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Sugar tong in a neutral or slightly extended wrist po splints and long-arm and short-arm casts sition. Depressed fracture of A the distal radius with a portion of the lunate fossa of the radius dorsally and proximally displaced. Treatment of the fracture with application of an external fixation device, carpal distraction, elevation of the depressed fragment and fixation with two K-wires, and cancellous bone grafting of the bony defect left behind by elevation of the depressed fracture fragment. Cancellous bone graft B dorsal articular involvement, the external Percutaneous pins or lag screws may be fixator must be applied in combination with used for fracture fixation. The surgi prevent collapse and hold the fragments out cal approach is dictated by fracture lo to length. For volar articular fragments, volar aspect of the bone where it is well tol an extensile volar approach, followed erated and tendon problems are minimized. Of particular concern is the and bone grafting can be performed through volar ulnar fragment of the distal radius, the fracture site by pronating the proximal which may be difficult to reduce and fix fragment. Fail earlier wrist motion and produced better ure to stabilize this fragment may lead results when compared to external fixation. This type Although most distal radius fractures are of lunate facet fracture should be ap amendable to volar plating, certain fractures proached through an extended carpal will still require a dorsal or radial approach. Tendon problems—Tendon problems are rela and many (30% to 50%) will need to tively common after distal radius fracture and be removed after fracture healing is include tendon adhesion, tendinitis (from a dor complete. Disabling pain, swelling, finger stiff out risk, which may include fluid extravasa ness, and osteopenia may develop and require tion and neurovascular injury. Treatment of ulnar styloid fractures— by aggressive hand therapy, edema control, and Treatment of these associated fractures fixator removal (as early as possible) helps pre has traditionally received little attention. Because of its at distraction of the fixator may limit tendon excursion tachments to the ulnar styloid, fracture fixa and should be avoided. Late Complications—For acute complications, see cast or fixator removal, exercises may be advanced as earlier section on associated soft-tissue injuries. Malunion—Extra-articular malunion usually allowing intermittent wrist motion while still protect involves dorsal tilt and loss of radial length. Overview—Scaphoid fractures are the dial opening wedge (triplanar) osteotomy most common carpal fracture and are typi with corticocancellous bone graft. Radial deviation and articular malunion is even more serious, with wrist dorsiflexion greater than 90° may lead an early onset of radiocarpal arthritis in 90% to scaphoid fracture during a fall on the out of wrists with more than 2 mm of articular stretched hand. Early evaluation and salvage-type procedure such as arthrodesis or appropriate treatment are important in avoid arthroplasty. Treatment—Treatment is determined by loca its blood supply from distal (volar and dor tion and degree of displacement. Evaluation—“Snuffbox tenderness” is a clas Proximal pole fractures heal more slowly sic sign and should alert the physician to the (12 to 24 weeks). Associated ligamentous injuries lation are considered unstable and re must be ruled out by careful radiographic as quire operative treatment. When no fracture is performed through a volar (Russe) approach seen initially, the wrist should be splinted for between the flexor carpi radialis tendon and 1 to 2 weeks, and another X-ray study should the radial artery. The volar blood supply is be performed after fracture resorption has oc compromised in this approach, but is not curred. Occult fractures may be detected in as crucial as the dorsal arterial branch, this manner or through the use of bone isotope which feeds 80% of the scaphoid. Classification systems—Most systems high tipitched (to provide fracture compression), light the importance of fracture location in and well suited for this purpose. Newer ver regard to treatment and risk of late complica sions include cannulated and tapered screw tions. When rigid fixation is achieved, im followed by proximal pole (25%) and distal pole mediate range of motion is possible. Nonunion—The incidence of scaphoid non ittal views are helpful in determining the union for undisplaced fractures is approxi degree of carpal collapse and “humpback mately 5% to 10%.

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Bone scan—Technetium 99m-phosphate complexes reflect increased blood flow and metabolism and are absorbed onto the hydroxyapatite crystals of bone in areas of infection, trauma, neoplasia, and so forth. It is particularly useful for the diagnosis of subtle fracture, avascular necrosis (hypo perfused [diminished blood flow] early, in creased uptake during the reparative phase), and osteomyelitis (especially when a triple phase study is performed in conjunction with a gallium or indium scan). Three-phase (or even four-phase) studies may be helpful for evaluating diseases such as complex re gional pain syndrome and osteomyelitis. Gallium x-ray beams to produce a much higher reso scan is frequently used in conjunction with a lution image. Measurement of Bone Density (Noninvasive lium is less dependent on vascular flow than Methods)—Several methods are available for technetium and may identify foci that would measuring bone density and assessing the risk otherwise be missed. These methods may be particularly tiate cellulitis from osteomyelitis on a gallium useful in geriatric patients with fractures related scan. Single photon absorptiometry—The basic (leukocytes) accumulate in areas of inflam principle of this technique is that the density mation and do not collect in areas of neo of the cortical bone being tested is inversely plasia. Indium scan is useful for evaluation of proportional to the quantity of photons pass acute infections (such as osteomyelitis). Dual photon absorptiometry—Similar to to evaluate osteonecrosis, neoplasms, infec single photon absorptiometry, dual photon tion, and trauma. Dual photon absorp in patients with pacemakers, cerebral aneu tiometry, however, allows for measurement rysm clips, or shrapnel or hardware in certain of the axial skeleton and the femoral neck locations. Quantitative computed tomography— crosis (detects early marrow necrosis and Allows preferential measurement of trabecu ingrowth of vascularized mesenchymal tis lar bone density (the bone which is at the sue) (tomography is the best method for greatest risk of early metabolic changes). By evaluating the difference in the abor showing a bright bone marrow signal bances of the two beams, the presence and relative to the surrounding fat suggests density of target tissues, such as bone, can be osteomyelitis). Children are commonly af out clinical or radiographic evidence of healing fected (boys are more commonly affected (and without evidence of the ability for progres than girls). Atrophic nonunion—These nonunions are the long bones and is more common in the avascular and lack the biological capac lower extremity than in the upper extremity. The ends of the bone are typi Radiographic changes of acute hematogenous cally narrowed (such as a pencil point) and osteomyelitis include soft-tissue swelling are avascular. The treatment of an atrophic (early), bone demineralization (10–14 days), nonunion is stimulation of the local biologi and sequestra (dead bone with surround cal activity (such as with a bone graft or a granulation tissue) and involucrum (perios corticotomy for bone transport). Adults, 21 years of age or older—The most are hypervascular and possess the biologi common organism is Staphylococcus au cal capacity to heal but lack mechanical reus, but a wide variety of other organisms stability. Initial empiric therapy hypertrophied, and they give the appearance includes nafcillin, oxacillin, or cefazolin; that the fracture has “attempted to heal. The initial biological is with one of the fluoroquinolones (only response of a hypertrophic nonunion to in adults); alternative treatment is with a plate stabilization is mineralization of third generation Cephalosporin. The treatment of choice is one adequate reduction with displacement at the of the penicillinase-resistant semisynthetic fracture site. The treat or following open reduction with internal fixa ment of an infected nonunion focuses first on tion)—Clinical findings may be similar to that eliminating the infection and then on healing of acute hematogenous osteomyelitis. Malunion (see Chapter 3, Principles of Deformities) ment with removal of orthopaedic hardware D. The most common bone and bone marrow which may be caused offending organisms are S. Empiric therapy prior to wound or by blood borne organisms (hema definitive cultures is Nafcillin with Ciproflox togenous). It is not possible to predict the acin; alternative therapy is Vancomycin with microscopic organism that is causing os a third generation Cephalosporin. Patients teomyelitis based on the clinical picture with acute osteomyelitis and vascular insuf and the age of the patient; therefore, a spe ficiency and those who are immunocompro cific microbiologic diagnosis via deep cul mised generally show a polymicrobic picture. Chronic osteomyelitis—May arise as a result essential (organisms isolated from sinus of an inappropriately treated acute osteomy tract drainage typically do not accurately elitis, trauma, or soft-tissue spread, especially kat. Intraoperative radiograph following segmental bony resection of infected and necrotic bone. Clinical photographs showing full weightbearing and excellent range of knee and ankle motion. Periods of quiescence (of the in commonly affects the femur and tibia; and fection) are often followed by acute exacer unlike acute osteomyelitis, it can cross the bations.

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The titer has little prognostic value in an individual patient, and remeasurements provide little added information. With the development of immunofluorescence microscopy techniques, different staining patterns were discovered, and it became clear that many different nuclear antigens can elicit an antibody response. Next, fluorescent anti-Ig is added, which binds to antibodies (if present) in the test serum. Different patterns of staining occur, and although they may provide some information, they do not identify the specific antibody present, nor are they specific for a disease entity or clinically relevant. For example, the rim or peripheral pattern (usually associated with antibodies directed against nuclear membrane proteins) may be obscured if another autoantibody (staining a homogeneous pattern) is present. Inflammatory arthritis tends to involve small joints, has a morning stiffness component, and improves with activity. To increase the diagnostic likelihood of a specific rheumatic diagnosis and provide prognosis. Calcific tendinitis Ehlers-Danlos Parathyroid disease Chondrocalcinosis syndrome Renal osteodystrophy Dermatomyositis Neoplasia Sarcoidosis Diabetes Neuropathic Scleroderma arthropathy Trauma 36. Describe typical radiographic features of inflammatory arthritis in early and progressive disease. Soft tissue swelling and juxta-articular osteoporosis in early disease and more diffuse osteoporosis with uniform loss of cartilage in chronic disease. Further inflammation will lead to synovial hypertrophy and erosions with marginal areas of the synovium. Peak incidence is in the fourth and fifth decades of life, but almost any age can be affected. Estrogen has been shown to inhibit T suppressor cell function and enhance T helper function, leading to stimulatory effects on the immune system. A 25 pack-year or more history of tobacco use is associated with more severe disease with greater seropositivity, nodules, and radiographic changes. A 1 to 2-cell-thick lining of the joint made up of two types of synoviocytes: type A (macrophage-like cells probably derived from bone marrow) and type B (fibroblast-like cells that are probably of mesenchymal origin). Increased numbers of type A and type B synoviocytes are added to the synovial lining. A term to describe the area of proliferating synovium that can erode the adjacent cartilage and bone. Pannus tissue adheres to articular cartilage, and the cells within the pannus produce proteinases thatcandestroycartilage. Synovial tissue analysis also reveals inflammatory mediators including cytokines, enzymes, adhesion molecules, and transcription factors. Larger joints of the upper and lower extremities, such as the elbows, shoulders, ankles, and knees, are also commonly affected, although symptoms may appear later. Less common are cervical spine, temporomandibular, and sternoclavicular joint involvement. Significant laxity at the atlantoaxial joint with subluxation makes patients prone to slowly progressive, spastic quadriparesis. If this laxity is present, the hyperextension of the neck that occurs during intubation for general anesthesia can produce quadriplegia. Therefore, patients with neck pain or longstanding disease should undergo cervical spine evaluation before any surgical procedure. Firm, usually movable nodules ranging in size from a few millimeters to 2 cm found over pressure areas. The classic rheumatoid nodule has a central area of necrosis surrounded by a rim of palisading fibroblasts surrounded by a collagenous capsule with perivascular collections of chronic inflammatory cells. Patients are more susceptible to bacterial infections and have a higher risk of development of non-Hodgkin’s lymphoma. Multiple perihilar lung nodules with pathology similar to rheumatoid nodules are also found. These patients can develop massive fibrosis and are at increased risk of tuberculosis. Because functional status may be one of the best predictors of premature mortality. Because the joints can be significantly structurally damaged early in the disease if not treated. The structural damage produces mechanical derangements in the joint leading to deformity and profoundly impaired joint function.

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Palpate the posterior shoulder for the “soft spot” (usually 2cm down, 1cm medial to posterolateral corner of the acro mion). Prepare skin (iodine/antiseptic soap) over the “soft spot” on posterior shoulder 4. If the needle hits bone it should be redirected (glenoid: move lateral; humerus: move medial). Inject preparation (local / corticosteroid) into joint (should flow easily if in the joint space) 6. Exacerbating/ Overhead worse Rotator cuff tear, impingement relieving Overhead better Cervical radiculopathy 3. Neurologic sx Numbness/tingling/”heavy” Thoracic outlet syndrome, brachial plexus injury 8. Axillary nerve Sensory: None Superior lateral cutaneous nerve Motor: Levator scapulae of arm (C5, 6) Rhomboid major & minor Long Thoracic (C5-7): Runs on anterior surface of serratus anterior with the lateral thoracic artery. Sensory: None Motor: Pectoralis major (clavicular portion) Pectoralis minor (via a branch to the medial pectoral n. It can be in arm (C8, T1, 2) jured in glenohumeral dislocations and lateral approaches. Superior thoracic To serratus anterior and pectoralis muscles vian after the 1st rib. Subscapular Has 2 main branches Circumflex scapular Seen posteriorly in triangular space Thoracodorsal Runs w/thoracodorsal nerve. Used for free flap Anterior circumflex humeral Primary supply of humeral head (via ascending br. Axillary fold capsule and periphery of humeral head and biceps brachii sheath visualized. Abduction of arm causes repeated impingement of greater tubercle of humerus on acromion, leading to degeneration and inflammation of supraspinatus tendon, secondary inflammation of bursa, and pain on abduction of arm. Calcific deposit in degenerated tendon produces elevation that further aggravates inflammation and pain. Often associated Communication between shoulder with splitting tear parallel to tendon fibers. Tender in lateral epicondylitis (“tennis elbow”) Medial epicondyle Site of common flexor origin. Transverse fracture of midshaft After initial swelling subsides, most fractures of B. Comminuted fracture with marked angulation brace of interlocking anterior and posterior components held together with Velcro straps. Entrapment of radial nerve in fracture of shaft of distal humerus may occur at time of fracture; must Open reduction and fixation Fracture aligned and held also be avoided during reduction. Fracture of medial one or two compression screws condyle less common Medial epicondyle of humerus Extensor carpi radialis Triceps brachii tendon longus muscle Anconeus muscle Olecranon Medial Ulnar nerve epicondyle Open (transolecranon) repair. Posterior incision skirts medial margin Olecranon osteotomized and reflected proximally with of olecranon, exposing triceps brachii tendon and olecranon. Ulnar triceps brachii tendon nerve identified on posterior surface of medial epicondyle. Incisions made along each side of olecranon and triceps brachii tendon Articular surface of distal humerus reconstructed and fixed with Olecranon reattached with longitudinal Kirschner wires transverse screw and buttress plates with screws. Ulnar nerve and tension band wire wrapped around them and through may be transposed anteriorly to prevent injury. Lateral column hole drilled in ulna fixed with posterior plate and medial column fixed with plate on the medial ridge. No apparent fracture on this view, but subsequent radiographs con firmed presence of a nondisplaced supracondylar humerus fracture. Note Divergent dislocation, anterior Lateral dislocation prominence of olecranon posterior type (rare). Medial-lateral (uncommon) posteriorly and distal humerus type may also occur (extremely rare).