive even when
growth has finished, cannot be controlled by bracing and Type I – Mildest and most common form, which may present with
requires early fusion. There can be associated kyphosis, and fractures in childhood. Typically fractures stop when they reach
correction deformity carries a high risk of paraplegia, pseu- skeletal maturity. They have blue sclerae and may or may not have
doarthrosis and loss of correction after anterior and posterior dentinogenesis imperfect
fusion. Neurological involvement is common and may be Type II – Fatal in the perinatal period
caused by the deformity itself, soft-tissue mass, intraspinal Type III – The most severe of the survivable forms of OI. They have
tumour or dural ectasia (saccular dilatation of the dura). white sclerae and typically have tooth involvement. They present with
MRI is, therefore, mandatory preoperatively. It is not the multiple fractures, progressive deformity of long bones and scoliosis.
condition itself that is the problem, but the extent of expres- Their ambulatory potential is limited by their fragility and deformity,
sion of the disease. traditionally ending up in a wheelchair
028
Type IV – Lies between types I and III. They will have multiple EXAMINER: Indeed. What are the other types in that classification?
fractures but do not necessarily develop any deformity. They have CANDIDATE: Type I is the mildest, with blue sclerae and occasional
white sclerae and may or may not have tooth involvement fractures in childhood. Type II is lethal in the perinatal period. Type III is
This was the original classification but there have been many additions since the most severe type with progressive deformity, scoliosis and multiple
this point. There have been nine subsets identified, but only type V is clinically fractures. Type IV is between types I and III with moderate numbers of
distinct. These children develop ossification of the forearm interosseous fractures, but deformity is relatively unusual, they have white sclerae.
membrane and get dislocation of the radial head. They are also prone to I know that they have added several other types of OI, but I think that type
developing hypertrophic callus formation following minor injuries which can V is the only one which is clinically distinct. They get ossification of the
easily be confused with an osteosarcoma. The other four groups have different interosseous membrane of the forearm and hypertrophic callus formation.
genetic mutations, histological appearances or are seen in specific populations. EXAMINER: So, if we assume that this child has got type III OI with this
deformity, what management would you advise?
For this child, I think it is most likely that she would be a type IV;
CANDIDATE: Assuming that the child has got ambulatory potential then
however, if she had blue sclerae I would revise that to type I.
I would advise osteotomy and intramedullary rodding with a growing rod.
EXAMINER: How would you manage her olecranon fracture?
This will provide them with straight limbs to support weight-bearing,
CANDIDATE: If it was displaced then I would treat it with a tension-band reduce the risk of fractures and prevent further deformity.
wire as I would with any other child. Children with OI will get fractures
EXAMINER: What age would you recommend the surgery?
easily but they heal normally. The problem is that they heal with OI bone
CANDIDATE: As soon as they show ambulatory potential. We know that
and so are just as prone to develop further fractures in future.
weight-bearing is good for increasing bone density and reducing fractures.
EXAMINER: What is the underlying defect in OI?
Getting them up and mobile is extremely helpful, and correcting their
CANDIDATE: It is a defect in the production of type I collagen. That defect mechanical axis helps reduce further injuries.
may be quantitative and qualitative. For instance in type I, the disease is
EXAMINER: What would you warn the family about before the surgery?
quite mild because the defect in quantitative. The collagen produced is
CANDIDATE: I would tell them that there is a bleeding problem in OI and
normal it is just that the levels produced are subnormal. Whereas in type
that we may need to give a blood transfusion. I would warn them that
III, there are reduced levels of collagen but they themselves are also
there is a risk of fracture in doing the rodding itself, and in particular
abnormal giving limited function.
trying to splint them for healing before you manage to rod all four bones.
EXAMINER: Indeed. Let’s move on.
I would tell the family that they will definitely require repeat surgery
through life as they will grow and need the rods exchanging, hopefully
The candidate is shown an x-ray of a lower limb in a child of
without osteotomy. When they reach skeletal maturity then it is advisable
2 with severe bowing in the sagittal plane and multiple trans-
to change the growing rods to a more rigid locked nail.
verse sclerotic lines running parallel to the physis at either end of
EXAMINER: Okay – Let’s move on.
the long bones.
EXAMINER: Tell me what you see on this x-ray?
CANDIDATE: These are AP and lateral projections of the right lower
Pes cavus
limb of a small child, approximately 2 years of age. The most obvious Definition
abnormality is significant bowing of the femur and tibia in the
A high-arched foot deformity where the longitudinal arch fails
sagittal plane. There does not appear to be any deformity in the
to flatten with weight-bearing. There is fixed plantar flexion of
coronal plane but this is difficult to say for sure due to the angulation.
the forefoot relative to the hindfoot. Clawing toes are almost
There are multiple transverse sclerotic lines related to each physis.
always present and the hindfoot is generally in varus.
EXAMINER: Yes. What would your guess be regarding the diagnosis?
CANDIDATE: I would guess that it would be OI due to the severe bowing
only in the sagittal plane, the deformity being mainly diaphyseal and the
Classification
multiple sclerotic lines look like they have probably been caused by
Congenital
bisphosphonates. Idiopathic
EXAMINER: Yes they are bisphosphonate-related sclerosis. What is the role Arthrogryposis
of bisphosphonate treatment in OI? Residual congenital talipes equinovarus
CANDIDATE: Bisphosphonates reduce osteoclastic activity and so prevent
bone resorption. In children with OI where the bone density is reduced,
Acquired
preventing resorption can increase bone density and help to reduce the Neuromuscular disorders
risk of fractures and progressive deformity. Muscular: Muscular dystrophies
EXAMINER: From those x-rays, what type of OI do you think that this child Peripheral nerves: hereditary motor sensory neuropathies (HMSN), polyneuritis
has got? Spinal cord: Spinal dysraphism, polio, spinal tumours, tethered cord, spina
CANDIDATE: According to the Sillence classification I would put her as a bifida
type III. There is significant deformity in a young child putting her in the Central: Cerebral palsy, Friedreich’s ataxia, Charcot–Marie–Tooth disease
most severe survivable type. Trauma: Compartment syndrome, crush injuries
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Most idiopathic cases are simple cavus, whereas neurological Consider transfer of tibialis anterior into the midtarsal
cases are usually cavovarus. Two-thirds of cases have a neuro- region for flexible inversion deformity
logical cause and most of these are HMSN. The cause of pes
cavus is neurological until proven otherwise. Therefore, a Jones procedure
thorough neurological examination is mandatory. Unilateral Performed for clawing of the hallux with associated
cases are less likely to have a neurological cause. weakness of tibialis anterior muscle
Coleman’s lateral block test assesses hindfoot flexibility in This procedure involves transferring the extensor hallucis
the cavovarus foot. A flexible hindfoot corrects to neutral longus to the neck of the first metatarsal with arthrodesis of
when a block is placed under the lateral aspect of the forefoot. the IP joint
This test relies on the ‘tripod’ of the first and fifth metatarsals Improves dorsiflexion and removes deforming forces at
and the calcaneus. Hindfoot mobility is an important factor in MTP joint
surgical planning. The most common complication is non-union of the IP
joint
Idiopathic pes cavus
This is a diagnosis of exclusion. Operative options for rigid deformities
Presents in adolescence/adult life Calcaneal osteotomy
Pressure effects on the deformed foot Dwyer medial opening wedge osteotomy
Painful calluses are present under prominent Performed for hindfoot involvement
metatarsal heads Usually combined with plantar fascia release
±Associated claw toes – Callosities over the dorsum of IP Translate the distal and posterior calcaneal fragment
joints laterally
Neuromuscular pes cavus Beak triple arthrodesis

Presents earlier with concern about the appearance of the Indicated in rigid deformity once growth has ceased
foot, difficulty with shoe-fitting, excessive uneven shoewear The technique involves mortising the navicular into the
(lateral aspect of the forefoot) and recurrent ankle giving head of the talus and depressing the navicular, cuboid and
way into inversion cuneiforms to improve the forefoot cavus deformity
Loss of sensation can lead to ulcers over prominent bones Lengthening of tendo-Achilles may be required
(fifth metatarsal) This procedure is complex and technically demanding
Radiology Examination corner

Standing AP and true lateral views. The first metatarsal and Paeds oral
talus long axes should be in line. The ‘Meary’ angle is measured Clinical photograph of pes cavus deformity
between them. Discussion of the Jones procedure
Management
Non-operative management has met with limited success, and
Congenital talipes equinovarus (CTEV)
includes stretching programmes, arch supports, ankle foot Definition
orthoses and special shoes. A deformity in which the forefoot is in adduction and supin-
Operative options for supple deformities ation, and the hindfoot is in equinus and varus.
Plantar release with or without tendon transfers
Epidemiology
Indicated in children <10 years old
1/1000 Caucasians, 3/1000 Polynesians
Fascia is cut while applying tension by dorsiflexion to the
Female : Male 2 : 1, bilateral 50%
metatarsal joints
Release of the abductor hallucis fascia is usually included.
The neurovascular bundle is traced distally from beneath
the abductor hallucis fascia and is thereby preserved
Syndromic associations
Medial release may be indicated in fixed varus angulations. Arthrogryposis
This involves releasing the medial structures such as the Streeter’s syndrome (constriction bands)
talonavicular joint capsule, the superficial deltoid ligament Möbius syndrome
and possibly the long toe flexors Larsen syndrome (autosomal recessive)
028
Pierre Robin syndrome (X-linked recessive) Forefoot: Inverted, adducted with forefoot supination
Diastrophic dwarfism (autosomal recessive) relative to the hindfoot (forefoot varus)
Freeman–Sheldon syndrome (autosomal dominant)
Clinical assessment
Aetiology Examine the whole child to exclude associated
Despite much research, the exact pathogenesis and aetiology abnormalities: Myelomeningocele, intraspinal tumour,
remain obscure. Most infants who have clubfoot have no diastematomyelia, polio, CP
identifiable cause. In this idiopathic group the cause is con- Also look for any associated developmental syndrome:
sidered to be multifactorial, including genetic and environ- Arthrogryposis, diastrophic dysplasia
mental components. Theories include: Look for other moulding conditions
Primary germ plasm defect Examine the spine (neurological cause)
Mechanical moulding theory: Fallen out of favour in Pulses: Usually present but vascular dysgenesis is possible.
recent years Dorsalis pedis artery may be absent
Neurogenic theory: Histochemical abnormalities secondary Examine foot creases: Medial, plantar, posterior
to denervation changes in various muscle groups of the leg/ Affected limb may be shortened, calf muscle is atrophic,
foot and foot is short compared to opposite side
Neurogenic imbalance deformity: Defect in nerve supply
(the incidence of varus and equinovarus deformity in spina Scoring systems
bifida is approximately 35%) The Pirani scoring system is a widely adopted scoring system
Myogenic theory: Primary muscle defect. Predominance in based on three midfoot and three hindfoot features. Each is
type I muscle fibres, fibre type IIB deficiency considered on a range of normal (0), moderately abnormal
Arrest of normal development of the growing limb bud (0.5) or severely abnormal (1). Maximum score is 6 points:
Congenital constriction bands/rings Hindfoot contracture score (maximum score = 3 points)
Retracting fibrosis: Increased fibrous tissue in muscles and :
Posterior crease
ligaments :
Equinus rigidity
Viral infection aetiology (variably demonstrated through :
Heel configuration
seasonality) Midfoot contracture score (maximum score = 3 points)
Heritability is well established. A polygenic model is most : Medial crease
likely, although an autosomal dominant gene with variable
penetrance is also a possibility
: Talar head coverage
: Curvature of the lateral border
The Clubfoot Assessment Protocol (CAP) is a more compli-
Pathology cated system based on the degree of joint mobility.
Mal-alignment of the talocalcaneal, talonavicular and
calcaneocuboid joints fixed by contracted joint capsules, Investigations
ligaments and foot/ankle tendons
Radiographs are not routinely taken in a newly presenting
Tendon contractures include tibialis anterior, extensor infant but may be of value if the case is resistant to therapy
hallucis longus, Achilles tendon, tibialis posterior, plantar
or other pathologies (e.g. congenital vertical talus) are
aponeurosis, abductor hallucis, flexor digitorum brevis,
suspected
extensor digitorum longus
MRI scan of the spine (if a neurological cause is suspected)
Ligament contractures include spring, bifurcate, deltoid,
calcaneofibular, talofibular and calcaneonavicular (spring) Radiographic assessment
ligaments
Weight-bearing AP view (kite’s)
Joint pathology On AP view the talocalcaneal (kite’s) angle is normally
20–40° (<20° is seen in clubfoot; Figure 25.23)
Ankle and subtalar joints: Are in fixed equinus
The first metatarsal talus angle is between the longitudinal
Hindfoot
axis of the first metatarsal and that of the talus and is
: Heel inverted (varus) normally 0–20° (a negative angle is seen in CTEV)
: Talus lies in equinus with its head palpable at the sinus
tarsi and marked medial angulation of the head and Forced dorsiflexion lateral view (Turco's)
neck talus Turco’s talocalcaneal angle is normally >35°. In CTEV, the
: Calcaneus is in equinus, varus and internal rotation angle is decreased and parallelism of calcaneus and talus is
Midfoot: Navicular and cuboid are medially displaced often seen
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028
There is now very good evidence that most idiopathic CTEV

can be successfully treated this way. Critics note that this
procedure is not a non-surgical technique in the strictest
sense – The Achilles’ tenotomy is commonly required and
later tibialis anterior tendon transfer is advocated in a signifi-
cant proportion.
Surgery
Posteromedial release
Incisions vary; however, the standard posteromedial
release has been performed through a medial
curvilinear incision, tracking the tibial neurovascular
bundle from the calf behind the medial malleolus and
into the foot. An alternative is the Cincinnati incision,
which is in the axial plane hemicircumferentially round
the hindfoot
Whatever the incision, it is mandatory to identify and
preserve the posterior tibial neurovascular bundle and,
where appropriate, the sural nerve
The release is generally undertaken on an ‘a la carte’
basis (i.e. incorporating release of structures in a
serial fashion until satisfactory correction has
been achieved). It can include: Z-lengthening of
tendo-Achilles
Divide and lengthen tibialis posterior, flexor hallucis
longus (FHL) and flexor digitorum longus (FDL)
Figure 25.23 Radiographic evaluation of clubfoot
Capsulotomies: Ankle posteriorly, subtalar joint,
calcaneocuboid joint
Management Release plantar ligament, abductor hallucis, flexor
The aim is to achieve a plantigrade, pliable, cosmetically digitorum brevis (FDB)
acceptable, pain-free foot (Ponseti). Up until the mid 1990s, Repair of tendons and insert K-wires into the talus and
soft-tissue surgery was often undertaken at around 1 year of calcaneus to hold reduction
age. Strapping and various splints were employed. The Ponseti
technique is long established but has taken time to gain wide Residual deformity
acceptance From the mid 1990s, it has become the treatment of Consider spinal cord MRI to rule out spinal lesion. Must
choice in all new cases. Surgery is now reserved for the very exclude a neurological cause. Residual deformity may be
small proportion of cases that do not respond. either:
Dynamic
Ponseti casting technique Fixed
Serial casts are applied weekly for approximately the first If it is dynamic, SPLATT (split anterior tibialis transfer) or,
6 weeks of life. The sequence of correction is: indeed, whole tibialis anterior tendon transfer is considered if
Correction of cavus – Always the sole aim of the first cast the patient is unable to evert their foot actively. A three-
Correction of adduction and heel varus incision technique allows harvesting, proximal pull-through
Correction of equinus and distal reimplantation (classically into the ossified inter-
Percutaneous Achilles tenotomy is required in 90% of cases mediate or lateral cuneiform). The foot is typically held in cast
(under local or general anaesthetic). Where this is required, for 6 weeks postoperatively.
a further cast is applied for 3 weeks post-tenotomy. Post- When the deformity is fixed, consider a repeat release if
reduction abduction splinting is required to maintain the there is not too much scarring and the patient is <5 years old.
position – For 23 hours per day for 3 months and then This is difficult, and in general poor results are reported. If
12 hours per day until age 5 (or as close to this as can patients are older than 5 years they may need bony procedures
realistically be achieved). Traditionally, this involved Denis to straighten the lateral border of the foot. The envelope for
Browne boots and bar; however, Mitchell boots are gaining successful treatment with Ponseti casting has been extending,
in popularity as they are well-tolerated by infants (and, and it can be attempted even in late presenting or relapsing
therefore, their parents) cases before surgery.
028
Bony surgery adduction deformity fixation of an aligned plantarflexed foot followed by further
Calcaneocuboid fusion (Dillwyn–Evans procedure) serial casting has recently been described and is a promising
Metatarsal osteotomy alternative approach.
These two procedures allow for lateral border shortening.
Lengthening the medial border of the foot is technically more Metatarsus adductus
challenging. A common (1/1000 live births) neonatal presentation
Involves adduction of forefoot at tarsometatarsal joints
Hindfoot deformity
Uncertain aetiology – Thought to arise by uterine close-
Varus heel packing
Opening medial wedge or laterally based closing wedge Historical association with DDH now disproved
osteotomy of the calcaneum Hindfoot and midfoot are normal
Residual cavus and adductus Bleck classified by degree of passive correctability
Wedge tarsectomy Most spontaneously resolve; the efficacy of passive
Triple arthrodesis salvage procedure for stiff, painful foot stretching is uncertain. Serial corrective casting for residual
in patients >12 years old deformity beyond 6 months of age. Surgery rarely required
This condition needs to be differentiated from skewfoot:
Ilizarov multiplanar external fixator
Also known as metatarsus varus, serpentine foot
Can be used as a primary procedure but is generally
reserved for recurrent CTEV Very rare
Medial forefoot, lateral translation of midfoot with heel in
Complications of surgery valgus
Overcorrection – A planovalgus overcorrected foot is a real Natural history uncertain – May resolve spontaneously,
problem that cannot be readily addressed and may require response to casting uncertain owing to multiplanar
hindfoot fusion deformity
Infection, wound breakdown
Stiffness/restricted range of movement
AVN of the talus
Calcaneovalgus
Dorsiflexion positioning of the feet is a common (1/1000
Scarring
live births) result of uterine close-packing
Rocker bottom deformity
May be associated with posteromedial bowing of tibia –
Residual deformity (undercorrection)
Both are benign
Foot generally spontaneously resolves over a period of
Examination corner weeks after birth
Serial casting may be considered if fails to correct to
Paeds oral 1: Clinical photograph of bilateral clubfeet beyond plantigrade
Discussion about causes: Arthrogryposis, dysraphism
It is important to differentiate from congenital
Association with DDH
vertical talus
: Congenital vertical talus is less flexible than
Congenital vertical talus calcaneovalgus
This rare condition is an important exclusion when evaluating : Congenital vertical talus navicular has fixed dorsal
a paediatric foot deformity. Its principal features are: dislocation on talus
The navicular is dislocated dorsally off the talar head
: A plantarflexion radiograph is diagnostic (see section
on congenital vertical talus)
There is equinus of the hindfoot
The cuboid is displaced dorsally
The dorsal soft tissues are tight
The plantar convexity of the foot gives a characteristic ‘rocker
Curly toes
bottom’ appearance. Common disorder in children
A lateral forced plantarflexion radiograph gives a pathog- Frequently runs in families
nomonic appearance of the forefoot remaining dorsal to and Often bilateral – Look for symmetrical deformity in the
misaligned with the long axis of the talus. opposite foot
Effective treatment is elusive. Serial casts to stretch dorsal There is malrotation of one or more toes along with a digit
structures must be supplemented by surgery. Traditionally this flexion deformity (contracture of FDL and FDB)
has involved single or two-stage releases; however, K-wire Noticed when child walks
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Almost always asymptomatic in the child, but highly Surgery may be indicated when pain cannot be
symptomatic for the parent! accommodated by footwear adaptations and/or significant
Child may occasionally complain of discomfort; their toe lifestyle modification
may catch when putting their socks on, callosity of the Metatarsal osteotomies tend to deliver better results, with
dorsum of the toe with footwear more proximal procedures, including cuneiform
osteotomy, being considered where metatarsus primus
Management varus is an issue
Reassurance is the mainstay of management
Surgical management involves FDL tenotomy at age
Pes planus
4 years Pes planus (flat foot) describes depression of the medial longi-
tudinal arch of the foot. There is associated valgus hindfoot
Girdlestone procedure is a flexor to extensor tenotomy that
has gone out of favour. It is technically difficult and often and supination/abduction of the forefoot on the hindfoot.
produces stiff toes in extension with a rotational element This is a very common presenting ‘problem’ to the
paediatric orthopaedic clinic
The crucial issue here is to differentiate between flexible
Examination corner and rigid pes planus. In a compliant child this is done by
observing the feet from behind and asking them to stand
Paeds oral 1: Clinical picture of child with curly toes
Management is conservative and operative on tiptoe. A flexible flat foot will then demonstrate an arch
(the great toe MTP joint acts as a windlass, ‘winding up’ the
plantar structures). At the same time the heel will correct
from valgus to neutral or even into varus (demonstrating
Juvenile hallux valgus normal subtalar function). If compliance is an issue, the
This is a lateral deviation of the great toe with apex at the MTP great toe can be manually wound into dorsiflexion and the
joint (where associated with medial prominence, it is a same features observed
bunion).
It is important to check that the Achilles tendon is not too
tight (and that dorsiflexion is possible beyond a plantigrade
Epidemiology position – If not, perhaps the flat foot is an ‘escape’
Variable prevalence – Approximately 25% of adolescents mechanism to allow an equinus foot to weightbear)
80% female Examination should include attention to the rest of the foot
Strong family history – X-linked dominant/autosomal and the lower limb
dominant with variable penetrance Radiographs are not indicated unless there are particular
Metatarsus primus varus is a risk factor (first to second indications (such as unexplained pain)
intermetatarsal ray angle of >10°)
Flexible pes planus
Assessment This is a normal variant in children and is almost
Usually asymptomatic – Check skin, mobility of foot joints, universally present in infants. Spontaneous elevation of the
shoewear longitudinal arch of the foot is the norm in the first
Be aware of central causes of muscle imbalance (CP, spinal 10 years of life
cord abnormality) Is a benign ‘problem’ (and arguably part of the normal
Standing AP and lateral radiographs of foot range!) in older children and adults and is almost never
responsible for symptoms
: First to second intermetatarsal angle (<9° normal)
: Hallux valgus angle (long axis of first MT and long axis There is evidence to suggest that expensive orthotic insoles
are not indicated and are not of any value in modifying the
of PP, <15° normal)
natural history of this condition. A recent study suggests
: Distal metatarsal articular angle (DMAA = first
there is a psychological cost in their indiscriminate use in
metatarsal shaft and perpendicular to first metatarsal
children
articular surface)
Reassurance is the mainstay of treatment. When exercise-
: Lengths of metatarsals
related fatigue pain is an issue, orthoses can be considered
Management Rigid pes planus

In contrast to many conditions, early intervention has not Is a rare problem, but when it occurs is generally caused by
been shown to positively influence outcome or reduce a tarsal coalition (also known as peroneal spastic flat foot),
subsequent need for surgery but important differentials include
028
Congenital vertical talus Harris view – Axial radiograph to visualize posterior and
Juvenile idiopathic arthritis middle facet
Trauma to subtalar joint Coalitions between calcaneum and cuboid and navicular
Requires treatment when symptomatic. and cuboid are rare
Prophylactic treatment to reduce abnormal joint
loading is controversial Clinical features
Tenderness at the location of the coalition
Tarsal coalition Antalgic gait
Valgus hindfoot which, on attempted correction, induces
Definition peroneal spasm (peroneal spastic flat foot) and discomfort
An autosomal dominant disorder of primitive mesenchymal Calf pain
segmentation and differentiation leading to fusion of tarsal Limited subtalar motion and peroneal tendon shortening
bones and rigid flat foot. The coalitions can develop from Increased laxity of the ankle joint
fibrous (syndesmosis), through cartilaginous (synchondrosis),
to osseous (synostosis).
Investigations
AP, lateral and oblique at 45° hindfoot radiographs,
Epidemiology Harris view
Prevalence between 2% and 6% depending on diagnostic CT or MRI scan to rule out subtalar coalition.
method (clinical, radiographic) Coronal cuts are helpful in evaluating talocalcaneal bony
Bilateral in 50% bridges while transverse cuts are used for calcaneonavicular
Multiple coalitions occur in one in five cases bars
Three in four are said to be asymptomatic
Management
Calcaneonavicular (C-N) coalition Conservative
Most common tarsal coalition, occurs in two-thirds In children with mild symptoms
of cases
Natural history unclear but only 25% are thought to
Rigid flat foot with contracture of the peroneal tendons, develop pain
lateral foot pain and limited subtalar movement
Supportive insoles or below-knee plaster of Paris (POP)
Radiographs: Blunting of the subtalar process, narrowing cast can be used
of the posterior subtalar joint, elongated anterior calcaneal
However, many children who present with pain have evidence
process, talar beaking
of degenerative changes in the hindfoot. Opinion is divided
Calcaneonavicular bony bridges are seen on lateral concerning timing and indications for surgery. Some consider
radiographs with the classic anteater nose sign arising from activity modification, NSAIDs, immobilization in cast and
the calcaneus joint injection to be sensible first steps with surgery reserved
Presents between 8 and 12 years of age when ossification of for persistent cases. Others opt for surgery earlier.
the coalition occurs
Surgery options
Talocalcaneal (T-C) coalition Calcaneonavicular coalition
Coalition between the calcaneus and talus may occur in any Ollier’s approach: Wide bar excision such that one should
of the three facets. Usually involves the middle facet of the be able to see across to soft tissues on the medial side of the
subtalar joint foot through the excised bar. To prevent recurrence, all
T-C coalitions account for approximately one-third of cartilage must be removed from both the calcaneus and
tarsal coalitions navicular. Interposition of extensor digitorum brevis (EDB)
Pain in the medial side of the subtalar joint, repeated ankle into the defect reduces the risk of refusion
sprains. The patient is not able to take part in sports
Contraction and spasm of the peroneal tendons with forced Talocalcaneal coalition
inversion, reduced subtalar movements Medial limb Cincinnati incision: flexor hallucis longus
T-C coalitions tend to ossify at 12–15 years of age (FHL) lies just plantar to the sustentaculum tali and the
T-C coalitions may be difficult to see on radiographs, tendon can be used for orientation to the coalition anomaly.
which can often be normal. May see irregularity of the talus The FHL tendon sheath is incised, and the tendon is
and calcaneus joint surfaces and occasionally the C sign of retracted inferiorly. The sustentaculum tali and its associated
Lateur may be present coalition are identified. Once the coalition is resected,
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interposition of one half of the FHL tendon will decrease the deviation of the wrist, fingers flexed at the MCP joints and
chance of recurrence IP joints, thumb adducted (similar to Erb’s palsy
Subtalar arthrodesis: Performed when >50% of the middle deformity)
facet is involved, with recurrence (failed resection), or if Lower limbs: Flexion, abduction and external rotation hip,
significant degenerative changes in the tarsal joints exist teratological hip dislocations, knee contractures (flexion),
(talar beaking is not considered a degenerative change) equinovarus (clubfoot), vertical talus
Triple arthrodesis may be indicated for severe symptoms Spine: C-shaped neuromuscular scoliosis (33%)
with significant degenerative changes
Investigations
Arthrogrypotic syndromes To establish the underlying diagnosis. Consider paediatrician,
neurologist and clinical geneticist input.
Definition Nerve conduction studies, enzyme studies, muscle biopsy,
Congenital non-progressive limitation of joint movement chromosome analysis, collagen biochemistry, head scan
owing to soft-tissue contractures affecting two or more joints. (CT/MRI) and radiographs of the whole spine,
Many different subgroups exist but it is easier to group them anteroposterior pelvis and the involved limb
into three major categories:
Arthrogryposis multiplex congenita (classic form) Management
In association with major neurogenic or myopathic
Physiotherapy is an absolutely essential part of the manage-
dysfunction
ment plan. The aim of management is to obtain maximum
In association with other major anomalies and specific function, independent mobility and self-care.
syndromes
Elbow: Passive manipulation, serial casts, tendon transfer,
posterior elbow capsulotomy, possibly osteotomies after
Aetiology the age of 4 years. One elbow should be left in extension for
Exact cause is unknown; multifactorial, reflecting such a use of crutches when walking and the other in flexion for
heterogeneous group, but factors likely to limit fetal feeding
movement in utero appear important, together with, Wrist: Flexion deformity common. FCU to extensor carpi
possibly, intrauterine viral infection, teratogenic or radialis transfer and volar capsulotomy may be beneficial
metabolic causes Hand: Release of thumb and palmar deformity by adductor
pollicis lengthening; MCP joint fusion can be considered
Arthrogryposis multiplex congenita (amyoplasia) Hips: Two-thirds have hip dysplasia or dislocation. Surgery
Non-progressive congenital disorder with multiple is nearly always associated with stiffness, which can be
congenitally rigid joints more disabling than a dislocated, but mobile, hip. In
It is a sporadic disorder with no known hereditary pattern general, unilateral dislocation is managed surgically
Incidence is variably quoted to be from 1 in 3000 to 1 in because of concerns over LLD and asymmetry.
50 000 Management of bilateral hip dislocation is controversial
Joints develop normally in arthrogryposis multiplex and there are two schools of thought: Either medial open
congenita, but periarticular soft-tissue structures become reduction without risking disabling stiffness or leave it
fibrotic, leading to development of an incomplete fibrous alone. For a stiff, located hip following surgery, excision of
ankylosis and muscle atrophy the upper end of the femur may be required
Associated with a decrease in anterior horn cells and other Knees: Both fixed flexion and fixed extension are common,
neural elements of the spinal cord the former being most common with associated pterygium
possible. Fixed extension responds well to stretching and
Sensory function is maintained whilst motor function
serial casting, although occasionally quadricepsplasty is
is lost
required. Fixed flexion is difficult to manage and often
requires extensive posterior soft-tissue release with
Clinical features prolonged splintage. Femoral osteotomy with or without
Normal facies and normal intelligence. Head and neck shortening (avoids stretching the neurovascular bundle) is
movements are normal indicated for recurrence towards the end of maturity
Skin creases are absent and there is tense, shiny skin with Foot: The most common deformity is equinovarus; more
underlying muscle wasting rarely, vertical talus is seen. Severe equinovarus is
Shapeless featureless cylindrical limbs traditionally managed with extended soft-tissue release;
Upper limbs: Adduction and internal rotation of the however, serial casting has been a successful alternative.
shoulder, extension of the elbow, flexion and ulnar Recurrences may need talectomy. Congenital vertical talus
028
does not prevent the patient from standing and walking, Transient synovitis, irritable hip
but it may cause problems with shoewear. Surgical Juvenile idiopathic arthritis
correction is only carried out if absolutely necessary
Scoliosis: Early surgical intervention is recommended –
Either posterior spinal fusion alone or combined with Kocher’s criteria
anterior spinal fusion Offer good discrimination for septic arthritis of hip
The aim is to have finished surgery by the time the patient is Fever + non-weight-bearing + ESR >40 + WCC >12 =
7 years old, if possible. septic hip (where all 4 have a positive predictive value
(PPV) of 93%, 3/4 have a PPV of 73% and 2/4 have a PPV
of 35%)
Examination corner
Paeds oral 1: Clinical photograph of a child with congenital
arthrogryposis multiplex
Investigations
Spot diagnosis ESR, CRP, FBC, blood cultures (especially if pyrexial)
Discussion about hip dislocation and other associated Plain radiographs (accepting bony changes may take
syndromes 7 days)
Tc–99m bone scan – Sensitivity 89%, specificity 94%
MRI – Sensitivity 88–100%, specificity 75–100%
Bone and joint infection (CT – Occasionally to assess bony destruction)
USS – Highly operator-dependent – Used to assess hip
Epidemiology effusion
Common organisms remain Staphylococcus aureus, Aspiration – To obtain fluid for culture advocated where
coagulase-negative staphylococci, group A β-haemolytic possible by some; however, risk of false-negative aspirate
streptococci, Streptococcus pneumoniae and group (thick fluid or inaccurate needle placement) leads to
B streptococci. The advent of vaccination has reduced elective exploration by others
Haemophilus influenzae infection dramatically
Usually occurs in under 10s Synovial aspirate
The possibility of contiguous septic arthritis and Normal WCC <200/ml
osteomyelitis must be considered – The blood supply to the Juvenile idiopathic arthritis WCC 15–80 000/ml
epiphysis in those under 18 months old predisposes to this
Sepsis >50 000/ml
Aetiopathogenesis
Requires the presence of a virulent organism in sufficient Septic arthritis
numbers to overwhelm (possibly suppressed or sometimes Management is not universally similar in all centres, and
immature) host defences you could not be reasonably criticized for answering that
Metaphyseal predilection for osteomyelitis may reflect where clinically there is a high index of suspicion of a septic
acute angle of vascular hoops described by Hobo hip it is a surgical emergency requiring formal open lavage.
Localized trauma has a proven association This would usually be via a Smith–Peterson approach with
Varicella predisposes to bacterial infection by lowering a small anterior capsulotomy to gain access to the joint and
host immunity with samples sent to microbiology
In Glasgow, practice differs with aspiration (repeated if
necessary) being the mainstay of treatment with very
Clinical presentation comparable results
Fever, malaise, anorexia and pseudoparalysis are common The important principle is that pus under pressure in the
presenting features hip joint is highly destructive to the joint surfaces and
Antibiotics may blunt the symptoms needs to be removed as soon as possible
Bone pain/joint pain + fever = osteomyelitis/septic arthritis Empirical IV antibiotic therapy should be started as soon as
until proven otherwise samples have been sent
Differential diagnosis – Osteomyelitis The duration of IV therapy has been the subject of
Neoplasm (in leukaemia 30% have bone pain) discussion and it is now generally accepted that it does
Trauma (but not normally with raised ESR) not need to be continued for 6 weeks but rather can be
Eosinophilic granuloma converted to oral therapy when a good response is
Bone infarction reflected in improving clinical picture and inflammatory
Differential diagnosis – Septic arthritis markers
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Osteomyelitis Chronic recurrent multifocal osteomyelitis

Acute – Without abscess formation Inflammatory bone disease >6 months with exacerbations
:Can be managed expectantly with antibiotics alone and and remissions
monitor response Lack demonstrable organism
Acute – With abscess formation (subperiosteal, etc) 70% females, 90% multifocal
:Abscess may be at 3–5 days following infection Lytic metaphyseal lesion, raised ESR/CRP but normal
:Requires surgical drainage WCC, mimics osteomyelitis at onset
Chronic – Poorly defined transition from acute –c. Commonly tibia and femur
>3 weeks Differential: Ewing’s sarcoma, eosinophilic granuloma,
: Abscess within bone generally indicates a need for leukaemia
surgical drainage 90% show response to anti-inflammatory drugs
: Samples for microbiology and histopathology should
be sent Brodie’s abscess
: When there is advanced chronic osteomyelitis (with This is a chronic localized bone abscess. The lesion is typically
sequestrum, surrounding involucrum and cloacae single and located near the metaphysis of the bone. Preferred
draining pus to the surface), the surgical decision sites are proximal femur, proximal and distal tibia.
should be influenced by the extent of involucrum –
Sequestrectomy may be deferred until there is
structurally sound involucrum in selected cases. Clinical features
Recovery often exceeds expectation, and any Subacute cases present with fever, pain and periosteal eleva-
consideration of amputation should be deferred in a tion. Chronic cases often present without pyrexia with long-
paediatric population standing, dull pain. There may be a limp, often slight swelling,
Management with antibiotics continues with muscle wasting and localized tenderness. The patient has few
monitoring of response clinically and with lab markers signs or symptoms to suggest an infection. The white cell
of infection (ESR, CRP and FBC). Conversion to oral count is often normal but the ESR may be raised.
antibiotics can be considered when sustained improvement
is noted
Pathology
Typically a well-defined cavity in cancellous bone containing
Discitis seropurulent fluid (occasionally pus). The cavity is lined
The most common spinal infection in children by granulation tissue containing a mixture of acute and
May present with refusal to ambulate but normal lower chronic inflammatory cells. Typically no organisms are found
extremity examination but, if one is present, it is usually a Staphylococcus aureus
ESR and CRP usually elevated (60%).
Bone scan is best investigation
Radiology
Neonates Well circumscribed, round or oval cavity 1–2 cm in diameter,
Immune immaturity renders increased susceptibility. most often in the tibia or femoral metaphysis. Sometimes the
There are two groups cavity is surrounded by a halo of sclerosis (classic Brodie’s
: Neonatal unit infants with indwelling lines get abscess). Metaphyseal lesions do not cause a periosteal reac-
staphylococcus or Gram-negative infections, with tion, whereas diaphyseal lesions may be associated with cor-
multiple sites in 40% and are systemically unwell tical thickening and periosteal new bone formation. A bone
: ‘Normal’ infants out of hospital get group scan reveals markedly increased activity.
B streptococcus infections at a single site
Metaphyseo-epiphyseal infections occur and may be Differential diagnosis
contiguous with a septic joint Osteoid osteoma
Poor immune response means laboratory indicators are of Ewing’s sarcoma
limited value – WCC may be normal; ESR is usually raised Langerhans cell histiocytosis
50% have positive blood cultures Aneurysmal bone cyst
Bone scan of value Pigmented villonodular synovitis (PVNS)
Initial broad antibiotic cover is required Giant cell tumour
A septic hip requires emergency surgical treatment Non-ossifying fibroma
028
Management Primary tibia valga

Previous trauma: Asymmetrical growth arrest following
Brodie’s abscess is usually managed with biopsy and surgical
fracture
debridement followed by intravenous antibiotics.
Metabolic bone disease, particularly renal osteodystrophy
Examination corner Iliotibial band neuromuscular contracture: Polio
Infection: Causing asymmetrical growth arrest
Paeds oral 1: Brodie’s abscess
Diagnosis Tumours: Osteochondromas
Differential diagnosis Congenital: Congenital absence of the fibula
Further tests Unilateral genu valgum is strongly suggestive of pathological
Management genu valgum.
Options
Surgical management, including types of incision and Clinical examination
techniques
Is it unilatersal or bilateral? If bilateral, is it symmetrical or
The examiner wanted to know what kind of material is
asymmetrical?
seen at curettage
Measure standing and sitting height to rule out skeletal
Paeds oral 2: Radiograph of classic Brodie’s abscess in the distal
dysplasia
metaphysis of the radius
Measure the distance between the medial malleoli with
EXAMINER: These are radiographs of a young boy who presents knees touching. The mechanical axis can be assessed by
with a several-week history of localized pain and swelling in his dropping a plumb line’ from the centre of the femoral head
wrist. What do you think of his x-rays? to the centre of the ankle – In a teenager this line should
CANDIDATE: There is a well-defined cavity in the distal metaphysis of the bisect the knee
radius. There is no periosteal reaction but a halo of sclerosis surrounding Determine the site of valgus angulation, the degree of tibial
the lesion. The radiograph is suspicious of a Brodie’s abscess. torsion (tibia valga is associated with excessive lateral
EXAMINER: These are his MRI scans, which did confirm the tibiofibular torsion) and carry out Ober’s test to rule out
impression of a Brodie’s abscess. How are you going to treat him? iliotibial band contracture
CANDIDATE: I would treat him conservatively initially with IV antibiotics If genu valgum is marked, the symptoms include:
and see if it settles down. The condition may resolve in timef. If
In-toeing to shift weight over the second metatarsal so the
necessary, with recurrent flare-ups, the abscess should be curetted out. centre of gravity falls in the centre foot
EXAMINER: What you find is that the wall of the cavity becomes
Lateral subluxation of the patella
sclerotic and lined by a thick membrane and cannot be easily
Fatigue
penetrated by antibiotics. The patient is then prone to recurrent
flare-ups of pain. You need to go in and curette the cavity out. Management
95% resolve spontaneously
Angular lower limb deformity Consider surgery if the intermalleolar distance (between
medial malleoli when the child is standing with knees
Natural history touching) is >10 cm or >15–20° valgus at age 10 years
Physiological genu varum (bowed legs) gradually improves as the Hemiepiphysiodesis of the distal femur and/or proximal
child starts to stand and walk. By the age of 18–24 months the legs tibial growth plate by either stapling, ‘8’ plates or fusing the
are straight. By 2–3 years of age, lower limbs have evolved medial-side physis
naturally to genu valgum (knock-knees). There is a gradual If skeletally mature, carry out a tibial or femoral osteotomy
transition to physiological valgus by 7 years of age, by which Valgus deformity in adults is usually caused by:
time the leg has assumed a normal adult value of 7–8° valgus. Sequel to childhood deformity
Secondary to osteoarthritis or rheumatoid arthritis
Genu valgum Ligament injury
Aetiology Malunited fracture
Pathological causes of genu valgum include: Paget’s disease
Skeletal dysplasias: Multiple epiphyseal dysplasia,
Morquio’s syndrome, Ollier’s disease
Examination corner
f Paeds oral 1: Clinical picture of a child with genu valgum within the
Incorrect answer. Some older textbooks suggest that the lesion in
certain circumstances may be managed with oral antibiotics alone. physiological limit
Most orthopaedic surgeons would disagree with this and fail you if Discussion of whether this is normal or abnormal
you mention it as primary management of the condition.
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028
proximal tibial epiphysis with a line through the transverse

How will you assess this child in the outpatient clinic?
Management plane of the metaphysis. Normal is <11°
Tibia vara (Blount’s disease)

Genu varum Tibia vara is a growth disorder of the proximal tibial physis
Aetiology caused by repetitive trauma to the posteromedial proximal
tibial physis from early walking on a knee with physiological
Normal in children under 2 years old. Pathological causes include:
varus alignment. The aetiology of late-onset tibia vara is
Metabolic bone disease unknown. The infantile form is commonly bilateral and is
Vitamin D resistant rickets associated with internal tibial torsion. The late onset or adoles-
Vitamin D deficiency cent form presents as a painful, unilateral, slowly progressive
Hypophosphatasia varus deformity of the knee:
Asymmetrical growth arrest or retardation Unilateral or bilateral, asymmetrical
Trauma Often a varus thrust
Infection The metaphyseal-diaphyseal angle (Drennan’s) >11°
Blount’s disease Upper tibial metaphysis is fragmented
Skeletal dysplasia: Metaphyseal chondrodysplasia, Upper tibial epiphysis slopes medially
achondroplasia, osteogenesis imperfecta
Upper tibial physis is widened laterally
Neuromuscular: Polio, spina bifida
Congenital: Deficient tibia with relatively long fibula Langenskiöld’s classification of tibia vara
Type I: Medial metaphyseal beaking
Type II: Cartilage-filled depression
Document height, weight and percentiles for age Type III: Ossification at the inferomedial corner epiphysis
Examine pelvis, knees and feet Type IV: Epiphyseal ossification filling the metaphyseal
Shortened limb relative to trunk may suggest dwarfing depression
condition Type V: Double epiphyseal plate
Document general appearance during standing and gait Type VI: Medial physeal closure
Assess deformity: Is there gradual bowing or abrupt
angulation? Management
Gait is characterized by painless varus thrust in
Bracing for Langenskiöld’s stage I and II disease in patients
stance phase
<3 years old
Measure the intercondylar distance: The distance between
Surgery for failed orthotic management and Langenskiöld’s
the knees when the ankles are held together
stages III–V
Internal tibial torsion: This is measured by the angular
Initial operation is proximal tibial valgus osteotomy
difference between the transmalleolar axis and the
distal to the tibial tubercle to avoid damaging the tibial
bicondylar axis of the knee
apophysis
Thigh-foot angle: This is measured with the child in the
If growth arrest has occurred, a physeal procedure also
prone position and knee flexed 90°, by observing the angle
needs to be performed, either stapling or epiphysiodesis of
of the foot and the thigh
the lateral tibial physis (selective closure of half of the
Indications for radiographs growth plate to allow the contralateral portion of the physis
to correct with growth) or, rarely, a partial physeal bridge
Deformity outside the normal range
resection with interposition fat. For late-onset tibia vara,
Deformity – Unilateral or asymmetrical carry out a tibial osteotomy below the growth plate with
Child over 3 years correction of the tibiofemoral angle
Positive family history (bone dysplasia, syndromes or renal
rickets)
Short stature or disproportion (bone dysplasia or Examination corner
endocrine disturbance)
Paeds oral 1
Spot diagnosis – Unilateral Blount’s disease
Radiographic evaluation
Differential diagnosis
Tibiofemoral angle: Measures varus severity Causes
Drennan’s metaphyseal–diaphyseal angle: Formed by Management
intersection of a line through the transverse plane of the
028
be expected to spot the diagnosis on a clinical photograph or

Paeds oral 2: Clinical photograph of a young child with mild bilateral radiograph (an overweight child with severe genu varum).
genu varum Recognition of the radiographic features of the disease is
CANDIDATE: This is a clinical photograph that demonstrates mild important.
bilateral genu varum. The most common cause of this is a benign
normal variant in which the knee will evolve into genu valgum
and then a normal adult valgus angle will develop in time. Congenital pseudoarthrosis of the tibia
EXAMINER: This child comes to clinic with her mother. The mother is This is a rare condition, with an incidence of 1/250 000. It is
worried about the appearance of the knees. How will you almost always unilateral. This is one of the most challenging
reassure her? conditions to manage in orthopaedics. The condition may not
CANDIDATE: I would say that it is a very common condition, which is be obvious at birth. It presents with a spectrum of disorders,
seen often in the clinic. In the vast majority of cases, it is just a ranging from anterolateral bowing to frank pseudoarthrosis or
feature of normal growth and development of the leg, and pathological fracture with an apex deformity.
corrects as the child grows. I would take a full history and perform
an examination to reassure the mother. I would want to exclude
any pathological cause for the genu varum.
Classifications
EXAMINER: (interrupts with) What pathological causes are you Boyd29
thinking about? Boyd’s is the best known and most complete classification of
CANDIDATE: Conditions such as Blount’s disease. the disease and the most appropriate one for use in clinical
EXAMINER: (interrupting) Come on, is the child black? How common practice. Cystic lesions tend to do better, whilst the dysplastic
is Blount’s disease in a young white girl with normal build? type is less favourable.
CANDIDATE: Not common. (Regains composure.) I would want to Type I: Born with anterior bowing and tibial defect
exclude rickets, a skeletal dysplasia or a syndrome. Other causes Type II: Born with anterior bowing and an hourglass
could include infection, trauma, tumours, but these are usually constriction. Spontaneous fractures occur before 2 years
unilateral. age. Often associated with neurofibromatosis
Next picture: clinical photograph of an obese girl, approximately Type III: Those developing bone cysts often at the junction of
15 years old, with severe unilateral genu varum with gigantism of upper and lower thirds. Anterior bowing may proceed or
the limb. follow a fracture
Type IV: Those originating in a sclerotic segment of tibia
CANDIDATE: (big influx of breath as answer is prepared) This is a
without narrowing or fracture. The medullary canal is
clinical photograph of a young girl, which demonstrates a severe
obliterated
genu varum of the left leg and gigantism of this leg. The situation
Type V: Those who also have a dysplastic fibula develop
is grossly abnormal and I would be worried about a pathological
pseudoarthrosis later
cause for the condition.
Type VI: Those with an interosseous neurofibroma or
EXAMINER: Can you name any causes that can give the limb this
schwannoma (very rare)
appearance?
CANDIDATE: The causes of gigantism are an arteriovenous (AV)
malformation, nerve tumours, neurofibromatosis, lymphoedema Management
of the leg, a neoplasm or idiopathic. Non-operative management includes prophylactic total con-
(Pass) tact bracing to try to prevent fractures or control developing
ones. Surgical management options include:
CANDIDATE: I did not sound very convincing to the examiners in
Intramedullary rodding and bone grafting
how I would have reassured the mother in the first picture or,
Vascularized fibular graft
more accurately, the examiners seemed unimpressed with my
answer. This was a failure to deliver the facts rather than any
Ilizarov frame
glaring omission. The examiner was making life just a little bit too Syme’s amputation
uncomfortable. In the second picture I had never seen anything ORIF includes excision of fibrous tissue at the pseudoarthrosis
like it before. Luckily I managed to say something sensible in my site, removal of sclerotic bone and correction of anterolateral
answer. The examiner was stony-faced and gave no feedback on angulation. Tibial pseudoarthrosis is a very challenging condition
my answer. Even a simple topic like genu varum can be made and optimal treatment is the subject of ongoing controversy.
difficult by an examiner’s line of questioning.
I think you need to be aware of this classification for the exam Complications
but without necessarily knowing specifics. You would, however, Re-fracture or non-union
Stiffness of ankle and subtalar joints
577
028
Limb shortening Mild deformity: Reconstruct

Progressive anterior angulation of tibia Severe: Amputate
Infection Intermediate: Obtain a second opinion
Repeated operations Reconstruction options include:
Soft-tissue scarring Posterolateral release to correct equinovalgus deformity of
the foot
Limb lengthening is indicated if the foot and ankle are
Fibular hemimelia relatively normal
Definition Syme’s amputation is ablation of the foot by ankle disarticu-
lation, producing a sturdy end-bearing stump that can be
This condition consists of a spectrum of anomalies from mild walked on.
fibular shortening to total absence of the fibula. It is the most
common long bone congenital deficiency.
Classifications Tibial hemimelia

30
Achterman and Kalamchi Definition
Type I: Hypoplastic fibula This condition represents a spectrum of deformities ranging
Type Ia: Proximal fibular epiphysis is more distal than normal, from total absence of the tibia to mild hypoplasia. It is often
and distal fibular epiphysis is more proximal than normal. associated with PFFD or a congenital short femur. This is the
There may be a ball and socket ankle joint only skeletal deficiency with a Mendelian pattern of inherit-
Type Ib: More severe deficiency with at least 30–50% of the ance. Both autosomal dominant and recessive patterns are
fibula missing and no distal support to the ankle described. Thirty per cent of cases are bilateral.
Type II: Complete absence of the fibula. Angular deformities of
the tibia are common and are associated with severe foot
and ankle problems (tarsal coalition, lateral ray deficiencies)
Classifications
Kalamchi (three types)
31 Based on radiographs, clinical appearance and functioning of
Coventry and Johnson (three types)
Based on the degree of fibular dysplasia and whether the the quadriceps mechanism:
deformity is unilateral or bilateral: Type I: Complete absence
Type I: Shortened fibula – Partial absence of upper portion Type II: Absence of the distal half of the tibia
Type Ia: Normal foot Type III:Hypoplastic
Type Ib: Equinovalgus foot
Jones classification
Type II: Complete absence of the fibula and foot
deformities, etc Classified into four types on the early radiographic appearance:
Type III:Bilateral Type I: Absent tibia
Type II: Proximal tibia present
Clinical features Type III: Distal tibia present
Type IV: Tibia shortened, proximal migration of the fibula
LLD always present
and diastasis. Distal tibiofibular syndesmosis
Anteromedial bowing with a dimple over the apex of
the tibia
Absence of lateral rays of the foot Clinical features
Equinovarus of the foot The involved leg is short with a varus or calcaneovarus foot
Stiff hindfoot with tarsal coalition, particularly talus and There is often a skin dimple over the front of the leg
calcaneus Quadriceps muscle is often underdeveloped or absent;
Ball and socket ankle joint there are various degrees of fixed flexion at the knee
Flexion contracture of the knee
Ankle and knee instability Management
Femoral shortening (if associated with PFFD) Reconstruction options
These include:
Management Distal fibulotalar arthrodesis or calcaneal-fibula fusion to
Management is difficult and complex. Generally, the following stabilise the hindfoot
principles apply in deciding on reconstruction vs amputation: Tibiofibular synostosis (fusion)
028
Tibial lengthening with epiphysiodesis of the ipsilateral Table 25.6 Causes of in-toeing and out-toeing
distal fibula and contralateral limb Causes of in-toeing Causes of
out-toeing
Amputation
Most common Persistent femoral
Through-knee amputation indicated in:
causes anteversion
Severe deformity Metatarsus adductus
If there is marked fixed flexion deformity of the knee Internal (medial) tibial
Knee is unstable torsion
Tibia is completely absent Femur and hip Persistent femoral Femoral
Avoid above- or below-diaphyseal amputations because of anteversion retroversion
associated problems with overgrowth of the residual diaphysis. Spasticity of internal Flaccid paralysis
rotators (CP) of IR
Leg and knee Internal tibial torsion External tibial
Popliteal cyst Genu valgum torsion
The common site is medial, originating in the gastrocnemius- Blount’s disease
semimembranosus bursa just below the popliteal crease. The Foot and ankle Pronated feet Pes planovalgus
cyst arises from the synovial sheaths of the surrounding Metatarsus varus Talipes
tendons and contains clear viscous fluid. In contrast to those Talipes equinovarus calcaneovalgus
in adults, they do not communicate with the knee joint and are
not associated with intra-articular pathology:
Presents at 5–8 years of age as a painless, firm, rubbery
about 3 cm by 2 cm; the skin overlying the swelling appears
swelling behind the knee
normal. The picture is very suggestive of a popliteal cyst.
Usually asymptomatic and of insidious onset; occasionally
EXAMINER: How will you manage this condition?
can cause vague mild local discomfort
CANDIDATE: Popliteal cysts are benign lesions, the vast majority
The mass is fluctuant and transilluminates. The rest of the
resolve in time, surgery is not indicated and parents should be
knee examination is normal
reassured about the condition.
Ultrasound and CT scan demonstrate the lesion well,
EXAMINER: How long on average do they take to resolve?
although this is not usually necessary unless the diagnosis
is in doubt CANDIDATE: Ninety per cent resolve over a 4-year period.
Management
Reassure the child’s parents that the lesion is benign; the vast
majority will resolve in time and the lesion should be left alone.
Assessment of rotational profile
There are very few indications for surgery: Generally presents as either in-toeing or out-toeing
(Table 25.6).
When the diagnosis is in doubt
Severe pain (check for other, more obvious, causes)
Sinister cause Foot progression angle (FPA)
There can occasionally be great parental concern about this Describes the direction in which the foot points during gait
swelling. The desire for surgery from parents must be fiercely with respect to the line of progression, and can be altered by
resisted because the majority (90%) resolve in time, surgery is any abnormality at any level in the leg. Normal –5° to +20°.
not without its risks and the cyst can reoccur following Average +10°.
excision.
Range of hip rotation (Staheli)

Examination corner Place the child in the prone position with their knee flexed at
Paeds oral: Clinical photograph of a child with obvious swelling at 90° and their ankle held in neutral position. The leg acts as a
the back of the knee protractor, indicating degrees of movement. Internal rotation
Spot diagnosis with discussion afterwards of management, (IR) is assessed by turning the legs away from the midline and
particularly how you deal with awkward parents demanding external rotation (ER) by turning the legs one at a time
surgery for their child (second opinion!). towards the midline of the body. Normally IR is <70°.
CANDIDATE: This is a clinical picture of a child, which shows an A value >70° suggests anteversion of the femur. A normal
obvious swelling in the popliteal fossa. The swelling appears to be value of ER is 20° and if it is <20° this suggests femoral
anteversion.
579
028
Ryder method Obstetric brachial plexus palsy

This calculates the degree of femoral anteversion. Place the This is said to occur in 1/2000 live births, with 75% of cases
child prone on the examination couch. fully recovering, though these figures are highly subject to case
Flex the knees to 90° and internally rotate the leg while ascertainment bias (i.e. it depends how hard you look for it).
palpating the greater trochanter. Rotate the leg until the The assessment of an older child with late presenting
greater trochanter is most prominent laterally. The degree obstetric brachial plexus palsy has been seen in the exam. It
of IR at this point corresponds with the degree of femoral is a challenging and highly specialized area of practice, but you
anteversion. must nevertheless have an appreciation of the condition and its
Anteversion is likely to be present if internal rotation consequences.
exceeds 70° and external rotation is <20°.
Aetiology
Thigh–foot angle (TFA) The cause is shoulder dystocia – In a cephalic delivery the
shoulders are too wide for the pelvis and the upper roots are
Tibial torsion is assessed by observing TFA. Flex the patient’s stretched to deliver the infant, whereas in breech delivery the
knee to 90° and hold the ankle in neutral position by applying lower roots are more vulnerable to being stretched.
gentle downward pressure on the sole of the foot. Estimate the
Risk factors include large birth weight, instrumented deliv-
angle made by an imaginary straight line along the axis of the
ery, C-section, breech.
thigh and an imaginary line along the axis of the foot. Nor-
mally, TFA is 10–20° in external tibial torsion. If it is <10°, this
indicates internal (medial) tibial torsion. Clinical picture
Presentation is of a flail limb or one with much reduced
movement – Classically held in the ‘waiters tip position’ for
Transmalleolar–thigh angle upper trunk (Erb’s) palsies
The transmalleolar axis is marked by palpating the medial and Assessment should pay attention to spontaneous shoulder
lateral malleoli joining the two points on the heel. A line elevation, elbow flexion and hand movements as indicators
perpendicular to this axis and the longitudinal axis of the thigh of root function
is assessed. The normal value is 0–45°. Less than this suggests Look for Horner’s sign (poor prognostic factor)
internal tibial torsion.
Narakas classification
Clinical approach This is done at 2–4 weeks of age:
In-toeing accounts for the greatest number of paediatric ortho- Group 1 = C5/C6, biceps and deltoid paralysis
paedic referrals in the developed world. Group 2 = C5/C6/C7, isolated long flexor function preserved
The natural history of most cases of in-toeing (owing to Group 3 = Whole plexus, slight finger movement only
wide normal variability in femoral anteversion) is of gradual Group 4 = Whole plexus ± Horner’s
spontaneous resolution over the first 7 or 8 years of life.
It is important to rule out an underlying pathology such as Differential diagnosis
undiagnosed cerebral palsy or, in the case of out-toeing, a Pseudoparalysis owing to isolated clavicular fracture
missed SUFE. (which improves within days)
Idiopathic in-toeing does not respond to orthoses – Its Arthrogryposis
natural history cannot be influenced save by derotation osteot-
Cerebral palsy
omy which is certainly not indicated (unless persistent and
disabling beyond 10 years of age).
There is no evidence to support the assertion that in-toeing Natural history
causes spinal or hip problems, etc. Function spontaneously recovers in most cases
(neurapraxia), usually distally first
Residual problems generally involve the shoulder
Examination corner Biceps recovery before 2 months of age is a good
Paeds oral 1 prognostic sign; conversely, failure of biceps to recover by
Clinical measurement of anteversion of a femoral neck 4 months is a poor prognosticator
Paeds oral 2: Clinical photo of in-toeing Management

How do you assess this child? Initially exercises (physiotherapy) to maintain range of
movement (unopposed internal rotation of shoulder
028
eventually leads to posterior subluxation and remodelling US assessment of the shoulder is gaining popularity and is
of the shoulder joint) likely to lead to increased intervention as more cases of
Referral of cases that fail to resolve fully by 2–3 months posterior shoulder subluxation are identified
of age to supraregional obstetric brachial plexus The consequences of profound plexus injuries are dealt
palsy service is the norm in the UK with by tendon transfer and bony realignment surgery
Radiographs, MRI and neurophysiology may be about the shoulder (e.g. denotation osteotomy of the
required proximal humerus).
References complication and indication for

prophylactic pinning in slipped upper
classification of the femoral head
involvement. J Bone Joint Surg Am.
1. Salter RB, Harris WR. Injuries of the femoral epiphysis. J Bone Joint Surg Br. 1984;66:479–89.
ankle in children. Orthop Clin North 2006;88B:1497–501.
Am. 1974;5:147–52. 21. Catterall A. The natural history of
12. Murgier J, Reina N, Cavaignac E, et al. Perthes’ disease. J Bone Joint Surg Br.
2. Poland J. Traumatic Separation of the The frequency of sequelae of slipped 1971;53:37–53.
Epiphysis. London: Smith, Elder & Co; upper femoral epiphysis in cam-type
1898. 22. Herring JA, Neustadt JB, Williams JJ,
femoroacetabular impingement. Bone Early JS, Browne RH. The lateral pillar
3. Dias LS, Tachdjian MO. Physeal Joint J. 2014;96B:724–9. classification of Legg–Calve–Perthes’
injuries of the ankle in children: 13. Uglow MG, Clarke NM. The disease. J Pediatr Orthop.
Classification. Clin Orthop Relat Res. management of slipped capital femoral 1992;12:143–50.
1978;136:230–3. epiphysis. J Bone Joint Surg Br. 23. Rajan R, Chandrasenan J, Price K, et al.
4. Vahvanen V, Aalto K. Classification of 2005;86:631–5. Legg–Calvé–Perthes’: Interobserver
ankle fractures in children. Arch Orthop 14. Phillips SA, Griffiths WE, Clarke NM. and intraobserver reliability of the
Trauma Surg. 1980;97:1–5. The timing of reduction and modified Herring Lateral Pillar
5. Price K, Dove R, Hunter J. Current stabilisation of the acute, unstable, Classification. J Pediatr Orthop.
screening recommendations for DDH slipped upper femoral epiphysis. J Bone 2013;33:120–3.
may lead to an increased rate of open Joint Surg Am. 2001;83:1046–9. 24. Rudd J, Suri M, Heinrich S, Choate S.
reduction. Bone Joint J. 15. Daniel AB, Joseph B. Orthopaedic Outcome of arthroscopically treated
2013;95B:846–50. challenges in Asia. Epidemiology, femoroacetabular impingement in
6. Jones D. Neonatal detection of pathogenesis, and treatment of adolescents with slipped capital femoral
developmental dysplasia of the hip Legg–Calvé–Perthes’ disease: Current epiphysis and Legg–Calve–Perthes’
(DDH). J Bone Joint Surg Br. concepts. Curr Orthop Pract. disease. J Invest Med. 2014;62:426.
1998;80:943–5. 2013;24:28–33. 25. Stulberg SD, Cooperman DR,
7. Marks DS, Clegg J, Al-Chaldi AN. 16. Perry DC, Machin DM, Pope D, et al. Wallensten R. The natural
Routine ultrasound screening for Racial and geographic factors in the history of Legg–Calvé–Perthes’
neonatal hip instability: Can it abolish incidence of Legg–Calvé–Perthes’ disease. J Bone Joint Surg.
late-presenting congenital dislocation of disease: A systematic review. Am 1981;63:1095–108.
the hip? J Bone Joint Surg Br. J Epidemiol. 2014;62:426. 26. Weinstein JN, Kuo KN, Millar EA.
1994;76B:534–8. 17. Perry DC, Bruce CE, Pope D, et al. Congenital coxa vara.
8. Meyer MD, Weinstein SL. Acetabular Comorbidities in Perthes’ disease: A retrospective review. J Pediatr
dysplasia after treatment for A case control study using the General Orthop. 1984;4:70–7.
developmental dysplasia of the hip. Practice Research Database. J Bone Joint 27. Greulich WW, Pyle SI. Radiographic
Implications for secondary Surg Br. 2012;94B:1684–9. Atlas of Skeletal Development of
procedures. J Bone Joint Surg Br. 18. Kim H. Current concepts review: the Hand and Wrist, Second Revised
2004;86B:876–86. Pathophysiology and new strategies for Edition. Stanford, CA: Stanford
9. Tosounidis T, Stengel D, Kontakis G, the treatment of Legg–Calvé–Perthes’ University Press; 1959.
et al. Prognostic significance of stability disease. J Bone Joint Surg Am. 28. Hägglund G, Andersson S, Düppe H
in slipped upper femoral epiphysis: 2012;94A:659–69. et al. Prevention of dislocation of
A systematic review and meta-analysis. 19. Perry DC, Green DJ, Bruce CE, et al. the hip in children with cerebral
J Pediatr. 2010;157:674–80. Abnormalities of vascular structure palsy: The first 10 years of a
10. Phillips SA, Griffiths WEG, Clarke and function in children with population-based prevention
NMP. The timing of reduction and Perthes’ disease. Pediatrics. programme. J Bone Joint Surg Br.
stabilisation of the acute, unstable, 2012;130:126–31. 2005;87:95–101.
slipped upper femoral epiphysis. J Bone 20. Salter RB, Thompson GH. 29. Boyd HB. Pathology and natural history
Joint Surg Br. 2001;83B:1046–9. Legg–Calvé–Perthes’ disease. The of congenital pseudoarthritis of the
11. Maclean JG, Reddy SK. The prognostic significance of the tibia. Clin Orthop Relat Res.
contralateral slip: An avoidable subchondral fracture and a two-group 1982;166:5–13.
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30. Achterman C, Kalamchi A. Congenital

deficiency of the fibula. J Bone Joint
Further reading Benson M, Fixsen J, Macnicol M, Parsch K.
Children’s Upper and Lower Limb
Surg Br. 1979;61B:133–7. Alshydra S, Jones S, Banazkiewicz PA. Orthopaedic Disorders. New York, NY:
Postgraduate Paediatric Orthopaedics: Springer; 2011.
31. Coventry MB, Johnson EW. Congenital The Candidates Guide to the FRCS (Tr
absence of the fibula. J Bone Joint Surg and Orth) Examination. Cambridge:
Am. 1952;34:941–55. Cambridge University Press; 2014.
028
Section 7 The trauma oral
General principles, spine and pelvis

Chapter
26 William Eardley and Paul Fearon
Introduction Subject areas

Setting the scene We will try and break the topics into general revision blocks as
follows:
In order to pass the trauma viva you need to confer to the
1. General trauma topics
examiner that you have the required level of knowledge, prac-
tical exposure and experience that displays safe accepted prac- 2. Implants and principles of fixation – Biomechanics of
tice for a newly appointed day 1 consultant in a District trauma
General Hospital. 3. Paediatric conditions
The ability to demonstrate local and regional knowledge of 4. Spinal trauma
accepted trauma pathway networks, in view of the establish- 5. Pelvic trauma
ment of Major Trauma Centres (MTCs) in England, should 6. Miscellaneous – Compartment syndrome, amputation
not be underestimated, especially with the establishment of
bypass protocols and the management of complex and multi- General trauma topics
system injuries.
The viva will cover simple fracture management/complica- Trauma networks – Creation of MTCs
tions and postoperative care, and the questioning can be diverse Good trauma care involves getting the patient to the right
and probing focusing on how you would manage postoperative place at the right time for the right care. It has been estimated
complications, within the resources available to yourself. that by improving the organization of trauma care, an add-
Be prepared to be shown laminated photographs of itional 450–600 lives could be saved in NHS hospitals.
implants, clinical illustrations, x-rays, CT and MRI scans, as Regional Trauma Networks went live across England in April
these should all be part of your normal clinical exposure and 2012. These are based on agreed principles of care using local
patient management. models and implementation in each geographical area. A map
Anything from adult and paediatric fracture management is of the current English MTCs is available1.
on the table, and the ability to approach the scenario in a logical Regional models all follow similar pathways, looking at:
stepwise fashion should not be made light of or put down. Prevention
Clinical case scenarios will be discussed and we try to
Initial contact
construct answers that follow a logical pathway, such as:-
Prehospital assessment
Indications for surgery Acute trauma care
Operative options and “your own” preferred method Appropriate rehabilitation
and why?
Results from the Trauma Audit and Research Network (TARN)
Consent – Process of informed consent and ‘special cases’ – national audit show that 1 in 5 patients who would have died
E.g. Jehovah’s Witnesses before these networks were established are now surviving
WHO checklist, special equipment required and briefing a severe injuries.
theatre team Patients are best treated in specialist centres that aren’t
Patient positioning and draping always closest to their home. Similar to stroke and cardiac
Surgical approaches services, we know that whilst patients may spend longer in
Reduction and stabilisation methods an ambulance the expert care provided at MTCs saves lives and
How to avoid complications, any intraoperative tips? improves outcomes for patients.
Rehabilitation and postoperative outcomes Professor Chris Moran, National Clinical Director for
What does current literature show? Trauma for NHS England said:
This at least creates a comprehensive informed management ‘Our patients now receive much more rapid care from specialist
plan for the subject area that you are dealing with. trauma teams who can identify life-threatening injuries much
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Section 7: The trauma oral
quicker, access key tests such as CT scans faster and perform life- is non-linear and there is pronounced variation in the fre-
saving operations earlier’. quency of different scores. By stratifying patients this allows
‘Patients with complex fractures and soft-tissue injuries, which predictors of survival to be established when national results
often cause permanent disability and require specialist surgery are are compared.
also benefiting. Before, patients often waited 7–10 days before
being transferred to specialist units, now over 90% of patients are
transferred to the right hospital within 2 days.’ Management of polytrauma patients
As well as improving survival, a key aim of the Major Trauma This is a common exam scenario and basic logical principles
Networks is to improve the quality of life in the survivors. The need to be addressed and applied. The questioning can cover
networks have redesigned rehabilitation pathways to give the the following subject areas:
patients the best chance of recovery following surgery. It is Multisystem patient involvement – Again this is an easily
predicted that for every additional survivor, three further patients approached question, using an ATLS® approach,
will make an enhanced recovery, which hopefully will allow them remembering the basics and approaching the patients in a
to return to their families and to work2. This development was logical management sequence
achieved by the coordinated efforts from the National Clinical Multiple casualty scenarios – Mass casualty incidents offer
Director for Trauma, improvements in inclusive trauma path- significant challenges for prehospital and emergency room
ways, the British Orthopaedic Association Standards for Trauma workers. Fire, Police and emergency personnel must secure
(BOAST) and the National Institute Clinical Excellence (NICE) the scene, establish communications, define individuals’
guidelines on good quality care Additional secondary levers roles and responsibilities, allocate resources, triage patients,
included the Best Practice Tariff, CQUIN (Commissioning for and assign transport priorities. Pre-alerts to appropriate
Quality and Innovation) and Dashboards for Major Trauma. emergency departments (EDs) in Trauma Networks allows
transfer out of patients and reorganization of the available
Trauma Audit and Research Network (TARN) physical resources and availability and type of manpower.
Established in 1990 by The Universities of Manchester and Mass-casualty incident trainings is pivotal, to ensure a well-
Leicester. Their core work is supporting improvements in coordinated response, such as communications, incident
trauma care through audit and research. They ensure Quality management system and triage. The use of triage skills in
Data coordination, with regular and informative feedback. By mass-casualty scenarios can only be improved with
doing so then can offer responsive local reports and specific training and paper exercises and follow up discussions are
local improvement and publish National reports to inform the simple tools for initial education3, prior to simulated major
planning of trauma services. All of which creates improve- incidents
ments in Trauma Care. Multispecialties input and professional management of
Understanding the benefits and the risks associated with teams – This is closely related to communication skills,
different types of treatment is important for all patients. How- team management and having a coordinated approach in
ever, it is not generally appreciated that there are variations in the management of such patients. You should be familiar
the success of treatments in different hospitals. It follows that with local major incident plans, and your potential role if
there are probably opportunities to improve care. called into action
TARN has enabled a system to benchmark practice Prehospital management and treatment in the field –
through monitoring and publishing process measures, Treatment is often initiated in the field for life-critical
allowing on-going and continued appraisal and improvement injuries/massive haemorrhage. It is difficult to
for the system. compartmentalize treatment stages, as resuscitation and
Those who are injured may have one or many injuries and treatment needs to be dynamic. An excellent review
the Injury Severity Score (ISS) is an anatomical score that looking at an evidence-based, practical guide for the
measures the overall severity of injured patients. orthopaedic surgeon4 covers these points in depth, but
All injuries are assigned an Abbreviated Injury Scale (AIS) especially from the practical perspective
code and score from an internationally recognised dictionary Pelvic binders, there usage in prehospital setting, with
that describes over 2000 injuries and ranges from 1 (minor correct application at the level of the greater trochanter is
injury) to 6 (an injury that is thought to be ‘incompatible with expected. Familiarity with the different commercial brands
life’). Patients with multiple injuries are scored by adding is required. The need for AP pelvic x-rays post binder
together the squares of the three highest AIS scores in three release to ensure the absence of an open book pelvic injury
predetermined regions of the body. This is the ISS which can that has been well reduced by the binder is also necessary.
range from 1 to 75. Scores of 7 and 15 are unattainable because The application of external fixators in the ED has been
these figures cannot be obtained from summing squares. The greatly reduced by the usage of binders, and if a binder fails
maximum score is 75 (25 + 25 + 25). By convention, a patient to stabilise haemodynamically a pelvic patient, it is unlikely
with an AIS 6 in one body region is given an ISS of 75. The ISS that a fixator will have any additive effect
029
Chapter 26: General principles, spine and pelvis
Addressing haemorrhage in the multiply injured patient– there is always debate in the literature as to the exact ratio of
Bleeding remains the leading cause of mortality in injured blood products that should be given. The safest and efficacious
patients and a rational, contemporary approach to approach to initial resuscitation in major haemorrhage is: The
resuscitation is mandatory in candidates presenting for the early transfusion of warmed blood along with platelets and fresh
examination frozen plasma in a 1 : 1 : 1 ratio.
The ATLS® evaluation of the injured patient is seen as Further management and blood product replacement once
baseline. Detailing the recognition and classification of haem- the initial ‘trauma pack’ of these components has been adminis-
orrhage, similarly is a basic requirement. To score well on a tered begins to go beyond the remit of the examination. The
question regarding haemorrhage, the candidate must be able to candidate, however, should be able to produce an answer
detail current concepts on both fluid resuscitation, laboratory that safely addresses ongoing haemorrhage. An ATLS® type
evaluation of ongoing bleeding and pharmacological adjuncts re-evaluation of potential bleeding sites, consideration of inter-
to haemorrhage control. ventional radiology input and laboratory assessment of the
All hospitals receiving seriously injured casualties are now blood parameters are all acceptable approaches. The latter
mandated to have a major haemorrhage protocol. The candi- involves mentioning the use of rotational thromboelastometry
date is advised to read the protocol in the hospital in which (ROTEM)5. Whilst previously considered out with the know-
they work. Answering the question in this manner, with refer- ledge base of the orthopaedic trauma surgeon, ROTEM, a vis-
ence to their own hospital protocol or a case in which they coelastic method for hemostasis testing in whole blood, is
were involved is much more likely to be a successful grounding becoming increasingly commonplace in trauma resuscitation.
from where to score points. In essence this is bespoke, targeted blood product resuscitation
What triggers a major haemorrhage protocol to be initiated for ongoing blood therapy, based on the viscoelastic behaviour
is decided on a local level; hence, why candidates are urged to on in-vitro assessment of the patients’ blood clot. This is pre-
be familiar with their own unit’s response. In the generality, dominantly dealt with by the critical care team but it is import-
however, receipt of prehospital information of hypotension ant that candidates are aware of this for the examination.
(systolic blood pressure <90 mmHg) significant tachycardia Alongside initial management, administration of a major
(heart rate >120 beats/min) and penetrating trauma in the haemorrhage protocol trauma pack, evaluating or arresting
casualty with a significant injury mechanism are useful base- ongoing bleeding and assessing the individual clotting needs
line approaches. of the bleeding patient, administration of tranexamic acid
Once the patient has arrived in the ED, additional infor- needs to be detailed.
mation that informs the decision to activate the protocol is the Tranexamic acid (TXA) is becoming familiar in both the
presence of free fluid on ultrasound scan of the abdomen, a trauma and elective setting of orthopaedics. TXA is an antifibri-
raised lactate and diminished haematocrit. nolytic that competitively inhibits the activation of plasminogen
In addition to the ATLS® approach, the focus of the ortho- to plasmin, thus, preventing the degradation of fibrin, the pro-
paedic surgeon should be on ensuring that continuing extrem- tein central to the framework of blood clots formed in trauma.
ity bleeding is addressed. Pre-hospital tourniquet efficacy can Major studies in both the civilian and military environments
be limited and a low threshold for supplementing these with a (CRASH6 and MATTERS7 respectively) have demonstrated sig-
padded pneumatic tourniquet should be maintained. A pelvic nificant benefits of the administration of TXA in patients requir-
binder should be in situ already but if not, one should be ing blood product resuscitation, particularly those where major
applied. These measures help to arrest ongoing ‘orthopaedic’ transfusion is required. What has been demonstrated is that
sources of haemorrhage. timing is fundamental and TXA given within 3 hours of injury
Candidates should be aware of what constitutes the blood has a proven benefit compared to that given late.
product resuscitation response of their hospital in the major By becoming familiar with the major haemorrhage proto-
trauma patient and which personalities (haematologist/labora- col in their own hospital and structuring an answer among the
tory technician) are mobilized when a major haemorrhage lines suggested above, candidates should be able to practice
scenario is activated. The simplicity of the situation is that in safe trauma care and score well in the examination. Massive
the bleeding patient, whilst ongoing sources of haemorrhage transfusion protocols with the early delivery of blood, fresh
are being arrested, missing blood should be replaced with, not frozen plasma, platelets and tranexamix acid improves mortal-
surprisingly, warmed blood. ity. All MTCs will have their own protocols and currently there
The candidate may be asked to define massive transfusion. is now a move to utilizing the major haemorrhage packs in the
As with all aspects of trauma, multiple definitions exist and the prehospital setting with auditing of results.
unwary candidate may fall foul of attempting to commit too Trauma team make-up in the ED – This should be a simple
many definitions to memory. Keeping things simple and mem- question to answer, as long as a structured reply has been
orable, ‘massive transfusion is transfusion of the total blood thought out. It leads onto
volume in a 24-hour period’. Trauma team training – How do you ensure ongoing
The candidate then may be asked to detail the fluid that continuing education if not based in MTC – Knowledge
they give and the ratio of blood products administered. Again of simulation models such as the European Trauma
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029
Course/Advanced Trauma Life Support. How human vascular reconstruction. Any decisions to amputate should
factors play a pivotal role in the dynamics of a team and be made by two senior consultants experienced in trauma
ultimately patient outcome management. If reconstruction proceeds, peripheral nerves
Whole body CT scan. The appropriateness of early contrast should be tagged for later repair or attended to at the same
enhanced CT with immediate reporting has greatly sitting. Post-reperfusion compartment syndrome is common
enhanced the management of trauma patients, with and as such there should be a low threshold for fasciotomies
appropriate body zone surgery in a more timely fashion. (Be Pelvic packing – Extra peritoneal pelvic packing. The aim is
able to identify abnormal organ findings on a trauma scan) to directly compresses the life threatening retroperitoneal
Damage control orthopaedics and resuscitation. This bleeders causing a direct pressure and tamponade effect that
subject area is not an excuse to apply spanning external stops venous and arterial pelvic bleeding. This is a rapid
fixators and then leave the patient for colleagues to sort out method for controlling pelvic fracture-related haemorrhage
later. Patients not physiologically robust to undergo that can supplant the need for emergency angiography. As
definitive surgery even after resuscitation will need staged part of the damage control resuscitation process, there is a
management and further supportive care in an ITU setting. significant reduction in blood product transfusion after
Often temporary splintage/external fixators/pelvic packing, extra peritoneal packing and this approach appears to
etc, is part of the resuscitation process. Knowledge of reduce mortality in this select high-risk group of patients9
coagulopathy measurement, lactate, renal function and Interventional radiology – Needs to be utilized as part of
body temperature will be expected in the further the MDT resusicitive process with coordinated senior
management of these patients, and close working relations clinical decision making. Unit protocols are modelled on
with trauma anaesthetists and intensivists is paramount North America experience, one such example is the Eastern
Spanning external fixators – Be able to talk through Association for the Surgery of Trauma practice10. Broadly
spanning the knee, ankle, elbow. Open or close procedures? speaking after non-pelvic sources of blood loss have been
Appropriate pin sizes in relation to body zones and patient ruled out, patients with pelvic fractures and hemodynamic
habitus. Difficulties encountered and how you deal with instability or signs of ongoing bleeding should be
them are all acceptable questions considered for pelvic angiography. Additionally patients
Amputation – A full knowledge of the levels and the with CT-scans demonstrating arterial intravenous contrast
structures encountered will be needed. Be able to describe extravasation in the pelvis may require pelvic angiography
the creation of myodesis for stump stability. What is and embolisation regardless of hemodynamic status
involved in the rehab setting? A knowledge of specialist ITU resuscitation – Most patients with multiple injuries will
limb fitting centres, psychological support and vocational have a raised lactate level. With resuscitation, splintage of
training as necessary, will be expected limbs, fluid replacement and re-warming, lactate levels will
Revasculariation (BOAST 6 guidelines)8. The basics still begin to normalise. However, a period of supportive care
apply. Resuscitation and management of all life-threatening may be necessary and the ITU is the most appropriate
injuries must take priority. A full and comprehensive setting. With trends in lactate levels being more predictive
neurological examination must be undertaken and regarding suitability for patient robustness under
documented in the medical notes. The pulseless deformed anaesthesia, there needs to be continued communication
limb should be realigned/reduced and appropriately splinted. between both anaesthetic and surgical teams. With lactate
A repeat examination should be undertaken and again levels >2.5 mmol/l continued resuscitation and damage
documented before appropriate radiological imaging tests control should be practiced and it is only when the trend of
obtained. A devascularized limb requires urgent surgical lactate is <2 mmol/l, should total care be instigated11
exploration and should only be delayed to attend to life
threatening injuries. All Trauma networks in conjunction
with MTCs and trauma units must have an emergency BOAST 4 guidelines12
referral protocol with appropriate specialty involvement The management of severe open lower limb fractures is fre-
(orthopaedics, plastics, vascular, etc). The limb must be quently asked. Essentially best outcomes are achieved by timely
revascularized as a surgical emergency. Warm ischaemic specialist surgery, rather than emergency surgery by less
time (in surgery, the time a tissue, organ, or body part experienced teams. Patients need to meet both certain fracture
remains at body temperature after its blood supply has been pattern and soft-tissue injury pattern criteria.
reduced or cut off but before it is cooled or reconnected to a Fracture pattern
blood supply) varies depending upon level of amputation comminuted tibial fracture
and is muscle dependant. On average a warm ischaemic time Segmental fractures
beyond 4–6 hours for a limb is associated with a higher rate Fractures with bone loss
of amputation. The sequence of surgical intervention can be Soft-tissue injury:
critical. Temporary shunts followed by skeletal stabilisation,
Skin loss, such that direct tension-free closure is not possible
allow re-evaluation of limb viability prior to definitive
Degloving
029
Muscle requiring excision extension of a discharge/transfer summary and should include

Associated arterial injury ongoing health and social care plans
Wound contaminated with marine, agricultural or sewage The goals are:
Standards for practice and TARN audit are set out in the above To record important demographic and historic clinical data
reference, but essentially the BOAST 4 guideline requires: To record the present situation
1. Early identification of severe open fractures of the tibia To specific the likely longer-term prognosis, acknowledging
2. Joint care from orthopaedic and plastic surgeons uncertainty but remaining realistic
3. Surgical wound debridement and operative fracture To specify the rehabilitation needs, both specific and
stabilisation within 24 hours immediate and more general and longer-term
4. Definitive soft-tissue cover within 72 hours of injury To specify the risks still extant at the time of transfer
Improving quality of emergency care and rehabilitation after
BOAST 3 guidelines13 trauma has become an NHS priority. The Rehabilitation Pre-
scription was incorporated into the Best Practice Tariff (BPT)
Major pelvic and acetabular fractures must be managed with for Major Trauma to drive improvements in rehabilitation but
an established trauma network system with defined acknow- was having little impact after hospital discharge. Currently
ledged referral pathways. A mismanaged pelvic injury can lead Regional Trauma Networks are concentrating on the enhanced
to early death from haemorrhage or major disability while postoperative care to improve function, using acute and com-
delayed or poor management of an acetabular fracture can munity rehabilitation providers.
lead to accelerated osteoarthritis and avoidable permanent
hip dysfunction. Additionally urological, pain, and psycho-
social dysfunction is common. As well as pelvic and acetabular Examination corner
evaluation as part of the resuscitative procedure, an index of
Laminated radiograph of open book pelvis shown (Figure 26.1)
suspicion for urological injures is required and early contrast
EXAMINER: This is a 24-year-old motorcyclist who has come off his
studies and urgent senior urological input is necessary.
bike at high speed. He has been brought to casualty with a blood
Concerning open pelvic fractures, with wounds to the
pressure of 90/60 and a tachycardia of 130. How would you
groin, buttock, perineum, vagina or rectum, these require
manage this patient?
urgent bladder drainage by cystostomy tube and bowel diver-
COMMENT: The viva question is all about emergency resuscitation
sion with an end-colostomy (with washout). These demand
of the patient and not so much initially focused on the open book
urgent senior general surgical and urologist input. Any colos-
pelvis injury itself. Candidates have to recognise that this is a life
tomy should be sited in an upper abdominal quadrant remote
threatening injury and manage appropriately. The examiners are
from potential definitive pelvic surgical fixation approaches.
testing whether you have practically encountered this situation
Hip dislocations must be reduced urgently and then an
and are you safe dealing with this injury. These are serious
assessment of stability recorded. The neurovascular status
injuries. For the unwary if you don’t answer in an appropriate
before and after reduction must be documented. Skeletal trac-
fashion you will fail and you could end up quite easily with a
tion should be applied. If the hip remains irreducible or
unstable, then urgent advice should be sought from a specialist
in acetabular reconstruction. Immediate transfer should be
considered.
Post reduction, a CT scan must be done to exclude bony
entrapment and to assess hip congruence and the extent of
any fracture. These images should be referred to an expert in
acetabular fracture reconstruction promptly. Displaced frac-
tures requiring reduction and internal fixation should undergo
surgery by an acetabular reconstruction expert as early as
possible, ideally within 5 days but no later than 10 days from
injury.
Rehabilitation pathways post-trauma

The rehabilitation prescription reflects the assessment of
the physical, functional, vocational, educational, cognitive,
psychological and social rehabilitation needs of a patient.
Patients with an ISS >8 undergo an initial rehabilitation
prescription within 2–4 days of admission. The prescription
states how these areas will be addressed. The prescription is an Figure 26.1 AP radiograph demonstrating open book pelvis injury
587
029
double 4 if you are unsafe which will significantly reduce your

CANDIDATE: Three.
chances of getting through the exam.
COMMENT: The correct answer is that you would put a pelvic binder
CANDIDATE: I would manage him according to ALTS® principles,
on first as the pelvic injury be a severe life threatening injury
I would establish a patent airway with adequate ventilation and
this manoeuvre should help with haemorhage control. Two
oxygenation. I would give supplementary oxygen via a face mask.
personnel gently lift the patient up slightly whilst maintaining a
EXAMINER: His airway and breathing are fine.
neutral spinal position whilst a third person slides the binder
CANDIDATE: I would control any obvious haemorrhage, obtain underneath the patient. Log rolling a patient with a possible pelvic
intravenous access with two large caliber cannulas. I would send fracture should be avoided as this may exacerbate any pelvic injury.
blood away for cross-matching, FBC, U&Es, coagulations screen.
We think the examiner may have been probing the candidate
I would give 1–2l of normal saline or lactated ringers. as they sensed he/she hadn’t actually put a pelvic binder on a
EXAMINER: The patient already has been given 2 litres of normal patient and just read it from a book. Examiners seem to sniff out
saline by the ambulance crew. candidates who have just read facts from a book rather than
CANDIDATE: I would give a further unit of normal saline until the having ‘on the job’ practical experience. They may then tailor
blood arrives. their questions to confirm this initial impression. Ultimately
EXAMINER: What are the dangers in giving large amounts of candidates lacking practical experience may lose scoring
crystalloid or normal saline in trauma patient. Is it safe practice? opportunities
CANDIDATE: (Pause and hesitancy) No. EXAMINER: How are you going to manage his patient’s low blood
COMMENT: The candidate didn’t get the chance to fully answer the pressure?
question. CANDIDATE: I would cross-match for 4 units of blood.
EXAMINER: How long does cross-match blood take to arrive in EXAMINER: When would you give this blood?
casualty? COMMENT: The patient needed O-negative blood immediately.
CANDIDATE: About 40 minutes. Pelvic fractures are one of the true (few) life-threatening
EXAMINER: You would be lucky if that was the case in our hospital. orthopaedic emergencies. The overall mortality rate is between
COMMENT: We think this is the examiner prompt that O-negative 10% and 20%, and this jumps to 38% if the patient is hypotensive
blood should be given instead of crystalloid. on admission, and to 50% if the patient has an open pelvic
EXAMINER: What about the pelvis? fracture. Underestimating the hemodynamic status of young
CANDIDATE: I would apply a pelvic binder. patients can be fatal, particularly because the retroperitoneum
can contain up to 4 l of blood.
EXAMINER: How do you apply a pelvic binder?
CANDIDATE: (No answer)
CANDIDATE: The ambulance crew should have applied this at the
scene of the accident. EXAMINER: Are you going to wait for cross-matched blood to arrive?
COMMENT: We don’t think this was a good answer to give in the CANDIDATE: I would give him O-negative blood.
exam and suggests the candidate doesn’t know. COMMENT: The candidate wasn’t convincing, an afterthought
EXAMINER: The ambulance crew haven’t done it. How do you put a or guess that this was what the examiners wanted. We are
pelvic binder on? not sure if the viva was recoverably at this stage but if it had
suddenly clicked for the candidate they should have
CANDIDATE: I would use the ones provided in casualty and wrap it
emphasized the need for immediate aggressive resuscitation and
round the pelvis.
gone on to discuss massive transfusion policy instead of letting
EXAMINER: The binder should be centered over the greater
the examiner continue to be in charge of the viva situation.
trochanter and not placed over the iliac crest or abdomen, as this
EXAMINER: What about a massive transfusion policy?
is ineffective. This provides the best mechanical stability of the
pelvic ring structures. A misplaced binder may exacerbate a pelvic CANDIDATE: Successful management of major haemorrhage
fracture if there is an injury through the iliac crest. When placed requires a protocol-driven multidisciplinary team approach with
too high it will also obstruct access for laparotomy. involvement of medical, anaesthetic and surgical staff of sufficient
seniority and experience, underpinned by clear lines of
Do you log roll the patient first and check for spinal injury or do
communication between clinicians and the transfusion laboratory.
you just put on the pelvic binder?
I would give blood, platelets and fresh frozen plasma is a
CANDIDATE: I would log roll the patient and check for a thoracic
1 : 1 : 1 ratio.
and lumber vertebral injury as there is a high chance of coexisting
injuries. EXAMINER: What is in a local hospital shock pack?
EXAMINER: How many personnel does it take to log roll a patient? CANDIDATE: Red blood cells and fresh frozen plasma.
CANDIATE: Four. EXAMINER: In what values?
EXAMINER: How many personnel does it take to put a pelvic CANDIDATE: Four units of red blood cells, 4 units of FFP, 1 bag of
binder on? platelets and 2 bags of cryoprecipitate.
EXAMINER: It is variable depending on local hospital policy.
029
Debrief allowing bidirectional axial compression or the placement

of a lag screw through the plate
This viva is all about if you adequately identify and resuscitate
2. The other part is threaded and conical, to accept a locking-
a patient in Grade 4 shock. Managing the unstable pelvic
head screw
fracture is a four-step process: Identification, resuscitation,
immobilization, and transportation (to a trauma centre). Combination plates may be useful in certain fracture patterns
It puts the candidate on the spot as to if they would in which one aspect of the fracture would benefit from ana-
immediately give O negative blood. There was a lot of probing tomic reduction and compression (i.e. intra-articular compon-
of the practicalities of how you would apply a pelvic binder. ent), whereas another fracture component would benefit from
This is trying to get away from book knowledge to test whether bridging fixation (ie, comminuted metadiaphyseal portion)
a candidate has actually performed the procedure As follows, stainless steel 316L. This type of stainless steel is
Other potential causes of shock in trauma such as tension particularly effective as a surgical implant when in cold-
pneumothorax, cardiac tamponade, cardiogenic shock, neuro- worked condition. What makes the type 316L ideal as an
genic/spinal shock were not discussed. The use of anti- implant device is the lack of inclusion in this material. Material
fibrinolytics was not discussed. The candidate did not manage with inclusion will also contain sulfur and this is a key com-
to progress the topic beyond the basics of massive transfusion ponent to encouraging corrosion of metals. Stainless steel is a
In 2011, the CRASH-2 trial identified that tranexamic acid metal alloy metal. By adding the chromium (16%) element to
significantly reduced all-cause mortality, in trauma patients stainless steel, this metal becomes corrosion resistant. The
with significant haemorrhage, if given within 3 hours of injury. addition of carbon and nickel (7%) to stainless steel helps
stabilise the austenite to stainless steel. With surgical implants,
molybdenum is added to the stainless steel alloy that forms a
Implants and principles of fixation protective layer sheltering the metal from exposure to an acidic
Key viva themes – Plate design and use in orthopaedics environment. It has to be stressed that the ferrite element
You may be handed a plate and asked to talk about the should not be incorporated into stainless steel as this gives
following points: What is it/application/mode of action/mater- the metal a magnetic property, which is never used for surgical
ial/footprint/sizs of drill/taps/screws, etc. (Figure 26.2). implants as it could interfere with magnetic resonance imaging
As an example, Figure 26.3 is a precontoured anatomical (MRI) equipment. These areas of questioning may also come
plate made from stainless steel used in the management of up in the basic science viva, but be prepared to talk about
periarticular tibial plateau fractures. This plate is intended for equipment used in fracture management.
use on the lateral tibial plateau and has combination holes to You may be handed a wrist plate and asked the above
allow the insertion of both standard and locking screws, and points but then asked what you know about the DRAFFT
so forth. study? (Distal Radial Acute Fracture Fixation Trial)14.
The new combination hole has two parts: Questions are not only limited to implants, as you may be
1. One part has the design of the standard Dynamic asked to explain how a vacuum-assisted closure wound system
Compression Plate/Limited Contact Dynamic works. Under negative pressure, VAC® therapy with propri-
Compression Plate. (LC-DCPTM) The dynamic etary VAC® GranuFoam™ dressings applies both mechanical
compression unit (DCU) accepts a conventional screw and biological forces to the wound to create an environment
that promotes wound healing. These forces are known as
macrostrain and microstrain.
Macrostrain is the visible alteration that occurs when negative
pressure contracts the open-pore VAC® GranuFoam™ dressing.
Draws the wound edges together
Provides direct and complete wound bed contact
Figure 26.3 Combination plate. The combi holes allow placement of

conventional cortex and cancellous bone screws on one side and threaded
Figure 26.2 Multiple varied plates used in fracture management conical locking screws on the opposite side of each hole
589
029
Figure 26.4 AP pelvic

radiograph and non-locking screw options. It should resist angular (varus/
demonstrating broken valgus) collapse. The plate is anatomically precontoured to the
proximal femoral
metaphyseal zone of the proximal femur.
locking plate
COMMENT: The candidate took the harder option in describing
plate features. The other route to take is to say the fracture hasn’t
healed and at 7 months it looks like an established non-union has
occurred. One of the first points the candidate should have
mentioned is that infection must be excluded. The candidate
should try and steer the viva down to the factors that influence
fracture healing and then move onto treatment options. This then
becomes a less challenging viva.
EXAMINER: Why has the plate failed?
CANDIDATE: The most likely cause is non-union at the fracture site
with plate failure occurring secondary to fatigue failure. Even with
stable fixation with sturdy implants, plate breakage is a risk in the
absence of bony healing.
Proximal femoral fractures are usually managed with either a
dynamic hip screw or intramedullary nail so the use of a proximal
femoral plate would suggest a more complicated proximal
femoral fracture such as multifragmentary pertrochanteric or
reversed intertrochanteric.
The stability of a locked plate construct is related to the length
of the plate, cross-sectional area, the material properties, the
Evenly distributes negative pressure screw density and diameter about the fracture site and the use of
Removes wound exudate and materials that may cause unicortical vs bicortical screws.
infection It is important to achieve anatomic reduction, as the PF-LCP
Microstrain takes place at the cellular level, leading to cell does not allow controlled collapsed of the fracture fragments.
stretching induced by the open-pore VAC® GranuFoam™ Fractures that are inadequately reduced result in high varus
contact with the wound bed. strains at the fracture–implant interface. This leads to progressive
Encourages moist wound healing loosening of the locking screws, varus collapse of the fracture and
Promotes granulation tissue formation eventual plate failure.
Promotes perfusion through angiogenesis Multiple locking screws increase bony purchase of the femoral
Increases cellular proliferation and migration neck and are especially advantageous in fractures with significant
Reduces oedema bone loss. It is important to plan well for the surgery, ensure good
fracture reduction, template for the plate size, ensure the correct
There is considerable overlap between basic science ques-
sequence of screw placement is adhered to. I am familiar with use
tioning and trauma applications, and not having an under-
of the plate but would make sure the company rep was available
standing of the biomechanics will be identified in the trauma
if the theatre team were unsure or inexperienced with the kit.
oral.
Examination corner Pelvic and acetabular fractures

Trauma oral 1
Broken femoral plate shown (Figure 26.4).
High-energy pelvis fractures
Key viva themes – Principles of resuscitation and polytrauma,
EXAMINER: This 67-year-old male sustained a right intertrochanteric
femoral fracture after a fall fixed with a locking plate 7 months
treatment of major haemorrhage
ago. He presented to casualty last night with sudden onset of There are now BOA guidelines for the management of pelvic
right hip pain and inability to weight bear. and acetabular fractures. These are discussed below.
CANDIDATE: This is an AP radiograph of the right hip. It shows a Initial assessment – ATLS® principles and resuscitation
comminuted extracapsular fractured neck of femur, which has Major haemorrhage may occur after pelvic fracture; these
been treated with a locking plate. The locking plate has broken. injuries are frequently associated with other major life
There is implant failure. This looks like a periarticular limited threatening injuries of the thorax and abdomen. A protocol
contact large fragment locking femoral plate, which has locking for managing haemodynamic instability in pelvic fractures
is shown in Figure 26.5
029
Young and Burgess’ classification15

This is based on the mechanism of injury and severity of pelvic
fracture. Type A (lateral compression), type B (AP compres-
sion) and type C (vertical shear). Within the AP compression
(APC) and lateral compression (LC) categories there are three
further subtypes
AP compression
: APC I – Symphysis widening <2.5 cm
: APC II – Symphysis widening >2.5 cm. Posterior
ligaments intact
: APC III – Disruption of anterior and posterior SI
ligaments. High risk of vascular injury
Figure 26.5 Managing major haemorrhage Lateral compression
: LC I – Rami fracture with ipsilateral anterior sacral ala
compression fracture
The early application of a pelvic binder will aid : LC II – Rami fracture with ipsilateral posterior ilium
resuscitation, control haemorrhage and facilitate a fracture
laparotomy if required. Pelvic binders control bleeding by : LC III – LC II injury with contralateral posterior injury
compressing and stabilising fractures, not by significantly Vertical shear
reducing pelvic volume. Binders may be used in all Vertically displaced injury with anterior and posterior
fracture patterns and not just open-book injuries. When disruption
there is ongoing haemorrhage with haemodynamic Combined mechanical injuries
instability, blood products should be given and the
Combination of other injury patterns: Lateral
bleeding stopped either through angiographic
compression/vertical shear or lateral compression/AP
embolisation (where possible), or pelvic packing/
compression
tamponade. A CT scan should be performed once the
patient is haemodynamically stable
Severe displacement of the pelvis and marked posterior Tile classification16
disruption are poor prognostic signs. The presence of This is based on the integrity of the posterior SI complex
severe neurological and vascular injury suggests significant Type A – Stable ring. The SI complex is intact
instability Type B – Rotationally unstable. Partial disruption of the
Around 5–10% of pelvic fractures are associated with posterior SI complex. Often requires operative fixation
major urological injury and this must be actively excluded Type C – Rotationally and vertically unstable. Complete
as their presence suggests greater energy and instability. disruption of the posterior SI complex
Contrast studies and specialist input is required urgently as
intraperitoneal injuries require open repair. Open pelvic
fractures (with groin, rectal or vaginal wounds) require
Definitive management of pelvic fracture
early senior specialist input with diversion. Ensure the end- Non-operative – Undisplaced fractures, patient too ill or sig-
colostomy is sited in an upper quadrant away from any nificant co-morbidities.
potential pelvic surgical approaches
Operative management
Specialist input should occur within 24 hours from a
specialist pelvic unit for treatment advice and to facilitate Pubic diastasis – External fixation or plate fixation of pubic
transfer if required. Definitive surgical treatment should be diastasis via a Pflannesteil approach. If associated rami frac-
carried out within 5 days ture, use ilioinginal or stoppa approach and plate fixation. In
cases of anterior comminution or soft-tissue injury, an anter-
ior internal fixator may be used (INFIX), using supra-
Investigations – AP pelvis with pelvic inlet and outlet views. acetabular pedicle screws connected by a subcutaneous con-
CT scan is part of the pelvic ring evaluation process and will necting rod17.
give better detail of posterior ring injuries, define comminu- Sacroiliac disruption – Open reduction and anterior plate
tion and fragment rotation fixation or posterior trans-iliac rods or closed reduction and
A plain radiograph may show displacement of the posterior percutaneous sacroiliac screw fixation.
sacro-iliac complex or avulsion fracture of the transverse pro- Complications – Chronic pain, mental health issues, pelvic
cess of the lower lumbar vertebrae. Anterior lesions may include obliquity, leg length or rotational discrepancy, gait abnormal-
pubic rami fractures and diastasis of the pubic symphysis ities, urological and sexual disabilities are common after pelvic
591
029
CANDIDATE: I would manage this injury according to ATLS®

principles. Appropriate attention must be paid to airway
management, spinal immobilization, adequacy of ventilation and
provision of supplementary oxygenation.
There is a high likelihood of associated injuries. I would put out a
trauma call so the patient can be managed with a multidisciplinary
team involving general surgeons and anesthetists.
Significant shortening or external rotation of one of the
patient’s lower extremities on inspection suggests a VS or an
open book APC type pelvic injury.
The patient needs aggressive resuscitation, two large bore
cannulae in the antecubital fossa, bloods for crossmatching, start
IV fluids.
EXAMINER: What IV fluids would you give?
CANDIDATE: I would give crystalloid or normal saline.
EXAMINER: Which one?
Figure 26.6 AP pelvis showing open book pelvis injury
CANDIDATE: I would initially give normal saline as a bolus as this
provides transient intravascular expansion and further stabilisers
fractures. Nerve injuries are common after vertical shear frac-
the vascular volume by replacing accompanying fluid losses into
tures. Vascular injuries may be associated with the initial
the interstitial and intracellular spaces.
injury, and care must be taken during the ilioinguinal
approach not to injury the corona mortis vessel. Non-union, EXAMINER: Are there any dangers in giving normal saline?
mal-union and DVT. Morel–Lavalle lesions (closed degloving CANDIDATE: There is some concern about loss of first clot.
injuries that lead to significant soft-tissue injury). EXAMINER: Go on. What else?
CANDIDATE: I would follow ATLS® protocol.
Examination corner COMMENT: Balanced resuscitation – Do not blow the clot. The
candidate has hinted at this but should have expanded on their
Trauma oral 1
answer instead of letting the examiner control the viva.
Laminated radiograph shown of open book pelvis (Figure 26.6)
EXAMINER: Studies have shown a detrimental effect of large volume
This is a 41-year-old male paedestrian hit by a car.
of fluids in diluting clotting factors, reducing blood viscosity, clot
CANDIDATE: AP radiographs demonstrate an open book pelvis disruption from increased blood flow, increased risk of ARDS
injury. There is significant diastasis of the pubic symphysis and along with GI and cardiac complications.
widening of the right sacro-iliac joint. This is a type B (APC II) COMMENT: There is now a trend in giving blood early, thus,
injury. There is >2.5 cm symphyseal diastasis, widening of the avoiding the rapid administration of IV fluids (filler fluid) that has
sacroiliac joints caused by anterior sacroiliac ligament disruption. been traditionally promoted by the ATLS® guidelines. This
Disruption of the sacrotuberous, sacrospinous and symphyseal involved giving 2 litres of crystalloids and continuing with packed
ligaments with intact posterior sacroiliac ligaments results in the red blood cells (PRBCs) and fresh frozen plasma (FFP) if there was
open book pelvis. The intact posterior SI joint acts as a hinge transient or no response, with the aim of rapid restoration of
allowing the right hemipelvis to externally rotate but vertical intravascular volume and vital signs towards normal and
stability is maintained. achieving normotension.
COMMENT: Two other pelvic injuries that would be reasonable to Duke et al.18 provided a retrospective analysis of 307 patients
viva on would be a type APC III injury and a vertical shear (VC) admitted to a level 1 trauma centre with penetrating torso injury
injury. With an APC III injury there is complete disruption of the and a systolic blood pressure below 90 mmHg. Patients were
anterior and posterior SI ligaments. This is a completely unstable divided into two groups – One receiving standard fluid
injury with the highest rate of associated vascular injuries and resuscitation (SFR) and one receiving restricted fluid resuscitation
blood loss. (RFR). The SFR group received more preoperative fluid then the
A vertical shear injury is associated with complete disruption of RFR group (2275 ml vs 129 ml) and had a higher intraoperative
the symphysis, sacrotuberous, sacrospinous and sacroiliac mortality rate (32% vs 9%) and overall mortality rate (37% vs
ligaments resulting in extreme instability most commonly in a 21%). This was attributed to the effect of a large volume of fluids
cephaloposterior direction because of the inclination of the in diluting clotting factors and reducing blood viscosity and the
pelvis. There is a high rate of significant neurovascular injury and increase of blood pressure. RFR was beneficial as it allowed
haemorrhage. permissive hypotension (systolic blood pressure of 90) until
EXAMINER: How would you manage this injury? damage control surgery was achieved19.
029
The candidate didn’t know this info and was trying to second that required urgent laporotomy. However, if the Level 1 trauma
guess what the examiner wanted. This is quite an important new centre was 40 miles away, the pelvic binder could become loose
concept which challenges traditional ATLS® teaching. In the in the ambulance journey so it would be advisable to apply an
setting of uncontrolled hemorrhage, aggressive fluid resuscitation external fixator to the pelvis before transfer. I would personally
may be harmful, resulting in increased hemorrhagic volume and have a low threshold in applying an EF but also take advice from
subsequently greater mortality. the on call pelvic surgeons, as I would not want the fixator to
EXAMINER: You would want to give blood early. compromise any definitive pelvic surgery.
COMMENT: Massive transfusion protocol (1 : 1 : 1). Candidates COMMENT: This type of question is not in the standard orthopaedic
should also mention giving FFP and platelets to support clot textbooks and is testing a candidate’s practical knowledge and
formation and prevent disseminated intravascular coagulation. reasoning of real-life dilemmas as an NHS consultanta.
The use of activated Factor VII as an adjuvant to massive EXAMINER: How do you rule out an open fracture?
transfusion is recommended in some situations. CANDIDATE: It is important to recognise open fractures early they are
EXAMINER: What do we mean by massive blood loss? dangerous injuries with a mortality rate reported in some studies
CANDIDATE: Class IV haemorrhage >40% blood volume loss. as high as 50%. A rectal examination should be performed during
COMMENT: This wasn’t the answer the examiner was looking for. the initial evaluation. Blood in the rectum should raise the level of
Major haemorrhage is variously defined as suspicion for an open injury. Palpable bony spicules within the
rectum or vagina may be present indicating an open injury.
Loss of more than 1 blood volume within 24 hours (around 70
Wounds must be adequately debrided and irrigated.
ml/kg, >5 litres in a 70-kg adult)
Management includes bladder drainage by a cystostomy tube
50% of total blood volume lost in <3 hours
and bowel diversion with a colostomy. The colostomy should be
Bleeding in excess of 150 ml/min
sited away from potential pelvic surgical fixation skin wounds.
EXAMINER: So how are you going to manage this patient? EXAMINER: What about bladder or urethral injury?
CANDIDATE: A major risk factor for mortality in patients with pelvic CANDIDATE: The overall incidence of genitourinary injury
ring fractures is hypotension not responsive to fluid resuscitation. associated with a fracture of the pelvis has been variably reported
The pelvis should be stabilised with a pelvic binder. A chest from 4.6% to 13.5%. Men and women are equally likely to sustain
radiograph (to rule out hemothorax) and a FAST scan (to rule out an injury to the bladder but damage to the male urethra is more
hemoperitoneum and need for exploratory laparotomy) should common than the female urethra.
be undertaken. If available a detailed trauma CT should ideally be A high-riding prostate may also be detected on rectal
obtained, which may obviate the need for a chest and lateral C-
examination, indicating the presence of a periurethral or
spine radiograph. These can be difficult to obtain out of hours in a
periprosthetic hematoma occurring secondary to genitourinary
District General Hospital but should be available on a 24-hour injury.
basis without any difficult in a Level 1 trauma centre.
Widening of the symphysis pubis and sacroiliac joint may
Once I have eliminated other sources of hemorrhage, the most predict bladder injury while fractures of the inferior and superior
likely source of bleeding is from the pelvic venous and arterial
pubic rami are more commonly associated with urethral injuries.
system or from the cancellous bone at the fracture site. If the
Where there is suspicion of a urethral or bladder injury a
patient continues to be unstable despite aggressive fluid
cystourethrogram should be performed.
resuscitation, they should be taken for pelvic angiography and
Traumatic urethral injuries may result in strictures,
embolisation. If a patient is hemodynamically stabilised, full
incontinence, recurrent infection and erectile dysfunction.
imaging (including inlet, outlet, Judet, and CT scan) can be
EXAMINER: How would you definitely manage this fracture?
performed. If the pelvic fracture type is unstable (Tile B or C;
CANDIDATE: The patient would be positioned supine on a
Young and Burgess APC II, APC III, LC II, LC III, VS), the patient will
require operative fixation and can be treated with more definitive fluorescent table. I would use a Pfannenstiel incision. I would
stabilisation, such as an external fixator in the interim until stabilise the anterior symphyseal distraction with a symphyseal
transfer to a dedicated Level 1 trauma centre can be arranged. plate and the posterior sacroiliac diastases with sacro-iliac screws.
A plate is fixed to the superior surface of the symphysis. The screws
EXAMINER: Would you apply the external fixation in casualty?
are inserted on the anterosuperior surface of the pubis on either
CANDIDATE: I would prefer to apply the external fixator in a more
side of the symphysis and directed to the full depth of pubis in a
controlled environment such as theatre under II control.
posteroinferior direction. Reduction is obtained using large pointed
EXAMINER: Why not just leave the pelvic binder in place and not
reduction clamps applied to the obturator foramen and closed.
delay transfer to the nearest Level 1 trauma centre?
CANDIDATE: If the Level 1 trauma centre is nearby and there wasn’t
the available expertise to apply an external fixator at the local
a
hospital there would be some merit in arranging immediate The exam board is attempting to develop questions that test
transfer provided the patient had no other sources of bleeding candidates on the practical difficulties of working in the UK NHS
system.
593
029
Low-energy pelvic fractures activity level, severe osteoporosis or presence of severe associ-
ated injuries.
These are common injuries affecting the elderly, frequently
Undisplaced fractures, secondary congruence in associated
after a simple fall:
both column fracture and very low transverse or anterior
Pubic rami fractures column fractures when most of the weight-bearing surface is
Acetabular fractures intact.
Operative management – Displaced fractures, incongruent
Acetabular fractures hip joint, fractures in the weight-bearing area acetabulum,
Key viva themes – Interpretation of Judet views, description intra-articular loose bodies, hip instability, unstable fractures
of surgical approaches and anatomy The approach (es) to the fracture depends upon the frac-
ture configuration. Pelvic anatomy is complex and visualisa-
There are BOA guidelines for the management of acetabular
tion within the pelvis is limited. The fracture is reduced to
fractures. These injuries are less likely than pelvic fractures to
ensure articular congruence and the columns are stabilised,
be associated with major haemorrhage or haemodynamic
often using reconstruction plates that are contoured to fit the
instability. Acetabular fractures may be associated with hip
shape of the pelvis.
dislocation.
Anterior column and/or anterior wall – Ilioinguinal
Mechanism – High energy trauma (posterior wall fracture
approach (be aware of Corona mortis – Anastomosis between
with dashboard injury). Low-energy trauma in elderly.
external iliac and obturator systems around the superior pubic
Initial management – ATLS® principles and resuscitation
ramus), or Stoppa approach.
as necessary. Hip dislocations must be reduced urgently and
Posterior column and/or posterior wall, transverse frac-
their subsequent stability assessed and documented. Neurovas-
ture – Kocher–Langenbeck approach.
cular status before and after reduction must be documented.
Anterior column with posterior hemitransverse, T fractures,
Skeletal traction should be applied. If the hip is not reducible,
associated both columns – Ilioinguinal ± Kocher–Langenbeck.
urgent specialist advice should be sought. A CT scan should be
Instrumentation includes straight and curved 3.5 locking
performed within 24 hours of reduction to assess articular
and non locking. Reconstruction plates that are contoured to
congruence and to exclude bone fragments within the joint.
fit the shape of the bone are used to stabilise the fractures.
Knee joint stability must be assessed as dashboard injuries can
Spring plates used for bone fragments too small for screw
be associated with PCL injuries.
placement.
Investigation – AP radiographs and Judet views (Iliac and
Plate bending instruments, specialised retractors (blunt,
obturator obilques). Assess the following lines to diagnose the
spoon, pelvic, sciatic nerve), large pelvic reduction forceps,
type of acetabular fracture: Iliopectineal line, ilioischial line,
pointed reduction forceps, collinear reduction clamp etc
anterior and posterior walls, acetabular weight-bearing surface
It is unlikely candidates will be asked specific details about
and tear drop. Obturator oblique demonstrates posterior wall
fracture fixation but it is useful to have an idea of the equip-
and anterior column; iliac oblique demonstrates the anterior
ment needed for surgery. Default back if pressed AO 4
wall and posterior column. Inlet, outlet and Judet views can be
basic principles (1) Anatomical reduction, (2) stable fixation,
reconstructed from CT scans. However, the argument for
(3) early active mobilisation and (4) preservation of blood
obtaining radiographic Judet views preoperatively is to com-
supply which is just as applicable to pelvic fractures as to any
pare against Judet views obtained during acetabular recon-
fracture.
struction to access fracture reduction.
Complications – Nerve injury (depends upon surgical
CT provides information on size and position of column
approach), vessel injury during surgery, heterotrophic
fractures, impacted fractures of the acetabular wall, degree of
ossification (rate depends on approach), thromboembolism
comminution and sacroiliac disruption. Retroperitoneal
haematoma and soft-tissue injury may also be evident on CT
scan. Look for any femoral head injury or loose bodies Table 26.1 Letournel and Judet classification
Classification – Letournel and Judet classification describes
five elementary (simple) and five associated (complex) types. Elementary (simple) Associated (complex)
An associated fracture includes at least two of the elementary Posterior wall (Posterior column and posterior wall
forms (Table 26.1).
Posterior column Transverse with posterior wall
Definitive treatment – Guidelines recommend that
patients requiring surgery have this performed by a specialist Anterior wall Anterior column and posterior hemi-
surgeon ideally within 5 days from injury but no later than transverse
10 days (as per BOAST 3). Anterior column T-shaped fracture
Non-operative management – Limited indications, possible Transverse Associated both column
role if severe medical co-mobidities, infection, poor premorbid
029
(a) (b)
Figure 26.7 (a) Acetabular fracture in an elderly patient. (b) Fracture in Figure 26.7a treated with fixation and THA
(consider IVC filter in high risk cases), wound infection (5%), pelvis is fixed first, any incongruity would lead to incongruity
non-union, mal-union, avascular necrosis (5%), secondary of the acetabular fracture, which is associated with a poor
osteoarthritis (20%). outcome.
Displaced acetabular fractures in the elderly

Issues – Bone is soft, often associated with fracture fragment Examination corner
impaction and comminution
Options – Non-operative management is a reasonable choice EXAMINER: Can you identify the lines on this drawing? (Figure 26.8a)
for undisplaced fractures and secondarily congruency COMMENT: This is a 30-second first question in a viva topic. You
associated with both column fractures. Consider THA when must know this info in order to proceed smoothly in the viva to
fracture has healed at 6 months. Operative management by the next level.(Figure 26.8b).
fracture fixation and total hip arthroplasty in same sitting
(Figure 26.7 a and b)
Spinal trauma
Combined pelvic and acetabular fractures With the FRCS (Tr & Orth) viva component in recent years
The initial resuscitation is the same including ATLS® prin- there has been a conscious move towards including a compul-
ciples and pelvic binder. When physiologically stable, surgery sory spinal elective question for the adult and pathology
should anatomically reduce and stabilise the acetabular frac- section. Less definite but still possible is a spine trauma topic
ture first, followed by stabilisation of the pelvic fracture. If the in the trauma oral section
595
029
(a)
(b)
Figure 26.8 (a) AP pelvis radiograph. (b) Radiographic lines on AP pelvis
Table 26.2 Subaxial cervical spine injury classification system Lower cervical spine injuries
Points The five major classification systems for acute subaxial cervical
trauma are: (1) Holdsworth classification20; (2) Allen and
Morphology
No abnormality 0 Ferguson classification21; (3) Harris classification22; (4) Subax-
Compression 1 ial Cervical Spine Injury Classification system (SLIC)23; and
Burst +1=2 (5) Cervical Spine Injury Severity Score (CSISS)24.
Distraction 3 The older classifications systems have focused on the
Rotation/translation 4 mechanisms of injury while the newer systems have dis-
Disco-ligamentous carded this in favour of radiological findings and, in the
complex (DLC) case of Vaccaro et al.23, neurological status. Comparisons
Intact 0 of the classification systems show that there are clear advan-
Indeterminate 1 tages to the system presented by Vaccaro et al.23 (SLIC scale)
Disrupted 2 because it may be used to guide treatment; however, it has
Neurological status lower reliability and validity compared to the older systems.
Intact 0
Root injury 1 Allen and Ferguson classification21
Complete cord injury 2 This is based on the mechanism of injury, and is divided into
Incomplete cord injury 3
six categories: (1) compression–flexion; (2) vertical compres-
Continuous cord +1
sion; (3) distraction–flexion; (4) compression–extension; (5) -
compression in setting of
neurological deficit distraction–extension; and (6) lateral flexion.
Subaxial cervical spine injury classification

system (SLIC)23
Very occasionally an osteoporotic vertebral compression The SLIC system consist of three main components: Injury
fracture will be shown in the adult and pathology viva that morphology, disco-ligamentous complex (DLC) and neuro-
will then lead on to a general discussion of osteoporosisb. logical status.
This contrasts sharply with the EBOT exam where one The DLC consists of the anterior and posterior longitu-
30-minute viva station is dedicated exclusively to spinal topics. dinal ligaments, the intervertebral disc, the facet capsules,
In this viva station around 7–8 questions are asked covering interspinous and supraspinous ligaments and the ligamentum
elective, trauma and paediatric spinal topics. flavum. Neurological status is ‘an important indicator of the
severity of spinal column injury’ and ‘significant neurological
injury’ infers a significant force of impact and potential
instability to the cervical spine.
If the score is between 1 and 3, the patient does not receive
b
In the basic science viva laminated results from a DEXA scan is the surgery, while for a score 5 surgery is recommended. Score
usual prop shown to lead into discussing osteoporosis. 4 is equivocal for surgery.
029
Cervical spine – Uni/bifacetal dislocation by posterior approach to reduce the dislocation and posterior
stabilisation and anterior intervertebral fusion.
Mechanism of injury – Motor vehicle accident, fall from
If MRI scan shows disc is intact, posterior approach to
height and diving accidents. Facet dislocations are classified
reduce the dislocation and posterior stabilisation is performed
as distraction–flexion injuries and account for
followed by anterior fusion.
approximately 10% of all subaxial cervical spine fractures
Level – Most common levels for dislocations are C4–C5,
C5–C6 and C6–C7. The lower cervical spine is particularly at Examination corner
risk because of its increased mobility (compared to upper This usually involves being shown a radiograph of either a
thoracic spine), more horizontally oriented and smaller unilateral or bilateral facet subluxation. Bilateral should be
superior facets fairly obvious so to make the viva difficult a unilateral or
Types – One or both inferior facets displace anteriorly over perched facet(s) may be shown instead. Management is con-
the superior facet or facets of the vertebra below. Perched troversial and complicated the issues being:
facets is a subtype of dislocation where there is complete loss If unilateral does the injury need reducing
Should a closed reduction be attempted without an
of apposition of the articular surfaces, but the tip of the
MRI scan
inferior articular process only abuts, without extending past,
The indications for surgical intervention
the superior articular process Surgical approach (es) used
Clinical – Unilateral may present with nerve root injury or Try and keep the discussion simple, straightforward and non-
incomplete neurological deficit. High incidence of cord controversial. We have seen the viva given where examiners
damage with bilateral facet dislocation wanted to discuss controversial areas of management and the
Investigations – Lateral radiographs reveal the amount of relevant evidence-based literature. The carefully prepared can-
anterior vertebral displacement with unifacet dislocation didates avoided this trap by saying that standard practice
leading to ~25% and bilateral ~50% subluxation. Loss of disc would be to reduce a unifacet dislocation, obtaining an MRI
scan pre-reduction because if there was an associated large
height may indicate retropulsed disc in canal. AP radiograph
disc herniation open surgery would be safer.
reveal altered spinous process alignment
MRI is used to detect associated disc herniation and any
compression haematoma Examination
Management – Non-operative management of unilateral
Cervical spine evaluation is part of ATLS® protocol. If a
dislocations more often results in treatment failure,
cervical spine injury is suspected or confirmed, repeated
neurological deterioration and persistent pain when
neurological examination is essential to assess any progression
compared to surgery. Halo vest immobilization is used until
of neurological compromise.
fusion occurs. However, around 50% of patients still
demonstrate persistent instability on flexion/extension views Local
requiring surgical fusion Bruising, local tenderness, gaps or asymmetric gap between
Reduction can be attempted as long as the patient is awake, alert spinous processes.
and frequent neurological examinations are possible. This is
achieved with Gardner–Wells skull tongs adding sequential Neurological
weights to the traction cord. The patient is supine and either Glasgow Coma Scale (to give an idea of how valid the
image intensier views or lateral cervical spine radiographs are peripheral neurological examination is), cranial nerves,
taken after each additional load is added. An initial 10 lb is nerve roots.
added, weights are increased by 5 lb increments every 20 min-
utes. After each addition of weight check for any change in Sensory
neurological status. Various reduction manoeuvres described. Touch (crude and fine), vibration, temperature, pain. C5 –
For unilateral facet dislocation (UFD) rotate head 30–40° past Over deltoid, C6 – Lateral aspect of forearm, C7 – Tip of
midline in the direction of the dislocation. middle finger, C8 – Little finger, T1 – Medial aspect of forearm
There is controversy as to whether an MRI is needed before T2 – Medial aspect of arm, T4 – Nipple area, T10 – Umbilicus,
attempting closed reduction with many experts believing there L1 – Groin, L2 – Upper and mid thigh, L3 – Lower thigh and
is no absolute need for this. The safe answer for the exam is to anterior knee, L4 – Medial aspect of lower leg, L5 – First dorsal
say you would prefer to have an MRI before reduction if it can space, S1 – Over the tendoachilles, S2 – Posterior thigh, S3, 4,
be done immediately without delay and you would also discuss 5 – Saddle and perineal area.
the case with the MTC spinal unit for advice.
If there is associated intervertebral disc rupture, facetal frac- Motor
ture or the dislocation does not reduce by traction then, surgical Tone, power (MRC grade). C5 – Deltoid, C6 – Extensor carpi
intervention is indicated. If MRI scan shows disc rupture, then, radialis longus and brevis, C7 – Flexor carpi radialis, C8 –
anterior approach is performed first to remove the disc, followed Long flexors of fingers, T1 – Intrinsics. L2 – Psoas major (hip
597
029
flexion), L3 – Quadriceps, L4 – Tibialis anterior, L5 – Extensor Neurogenic shock

hallucis longus, S1 – Flexor hallucis longus. This is a loss of circulatory blood volume due to loss of
sympathetic tone to the peripheral vasculature leading to
Reflex
hypotension and bradycardia. It most commonly occurs
Tendon reflexes (biceps, triceps, supinator, knee and ankle) and following cervical and upper thoracic trauma. Patients may
superficial reflexes (abdominal, bulbocavernal and plantar). also experience flaccid paralysis and absence of sensation and
reflexes below the injuried level
Frankel’s grade of function
A – Complete motor and sensory loss below level of injury Blood supply to spinal cord
B – Preservation of sensory but not motor function below Two posterior spinal arteries and one anterior spinal artery (all
level of injury branches of vertebral arteries). Radicular arteries are segmental
C – Some motor function preserved below level of injury but supply from ascending cervical, intercostal, lumbar and sacral
mostly < MRC grade 3 arteries. In the thoracic and lumbar regions radicular arteries
D – Motor function preserved below level of injury with are on the left side. Artery of Adamkiewicz segmental supply
most at MRC grade 3 or more between T8 and L2 on the left side.
Examine both sides. Level of spinal cord lesion is the lowest
level of normal sensory or motor function Spinal cord anatomy
E – Normal motor and sensory function White matter
Complete spinal cord injury – No motor and sensory function Dorsal column – Cuneate and Gracilis tracts – Gross touch,
in the anal and perineal region representing the lowest sacral vibration and pressure
cord (S4–S5). Lateral column – Ventral and lateral spinothalamic tracts –
Incomplete spinal cord injury – Some sensory or motor function Pain and temperature
caudal to the injury level and in the S4 and S5 segments. Anterior column – Corticospinal tracts – Axons of the
motor neurons
American Spinal Injury Association (ASIA) classification
ASIA grading is an important predictor of recovery of ambu- Grey matter
lation after spinal cord injury. Dorsal horn – Sensory neurons
A = Complete (paralysis): No sensory or motor function in Intermediate horn – Preganglionic sympathetic or
sacral segments S4–S5 parasympathetic neurons
B = Incomplete (sacral sensory sparing): Sensory, but not Ventral horn – Motor neurons
motor function below the neurological level and extends
through sacral segments S4–S5 Incomplete spinal cord syndromes
C = Incomplete: Motor function is preserved below the Central cord syndrome – Usually hyperextension injury,
neurological level, with most key muscles below the motor loss more in upper limbs (flaccid paralysis) than
neurological level having muscle grade <3 lower limbs (spastic paralysis), bladder dysfunction, sacral
D = Incomplete: Motor function is preserved below the sparing occurs, good prognosis. Often no bony fracture
neurological level, with most key muscles below the seen but underlying cervical spondylosis
neurological level having muscle grade 3 Anterior cord syndrome – Flexion injury, motor and pain
E = Normal: Sensory and motor functions are normal sensation loss, gross touch and vibration preserved,
guarded prognosis
Spinal shock Posterior cord syndrome-Absent proprioception and
In the immediate aftermath of a spinal cord injury, there is vibration sense, with preservation of all motor and other
complete absence of motor, sensory and autonomic function sensory modalities
distal to the level of injury. This relates to a physiological, Brown–Sequard syndrome – Hemiresection of cord most
rather than structural disruption. There is loss of muscle tone, commonly following penetrating trauma. Motor, gross
and with no autonomic function, hypotension and bradycardia touch, vibration and pressure loss below the level of injury
occur. This can last from 24 hours to 72 hours. The return of on same side, pain and temperature loss from one or two
the bulbocavernosus reflex, marks the end of spinal shock. levels below on the opposite side. Pain and temperature
Later, there is gradual recovery of nerve functions that have fibres cross over to the opposite side one or two levels
not been injured which leads to hyperreflexia and clonus of the above the level they enter the spinal cord
affected muscles. The persistence of a complete absence of Conus medullaris syndrome – All the lumbar and sacral
neurological function below the injury level after return of segments are very close to each other behind T12 and L1
the bulbocavernosus reflex is a poor prognostic sign for neuro- vertebrae and any injury at this level can cause a
logical recovery combination of upper and lower motor neuron deficits
029
with bladder and bowel dysfunction due to injury at conus Table 26.3 Levine classification of C1 fractures
medullaris Classification Mechanism of Stability
Cauda equina syndrome – Damage to lumbar and or sacral injury
roots leading to bladder and or bowel dysfunction, perianal
I – Extra-articular Avulsion Stable may involve
sensory loss, loss of reflexes and often asymmetric
fracture of vertebral foramen/
Initial cord or nerve root injury due to compression, traction transverse process artery
or laceration can be compounded by ischaemia and oedema.
Primary care of spinal cord injured patients is to avoid sec- II – Isolated Hyperextension Stable
posterior arch
ondary injury due to hypoxia, ischaemia and oedema by main-
fracture (28%)
taining blood pressure, oxygenation, preventing raised intra-
cranial pressure and hypovolaemia. III – Isolated Hyperextension, the Unstable if
anterior arch Dens is forced displaced
Management of bony/soft-tissue injury fracture anteriorly through
Initial management – Triple immobilization of cervical the arch
spine, endotracheal intubation (if required) IV – Comminuted Axial compression Unstable
Investigations – Lateral view of cervical spine is part of lateral mass and lateral bending
ATLS® protocol. However, absence of any injuries identified fracture
does not rule out cervical spine injury, especially in a V – Burst fracture, Axial compression Depends on
multiply injured patient, associated head injury and three or more displacement/
substance misuse fragments (33%) integrity of
CT and MRI scans provide information about the bony and transverse atlantal
soft-tissue injury respectively ligament
Other cervical spine injuries

Atlanto-occipital dissociation Type I and III – Non-operative management with Halo
It is often fatal secondary to respiratory arrest caused by injury vest. Type II – Due to involvement of cortical bone risk of non-
to lower brain stem. Mechanism of injury is extreme hyper- union is higher. Hence, internal fixation is preferred for fresh
extension with distraction. More common in children as flat fractures and fusion for delayed presentation.
articulation between occiput and atlas, increased ligamentous
laxity. If patient survives, skull traction is contraindicated.
Classic reference
Temporary reduction and stabilisation using halo vest
followed by occipitocervical fusion using plates and screw. Anderson LD, D'Alonzo RT. Fractures of the odontoid process
Survivors usually have severe neurological deficit. of the axis. J Bone Joint Surg Am. 1974;56:1663–74.
Fractures of the cervical spine may lead to pain and disability
C1 fracture (Jefferson’s fracture) from non-union or may result in devastating neurological
The atlas is a ring of bone that surrounds the spinal cord and complications or even death if they displace. The authors
the odontoid process. The lateral masses joined by the anterior present their classification of Odontoid Peg (Dens) fractures
and posterior arches articulate with the occipital condyles based on a review of 49 patients. Fractures are classified into
three types based on the location of the fracture. This classic
by the superior facets and with C2 by the inferior facets.
article identifies a high rate of non-union in type 2 fractures
A complex series of ligaments provides stability. (junction odontoid process with body C2) that are managed
Burst fracture of the ring of C1. Normally caused by axial conservatively. The classification into three types predicts
loading. There are usually no neurological deficits as the space prognosis and guides treatment. Despite being published over
available for spinal cord is large. Treatment is by Halo vest till 50 years ago it remains the definitive classification system used
fracture heals. for this fracture.
Levine described five variants of C1 fractures (Table 26.3).
Fifty per cent of these fractures are associated with other
cervical spine fractures, especially odontoid fractures and Spondylolisthesis of C2 (Hangman’s fracture)
spondylolithesis of the axis. Fracture of the pars articularis of C2 and disruption of the C2–
C3 junction. Mechanism of injury includes motor vehicle
Odontoid fracture accidents, diving and falls. Hanging lesion is hyperextension
Anderson and D’Alonzo classification and distraction but most injuries are caused by a combination
Type I – Oblique apical avulsion #, Type II – # base of of flexion, extension and axial loading.
odontoid, Type III – # extending through the cancellous bone The incidence of spinal cord injury is low with types I and
of C2 body. II and high with type III.
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029
Levine and Edwards classification Major

Type I: Minimally displaced with no angulation; 1. Compression fractures are classified according to whether
translation<3 mm; stable they are caused by anterior or lateral flexion. These injuries
Type II: Significant angulation at C2–C3; translation cause anterior column compression and sometimes
>3 mm; unstable; C2–C3 disc disrupted. Subclassified into associated posterior column distraction
flexion, extension, and listhetic types 2. Burst fractures are classified according to whether an axial
Type IIA: Avulsion of entire C2–C3 intervertebral disc in load alone caused the fracture, or whether flexion, rotation, or
flexion, leaving the anterior longitudinal ligament intact. lateral flexion was also involved. These injuries cause anterior
Results in severe angulation. No translation; unstable due and middle column compression, and may sometimes also
to flexion–distraction injury produce associated posterior column distraction
Type III: Rare; results from initial anterior facet dislocation 3. Flexion with distraction (chance fracture or seat belt
of C2 on C3 followed by extension injury fracturing the fracture). These fractures are defined by their distinctive
neural arch. Results in severe angulation and translation flexion–disruption mechanism of injury. The anterior
with unilateral or bilateral facet dislocation of C2–C3; column may be intact or compressed, but the middle and
unstable posterior columns are distracted
Type II, IIA and III are treated surgically by open reduction 4. Fracture–dislocations are classified according to whether
and posterior C2–C3 fusion. the dislocation involves rotation, shear, or flexion–
distraction. These injuries can produce any pattern of
Thoracic/lumbar spine column involvement
Fracture classification
The Magerl (AO) system27 classifies fractures on a grid
Historical aspect system using the standard AO letter and number system. The
Watson–Jones first introduced the concept of instability and system was constructed from an analysis of CT scans and plain
believed that the integrity of the posterior ligamentous complex radiographs of over 1400 injuries. Three main groups are type
was essential for spinal stability. Nicoll further attempted to define A (compression injuries), type B (posterior or anterior distrac-
the concept of instability using an anatomical classification. tion injuries) and type C (rotational/shear type injuries). Each
In 1963, Holdsworth reported that although Watson–Jones are then assigned two numbers to indicate the severity and
had previously published good results using extension bracing overall severity increases as the classification moves from A1.1
for thoracolumbar fractures he could not replicate these (most simple) to C3.3 (most severe). This results in a total of
results25. He went on to expand the previous classification 53 patterns.
system proposed by Nicoll26. Neither reduction nor mainten- Vaccaro and the Spinal Trauma Study Group proposed the
ance of position could be achieved by extension casting. He Thoraco-Lumbar Injury Classification and Severity Score
described a two-column theory emphasizing the importance of (TLICS)28. The TLICS scoring system aids surgical decision-
the posterior ligamentous complex for spinal stability. He making and takes into account three parameters: (1) injury
observed that fractures involving both anterior and posterior morphology; (2) neurological status; and the (3) integrity of
columns of the spine were less stable. In 1983 Denis reported the posterior ligamentous complex. Each of these features
that this two-column theory was not compatible with biome- is given a score and surgery recommended if the final score
chanical reports, the experience of scoliosis surgeons or experi- is >4 (Table 26.4).
ments in the anatomy dissecting room. Denis suggested that
unstable injuries (both neurological and mechanical) could
occur with an intact posterior ligamentous complex and, fur-
thermore, that an injured posterior ligamentous complex Table 26.4 Thoraco-Lumbar Injury Classification and Severity Score (TLICS)
didn’t necessarily lead to instability. Denis defined a middle Injury Posterior Neurological
column and proposed his three-column theory. The anterior morphology ligamentous status
column is made up of the ALL and anterior two-thirds of the complex
vertebral body and disc, the middle column compromises the
Compression 1 Intact 0 Intact 0
PLL and posterior one-third of the vertebral body and disc.
The posterior column includes the facet joints, pedicles, and Compression Indeterminate 2 Nerve root 2
supraspinous ligaments. All fractures can be described as one, burst 2
two or three column. Fractures involving only one column are Translation/ Injured 3 Spinal cord injury
stable whilst those affecting two or three columns are unstable. rotation 3 (complete) 2
Minor Distraction 4 Spinal cord injury

(incomplete) 3
Fractures of the transverse process, pars interarticularis or Cauda equina 3
spinous process
029
Spinal instability vertebral body resection, decompression of the anterior spinal

White and Panjabi defined instability of the thoracolumbar canal and anterior fixation with plates.
fracture as inability to maintain structural integrity under Flexion distraction injuries
physiological loads to prevent progression of neurological
Chance fracture or seat belt fracture. This can be either bony
deficit or pain29.
or purely ligamentous. Unstable injury with high risks of
The thoracolumbar junction is most commonly involved as
neurological deficit and associated abdominal injuries. This is
it is a transitional zone between the mobile lumbar vertebrae
an unstable injury with a risk of developing post traumatic
and immobile thoracic vertebrae (due to rib cage).
kyphosis, neurological deficit and a poor outcome.
Mechanisms of injury Fracture–dislocations
Although there are often complex forces occurring at the time These injuries have the highest incidence of neurological def-
of injury, most thoracic and lumbar fractures can be described icit. Patients who are neurologically intact should be surgically
as one of the following: (1) axial compression; (2) flexion; stabilised to prevent neurological injury and allow early mobil-
(3) lateral compression; (4) flexion/rotation; (5) shear; (6) ization. Patients with complete neurological injuries are also
flexion/distraction; and (7) extension. surgically stabilised to improve nursing care and rehab.
Compression fractures Imaging
Axial loading on a flexion spine. The anterior column fails in CT scans best demonstrate the extent of bony injury, com-
compression, middle column remains intact. The posterior minution, spread of fragments and involvement of the poster-
column may remain intact or fail in tension, depending on ior elements.
the energy level of the injury. It is easy to miss posterior An MRI scan is the best modality for assessing soft-tissue
column injury on radiographs and incorrectly assume a stable injury including spinal ligaments, neural elements and inter-
injury. If any doubt organize a CT scan vertebral discs.
Radiographic features include:
Anterior wedging of vertebra Indications for surgical management
Loss anterior body height and NO loss of posterior body Progressive neurological deficit, unstable fracture with pro-
height gressive deformity, part of multiple injuries, paraplegia
Measure and compare with vertebrae above and below (enables early sitting out, nursing care).
Posterior cortical disruption or widening of the pedicles Surgical options
suggests a burst fracture
Posterior decompression and instrumentation alone is suffi-
If the injury involves <50% of anterior column and there is no cient for flexion distraction type injury. However, an anterior
involvement of posterior column then, non-operative manage- approach provides excellent visualisation for anterior decom-
ment in an extension brace is sufficient. pression and instrumentation. Anterior instrumentation has
better biomechanical strength. In thoracic fractures with retro-
Burst fractures pulsed fragments and spinal cord involvement – Access to
There is involvement of the middle column and often some retropulsed fragments is not possible via a posterior approach
degree of canal compromise. The extent of collapse and without risk to the spinal cord. The anterior approach provides
kyphosis as well as the integrity of the posterior column are excellent exposure to the spinal cord and facilitates removal of
key determinants of stability. Management continues to be incarcerated bony fragments.
controversial. Two decisions need to be made: (1) Should the
patient be treated with or without surgery? (2) If surgery,
which approach? Classic reference
Non-operative care may involve the use of a thoracolumbar Denis, F. The three column spine and its significance in the
sacral orthosis (TLSO), body cast, hyperextension brace or no classification of acute thoracolumbar spinal injuries. Spine.
orthosis. Surgery may involve an anterior approach, posterior 1983;8:817–31.
approach or combined. Aided by the relatively recent introduction of CT scanning,
Non-operative management is recommended for burst Denis presents a novel biomechanical model applicable to
fractures as long as there is no neurological involvement, thoracolumbar fractures. The model allows the classification of
significant posterior element disruption or significant deform- spinal fractures into minor and major types with four different
ity (kyphosis over 25–30°). Surgery would be indicated in types of major fracture.
The results of previous biomechanical studies (undertaken
higher degrees of kyphosis and posterior ligament injuries. In
by other authors) are commented on, the three-column theory
the presence of neurological injury these injuries are generally
proposed, and 412 acute thoracolumbar injuries are
stabilised. Longer segment posterior fixation reduces the risk retrospectively reviewed and classified
of instrumentation failure. Anterior surgery is performed for
601
029
In this paper Denis presents his attempt to classify acute

spinal fractures in order to detect those fractures that are at EXAMINER: Fracture dislocations are severe injuries with disruption
high risk of neurological complications and those in which of all three columns of the spine. These are distinguished from
intervention might prevent secondary deterioration. The paper the simple Chance fracture by the presence of significant
seeks to integrate, the basic science (biomechanics), the translation.
mechanism of injury, the radiological appearance and So you have a patient with a burst fracture how do you go
outcome. It highlights burst fractures are at risk of subsequent about treating him?
neurological deterioration. COMMENT: The candidate has lost the thread of the viva question
and the examiner has recognised this and brings him back into
the topic.
Examination corner CANDIDATE: I think the fracture needs an operate and you have to
decompress the fracture.
Trauma viva 1: Burst fracture
EXAMINER: Decompression from posterior or anterior?
In the trauma viva a lumbar burst fracture is a common topic
that regularly crops up. Try and keep your answer ‘neutral, CANDIDATE: Anterior.
down the middle’ as the treatment of burst fractures continues COMMENT: Surgery is generally recommended if there is an
to be one of the most controversial areas in spinal trauma associated neurological deficit. Patients with no neurological
despite the high incidence of this injury and extensively pub- deficit can be managed conservatively but patients with a
lished research. mechanically unstable burst fracture, defined by a disrupted
EXAMINER: This is a radiograph of a 17-year-old male after a fall posterior ligamentous complex (PLC), are at high risk for
10 feet from a height (Figure 26.9a). He presents to your local neurological decline without surgical stabilisation. An anterior
hospital complaining of severe lumbar pain. approach is favoured for surgical decompression of the cord,
CANDIDATE: This is an AP radiograph of the lumbar spine. posterior approach for stabilisation only.
There is a loss of height of the vertebral body of L1 with a COMMENT: The whole viva question wasn’t answered well.
widening of the interpedicle distance.
Trauma viva 2
EXAMINER: This is the lateral radiograph (Figure 26.9b).
What is your diagnosis? EXAMINER: This is a radiograph of a 17-year-old male after a fall
CANDIDATE: I will be honest I don’t know. 10 feet from a height (Figure 26.9a). He presents to your local
hospital complaining of severe lumbar pain.
(Recovering composure) I think he has a fracture of the
lumbar spine. CANDIDATE: This is an AP radiograph of the lumbar spine.
The posterior wall of the vertebral body has been pushed There is a loss of height of the vertebral body of L1 with a
backwards. widening of the interpedicle distance compared to the level
above and below. I cannot definitely visualize a fracture so
EXAMINER: Do you see any fragments in the canal?
I would want to see a lateral radiograph.
CANDIDATE: Yes.
EXAMINER: This is the lateral radiograph (Figure 26.9b).
EXAMINER: These are retropulsed fragments. So this is a what
CANDIDATE: This confirms a burst fracture. There is anterior
fracture.
wedging and posterior body height loss. There is disruption of the
CANDIDATE: Burst.
posterior vertebral body line and retropulsion of fracture
EXAMINER: Burst???
fragments. I cannot see any posterior element fractures or other
CANDIDATE: Burst.
evidence of a posterior distraction injury.
EXAMINER: What other types of vertebral fracture do you know?
I would manage this fracture as unstable as the PLC has been
CANDIDATE: There is the AO classification and there is the Denis disrupted. The patient should be immobilized with full spinal
classification. protection. Initial assessment should be with airway, breathing
COMMENT: The examiner didn’t ask for a classification system for and circulation as per ATLS® guidelines.
lumbar spine fractures but let this pass as the candidate was A semi-rigid cervical collar should be applied and a long
struggling. backboard. There must be a search for associated injuries such as
EXAMINER: Tell me about the Dennis classification? abdominal or chest injuries. There may be a neurological deficit,
CANDIDATE: The fracture can affect one or two columns. The so I would want to perform baseline neurological status and serial
mechanism of injury is flexion and distraction. assessments. I would want to exclude other spinal trauma and
EXAMINER: Flexion–distraction injuries are called Chance fractures prevent secondary spinal injury.
and result from compression failure of the anterior column and EXAMINER: Any other investigations you would perform?
tension failure of the posterior and middle columns. CANDIDATE: I would obtain a CT scan. Kyphotic and translation
CANDIDATE: The mechanism of injury is fracture–dislocation. injuries can be visualized on sagittal and coronal reconstructions.
029
(a) (b) Figure 26.9 AP (a) radiograph and lateral (b) of

burst fracture
Vertebral body height, disc spaces, interpedicular distances and >50% of the posterior height and kyphotic angulation <25°.
interspinous process intervals can be compared between injured More than 50% spinal canal compromise, initially considered a
and the non-injured levels. The amount of osseous retropulsion surgical indication, has been debated in patients with intact
can be measured in terms of AP diameter as well as the relative posterior elements.
percentage of central canal involvement. Mumford et al.30 showed that approximately 65% of intraspinal
I would also obtain an MRI scan as CT scans have a limited role fragments are resorbed and most are completely remodelled
in visualizing soft-tissue injuries. Disc herniations, epidural within 1 year after the injury. De Klerk et al.31 also showed
hematomas (indirect sign of ligament injury) and spinal cord reduction of canal compromise by 50% within the first year after
parenchymal injury are best assessed on MRI. The PLC is non-operative treatment, even in patients with neurological
frequently torn secondary to osseous retropulsion and on MRI, injury.
the ligament may be either discontinous or lifted off the posterior
The indications for operative treatment for a thoracolumbar
vertebral body with interposed fluid. burst fracture remains controversial, especially in neurologically
EXAMINER: What is the mechanism of such an injury? intact patients. Progressive neurological deterioration is gener-
CANDIDATE: Burst fractures are the result of axial loading and ally accepted as an absolute indication for early surgical inter-
compression forces to the anterior and middle columns. They vention. Other strong surgical indications include incomplete
typically occur in patients who have either been involved in a neurological injury, >50% spinal canal compromise, >50%
motor vehicle accident or sustained a fall from significant height. anterior vertebral body height loss, more than 25°–35° angle
of kyphotic deformity, and multiple noncontiguous spinal injur-
Burst fractures are more common at the thoracolumbar junction
ies. Relative indications include associated nonspinal injuries
with T12, L1 and L2 the most commonly affected. Neurological
and patients with nursing or comorbidities such as obesity that
deficit is present in up to 40% of patients.
make nonoperative treatment extremely difficult.
EXAMINER: How are you going to manage this patient? The main goal of surgery is to decompress the spinal canal
CANDIDATE: If the patient has no neurological compromise and and nerve roots, realign the spine, correct and/or prevent the
intact posterior ligament complex then I would treat the fracture development of post-traumatic kyphotic deformity, and pro-
conservatively. The anterior vertebral body height should be vide long-term stability of the injured spinal segments32.
603
029
Be able to discuss the safe administration of analgesia and

The type of surgical procedure is based on the fracture
pattern, the severity of neurological injury, and the surgeon’s how you would monitor for compartment syndrome.
experience. Explain consent process
Accepted methods for operative decompression and stabil- https://www.gov.uk/government/uploads/system/uploads/
isation of thoracolumbar burst fractures include: attachment_data/file/138296/dh_103653__1_.pdf
Posterior reduction and instrumented fusion without This is an excellent and comprehensive review of the con-
decompression sent process as published by the Department of Health. You
Posterolateral decompression and posterior instrumented may be simply asked who is able to seek consent.
fusion ‘The clinician providing the treatment or investigation is
Anterior decompression and instrumented fusion. responsible for ensuring that the person has given valid con-
Especially indicated for radiographically demonstrated
sent before treatment begins, although the consultant respon-
neural compression by bone or disk fragments
sible for the person’s care will remain ultimately responsible
Combined anterior and posterior approach. Used if the PLC
is injured in association with a significant anterior column for the quality of medical care provided. The GMC guidance
injury (loss of anterior height >50%) states that the task of seeking consent may be delegated to
another person, as long as they are suitably trained and quali-
Trauma viva 3 fied. In particular, they must have sufficient knowledge of the
Burst fracture again but most of the viva was spent discussing proposed investigation or treatment, and understand the risks
the classification systems for spinal injuries. There was particu- involved, in order to be able to provide any information the
lar emphasis on discussing the TLICS system33 and the Magerl patient may require.
(AO) classification34. The candidate was also asked about the
Review of this document is mandatory for all parts of your
American Spinal Injury Association (ASIA) classification system.
elective and trauma practice. The legal position concerning con-
sent and refusal of treatment by those under the age of 18 is
different from the position for adults. For the purposes of this
Sacral fractures guidance ‘children’ refers to people aged below 16 and ‘young
Sacral fractures often occur during high-energy trauma as part people’ refers to people aged 16–17. The Children Act 1989 sets
of pelvic or spinal injuries. The Denis classification is: out persons who may have parental responsibility. These include:
Zone 1 fractures are lateral to the neural foramina, The child’s mother
Zone 2 fractures pass through the foramina, and The child’s father, if he was married to the mother at the
Zone 3 fractures are medial to the foramen and involve the time of birth
spinal canal. Unmarried fathers, who can acquire parental responsibility
in several different ways, depending on when their children
Displaced fractures require specialist input and fixation. Bilateral
were born but please review the above documentation
sacral fractures may lead to a spino-pelvic dissociation. The
This area of the law needs constant review and is particularly
mechanism of injury is axial loading often as a result of fall from
important in ‘blended families’ where multiple fathers may
a height. Types of bilateral sacral fractures include ‘U’ or ‘H’ type
have no legal responsibility.
fractures. These fractures often require closed or open (posterior
You would be very unlucky to be questioned in such depth
approach) reduction. Stabilisation options include percutaneous
and if unsure, you would seek appropriate senior informed
iliosacral screws, posterior sacral tension band fixation, lumbo-
advice.
pelvic fixation and triangular osteosynthesis. Decompression is
You may as be questioned in relation to radiation protec-
indicated in fractures with neurological deficit.
tion measures (ALARA principle: As Low As Reasonably
Achievable). In order to minimize the potential risks of
Paediatric conditions biological effects associated with radiation, dose limits and
Expect to be questioned in a logical sequence along the guidelines have been established. The ALARA programme
following lines. and associated work practices further reduces risks by keep-
You will be given laminated radiographs (Figure 26.10a ing doses well below the limits. Persons operating x-ray
and b). You would be expected to answer the following. equipment should practice dose-reduction methods when-
Describe the x-rays – Use accurate clear language – Be ever using the equipment. Basic safety measures include
prepared to explain deformity in relation to muscle forces/ keeping exposure time short, keeping distance from the
attachments. Explain the importance of maintaining alignment source large, and using appropriate shielding, such as lead
in order to preserve forearm rotation. aprons. All users of x-ray equipment must have specific
What is the initial management and assessment? Analgesia, training to maintain safety at work.
history, examination, splintage, etc. Eventually you may now get to answer the question of the
Review the neurovascular anatomy – You need a full bent forearm. Structure your answer in a stepwise progressive
detailed understanding of clinical anatomy. Show me how manner. Your thought process should be logical and safe with
you test for the nerves at risk? What muscles are affected? alteration of your surgical plan as necessary.
029
(a) (b)
Figure 26.10 AP (a) and lateral (b) radiograph left forearm. Postoperative radiographs TEMS left forearm
Patient positioning – Supine on radiolucent arm board/ : Technique – Talk me through how you would do it?
table with tourniquet applied, should closed reduction and : What size of flexible nails would you use?
casting fail to maintain a stable reduced fracture configuration. : Postop management – Cast, short arm vs above elbow?
Theatre layout and image intensifier location – Position : Removal of metal work
yourself so that not only can you have surgical access to There are multiple paediatric fracture cases that can be dis-
efficiently operate but radiology have access to undertake cussed, but an extensive knowledge of supracondylar elbow
imaging and that you can easily see these images on the fractures, with and without neurovascular compromise and the
radiology VDU. Be prepared to draw an outline diagram of subsequent timing of surgery is a frequent question. The cases
theatre setup with positioning of equipment and personnel. you will be examined upon are those that you will deal with
Steps of reduction frequently and those cases which are likely to have compli-
Assessment of stability cations or adverse effects, e.g. physeal injuries with growth
Casting material – Differences/pros-cons plate arrest. Can you work out remaining growth from growth
Cast index – Explain as predictor of loss of reduction – charts? Do you need to investigate using CT scans for a physeal
Mention fracture/surgeon factors bar? And how might you treat the resulting growth deformity?
Be prepared to sensibly explain your This area of paediatric fracture management is just as import-
Follow up ant as adult trauma, but trainees’ exposure can be limited if
there are not sufficient opportunities for such placements in a
If there is secondary loss of position – What now?
training programme. Although not trauma, the presentation of
Open reduction vs flexible nails
a limping child may be discussed. What is a limping child? An
: Pros/cons of each procedure abnormal gait pattern usually caused by pain, muscular weak-
: Approaches ness or bony deformity. There is usually a shortened stance
605
029
phase – Antalgic pattern, whereby the patient will hurry off the had undergone arthrocentesis. Of those 10% had septic arthritis
painful side confirmed microbiologically, and the remaining 90% had a
How would you assess? variety of other inflammatory conditions or no diagnosis con-
History firmed. The authors concluded that of the three tests, the syn-
: Consider age of patient ovial fluid WCC was the most informative. The diagnostic utility
: Duration of symptoms of the test was optimal using a threshold of 17 500/mm3 above
which the diagnosis of sepsis could be made with a sensitivity of
: Presence of pain 83% and a specificity of 67%. The positive likelihood ratio at this
: Associated features – Unwell, off food, smelly urine level was 2.5 with a negative likelihood ratio of 0.25.
: Referred pain? You need to be able to discuss the surgical management of
Exam – Hip/knee/back/groin/abdomen hip drainage/aspiration. Do you know the surgical approach
: Look, feel move approach and the steps involved? (Smith–Peterson) Do you use a vertical
: Interaction with carers or bikini skin incision? And do you leave a drain in situ? Have
Investigations – Bloods/temp/cultures as necessary/ you performed this procedure or at the very least would be able
urine/radiology to undertake as necessary, even though most such procedures
Differential diagnosis by age are undertaken by surgeons with paediatric orthopaedic
0–3 years Septic arthritis/osteomyelitis, DDH, experience. Septic arthritis in children affects the hip in a third
fracture, NAI of cases, the knee in a third, and other joints in the remaining
3–10 years Irritable hip, septic arthritis/osteomyelitis, third. Septic arthritis can occur at any age in childhood but is
Perthes’, fracture most common among infants, toddlers, and children of pre-
10–15 years SUFE, septic arthritis/osteomyelitis, Perthes’, school age. Transient synovitis is a common idiopathic inflam-
fracture, blood diseases, neoplasia, discitis, inflammatory matory condition which presents in a similar manner to the
disease ‘do not miss’ diagnosis of septic arthritis, but must remain a
Kocker’s criteria is a useful diagnostic tool when dealing with diagnosis of exclusion. We advise you to obtain paediatric
conditions that you many not deal with frequently trauma experience, as often these are the more challenging
cases that you will be required to deal with.
Fever >38.5°C
The following paediatric topics are not an inclusive list but
Cannot weight bear
are frequently asked subjects:
ESR>40 mm
Non-accidental injury
WBC >12 × 109/l
Simple buckle fractures – Discuss virtual clinic
Probability of septic arthritis
establishment
No factors: <0.2% What is an acceptable deformity – Discuss remodelling
1 factor: 3% potential in relation to zones of bone
2 factors: 40% Open paediatric fracture management
3 factors: 93.1% Supracondylar elbow fracture management
4 factors: 99.6% Assessment/timing/dysvascular/method of management
You would then be expected to formulate a plan. An ultrasound Off-ended distal radius – Management – Technique
scan may well tell you that there is an effusion but doesn’t add to
Both bone forearm fracture management – Open/
the diagnostic process, unless facilities exist for aspiration at the percutaneous/compartment syndrome/single bone
same time. It may not be possible to obtain an MRI scan in your fixation, removal of metal ware and when
facility but you need to be able to discuss the relationship of
Pulled elbow
septic arthritis secondary to osteomyelitis. The examiner may
Femoral fractures in varying age groups – Flexible/ORIF/
push you in giving antibiotics before a sample of hip fluid can be
adolescents
obtained, but what antibiotics should be administered? Causa-
tive organisms of septic arthritis can be related to the age of the Tibial fractures – Pop/flexiblenails/x-fix/percutaneous
patient and possible underlying medical conditions. The pre- plating
dominant causative pathogens in septic arthritis are Staphylo- Triplane fractures – Diagnosis/management/classification
coccus aureus and Streptococcus, accounting for up to 91% of SUFE – Diagnosis, associations, evaluation, contralateral
cases. In the elderly, the immunocompromised and in those fixation, management – Pinning in situ/osteotomy, use of
patients who have had intravascular devices or urinary catheters traction prior to surgery, risk factors for poor results
inserted, infection with a Gram-negative enteric bacillus is more Damage control orthopaedics – Polytrauma
common. A retrospective cohort study by Li et al.35 looked at the paediatric cases
serum WCC, erythrocyte sedimentation rate (ESR) and the Spinal/head injuries/vascular/abdominal injuries/respiratory /
synovial fluid WCC in 156 adult and paediatric patients who CV/fluids IV access/splintage/head and neck trauma
029
Miscellaneous conditions Forearm – three compartments (superficial flexor,

deep flexor, extensor)
Compartment syndrome Typically an anterior Henry approach is utilized to release the
Definition (What is it?) superficial compartment, which is easily identified, before
A condition characterized by raised intracompartmental pres- fascia over the deep flexors is released, care is need to release
sure within a closed fascio-osseous compartment, that if left all muscles in the deep compartment. A separate posterior
untreated will result in muscle necrosis and cell death or Thompson approach is the utilized to attend to the extensor
permanent damage to nerve in the compartment. compartment. The medial nerve and ulnar nerve should be
released and covered by skin post release.
Causes
It can result from tight dressings or casts, long bone fractures Tibia – 4 compartments (anterior, lateral/peroneal, superficial
(closed or open), burns, haemorrhage into compartment, soft- posterior, deep posterior)
tissue injuries, electrocution, infection, arterial injury, snake bite Standard 2-incision fasciotomy – The anterior and lateral
and clotting disorders. In orthopaedic trauma the majority of cases compartments are the easier to release with a laterally based
will be in young males who have suffered a closed tibial fracture. incision, and either two incisions on the lateral fascia of both
Pathophysiology compartments, or release of the anterior compartment and
then release of the lateral compartment via the anterior com-
Normal tissue pressure ranges from 0 mmHg to 4 mmHg. The
partment, care being taken with the superficial peroneal nerve
gradient between tissue pressure and diastolic pressure allows
in the distal one-third of the tibia.
tissue perfusion to occur. When the tissue pressure rises to
The posterior compartments are released by an incision
near diastolic pressure, tissue perfusion will be impaired or
approximately 2 cm posterior to the medial tibial border. This
cease. Ischaemia of <4 hours is usually reversible, but after
gives access to the fascia over gastrocnemius, which is released,
8 hours the outlook is guarded.
before the deep compartment is identified distally, and the
Tight compartments ! increased interstitial pressure !
fascial attachment of soleus to the tibia are released. This then
reduced venous outflow ! further increasing interstitial pres-
allows access to carefully release the fascia over flexor digi-
sure (vicious cycle) ! critical interstitial pressure is reached !
torum and the remaining deep compartment muscles.
cellular level hypoxia due to reduced inflow and outflow.
Be able to discuss treatment of compartment syndrome in
Diagnosis the thigh. Again, cross-sectional anatomical diagrams are to be
expected.
Relying on pain, pallor, paralysis, pulselessness and paraesthe-
sia is negligent, as these are associated with established com- Figure 26.11 AP x-ray
partment syndrome and effective treatment is often too late. of transhumeral
The earliest clinical sign is pain out of proportion to the injury amputation
and pain on passive stretch of the affected compartment.
However, in unconscious patients objective measures are
required and continuous compartment pressure monitoring
should be utilized when available. This requires the use of a
slit catheter placed within 5 cm of the fracture site. The
difference between the compartment pressure and the diastolic
pressure (ΔP) is the most important determinant and values of
30 mmHg or less are diagnostic.
What is your unit practice and why? Be able to discuss
setting up arterial line slit catheter in an unconscious patient.
Management. When associated with fractures, do you fix
the fracture first then perform fasciotomy or not and why?
Remember to remove all constricting bandages or casts
while waiting to get the patient to theatre.
Do you use tourniquet or not?
Explain you set up and exact surgical procedure
Structures at risk list
How do you assess muscle viability?
: Colour/consistency/contractibility/capacity to bleed
when cut
When have you performed fasciotomies?
607
029
Is there any evidence to suggest a delay to healing post Relative: Individual digits distal to the insertion of flexor
tibial fractures associated with compartment syndrome? digitorum superficialis (FDS) (Zone I)
Differentiate between compartment syndrome and a crush
syndrome Contraindications
Crush syndrome. Reported in World War II blitz second- Primary: Single digit proximal to FDS insertion (Zone II)/
ary to entrapment under rubble. Essentially crush syndrome is mangled limb or crush injury/segmental amputation/
a reperfusion injury secondary to traumatic rhabdomyalysis prolonged ischemia time
causing acute renal failure. Seen in earthquakes, mine cave ins, Relative: Medically unstable patient/disabling psychiatric
terrorist acts, e.g. 9/11. illness/tissue contamination
Treatment is supportive prior to removal of the crushing
substances. Toxins released from direct cell death, ischaemia Transport of amputated tissue
and vascular compromise results in electro cardiac events, Any salvageable tissue should be transported with the patient
renal failure and systemic/multiple organ failure. Haemodialy- to hospital. Keep amputated tissue wrapped in moist gauze in
sis, and inotophic support is often required. isotonic solution. Place in sealed plastic bag and place in ice
water (avoid direct ice or dry ice). Wrap, cover and compress
Traumatic amputations stump with moistened gauze
Although rare (Figure 26.11), a structured management
Replantation times
plan needs to be delivered to the examiners. Remember to fall
back onto first principles and a saving life approach (ATLS®). Proximal to carpus Distal to carpus (digit)
Warm ischemia time <6 hours Warm ischaemia time
History <12 hours
Timing of injury Cold ischemia time <12 hours Cold ischemia time
Type and location of amputation <24 hours
Number of digits involved
Preservation of amputated tissue Operative sequence of replantation – BEFAVNS:
Associated injury Bone/extensor tendons/flexor tendon(s)/arteries/veins/
nerve/skin)
Past medial history
In reality this topic is out with most people’s clinical
Examination experience, but something which is encountered in the exam.
Stump examined for: Zone of injury/tissue viability/support- We hope that this chapter has given you a better under-
ing tissue structures/contamination standing of the trauma oral which can cover all aspects of
Amputated portion inspected: Segmental injury/bone and adult/paediatric trauma management both clinical and organ-
soft-tissue envelop/contamination isational as well as related basic science topics. The variety and
exposure of trauma management that requires constant patient
Indications for reimplantation re-evaluation from initial care to postoperative management
Primary: Thumb/multiple digits/wrist level or proximal to and rehabilitation, is what makes this our main specialist
wrist/almost all parts in children clinical area of interest.
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3. Kilner T. Triage decisions of estimation based on WHO mortality
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2007;62:834–9; discussion 839–42.
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systematic review. J Trauma. 19. Sayad El M, Noureddine H. Recent thoracolumbar injuries: The
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Upper limb trauma oral core topics

Chapter
27 Nirav K. Patel and Charalambos P. Charalambous
Sternoclavicular joint dislocation sandbag between the scapulae, longitudinal traction of the
arm with the shoulder extended and abducted (usually snaps
Mechanism back and stable). Should this be unsuccessful, bone forceps
Usually high-energy trauma (road traffic accident (RTA), can be used to grasp the medial clavicle and pull anteriorly,
contact sports), direct/indirect impact or failing that cautious open reduction. Once reduced, these
are usually stable. A figure-of-8 bandage to brace back
shoulders is worn for 3 weeks
Assessment Chronic reducible dislocation: Reduction with
Examination reconstruction of costoclavicular (CC) ligaments with
Localized swelling, bruising and deformity (position of medial thoracic surgeon on standby
clavicle in relation to sternum according to type of dislocation). Chronic irreducible dislocation: Resection of medial clavicle
with preservation (<15 mm resection) or reconstruction (if
Imaging torn) of CC ligaments. Thoracic surgeon on standby
‘Serendipity’ radiograph views or CT scan (better) to confirm Complications: Infection, blood vessel injury (thoracic
diagnosis. surgeon) and cosmetic deformity
Classification Clavicle shaft fracture

Anterior: Most common, usually asymptomatic despite
being unstable Mechanism
Posterior: 30%, may compress posterior structures causing Direct trauma or indirect injury from fall onto an
dysphagia, dyspnoea and sensation of fullness in the throat outstretched hand.
Pseudodislocation: Rare fracture mistaken for dislocation.
Salter–Harris type I or II in patients <25 years who have an Assessment
open medial clavicular epiphysis Examination
Localized swelling, bruising and deformity. Assess skin integ-
Management rity for tenting and blanching. Open or comminuted fractures
Non-operative are associated with high rates of pulmonary and head injuries.
Sprains, subluxations and the majority of anterior and poster- Other complications include neurovascular injury. Assess for
ior dislocations. Only treatment for symptoms (pain, swelling) scapula tenderness (floating shoulder).
is warranted.
Imaging
Operative Anteroposterior (AP) and 10–15° cephalad radiograph views
Acute dislocation: Anterior and posterior closed reductions of the clavicle, including the acromioclavicular (AC) joint and
are performed under general anaesthesia in theatre with a sternoclavicular (SC) joint.
thoracic surgeon on standby. The patient is supine with arm
at edge of table. Anterior dislocation is reduced using
longitudinal traction of the arm with the shoulder abducted
Classification
whilst applying direct posterior pressure over medial Anatomical according to thirds (Allman):
clavicle. These are usually unstable reductions, but function Middle: 80%
returns eventually despite this, so either accept the deformity Lateral: 15%
or excise the medial clavicle. Posterior dislocation requires a Medial: 5%
030
Chapter 27: Upper limb trauma oral core topics
Management Assessment
Non-operative Examination
The majority of middle third fractures treated in a sling for Localized swelling, bruising and deformity. Assess overlying
7–10 days, with early range of motion exercises. A ‘figure-of-8’ skin integrity (tenting and blanching), neurovascular status
provides no advantage in outcomes. Serial radiographs to and scapula for tenderness (floating shoulder).
monitor union. Although difficult to predict which will go into
non-union, the risk it may be higher in fractures that are Imaging
displaced, shortened >2 cm, comminuted, in females and the AP and 10–15° cephalad radiograph views.
elderly.
Complications: Non-union (open reduction with internal
fixation (ORIF) with compression plate and bone graft – auto-
Classification (Neer)
logous cancellous or tricortical for shortening/comminution, Type I – Fracture lateral to CC ligaments (trapezoid,
conoid) or interligamentous with minimal displacement
with good results), symptomatic mal-union (osteotomy in
(CC, AC). Stable
young active patients) and reduced shoulder strength and
endurance (15% of middle third fractures, if shortened and Type IIA – Fracture medial to CC ligaments (conoid/
comminuted). trapezoid ligaments attached to distal fragment). Medial
clavicle unstable
Operative Type IIB – Fracture either inbetween (conoid torn and
intact trapezoid attached to distal fragment) or lateral (both
Indications
torn) to CC ligaments. Medial clavicle unstable
Absolute: Skin under tension, skin viability threatened Type III – Intra-articular fracture Involving AC joint.
Relative: Displacement, severe shortening, open fracture, Intact CC ligaments and stable
neurovascular deficit, polytrauma and ipsilateral glenoid Type IV – Periosteal sleeve avulsion/ physeal fracture in
neck fracture skeletally immature patients. Intact CC ligaments attached
ORIF: Anatomical dynamic compression or locking plate. to periosteum and stable
Superior plating has better biomechanical strength but Type V – Comminuted fracture with intact CC
more prominent and may require removal of metalwork, ligaments attached to comminuted fragment. Medial
compared to anterior clavicle unstable
IM fixation: Percutaneous insertion (e.g. Rockwood pin,
Hagie pin and Knowles pin), but higher rates of metalwork
irritation and complications Management
Kirschner-wires (K-wires) and Steinman pins: Can Non-operative
migrate and so must be avoided In a sling supporting the elbow, if minimally displaced,
Outcomes: ORIF results in a faster time to union (16 vs 28 extra-articular and stable (type I/II).
weeks) and less non-unions (2% vs 7%) compared to non- Type III non-operatively initially with delayed AC joint
operative treatment. Patient satisfaction and outcomes are excision should post-traumatic AC joint osteoarthritis occur.
better with ORIF at 1 year postoperatively, although there Paediatric distal clavicle fractures (type IV).
may be hardware problems requiring removal1. However, a
recent Cochrane review2 concluded that there is limited Operative
randomised evidence on whether to manage acute Indications
middle-third clavicle fractures operatively or Absolute: Skin under tension, skin viability threatened
non-operatively. They recommended an individualized Relative: Displaced (non-union rate of up to 56% of type IIA
treatment approach based on risks, benefits and patient and 30–45% of type IIB fractures), extension into AC joint
preference and unstable fractures. However, many non-unions are
Complications: Infection, subclavian vein injury, brachial asymptomatic and require no intervention
plexus injury, supraclavicular cutaneous nerve injury ORIF: Anatomical lateral clavicle locking plate – Requires a
(numbness distal to scar), pneumothorax, non-union, large enough lateral fragment to gain purchase with screws
hardware intolerance (30% removal rate with superior (minimum of 2–3 bicortical). Hook plate – If the lateral
plates) fragment is too small and invariably requires removal of
metalwork due to subacromial impingement. Tightrope
Lateral clavicle fracture technique (e.g. 'Surgilig') using an open or arthroscopic
technique
Mechanism Non-union: If symptomatic, options are ORIF with bone
Usually a direct injury to the shoulder (e.g. contact sports). grafting or excision of the lateral fragment (Mumford
611
030
procedure) which may also require stabilisation of the Acute: Hook plate (rests in subacromial space and limits
medial clavicle if unstable (like AC joint stabilisation) abduction to 90°, with inevitable need for removal),
Outcomes: Hook plate had significantly lower complications Bosworth procedure or open/arthroscopic CC ligament
and hardware problems, as well as better return to work and reconstruction (e.g. Endobutton, Surgilig).
functional activity compared to tension-band wiring3 Chronic: Weaver–Dunn procedure, open CC ligament
Complications: Non-union (11.5% of fractures treated non- reconstruction (Surgilig, Endobutton).
operatively4), infection, metalwork failure/cut out, need for Complications: Infection, bleeding, nerve damage,
removal and stiffness pneumothorax, AC joint osteoarthritis, shoulder stiffness,
fractures coracoid process and clavicle, osteolysis lateral
clavicle and persistent AC joint instability.
Acriomioclavicular joint dislocation Outcomes: A meta-analysis comparing operative and non-
Mechanism operative treatment of type III injuries showed better
cosmetic outcomes but greater sick leave with operative
Direct injury to the point of the shoulder (e.g. rugby players
treatment without any difference in strength, pain, throwing
and motorcyclists), or an indirect injury (e.g. fall onto an
ability and AC joint osteoarthritis, although there are a lack
outstretched hand).
of well-designed studies to identify the optimum treatment5.
Assessment Scapula fracture

Examination
Localized swelling, bruising and deformity. Assess integrity of Mechanism
the skin and scapula (floating shoulder). Usually a significant mechanism of direct injury (e.g. RTA),
although may be indirect (e.g. fall onto an outstretched hand).
Imaging
AP and 10–15° cephalad (Zanca) radiograph views. Bilateral AC Assessment
joint stress radiographs (holding a weight) if diagnosis in doubt. Examination
Associated commonly with head injury, pulmonary injury, rib
Classification (Rockwood) fracture, proximal humerus/ clavicle fracture (floating shoul-
Type I – Sprain of AC joint ligaments (AC and CC ligaments der), brachial plexus injury, vascular (axillary artery) injury,
intact) spine fracture and pelvic injury.
Type II – Rupture of AC ligaments and sprain of CC ligaments
Type III – Rupture of AC and CC ligaments with <100% Imaging
displacement Radiographs: AP and lateral shoulder views. Chest
Type IV – Posterior displacement into or through trapezius radiographs to exclude a pneumothorax.
(rupture of AC and CC ligaments) CT scan: For intra-articular glenoid fractures.
Type V – Detachment of trapezius and deltoid (rupture of
AC and CC ligaments, separating clavicle and acromion) Classification
with >100% displacement Scapula fractures (Zdravkovic and Damholt)
Type VI – Inferior displacement to coracoid process and
Type I – Body
posterior to the conjoined tendon (rupture of AC and CC
Type II – Coracoid and acromion
ligaments)
Type III – Neck and glenoid
Glenoid fractures (Ideberg)
Management Type I – Anterior avulsion fracture
Non-operative Type II – Transverse/oblique fracture, inferior glenoid free
Sling and 7–10 days of immobilization/rest (type I/II). Type III Type III – Upper third of glenoid and coracoid
also treated non-operatively in the majority of cases, unless Type IV – Horizontal glenoid through body
occupation requires significant overhead activity (or sports
Type V – Combination of types II–IV
throwers).
Operative Management
Indications Non-operative
Absolute: Skin under tension, skin viability threatened Preferred option for most fractures
Relative: Reduction and repair of AC joint in some type III, Scapula body: Sling to rest/immobilize for 7–10 days, then
and all type IV–VI injuries. early range of motion exercises
030
Glenoid: Undisplaced and <25% of articular surface

involvement, small fragments and no humeral head
Shoulder glenohumeral joint dislocation
instability – Sling to rest/immobilize for 7–10 days, then ± fracture
early range of motion exercises. Glenoid neck predominantly
all managed non-operatively
Mechanism
Anterior: Fall onto abducted, externally rotated arm
Operative Posterior: Violent muscle contraction (e.g. tonic clonic
Scapula: Large, displaced and unstable fragments (e.g. seizure, electric shock), or direct injury
glenoid with clavicle fracture) with ORIF using precontoured Inferior: RTA or sports injury
locking plates. The posterior (Judet) approach is most
common using an internervous plane between infraspinatus Assessment
(suprascapular nerve) and teres minor (axillary nerve)
Examination
Glenoid: Intra-articular fractures displaced >2 mm or
Traumatic have unilateral, deformed (loss of shoulder contour,
significantly displaced extra-articular fractures with ORIF.
asymmetrical anterior axillary fold), painfully reduced range of
An anterior approach may also be used depending on the
motion in shoulder held with arm in external rotation (anter-
type of fracture and site of fragments
ior), internal rotation (posterior) or abduction 100–160° (infer-
Glenoid neck: Anterior translation or medial displacement of
ior). Assess neurovascular status (damage to axillary nerve,
glenoid neck and humeral head, with ORIF. Displaced glenoid
brachial plexus and axillary artery) and rest of limb for ipsilat-
neck fracture with ipsilateral clavicle (‘floating shoulder)
eral injuries. Of note, multidirectional are bilateral, not painful,
usually requires ORIF, but the stability of the superior shoulder
subluxation anteriorly and posteriorly with ligamentous laxity
suspensory complex (SSSC) should be considered
Complications: Suprascapular nerve and artery (when
retracting infraspinatus) in posterior approach Imaging
Radiographs: AP, Y view and axillary (most useful) shoulder
Scapulothoracic dissociation radiographs to assess direction of dislocation. If there is too
much pain for an axillary view, a Velpeau view is useful.
Mechanism Anterior dislocations have an abducted humerus and may
Significant mechanism of injury to the arm, shoulder and have a greater tuberosity fracture. Posterior dislocations can
chest wall. be missed (‘light bulb' sign, humerus adducted) and often
have associated lesser tuberosity (revere Hill–Sachs) fracture
Assessment CT scan: Confirm position and identify associated fractures
Examination (e.g. glenoid rim, proximal humerus)
Life-threatening injury with a 10% mortality rate due to asso-
ciated chest wall (heart, lung) injury. Specifically, there may be Classification
avulsion of brachial plexus, injury to subclavian or axillary Anatomical
artery or AC joint/sternoclavicular dislocation and clavicle Anterior, posterior and inferior (luxata erecta).
fractures. High suspicion of scapulothoracic dissociation when
neurological and/or vascular compromise.
Management
Imaging Closed reduction
Radiographs: AP and lateral shoulder views. Chest Anterior
radiograph with >1 cm lateral displacement of scapula Multiple closed reduction techniques available under analgesia
Angiography: In haemodynamically stable patients and sedation:
1. Kocher: Elbow at 90° with adduction, traction, external
Management rotation 70–8 until resistance) and medial (internal)
Non-operative rotation (after lifting arm in sagittal plane and bringing
Haemodynamically stable patients with vascular injury but hand to contralateral shoulder) (ATEM)
good collateral blood supply around shoulder, may not require 2. External rotation: Modification of Kocher’s, using first
any musculoskeletal surgery. stage of adduction and progressive external rotation
3. Spaso: Arm lifted vertically in supine position by the wrist
Operative with gentle traction and external shoulder rotation
Haemodynamically unstable patients may need high lateral 4. Matsen’s: Traction–counter-traction with a folded sheet in
thoracotomy or midline sternotomy to control bleeding. the axilla and traction in abduction. External and internal
Severe cases require forequarter amputation. rotation to disengage humeral head
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General anaesthesia when the above fails (e.g. muscular dislocation, a deltopectoral approach (preferable), posterior
patients), fracture–dislocations (e.g. greater tuberosity, to shoulder approach or a combination of the two is suggested.
avoid fracture propagation), posterior and inferior (50% suc-
cess) dislocations. Additional operative
Anterior dislocation may require a sling (in internal rota- Anterior
tion) until pain settles down for up to 2 weeks in elderly There is controversy on the management of first-time disloca-
patients and up to 4 weeks in young patients, although there tion in a young active patient (initial primary stabilisation vs a
is no evidence for prolonged use. A suggested approach is to ‘wait and see’ approach) and a Cochrane review found the
repeat radiographs in 1 week to exclude a recurrent dislocation limited evidence favoured primary surgery for young, male,
and start gentle mobilization with physiotherapy for range of highly active patients with their first acute traumatic shoulder
motion and rotator cuff strengthening exercises. Formal dislocation, and non-operative treatment for all other patient
delayed assessment of stability and cuff (e.g. with ultrasound types6.
scanning) is useful. Soft tissue – Anterior labral repair, ± ramplissage of Hill–
Posterior Sachs defects, in young patients. Open or arthroscopic repair
of rotator cuff if significant tear, commonly in those >45 years.
Posterior dislocations should have an attempted closed reduc-
Bony – For those with large glenoid or humeral head bony
tion if the dislocation is acute (<3–6 weeks old). Reduction
defects the options are a Latarjet procedure, iliac crest bone
technique involves 90° flexion and adduction with axial trac-
graft or shoulder arthroplasty.
tion on the arm, and direct posterior pressure on the humeral
head. For humeral heads locked on the glenoid rim, internal Posterior
rotation to stretch the posterior capsule and rotator cuff and/or If the shoulder is unstable with a <25% reverse Hill–Sachs
lateral traction of the proximal humerus may help. Once defect then the upper third of the subscapularis tendon is
unlocked, external rotate the humerus to reduce. Shoulder transferred into the defect using non-absorbable transosseus
stability is then assessed. sutures. The patient is immobilized in external rotation for 3–4
Once reduced posterior dislocation can be managed in a weeks. With a 25–50% humeral head defect, open reduction
similar way to anterior dislocation with a sling for up to with lesser tuberosity transfer (with attached subscapularis) to
3 weeks if stable in internal rotation. Radiographs should be the defect (modified McLaughlin’s procedure). Other options
repeated in 1 week before starting gentle mobilization. In those for defects of this size are rotational osteotomies of the prox-
cases that are unstable in internal rotation but stable in exter- imal humerus or allo/autograft reconstruction to restore
nal rotation, immobilization for 3–6 weeks in an external humeral head sphericity. With a >50% defect, hemiarthro-
rotation brace (20°), followed by rotator cuff strengthening is plasty or total shoulder arthroplasty if significant glenoid wear
required. should be considered.
Chronic missed posterior shoulder dislocations can be very
difficult to reduce beyond 6 months. Despite the cosmetic Inferior
deformity and loss of rotation, many activities of daily living Unstable inferior dislocations may require capsular
can be performed as there is little pain and some forward reconstruction.
flexion persists. ‘Supervised neglect’ can, therefore, be used in
the elderly with limited functional demands, a functional range
of motion and normal contralateral shoulder. In more Recurrent shoulder dislocations/instability
demanding patients open reduction, with reconstruction of
the defect is required (see below). Mechanism
Complications: Recurrent dislocation, fracture propaga- Direct or indirect injury. May be atraumatic depending on the
tion, surgical neck of humerus fracture (especially Kocher type below.
method if performed incorrectly), axillary nerve injury, rotator
cuff tear (older patients) and recurrence (<25 years of age,
high-energy injury, large bone defects and non-compliance).
Assessment
Examination
Open reduction As for shoulder dislocation above but with Beighton score
Indications (hypermobility), apprehension test, sulcus sign, scapula dyski-
Failure of closed reduction (e.g. button holing) or where nesia and drawer test.
humeral head is locked onto glenoid rim (acute or chronic).
Imaging
Approach Radiographs: AP, Y view and axillary (most useful) shoulder
For anterior dislocation, a deltopectoral approach (± coracoids views. West Pint view for glenoid rim fracture, Stryker notch
osteotomy and re-fixation) is suggested. For posterior view for Hill–Sachs lesion
030
modified McLaughlin’s procedure (<50% defect, >6 months

old) or hemi/total shoulder arthroplasty (>50% defect, >6
months old) depending on bone stock and pattern of
osteoarthritis
Proximal humerus fracture

Mechanism
Direct fall onto shoulder or indirect onto outstretched hand.
Assessment
Examination
Painfully reduced range of motion of shoulder, with swelling
and bruising which can be significant down the arm. Assess
axillary nerve and rest of neurovascular status of arm.
Figure 27.1 Stanmore classification of shoulder instability
Imaging
MRI: For capsulolabral and superior labrum from anterior Radiographs: AP, Y view, and axillary views of the shoulder
to posterior (SLAP) lesions to look at fragment number, displacement, angulation and
CT scan: For bony pathology (Hill–Sachs, glenoid, glenoid dislocation. Double shadow signifies a head-splitting fracture
version and bone stock) CT scan: Useful to assess articular surface and tuberosities,
and surgical planning
Classification
Matsen Classification (Neer)
Traumatic (TUBS) – Traumatic, Unidirectional, Bankart Parts are humeral head, greater tuberosity, lesser tuberosity
lesion treated with Surgery. Often a rotator cuff tear in those and shaft, which are counted when there is displacement of
>45 years >1 cm or angulation >45°:
Multidirectional (AMBRI) – Atraumatic, Multidirectional, One part – Undisplaced or minimally displaced fracture of
Bilateral, treated with Rehabilitation and Inferior the surgical neck, anatomical neck, greater tuberosity or
capsular shift lesser tuberosity
Two part – Displaced or angulated fracture of the surgical
Stanmore neck, anatomical neck, greater tuberosity or lesser tuberosity
Overlap between traumatic structural, atraumatic structural Three part – Displaced or angulated fracture of greater or
and habitual non-structural (muscle patterning) dislocations, lesser tuberosity and articular surface
which change with time (Figure 27.1). Four part – Displaced or angulated fracture of greater
tuberosity, lesser tuberosity and articular surface. The
Management articular surface may be split (‘head splitting’) and require
arthroplasty
Non-operative
Predominant management for multidirectional instability. Management
Non-operative
Operative Sling for comfort and early mobilization for one-part fractures
Anterior: Arthroscopic anterior capsulolabral repair and two-part surgical neck of humerus fractures. Some three-
(Bankart), unless there is a significant glenoid defect (possibly four-) part fractures with a relatively good position of
(>25%), which may require coracoid transfer (Bristow– articular and greater tuberosity fragments may be treated with
Laterjet), or iliac crest bone block. Inferior capsular shift for initial rest in a sling, then early pendular exercises and pro-
multidirectional instability only if prolonged non-operative gressive rehabilitation with regular radiographic evaluation,
management unsuccessful particularly in those with multiple co-morbidities.
Posterior: Open or arthroscopic repair of posterior defect
with posterior capsular shift if no bone defects for chronic Operative
recurrent instability and pain on loading of arm in forward Indications: Displacement, open fracture, fracture–
flexed position. Bone defects may require bone grafting, dislocation and neurovascular deficit
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030
Simple: Suture, tension-band or screw fixation for two-part

tuberosity fractures or anchor fixation
Humeral shaft fracture
ORIF: With a periarticular anatomical locking plate Mechanism
(e.g. Philos) for significantly displaced two-part surgical/ High-energy direct or bending forces or low-energy rotational
anatomical neck fractures, or three- and four-part fractures forces (e.g. arm wrestling).
with tuberosity/rotator cuff repair especially in younger
patients
Hemiarthroplasty (e.g. Neer): In three- and four-part Assessment
fractures with tuberosity/rotator cuff repair in elderly Examination
patients, or head-splitting fracture types. Hemiarthroplasty Painfully reduced range of motion of shoulder and elbow, with
can restore comfort and function in four-part fractures, possible deformity, pain and crepitus mid arm. Assess soft-
compared to non-operative management, which often leads tissue condition, radial nerve and rest of neurovascular status,
to pain, stiffness and shoulder dysfunction. However, they including compartment syndrome.
are not good overall with regards to function and motion
and should be reserved for low demand/frail patients. In
Imaging
those with a pre-existing massive rotator cuff deficiency, or
in elderly, a reverse total shoulder arthroplasty (RSA) is an AP and lateral radiographs of the humerus, including the
option. One systematic review showed that RSA had shoulder and elbow joints.
improved forward flexion and functional outcomes over
hemiarthroplasty with similar complication rates, although
studies with longer follow-up are needed2
Classification
No formal classification but based on fracture type.
Postoperative rehabilitation: Range of motion exercises as
Holstein–Lewis fracture is a distal third humeral shaft
tolerated
spiral fracture commonly associated with a neurapraxia of
Complications: Avascular necrosis – Patients with the
the radial nerve (22% incidence). The nerve is in a fixed in
following radiographic Hertel criteria7 are more likely to
position when winding round the lateral intermuscular septum
develop this
and, therefore, at high risk of injury.
<8 mm of metaphyseal extension remaining attached
to the head
>2 mm disruption of the medial hinge (shaft
Management
displacement) Non-operative
basic fracture type (anatomical neck) Indications: <20–30°AP angulation, <30° varus/ valgus
angulation and <3 cm of shortening as the shoulder
A positive predictive value of 97% for avascular necrosis was compensates for any mal-union
obtained when the above criteria were combined (short calcar, ‘U-slab’: Applied after manipulation acutely for comfort
disrupted hinge and anatomical neck). and allowing swelling to settle, although they are difficult
Other complications: Infection, neurovascular injury – to apply well and often lead to further fracture
Axillary nerve, musculocutaneous nerve and cephalic vein, displacement. The radial nerve must be assessed pre- and
stiffness, metalwork failure – Screw cut out most common post change
after locking plate fixation, non-union – Most common after Functional humeral (Sarmiento) brace: With careful
two-part surgical neck of humerus fracture and mal-union assessment of rotation is applied as soon as possible, with
Outcomes: There has traditionally been insufficient evidence frequent adjustments (avoid fracture distraction) and serial
to determine whether operative management produces clinical assessment/radiographs (assess fracture position
better outcomes than non-operative management. A recent and healing). Of note, standard ‘off-the-shelf’ braces may
meta-analysis comparing both options for complex 3- and not be able to reproduce the excellent results shown by
4-part fractures found no difference in functional outcomes, Sarmiento
although there was a higher rate of additional surgery up to
24 months with operative management8 Operative
The ProFHER (Proximal Fracture of the Humerus: Evaluation Absolute indications: New radial nerve palsy after
by Randomization) multicentre RCT examined the cost and manipulation
clinical effectiveness of surgical vs non-surgical management Relative indications: Open fractures, brachial plexus
of acute displaced proximal humeral fractures involving the injury, pathological fracture, segmental fractures,
surgical neck and found no differences in outcomes, compli- polytrauma, floating elbow, neurovascular injury, fracture
cations or secondary surgery. Surgery was, therefore, found displacement/distraction (Figure 27.2) and initial radial
not to be cost-effective9 nerve palsy, obese females
030
rate than for ORIF (see below) and contraindicated in radial

nerve palsy
Multiple flexible nails (e.g. Rush pins, Enders nails):
Inserted distal to proximal
External fixation (e.g. monolateral or circular frame): For
open or infected fractures, as a temporary or definitive
treatment
Complications
Radial nerve palsy (5–10%)
Occurring at time of injury: Observe when treating non-
operatively as it is most often a neurapraxia with 92%
recovering in 3–4 months (firstly with brachioradialis, then
ECRL and lastly EPL, then EIP). The mean time to onset of
first recovery was at 7.3 weeks and a limited period of
waiting had no effect on final recovery11
Occurring following closed manipulation: Explore radial
nerve. There is some evidence to suggest that even radial
nerve palsies occurring after manipulation is not an absolute
indication for exploration. Shao et al.5 reported that there
was no significant difference in the recovery rate between
primary (occurring at the time of injury) and secondary
(occurring after the injury, or as a result of a closed
reduction) nerve palsies. The recovery rate in primary nerve
Figure 27.2 Humerus fracture initially treated with brace that ended with
distraction at the fracture site palsies was 88.6% and 93.1% in secondary nerve palsies.
Be aware of this controversy, but for the exam nerve
exploration should be the answer, and only discuss
ORIF: Gold standard option which allows radial nerve controversy if specifically asked about other options of
exploration. The approach varies according to the level of management
the fracture: Occurring following open reduction internal fixation
Proximal shaft: Anterolateral approach, which is the (plating): If the nerve was identified and protected during
deltopectoral approach extended distally (Henry’s). The surgery, and the surgeon is confident that it was not under
radial nerve can be identified between the brachialis and plate, observe. If nerve was not identified during surgery but
brachioradialis distally. ORIF using a long proximal still sure not under plate, still observe. If any doubt that nerve
periarticular locking plate (e.g. Philos) may have been trapped in fixation then explore
Middle shaft: The commonly used posterior approach Occurring following IM nailing: Explore
where the triceps can be split or elevated with a lateral Radial nerve palsy and open fracture: Explore due to higher
tricipital exposure. It allows radial nerve exploration as likelihood of transection
it is located medial to the long and lateral heads and Tardy palsy (e.g. due to callus formation): Explore
2 cm proximal to the deep head, and as it exits the Radial nerve palsy treated by observation, that does not
posterior compartment 10 cm proximal to the recover: Requires baseline nerve conduction studies at 4–6
radiocapitellar joint by piercing the lateral intermuscular weeks to confirm type of injury and early referral to a
septum. ORIF using lag screws and compression plate peripheral nerve injuries unit if recovery does not occur by
with simple fractures, and bridge plate with comminuted 3 months (nerve fibres regenerate by this time). The timing
fractures of nerve exploration and neurolysis/nerve grafting is
Distal shaft: Posterior approach. ORIF using single controversial and suggested to be at 4–6 months if there is
posterolateral periarticular anatomical plate, or double no resolution. Splint and maintain passive joint movements
medial and lateral plates to avoid contractures with consideration of early tendon
ORIF has shown to have a lower rate of delayed union, with transfers whilst awaiting recovery
similar rates of non-union, infection and radial nerve palsy Other complications: Infection, nerve injury from distal-
to intramedullary nailing10. locking screws: Radial (lateral to medial), musculocutaneous
Intramedullary nailing: Antegrade for midshaft/proximal, (anterior to posterior); non-union: Higher risk for transverse
segmental and pathological fractures with distal locking fractures and intramedullary nailing with distraction (treat
screws. Retrograde for distal fractures. Higher complication with ORIF with compression plate and bone graft); shoulder
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030
pain: Secondary to rotator cuff damage following

intramedullary nailing and iatrogenic distal humerus
fracture/elbow motion restriction from retrograde
intramedullary nailing
Outcomes: A Cochrane review12 examining surgical vs
non-surgical management of humeral shaft fractures in
adults found there is no evidence available from
randomised trials stating that one is better or worse than
the other. When comparing the outcomes of intramedullary
nailing and plate fixation, a Cochrane review found there
was insufficient evidence to determine any difference in
functional outcome. It found similar union rates but nailing
was associated with an increased risk of shoulder problems
(pain, impingement, stiffness) and need for metalwork
removal13. Hence, along with other meta-analyses10, ORIF
may be considered the gold standard for treating humeral
shaft fractures
Holstein–Lewis fracture
These are fractures of the distal humerus shaft with associated
radial nerve palsy. As the radial nerve winds round the radial
groove and enters the anterior compartment of the arm via the
lateral intermuscular septum, it is fixed in position. Any frac-
ture of the humerus shaft around this area (Figure 27.3) that is
displaced tugs on the radial nerve, which is ‘fixed’ at the lateral
intermuscular septum and may cause a radial nerve palsy.
Holstein and Lewis recommended surgical exploration of
the nerve.
Several authors believe, however, that the special rela-
tionship between this fracture pattern and radial nerve
palsy is not as strong as Holstein and Lewis suggested. As
such, a spiral fracture pattern of the distal humerus with Figure 27.3 Distal humerus fracture in a patient with associated radial nerve
palsy
associated nerve palsy is not an absolute indication for
radial nerve exploration. Be aware of this controversy, but
for the exam nerve exploration and fracture fixation is
recommended.
Classification
Supracondylar (AO/OTA):
Distal humeral fracture Type A: Extra-articular
Type B: Intra-articular, single column
Mechanism Type C: Intra-articular, both column, with joint and shaft
Indirect fall onto outstretched hand or direct fall onto the dissociation
elbow.
Single column (condyle) – Milch:
Types I and II lateral condyle fractures (more common) –
Assessment Type I lateral trochlear ridge intact and type II it is not
Examination Types I and II medial condyle fractures
Swollen, bruised and limited range of motion elbow. Assess Both column (Jupiter):
soft-tissue and distal neurovascular status. High T – Transverse component proximal or at level of
olecranon fossa
Imaging Low T (common) – Transverse component just proximal
Radiographs: AP and lateral radiographs of the elbow to the trochlea
CT scan: In displaced intra-articular fractures to fragments Y – Oblique fracture through both columns with a vertical
and plan surgery distal fracture
030
H – Trochlear fragment is free and at risk of AVN Operative

Medial lambda – Proximal fracture exits medially ORIF using a posterior approach with an olecranon osteotomy
Lateral lambda – Proximal fracture exits laterally (for complex intra-articular fractures) which gives the best
Multiplanar – T type with coronal plane fractures articular surface exposure. The same exposure as the triceps
Capitellum (Bryan–Morrey with McKee modification): sparing approach (see above), with a distal pointing chevron
Type I (Hans–Steinthal): Complete fracture of capitellum apex osteotomy, fixed with a 6.5 mm screw, plate or tension-
Type II (Kocher–Lorenz): Shear osteochondral fracture band wiring. Anatomical periarticular locking pates are placed
in parallel to reconstruct the medial and lateral columns.
Type III: Comminuted
Alternatively, plates may be placed at 90° to each other with
Type IV (McKee modification): Coronal shear fracture of
equivalent biomechanical strength, although recent evidence
capitellum and part of trochlea
favours the parallel technique. For intra-articular fractures,
provisional K-wire fixation is followed by countersunk screws
Management to fix articular fragments and the condyles first. The articular
Supracondylar segment is then fixed to the shaft. Early mobilization with <3
weeks in a cast is the aim.
Non-operative Total elbow arthroplasty: Patients >65 years with poor
Cast for up to 6 weeks with serial radiographs in undisplaced bone quality or rheumatoid arthritis with unreconstructable
or minimally displaced supracondylar fractures. intra-articular fractures. Alternatively, it can be used in the
healthy elderly patient with displaced transcondylar fractures.
Operative Two-year functional outcomes in the elderly with distal
ORIF for displaced supracondylar fractures. A posterior humeral intra-articular fractures were better with arthroplasty
triceps-sparing approach can be used for extra-articular and compared to ORIF, with lower re-operation rates14.
simple intra-articular fractures with full thickness medial and Complications: Stiffness (most common, initial treat with
lateral flaps, and identification of ulnar and radial nerves by static progressive splinting, although 50% of low T types
elevating the deep fascia. Can be converted to an olecranon require revision with good results), loss of elbow muscle
osteotomy if needed. strength of 25%, ulnar nerve injury (anterior transposition),
Complications: Infection, neurovascular damage, non- AVN of trochlea fragment in H-type, osteotomy non-union
union (1–11% with ORIF), mal-union and stiffness (contrac- and heterotopic ossification (4% with ORIF).
ture, bony block, fibrosis).
Capitellum
Single column Non-operative
Non-operative Cast for undisplaced (<2 mm) types I, II and III capitellum
Cast for Milch type 1 undisplaced condyle fractures in supin- fractures for up to 3 weeks, before mobilization.
ation (lateral condyle) or pronation (medial condyle).
Operative
Operative ORIF for displaced type I fractures (>2 mm) and all type IV
fractures. A lateral approach is predominantly used, unless
Closed reduction and percutaneous K-wires, screws or plating
there are other elbow injuries warranting a posterior approach.
(depending on the size of the fragment) for displaced Milch
Fixation using headless compression screws if anterior to pos-
type I fractures.
terior, or minifragment screws if posterior to anterior. Blood
ORIF for Milch type II fractures. A lateral approach can be
supply to the capitellum is posterior; thus, the posterior soft-
used with elevation of ERCB and part of ECRL off supracon-
tissue attachments must be maintained.
dylar ridge, anterior to LCL, allowing visualisation of the
Excision of comminuted fragments in displaced types II
articular surface.
and III fractures (>2 mm) which cannot be reduced and
Complications: Cubitus valgus (lateral), cubitus varus
fixed15.
(medial), ulnar nerve injury and joint degeneration
Total elbow arthroplasty in elderly patients with unrecon-
Both columns stuctable fractures and medial column instability in particular.
Complications: As above, including avascular necrosis of
Non-operative
capitellum.
Cast and ‘bag of bones’ treatment with early mobilization
for unreconstructable intra-articular fractures in cogni-
tively impaired patients with poor bone quality and mul- Radial head fracture
tiple co-morbidities. Even if fracture does not heal, the
non-union site may be painless and good motion may be Mechanism
present. Fall onto outstretched hand
619
030
ORIF: With headless compression screws (two-part

partial articular or comminuted partial articular fractures),
or periarticular plates (comminuted complete articular,
radial neck fractures). The approach can be posterolateral
(Kocher) using the interval between ECU and anconeus;
lateral (Kaplan) using the interval between EDC and
Figure 27.4 Charalambous classification of radial head fractures16 ERCB; or Wrightington with elevation of anconeus
off the ulna and osteotomy of the supinator crest
which is re-attached following fracture fixation (does
Assessment not disrupt the substance of LCL). Forearm pronation
helps to protect the PIN. The safe zone for plate placement is
Examination
a 110° arc from radial styloid to Lister’s tubercle laterally
Lateral elbow pain, with tender radial head and limited elbow (~25%)
range of motion. Assess for coronoid process fracture and Radial head excision: In comminuted partial or complete
elbow instability, as well as distal radius fracture and Essex– articular fractures, isolated radial neck fractures, patients
Lopresti injury. with low functional demands. Avoid in elbow instability or
Imaging Essex–Lopresti injury
Radial head replacement: In comminuted partial or
AP and lateral radiographs of elbow and wrist (based on
complete articular, isolated radial neck fractures, high
clinical examination).
demand patients or those with elbow instability or Essex–
Lopresti injury. Avoid overstuffing the radiocapitellar joint
Classifications Outcomes: Patients with comminuted fractures undergoing
Mason (with Hotchkiss modification) ORIF had better range of motion, strength and function
Type I – Undisplaced or minimally displaced (<2 mm) than those patients undergoing radial head excision17.
head or neck fracture. No mechanical block to motion Complications: Stiffness, posterior interosseous nerve injury
Type II – Articular or neck displacement/ angulation (pronate to avoid injury), proximal migration of radius
(>2 mm). Possible mechanical block to motion (Essex–Lopresti)
Type III – Comminuted and displaced head and neck
fracture. Mechanical block to motion Elbow dislocation
Type IV (Hotchkiss modification) – Radial head fracture
with concomitant fractures or ligamentous injuries/ elbow Mechanism (for posterolateral dislocation)
dislocation Fall onto outstretched hand with a combined mechanism of
axial loading, supination of the forearm and a posterolateral
Charalambous valgus force.
Based on the number and location of fragments and whether Elbow dislocation results from complete or near complete
the fracture is un-displaced (U) or displaced (D) as shown in disruption of circle of capsuloligamentous stabilisers and bone
Figure 27.416: (Horii circle). This occurs sequentially from lateral to medial
Two-part partial articular (U or D) in thre stages. Stage 1 (posterolateral rotatory instability) from
Comminuted partial articular (U or D) partial or complete LCL failure (usually epicondyle avulsion
Comminuted complete articular (U or D) and less commonly a midsubstance tear); stage 2 (perched
ulna) with additional anterior and posterior capsular structure
Isolated radial neck fractures (U or D)
injury; and stage 3 (dislocation) with MCL failure depending
Management on the degree of injury (often intact).
Non-operative
Indication: Undisplaced fractures. Assessment
Sling for pain relief then early range of motion exercises, Examination
which may be facilitated by aspiration of elbow joint and local Swelling and deformity of elbow. High energy (anterior and
anaesthetic injection. Similar for displaced fractures associated divergent types) associated with open and neurovascular injur-
with a stable elbow, cause no block to motion, and displace- ies. Exclude compartment syndrome.
ment acceptable (<3 mm).
Imaging
Operative Radiographs: AP and lateral views of the elbow to assess
Indication: Substantial displacement, block to motion, joint congruency, direction of dislocation and associated
elbow instability fractures, with an optional oblique view for periarticular
030
bony involvement. Wrist views to exclude Essex–Lopresti Operative

injury Indications: Inability to reduce, incarceration, incongruent
CT scan: To assess type and displacement of fractures reduction, gross instability
MRI: To assess both ligaments and fractures. Simple dislocations: Gross instability with congruent
reduction requires a cast and MRI scan to plan
Classification reconstruction
Complex dislocations: Reconstruction required for unstable
Anatomical
injuries (e.g. ‘terrible triad’) and displaced fractures (CT
Posterolateral (80%) scan). A lateral approach is used, with a medial approach if
Posterior needed. A posterior ‘utility’ approach can be used to access
Anterior (high energy) medial and lateral elbow. A stepwise approach I used starting
Medial with radial head ORIF (reconstructable) or replacement
Lateral (comminuted and unreconstructable) with a lateral collateral
Divergent (high energy) ligament repair. Only if still unstable, coronoid process
ORIF (same lateral approach if radial head excised for
Severity replacement or separate medial approach). If instability
Simple: No associated fracture, often first-time dislocation persists, medial collateral ligament repair via a medial
Complex: Associated fracture including medial/lateral approach
epicondyle avulsion, osteochondral injury, radial head/ Coronoid process: ORIF with cerclage wire, intraosseous
neck fractures and coronoid process fractures sutures or plate if fragment large enough. Type I fractures
with persistent instability – These are a marker of anterior
Coronoid process fractures (Regan and Morrey) capsular injury, and surgical fixation aims to reattach the
Type I – Tip of coronoid process stripped off anterior capsular structures rather than fixing
bone. Types II and III
Type II – <50% of coronoid process
Postoperative rehabilitation: Range of motion exercises as
Type III – >50% of coronoid process
tolerated
‘Terrible triad’ Complications: Infection, recurrence of instability in high-
energy injuries, stiffness/ flexion contracture (if immobilized
Elbow dislocation with lateral collateral ligament injury (avul-
>3 weeks), heterotopic ossification of collateral ligaments,
sion from humeral origin), radial head fracture and coronoid
joint degeneration, brachial artery injury, median or ulnar
process fracture.
nerve injury and capitellar erosion (‘overstuffing’ of radial
head replacement)
Management
Initial Olecranon fracture
Emergent closed reduction using analgesia and sedation, or
failing that general anaesthesia, which allows assessment of Mechanism
stability and appropriate reconstruction. Neurovascular status Direct fall onto elbow or indirect violent contracture of triceps.
must be assessed pre- and post manipulation. Radiographs are
assessed for congruency of reduction. Assessment
Examination
Non-operative
Swollen, bruised elbow, often with skin contusions. Assess-
Simple dislocation: Stability in a functional range of
ment of elbow extension, radial head tenderness and neuro-
motion with a congruent reduction can be placed in a sling
vascular status.
with early range of motion exercises. Instability at
extreme range of motion with a congruent reduction Imaging
requires 1-week cast immobilization, followed by range of
AP and lateral radiographs of the elbow to assess fracture for
motion exercises
fragment size, type (see classification below), displacement,
Complex dislocations: Undisplaced fractures post reduction extension distally (making elbow unstable) and dislocation.
with a congruent joint can be treated in a cast for up to
3 weeks with serial radiographs followed by range of motion
exercises Classification (Colton)
Coronoid process: Type I fractures without symptoms Type I – Avulsion
of instability, and types II/III which are stable on Type II (A–D) – Oblique fracture, with increasing
examination complexity
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030
Type III – Fracture–dislocation Imaging

Type IV – Atypical, high-energy comminuted fracture Radiographs: AP and lateral views of elbow, forearm and
wrist. Interosseous membrane injury when >3 mm
Management instability when radius pulled proximal, and both
Non-operative interosseous membrane and TFCC when >6 mm.
USS or MRI: To confirm interosseous membrane injury.
Indications: Undisplaced (<1–2 mm) fractures and displaced
fractures in low-demand elderly patients. Classification (Bado)
Immobilize in a cast at 60–90° for 1–2 weeks (maximum 3
Based on direction of radial head dislocation:
weeks), followed by gentle range of motion exercises.
Type I (80%) – Anterior radial head dislocation and apex
Operative: anterior proximal ulna fracture
Indications: Displaced >1–2 mm Type II (15%) – Posterior radial head dislocation and apex
Tension-band wiring: With stainless steel wire, with two posterior proximal ulna fracture
dorsal loops to allow tension forces to be converted into Type III – Lateral radial head dislocation and proximal
compression forces at the fracture site. K-wires buried into ulna metaphyseal fracture
the anterior ulnar cortex increase stability, but may reduce Type IV – Anterior radial head dislocation and proximal
pronosupination if protrude beyond. Migration of these ulna and radial shaft fractures
wires and metalwork irritation occurs in 70% with a high ‘Monteggia equivalent/ variant’: Radial head fracture instead
chance of requiring removal of dislocation
ORIF: More stable than tension-band wiring.
Contoured third tubular or periarticular-locking plate Management
applied to the dorsal (tension) side for comminuted Initial
fractures, oblique fractures and those extending distal to the
Emergent closed reduction and above elbow plaster 'backslab'
coronoid process
application under sedation and analgesia.
Intramedullary screw: Partially threaded 6.5 or 7.3 mm
cancellous crew with a washer, ideally with tension-band Operative
wiring.
Indications: All adult injuries as unstable requiring
Excision with triceps advancement: Highly comminuted operative management. Non-operative management leads to
fractures in patient with poor bone stock and low demands. late radial head dislocation
Excise <50% of olecranon and attach triceps close to
ORIF using plate fixation of the ulna using a subcutaneous
articular surface suture anchors or intraosseous sutures to
border approach usually allows reduction of the radial head,
attach triceps
which remains stable (Figure 27.5). Ensure the fixation is
Postoperative rehabilitation: Early range of motion anatomical, and assess stability of the radioulnar joint. If
exercises there is comminution of the ulna shaft fracture, the length
Complications: Infection, stiffness, metalwork failure must be restored to achieve stability. If the radial head
or prominence (requiring removal), joint degeneration, cannot be reduced despite this (e.g. delayed presentations,
non-union (usually a fibrous non-union which is annular ligament interposition in radiohumeral joint), then
stable enough to avoid revision), ulnar nerve injury and an open reduction is required via a posterolateral (Kocher)
instability approach with reconstruction of the annular ligament
Monteggia fracture–dislocation
Radial head dislocation with proximal ulna fracture.
Mechanism
Fall onto outstretched hand.
Assessment
Examination
Swollen, deformed and reduced elbow range of motion. Assess
for tenderness at the wrist for possible TFCC/interosseous Figure 27.5 Monteggia fracture of the ulna and radial head stabilised with
membrane injury and distal neurovascular status. plate fixation for ulna and screws for the radial head
030
Monteggia equivalent/variant: Injuries may require a

posterolateral or lateral approach to the elbow (See Radial
Assessment
Examination
head fracture section) to address the radial head fracture
Postoperative rehabilitation: Early range of motion Deformity, crepitus, swelling. Assess for open injury and distal
Complications (higher for type II and Monteggia-equivalent): neurovascular status.
Infection, PIN palsy (e.g. annular ligament reconstruction) – Imaging
Observe for 3 months, as resolves spontaneously usually; AP and lateral radiographs of the forearm, including the wrist
stiffness, late radial head subluxation/dislocation (non- and elbow.
operatively treated injuries) and radioulnar synostosis
Isolated ulnar shaft fracture Management

Operative
(‘Nightstick’ fracture) Indication: Displaced radius and ulna fractures in adults
Mechanism ORIF with two incision technique using subcutaneous
border for ulna and volar Henry’s approach for radius.
Direct trauma to the ulnar border of the forearm.
Both fractures are exposed and provisionally reduced with
the least comminuted bone (usually the ulna) fixed first.
Assessment Compression or bridge (comminuted fractures) plating with
Examination bone graft for bone loss and open injuries
Swelling and crepitus over ulnar fracture. Assess proximal Complications: Infection, PIN palsy for proximal radius
radioulnar joint (?Monteggia fracture dislocation) and distal fractures, vascular injury, radioulnar synostosis and stiffness
neurovascular status.
Imaging Galeazzi fracture–dislocation
AP and lateral radiographs of the forearm, including the wrist Distal radius fracture with a distal radioulnar joint (DRUJ)
and elbow. dislocation.
Classification (anatomical) Mechanism

Fall onto outstretched hand.
Location and type of fracture, whether undisplaced or displaced.
Greater than 25–50% displaced or greater than 10–15°
angulated are considered unstable. Assessment
Examination
Management Swelling, deformity and crepitus at the fracture site and wrist.
Non-operative Assess soft-tissue and distal neurovascular status.
Below elbow moulded (interosseous) cast in distal two-third Imaging
shaft and stable fractures. Consider 3 weeks initially an above
Radiographs: AP and lateral views of the forearm and wrist,
elbow cast, although studies have demonstrated no difference
including the elbow. Signs of DRUJ instability: Widened
in outcomes between a below elbow and above elbow cast18.
DRUJ on PA view, dislocated on lateral view, >5 mm radial
Operative shortening, ulnar styloid fracture and distal radius fracture is
>7.5 cm from the articular surface (55% unstable, vs 6% for
Indication: Unstable injuries, proximal third or very distal
<7.5 cm)
fractures
CT scan: Of both wrists in a similar position often
ORIF using compression plating via a subcutaneous
postoperatively if there is any doubt on the DRUJ on the
border approach. Also used for those fractures initially
radiographs
treated non-operatively with displacement, delayed- or non-
union (with bone grafting)
Complications: Infection, mal-union, delayed-union and Management
non-union Initial
Emergent closed reduction and above elbow plaster ‘backslab’
Radius and ulna shaft fracture application under sedation and analgesia.
Mechanism Non-operative
Indirect fall onto outstretched hand or direct trauma to fore- Isolated DRUJ dislocations may be reduced using analgesia
arm (e.g. high-energy RTA). and/or sedation.
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030
Operative Type I – Bending fractures, usually extra-articular

Indication: All unstable injuries and non-operative metaphyseal (volar (Smith’s) and dorsal (Colles’))
management results in displacement Type II – Shear of the articular surface (volar or dorsal
ORIF: Plate fixation of distal radius using a volar Henry’s rim (Barton’s), radial styloid (Chauffer’s))
approach. The DRUJ is reduced and assessed for stability Type III – Compression (e.g. die-punch)
using forearm supination. If well reduced and stable – An Type IV – Fracture–dislocations (rare, high-energy
above elbow cast or splint in supination with early range of trauma – Avulsion fractures with radiocarpal fracture
motion is applied. If well reduced and unstable – dislocations)
Percutaneous K-wire fixation into ulna and radius across Type V – Combined mechanism of types I–IV (severe,
DRUJ in supination with cast. If irreducible – Open dorsal high-energy trauma)
approach to DRUJ to remove block (usually ECU tendon), Universal: Useful in treatment planning
followed by K-wire fixation and above elbow cast in Extra-articular or intra-articular
supination
Stable or unstable
Complications: Infection, mal-union, non-union, DRUJ
Indicators of instability are (RADIUS): Radial shortening
subluxation/ dislocation and stiffness (fractures treated in a >5 mm, Angulation >20°, Dorsal comminution, Intra-
cast) articular (depression >2 mm), Ulna styloid fracture and
Severe displacement
Distal radius fracture
Management
Mechanism Initial
Fall onto a dorsiflexed or volarflexed hand, violent radial
Emergent closed reduction of displaced fractures using anal-
deviation of the wrist.
gesia and sedation or a haematoma block, with application of a
below elbow plaster ‘backslab’.
Assessment
Examination Non-operative
Swollen, bruised and deformed (e.g. dinner fork). Assess ana- Indication: Undisplaced stable fractures or displaced
tomical snuff box and elbow. Assess soft-tissues and distal fractures reduced and remain stable
neurovascular status – If signs of median nerve neurapraxia Closed reduction (if appropriate) and below elbow cast.
perform a carpal tunnel decompression at the same sitting as Acceptable parameters: <10° dorsal angulation, <2 mm of
ORIF. This should be using a two-incision technique to avoid articular step-off and <2 mm radial shortening with radial
damage to palmar cutaneous branch of median nerve. inclination of 21° less important. Regular (up to weekly)
radiological monitoring for displacement according to
Imaging stability. Indicated for type I and undisplaced type II/III
Radiographs: PA (radial shortening, DRUJ disruption, distal fractures
ulna fracture, radial styloid fracture, radial displacement and Elderly patients with poor bone quality, multiple co-
intra-articular extension) and lateral (dorsal/ volar tilt or morbidities, cognitive impairment and low functional
displacement, DRUJ dislocation and intra-articular demands may accept more unstable/displaced fractures for
extension) views of the wrist casting
CT scan: For displaced intra-articular and often distal
fractures to assess fragments and plan fixation Operative
Indication: All unstable fractures, particularly volarly
Classification angulated/ displaced fractures
Closed reduction and K-wire fixation: Percutaneous
Multiple, none definitively useful.
technique using 1.6 or 1.8 mm wires into radial styloid and
Frykman: Based on anatomy, no correlation to treatment or dorsally as positional wires. Alternatively, the Kapandji
outcomes technique corrects dorsal displacement/angulation and then
Type I – Extra-articular maintains reduction(Figure 27.6). Indicated in type I and II
Type III – Radiocarpal joint (Chauffer) fractures, ideally young patients with extra-
Type V – Radioulnar joint articular stables fractures (e.g. no dorsal comminution)
Type VII – Both radiocarpal and radioulnar joints ORIF: Volar (or dorsal in type II) anatomical periarticular
(Above plus ulnar styloid fracture for types II, IV, VI locking plate or fragment specific fixation
and VIII) (multifragmentary) with bone graft in significantly
Fernandez: Based on mechanism of injury depressed fractures. Solitary screws may be used for radial
030
superficial radial nerve injury, loss of reduction/ mal-union,

non-union, stiffness (particularly pronosupination if the
DRUJ), median nerve neuropathy, ulnar neuropathy (DRUJ
fracture), tendon injury/ adhesion/instability, EPL
rupture (cast treatment), joint degeneration, compartment
syndrome (leading to Volkmann ischaemic contracture)
and DISI
Figure 27.6 Kapandji technique of K-wire fixation of extra articular distal
radius fracture
Examination corner
Trauma case 1
styloid or avulsion fractures. Unstable and/or displaced
intra-articular fractures, articular margin fractures (buttress) EXAMINER: This is a 25-year-old patient with a midshaft humeral
and extra-articular fractures with dorsal comminution. fracture treated with flexible intramedullary nailing 5 months ago
Indicated in type II (where carpal subluxation may be (shown radiograph).
present), displaced type III (disimpaction and bone graft CANDIDATE: Radiographs show a transverse fracture of midshaft of
of compressed articular surface), type IV and type V the right humerus with flexible intramedullary nails in-situ and
fractures lack of bony union.
External fixation: Bridging construct for intra-articular EXAMINER: What is your plan?
fractures (static or dynamic), with some evidence of CANDIDATE: I would like to take a full history and examination.
non-bridging construct for extra-articular fractures to allow History should focus on the symptoms, treatment received and
radiocarpal motion. Adjunctive K-wire fixation may be complications of surgery, co-morbidities and smoking status.
useful for intra-articular fragments. High-energy injuries Examination would focus on vital signs, wound mobility at the
which cannot be reconstructed for bony (comminuted, often fracture signs and neurovascular status.
distal, intra-articular fractures) and/ or soft-tissue (severe EXAMINER: There is pus at the pin sites. Now what?
soft-tissue and open injuries) reasons. The latter may be CANDIDATE: Pus suggests infected non-union. I would obtain a
converted to ORIF within 2 weeks if required, particularly as wound swab, inflammatory markers and consider a CT scan to
there is diminishing effect of ligamentotaxis with time due to assess for any union. If there are bridging trabeculae then the pins
viscoelastic properties of ligaments19 may be removed with pin site debridement and antibiotic
After all surgical fixations assess pronosupination (DRUJ) therapy according to sensitivities.
and scapholunate joint stability. Intra-articular fragment EXAMINER: There is no evidence of union.
reduction, TFCC integrity and carpal joints may be
CANDIDATE: In that case I would remove the nails, debride the pin
formally assessed with wrist arthroscopy although rarely
sites and the fracture site/intramedullary canal where possible.
done acutely
The bone ends would be debrided until there are bleeding edges
Outcomes: Dorsally displaced, unstable, extra-articular with bone grafting. I would use an external fixator for skeletal
or simple intra-articular fractures of the distal radius stabilisation with antibiotic therapy according to microbiology
treated with closed reduction and K-wires or ORIF (volar advice.
plate) had similar functional outcomes at 1-year
EXAMINER: How would you consent the patient?
postoperatively. However, better functional results were seen
CANDIDATE: I would explain the name of the procedure and
in the early postoperative period only with ORIF20. In
explain in lay terms, including the benefits of achieving union,
addition, the multicentre randomised controlled DRAFFT
treating infection, reducing symptoms and improving function.
(Distal Radius Acute Fracture Fixation) trial compared K-
I would offer alternatives including a non-operative approach
wire fixation to locking plate fixation in adults and found no
and the sequelae of persistent symptoms and infection. The
difference in functional outcome and complications at 12
risks would include infection, bleeding, nerve damage,
months, with K-wires being quicker and cheaper to
scar, stiffness, further procedure, delayed/mal-/ non-union and
perform21
failure.
Postoperative rehabilitation: ORIF (and non-bridging
external fixator) allows early range of motion exercises out of Good points – Suggested a reasonable plan and followed
a cast if the construct is stable enough. Other options require through with confidence. Detailed consent process made
cast immobilization for a longer period so the emphasis on easy to understand for the patient
Could improve – Mention the difficulties associated with
finger, elbow and shoulder range of motion exercises.
an upper limb external fixator. Offer other alternative
Routine postoperative physiotherapy has not shown to options such as retaining the metalwork until union
improve outcomes achieved or intramedullary nailing. Mention any evidence
Complications: CRPS (one of the commonest complications in the literature
and vitamin C may help in prophylaxis), infection,
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030
Trauma case 2
EXAMINER: Why?
EXAMINER: A 45-year-old woman with this injury following a fall CANDIDATE: The shortening of the clavicle leads to shortening of the
from height sustains this injury (shown radiograph). Describe what moment arm of shoulder and, hence, the strength of shoulder
you see. abduction.
CANDIDATE: Radiographs show right elbow fracture–dislocation with EXAMINER: Do you have any evidence for this?
a displaced coronoid process fracture and possible radial head CANDIDATE: Yes. Paper published in . . . showed . . .
fracture, suggestive of a terrible triad injury.
EXAMINER: How valid is that paper? What are its drawbacks?
EXAMINER: How would you manage the patient?
CANDIDATE: Errr, don’t know.
CANDIDATE: I would approach the patient according to ATLS®
EXAMINER: OK. What are the indications for fixation of clavicle
protocol.
fractures?
EXAMINER: This is an isolated injury and the patient is stable.
CANDIDATE: Open fractures, polytrauma, multiple fractures in same
CANDIDATE: I would like to know whether this is a closed injury and limb, neurovascular injury, shortening >2 cm, symptomatic non-
the neurovascular status. union.
EXAMINER: It is closed and neurovascularly intact. EXAMINER: OK. What are the risks of plate fixation of clavicle?
CANDIDATE: Following appropriate consent and analgesia I would CANDIDATE: Infection, wound healing problems, vascular injury,
reduce the dislocation in casualty, placing the patient in an above prominent plate, numbness distal to scar, plate breakage.
elbow 'backslab' with check anteroposterior and lateral
radiographs. I would check neurovascular status again.
EXAMINER: It is neurovascularly intact and the radiographs confirm Good points – Had a plan for this injury and did not beat
around the bush
reduction of the elbow joint.
Could improve – When quoting any reference, it is
CANDIDATE: I would arrange for a CT scan to make an operative plan. necessary to have read more than just the abstract and to
EXAMINER: CT is performed. What is you approach and be able to appraise the paper critically and give reasons as
operative plan? to why you would accept or not accept the conclusions
CANDIDATE: My preference is a lateral Kocher approach in between offered. In the paper quoted there were high rates of
ECU and anconeus, with initial fixation of the coronoid process via complications in the operated group and secondary
the radial head fracture, then the radial head ORIF (replacement if surgery to remove plate and screws
not reconstructable) and LCL repair if needed. I would assess
Trauma case 4
stability at each stage and at the end, with a temporary above
elbow 'backlslab' for 2 weeks followed by an elbow brace with EXAMINER: A 25-year-old man suffers a grand mal seizure and
graduated active ROM exercises. presents with a painful shoulder with a limited range of motion.
EXAMINER: What are the static and dynamic stabilisers of the elbow? This is his injury – Describe what you see (shown radiograph).
CANDIDATE: Static – Primary: Ulnohumeral joint, anterior MCL bundle CANDIDATE: This is an anteroposterior and lateral ‘y-view’ lateral
and LCL and secondary: Radiocapitellar joint, capsule and CFO/ radiographs of the right shoulder, demonstrating a possible
CEO. Dynamic – Muscles crossing the elbow including anconeus, undisplaced fracture of the greater tuberosity. There appears to
brachialis and triceps. be a ‘light-bulb sign’ making me suspicious of a posterior
dislocation – May I see an axillary lateral or Velpeau view?
Good points – Systematic and confident approach to EXAMINER: Here you go.
managing an emergent situation, with good planning for
CANDIDATE: This is a posterior dislocation with an engaging reverse
definitive fixation
Hill–Sachs lesion in the region of 20%.
Could improve – Beware of mentioning an ATLS®
approach in managing isolated injuries. Perhaps EXAMINER: What is your management?
describe posterior utility approach as an option. Offer CANDIDATE: Assuming this is an isolated injury and the patient is
evidence from the literature on management and stable I would take a full history, when they are starved from, co-
expected outcomes morbidities, allergies and medications, in preparation for theatre.
On examination, I wish to confirm this is a closed injury and it is
Trauma case 3
neurvascularly intact.
EXAMINER: A 30-year-old skateboarder fell on to left shoulder and EXAMINER: He is starved and healthy, with no allergies and no
this is the radiograph. regular medications. It is closed and neurovascularly intact.
CANDIDATE: Radiographs show transverse fracture of midshaft left CANDIDATE: I would take this man to theatre, where under a general
clavicle with shortening of about 2 cm. anaesthetic (and muscle relaxation if required) and an image
EXAMINER: What will you do? intensifier attempt a closed reduction using a traction-counter
CANDIDATE: I will offer surgery in the form of open reduction and traction technique with a pillow case across the axilla. I would also
plate fixation. consent him for an open reduction ± stabilisation in case the
030
closed reduction is unsuccessful or the shoulder is highly

EXAMINER: What if he continues to suffer from posterior instability?
unstable.
CANDIDATE: I would obtain an MR arthrogram to assess. If there is
EXAMINER: Would you not attempt this in casualty?
posterior Bankart lesion, I would perform an open or arthroscopic
CANDIDATE: No in my experience these injuries are very difficult to
Bankart repair with a posterior capsular shift, which has outcomes
reduce under sedation, particularly as there is an engaging Hill–
of 80–85% success at 5–7 years. If there is <50% Hill–Sachs lesion
Sachs lesion with possible fracture to the greater tuberosity and/
I would consider a subscapularis and lesser tuberosity transfer to
or the posterior glenoid rim.
the defect (McLaughlin’s procedure).
EXAMINER: Carry on . . .
CANDIDATE: Assuming I have a closed reduction, I would assess the
shoulder for fractures and stability.
Good points – Clear experience of managing these injuries
and good knowledge of the surgical indications and
EXAMINER: The shoulder is stable and there is only a Hill–Sachs
options
lesion. Could improve – Remember to enquire whether this is a
CANDIDATE: I would place in a sling with the elbow at the side for 6 first-time dislocation and consider control of epilepsy.
weeks. In the meantime I would obtain a CT if there is any doubt Volunteer early why not to reduce in casualty and describe
about bony injury to the humeral head or glenoid. This followed the deltopectoral approach. Useful to name authors/study
by physiotherapy (rotator cuff strengthening and periscapular groups of the outcome data mentioned, as well as the
stabilisation) and activity modification. McLaughlin’s procedure
References 7. Hertel R, Hempfing A, Stiehler M,

Leunig M. Predictors of humeral head
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Elbow Surg. 2004;13:427–33. A multicenter, prospective,
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Estimating the risk of nonunion Int J Surg. 2013;11:864–8. 2011;20:996–1007.
following nonoperative treatment of a
clavicular fracture. J Bone Joint Surg 11. Shao YC, Harwood P, Grotz MR, Limb 17. Ikeda M, Sugiyama K, Kang C,
Am. 2004;86A:1359–65. D, Giannoudis PV. Radial nerve palsy Takagaki T, Oka Y. Comminuted
associated with fractures of the shaft of fractures of the radial head.
5. Smith TO, Chester R, Pearse EO, Hing the humerus: A systematic review. Comparison of resection and internal
CB. Operative versus non-operative J Bone Joint Surg Br. 2005;87:1647–52. fixation. J Bone Joint Surg Am.
management following Rockwood 2005;87:76–84.
grade III acromioclavicular separation: 12. Gosler MW, Testroote M, Morrenhof
A meta-analysis of the current evidence JW, Janzing HM. Surgical versus non- 18. Van Leemput T, Mahieu G.
base. J Orthop Traumatol. surgical interventions for treating Conservative management of
2011;12:19–27. humeral shaft fractures in adults. minimally displaced isolated fractures
Cochrane Database Syst Rev. 2012;1: of the ulnar shaft. Acta Orthop Belg.
6. Handoll HH, Almaiyah MA, Rangan A. CD008832. 2007;73:710–13.
Surgical versus non-surgical treatment
for acute anterior shoulder dislocation. 13. Kurup H, Hossain M, Andrew JG. 19. Hove LM, Krukhaug Y, Revheim K,
Cochrane Database Syst Rev. 2004;1: Dynamic compression plating versus et al. Dynamic compared with static
CD004325. locked intramedullary nailing for external fixation of unstable fractures of
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the distal part of the radius: reduction and internal fixation or Percutaneous fixation with
A prospective, randomised multicenter closed reduction and percutaneous Kirschner wires versus volar
study. J Bone Joint Surg Am. fixation. A prospective randomised locking plate fixation in
2010;92:1687–96. trial. J Bone Joint Surg Am. adults with dorsally displaced fracture of
20. Rozental TD, Blazar PE, Franko OI, 2009;91:1837–46. distal radius: Randomised controlled
et al. Functional outcomes for unstable 21. Costa ML, Achten J, Parsons NR, trial. BMJ. 2014;349:g4807.
distal radial fractures treated with open et al. DRAFFT Study Group.
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Lower limb trauma oral topics

Chapter
28 Jonathan R. A. Phillips and Gunasekaran Kumar
Introduction The viva pattern

The trauma viva component of the FRCS (Tr & Orth) The spectrum of case discussed can be from a ‘straightforward’
examination is a 30-minute slot with 2 examiners. There may intracapsular femoral neck fracture in a young adult to poly-
sometimes be an observer, trainee examiner or external exam- trauma involving multiple long bone fractures ± visceral injur-
iner assessor also present and, if so, the examiners will clearly ies. The anticipated responses to these two scenarios are
explain this to the candidate before the start of the viva. different. In the intracapsular femoral neck fracture case, the
In view of the large variations in cases discussed and the candidate is expected to discuss in detail the various manage-
possibility of biases, the examination has being structured and ment options available, complications (early and late) and how
standardized so that examiners now have a previously agreed to manage each of these complications. In the polytrauma case,
set of cases and questions. Laptops have been discouraged and the candidate is expected to have a logical and coherent plan
in its place printed images that have gone through a rigorous with respect to management in Casualty, team effort, logical
process of standardisation to ensure good quality images are sequence of investigations and surgical interventions (prin-
used. The same sets of pictures are used by all the examiners, ciples of Damage Control Orthopaedics (DCO) and Early
which ensures each candidate will see exactly the same pictures Total Care (ETC)). The discussion should be tailored to save
as well. life, limb, prevent infection and achieve good function, in that
In general, there will be three scenarios from each exam- order. In general, the discussion is going in the right direction,
iner. This means that there will be lot more scope for in depth if the patient has reached the Intensive Care Unit (ITU).
probing into a candidates’ knowledge base. In general most The primary aim of saving life has been achieved, at least
candidates feel confident about their trauma knowledge due temporarily and there is more time available for planning
to good exposure to a variety of cases in fracture clinics, ward definitive care.
rounds and operation theatres. In addition, many candidates Each topic will start off with a radiograph or clinical
will spend time as part of their orthopaedic rotation working photograph with a relevant history. The description of the
in a Major Trauma Centre (MTC). As a good working know- radiograph or clinical photograph has to be clear and concise.
ledge of trauma is expected, the exam is structured to test This does not mean cutting corners. This is where practicing
this knowledge in detail. A good solid start to the trauma viva again and again describing a radiograph helps. It would
is needed. As with any exam scenario, the start should be be safer not to say, ‘the obvious pathology is . . .’ as in the
as non-controversial as possible, in order to avoid getting tension of the examination circumstances; you might miss
side-tracked. Candidates should discuss cases as if they were something that is more obvious. Time is of the essence; there
a first year Consultant Orthopaedic Surgeon. The general is no point going on and on about what is normal. Move
principles for any viva are not to get into an argument with swiftly onto describing the problem to score the maximum
the examiners or be controversial. The aim is to present possible marks. A typical scenario would be either a single
yourself as a safe surgeon with sound rationale behind your bone/limb fracture or a polytrauma. After describing the
decision making process that will lead to you scoring high radiograph/clinical photograph, ask for more radiographs if
marks. Quoting literature is not essential for every case that is the radiograph shown is not adequate. For example, if
discussed. However, evidence in support of managing the radiograph is of a pelvis showing a hip dislocation, fur-
common injuries like low-energy femoral neck fractures, ther radiographs required would be – a lateral view of hip,
wrist fractures, etc, will go towards passing the section with full-length femur (to rule out an associated femoral shaft
flying colours. Complex trauma may require specialist input, fracture).
but the principles of managing these patients in the acute When approaching a trauma scenario, it is vital to say that
phase and their definitive management has to be part of the you would approach the patient using ATLS® principles. Prac-
discussion. tice your opening sentence so that it sounds slick and polished.
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An example of a good opening sentence would be: mation on type of antibiotics and length of treatment is
‘I would approach the patient using ATLS® principles, firstly given in British Orthopaedic Association (BOA) guidelines
ensuring there were no life-threatening injuries that require published in October 20091. Deep vein thrombosis (DVT)
treatment before assessing for any limb-threatening injuries. prophylaxis, irrespective of upper or lower limb injuries
I would ensure that the injury is isolated, closed and there is no should be on assessment of patient as a whole, age, co-
neurovascular deficit.’ morbidities, previous DVT, multiple injuries, mobility
The examiners need to hear you say this once at the begin- status, malignancy, venous thromboembolism (VTE), etc.,
ning of your viva. Once it has been established that you risk assessment form is available at the Department of
understand the principles of ATLS®, do not repeat the same Health website2.
sentence for each scenario (especially if the scenario is a low- Be aware of the published guidelines to common condi-
energy wrist fracture). A simple ‘I would approach the patient tions; for example, the BOA Standards for Trauma (BOAST)
using ATLS® principles’ should suffice. If the examiners say it guidelines for severe open lower limb fractures. Many more
is ‘an isolated injury’ at the beginning of a question take the BOAST guidelines can be found on the BOA website. Also be
hint and do not go on about ATLS® management, as the aware of the NICE guidelines for the treatment of hip fractures
examiners want you to quickly get to the main thrust of the and VTE prophylaxis.
questiona.
In the examination, if the candidate needs an investigation Fracture description
as part of management, then, they have to ask for it. For Always look at or ask for two orthogonal views that are well-
example, if you think the situation requires an MRI scan, you centered, adequate, with good exposure and of the correct
would be shown an MRI scan (provided you are right in asking patient.
for an MRI!!).
An AMPLE history (Allergies, Medication, Past history, Anteroposterior and lateral view
Last meal and Environment of injury) should be taken from Displacement – Shortening, medial or lateral translation
the patient and then further enquiries depend on the scen- as a percentage of bone width
ario. For example, a pathological fracture requires a detailed Angulation – Varus or valgus. Another method of
history with respect to weight loss, systemic features, sources describing angulation is ‘angulation with apex medial or
of primary, etc. A candidate will not score many marks lateral’
saying, ‘you could do . . .’ or ‘you would . . .’. Your manage-
ment plan should be logical and clear, including a sequence of Lateral view
investigations. There will always be more than one way to Displacement – Shortening, anterior or posterior
manage any given injury. A candidate has to have a particular translation as a percentage of bone width
mode of treatment as the first-line choice and should be able Angulation – Procurvatum or recurvatum. Another
to rationalize it. It is also preferable not to mention method of describing angulation is ‘angulation with apex
any names. anterior or posterior’
The examiners have a prepared set of questions to ask. Look for associated injuries. For example, in femoral shaft
They will be bored asking the same questions again and again. fracture, look for patella fracture, femoral neck fracture
It would be best not to give them a chance to ask something and hip dislocation
different. There are a few scenarios that the candidate should
Indirect evidence of soft-tissue injury includes gauze
have practiced several times and should be able to go through dressing and soft-tissue swelling
with the examiners without a hitch.
If there is a classification for the fracture pattern, then,
In the following case scenarios, the discussion starts
describe it clearly. For example, an ankle fracture –
after ATLS® management, AMPLE history, essential investi-
Supination external rotation injury stage IV according to
gations and after the first line of management like pain
Lauge–Hansen classification
relief, splinting have been discussed. Antibiotic prophylaxis
for surgical intervention in closed fractures is generally a Always consider non-accidental injury (NAI) in children
one-off dose of an antibiotic that is broad spectrum and has Fracture patterns that provide information on mechanism of injury
a half-life of minimum inhibitory concentration (MIC) to
cover the operative time. For open fractures detailed infor-
in long bones
Transverse – Three-point bending
a
Butterfly fragment – Three-point bending with axial
It is difficult to give absolutes, but if the examiners say ‘isolated’ it loading
means that they don’t want you to discuss ATLS®. Examiners can
moan about candidates who repeatedly mention ATLS® at the Spiral – Torsion
beginning of each scenario, but this is a bit unfair as candidates are Multifragmentary or segmental – HIGH-ENERGY
nervous and don’t want to slip up and miss an associated life- injury with possible combination of direct and indirect
threatening injury that will end up causing them to fail the oral. forces
031
Chapter 28: Lower limb trauma oral topics
Polytrauma The approach of ‘Balanced Resuscitation’ is now used in

most trauma units. Recent literature has shown that resusci-
Key viva themes
tation with large amounts of crystalloids is not beneficial due
Major Trauma Centres to dilution, loss of first clot and an imbalance in coagulation
Acute care and resuscitation of the polytraumatized patient homeostasis. The aim of balanced resuscitation is to reduce
Damage control orthopaedics vs early total care the risk of tissue hypo-perfusion, thereby avoiding metabolic
Mechanism of injury: HIGH-ENERGY injury (road traffic acidosis, coagulopathy and hypothermia which in turn reduce
accident (RTA), fall from height) the systemic inflammatory response.
Assessment: At present, patients with suspected polytrauma Aggressive management is undertaken to compensate for
are taken to the nearest MTC. Patients with suspected pelvic blood loss and to stop the bleeding, to maintain circulatory
injuries have a pelvic binder put on by the paramedics. In the volume:
Casualty department (which has been pre-warned by the Compensation of blood loss: Major transfusion protocols are
paramedic team), the polytraumatized patient is received by now in place in most Trauma Centres. The Major
a trauma team who use the ATLS® principles of primary Transfusion Protocol is activated by the trauma team on the
survey, secondary survey and resuscitation. The trauma basis of mechanism of injury, physiological status of patient
team should, at least, consist of senior members of the and identified and suspected injuries. The urgency of the
Emergency Department (ED) staff, Orthopaedics and blood product transfusion based on patient status will decide
General Surgeons. Many large trauma centres now have whether O-negative blood or type-specific or cross-matched
other members of staff present at trauma calls including blood is used. Major trauma transfusion is in the form of,
radiologists and radiographers, and specialist paediatric packed cells, fresh frozen plasma and platelets (1 : 1 : 1)
surgeons and nurses for paediatric cases. Even though Stopping the blood loss: Permissive hypotension, haemostatic
primary survey and resuscitation is described in sequence, resuscitation and damage control surgery
the steps occur simultaneously with different members of the
trauma call team performing their duties in tandem at the Permissive hypotension
appropriate stage, not unlike a symphony. Systolic blood pressure is maintained at 90 . This level keeps
the balance between losing too much blood due to high pres-
sure vs tissue hypo-perfusion due to low pressure.
The ‘Trauma Triad of Death’ has been described as a
combination of coagulopathy, hypothermia and acidosis Haemostatic resuscitation
(Figure 28.1). There is a complex relationship between the
three with each factor compounding the other. Severe haem- The primary clot that is formed is the best clot and has to be
orrhage diminishes oxygen delivery and may lead to maintained to promote further consolidation of this clot. If
hypothermaia. This can interfere with the coagulation cas- a pelvic binder has not been applied by paramedics, then,
cade preventing blood from clotting. Anaerobic metabolism a pelvic binder should be applied with gentle internal rotation
due to hypoperfusion will lead to lactic acid generation and of both hips and flexion of knees. Intravenous tranexemic acid
metabolic acidosis. Lactic acidosis damages tissues and may as bolus of 2 g or bolus of 1 g and another 1 g over a period of
lead to myocardial hypoperfusion. Aggressive resuscitation 8 hours has been shown to assist control of bleeding. Inotropes
should be undertaken to prevent the development of these should be avoided. The primary cause of falling cardiac output
conditions. in the trauma patient is low circulatory volume. Hence, flog-
ging the heart will not improve the circulatory status.
Similarly, crystalloid and colloids should be avoided as they
dilute and increase the risk of loss of the first clot.
Tranexamic acid and the CRASH-2 trial

This was a large international, randomised multicentre trial
that showed that tranexamic acid, when given to trauma
patients, reduced the risk of death in bleeding patients (rela-
tive risk (RR) 0.85; 95% confidence interval (CI) 0.76–0.96;
P = 0.0077), and reduced the risk of all cause mortality
(RR 0.91; 95% CI 0.85–0.97; P = 0.0035). Further in-depth analy-
sis of the data has shown that tranexamic acid should be given
as early as possible to bleeding patients – Ideally <1 hour after
injury. Tranexamic acid given >3 hours after injury was less
effective and could be harmful.
Figure 28.1 Trauma triad of death
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The CRASH-2 trial collaborators. Effects of tranexamic acid on Reduction and splinting of fractures
death, vascular occlusive events, and blood transfusion in Traction
trauma patients with significant haemorrhage (CRASH-2): External fixation of long bones
a randomised, placebo-controlled trial. Lancet. 2010;376: Open fracture – Debridement and external fixation
23–32. Amputation (only when 100% certain)
Damage control orthopaedics (DCO) vs early trauma care
(ETC):
Traditionally, the diagnosis of coagulopathy was made
It is a dynamic situation. As resuscitation progresses,
using Activated Partial Thromboplastin Time (APTT), Pro-
the patient could be moving in and out of
thrombin Time (PT) and International Normalized Ratio
haemodynamic stability
(INR). However, these take time to be reported. Bedside vis-
coelastic tests of blood can now identify the imbalance between DCO is considered when resuscitation is deemed
adequate. Tests that help to assess adequate
thrombosis and bleeding. Two commonly used tests are
perfusion include: Stable haemodynamics, no
thromboelastography and rotational thromboelastometry
hypoxemia or hypercapnia, serum lactate
(ROTEM). These tests can identify whether packed cells or
≤2.0 mmol/l, normal coagulation, normothermia
FFP or platelets are required in 5 minutes and assess fibrino-
and normal renal function (urinary output
lysis in about 30 minutes (Figure 28.2).
>1 ml/kg/h)
Damage control surgery Second hit: This is a phenomenon where the
In order to control bleeding surgically, we need to identify the patient’s condition worsens after a surgical
source of bleeding. Depending on the patient’s status, CT with intervention. There is controversy as to whether this
intravenous contrast from head to mid-thigh is the best inves- is a reaction to a second trauma or whether a
tigation for identifying major injuries. In casualty, a FAST scan subclinical under-resuscitation is revealed by the
can identify free blood in the abdomen and chest. Bleeding surgery
from open wounds in the torso are controlled by direct pres- When resuscitation is adequate and damage control surgery is
sure and bleeding from open wounds in the limbs are con- completed the patient is taken to the ICU for further close
trolled by direct pressure or by use of a tourniquet (tourniquet monitoring and reassessment including hyperfibrinolysis and
inflation time should be recorded clearly and a named person hypocalcaemia. Over the next few days, injuries are definitively
should be monitoring it). managed as appropriate.
Interventional radiology: If contrast CT does show an arterial
bleed in the pelvis that is amenable for selective Venous lactate
embolisation, then it should be undertaken if such facilities The venous lactate provides a real-time marker of the
are available. adequacy of tissue perfusion and, therefore ,of resuscitation
If visceral bleeding is identified then laparotomy or in the trauma patient. It can be measured in most blood–
thoracotomy to control bleeding may be considered by the gas machines. When anaerobic metabolism occurs (ie
surgical team. when the patient is under-resuscitated), pyruvate metabol-
Orthopaedic trauma damage control: ises to lactate. Venous lactate is now used as a marker
in come large trauma centres in the decision making for
Closed reduction of dislocations when to proceed with definitive surgery, or to undertake
damage control surgery and continue resuscitation in
the ICU.
Venous lactate:
<2.0 mmol/l – Safe to proceed with definitive surgery
>2.5 mmol/l – Damage control surgery, continue
resuscitation on ITU
2.0–2.5 mmol/l – Observe for the trend. If worsening,
continue to resuscitate, if improving it may be safe to
proceed with care
Venous lactate is also being used for decision-making intrao-
peratively for the polytraumatized patient. If after one proced-
ure is completed, the venous lactate is measured and is
>2.5 mml/l, further definitive procedures should be postponed
and the patient should undergo further aggressive resuscitation.
Figure 28.2 Thromboelastogram
Once lactate markers improve again, surgery can continue.
031
Intracapsular hip fracture in the young adult threaded cannulated screws may be used but all threads must
cross the fracture to achieve compression. Anterior
Key viva themes: Reduction techniques. Surgical approach.
capsulotomy is controversial; capsulotomy may reduce
Decision making and timing of treatment intra-articular pressure but there is no evidence to show any
Mechanism of injury – HIGH-ENERGY injury (RTA, fall significant difference.
from height)
Assessment – Closed or open fracture, soft-tissue injury, any Factors that increase the risk of avascular necrosis (AVN)3.
distal neurovascular deficits and identify any other injuries Degree of initial fracture displacement (disruption of blood
Radiological assessment –AP view of pelvis with both hips supply)
and lateral view of affected hip Quality of fracture reduction
Radiographic classification – Garden’s I–IV on AP view but Loss of reduction post surgery
poor inter- and intraobserver reliability. Hence, it is better Fracture non-union
classified as undisplaced and displaced
Postoperative regimen is either toe touch weight-bearing for
Fracture orientation – The more vertical the fracture, more
6–12 weeks or full weight-bearing from day 1b. Range of
shearing forces at the fracture site which potentially
movement exercises is started from day 1.
increases risk of loss of fracture reduction and non-union
Radiological follow up is for at least 2 years to assess for
Timing – Literature has not shown much difference in
avascular necrosis of femoral head.
outcome (non-union or avascular necrosis) when
Serious complications – Loss of reduction and implant
considering time to surgery as within 12 hours or beyond
failure, AVN femoral head 6.6–45%; non-union 10–30%;
12 hours. Traditionally these injuries were treated urgently.
and secondary osteoarthritis. Loss of reduction often follows
It is now reasonable to say that this should be taken to
when the fracture has not been reduced adequately. Avascular
theatre first thing in the morning with an appropriate
necrosis is often obvious or when suspected after fracture
surgeon and theatre staff
healing, removal of implants and an MRI scan will confirm
Management options – All attempts should be made to the diagnosis and assess the volume of femoral head involve-
preserve the femoral head. There is no role for prosthetic ment. Non-union is associated with pain on weight-bearing and
replacement unless radiographs show associated advanced often obvious on radiographs with implant cut out or, if not
osteoarthritis obvious, a CT scan will confirm the diagnosis. One possible
Closed reduction technique – Leadbetter manoeuvre. On a surgical option for non union in a young person following
fracture table, gentle flexion, adduction, axial traction and fixation failure is valgus intertrochanteric osteotomy described
the hip is brought back into extension and abduction by Pauwels. Surgery involves ruling out infection, valgus tro-
maintaining traction. Reduction is assessed clinically by the chanteric osteotomy (as described by Pauwels), stabilisation
heels on palm test and by image intensifier. The heel palm with 135° angled blade plate and bone graft. If fixation is
test involves the surgeon holding both heels in their palms deemed to be sound, then, options of augmenting fracture
with both legs in abduction and internal rotation. Internal healing with bone graft or vascularized quadratus femoris bone
rotation is then released, and if the fractured site has graft. If all else fails consider total hip arthroplasty. Managing
significantly more external rotation than the non injured complications of femoral neck fracture fixation should be
side, suggests reduction is not satisfactory. Whichever undertaken by a subspecialist but principles of that manage-
technique is used, it should be minimally traumatic to avoid ment should be discussed.
further damage to femoral head blood supply. Repeated
attempts at closed reduction could increase risk of damage to
femoral head blood supply and should be avoided. Only Femoral neck fractures in the elderly
anatomical reduction is acceptable and therefore be prepared Key viva themes: NICE guidelines
to go on and perform an open reduction if necessary Mechanism of injury – Fall from standing height
Quality of fracture reduction – Garden Alignment Index is Clinical assessment – Limb shortening, external rotation,
based on angle between compression trabeculae and long axis distal neurovascular status, co-morbidities, ambulatory
of femoral shaft in both anteroposterior (160°) and lateral status, mini mental status, domestic circumstances
(180°) views and has moderate interobserver reliability Radiological assessment – AP view of pelvis and lateral view
Open reduction technique – Chose either the anterolateral of the affected hip
(Watson–Jones approach) or anterior (vertical limb of Full-length femoral view if concern that fracture may be
Smith–Petersen) approach. Direct reduction under vision by pathological
manipulating the leg and two K-wires in the femoral head as
a joystick to control rotation and reduce the fracture
b
Definitive treatment – This is with cannulated screws or What is it going to be? Make up your mind. It will depend to a
certain extent on quality of fixation, presence of osteoporosis and
sliding hip screw with derotation screw. Short- or long-
any coexisting co-morbidities
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031
Management options
Management of all elderly patients with proximal femoral
fractures should follow NICE guidance4.
The key priorities of the NICE guidelines are:
Timing of surgery
: On the day of or day after admission
: Identify and treat correctable co-morbidities
immediately to avoid delay in surgical treatment
Hip fracture surgery should be performed on a planned
trauma list
Perform replacement arthroplasty for displaced
intracapsular fracture. Use extrameduallary implants for
trochanteric fractures for AO classification types A1 and A2 Figure 28.3 Basic cervical fracture stabilised with derotation screw and
sliding hip screw
Mobilize patients on the day after surgery and daily
thereafter with physiotherapy
Multidisciplinary management
Complications – AVN, non-union, subtrochanteric fracture
: Orthogeratric assessment with rapid optimisation of if cannulated screws inserted below level of lesser trochanter,
fitness for surgery chondrolysis if screws penetrate joint, screw cut-out
: Early identification of individual goals for rehabilitation
to recover mobility and independence and facilitate
return to pre-fracture residence and long-term well-
Displaced
being Surgical management – High rates of non-union or AVN
when fixed in elderly patients. Treated with cemented
: Integration with related services including mental hemiarthroplasty or total hip arthroplasty
health, falls prevention, bone health and social services
Complications (hemiarthroplasty) – Dislocation, infection,
: Consider early supported discharge periprosthetic fracture (higher if uncemented), leg length
In the UK there are currently six standards for hip fracture
discrepancy, acetabular erosion, aseptic loosening (long term)
care (Blue Book). Trusts are audited against these targets, and
Complications (total hip arthroplasty (THA)) – Dislocation
if successful the Trust receives additional payments (a carrot
(higher risk), infection, periprosthetic fracture, leg length
rather than a stick to drive quality of care).
discrepancy, aseptic loosening (long term)
1. All patients with hip fracture should be admitted to an
acute orthopaedic ward within 4 hours of presentation
2. All who are medically fit should have surgery within 48
Viva question – What type of surgery will you perform for a
hours of admission and during normal working hours
patient with a displaced intracapsular hip fracture?
3. All should be assessed and cared for to minimize the risk
of pressure ulcers Answer – Current NICE guidelines suggest that elderly patients
4. All presenting with a fragility fracture should have routine with a displaced intracapsular fracture should receive replace-
access to acute orthogeriatric medical support ment arthroplasty rather than fixation. Cemented hemiarthro-
plasty should be performed rather than an uncemented
5. All presenting with a fragility fracture should have bone
prostheses as they offer lower rates of periprosthetic fracture,
health assessment lower incidences of thigh pain and improved hip scores and
6. All presenting with a fragility fracture should be offered function. Patients who are able to walk independently out of
multidisciplinary assessment and intervention to prevent doors with no more than the use of a stick and are not
future falls cognitively impaired should be offered a THA. However, this
is balanced against the increased risk of dislocation (RR 1.48)
Intracapsular femoral neck fracture and general complications (RR 1.1). The choice of treatment
mainly depends on the general and biological condition of the
Garden classification – Type I – Abduction valgus impacted.
patient. In general, the biological rather than chronological age
Type II –Undisplaced complete fracture. Type III– Complete
should determine management.
fracture that is not completely displaced. Type IV –
Complete fracture that is completely displaced.
Undisplaced Viva question – What are the advantages of THA over hemi-
Surgical management – Fixation in situ using percutaneous arthroplasty in the treatment of elderly patients with hip
cannulated screws fixation or two-holed sliding hip screw fracture?
with a derotation screw (Figure 28.3)
031
failure (cut out), increased rate of revision surgery,

Answer – THA offers the patient a better functional outcome.
periprosthetic fracture around the tip of a short nail
A systematic review in 2010 showed that functional scores
have shown consistently higher results after total hip replace-
ment (THR) (mean Harris Hip Score 5 points better after THA
than hemiarthroplasty). Rates of re-operation are also lower Trochanteric fracture in an arthritic hip
(RR 0.57). However, this must be balanced against an increased Mechanism of injury – Fall on to hip from standing height
rate of dislocation (RR 1.5) and general complications (RR 1.1). Assessment – History of pre-existing groin pain and
A THA is a more technically difficult operation that takes longer stiffness, limb deformity, external rotation and or shortening
with higher amounts of blood loss . A recent paper suggested and distal neurovascular deficit
that surgeons performing fewer than 35 THAs each year have Radiographic assessment – Usually two part
higher complications . Surgeons who perform THR for fracture
intertrochanteric fracture of proximal femur with features of
should, therefore, be performing this surgery regularly.
moderate to advanced osteoarthritis
Proximal femoral fractures in an osteoarthritic hip is most
often a pertrochanteric fracture. In a stiff hip, it is easier for
Extracapsular femoral neck fracture the femur to fracture in pertrochanteric rather than
Intertrochanteric fracture – Classically described as being subcapital region due to a longer lever arm
two to four part, with increasing instability of fracture Management options – In a patient who is fit and healthy
configuration with increased number of fragments with a trochanteric fracture with advanced osteoarthritis,
Stable and unstable fractures with small lesser trochanter THA with a calcar replacing femoral prosthesis is a good
fragment – Fracture reduction on traction table and option. The advantage is that one operation solves both
insertion of sliding hip screw to compress across problems. The disadvantage is that it is a major procedure
fracture site. with increased surgical risks, including infection and
Radiological assessment of position of femoral neck screw dislocation.
is by Tip Apex Distance (TAD) – Risk of fixation failure
increases when the TAD (sum of distance from screw tip to In moderate osteoarthritis in a fit and healthy patient or a
the midpoint of the femoral head in both the anteroposterior patient with significant medical co-morbidities, a dynamic hip
and lateral views after correction for magnification) is screw fixation is preferred. The advantage is that it is a short
>25 mm5. surgical procedure with limited risks. The disadvantage is that
Unstable fracture with large posteromedial fragment – there is an increased risk of non-union, which may need further
Sliding hip screw or consider cephalomedullary nail (short) procedures in a staged fashion if osteoarthritis symptoms get
(Figure 28.4) worse (removal of implants followed by total hip arthroplasty).
Reverse oblique fracture – This is an unstable variant. The
fracture line extends from proximal–medial to distal–lateral Femoral shaft fracture
in the trochanter. The biomechanics work against using a
Key viva themes: Timing of treatment, ETC vs DCO, femoral shaft
sliding hip screw. Treatment is with a cephalo-meduallary
nail after fracture reduction. If closed reduction of fracture is
fractures with chest injuries
not possible due to flexion, external rotation and abduction Mechanism of injury – Motor vehicle accident or fall from
of the proximal fragment then, open reduction of fracture is height
performed before nail insertion. Initial management – ATLS® principles of resuscitation,
Subtrochanteric fracture – This fracture may be either traction splint, analgesia, IV fluids
principally a trochanteric fracture with subtrochanteric Radiographic assessment – AP and lateral radiographs.
extension or the reverse. Consider mechanism as differential Whole length femoral views. AP pelvis to assess
diagnosis includes pathological fracture secondary to femoral necks
malignancy and fracture related to bisphosphonate treatment Surgical treatment – Rule out pathological fracture due to
Surgical treatment – Fracture reduction on fracture table. malignancy or bisphosphonate treatment. If young patient,
May require open reduction and cable reduction. Long reduce fracture and use intramedullary nail (superior
cephalomedullay nail fixation biomechanics). If older patient or presence of metastases,
Technique – Entry point challenging in obese patients, reduce fracture and use cephalomedullary nail to protect
ensure correct entry point for specific nail and consider the femoral neck
anterior bow of the femur, ensure correct rotation of At the end of procedure – Assess knee joint for ligamentous
fracture prior to distal locking, more difficult reduction in integrity and rotational alignment of hip
coexisting osteoarthritis, avoid fixing in varus Complications – Non/mal-union, rotational mal-
Complications of internal fixation– Mortality, infection, alignment and shortening if comminuted or bone loss, fat
avascular necrosis of femoral head, non-union, implant embolism
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not recommended. It is a load bearing device with a higher

Viva question – Would you perform intramedullary nailing of
rate of implant failure and non-union. There is a need for an
bilateral femoral shaft fractures where there is an associated
extensive surgical approach with associated blood loss, risk
chest injury?
of infection and soft-tissue insult
Answer – On the basis of animal experiments, it is safe to At the end of procedure – Assess knee joint for ligamentous
perform bilateral nailing in a haemodynamically stable patient integrity, rotational alignment of hip in comparison with
but the patient requires close monitoring prior to the second other hip and compartment syndrome
nailing. When the patient has poor oxygenation in association
with a chest injury, external fixation should be performed
Postoperative rehabilitation – Varies from non-weight-
regardless of whether there is an isolated or bilateral femoral bearing for 6 weeks to allowing immediate weight-bearing as
fracture. In haemodynamically stable patients with bilateral tolerated depending on fracture pattern, fixation techniques
femoral fractures and pulmonary contusions, consider intra- and associated injuries
medullary nailing of one fracture and either plating or external Complications – Fat embolism, acute respiratory distress
fixation of the other fracture6. syndrome (ARDS), missed femoral neck fracture, non-
union, rotational mal-alignment
Viva question – Would you perform intrameduallary nailing of

Viva question – Laminated radiograph shown of a comm-
a femoral shaft fracture overnight in a case of polytrauma?
united femoral shaft fracture with part of the lateral cortex
Answer – This opens the debate of early total care vs damage displaced and associated displaced intracapsular hip fracture.
control orthopaedics. I would ensure firstly that the patient This is a 27-year-old motorcyclist who has come off his
was adequately resuscitated according to ATLS® principles. motorbike sustaining these isolated injuries. The femoral
I would monitor physiological markers such as haemodynamic shaft fracture is open with a large skin laceration. How will
status, coagulation profile and venous lactate prior to making a you manage the patient?
decision. Operating at night with non-specialist theatre staff
Answer – The patient should be managed according to ATLS®
who are not familiar with the implants can be challenging.
protocols. I would ensure airway maintenance with cervical
A retrospective study by Morshed7 in the American JBJS in
spine protection, adequate breathing and ventilation, circula-
2009 demonstrated that delayed fixation of femoral shaft frac-
tion with haemorrhage control, insert two large-bore cannulas
tures beyond 12 hours in polytraumatized patients may reduce
into his antecubital fossa, take blood off for cross-matching,
mortality by 50%, especially in cases associated with serious
FBC, U&Es and run in a bolus of IV crystalloid
abdominal injury. It is likely that this finding was due to time
being taken to adequately resuscitate the patient prior to COMMENT: The initial management of this patient using ATLS®
performing surgery to the fracture. principles wasn’t asked for by the examiner so that although the
candidate answered this part well he didn’t score any points.
The key words used by the examiner were ‘isolated injuries’. If the
Femoral shaft fracture associated with examiner hasn’t said this and you have already gone through
femoral neck fracture ATLS® management in an earlier question you could play safe
and say ‘assuming these are isolated injuries’.
About 5% of femoral shaft fractures are associated with fem-
EXAMINER: This is his only injury.
oral neck fractures. If you are given a patient with a femoral
shaft fracture in the exam always look carefully at the femoral
neck!
Surgical treatment options

Both fractures can be stabilised by using one device, or two
separate devices can be used for each fracture.
Single device – Cephalomedullary nail. This is more
technically challenging, to achieve reduction of the neck
fracture at the same time as fixation of the femoral shaft.
Insertion of the nail may displace the femoral neck fracture.
Technique includes fracture table with temporary wire
fixation of neck fracture followed by nail insertion and neck
screw with or without a second de-rotation screw8
Two devices – Cannulated screws or sliding hip screw for
femoral neck fracture and retrograde nail for femoral shaft Figure 28.4 Unstable trochanteric fracture with large posteromedial fragment
fracture. Plate fixation for femoral shaft fracture is generally treated with an intramedullary nail
031
CANDIDATE: This is a difficult problem. I would go for two devices

Femoral shaft fracture with hip dislocation
for fixation rather than one. I would treat the displaced Mechanism of injury – Motor vehicle accident, fall from
intracapsular fracture with a two-hole DHS and supplementary motorcycle, fall from height
screw. I would manage the femoral shaft fracture with a plate. Radiological assessment – Direction of hip dislocation, level
EXAMINER: Why do you want to do this? What fracture will you and type of femoral shaft fracture, rule out any associated
fix first? femoral neck fracture or acetabular fracture
CANDIDATE: This is a difficult problem. Initial management – Thomas splint, analgesia, frequent
EXAMINER: This is real life. The FRCS (Tr & Orth) is a difficult exam to assessment for sciatic nerve and distal vascular status
pass with standards to maintain. Definitive management – Hip reduction takes priority. If
COMMENT: This is a difficult clinical problem and a candidate may closed reduction is not possible, which is often the case, then,
have some difficulty thinking up a sensible safe management in a couple of Schanz pins are inserted into the proximal
the heat of the moment. Mentioning the complexities of the case femoral fragment in the linea aspera, avoiding the femoral
once to the examiners is acceptable but twice was inviting canal, if possible. A rod is used to connect the pins and use it
trouble. reduce the hip joint. Options for treating femoral shaft –
EXAMINER: You would use a plate for the femoral shaft fracture
External fixation (as part of damage control orthopaedics),
even though it is open fracture?
femoral plate fixation (if significant chest injury), femoral
nail fixation. External fixation can be safely converted to nail
CANDIDATE: If there is a large wound there already then this may
fixation up to 2 weeks without increased risk of infection
help me as I will have to debride, extend and irrigate the
wound. A retrograde nailing may introduce infection into the
If hip joint cannot be manipulated, then, open reduction is
knee joint.
performed depending on the direction of dislocation.
Anterior dislocation – Smith–Petersen approach; posterior
EXAMINER: There is quite a lot of bone loss around the lateral cortex
dislocation – Posterior approach.
and when you debride the wound it a large piece becomes loose
and you end up with a big defect in the femoral cortex. What are
you going to do? Hip dislocation ± posterior wall fracture or
CANDIDATE: I would replace the bony fragment back into the femur femoral head fracture
to make the fracture more stable which will allow a better plate
Key viva themes – neurovascular injury. Treatment of associated
fixation and more chances of healing.
acetabular or femoral head fracture
EXAMINER: Are you sure? Would the devitalized bone not be an
infection risk.
Mechanism of injury – Fall from motorbike, motor vehicle
accident (dashboard injury)
CANDIDATE: I would remove the bone.
Initial management – ATLS® principles and resuscitation,
EXAMINER: What do you want to do? Do you want to put the bony
assess position of limb, sciatic nerve, analgesia
fragment back into the femur or take it out?
Radiographs – Pelvis with both hips, full-length femur
CANDIDATE: I would take it out as it is dead and devitalized.
radiographs including knee. Assess for posterior or
EXAMINER: Are you sure and then leave a big defect to heal?
anterior acetabular wall fracture (Judet views), femoral head
CANDIDATE: Yes.
or neck or shaft fracture, patella fractures. Preoperative
EXAMINER: Would you bone graft the defect? CT scan if it will not delay treatment. If there are large
CANDIDATE: No. The risks of infection would be increased. intra-articular fragments, definitive open debridement could
COMMENT: You should know about the principles of dealing with be planned
bone loss associated with open fractures and moreover be
confident with your answer. The candidate was unsure but Classification – posterior dislocation of hip (Thompson and Epstein
recovered with their answer. classification)
With the femoral fracture being open and life threatening Type I – Dislocation with or without minor posterior wall
this should generally be fixed first. If the femoral shaft fracture fracture
was closed you can debate which one to fix first. The Type II – Dislocation with a large posterior wall fracture
arguments for fixing the femoral head fracture first is that if this Type III – Dislocation with comminuted posterior wall
injury is not perfectly reduced and fixed well this may lead to fracture
life long disability and it may be easier to get this more difficult Type IV – Dislocation with acetabular floor fracture
fracture out of the way first and then manage the more Type V – Dislocation with femoral head fracture
straightforward femoral shaft fracture with a retrograde nail.
The opposite argument is that you should fix the more life Classification – Femoral head fracture (Pipkin)
threatening fracture first and then afterwards deal with the Type I – Femoral head fracture below fovea. These fractures
femoral neck fracture. occur in the non-weight-bearing surface
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031
Type II – Femoral head fracture above fovea. The weight-

bearing surface is involved
Pathological fracture of femur
Key viva themes – Diagnosis of metastatic disease. BOA guidelines
Type III – Femoral head fracture with associated femoral
neck fracture Typical history – Fall from standing height, pre-existing
Type IV – Femoral head fracture with associated acetabular pain in the injured limb. History of malignancy,
fracture infection, metabolic disease, Paget’s disease or
bisphosphonate use
Definitive management – Requires urgent closed
reduction under anaesthetic. Do not leave overnight. History of malignancy – Site, type, treatment (curative or
Anterior dislocation – Traction in line with lateral traction palliative), previous pain in the injured limb, weight loss,
of thigh. Posterior dislocation – Traction in line with appetite loss, under regular follow-up
adduction and flexion. Once the hip is reduced, Common malignancies that metastasize to bone – Thyroid,
dynamic assessment for instability is done under renal, GI, lung, breast, prostate, myeloma
anaesthetic by figure of four for anterior dislocation and Initial management – Splint, analgesia, check distal
flexion with adduction and axial loading for posterior neurovascular status, observe for compartment syndrome
dislocation Blood tests – FBC, renal function tests, calcium, liver
If closed reduction fails, then open reduction depending on function tests, clotting profile, peripheral smear, group and
the direction of dislocation. Posterior approach for posterior save, serum electrophoresis
dislocation and Watson–Jones(anterolateral) approach for Staging – Local: Full-length radiographs of fractured bone,
anterior dislocation CT ± MRI
Post-reduction management – Skin traction or skeletal Systemic: Staging CT chest, abdomen and pelvis, Isotope
traction (if associated with fractures or unstable). CT should bone scan or Positron emission tomography (PET). Seek
be performed post-reduction to assess for retained intra- oncology opinion regarding life expectancy and
articular fragments postoperative radiotherapy
If stable following closed reduction, range of movement Key Points from BOA Blue Book on Metastatic Bone Disease9:
exercises should be started with weight-bearing as tolerated. The prognosis for patients with bone metastases is
If unstable or associated with dislocations: improving. Many will survive >3 years
Posterior wall fracture – Posterior approach, reduction Never assume that a lytic lesion, particularly if solitary is a
and plate fixation of fracture metastasis
Anterior wall fracture – Ilioinguinal approach, reduction Metastatic pathological fractures rarely unite
and plate fixation of fracture Prophylactic fixation on long bone metastases is easier for
Femoral head fracture – Often associated with anterior the surgeon and less traumatic for the patient
dislocation. Watson–Jones approach Fixation of pathological fractures or lytic lesions around
Large fragment – Reduction and fixation with screws with the hip or proximal femur have high failure rates.
heads buried below level of articular cartilage Cemented hip prostheses have lower failure rates
Multiple small fragments <50% femoral head size below Never rush to fix a pathological fracture. Ensure
level of fovea centralis – Removal of fragments investigations are performed and surgical intervention is
Non-reconstructable fragments involving >50% – Total discussed with appropriate colleagues
hip replacement Constructs should allow immediate weight-bearing and
Femoral neck fracture – Either a Watson–Jones or aim to last the lifetime of the patient
Smith–Peterson approach. The neck–head fragment must Each trauma group requires a lead clinician for metastatic
first be reduced into the acetabulum. If the femoral head bone disease
fragment is small, fixation of the femoral neck first Management should be within the context of a
allows manipulation of the leg to assist in the reduction of multidisciplinary team10
the femoral head fragment. Use cannulated screws or Definitive management is planned after all investigations
DHS to fix the femoral neck fracture followed by and life expectancy is known.
counter sunk screw fixation of the femoral head. Known primary with multiple metastases – Stabilisation
Consider THA with displaced femoral neck fracture in the with locked nail unless life expectancy is very limited then,
elderly palliative management
Complications – Avascular necrosis of femoral head, Known primary with solitary metastasis or unknown
sciatic nerve palsy, recurrent instability, heterotrophic primary with solitary metastasis or primary bone tumour –
ossification, secondary osteoarthritis. Risk factors Referral to bone tumour centre. Principles of management
for post-traumatic osteoarthritis include are wide or radical excision and endoprosthetic
transchondral fracture, indentation fracture >4 mm replacement, postoperative radiotherapy ± chemotherapy
depth and AVN and surveillance
031
Identification of metastatic deposit in bone – B1 – Well-fixed stem

– B2 – Loose stem with good bone stock
(no fracture) – B3 – Loose stem with inadequate bone stock
Mirel’s score is helpful to decide management of a metastatic
deposit, based on radiological and clinical symptoms11. Type C – Fracture well-distal to the tip of the stem
Site – Upper limb, lower limb, pertrochanteric region
(score 1–3)
Size – Cortical involvement <1/3, 1/3 to 2/3, >2/3 (1–3) Management
Type – Osteoblastic, mixed, osteoclastic (1–3) The stability of the femoral stem is the most important
Pain – Mild, moderate, severe (1–3) factor in decision making. If the implant is stable, fixation
Total score >8 indicates surgical stabilisation of the involved can be performed. If the implant is loose, the prosthesis
bone but specificity and sensitivity is poor. should be revised
Fixation of an isolated metastatic deposit should only be Type A – Non-operative management provided the
performed when the primary is known prosthesis is stable and in a satisfactory position without
any signs of loosening or infection
Type B1 – Open reduction internal fixation. Depending
Atypical fractures related to bisphosphonate upon fracture configuration, fixation either with a single
treatment plate (four bicortical screws distal to stem with
Several publications have shown association between long- combination of unicortical screws, cables and bicortical
term bisphosphonates (especially Alendronate) and femoral screws (where possible) around the stem), or double
fractures12. orthogonal plating (anterior and lateral) with or without a
Characteristic features include: strut allograft
Transverse fracture pattern Type B2 – Revision of femoral stem (and acetabular cup if
Fracture in proximal or mid-femoral shaft required)
Localized thickening of lateral femoral cortex (beaking) Type B3 – Revision; may require proximal femoral
Follow minimal or no trauma replacement
Prodromal symptoms of thigh pain Type C – Fracture stabilisation based on fracture pattern
Treatment options include cephalomedullary nail, modifica- In all periprosthetic fractures, infection must be ruled out. If
tion of osteoporosis treatment and surveillance of the contral- any suspicion of infection, two-staged revision should be
ateral side or staged prophylactic nail fixation of the performed. First stage should consist of removal of all
uninvolved side in presence of radiological features and pain. implants, insertion of antibiotic cement spacer, with 6–8
weeks of antibiotics based on microbiology cultures. Second
stage should consist of removal of the antibiotic spacer,
Periprosthetic femoral fracture around a THA samples for culture
Key viva themes – treatment based on stability of prosthesis. Routine follow up of joint replacements help identify loose
prosthesis. Vancouver type B fracture subtype is often difficult
Treatment in presence of infection
to identify, hence, assessing fixation of femoral stem is
Mechanism of injury – Usually low-energy injury (fall from essential14.
standing height)
Assessment – Pre-injury symptoms (thigh pain worsening
on weight-bearing, night pain). Time since primary or
Periprosthetic fracture around a TKR
revision THA. Type of THA (company, model, femoral Key viva themes: Fixation vs revision, extensor mechanism
taper size, femoral head size, cup size). Indication for THR. problems
Perioperative issues. Postoperative complications including 1. Fracture around femoral component
infection, dislocation and persistent pain. Associated co- Typical history – Elderly patient with low-energy fall
morbidities. Pre-injury ambulatory status. Presence or
Assessment – Neurovascular status. Time since TKR, type
absence of ipsilateral TKR
of TKR (primary or revision, posterior cruciate sacrificing
Radiological assessment – Level of fracture, fracture or retaining, company that made it and the model of TKR).
pattern, loosening of prosthesis (compare serial radiographs) Previous skin incisions. Any postoperative issues:
and bone stock. All these factors are combined together in Infection, stiffness, persistent pain. Associated co-
Vancouver classification13 morbidities. Pre-injury ambulatory status. Presence of
G L
Type A – Fracture of greater (A ) or lesser (A ) ipsilateral THR
trochanters Radiological assessment – Is the TKR implant now loose
Type B – Fracture around the femoral prosthesis as a result of the fracture? Is the fracture very low (little
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031
bone left to fix distally), or in the metaphyseal region? back plating across the unprotected femoral shaft to prevent
Is there comminution (especially medially)? future fracture.
Review previous films – Was the implant loose before the
periprosthetic fracture?
Early management – Splint, analgesia, record Viva question – Should a periprosthetic fracture around a
neurovascular status, check radiographs in splint well-fixed TKR in an elderly patient always be fixed?
Definitive surgical management options – Very similar to Answer – There is a growing opinion that patients who sustain
periprosthetic fractures of the hip. Rule out infection. If the this fracture pattern are similar to the hip fracture group of
implant is loose either as a result of a low fracture or prior patients. As such, fixation and protected weight-bearing may
to fracture, revision surgery should be performed. leave them bedbound and at risk of the complications of
Consider referral to specialist arthroplasty unit for distal prolonged hospitalization (and financial cost). Revision TKR
femoral hinged replacement (collateral ligaments are likely using a cemented, stemmed hinged prosthesis is, therefore,
to be compromised) an option. There are the risks of a larger initial operation, but
If the implant is well fixed and the distal fracture fragment has these may be outweighed by the benefits of early full weight-
bearing mobilization and discharge (such as in the hip fracture
adequate space for fracture stabilisation then internal fixation
patients). Financial costs may also be outweighed by reduced
of the fracture is preferred. Consider the surgical approach. length of stay. The Knee fix or replacement (KFORT) trial is
Either direct lateral approach – Closed reduction and bridge currently underway assessing DFR surgery or surgical fixation
fixation with lateral distal femoral locking plate. Or midline on the recovery of elderly patients with a distal femur fracture.
incision and lateral parapatellar approach (use this approach if
there is concern that the fracture is unreconstructable and
endoprosthetic replacement may be required). Minimally inva- 2. Around the tibial component
sive lateral approaches may be used as long as fracture reduc- Less common. Most vital is the integrity of the extensor
tion is adequate. Where there is medial comminution, the mechanism and tibial tuberosity.
failure rate of lateral plate fixation is higher; consider add- If tibial component is stable, then fix in situ. If the tibial
itional medial plate fixation. Bridge the fracture with locking component is unstable, revise to a stemmed component.
screws in the distal fragment with a long plate that spreads the Sleeves and/or cones may be used to achieve stable fixation
stress across the bone (Figure 28.5). within intact tibial bone, otherwise fix distally with stem in
Retrograde nail fixation is technically possible but careful diaphysis or cement stem. If the collateral ligaments are
preoperative planning is required to ensure this is possible compromised, a hinge is required.
(check with knee implant company), and to ensure that appro- 3. Disruption of the extensor mechanism
priate sized nails are available. Clearly nailing is not possible This may include fractures of the tibial tuberosity or
where a posterior cruciate sacrificing implant with a box has patella, or rupture of the patellar tendon or quadriceps
been used. mechanism. Extensor failure leads to poor results after
In the presence of ipsilateral THA, retrograde nail is not knee replacement. If the patella is unresurfaced, primary
recommended due to the stress riser effect of a short length of fixation should be performed. Fixation in the presence of a
‘unprotected’ femoral shaft between tip of retrograde nail and patella resurfacing is likely to fail, especially if the button
tip of femoral stem. In this situation, the lateral locking plate is loose. Excision of the patella and suturing of the
fixation should overlap the femoral stem. If the fracture has remnants may be required.
dictated a stemmed revision TKR in the presence of an ipsilat- Any primary repair (of the tendons or patella) may
eral hip replacement, careful planning is required to ensure the benefit from augmentation with the ipsilateral hamstring
stems fit within the remaining femoral bone; consider piggy- tendons or an artificial graft
The dislocated knee and multiligament

knee injury
Key viva themes – Management of neurovascular injury,
anatomy of posterolateral corner
Mechanism of injury – High energy injury. A second cohort
of morbidly obese patients sustain knee dislocations after
low-energy falls
Structures that may be injured (in any combination) – Both
cruciate ligaments, medial collateral ligament, posteromedial
structures, posterolateral structures, tibial artery or vein,
Figure 28.5 Periprosthetic fracture treated with a long locking plate common peroneal nerve, menisci, patellar tendon
031
Initial assessment – ATLS® principles and resuscitation. Early management – ATLS® principles and resuscitate.
Assess for neurovascular injury (high risk of injury). Reduce Splint the limb after reducing any deformities
knee and splint Practical difficulties in applying the external fixator – If the
Vascular injuries should be managed according to the arterial injury is in the popliteal fossa, the surgical approach
BOAST guideline for arterial injuries. These can be applied requires a prone position. Pins in the femoral shaft can be
to any vascular injury associated with a fracture or applied laterally with patient prone though the orientation
dislocation can be confusing. However, tibial shaft pins application is
Re-align the pulseless limb. Detailed documentation of difficult if not impossible in the prone position. The knee
neurovascular status before and after intervention can carefully be flexed and pins inserted. After the vascular
Early referral to vascular surgeon reconstruction is performed, rods can be attached to the pins
Revascularization should take place within 3–4 hours in femur and tibia to reduce the fractures and maintain a
The sequence of surgical interventions can be crucial. In tension free vascular repair/reconstruction
general, vascular perfusion should be restored using Definitive surgical management
temporary shunts followed by assessment of viability. Fractures in the diaphyseal regions – Retrograde
Skeletal stabilisation should then be performed, followed reamed locked femoral nail and antegrade reamed
by definitive reconstruction with autologous vein grafts. locked tibial nail through same incision17
In the case of the dislocated knee with a vascular injury, One or both fractures in the metaphyseal region –
temporary stabilisation with a bridging external fixator Fixation with precontoured plates as nail fixation of
should be performed metaphyseal fractures more challenging
Observe for compartment syndrome After stabilisation of both fractures, assess the knee for
Postoperative care should be by nursing and medical ligamentous injury
staff competent in the assessment of the critically
injured limb
Once the knee is temporarily stabilised (normally in a splint if
Distal femoral fractures
Mechanism of injury – High energy
there is no neurovascular deficit), an MRI scan is required to
evaluate the extent of injury and plan for definitive Initial assessment – ATLS® principles and resuscitation.
stabilisation. Assess neurovascular status, analgesia, splint after reducing
the deformity
Surgical treatment – Non-operative management Definitive management depends upon the fracture pattern
historically yields poor results. Surgery should be within the
Supracondylar femoral fracture (extra-articular) –
first three weeks, and there is no consensus on the optimal
Retrograde nail or precontoured distal femoral locking plate
graft choice (autograft, allograft or synthetic). Structures may
fixation (can be performed using minimally invasive incision
be directly repaired, reconstructed or both. Two studies have
is satisfactory reduction can be achieved)
found surgical repair alone leads to a higher incidence of
Intra-articular fracture – Open reduction of intra-articular
failure with recurrent instability and, therefore,
fragments usually via anterolateral approach (or midline
reconstruction is recommended15,16.
incision and lateral parapatellar approach if patient is elderly
or has pre-existing arthritis). If severe arthritis present in
Anatomy of posterolateral corner elderly patient consider endoprosthetic replacement.
Layer 1 (most superficial) – Superficial fascia (fascia lata), Anatomic reduction and stabilisation is required to fix the
iliotibial tract, biceps femoris intra-articular fragments. The plate acts as a neutralisation
Layer 2 – Anterior: Quadriceps retinaculum; Posterior: Two device. Care must be taken to achieve correct alignment,
patellofemoral ligaments length and rotation, especially in comminuted fractures.
Layer 3 – (most deep) – Superficial: Lateral collateral The gastrocnemius will act to push the distal fragment into
ligament, fabellofibular ligament; Deep: Arcuate ligament, extension. This can be overcome through the use of a bolster
coronary ligament, popliteus tendon, popliteofibular under the knee and precise surgical technique
ligament, capsule
Patella fracture
Key viva themes: Fixation methods, description of tension-band
The ‘floating’ knee principle
Key viva themes: Surgical decision making
Mechanism of injury – Indirect through pull of quadriceps
This is the presence of ipsilateral femoral and tibial fractures. (transverse fracture), direct blow (multi-fragmentary
High-energy injury. Associated with polytrauma. Femoral fracture), special cases (following patella tendon graft for
or tibial fractures may be open with an associated ACL reconstruction, following TKR or MPFL
neurovascular injury. High risk of compartment syndrome reconstruction)
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031
Assessment – Soft-tissue status. Ability to straight leg raise Types IV–VI fractures are associated with higher levels of
Fracture pattern – Level of fracture (superior or inferior neurovascular injury and compartment syndrome and can
pole, body), type of fracture (transverse, multifragmentary). be associated with knee dislocation or subluxation.
Differential diagnosis: Bipartite patella Initial management – ATLS® principles and resuscitation if
high-energy injury. Reduce and splint fracture. Evaluate for
Management neurovascular injury and compartment syndrome. High
level injuries may require spanning external fixation. Once
Non-operative if undisplaced (due to intact patellar retinacu-
stable, CT scan to assess fracture pattern and configuration.
lum). Cylinder cast for 2 weeks followed by hinged knee brace
The CT is useful for identifying the degree of displacement
with progressive increase in range of movements and serial
and joint depression and for planning definitive surgery
radiographs to assess for fracture displacement.
(Figure 28.7).
Displaced fractures – Operative treatment. Transverse
fractures can be treated with tension-band wire fixation
(Figure 28.6), screws or cannulated screws with tension- Definitive surgical management
band wire This should only be undertaken once the soft-tissue injury
Multifragmentary fractures – Tension band wire with has settled, which may take up to 3 weeks. The principle of
cerclage wire fixation surgical treatment is to reduce and stabilise the fracture and
Displaced inferior pole of patella fracture – If fragment is articular surface, bone graft any defects and allow early range
small, it can be excised and the patella tendon reattached to of movement exercises. Surgical incisions should be planned
the main fragment to allow access to the fracture and articular surface. Care
Patellectomy is not considered as a primary procedure for should be taken to avoid excessive stripping of soft tissues
patella fractures. during exposure, and a wide skin bridge of at least 5–7 cm is
required between incisions. A single incision to expose both
Complications – Implant related prominent wires (often
the medial and lateral sides of the knee is generally not
require subsequent removal), knee stiffness, wound healing
recommended.
issues
Operative management options include:
Percutaneous lag screws or anterolateral plate fixation can
Tibial plateau fracture be used for undisplaced or minimally depressed fractures
Key viva themes: Surgical approach, care of soft tissues For depressed fractures, a window may be made in the
Mechanism of injury – High energy injury (RTA, fall from anterolateral tibia to then ‘punch’ up the articular surface,
height) in young or low-energy injury (fall from standing followed by bone grafting and raft screw fixation
height) in osteoporotic bone Bone graft may include autograft, allograft or bone
Initial assessment – Closed or open fracture, soft-tissue substitute
status, distal neurovascular status, compartment syndrome Lateral fractures may be fixed using either open reduction
Radiological assessment – AP and lateral views of knee and internal fixation (ORIF) using precontoured plates, often as
proximal tibia. Schatzker classification18 a buttress plate after articular surface reconstruction, or
Type I – Lateral split fracture using a circular frame
Type II – Lateral split-depression fracture
Type III – Lateral pure depression fracture
Type IV – Medial fracture
Type V – Bicondylar fracture
Type VI –Fracture extending into metaphysis
The classification increases with increasing severity of injury,
energy and soft-tissue damage.
Figure 28.7 CT scan of tibial plateau fracture showing severe depression of

Figure 28.6 Transverse fracture of the patella stabilised by tension-band the lateral tibial plateau, caused by the lateral femoral condyle driving through
fixation the lateral tibial plateau
031
The anterolateral approach to the knee allows access to

However, pragmatically, certain fracture such as those with
most lateral fractures. The meniscus may be elevated to
significant soft-tissue injury may benefit from a less invasive
visualize the joint and remove any incarcerated meniscus approach. In the same way there may be other fractures, such
that may prevent fracture reduction. The joint may then be as those with significant instability that buttressing the fracture
elevated, bone graft inserted and the fracture fixed with a plate may be preferable.
Arthroscopy has been described to aid fracture reduction.
This is often technically difficult due to the presence of
bleeding, and is associated with a risk of compartment Tibial shaft fractures
syndrome
Key viva themes: Management of open fracture, compartment
Once the fracture has been fixed, check for any
ligamentous instability within the knee syndrome, fixation of proximal or distal tibial shaft fractures
Mechanism of injury – May be high-energy injury, often
isolated sporting injury in young adult
Types I–III: Undisplaced or depression <2 mm –
Examination under anaesthesia, if stable hinged knee brace Initial assessment – Assess level of soft-tissue or
neurovascular injury
Types I–III: Displaced, unstable or depression >2 mm –
Operative management Initial management – Above knee back slab, analgesia,
observe for compartment syndrome
Types IV–VI: These fractures require careful surgical
planning and evaluation of the fracture configuration
(Figure 28.8). Posterior fragments where there has been Definitive management
posterior subluxation require a posterior approach and Non-operative management
buttressing of the fracture. This may be accessible via a Stable isolated fractures, <10° angulation or rotational mal-
posteromedial incision but a posterior approach to the knee alignment, <50% translation may be treated non-operatively in
may be required. An additional anterior or anterolateral plaster. Allow swelling and soft tissues to settle then apply above
incision may also be required to reduce and hold all of the knee full cast either in theatre or plaster room and observe regu-
fragments. This may require the patient to start prone to larly to check for fracture displacement. Wedging may be used to
achieve posterior buttressing of the fracture followed by correct small amounts of fracture displacement or angulation. At
turning the patient supine to perform the remainder of the 4–6 weeks the above knee cast may then be converted to a Sar-
procedure miento or patella tendon bearing cast until the fracture is united8.
Adjuncts to fracture fixation – If the fracture is unstable, a Some authors recommend patella tendon bearing cast as
femoral distractor may be used, or the external fixator may the definitive management8. If the fracture starts to angulate in
be left on during definitive surgery. Remember that fractures the cast, then, wedging of the fracture can be performed to
are easier to reduce when body weight is working in your correct it.
favour (such as choosing to go prone to reduce posterior
fractures) Operative management
Indications – Open fracture, associated vascular injury,
segmental fracture, tibia and fibula fractures at same level,
Viva question – Which is better? Circular frame or ORIF to multiple fractures, compartment syndrome, and failed non-
treat severe tibial plateau fractures? operative management
Answer – The evidence suggests that the outcomes using Surgical treatment options –
either approach are similar as long as the level of expertise is Closed reamed interlocked nail fixation is the treatment
high . . . of choice in tibial shaft fractures
In fractures at metaphyseo-diaphyseal junction (either
proximal or distal), nail fixation is possible but is
technically demanding
– Distal shaft fractures require tibial nails with multiple
locking screw holes near the tip of the nail and nail
length increments in 10 mm to allow accurate nail
length. Distal fractures often
– Proximal tibial fractures can be stabilised with a nail
via a suprapatellar entry portal which requires special
instruments and is technically demanding. There is a
high incidence of valgus, apex anterior (precurvatum)
mal-union in proximal tibial shaft fractures so
Figure 28.8 Medial tibial condylar fracture stabilised by a buttress plate
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measures need to be taken intraoperatively to takes place at the specialist centre (normally the regional
prevent this MTC) whenever possible
– Special techniques like use of blocking screws These guidelines have a huge amount of information that are
(Figure 28.9), fixation of the fibula fracture, external essential reading for any surgeon managing trauma. Other
fixator assisted or plate assisted fracture reduction significant messages include:
and angular stable locking screws all have extended The specialist centre should include expertise in
the indications for nail fixation of tibial shaft orthopaedic and plastic surgery, microbiology, radiology,
fractures limb fitting and rehabilitation services and intensive care
– Minimally invasive precontoured plate fixation is also facilities. Dedicated theatre sessions during the working
an option in shaft fractures that are either in the day are necessary for the combined orthoplastic
proximal or distal metaphyseo-diaphyseal junction management of these patients
®
ATLS principles should be used. Wounds should not be
External fixation may be used either as a temporary
‘provisionally cleaned’; only gross contaminents should be
measure such as in cases of severe open fracture, or can
removed. Immobilization of the limb using simple
be used as a definitive treatment (using a circular frame
splintage should be performed. A photograph of the wound
or monolateral fixator)
should be taken and the sterile dressing applied
Complications – Compartment syndrome, rotational
Antibiotics should be administered as soon as possible,
deformities, anterior knee pain (after tibial nailing),
certainly within 3 hours. Anti-tetanus prohylaxis is given
non-union, mal-union
The only reasons for immediate surgical exploration are
the presence of gross wound contamination, compartment
Open tibial fractures syndrome, a devascularized limb and in the multiply
Regarding the BOA guidelines in the treatment of severe open injured patient. In the absence of these criteria,
fractures, the principle recommendations are: debridement should be performed on a scheduled trauma
A multidisciplinary team, including orthopaedic and list by senior orthopaedic and plastic surgeons within
plastic surgeons with appropriate experience, is required 24 hours of injury
for the treatment of complex open fractures A typical sequence of events should be followed
Hospitals that lack a team with requisite expertise to treat :
Initially the limb is washed with a soapy solution and a
complex open fractures have arrangements for immediate tourniquet applied
referral to the nearest specialist centre : The limb is prepped with alcoholic chlorhexidine
The primary surgical treatment (wound debridement/ (avoiding the open wound)
excision and skeletal stabilisation) of these complex injuries : Soft-tissue debridement and excision is performed
under tourniquet control. Debridement means the
excision of all devitalized tissue (except for
neurovascular bundles)
: Visualisation of the deeper structures is faciliatated by
wound extensions along the fasciotomy lines. Tissues
are assessed systematically in turn. Bone ends should be
carefully delivered through the wound. Loose fragments
that fail the ‘tug test’ should be removed, including
large unviable fragments. Use copious lavage (but high
pressure pulsatile lavage is not recommended).
Negative pressure dressings may be used temporarily
but not as a definitive treatment. Antibiotic
impregnated bone cement beads are recommended in
cases with segmental bone loss, gross contamination or
established infection
: After debridement the injury can be classified and
definitive reconstruction can be planned. This may be
as a single or multiple stage procedure
Spanning external fixation is recommended when
definitive fracture stabilisation and immediate wound
cover is not carried out at the time of primary
Figure 28.9 Distal tibial fracture – guidewire insertion aided by a blocking debridement. Internal fixation is safe if there is minimal
screw
031
contamination and soft-tissue coverage is achieved at the

Question – How would you perform the fasciotomy?
same time as insertion of the implant. Exchange from
spanning fixator to internal fixation is done as early as Answer – The BOA guidelines for the treatment of open
possible. Definitive external fixation can be used if there is fractures recommend a two-incision technique. I would per-
significant contamination, bone loss and multilevel tibial form long longitudinal anterolateral and a medial incisions.
fractures Through these incisions I am able to expose all four tibial
compartments, and I would split the fascia longitudinally to
Definitive soft-tissue reconstruction should be undertaken
release the pressure within each of the compartments. I would
within the first 7 days after injury. All open fractures
take care with my anterolateral incision to preserve the super-
should be covered with vascularized soft-tissue. Muscle ficial peroneal nerve distally. I would leave the wounds open,
flaps are better to treat diaphyseal tibial fractures while covering them with a sterile dressing and I would arrange for
fasciocutaneous flaps are better to treat metaphyseal the patient to return to theatre in 48–72 hours for a ‘second
fractures especially around the ankle look’ with a plastic surgeon, where any devitalised tissue may
Primary amputation should only be performed as a be debrided or the wound closed if possible. If the wound
damage control procedure if there is uncontrollable does not close at this point I would liaise with the plastic
haemorrhage (usually from multiple levels of arterial/ surgeons to arrange soft-tissue coverage, likely in the form of
venous damage in blast injuries), for crush injuries a skin graft.
exceeding a warm ischaemic period of 6 hours, or for
incomplete traumatic amputations where the distal
remnant is significantly injured. The decision to amputate
should be taken by two consultants with, if possible, patient Pilon fracture
and family involvement Key viva themes – ORIF vs external fixator, soft-tissue
management
Classification of open fractures (Gustillo–Anderson) Mechanism of injury – HIGH-ENERGY injury (axial
Type I – LOW-ENERGY trauma, wound <1 cm compression) – Fall from heights, road traffic accidents,
Type II – Wound 1–10 cm in size, without extensive soft- skiing injuries) in the young. Low-energy injury(rotational)
tissue damage twisting injury – Fall from standing height in osteoporotic
Type IIIA – Any high-energy open injury. Extensive soft- bone
tissue damage with adequate soft-tissue coverage Initial assessment – ATLS® principles and resuscitation if
Type IIIB – Any high-energy open injury with extensive associated injuries (calcaneus, tibial plateau, pelvis, vertebral
soft-tissue loss where soft-tissue coverage is not possible spine), status of soft tissues, neurovascular status, assess for
Type IIIC – Any open injury associated with an arterial compartment syndrome. Reduce fracture and stabilise with
injury requiring repair temporary cast. If fracture is open, refer to the BOA
guidelines for severe lower limb open fracture. Admit and
elevate limb
Radiological assessment – AP, lateral and mortice
Viva question – How would you evaluate and manage
a clinical case of compartment syndrome at midnight in a radiographs of ankle. Full length tibia/fibula and foot
tibial fracture that had undergone tibial nailing that morning? radiographs to assess alignment and look for fracture
extension. CT scan to evaluate fracture pattern and to plan
Answer – The main clinical feature of compartment syndrome definitive surgery
is pain out of proportion to the injury. It is a surgical emer-
Classification – Ruedi and Allgower19. Based on the
gency that I would diagnose and treat urgently. I would
clinically evaluate the patient, looking in particular for pain severity of comminution and displacement of the articular
of passive stretching of the muscles that pass through the surface
tibial compartments. I would review the anaesthetic chart I – No comminution or displacement
to see if the patient had received any nerve blocks II – Some displacement but no comminution or
during surgery that may mask symptoms of compartment impaction
syndrome. I would then split all dressings to the skin to
relieve any external pressure and re-evaluate the situation.
III – Comminution and/or impaction of the joint
If available, I would measure intracompartment pressures. surface
A difference of 30 mmHg or less between the measured
pressure and the diastolic pressure is a reasonable threshold Classification – AO
for decompression. Compartment syndrome, however, is a AO 43A – Extra-articular fracture
clinical diagnosis and if I can any cause for suspicion, such AO 43B – Partial articular fracture
as in this case, I would proceed to urgent fasciotomy to AO 43C – Complete articular fracture
decompress of the compartments.
43C1 – No comminution
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43C2 – Comminution of metaphysis stiffness, chronic pain, association with significantly poorer
43C3 – Comminution of epiphysis and/or metaphysis general health scores after injury
(roughly corresponds to R&A group III)
Initial management – If alignment and articular fragments
are reasonable then back slab, elevation, analgesia and Viva question – Is there any evidence for early definitive
CT scan. In presence of significant fracture displacement treatment of pilon fractures?
and/or ankle is subluxed or dislocated or significant soft-
Answer – The Vancouver group (White et al. JOT 2010)20
tissue damage is present, then, closed reduction and published their results of early definitive fixation within
spanning external fixation is performed followed by 48 hours. They demonstrated excellent results with low com-
CT scan plication rates. However, all fractures were treated by experi-
Classification – Soft tissues based on Tscherne classification. enced high volume trauma surgeons. Historically early fixation
Fracture – Partial articular or complete articular (further has been associated with high complication rates, and in view
subdivided based on degree on metaphyseal and or articular of this surgeons should proceed with care and the generally
comminution) accepted practice is to perform surgery once the soft tissues
and swelling have improved.
Management – This depends upon the patient’s co-
morbidities, soft-tissue status and fracture pattern
Undisplaced fractures may be treated non-operatively in a
cast for 6 weeks Ankle fractures
Displaced fractures – The conventional treatment of this Key viva themes – Mechanism of injury, methods of fixation
injury to perform an early spanning external fixation Mechanism of injury – Most commonly twisting injury
(using an ‘A or Delta frame’ leaving pins clear of the Immediate assessment – Assess neurovascular status, an
zone of injury and from potential incisions). This allows x-ray of the displaced fracture provides a lot of
better control and visualisation and treatment of the information on the pattern of the fracture but should only
soft tissues. The CT scan should be performed at this be performed if it can be done immediately, a displaced
point. Only when soft-tissue swelling has subsided fracture should then be reduced under sedation with
can surgery safely be performed(7–14 days on analgesia, placed in a split plaster or backslab, x-rays
average) repeated and the limb should be elevated. Gross
dislocation clinically should be reduced and not delayed
Surgical options for radiographs as skin necrosis can progress rapidly.
ORIF. The principles as described by Ruedi and Allgower If left unreduced there is a risk of vascular compromise,
are fibula length restoration, precise articular restoration, pressure necrosis, articular damage and prolonged ankle
bone graft of the metaphyseal defect and stabilisation of soft-tissue swelling
the fracture. The axial CT provides information on how Classification – Weber. The easiest and simplest
best to choose the fixation method. The fixation method classification, but only of the fibula and are based on the
then dictates the approach. Many approaches may be relationship to the syndesmosis: A = distal; B = at the level of
used (anteromedial, posteromedial or anterolateral to the the syndesmosis; C = proximal. Associated medial and
tibia; posterolateral to fibula), but it is vital that the soft posterior injuiries should be described
tissues are handled carefully. Skin bridges should be at Lauge–Hansen classification is based on mechanism of
least 7 cm injury and is well worth learning as it helps you to
Closed reduction and percutaneous fixation of articular understand the direction of the forces involved and the
surface. A minimally invasive approach may then be used structures injured
to apply a percutaneous plate Supination external rotation (SER) injury is the
Acute limited fixation and external fixation with a ring commonest type. A candidate should be able to discuss the
fixator. The articular surface is reconstructed using K-wires four stages of SER injury and differentiate stable and
(with or without olives) and/or lag screws. A ring fixator is unstable SER injuries. Local features of medial injury
then applied include bruising, tenderness and swelling but these are not
100% sensitive
Complications – Wound complications (soft-tissue slough,
necrosis, haematoma), ankle stiffness and infection. Non-
union if significant comminution, bone loss, hypovscularity Definitive treatment
and infection. Mal-union common with non-anatomic Stable fractures may be treated non-operatively. These frac-
reduction, inadequate buttressing followed by collapse or tures consist of Weber A injuries, and fractures where there is
premature weight-bearing). Reported incidence of up to no evidence of joint incongruity. Stress testing may be used to
25%. Tibial shortening, secondary osteoarthritis, ankle aid in this diagnosis.
031
Unstable fractures are more often treated operatively. If an ankle is too swollen and/or has blisters, then elevate
Ankle joint incongruity of >2 mm has the effect of redu- the leg. Surgery is delayed until skin wrinkles start to appear
cing articular surface contact by 60%. If elected to treat non- and blisters settle. If the ankle is grossly swollen or significant
operatively, there must be no evidence of joint incongruity and blisters develop or the fracture redisplaces in the back slab,
serial radiographs are required until fracture union has consider a spanning external fixation which that allow blisters
occurred, possibly with changes of plaster as the ankle swelling to be daily dressed and swelling more easily assessed.
subsides. An ankle that has been dislocated or previously Standard AO techniques of anatomic reduction and absolute
displaced is an unstable injury. Weber B fractures may be stability should be lateral malleolus fracture:
unstable if the joint has ever been incongruent, or has been
Lag screw and contoured one third tubular neutralization
associated with a medial-sided injury. A Weber C fracture is an
plate or pre-contoured locked plate applied laterally
unstable injury.
A posterior gliding plate with possible lag screw has the
potential advantage of a buttress plate and allows
bicortical fixation for screws in the distal fragment but
Viva question – How do you assess for ankle joint
incongruity? peroneal tendons irritation is a potential issue
Other options include Rush pin, fibula nail with locking
Answer – The mortice view allows assessment of the fibula screw option. In the elderly, with significant soft-tissue
length by talocrural angle, talar shift by medial clear space
and/or vascular pathology, a tibio-calcaneal nail can be
>4 mm, syndesmosis by tibiofibular clear space and a broken
considered to maintain alignment and allow early weight-
circle sign. A circle sign is the curve between the lateral pro-
cess of the talus and the recess of the distal tip of the lateral bearing
malleolus. It is vital that the ankle is fully dorsiflexed as the Medial malleolus fracture:
talus is cuboidal shaped and a plantarflexed ankle may look Lag screws with or without washers (either uni or
abnormal. I may also choose to compare x-rays of the other bicortical). If fragment is small or comminuted then,
ankle or perform stress testing under image guidance. I am consider tension-band wire fixation or fixation with
fully aware that an undisplaced fracture may still represent an
suture anchors. Vertical medial malleolus fracture
unstable injury.
(in supination–adduction type fracture) cannot be
adequately stabilised with just screws. A buttress plate
provides satisfactory stability to the fracture
(Figure 28.10). The site of plate application depends on
the plane of posteromedial fragment (coronal or oblique)
Posterior malleolus fracture

In injury patterns involving the posterior malleolus, the PITFL is
usually still attached to the posterior malleolus fragment. A CT
scan may be required for further evaluation. Posterior malleoli
fractures benefit from fixation when they represent >25% of
the articular surface, or when the fragment is displaced as
ankle stability is restored. Fixation options include anteropos-
terior lag screws fixation after reduction with a pointed reduc-
tion clamp or a posterior buttress plate via posterolateral
approach (Figure 28.11).
Figure 28.11 Posterior buttress plate fixation of a large posterior malleolus

Figure 28.10 Medial malleolus treated with a plate fracture
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031
reduced and the fibula is in the correct length and rotation

in relation to the talus.
Screws need not be removed prior to mobilization In such
injuries, the screw should not be removed early as that may lead
to late displacement. There is currently controversy on what is
considered to be a ‘reduced’ syndesmosis, as the syndesmosis is
a mobile joint and, therefore, does not have a single position
where is considered ‘reduced’22. Regular removal of syndes-
mosis screw is controversial. An intact syndesmosis screw is
associated with a worse functional outcome compared with
loose, fractured, or removed screws23. However, there were no
differences in functional outcomes comparing loose or frac-
tured screws with removed screws. Screw removal is unlikely to
benefit patients with loose or fractured screws but may be
indicated in patients with intact syndesmosis screws.
In special cases such as in very elderly patients, patients
with severe neuropathy or as a salvage procedure, hindfoot
nailing may be performed.
There is also no considered optimal protocol for the post-
operative management of ankle fractures. Braces may be used;
however, cast immobilization and gentle increase in weight-
bearing and mobilization over a 6-week period is considered
usual practice.
Complications – Wound breakdown and infection (1–3%).
Outcomes are worse in the elderly and diabetic patients.
Figure 28.12 Hook test after lateral malleolus fixation Post-traumatic arthritis has been described to occur in 14%
of cases, most likely as a result of chondral injury sustained
at time of the initial injury. Nerve injury (superficial
Syndesmosis Injury peroneal nerve), ankle tiffness, RSD and compartment
Distal tibio-fibular syndesmosis injury can be subtle or syndrome (rare)
obvious on radiographs. The commonest mechanism of
syndesmosis injury is pronation external rotation (as per
Lauge–Hansen classification). However, syndesmosis injury is Talus neck fracture
possible in Weber B fractures. The integrity of the syndesmosis Key viva themes – Surgical approach, complications
should be tested in all ankle fracture fixations by the hook test Mechanism of injury – Usually high-energy trauma.
(Figure 28.12) or stressing the ankle in external rotation Hyperdorsiflexion with axial loading of the ankle that causes
(thought more reliable). impingement of talus neck against the anterior tibial lip
There is no single preferred method of treating syndesmosis Radiological assessment – AP and lateral views of ankle.
injuries21. One or two 3.5 mm or 4.5 mm fully threaded screw at Preoperatively – Canale view (Plantar flexion, pronated and
2 - 5 cm proximal to the ankle joint, running posterolateral to fluoroscopy directed 75° cephalad)
anteromedial, parallel to the ankle joint, across three or four
cortices with ankle held in neutral. It is probably preferable to
use two screws to reduce and hold the syndesmosis in an isolated Hawkin’s radiological classification
syndesmotic injury such as in a Maisonneuve fracture The screw Based on the amount of displacement and the associated disloca-
(s) should be used as positional screws not compression screws. tions or subluxations. Rates of dislocation shown in brackets:
Other options include suture techniques using a ‘Tightrope’ or Type I – Undisplaced with no subtalar incongruity (up to
bioabsorbable screws. If the syndesmosis injury is part of a bimal- 15%)
leolar fracture, then a syndesmosis screw is introduced through the Type II – Displaced with subluxed or dislocated subtalar
plate fixation of the lateral malleolus. If it is a high pronation- joint (up to 50%)
external rotation (PER) type injury, then fibula length is first Type III – Displaced with dislocated subtalar and ankle
restored by traction and then a large pointed reduction clamp is joints (up to 100%)
applied across the lateral malleolus and tibia to maintain syndes- Type IV – Displaced with dislocation of subtalar, ankle and
motic reduction. The syndesmosis is checked under image inten- talonavicular joints (100%). This category was not included
sifier (talocrural angle, Shenton line, etc) before application of in Hawkin’s original paper but later added by Canale and
syndesmosis screws. It is important that the syndesmosis is Kelly24
031
Management
Undisplaced – Non-weight-bearing cast for 6 weeks. Serial Classic reference
radiographs to assess for displacement. If any doubt, Hawkins LG Fractures of neck of talus. J Bone Joint Surg Am.
CT scan 1970;52:991–1002.
Displaced – If a closed reduction is achieved and the The Hawkin’s classification is still one of the most widely used and
alignment is satisfactory by Canale’s view, percutaneous accepted classification for talar neck fractures. It is based on
screws fixation anterior to posterior. This fracture is often displacement and dislocation, and therefore, presumed damage
associated with medial comminution, and varus mal-union to the blood supply of the talus. The paper reviewed the outcome
should be avoided. If the fracture cannot reduced using of 57 such fractures following various treatment methods.
closed means, proceed to an open reduction
Open reduction Talar body fracture

Approaches to the talus are a compromise of visualizing Talar body fractures are commonly caused by axial compres-
enough to achieve a satisfactory reduction while not further sion, such as a fall from a height, with a worse prognosis than
damaging the tenuous blood supply to the bone. The following talar neck fractures (rate of avascular necrosis around 50%).
approaches may be used – Anterolateral (with minimal vascu- Surgical management – Medial malleolus osteotomy pro-
lar risk), anteromedial (risk to artery of tarsal canal) or poster- vides visual access to accurately reduce the fracture and stabil-
olateral. Combined anterolateral and anteromedial approaches isation could be performed percutaneously with screws
maybe needed. A medial malleolus osteotomy may help to running posterolateral to anteromedial.
visualize proximal fractures while also preserving the deltoid
branches of the posterior tibial artery. Talar lateral process fracture
Usually lower energy axial loading/inversion injuries to ankle
frequently occurring with sporting activities. An intra-articular
Viva question – What is the blood supply to the talus? fracture that may be difficult to identify on plain ankle radio-
Answer – The talus is supplied by the posterior tibial artery graphs. A CT scan is often necessary to appreciate extent of the
(artery of tarsal canal, calcaneal branches), anterior tibial artery fracture. Increased incidence with snowboarding.
(branch to artery of tarsal sinus, medial tarsal branches), and Undisplaced fracture – Non-weight-bearing cast for 6 weeks
the peroneal artery (branch to artery of tarsal sinus). The talar Displaced fracture – Reduction and headless screw fixation
head is supplied by branches of dorsalis pedis artery and
anastomosis of arteries of tarsal canal and tarsal sinus. The
Comminuted fracture – Excision of fragments
talar body is supplied by anastomosis of arteries of tarsal canal
and tarsal sinus. The talus is an unusual bone in that 70% of it Talar posterior process fracture
is covered by articular cartilage. The proximal body of the talus Mechanism of injury – Hyperplantar flexion
is particularly vulnerable to avascular necrosis after displaced
Radiographs – Anteroposterior and lateral views of ankle
talar neck fractures, which can be made further worse through
the final remaining blood supply being damaged (entering and CT scan. Differential diagnosis is os trigonum
medially) by surgical approaches to reduce and fix fractures. Non-operative management with non-weight-bearing cast
for 6 weeks followed by weight-bearing as tolerated and
range of movement exercises
Complications Complications – Non-union
Due to its unique anatomy, the tenuous blood supply, and the Symptomatic non-union – If the fragment is large, then,
multiple complex articulations in the hindfoot, these injuries are either bone graft and fixation or excision. Smaller or
associated with varus mal-union, non-union, avascular necrosis, comminuted fragments are excised
secondary osteoarthritis of subtalar and or ankle joints25.
Avascular necrosis – The talus is at risk of avascular necrosis Talus dislocation
after displaced talar neck fractures. Postoperative serial Mechanism of injury – High energy with associated
anteroposterior radiographs will show indirect signs of rotational forces
vascular viability. Hawkin’s sign – Subchondral lucency in Assessment – May be closed or open dislocation, assess local
the talus on anteroposterior view of ankle at 6–8 weeks soft-tissue and neurovascular status. Could be medial
demonstrates vascular viability. The lucency occurs (most common) or lateral dislocation (associated with distal
secondary to an intact blood supply causing bony resorption fibula fracture)
during fracture healing. Sclerosis is an indication of an Management – Closed reduction under anaesthetic as soon
inadequate blood supply and may be associated with as possible. If unsuccessful, there may be tendon
non-union interposition (extensor digitorum brevis/peroneals in
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031
medial dislocation or tibialis posterior in lateral dislocation). soft-tissue flaps and meticulous surgical technique), with
If closed reduction is unsuccessful then open reduction is interfragmentory screws and a neutralisation plate to the
performed using anteromedial and/or anterolateral lateral wall of the calcaneus. Broden’s view intraoperatively
approaches. Once reduced, check stability; if unstable a confirms posterior facet articular reduction. The aim of
spanning external fixator or K-wires may be used to reduce surgical treatment is to reduce the calcaneo-cuboid and
the talo-calcaneal and talo-navicular joints subtalar joints and to restore the shape and normal width of
Complications – Soft-tissue problems, AVN (consider the foot. Again, gentle tissue handing with wound close
calcaneotibial arthrodesis), secondary arthritis (consider avoiding tension must be performed to avoid soft-tissue
subtalar arthrodesis) problems and skin necrosis
Percutaneous techniques have also been developed. These
Calcaneal fracture are performed primarily for Essex–Lopresti tongue type
Key viva theme – Discussion of management options, factors associated fractures, using closed reduction and screw fixation,
with poor outcomes although techniques are now described for joint-depression
fractures using leverage techniques to achieve fracture
Mechanism of injury – Axial loading (fall from height)
reduction with percutaneous screw fixation.
Immediate assessment – Can be associated with limbs,
Factors associated with less satisfactory outcomes after
pelvis and spine related to the mechanism. Assess soft tissues
surgical treatment are male sex, manual work, diabetes,
and observe for compartment syndrome of the foot
steroids, smoking, alcohol, non-compliance and worker’s
Radiological assessment – Ankle lateral view (angle of
compensation (medico-legal claims)27.
Gissane, Bohler’s angle) and calcaneal axial view (widening,
Complications – Wound-healing problems, infection,
lateral impingement). Broden view – Posterior facet of
prominent metalwork, subtalar arthritis, widened heel and
subtalar joint
difficulty fitting shoes (with non-operative treatment)
CT scans in the axial and coronal planes help to fully
understand the fracture pattern and plan for surgery.
Classification – The Essex–Lopresti classifies intra-articular Calcaneal tuberosity fracture
fractures into joint-depression types, where the primary Key viva theme – Skin necrosis
fracture line exits close to the subtalar joint, and tongue- Mechanism of injury – Eccentric contraction of gastrosoleus
types where the primary fracture line exits posteriorly. causing calcaneal tuberosity avulsion fracture
Sander’s classification is based on the coronal section of the Initial assessment – This injury is associated with skin
posterior facet of a CT scan and number of fracture lines necrosis and, therefore, requires prompt reduction and
fixation
Treatment options
Management – Initial treatment is a cast in equinus.
A recent multicentre randomised controlled trial has been Undisplaced fractures may be treated non-operatively.
published questioning the surgical treatment of calcaneum Displaced fractures should be reduced and held with
fractures26. This paper suggests that non-operative treatment interfragmentory screws (Figure 28.13)
of calcaneum fractures is associated with fewer complications
and no difference in outcome scores in the short term. The
strengths of its study were in its design and that surgery was Lisfranc fracture dislocation
performed by specialist surgeons. Its weaknesses include the Key viva theme – Assessment of displacement and stability
large number of patients identified as suitable but then not Mechanism of injury: plantar flexion with axial loading or
included in the study, and its exclusion criteria – Patients were crushing injury
excluded if the fracture had gross deformity of the hindfoot
(this is the criteria that many surgeons use as an indication
for surgery). However, what this paper does suggest is that
operative treatment of displaced calcaneal fractures does not
lead to improved outcomes at 2 years
Undisplaced fracture – Elevation, maintain subtalar and
ankle movements. Non-weight-bearing for 6–12 weeks
Displaced fractures – Fractures with gross hindfoot
deformity (fibular impingement), open fractures or fractures
causing soft-tissue compromise may benefit from surgery.
The aim of surgery is to achieve reduction of posterior facet
and reduce the widening of calcaneum. Surgery should wait
until the soft tissues and swelling have subsided. An
extended lateral approach is performed (maintaining thick Figure 28.13 Calcaneal tuberosity fracture
031
Assessment: Local soft-tissue status, ensuring correct may lead to long-term foot dysfunction, pain, stiffness and
diagnosis (as this is a commonly missed injury). It is disability
important to exclude diabetes and peripheral neuropathy as
treatment of a Charcot injury is different Tendoachilles rupture
Key viva themes – What are the benefits of surgery?
Viva question – What is the Lisfranc joint?
Mechanism of injury – Eccentric loading of gastrosoleus, in
Answer – The Lisfranc joint consists of three cuneiform middle-aged ‘weekend warriors’ often presents as a sudden
and two metatarsal articulations – The first and second. The pop or crack at the back of the ankle while playing sport
Lisfranc ligament runs obliquely from the plantar aspect of Associated factors include the use of steroids use, gout,
the base of the second metatarsal to the plantar surface quinolones and chronic renal failure
of the medial cuneiform.
Assessment – Gap in the tendoachilles. Symond’s or
Thompson’s test (Squeezing calf produces passive plantar
flexion in intact tendoachilles.) Often ruptures about 5–6 cm
Radiological assessment – Three views required – dorso- from insertion. If diagnosis uncertain, ultrasound can
plantar view (medial border of second metatarsal in line with be used
medial border of middle cuneiform), oblique view (medial There is controversy with incomplete tendoachilles ruptures.
border of fourth metatarsal in line with medial border of Often, when ultrasound examination demonstrates an
cuboid) and lateral view (dorsal displacement of metatarsal incomplete rupture, at surgery, the rest of tendon that
bases). If uncertain, obtain CT scan, MRI scan or stress view appeared to be in continuity is, in fact, stretched and often
non-functional
Classification (Hardcastle)
Total incongruity (medial or lateral) Treatment options
Partial incongruity (medial or lateral) The treatment of Achilles tendon ruptures remains controver-
Divergent (total or partial) sial. Good functional outcomes can be achieved using serial
casting or functional bracing. Non-operative treatment has
Management options been associated traditionally with higher rates of rerupture
If truly undisplaced or stable on stress views – Plaster with when compared to surgery (8.8% vs 3.6% in a recent meta-
non-weight-bearing and serial radiographs analysis of level 1 trials). Surgery, however, is obviously asso-
Displaced/unstable fracture – Surgical fixation after soft ciated with higher rates of deep infection, problems with the
tissues have settled. CT scan will help plan surgery. The scar and sural nerve dysfunction. This has also been confirmed
principle of surgery is that the second metatarsal base is the by a recent Cochrane review.
‘keystone’ fitting into the mortice between the cuneiforms. Surgery may be performed open or percutaneously. Percu-
The second metatarsal base connects to the medial taneous repair was traditionally associated with high rates of
cuneiform via the plantar (Lisfranc) ligament. The medial sural nerve injury (13%); the sural nerve runs posterolaterally
column is less mobile than the lateral column. Two dorsal down the calf in close proximation to the lateral border of the
incisions are routinely used to visualize the joint (the first Achilles tendon. More modern techniques have demonstrated
over the first/second TMT joints and the other over the lower rates of sural nerve injury, with fewer complication rates
fourth metatarsal). The joint should be visualized and when compared to open repair28.
reduced. K-wires may achieve a temporary reduction. The The non-operative treatment of Achilles tendon ruptures
medial column may be fixed with screws; however, more has improved and now functional bracing with intense
recently bridging plates may be used to hold the reduction rehabilitation may now achieve similar low rates of re-rupture
without compromise the articular surface. These are when compared to surgical repair. Many historical papers
particularly useful in more comminuted fractures. The with high rerupture rates consisted of casting for prolonged
lateral rays are more mobile and may be held with K-wires. periods of time. Willits et al.29 published an RCT comparing
Primary arthrodesis of the TMT joints may be performed in functional bracing with intense rehabilitation to surgical repair
more comminuted cases or in cases of delayed presentation (with the same rehabiliation regime) and found similar
Charcot midfoot fractures – Treatment is primarily non- low rates of re-rupture with fewer complications in the non-
operative. In the acute phase, immobilize (total contact operative group.
casting) with non-weight-bearing. This treatment may be Delayed presentation – Open repair may be augmented
necessary for 3–6 months. The underlying diagnosis using fascia, the plantaris tendon, flexor hallucis longus, flexor
including diabetic control and vascular supply should be digitorum longus or peroneus brevis. Techniques to lengthen
optimized the gastro-soleus complex may also be required. Chronic
Prognosis – This is a serious injury. Post-traumatic arthritis injuries are associated with worse outcomes and higher rates
may occur. It is frequently missed at first presentation and of complications.
651
031
Classic reference when tetanus cover is not known or in severe contamination

and/or severe muscle damage.
Willits K, Amendola A, Bryant D, et al. Operative versus Intravenous antibiotics – Co-amoxiclav (1.2 g) or cefur-
nonoperative treatment of acute Achilles tendon ruptures:
oxime (1.5 g) 8 hourly for 72 hours or till wound closure.
A multicenter randomised trial using accelerated functional
Clindamycin 600 mg, 6 hourly is administered in cases of
rehabilitation J Bone Joint Surg Am. 2010;92:2767–75.
penicillin allergy. Metronidazole is added in cases of severe
Operative treatment of acute Achilles tendon rupture does not contamination with sewage or farmyard injuries.
offer any clinically significant benefit over accelerated
Debridement can be done at up to 24 hours from injury
functional rehabilitation alone and is associated with a higher
complication rate.
unless significant contamination with sewage or farmyard
This is one of the largest multicentered RCTs using the injuries or associated injuries requires surgical management.
functional rehabilitation protocol. It refutes the previous Debridement includes excising the wound edges, extension
notions of very high rerupture rates after conventional non- of wounds in line with compartment release incision, bone
operative treatment of plaster immobilization of the lower ends are delivered, fragment edges are gently curreted to
limb for 6–8 weeks. remove any debris and any loose fragments removed. Soft
Strengths included being a well-conducted large tissues that are not viable are also excised. Lavage of the wound
multicentered RCT that had clearly defined aims and inclusion/ is performed with warmed Normal saline via a giving set with
exclusion criteria.
In this multicentre study, 144 patients were randomised to
a large bore. Pulse lavage is not used as pressurised fluid can
two groups. Both groups underwent a prescribed accelerated push the debris further into the wound. Once the surgeon is
rehabilitation protocol. One group also had operative repair. happy that the wound is clean photographs are taken (for
Primary outcome measure was rerupture rate. plastic surgeon to review). External fixator pins are introduced
away from zone of injury in a ‘near/far’ configuration and
fracture reduction is maintained with rods away from the
Open fractures wound. In cases of bone loss Gentamicin beads or calcium
Definition – A fracture that communicates with the external sulphate with antibiotics are introduced and vacuum-assisted
environment through a skin wound. Open tibia fracture is wound closure is performed. Rest of the rods are connected to
the commonest open fracture increase stability of external fixation.
Goals of management – Prevent sepsis, achieve skin cover, Combined orthopaedic and plastic approach.
promote healing and regain good function Definitive stabilisation of fracture and wound cover should
Local factors – Mechanism of injury, soft-tissue injury, be achieved within 3–7 days.
contamination, fracture pattern Usually, in type I, II and IIIA definitive stabilisation with
Gustilo and Anderson classification (after debridement) – intramedullary device and wound cover can be achieved.
Type I – low energy injury, <1 cm wound, minimal In IIIB – Nail fixation can be performed if soft tissues and
contamination, simple fracture. Type II – Higher energy, bone are in a satisfactory condition. If there is any doubt,
>1 cm wound, moderate contamination and comminution. circular frame fixation of the fracture is performed after
Type III – High energy, > 10 cm wound, severe wound cover is achieved.
contamination (including sewage, marine and farm yard Type IIIC injuries are to be dealt with as an emergency.
injuries) and comminution. Further subdivided into IIIA – Arteriography is not essential unless there are other proximal
Soft-tissue stripping but periosteal cover maintained injuries and delay in achieving arteriography does not com-
(delayed primary closure or split skin graft), IIIB – Soft- promise ischemic time. On table arteriography is another
tissue stripping with exposed bone (local or remote flaps) option. Temporary vascular shunt, external fixation, debride-
and IIIC – Associated arterial injury. This classification does ment of the wound, vascular repair or reconstruction is per-
not take into account presence or absence of bone loss. formed. Definitive stabilisation and skin cover is based on the
Interobserver reliability is about 60% available vascular branches.
BOAST guidelines for severe lower limb open fractures are
Management available online1.
The BOA has published guidelines on managing open fractures. Mangled Extremity Severity Score
Initial management Mangled Extremity Severity Score (MESS):
Remove any gross contamination, photograph the wound, apply Energy – Low, moderate, high, very high (1–4)
clean saline soaked wet swab to the wound, cover the wound with Ischaemia – Pulse present/absent but normal perfusion;
impregnable film, reduce the fracture and splint the limb, radio- pulseless with reduced capillary refill; cool, paralysed,
graphs of the limb including joint above and below are obtained. insensate, numb (1–3)
Tetanus cover – If patient was fully covered but booster Shock – Systolic >90 mmHg, transient hypotension,
dose was >5 years back, then tetanus toxoid 0.5 ml is adminis- persistent hypotension (0–2)
tered. Intramuscular tetanus immunoglobulin is administered Age – <30 years, 30–50 years, >50 years (0–2)
031
There are other scores but all the scores have high specificity DCO is based on avoiding the second hit or minimizing
(high probability of a low score leading to limb salvage) and the effect of second hit by performing only essential surgery
low sensitivity (low probability of high score leading to which will allow overall care of the patient, control bleeding,
amputation). remove devitalised tissues, reperfuse ischaemic tissues.
Decision to salvage or amputate the limb depends on DCO is considered when the ISS is >20 and associated
presence or absence of other limb injuries or life threatening with chest trauma or >40 without chest trauma in difficult
injuries, MESS, associated co-morbidities. If in doubt, salvage resuscitation, hypothermia and massive blood transfusion.
is a safe option with low threshold for later amputation in Cytokines, vascular endothelial cells interact to increase
consultation with another surgeon which also gives patient permeability of the capillary bed, especially in lungs, gut and
more time for informed consent. muscles. In lungs interstitial fluid increases leading to pulmon-
ary dysfunction, in gut there is translocation of bacteria
Injury Severity Score leading to sepsis and in muscles increased interstitial fluid
The Injury Severity Score (ISS) provides an overall score for can lead to compartment syndrome. Commonly used biomar-
multiply injured patients using an anatomical scoring system. kers are serum lactate >2.5 mmol/l and IL-6 >5 μg/l which
Body is divided into six regions (head, face, chest, abdomen, indicate that patient still not completely resuscitated.
extremities (including pelvis) and external) and each injury is
given an Abbreviated Injury Scale (AIS) score (0–6). Only the Management (DCO)
highest AIS score in each body region is used. The square of the Total surgical time is kept below 90 minutes. External fixation,
three most severely injured body regions are added together to cast application, reduction of dislocations and plate fixation all
produce the ISS score. The ISS ranges from 0 to 75. An AIS of 6 play a role in achieving temporary stabilisation of fractures.
(unsurvivable injury) in 1 body region automatically brings the Timing of definitive surgery is based on achieving haemo-
ISS to 75. The ISS correlates with morbidity, mortality and dynamic resuscitation, serum lactate <2 mmol/l, no coagulo-
hospital stay. However, several different injuries can add up pathy, normothermic, urine output >1 mg/kg/h, negative fluid
to same ISS as different body regions’ scores are not weighted. balance and no inotropic support.
In general terms, polytrauma patients can be classified as
Damage control orthopaedics (DCO) vs early stable, borderline, unstable and in extremis. Stable patients can
undergo definitive surgical stabilisation of fractures as soon as
total care (ETC) possible. Borderline patients can undergo ETC, but plan can be
DCO is performing just minimal surgical intervention that changed to DCO if patient’s condition deteriorates. Unstable
would assist achieving haemodynamic stability and nursing patients are treated by DCO. In extremis patients require ITU
care30. care and possibly closed reductions of dislocations and exter-
nal fixation of long bone fractures.
Pathophysiology
Response to injury
Principles of management of non-union
Ebb phase – Fight or fright response and usually lasts for <24
Generally, long bone fractures are considered to be non-unions
hours. During this period release of catecholamines, activation
if they have not healed by double the time required for the
of hypothalamus–pituitary–aldosterone and rennin–angioten-
fracture to heal usually. Non-progression of radiological healing,
sin–aldosterone axis occurs. All these responses tend to main-
pain and mobility at fracture site all point to non-union.
tain circulating blood volume.
Flow phase is divided into catabolic and anabolic phases. Patient factors
Catabolic phase usually lasts for 3–10 days and is charac- Co-morbidities – Diabetes, steroids, smoking, rheumatoid
terized by increased BMR, increased temperature, breakdown arthritis. Type of host
of fats and protein (negative nitrogen balance) and insulin Previous surgery – Number of surgeries, approaches,
resistance. The purpose of this phase is continued maintenance infection, implant type, bone graft
of energy available. Local soft-tissue status – Poor skin, open wounds
Anabolic phase usually lasts 10–60 days. This phase is the
recovery period with positive nitrogen balance when there is Weber–Cech classification
rebuilding of lost tissues. Hypertrophic (intact blood supply and mechanical
Concept of first hit and second hit. The initial trauma of instability)
injury produces inflammatory response which is essentially the Atrophic (loss of blood supply and mechanical instability)
first stage of repair process but this can be aggravated by a
second hit in the form of trauma due to surgical intervention. Host type in infected non-unions
This second hit can compound the first hit and push the Cierny classification
patient over to irreversible physiological damage including : Type A – Good immune system
multiple organ failure and acute respiratory distress syndrome. : Type B – Compromised systemically or locally
653
031
: Type C – Significant immune compromise that surgery Fracture non-union management is a subspecialty and needs a
is not contemplated dedicated multidisciplinary team including surgical team,
physiotherapists, occupational therapists, specialist nurses,
Goals of non-union management microbiologist, pathologist and radiologist.
Achieve fracture union
No shortening or mal-alignment
Other trauma scenarios to consider
Good function of the limb
THA presents with a first-time dislocation
Investigations Osteochondral fracture of the knee
Blood tests – FBC, ESR, CRP 15-year-old boy club football player with acute ACL injury
Imaging – Radiographs, CT and or MRI scans – To assess Tibial plateau fracture with associated tibial pilon feature
bony defects, osteomyelitis, arteriography in cases where Draw Hamilton–Russell traction for a femoral fracture
plastic surgery is anticipated due to poor soft-tissue status High-energy midshaft tibial fracture and chest injury
Planning management Inferior shoulder dislocation
Host type Treatment of distal biceps rupture and describe surgical
Soft-tissue status – Coordinate with plastic surgeon approach
Bone factors – Alignment, shortening, bone loss, joint Tibial tuberosity avulsion in a child
stiffness Segond fracture
Secondary prevention of osteoporosis and effects on bone
Options healing
No previous surgery Ankle instability
Hypertrophic non-unions in good alignment and no Intertrochanteric fracture non-union
shortening or gap
Pathological fracture of humerus
: Functional cast brace and or electromagnetic Femoral neck fracture in Paget’s disease
stimulation or LIPUS (Low Intensity Pulsed Late presentation of shoulder dislocation
Ultrasound) Multiple metatarsal fractures and calcaneal fractures
: Nail fixation for diaphyseal non-union Tibial spine fracture
: Plate fixation for metaphyseal/diaphyseal junction non- Posterolateral corner injury of knee
union
Dislocated knee
Atrophic non-union, shortening, gap, mal alignment, poor
Long bone non-union with in situ implant
soft tissues
: Circular frame fixation for bone transport or
lengthening or gradual correction of mal-alignment Examination corner
Case 1
Previous surgery Radiograph of pelvis and right femur in a 20-year-old female
Investigations to rule out infection and other investigations passenger involved in a RTA.
as described above
CANDIDATE: Described the radiographic findings, displaced right
Aseptic non-union
femoral midshaft fracture, minor comminution.
: Single-stage revision fixation (fixation options as above) EXAMINER: What will you do?
with or without augmentation with autologous bone CANDIDATE: Assess patient according to ATLS® protocols.
graft or demineralised bone graft or recombinant bone
morphogenic protein (BMP) Before candidate could proceed . . .
Septic non-union – Staged procedure EXAMINER: Patient is stable, no head, neck, spine, chest or
: First stage – Removal of implants, resection of abdominal injury.
devitalised bone and soft tissues, local and systemic CANDIDATE: Is it a closed injury? Any distal deficits? Any other areas
antibiotics, temporary spanning external fixation. Serial of tenderness in knee, tibia, ankle or foot?
blood markers of infection, blood cultures, Repeat EXAMINER: Closed injury and no other distal injuries.
debridement if required. Temporary vacuum-assisted CANDIDATE: Femoral shaft fractures are best treated
dressing operatively. I will stabilise this fracture with a reamed femoral
: Second stage – Soft-tissue cover by plastic surgery, if locked nail.
required EXAMINER: OK. This is the postoperative radiograph. What do
: Third stage – Definitive procedure with either plate or you think?
nail or circular frame as discussed above
031
Opportunities for other questions – If femoral neck fracture

CANDIDATE: Radiographs show locked femoral nail fixation.
was identified prior to surgery, then surgical options should
Alignment, nail and screws lengths are satisfactory. be discussed. Either single or two implants but femoral neck
EXAMINER: You go to see the patient on the first postoperative day fracture is the more important of the two fractures. Timing of
and patient is breathless. What do you do? nail fixation of femoral shaft fractures. Reamed or unreamed
CANDIDATE: My worry is whether this is fat embolism. I will assess nail. Dynamic or static locking.
patient’s respiratory status by getting history as to when the
breathlessness started any chest pain or palpitations. I will Case 2
examine patient for respiratory rate, air entry bilaterally, tracheal EXAMINER: This 20-year-old injured his left tibia while playing
position, Oxygen saturation, pulse rate, blood pressure, what football.
percentage of oxygen patient is on. Obtain ECG, chest radiograph, CANDIDATE: Transverse fracture of left tibia midshaft and fibula
ABG immediately. Contact medical on call team and ITU for with >50% cortical contact in both views. Angulation appears to
further medical assessment. be around 20°.
EXAMINER: Patient did have PE but recovered and was sent back to EXAMINER: How will you treat this fracture?
orthopaedic ward 4 days later. In the ward physiotherapist is CANDIDATE: If this is an isolated closed fracture with no distal
concerned that the patient is not weight-bearing due to pain and neurovascular deficits and no compartment syndrome, then,
is limping. What will you do? options of management are manipulation and above knee cast or
CANDIDATE: I will get a full length radiograph of right femur AP and locked nail fixation. I will discuss the advantages and
lateral views. disadvantages of both with patient.
EXAMINER: This is the radiograph. EXAMINER: What are the important advantages and disadvantages
CANDIDATE: Radiographs show a displaced subcapital femoral neck of both treatments?
fracture. CANDIDATE: In cast treatment there are no risks of infection or
EXAMINER: What to do now? Do you want to look at the first anaesthetic-related complications but prolonged immobilization
radiograph? of limb, frequent radiographs and mal-union are risks. In nail
CANDIDATE : Yes (after looking at the first radiograph). Even fixation, advantages include early mobilization of knee and ankle,
retrospectively looking at this radiograph I am not able to identify reduced risk of mal-union but risks include infection,
a femoral neck fracture. compartment syndrome and anterior knee pain.
EXAMINER: Yes, why is there a fracture now and what to do now? EXAMINER: Patient opts for cast treatment. What will you do?
CANDIDATE: It may have been an undisplaced fracture that CANDIDATE: If patient can tolerate it, I will reduce and apply a
has displaced on weight-bearing or iatrogenic fracture as the moulded above knee cast in plaster room under entonox. If not,
femoral nail entry point is in the piriformis fossa. Even then in theatre. Weekly radiographs for first 3–4 weeks and if
though it may be a few days since femoral neck fracture due to there is satisfactory early callus formation, I will apply patellar
patient’s age I will still try to reduce and stabilise the fracture. tendon weight-bearing cast and allow full weight-bearing. Cast
Options are: treatment will continue till there is three out of four cortical
bridging callus and there is no pain or abnormal mobility at
1. Closed reduction and screw fixation with miss a nail technique fracture site.
exchange the femoral nail for a reconstruction type nail EXAMINER: This is the radiograph at first follow-up.
2. If closed reduction fails, then, open reduction via anterolateral CANDIDATE: Radiographs show satisfactory bony contact but there
approach and fixation as above
is valgus angulation of about 20°.
EXAMINER: What will you do now?
EXAMINER: Could not do miss a nail screw fixation so I exchanged
CANDIDATE: Since it is only angulation deformity, I will wedge the
the nail (shows radiographs). What will you do?
cast laterally and get another radiograph.
CANDIDATE: I will allow toe touch weight-bearing for 6 weeks
EXAMINER: This is the radiograph after wedging.
followed by increasing weight-bearing over the next 6 weeks to
CANDIDATE: Alignment and angulation is satisfactory. So, will
full weight-bearing and obtain serial radiographs at 2, 6, 12 weeks
continue cast treatment with weekly radiographs.
and 6 monthly till 2 years follow-up looking for AVN of femoral
head and non-union of femoral neck fracture. EXAMINER: What do you mean by satisfactory alignment?
CANDIDATE: There is >50% cortical contact, angulation <10° and
no shortening. Rotational alignment has to be checked clinically.
Good points – Answered all questions directly without
beating around the bush. Candidate had practised for a EXAMINER: Yes. This is radiograph of another tibia fracture. What do
similiar viva scenario you think?
Could have done better – Looked for femoral neck fracture CANDIDATE: Locked nail fixation with satisfactory alignment but
but failed to mention that I looked for it there is minimal distraction at fracture site.
655
031
operated group, secondary surgery to remove plate and

EXAMINER: this is the clinical photograph of leg at 2 weeks post
screws
surgery.
CANDIDATE: There is external rotational deformity of the tibia.
Case 4
EXAMINER: What will you do?
CANDIDATE: I will assess the external rotation deformity and EXAMINER: This 40-year-old motor bike rider fell off the bike at 50
compare it to the opposite leg. If thigh foot angle difference is miles/hour. This is the pelvis radiograph.
>15–20° CANDIDATE: Pelvic radiograph is not adequate but from the
EXAMINER: Between two sides I will offer revision surgery after available radiograph there is pubic symphysis widening. I will
ruling out infection by examination and blood tests with FBC, ESR assess the patient according to ATLS® protocol and get an AMPLE
and CRP. history.
EXAMINER: What surgery will you do? EXAMINER: If the patient is haemodynamically unstable what will
CANDIDATE: I will remove the distal locking screws and correct the you do?
rotational alignment by rotating the distal fragment on the nail CANDIDATE: Obtain intravenous access with two large cannulae
and insert the locking screws again. and get blood samples for FBC, U&E, Grouping and cross-match
6 units urgently and infuse 2 litres of crystalloids. I will look for
Good points – Candidate had prepared for this scenario and areas where patient could be losing blood – Chest, abdomen,
had decided on what his/her cut off points would be for long bone fractures, and open injuries. Chest x-ray will show
acceptable fracture alignment and had back up plans if Plan presence of haemothorax or mediastinal injury. FAST scan will
A did not work show any free fluid in the abdomen.
EXAMINER: FAST scan shows free fluid in abdomen and surgeons
Case 3 want to take patient to theatre straight away. What will you do?
EXAMINER: A 30-year-old skate boarder fell onto left shoulder and CANDIDATE: Before they perform laparotomy I will apply an
this is the radiograph. external fixator such that it will not interfere with laparotomy
CANDIDATE: Radiographs show transverse fracture of midshaft left incision.
clavicle with shortening of about 2 cm. EXAMINER: Let’s go back to assessing patient in A&E. Patient is
EXAMINER: What will you do? haemodynamically stable. How will you assess the pelvic injury?
CANDIDATE: I will offer surgery in the form of open reduction and CANDIDATE: I will look for any areas of bruising or skin injuries,
plate fixation. perineal or urethral injuries and perform per rectal examination to
EXAMINER: Why? assess for any rectal injuries.
CANDIDATE: The shortening of clavicle leads to shortening of the EXAMINER: Will you do anything else? How will you know whether
moment arm of shoulder and hence, the strength of shoulder pelvis is stable or not?
abduction. CANDIDATE: Compression distraction test will show pelvic
EXAMINER: Do you have any evidence for this? instability but it can dislodge any pelvic clots and make patient
CANDIDATE: Yes. Paper published in . . . showed . . . haemodynamically unstable.
EXAMINER: How valid is that paper? What are its drawbacks? EXAMINER: What first-aid measures can be done for this pelvic
CANDIDATE: Err, don’t know. injury?
EXAMINER: OK. What are the indications for fixation of clavicle CANDIDATE: Pelvic binder.
fractures? EXAMINER: How will you apply the binder and what will you do after
CANDIDATE: Open fractures, polytrauma, multiple fractures in same applying the binder?
limb, neurovascular injury, shortening >2 cm, symptomatic non- CANDIDATE: Binder is applied around the greater trochanter area
union. and I will get a pelvic x-ray to check whether the pubic symphysis
EXAMINER: OK. What are the risks of plate fixation of clavicle? is reduced.
CANDIDATE: Infection, wound healing problems, vascular injury, EXAMINER: What is the definitive management of this injury?
prominent plate, numbness distal to scar, plate breakage. CANDIDATE: Definitive management of this injury is pubic
symphysis plate fixation.
Good points – Had a plan for this injury and did not beat
around the bush Good points – Candidate had good insight into immediate
Could improve – When quoting any reference, it is necessary assessment and management
to have read more than just the abstract and to be able to Could improve on – In discussing definitive management,
critically appraise the paper and give reasons as to why you CT scan should have been mentioned as it will assist in
would accept or not accept the conclusions offered. In the deciding whether posterior stabilisation is also needed
paper quoted there were high rates of complications in the or not
031
(a) (b)
(c)
Figure 28.14 (a) Open femoral shaft fracture. (b) Fracture end is delivered and debrided. (c) Photograph showing comminuted bone fragments with no
soft-tissue attachments that were removed
Further discussion – Uncontrolled haemodynamic instability

CANDIDATE: I will assess patient according to ATLS® protocol.
protocol, massive transfusion protocol, pelvic fracture
classification – Tile, Young and Burgess If patient is stable and with no other injuries, it will require
internal fixation with nail fixation.
Trauma case 5 EXAMINER: This is the clinical photo of patient’s thigh
(Figure 28.14 a–c)
EXAMINER: A 28-year-old motorcyclist travelling at about 40 miles/
CANDIDATE: It shows a possible puncture wound that is oozing
hour skidded and came off the bike. These are his right femur
blood. This is an open fracture.
radiographs.
EXAMINER: How will you grade it?
CANDIDATE: Radiographs show a distal third shaft of femur fracture
that is completely displaced. It is mainly transverse type with CANDIDATE: According to Gustilo and Anderson grading it will be III
some comminution. whether it is A or B will be decided after debridement.
EXAMINER: What will you do next? EXAMINER: How will you manage this patient?
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031
CANDIDATE: IV fluids, analgesia, IV antibiotics, splint, early EXAMINER: What do you do with the wound?
debridement of the wound and stabilising the fracture. CANDIDATE: I will leave the wound open and check the
EXAMINER: How soon will you do the surgery and what are the wound again in theatre at 48 hours. If it is clean I will close the
steps involved? wound.
CANDIDATE: BOA guidelines do not recommend the 6-hour rule
anymore. I will do surgery as soon as possible. It will involve Good points –Covered most of the aspects of open fracture
extending the wound, debriding the wound and removing any management
non-viable tissues. After changing instruments and rescrubbing Could have improved –Instead of waiting to be
I will stabilise the fracture with a femoral nail, if the wound is prompted could have explained in detail about surgical
clean. If there are any signs of contamination, I will perform management options depending on the wound
status and definitive stabilisation. Mention the
external fixation to stabilise the fracture temporarily and continue
possibility of associated femoral neck fracture
IV antibiotics.
and assessment of knee joint at the end of the
EXAMINER: Wound is clean, what type of femoral nail will you use – procedure
Reamed or undreamed, antegrade or retrograde and why? Further discussion –Type of antibiotic, length of
CANDIDATE: If wound is clean I will use a reamed antegrade nail. antibiotic cover, BOA guidelines in depth, recent advances in
Reamed nail will allow me to use a nail that is thicker and hence, open fracture assessment31, associated femoral neck
stronger. Antegrade nail to avoid involving the knee joint. fracture
References and treatment. J Bone Joint Surg Am.

2009;91:1518–30.
experience 1968–1975. Clin Orthop Rel
Res. 1979;138:94–104.
1. http://www.boa.ac.uk/publications/boa-
standards-for-trauma-boasts/#toggle- 11. Mirels H. Metastatic disease in long 19. Muller M. Allgower M, Schneider R,
id-4 bones a proposed scoring system for et al. Manual of Internal Fixation,
diagnosing impending pathologic second edn. New York: Springer-
2. http://www.boa.ac.uk/publications/vte- fractures. Clin Orthop Rel Res KW. Verlag, 1979.
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Applied trauma oral topics

Chapter
29 Jonathan R. A. Phillips, William Eardley and Paul Fearon
The trauma viva is sometimes regarded by candidates as ‘the types without ligament injury in the generality. The position of
one’ that caught them out. This really should not be the case as the leg, the direction and quantity of force and the degree of
with a bit of preparation, familiarity with the type of question knee flexion at time of injury also contributes.
asked, refining your technique and understanding general All of these factors need to be considered and the candidate
trauma principles this viva should be nailed. This chapter drills should be ready to volunteer this information early in the
down onto more specific questions that regularly pitch up in question whilst discussing the fracture. This will impress the
the viva. We begin by exploring the principles of intra- examiners and result in a smoother experience overall.
articular fracture management. (Figure 29.1 a and b)
Distal femoral fractures, tibial plateau Evaluation

fractures and pilon fractures The energy of injury will dictate the approach. A full ATLS®
workup is required for the high-energy fracture – This may be
Intra-articular lower limb fractures are grouped together to
avoid repetition. As with all intra-articular injuries, there are overkill for a fracture resulting from a stumble, however. The
examiners are looking for this distinction as it identifies the
many avenues that the examiners may take a candidate in the
strong candidate from one with a purely formulaic approach.
viva through. Applied anatomy, classification, early manage-
The skin condition should be assessed and the distal pulses
ment and fracture healing principles are all fair topics on
should be documented with a hand held Doppler. Documen-
which to concentrate. The candidate must not jump straight
tation of the integrity of the common peroneal branches and
into ‘This is a Schatzker III fracture, I would plate it’. This is
the tibial nerve in the foot is essential. Compartment syndrome
categorically not what is required. Clear descriptions, accept-
may occur and appropriate assessment for this is required.
ance of potential for other bony and soft-tissue injuries, sens-
ible early management and a sound grasp on how you wish to A high index of suspicion for meniscal and ligament injury
must be maintained. Similar points need to be addressed with
encourage this fracture to heal and how to rehabilitate your
pilon fractures also.
patient is paramount.
Following initial resuscitation and evaluation, stabilisation
The following points will assist in developing this frame-
with above knee plaster and analgesia, two plane radiographs
work, taking the tibial plateau as an example. Like many
of the joint including the full tibia and ankle are taken. A CT
fractures, it may be divided into low-energy (insufficiency)
scan is a necessity as it helps to evaluate the joint surfaces,
injuries and high-energy (traumatic) injuries. Whilst seem-
delineating the articular fracture fragments and revealing
ingly basic, this approach allows for a reasoned evaluation of
the injury in front of an examiner. occult fracture lines, unseen on plain films (Figure 29.1c–f).
This rationale should be given to the examiners, don’t just state
High-energy injuries – The young motorcyclist with a
that you would ‘get a CT’. If the skin/soft-tissue envelop is
medial tibial plateau fracture – Are a spectrum of injury
contused/bruised and swollen, the application of a spanning
intensity away from the osteoporotic elderly lady who
external fixator is highly desirable, in order to stabilise the
stumbles getting off the bus, sustaining a depressed lateral
fracture configuration, and allow the soft tissues to recover.
plateau injury.
Be prepared to talk through how you would apply a spanning
The unwary candidate will neither assess nor deal with
external fixator to the knee/ankle region. It’s only then should
these injury profiles differently. They are both fractures of
the tibial plateau, but this is the only similarity they share. a CT scan be requested for surgical planning.
The medial tibial plateau is stronger and its fracture carries
a greater association with soft-tissue injury. Young adult bone Classification
more often demonstrates a simple split with associated liga- Another favourite – The Schatzker method of classifying these
ment damage where the osteoporotic yields depressed fracture injuries must be committed to memory. Types IV–VI are
032
Chapter 29: Applied trauma oral topics
(b)
(a)
(c) (d)
Figure 29.1 AP (a) and lateral (b) radiographs of complex tibial plateau fracture in an obese middle-aged patient. (c–f) CT of knee in bone window in axial (c, d),
sagittal (e) and coronal (f) reformations. (g, h) AP (g) and lateral (h) postoperative radiographs showing dual plating of tibial plateau fracture
661
032
(e) (f)
(h)
(g)
Figure 29.1 (cont.)
032
associated with increased energy and neurovascular injury. a standard anterolateral approach allowing joint elevation,
Medial meniscal tears are most commonly seen with type IV grafting and plating (Figure 29.1 g and h).
and lateral meniscal injury with type II, the overall most The high-energy intra-articular injury may lead to a dis-
common fracture type. cussion on many aspects of trauma management. Following
I Split of the lateral plateau this theme of evaluation, stay broad and flexible in the initial
II Split and depression of the lateral plateau approach and use overall stability and the effect on the mech-
III Depression of the lateral plateau anical axis to guide your response. Remember, arthroplasty is
IV Medial plateau fracture always an option and discussing the case with a senior arthro-
plasty colleague is an appropriate management step in the
V Fracture involving both the medial and lateral plateau
elderly osteoporotic highly comminuted injury.
VI Tibial plateau fracture with an associated shaft fracture
distally – A complete metaphyseal/diaphyseal separation
Associated injury is common, especially with the high-energy Diaphyseal femoral/tibial fractures
injuries. Overall 50% of plateau fractures will have a meniscal There are no ‘easy’ questions and so beware falling into the
tear, 30% will have an associated ligament injury and up to trap of relaxing if you get shown a fractured femur or tibia.
50% of young high-energy injuries will have disruption of the This injury is a starter for a possible multitude of question
anterior cruciate ligament. directions. Fracture healing, implant selection, soft-tissue
management, compartment syndrome and late reconstruction
Management are all appropriate and are just some of the associated
topics. The candidate must stay flexible and not dive straight
The key to the treatment of intra-articular fractures, once
into addressing the fracture in isolation without listening
associated injury is ruled out, is the resultant stability of the
to the examiners and ensuring you are answering their
joint and articular alignment. Laboratory studies suggest toler-
questions.
ances of around 3 mm of articular step off in the knee but it is
the effect of articular depression and widening on stability and
the effect of fracture displacement on the mechanical axis that Initial management
matters. After detailing the salient points in the history such as the
Non-operative management may be considered for some mechanism and overall injury pattern, candidates must be able
pure depression injuries due to the likely integrity of the to provide a concise early management plan.
ligaments and also the retained cortical rim of bone to prevent Points which must be mentioned are assessment of
varus/valgus collapse. Examination under anaesthesia and long the limb from a perfusion perspective, a neurological perspec-
leg casting converted to protected mobilization in a hinged tive and a soft-tissue perspective. Instead of saying ‘I would
brace is an option for these injuries. assess the limb’ be specific as to the action you would
The more unstable fractures involving a significant joint actually take.
disruption or metaphyseal discontinuity are normally treated Circulation is addressed through seeking and documenting
operatively. The goals of surgery are anatomical restoration of pulsatile flow on hand held doppler in both the dorsalis pedis
the joint line with absolute stability, connection of the articular and posterior tibial arteries. Sensation in the named distribu-
block to the diaphysis and early mobilization. There is cited an tion of the branches of the common peroneal and tibial nerves
articular step off of 3 mm and joint widening of >5 mm and is documented. Power on an MRC scale is noted in the long toe
whist these are slightly arbitrary they represent increased extensors and flexors. Soft-tissue trauma is detailed according
instability and so may be used in the theme of this answer. to the classification of Tscherne and the 1984 modification of
The surgical approaches and technique must be learned – Be Gustillo–Anderson for closed and open fractures respectively.
able to detail in brief the approach to the knee and ankle, It is important to caveat that, whilst the latter is widely used, it
including the less well-known ones. Marks can be gained by is only intended to be used following initial surgical debride-
demonstrating awareness of the planning needed for these ment and so it is worth mentioning this if using it to answer a
cases. Review of the CT scan to enable fragment specific surgery, question.
tourniquet application, use of a radiolucent table and correct Detailing these points rapidly in the above manner demon-
positioning of the image intensifier, availability of a femoral strates experience in the structured management of lower limb
distractor, etc are points that you want to get across to the trauma. It establishes a baseline against which further clinical
examiner when detailing your operative plan. DO NOT just change can be contrasted should concern arise regarding com-
go straight for ‘I would plate this fracture’. In this illustrated partment syndrome for instance.
example there is a posterior and anterolateral fracture compon- Following assessment, the basic measures of splinting/
ent, with a medially exiting fracture line also (Figure 29.1c–f). In immobilization, elevation, prescription of analgesia and anti-
this case the patient was positioned prone initially and the biotics where appropriate and admission with serial clinical
fracture buttressed, using a posterior plate applied after a tenot- assessment for compartment syndrome completes the early
omy of the medial head of gastrocnemius. The patient then had management.
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032
Definitive management Implant selection

Following initial assessment, definitive orthopaedic manage- Having resuscitated and ensured optimum early management,
ment of the fractured long bone with consideration of the soft the question will come, ‘So what are you going to do’? Don’t
tissues can be addressed. Non-operative management is fall into the trap of ‘I’d nail it’.
acceptable in closed, low-energy, minimally displaced tibial This question requires another prompt, concise approach
fractures. Alignment of these fractures may be considered to the generic preoperative assessment of trauma patients
acceptable if there is: including full informed consent. It is not a one-line ‘implant
<5° angulation in the coronal plane of choice’ question.
<10° angulation in the sagital plane Time is short and a full preamble of preoperative work up
<15° rotation will both bore the examiners and prevent you from scoring
further marks. Again, it is useful to acknowledge a structured
<1 cm shortening
approach but choose an element in particular to focus on. If
>50% cortical apposition
the examiners don’t want this, they will simply guide you in
These figures are to guide management only. It must be
the right direction, it is better to offer knowledge than to have
remembered that sagital plane deformity is much better toler-
it drawn out of you.
ated than that in the coronal plane due to compensatory
There is no right answer when it comes to fracture fixation, it
movement of the hip and knee in the sagital plane and the
is a matter of supporting your treatment philosophy with a sound
asymmetric joint loading seen in coronal deformity.
rationale based on both experience and appropriate literature.
Non-operative management for tibial fractures consists of
Be careful, therefore, not to appear inflexible with regard to
the application of a long leg cast in the operating theatre under
implant choice. It is important to show an awareness of the
general anaesthesia in which the patient remains for 4 weeks
range of options but to quickly focus on your particular
before conversion into a patellar bearing Sarmiento cast.
management plan. This demonstrates to examiners a level of
Whilst healing times will vary, the patient must be aware that
experience and reassures them that you have more than one
splinting may need to be continued for 4–5 months before the
way of dealing with tibial fractures whilst quickly moving you
fracture healing occurs and that in the early phase, weekly
on to score points on areas where you can demonstrate your
attendance at fracture clinic is required.
knowledge. The example in Figure 29.2 a and b had marked
soft-tissue blistering and was not appropriate for plating, leav-
Operative management ing the options of external fixation or intramedullary nailing as
The majority of femoral fractures will require surgical stabil- definitive treatment. However, maintaining reduction while
isation whereas a large number of tibial fractures may be reaming and nail insertion can be problematic and technically
treated in a cast. There are a number of situations where demanding, so be prepared to explain what works best in your
operative management may be chosen. These include: Patients experience (Figure 29.2 c and d).
that have failed non-operative management, those in which the In general, an interlocked intrameduallry nail is the treatment
initial deformity exceeds accepted tolerances or where there is of choice for diaphyseal tibial fractures as compared to plating,
a same level fibula fracture, open injuries, fractures associated there is less associated disruption of the periosteal blood supply
with nerve or vessel injury, segmental fractures and fractures whilst the implant affords a load sharing capacity of relative
with compartment syndrome. stability and faster union time. Caution must prevail if the
In addition to the above, operative management of simple fracture involves the distal third of the tibia where the evidence
tibial fractures (i.e. those that may be considered for casting) for implant choice is less conclusive and is currently the subject of
has been shown to decrease time to union, to be associated a multicenter randomised controlled trial (FIXDT).
with a faster return to activities of daily living and whilst there When using an intramedullary nail for diaphyseal fracture
is an increase in superficial wound problems in this group fixation, the nature of reaming is an important point to
compared to non-operative management, there is minimal address and is an area of opportunity to demonstrate a wider
deep-tissue infection risk. knowledge base.
For unstable fractures with unacceptable alignment toler- Reaming the medullary canal enables increased contact
ances (Figure 29.2a and b) complex distal third tibia and fibula between the nail and the bone and allows for the use of implants
fracture with x-rays showing AP view of knee and lateral of of greater diameter and potentially larger locking bolts, both
ankle) comparing cast treatment to intramedullary nailing, the factors which increase stability. Biologically however, the
latter is associated with decreased time to union, decreased potential benefits of ‘reaming debris’ in an osteogenic capacity,
hospital stay, decreased time off work, lesser angular deform- whilst often cited are not proven. In addition, reaming further
ity, less shortening and less secondary procedures. There is a disrupts the internal, endosteal blood supply although this is
balance of increased knee pain in the operative group of reversible. Entry point is crucial, depending on the type of nail
around 50% of cases, which is independent of the approach (trochanteric femoral nail will have a lateral bend proximally,
used to the nail entry point. compared to the straight piriformis nail); however, examples of
032
(a)
(b)
Figures 29.2 (a, b) AP and lateral radiographs of complex distal third tibia and fibula fracture. (c, d) AP and lateral radiographs following reamed tibial IM nailing
poorly reduced fractures and complications are still frequently tibial fractures. Proximal tibial fractures when nailed have a
seen due to a lack of understanding of the implants being used. tendency to go into procurvatum and valgus and their distal
In order to address the question of reaming in tibial shaft counterpart into varus and recurvatum. An awareness of this is
fractures and of use for answering questions, candidates are essential and may be addressed with correct entry site position
advised to be aware of the Study to Prospectively Evaluate (more lateral and posterior in proximal fractures), the use of
Reamed Intramedullary Nails in Patients with Tibial Fractures blocking screws, unicortical plates or percutaneous clamp
(SPRINT) trial. To summarize, this large, multicentred study application to maintain reduction.
demonstrated that there was, in closed tibial fractures a pos-
sible benefit for reamed intramedullary nailing when end-
points of late surgical intervention or autodynamisation are Calcaneal fractures
used. No benefit is seen with open fractures. From the history assimilate whether low or high-energy injury,
In addition to reaming, the particular behaviour of both age, co-morbidity (diabetic, pelvic disease (PVD)).
proximal and distal shaft fractures when treated with intrame- Fall from height (scaffolding, ladder, wall) or road traffic
dullary nailing is worth mentioning in questions relating to accident (RTA).
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032
(c) (d)
12pt
Figures 29.2 (cont.)
Associated injuries – Tibial plateau, tibial plafond, lumbar Gissane’s angle is formed by the intersection of two lines-
spine, acetabulum and contralateral os calcis. the first along the downward slope of the posterior facet
Following appropriate emergency care treatment and and the second running upwards towards the beak of the
resuscitation according to ATLS® protocols, I would take a talus. Normal value is 95–105°, an increase in value
relevant history asking about . . . suggests collapse weight-bearing posterior facet
I would start by assessing the patient as a whole following Be able to discuss primary and secondary fracture lines
ATLS® protocolab. Associated injuries may include . . . Know the Saunder’s classification
‘Examination of the foot would include neurovascular status, any Non-operative care includes elevation, application of ice, early
evidence of compartment syndrome in particular I would look for . . .’ mobilization, and the use of a splint.
‘My initial management of this fracture would be . . . I would
Know some technical details about surgeryc.
arrange urgent admission for elevation and more formal
Complications of conservative management include post-
assessment of the fracture with an urgent CT scan.’
traumatic osteoarthritis (OA), peroneal tendinitis.
Be able to describe radiographs and CT scan. Complications of surgery include infection, skin necrosis
Bohler’s angle is the angle between two lines joining the and breakdown, non-union/mal-union.
anterior process-posterior facet and superior There is a considerable controversy about the role of sur-
tuberosity-posterior facet. This should be between 20° and gery. Grifin et al. reported the results of a pragmatic multi-
40°, decreased or even reversed with severe fractures centre randomised control trial comparing operative vs non-
operative treatment of displaced intra-articular calcaneal frac-
a
tures1. They concluded that no symptomatic or functional
This is an appropriate general statement that can equally be applied advantage existed with surgery at 2 years with the risks of
to a number of different fractures.
b complications higher following surgery. They did not
If the examiners have already told you it is an isolated closed injury
and you come out with this statement, at best you come across as
c
not listening to what is being said and, at worst, just tactically See minute 3, Chapter 8, Lower limb trauma, p. 116, Postgraduate
limited in your ability to pick up clues. Orthopaedics. Viva guide.
032
recommend ORIF of these fractures. They excluded open

fractures and grossly displaced fractures. CANDIDATE: These are AP and 30° oblique radiographs of the
In 2002 Buckley et al. published a prospective, randomised left foot.
multicenter study involving 424 patients. They concluded that there On the AP view:
was no overall benefit from surgery on the basis of two principle There is diastasis of >2 mm between the base of the first and
outcome measures: The visual analog pain scale and the SF-36. second metatarsals, features suggestive of Lisfranc
However, stratification of the patient population distinguished tarsometatarsal fracture dislocation
certain features favouring surgery: Patients who were younger There is a small avulsed fragment of bone in the Lisfranc space.
(<29 years), female, had a light or moderate workload involving This avulsion fracture is from the insertion of the Lisfranc
the foot, those who were not receiving Workers’ Compensation. ligament into the base of the second metatarsal-the ‘fleck sign’
The best patients to treat non-operatively are those who are Medial border of the second metatarsal should be collinear/
50 years or more, males, those who are receiving Workers’ Com- perfectly aligned with the medial border of the middle/
pensation and have an occupation involving a heavy workload. intermediate cuneiform
There are some methodological criticisms of this study The space between the first and second metatarsals bases
including the fact that one surgeon performed the majority should be equal to the space between the medial and
of operations (73%) and concerns with selection bias with the intermediate cuneiforms2,f
study using a pre-randomised strategy.
On the 30° oblique radiograph in normal radiographs:
Agren et al. published a randomised control trial from five
Medial border of the fourth metatarsal should also be in line
centres in Sweden. Outcome measures were similar to the
(collinear) with the medial border of the cuboidg
Buckley paper. Eighty-two patients were randomised to open
The medial and lateral borders of the third metatarsal are
reduction with internal fixation (ORIF) or non-operative care.
perfectly aligned with the medial and lateral borders of the
At 1 year there was no difference between the 2 groups.
lateral cuniform
A recent Cochrane review concluded that there was insufficient
There is a compression fracture of the cuboid which supports
high quality evidence to establish whether surgical or conser-
the diagnosis of a Lisfranc injuryh
vative treatment was better for adults with displaced intra-
Timpone described the ‘intermetatarsal fat pad sign’ on plain
articular calcaneal fractures, and called for an adequately
radiographs between the first and second metatarsals from
powered, multicentre controlled trial.
oedema and hemorrhage from a Lisfranc ligamentous injury. This
In summary, recent evidence-based studies suggest the
is similar to the sail sign of the olecranon
results of operative intervention may be ineffective and, there-
fore, any patient with a significant risk of developing post- ‘I would like to see a lateral radiograph to check for dorsal
operative complications may be best managed conservatively. displacement of the lateral metatarsals which would suggest
ligamentous injury’
Lisfranc injuries (Always ask for the lateral radiograph.)
These are rare injuries but a common topic for the trauma (Minute 2)
viva. Diagnosis and principles of treatment are important.
EXAMINER: What is the Lisfranc joint?
CANDIDATE: This consists of three cuneiform and two metatarsal
Examination corner
articulations. Joint stability is provided by strong ligaments and
Trauma oral 1 the recessing of the second metatarsal head.
EXAMINER: This is an AP radiograph of a cyclist who caught his foot EXAMINER: What is the Lisfranc ligament?
in a toe strap and presents to casualty with forefoot paind. You are CANDIDATE: The Lisfranc ligament runs obliquely from the plantar
called down to see him. aspect of the base of the second metatarsal to the plantar surface
What do you think of the x-ray? of the medial cuneiform.
What do you look for on a plain film? EXAMINER: How will you manage this patient?
(Minute 1e)
f
This is getting into small detail.The examiners may move you along
from this as they want to get to how you will manage the injury.
d
The clue that this may be a Lisfranc injury is contained in the However, it is part of the specifics of diagnosing the injury
mechanism of injury.There is a twisting injury with forced radiographically.
g
abduction on the forefoot on the tarsus. Added for completeness. This radiographic feature is not always
e
In the lower limb trauma section of the viva book each question was mentioned in textbooks.
h
treated as a chess game lasting 5 minutes and we have kept this The examiners may move you along from this as they want to get to
format in this question. Some candidates found this different how you will manage the injury. However, it is part of the specifics
approach both useful and tactically challenging. of diagnosing the injury radiographically.
667
032
Total incongruity (type A)

CANDIDATE: Following appropriate emergency care and
A – In any plane or direction
resuscitation according to ATLS® protocols and assuming that
Partial incongruity (type B)
this injury is both isolated and closed I would take relevant
B1 – Medial (only the first ray is involved)
history: Mechanism of injury, patient’s general condition, past
B2 – Lateral (one or more of the lateral rays) with the first
medical history, allergies, smoking as well as occupation and
metatarsal unaffected
previous level of activity.
Divergent displacement (type C)
Examination of the injured foot:
C1 – Partial divergent (incongruence). The first metatarsal
Soft-tissue status, swelling, pain, tenderness and ecchymosis displaced medially and a portion of the lateral complex
Painful passive abduction/pronation displaced laterally in the sagittal and/or transverse planes
Neurovascular status, dorsalis pedis and posterior C2 – Total divergent
tibial pulse
Tendon entrapment may be demonstrated with an altered, EXAMINER: What is the mechanism of injury?
uncorrectable position of the toes or midfoot CANDIDATE: These injuries are most commonly high-energy
Compartment syndrome must be excluded injuries, but some can occur from low-energy twisting injuries.
Following assessment, my initial management includes Mechanism can be categorized as direct or indirect:
analgesia, elevation and splinting using a below-knee backslab. Direct – Crushing injury. Associated with soft-tissue injury and
On admission to hospital I would arrange for regular clinical compartment syndrome (foot run over by a car)
examinations and monitoring in order not to miss an early Indirect – Axial loading of a plantar flexed foot or severe
developing compartment syndrome. abduction, leading to dorsal ligamentous disruption. This
EXAMINER: What would you do if the radiographs were inconclusive typically occurs with falling on the heel of a plantar flexed foot,
in diagnosing this condition? missing a step off a curb, falling off a horse with the foot in the
CANDIDATE: I would consider further radiographic imaging, a lateral stirrup
view, stress views and a CT scan or may opt for an MRI scan.
EXAMINER: How do you treat Lisfranc tarsometatarsal fracture
EXAMINER: What is it – An MRI or CT scan?
dislocation?
CANDIDATE: An MRI allows direct visualisation of integrity of the
CANDIDATE: This depends on severity of injury and degree of
Lisfranc ligament and surrounding soft-tissue structures. It is
displacement of fracture. There is a role for non-operative
especially useful in low velocity injuries and in the setting of
management of an undisplaced stable injury or sprain that
equivocal radiographic studies
includes a non-weight-bearing cast for 6 weeks and regular
A CT scan is more useful in high velocity injuries as it assesses
clinical and radiological review. However, in the presence of
degree of fracture comminution.
subluxation or dislocation, then accurate reduction and stable
(Minute 3) fixation is essential. In this case, I would consider open reduction
EXAMINER: How do you classify Lisfranc injuryi? and internal fixation with screws and possible plating, as required.
CANDIDATE: Quenu and Kuss were the first to classify Lisfranc Position is supine. Knee flexion allows plantarflexion of the foot
injuries (1909). They divided injuries into: for easier exposure and imaging. I would use two longitudinal
dorsal incisions; one centered over the first web space and the
Homolateral: All five metatarsals displaced in the same
other the fourth metatarsal. The skin bridge should be as wide as
direction
possible and the incisions should not be undermined. The key to
Isolated: One or two metatarsals displaced from the others
success is to achieve initial reduction of the second metatarsal
Divergent: Displacement of the metatarsals in both the
into its mortice between the 3 cuniforms. The other joints can
sagittal and coronal planes
then be reduced around it. Temporary stabilisation can be
This classification was modified by Hardcastle (1979) by
achieved with K-wires.
dividing injuries into three categories: A, B and C. Type
There has been a trend in recent years to be more
A injuries were complete displacement of all metatarsals
aggressive in the management of this injury using compact
(total incongruity) in the sagittal or transverse plane). Type
foot plates or bridging plates instead of screw fixation.
B injuries were partially incongruous and type C injuries were
A bridging plate avoids articular cartilage damage with no
divergent.
loss of rigidity. This is especially helpful with a severely
Myerson (1986) revised the classification dividing B and
comminuted fracture/dislocation in which screw fixation is not
C injuries into subtypes 1 and 2.
possible. They can be used on the first, second and third
metatarsals.
With a severely comminuted fracture or a late presentation
i
There has been a move away from rote-learning classification (8–12 weeks), then primary arthrodesis of tarsometatarsal joints
systems to concentrate more on evidence-based management.
032
may be required. Joint preparation is by standard methods and procedure. In the past arthrodesis has been reserved as a salvage
bone graft is often required. procedure after failed ORIF, for a delayed or missed diagnosis and
Informed consent should be taken. The management options, for severely comminuted intra-articular fractures of the TMT
postoperative rehabilitation, outcome and potential joints.
complications should be discussed in detail with the patient and However, in the more recent literature, a strong indication for
documented in medical records. primary arthrodesis of the TMT joints has been discussed often for
EXAMINER: What are the complications from treatment? purely ligamentous injuries. Such injuries are less likely to stabilise
CANDIDATE: following fixation and may go on to develop degenerative
Post-traumatic osteoarthritis changes.
Compartment syndrome Ly and Coetzee have described their selective indications for
Infection primary fusion of Lisfranc joints3. They perform primary fusion
CRPS with:
Neurovascular injury Major ligamentous disruption and multidirectional instability
Metalwork breakage/migration Comminuted intra-articular fractures at the base of the first
and second metatarsal
(Minute 4) Crush injuries of the midfoot with an intra-articular fracture–
dislocation
EXAMINER: What prognosis will you give this patient?
Contraindications are:
CANDIDATE: This is a serious injury with potentially a poor outcome.
Lisfranc injuries in children with open physis
Residual pain and a stiff foot are not uncommon complications of
Subtle Lisfranc injuries with minimal or no displacement
this injury. Post-traumatic osteoarthritis is related to the initial
Unidirectional Lisfranc instability
injury and adequacy of reduction. It may occur in >50% of cases,
Unstable extra-articular fractures of the metatarsal bases with
even if well-fixed operatively
unknown amounts of ligamentous injury
Patients must be informed about the length of treatment,
Henning et al.4 reported a random control trial in
recovery period and future implications for work and lifestyle.
31 patients comparing primary fusion with ORIF in a wider
About 10–20% of patients will develop symptomatic arthritis
range of injuries including fracture–dislocations, although
requiring arthrodesis despite ORIF.
‘major intra-articular fracture patterns’ were excluded. Fourth and
(Minute 5) fifth TMTJs were stabilised with wires. The trial was
EXAMINER: If this patient developed compartment syndrome, then underpowered due to problems with recruitment. There was a
how would you manage it? trend towards better Short Musculoskeletal Functional Analysis
CANDIDATE: Once compartment syndrome has been diagnosed scores in the fusion group but no difference in SF-36 scores,
clinically, emergency decompression is required. Theatre staff and complications and pain or return to work or to wearing normal
anaesthetic on call team should be informed, informed consent shoes.
must be obtained. I will take patient to theatre as soon as it is safe
to do that. There is more than 1 technique described to EXAMINER: Any new methods of fixation?
decompress compartment syndrome of the foot, but I have been CANDIDATE: Several recent papers have reported the use of
trained to decompress the nine compartments of the foot suture button fixation in the hope of allowing some
through three incisions, two dorsal over the second and third physiological motion and to avoid putting screws across the
metatarsals and one on the medial side, just under the medial articular cartilage of the first cuneiform and the second
border of the first metatarsal. The patient will need to go back to metatarsal. Ahmed et al.5 did a cadaveric study that showed more
theatre to have the wounds closed, once the soft-tissue swelling displacement with suture button fixation of isolated Lisfranc
has gone down. ligament injuries in cadaver specimens, which was in
EXAMINER: What is the natural history of an untreated Lisfranc contradiction to the study by Panchbhavi et al.6 that showed
injury? equivalence. A clinical trial would be useful to compare the two
CANDIDATE: The long-term consequences of the untreated injury methods of treatment.
are the development of post-traumatic TMT arthritis. This may EXAMINER: Should the fusion be complete or partial?
lead to the need for midfoot arthrodesis. Progressive deformity is CANDIDATE: The literature suggests partial fusion of the medial
also a problem with midfoot collapse, forefoot abduction and column has a better outcome than complete fusion. Mulier et al.7
development of a rocker bottom foot. compared ORIF of severe Lisfranc injuries (16 patients) with
EXAMINER: What is the role of primary arthrodesis? partial (5) and complete (6) arhrodesis. At the 30-month follow-up
CANDIDATE: It is controversial as to whether the Lisfranc joint period, patients who underwent fusion had more pain than the
complex should be fused primary or strictly reserved for a salvage
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inability to weight bear in his right foot. This is an isolated injury; he has
ORIF and partial arthrodesis group. Complete fusion causes
no other injuries of notej.
stiffness of the relatively mobile lateral column.
How would you proceed?
Primary partial arthrodesis should be considered in patients
CANDIDATE: I would order an x-ray.
with either severely comminuted injuries or significantly
COMMENT: Gaff 1. This is the wrong thing to start with in this particular
displaced purely ligamentous injuries.
scenario. At the very least the candidate should have mentioned
examining the foot to exclude a fracture/dislocation and to check for any
compartment syndrome or developing compartment syndrome
EXAMINER: Hold on is that the first thing you would do? Would you not
Classic reference want to take a history first and examine the patient?
Ly, TV, Coetzee, JC. Treatment of primarily ligamentous CANDIDATE: (Silence)
Lisfranc joint injuries: Primary arthrodesis compared EXAMINER: Here are the radiographs.
with open reduction and internal fixation. CANDIDATE: This shows an abnormal area around here. (Candidate
A prospective, randomised study. J Bone Joint Surg Am. pointing to x-ray.)
1996;88:514–20. COMMENT: Gaff 2. The candidate was unable to describe the radiographs
Department of Orthopaedic Surgery, University of Minnesota correctly.
Level 1 evidence The radiograph was an anteroposterior (AP) weight-bearing
Prospective randomised control trial of 41 patients with an isolated radiograph of the left foot. This would have been the first thing to have
acute or subacute purely ligamentous injury only
mentioned. The abnormality on the radiograph was identified but the
Twenty patients were treated with ORIF and 21 patients with primary Lisfranc injury couldn’t be accurately described.
arthrodesis of the medial 2 or 3 rays. At 2 years after surgery the The candidate didn’t mention obtaining a lateral non-weight-bearing
American Orthopaedic Foot and Ankle Society midfoot score was 68.6
radiograph. This radiograph may have shown dorsal displacement of the
in the ORIF group and 88 points in the arthrodesis group.
Of the 20 patients in the ORIF group, 16 underwent a secondary proximal base of the second metatarsal. The step-off point is where the
surgery to remove prominent or painful hardware. Follow-up dorsal surface of the second metatarsal is higher than the dorsal surface of
radiographs showed evidence of loss of correction, increasing the middle cuneiform.
deformity and degenerative joint disease in 15 patients. EXAMINER: What is the injury?
The study concluded that primary stable arthrodesis of the Lisfranc
joint complex had a better short-term and medium-term outcome CANDIDATE: (Long pause and then recovery) This is a Lisfranc injury of
than ORIF. the foot.
EXAMINER: The patient was taken to theatre and the injury fixed. These
radiographs are shown to you the next day on the ward round. What do
you think about the fixation?
Classic reference
A radiograph of a poor k-wire fixation of this injury was
Kuo RS, Tejwani NC, Digiovanni CW, Holt SK, Benirschke SK,
Hansen ST, Sangeorzan outcome after open reduction and
shown without proper reduction of the Lisfranc dislocation
internal fixation of Lisfranc joint injuries. J Bone Joint Surg and the candidate asked to comment. The candidate correctly
Am. 2000;82A:1609–18. identified the poor fixation and volunteered that it needed re-
fixation.
Harborview Medical Center, Seattle, Washington
Level IV evidence
A discussion then took place about exactly what was meant
by the Lisfranc ligament and joint.
This paper was a retrospective review of 48 patients with both This was answered extremely well by the candidate.
ligamentous and combined ligamentous and oosseous injuries that
A radiograph was shown of the re-fixed injury and the
were followed for outcomes for an average of 52 months. Results
showed that stable anatomical reduction of the fracture dislocation candidate asked to comment. A discussion of the current
leads to the best long-term outcomes. Theses patients were shown to treatment recommendations in the literature then took place.
have less arthritis and better American Orthopaedic Foot and Ankle In recent years there has been a move towards more aggressive
Society ankle–hindfoot scores. fixation of this injury with plates rather than just using K-wires
and screws.
Candidate debrief
Trauma oral 2 The candidate never got past a 6 because of the 2 big gaffs at
the beginning.
Lisfranc injury
EXAMINER: You have been called to see a 21-year-old male who has fallen j
Indirectly hinting to the candidate not to jump straight into a talk
10 feet onto his right foot. He is complaining of pain, swelling and about ATLS® management.
032
Figure 29.4 Dynamic

compression-sliding hip
screw. Functional loading
of a sliding hip screw
causes dynamic
compression at the
fracture site. With
functional loading, the
screw slides through the
barrel of the side plate,
allowing the fracture to
impact or compress
shaft to slide through the barrel, resulting in impaction of the

fracture surfaces and a stable load-sharing construct.
There are two important biomechanical principles that
must be respected when using a hip screw:
Figure 29.3 Photograph of DHS and IMHS. Lead in prop to discuss the 1. Fracture compression can occur only if the lag screw and
biomechanics of both fixation devices
barrel are inserted across the fracture site. This occurs with
intertrochanteric fractures but when used to fix a high
The candidate did, however, recover very well, identifying a subtrochanteric fracture, the lag screw and barrel are
poorly fixed fracture requiring re-do surgery and knowing the located exclusively in the proximal fragment and do not
latest literature on fixation strategies. cross the fracture site. In these circumstances, the lag screw
Overall, a patchy performance with some very good acts only as a fixation device and does not contribute to
answers later on, which saved the day for the candidate as fracture compression by sliding
the viva was passed, but the overall performance was a bare 6. 2. The lag screw must slide far enough through the barrel to
Without this poor start the candidate would have definitely allow the fracture gap to close sufficiently for the proximal
scored a 7. The examiners gave the candidate an opportunity and distal fragments to impact completely
to recover The dynamic compression hip screw has several modes of
failure, the most common being varus cut out of the lag screw
Trauma oral 1: Biomechanics of the intramedullary from the femoral head, collapse resulting from excessive
medial displacement of the femoral shaft and bone erosion in
hip screw (IMHS) and dynamic hip screw (DHS) the femoral head.
This may be asked in the trauma viva, less likely a basic science Biomechanically the IMHS offers four main advantages
question. over DHS fixation: (1) Load-sharing device rather than load
A dynamic compression hip screw uses the principle of bearing (DHS); (2) decreased implant bending strain because
dynamic compression that modifies functional physiologic the shaft fixation is moved from the lateral cortex to the
forces into compression at the fracture site. The implant consists intramedullary canal, decreasing the lever arm on the implant;
of two major parts: A wide-diameter cannulated lag screw which (3) the device acts as a robust intramedullary buttress, limiting
is inserted into the femoral head and a side plate with a barrel at excessive shaft medialisation in unstable and reverse oblique
a set angle which is attached to the femoral shaft (Figure 29.3). fractures; (4) it can allow impaction/collapse along the axis of
Weight-bearing and abductor muscle activity cause the screw the shaft (Figure 29.4).
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Figure 29.5 AP pelvic radiograph of subtrochanteric fracture Figure 29.6 AP pelvic radiograph of broken IMHS
Randomised prospective studies for routine intertrochan- CANDIDATE: A more rigid, larger implant that minimizes motion at
teric fractures with an intact lateral buttress show no difference the subtrochanteric region and minimizes stress risers may lesson the
in operating time, complication rate, blood loss, hospital stay, risk of implant failure and aid subtrochanteric fracture-healing. If the
time to ambulation or patient satisfaction. patient is on biphosphonates this should be stopped until the fracture has
However, several randomised prospective studies have healed.
reported improved results using IMHS with unstable fracture COMMENT: The candidate could have mentioned smoking, alcohol and
patterns including reverse obliquity intertrochanteric frac- poor nutrition as possible causative factors for the non-union developing.
tures, fractures with posterior and medial comminution, and The easiest option would be to go through the possible local, general and
fractures with extension into the femoral neck or subtrochan- fixation factors which influence fracture union.
teric region.
EXAMINER: What causes the fatigue fracture?
CANDIDATE: Fatigue fracture of the nail starts at the aperture of the lag
Trauma oral 2 screw. It is the location of the highest von Mises stress, which is the failure
EXAMINER: This is a AP pelvic radiograph of a 83-year-old female who criterion for ductile materials. A possible reason could be eccentric
sustained a subtrochanteric fracture of her left femur (Figure 29.5) insertion of the lag screw causing a localized defect in the material which
managed with IMHS which has failed (Figure 29.6). What are your acts as a stress riser.
thoughts? COMMENT: The examiner is steering the topic back to applied biomechanics
CANDIDATE: Do we have an immediate postoperative radiograph? rather than clinical.
EXAMINER: No. These are the only radiographs we have. EXAMINER: How would you manage this fracture now?
CANDIDATE: The IMHS has failed. It has fractured by metal fatigue CANDIDATE: Re-nailing with a long IMHS and bone grafting to the non-
cracking. The fatigue cracking has propagated to an extent that the union site is an option, but there could be a high chance of failure and
remaining cross-sectional area of the nail could not bear the imposed I would prefer to avoid this option. This method has failed once and may
patient loading, leading to overload fracture. Fatigue cracking is caused by easily fail again. (Figure 27.7a and b.) I would prefer to use compression
the nail bearing cyclic (i.e. repeated) stresses in excess of the material plating with use of a fixed-angle device along with protected weight-
endurance limit for an extended period of time. These excessive cyclic bearing postoperatively.
stresses may be caused by any number of conditions, including but not
limited to excessive patient activity levels prior to full bone union, poor Further lower limb topics candidates should explore for the
bone quality, excessive patient weight and chronic non-union or mal- viva would include:
union of the bone fracture. Periprosthetic fracture: Hip/knee
8
EXAMINER: What do you think has happened here? Unified Classification System – The next stages of
CANDIDATE: It is difficult to say entirely but it looks as though the fracture Vancouver classification
wasn’t fully reduced before the nail was inserted and this can predispose Intracapsular hip fracture – Young and old – THA debate –
to non-union and nail breakage. NICE Guidelines. Extracapsular hip fracture : A2 fractures –
EXAMINER: How do you prevent nail failure occurring? DHS vs nail, etc. Bisphosphonate fractures
032
(a)
(b)
Figure 29.7 (a, b) Photographs of retrieved broken IMHS
Femoral nailings set up and complications – Medial wall Tendon injuries – Ligamentum patella, quadriceps, acute
blow out with incorrect entry point. Freehand vs injuries and delayed presentations
traction table
Combined intra-capsular hip fracture and associated
diaphyseal fracture Adult upper limb
Rotational profile assessment of long bone fractures Anterior shoulder instability
Management of delayed union – Exchange nailing/rule out A common trauma scenario, dislocation of the glenohumeral
infection/grafting joint may function as a case from which examiners may choose
Femoral head fracture/native hip dislocation management to explore assessment, management, applied anatomy and
P&A – Pelvic fracture – Building on above – Resuscitation rehabilitation domains of trauma care.
and evaluation/classification/haemodynamic and The humeral head, spherical in nature, is retroverted
mechanical instability. Approaches, e.g. posterior approach, around 30° from the transepicondylar axis of the distal
sciatic nerve assessment humerus with the articular surface inclined 130° from the
Talk me through surgical hip dislocation, for Pipkin shaft. This angulation is additive to the 30° that the scapula
management!! sits anterior to the coronal plane on the chest wall. These
Floating knee/knee dislocation: Revascularization/ features contribute to the large freedom of movement around
reperfusion/stabilisation/fasciotomy. Pin positions – To the joint and also in its stability.
allow for plating with X-fix still in situ When discussing anterior shoulder instability, a simple way
Pilon fracture: Staged management – Span scan plan, etc. of answering questions is to breakdown the restraints to dis-
Approaches. Fixation options location into static and dynamic elements.
Static restraints of the glenohumeral joint:
Syndesmosis injuries and late presentation
1. Joint capsule
Talus fracture : Recognition/surgical anatomy/phased 2. Negative intra-articular pressure
management/complications and follow up.
3. Articular congruity and joint version
Compartment syndrome of foot 4. Glenoid labrum
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5. The glenohumeral ligaments Whilst in reality these are often done before orthopaedic
Of these structures, the glenoid labrum and the glenohumeral referral is sought, it should be emphasized that a dedicated
ligaments are key to static control of the joint. In particular the AP view of the glenohumeral joint and an axillary lateral are
capsuloligamentous condensation of the anterior band of the the minimum acceptable radiographs to allow evaluation of
inferior glenohumeral ligament (IGHL) affords static control the joint. Single image radiographs, which include the hemi-
of the joint in its most exposed position, that of maximal thorax and neck with the glenohumeral joint on the periphery
external rotation with 90° abduction. Rupture of this ligament often partly obscured, are not acceptable as posterior disloca-
along with the anterior labrum where it anchors produces the tions may be missed.
pathognomic Bankart lesion. There are many methods available to reduce a dislocated
Dynamic restraints of the glenohumeral joint: shoulder and can be accessed elsewhere. What is of most
1. Rotator cuff muscles importance is that with any fracture dislocation of the
2. Biceps brachii humerus, a low threshold for controlled reduction under
3. Deltoid imaging and general anaesthesia is advised to prevent propa-
gation of fracture and conversion to a surgical neck extension.
4. The periscapular muscles
This last point is of greatest worth and should be emphasized
Providing dynamic control of humeral head dislocation, the
in the exam.
rotator cuff musculature centres and compresses the humeral
With regards immobilization, there is no evidence for
head against the glenoid. Both the rotator cuff and the peri-
immobilization further than 1 week from injury and so a
scapular muscles which position the scapula and orientate the
simple sling and 1-week fracture clinic or subspecialist shoul-
glenohumeral joint in addition to affording restraint, are cru-
der assessment clinic is satisfactory. Bracing in external rota-
cial in the rehabilitation from shoulder injury and must feature
tion has been demonstrated in some series to reduce
in any answer dealing with the rehabilitation of a patient with a
recurrence but these results are not reproducible and compli-
dislocated shoulder.
ance is a real issue.
The main indicators of recurrence are: Young age, high-
Classification of shoulder dislocation
energy injury, glenoid bone loss, an engaging Hill–Sachs lesion
It is worth remembering that classification of an injury should and non-compliance with rehabilitation.
guide its management. Classification systems have been The ‘ideal’ patient for operative management is the young
applied to shoulder instability but they do not fully address (<25 years), high demand primary dislocator with an acute
the large spectrum of conditions that can masquerade as anter- traumatic injury with no associated bone loss, such as a soldier
ior instability. injured playing rugby. For these individuals, following a
The key to classifying or ordering ones thoughts when period of ‘pre’rehabilitation, arthroscopic stabilisation with
assessing instability is to fully appreciate a few significant factors: biodegradable anchors has been shown to have a similar recur-
Patient age, index event or recurrent, frequency if recurrent, the rence and re-operation rate to open anterior capsulolabral
degree of instability (dislocation vs subjective subluxation), asso- reconstruction but with less pain and greater range of
ciated trauma, the direction and volition. In particular, age is movement.
important for two reasons. Firstly, recurrence rate of dislocation Success of surgery diminishes in the presence of general-
following index traumatic injury is greatest in the teenager and ized laxity (as assessed by the Beighton score9), multidirec-
young adult. Secondly, and often under appreciated, there is a tional instability and abnormal glenoid morphology through
significant correlation between increasing age and associated bone loss.
rotator cuff tear with index traumatic dislocation. In patients with glenoid bone loss, a large engaging Hill–
These features are important in assessing instability and Sachs lesion or humeral avulsion of the glenohumeral ligament
will inform management. In essence, unilateral, unidirectional open reconstruction and augmentation where appropriate
traumatic dislocations, particularly in the young often require with a Laterjet type procedure is recommended.
surgery. By contrast, atraumatic, multidirectional, bilateral
and/or volitional instability requires rotator cuff and periscap-
ular musculature rehabilitation. This concept is delivered in Fractures of the clavicle
the Stanmore classification as: As with the humeral shaft, the management of the vast major-
Traumatic structural (the young sportsman with an IGHL ity of clavicle factures is no different in the viva table than it is
lesion and Bankart lesion), atraumatic structural (due to in a busy fracture clinic setting. Non-operative management is
abnormal static restraint) and habitual non-structural (muscle the baseline with variance from this acceptable within certain
patterning abnormality). circumstances although indications for operative management
remain surgeon specific and open to some debate. These vari-
Management of glenohumeral joint dislocation ations which attract debate affect the minority of cases but can
Following initial global assessment of the limb, including axil- derail the examination candidate. An appreciation of the evi-
lary nerve sensation, adequate radiographs should be obtained. dence is key here.
032
Again as with the humerus, disruption of anatomical bal- Having covered the basics, the question of management
ance seen subsequent to clavicle fracture is a good basis on of clavicle fracture may arise and with particular reference
which to build an argument for the management of clavicular to recent literature regarding middle third (Group I)
injury. The sternocleidomastoid causes elevation of the medial fractures. Much debate arose on publication of the Canadian
fragment upon fracture, in contrast to the relative depression Orthopaedic Trauma Society multicentre, randomised trial of
of the lateral fragment consequent to the static control of the non-operative treatment compared with plate fixation of dis-
coracoclavicular and coracoacomial ligaments and the effect of placed midshaft clavicular fractures12. One hundred and thirty
the weight of the arm. two patients with a displaced midshaft fracture of the clavicle
The clavicle is unique in its osteology. It is the first bone to were randomised and significant improvements in time to
ossify and its medial physis is the last in the body to fuse, often union, mal-union and function were reported in the
as late as the third decade. Its morphology is also characteristic operative group.
and contributes to injury patterns and fixation strategy. It has a There is no question that operative intervention reduces
double curve in the coronal plane with its medial two thirds non-union rate and this has been shown in other studies. What
convex and its lateral third concave. The junction between is in question is true improvement in overall function and this
these curves is a weak point and is commonly where fracture is at the cost of complications such as hardware removal and
occurs. infection. Increasingly important, the cost of routine fixation
Fractures of the clavicle are often classified according to the of middle third clavicle fractures is considerable, and you need
location of the fracture within this coronal plane as involving to be able to justify your management option.
the medial third, the middle third or the lateral third. Distri- More recently and perhaps to strengthen the argument for
bution of fracture is roughly 80% involving the middle third, initial non-operative management, evidence has been shown to
19% the lateral third and only 1% of fractures are seen in the recommend delayed intervention when required for midshaft
medial third of the bone. Although the majority of fractures fractures. Potter et al.13 report similar outcomes in patients
involve the middle third, these afford less complication to undergoing operative intervention acutely and in those having
surgeon or patient. Due to the energy required to fracture a delayed fixation for symptomatic non-union.
the medial clavicle with its strong ligamentous attachment to It can be seen, therefore, that there are gains to be made
the sternum, it has a higher association with underlying injury from fixation although it would seem that accepting that the
and is less benign than fractures of the middle third. Similarly, vast majority of midshaft fractures heal with little concern, a
fractures of the lateral third may be problematic, not with great delayed intervention strategy may be a sound approach. With
vessel injury or organ damage as seen medially but in non- regard to the lateral clavicle, it is accepted that a higher non-
union. The non-union rate of lateral clavicle fractures is union rates area is associated with these injuries and operative
around 10% but it is important to note that only a small management for type 2 and type 5 fractures may be con-
number of these patients come to require intervention. sidered. Operative intervention, however, is associated with a
Allman10 classified clavicle fractures according to location risk of hardware failure and this must be balanced in the
with group I representing middle third fractures, group II decision making.
lateral third fractures and group III representing fractures of
the medial third. Subsequently, due to the range of fracture
patterns seen and the impact of exact fracture location on Humeral diaphyseal fracture
outcome; the Group II or lateral fractures have been further There are three main aspects to questions involving the non-
subdivided by Craig 11: articular element of the humerus. Firstly, fracture management
Group II type: with regard to tolerances of non-operative intervention and in
1. Minimal displacement – An interligamentous fracture, not the context of special circumstances, such as multiple injuries,
involving the acromioclavicular joint, occurring between open fractures, pathological fractures, etc. Secondly, the
the coracoclavicular and acromioclavicular ligaments applied anatomy of the humerus with regard to its behaviour
2. Injury medial to the coracoclavicular ligaments. Further once fractured. Lastly, and most likely to be enquired about
subdivided as group II type 2 (a) conoid and trapezoid with any case involving humeral shaft injury – The impact of
attached and group II type 2 (b) conoid torn trapezoid radial nerve palsy either associated with the primary trauma or
intact following manipulation or fixation.
3. Involvement of the AC joint articulation A clear and reasoned approach to all elements of this
fracture will result in a satisfactory and comfortable viva
4. Periosteal (paediatric) fractures
performance.
5. Comminuted fractures with neither ligament attached
Overall tolerances of non-operative management may be
A grasp of the relevant anatomy and its relationship to injury simplified as <3 cm shortening or <30° angulation in either
and widely used classification systems is a good baseline from the coronal or the sagittal plane. Mal-union of up to 30° is
which to develop your answer to clavicle fracture viva accepted due to the ability of the shoulder to compensate in
questions. placing the hand in space.
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With regard to applied anatomy, part of the issue with secure a solid viva performance, converting this from a poten-
regard to humeral fracture management is the deforming tial problem question to a gift exam scenario.
forces particularly around the proximal humeral diaphysis. Traditionally the Holstein–Lewis fracture15; a distal third
With a fracture line that runs above the insertion of both extrarticular humeral fracture with proximal and medial dis-
pectoralis major and the deltoid, the proximal fragment is placement of the distal fragment; was associated with an
pulled into abduction and external rotation by the rotator cuff increased incidence of radial nerve injury. As with a number
and the distal segment is pulled medially and anteriorly by the of ‘classic’ orthopaedic references, this paper has little scientific
insertion of pectoralis major which is attached to the diaphy- rigour, being based on seven cases, four of which were lost to
seal portion. follow up. Whilst some still propose an increased incidence of
Slightly more distal, should the fracture line extend distal to radial nerve injury with this pattern, the bulk of literature
the insertion of pectoralis major but remaining proximal to suggests that it is with the middle and middle/distal third
that of the deltoid tendon, the distal segment is abducted by fractures together that put the nerve at greatest risk. Anatom-
the unopposed deltoid and the proximal fragment is pulled ically this reflects the close apposition to the bone in the spiral
medially by the combined vector of the triple insertion of groove and the tethering it may undergo due to fracture
pectoralis major, latissimus dorsi and teres major. angulation when it pierces the lateral intramuscular septum.
With a distal diaphyseal fracture, the fracture line is distal In addition, the nerve is at greater risk with a transverse or
to all the major muscle group insertions. The proximal frag- spiral fracture than a comminuted one.
ment, therefore, is pulled into abduction, flexion and external Whilst this pattern recognition is of value, it is not the
rotation, mimicking the situation seen at the proximal femur. main issue with this question. Candidates must have an answer
When answering viva questions, as with the reality of to the question of how they would manage the patient with
fracture clinic, the fractured diaphyseal humerus is managed radial nerve palsy both at initial presentation with a fracture
non-operatively in the majority of cases. Good results can be and that manifesting after manipulation or surgical
obtained within the described tolerances with splinting and intervention.
functional bracing. There is good evidence for functional For the closed humeral shaft fracture with a radial nerve
bracing following a two-week period of splinting with the vast palsy identified at presentation, the literature is supportive of
majority of these fractures healing with a good functional non-operative management as the majority of cases are of
result without an operation14. contusion and tractional injury. There has been raised the
There are relative indications for operative intervention concept of early ultrasound as an adjunct to nerve assessment
out with the accepted tolerances of simple fracture patterns and this may have prognostic power in future care of these
as described. These are segmental fractures, the humeral frac- cases but the ‘exam answer’ is non-operative management as
ture in the setting of multiple trauma, open fracture, dysvas- complete recovery occurs in over 70% of cases.
cular limb and loss of alignment following non-operative The next issue that may be raised is how to proceed if no
management. radial nerve deficit is recorded on presentation but one occurs
It can be seen, therefore, that for the majority of humeral following manipulation, such as when applying a splint. Whilst
shaft fractures, non-operative management is appropriate. For opinion is divided, having documented that a nerve is func-
the small numbers that require an operation the two main tioning normally then finding it is not following a manipula-
options are intramedullary nailing and plate fixation. tion, the safe examination answer is to recommend nerve
The evidence surrounding the use of either implant is poor exploration. Having established that the bulk of injury is by
but meta-analyses suggest that the overall outcomes in terms contusion, this occurs at the time of injury. If contusion suffi-
of fracture union, radial nerve injury and infection are similar. cient to cause palsy is not manifest at admission then when a
What is known is that intramedullary nailing is associated with palsy occurs following manipulation, it must be presumed that
an increased risk of shoulder dysfunction, implant failure and the nerve is no longer in continuity. Personally we would
requirement for further surgery. Pragmatically, nailing is con- explore via a posterior approach, with the patient in the lateral
sidered for pathological fractures and segmental injuries with or prone position with fixation, using a standard large frag-
plating chosen predominantly for the remainder. ment plate. Highlight the importance of documenting the
position of the nerve in relation to the screw holes in the plate,
The humeral shaft fracture with radial nerve should revision surgery ever be necessary.
The last scenario is that of the nerve palsy following fix-
compromise ation. The approach to this is straightforward. If a nerve stops
It is the question of the radial nerve that opens the humeral working after a surgeon has been near it with an instrument or
diaphyseal fracture to further exploration at the viva. Examin- drill, then it must be assumed cut until proven otherwise
ers are looking for a safe and sensible approach and adding in a unless integrity of the nerve was confirmed prior to closing
radial nerve injury to a closed diaphyseal fracture opens up the wound. Postoperative neuropathic pain similarly is an
potential pitfalls for the unwary candidate. A reasoned absolute indication for exploration. Delay in these situations
approach, supported by limited, basic evidence will, however, is unacceptable.
032
By applying these principles, candidates should be able to

navigate through the management of humeral shaft injury with
Management of ‘complex’ forearm fractures
Monteggia fracture dislocations (Proximal ulna fracture
ease.
with radial head dislocation)
This is a combination of a proximal ulna fracture and a radial
Adult forearm fractures – Simple and complex head dislocation and it is the nature of the latter that dictates
A radiograph of a deformed forearm may be used as a position its subtype in classification.
from where to examine the candidate’s grasp of anatomy, As with any forearm injury, prompt assessment of circula-
fracture healing, operative fracture management, compart- tion and documentation of the integrity of the anterior inter-
ment syndrome and multiple trauma management. Be aware osseous, posterior interosseous and ulnar nerves is mandatory
and listen to what the examiner is asking. It is impossible followed by splintage and re-assessment. Radiographs in two
to detail sensible responses to all of the possibilities here and planes of the forearm and focused two plane views of the elbow
so aspects relating primarily to the assessment and manage- and wrist are required.
ment of forearm fractures and complex injuries will be Classification – A favourite with examiners and trauma
concentrated upon. meeting discussion alike, the Bado classification is required
knowledge:
Applied anatomy of the forearm I. Anterior dislocation of the radial head
A highly complex entity, packed with muscles, tendons, liga- II. Posterior dislocation of the radial head
ments and neurovascular structures, the compartments of the III. Lateral dislocation of the radial head
forearm their contents and implications for injury and surgical IV. Type I, i.e. anterior, with an additional radial fracture
approach must be immediately available to the candidate and Type I fractures are the most common and represent a fall on
is assumed knowledge. You may be shown a cross-sectional an outstretched hand with the elbow failing in hyperextension
diagram for the forearm/elbow/upper arm and asked to iden- and the radial head being pulled out by the biceps tendon.
tify structures.
The ulna acts as an axis around which the laterally Management
bowed radius rotates in supination and pronation. This con- Operative management is mandatory in these fractures and it
cept is key to understanding the requirement for fracture is important to note at the viva that screening the elbow at the
fixation. The ‘radial bow’ is fundamental for movement and beginning of the case under image intensification is mandatory
function. to exclude other injuries such as radial head fracture and
capitellar injury. If any doubt occurs preoperatively, a low
Management of ‘simple’ forearm fractures threshold for early CT scanning is sensible to inform operative
planning.
An ‘intra-articular’ injury, all radial fractures, even minimally
Open, anatomical reduction of the proximal ulna will often
displaced should be considered for fixation to allow optimised
suffice as the radial head usually reduces following fixation of
forearm function and early rehabilitation.
the ulna. If this is the case, stability of the elbow should be
The relationship between the radial and ulnar shafts and,
assessed by intraoperative on table screening. In comminuted
therefore, the ability for the bones to achieve a satisfactory
fractures of the ulna, care should be taken to attempt to regain
pronosupination arc is determined by the interosseous
ulna length as a minimum to aid proximal radioulnar joint
membrane, the tension of which may be altered by
congruency. Should ulnar shaft reduction and fixation be
poor fracture fixation. Anatomical reduction and absolute
satisfactory but the radial head still will not reduce, interpos-
stability of the radius is required although care must be
ition of the annular ligament must be ruled out and this
taken to restore the radial bow as well. A huge torsional
mandates an open exploration of the ligament laterally. One
stress goes through the radius and, hence, short plates are
of the complications associated with this injury is a deficit of
discouraged and a minimal 3.5 mm small fragment LCDCP
the posterior interosseous nerve. Hence, as per all limb injur-
is required.
ies, precise documentation, serial evaluation and postoperative
Ulnar fractures are treated subtly differently. Non-
assessment of the named nerves of the limb is essential.
operative management may be considered in the distal third
segment, if >50% cortical contact is present and <10° angula-
tion seen. Proximal ulna fractures are generally treated opera- Galleazi fractures (radial shaft – most commonly distal third-
tively. Initial management in a cast/splint is acceptable for fracture with disruption of the distal radioulnar joint)
distal fractures although prolonged time to union and With the focus on the broken radius, disruption of the distal
increased risk of non-union is encountered. For the young fit radioulnar joint (DRUJ) may be missed and so it is important
patient in order to minimize time off work and limit non- with all radial shaft injuries to both clinically and radiograph-
union, an operative approach is acceptable for these fractures ically assess the joint above and below the fracture. Two plane
although there is no robust evidence to support this. radiographs of the forearm and focused views of the wrist and
677
032
elbow are again mandatory. The closer to the wrist the radial maintenance in the former of the tenodesis effect of digit
shaft fracture, the greater the risk of DRUJ disruption. extension on passive wrist flexion.
Management Anterior interosseous nerve (AIN) palsy

The Galeazzi fracture is one of operative necessity – Unless the This injury to the branch of the median nerve serving the long
patient has significant co-morbidity, operative management flexors of the index and middle finger, the long flexor of the
should be chosen due to the considerable morbidity associated thumb and the pronator quadratus may occur in forearm
with DRUJ dysfunction. fracture either at injury or operation. It is distinguished by a
The radial shaft fracture should be approached and median nerve proper lesion due to the maintenance in the AIN
reduced through a standard volar approach and the DRUJ lesion of sensation and function of the thenar musculature.
screened once the radius is fixed. If the DRUJ is stable, it Classically, the AIN palsy manifests as an inability to perform
should be left and an above elbow cast in supination is applied. the ‘okay’ sign due to an inability to flex either the thumb or
The patient should have a check radiograph in 1 week in the the index finger at the interphalangeal joint (distal).
clinic. If the DRUJ is unstable but reducible, the joint should
be stabilised with 2 percutaneous 1.6 mm wires with the
forearm in neutral and rested in an above elbow cast for 4 Infected non-union and loss of fracture reduction
weeks. The wires can be passed through and through the distal Can you formulate a plan in order to find an infective organ-
radius and ulna, so if the wires did break they can be removed ism, treat appropriately, and obtain bony stability while the
from either side, leaving no metal work in situ. If the DRUJ is fracture heals?
irreducible once the radius is fixed, then interposition of the
extensor carpi ulnaris should be suspected and this warrants
open assessment. Refracture after plate removal
More applicable to the paediatric population although may still
be seen in adults should plate removal be required. Refracture
Complications of forearm fractures is associated with early (<1 year) plate removal, presence of
Whilst a wide range of possible complications may occur comminution at original injury, mismatch between bone and
following forearm fractures, there are a number that must be plate stiffness, i.e. using a 4.5 mm plate, will dispose towards
focused upon. These include: refracture on removal due to stress shielding effect. Finally,
lack of compliance or repeat trauma is also associated with
Compartment syndrome refracture.
Discussed in greater detail elsewhere, compartment syndrome It can be seen that forearm fractures are a straightforward
is essentially an increased pressure in an enclosed osseofascial exam topic if sound knowledge of key anatomy and surgical
compartment leading to ischaemia through diminished capil- principles are understood and demonstrated efficiently.
lary inflow. With regard the forearm, there are three compart- Remember that if a forearm radiograph is put up in front of
ments, the mobile wad, the dorsal and the volar with the latter you at the viva, any one of the above issues may be discussed so
split into superficial volar and deep volar. The deep volar is stay flexible and be thinking of the associated complications as
most susceptible as it is compressed against rigid bone and the well as the proposed management.
interosseous membrane. When discussing management,
decompress the superficial volar first, then the deep volar and
ensure that the lacertus fibrosis proximally and the carpal Examination corner
tunnel distally are included in the decompression. Approach- Distal radial fracture viva 1
ing the hand, it is important to not extend the incision any
more radial than the radial border of the ring finger in order to EXAMINER: Talk me through how you would manage this from
avoid injury to the superficial branch of the median nerve. The attendance in the ED onwards
dorsal musculature is decompressed through a separate inci- CANDIDATE: History, exam, analgesia, haematoma block – Describe,
sion between the two compartments allowing both to be check x-rays describe x-rays – ?acceptable – Discuss the
decompressed through one incision. parameters you are using.
EXAMINER: Describe factors that correlate to loss of reduction16?
Posterior interosseous nerve (PIN) palsy CANDIDATE:
This leads to total loss of extension of the fingers and the Initial dorsal angulation>20°
thumb. Note, wrist drop does not occur although radial devi- Dorsal comminution
ation with the wrist in extension may be seen as the long Radio carpal intra-articular involvement
extensors of the wrist are innervated by the motor branch Associated ulnar fracture
before PIN arises in supinator. Note that a PIN palsy may be Age >60
distinguished from a pure extensor tendon injury due to
032
Figure 29.8 AP and lateral radiograph of distal radial fracture
Figure 29.9 AP and lateral radiograph of distal radial fracture managed with
If 3 of the above and cast treatment this results in loss of closed reduction and K-wire fixation
reduction.
The risk of loss of reduction increases with advancing patient
age17 (>58 years ! 50% risk of slippage, >80 years ! 77% risk of
slippage).
EXAMINER: What next? What would you do and why? Explain the
findings from DRAFFT study?
COMMENT: Please review the paper but in summary ‘Contrary to the
existing literature, and against the rapidly increasing use of
locking plate fixation, this trial found no difference in functional
outcome in patients with dorsally displaced fractures of the distal
radius treated with Kirschner wires or volar locking plates.
Kirschner wire fixation, however, is cheaper and quicker to
perform.’
EXAMINER: Has this altered the way you manage wrist
fractures?
EXAMINER: The patient presents with or develops carpal tunnel
syndrome. What now? Discuss management, single incision
approach and release18? Or separate fixation and release?
What are the benefits if any of polyaxial locking screws?
Outline your postoperative management plan. Figure 29.10 Removal of wires and volar plating performed
Early mobilization/late mobilization? Benefits if any?
Describe complex regional pain syndrome – Diagnosis and
management. You review a patient (Figure 29.9) in fracture clinic 2 weeks
When would you consider dorsal plating and describe you after closed manipulation and K-wiring.
surgical method Discuss the current position. Why has this happened?
Explain the benefits of volar plating over dorsal plating? Outline the problems you may now encounter.
What next? What are you going to tell the patient?
(Figure 29.10)
More space available – Pronator quad. Interposed between
bone and tendons Distal radial fracture viva 2
Volar cortex typically less comminuted – Reduction easier These are the radiographs of a 21-year-old male who has come
Volar scars better tolerated off his motorbike at high speed sustaining this isolated closed
Less disruption of blood supply to radius injury. He is right hand dominant
679
032
In a retrospective review of 40 young adults at a mean follow-up of

COMMENT: Even though the history may suggest other potential 6.7 years, Knirk and Jupiter showed that a step-off 2 mm was
injuries the clue that the ATLS® default statement is not needed is associated with 100% incidence of radiological arthritis of which 93%
‘isolated’. (26 of 28) were symptomatic.
Intra-articular fractures (AO types B and C) with a step of 2 mm in
CANDIDATE: These are AP and lateral radiographs which
the radiocarpal joint inevitably result in osteoarthritis and functional
demonstrate an intra-articular displaced highly communited impairment. Knirt and Jupiters article is one of the most important
fracture of the right distal radius. There is radial shortening and studies on the management of intra-articular fractures of the distal
involvement of the distal radioulnar joint radius. Prior to its publication, the critical factors that determined
EXAMINER: How would you classify this fracture? successful long-term management of intra-articular distal radius
fractures in young patients had not been determined. Fractures of the
CANDIDATE: Various classification systems are used including the distal radius at the time were thought to be relatively benign injuries
AO, Frykman, Melone and Fernandez classifications. I would use and were often all treated with the same methods and post-traumatic
the classification described by Frykman, which defines the arthritis and associated disability not well appreciated.
fracture according to pattern of intra-articular involement and is Knirt and Jupiter’s conclusions challenged the contemporary
understanding of the injury. They found that the most important factor
useful for planning surgical strategy.
determining a successful outcome from this type of injury and
COMMENT: Candidates may not always get asked to classify a wrist preventing long-term arthritis was accurate articular restoration.
fracture but should still should be able to discuss the various Haus and Jupiter19 revisited the article in 2009 reviewing the
classification systems used and the one ‘you yourself’ prefer and why. methodological flaws contained in the original study. This paper is an
excellent illustration of how to critically review a paper. It is a good
EXAMINER: How would you manage this fracture?
educational article for a journal club to use.
CANDIDATE: I would manage this fracture with open reduction
internal fixation using a fixed angle locking plate to achieve
anatomical articular reduction and stable fixation of the
fragments
Trauma oral 3
COMMENT: A candidate may then be asked to describe the volar The viva can surprise some candidates in starting off with the
distal Henry’s approach to the wrist or the evidence for using a complication of a distal radius fracture. These include median
volar locking plate. nerve dysfunction, non-union or mal-union, post-traumatic
There is no Level I clinical evidence suggesting a superior mode
osteoarthritis, complex regional pain syndrome and tendon
for treatment of distal radial fractures. I would choose open
rupture. The viva would then concentrate in more detail on
reduction and internal fixation since this will allow accurate
one or two of these in particular EPL rupture and its manage-
fracture reduction and restoration of radial length and inclination.
ment or CRPS.
I would be concerned with using k-wire fixation with this degree
Other upper limb areas to review include the following:
of fracture comminution if we could achieve fracture reduction Proximal humeral fractures
closed, if we could maintain fracture reduction without PROFHER study, etc
redisplacement as it is a highly unstable injury. The patient is A multicentre RCT that aims to obtain evidence of the
young and it is his dominant hand, so I think volar locking plate is effectiveness and cost-effectiveness of surgical vs non-
a safer option. surgical treatment for the majority of displaced proximal
Candidates may be asked about factors which may determine humerus fractures in adults
a poor outcome for a wrist fracture. Know the literature on There is great variation in the treatment of these fractures,
thisk. both in basic (the use of surgery) and specific (type of
Several studies suggest that inaccurate reduction and articular implants and surgical technique; non-surgical management
incongruency of >2 mm, failure to restore radial length to and rehabilitation packages) terms. There is a lack of
within 5 mm and articular comminution correlate with a poor evidence from RCTs to inform management decisions for
outcome.
proximal humerus fractures
The difficulty for candidates sitting the exam is that you
can not default to the view that we don’t know what to do
with these fractures and are awaiting results form ongoing
Classic reference RCTs. Candidates need to be aware of the factors that will
influence when best to operate and when to treat
Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of
conservative
the radius in young adults. J Bone Joint Surg Am.
1986;68:647–59. The default statement is ‘Although I are not aware of any
Level-I randomised controlled trials or high quality
prospective studies that have evaluated any of the treatment
options for proximal humeral fractures there is evidence
k
The Jupiter paper is a good paper to pull out of your pocket as most from prospective comparative studies, case-control studies,
examiners are vaguely familiar with this. and retrospective comparative studies. This data represent
032
fair evidence for or against recommending an intervention

united with 80% good to excellent results at one year using
and I would consider papers presented in the peer-reviewed the Neer criteria.
journals’20
COMMENT: Methods of fixation include percutaneous
Reverse polarity replacement for trauma
techniques with pins or screws and open reduction and internal
Multilock nail/locked plates for proximal humeral fractures
fixation with contoured locking plates or intramedullary
Approaches/setup for images
fixation. Fractures that are not amenable to operative fixation,
including comminuted fractures, head-split injuries, and
associated fractures.
Examination corner
EXAMINER: Which fractures are prone to AVN?
Three part valgus impacted humeral fracture
CANDIDATE: Hertel et al.23. devised a method of assessing the risk
Plain radiographs shown to candidate and correct identifica-
of osteonecrosis and concluded that the critical components
tion of fracture pattern.
include the integrity of the medial hinge and the length of the
Discussion of the deforming forces on the fracture frag-
ments.The supraspinatous and infraspinatous pull the greater posteromedial metaphyseal head extension. Fractures resulting in
trochanter posterosuperiorly and externally rotate the the disruption of the medial hinge and those with 8 mm of calcar
fragment.The subscapularis pulls the lesser trochanter medi- bone attached to the articular segment were more likely to be
ally.The pectoralis major pulls the proximal humeral shaft associated with the development of osteonecrosis.
anteromedially. COMMENT: This is a difficult question which probes indepth
EXAMINER: What next? understanding of this fracture.
CANDIDATE: I would order a CT scan of the shoulder.
EXAMINER: Here is the CT scan. Intramedullary nailing (IMN) vs plating
of humeral shaft fractures
The candidate didn’t understand how to interpret the pictures
‘I was shown a radiograph of a comminuted midshaft humeral
and gave a poor description of the anatomy being unable to
fracture. It was a young patient and the inference from the
identify the lesser and greater tuberositiesl
examiners was that that was unsuitable for conservative treatment.
EXAMINER: The candidate knows how to order a CT scan but not Almost immediately we began discussing the pros and cons of IMN
how to interpret the scans. vs plating along with various radial nerve scenarios.’
COMMENT: Practice looking at a CT scan of the shoulder, be able to ‘The examiners were keen to know about the literature evidence
identify the relevant anatomy and follow on from this with a which I vaguely knew about but not to any great degree.’
fracture description. ‘In retrospect I should have been more skillful with
A CT scan more clearly defines fracture configuration and is
the question steering the discussion onto safer territory for
indicated for comminuted intra-articular fractures involving myself.’
the humeral head. It gives an idea of fracture pattern, need ‘For starters I should have begun by stating that the vast majority of
for fixation and additional info for planning surgery. humeral shaft fractures are treated conservatively. The indications
Only a brief discussion of Neer’s classification. Much greater for operative treatment included polytrauma, floating elbow,
part of the viva spent discussing which fracture pattern needs segmental fracture, pathological fracture, open fracture, non-union,
fixing and which could be managed conservatively. Little was mal-union, progressive vascular impairment and inability to
discussion about age and co-morbidity factors influencing maintain reduction with conservative treatment. This would have
management options. scored me some initial points.’
The impacted bifocal fracture pattern (AO11–B1.1) represents When comparing plating vs IMN the arguments should focus
nearly 15% of all proximal humerus fractures. This type B1.1 on biology and principles of fracture healing, biomechanics
fracture may be represented by a minimally displaced fracture,
and complications.
a displaced two-part surgical neck fracture, a displaced two-part
greater tuberosity fracture, or a three-part variant with signifi-
Intramedullary nailing results in higher rates of re-
cant displacement of both the surgical neck and greater tuber- operation and no differences between rates of non-union,
osity with valgus impaction21. These fractures occur in elderly infection or iatrogenic nerve injury when compared to com-
patients in whom reconstructive surgery is difficult. pression plating. IMN is associated with more shoulder pain,
Court-Brown et al.22 reviewed 125 patients with B1.1 frac- reduced range of shoulder movement and possibly shoulder
tures with a mean age of 71 years who all had a valgus impingement. IMN may cause considerable shoulder morbid-
impacted B1.1 fracture treated non-operatively. All fractures ity and be poorly tolerated in a younger more active patient.
There are some types of humeral shaft fracture best suited
for IMN. An extensively communited long fracture is better
l
The candidate appears stupid to us – asking for a CT scan of the nailed as plating would involve widespread stripping of soft
proximal humerus but not being able to even remotely identify any tissue that may result in delayed or non-union . If the fracture
structure. The examiners were more objective and forgiving. pattern is nearby the radial nerve it is best be reduced and fixed
681
032
under direct vision protecting the nerve rather than blind develops then this may be observed. However, if a nerve
closed reaming and nailing as this may injure the radial nerve. palsy develops following a blind closed IMN it is necessary
to explore
Associated radial nerve injury 6. Radial nerve following plating
Radial nerve injury occurs in approximately 10% of humeral If the nerve was seen at surgery and protected,
shaft fractures with an increased risk with middle third and the plate applied to the humerus avoiding the
junction of middle/lower one-third fractures. Around 90% are nerve then the palsy can be observed. Failure to
neuropraxia and recover fully, but the nerve may also be adequately identify the nerve would be an indication for
lacerated or caught between fracture ends. Transverse and exploration
spiral fracture patterns are significantly more likely to be
associated with a radial nerve palsy than oblique or commin-
uted fractures.
There are essentially six scenarios of radial nerve Other upper limb trauma topics
dysfunction: Other upper limb trauma topics include:
1. Open fractures Principle of scapular fixation
Because irrigation and debridement is required for open Floating shoulder SCC
fractures, it is reasonable to explore the nerve at this same Brachial plexus management principles
operation Diagram of clockwork
2. Radial nerve palsy following closed reduction MRI
Although there is some controversy in the literature the Stanmore peripheral nerve service or your local referral
safe exam answer is that if the nerve was functioning before pathways
the manipulation then nerve exploration is required to Complex C3 elbow fractures
ensure the nerve has not been trapped or lacerated Fix
3. Radial nerve palsy with an unstable fracture pattern Total elbow replacement/distal humeral resurfacing
The fracture should be plated and nerve exploration Open elbow fracture dislocations and their management
undertaken at the same time Articulating elbow X-fix application
4. Radial nerve palsy with a stable fracture pattern Distal biceps avulsion
A conservative approach may initially be adopted 1 vs 2 incision reconstruction: Boyd–Anderson24
5. Radial nerve palsy following IMN Terrible triad. Management. It still dislocates, what
This depends on the level of the fracture and the next? Coronoid reconstruction. Articulating external
placement of locking screws.Either avoid IMN if the fixator
fracture is at the level of the spiral groove, wide fracture Radial head fracture: Anatomy approaches/classification/
gaps or significant comminution present or expose the fixation vs spacer.
nerve to ensure no injury during fracture reduction or Scaphoid fractures
reaming. Gentle fracture reduction and minimal reaming. Complex carpal injuries
If the nerve has been directly visualized and a palsy Hand/tendon injuries and infections
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fractures of the distal end of the radius 24. Boyd H, Anderson L. A method of
fractures of the clavicle. J Shoulder reinsertion of the distal biceps brachii
Elbow Surg. 2007;16:514–18. in young adults: Reexamined as
evidence-based and outcomes medicine. tendon. J Bone Joint Surg Am.
14. Koch PP, Gross DF, Gerber C. The J Bone Joint Surg Am. 2009;91:2984–91. 1961;43:1041–3.
results of functional (Sarmiento)
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Section 8 The basic science oral
Basic science oral topics

Chapter
30 Kevin P. Sherman
Introduction various topics; write these headings on revision cards. This will
enable you to structure your answers better and not just
The basic science oral is often approached with trepidation by
produce a series of random one-line answers.
candidates; in many cases this trepidation is justified because
When organizing your revision for the basic sciences, make
‘revision’ of the basic sciences has in fact been learning for the
sure that you refer to the curriculum, which will guide you on
first time and often at the last minute.
the levels of knowledge that are expected on the various topics.
Despite this a working knowledge of the basic science that
The basic science section of the examination syllabus
underpins clinical practice is essential for an understanding of
includes the following headings:
why we do what we do.
Basic science should not, therefore, be seen as a topic in Anatomy
isolation but should be seen as integral to the various clinical Tissues
and technical aspects of Orthopaedics and it should be learnt Physiology
throughout training; unfortunately, this is often not the case. Biochemistry
When revising for the examination the basic science topics Genetics
should be learnt in relation to their clinical context as the Biomechanics
questions will usually be posed in a clinical scenario-based way. Bioengineering
When revising for the basic science oral it is essential to
Bone and joint diseases
ensure that you really understand each topic and not just that
you can reproduce various equations and diagrams from text- : Osteoarthritis
books; all too often candidates become stuck when asked to : Osteoporosis
draw a diagram that differs slightly from the ones in the : Metabolic
textbooks (which are, of course, known to the examiners!), : Bone diseases
such as the free body diagram for the left hip rather than the : Rheumatoid and other inflammatory arthropathies
right. Examiners can pick up very quickly when a candidate is : Haemophilia
just reproducing something rote fashion. : Inherited musculoskeletal disorders
A good way of ensuring that you really understand a basic : Neuromuscular disorders
science topic is to revise in small groups and make sure that : Osteonecrosis
you can explain the ‘how’ and ‘why’ of the topic to another : Osteochondritides
member of the group and, where appropriate, draw a diagram. : Heterotopic ossification
The ability to draw a diagram during the examination is a skill : Bone and soft-tissue primary tumours
that should be practised well beforehand and not done for the
first time during the examination itself.
: Metastases
Investigations (radiological, etc)
Some tips for drawing diagrams:
Operative topics
Make the diagram big enough
Infection
Make sure you can label the diagram
Thromboembolism
Make sure you can explain what the diagram shows
Pain
Where the diagram refers to a three-dimensional object,
Prosthetics and orthotics
make sure that you can draw it from another angle or with
the left and right sides reversed Statistics
An organized, structured answer will score much more highly Research and audit
than a disorganized one. Final revision for the basic science Medical ethics
oral is more usefully devoted to ensuring that you can produce This section of the book will take you through areas that are
a logical list of headings under which you could discuss the commonly tested from the above list. The content cannot be
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Section 8: The basic science oral
comprehensive; you should check through the above list after Finally, although this chapter is organized under discrete
reading this chapter and identify areas of weakness in your headings, your understanding should not be too compartmen-
own knowledge. Preferably obtain objective evidence of areas talized; you should be able to discuss a topic that ranges across
of weakness from others in a revision group as it is easy to these various headings. An example would be a question that
convince yourself that you know about a topic and then find starts by asking about the ultrastructure of articular cartilage
that, when you are asked to draw a diagram or to explain the and then develops into a question about the kinematics of a
topic in a clinical setting, you do not in fact know it as well as joint. Another example would be a question on the kinematics
you think you do. One of the commonest fallacies I have heard of the subtalar joint that went on to explore the gait cycle. The
is ‘I know it, I just can’t describe it/draw it’ – This phrase is, most important thing to be able to demonstrate to the exam-
unfortunately, an exercise in self deception; if you cannot iners is that you have a true understanding of the topic and that
describe something to someone else you do not in fact you can apply it in a clinical setting; this is much more
understand it. important than memorizing some minute detail or figure and
Anatomy is an important component of the basic science then reproducing it out of context.
oral but it will not be covered in this chapter as it is dealt with
comprehensively in other texts. It is important not to forget to Genetics
revise surgical approaches as you are very likely to be given a
A number of orthopaedic conditions display genetic inherit-
question on this subject. You will be expected to be familiar
ance patterns and an understanding of these patterns is
with commonly used approaches, such as those to the bones of
important1. You should be able to talk about one or two
the forearm, or the surgical approach for decompressing a
examples of each of the main inheritance patterns.
compartment syndrome. However, do not neglect the less
Genetic abnormalities may be grouped into chromosomal,
commonly used approaches, as you will be expected to have
single gene or multiple gene abnormalities.
an adequate knowledge about surgical approaches that are not
Before discussing examples of these abnormalities it will be
necessarily in the day-to-day practice of the more generalist
useful to revise the structure of DNA and the way in which it is
orthopaedic surgeon. The posterior approach to the shoulder,
structured functionally.
the anterior approach to the cervical spine, the brachial plexus,
the posterior approach to the knee and approaches to the
subtalar joint have all been asked on several occasions and The structure of DNA
are good vehicles for exploring a candidate’s knowledge of the The whole structure of DNA can be described as a double helix
topographical anatomy of the area. consisting of two spiraling sugar-phosphate backbones with a
The principles of the management of bone tumours are chain of paired bases between them, like the steps on a spiral
frequently asked in the basic science oral, but this topic is staircase.
discussed elsewhere in this book. The building blocks are a sugar (deoxyribose), a phosphate
Candidates frequently ask which topics have been asked in group and a base
recent years. The examination is constantly evolving, and new The 5 carbon atoms of the deoxyribose are numbered 1’ to
topics can arise in any diet, or old questions may be asked in a 5’ (1-prime to 5-prime) clockwise from the Oxygen atom to
new way. The following are popular topics that it is essential to 4’ with 5’ being in the HOCH2 side chain attached to the 4’
understand well, although there are, of course, no guarantees carbon atom of the ring. Figure 30.1 illustrates the
of what will come up in any particular examination – The only structure of deoxyribose
way to be confident is to have a good understanding across the A phosphate group becomes attached to the 5’ carbon atom
breadth of the curriculum and in sufficient depth: in place of the –OH group
The ultrastructure and mechanics of articular cartilage
The structure and function of the meniscus O Figure 30.1
5’ Deoxyribose
Structure and function of the intervertebral disc
HOCH2 OH
Osteoporosis – Pathology and diagnosis
Calcium and vitamin D metabolism
The gait cycle 4’ 1’
Mechanical properties of metals
Mechanical properties of viscoelastic materials
H H H H
Prosthetic design (e.g. hip and knee replacements)
Tribology, including wear modes and mechanisms, and
3’ 2’
joint lubrication
Working length of intramedullary nails and plates
Genetics
OH H
The science of radiological investigations
033
Chapter 30: Basic science oral topics
The bases are four in kind – Cytosine, thymine, adenine completely understood and may include interference from
and guanine. Adenine and guanine are both purines (single other genes or the need for some environmental factors to be
ring structures). Cytosine and thymine are both present for the genotype to be reflected in the phenotype.
pyrimidines (double ring structures) The importance of incomplete penetrance is that even if the
One of the four bases attaches to the 1’ carbon atom with condition is not apparent, due to lack of penetrance, the
the loss of OH group on the 1-prime carbon atom in a genotype is present and the condition can, therefore, be
‘condensation reaction’ passed on to children
The chain of the nucleotide is built up by the phosphate Expression: This term describes the degree to which the
group attached to the 5’ carbon linking with the 3’ carbon features are expressed in an individual. Only a proportion of
atom on the next nucleotide with the loss of an –OH from the typical features may be manifested in the individual. An
the phosphate group and an –H from the 3’ carbon example is Marfan’s syndrome
(another condensation reaction leading to the loss of a Incomplete dominance – Intermediate expression: There is
molecule of water) incomplete dominance resulting in a range of the
The resulting chain will have a ‘spare’ –OH attached to the characteristic being expressed (example is human voice
5’ carbon atom at one end (the ‘5’’ end) and a ‘spare’ –OH pitch – No obvious orthopaedic example)
attached to the 3’ carbon atom at the other (the ‘3’end’; the Co-dominance: Both forms expressed – Example is blood
chain has direction. When the two chains are joined to grouping – No obvious orthopaedic examples
form the DNA one sugar-phosphate backbone will have the Multiple alleles: Characteristics controlled by multiple sets of
spare –OH attached to the 5’ carbon atom at the ‘top’ and genes – Many examples, including the HLA immune system
the spare –OH attached to the 3’ carbon atom at the Spontaneous mutations – Not all genetic abnormalities are
‘bottom’, and the other will be the other way up. The base inherited from parents – In achondroplasia 83% of cases are
pairs are always formed with one purine and one spontaneous mutations
pyrimidine Mosaicism (Lyonisation) – Not all cell lines are affected.
One of the two strands in the DNA is the coding strand and Lyonisation is also instrumental in X-linked conditions
the other is the template strand being found in males but females only being carriers – This
A sequence of three bases in the coding strand of the DNA depends upon the affected X-chromosome being suppressed
forms a Codon, which codes for amino-acid synthesis. The Regulator genes: These are responsible for turning other
codons are read from the 5’ end to the 3’ end. Only two genes on and off. Examples include the Homeobox and Hox
amino acids are coded by a single codon, the others require genes, which regulate the formation of body parts, such as
more than one codon. Other codons signal the start and limbs, etc. These also regulate maturation and ageing
stop of sequences; these are called signaling codons Modifier genes: These genes modify the effects of other
A section of DNA that controls the formation of an amino genes
acid chain or polypeptide chain is a gene. To date only Stuttering alleles: The defective gene segment doubles with
about 5% of the DNA has been identified as forming each successive generation leading to progressively
coding genes; the function of most of the rest of the DNA worsening symptoms in each successive generation – An
(about 95%) is unknown example is myotonic muscular dystrophy
Each of a pair of genes occupying equivalent sites on the In the following section the differing types of inheritance
two matched chromosomes is called an allele; if they are the patterns will be described, with some examples of orthopaedi-
same the then the genes are homozygous and if they are cally relevant conditions. The clinical features of these condi-
different there are heterozygous tions are beyond the scope of this chapter.
Some key terms

Despite the genes for certain conditions being present (i.e. the
Chromosome abnormalities
genotype is present) some people may not have the condition Whole chromosome abnormalities – Incorrect number of
or they may have a condition to a greater or lesser extent. The chromosomes (aneuploidy)
terms variable penetrance and variable expression can cause : Loss of a chromosome – Only survivable if affecting
confusion: X chromosome (XO – Turner’s syndrome, 1 in 2000
Penetrance: Despite the genes for the condition being live births, loss of paternal X, short-stature female,
present only a proportion of the population with these genes scoliosis, hip dislocation, cubitus valgus, short fourth
may exhibit the condition. Penetrance describes the metacarpal/metatarsal)
percentage of the group with the genes for the condition who : Extra chromosome – E.g. trisomy 21; 1 in 600 live
actually show the features of that condition – It is a statistic births, increasing risk with increasing maternal age,
for a group. Examples include osteogenesis imperfecta and usually failure of separation at meiosis (94%)
achondroplasia. The cause of incomplete penetrance is not : Structural abnormalities of chromosome
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Growth Factor 23 (FGF23) resulting in lack of

reabsorption of phosphate in the renal tubules)
X-linked recessive
Figure 30.2 Punnet square : Homozygous affected, heterozygous carriers
: Males more commonly express the condition than
females
: Point mutations, deletions, inversions, translocations
: Probabilities: If the mother is a carrier, 50% of sons will
: may be autosomal or X-linked
have the condition and 50% of daughters are carriers. If
: Often variable penetrance or expression the father has the condition and the mother a carrier,
50% of the daughters carry the gene, 50% of the
Mendelian inheritance (single gene) daughters have the condition, 50% of sons have the
condition
Single gene traits are predictably inherited in fixed propor-
tions. Many candidates become confused when asked to calcu-
: Examples – Duchenne’s muscular dystrophy (fault in
the dystrophin gene, which has an adverse effect on the
late the probability of a particular condition being inherited
muscle cell membrane), haemophilia
from a parent who has, or carries, a condition, and you should
be well practised at drawing Punnett squares. Figure 30.2 illus-
trates a Punnett square, where capital letter ‘A’ indicates a
dominant gene and ‘a’ indicates a recessive gene. Non-Mendelian inheritance
Autosomal dominant conditions For chromosomal and single gene conditions the inheritance
pattern can be relatively accurately predicted, but many condi-
: Clinical cases usually heterozygous (homozygous
tions, including orthopaedic conditions, have a less predictable
usually fatal)
pattern of inheritance. There are many causes of this but some
: Males = females of the factors are as follows:
: Probabilities: If one parent has the condition 50%
chance of inheritance of abnormal gene Polygenic inheritance
: Examples – Achondroplasia, multiple epiphyseal Variable penetrance and expressivity
dysplasia and most cases of osteogenesis imperfecta The effect of modifier genes
(although some cases of OI are autosomal recessive) Environmental factors may cause the phenotype to become
Most cases of achondroplasia have normal parents; this is expressed
due to a high spontaneous mutation rate. Most cases are In conditions with non-Mendelian inheritance closer relatives
due to a defect in the Fibroblast Growth Factor Receptor of someone affected will have a higher risk of developing the
gene 3 (FGFR3), which is found on chromosome 4. The condition than more distant relatives.
defect causes a deficiency of chondrocyte growth Example – Talipes equinovarus; 1 in 1000 live births. Risk
Autosomal recessive increased by 25 in first-degree relatives (1 meiosis away –
parent, sibling, offspring); risk increased by 5 in second-
: Homozygous have the condition, heterozygous carry
degree relatives (2 meioses away – Grandparent,
the condition
grandchild, aunt, uncle, nephew, niece)
: Males = females Another relevant example is low back pain, where there is
: Probabilities: If both parents carriers, 25% chance of probably a significant genetic factor (including the PARK2
child being affected, 50% chance of children being
gene and a gene regulating Collagen IX formation) but where
carriers
other factors also influence the development of symptoms.
: Examples – Mucopolysaccharidoses (except type II),
sickle cell disease, the severe forms of hypophosphatasia
(milder forms of hypophosphatasia may be autosomal Embryology
dominant) Although a detailed knowledge of embryology is not required,
X-linked dominant some understanding of the formation of the spine and limbs
: Females more commonly affected than males helps to explain the anatomical arrangements of nerve roots
: Inheritance pattern depends on whether the mother or and spinal nerves and limb development abnormalities.
father has the affected gene. If mother has the gene 50%
of sons and daughters inherit the condition Somite formation
: Probabilities: If father has the gene 100% of daughters The spine forms from somites, which develop as paired struc-
and none of sons inherit the condition tures in the paraxial mesenchyme either side of the notochord
: Example – Hypophosphataemic rickets (defective and neural tube. Somitic condensation is regulated by the
PHEX gene, causing failure to break down Fibroblast paraxis gene. Initially a spherical epithelial somite forms
033
around free somitocele cells. The somites then condense into replaced by cells from the inner layer of the annulus fibrosus.
three layers: The sclerotome, the myotome and the adjacent The intervertebral joints also form from somitocytic mesench-
dermatome. ymal cells in the same region.
The intervertebral discs and the spinal nerves are segmental
Sclerotome formation The vertebrae are intersegmental
The somite boundaries from the ventral and ventromedial The process of segmentation progresses from cranial to
walls of the somite develop into the sclerotomes, which will caudal
develop into the vertebral bodies and vertebral arches. Scler-
otome condensation is regulated by the Pax1 gene. The ventral Limb formation
and medial mesenchymal cells move around the notochord Limbs form between the fourth and eighth week of gestation.
and neural tube. The dermomyotome forms from the epithe- At limb levels the ventrolateral border of the sclerotome
lial plate of the somite. proliferates to form the limb bud. The limb buds develop from
a combination of mesenchymal cells (note that the dermomyo-
Sclerotome division tome gives rise only to the epaxial skin and muscle, i.e. dorsal
Each sclerotome divides into a cranial and caudal part (the line to the spine, and not to the limb muscle and skin). Initial limb
of division being von Ebner’s fissure). The division of the bud formation is controlled by fibroblast growth factor.
sclerotome is regulated by the Mox1 gene. The caudal part of
the sclerotome fuses with the cranial part of the next sclerotome Limb bud axes
to form a vertebra. The cranial portion of the first cervical The limb can be divided into three axes:
sclerotome fuses with the occiput and the caudal portion of
Proximodistal axis
the eighth sclerotome fuses with the cranial part of the first
Craniocaudal axis – Any line running from the pre-axial to
thoracic sclerotome to form the first thoracic vertebra. The
the post-axial border perpendicular to the
spinal nerve grows through the cranial half of the sclerotome
proximodistal axis
(which becomes the caudal half of the vertebra). These arrange-
ments explain the relationship of the nerve root to the vertebrae Dorsoventral axis – Any line perpendicular to both the
proximodistal and craniocaudal axes
in the region of the foramina and also explain why there are
eight cervical nerves and only seven cervical vertebrae. Growth along the proximodistal axis is controlled by the apical
ectodermal ridge (AER), which maintains the adjacent rapidly
dividing underlying mesenchymal cells (the progress zone) in
Vertebra formation an undifferentiated condition. Severe transverse phocomelic
The sclerotome consists of central, dorsal, ventral and lateral defects may be caused by damage to the AER.
parts, with the dermomyotome covering the dorsal, central Differentiation along the craniocaudal axis is controlled by
and lateral parts. The ventral part lies close to the notochord. a small population of somatopleuric mesenchymal cells on the
The sclerotomal cells surrounding the notochord develop into post-axial border of the limb bud: The zone of polarizing
chondroblasts and become the centrum of the vertebral body. activity (ZPA). The type of digit formed depends on the
The pedicles and ventral part of the neural arches also form distance from the ZPA and the number of digits depends on
from the central part of the sclerotome. The dorsal part of the the width of the AER. ZPA function is controlled by the shh
vertebral arches form from the dorsal part of the sclerotome, gene (sonic hedgehog) via HOX genes.
which invades the space between the neural tube and the Growth along the dorsoventral axis is controlled by the
surface ectoderm. surface ectodermal covering of the limb bud. The dorsal sur-
The neural arch forms from coalescence of paired bilateral face grows faster than the ventral, leading to ventral curving of
pedicles and laminae. Three projections arise from the junction the limb.
of the pedicle and lamina: Cranial and caudal articular processes
and lateral projections to form the transverse processes.
Bone
Intervertebral disc formation As it is one of the main ‘raw materials’ in orthopaedics, an
understanding of the structure and function of bone is essen-
The intervertebral discs form from both notochordal cells and
tial for the examination. This section will deal initially with
somitocele that have remained mesenchymal. The notochordal
normal bone and its development and will then go on to cover
cells in the region of the centrum of the vertebral body are
diseases and disorders of bone and bone metabolism.
replaced by sclerotomal mesenchymal cells, but those in the
region of von Ebner’s fissure expand to form the nucleus
pulposus of the disc. The annulus fibrosus forms from the Function
sclerotomal mesenchymal cells surrounding the notochord. Biomechanical – Framework for support and propulsion
By the second decade of life the notochordal-derived cells are Biomechanical – Protection of soft tissues
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Biochemical – Mineral homeostasis Cortical bone (compact bone)

Haematological – Marrow cells Forms the cortex of long bones and also occurs in
flat bones
Development Osteoblasts deposit bone matrix in thin sheets, or lamellae
Long and short bones develop in cartilaginous precursors – : Some of the osteoblasts become left in small lacunae
Enchondral ossification. and become osteocytes (others become bone lining cells
Flat bones develop in loose condensations of mesenchymal and others apoptose)
tissue – Intramembranous ossification. The structure has a cylindrical arrangement with
concentric lamellae osteons, or a Haversian canal system
Structure around a central Haversian canal containing neurovascular
Bone consists of cells (10%) within a matrix (90%) that has structures
inorganic and organic components. The proportion of inor- Osteons usually have about 5–7 lamellae
ganic to organic matrix is approximately 60 : 40. The mechan- The osteon is surrounded by a cement line, which can be
ical properties of the bone are greatly influenced by the relatively weak
organization of the structure (trabecular or cancellous). Volkmann’s canals run perpendicular to the Haversian
Primary bone (in embryo, in growing metaphysis and canals and connect them to each other
following fracture) is usually formed as woven bone, which Interstitial lamellae are found between osteons and are the
has a relatively random orientation of collagen fibres; this then remnants of remodelling of cortical bone; these do not
becomes remodelled into lamellar bone, which has an organ- contain Haversian canals
isation appropriate to its mechanical function The concentric arrangement of lamellae, and possibly also
the cement lines, help to resist crack propagation through
Woven (immature) bone the bone
Forms more quickly than lamellar bone
Has less mineral content than lamellar bone, with smaller
crystals
Constituents of bone
Bone consists of an extracellular matrix (ECM) and cells.
Is more flexible than lamellar bone and has a higher
These will be discussed below.
turnover
Contains more osteocytes than lamellar bone Extracellular matrix
Is isotropic – Collagen fibres are aligned randomly The bone matrix forms provisionally as osteoid, which is
formed by osteoblasts. The bone ECM consists of a mineral
Lamellar (mature) bone
inorganic component (60–70% dry weight) and an organic
Lamellar bone is organized into layers, or lamellae component (30–40% dry weight).
Collagen fibres arranged according to the stresses on
the bone Inorganic matrix
Is anisotropic The bone matrix differs from the extracellular matrix of
Stronger than woven bone osteoid or lacunar ECM in having a large inorganic
Has lower turnover than woven bone component
Primary lamellar bone forms at the periosteal surface of Bone surfaces have a thin layer of non-mineralized osteoid
long bones Mineral is closely associated with collagen fibres
Calcium hydroxyapatite – Ca10(PO4)6(OH)2 crystals are
Trabecular bone laid down in the holes and pores of the helically arranged
Found in epiphyses and metaphyses of long bones, and the collagen fibrils
major part of short bones (short bones are mainly cortical The mineral content of the matrix gives it compressive
in thin areas and have a trabecular layer in thicker areas) strength and stiffness
Made up of lattice of plates and/or rods (called struts) in a
‘honeycomb’ arrangement Organic matrix
The arrangements of the plates and rods dictates the Collagen
mechanical properties Non-collagenous proteins
In lamellar trabecular bone the lamellae are approximately Growth factors
parallel to the strut surfaces and form packets Proteoglycans
Packets are separated from each other by cement lines
In osteoporosis the thickness and number of struts decreases Collagen
No Haversian system Approximately 90% of organic matrix
033
Mainly type I collagen (the word bone contains one as its Secretory pathway – Rough endoplasmic reticulum !
last three letters, making it easy to remember type one Golgi apparatus ! secretory vesicles
collagen Important regulator of activity is LRP5 (low-density
Collagen is arranged in a triple helix, with two α1 chains lipoprotein receptor-related protein 5)
and one α2 chain Osteoblasts differentiate from mesenchymal stem cells
Gives the bone tensile strength under the influence of a number of factors, including
The collagen (tropocollagen) helices form large complexes BMPs, cytokines and growth factors. The process is not
called fibrils. Fibrils combine to form collagen fibres completely understood but Runx 2 and Osterix
Collagen fibrils have a staggered arrangement of helices, transcription factors are required. Loss of Runx 2 causes
with gaps (holes) between the ends and pores running cleidocranial dysostosis
between the fibrils, into which the mineral is deposited Once differentiated an osteoblast has a half-life of
approximately 100 days, after which it will become either a
Non-collagenous ECM proteins bone-lining cell or an osteocyte or apoptose3
Osteocalcin – Associated with mature osteoblasts, so a
good marker of bone turnover (urine levels increase both Bone-lining cells
when bone formed and also when released from matrix Flat cells lining the surface of bone
when bone resorbed) Inactive cells whose function is not fully understood; may
Adhesive proteins – E.g. fibronectin, vitronectin, etc be capable of becoming osteoblasts or may prevent the
interact with osteoblasts and osteoclasts to control their ingress of osteoclasts
adhesion to bone surfaces
Matricellular proteins – E.g. osteonectin are involved in Osteocytes
cell-mediated functions and control of mineralization Form approximately 90% of bone cells
Phosphoproteins – May be involved in the initiation of Form from osteoblasts that become embedded in bone
mineralization (approximately 30% of osteoblasts will do this)
Growth factors and cytokines – E.g. bone morphogenetic When osteoblasts becomes osteocytes they lose much of
proteins (BMPs), insulin-like growth factor (IGF), basic their secretory apparatus and become non-polarized
fibroblast growth factor (bFGF), etc, involved in regulating Have high nuclear to cytoplasm ratio
bone turnover and bone cell differentiation Produce small amounts of matrix proteins
Proteoglycans Have many narrow cytoplasmic cell processes that extend
into bone through the canaliculi to connect with processes
Linear protein core with long chain glycosaminoglycan
from other osteocytes4
side chains
It is postulated that they act as mechanosensors
Many different types
Less abundant in bone than in cartilage
Mainly regulatory function Osteoclasts
Osteoclasts are of different lineage from osteoblasts,
Bone cells osteocytes and bone-lining cells. Osteoclasts differentiate
from haematopoietic precursors
Osteoblasts, osteocytes and bone lining cells all arise from
RANK on the surface of the osteoclast precursor binds to
mesenchymal stem cells (MSC) originating in the bone
RANKL (RANK Ligand) on the surface of osteoblasts to
marrow. Osteoprogenitor cells are cells that are committed to
trigger differentiation – Physical contact between the
osteoblastic differentiation.
osteoblast and osteoclast may be required
In the presence of macrophage-colony stimulating factor
Osteoblasts2 (MCSF) the RANKL–RANK interaction stimulates
Bone-forming cells found on surface of bone transformation of the osteoclast precursor into an
Regulate activity of osteoclasts osteoclast
Form bone matrix and may also facilitate mineralisation Osteoprotegerin binds to RANKL and prevents it reacting
Deposit osteoid (type I collagen) on mineralized with RANK. Formation of osteoprotegerin is increased by
ossification front oestrogen and by strontium
Eccentric nucleus. Detect hormones at apical surface, Osteoclasts are large (20–100 μm), multinucleated giant
secrete matrix at basal surface cells, usually with between 3 and 20 nuclei
Have a number of different receptors, including PTH Osteoclasts resorb mineralized bone matrix (they cannot
receptor, 1,25-diydroxyvitamin D receptor, prostaglandin, resorb unmineralized matrix) – This action is stimulated
oestrogen and glucocorticoid by interleukin-6 (IL-6) produced by osteoblasts
691
033
Osteoclasts adhere to the bone surface at the sealing zone. Contains germinal cells
Cell attachment anchoring proteins (integrins) are Cells not organized into columns
important in this process Low oxygen tension (epiphyseal arteries pass through but
Carbon dioxide is used in the cell to form carbonic acid do not form terminal capillaries)
Matrix degrading enzymes (acid-resistant proteolytic
lysosomal enzymes such as tartrate-resistant acid Proliferative zone
phosphatase and cysteine proteinases) are synthesized Chondrocytes ordered into columns
Carbonic acid and matrix degrading enzymes secreted Cells have flattened appearance
through the ruffled border into the resorption space Cells dividing (cell at epiphyseal side of zone is mother cell)
formed by the sealing zone High oxygen tension
Removal of bone from the bone surface leaves a pit or Proliferation of cells is controlled in a local feedback loop
Howship’s lacuna by three substances synthesized by growth plate
Degradation products are absorbed back through the chondrocytes: Parathyroid hormone-related peptide
ruffled border and are then either further broken down or (PTHrP), transforming growth factor-beta (TGF-β) and
secreted into the extracellular space Indian hedgehog (Ihh)5
There are surface receptors for calcitonon. Calcitonin
causes dissolution of ruffle border Hypertrophic zone
Bisphosphonates cause loss of the ruffled border and, Production of ECM separates cells from each other
therefore, interfere with the action of osteoclasts. Matrix is mainly type II collagen and proteoglycans. The
Bisphosphonates may also induce osteoclast apoptosis main proteoglycan is aggrecan. Proteogylcans inhibit
The half-life of osteoclasts is approximately 10 days mineralization
Summary of osteoclast activity regulation: Cell division ceases
Osteoclast activity is increased by: RANKL, IL-6 Chondrocytes increase in size with proliferation of
Osteocast activity is degreased by IL-10, bisphosphonates, mitochondria and endoplasmic reticulum
calcitonin Increase in cell height responsible for about half of growth
in length of bone
Type X collagen formed (uniquely in this zone although its
Bone growth function is unknown)
Bone growth, and in particular the growth plate, is a popular Alkaline phosphatase activity high
topic in the basic science section of the examination. You
Oxygen levels low
should be able to draw a growth plate and describe its com-
Calcium accumulated in mitochondria
ponents. You should also be able to recognise a photomicro-
Matrix vesicles deposited in ECM
graph of a growth plate and not confuse it with articular
cartilage! Cell death by apoptosis (no inflammatory response, unlike
In the following section the zones of the growth plate will necrosis), with release of calcium in the zone of provisional
be desribed, followed by a list of some of the disease processes calcification
that can affect the different zones, and then finally the effects of
Zone of vascular invasion
various hormones on the growth plate will be considered.
Capillary loops break through the mineralized transverse
septum and invade the lacunae left by the apoptosed
Zones of the growth plate chondrocytes
The growth plate can be divided into a number of zones: Calcified cartilage bars replaced with woven bone
Reserve zone
Proliferative zone Secondary spongiosa
Hypertrophic zone Finally, deep to the growth plate, the woven bone remodels in
Maturation zone the metaphysis to form lamellar bone.
Degeneration zone
Zone of provisional calcification Hueter–Volkmann law
Vascular invasion zone (primary spongiosa) Increased compression at the growth plate slows longitudinal
The features of these individual zones are given below. growth.
Delpech’s law states that increasing tension on the growth
Reserve zone plate speeds growth.
Cells relatively quiescent The underlying mechanisms for this phenomenon remain
High proportion of ECM to cells unexplained.
033
Physeal–metaphyseal junction Secondary spongiosa

The physeal–metaphyseal junction is the ‘weakest’ part of the Osteopetrosis (abnormality of osteoclasts, internal
growth plate. remodelling)
Shearing forces are reduced by: Osteogenesis imperfecta
Microscopic irregularities – Mammillary processes Scurvy
Macroscopic contouring – Undulations
Effect of hormones and growth factors on the growth plate
The growth plate is affected by:
Periphery of the physis
Hormones (growth hormone, thyroxine, insulin,
Groove of Ranvier – A peripheral wedge-shaped area of
parathyroid hormone (PTH), calcitonin)7,8
chondrocyte progenitor cells that supplies reserve zone
cells to the periphery of the growth plate for lateral growth Growth factors (transforming growth factors, bone-derived
growth factor (BDGF), epidermal growth factor (EGF) and
Perichondral ring of Lacroix – Dense fibrous band at the
fibroblast growth factor (FGF))
periphery of the growth plate, which anchors and supports
the physis Vitamins (vitamins A, C and D)
These factors influence chondrocyte proliferation and matur-
ation and matrix synthesis and mineralization. Some factors
Growth in width of long bones have a specific effect on a particular zone whilst others affect
Long bones increase in width by intramembranous ossification the entire growth plate.
(appositional growth) from the osteogenic cells in the inner
layer of the periosteum. Reserve zone
Parathyroid hormone
Premature growth plate arrest (physeal injuries) Interleukin-1 (IL-1)
Physeal injuries can result in a bridge (bar) of bone forming
across the physeal cartilage. The bars can be central, periph- Proliferative zone
eral or linear. A central bar may lead to limb length discrep- Thyroxine
ancy and a more peripheral bar may cause angular Growth hormone
deformity. Insulin
Transforming growth factor-beta (TGFβ)
Diseases affecting the growth plate
Reserve zone Hypertrophic zone
TGFβ
Diastrophic dwarfism
BDGF
Pseudoachondroplasia
Vitamin D
Gaucher’s disease
Calcitonin
Proliferative zone Specific effects of hormones and vitamins
Achondroplasia Thyroxine
Gigantism
Increases DNA synthesis in cells in the proliferative zone.
Malnutrition
Irradiation
Parathyroid hormone
Direct mitogenic effect on epiphyseal chondrocytes and stimu-
Hypertrophic zone (zones of maturation, degeneration)
lates proteoglycan synthesis.
Mucopolysaccharidoses
Hypertrophic zone (zone of provisional calcification) Calcitonin

Rickets Accelerates growth plate calcification and cellular maturation.
Osteomalacia
Glucocorticoids
Slipped upper femoral epiphysis (SUFE)
Decrease proliferation of chondroprogenitor cells.
Primary spongiosa
Metaphyseal chondroplasia Growth hormone
Acute oteomyelitis Affects cellular proliferation.
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Vitamin D Control of bone remodelling and modelling6,7

Vitamin D deficiency results in an elongation of the cell Hox and Pax genes are involved via systemic hormones and
columns in the growth plate. local cytokines, growth factors, matrix metalloproteins and
other factors. Mechanical loads on bone also affect bone
Bone remodelling remodelling, probably in response to piezoelectric phenomena.
Bone remodelling is essential to bone function. Bone is Wolff’s law
a dynamic material and remodelling is occurring con-
Bone remodels according to the stresses applied to it: More
tinuously. You should be well practised in drawing a
stress results in more bone formation and vice versa.
cutting cone, or in recognising its features on a
photomicrograph. Molecular mechanisms
Bone adjusts to match its functions by the process of Control of remodelling is not completely understood
remodelling; woven bone remodels to lamellar bone, There is a ‘coupling’ between resorption and formation
damaged bone is replaced and bone adjusts to the forces that is regulated through a complex mechanism
placed through it by this process
PTH can cause bone-lining cells to retract, thus, exposing
In coupled bone remodelling there is no net change in bone the bone surface to osteoclasts. Osteocytes may also be
mass, but if uncoupling occurs between resorption and involved in this regulation
formation there will be a change in bone mass
PTH acts on osteoblasts but not on osteoclasts. For PTH to
Bone turnover in adults amounts on average to stimulate osteoclasts it must first act on osteoblasts, which
approximately 5% per year form M-CSF (see osteoclast section bullet point 2) and
The sequence of events consists of resorption of bone RANKL, which in turn binds to RANK on the osteoclast
from a surface (possibly being preceded by retraction of precursor surface to cause differentiation and stimulation
bone lining cells), leading to the formation of a of the resulting osteoclasts
Howship’s lacuna, followed by the appearance of Osteoblasts produce IL-6, which stimulates the osteoclasts
osteoblasts that lay down new bone. Finally, the to resorb bone
osteoblasts become osteocytes, bone-lining cells or
Osteoblasts also respond to RANKL to increase bone
apoptose formation
The group of cells involved in the process is termed a basic OPG (osteoprotegerin) binds to RANKL and inactivates it,
multicellular unit (BMU) thus, blocking the differentiation of osteoclasts. OPG
A remodelling unit (BRU) is an area of bone that has been production is stimulated by oestrogen
remodelled by a BMU
Bone resorption may also release BMP, TGFβ and IGF-1
The change from resorption to bone formation is termed a from the matrix, which then stimulate osteoblast
reversal differentiation
The junction between the original bone and the site where When coupling is balanced the bone mass will not change
resorption ceased and new bone formation commenced In summary, the control of bone adaptation to stresses placed
forms a cement line or reversal line through it, and the general process of bone remodelling, is not
The resorption phase is much shorter than the formation completely understood. There is known to be a complex mech-
phase, in line with the half lives of osteoclasts and anism of homeostasis with interaction between the osteoblasts
osteoblasts, respectively and osteoclasts, which probably also involves osteocytes and
In trabecular bone the result of a remodelling cycle at a bone-lining cells. Control is mediated by a number of factors.
particular site is the formation of a packet
Remodelling can only take place at a bone surface, so in
cortical bone a surface must be created; this is done by the
Biomechanics of bone
formation of a cutting cone Bone, like all biological materials, is viscoelastic and aniso-
A cutting cone consists of a group of osteoclasts at the tip tropic; this means that its mechanical properties are time-
of the cone, which resorb the bone to create a tunnel. dependent and that they vary with the direction of loading.
Behind the cutting cone a blood vessel forms and Cortical bone tends to be stiffer and stronger in the axis of
osteoblasts differentiate. The osteoblasts lay down bone the osteons
matrix, which then becomes mineralized at a calcification Cortical bone demonstrates transverse anisotropy – The
front. Some of the osteoblasts become entombed in the new mechanical properties within a given plane are similar but
bone to form osteoclasts. The result is a new osteon with a differ from those through a plane perpendicular to the
Haversian canal given plane
The new bone may cut across previous osteons to leave Cortical bone stiffness and strength are higher at higher
partial osteons or interstitial lamellae strain rates
033
Cortical bone become less ductile and more brittle at very Chondroblasts and fibroblasts differentiate and form
high strain rates collagen (mainly type II) and fibrous tissue. Proteoglycans
Trabecular bone has lower stiffness and strength than are produced, which suppress mineralisation. The
cortical bone chondrocytes then release calcium into the ECM and also
Trabecular bone is less anisotropic than cortical bone protein-degrading enzymes that break down the
Trabecular bone compressive strength is highly dependent proteoglycans, thus, allowing mineralization to take place
on its density Stage 3: 1–4 months. Hard callus forms. The soft callus is
Trabecular bone is relatively tough (it absorbs a high invaded by new blood vessels and chondroclasts break
amount of energy before failing completely) down the calcified callus, which is replaced by osteoid (type
Trabecular bone yield point is independent of its mass or I collagen) formed by osteoblasts. The osteoid calcifies to
the applied load but depends almost entirely on the strain - form woven bone. The osteoid callus is stiffer than the soft
the strain before yield will, therefore, be the same for chondroid callus
osteoporotic and normal bone; the applied load to achieve Stage 4: Remodelling – Several years. The woven bone is
that strain will, however, differ between the two as the remodelled to lamellar bone. The medullary canal reforms
normal bone is stiffer than the osteoporotic bone as the bone remodels in response to the stresses placed
upon it
Fracture healing
Fracture healing can occur by primary or secondary bone Bone graft
healing. Function
Mechanical (structural support)
Primary bone healing Biological (bone healing)
Requires close anatomical reduction with minimal
movement at the fracture site (<2% strain)
In the initial stages, osteoblasts differentiate from Graft properties
mesenchymal cells and lay down woven bone in any gaps. Osteoconductive
Lamellar bone may be laid down directly if there are Acts as three-dimensional scaffold or matrix on which new
no gaps bone forms
Remodelling then occurs across the fracture site, with Supports ingrowth of capillaries, perivascular tissues and
cutting cones passing across the fracture site osteogenic precursor cells
Healing is slow Example – Coral scaffolds
Secondary healing (by callus) Osteoinductive

Requires some motion at the fracture site (>2% but Provides a biological stimulus that has the capacity to
<10%)8 activate and recruit from the surrounding mesenchymal-
type cells, which then differentiate into cartilage-forming
Hard callus forms under periosteum at periphery
and bone-forming cells
Endochondral callus – Fibrocartilage forms, becomes
calcified and is then replaced with bone Mediated and regulated by graft-derived factors, including
TGF, BMPs (bone morphogenetic proteins), IGF-1 and
In secondary healing by callus, the callus undergoes a
IGF-2 (insulin-like growth factors), interleukins, etc
process of progressive stiffening. In the earlier, less stiff,
stages it is more resilient to movement at the fracture site Example – Fresh frozen allograft
but less good at taking loads or resisting deformation. The
strength of the healing fracture does not necessarily Osteogenic
correlate with its stiffness Graft contains living cells that are capable of differentiation
into bone
Stages of secondary fracture healing by callus Graft has inherent biological activity
Stage 1: First week. Haematoma formation with invasion Example – Fresh allograft
of macrophages, leukocytes and lymphocytes.
Proinflammatory cytokines (including IL-1 and IL-6 and
tumour necrosing factor α), and peptide signal molecules
Genetics
(including BMPs, TGFβ and PDGF) are present. Autograft (same individual) – Including vascularized and
Progenitor cells invade. Granulation tissue forms free grafts
Stage 2: 1 week to 1 month. Soft callus forms. In this stage, : No immunogenicity
fibrous tissue, cartilage and woven bone form. : No risk of disease transmission
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: Cheap Table 30.1 Autograft incorporation in cancellous and cortical bone

: Donor site morbidity Autograft Cancellous Cortical
Allograft (another individual, same species) incorporation
:No donor site morbidity Revascularization Rapid Slow, used for
:Slow incorporation rate structural defects
:Risk of disease transmission Mechanism and Osteoid laid down Donor bone
:Immunogenic order of repair on dead bone, reabsorbed before
Xenograft (different species) donor bone later laying down of
reabsorbed appositional new
: As allograft but greater potential for rejection bone
Isograft (genetically identical – Twins or clones!)
Radiographs Radiodense Loss of mechanical
strength and
Tissue composition reduced
Cortical radiodensity
Cancellous Completeness of All donor bone Some necrotic
Corticocancellous repair eventually removed. bone remains.
Osteochondral Creeping Cutting cones
Bone marrow aspirate substitution
Preservation methods
3. Osteoinduction: Osteoblast and osteoclast function
Fresh graft: Highest antigenicity. Viable cell population
4. Osteoconduction: New bone forms over scaffold
with associated cytokine growth factors
5. Remodelling: Process continues for years
Fresh frozen: Less immunogenic than fresh.
Preserves BMPs Following bone grafting, a haematoma rich in nutrients forms
Freeze dried: Least immunogenic. Loss of structural around the bone graft. Platelet-derived growth factor (PDGF)
integrity. Depleted BMPs attracts lymphocytes, plasma cells, osteoblasts and polynuclear
In bone matrix gelatin (BMG) cells to the bone graft. Necrosis of the graft occurs and an
inflammatory response is established, with which granulation
tissue forms, with an ingrowth of capillary buds bringing
Processing macrophages and mesenchymal cells. Fibrovascular stroma
To remove superfluous proteins, cells and tissues to: develops with an influx of osteogenic precursors and blood
Reduce disease transmission vessels. IL-1, IL-6, BMP and IDGF are secreted, stimulating
Reduce immune sensitization osteoblast and osteoclast activity. The graft is penetrated by
Allow better graft preservation osteoclasts, which initiate the resorptive phase and
Methods: incorporation.
Physical debridement of unwanted tissue These earlier stages are similar for both cortical and can-
cellous bone, but the osteoconduction and remodelling
Ultrasonic processing with or without pulsatile washing to
remove remaining cells and blood stages differ between the two types of bone, as indicated in
Table 30.1.
Ethanol to denature cell proteins and reduce bacterial and
In cancellous bone graft the graft is eventually replaced
viral loads
during the remodelling phase by a process of creeping substi-
Antibiotic soak to kill bacteria
tution; osteoblasts laying down new bone on the scaffold of
Freezing or freeze drying dead trabeculae with simultaneous osteoclastic resorption.
Sterilization (aseptic vs irradiation if contaminated) In cortical bone graft the initial inflammatory response is
slower and osteoclastic resorption then occurs by cutting cones
Graft incorporation entering the graft. Mechanical strength is lost in the first 3–6
The process by which invasion of the graft by host bone months and returns over 1–2 years.
occurs, such that the graft is replaced partially or completely
by host bone. Bone banking
Contraindications to allograft donation:
Five stages of graft healing (Urist) Any evidence of current symptomatic infection
1. Inflammation: Chemotaxis stimulated by necrotic debris History, or suspicion, of past infections: TB, hepatitis B and
2. Osteoblast differentiation: From precursors C, sexually transmitted diseases
033
HIV and high-risk activities for HIV Bioactive glass

Malignancy Silica-based, containing calcium oxide and phosphate
Dementia Form surface layer of hydroxyapatite when implanted
Long-term steroid use Current versions have no structural strength
Metabolic bone disease
Any condition of uncertain aetiology where altered Bone morphogenetic proteins
immune competence or viral involvement is suspected or BMPs are cytokines
implicated: Rheumatoid arthritis, CJD, multiple Over 20 discovered
sclerosis, etc
Most useful appear to be BMP-2, BMP-7 and BMP-14,
Detailed past medical history and social history is obtained. which are all members of TGFβ supergene family
Serological testing is carried out for:
BMP-2 and BMP-7 shown to have osteogenic properties
Hepatitis B and C Current versions not yet proven but may work best in
Syphilis conjunction with matrix
HIV
Rhesus status
Bone circulation
Bone receives 5–10% of the cardiac output.
Bone graft substitutes
Calcium sulphate
For use as bone substitute the crystals need to be regular
Anatomy
shaped and uniform in size The blood supply is from three sources:
Osteoblasts can attach to calcium sulphate and osteoclasts High pressure nutrient artery system
can resorb it Metaphyseal–epiphyseal system
Low pressure periosteal circulation
Calcium phosphate ceramics
Calcium phosphate ceramics are made from mineral salts by Nutrient artery system
sintering. They form an osteoconductive material. High pressure system
The nutrient artery originates as a branch from the major
Hydroxyapatite artery of the systemic circulation
Based on corals. The calcium carbonate in natural coral can The nutrient artery enters the mid-diaphyseal cortex (outer
be substituted with hydroxyapatite and inner tables) through the nutrient foramen to enter the
Form a good scaffold for bone formation medullary canal. The foramen passes at an angle to the
Brittle and poor strength cortex with respect to epiphyseal growth centres in long
bones; hence, ‘from the knee I flee, to the elbow I go’
Tricalcium phosphate The nutrient artery branches into ascending and
Partially converted to hydroxyapatite once implanted descending arteries, which divide into arteriole branches
supplying the inner two-thirds of the diaphyseal cortex
Calcium phosphate-collagen composites from within (endosteal supply)
Collagen (types I and III) combined with hydroxyapatite or
tricalcium phosphate Metaphyseal–epiphyseal system
No structural strength The periarticular vascular complex penetrates the thin
Osteoconductive properties cortex and supplies the metaphysis, physis and epiphysis
In epiphyses with large articular surfaces, such as the
Calcium phosphate cement femoral and radial heads, the vessels enter in the region
Paste made from calcium and phosphate between the articular cartilage and the physis and, hence,
When mixed forms dahllite the blood supply can be tenuous
Has osteoconductive properties but is mainly used as an aid
to fixation Periosteal system
Examples include Norian SRS and α-BSM Low pressure system
The periosteal system forms an extensive network of
Polymers capillaries covering the entire length of the bone shaft
Polyglycolic acid and polylactic acid have osteoconductive Supplies the outer one-third of the cortex
properties Very important in children, for circumferential bone
Structural scaffold growth (appositional)
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033
Physiology: Direction of flow Calcium and phosphate levels are primarily regulated by
two hormones
In mature bone the flow is centrifugal (inside to outside)
The direction is reversed in a displaced fracture when there : PTH
is disruption of the endosteal supply : Vitamin D and its metabolites
Arterial flow in immature developing bone is centripetal The interaction between PTH and Vitamin D is complex and
(outside to inside) because the periosteum is highly regulated by a series of feedback loops.
vascular and is the predominant component of bone
blood flow Parathyroid hormone
Venous flow in mature bone is centripetal, with cortical Parathyroid hormone (PTH) is the primary immediate regula-
capillaries draining into venous sinusoids to the emissary tor of calcium levels in the blood.
venous system PTH is a peptide containing 84 amino acids, secreted by the
Remember Batson’s valveless venous plexus – Accounting chief cells of the parathyroid glands. PTH has effects on bone
for the spread of infection/tumour between the metabolism both as a result of direct effects and also via its
retroperitoneum and the spine effect on the vitamin D pathway, in stimulating production of
the active form of vitamin D (1,25-dihydroxycholecalciferol)
Regulation rather than the inactive form (24,25-dihydroxycholecalciferol).
Blood flow to bone is under the regulation of metabolic, Active PTH is formed from a 115 aminoacid polypeptide
humoral and autonomic inputs ‘Pre-pro-PTH’, the 115 precursor is initially cleaved to a
The vessels within bone possess a variety of vasoactive 90 amino acid chain and then to the 85 amino acid chain
receptors If serum calcium levels fall there is an increase in secretion
The arterial system of bone has greater potential for of the active 85 amino acid form within seconds to minutes
vasoconstriction than for dilatation The half life of the 84 amino acid form is 2 to 4 minutes
If the calcium levels remain low degradation of the active
Blood flow to bone after fractures PTH in the parathyroid cells is decreased within about
an hour
Bone blood flow is the major determinant of fracture
If levels of calcium remain low increased gene expression of
healing
PTH occurs within hours to days
Bone blood flow delivers nutrients to the site of bony injury
If levels of calcium still remain low the number of
The initial response after fracture is decreased bone flow parathyroid cells increases within days to weeks
after vascular disruption at the fracture site, with reversal of
flow to become centripetal if the endosteal flow is disrupted Effect on intestine
Within a few hours to days bone blood flow increases (a No direct effect
regionally accelerated phenomenon) and peaks at 2 weeks, Indirectly increases calcium absorption via effect on
returning to normal at between 3 and 5 months vitamin D pathway
Effect on kidney
Bone metabolism
Increases reabsorption of filtered calcium in the kidney
Questions on calcium and vitamin D metabolism are common
in the basic science section of the exam and yet many candi- Increases phosphate urinary excretion (decreases
dates come completely unprepared on this topic. re-absorption)
Stimulates hydroxylation of 25-hydroxycholecalciferol in
99% of body calcium is stored in the bone
the proximal tubular cells
The extraosseous fraction, although constituting only 1%
of the total, is vital for functioning of nerves and muscles, Effect on bone
and also in the clotting cascade
Stimulates osteoclastic resorption of bone (this requires a
Many disorders of bone metabolism are ‘side effects’ of ‘permissive’ level of active Vitamin D)
problems with calcium and phosphate control systems
Mobilizes calcium and phosphate from bone
Calcium circulates in the plasma in two forms
: Bound to albumin, amounting to just under half the total. Net effect
The calcium bound to albumin is physiologically inactive Increases serum calcium
: Free ionized calcium, which is physiologically active Effect on phosphate levels may be neutral due to the
The normal plasma concentration of phosphate is between opposing effects on bone and kidney
2.2 and 2.6 mmol/l. When interpreting the plasma level of If continuous effect is to increase bone resporption, mainly
calcium, the level of free ionized calcium should be assessed through effect on RANKL and osteoprogeterin
by noting the albumin concentration in the specimen If intermittent facilitates bone formation
033
In bone
Regulates osteoblast function
Facilitates PTH induced osteoclast activation
Net effect of vitamin D

Increases calcium levels in the blood/serum
Usually increases phosphate level in blood (effect on gut is
partially balanced by effect on kidney via FGF23)
Facilitates bone formation
If blood levels of calcium and phosphate are low can cause
bone resporption
Figure 30.3 Vitamin D metabolism

Calcitonin
Calcitonin is a peptide containing 32 amino acids, secreted by
Factors stimulating production the parafollicular C cells of the thyroid gland. It is of lesser
importance in the regulation of calcium than PTH and
Decreased serum calcium
vitamin D.
Factors inhibiting production
Effect of calcitonin
Raised serum calcium
Kidney – Decreases calcium reabsorption
Raised serum 1,25-dihydroxycholecalciferol
Gut – Decreases calcium absorption
Bone – Decreases osteoclast resorption of bone
Vitamin D
Figure 30.3 shows the metabolic pathway for vitamin Factors stimulating production
D metabolism. 1,25-vitamin D is broken down into at least Elevated serum calcium
25 different metabolites, which have different metabolic
actions. The overall action of vitamin D is, therefore, complex. Factors inhibiting production
Vitamin D is both manufactured in the skin and ingested Decreased serum calcium
in the diet
Vitamin D is fat soluble Feedback loops
In the skin UV radiation converts the precursor There are a number of feedback loops in the control of calcium
7-dehydrocholesterol into vitamin D3. Between 10 and 15 and phosphate levels. These are shown in Figure 30.4.
minutes’ exposure of the face and hands to sunlight is sufficient
Increased serum calcium causes a decrease in PTH and a
to produce the minimum daily requirement of vitamin D
decrease in production of the active form of vitamin D
Vitamin D (vit D2) is ingested as ergocholesterol in the
Decreased serum calcium causes an increase in PTH and an
diet; this is found in fish oils and some plants
increase in production of 1,25 vitamin D
: Vitamin D undergoes two hydroxylations to form the Increased serum phosphate causes a decrease in production
active form – 1,25-dihydroxycholecalciferol of 1,25 vitamin D
: The first hydroxylation takes place in the liver Increased levels of 1,25 vitamin D cause a decrease in PTH
: The second hydroxylation takes place in the kidney Increased levels of 1,25 Vitamin D cause an increase in
: The vitamin D2 from the gut is incorporated into production of FGF23, which suppresses re-absorption of
micelles and transported to the liver in chylomicrons phosphate
: The vitamin D3 from the skin is transported to the liver It is of note that in autosomal dominant hypophosphataemic
bound to Vitamin D binding protein rickets degradation of FGF23 is impaired, leading to excessive
loss of phosphate.
Effects of vitamin D
In intestine Clinical manifestation of abnormal calcium levels
Causes increased calcium absorption Hypercalcaemia
Causes increased phosphate absorption
Clinical features
In the kidney May be asymptomatic
Causes increased calcium retention ‘Bones’ – Excessive bone resorption
Causes increased phosphate excretion (via effect on FGF23) ‘Stones’ – Renal calculi, polyuria, polydipsia
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033
Ca PO4
– Multiple endocrine
– Familial hypocalciuric hypercalcaemia
Sarcoidosis
1,24 Vit D Steroids
PTH Vitamin D intoxication
Hypocalcaemia
Clinical features – Acute
+ve Neuromuscular irritability (tetany, seizures, Chvostek’s
FGF23 (Fibroblast sign, Trousseau’s sign)
Growth Factor 23) Depression
Kidney Perioral paraesthesia
ECG shows prolonged QT interval
Clinical features – Chronic

1,25 – dihydroxyvitamin D Cataracts
Fungal nail infections
Causes
Thyroid surgery or hypothyroidism
Kidney Bone Gut
Re-absorb Mobilise Ca++ Absorb
Hypoparathyroidism
Ca++ Ca++& PO4
Hyperparathyroidism
Hyperparathyroidism may be either primary or secondary.
Secondary parathyroidism occurs in response to low serum
calcium levels.
Ca PO4
Primary hyperparathyroidism
Parathyroid adenoma (up to 90% of cases) – Usually
solitary, occasionally multiple
Parathyroid chief cell hyperplasia
Figure 30.4 Feedback loops in calcium regulation Parathyroid carcinoma (rare – 1%)
‘Groans’ – (gastrointestinal) nausea, vomiting, Secondary (elevated PTH secretion in response to low calcium levels)
constipation, abdominal pain, anorexia Chronic renal failure (see section on chronic renal
‘Moans’ – (CNS) lethargy, disorientation, hyperreflexia failure)
Other side effects – Sudden cardiac arrest, Vitamin D deficiency or calcium deficiency in diet
hypotension Malabsorption
Causes Effects of hyperparathyroidism phosphate and calcium levels in blood

Malignancy Decreased phosphate levels
:Bone destruction from bone metastases or myeloma : Increased excretion in urine
:PTH-like secretion of malignant tumours, e.g. Increased calcium levels
squamous cell carcinoma
: 1,25-dihydrocholecalciferol synthesis in lymphoma : Increased absorption from intestine
Endocrine
: Increased reabsorption from kidney
: Increased mobilization from bone
:Pituitary
:Thyroid
Effects of hyperparathyroidism on bone
:Adrenal
Calcium from bone is predominantly mobilized from the
Genetic
cortical bone, leading to loss of the lamina dura in the teeth,
: Familial subperiosteal resorption and osteitis fibrosa cystica.
033
Radiological features of hyperparathyroidism Pigeon chest

Diffuse demineralization (osteopenia) Protuberant abdomen, hepatomegaly
Subperiosteal resorption (radial borders of proximal Kyphosis
phalanges and tufts of terminal phalanges, skull, medial Genu valgum or varum, anterolateral bowing of distal tibia
end of clavicle) and secondary adaptive changes in the foot
Osteitis fibrosa cystica (‘brown tumours’) – Increased giant Coxa vara, anterolateral bowing of the femur
cells, extravasation of RBCs, haemosiderin staining, fibrous Waddling gait
marrow replacement
Chondrocalcinosis and metastatic calcification of soft
tissues
Clinical features of osteomalacia
Much more insidious onset that rickets
Shaggy trabeculae
Bone pain initially vague and non-specific but gradually
Deformed osteopenic bones
becoming more severe and sometimes localized
Rugger jersey spine
Proximal muscle weakness
Bilateral sacroiliac joint widening and erosion
The appearances are caused by increased osteoclastic resorp-
tion of bone. Attempts at bone repair fail because of poor Radiology
mineralisation caused by low phosphate. Both rickets and osteomalacia
Looser’s zones (stress fractures on concave side of bones)
Laboratory findings Milkman ‘pseudofractures’ on concave side of bones
Elevated PTH levels (fractures that have united but not mineralized)
Elevated plasma calcium Biconcave ‘cod fish’ vertebrae – Can lead to kyphosis
Depressed plasma phosphate Generalized osteopenia
Osteomalacia and rickets Rickets

Osteomalacia is a defect of skeletal mineralization caused by a Growth plate enlarged, thickened and widened,
deficiency of the active metabolites of vitamin D or a defi- disorientated
ciency of phosphate. The result is an accumulation of Metaphysis cupped, flared and jagged
increased amounts of unmineralized matrix (osteoid) and a Trefoil pelvis
decreased rate of bone formation.
Rickets is the juvenile form of osteomalacia with impaired Causes of osteomalacia
mineralisation of cartilage matrix (chondroid) affecting the
Candidates frequently have difficulty remembering the long
physis in the zone of provisional calcification. There is a failure
list of potential causes of osteomalacia and rickets. It is helpful
to form primary spongiosa.
to group the causes in a systematic way. A useful way of doing
this is to think of the causes as falling into three main categor-
Clinical features of rickets ies: Intake problems, processing problems and output
The clinical features depend on the severity of the deficiency problems.
and the age of onset. Intake problems – Affecting the supply of ‘raw materials’
Inadequate exposure to sunlight
General features Nutrional deficiency (usually vitamin D)
Retarded bone growth causing short stature
Symptoms of hypocalcaemia
:Vitamin D deficiency
Under the age of 18 months may present with failure to
:Calcium chelators – E.g. oxalates
thrive, restlessness, muscular hypotonia, convulsions or
:Phosphorus – E.g. aluminium antacids
tetany but only minimal bone changes Failure to absorb in the gut
Localized features – ‘skull to toe’ :Biliary disease – Interferes with fat-soluble vitamin D
Delayed fontanelle closure and frontal and parietal bossing :Short bowel syndrome
Dental disease :Rapid transit syndrome
Rachitic rosary (enlargement/hypertrophy of :Crohn’s and coeliac disease
costochondral junction) Processing problems – Affecting the processing of the raw
Harrison’s sulcus (groove/sulcus/depression in the sternum materials. Problems with synthesis or activity of 1,25-
where the diaphragmatic attachments pull on the dihydrocholecalciferol.
softened ribs) Vitamin D-resistant rickets
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: Type I – Genetic or acquired deficiency of the Renal osteodystrophy

enzyme converting 25-hydrocholecalciferol to
Renal osteodystrophy is a topic that many candidates find
1,25-dihydrocholecalciferol
difficult. The subject can be simplified by thinking of the two
: Type II – Organ insensivity to 1,25- main routes by which renal disease affects bone:
dihydrocholecalciferol
Anticonvulsant medication As a result of damage to the renal tubules, the synthesis
of the active form of vitamin D is impaired, resulting in
: Enzyme that increases vitamin D metabolites induced impaired calcium absorption in the gut and loss of calcium
in liver (phenytoin, phenobarbitone, etc) from the kidneys
Autosomal dominant hypophosphataemic rickets – As a result of glomerular damage, uraemia and
Deficient enzyme that degrades FGF23 phosphate retention occur. The elevated phosphate
Hypophosphatasia – Autosomal recessive; defective levels further suppress activation of vitamin D in the
phosphate synthesis; increased urinary kidney
phosphoethanolamine The low serum calcium levels can then lead to excessive
Output problems – Affecting the preservation/recycling of parathyroid production, which leads to the features of
essential ingredients hyperparathyroidism, which can be further exacerbated by
X-linked hypophosphataemic vitamin D-resistant rickets/ the elevated phosphate levels, resulting in ectopic
osteomalacia calcification
Albright’s syndrome Renal osteodystrophy can, therefore, be divided into two
Fanconi syndrome – Several types main types
Phosphaturia and glycosuria ± aminoaciduria : High turnover where there is a chronic elevation of the
Renal tubular acidosis PTH levels
: Acquired (systemic disease) : Low turnover where the PTH levels are normal or
: Genetic reduced
The resulting clinical and radiological picture is complex
– Debré-de Toni–Fanconi syndrome The changes seen in renal osteodystrophy are summarized in
– Lignac–Fanconi syndrome Figure 30.5 and Table 30.2.
– Lowe’s syndrome
Renal osteodystrophy Osteoporosis

Predicted demographic changes indicate that fragility fractures
Most common causes of rickets/osteomalacia will probably become increasingly common over the next few
To make sense of this list it is also useful to bear in mind the decades. Questions on osteoporosis are, therefore, very likely
most common causes, which are: to arise in the exam as they have great relevance to clinical
Chronic renal failure practice.
Vitamin D deficiency The WHO consensus definition states that osteoporosis is a
Vitamin D pathway abnormalities systemic skeletal disease characterized by low bone mass and
Hypophosphataemic syndromes microarchitectural deterioration of bone tissue, leading to
Rarer causes include: enhanced bone fragility and a consequent increase in
fracture risk.
Renal tubular acidosis
The usually accepted diagnostic criterion is a bone mineral
Aluminium toxicity
density lower than 2.5 standard deviations below the mean for
Hypophosphatasia a race- and sex-matched young adult (i.e. below peak bone
Mesenchymal tumours causing hypophosphataemia mass for a group of the same race and sex).
The biochemistry in osteoporosis is normal.
Diagnosis of osteomalacia
Clinical Risk factors
: Proximal muscle weakness Primary osteoporosis
: Bone pain and tenderness Genetic: Positive family history, white or Asian, thin
: Fracture (incomplete or bilateral) Hormonal: Loss of oestrogen protection
Blood tests depend on cause Environmental/lifestyle: Smoking, excessive alcohol,
Tetracycline-labelled bone biopsy best (also needed to inactivity
detect aluminium deposition) Diet: Deficiency of calcium or vitamin D
033
Secondary osteoporosis Radiographic absorptiometry

Chronic medical conditions: Endocrine, GI, chronic liver DEXA scan
disease, chronic renal failure Dual energy x-ray absorptiometry (DEXA): This is currently
Drugs the ‘gold standard’ method for detecting and assessing osteo-
porosis. It is quick and accurate and involves a low radiation
Type I and type II osteoporosis dose. The technique involves simultaneous measurement of the
Type I: Affects mainly cancellous bone at the time of passage through the body of x-rays with two different energies.
menopause, so vertebral and distal radial fractures are By using two different energy beams it is possible to minimize
common: Related to loss of oestrogen at the menopause; the effect of soft tissues, particularly fat, on the result.
high turnover osteoporosis Causes of false-negatives in the spine
Type II: Age-related and affects cortical and cancellous bone; :
Osteoarthritis with resulting osteophytes and sclerosis
occurs 10–15 years later than type I; poor calcium
Cause of false-positive in the spine
absorption; low turnover osteoporosis
: Previous laminectomy
Assessment Quantitative CT
Pitfall: Avoid commenting on osteoporosis on a single plain
Accurate for vertebral cancellous bone, but expensive and
radiograph; the most you can say is that the bones appear
involves a high radiation dose.
osteopenic.
Quantitative ultrasound
Table 30.2 Renalosteodystrophy This is inexpensive and the machine is portable. It involves no
ionizing radiation. It is not at present as accurate as DEXA
High bone turnover Low bone turnover
scanning but gives information about the architecture and
• Phosphate retention • Aluminium elasticity of bone.
deposition
T- and Z-scores
– Reduced 1,25-dihydrocholecalciferol – PTH release
inhibited T-scores present the result as the number of standard devi-
ations above or below the mean peak bone mass for a popula-
• Low PTH
tion matched for sex and race.
• Osteomalacia Z-scores present the result as the number of standard
• High PTH (secondary deviations above or below the mean bone mass for population
hyperparathyroidism) matched for age, race and sex.
As the Z-score is measured against an age-matched group
– Osteitis fibrosa cystica
it cannot detect age-related osteoporosis. The T-score is used
– Osteosclerosis for diagnosis of osteoporosis. A low Z-score, however, indi-
– Soft-tissue calcification cates that the osteoporosis is not age-related and, therefore, a
cause for the condition should be sought as there may be some
But pattern of calcium and bone changes is complex
treatable condition.
(a) (b)
Figure 30.5 (a, b) Renal osteodystrophy
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Treatment and management Teriparatide (recombinant PTH)

Evaluation of vertebral fractures in the osteoporotic patient Increases bone formation and improves microarchitecture
(acronym TOMEO) Activates bone-lining cells and osteoblasts
Reduces the likelihood of both vertebral and non-vertebral
Screen for:
fractures
T – Tumour (radiographs, bone scan, MRI and CT)
O – Osteopenia (DEXA scan)
M – Marrow (full blood count and serum electrophoresis) Paget’s disease
E – Endocrine (parathyroid, Cushing’s disease, thyroid
function, diabetes) Epidemiology
O – Osteomalacia (screening for Vitamin D deficiency) Prevalence is 3–4% in the over 40-year-old age group, 10%
in >90 years
Simple measures Most common in North America, England, Northern
Stop smoking Europe and Australia
Reduce excessive alcohol intake Very rare in Scandinavia, Asia and Africa
Exercise and healthy diet Family history in 15–25% of cases
Polyostotic 83%, monostotic 17%
Calcium and vitamin D
Decreases bone resorption but does not increase bone mass
or density
Pathology
Evidence to suggest modest protective effect – More Increased osteoclast size and number leading to increased
effective for type II osteoporosis bone resorption, followed by compensatory increase in
disorganized osteoblastic bone formation
Bisphosphonates Accelerated but disorganized bone remodelling; a chaotic
over-activity in bone
Inhibit/kill osteoclasts
Preferentially bind to mineral component of bone, which is Bone is rapidly laid down and also rapidly resorbed
exposed by osteoclasts Bone is both enlarged and biomechanically weak
Non-nitrogen containing Bisphosphonates cause loss of Bone is:
function/apoptosis of osteoclasts by causing accumulation Poor quality
of ATP metabolites within the cell Very vascular
Nitrogen containing bisphosphonates inhibit production Thickened and bent
of cholesterol, which in turn interferes with the cell Weak
membrane Mosaic pattern with irregular areas of lamellar bone
Consider in cases where steroid intake implicated Erratic cement lines
Be aware of the risk of osteonecrosis of the jaw in patients Marrow tends to become fibrous
undergoing bisphosphonate treatment
For post-menopausal women and men alendronate is
currently the most commonly used, with risedronate and Pathological phases (acronym: LAB)
etidronate as alternatives L – Lytic (osteolytic): A front of osteoclastic resorption is
seen, usually near the metaphyseal region of a long bone or
Oestrogen therapy (HRT) osteoporosis circumscription in the skull
Increases risk of breast cancer and uterine cancer A – Active (mixed): Both osteoblastic resorption and
(if progesterone not included) osteoblastic bone formation occur in the same area of bone
Helps to decrease bone resorption and slows progression B – Burnt-out (sclerotic): A dense mosaic pattern of bone is
of osteoporosis but does not increase bone mass seen
Best within 6 years of menopause
Doubles the risk of DVT/PE
Laboratory
Selective oestrogen receptor modulators (e.g. raloxifene) Serum calcium usually normal
Works like oestrogen to prevent bone loss but may increase Raised alkaline phosphatase (bone)
menopausal symptoms Raised serum acid phosphatase
Good evidence for protection against vertebral but not hip Raised urinary hyroxyproline and collagen-derived cross-
fractures linked peptides (markers of collagen turnover)
033
Aetiology Osteitis fibrosa cystica (hyperparathyroidism)

Fibrous dysplasia
Precise cause unknown
Osteoblastic secondaries
Probably a viral origin as Pagetic osteoclasts have been
shown to contain mRNA from paramyxoviruses and Osteopetrosis
canine distemper virus Lymphoma
Clinical features Management

A: Arthritis Most patients require no active treatment.
B: Blood flow complications (high output cardiac failure)
C: Cranial nerve compression Calcitonin
D: Deformities (long bones, spine) Lowers bone turnover by decreasing activity and number of
P3: Pain, pathological fracture, pseudarthrosis osteoclasts
M2: Metabolic abnormalities (hypercalcaemia), malignant Must be given parenterally. When discontinued, bone
change activity levels quickly return to pre-treatment levels but relief
Lesions detected on bone scan are usually painful, but many of of pain may persist for months
those seen on x-ray are not. Bone pain is unrelated to activity
and is worse at night. Acute pain is related to fractures. Severe Bisphosphonates
pain should arouse suspicion of sarcomatous change. Slow down both the formation and dissolution of calcium
hydroxyapatite
Radiological features Narrow therapeutic window between resorption inhibition
Long bones and mineralization defect
Trabeculae of cancellous bone thickened, coarse, irregular Early complication – Hypocalcaemia
and wide Delayed complications – Musculoskeletal pain,
Cortex thickened, irregular and sclerotic osteonecrosis of jaw, bisphosphonate fractures
Bones thick, bent and widened (lateral bowing of femur, Nitrogen containing bisphosphonates usually used
anterior bowing of tibia) IV bisphosphonates, such as pamidronate or zoledronic
Candle flame-shaped lesions (arrow or flame sign) and acid more effective and last longer
V-shaped lytic defects in the diaphysis Oral bisphosphonates, such as alendronate or risedronate
Loss of corticomedullary differentiation less well absorbed
Involvement from one end of bone (proximal) along
the shaft
Stress fractures (convex side)
Paget’s in total hip arthroplasty
Problems with hypercalcaemia and metabolic acidosis
Skull Problems with excessive intraoperative bleeding
Osteoporosis circumscription: Discrete areas of osteolysis Problems with deformity of bone, including bowing of
(well-defined lytic lesions) femur and acetabular protrusion
Cotton-wool appearance: Mixed lytic and blastic pattern of Increased incidence of heterotopic calcification
thickened calvarium postoperatively
Diploic widening with inner and outer table involvement Bisphosphonates given for 3 months preoperatively
Pelvis
Acetabular protrusio
Osteopetrosis – Marble bone disease or
Albers–Schonberg disease
Spine A group of rare congenital diseases characterized by a
Picture frame vertebral body: Enlarged, square vertebral marked increase in bone sclerosis
body with thickened peripheral trabeculae and radiolucent Many types described – nine or more
inner portion Impaired osteoclast function. Osteoclasts lack normal
Ivory vertebra (increased density) ruffled border and clear zone required for effective
resorption
Differential diagnosis Increased sclerosis and obliteration of medullary canal
Other causes of increased and disorganized bone turnover with Marrow spaces filled with necrotic calcified cartilage
fibrosis, including: Empty lacunae and plugging of Haversian canals
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Genetics Table 30.3 The make up of cartilage
Autosomal recessive Cells (chondrocytes)

(5%)
Infantile malignant form
Bone encroachment on marrow results in pancytopenia, Extracellular matrix Fibres Collagen(10–20%) Type II,
anaemia, haemolysis and hepatomegaly IX, XI
Repeated infection or haemorrhage usually leads to death Type VI,
More benign and rarer condition – Carbonic anhydrase II X
deficiency – Associated with renal tubular deficiency. In Elastin
this condition CO2 is not converted to carbonic acid in
Ground Water
osteoclasts, so osteoclasts cannot acidify the lacuna
substance
Autosomal dominant Proteoglycans and
Tarda – ‘benign’ form glycosaminoglycans
(10–15%)
Patients survive to adult life
Often asymptomatic Glycoproteins
Lifelong risk of fractures that heal poorly Degradative
enzymes (matrix
Radiological features metalloproteinases)
Increased bone density

Cortices widened
Narrow medullary canals Responsible for maintaining the ECM
Sandwich vertebrae: End plates densely sclerotic giving Ability to synthesize some proteoglycans decreases with age
appearance of sandwich. Demarcation between cancellous
and cortical bone is lost Water
Do not confuse with ill-defined bands of sclerosis seen in Up to 80% of the ECM
the rugger jersey spine of HPT Permits deformation of the articular cartilage by the
Skull thickened and base of skull densely sclerotic movement of water in and out of the cartilage and also
within the cartilage
Articular cartilage Increased water content leads to increased permeability,
decreased strength and decreased elasticity
This is a very popular topic. The usual format is to be asked to
Water content decreases through the deeper layers
draw the ultrastructure of articular cartilage and explain the
appearances in relation to function. Responsible for lubrication and nutrition
Collagen
Function About 60% of dry weight
Shock absorption Gives the articular cartilage its tensile stiffness
Provides low friction surface for joints (coefficient of Main type is type II (90%)
friction 0.002 – 30 times better than the best artificial Type VI helps chondrocytes adhere to the matrix
joint!) Type XI constrains proteoglycan matrix
Type X only found near calcified zone
Contents
The contents are shown in Table 30.3. The main components Proteoglycans
of the ECM are water, collagen and proteoglycans. Articular Give the articular cartilage its compressive strength and elasticity
cartilage has: Consist of a protein core and glycosaminoglycan chains
Few cells with negatively charged carboxyl or sulphate group,
No blood supply (nutrition supplied via synovial fluid) resulting in long strings of negative charges that repel
No nerve supply each other
No blood supply Negative charges hold water9
No lymphatics Glycosaminoglycans in articular cartilage include
hyaluronic acid, chondroitin sulphate, keratan sulphate
Chondrocytes The large aggregating proteoglycan molecules are called
Comprise 1% of articular cartilage aggrecans, and have large numbers of chondroitin sulphate
033
and keratin sulphate charges attached to the core protein.

This appearance looks rather like a ‘test tube brush’
Nutrition
Articular cartilage obtains its nutrition from the synovial fluid.
Aggrecans are associated with hyaluronic acid (HA) by link
Nutrients diffuse through the matrix. Intermittent loading and
proteins to form proteoglycan aggregates
motion are essential to produce the flux of water required for
The compressive stiffness is largely directly proportional to this nutrition.
the aggregate (proteoglycan) content
Loss of cartilage integrity in arthritis is associated with
impaired aggrecan function due either to proteolytic
cleavage of the aggrecan core protein, which decreases Biomechanics of articular cartilage (Table 30.4)
aggrecan charge, or to cleavage of the HA, which decreases Articular cartilage is a viscoelastic material. When loaded,
aggregate size water moves through the matrix. The speed of water
movement depends on the internal friction caused by
aggrecans in the matrix. For a short duration the loading
Structure strain is relatively low, but it increases substantially if the
The histological structure can be divided into zones. load is maintained (increasing by up to a factor of 10 if the
1. Superficial (tangential) zone: 10–20% of thickness load is maintained for up to 30 min)
Under very high compressive load the internal friction is
Thinnest articular cartilage zone increased in the fluid due to compression of the
High concentration of collagen fibres arranged parallel macromolecules; this results in cartilage being stiffer
to surface, forming a dense mat under very high loads
Most superficial part of this layer contains no cells Deformation speed under maintained load is relatively
(lamina splendens) high initially as water diffuses through the matrix (the fluid
Deep to the lamina splendens is a cellular layer with phase), but as the matrix becomes compressed the load is
chondrocytes parallel to surface, flat shaped, high eventually taken by the solid matrix and the rate decreases
density, many cells 1–3 cells thick (solid phase). The mechanical behaviour of the cartilage is,
Good resistance to shear forces therefore, biphasic10.
Proteoglycan at low concentration
Water at high concentration, can be squeezed out to
help create lubrication
Table 30.4 Biochemical changes of articular cartilage: Ageing vs
2. Middle (transitional) zone: 40–60% of thickness osteoarthritis
Collagen fibres oblique Ageing Osteoarthritis
High concentration of proteoglycan
Water content Decreases Increases then
Cells round shape, random, oblique arrangement,
decreases
progressively lower density, fewer cells
3. Deep (radial) zone: 30% of thickness Synthetic activity Decreases Increases
Collagen fibres vertically arranged (perpendicular to Collagen Unchanged Breakdown of cartilage

tidemark) collagen network
High concentration of proteoglycans PG content Decreases Decreases
Cells spherical, in vertical columns PG synthesis Decreases Increases
4. Tidemark
PG degradation Decreases Increases
Resistant to shear
Keratan sulphate Increases Decreases
5. Calcified zone
Chondroitin sulphate Decreases Increases
Hydroxyapatite crystals anchor articular cartilage to
subchondral bone Hydroxyapatite Increases Decreases
Forms a barrier to blood vessels supplying Enzymes Increased activity MMPs
subchondral bone
Matrix subunit Increases
The superficial, transitional and radial zones are only poorly molecules
differentiated on cross-section. The appearance is due to
Chondrocyte size Increases
the cartilage being cross-sectioned in one plane. The three-
dimensional structure shows arcades (Arcades of Beninghoff ) Chondrocyte number Decreases
of collagen that arch through the articular cartilage, giving Modulus of elasticity Increases Decreases
rise to the appearance of the three zones when cross-
MMPs = metalloproteinases; PG = proteoglycan.
sectioned.
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Cartilage repair and healing enable muscles to work at varying angles. Tendons fall into two
main groups: Those with a synovial covering running in tendon
Classification of cartilage degeneration (Jackson)
sheaths and those covered by paratenon. Some tendons arise
1. Softening from deep within the muscle, allowing a multipennate arrange-
2. Fibrillation and fissuring ment of muscle fibres; this increases the relative power of the
3. Partial-thickness loss, clefts and chondral flaps muscle but at the expense of range of movement.
4. Full-thickness loss with exposed bone
Osteoarthritis vs ageing Composition and structure

The main component of tendon is type I collagen,
Table 30.4 above illustrates the changes that take place in contributing up to 80% of dry weight
articular cartilage with ageing and contrasts these changes with
Where tendons change direction they become subject to
those that occur in osteoarthritis.
forces other than pure tensile ones and in these areas the
composition may change, with some type II collagen and
Acute trauma to articular cartilage11 an increase in glycosaminoglycan content and formation of
Superficial laceration, not reaching tidemark aggrecan proteoglycan. The arrangement of collagen fibres
also becomes less parallel and more ‘woven’
Chondrocytes die, matrix disrupted
Proteoglycan contributes up to 5% of the dry weight
Chondrocytes do not migrate to the site of injury
Proteoglycan molecules play a large part in maintaining the
Defect does not fill
water content of tendons through their highly negatively
No adequate cellular response – Repair does not
charged glycosaminoglycan side chains
take place
The main constituent of tendon, when not considered as
Deep laceration, crossing the tidemark dry weight, is water, which contributes up 60% of the wet
weight
Haemorrhage and fibrin clot formation
The collagen molecules generally form into a triple helix
Growth factors released, attracting inflammatory cells and
pattern, made up of three α chains
fibroblasts
The collagen fibrils combine together to form fibre bundles
Fibrocartilaginous scar formation
and collections of fibre bundles form fascicles. The fibrils
No organisation into ‘zones’ are arranged in a closely packed parallel formation. Groups
Poor loadbearing properties of fascicles form the tendon
V-shaped defects more likely to form some hyaline-like The collagen fibres also demonstrate crimping, a wavy
cartilage appearance, which influences the mechanical behaviour of
May progress to osteoarthritis tendon material
Blunt trauma
Chondrocyte death, matrix damage, fissuring of surface, Insertion into bone
injury to underlying bone Tendons may insert into bone by a fibrous insertion (typically
Loss of proteoglycans and chondrocyte clumping found when the tendon inserts into the diaphyseal or meta-
Increase in subchondral bone stiffness physeal region) or by a fibrocartilaginous insertion (typically
Cartilage fibrillation, causing an increase in water content where the tendon inserts into an apophysis or epiphyseal
and softening region).
In fibrocartilaginous insertions there are four transitional
Treatment of cartilage defects tissues/zones:
Abrasion arthroplasty Zone 1: Parallel collagen fibres at the end of the tendon
Microfracture Zone 2: Collagen fibres intermeshed with unmineralized
Mosaicplasty fibrocartilage
Autologous chondrocyte implantation Zone 3: Mineralized fibrocartilage
Comparative results of these treatments have been inconclusive. Zone 4: Cortical bone
These zones allow a gradual increase in the stiffness of the
tissue, so there is less of a stress-concentrating effect at the
Tendons insertion into bone, minimizing the risk of insertion site fail-
Tendons are dense, regularly arranged collagenous structures ure at these insertions, where the applied loads tend to be
that transmit loads generated by muscle to bone. Tendons enable greater than in those of tendons inserting further away from
muscles to act at a distance through confined spaces and they also the epiphysis.
033
Surrounding connective tissue

The fascicles within a tendon are surrounded by loose areolar
tissue – The endotenon, which permits longitudinal movement
between collagen fascicles. The endotenon is surrounded by
the epitenon.
The tendon is surrounded either by a paratenon or by a
synovial sheath.
Neurovascular supply
The blood supply to tendons is derived primarily through
the musculotendinous junction, with some further
communication with the periosteal vessels at the insertion
In those tendons with a paratenon, blood vessels penetrate
the tendon throughout its length
In those tendons with a synovial sheath, the outer and
Figure 30.6 Load–elongation curve for tendon
inner sheaths (parietal and visceral, respectively) are linked
by a mesotenon, which transmits the vessels. The
mesotenon may be continuous, or it may be confined to Haemorrhagic/inflammatory phase
vinculae, as in the long flexors of the digits Formation of haematoma
Further nutrition is derived from the synovial fluid, and Invasion by polymorphonuclear cells and monocytes/
this may be the major source of nutrition for some long macrophages with release of cytokines and growth factors
tendons, such as the long flexors of the fingers Debris removed and replaced with fibroblasts and
The blood vessels form a network in the epitenon and then capillary buds
pass between fascicles in the endotenon
The nerve supply is derived from the corresponding Proliferative/fibroblastic phase
muscle, and tendons contain both fast and slow adapting Fibroblasts produce dense disorganized collagen laid down,
sensory organs (Golgi organs, Pacinian corpuscles and bridging the gap between tendon ends to form tendon
Ruffini endings) callus
Early collagen is mainly type III
This phase may commence within 3–5days of injury and
Mechanical behaviour continues for several weeks, usually peaking at about
Tendons are viscoelastic structures and, like all viscoelastic 4 weeks
structures, they display creep, hysteresis and stress relaxation.
As a result of their viscoelastic behaviour, tendons not only Remodelling phase
transmit forces but are also capable of storing energy, which Collagen fibres reorganize to become orientated along the
improves the efficiency of the muscle–tendon unit during long axis of the tendon
repeated high impact activity. Type III collagen is replaced by type I
The load–elongation curve for tendons is non-linear and
Fibroblasts become tenocytes
can be divided into regions, as illustrated in Figure 30.6.
This phase may last many months or even years
I Non-linear region: The tendon starts off relatively non- The above sequence is found in tendons with a paratenon. In
stiff and becomes progressively stiffer with increasing tendons with a synovial sheath there is controversy over the
elongation. This ‘toe’ region probably reflects relative contributions from two healing processes:
straightening out of the crimping of the collagen fibres
Intrinsic: Cell invasion occurs from the tendon ends and
II Linear region: There is a linear relationship between
from the epitenon
increase in load and increase in length
Extrinsic: Healing occurs via granulation tissue that
III Early sequential failure: There can be small dips in the
invades via the tendon sheath. Extrinsic healing is more
curve as failure of some stretched collagen fibres occurs
likely to produce adhesions and lead to a less satisfactory
IV Ultimate stress/strength: The maximum load/stress clinical outcome
before the ligament fails completely
Ligaments
Tendon healing12 Ligament structure is generally similar to that of tendons
Tendon healing generally follows three overlapping phases. although there are some differences. Ligaments:
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033
Connect bone to bone The sarcomeres are arranged end to end to form myofibrils
Tend to be shorter and wider than tendons Groups of myofibrils in parallel form the muscle fibres.
Most ligament-bone insertions are direct, with the collagen The myofibrils are mechanically connected to each other by
fibres running directly into bone, where they become proteins, mainly desmin; the muscle fibres are surrounded
anchored by bone that grows around them (Sharpey’s fibres) by epimysium
Are mainly composed of type I collagen The muscle fibres, or cells, in turn are grouped into
Have a higher elastin content than bone fascicles surrounded by a perimysium
Ligaments tend to be strongest when forces are applied parallel Fascicles are grouped into a muscle surrounded by an
to their fibres and weakest when shear forces are applied at epimysium
their insertions into bone.
Ligaments are viscoelastic15 and display the viscoelastic Muscle contraction
properties of creep, stress relaxation and hysteresis. The Muscle contraction is initiated by release of acetylcholine at
load–elongation graph has a toe region, as for tendons. Beyond the neuromuscular junction
the ultimate stress there may be low resistance to elongation,
The acetylcholine diffuses into the synaptic clefts
resulting in a ligament that is intact but very lax.
Muscle contraction is controlled by calcium, which is
Ligaments do not function homogeneously; they are com-
stored in, and controlled by, the sarcoplasmic reticulum
posed of functional bands, which come under tension at dif-
ferent joint positions. Calcium is transmitted into the muscle via the transverse
tubular system (T system)
Sprains can be divided into three grades:
Calcium binds to troponin on the actin filaments, thus,
Grade I sprain – Partial tear disrupting at least one
releasing the actin filament and enabling it to interact with
functional band. No clinically detectable instability
the myosin, resulting in contraction
Grade II sprain – Sufficient disruption to cause clinically
Contraction velocity of muscle is proportional to fibre
detectable instability
length (i.e. number of sarcomeres)
Grade III sprain – Complete rupture
Maximal muscle power is proportional to the physiological
Ligament healing follows a similar pattern to that for tendons. cross-sectional area, which is proportional to the muscle
mass and the surface pennation angle
Muscle The relationship between length and muscle tension
follows an approximate inverted U pattern
Structure The excursion of a muscle needs to be considered when
The basic muscle cell, or fibre, which is surrounded by the choosing muscles for transfer
basal lamina. Within the muscle cells there is a hierarchical
arrangement of contractile elements
Muscle spindle
Fundamental units are actin and myosin molecules, which
are arranged linearly. The myosin ‘ratchets’ along the actin Sensory structure within a muscle that regulates tension
and acts as a proprioceptive organ
to achieve shortening, using energy from adenosine
triphosphate (ATP) : Primary afferent endings (annulospiral fibres), which
Troponin blocks the binding sites on the actin to limit respond mainly to the rate of change of length
contraction; calcium unblocks these sites : Secondary afferent endings (flower spray fibres),
The actin and myosin filaments form sarcomeres, which sensitive to steady level tension
have a characteristic pattern on light microscopy
: I band = actin (thin) filaments (lightest band on Fibre types
electron microscopy) where there is no overlap with Histochemical classification
myosin filaments Slow oxidative: Slow to fatigue, require oxygen for
: A band = myosin (thick) filaments sustained activity, large concentration of myoglobin (red in
: H band = myosin filament segments where there are no colour), many mitochondria – For endurance
interdigitating actin filaments Fast oxidative and glycolytic: Resist fatigue (white in
: M line in the middle of the A band where myosin colour), rich in mitochondria
filaments are joined together Fast glycolytic: High levels of ATPase, few mitochondria,
: Z line in the middle of the I band where actin filaments anaerobic and quick to fatigue – For sprinting
are joined together
The arrangement of actin and myosin filaments is that of a ATPase stability classification
hexagonal lattice in the centre of a sarcomere, i.e. each Type 1, 2A and 2B fibres have been identified according to
myosin filament is bounded by six actin filaments their ATPase response to varying pH. These three types are
033
often equated to slow oxidative, fast oxidative and Myelinated nerve fibre – Axon/dendrite with associated
glycolytic, and fast glycolytic, respectively, although this is Schwann cell and surrounding endoneurium (basement
probably not justified membrane)
Fibre types are not immutable and fibres can change their type Unmyelinated nerve fibre – Single Schwann cell with several
in response to their mechanical environment. axons/dendrites embedded in it, called a Remak bundle
Hill model – Biomechanically, muscle can be considered to Perineurium – Cellular layer round groups of fibres,
have a force because of both its elasticity and its contractility. creating fascicles
The passive stiffness of muscle is probably largely related to the Epineurium – Everything outside the perineurium that is
protein titin and is not related to the length-tension curve for not blood vessel or nerve; mostly collagen
active contraction.
Physiology
Types of muscle contraction +
Action potential results from Na ions entering the cell and
Isotonic (dynamic) depolarizing the cell membrane
Muscle tension is constant through the range of motion Potassium ions leave cell
+ +
Muscle length changes (e.g. biceps curls) After impulse the resting potential restored by the Na /K
exchange pump
Isometric (static) Myelinated conduction velocity is proportional to diameter
Muscle tension is generated but the length of the muscle Unmyelinated conduction velocity is proportional to the
remains unchanged, e.g. pushing against a wall square root of the diameter
Type A fibres: >2 mm in diameter, fast, motor, touch, pain
Isokinetic (dynamic) Type B fibres: 3–15 mm in diameter, autonomic
Muscle tension is generated as the muscle contracts at a preganglion
constant velocity over a full range of motion Type C fibres: 0.5–2.0 mm in diameter, chemonociceptors
Concentric contraction
Muscle shortens during the contraction Nerve injury (Seddon)
Neurapraxia
Eccentric contraction Nerve contusion involving reversible conduction block
Muscle lengthens whilst contracting against an opposing without Wallerian degeneration
force Selective demyelination of the axon sheath
Axonotmesis
Muscle-tendon junction Conduction block with axonal degeneration
Muscle and tendon fibres are almost parallel, which
Axon and myelin sheath degenerate but endoneurial tubes
generates high shear forces
remain intact
A high degree of membrane folding generates a large
surface area, reducing stress at the junction and reducing Neurotmesis
the angle of force vector. The net result is that the junction
All layers of nerve disrupted and there is Wallerian
is very strong degeneration
This area has a specific morphology, which is adapted to its No recovery without repair
function. Specific features include: Shorter sarcomere
1 mm/day in adults after repair, 3–5 mm in children
lengths, greater synthetic ability, greater number of
organelles per cell, interdigitation of the cell membrane and Sunderland
intracellular connective tissue
First degree – Same as neurapraxia
Second degree – Same as axonotmesis
Nerves Third degree – Axonal injury associated with damaged
basal lamina and endoneurial damage (perineurium is
Anatomy intact); most variable degree of ultimate recovery
Cell body – Site of metabolic activity, must be in continuity Fourth degree – In continuity but, at the level of injury, is
for regeneration complete, scarring across the nerve preventing
Axon – Always carries impulse away from cell body; regeneration. Both perineurium and endoneurium are
dendrite carries impulse towards it. Thus, sensory fibres disrupted, continuing of nerve maintained by epineurium
are always dendrites and motor fibres are always axons! Fifth degree – Same as neurotmesis
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Wallerian degeneration latency (the time from stimuation to first response) will
Axon and myelin degraded and removed by phagocytosis give the conduction velocity. The amplitude is the voltage
difference between the baseline and the peak upward
Existing Schwann cells proliferate
deflection (negative is upward)
Nerve cell body swells up and enlarges
The sensory nerve action potential (SNAP) can be
Rate of structural protein synthesis increases
measured orthodromically (stimulate distally and measure
Wallerian degeneration will not occur in a sensory nerve if
more proximally – I.e. in the direction the nerve normally
the nerve is still in continuity with the cell body, as is seen
conducts), or antidromically (stimulate proximally and
in pre-ganglionic injuries
measured more distally)
A preserved SNAP implies that the dorsal root ganglion is
Factors affecting nerve recovery
in continuity; if motor function is reduced, pathology at
Age – Noticeable change after age 30 the root or more proximally is implied
Level of injury – Distal repairs have more favourable After motor fibre transection the CMAP measured
prognosis than proximal ones on stimulation distal to the injury will remain
Nature of injury – Sharp lacerations do better than crush or normal for several days as degeneration of the nerve
avulsion injuries takes time
Type of nerve – Pure motor or pure sensory do better than When some motor axons are lost but some intact the
mixed nerves conduction velocity may be normal but the CMAP
Delay before repair – 1% of neural function permanently amplitude will fall (after a few days)
lost for each week of delay beyond third week from injury Chronic axonal loss, as in neuropathies, leads to CMAP
Gap between nerve ends becoming more dispersed due to immature regenerating
fibres, which conduct more slowly
Repair In standard conduction velocity tests only the fastest 20%
Epineural of fibres are measured
Fascicular – Repairs the perineural sheaths Note that because the SNAP is measured using the
Group fascicular fastest 20% of fibres it is possible to have a normal SNAP
even though the patient has a small fibres sensory
neuropathy
Neuropathy The following properties can be investigated
Acute
: F response – When a motor nerve is stimulated there
:Autoimmune – Guillain–Barré will be a distal impulse that causes the CMAP and a
Chronic proximal impulse that reaches the anterior horn cells
: Genetic and causes depolarisation followed by a ‘backfire’
: Metabolic (including vitamin B12 deficiency, diabetes) impulse that causes a second small muscle
: Nutrition (alcoholism) depolarisation – The F wave. This may be abnormal
: Amyloidosis immediately after nerve root injury. Detects proximal
: Neoplasia nerve lesions early
: Iatrogenic (phenytoin, bleomycin) : H reflex – Equivalent to tendon reflex; monosynaptic
reflex; absent in radiculopathies and polyneuropathies
Neurophysiological tests : Latency – Time between onset of stimulus and response

: Amplitude – Size of response or ‘evoked potential’
It is well worth visiting a neurophysiologist and observing how (from baseline to peak upward deflection). Usually an
neurophysiological studies are performed. average recording to reduce background ‘noise’.
Normal for median and ulnar nerve sensory >5 μV,
Nerve conduction studies14
and for motor >5 mV
These use stimulating and recording electrodes and a ground : Nerve conduction velocity – Distance between
electrode. Stimulation of a peripheral nerve generates: stimulating and recording electrodes divided by time;
A nerve action potential (NAP) of 5–30 μV may be slowed by demyelination or focal entrapment.
A compound muscle action potential (CMAP) of 5–10 μV ‘Normal’ motor and sensory velocities for median and
(in response to supramaximal stimulus) ulnar nerve >50 m/s. Values differ with age; the
The CMAP is measured by stimulating the nerve at one ‘normal’ motor conduction slows by 0.4–1.7 m/s per
point with increasing current or voltage until no further decade and ‘normal’ sensory velocity slows by 2–4 m/s
increase in amplitude occurs. The process is the repeated at per decade. Nerve conduction study is also influenced
a more proximal point on the nerve. The difference in by the temperature of the limb
033
Electromyography Non-collagenous proteins – E.g. link protein and

Two needle electrodes are placed in the muscle to be studied: fibronectin
Electrical activity in response to voluntary contraction Collagen fibres are mainly arranged circumferentially, with
other fibres arranged radially
Characteristic recruitment of motor units with increased
force in the muscle
Normal: No muscle activity at rest Vascular supply
Immediately after section EMG in supplied muscle is Mainly from the medial and lateral genicular arteries –
normal In the adult blood vessels penetrate the outer 10–30% of
Between 5 and 14 days: Positive sharp waves consistent the meniscus (slightly less penetration in the medial
with denervation meniscus)
Between 15 and 30 days: Denervation, fibrillation
potentials present
Evidence of re-innervation: Highly polyphasic motor unit Function15,16
potentials Loadbearing
Somatosensory evoked potentials :

The meniscus is anisotropic
Stimulation of a peripheral nerve (median or posterior

:
Compressive forces are resisted by hoop stresses in the
circumferential collagen fibres
tibial is standard)
Electrical recordings at scalp electrodes are very small,
: For hoop stresses to be generated the ‘hoop’ must be
complete, i.e. the attachments to the bony structures
therefore averaged over 100 or 200 stimulations
and the circumference of the meniscus must be intact –
Used for intraoperative monitoring of cord function The anterior and posterior horn attachments are
Not absolute particularly important
: 50% of compressive loads through the medial
Symptoms compartment pass through the medial meniscus
Allodynia – Painful response to a normally painless : 70% of compressive loads through the lateral
stimulus compartment pass through the lateral meniscus
Causalgia – Burning pain extending beyond a nerve : A greater proportion of the compressive load is taken
territory (sympathetic involvement) by the meniscus during flexion of the knee
Dysaesthesia – Spontaneous unpleasant sensation : Shear forces within the meniscus are resisted by the
Hyperalgesia – Increased level of pain to a normally radial collagen fibres (‘ties’)
painful stimulus : The collagen and glycosaminoglycan network resists
Paraesthesia – Spontaneous abnormal sensation movement of water through the ‘solid phase’ of the
Post-traumatic neuralgia – Pain within a nerve territory meniscal tissue
: Meniscal tissue is less stiff than articular cartilage;
The meniscus of the knee this is because of the lower concentration of
proteoglycans
This is another favourite topic. You should be able to relate the
anatomical structure of the meniscus to its function.
: Meniscal tissue is more resistant to the internal
movement of water through its tissue than articular
cartilage
Structure and composition Shock absorption
The meniscus is a fibrocartilaginous structure consisting :
The presence of intact menisci reduces the peak forces
of cells and ECM on the articular cartilage and underlying bone from
There are three types of cells: Fibrochondrocytes (mainly in impacts by approximately 20%
middle and inner parts), fibroblast-like cells (mainly outer
Stabilisation
half) and superficial zone cells (at the surface)
The ECM consists of water (approximately 70% of total :
The shape of the meniscus contributes to the stability of
weight), collagen, proteoglycans and non-collagen proteins the knee
The collagen within the meniscus is mainly type I (90%) : Loss of the meniscus leads to an increase in AP
movement between the articular surfaces
Proteoglycans have glycosaminoglycans attached
(chondroitin sulphate, keratan sulphate and dermatan Lubrication and nutrition
sulphate), which bind to water. The concentration of : The increased conformity of the surfaces contributes to
proteoglycans in the meniscus is less than in articular nutrition and probably also to the lubrication of the
cartilage joint
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The intervertebral disc Changes with ageing

Proteoglycan content decreases (reducing resistance to
Structure compression)
Outer annulus fibrosus – Type I collagen fibres arranged Water content decreases
obliquely in lamellae that insert into the adjacent vertebral Uniformity of nucleus pulposus decreases – Fibrous areas
bodies via Sharpey’s fibres. The collagen fibres in adjacent and softer areas
lamellae lie perpendicular to each other Load distribution becomes uneven
Inner annulus fibrosus – Type II collagen, less structured Composition of nucleus pulposus approaches that of the
than outer annulus inner annulus and the junction between the two becomes
Nucleus pulposus – Relatively high proportion of indistinct
proteoglycans and low proportion of collagen compared Collagen content increases
with annulus fibrosis (particularly outer annulus). In Ability to withstand loads diminishes
young patients it is a hydrated gel
Collagen in disc has high proportion of cross-links
There is evidence that in some people there is a genetic Disc injury
predisposition to back pain due to a fault in the synthesis of Under direct compression the normal disc is stronger than
Collagen 9 caused by a defective COL9A3 gene on the end plates
chromasome 20 The normal disc is not damaged by pure compression
Disc protrusion occurs when the degenerative young disc is
subjected to bending with compression
Function
The intervertebral disc forms part of the functional
spinal unit: Disc, facet joints, vertebral end plates and Osteoarthritis/osteoarthrosis
ligaments Arthrosis is the preferred term since there is no inflammation
The intervertebral disc and the adjacent endplates should at the onset of the disease.
be considered together – On loading there is deformation
of the endplates
The disc must be able to resist compression, bending, shear Classification
and torsional (rotational shear) forces Primary – No cause identified
Compressive forces on the disc are greater when sitting Secondary – Rheumatoid arthritis and other inflammatory
than when standing arthritides, trauma, etc
Proteoglycans resist compressive forces (resulting from
body weight above disc and action of paraspinal muscles)
Collagen fibres resist tensile forces
Aetiology
Genetic18 – Heberden’s nodes are strongly heritable
Under compression the nucleus pulposus resists the force
by converting it into radial forces, which are resisted by Developmental – DDH, Perthe’s, SUFE, etc
circumferential hoop stresses in the annulus fibrosus Mechanical factors – Microtrauma and macrotrauma
Twisting and tensile forces are resisted by the oblique Metabolic – Raised uric acid, diabetes, etc
arrangement of the collagen fibres in the lamellae of the Hormonal (acromegaly)
annulus fibrosus Occupation
Without the pressure within the nucleus pulposus the Obesity
annulus fibrosus can buckle, impairing its mechanical Age – Early; 45 years is the peak for IP joint and CMC joint
properties of thumb, later for hip and knee
Disc is less stiff at low loads than at high loads Polyarthrosis (primary) is more common in females
Hysteresis decreases with repeated loading, thus, reducing
ability to withstand further load cycles
Pathology19,20
Degenerative process in hyaline cartilage starts at the
Nutrition17 surface and eventually results in exposure of bone, the bone
Nutrition is by diffusion through the avascular disc eventually becoming polished (eburnated)
material from the vascular plexus around the annulus There is controversy regarding the primary event; theories
fibrosus and cartilaginous end plates include altered proteoglycans within articular cartilage,
Nutrition may be affected by factors that interfere with the impaired subchondral venous drainage and altered
vascular plexus, e.g. smoking synovial biochemistry
033
Osteoarthrosis is thought to be a failed attempt by Table 30.5 Radiographic features of osteoarthritis vs rheumatoid arthritis
chondrocytes to repair damaged articular cartilage; an Osteoarthritis Rheumatoid arthritis
imbalance of wear and repair
Loss of joint space Loss of joint space
Chondrocytes attempt to compensate by increasing their
rate of synthesis Osteophytes No osteophytes
The earliest features are fibrillation of articular cartilage in Subchondral cysts Marginal erosions
superficial and transitional zones, penetration of tidemark
Bony sclerosis Osteoporosis
by blood vessels from subchondral bone and subchondral
bone remodelling Deformity and mal-alignment Deformity and mal-alignment
Subchondral bone cysts and peripheral osteophytes form Loose bodies Loose bodies uncommon
Asymmetrical Symmetrical
Changes in articular cartilage Normal soft tissue Soft-tissue swelling
Early changes
Alterations in proteoglycans
Decreased aggrecan concentration Morning stiffness >1 hour for >6 weeks
Increased water content Swelling of at least 3 joints for >6 weeks
The increased permeability to water within the matrix and Involvement/swelling of wrist or hands for >6 weeks
decreased stiffness Bilateral symmetrical polyarthritis for >6 weeks
Rheumatoid nodules
Cellular repair response Positive serum rheumatoid factor
Chondrocyte proliferation Radiographic changes typical of rheumatoid arthritis
Anabolic and catabolic activity (periarticular erosions, osteopenia, etc). Table 30.5
Increased proteoglycan synthesis demonstrates the key differences between osteoarthritis
Simultaneous increase in degradation of matrix and rheumatoid arthritis
Degradation of type IX and type XI collagen
Weakening of type II collagen network Rheumatoid factor
Increased levels of metalloproteinases (collagenase, Positive in 80%. Rheumatoid factor has significant false-
gelatinase, stromelysin) positive and false-negative rates and is not diagnostic for the
Increased levels of IL-1 and IL-2 disease, but a positive rheumatoid factor is associated with a
Proteoglycan content decreases more severe disease course.
Progressive loss of tissue Aetiology

Decreased anabolic response of chondrocytes The aetiology is still unclear; it is thought to be a
Modulus of elasticity and strength decreased owing to disordered immune response that causes an inflammatory
increased water content response against soft tissues, cartilage and bone involving
Articular cartilage progressively lost antigen-presenting cells, T-helper cells22, natural killer cells
Subchondral bone changes include thickening of the subchon- and plasma cells
dral bone by the laying down of new bone on existing trabecu- Autoimmune mediators of tissue destruction:
lae and the formation of bone cysts. Macrophages, lymphocytes and plasma cells
Environmental trigger is superimposed on a genetic
Rheumatoid arthritis21 predisposition (HLA DW4, HLA DR4)
Symmetrical, erosive, deforming, inflammatory polyarthropa-
thy involving both small and large joints Staging of rheumatoid disease
Early
Incidence Acute or subacute synovitis without destruction of soft tissues
Approximately 1% of population or articular cartilage.
Diagnostic criteria Intermediate

Rheumatoid arthritis is defined by the presence of four of the Involvement of synovial-lined tendon sheaths impairs tendon
seven diagnostic criteria established by the American College excursion and may lead to rupture. Erosions appear in articu-
of Rheumatology: lar surfaces.
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Late Principles of management

Destruction and deformity of joints, etc.
Control synovitis and pain
: Rest, splintage, non-specific drugs, specific disease-
Radiological classifications altering drugs and synovectomy
I. Osteopenia and soft-tissue swelling Modify the disease progression
II. Marginal erosions and very slight narrowing of joint space : Drugs
III. Marked narrowing of joint space Maintain joint function
IV. Punched-out erosions through subchondral plate : Drugs, physiotherapy and sometimes surgery
V. Normal anatomical contours of the articular surface are Prevent deformity
destroyed : Physiotherapy and splintage, tendon reconstruction
and soft-tissue stabilisation surgery
General characteristics Reconstruction
Insidious onset of morning stiffness, joint pain (polyarthritis), : Excision arthroplasty and joint replacement
symmetrical swelling of the peripheral joints, hands and feet
involved early.
Extra-articular systemic manifestations Ankylosing spondylitis

Rheumatoid nodules
Vasculitis
Background
Ocular inflammation One of the seronegative spondyloarthropathies. A generalized
chronic inflammatory condition with a predilection for the
Amyloidosis
sacroiliac joints and spine. Strong familial tendency. Cause
Nephropathy and renal failure
unknown but 90% of patients are HLA B27-positive, as are
Cardiac (pericarditis, myocarditis, conduction defects,
half of their first-degree relatives (but HLA B27 is not diagnos-
aortitis)
tic and there is a high false-positive rate). More common in
Respiratory (pneumonitis, pleurisy, interstitial males than females with estimates of ratios ranging from 2 : 1
fibrosis) to 10 : 1.
Myositis and muscle atrophy
Neuropathy
Anaemia (normochromic and microcytic) Clinical features
GIT (salivary problems and peptic ulceration) Insidious onset low back pain and stiffness in an adolescent
Cerebral complications or young adult reoccurring at intervals
Felty’s syndrome (splenomegaly, leukopenia, Progressive spinal flexion deformities
lymphadenopathy, anaemia, skin pigmentation, weight Early – Little to find on clinical examination apart from
loss) slight loss of lumbar lordosis, limitation of spinal extension
Sjögren’s syndrome (conjunctival dryness or Sicca and sacroiliac joint tenderness
syndrome) Late – Characteristic posture with loss of the normal
lumbar lordosis, thoracic kyphosis, chin on chest
Atypical presentations deformity, flexed hips and knees
Explosive arthritis Inability to perform the wall test
Monarticular arthropathy (chronic pain and Entire spine is ankylosed
swelling) Limited chest expansion
Isolated second MTP joint swelling Peripheral joint involvement; usually the hips
Pronounced morning stiffness
Protrusion acetabuli
Differential diagnosis Heterotopic bone formation
Seronegative arthropathy (psoriatic arthritis, ankylosing Whiskering enthesis
spondylitis, Reiter’s disease) Differs from rheumatoid arthritis in that the disease is
SLE asymmetrical and affects large joints more than small
Polyarticular gout joints.
Calcium pyrophosphate deposition disease Atypical presentation in 10% of cases. The disease can start
Sarcoidosis with an asymmetrical inflammatory arthritis, usually of the
Polymyalgia rheumatica hip, knee or ankle.
033
Extraskeletal manifestations (eyes, heart, lungs, Pathological changes proceed in three stages:
1. Inflammatory reaction with round cell infiltration,
gastrointestinal, etc) granulation tissue and destruction of bone
Heart disease (carditis, aortic valve disease) 2. Replacement of the granulation tissue with fibrous tissue
Pulmonary fibrosis, osteoporosis, uveitis, colitis, 3. Ossification of the fibrous tissue leading to ankylosis of
arachnoiditis, amyloidosis joints
Poor outcome if there is pulmonary involvement, hip
involvement or young age at onset of the disease
Psoriatic arthritis
Radiographic features in the spine Definition
Earliest vertebral change is flattening of the normal Seronegative polysynovitis with an erosive, destructive arthritis
anterior concavity of the vertebral body (squaring due to and a significant incidence of sacroiliitis and spondylitis.
ossification of the anterior longitudinal ligament)
Erosion and fuzziness of the sacroiliac joints occur and Clinical features
then later sclerosis, especially on the iliac side of the joint, Mild asymmetrical polyarthritis affecting some of the IP joints
and finally bony ankylosis and obliteration of the of the fingers or toes. Sacroiliitis and spondylitis are seen in
sacroiliac joint about one-third of patients and are similar to those in anky-
Ankylosis of sacroiliac joints is followed by ossification of losing spondylitis. Affects up to 10% of patients with psoriasis.
the interspinous and interlaminar ligaments, ankylosis of HLA B27-positive in 50% of cases (other loci also involved).
the facet joints, ossification of the annulus fibrosus and
syndesmophyte formation. The features proceed in a Diagnosis
cranial direction and may produce a characteristic The main differential is from psoriasis with seronegative
appearance – Bamboo spine rheumatoid arthritis.
Important characteristic features:
Radiographic differential diagnosis of the Asymmetrical joint distribution
sacroiliac joint lesions Involvement of distal finger joints
Presence of sacroiliitis and spondylitis
Reiter’s disease
Absence of rheumatoid nodules
Psoriatic arthritis
Nail pitting, fragmentation
Ulcerative colitis
Sausage digits
Crohn’s disease
‘Pencil-in-cup’ deformity (the distal end of the middle
phalanx is the pencil in the cup of the distal phalanx)
Differential diagnosis Rheumatoid factor usually negative
Mechanical disorders
Ankylosing hyperostosis (Forestier’s disease) – A common
disorder in older men with widespread ossification of
Systemic lupus erythematosus (SLE)
A chronic inflammatory disease of unknown aetiology associ-
ligaments and tendons. Superficial resemblance to ankylosing
ated with multisystem involvement.
spondylitis but not an inflammatory condition, the spinal
pain and stiffness are rarely severe and blood tests are normal
Other seronegative spondyloarthritides
Pathogenesis
Distension of soft tissues rather than direct destruction or
fibrosis of supporting elements.
Pathology
Preferential involvement of tendon and ligament insertions. Clinical features
Inflammatory and erosive destruction of: SLE arthritis affects >75% of patients with SLE although this is
1. Diarthrodial joints often overshadowed by systemic symptoms. Typically the arth-
Sacroiliac joints, vertebral facet joints, costovertebral ritis is not as destructive as rheumatoid arthritis. Mainly
joints (chest pains aggravated by breathing indicate occurs in young females.
involvement of costovertebral joints) Fever
2. Fibro-osseous junctions, syndesmotic joints and tendons Butterfly malar rash across cheeks and bridge of nose
Affecting intervertebral discs, symphysis pubis, Pancytopenia
sacroiliac ligament, manubriosternal joint and bony Pericarditis
insertions of large tendons Nephritis
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033
Raynaud’s phenomenon Chronic gout – Recurrent attacks merge into polyarticular

Peripheral vasculitis gout. Joint erosion causes chronic pain, stiffness and
Splenomegaly deformity
Polyarthritis
Laboratory tests Infection
Anaemia, leukopenia, elevated ESR, autoantibodies positive Reiter’s disease
Pseudogout
Gout Rheumatoid arthritis
Definition Radiographs
A disorder of nucleic acid metabolism causing hyperuricaemia, Radiographic changes are a late feature and are usually associ-
which leads to monosodium urate crystal deposition in joints ated with the chronic tophaceous stage:
and recurrent attacks of synovitis.
Well-circumscribed, punched-out periarticular cystic
erosions with sclerotic overhanging borders. The size of the
Pathology cysts is the differentiating feature from other arthritides;
Humans lack the enzyme uricase, which is involved in the cysts larger than 5 mm are suggestive of gout
elimination of excess nucleic acid purines and nitrogenous Degenerative arthritis with joint-space narrowing,
waste products through the production and excretion osteophyte formation and sclerosis
of allantoic acid; hence, in humans uric acid is the
end-product of purine degradation
Diagnosis
Characterized by the presence of crystals in and around
joints, tendons and bursae Elevated serum uric acid levels not diagnostic
Diagnosis made by the demonstration of thin, tapered
Crystals activate macrophages, platelets, phagocytosis and
intracellular and extracellular needle-like crystals that are
the complement system
strongly negatively birefringent under polarized light
Release of inflammatory mediators into the joint
microscopy
Cartilage erosion and periarticular cyst formation
secondary to deposition of monosodium urate
Recurrent attacks of arthritis, usually in men aged 40–60 Osteonecrosis/avascular necrosis
years, often in great toe Death of cells within bone as a result of transient or permanent
Crystals deposited as tophi (ear, eyelid, olecranon, Achilles ischaemia of the bone; either traumatic or non-traumatic.
tendon)
Aetiology
Clinical Primary/idiopathic
Two types described: One-third of cases of AVN
1. Primary (95%) – Inherited. Overproduction or Young adults
underexcretion of uric acid Usually bilateral
2. Secondary (5%) – Resulting from acquired conditions that Males > females
cause either overproduction or underexcretion of uric acid
(renal disease, multiple myeloma and polycythaemia) Secondary
The distinction may be somewhat arbitrary as people with a Trauma (e.g. subcapital femoral neck fracture or hip
susceptibility to gout may develop the condition only after sec- dislocation, etc)
ondary precipitating factors are introduced, such as diuretic treat- Sickle cell disease – Causes rapidly progressive femoral
ment, excessive alcohol intake, aspirin or localized trauma. Only a head disease
small proportion of people with hyperuricaemia develop gout. Alcohol
Steroids
Clinical presentation SLE
Acute attack – Sudden onset of severe joint pain lasting for a HIV
week or two. Commonest sites great toe, elbow, finger joints Caisson’s disease and rapid decompression in divers
and ankle. The joint is swollen and the overlying skin is Chronic liver disease
shiny and red. Large joints not frequently involved. Spine Radiotherapy/radiation
very rarely affected Chemotherapy
033
Hyperlipidaemia
B = Bone marrow hyperplasia
Renal transplantation
Gaucher’s disease S = Stroke
Haemophilia S = Skin ulcers
Pregnancy
P = Pain
Smoking
Endotoxins from bacteria (Shwartzman reaction leads to A = Anaemia
hypercoagulability)
I = Infections
Pathology N = Nocturia
Early stage – Within 2 weeks of precipitating event C = Congestive heart failure
-necrosis of cells in marrow and bone – Empty lacunae
R = Renal failure
Increased water content in marrow (visible on MRI
scanning) I = Infarction of bone
Reactive hyperaemia and ingrowth of vascular tissue S = Sequestration in spleen
(reparative stage)
Creeping substitution of cortical bone by cutting cones I = Increased spontaneous abortion
Osteoid laid down on dead trabeculae in cancellous bone S = sepsis.
Ficat and Arlet radiographic staging for femoral AVN occurs in up to 10%
Osteomyelitis – Usually with Staphylococcus aureus
head AVN
0. (Preclinical) – Normal radiographs and MRI scan
I. (Preradiographic) – Normal radiographs, early changes on
Vitamin C deficiency – Scurvy
MRI scan (increased T2 signal and decreased T1 signal, Characterized by haemorrhage secondary to capillary
indicating increased marrow water content) fragility
II. Radiographs show osteopenia/sclerosis, femoral head Haemorrhage occurs in skin, gums, muscle attachments
spherical, Tc and MRI scans positive and, in children, subperiosteally
III. Radiographs show flattening of femoral head, crescent sign Vitamin C deficiency leads to failure of collagen synthesis
(necrosis of subchondral bone); Tc and MRI scans positive and repair and decreased osteoid formation
IV. Radiographs show secondary degenerative changes; Tc Decreased chondroitin sulphate synthesis
and MRI scans positive
Symptom of pain in the groin starts in stage I. Technetium Clinical features
scan may be cold initially and then hot at about 2 months. Fatigue
Core decompression, with or without vascular bone graft, Anaemia
may be useful in stage I. Bleeding gums
Ecchymosis
Sickle cell disease Intra-articular haemorrhages
Inherited substitution of normal HbA with HbS (mutated Poor wound healing
chromosome 11). Homozygotes have disease, heterozygotes
have trait. Common in malarial endemic areas owing to pro- Radiology
tective quality. Generalized bone rarefaction, most marked in long bone
metaphyses
Pathology Thin cortices and trabeculae
Low O2 tension causes polymerisation of HbS into longitu- Metaphyses may be deformed or fractured
dinal fibres, with deformity of erythrocytes, which then clump. Subperiosteal haematomas in children
Only manifests when HbF is lost, after 1 year of age. Reduced
RBC lifespan from normal of 120 days to 20 days.
Bleeding disorders
Clinical Haemophilia A
Remember HBSS PAIN CRISIS: 1 per 100 000 male births
H = Haemolysis Lack of factor VIII
719
033
X-linked recessive Brittle – A brittle material exhibits elastic behaviour up to

One-third are new mutations the point of failure. The material undergoes little or no
plastic deformation prior to failure. The yield stress equates
Haemophilia B (Christmas disease) to the failure stress
Lack of factor IX Compressive force – A pushing force
X-linked inheritance Ductile – A ductile material undergoes a large
amount of permanent (plastic) deformation before
Von Willebrand’s disease complete failure
Lack of factor VIII and cofactor Elastic deformation – Deformation of a material or object
Affects mucosae more than joints that reverses when the deforming force is removed
Endurance limit – The maximum stress below which a
Pathology material will not fail regardless of how many loading cycles
are applied (by convention a figure of 10 million cycles is
Atraumatic joint haemorrhages cause synovial
used for orthopaedic applications)
hypertrophy, synovitis and more bleeding
Fatigue failure – Occurs as a result of repetitive
Haemosiderin deposition in synovial villi
applications of load at stresses below the ultimate stress and
Release of enzymes causes cartilage destruction
above the endurange limit
Disuse osteoporosis
Hardness – A surface property that describes a material’s
Asymmetric physeal arrest in juvenile skeleton ability to resist scratching or indentation of the surface
Isotropic – The mechanical properties are independent of
Clinical the direction of loading
Family history Plastic deformation – Permanent deformation of a
Haemarthroses in walking children material or object that does not reverse when the
Joint pathology during childhood, especially in weight- deforming force is removed
bearing joints Shear force – A force that is applied parallel to the surface
Investigate with clotting screen and specific factor tests Strain – Change in length per unit length (no units or%),
or angulation for shear strain
Radiology 2
Stress – Force per unit area (N/m or MPa)
Synovitis, distended capsule Stress riser – A change in contour that increases the
Thin cartilage concentration of stresses, thus, increasing the risk of fatigue
Widened intercondylar notch on knee AP failure
Enlarged ossification centres and widened epiphyses Tensile force – A pulling force applied to an object
Flat femoral condyles Toughness – Describes the amount of energy per unit
Osteopenia volume absorbed by a material before breakage. There are
several types of toughness – Impact toughness, notch
toughness and fracture toughness – The latter two refer to
Biomaterials the ability of a material that contains a flaw to resist
The main groups of biomaterials encountered in orthopaedics propagation of a crack leading to a ‘brittle fracture’. Fracture
are metals, ceramics, polymers and composites of these. Some toughness is probably the most relevant to Orthopaedics as
knowledge of the different properties of these materials is cracks tend to develop in materials over time
important for their correct use, and questions on material Fatigue toughness – Describes the work done to failure
properties are common in the exam. under fatigue conditions
Biomechanics of materials Deformation and the stress–strain curve
It is important to have a clear understanding of the terms used When a force is applied to an object made from a material it
to describe the mechanical properties of materials. The stress– will deform. The stress–strain curve describes the pattern of
strain graph for metal has been a long-term favourite examin- deformation of a standardized sample of material.
ation topic although you should be prepared to demonstrate An idealized stress–strain curve for metal is shown in
your understanding of what the graph means, not just be able Figure 30.7. You should be able to ‘talk through’ the various
to reproduce it rote fashion. parts of this curve. In the first part of the curve there is a
straight line, which represents the elastic phase of the material.
Definitions For every incremental increase in stress there is a proportional
Anisotropy – The mechanical properties differ when increase in strain. The slope of the linear part of the plot is
loading occurs along different axes Young’s modulus and it indicates the stiffness of the material
033
The following are key terms that relate to the stress-strain

curve:
Young’s modulus – The slope of the linear portion of the
graph. This indicates stiffness
Yield point – That point at which elastic behaviour changes
to plastic, resulting in permanent deformation
Proportional limit – The limit of the linear relationship
between stress and strain. Although often found at the same
point as the yield point it does not have to be; some materials
have a non-linear elastic part to the plot
Elastic limit – The same as the yield point
Ultimate strength – Indicated by the ultimate stress
Ultimate stress – The highest stress on the stress–
strain curve
Breaking point – The point where the material fractures
Strain energy – The area beneath the elastic portion of
the curve
Toughness – The area under the whole plot
Ultimate strain – The strain reached at the point where the
material breaks
It is very important to understand that stiffness, strength,
toughness, brittleness and hardness describe different and
largely independent properties of materials, and that it is not
possible to deduce one from the other.
Most stress–strain curves are drawn for tensile forces, but
similar curves can also be drawn for compressive and shear
forces so a material will have elastic moduli for tension, com-
pression and shear. NB. Do not confuse this with anisotropy,
which refers to the direction of loading along the x, y and z
axes and not to the type of loading.
A brittle material will not have a plastic phase on the
stress–strain curve. When brittle materials break, the opposing
broken surfaces will still match if they are reassembled.
It should be noted that stress–strain plots are drawn for
standardized samples of a material. For objects made from a
material the plot should be termed a load deformation plot.
Figure 30.7 Idealized stress–strain curve for a metal. UTS = ultimate strength Viscoelastic materials
(E = stress/strain). In the elastic phase the material will return Viscoelastic materials display time and/or rate-dependent
to its original dimensions if the deforming force is removed. physical properties.
The yield point or elastic limit is that point at which the The mechanical properties of viscoelastic materials can be
material starts to undergo permanent deformation and beyond modelled as a spring (representing the elastic component) and
this point the deformity will not completely recover if the force a ‘dashpot’ or syringe, representing the viscous component.
is removed. Unloading beyond the yield point will result in a All biological materials and most polymers encountered in
linear plot parallel to the initial linear component of the plot orthopaedics are viscoelastic.
but not returning to the intersection of the x and y axes. In the Many viscoelastic materials (including bone) become stiffer
stress-strain curve for metal, the curve continues on an upward and stronger when they are loaded more rapidly.
plot beyond the yield point and this represents work hardening Viscoelastic materials display some characteristic proper-
of the material. The final downward slope before failure is a ties that are not seen in non-viscoelastic materials:
result of necking of the sample (the cross-section becomes Creep – Deformation over time when under constant load
smaller) prior to final failure. Fracture toughness is calculated (Figure 30.8). Creep has a more rapid initial phase, followed
from the area under the stress-strain curve and represents the by a slower phase of deformation. At sufficient load levels,
energy to fracture. creep can eventually lead to a creep fracture
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Figure 30.8 Creep Figure 30.9 Hysteresis
Figure 30.11 Dislocations in metal
Metals
Solid metals have a crystalline structure. The positive metal
ions can be packed in different arrangements: Hexagonal
close packed, face-centred cubic or body-centred cubic. The
number of close contacts each metal has with neighbouring
Figure 30.10 SN curve positive ions is the coordination number. Hexagonal close
packed and face-centred cubic arrays have coordination
numbers of 12, and body-centred cubic has a coordination
Stress relaxation – Decreasing stress when held under number of 8. As molten metal cools, crystals start to grow.
constant strain The crystals form grain boundaries where they meet other
Hysteresis – When the stress-strain curve of the material to crystals. Dislocations are irregularities in the crystalline
which a stress is applied and then removed from follows a arrays. There may be millions of dislocations within a cubic
different downward plot when in the elastic phase millimetre of metal. The physical properties of the metal are
(Figure 30.9). The area between the loading and unloading greatly influenced by the grain size and the number of
curve represents energy lost, usually in the form of heat dislocations.
The properties of a viscoelastic material cannot be described by Metals are ductile; a large amount of plastic deformation
a single stress-strain curve as there would be an infinite occurs before failure. Ductility is the result both of slipping of
number of potential curves depending upon the rate and the positive ions over each other to form new bonds with
duration of loading. delocalized electrons, and also of movement of the dislocations
Viscoelastic fluids (such as synovial fluid) are called non- through the lattice structure (Figure 30.11). Grain boundaries
Newtonian fluids. hinder the movement of dislocations.
The three most commonly used metals in orthopaedics are
Fatigue failure stainless steel, cobalt chrome alloy and titanium alloy.
The stress-strain curve shows the stress required to break the
material on a single loading. If a material is put through
repeated loading cycles, the stress required to cause failure
Metal processing
becomes progressively smaller with increasing numbers of
Casting
load cycles, and the relationship between stress to failure and Liquid metal is poured into a mould. Cooling does not occur
load cycles is plotted on an S–N curve. completely uniformly and this can result in internal cracks and
In many materials there is a stress below which the material shrinkage voids.
could theoretically be loaded an infinite number of cycles
without failure, and this is called the endurance limit Wrought
(Figure 30.10). The cast material is modified by rolling and extending.
033
Cold working Types of metals

The metal is forced into new shapes at room temperature by Stainless steel 316L
cold rolling, drawing or pressing (forcing onto a die or mould).
The number 316 refers to 3% molybdenum and 16% nickel
During cold working, new dislocations are formed. Work
that is added to the alloy of iron, chromium and carbon
hardening describes the increasing stiffness of metal when it
is shaped and it is the result of increasing numbers of disloca- The letter ‘L’ denotes low carbon (<0.03%)
tions, which crowd up against the grain boundary, interfering Strong and cheap
with each other’s movement through the material. Relatively easy to manufacture components
Relatively ductile so easy to alter shape; useful in
Annealing contouring of plates, etc during operative procedures
The metal is heated to about half its melting point. The grain Relatively biocompatible
structure re-forms at the recrystallisation temperature as the High Young’s modulus of elasticity; can lead to stress
metal cools and this reduces the number of dislocations, shielding of lower modulus bone
making the material more ductile again. Usually cold worked by 30% to improve its yield and
ultimate stress
Hot working Good fatigue resistance
The metal is heated above its recrystallisation temperature Reasonably resistant to corrosion although susceptible to
(usually to about 60% of melting temperature) and is then pitting, stress and crevice corrosion – Stress corrosion
shaped whilst still hot. As annealing is occurring during the cracking
working, the metal does not become work hardened. Hot
working is performed by rolling or by forging (the metal is Cobalt chromium
hit by hammers or squeezed between a pair of dies). Chromium, cobalt and trace amounts of molybdenum,
carbon and nickel
Alloying
Similar Young’s modulus to stainless steel
Small amounts of other elements are added to the pure metal
Very high ultimate strength and fatigue strength
to alter the physical properties. The addition of larger ions
Good biocompatibility
disrupts the regular metal lattice arrangement, making it more
difficult for layers of the lattice to slip over each other; the Better wear properties than stainless steel or titanium when
material becomes less ductile. Smaller ions such as carbon and used as an articular surface in joint replacement surgery
nitrogen fit into the holes in the lattice structure and also Excellent resistance to corrosion, especially crevice
decrease the ability of the lattice layers to slip. The carbon corrosion
content of steel greatly affects the stiffness and wear resistance.
Titanium alloys
Adding small quantities of nickel and chromium increases
corrosion resistance, and addition of other metals (such as Titanium 64 most commonly used (6% aluminium,
molybdenum, cobalt, etc) affect strength and other properties. 4% vanadium)
Steels with <4% chromium are called alloy steels. Stainless Lower Young’s modulus than stainless steel and cobalt
steel contains more than 4% chromium. chrome (approximately half), so less stress shielding of
bone when used as implant, although Young’s modulus
Quenching still higher than cortical bone
The heated metal is suddenly immersed in cold water or oil. Forms a passivating oxide layer on surface so excellent
When alloyed metals are quenched, the alloying elements resistance to corrosion
become trapped within the crystals, rather than being precipi- Excellent resistance to pitting and intergranular corrosion
tated out, making the metal harder. The brittleness of a Less interference with CT/MRI than stainless steel or cobalt
quenched metal can be reduced by tempering; the metal is chrome
heated to its tempering temperature (less than the recrystal- Poor hardness when used as articulating surface
lizing temperature) and then re-quenched. High coefficient of friction
Notch-sensitive – Surface flaws or scratches predispose to
Passivation fatigue failure
An oxide layer is formed on the surface of the material to Relatively expensive
improve the mechanical properties and increase resistance to Low tensile strength
corrosion. If the passivating layer has the same volume as the
underlying metal it will passivate. If the volume of the oxide is
greater or less than that of the underying metal then the oxide Ceramics
layer will buckle or split respectively and passivation will not There does not appear to be a satisfactory comprehensive
occur. definition of what a ceramic is (the word ceramic comes from
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033
the Greek for ‘clay’ or ‘pottery’). Most ceramics are com- Made by low-pressure oxygen-catalysed addition
pounds of metallic and non-metallic elements. polymerisation of ethylene (C2H4)
Orthopaedic ceramics may be bioinert (alumina, zirconia) Each molecule of UHMWPE can contain more than
or bioactive (hydroxyapatite, glass ceramic). 200 000 units of ethylene
Orthopaedic ceramics can be manufactured into implants UHMWPE has a molecular weight of 2 × 106–5 × 106
by the process of sintering, in which the material in powder When used as a bearing surface the material can undergo
form is heated to a temperature below its melting point, and work hardening in the direction of movement, an
often subjected to high pressure. advantage for bearings where the movement is
predominantly in one direction, such as the knee
Properties of bioinert ceramics
Very hard materials with good wear resistance (wear Factors affecting wear properties
particles very small) Manufacturing technique for the UHMWPE material
Surfaces can be made very smooth to give low coefficient of
friction
:
Molecular weight
Excellent wettability
:
Presence of calcium stearate (used as a stabiliser) can
result in crystals that can cause weakness
Strong under compression
Relatively weak under tension
: Fusion defects can cause stress concentrations, leading
to fatigue failure
Stiff (high Young’s modulus)
Production methods for the component
Brittle (little or no plastic phase before failure)
Low moisture absorption :
Machining produces sharp edges that can act as stress
risers
Biocompatible
Implants manufactured from ceramics have in the past been
: Direct compression moulding and isostatic moulding
produce components with more uniform UHMWPE
associated with susceptibility to fracture, resulting in many 23
very sharp, hard and abrasive fragments. Although zirconia The sterilisation method
is tougher than alumina it can have poorer wear properties. : Oxidation during sterilisation can lead to chain scission
The process of transformational toughening, with the and make the material susceptible to subsequent fatigue
introduction of small quantities of zirconia into alumina, failure (delamination, typically commencing a few
produces a material that is much tougher and, therefore, millimetres below the surface where shear forces
less susceptible to fracture. Figures of 0.04% breakage for are high)
hip implants are now being reported
Hot isostatic pressing has also led to improved mechanical
Production methods
properties
Other methods of improving the Fracture Toughness of Ram extrusion – Powdered resin is forced through a die at
ceramics are being explored, often using composite high pressure with heat applied to form a block.
materials Components are made from the block by machining.
A disadvantage is the product’s susceptibility to
non-uniformity
Bioactive ceramics
Sheet compression moulding – The resin is heated and then
There is increasing interest in bioactive ceramics. These are of
cooled under pressure between two metal sheets.
less interest as mechanical devices but are used for their ability
A disadvantage is the potential for pressure differences to
to interact with the biological tissues. Hydroxyapatite and
affect consistency
tricalcium sulphate are examples.
Direct compression moulding – The material is directly
Bio glasses have the ability to allow ions to leach out of the
moulded onto a metal backing or into a shaped mould. This
material over time.
method has been associated with good wear properties
Isostatic moulding – The resin is packed cold into a mould
Polymers under vacuum. Heat and isostatic compression is applied.
Polymer = poly + mer (unit) A uniform polymer is produced with reduced oxidative
The most commonly used polymers in orthopaedics are degradation
ultra-high-molecular-weight polyethylene (UHMWPE) and Sterilisation of polyethylene – Gamma irradiation of
polymethylmethacrylate. polyethylene causes some of the carbon-hydrogen bonds to
break, producing free radicals. The free radicals can cause
UHMWPE chain scission, breaking the long UHMWPE molecule chains
Polyethylene is a long chain polymer formed of ethylene After chain scission the polyethylene molecules may undergo
monomer molecules recombination to form the original long polymer molecules,
033
they may remain as shorter molecules with reduced wear Mechanical properties
properties, or cross-linking may occur, in which the free Poor tensile strength (25 MPa)
carbon atoms from one polyethylene molecule reattach to the Moderate shear strength (40 MPa)
carbon atoms of adjacent polyethylene molecules, resulting in Strong in compression (90 MPa)
side-to-side links between the molecules.
Brittle
In the presence of oxygen the free radicals cause rapid
Notch-sensitive
oxidation of the material with resulting chain scission and
impaired mechanical properties. Young’s modulus between that of cortical and cancellous
bone (E = 2400 MPa)
Gamma irradiation in the presence of oxygen has been
found to lead to implants that are susceptible to fatigue Young’s modulus much less than orthopaedic metals
failure (delamination). For this reason implant sterilisation Viscoelastic
by gamma irradiation is now carried out in an inert gas. : Undergoes creep
Despite this, some free radicals may remain in the material, : Undergoes stress relaxation
allowing subsequent oxidation to occur; implants should be
used within a relatively short time interval to prevent degrad-
ation of the material (once implanted, the oxidation risk is Composition
reduced as synovial joint fluid has a relatively low oxygen Depending on the brand the liquid is added to the powder or
content). vice versa.
Incorporation of antioxidants, such as vitamin E, may also Liquid monomer – Supplied in glass vial, containing
reduce the effects of oxidation methylmethacrylate monomer; an inhibitor/stabiliser
Post-production heat treatment (annealing) reduces the (usually hydroquinone) is usually added to prevent
free radicals spontaneous polymerisation during storage and an
Sterilisation in ethylene oxide does not produce free activator (N, N-dimethyl-p-toluidine) is also added to
radicals and cross-linking does not, therefore, occur; this promote the cold curing process and to offset the effect of
will result in a polyethylene with different mechanical hydroquinone once the reaction has begun
properties when compared with polyethylene sterilized by Powder polymer – Contains polymer granules of PMMA, a
irradiation polymerisation initiator (1% benzoyl peroxide) and a radio-
Cross-linking caused by gamma irradiation in an oxygen-free opaque material (zirconium oxide or barium sulphate)
environment improves the hardness of the material, thus,
improving its performance as a bearing material. The amount Polymerisation process
of cross-linking increases with increased radiation dose. Carbon-to-carbon double bonds are broken down and new
Highly cross-linking polyethylene results in: carbon single bonds are formed to give long-chain polymers
that are largely linear and relatively free of cross-linking. The
Increased surface hardness
reaction is exothermic. The curing process has the following
Improved wear characteristics
time periods, which are affected by humidity, temperature and
A more brittle material
rate of mixing:
A stiffer material
Dough time – Starts from the beginning of mixing and
Reduced ultimate tensile strength
ends when the cement will not stick to an unpowdered
Reduced ability to undergo work hardening
surgical glove
The optimal amount of cross-linking has not yet been estab-
Setting time – The time from the beginning of mixing
lished, and may differ for different joints (the reduced work
until the surface temperature is half maximum
hardening may affect the knee more than the hip, which has
Working time – The difference between the dough time
multiaxial movement at the joint surfaces).
and the setting time
Composite materials Factors affecting bone cement strength

®
Oxidized zirconium (Oxinium ) is produced by diffusing Storage temperature
thermally driven oxygen into the surface layers of metallic Moisture content
zirconium alloy to transform the surface layers into zirconium Incorporation of antibiotics
oxide, producing a surface with ceramic properties of hardness Incorporation of radio-opaque material
and smoothness. Inclusion of air pockets
Inclusion of blood or tissue
Bone cement Age after implantation
Polymethylmethacrylate (PMMA) has the same chemical for- Presence of stress risers (e.g. sharp edges on implant,
mula as Perspex® and Plexiglas®, but the formulation differs. increasing risk of fatigue failure)
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033
Figure 30.12 Asperities

Mode of action in arthroplasty at the surface of materials
Bone cement acts as a grout and not as glue; there is no
chemical bond between the PMMA and the bone or implant
surface. In PMMA/bone interface strength depends upon the
mechanical interface between the cement and the cancellous
bone interstices. The frictional force (F) is directly proportional to the
In hip arthroplasty there are two main femoral component applied load (W) across a bearing surface (applied normal
design concepts that rely on different implant/PMMA interface to that surface)
mechanisms:
F = μW, where μ is the coefficient of friction of the
Shape closed prostheses (complex cantilever designs) rely combination of surface materials
on frictional shear forces between the femoral stem The force needed to start movement is greater than
component surface and the bone cement that required to maintain it, so there is both a dynamic
Force closed design (the polished double taper design) coefficient (μd) and a static coefficient (μs); the
relies on subsidence of the femoral stem component to dynamic coefficient is typically approximately 70% of
cause radial compression of the cement, which is resisted the static coefficient
by hoop stresses generated in the femoral cortex. In this In most situations the frictional force is independent of the
design concept it is intended that the femoral component apparent contact area
should be able to slide against the bone cement surface
Frictional wear is proportional to the sliding distance
Cementing techniques in hip replacements
The aim of cementing techniques is to consistently produce a Contact area
homogeneous cement mantle of uniform mechanical proper- The true contact area is between the asperities (bumps and
ties with good interdigitation into the bone interstices. peaks) on the surfaces, and will typically be <1% of the
apparent surface area (Figure 30.12)
First-generation
As the force normal to the surface increases, the number of
Hand mixed cement asperities in contact increases, explaining the relationship
Finger packing of cement between force and friction
No cement restrictors The asperities deform in proportion to load and are
inversely proportional to the surface hardness
Second-generation
Bonds form at contact points and must be broken to
Femoral canal plug initiate movement (hence μs > μd)
Pulsatile lavage to remove debris/fat, etc
Cement gun to allow retrograde filling of femoral canal
Lubrication
Third-generation Lubrication mechanisms can be divided into two main groups:
Cement porosity reduced during mixing by vacuum or 1. Boundary lubrication
centrifugation Occurs when the bearing surfaces are separated only by
Femoral canal plug a boundary lubricant of molecular thickness
Pulsatile lavage Involves the adsorption of a single monolayer of
Cement gun to allow retrograde filling lubricant on each surface of the joint
Use of pressurisation both before and during implant In synovial joints the glycoprotein lubricin, found
insertion in synovial fluid, is believed to be the adsorbed
Spacers to ensure centralisation of implant molecule
2. Fluid film lubrication
Tribology The two bearing surfaces are separated by a fluid film
Tribology is the study of interacting surfaces in relative whose minimum thickness exceeds the surface
motion roughness (i.e. the heights of the asperities), thus,
Derivation: Tribos (Greek), meaning rubbing preventing asperity contact
As there is no asperity contact there is no wear
Lambda value λ = fluid thickness/composite surface
Friction roughness of the two bearing surfaces
Defined as the resistance to sliding motion between two In practice, in many situations the lubrication is mixed, con-
bodies in contact sisting of a combination of boundary and fluid film.
033
Fluid film lubrication in artificial joints

Squeeze film
Occurs when two bearing surfaces approach each other
without a significant relative sliding motion
Pressure builds up in the viscous fluid because it cannot
instantaneously be squeezed out from the gap between the
two surfaces
As the fluid is forced out, the layer of lubricant becomes
thinner and the joint surfaces eventually come into contact
This mechanism is capable of carrying high loads for short
lengths of time
This mechanism of lubrication is probably active at initial
contact during the gait cycle or during high-impact activities
Hydrodynamic
Rigid bearing surfaces that are not parallel slide Figure 30.13 Lubrication mechanisms
tangentially in relation to each other (note that a ball and
socket joint requires a clearance between the two surfaces
-the radii should not be identical)
Boosted lubrication
A converging wedge of fluid forms, and viscosity within the Under squeeze film conditions, water and synovial fluid may
wedge produces a pressure within it that separates the two be pressurized into the articular cartilage, leaving behind a
surfaces concentrated pool of hyaluronic acid protein complexes to
lubricate the surface.
The fluid is entrained between the two surfaces
Figure 30.13 illustrates the differing mechanisms of lubri-
Entrainment requires a relatively high sliding speed
cation that may occur between two biological materials.
A rougher surface with higher asperities will require a
thicker film to achieve fluid film lubrication Synovial fluid
The ideal lambda value is about 3. If λ exceeds 3, friction Produced by type B fibroblast-like cells of the synovium
starts to increase again due to viscosity within the fluid film (type A cells are involved in phagocytosing debris)
itself
Made up of proteinase, collagenase, hyaluronic acid,
λ values between 1 and 3 generally lead to mixed lubrication lubricin and prostaglandins
May occur during relatively rapid movement such as Is a dialysate of blood plasma without clotting factors or
during the swing phase of the gait cycle erythrocytes
Has unique fluid properties conferred by the hyaluronic
Additional lubrication mechanisms that may act acid (it is a non-Newtonian fluid)
in the synovial joint :When the shear rate is varied, the shear stress does not
The precise mechanisms of lubrication in the synovial joint are vary in the same proportion (or even necessarily in the
not known. Synovial joints have a very low coefficient of same direction)
friction (about 0.02), suggesting that they are at least partly : Exhibits pseudoplasticity; a decrease in viscosity when
lubricated by fluid film lubrication. There are several add- the shear rate increases
itional mechanisms that may be present in the synovial joint : Exhibits thixotropy; a time-dependent decrease in
that are not found in artificial joints. viscosity under constant shearing
In conditions where hyaluronic acid is reduced (such as in
Elastohydrodynamic
rheumatoid arthritis or after joint replacement), the
Non-rigid bearing surfaces, such as those formed from articu- lubricating properties are impaired
lar cartilage, are able to deform under load and this can trap
The Sommerfeld number is a property of a given lubricant
pressurized fluid and increase the surface area. Elastohydrody- = viscosity × velocity/stress and describes the relationship
namic lubrication can enhance both squeeze film and hydro- between the lubricant, the fluid film thickness and the
dynamic lubrication. potential types of lubrication
Weeping lubrication
Because articular cartilage is fluid-filled, porous and permeable Wear
lubricant fluid can be squeezed from the surface of the articu- Lubrication and wear are closely related topics and questions
lar cartilage when relative motion occurs. on both frequently arise in the basic science oral.
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Wear is the progressive loss of material from the surface of Decreased by greater conformity of the bearing surfaces
a body due to relative motion at that surface. Decreased by thicker bearing surfaces (in UHMWPE) due
Wear generates further ‘third body’ wear particles to less concentration of shear stresses near the surface
The softest material is worn Mainly a problem in knee replacements where there are less
When thinking about wear it is important to distinguish conforming joint surfaces
between Modes, Mechanisms and Measurement.
Corrosive/oxidative wear24
Modes of wear in artificial implants Corrosion results from degradation to oxides, hydroxides and
other compounds. Corrosion is frequently associated with
Mode describes between which parts of a component wear is
mechanical stress. There are many different kinds of corrosive
taking place:
processes and in many cases several of these processes may be
Mode 1 wear occurs between the two surfaces that are occurring simultaneously:
articulating together in the manner intended by the
Galvanic corrosion
designer
Mode 2 wear occurs between a bearing surface and a non- :
Two different conducting materials are in contact and
bearing surface form an anode and a cathode
Mode 3 wear occurs as a result of third body particles : Galvanic corrosion may be seen in many different
coming between the bearing surfaces settings; such as crevice and pitting corrosion
Mode 4 wear occurs between two non-bearing surfaces discussed below
: As a metal cools during manufacture, impurities and
additional trace metals crystallize differentially in
Wear mechanisms different grains and this allows galvanic currents
Wear is usually either mechanical or chemical. Mechanical between the grains; this can lead to intergranular
wear mechanisms include abrasive, adhesive, fatigue and third corrosion due to galvanic currents at the grain
body wear. Chemical mechanisms involve corrosion. boundaries
The surface roughness of the two materials influences the : Galvanic currents can also occur within the grains of
amount of mechanical wear. the metal – Leaching corrosion
Abrasive wear : Inclusion corrosion can occur as a result of impurites
left on the surface of the material, such as from surgical
Asperities on the harder material come into contact with
implements
the softer material
Crevice corrosion
The harder material asperities plough and cut the softer
surface, causing grooves and detached particles :Occurs as a result of galvanic currents formed due to
The detached particles become third bodies, causing different oxygen tensions in the superficial and deep
further wear (see fretting below) parts of a crack or defect
When abrasion occurs to the surface of a ceramic the dull : Lack of Oxygen in the depth of the crack prevents
appearance is termed scuffing Passivation
: Can be exacerbated by mechanical factors such as
Third body wear abrasion removing the passivating layer
This is really a form of abrasive wear Pitting corrosion – Where the passivating layer is removed
Particles become trapped between the articulating surfaces in very localized areas and joint fluid (containing saline) gains
Very high local stresses produced access the exposed area of metal alloy re-oxidises, with the
Cause localized abrasive and fatigue wear release of Hydrogen ions from the water. This results in a very
small anodic area and a large cathodic area causing a galvanic
Adhesive wear current. The positively charged hydrogen ions are balanced
The softer surface forms a bond with the harder surface by negatively charged chloride ions to form hydrochloric
The intermolecular bonds cause friction and if the junction acid, which can dissolve titanium and cobalt chrome
is stronger than the cohesive strength of the softer bearing
material fragments of the softer material become adherent Wear processes
to the harder material or become smeared Two wear process are of particular importance in Orthopaedic
Tends to cause steady low rate wear applications, in particular in relation to joint replacement
arthroplasty; fretting and galling.
Fatigue wear
Repetitive/cyclical stressing of the asperities causes Galling
accumulation of microscopic damage Is a particular type of adhesive wear
033
Occurs as a result of friction and adhesion between two

surfaces sliding on one another, typically described as
Laws of wear
The volume of material (V) removed by wear increases with
relatively converging contact; this can occur during
load (L) and with sliding distance (X) but decreases as the
assembly of a Morse taper or due to micromovement
hardness of the softer material (H) increases:
between the two surfaces of a Morse taper
Part of the softer material will be gouged out and may form V∞LX=H
lumps stuck to the surface, whilst other parts of the softer
Wear is also proportional to surface roughness:
material will become stuck to the harder material (a form
of adhesive wear). Some materials are more prone to V ¼ kLX
galling than others
Where k = a wear factor for a given combination of materials
that incorporates the hardness of the softer material, material
Fretting
properties (stiffness, wear resistance), local environment
Caused by micromovement between two surfaces resulting (lubrication) and surface roughness.
in abrasion of asperities
Amount of movement may be as little as a few nanometres
Bearing couples in hip replacements
The abrasion results in loss of the passivating surface
The four main bearing couples currently in use are metal/
Depending on the tolerances joint fluid may ingress
UHMWPE, ceramic/UHMWPE, metal on metal and ceramic
between the two fretting surfaces
on ceramic. The first two can be described as hard on soft and
Where the passivating layer is lost and joint fluid gains
the latter two as hard on hard.
ingress corrosion occurs due to galvanic currents causing
pitting corrosion Hard on soft bearing couples can, at best, achieve mixed
lubrication, but some surface asperity interaction cannot be
The loose particles caused by the abrasion of the surface
become oxidised. Oxides of most metals are much harder avoided
than the non-oxidised metal Hard on hard bearing couples can potentially achieve true
fluid film lubrication, at least during some parts of the
Large quantities of wear debris can be produced which can
then migrate between the bearing surfaces, causing third gait cycle
body wear Both ceramic on ceramic and metal on metal bearing
couples can theoretically achieve fluid film lubrication
Third body wear also occurs between the fretting surfaces,
increasing the rate of fretting and causing ‘false brinelling’ Metal on metal bearings are vulnerable to scratching
Fretting wear at Morse junctions has been implicated in Ceramic on ceramic bearings are more scratch-resistant
adverse reactions to metal debris and smoother than metal and ceramic also has high
Two further processes are of relevance in the manufacture of wettability
implants’ If the lubrication mechanism changes from boundary or
Polishing refers to the use of a fine abrasive glued to a work mixed to fluid film, the wear rates will reduce to very
wheel. low levels; this can potentially be achieved in hard on
Buffing refers to the use of a fine abrasive powder applied hard bearings but only if the head diameter is large enough
to a work wheel. Buffing results in a higher polished finish than to give sufficient sliding velocity to entrain the synovial
polishing. fluid
Measurement of wear Wear rate

Linear wear and volumetric wear are two methods of measur- For a hard on hard bearing couple debris volume will be
ing wear in an implant. The mechanisms of wear are the same highest in the first year (bedding in)
in both. For a hard on hard bearing couple the bedding-in wear
Volumetric wear measures the volume of material lost volume will be greater with a greater radial clearance
(described as cubic millimetres per year or per million cycles) (radius of acetabular component minus radius of femoral
Linear wear measures the penetration of one component head component)
into the other and is measured on a radiograph. For hard on soft bearings wear is nearly linear over time
For any given amount of linear wear in a hip replacement, but greatest creep occurs during the first year
the proportional volumetric wear will be greater for a large Once bedding-in has been achieved, wear rate will depend
femoral head component than for a smaller one for on the applied load and the sliding distance
geometric reasons In a ball and socket joint the sliding distance will be greater
Linear wear measurements cannot distinguish between true with a larger head diameter, although the applied load per
wear and creep unit area will be smaller
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033
The overall sliding distance for an individual joint will be forces. These stems must be polished to allow the slight
proportional to activity subsidence26
A small head diameter will, overall, lead to a reduced : Shape closed stems rely on shear forces between the
volume of wear particles for any given bearing couple implant and the cement. The compression forces on the
cement are relatively low. The tensile forces are
‘The ideal hip implant’ medium
Candidates become very anxious about what to say if they are Cementless stems can have a porous surface or be pre-
coated with hydroxyapatite, or both. Hydroxyapatite can
asked what their ideal implant is or what they use. It must be
either be confined to the proximal region or cover the
realized that this question is just a ‘setting’ question to intro-
entire stem. Long-term dissociation of coating from the
duce the topic, and the question is really about the basic
stem has led some experts to conclude that the ultimate
science underlying choice of implant. There is no right or
effect of hyroxyapatite coating is to generate an effect
wrong answer to the actual choice of implant.
similar to a cemented polished stem
In the basic science oral it would be reasonable to discuss
the relative merits of existing implants, covering topics such as
Head size
levels of evidence, survivorship analysis, etc. In many cases,
however, the topic is going to move onto prosthesis design. For hard on soft bearing couples there is a compromise to be
A number of factors could be considered in relation to made between conflicting biomechanical principles:
implant design25, but the overall aim is to have: Increasing head diameter results in
Materials that are biologically compatible :Reduced dislocation risk: The jump distance is greater
An implant that reproduces the ‘normal’ anatomy of the for a large femoral head diameter
hip joint : Increased range of movement before impingement
Both early- and long-term stability of fixation (owing to the potential increase in the
A stable articulation head : Neck ratio)
Low wear rates : Increased volume of wear particles owing to increased
Minimal adverse effects on surrounding tissues, including sliding distance
bone and soft tissues For hard on hard bearing couples there is less of a conflict:
Aspects to consider include the following. Increasing head size results in
Stem geometry : Reduced dislocation risk

Stem geometry is interlinked with stem fixation
: Increased range of movement before impingement
Double tapered stems designed for cemented fixation
: Potential for fluid film lubrication, resulting in greatly
reduced wear
require the necessary surface to allow slight subsidence to
generate the appropriate hoop stresses Head fixation and taper junctions
Medial offset (horizontal distance between the long axis of
Monoblock femoral components avoid head/neck interface
the stem and the centre of rotation of the head) –
problems but prevent adjustment of neck length after stem
Increasing the offset will reduce joint reaction forces but
implantation and require larger inventories
increase torque forces on the fixation interface and may
Modular head fixation is achieved by one of the varieties of
also alter tension in the soft tissues
Morse taper
Length of stem
Whether or not to use a collar – In theory a collar transmits The concept of Morse tapers in general will now be discussed
loads to the proximal part of the femoral stem, which in more detail:
avoids stress shielding, but in practice it is not possible to A Morse taper is a method of joining to components
achieve reliable load transmission both through the collar together that is commonly used in engineering
and through the proximal part of the prosthesis itself and construction
overall fixation may, therefore, be impaired The Morse taper consists of a male (trunnion) and female
component (bore), both of which have the shape of a
Stem fixation truncated cone (frustrum). The angle of the taper is the
For cemented stems there are two fundamental angle of slope of the cone measured against the
philosophies longitudinal axis of the taper. A stylized Morse taper is
: Tapered polished stems (e.g. Exeter) rely on slight illustrated in Figure 30.14
subsidence to produce high radial compression forces Contact is side to side – The Morse taper is not end loading
in the cement, supported by hoop stresses in the bone, Tapers with an angle of >7° are called ‘self releasing’ or
the shear forces are low and there are almost no tension ‘fast’ tapers and can easily be pulled apart but If the angle of
033
match. A design decision is, therefore, made about whether

maximum contact loads occur near the tip of the trunnion
(negative mismatch) or near the base of the trunnion
(positive mismatch). There is some evidence to suggest that
Bore
negative mismatch results in less fretting
Stem modularity at other sites –– Morse taper junctions are
used at other sites as well as at the head–neck junction,
particularly for revision components; these sites include the
neck–stem junction and the mid-stem junction. These other
junctions may also be the source of particles as a result of
Trunnion fretting and fretting corrosion.
Acetabular component geometry
For cemented acetabular components a flange may
provide better pressurisation of cement
For non-cemented components supplementary screw
fixation may be used or not
For non-cemented acetabular components with UHMWPE
inserts the presence of screw holes may allow polyethylene
Taper half angle particles to pass to the interface and lead to cyst formation
(< 7˚ = self locking) and/or loosening
Figure 30.14 Morse taper
The geometry of the acetabular component may be a full
hemisphere (for increased stability) or not a complete
hemisphere (smaller jump distance but less potential
the cone is sufficiently small the taper will be self locking – impingement)
I.e. it will not require an additional locking device to keep Constrained components may increase stability but
the two components together increase the load on the component-cement interface
As a general rule a combined angle of 14° (7° each side) or
less will result in a self locking taper. The smaller the angle Bearing couple
the harder it will be to separate the two components. When Hard on soft or hard on hard bearing couples can be
the two components are forced together cold welds (transfer considered and their relative merits discussed27
of the soft material to the harder one) occur at the interface The wear rate for hard on soft bearings can be improved
Another factor influencing the tightness of fit include the with the use of highly cross-linked polyethylene or
surface finish of the two materials polyethylene with antioxidant treatment, although consider
The two components of the Morse taper form a very rigid and the other mechanical consequences of increased cross-
firm fit that depends on friction between the two surfaces, linking of the polyethylene
Van der Waals forces, and the formation of cold welds Metal on metal bearings offer the potential for very low
Wear may occur at the Morse taper interface due to fretting wear rates but they may be susceptible to scratching and
and fretting corrosion cup orientation may be critical for low wear rates, open
The wear particles, typically oxides, are often hard and they cups being associated with ALVAL – See below
can migrate between the bearing surfaces of the hip causing Ceramic on ceramic bearings have historically been
third body wear associated with the problem of fracture of components. There
Wear at the Morse taper is Mode IV wear are some concerns about stripe wear, which is probably
Wear at the Morse taper (trunnionosis) has been implicated caused by microseparation of the components, although the
in Adverse Reactions to Metal Debris and has been very small sized wear particles may be less problematic than
described as being characterized by a high level of cobalt the larger particles produced by polyethylene wear. A further
ions in the blood problem with some ceramic on ceramic bearings is
Note that although wear at the Morse taper is often squeaking, which is probably due to impingement
described as trunnionosis the main site of wear is often the
bore rather than the trunnion despite the bore being in a ARMD and ALVAL
harder material There has been a great deal of concern about metal on metal
To minimize the risk of fretting occurring at the Morse bearing couples and ARMD (adverse reactions to metal debris)
taper dimensions and geometry and the surface finishes are and ALVAL (aseptic lymphocyte-dominated vasculitis-associ-
critical. As it is practically impossible to achieve a perfect ated lesions).
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033
Pathology recommendations for monitoring have been laid down by

When excessive wear occurs at metal on metal bearing couples the Medicines and Healthcare products Regulatory Agency
or junctions, nanometer-sized cobalt chrome wear particles (MHRA). These include the following:
become deposited in the periprosthetic tissue. Annual measurement of levels of chromium ions and
None specific reaction: The metal wear particles are taken cobalt ions in the blood. The blood tests must be taken in
up by macrophages. The release of high levels of metal ions the specified way to avoid contamination of the sample by
causes cell necrosis, which histologically is seen in the more metal in the hypodermic needle
superficial layers of membrane surrounding the implant The MHRA threshold is put at >7 ppb (μg/l) of either
Specific reaction in which high numbers of lymphocyts and chromium or cobalt: 7 ppb equates to 134 nmol/l for
plasma cells are seen in the perivascular areas in the per- chromium and 119 nmol/l for cobalt
implant tissues. The pathological process is thought to be a MRI scanning with MARS (metal suppression) protocol, or
T-cell type IV delayed hypersensitivity to cells and tissues an ultrasound scan should be performed in symptomatic
altered by the cobalt and chromium wear debris. The patients or patients with levels of chromium or cobalt
reaction causes further macrophage recruitment and elevated above the MHRA threshold
further inflammation and damage
The process can lead to the formation of cystic and/or solid Biomechanics
masses near prostheses, with marked necrosis and both the Many candidates turn pale when asked to draw free body
specific ALVAL and the non-specific macrophage responses diagrams or when asked to explain the mechanics of con-
outlined above. structs. The examiners are not expecting candidates to be
The metal debris may arise both at the metal on metal qualified engineers but they do expect them to have some
bearing couple itself and at the site fretting corrosion at Morse understanding of the basic concepts underlying orthopaedic
tapers (either at the head/neck junction or at the neck/shaft constructs and locomotor systems. It is best to start with
taper in modular components. simple concepts and build them up progressively. It cannot
The probable sequence for production of metal wear debris be emphasized enough that practice at drawing vector dia-
at Morse tapers is fretting – Oxidation of wear particles – grams and free body diagrams for different situations will
Further fretting and third body wear – Pitting corrosion – make the answering of biomechanics questions much easier.
Further debris, etc, the whole process being called fretting Do not try to memorize specific diagrams; understand the
corrosion. Third body wear also then occurs at the metal concepts and be able to apply them to new situations.
on metal bearing couple. The debris cause specific and
non-specific inflammatory changes in the periprosthetic Scalars and vectors
soft tissues, with tissue necrosis
A scalar is a value (e.g. temperature, speed)
Risk factors for adverse reaction to metal debris A vector has both a value and a direction (e.g. force,
There are a number of factors that may predispose to excessive velocity)
wear of metal on metal hip replacements:
Vector analysis
Acetabular component design
Vectors may be represented by a scale drawing, where the
: Relatively shallow acetabular components predispose to length of the line represents the magnitude of the vector
edge loading and the arrow its direction
: Suboptimal clearance – The clearance (the difference in A vector direction must be referenced to a set of Cartesian
radius between the acetabular and femoral head coordinates (x, y, z axes)
components) influences the lubrication of the bearing Vectors may be added and subtracted using scale drawings
Surgical factors (Figure 30.15) – Using parallelograms or, in the case of
: Angle of inclination of the acetabular component – forces at right angles to each other (such as along the x, y
A high cup angle predisposes to edge loading and z axes), using geometry
: Retroversion of the acetabular component – This may A vector can be decomposed to give its components along
predispose to impingement and wear individual x, y and z axes using right angled triangles.
: Size of component – For resurfacing arthroplasty Figure 30.16 illustrates how a force V can be decomposed
problems have more commonly been associated with into two components along the x and y axes
relatively small acetabular component sizes, which have The magnitude of the components along the x, y and z
usually been those used in female patients axes can be found from a scale drawing or by utilizing
geometry
Investigation of patients with suspected ARMD The mnemonic SOHCAHTOA is useful for remembering
Patients who have had hip replacements with metal on the geometry
metal bearings should be regularly monitored. The Sine = Opposite/Hypotenuse
033
Figure 30.15 Vector Figure 30.16 Vector

addition decomposition
V
Vy
Shear Force Shear Force
Vx
q
F Figure 30.18 Moment
arm and pivot point
Figure 30.17 Deformation under shear
Moment arm
Cosine = Adjacent/Hypotenuse
Tangent = Opposite/Adjacent
Newton’s laws
Newton’s first law: For a body in equilibrium the sum of Kinematics
forces and moments = 0 Newton’s second law of motion can be summarized as
Newton’s second law: Force = mass × acceleration F = m× a, where F = force, m = mass and a = acceleration
Newton’s third law: To every force there is an equal and Any shape can be represented as having a centre point, the
opposite force centroid, which is calculated using calculus
A solid body also has a centroid
Statics An ‘extruded shaped object, e.g. a cylinder’ with a regular
A force applied normal to the surface of an object will cross-sectional area has a centroidal axis
cause either compression or tension According to Newton’s second law, when a net force is
A force applied tangentially to the surface of a body will applied to an object that object will accelerate
cause shear If the force acts through the centroid the object will
Newton’s second law indicates that an object will remain accelerate in the direction of the applied force and a
in a state of equilibrium unless a (net) force is applied to it translatory movement will occur
If a compression force is applied to an object and the force If the force does not act through the centroid then the
is opposed by an equal and opposite force, the object will imparted movement will be both translatory and rotatory;
shorten along the line of action of the forces; the the rotatory component being imparted by the moment of
shortening is described as strain, measured as change in the force
length per unit length, or expressed as a percentage. The The moment arm is the length of the line drawn
stress causing this strain is expressed as force/unit area (N/ perpendicular to the vector and passing through the pivot
m2 or Pascals, often expressed as MPa) point (Figure 30.18)
If a tension force is applied and opposed by an equal and The moment is calculated by multiplying the magnitude of
opposite tensile force, a tensile stress and strain will result the force by the length of the moment arm
If a force is applied tangential to the surface and opposed
by an equal and opposite force applied to the opposite
surface, a shear stress will occur and the object will deform Bending forces
as shown in Figure 30.17, the shear being expressed as an If two or more forces are applied to an object the object will
angle. When a cylinder is twisted at opposite ends, the deform. In orthopaedics the deformation behaviour of beams
result is a torque shear stress and cylindrical objects is of paramount importance, particu-
Shear stress causes compression and tension forces that lie larly for fracture fixation. The basic understanding of simple
at 45° to compression and tension forces resulting from beam characteristics is, therefore, a common area that is
forces applied normal to the surface explored in the basic science oral.
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033
The engineering aspects of stresses and strains in beams are maximal at the surfaces and running down the middle
complex and depend upon many factors, such as the distribu- there will be a neutral axis (usually corresponding with the
tion of the application of the force, etc. A detailed analysis of centroidal axis in a uniform beam) where the tension and
beam mechanics is beyond the requirement of orthopaedic compression forces are zero
trainees and the descriptions given below are at a relatively There is a linear relationship between the magnitude of the
simple level but sufficient for a working practical knowledge as tensile and compressive forces within the beam and the
necessary for the practice of orthopaedics. For more detailed distance from the neutral axis (Figure 30.19)
analyses it would be necessary to consult with an engineer. The resistance to bending of a beam, or any other object,
Cantilever bending will depend not just on the modulus of elasticity of the
material from which it is made but also on the distribution
A cantilever is a beam that is fixed at one end of the material around the centroidal axis; this distribution
If a downward force is applied to one end of a cantilever, is described by the term second moment of area, or second
tension will occur on the upper surface and compression moment of inertia
on the lower. The tension and compression forces will be
For a solid beam the second moment of area I = bh3, where
b is the breadth and h is the height (or thickness). It can be
seen that if the thickness of the beam is doubled the
stiffness will increase by a factor of 8, whereas if the width
is doubled the stiffness will just double
For a solid rod the second moment of area I = ¼ πr4
The tensile and compressive forces increase in a linear
fashion with distance from the fixation point (assuming a
weightless beam), as illustrated in Figure 30.20 a for
cantilever bending
The strain of the beam will be proportional to the square of
the distance of the force from the fixation point
For a weightless beam the sheer forces will be uniform
Figure 30.19 Stresses across a beam when being bent along the length of the beam
(a) Figure 30.20 (a) Stresses along a (weightless) beam

under Cantilever bending. (b) Stresses along a beam
(b) under three point bending. (c) Stresses along a beam
under four-point bending
Stress
Stress
(c)
Stress
033
Three- or four-point bending The stiffness to bending of screws, intramedullary nails and
A beam supported at both ends can be considered as external fixation components will also depend upon the
equivalent to two cantilevers joined back to back modulus of elasticity of the material from which they are
The tensile and compressive forces applied to a beam when made and their second moment of area
subjected to three- and four-point loading are illustrated in The stiffness of intramedullary nails, etc to torque forces
Figures 30.20 b and c will depend upon their sheer modulus and their polar
moment of inertia
Torque forces When these device are applied or inserted, however, an add-
When a turning couple is applied to an object torque forces itional concept will need to be considered: The working length
result The working length of a device refers to the total
If the turning moment at one point is resisted by an equal unsupported length
and opposite turning couple at another point on the same Increasing the working length will decrease the stiffness of
axis, torque (shear) strain will be applied, resulting in the construct, i.e. strain increases with increased working
torque shear length
The resistance to deformity when a torque strain is applied For a cantilever beam loaded at its free end the maximum
is also related to the distribution of material within the deflection at its free end is proportional to the length
object; the term to describe this distribution is the polar cubed – Maximum deflection = FL3/3EI, where E is the
moment of inertia modulus of elasticity and I is the second moment of area
For a rod-shaped object, the polar moment of inertia, The angulation at the end of the cantilever beam,
J = πr4/2 when loaded at its end, is proportional to the length squared
It can be seen that the stiffness of a cylindrical object to The stiffness of an external fixation pin will be proportional
twisting is proportional to the fourth power of the radius to its Young’s modulus, and the fourth power of its radius.
The stiffness of a hollow cylinder is proportional to the The working length of the pin will be the distance between
fourth power of the outer radius minus the fourth power of its attachment to the bar and the point at which it reaches
the inner radius the bone. Far cortex locking screws and dynamic locking
A hollow intramedullary nail is less stiff than a solid nail of screws deliberately lengthen the working length of the
the same diameter, but if a constant volume of the same screws to allow more movement (strain) at the fracture site.
material is used to make two nails the hollow nail will be By increasing the working length of either the entire device
stiffer than the solid nail because of the greater outer or of component parts of it the stiffness of the applied
diameter construct can be reduced, and vice versa
The same fourth power relationship applies to the bending The working length of an intramedullary nail will depend
stiffness of a bone screw, which is important in the design upon whether or not it is firmly wedged in the cortical bone
of the screws used in locking plates, which depend on their near the fracture site. For an unreamed nail the working
bending stiffness to fix the fracture, rather than on their length will usually be the distance between the interlocking
pull-out strength; hence, locking screws have a larger core screws nearest the fracture but for a reamed nail the
diameter and small thread depth than conventional screws working length may be much shorter if the nail is firmly
Table 30.6 gives the moments of area/inertia for elements of jammed in the bone at the isthmus on one or both sides of
circular and rectangular cross-section28. the fracture
The working length of an intramedullary nail may differ
Stiffness of constructs and working length for rotation and bending forces, as when the bone bends at
the fracture site the nail may become fixed to the bone by
Another popular topic is the stiffness of constructs used for
three-point fixation
fixation of fractures.
For an external fixation device the working length is the
The stiffness of plates will depend on the modulus of distance between the two pins nearest to the fracture
elasticity of the material from which they are made and
In theory a longer working length of a device decreases the
their second moment of area (which will be affected by the stiffness of the construct but, for any given bending force
shape and profile of the plate) applied to the fractured limb, the stress within the fixation
device should decrease because the load is shared along the
Table 30.6 Moments of area/inertia for simple beams and rods
length of the device. Experimental results, however, have
Second moment Polar moment not always confirmed that the stress in plates reliably
of area (I) of inertia (J) decreases as the working length increases and it is possible
Rectangular beam 1=12 bh3 that the greater deflection with increasing working length
may give rise to fatigue problems, particularly at the
Cylinder ½ πr4 ¼πr4
nearest fixation points
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033
Free body diagrams

Free body diagrams are one of the most popular topics in the
basic science oral. In the past this has usually involved the free 4/5W
FAb
body diagram for the hip, but other joints may be used as the JRF (Unknown)
basis for discussion.
JFR
Basic underlying limitations Fixed
Free body diagrams are a simple method for calculating the

mAb
forces around a stationary structure or an element of that struc- Ab
ture. It is important to realize the limitations of the method: mW
The body must be in equilibrium

4/5 W
The number of unknown forces must not be too great Mobile
otherwise the problem becomes statically indeterminate
The calculation only considers two dimensions
Underlying principles Figure 30.21 Free body diagram for the hip when standing on one leg
If a body is in equilibrium, the anticlockwise (positive) and

clockwise (negative) moments must add up to zero draw the line from the centre of rotation of the hip to the
If a body is in equilibrium, the sum of the vectors must add tip of the greater trochanter, or in the shoulder from the
up to zero centre of the humeral head to the insertion point of the
If a vector diagram is drawn, the result will be a closed deltoid on the humerus, both usually incorrect
polygon (triangle for three vectors) Confusing the anatomical length of the muscle with the
length of the line representing the magnitude of the vector
Steps in drawing a free body diagram Forgetting to establish which component is the moving
Select the area to be studied (this is your choice – As these part and which the fixed; the direction of the vectors is
are static free body diagrams all parts must be in decided by their attachment to the moving part and not the
equilibrium with all other parts; therefore, it is legitimate to fixed part (an important point when looking at the
select just one part of a complex system for analysis) femoral/tibial articulation or the patellofemoral
Decide which is the moving part and which is the static part articulation, respectively)
Draw the known forces and moment arms (when deciding Making the diagram too small
in which direction a muscle vector should point, think of
yourself inside the fixed part and imagine the moving part Example for the hip joint30
pivoting around you) Figure 30.21 shows a stylized free body diagram for the hip
Ignore forces passing through the pivot point as these do for standing on one leg
not produce any moments around that point The unknown abductor force (FAb) can be calculated by
Find any unknown force that exerts a moment by balancing the moments
balancing the moments Force of abductors (FAb) × moment arm of abductors (mAb) =
Now that the forces causing moments are known, the the weight of the body (minus the weight of the stance leg) ×
unknown translatory force passing through the pivot point the moment arm mw
can be calculated as the sum of the translatory forces must As the joint reaction force acts through the pivot point it
add up to zero has no moment arm and does not need to be considered
In a simple see-saw example the forces are all along the when the moments are being balanced
same axis; when the forces are not along the same axis then Once FAb is known a force triangle can be drawn to scale
the vectors must be decomposed to give the components to calculate the joint reaction force (JRF), which will be
along the x and y axes, or the resultant force can be worked equal and opposite to the sum of the two vectors FAb
out by making a scale drawing (remembering that the and W
length of the line is proportional to the magnitude of the
force and not, for example, the anatomical length of the Effect on hip joint reaction force of using a walking stick
muscle that may be producing it) The use of a walking stick in the hand opposite to the
affected hip provides a moment that partially balances the
Common mistakes when drawing free body diagrams moment produced by body weight and the force required
Forgetting that the moment arm meets the vector at a right to be produced by the abductor muscle is, therefore,
angle; when drawing the hip diagram many candidates correspondingly reduced. The moment arm of the force
033
PTF
Dm
W2
Mobile Fixed Joint
reaction
Fixed force
wm2
W1
GRF
wm1
mGRF
GRF
mPTF
Horizontal component = R Cos ° PTF
a
Mobile
Figure 30.22 Free body diagram for the shoulder when holding a weight in
the hand
GRF = Ground reaction force – passing

through the walking stick is long, so as a result a force of through ball of foot when heel off ground
15% of body weight through a walking stick may reduce the Figure 30.23 Free body diagram for the knee – Tibio-femoral joint reaction
JRF by up to 60% force when standing on one leg with knee flexed
Free body diagrams for other joints

Although the hip joint free body diagram is the most common femur and the tibia; this is because the free body diagram is
one encountered in the exam, you should also be able to do looking at the situation in static equilibrium. The instantan-
similar diagrams for the ankle, knee, patellofemoral joint, eous pivot point is different from the axis of rotation of the
elbow and shoulder. All are based on variations of the balance knee, which considers the dynamic situation. It can be seen
beam principle. Be prepared conceptually to ‘turn the balance that in roll back the instantaneous pivot point moves back-
beam upside down’ to do diagrams for, for example, the ankle, wards, thus, increasing the moment arm of the force being
or to put both forces on the same side of the pivot point (but transmitted through the patella tendon, which in turn
with opposite sign moments), for example, in the elbow and decreases the joint reaction forces when the knee is in deep
the shoulder. flexion.
Figure 30.22 shows an example for the shoulder. In this Once the patellar tendon tension has been calculated from
free body diagram, wm1 is the moment arm for the weight the free body diagram as in Figure 30.23, the patellofemoral
being carried and wm2 is the moment arm for the weight of the compression force can then be calculated by constructing a
arm itself. Dm is the moment arm for the deltoid muscle force. parallelogram from the two vectors made up of the tension in
Once Dm has been calculated by balancing the moments, the the quadriceps ligament and patellar tendon proximal and
JRF can be calculated by drawing a vector diagram. The hori- distal to the patella respectively (which are assumed to be of
zontal and vertical components of the JRF can be calculated equal magnitude for this simplified calculation) then drawing
using geometry. the resultant force; the JRF will be equal and opposite to this
Figure 30.23 shows an example for the knee in equilibrium force (Figure 30.24). It should be noted that this is a simplica-
standing on one leg (such as on a step). In this particular tion as in the actual knee the patella tilts and as a result the
example the femur is taken as fixed and the tibia as mobile. tensions proximally and distally are not equal.
The ground reaction force (GRF) acts upwards through the
ball of the foot and exerts a counterclockwise moment on the Hamilton–Russell traction
tibia, which is countered by the clockwise moment exerted by The principles of the free body diagram can also be used to
the quadriceps mechanism via the patellar tendon. The JRF show how traction works. A compound pulley can be analysed
can be calculated by drawing a force triangle. in the same way as any other system. It is important to
When calculating the joint reaction force for the knee the establish which is the moving part and which is the fixed; the
instantaneous pivot point is the contact point between the total traction force applied by the traction cord at the pulley
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033
T2
Skin
traction
T1 F F
Approx 30°
Resultant
force 2F
Figure 30.25 Hamilton–Russell traction
Figure 30.24 Free body diagram for the patellofemoral compartment of the
Pitch: The distance between the tips of two successive
knee threads
Lead: The distance the screw advances with one complete
turn of the screw
will depend upon the number of cords acting on that pulley so Length
the number of cords reaching the moving pulley will be the
number to use for calculating the total force. For a more Screw heads
detailed analysis allowance should be made for friction in the The driver of the screw needs to be considered:
pulleys (allow for 10% loss in traction for each pulley) and for
Non-self aligning
the effect of gravity when the foot end of the bed is tilted to
prevent shear forces between the patient and the bed. The Slot
principle of Hamilton–Russell traction is shown in Cross head
Figure 30.25. Phillips
Self aligning
Screws Hex
Definition Star – The star head is less likely to strip than the hex and,
A screw is a machine that converts a rotational movement therefore, has better torque transmission
around an axis into a translational one along the same axis
Shaft and core diameter
Component parts The resistance to bending is proportional to the fourth power
If asked to describe a screw consider the following component of the core diameter.
parts: For cannulated screws the resistance to bending is propor-
tional to the fourth power of the outer diameter of the core
Head
minus the fourth power of its inner diameter
Countersink A larger core diameter screw allows a larger guidewire
Shaft whilst maintaining the bending stiffness of the screw.
Thread Locking screws need to be resistant to bending and are less
Tip reliant on pull out strength and are, therefore, designed with a
Also consider the material the screw is made from. relatively larger core diameter.
Although screws are designed for specific purposes remem-
ber that a particular screw may nevertheless be used in differ- Thread
ent ways or to fulfill different functions depending upon the Compression screws may be designed partially threaded to
may it is inserted. ensure they only grip distally.
‘Double start’ screws have a lead that is twice the pitch –
Key dimensions They have two parallel threads – Double start screws advance
Core or inside diameter much quicker whilst retaining pull-out strength.
Outside diameter: The diameter across the threads Conventional screws in plates work by applying compres-
Shaft diameter sion force to increase the friction between the plate and the
033
bone – These screws, therefore, require high pull-out strength The lunate and scaphoid are narrower on their dorsal
and are designed with a relatively high outer to core surfaces than on their volar surfaces, tending to force the
diameter ratio. wrist into extension when compressed longitudinally. This
Locking screws require less pull-out strength as they work with is countered by the trapezium and trapezoid, which
a plate as a fixed angle device; they are, therefore, designed with a articulate with the dorsal aspect of the distal scaphoid
narrower outer (thread) width to allow a larger core diameter. Flexion/extension rotation and radioulnar deviation occur
around instant centres of rotation in the proximal part of
Tip the capitate
Self tapping screws have a cutting flute at the tip About two-thirds of flexion occurs in the midcarpal joint
The first few threads of self tapping screws are of progres- with one-third in the radiocarpal joint
sively greater diameter and are designed for tapping the hole; About one-third of extension occurs in the midcarpal joint
these threads do not hold the bone well and the screw should with two-thirds in the radiocarpal joint
be advanced beyond these threads On radial deviation the scaphoid and proximal carpal row
Self cutting, self tapping tips – These screws may strip their flex and on extension they extend
threads proximally if the screw does not advance sufficiently as
the tip cuts the bone on the far cortex, they are, therefore, best The spine
suited for use in cancellous bone or as unicortical screws The motion segment consists of two adjacent vertebrae and
Special screws the intervening soft tissues
The motion segment can be divided into anterior and
Dynamic compression screws – These have an outer cylinder
posterior columns; the anterior column contains the vertebral
with thread and an inner component that allow lateral move-
bodies, disc and longitudinal ligaments; the posterior column
ment proximally but not distally. They allow controlled axial
contains the facet joints, transverse and spinous processes,
movement at a fracture site.
vertebral arches and intervening ligaments
Dual thread screws (such as Herbert screw) – These have a
relatively large pitch smaller diameter thread distally and a The movements of the motion segments are interlinked
narrower pitch wider diameter thread proximally. As a result of Movements in one plane involve obligatory motion in
the differential pitch they compress the fracture surfaces together. other planes
Conical screws – These screws become loose very quickly Although six degrees of freedom are possible at all levels,
on being ‘unscrewed’. the proportional freedom varies with the differing
morphology of the vertebral bodies
When considering the thoracic and lumbar spine
Kinematics of joints
Knowledge of the kinematics of some specific joints and struc- :Flexion and extension movement increases
tures is frequently explored in the basic science oral. The most progressively with more caudal motion segments
popular topics are the knee, the subtalar joint and the spine : Lateral flexion is maximal in the lower thoracic spine
motion segments
The wrist30
: Rotation movement is maximal in the upper thoracic
motion segments, decreasing caudally with the
Anatomically the bones of the carpus are usually exception of the lumbosacral motion segment, where
considered as two rows: Proximal and distal there is some increase in rotational movement
Functionally the carpus can be considered as three columns The integrity of the curves (cervical, thoracic and lumbar)
: Central – The distal row and the lunate of the spine is an important consideration in its ability to
: Lateral – The scaphoid withstand forces applied to it
: Medial – The triquetrum The compressive and shear forces on the intervertebral disc
Palmarflexion range is greater than dorsiflexion can be calculated using a free body diagram of a motion
Ulnar deviation range is greater than radial deviation segment. The moments of the body weight and any weight
The volar ligaments are important stabilisers being lifted are resisted by the spinal muscles, acting with a
Volar extrinsic ligaments pass from the radius and ulna to very short moment arm
the carpal bones The knee joint
Volar intrinsic ligaments pass between the carpal bones The knee joint has a complex shape and motion pattern. When
The carpal bones form a double hinge viewed from the anatomical Cartesian coordinates it is complex,
Activity of the wrist muscles tends to cause the double with sliding and rolling occurring at the articular surfaces.
hinge to buckle The instant centre of rotation around the transverse axis,
The tendency to buckle is resisted by the shape of the seen within these coordinates, moves posteriorly during
articular surfaces and the ligaments flexion, describing a J-shaped curve when seen from the side.
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The rigid four bar mechanism position of the instant axis of rotation moves slightly
Classically the motion pattern has been modelled as a rigid during flexion and extension
four bar mechanism, in which the anterior and posterior
cruciate ligaments form two bars of the mechanism and the The subtalar joint
bones connecting their proximal and distal attachments, The orthopaedic’ subtalar joint is composed of the
respectively, form the other two rigid bars. posterior, middle and anterior subtalar facets
The kinematic model based on the rigid four bar mechan- The ‘anatomical’ subtalar joint consists only of the
ism is largely two-dimensional. posterior facet; the middle and anterior facets and the
talonavicular joint forming the ‘talonaviculocalcaneal
The transepicondylar axis and the medial pivot mechanism joint’, which, together with the spring ligament, form a
More recent work has studied the rotation of the knee around ‘ball and socket’ joint
the transepicondylar axis. When viewed along this axis the The axis of the subtalar joint varies widely from one person
femoral condyles appear spherical rather than ellipsoidal in to another but averages about 42° directed upwards from
shape and during the functional arc of flexion/extension there the heel, and 23° directed medially
is very little movement of the medial condyle on the medial The oblique axis of the subtalar joint results in the subtalar
tibial plateau in the AP plane. joint acting like a mitred hinge or a torque convertor;
The spherical radius of the femoral condyles, when viewed rotation around the axis of the tibia is converted to rotation
along the transepicondylar axis, has given rise to the concept of around the long axis of the foot, and vice versa
the single radius knee replacement31. Mechanical junctions are not unidirectional and it follows
Current thinking on knee kinematics divides flexion of the that a rotation of the foot along its axis will lead to a
knee into three arcs: rotation of the talus around the axis of the tibia; as a result
From full extension to 10° of flexion the ‘screw home’ of supination of the midfoot will cause external rotation of
mechanism operates the talus within the mortice of the ankle and this can lead
The arc of flexion from approximately 10° to 120° is the to external rotation fracture patterns in the ankle
functional arc’, within which most activities of daily living As a result of the axis of the subtalar joint extending laterally
occur. Within this functional arc there is very little AP to the posterior aspect of the ankle the tendo-Achilles lies
movement in the medial compartment, most AP medial to the axis. The gastrosoleus, therefore, exerts a
translation taking place in the lateral compartment; the powerful inversion force on the hindfoot. If, however, the
knee can be seen as operating with a medial pivot, with calcaneum goes into sufficient valgus this may convert the
rotation occurring around the longitudinal axis gastrosoleus into a powerful evertor. The work capacity of the
Beyond approximately 120° of flexion AP translation gastrosoleus far exceeds that of tibialis posterior
occurs in both the medial and lateral compartments, with
the femoral condyles rolling back on the tibial surfaces The midtarsal joint
The joints between the talus and navicular and between the
Anatomical correlations calcaneum and cuboid form the midtarsal joint
The medial tibial plateau has a concave contour When the heel is inverted by tibialis posterior the midtarsal
The lateral tibial plateau has a convex contour, mainly joint becomes ‘locked’ and the mid foot becomes stiff
caused by thicker articular cartilage in the centre of the When the heel is everted the mid foot becomes flexible
plateau The locking of the midtarsal joint is caused by the
The lateral meniscus is more mobile than the medial calcaneocuboid joint moving beneath the talonavicular
The lateral collateral ligament is less closely attached to the joints such that the two components of the midtarsal joint
periphery of the meniscus than the medial become incongruent with each other
These anatomical features correlate with the greater AP The interplay between the eversion/inversion of the
mobility within the lateral compartment when compared hindfoot, the unlocking and locking of the midfoot and the
with the medial windlass effect of the plantar fascia is integral to the foot’s
changing function during various stages of the gait cycle,
The ankle
ensuring flexibility for walking on uneven surfaces and
The distal tibial and corresponding upper talar articular rigidity for optimal push-off
surfaces slope upwards towards the lateral side by about 3°
The talar body forms a truncated cone (frustum) with its
apex facing medially The gait cycle
The talar body is wider anteriorly than posteriorly The gait cycle may be discussed in various ways in the basic
The axis of rotation approximates to a line drawn through science oral; the components of the cycle may be discussed, or
the tips of the medial and lateral malleoli although the the way that the gait cycle is affected by various interventions.
033
The gait cycle could also be used as a vehicle to discuss postural Knee flexing
changes in the foot during activity, etc. Commencement of double stance phase
Background Midstance
The centre of gravity of the body lies above the centre of Centre of gravity passes forward over foot
rotation of the hip Ankle dorsiflexes
Translatory forces on the body tend to make the system less Eccentric contraction of gastrocnemiu–soleus muscles
stable; in bipedal gait the system is metastable Ground reaction force passes posterior to hip
Falling is prevented by postural reactions and moving the Terminal stance
lower limb to brace against the fall Heel leaves ground
Walking can, therefore, be considered a series of Ankle plantarflexes
controlled falls
Gastro-soleus contracts concentrically
Step = initial contact of one foot to initial contact of
the other Pre-swing
Cadence = steps per minute Knee flexes
Stride length = one full cycle Ground reaction force directed upwards and slightly
Foot progression angle = axis of stance foot to axis of anteriorly
motion The three rockers
An alternative way to break down the stance phase is to
The gait cycle consider the three rockers. The three rocker concept is in
Defined as the sequence occurring between two consecutive may ways more useful for orthopaedic surgeons.
initial contacts of one foot
First rocker or heel rocker
Two main phases – Swing phase (35–40%) and stance
phase (60–65%) Initial contact to ‘foot flat’ – The ankle is plantarflexing
Perry32 divided the gait cycle into eight subphases, or Eccentric contraction of ankle dorsiflexors
instants; five in the stance phase and three in the
swing phase Second rocker or ankle rocker
In walking there is a double stance phase during which Controlled ankle dorsiflexion, resisted by eccentric
both legs are in the stance phase simultaneously contraction of gastrocnemius – soleus, as body moves
In running there is an additional float phase, during which forwards over foot
neither leg is in the stance phase
Third rocker or forefoot rocker
During the stance phase the lower limb operates as a closed
kinetic chain Ankle moves into slight dorsiflexion before unloading
During the swing phase the lower limb operates as an open Windlass mechanism in foot ‘winds up’ plantar fascia
kinetic chain Concentric contraction of gastrocnemius-soleus
During the stance phase the kinetic energy of the lower Swing phase
limb is transferred upwards to the centre of gravity of Initial swing
the body
Knee and hip flex, ankle dorsiflexed
During the swing phase, energy is transferred downwards In relaxed walking the momentum given to the lower limb
through the lower limb during the initial swing subphase is one of the main
sources of forward momentum of the body
The subphases of the stance phase
Initial contact Mid swing
Foot makes contact with the ground Tibia swings forwards under thigh
Hip flexed, knee nearly extended
Terminal swing
JRF directed upwards and slightly posteriorly
Prepositioning of foot prior to initial contact
Load response
Ankle plantarflexes to allow foot to make full contact with Efficiency of gait
ground Efficient gait is achieved by minimizing the upward and down-
Eccentric contraction of ankle dorsiflexors ward excursion of the centre of gravity and by preserving
Hip extending – JRF passes anterior to hip forward momentum imparted to the lower limb by
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transferring energy up and down the limb via the muscle :Total dose is measured in Grey
contractions (particularly the eccentric contractions). :Effective dose is measured in Sieverts, enabling
Gage33 described the five prerequisites for efficient gait: comparison of risk between procedures
Stability in stance : Chest x-ray = 0.05 mSv
Foot clearance in swing : Flight to USA = 0.10 mSv
Adequate step length : CT spine = 3.6 mSv
Appropriate pre-positioning of the swing phase foot : Bone scan = 5.0 mSv
Energy conservation Remember – x-rays are a form of radiation; radiographs
are the recorded images made with these x-rays
Radiology Image intensifier images

X-rays X-ray photons are converted into light photons at the
X-rays lie at the upper end (high frequency, short image intensifier input phosphor
wavelength) of the electromagnetic spectrum Visible light photons are converted into an electron beam
X-rays are produced by electrons, generated from an at the photocathode, which passes by focusing electrodes
electron source (cathode), striking a rotating target (anode) and strikes the back of the output phosphor, which has a
made of tungsten thin aluminium covering on the inner side to stop photons
but allow electrons through
The process is only 1% efficient, the remainder of the
energy being dissipated as heat; hence, the rotating target to Electrons are converted back into visible light at the output
avoid meltdown! phosphor
Parameters Input phosphor has larger area than output phosphor,
resulting in a minification gain
: kV – Unit of measurement of penetration ability of
Each photon at the input phosphor generates about
x-rays (i.e. how much energy they carry). Increasing
100 photons at the output phosphor because of the increase
kV increases the forward scatter
in energy levels from acceleration; this is the flux gain
: mA – Unit of measurement of the strength of the x-ray Result is an increase in brightness of several
beam current (increasing the mA increases the
thousand times
exposure, which can also be increased by increasing the
The image can be magnified by increasing the voltage
exposure time interval)
applied to the electronic lenses; a smaller area of input
Two types of x-rays result from the x-ray beam striking
phosphor is used and the x-ray dosage must be increased to
the patient
maintain the same noise levels
: Primary – Direct from the tube to the x-ray plate,
producing the desired image
: Secondary – Reflected from and within the patient/ Computerized tomography
other objects and can blur the image. Reduced by grids X-rays in a fan-shaped rotating beam are received by a
of lead/aluminium circle of stationary detectors
NB. When taking x-rays in theatre there may be a greater Data is digitized such that every ‘point’ within the patient is
exposure of theatre staff to radiation from the x-rays a labelled pixel; because each slice has a depth, each unit of
reflected back from the patient than from those passing space is called a voxel
through the patient Slices are imaged sequentially, or on faster and newer
Resolution is the minimum separation between objects for machines, in a helical or spiral fashion. The fastest
their identification as separate objects machines use multiple slices in a spiral fashion
Contrast indicates the ability to identify objects of differing Transverse anatomical sections can be produced with high
density resolution. Data can now be reformatted to any chosen
Contrast medium – A high-atomic-element substance used plane, but coronal and saggital planes are the
to enhance contrast between anatomical structures traditional ones
Analogue images have an infinite range of density between CT is better at looking at bone than it is at looking at soft
black and white tissues
Digital images have a discrete greyscale (levels of grey) Windows:
between black and white : Hounsfield units (HU) are a measure of attenuation
Orthogonal images are captured at 90° mutual planes to -the attenuation coefficient
convey three-dimensional images in two dimensions : Image is centred on a particular attenuation value and
Dose greyscale compressed within a window
033
: The result is a contrast range appropriate to the desired

tissues; ‘bony windows’ are usually centred on 300 HU
with a width of 1200 (the greyscale of the scan is greater
than that of the human eye)
: Hounsfield units – Bone 1000, water 0, air 1000
Resolution – Is less on CT than on plain radiography
owing to the averaging within a voxel that occurs at the
edges of objects
DEXA scans
These have been described in the section on osteoporosis
MRI34
Utilizes the fact that hydrogen atom nuclei (protons) spin
on their axis and as they carry a charge they generate a
small magnetic field (magnetic moment)
Outside a magnetic field the protons are orientated
randomly
When the body is placed in a strong uniform magnetic field
the protons align themselves with the field, although after
about a second there is a slight difference (about one in a
million) in the number aligning ‘with’ or ‘against’ the
magnetic field, so the body becomes magnetized with a Figure 30.26 Precession
‘longitudinal’ component
Smaller electromagnetic coils, which can be turned on and
off, provide magnetic field gradients to allow spatial Field echo is produced by symmetrically reversing the
localization when imaging gradient fields
If a radiofrequency pulse is applied at a frequency specific to Precession – The protons spin like a top and if they precess
the strength of the magnetic field (the Larmor frequency), in phase they produce a signal. As the phase coherence is
the magnetisation is tipped into the ‘transverse’ plane lost the signal decays. The time constant for the decay in
A 90° radiofrequency pulse tips the magnetisation through transverse signal as phase coherence is lost is T2*
90° and a 180° radiofrequency pulse tips it through 180° (Figure 30.26.)
Only transverse magnetisation sends back a radiofrequency T2* decay is a result of non-uniformities in the magnet as
signal (spin echo) well as randomly fluctuating internal fields in the substance
Echo signal is composed of multiple frequencies according being scanned
to the position along the field gradient T2 relaxation time is the time constant for loss of
The multiple spin echo frequencies are mathematically transverse magnetisation resulting only from fluctuating
manipulated using a Fourier transform to produce an fields in the substance
image, the signal strength at each frequency being T2 relaxation involves only loss of phase coherence, not
dependent upon the local hydrogen density loss of energy
T1 relaxation time is the exponential time constant that T2 tends to be long in tissues with highly mobile water
represents the time to recover 63% of the equilibrium molecules, e.g. in chondromalacia where there is loss of
longitudinal magnetisation when the radiofrequency is matrix structure – Hyperintense on T2 images
turned off Pulsed sequences can be chosen with different repetition or
T1 relaxation tie depends on difference between frequency echo times
of molecular motions and the Larmor frequency; if they are TR = time to repetition of radiofrequency pulse (msec)
similar, T1 is short Long TR times (>5 times T1) allow full T1 relaxation to
Flips of <90° do not convert all the longitudinal occur before the next pulse
magnetisation into transverse and the equilibrium is, With short TR times tissues with high T1 value (e.g. fat)
therefore, regained more rapidly, allowing multiple rapid appear bright
repeating of the flips TE = time to echo – From when the radiofrequency pulse stops
Spin echo is produced by the sequential application of 90° to when the signal is measured (msec). Range 2–100 msec
and 180° pulses Short TE times are relatively insensitive to differences in T2
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Summary The methylene diphosphonate interacts with the

T1 relaxation time = first order time constant for hydroxyapatite in bone to form insoluble technetium
substance to become magnetized after being placed in a calcium phosphate complexes
magnetic field, or to regain such magnetisation following a The technetium-99m emits gamma rays, which are
radiofrequency pulse. Energy is lost to the ‘lattice’ – The detected with a gamma camera
magnetic environment Uptake is found in areas of
T2 relaxation time = first order time constant for loss of :
Increased blood flow
transverse magnetisation resulting from loss of phase :
Increased cellular activity with osteoid formation – In
coherence owing to local non-uniformities in the other words, osteoblastic activity
magnetic field Three phase scan
Tl-weighted images – Short TR (<1000 msec), short TE
(<60 msec)
: First phase: Vascular phase
T2-weighted images – Long TR (> 1000 msec), long TE – 1–2 minutes; angiogram of blood in the arterial
(TE >60 msec) system
T2* gradient echo – Variable TR, TE short (<60 msec),
flip angle 10–80° : Second phase: Blood pool
Proton density images – TR long (>1000 ms), TE short – After about 5 minutes; equilibrium of tracer
(TE <60 ms) throughout the extracellular space
STIR – Short Tau inversion recovery – Increased uptake in this phase indicates increased
Fast spin (turbo) echo – Can be used for T2 and PD vascularization of the soft tissues (most commonly
images (T1 fast anyway) due to inflammation)
Image interpretation : Third phase: Delayed images – Bone phase
T1-weighted images – Fat bright, subacute haemorrhage – After about 4 hours; tracer accumulates at sites of
bright, free fluid dark, good anatomical detail osteoblastic activity
T2-weighted images – Fluid bright – E.g. oedema
Potential false-negative results from technetium-
Proton density – Good for menisci, low contrast 99m scans:
T* gradient echo – Good for ligaments, articular cartilage
and fibrocartilage :
Overwhelming bone destruction with no osteoblastic
activity – Myeloma, thyroid and renal cell tumours, very
Fast spin echo – Good for use in vicinity of metal
prostheses aggressive secondary deposits – E.g. breast carcinoma
: Superscan – Can be found with multiple secondaries
(especially breast carcinoma). The entire skeleton is hot
How to recognise type of sequences
so can appear normal, but kidneys not seen as easily as
If fluid and fat both bright, probably T2-weighted normal (owing to lack of contrast between the normal
If fluid bright and fat dark, probably fat-suppressed T2 increase in signal from the kidneys and that from
(e.g. STIR) the bone)
If fat bright and fluid dark, probably T1-weighted Tc-99m scans can take more than a year to return to
It should be noted that fat suppression sequences can be normal following hip replacements, and 18 months or
used with both T1 and T2 images more following knee replacements
If contrast low, may be PD Tc-99m scans have high sensitivity but low specificity
Nuclear medicine bone scans Other radioisotopes

Nuclear medicine scans involve the use of a radioisotope and a Gallium (67-citrate)
carrier substance that binds to the target tissue. Binds to plasma proteins
Increased uptake found in areas of inflammation or
Technetium-99m scan neoplasia
This is the most commonly used ‘bone scan’ Less sensitive to blood flow than Tc-99 scans
99m
Tc the ‘m’ indicates the metastable form of the isotope, Delayed images at 24–48 hours required
which has a half life of 6 hours, compared with 200 000
years for the Tc99 isotope Indium scan (indium-111-labelled white cells)
Technetium-99m is attached to MDP (methylene Labelled white cells accumulate in areas of inflammation
diphosphonate) but not in areas of neoplasia
033
Can be useful for diagnosing osteomyelitis or infection Inflation pressure

around joint replacements (but not completely reliable for
There is no absolute value for pressure of inflation; the
this)
surgeon should consider
Radiolabelled monoclonal antibodies :Age of patient
Labelling specific to particular cell lines, e.g. granulocytes
:Condition of the soft tissues
:Intercurrent medical conditions (especially vascular
pathology)
PET : The circumference of the limb
Positron emission tomography In the upper limb the inflation pressure should be
Specific radioisotopes, with short half lives (11C, 15O, 18F), 50 mmHg higher than the systolic pressure
manufactured in a cyclotron In the lower limb the inflation pressure should be double
When a positron is emitted by the isotope it interacts with the systolic pressure
an electron, to emit 2 gamma-rays at 180° to each other
which can be detected by a detector Contraindications
Isotopes are used to label biologically active molecules that Severe crushing injuries
are introduced into the subject Sickle cell disease
Good for active cells Peripheral vascular disease (relative)
SPECT Exsanguination
Single photon emission computed tomography Either by elevation or expression
Tomographical images obtained by rotating a camera Expression should be avoided in the presence of venous
around the patient 360°. The images are then reconstructed thrombosis, malignancy or infection, all of which may be
in sagittal, coronal and axial planes spread by embolism
Enhances sensitivity In frail patients cardiac arrest may occur from circulatory
Improves anatomical localisation overload if both lower limbs are exsanguinated at the same
time
Ultrasound Complications
Utilizes high frequency sound waves, which are reflected Local
back from the tissues
Compression neurapraxia
Sound waves are produced and received with a transducer
containing a piezoelectric ceramic crystal Bone and soft-tissue necrosis
Higher frequencies give higher resolution but greater signal Direct vascular injury
attenuation so better for superficial tissues Postoperative swelling and stiffness
Delayed recovery of muscle power
Wound haematoma
Tourniquets Wound infection
Tourniquets can be useful in providing a bloodless field but
there are a number of complications that can arise from their Systemic
use. Proper use of tourniquets is an important aspect of
Cardiorespiratory decompensation
patient care.
Increased CVP
Tourniquets may be non-pneumatic or pneumatic:
Deep vein thrombosis
Non-pneumatic tourniquets are only used for short
Cerebral infarction
operations on the digits
Alterations in acid-base balance
Pneumatic tourniquets may be non-automatic or
automatic. The non-automatic types have a hand-
operated pump and a pressure gauge and they cannot Tourniquet paralysis syndrome
compensate automatically for leaks in the system. The Caused by cuff pressure rather than ischaemia
automatic type operate from either an air line or an Flaccid motor paralysis with sensory dissociation
electric pump Pain sensation often altered although temperature
Tourniquets not attached to a fixed air line carry a risk of appreciation is usually preserved
being inadvertently left in place at the completion of Colour, skin temperature and peripheral pulses are usually
surgery normal
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033
EMG – Nerve conduction block at the level of the Compartment palpably tight
tourniquet Paraesthesia
May take up to 3 months to recover Paralysis
Nerves in patients with diabetes, alcoholism and Disproportionate pain, pain on passive movement and a tight
rheumatoid arthritis have increased susceptibility compartment on palpation are the most important as all the
others are too late and tissues may necrose even though a pulse
Post-tourniquet syndrome (tourniquet-induced is still present distally
At 1 hour of ischaemia, a reversible neurapraxia develops
skeletal muscle ischaemia) At 8 hours of ischaemia, axonotmesis occurs
This is a reperfusion injury and is due to ischaemia. After
release of the tourniquet the following occur:
Oedema Measurement
Stiffness Compartment syndrome is a clinical diagnosis except when pain
Pallor cannot be assessed (e.g. in impaired consciousness or in the
Weakness presence of regional anaesthesia), when a pressure monitor can
be used.
Subjective numbness
A catheter/needle and pressure transducer are used with
simultaneous blood pressure measurement
Myonephropathic metabolic syndrome In trauma the measurement is taken within the zone of injury
Metabolic acidosis and should be undertaken in all relevant compartments
Hyperkalaemia
The threshold can be an absolute value of 30 mmHg or
Myoglobinuria pressure within 20–30 mmHg of diastolic blood pressure -
Renal failure Edinburgh group
Compartment syndrome Fasciotomies

This is a very important topic and you must be able to explain A diagnosis of acute compartment syndrome is a surgical
the mechanism clearly. emergency
Compartment syndrome is defined as increased pressure in Leg compartments – Two-incision technique (anterolateral
an enclosed osteofascial space resulting in decreased capillary and medial) is used to decompress all four compartments
perfusion below that necessary for sustained tissue viability.
Forearm – Volar decompression to include carpal tunnel,
Normal compartment pressures are of the order of 5 mmHg. then check the dorsum and decompress if necessary
Two possible mechanisms can precipitate compartment
Foot – Several different methods have been described,
syndrome:
depending on the part of the foot affected (i.e. if calcaneal
1. Increased content within the compartment – fracture or not). There is controversy over the best method
Haemorrhage, ischaemic swelling, reperfusion injury, etc of treating compartment syndrome in the foot. Nine
2. Decreased space – Tight cast, premature closure of fascia compartments (possibly 10) have been described in the sole
The final common pathway involves: of the foot although it is not certain whether these are
1. Compartment pressure exceeds the venule/venous pressure clinically and functionally separate. A three-incision
2. The venous outflow from the compartment is impaired technique has been described with two incisions dorsally
and tissue ischaemia follows and one medially but complications, including skin
3. Pressure within the compartment increases whilst arterial necrosis and below knee amputation, have been described,
inflow is not impaired and some foot surgeons advise one incision only whilst
4. As compartment pressure approaches systolic pressure, others advocate a non-operative approach
flow into the compartment will cease Closure – Not before 48 hours; there is a low threshold for
NB. It is important to be aware that at a pressure well below skin grafts rather than delayed primary closure
arterial pressure there will be no perfusion of the tissues within Late presentation – Once muscle necrosis is established
the compartment, although at such a pressure there will still be there is no indication for fasciotomy, which may lead to
a distal pulse. rhabdomyolysis and infection. The definition of ‘late’ is
controversial
Clinical presentation
Pain out of proportion to the injury Electrosurgery
Pain on passive movement (pain on stretching the muscles An electric circuit is made involving the patient, where the
of the compartment) patient is the point of current resistance, generating heat
033
Frequency chosen is above 100 kHz to avoid nerve and/or Skin cleanliness (not antisepsis – As this encourages
muscle stimulation resistance)
Monopolar electrosurgery involves an active electrode Theatre design and practice (see below)
(high current density) at the surgical site and a return Limiting dressing changes
electrode elsewhere on the patient. The return electrode
must be of large surface area to reduce the current density
and avoid burns
Enhancing host defences
Good nutrition
Waveforms
Antibiotic prophylaxis where appropriate
: ‘Cut’ – Involves continuous current to generate heat Tetanus prophylaxis
and vaporize tissue
Optimize the skin preoperatively (e.g. psoriasis treatment,
: ‘Coag’ – Involves intermittent current (on for <10% of avoidance of blisters)
the time) with less heat and this permits a coagulum to
Avoid unnecessary antibiotics (resistance)
form. If this waveform is used to cut, higher voltages
are required with more surrounding tissue damage
: ‘Blend’ – Involves a longer ‘on time’ than coag Bacteria
: ‘Fulguration’ means the coagulation/charring of tissue Gram staining involves staining with crystal violet, fixing with
over a wider area and employs a coag waveform with iodine then washing with alcohol: Gram-positive retain dye;
the diathermy point held slightly away from the tissue Gram-negative dye washes out and then re-stained with
Safety safranin O:
Gram-positive cocci: Staphylococci, streptococci
: ‘Grounded system’ – Original technology; the risk of a
return electrode being formed by patient contact with :Staphyloccoci may be coagulase-positive (Staph.
metal on the operating table resulting in iatrogenic aureus), or coagulase-negative (Staph. epidermidis)
skin burns : Panton–Valentine leukocidin (PVL) is a toxin
: ‘Isolated system’ – The return electrode becomes the produced by Staph. aureus, which may cause
only route back to the generator so ‘grounding’ is no necrotizing fasciitis
longer a risk : Streptococci may be alpha-haemolytic (Strep.
: Return electrode placement should be over well- viridans, Strep. pneumoniae), or beta-haemolytic
vascularized muscle mass. Most systems now monitor (group A – Strep. pyogenes, group D – Strep. faecalis)
the impedance at the return electrode to reduce Gram-negative cocci: Neisseria
burn risk Gram-positive bacilli (rods): E. coli, Proteus, Klebsiella,
: Care should be taken with flammable prep solutions, Pseudomonas
which may soak into drapes and then catch fire – Gram-negative bacilli: Clostridia (tetani, difficile,
Alcohol burns without a visible flame perfringens)
Bipolar electrosurgery involves active and return point
electrodes at the surgical site. The forceps points Antibiotic actions
(electrodes) must be separated for current to pass through Bacteriostatic
tissue. Advantage of bipolar – Avoids risk of damage from
Bacteriocidal
passage of current through surrounding tissues
Mixed
(particularly arteries in digits, etc), but still a risk of burns
from alcohol-based prep solutions Penicillin/cephalosporins – Prevent bacterial cell wall
synthesis – Cell wall enzyme
Note that, in electrocautery, direct current is used, in
contrast to electrosurgery, which involves alternating Glycopeptides (vancomycin, teicoplanin) – Interfere with
cell wall enzyme
current
Fucidin and clarithromycin – Block ribosomal peptides
Linezolid – Inhibits protein synthesis
Infection control
Two approaches are taken to address this issue: Bacterial resistance
Reducing the size of the inoculum Resistance acquired in one of two ways:
Enhancing the host defences
Genetic – Resistance transferred via DNA — plasmids
(small circles of double-stranded DNA), integrons and
Reducing the inoculum transposons
Ward hygiene Proteomic – Altered target site on bacterium or altered
Screening/separation of infected cases enzyme that is the target of drug actions
747
033
Skin flora Operating theatre design and practice

Includes coagulase-negative Staph. epidermidis, Staph. Source of pathogens
aureus and Gram-positive diphtheroid bacilli. These are Airborne contamination responsible for 95% of problem
accessed by lipophilic antibiotics secreted in perspiration
Floor is source of 15% of airborne contamination
98% of floorborne pathogens are from skin scales
MRSA
Axillae and groin heavily colonized – Most organisms from
Acquired penicillin-binding protein PBP2a, encoded by gene below level of neck
mecA.
If found on screening swabs: Theatre design35
5 days intranasal mupirocin Separate preparation and disposal areas
4% chlorhexidine baths Four zones
Re-swab and repeat if necessary :
Outer zone – Theatre reception and rest of hospital
Treatment: :
Clean zone – Theatre reception to theatre doors
Glycopeptides – Vancomycin and teicoplanin :
Aseptic zone – Theatre itself
Oxazolidinones – Linezolid :
Disposal zone
Air flow
Biofilms : Plenum – Air pressure highest in preparation area >
Biofilms are ubiquitous in nature and affect many other theatre > anaesthetic room > disposal room. Subject to
walks of life apart from orthopaedics turbulence and eddies
Bacteria on surface of implants secrete a glycoprotein : Laminar flow – Air moves at constant velocity along
biofilm constant flow line with no turbulence
Within the film bacteria change from being planktonic to – Horizontal
being surface attached community, in which many may be – Vertical
dormant
This biofilm reduces access of antibiotics to bacteria :
Exponential (airflow like an inverted trumpet) –
(rifampicin has good penetration of biofilms) Minimizes entrainment of contaminated air from
A proportion of bacteria within the biofilm are dormant so operating personnel
resistant to bactericidal antibiotics Ultraclean air
Bacteria within the biofilm can exchange resistance :HEPA (high efficiency particulate air filters) filter
information particles of 0.5 micron
Bacterial within a biofilm exhibit the phenomenon of : Can achieve reduction to <10 colony forming units
Quorum Sensing, in which the members of the population (CFU)/m3 in centre of theatre
are able to communicate with each other and to Liddell showed reduction in deep sepsis by 50% with
simultaneously transform into their planktonic versions ultraclean air systems, a further 25% reduction with body
when external conditions are favourable; this phenomenon exhaust suits, and 0.06% reduction with systemic antibiotics
explains recurrences of infection after long delays
Biofilms may form within 3 weeks of initial infection and
Handwashing
this will dictate methods used for treating periprosthetic Bacterial counts are reduced by 99% with chlorhexidine,
infections, etc 97% with povidone-iodine
In most cases need to remove biofilm physically to allow Residual effect after time 97% with chlorhexidine, 90% with
adequate treatment of infection iodine
Therapeutic index = effective concentration at site/minimum Theatre clothing
inhibitory concentration. Cotton clothing has pore sizes of 80 microns – Allow skin
scales to pass through
Instrument sterilisation methods Single use non-woven clothing with spun-laced fibres
Dry heat (ineffective, used for glass, liquid and powders) impede bacterial passage but allows ventilation
Moist head (under pressure, requires less heat for less time) ®
Gore-Tex has very small pore size (0.2 micron) but is
UV light (surface sterilization only) expensive
Radiation (used commercially)
Filtration (for sterilization of liquids) Orthotics and prosthetics
Gas (ethylene oxide – Slow) Orthotics is a subject often neglected during revision but is an
Liquid bath (4–8% glutaraldehyde, for heat-sensitive important topic. Orthotics aspects may be incorporated into
instruments – Carries risk of staff sensitisation) other topics, such as gait, hand injuries, etc.
033
Orthoses Orthotic materials

Definition: Orthotics are external devices that control the move- Orthotic materials need to be light, strong and sufficiently hard
ment of segments of the body. wearing to survive for the duration of their intended use.
Common materials include the following’
Uses Thermoplastic (low temperature thermoforming, e.g.
Orthotics may be used to: Orthoplast)
Correct a flexible deformity :
Can remould to adjust, for example where there is
Control motion at a joint pressure on bony prominences
Augment weak muscles : Not as durable as thermosetting materials so usually
Redistribute forces used for temporary orthotics
Relieve weight Thermoplastic (high temperature plastics – E.g.
Polyproplylene)
Types of orthotics :setting temperatures above safe limit for contact with
Orthotics can be classified as therapeutic or functional: skin so made by taking a plaster of Paris mould and
then fitting heated plastic to mould
Therapeutic orthotics Thermosetting materials – composites, usually laminated
Static fabric with resin. Example carbon fibre composites. Cannot
Dynamic be remoulded once made
Static progressive – Serial casting Leather – Traditional material, hard wearing and flexible,
Gravity drop out (upper limb) but skilled labour intensive so expensive
Articulated – Guide arc of motion Other materials, such as irons
Static orthotics cannot be used to correct a fixed deformity.
Serial casting utilizes stress relaxation, a viscoelastic prop- Mechanism of action
erty of biological tissue. Orthotics may use a number of different mechanism to achieve
their effect. These are well illustrated by considering the differ-
Functional orthotics ent types of AFO in frequent use:
Stabilise proximal or distal joints Three-point pressure – Many orthotics use this
Enable or maximize muscle action principle, as used in casts for control of angulated fractures
Assist movement once they have been reduced. Applying force at three
Substitute for muscle action points enables a bending force to be applied to counter
the intrinsic deforming force. To control a twisting
Terminology force it is necessary to apply a turning couple,
Orthotics are named by the joints that they cross which requires a minimum of four points of application
Upper limb: of force
SO – Shoulder orthosis A particular example of the three-point pressure principle is
EO – Elbow orthosis the use of irons, which fit into the heel of the shoe.- three point
EWHO – Elbow wrist hand orthosis pressure is applied by the use of an iron and T-strap (e.g. inside
WHO – Wrist hand orthosis iron and outside T-strap to apply a valgus force at the level of
the ankle/hindfoot). The use of square sockets prevents ankle
HO – Hand orthosis
dorsiflexion and plantarflexion, round sockets allow such
Lower limb:
movement.
HO – Hip orthosis The same biomechanical principles as described for bones
KO – Knee orthosis and joints apply to orthoses. Long lever arms help to minimize
FO – Foot orthosis the contact pressures but increase the bulk and weight of the
HKAFO – Hip knee ankle foot orthosis orthotic.
KAFO – Knee ankle foot orthosis Total contact – Total contact orthotics spread the loads
AFO – Ankle foot orthosis across the entire surface
Spine: Unweighting – The loads pass through the orthotic, thus,
CO – Cervical orthosis bypassing the joint – E.g. patellar tendon bearing AFO
LSO – Lumbosacral orthosis Immobilizing
CTLSO – Cervical, thoracic, lumbosacral orthosis Ground reaction – Ground-reaction orthotics are
TLSO – Thoracic, lumbosacral orthosis discussed below
749
033
Figure 30.27 Ground Maximizing the conformity between the orthotic and the
reaction force orthotic
underlying limb/trunk
Minimizing pressure through unprotected bony
prominences
The material at the interface should also be moisture-
absorbant to avoid maceration of the skin.
Prosthetics
Prosthetics replace a body part. Things to consider:
Functional vs cosmetic
Suspension – Belt or socket
Endoskeletal (modular) vs exoskeletal (formed plastic
or wood)
Limb-fitting for infants from 8 months (when they are
starting to stand and can manage 2-handed play)
Levels
: Hip disarticulation
: Transfemoral – Silicone Iceross® sockets
a b : Through-knee – Problematic for artificial knee
mechanism
: Transtibial – Patellar tendon bearing, supracondylar
Ground-reaction orthotics suspension
Three-point pressure orthotics must cross the joint being : Ankle disarticulation ‘symes’ – Silicone feet
controlled. Ground-reaction orthotics control joint posture : Prosthetic feet – SACH (solid ankle cushion heel),
by positioning the ground-reaction force optimally; they do multi-axis, dynamic response (carbon fibre springs)
not cross the joint being controlled and are, therefore, smaller : Upper limb – Body powered (shoulder) or external
and lighter than three-point pressure orthotics. Ground- power (myoelectric or switch)
reaction orthotics suffer from the disadvantage that they are If asked to describe a prosthetic think of the following
less reliable as changes in the slope of the ground or in, for components;
example, trunk posture may reverse the effect. Examples of Socket
ground-reaction orthotics are: Suspension system
Shoe wedge – A lateral heel wedge will push the hindfoot Joint
into valgus, resulting in the ground-reaction force passing Terminal device/end effector
lateral to the axis of the subtalar joint, thus, helping to
prevent the hindfoot going into varus
Ground-reaction orthotics for controlling knee posture. In Wheelchair design
quads paralysis (usually from polio) the knee may collapse Depends on daily use, fixed deformities, head/trunk
into flexion or may become hyperextended. By fixing the control, environment
angle of the ankle the ground reaction force can be Frame weight – Rigid/portable
positioned anterior or posterior to the knee joint to Wheel/tyres
encourage either flexion or extension; these orthotics Back – Height, reclining or fixed
utilize the principle of linked movement. Figure 30.27 Foot rests
illustrates the use of an AFO to control knee posture Seat cushion, trochanteric pads, scoliosis pads
Strapping – Seatbelt, pelvis belts
Minimizing the risk of skin problems
Ambulation – Hand-operated (requires good upper limb
Problems with orthotics are frequently at the orthotic–skin function), electric
interface and it is important to understand the ways in which
the interface pressures can be reduced:
Maximizing the lever arm of the orthotic in relation to the Venous thromboembolism
lever arm of the deforming force You should make sure that you are familiar with the current
Maximizing the surface area through which the forces are NICE guidelines on DVT prophylaxis as this is likely to be a
applied from the orthotic to the skin popular topic for discussion in the oral examination.
033
Epidemiology Increased bleeding risk has been found with all forms of
chemical prophylaxis except aspirin
DVT occurs in 1/1000 of the general population but in up
to 50% of lower limb arthroplasty patients without One issue has been whether the goal of treatment is to
minimize the incidence of deep vein thrombosis, or the
prophylaxis, but is usually asymptomatic
incidence of symptomatic VTE. Current thinking is that
Asymptomatic DVT is diagnosed by ultrasound,
125 the aim should be to minimize symptomatic VTE and
I-fibrinogen or venography (the ‘gold standard’)
bleeding complications
Symptomatic DVT involves leg swelling and pain
Candidates should be familiar with the NICE guidelines
90% of cases of pulmonary embolism are due to DVT but and the BOA documents
pulmonary embolism is a rare complication of DVT. Risk
The most appropriate form of prophylaxis must be
is increased 10 times by surgery or trauma
considered for all patients but the precise form of that
Post-thrombotic syndrome (ulceration, dermatitis, chronic prophylaxis will depend upon the relative risk of
swelling) occurs in up to 10% of DVT patients within
thromboembolism balanced against the risk of
10 years
complications; in particular bleeding
Routine prophylaxis is used to reduce the morbidity Methods of prophylaxis can be classified into mechanical and
and mortality of thromboembolism; however,
chemical.
treatment of asymptomatic DVT has not been shown to
be effective Mechanical methods
Aspirin is not as effective as heparins in reducing the risk of NICE guidelines recommend the use of mechanical methods
asymptomatic DVT from the day of admission. Options include:
Aspirin carries a lower relative risk of bleeding than the
Anti-embolic stockings – Knee or thigh length
heparins (1.24 and 1.75, respectively)
Intermittent compression devices
Fatal pulmonary embolism is catastrophic and, therefore,
Foot impulse devices
the most relevant endpoint
Chemical methods
Risk factors NICE guidelines are for chemical prophylaxis to be used
Age – Exponential increase in risk (unless contraindicated) for 28–35 days
Obesity – 3 times the risk Meta-analysis results:
Varicose veins – 1.5 times the risk Benefit in terms of reduction in DVT rates from the use of
Prior venous thromboembolism – 5% recurrence per aspirin, LMWH and unfractionated heparin
annum, increased by surgery Benefit in terms of reduction in PE for all chemical
Thrombophilias – E.g. factor V Leiden, antiphospholipid methods in current use; the evidence is inconclusive on
syndrome which regime is optimal
‘Thrombotic states’ – Neoplasia (7 times the risk), cardiac All chemical regimes show a significant increase in the risk
failure, recent myocardial infarction or cerebrovascular of major bleeding when compared with controls with no
accident, infection, polycythaemia prophylaxis, in proportion to their effectiveness in
Combined oral contraceptive pill, hormone replacement preventing DVT
therapy, high-dose progestogens For every patient a DVT/PE risk assessment should be
Pregnancy – 10 times the risk performed.
Immobility – Bed rest for >3 days can increase risk Where chemical prophylaxis is used in high risk patients
10 times treatment should be continued for four to six weeks.
Hospitalisation – 10 times the risk
Anaesthesia – Risk associated with GA is twice the risk Statistics
associated with a spinal Although it is not necessary to have an in depth knowledge of
specific statistical tests it is important to have sufficient under-
DVT/PE prophylaxis standing of statistics to be able to interpret and evaluate the
DVT and PE are major risks for many orthopaedic operations claims made in research papers in the journals and claims
but there is not universal agreement over certain aspects of made by manufacturers.
treatment. Statistics can be:
Guidelines have been produced by NICE, AAOS, American Descriptive – Describes a population, study group, etc
College of Chest Physicians (ACCP), the BOA, etc. These Inferential – Allows conclusions, or inferences, to be
guidelines continue to evolve as more research becomes drawn about the populations from which samples have
available been drawn
751
033
Describing a set of data Figure 30.28 Box and

Whisker plot
There are numerous ways of describing a set of data. These
methods depend upon the nature of the data that is available.
The types of data will be described below. The measures used Interquartile Median
for describing the data will depend upon the type (level) of range
data involved. The tests used for drawing inferences will Range
depend upon the type of data, the patterns of distribution of
the data (normal or otherwise) and the questions being asked.
Types (levels) of data

Nominal = Not ranked, just named (e.g. blue, green, red)
Ordinal – Ranked (e.g. first, second, third . . ., or mild,
moderate, severe)
Interval (numerical)
out the data are either side of the central area or values – The
: Discreet integers (e.g. 1, 2, 3, 4 . . .) ‘measure of dispersion’. The methods available again depend
: Continuous (e.g. 0–100 and all decimals in between) upon the level of data and the chosen measure of central
: Ratio (this is a particular form of quantitative data in tendency:
which there is an absolute zero Variation ratio – Used when the mode is the measure of
Although discreet and continuous data does not have to have central tendency. It is described as the percentage of values
an absolute zero it is only possible to compare proportions if not at the modal value expressed as a percentage of the total
there is such a zero – The advantage of ratio data is that they values
allow proportional comparisons between data – E.g. 6 is 50% Range: Extreme values of the data set. The lowest and
larger than 4, etc. highest values of the data. The range does not give much
Nominal, Ordinal and Interval data describe increasingly information about the spread of data about the central
high levels of data value
Interquartile range (IQR) – Often used when the median
Describing a population is the measure of central tendency. The first quartile point
When describing a set of data two important parameters are has one quarter of the data below it and the third quartile
key to giving a mathematical meaning to the data set. These point has three quarters of the data below it so the
two parameters are the measure of central tendency and the interquartile range (from the first to third quartile points)
measure of spread. The measures used to measure these par- contains half the data. When the median is used the spread
ameters depend upon the level of data gathered. is often expressed as a ‘box and whisker’ plot – With the
box representing the IQR and the whisker the range.
The measure of central tendency Figure 30.28 illustrate a Box and Whisker plot
Mode – The value that occurs with greatest frequency Variance: The measure of the spread, where the mean is
: Usually used for nominal data but can be used for all the measure of the central tendency. Variance is the
levels of data corrected sum of the squares about the mean of the data.
: Ignores extremes, can be used for all levels The F-test is used to compare the variance of two
Median – The central value of the set of data; i.e. the value populations. The advantage of using Variance to describe
that has an equal number of values above and below it spread of data is that it distinguishes between a relatively
‘smooth spread’ either side of the mean and an ‘irregular
:Useful for ordinal data and skewed data
spread’, which a simple mean deviation would not
:Ignores extremes, can be used for ordinal level or above
Standard Deviation (SD): The square root of the
Mean – The average variance – The Standard Deviation gives more information
: Used for interval data – Maximum use of information about the nature of the spread either side of the mean
: Sensitive to extremes The above measures of Central Tendency and Spread can be
: Sensitive to skew used as descriptive statistics to describe an entire population.
: Cannot be used for nominal or ordinal data Usually, however, entire populations cannot be measured and
measurements are made on a sample drawn from the whole
population. The question then arises as to how representative
Measures of spread/variability the sample is of the population from which it has been drawn,
The measure of central tendency will give an idea of the most or if two samples are drawn from different populations; these
common values but it is also necessary to describe how spread questions are answered by inferential statistics.
033
Inferential statistics Confidence Intervals can be calculated from the Standard

A common sequence in performing a study is: Errors of the Mean (SEM)
1. Take a sample of measurements Confidence intervals are equal to the values between the
2. Describe the data in the sample mathematically (measure confidence limits and are a chosen number of Standard
of central tendency and measure of spread Errors of the Mean on either side of the mean
3. Take a further sample, or further samples For a large sample 95% confidence intervals are 1.96 SEM
from the mean on either side
4. Describe the further sample or samples mathematically
When comparing two groups, if the 95% confidence
5. Perform tests to determine whether the different samples
intervals do not overlap there is a significant difference
were drawn from the same, or different, parent populations
between the two study groups. If there is an overlap of up
6. Assess sources of error (Bias)
to 25% there may be a significant difference and this can be
7. Draw conclusions calculated using a two tailed t-test
The following measures and terms are used in inferential
statistics:
Outcome measures
Standard Error of the Mean
Outcome measures need to be valid, reproducible,
Use Corrected SD – For calculating the SD of a sample use responsive to change, clinically relevant and easily measured
the variance squared divided by the number in the
Outcome measures may be primary or secondary, objective
sample – 1 (because the variance of a sample is nearly
or subjective
always less than the variance of the population from which
it is drawn)
If multiple samples are taken from the population of data
Data interpretation
the means of each of the samples can be calculated and the Null hypothesis: That no difference exists between two
Variance of these sample means can be measured groups (hence that any difference seen has occurred purely
The Central Limit Theorem shows that if multiple samples by chance). Tests including outcome measure are then
are taken from a population with any distribution (i.e. the employed to disprove the null hypothesis
distribution does not have to be Normal) the distribution Alternative hypothesis: That there is a difference between
of the sample means will be nearly Normal the two groups
The SEM measures how closely a sample mean P value: The probability that the difference seen has
approximates the population mean. The SEM is a occurred by chance. The level of significance is usually set
probabilistic statistic describing how far the sample mean at a 5% probability (P = 0.05) that the difference was due to
probably differs from the sample mean chance. Other levels can be set
The larger the sample size the more likely is the sample Type I (α) error: A false-positive result; incorrectly
mean to match that of the mean of the population from rejecting the null hypothesis, i.e. deciding there is a
which it has been drawn – With very large samples the difference when there isn’t one. Reduced by setting the P
SEM approaches 0 value smaller but then bigger sample sizes are needed to
The larger the sample size the more the SD of the sample protect against a type II error
will approach the SD of the population from which it Type II (β) error: A false-negative result, incorrectly
is drawn accepting the null hypothesis, i.e. finding no difference
SEM is calculated as the SD divided by the square root of when there is one. Increased risk if sample size too small or
the sample size by setting the P value too small
It is important to realize that the Standard Deviation is a Type III (γ) error: Occurs when the researcher correctly
descriptive statistic that describes, for a particular sample or rejects the null hypothesis but incorrectly attributes the
population, the distribution of the data about the mean. cause. In other words the researcher misinterprets cause
The Standard Error of the Mean, however, is a probabilistic and effect
statistic that describes how far the mean of a particular
sample probably differs from the mean of the entire
Power analysis
population of data from which that particular sample is Power = 1–β: The probability of demonstrating a true
drawn effect and correctly rejecting the null hypothesis i.e. the
ability of a study to detect a difference of a certain size. The
Confidence intervals: method of determining the number of subjects needed in a
Confidence intervals are the ranges on either side of a sample study to have a reasonable chance of showing a difference,
mean indicating the probability that the true figure lies if one exists. Usually set at 80%
between these two values. Factors affecting power analysis:
Only applicable to normal distributions (parametric data) Significance level chosen (P-value)
753
033
Sample size (power increases with increasing sample size) Chi-squared test to compare the difference between actual
Variability in observations (power decreases with and expected frequencies (contingency tables)
increasing variability) Fisher’s exact test – Also used with contingency tables –
Size of the difference between the means considered to be Useful when the numbers are small
the smallest acceptable difference
Non-parametric tests
Spread of the data
Experimental design Used when data is not normally distributed; e.g. when the
data is skewed
Type of data (parametric vs non-parametric)
The most important factors to consider in setting up a study Less powerful than parametric tests
are the variance of the subjects and the smallest difference that Examples include the Mann–Whitney U test, the Wilcoxon
is considered relevant; hence, the value of pilot studies in Signed Rank test and the Kruskal–Wallis test
establishing the variance. Less likely to be find a significant difference between the
groups
It is essential to distinguish between Clinical Significance
(how important a difference is clinically) and Statistical No assumptions made about origins of the data
Significance (a mathematical calculation) – A result may be Less likely to give type II errors
statistically significant but not clinically significant Use rank order of value
There are a large number of statistical tests. Although it is not Cannot relate back to any parametric properties of the data
necessary to know the details of how these tests work it is Transformation: A process by which non-parametric data are
important to have an understanding of when different tests are converted to a parametric form to permit more powerful
appropriate. analysis, e.g. logarithmic scale.
Note: Scoring systems (e.g. Harris Hip Score, etc) include
Parametric and non-parametric tests ordinal data. Even if the final values appear to be continuous
they remain non-parametric data and appropriate non-
Parametric tests
parametric tests must be used.
Used when the data is predicably distributed – This usually Some other terms and concepts that are useful are given
means Normally distributed; i.e. it is distributed on a below:
Gaussian curve
Accuracy: How often the test is correct
The Kolmogorov–Smirnov test can be used to analyse a set
Constructive Validity: Evidence that a test measures what
of data to assess whether it is drawn from a normally
is intended to measure
distributed population
Precision: Repeatability of measurement
More powerful than non-parametric tests
Incidence: The rate of occurrence of new disease in a
Observations must be independent
population previously free of the disease. It is found by
Populations under study must have similar variance dividing the number of new cases per year by the number
Examples include of the population at risk
Student’s t-test for comparing the means of two samples:
Prevalence: The frequency of a disease at a given time.
A one tailed t-test can be used if the alternate hypothesis Found by dividing the number of existing cases by the
allows a difference in only one direction (e.g. x is number of the population at risk
bigger than y) but one tailed tests should be used with Surveillance: The study of trends in a population
caution
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Cambridge University Press

978-1-107-45164-3 — Postgraduate Orthopaedics

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University Printing House, Cambridge CB2 8BS, United Kingdom

Cambridge University Press is part of the University of Cambridge.

© Cambridge University Press (2009, 2012) 2017

This publication is in copyright. Subject to statutory exception

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The third edition of Postgraduate Orthopaedics is dedicated to the

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Section 2 The written paper Section 4 The general orthopaedics

11 Hip clinical cases 113 22 Elbow oral core topics 495

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Section 6 The paediatric oral

28 Lower limb trauma oral topics 629 36 Examination failure 909

29 Applied trauma oral topics 660

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Preface to third edition

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Our special thanks to Caitlin Monney and Emily McDougall

Caitlin C. Monney BSc (Hons) MSc MIMI RMIP

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1,2-ISCRA 1,2-intercompartmental supraretinacular artery ATLS® Advanced Trauma Life Support®

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CP cerebral palsy ESWL extracorporeal shock wave lithotripsy

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HVA hallux valgus angle MC metacarpal

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OK Outerbridge and Kashiwagi RANKL receptor activator of nuclear factor kB ligand

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ST scaphotrapezial TORCH toxoplasmosis, other, rubella, cytomegalovirus,

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1 Niall Breen, Benjamin W. T. Gooding and Jonathan R. A. Phillips

‘Plan, prepare, practice, perform’ Prepare

Table 1.1 (cont.)

2 Jonathan R. A. Phillips and Benjamin W. T. Gooding

Briggs’ Operative Orthopaedics8 Joseph et al.’s Paediatric Orthopaedics17

Paediatrics Trauma for the FRCS (Tr & Orth) Examination25

References 13. Einhorn TA, O’Keefe RJ, Buckwalter

MCQ and EMI paper guidance

3 Mark Dunbar, Andrew P. Sprowson and David Limb

 They are easy to administer and mark as a computer-based

A few examples are given below.

Advice for paper 2 MCQ writing

a number of questions are discardedb. Banked questions may

Figure 3.2 Bloom’s revised taxonomy. Asking thinking questions

Introduction to clinical examination techniques

4 Karen Robinson and Fazal Ali

Expose the patient Sequence of examination

Treat it like a driving test

4. How do you do Thomas’ test in a patient with a ﬁxed spine

Table 4.3 Sensitivity of clinical tests

Name of test Sensitivity

They are easy to administer and mark as a computer-based

Foot and ankle Tumour prosthesis of the humerus

Describe the radiograph (superior head migration

Duration If the elbow pain has a radicular pattern it is important

Generalized CANDIDATE: In everyday clinical practice I would start by examining the

Rheumatoid elbow Median nerve