Section 3: Trauma
Table 1
Requirements for Tetanus Prophylaxis
Immunization History
dT
TIG dT
TIG
Incomplete (<3 doses) or not known +
-
+
+
Complete but >10 years since last
dose
+
-
+
-
Complete and <10 years since last
dose
-
-
-*
-
dT = diphtheria and tetanus toxoids; TIG = tetanus immune globulin; + = prophylaxis required; − = prophylaxis not required
* = required if >5 years since last dose
2. CT is ordered as clinically indicated. In cases of
periarticular fractures when temporary spanning
external fixation is planned, CT often is best delayed until after the joint has been spanned so as
to provide the most information possible.
3. Angiography is obtained based on the clinical sus-
picion of vascular injury, the type of injury, and
the following indications:
a. Knee dislocation (or equivalent; eg, medial tib-
ial plateau fracture) with asymmetric pulses
b. A cool, pale foot with poor distal capillary re-
fill
c. High-energy injury in an area of compromise
(eg, trifurcation of the popliteal artery)
d. Any lower extremity injury with documented
ankle brachial index <0.9
D. Classification of open fractures—The Gustilo classi-
Figure 2
Clinical photograph (A) and AP radiograph (B)
of a Gustilo grade IIIB open tibial shaft
fracture.
fication (Table 2) requires that surgical débridement
be performed before assigning a grade. All factors
are considered in assigning the grade, but typically
the highest possible grade should be assigned based
on each factor.
E. Nonsurgical treatment
vascular injury.
3: Trauma
d. The open wound can be covered with saline-
moistened gauze, and the extremity can be
splinted.
3. Compartment syndrome must be considered a
possibility with all extremity fractures.
C. Radiographic evaluation
1. In any case of suspected open fracture, AP and
lateral radiographs should be obtained of the affected area, in addition to radiographs that include the joints above and below. These radiographs should be obtained as soon as possible to
allow preoperative planning to begin.
4
AAOS COMPREHENSIVE ORTHOPAEDIC REVIEW 2
1. Tetanus prophylaxis (Table 1)
a. The dose of toxoid is 0.5 mL.
b. The dose for immune globulin is 75 U for pa-
tients younger than 5 years, 125 U for patients
aged between 5 and 10 years, and 250 U for
patients older than 10 years.
c. Both shots are administered intramuscularly,
into different sites and from different syringes.
2. Antibiotic coverage
a. A Cochrane systematic review showed that in
cases of open fracture, the administration of
antibiotics reduces the risk of infection by
59%.
© 2014 AMERICAN ACADEMY
OF
ORTHOPAEDIC SURGEONS
4: Orthopaedic Oncology and Systemic Disease
Section 4: Orthopaedic Oncology and Systemic Disease
Figure 1
Intramuscular lipoma. Axial T1-weighted fat-suppressed (A) and T2-weighted fat-suppressed (B) MRIs of the right
thigh reveal a well-circumscribed lesion with the same signal as the subcutaneous fat. Note that the lesion is suppressed on the fat-suppressed images, as is classic for an intramuscular lipoma. C, The histologic appearance is of
mature fat cells without atypia. A loose fibrous capsule is visible.
Figure 2
Atypical lipoma. A, Axial MRI reveals an extensive intramuscular lipomatous lesion infiltrating the posterior thigh
musculature. Note the extensive stranding within the lesion. From this appearance, an intramuscular lipoma cannot be differentiated from an atypical lipoma. B, The histologic appearance of this atypical lipoma is more cellular
than a classic lipoma.
1. Treatment is observation or local excision (exci-
sional biopsy with marginal margin can be performed if imaging studies clearly document a lipoma).
2. Local recurrence is less than 5% if removed.
3. Malignant transformation is not clinically rele-
vant; few cases have been reported.
G. Atypical lipoma/well-differentiated liposarcoma
2
2. Usually very large, deep tumors
3. May look identical to classic lipomas or may have
increased stranding on MRI (Figure 2, A and B)
4. Histology shows greater cellularity than classic li-
poma (Figure 2, C).
5. Treatment is marginal excision; often not differ-
entiated from classic lipoma until after excision
(based on histology).
1. Often called atypical lipoma in the extremities
6. Higher chance of local recurrence (50% at 10
and well-differentiated liposarcoma in the retroperitoneum
years) compared with lipoma, but does not metastasize
AAOS COMPREHENSIVE ORTHOPAEDIC REVIEW 2
© 2014 AMERICAN ACADEMY
OF
ORTHOPAEDIC SURGEONS
7: Shoulder and Elbow
Section 7: Shoulder and Elbow
Figure 2
Illustration depicts the brachial plexus and its terminal branches. (Adapted from Thompson WO, Warren RF, Barnes
RP, Hunt S: Shoulder injuries, in Schenck RC Jr, ed: Athletic Training and Sports Medicine, ed 3. Rosemont, IL,
American Academy of Orthopaedic Surgeons, 1999, p 231.)
lar ligament), where it innervates the supraspinatus.
b. Posteriorly, it traverses the spinoglenoid notch
to innervate the infraspinatus.
c. It is found approximately 1.5 cm medial to the
posterior rim of the glenoid and can be endangered in this location with transglenoid fixation techniques.
d. Suprascapular nerve compression at the supra-
scapular notch causes denervation of both the
supraspinatus and the infraspinatus. Nerve
compression at the spinoglenoid notch leads to
selective denervation of the infraspinatus muscle.
e. Traction injury may occur from repetitive over-
head activity or secondary to a retracted rotator cuff tear. Space-occupying lesions (eg, large
perilabral cysts) can cause a direct compression
injury, typically at the spinoglenoid notch.
Figure 3
Illustration shows muscles and nerves of the
posterior aspect of the shoulder.
5. Long thoracic nerve (preclavicular branch)—In-
jury (from axillary dissection or aggressive retrac4
AAOS COMPREHENSIVE ORTHOPAEDIC REVIEW 2
© 2014 AMERICAN ACADEMY
OF
ORTHOPAEDIC SURGEONS
Section 7: Shoulder and Elbow
Figure 6
Illustration of the lateral aspect of the elbow
depicts the lateral collateral ligament complex.
Figure 7
Illustration of the medial aspect of the elbow
depicts the medial collateral ligament complex.
7: Shoulder and Elbow
Table 2
Musculature of the Elbow
Muscle
Origin
Insertion
Innervation
Action
Biceps brachii
Long head—superior
glenoid/labrum
Short head—coracoid
Radial tuberosity
Musculocutaneous
Elbow
flexion/supination
Brachialis
Humerus, intermuscular Coronoid
septum
Musculocutaneous
(medial), radial
(lateral)
Elbow flexion
Brachioradialis
Humerus
Radial
Elbow flexion
Triceps brachii
Medial head—humerus Olecranon
Lateral head—humerus
Long head—inferior
glenoid
Radial
Elbow extension
Anconeus
Lateral condyle
Radial
Stability
Radial styloid
Ulna
c. Lateral ulnar collateral ligament—Acts as the
primary stabilizer to posterolateral rotatory
instability.
d. Medial collateral ligament (Figure 7)
• Anterior band: acts as the primary stabilizer
to valgus stress
• Posterior band: forms the floor of the cubi-
tal tunnel; limits flexion when contracted
C. Musculature—The origin, insertion, innervation,
and action of the muscles of the elbow are given in
Table 2.
D. Nerves
1. Lateral antebrachial cutaneous nerve
8
AAOS COMPREHENSIVE ORTHOPAEDIC REVIEW 2
a. This nerve is the terminal branch of the muscu-
locutaneous nerve (lateral cord).
b. The musculocutaneous nerve runs between the
biceps and the brachialis and emerges lateral
to the distal tendon of the biceps brachii as the
lateral antebrachial cutaneous nerve.
c. The lateral antebrachial cutaneous nerve is at
risk for injury during distal biceps repair (oneincision anterior approach).
2. Radial nerve (posterior cord)
a. The radial nerve exits the triangular interval
(teres major, medial humeral shaft, long head
of the triceps).
b. It travels with the profunda brachii artery, lat-
© 2014 AMERICAN ACADEMY
OF
ORTHOPAEDIC SURGEONS
Section 7: Shoulder and Elbow
ation should be given to open shoulder stabilization.
d. The open Bankart procedure with capsulor-
rhaphy is an extremely reliable procedure with
very high patient satisfaction indices and recurrence rates of approximately 5% to 10%.
e. Bony deficiencies involving more than 20% of
the anteroinferior glenoid require procedures
such as open reduction and internal fixation of
acute fractures, structural bone grafting, and
coracoid transfer procedures (eg, BristowLatarjet).
f. Surgical options for engaging Hill-Sachs lesions
7: Shoulder and Elbow
Figure 9
Arthroscopic view shows a completed arthroscopic Bankart repair, with restored labral bumper. L = labrum, G = glenoid. (Adapted from
Arciero RA , Spang JT: Complications in arthroscopic anterior shoulder stabilization: Pearls
and pitfalls. Instr Course Lect 2008;57:113-124.)
b. Patients younger than 25 years who engage in
athletics or other high-demand activities may
benefit from immediate arthroscopic Bankart
repair.
c. Patients with notable bone injuries or rotator
cuff tears require immediate surgical intervention.
4. Surgical contraindications
a. Surgery is contraindicated for patients with vo-
litional instability and medical comorbidities.
b. Contraindications for arthroscopic stabiliza-
tion
• Engaging Hill-Sachs lesions—If the Hill-
Sachs lesion is large enough, positioning the
arm in abduction and external rotation allows the shoulder to dislocate with the anterior glenoid falling into or “engaging” the
humeral defect.
• Bony deficiencies involving more than 20%
of the anteroinferior glenoid (the inverted
pear defect)
5. Surgical treatment
a. The goals of surgery are to repair the Bankart
lesion and re-tension the anterior capsulolabral
complex (Figure 9).
b. Large randomized studies show equivalent re-
sults with open and arthroscopic techniques.
c. As a subgroup younger (<22 years) patients en-
gaging in overhead or collision sports have a
higher recurrence rate after arthroscopic-only
stabilization. In this subgroup, extra consider6
AAOS COMPREHENSIVE ORTHOPAEDIC REVIEW 2
include remplissage, allograft reconstruction to
restore the humeral surface, and arthroplasty.
6. Surgical complications
a. Recurrence—The recurrence rate after arthro-
scopic techniques is 4% to 15%; after open
surgical techniques, the rate is 5% to 10%.
b. Stiffness, overtightening
c. Subscapularis failure can occur with open sur-
gical techniques.
d. Anchor pull-out
e. Injury to the axillary nerve
7. Surgical pearls and pitfalls—Reasons for postop-
erative clinical failures
a. Failure to rule out concomitant rotator cuff in-
jury
b. Failure to anatomically reconstruct the antero-
inferior labrum of the IGHL
c. Failure to recognize bony defects
d. Inadequate capsular shift to re-tension the
IGHL
IV. Posterior Instability
A. Epidemiology and overview
1. Posterior shoulder instability is much less com-
mon than anterior instability, accounting for 2%
to 5% of all unstable shoulders.
2. Approximately half of presenting cases are caused
by traumatic injury.
3. Posterior shoulder dislocation can occur after a
seizure or electrical shock.
4. Up to 50% of traumatic posterior shoulder dislo-
cations go undiagnosed when patients are examined in hospital emergency departments.
B. Pathoanatomy
© 2014 AMERICAN ACADEMY
OF
ORTHOPAEDIC SURGEONS
Section 8: Hand and Wrist
8: Hand and Wrist
Figure 2
Illustration shows patterns of diseased cords.
The spiral cord (derived from the pretendinous
band, spiral band, Grayson ligament, and lateral digital sheet) displaces the neurovascular
bundle toward the midline. The Grayson ligament is seen as an isolated thickened structure.
The lateral cord comes off the natatory cord to
merge with the lateral digital sheet along the
midaxial line.
5. The Grayson ligament can become part of a lateral
cord when it joins the diseased lateral digital sheet.
F. Bands and cords—Normal anatomic structures are
called bands; diseased or contracted structures are
referred to as cords (Figure 2).
1. Central cord
a. The central cord results from disease involve-
ment of the pretendinous bands.
b. Palmar nodules and pits form beyond the
DPC.
c. Fibers from the cord extend and insert along
the flexor sheath around the proximal interphalangeal (PIP) joint level; this usually results
in MCP joint contracture.
d. The central cord is not involved with the neu-
rovascular bundle.
2. Spiral cord
a. The spiral cord results from contracture of the
spiral bands that pass dorsal to the neurovas2
AAOS COMPREHENSIVE ORTHOPAEDIC REVIEW 2
Figure 3
Illustration shows the retrovascular cord, which
arises from the preaxial phalanx and courses
dorsal to the neurovascular bundle to insert in
the side of the distal phalanx. It is the usual
cause of distal interphalangeal joint
contractures.
cular bundle to merge with the lateral digital
sheet and the Grayson ligament; this generally
results in contracture of the PIP joint.
b. The term “spiral cord” may be a misnomer be-
cause the structure actually becomes thickened
and straight as it becomes diseased; as this occurs, it displaces the neurovascular bundle superficially and at the midline, rendering the
bundle vulnerable to injury during disease resection.
c. The components forming the spiral cord are
the pretendinous band, spiral band, lateral digital sheet, and Grayson ligament.
3. Natatory cord
a. The natatory cord develops from the distal fi-
bers of the natatory ligament, just under the
commissure skin.
b. It results in a web space contracture.
4. Retrovascular cord (Figure 3)
a. The retrovascular cord can arise dorsal to the
© 2014 AMERICAN ACADEMY
OF
ORTHOPAEDIC SURGEONS
Trauma: Questions
Q-18: Which of the following is an advantage of unreamed nailing of the tibia compared to reamed nailing?
1. Less surgical time
2. Lower risk of nonunion
Section Title: Questions
3. Lower rate of malunion
4. Faster time to union
5. Less secondary procedures to achieve union
Q-19: An otherwise healthy 35-year-old woman reports dorsal wrist pain and has trouble extending
her thumb after sustaining a minimally displaced fracture of the distal radius 3 months ago. What is the
next most appropriate step in management?
1. Neurophysiologic test to evaluate the posterior interosseous nerve
2. Transfer of the extensor indicis proprius to the extensor pollicis longus tendon
3. Interphalangeal joint arthrodesis of the thumb
4. Extension splinting of the thumb
5. Fine cut CT of the distal radius to evaluate Lister’s tubercle
Q-20: Figure 9a shows the radiograph of a 34-year-old woman who sustained a basicervical fracture of
the femoral neck. The fracture was treated with a compression screw and side plate. Seven months postoperatively, she continues to have significant hip pain and cannot bear full weight on her hip. A recent
radiograph is shown in Figure 9b. Management should now consist of
1. continued non-weight-bearing and a bone stimulator.
2. removal of the hardware, bone grafting of the femoral neck, and refixation.
3. removal of the hardware and hemiarthroplasty.
4. removal of the hardware and total hip arthroplasty.
5. removal of the hardware and a valgus osteotomy.
12
AAOS Comprehensive Orthopaedic Review 2
© 2014 AAOS American Academy of Orthopaedic Surgeons
Trauma: Questions
Q-24: What is the treatment of choice for the injury shown in Figures 12a through 12c?
1. Closed reduction and a short arm cast
2. Splinting in a functional position and early motion
3. Closed or open reduction and internal fixation with Kirschner wires
Section Title: Questions
4. Open reduction and internal fixation with mini-fragment screws
5. Primary arthrodeses of the carpometacarpal joints
Q-25: A 55-year-old woman fell and sustained an elbow dislocation with a coronoid fracture and a
radial head fracture. The elbow is reduced and splinted. What is the most common early complication?
1. Brachial artery intimal tear
2. Recurrent dislocation
3. Forearm compartment syndrome
4. Posterior interosseous nerve injury
5. Ulnar nerve palsy
© 2014 AAOS American Academy of Orthopaedic Surgeons
AAOS Comprehensive Orthopaedic Review 2
15