CURRENT Essentials Orthopedics by Harry Skinner, Michael Fitzpatrick

By Harry Skinner, Michael Fitzpatrick

present necessities: Orthopedics -- the final word at-a-glance bedside guide!

  • “Nutshell” info at the analysis and remedy of the two hundred commonest orthopedic illnesses and problems
  • One affliction in line with web page, with bulleted lists for simple entry
  • Covers all correct strategies, from grownup reconstructive surgical procedure to foot and ankle surgical procedure
  • ICD9-CM codes for every subject, permitting you to code and classify morbidity information after making the analysis
  • Included in every one subject --Essentials of analysis --Differential analysis --Treatment --Pearl --Reference
  • Handy tabs

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J Bone Joint Surg Am 2005;87(suppl 1, Pt 1):113. 3 ■ Essentials of Diagnosis • Can be traumatic or congenital • Higher incidence in females, valgus knee, shallow femoral trochlea, hypoplastic lateral femoral condyle, and patients with generalized ligamentous laxity • The patella dislocates laterally; the medial retinaculum is stretched, if not torn • Often spontaneously reduces, so that effusion is the only sign • Tenderness to palpation is present at the medial superior pole of the patella (medial retinaculum); may be ecchymotic • Obtain radiographs to rule out patellar fracture • Rule out concomitant ligamentous injury ■ Differential Diagnosis • • • • ■ Patellofemoral pain Knee dislocation Patellar fracture Quadriceps rupture Treatment • Extension bracing for 6 wk is the best course (poor compliance) • Patellar stabilizing brace and early physical therapy • About 5% of acute dislocations require further stabilization procedures • The Merchant view is essential to assess the femoral trochlea ■ Pearl Consider arthroscopy if intra-articular chondral damage is suspected.

Fractures of the calcaneus: a review with emphasis on CT. Radiographics 2005;25:1215. [PMID: 16160107] de Souza LJ, Rutledge E: Grouping of intraarticular calcaneal fractures relative to treatment options. Clin Orthop Relat Res 2004;(420):261. [PMID: 15157107] Rammelt S, Zwipp H: Calcaneus fractures: facts, controversies and recent developments. Injury 2004;35:443. 31 Open ■ Essentials of Diagnosis • Most common cause is an automobile accident • Most common complication is osteonecrosis (avascular necrosis [AVN]); timing of surgery has no correlation • Presence of swelling, tenderness, and crepitus • 50% of fractures occur at the talar neck • Hawkins classification: type I—nondisplaced (AVN 0–10%); type II—displaced talar neck with subluxed or displaced subtalar joint (AVN 20–50%); type III—displaced talar neck with body dislocated from both subtalar and ankle joints (AVN 50–100%); type IV—same as type III but talar head is dislocated from talonavicular joint (AVN 100%) • Obtain lateral radiographs; may need Canale view (plate on plantar surface with ankle in equinus, pronate foot 15 degrees, and angle the x-ray tube 75 degrees cephalic) to check for varus angulation or rotation • Osteochondral fracture of the talar dome is best seen with MRI ■ Differential Diagnosis • Fractures of the lateral or posterior talar process • Compression fracture of the talar dome ■ Treatment • Neck types I–II: closed reduction and non-weight bearing below the knee cast for 2–3 months; open reduction with internal fixation (ORIF) if this fails • Neck types III–IV: ORIF with progressive weight bearing after obtaining evidence of fracture union on radiographs • Body: difficult closed reduction and casting via traction and forced plantar flexion, followed by casting in the neutral position 8 wk later; usually requires open treatment to reduce and fix the fracture ■ Pearl Hawkins sign, an area of radiolucency visible radiographically under the subchondral bone of the talar dome 6–8 wk after injury, indicates disuse osteopenia, not osteonecrosis.

Displaced femoral neck fractures in the elderly: hemiarthroplasty versus total hip arthroplasty. J Am Acad Orthop Surg 2006;14:287. 31 Open ■ Essentials of Diagnosis • Fracture of the lesser trochanter (rare) is due to avulsion by the iliopsoas • Fracture of the greater trochanter is due to direct injury or avulsion by the gluteus medius and minimus • Intertrochanteric (IT) fracture is a result of a fall (elderly patients); presents as a shortened leg with external rotation; patients are unable to bear weight • Stable fracture: has good cortical contact medially and posteriorly; prevents fracture displacement into varus or retroversion when weight bearing • Unstable fracture: cortical overlap or comminution; gap medially and posteriorly; femoral head can slip into varus, and retroversion leads to shortening (>13 mm overlap will affect abductor lever arm, causing difficulty walking and limp) ■ Differential Diagnosis • Femoral neck fracture • Subtrochanteric fracture ■ Treatment • Pure greater trochanter fracture: if >1 cm displacement, use open reduction and fixation; if stable and <1 cm displaced, place on protected weight bearing (full weight bearing by 6–8 wk) • IT fracture: treat expeditiously with surgery, limited only by the patient’s medical status • Stable IT fracture: reduce on a fracture table; a sliding compression screw and sideplate allows the fracture to impact into stability • Unstable IT fracture: use second-generation locking nail or sliding hip-screw with long side-plate, combined with limited interfragmentary fixation and bone grafting of subtrochanteric region • Hip arthroplasty: may be required in severely comminuted or markedly osteopenic cases, or in patients with rheumatoid arthritis ■ Pearl Hip screw-plate devices have been shown in limited randomized trials to be as effective as intramedullary nails in treating extracapsular IT fractures.

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