Orthopedics

ORTHOPEDICS e d i t e d

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Semmelweis Publisher www.semmelweiskiado.hu

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, 2008

We would like to express our great thanks for the donations of our sponsors Dimenzi6 Egeszsegpenztar, Dimenzi6 Biztosit6 Egyesiilet, Berlin-ChemieIA.Menarini Kft. , ScanMedic Kft., Mr. Gyorgy Laszl6 whi ch enabled us to publish this book. Editor and authors Instru ctor in orthopaedi cs :

Pro! Tibor Vizkelety, M.D., Ph.D . , D . S c Orthopaedi c Department Semmelweis University, Budapest Pro! Kalman Szepesi, M.D., Ph.D., D.S c Orthopaedi c Depar tment University of Debre cen, Hungary

Language master:

Dr. David Durham

Translator:

Dr. Andras Vajda, M.D. Orthopaedi c Department Semmelweis University, Budapest George Szoke M.D., M . S c. (Oxon), Ph.D. Head of Pediatri c Orthopaedi c Department Department of Orthopaedi cs Semmelweis University, Budapest Tamas de Jonge M.D., Ph.D. Head of Orthopaedi c Department Markusovszky Hospital, Szombathely, Hungary

Photographer

Peter Kovacs Orthopaedi c Department Semmelweis University, Budapest

. © Mikl6s Szendroi, 2008

ISBN 978 963 9656 93 2 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or trasnmitted in any from or by any means, electronic, mechanical, photocopyring, recording or otherwise, without either prior permission of the publishers. Semmelweis Publisher 1089 Budapest, Nagyvarad ter 4. www.semmelweiskiado.hu

Responsible editor: L asz 16 T an cos Editor-in- chief, layout: Judit Vin cze Illustrations : Csilla Koszeghy Cover design : L asz 16 T an cos SKD 1 75 Printed by Gyomai Kner Printing House Zrt., in Hungary Responsible exe cutive : Lajos Papp CEO

Editor: Pro! Mikl6s Szendroi, M.D., Ph.D., D.Se. Head of Orthopaedi c Department Semmelweis University, Budapest Authors: Pro! ArpQd Bellyei, M.D., Ph.D., D. Se. Orthopaedi c Department University of Pe cs, Hungary Pro! Tamas Bender, M.D., Ph.D. Poly clini c of the Hospitaller Brothers of St. John of God, Budapest Laszl6 Bucsi, M.D., Ph.D. Head of Orthopaedi c Department St. George Hospital, Szekesfeherv ar, Hungary Associate Pro! Zoltan Csernatony, M.D., Ph.D. Head of Orthopaedi c Department University of Debre cen, Hungary Pro! Laszl6 Hangody, M.D., Ph.D., D.Se. Head of Orthopaedi c Department Uzsoki Hospital, Budapest Pro! Tamas !llb, M.D. , Ph.D., D. Se. Head of Orthopaedi c Department University of Pe cs, Hungary Jeno Kiss, M.D. , Ph.D. Head of Orthopaedi c Department St. John Hospital, Budapest Katalin Kolto, M.D. Radiologist Orthopaedi c Department Semmelweis University, Budapest Pro! Janos Kranicz, M.D., Ph.D. Head of Orthopaedi c Department University of Pe cs, Hungary Prof. Lajos Kullmann, M .D ., Ph.D. Medi cal Rehabilitation Institute, Budapest Associate Pro! J6zsejLakatos, M.D., Ph.D. Orthopaedi c Department Semmelweis University, Budapest

Associate Pro! Ferenc Mady, MD., Ph.D. Orthopaedi c Department Semmelweis University, Budapest Associate Pro! Adam Mester, MD., Ph.D. Radiologist Radiologi c Department Semmelweis University, Budapest Pro! Tamas Meszaros, MD., Ph.D. Orthopaedi c Department University of Szeged, Hungary Pro! Gyula Poor, MD., Ph.D. Head of Rheumatology Department Semmelweis University, Budapest Pro! Miklos Szendroi, MD., Ph.D., D.Sc Head of Orthopaedi c Department Semmelweis University, Budapest Pro! Kalman Toth, MD., Ph.D. Head of Orthopaedi c Department University of Szeged, Hungary Peter Pal Varga, MD. Head of National Spine Centre, Budapest Pro! Tibor Vizkelety, MD., Ph.D., D.Sc Orthopaedi c Department Semmelweis University, Budapest

Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . XVII

1.

History and subj e ct of orthopedi cs (Tibor Vizkelety) .

2.

Stru cture and development of bones (Zoltcm Csernatony) . 2 . 1 . Stru cture of bones . . . . . . . . . . . 2 . 1 . 1 . The composition of bone . 2 . 1 .2 . The bone tissue . . . . . . 2 . 1 .3 . Bones as organs . . . . . 2 . 1 .4. The development and growth of bones . 2.2. Biologi cal adaptation of bones . . . . . . . 2 . 3 . Hormones regulating the bone metabolism . . . . .

3.

Bone healing after various types of fra ctures (Mikl6s Szendroi) . . . . . . . 3 . 1 . Traumati c fra ctures . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 .2 . Fra cture healing. Types and stages. Factors influen cing fra cture healing 3 . 3 Pathologi cal fra cture healing. Pseudo-arthrosis . 3 .4. Pathologi cal fra ctures . 3 . 5 . Stress fractures . . . . . . . . . . . . . . . . .

11 11 11 13 14 16

4.

Examination methods in orthopedi cs (Katalin Kollo, Adam Mester, Tamas Meszaros) 4. 1 . Case history (anamnesis) . 4.2. Examination. . . . . . . 4.2. 1 . Inspe ction . . 4.2.2. Palpation . . . 4.2 . 3 . Alignment, axial deformities of the limbs. 4.2.4. Examination of the j oints . . . . . 4.2 . 5 . Range of motion of j oints (ROM) . 4.2.6. Assessment of mus cle power . 4.2.7. Assessment of mus cle tone . . . . 4.2 . 8 . Limb length assessment . . . . . . 4.2.9. Measurement of limb circumferen ce 4.3 . The standing position and the gait 4.3 . 1 . Standing position 4 . 3 . 2 . Gait . . . . . . 4 .4 . Limping . . . . . . . . . . . 4 . 5 . Neurologi cal examinations . 4.6. Laboratory tests . 4.7. Arthros copy . . 4 . 8 . Histology tests .

17 17 19 19 19 20 20 24 25 25 25 27 27 27 28 30 31 31 32 32

5 5 5 5 7 7 7 9

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4 .9. Imaging modalities . . . . . . . . . . . . . . . . . . 4 . 9 . l . X-ray tests, spe cial X-ray investigations 4.9.2. Mus culoskeletal ultrasonography : 4 . 9 . 3 . Isotope pro cedures 4.9.4. CT s canning . . . . . . . . . . . 4 . 9 . 5 . MRI . . . . . . . . . . . . . . . . 4.9.6. Invasive and interventional radiology .

32 32 35 36 37 38 38

5.

Surgi cal therapy i n orthopedi cs (Tamas Meszaros) . 5 . 1 . Mus cle - tendon operations . 5 .2 . Fas cia surgery . . . . 5 . 3 . Bone operations . . . 5 .4. Operations on j oints . 5 . 5 . Arthroplasty . . . . . 5 . 6 . Operation on nerves .

41 41 42 42 42 44 47

6.

Conservative treatment pro cedures (Zoltan Csernatony) . 6 . 1 . Immobilization . . . 6 . 2 . Mobilization . . . . 6 . 3 . Non-weight-bearing . 6.4. Irradiation . . . . . . 6 . 5 . Laser therapy . . . . 6 . 6 . Pharma ceuti cal treatment .

49 49 51 51 51 51 51

7.

Physiotherapy (Tamas Bender) 7 . l . Exercises . . . . . . . . . 7 . 2 . Immobilization, mobilization, exer cises 7 . 3 . Massage . . . . . . . . 7.4. Ele ctrotherapy . . . . . . . . . . . 7 . 5 . Ultrasound treatment . . . . . . . . 7 . 6 . Pulsating ele ctromagneti c treatment 7 . 7 . High-frequen cy treatment 7 . 8 . Cryotherapy . . . . . . . . 7 . 9 . Balneotherapy-health spas 7 . 1 0. Compresses and pa cks . .

57 57 58 59 59 60 60 60 61 61 62

8.

Manual therapy, acupun cture ( Tamas Bender)

63

9.

Amputation - artifi cial limbs (Lajos Kullmann) 9 . 1 . Lower limb amputation . . . . . . . . . . . 9 . l . l . Indi cations of lower limb amputations 9 . l .2 . Surgi cal te chnique of amputations 9 . l .3 . Criteria of proper stump . 9 . 2 . Lower limb prostheses . . . . . . . 9 . 2 . 1 . Temporary prostheses . 9.2.2. Final prosthesis . . . 9 . 3 . Upper limb amputation . . . . . . 9.4. Upper limb prosthesis appli cation 9.4. 1 . Cosmeti c prostheses .

65 65 65 66 66 68 68 69 70 70 71

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9.4.2. Me chani cal prostheses . . . . . . . . 9.4. 3 . Prostheses powered by external force . Orthoses, applian ces for mobility (Lajas Kullmann) 1 0. 1 . Lower limb orthoses . . . . . . . . 1 0. 1 . 1 . Ankle - foot orthoses . . . . . 1 0. 1 .2. Knee orthoses . . . . . . . . 1 0. 1 .3 . Knee - ankle - foot orthoses . 1 0. 1 .4. Hip orthoses . . . . . . . . . 1 0. 1 .5 . Hip - knee - ankle - foot orthoses 1 0.2. Upper limb orthoses . . . . . . . . 1 0. 3 . Spinal orthoses . . . . . . . . . . . . . . . 1 0. 3 . 1 . Lumbosa cral orthoses . . . . . 1 0. 3 .2 . Thora co-Iumbo-sa cral orthoses 1 0. 3 . 3 . Cervi co - thora co - lumbo - sacral orthoses . 1 0.3 .4. Cervi cal orthoses . 1 0.4. Preventive sport applian ces . 1 0. 5 . Walking aids . . . . . . . . 1 0. 5 . 1 . Walking sti ck . 1 0. 5 . 2 . Crut ch . . . . . 1 0. 5 . 3 . Walking frame . 1 0. 5 .4. Wheel chair . . .

71 72 73 74 74 74 74 74 75 75 76 76 76 77 77 77 77 77 77 78 78

1 1.

Orthopedi c shoes and insoles (Kalmim T6th) . 1 1 . 1 . Shoes and orthopedi c shoe 1 1 .2. Shoes for children . . 1 1 . 3 . Shoe and sole insoles . . .

81 81 82 83

1 2.

Normal growth, growth disturbances (Kalman T6th) . 1 2 . 1 . Physiologi cal growth . . . . . . . . . . . . . 1 2 .2. Growth disturban ces . . . . . . . . . . . . . . . 1 2 .2. 1 . Treatment options for growth disturban ces 1 2 . 3 . Limb deformities . . . . . . . . . . . . . . . . . . . .

85 85 86 87 88

Bone dysplasias and developmental anomalies (Tibar Vizkelety) . 1 3 . 1 . Frequently o ccurring osteo chondrodysplasias . . . . . . . 1 3 . 1 . 1 . Skeletal dysplasias with predominant metaphyseal involvement . 1 3 . 1 .2 . Skeletal dysplasias with predominant epiphyseal involvement . 1 3 . 1 .3 . Skeletal dysplasias with maj or involvement of the spine . . . 1 3 . 1 .4. Dysostosis multiplex, complex carbohydrate storage diseases 1 3 . 1 .5 . Skeletal dysplasias with de creased bone density . . . . . . . 1 3 . 1 .6. Skeletal dysplasias with in creased bone density . . . . . . . . 1 3 . 1 .7 . Skeletal dysplasias due to the disorganized development of bone constituens . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

89 90 90 92 92 93 93 95

1 0.

.

13.

1 4.

Metaboli c diseases of the bone (Laszl6 Bucsi) . 1 4. 1 . Osteoporosis . . . . . . . . . . . . . . . 1 4.2. Osteomalacia (mollities ossium) . . . . 1 4.2. 1 . Ra chitis (ri ckets, avitaminosis D)

97 101 101 1 05 1 06

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1 4.2.2. Vitamin D resistant ra chitis (Fan coni syndrome, phosphate diabetes) . . . . . . . . . . . . . . . . . . . . . . . . . 1 4 . 3 . Hormonal metaboli c bone diseases . . . . . . . . . . . . . . . . . 1 4 . 3 . 1 . Hyperparathyroidism (Osteodystrophia fibrosa cysti ca generalisata, von Re cklinghausen ' s disease) . . . . . . 1 4 . 3 . 2 . Hypogonadism (Adiposogenital dystrophy, Frohli ch ' s disease) . 1 4. 3 . 3 . Cushing' s disease . . . . . . . . . . . . . . . . . . . . . . . . . 15.

Developmental anomalies o f the extremities (Tibor Vizkelety) . . . . . . . .

1 6.

Neuromus cular diseases (Tibor V izkelety) . . . . . . . . . . . . . . 1 6. 1 . Spinal dysraphisms, myelodysplasia . . . . . . . . . . . . . . . 1 6. 1 . 1 . Meningo cele, myelomeningo cele, myelodysplasia. 1 6.2. Cerebral palsy (infantile cerebral paresis, Little disease) . . . . 1 6. 3 . Poliomyelitis (poliomyelitis anterior a cuta, Heine-Medin disease) 1 6.4. Developmental anomalies and diseases of the mus cle system . 1 6.4. 1 . Congenital mus cle absen ces . . . . . . . . . . 1 6.4.2. Mus cular dystrophy . . . . . . . . . . . . . . . 1 6.4. 3 . Myopathies due to inflammation, polymyositis . 1 6.4.4. Myositis ossifi cans progressiva (fibrodysplasia ossifi cans progressiva) . . . . . . . . . . . . . . . . . . . . . . 1 6.4.5 Arthrogryposis (arthrogryposis multiplex congenita) . 1 6.4.6. Congenital laxity of the joints . . . . . . . . . . . .

.

.

.

1 08 1 08 1 08 1 09 1 09 . 111 1 15 1 15 1 15 1 18 1 22 1 23 1 23 1 23 1 25 1 25 1 25 1 26

1 7.

Tunnel syndromes (Zoltim Csernatony) . . . . . . . . . . . . . . . . . . . . . . . . 1 27

1 8.

Disorders of tendons, tendon sheaths, bursae, fas ciae and ligaments (Zoltan Csernatony) . . . . . . . . . . . . . . . . . . 1 8 . 1 . Disorders o f the tendons . . . . . . . . . . . . . 1 8 .2. Illnesses o f the paratenon and the tendon sheath 1 8 . 3 . Diseases o f the bursae . 1 8 .4. Illnesses of fas cia. . . . 1 8 . 5 . Disorders of ligaments .

1 9.

Diseases of joints (Zoltan Csernatony, JozsejLakatos, Tamas Meszaros, Gyula Poor, Miklos Szendroi) . . . . . . . 1 9. 1 . The stru cture of the joints . . . . . . 1 9.2. The biome chani cal aspe cts of j oints . 1 9. 3 . Arthritis . . . . . . . . . . . . . . . 1 9. 3 . 1 . Autoimmune lo comotor diseases . 1 9. 3 . 1 . 1 . Rheumatoid arthritis . . 1 9. 3 . 1 .2 . Polysystemi c auto immune diseases affe cting the lo comotor organs . . . . . . . . . . . . . 1 9. 3 . 2 . Seronegative spondarthritis . . . . . . . . . . . . . . . 1 9. 3 . 2 . 1 . Spondylitis ankylopoeti ca ( ankylosing spondylitis) 1 9. 3 .2 .2 . Other forms of seronegative spondarthritis (SNSA) . 1 9. 3 . 3 . Juvenile chroni c arthritis . 1 9. 3 .4. Crystal-indu ced arthritis 1 9. 3 .4. 1 . Gout . . . . . . .

135 135 136 1 36 1 37 137

1 39 1 39 1 40 1 40 1 40 141 1 44 1 44 1 44 1 47 1 48 1 49 1 49

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1 9. 3 .4.2. Other forms of crystal indu ced arthritis 1 9.4. Arthropathies . . . . . . . . . . . . . 1 9.4. 1 . Neurogeni c arthropathy . 1 9.4.2. Hemophili c arthropathy 1 9. 5 . Performing surgery in arthritis . . . . 1 9.6. Synovial chondromatosis . . . . . . 1 9. 7 . Pigmented villonodular synovitis (PVNS) . 1 9. 8 . Arthrosis (osteoarthritis) . . . . . . . . . . 1 9. 8 . 1 . Alterations in various parts of the joint . 1 9. 8 .2 . Alterations in the arti cular endings of bones . 1 9. 8 . 3 . Transformations in the non-loaded zone, osteophytes . 1 9. 8 .4. Changes in the arti cular capsule 1 9. 8 . 5 . Symptoms . . . . . . . 1 9. 8 . 6 . Treatment of arthrosis . . . . .

151 151 151 1 52 1 53 1 58 158 1 59 1 60 1 62 1 62 1 63 1 63 1 64

20.

Bacterial infe ctions of bones and joints (JozseJLakatos) 20. 1 . Osteomyelitis . . . . . . . . . . . . . . . . . . 20. 1 . 1 . A cute hematogeni c osteomyelitis . . 20. 1 .2 . Chroni c osteomyelitis . . . . . . . . 20. 1 .3 . Spe cial forms of primary chroni c osteomyelitis 20. 1 .4. Spe cial forms of inflammatory bone alterations . 20.2. Purulent arthritis . . . . . . . . . . . . . . . . . . . . . . 20.3 . Bone and joint tuberculosis . . . . . . . . . . . . . . . . . . 20.3 . 1 . Coxitis tuberculosa (tuber culosis of the hip) . . . 20. 3 . 2 Gonitis tuberculosa (tuberculosis of the knee-j oint)

1 65 1 65 1 65 171 1 72 1 74 1 77 1 79 1 82 1 83

21.

Tumors of the mus culoskeletal system (Miklos Szendroi) . 2 1 . 1 . General . . . . . . . . . . . . . . . . . . . . . . . . 2 1 .2. Primary bone tumors . . . . . . . . . . . . . . . . . 2 1 .2 . 1 . Histologi cal classifi cation of bone tumors . 2 1 .2.2. Bone forming (osteogeni c) tumors . . . . . 2 1 .2.2. 1 . Benign bone forming tumors . . . 2 1 .2.2.2. Malignant bone forming (osteogeni c) tumors 2 1 .2.3 . Cartilage-forming tumors . . . . . . . . . . . 2 1 . 2 . 3 . 1 . Benign cartilage-forming tumors . . 2 1 . 2 . 3 . 2 . Malignant cartilage-forming tumors 2 1 .2.4. Bone marrow tumors . . . . . . . . . . . 2 1 . 2 . 5 . Giant cell tumor of bone. (osteo clastoma, "brown tumor of bones") . 2 1 .2.6. Other rare bone tumors . 2 1 .3 . Bone metastases . . . . . . 2 1 .4. Tumor-like bone pro cesses . . . . . . 2 1 . 5 . Soft-tissue tumors . . . . . . . . . . 2 1 . 5 . 1 . Some soft-tissue tumors of orthopedi c signifi can ce

1 85 1 85 1 92 1 92 1 92 1 93 1 94 1 99 1 99 20 1 204 206 207 208 212 215 218

Reflex dystrophy (Sude ck ' s syndrome) (Zoltim Csernatony) . . . . . .

225

22.

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23 .

Asepti c bone ne crosis (Arpad Bellyei) . . . . . . . . . . . . . . . . . . . . . . . . . 229 23 . 1 . Childhood bone ne crosis (j uvenile osteo chondrosis, juvenile osteo chondritis, 229 juvenile osteo chondrone crosis) 2 3 . 2 . Adult asepti c bone ne crosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1

24.

Diseases of the spine (Tamas Illes, J6zsejLakatos, Peter Pal Varga) . 24. 1 . Biome chani cs, fun ctional anatomy, fun ctional units of the spine . 24.2. Examination of the spine . . . . . . . . . . . . 24.2. 1 . Assessment of the cervi cal spine . 24.2.2. Assessment of the lumbar spine 24.2 . 3 . Radiologi cal assessment . . . . . 24. 3 . Classifi cation of deformities of the spine . . . 24. 3 . 1 . Chara cteristi cs of deformities in one plane . 24.3 . 1 . 1 . Fun ctional hyperkyphosis 24.3 . 1 .2 . Fun ctional hyperlordosis . . . . . 24.3 . 1 . 3 . Stru ctural kyphosis . . . . . . . . 24. 3 . 2. Spinal deformities 3 dimension: S coliosis . 24. 3 . 2 . 1 . Fun ctional (nonstru ctural) s coliosis 24. 3 .2 .2 . Stru ctural s coliosis . . . 24.4. Congenital abnormalities . . . . . . . . . . . . 24.4. 1 . Spondylolysis, spondylolisthesis . 24.4. 2 . Sacralization, lumbarization 24.4. 3 . O ccult spina bifida . . . . . . . . 24.5 . Other diseases . . . . . . . . . . . . . . . . . 24. 5 . 1 . Baastrup syndrome (interspinous arthrosis) 24. 5 . 2 . Sacrum a cutum . . . . 24. 5 . 3 . Co ccygodynia . . . . . . . . . 24. 6 . Degenerative disorders of the spine . . . . 24. 6 . 1 . Degenerative spinal disorders 24.6. 1 . 1 . Degenerative pro cess of the dis c . 24.6. 1 .2 . Dis c prolapse, hernia . . . . . . . 24.6. 1 .3 . Degenerative spine instability . . 24. 6 . 1 .4. Clini cal examination of degenerative spinal disorders . . . . . . . . . . . . . . . . . . . 24. 6 . 1 . 5 . Conservative treatment of a herniated dis c and degenerative spinal stenosis . . . . . . . . . . 24.6. 1 . 6. Surgi cal treatment of degenerative spinal disorders 24. 7 . Spinal changes in osteoporosis . 24. 8 . Tumors . . . . . . . . . . . . 24. 8 . l . Primary tumors . 24. 8 . 2 . Metastases . . . 24.9. Inflammations of the spine . . 24.9. 1 . Spondylitis tuberculosa (Pott ' s disease) 24. 9 . 2 . Pyogeni c spondylitis (spinal osteomyelitis) 24. 9 . 3 . Spondylodis citis . . . . . . . . . 24. 1 0. Chest deformities . . . . . . . . . . . . . . . 24. 1 0. 1 . Pe ctus ex cavatum (funnel chest) 24. 1 0.2. Pe ctus carinatum (pigeon chest) .

235 235 236 237 240 242 245 245 246 247 247 253 253 253 267 267 272 273 274 274 274 274 274 275 275 275 276 277 28 1 28 1 282 284 284 285 286 286 288 29 1 292 292 294

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25.

Disorders of the ne ck and the shoulder girdle (Jeno Kiss) . . . . . . 2 5 . 1 . Fun ctional anatomy and biome chani cs of the shoulder girdle . 25.2. Examination of the shoulder girdle . . . . . . . . . . . . . . 2 5 . 3 . The congenital and a cquired disorders of the of the shoulder girdle 25.4. Disorders of the shoulder . . . . . . . . . . . 2 5 . 5 . Other painful shoulder conditions briefly . . . 25.6. Glenohumeral instability, shoulder dislo cation

295 295 296 297 3 02 307 308

26.

Disorders of the elbow and forearm (Jeno Kiss) . . . 26. 1 . Fun ctional anatomy of the elbow and forearm 26.2. Assessment of the elbow . . . . . . . 26. 3 . Signifi cant developmental anomalies . . . . . 26.4. A cquired disorders of the elbow . . . . . . . . 26. 5 . Volkmann' s is chemi c contra cture of the forearm and the hand .

311 311 311 311 313 317

27.

Disorders of the hand and the wrist (Ferenc Mady) . 27. 1 . Fun ctional anatomy of the hand and the wrist . 27.2. Congenital anomalies of the hand . . . . . . . 27. 3 . A cquired hand disorders . . . . . . . . . . . . 27. 3 . 1 . Avas cular ne crosis of the carpal lunate bone (Kienb ock ' s disease) . . . . . . . . . . . . . 2 7 . 3 . 2 . Cyst and pseudoarthrosis of the s caphoid bone 27.3 . 3 . Osteoarthritis (OA) of the wrist and the hand 27.3 .4. Inflammatory pro cesses . . . . . . . . . . 27.3 . 5 . Ganglioni c cysts of the wrist and the hand . . 27.3.6. Dupuytren ' s contra cture . . . . . . . . . . . 27.3.7. Tumors and tumorous conditions in the hand

319 319 32 1 322

28.

Hip disorders (Arpad Bellyei, J6zsejLakatos, Mikl6s Szendroi) 28. 1 . Pediatri c hip disorders . . . . . . . . . . . . . . . . . . . 2 8 . 1 . 1 . Normal development of the hip joint . . . . . 2 8 . 1 .2. Congenital dislo cation and dysplasia of the hip 2 8 . 1 .3 . Osteo chondritis capitis femoris juvenilis (Perthes ' disease, Legg-Calve-Perthes ' disease) . . . . . . . . . . . . . . . . . 2 8 . 1 .4. Slipped capital femoral epiphysis (SCFE, epiphyseolysis capitis femoris juvenilis, coxa vara adoles cent) 2 8 . 1 .5 . Coxa vara infantum ( congenital) . . . . . . . 2 8 . 1 . 6 . Symptomati c coxa vara . . . . . . . . . . . . 2 8. 1 . 7 . Growth disturban ces of the proximal femur . 2 8 . 1 . 8 . Transitory arthritis coxae (transitory hip j oint inflammation) 2 8 . 1 .9. Juvenile a cetabular protrusion . . . . . 2 8 . 1 . 1 o . Snapping hip, external coxa saltans . . 2 8 . 1 . 1 1 . Inward o r outward rotation of the legs 2 8 . 1 . 1 2 . Limb shortening . . . . . . . . . . . . 2 8. 1 . 1 5 . Congenital hemiatrophy and hemihypertrophy . 28.2. Hip disorders i n adults . . . . . . . . . . . . . . . 2 8. 2 . 1 . Fun ctional anatomy . . . . . . . . . . 28.2.2. Deformities o f the hip - prearthrosis . 28.2.2. 1 . Valgus hip, coxa valga . . .

322 323 324 325 326 327 328 329 329 329 33 1 342 347 350 35 1 352 352 353 354 35 4 355 358 358 358 359 361

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2 8 . 2 . 2 . 2 . Varus hip, coxa vara . . . . . . . . . . . . . . . . . . 2 8 . 2 . 2 . 3 . Antetorsion and retrotorsion of the hip (coxa antetorta and coxa retrotorta) . . . . . . . . . . . . . . 2 8 .2.2.4. Other prearthroses . . . . . . . . . . . . . . . . . . 2 8 . 2 . 2 . 5 . Surgical treatment of prearthrotic conditions . . . . . 2 8 . 2 . 3 . Idiopathic femur head necrosis (aseptic, avascular femur head necrosis) . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 8 .2.4. Coxarthrosis (hip osteoarthritis, arthrosis deformans coxae) . . 29.

30.

362 362 363 363 365 368

Disorders of the knee (Laszl6 Hangody, Mikl6s Szendroi) 29. 1 . Structure and functional anatomy of the knee . 29.2. Congenital developmental disorders . . . 29.2. 1 . Congenital knee dislocation . . . 29.2.2. Genu recurvaturn . . . . . . . . . 29.2 . 3 . Developmental disorders of the patella . 29.3 . Repeated patella dislocation and subluxation . . . . 29.3 . 1 . Habitual dislocation of the patella . . . 29.3 . 2. Recurrent dislocation and subluxation of the patella . 29.3 . 3 . Luxatio patellae congenita . . . . . 29.4. Developmental disorders of the menisci . . . . 29. 5 . Developmental disorders of the tibia and fibula . 2 9 . 5 . 1 . Tibia, fibula aplasia, hypoplasia 2 9 . 5 . 2 . Congenital tibia pseudarthrosis . 29.6. Axial deformities . . . . . . . . . . . . . . . 29.6. 1 . Genu varum - crus varum . . . 29.6.2. Tibia vara epiphysarea (Blount' s disease) . 29.6. 3 . Genu valgum - crus valgum . 29.6.4. Torsion o f the tibia . . . . . . . . 29.7. Aseptic osteochondroses around the knee . . . 29.7. 1 . Osteochondritis dissecans genus . 29.7.2. Osteochondritis of the tibial tubercle (Schlatter-Osgood' s disease) . . . . . 29. 7 . 3 . Adult aseptic femur condyle necrosis (Ahlb ack' s disease) . 29. 8 . Knee contractures . . . . . . . . . . . . . 29.9. Fluid accumulation (effusion) i n the knee . 29. 1 0. Cysts i n the knee region . . 29. 1 0. 1 . Ganglion . . . . . . . . . . . 29. 1 0.2 . Meniscus cyst . . . . . . . . 29. 1 0. 3 . Popliteal cyst (Baker' s cyst) . 29. 1 0.4. Bursitis praepatellaris . . . . 29. 1 1 . 1 . Collateral ligament injuries . 29. 1 1 .2 . Chronic collateral ligament insufficiency . 29. 1 1 . 3 . Cruciate ligament injuries . 29. 1 1 . 5 . Meniscal tear . . . . . . . . . . . . . . 29. 1 3 . Chondromalacia patellae . . . . . . . . . . . . . . . 29. 1 4 . Chondropathies, osteoarthritis (arthrosis) of the knee

375 375 377 377 377 377 378 378 378 379 379 379 379 379 3 80 380 381 381 3 82 3 82 3 82

Disorders of the foot (Janos Kranicz, Kalman T6th) . . . . 3 0. 1 . The functional anatomy and biomechanics of the foot

399 399

3 83 3 84 385 385 3 86 3 86 386 387 387 388 388 38 9 391 392 393

Co n t e n s

30.2. Foot deformities in childhood . . . . . . . . . . . . . . . . . . 30.2. 1 . Congenital foot deformities, developmental abnormalities 30.2.2. Pes equinovarus congenitus (congenital club foot) . 3 0 .2 . 3 . Pes adductus . . . . . . . . . . 3 0 .2.4. Pes excavatus . . . . . . . . . 3 0 . 2 . 5 . Pes calcaneovalgus congenitus 30.2.6. Accessory ossicles on the foot . 30 . 2 . 7 . Tarsal coalition . . . . . . . . . 3 0 . 2 . 8 . Osteochondrosis calcanei (apophysitis calcanei) 30.2.9. Osteochondrosis ossis navicularis pedis (K6hler' s I disease) 30.2. 1 0. Ostechondrosis capitis metatarsi 11. (K 6hler' s 11 disease) 3 0 . 3 . Foot deformities in adulthood . . . . . . . . . . . . . . . . . . 3 0 .3 . 1 . Pes planus (pes planovalgus, flat foot, fallen arch) . 3 0 . 3 . 2 . Hallux valgus, metatarsus I. varus 30 . 3 . 3 . Hallux rigidus . . . . . . . . . . 3 0 . 3 .4. Diseases o f the 5th ray . . . . . 30 . 3 . 5 . Diseases o f the sesamoid bone . 3 0 . 3 . 6. Metatarsalgia . . . . . . . . . 3 0 . 3 . 7 . Digitus malleus (hammertoe) . . 3 0 . 3 . 8 . Morton's neuroma . . . . . . . 3 0 . 3 . 9 . March fracture (stress fracture, fatigue fractures on the metatarsals) . . . . . . . . . . . . . . . . 30. 3 . 1 0. Achillodynia (paratenonitis of the Achilles tendon) 30 . 3 . 1 1 . Haglund heel . . . . . . . 30.3 . 1 2 . Calcaneus spur . . . . . . 30.3 . 1 3 . Arthrosis of the foot joints 3 0 . 3 . 1 4. Tarsal tunnel syndrome . 3 0 .3 . 1 5 . Diabetic foot . References . .

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xv

400 400 40 1 405 406 407 408 408 409 409 410 41 1 41 1 414 417 417 418 418 419 419 420 420 420 420 42 1 42 1 422 423

Preface

One of the most dynamically developing fields of medicine is orthopedics. Products of high technology have become part of our ev­ eryday practice. One of the most successful operations is hip- and knee joint replacement using endoprostheses. More than 90 per cent of the devices last longer than 1 0 years in the patient. A separate branch of science tribology deals with their wear-out proce­ dures. The development of technology has en­ abled us to introduce arthroscopic techniques for joints like the knee, shoulder, hip, ankle and wrist. By this minimal invasive surgery we can remove menisci, replace the anterior crucial ligaments in the knee and refix the labrum in the shoulder joint. In tumor surgery limb saving procedures are more and more fa­ vored, which however requires the evolution of reconstruction surgery, i.e. development of

modular type tumor endoprostheses systems. The implementation of modem imaging tech­ niques, like CT, MR and PET examinations have made diagnostic procedures more pre­ cise and accurate, which is crucial for surgical planning. This book is intended to fill the need for up-to-date information on disorders and dis­ eases treated by orthopedic surgeons and re­ lated physicians. The numerous illustrations, photos taken of patients and removed surgical specimens, MRI and CT pictures as well as drawings have been carefully selected to max­ imize their benefits in pointing out orthopedic principles and concepts and serve the better understanding of diseases. M. Szendroi, MD, PhD, DrSc.

1.

T i b o r Vf z k e l e t y

History and subject of orthopedics

Orthopedic conditions are probably basi­ cally as old as mankind itself. Neolithic skele­ tal remains for instance show changes due to tuberculotic spondylitis. Tuberculotic gibbus or coxitis, clubfoot and degenerative disor­ ders are often to be seen on Egyptian mum­ mies. Throughout history achondroplastic dwarfs have frequently been the subject of il­ lustrations, and one picture suggests that epi­ demic poliomyelitis was not unknown. In an­ cient Baghdad, in Persia surgical and orthope­ dic patients were treated in separate wards in hospitals as long ago as 1 000 BC. In Hippocrates ' book on the joints we may read about congenital clubfoot, hip disloca­ tion and the treatment of spine curvatures, and his statements remain essentially today. Hip-

Fig. 1.1. Fabricius ab Aquapendente: Opera Chirurgica

pocrates was perfectly familiar with the con­ genital hip dislocation. Following Hippocrates, exercises were proposed by Celsus for the treatment of spinal deformities in the 1 st century AD . In the 2nd century Galenus created the nomenclature for the names of spinal curvatures : kyphosis, lordosis and scoliosis. In the Middle Ages, similarly to surgery the treatment of the musculoskeletal diseases was the task of healers and blacksmiths. This played a certain role in the predominance of mechanical treatment methods, enforced cor­ rections and fixations and by the 1 6th century the field of the mechanical orthopedics was established. The first and most noteworthy representatives of this trend were Ambroise Pare ( 1 5 1 0- 1 590) and Hieronymus Fabricius ab Aquapendente ( 1 5 3 7- 1 6 1 9), who de­ scribed the origin of congenital clubfoot, hip dislocation and torticollis and proposed vari­ ous treatment procedures. The book by Fabricius ab Aquapendente illustrates a con­ struction of metal frames to fix and correct all parts of the body and the j oints (Fig. 1 . 1 .) . The term ' orthopedics ' was first used by Nicolas Andry ( 1 65 8- 1 742) in his book titled "L 'Orthopedie ou I 'art de prevenir et de corriger dans les enfans des difJormites du corps" (Orthopedics, the art of preventing and correcting bodily deformities in children) published in 1 74 1 . The picture in this book il­ lustrating a growing curved tree fixed to a pole in an effort to make it erect has become the symbol of orthopedics (Fig. 1 .2.). The word ' orthopaedia' is of Greek origin created according to Andry is originated from the as­ sociation of words orthos (straight) and paidos (child). The book was also published not only in French, but also in English and in German.

2

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1 . H i st o ry a n d s u bject of o rt h o p e d ics

Fig. 1.3. Scu ltety 1666: appliance to correct spinal curvature

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retl

Fig. 1.2. The symbol of orthopedics from And ry's book

With this name, the new specialty of or­ thopedics was born, and clear proof of its ex­ istence and development was the founding of the first specialist orthopedic institution of the world which was established in Orbe, Swit­ zerland in 1 779 by Jean Andre Venel ( 1 740- 1 79 1 ) . That institution, which may be considered most sophisticated even today provided the patients with medical treatment, aftercare, a supply of appliances and educa­ tion. During many decades orthopedic care tended primarily to concentrate on fixation, mobilization by means of various appliances, or manual correction (the mechanical trend) (Fig. 1 .3.). The dynamic trend, involving the utiliza­ tion of exercises also has a long history. The first book, titled "Medicina Gymnastica . " by Francis Fuller was published in 1 705 and was reprinted 9 times. The term "orthopedie" in Andry book likewise refers to the impor­ tance of exercises for the development of a straight posture. These exercises took the pa. .

tients to the open fields, adding the healing ef­ fects of the open air and the sunshine. In the early of 1 9th century, Ling in Sweden intro­ duced medical exercises, for the active and passive mobilization of certain parts of the body. Accepted into practice under the name of "Swedish gymnasty" and the essence of these procedures is made use of in modem times. Surgical procedures were resorted for the correction of contractures and deformities, es­ pecially in cases where mechanical solutions had failed. The sequence of evolution of sur­ gical treatment was first closed interventions, followed by subcutaneous tenotomies and fi­ nally open-exposure operations . The tech­ niques of asepsis and antisepsis introduced by Semmelweis and Lister played an important role in this development. The early surgical interventions were ob­ viously the work of the bone setters, who could successfully treat certain conditions, and who handed on their art through many generations. Revolutionary changes in the performance of mechanical and surgical treatment fol­ lowed the introduction of plaster of Paris casts, first used by Dutch physician Mathysen in 1 85 1 and applied extensively ever since. Thus the mechanical, functional and sur gi­ cal approaches for the treatment of orthopedic conditions developed in parallel. In recent de-

1. H i st o ry a n d s u bject of o rt h o p e d ics

cades, the changes have conside rably accele r­ ated and at p resent pe rhaps the most inten­ sively and dynamically developing b ranch of medicine. The p rog ress in science ove rall has naturally played a g reat role in this. The achievements in anesthesiology and intensive care now pe rmit successful extensive and timely surgical p rocedu res that we re ea rlie r impossible. The development is basically proceeding i n two directions: •

•

The prevention of diseases, and the early diagnosis and treatment, leading to the prevention of permanent deformities; Utilization of the available technical achievements in the therapy.

Medicine is most effective if disease is p revented when the rapy is unnecessa ry. The best example in o rthopedics is the int roduc­ tion of vaccination Salk and Sabin, which has eradicated poliomyelitis epidemics in those count ries whe re it is used systematically. Well-o rganized hip sc reening can p revent hip dislocation and dysplasia, fo r early t reat­ ment can solve it without any residual defo r­ mity. Besides the developments in su rge ry and anesthesiology p rog ress in othe r p rofessions has also played an impo rtant role in orthope­ dics. One good example is metallu rgy, with the p roduction of various new alloys, with special mechanical p rope rties, which have re­ sulted in the manufactu ring of app rop riately shaped endop rostheses and implants of excel­ lent quality which g reatly p romote successful surge ry. The re have simila rly been g reat develop­ ments in the field of tissue adaptive plastic mate rials, whe re the new techniques have rad­ ically changed the system of traditional limb- replacing p rostheses.

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3

Following the discove ry of x- rays and the int roduction of radiology, which was a revo­ lutiona ry step in o rthopedic diagnostics, the cu rrently applied imaging p rocedu res also re­ flect impo rtant imp rovements both in the di­ agnostics as well as in the surgical t reatment. The int roduction of a rth roscopic diagnos­ tics and su rge ry too has also resulted in revo­ lutiona ry changes in o rthopedics. O rthopedic activity sta rted in Hunga ry ve ry early. Some 50 yea rs afte r the establish­ ment of the fi rst o rthopedic institution in Switze rland by Venel, Agoston Schopj Merei founded a p rivate "Pesti Orthopedical P rivate Institute" in 1 836 . Modem su rgical o rthopedics was int ro­ duced by Gyula Dollinger. In a textbook pub­ lished in 1 942 J Kopits states that "the p res­ ent gene ration of physicians owe thei r thanks to Dollinger fo r thei r o rthopedic knowledge". A definite change was the inclusion of o r­ thopedics into the cu rriculum of the medical school, when the O rthopedic Clinic of Buda­ pest Unive rsity was established in 1 95 1 . The subj ect of o rthopedics being desc ribed b riefly as the specialty of medicine dealing with p re­ vention , t reatment and resea rch of diseases of the musculoskeletal system. In Hunga ry, simila rly as in Ge rman­ speaking a rea t raumatology and o rthopedics sepa rated from gene ral su rge ry, which was in cont rast with the situation elsewhe re in Eu­ rope. T raumatology deals with acute inj u ries, including polyt rauma, while o rthopedics t reats post-t raumatic conditions, axial defo r­ mities, congenital and inhe rited systemic bone diseases, limb developmental deficien­ cies, inflammato ry diseases of bones and joints, musculoskeletal tumo rs, etc . Natu rally howeve r, the re a re conside rable ove rlaps in the activities of these two p rofessions. Finan­ cial conside rations and effo rts to confo rm to the p ractice in Eu ropean Union will ce rtainly result in common t raining and ultimately the union of the two specialties.

Zo lta n Cse r n a t o n y

2.

Structure and development of bones

2.1. Structure of bones The bones have a numbe r of functions : they suppo rt the body, thei r rigidity playing role in maintaining the shape of the body. They fo rm the joints with thei r ca rtilaginous ends, the j oints a re fixed by ligaments. They se rve as leve r a rms around joints; the j ointed bones are moved and at the same time stabi­ lized by the muscles via the tendons . They p rotect vital o rgans and include a significant part of the hemopoetic system. Finally they are impo rtant as mine ral rese rves in the cal­ cium and phospho rus metabolisms of the o r­ ganism. Summa ry: the bones play p rotective, mechanical and metabolic roles in the body.

2.1.1. The composition of bone Chemically all bones have almost identi­ cal composition. Roughly 1 13 of the adult bone consists of wate r. D ry matte r content of 1

----

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2 3

fat free bone tissue contains 65% ino rganic mate rial (mainly hydroxyapatite), while 3 5 % i s o rganic (chiefly collagen). The bones ac­ counts fo r holds about 99% of the calcium content of the body.

2. 1.2. The bone tissue Histologically bone is st ructu red by cells and a mat rix. The cells which comp rise 1 -5% of the ove rall mass a re responsible fo r the bio­ logical p rope rties, the mat rix accounting fo r the mechanical p rope rties. The inte rcellula r mat rix, and specifically the osteons equips the adult bone with excellent mechanical quali­ ties. Mac roscopically the bone tissue can fo rm compact (substantia compacta) o r spongious (substantia spongiosa or cancellous) mate ri­ als. Since the compact fo rm mainly c reates the co rtex of the bones, it is often refe rred to as co rtical.

7

8 9 10

4 -kmf:l���

5 --III-'IIII+H" 6 ----+'!I-I...u

Fig. 2.1. Histological structure of human bone

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1 central canal

2 central canal

3 Havers- lamella

4 vessels and nerves

5 6 7 8

osteocyte Volkmann-canal basic lamella cemen- line 9 Havers-canal 10 connecting lamella 11 bone trabecules

6

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2 . St r u ct u re a n d d eve l o p m e n t of b o n e s

The basic s truc tural elemen t of subs tan tia compac ta is the o s teon (Havers sys tem). This is a thick-walled tube tha t includes a narrow canal con taining, concen tric pipes 5 - 1 0 �m thick (Fig. 2 . 1 .) . Small plum- s tone-shaped holes loca ted sparsely in the walls of the os teons serve to accommoda te the real bone cells ( o s teocy te). These holes are connec ted via Volkmann canals, which are no t sur­ rounded by lamellar sys tems. The lamellae tha t form the wall of the os teons con tain colla­ gen fibers, which may be loca ted longi tudi­ nally, crosswise or in spirals. Calcium crys tals are connec ted to the collagen fibers, the orien­ ta tion of the collagen fundamen tally de ter­ mining the loca tion of the crys tals. The irreg-

1 2.......:: 3

4

9

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ular spaces be tween the "comple te" osteons are filled wi th the remnan ts of os teons . One of the mos t importan t phenomena ex­ hibi ted by bones is their permanen t res truc tur­ ing. In 1 year 5 - 1 0% of the os teons, and up to 20% of the cancellous bone in adul ts undergo res truc turing. Cancellous bone does no t display os teon s truc turing: i t con tains fine lamellae and tubes enclosing a complica ted cavi ty sys tem. The s truc ture of bone is perfec tly adap ted for i ts role in the body. The alignmen t and spi­ raling of the os teons ma tch the main load-bearing lines of the bone, they ru n ap­ proxima tely parallel to the longi tudinal axes of the bones.

tl'-'ori �§&7� 10

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11 12 13

1 .... 1

5

14

15

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6 7 8

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16 17 \

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Fig. 2.2. Structu re of a long tubular bone (femur)

18

1 epiphysis

2 physis (growth plate)

3 4 5 6

apophysis metaphysis diaphysis metaphysis

7 physis 8 epiphysis 9 joint ca rtilage 10 spongiosa (cancellous bone) 1 1 periost 12 cortical bone 13 vessel 14 med ullar cavity 15 periost 16 nerve 17 vessel 18 joint cartilage

2 . St r u c t u r e a n d d eve l o p m e n t of b o n e s

2.1.3. Bones as organs The bones are built up of bone tissue con­ taining cancellous and compact bone in vari­ ous distributions and with complicated geom­ etry. Morphologically we may distinguish flat, cubic, cavital, short and long tubular bones. As regards their function we may refer to permanent load-bearing (the lower limbs and the spine), occasional load-bearing (the upper limbs) and non-load bearing (the facial skull) bones. The nomenclature of the tubular bones is based on the growth plate, the physis (phyestar to grow, Gr). The part between two physes is the diaphysis, the part in the vi­ cinity of physis is the metaphysis, and the ends form the epiphyses. The protruded bone - ends that have their own growing plate and serve for the origin and attachment of muscles are the apophyses (Fig. 2.2). =

2.1.4. The development and g rowth of bones Development of bones starts from the em­ bryonic connective tissue, the mesenchyma when the embryo is 2 months old. This pro­ cess requires a good supply of blood and oxy­ gen. There are three different developmental histological forms depending on the mechani­ cal environment: I. Desmal ossification

In locations subj ected to pulling forces a preliminary ossifying focus is created con­ taining connective fibers. The ossification starts from the so called ossification centers. 2. Chondral ossification

In locations subjected to compressive forces, a preliminary focus is created that con­ tains cartilage, which is a rough miniature replica ofthe final bone. The vessels enter this cartilaginous tissue and trigger the ossifica­ tion process via osteoblasts.

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7

3. Primary angiogenic ossification

This process occurs in areas lacking me­ chanical forces. It is characteristic for in­ stance, in the spaces between the skull bones. No precursor tissues are present, the bony de­ velopment starts with the invasion of vessels. In the growth plate in the vicinity of the end of the bone, the cartilaginous cells prolif­ erate, and on the opposite side the chondral ossification process continuously progresses. By the end of the growth the growth plates are ossified and closed. The whole procedure is regulated by hormones. The bones thicken by transversal growth. In the inner, cambium layer of periosteum covering the bone, bony apposition progresses via osteoblasts, while at the inner surface of the tubular bone the osteoclast activity leads to bone resorption. This is the reason why the proportions of tu­ bular bone are protected during the growing period (see Chapter 1 2. ) .

2.2. Biological adaptation of bones The composition, histological structure and shape of the bones are influenced not only genetically, but also by various mechanical factors . As living tissue, bone responds to chang­ ing external circumstances, and especially to compression and traction forces with perma­ nent restructuring, i.e. remodeling. For opti­ mal load distribution the bony trabeculae thicken so as to correspond to the compres­ sion - traction force alignments creating the traj ection lines. In this way, minimal material is required for the maximal bearing force. If the alignment of the load changes, e.g. in cases of different collodiaphyseal angles of the femoral bone, then the traj ection lines of the bony trabeculae also change (Fig. 2.3. a-b). As Julius Wolfformulated in his law: "The persistence or transformation of the shape of the skeleton is influenced by the forces acting on the bone." In other words : remodeling ad­ aptation of bone allows the musculoskeletal

8

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2 . St r u ct u re a n d d e ve l o p m e n t of b o n e s

system to adjust most appropriately to re­ peated utilization (Fig. 2.4. a-c. ) . The law of Jansen states that "The sensi­ tivity of the organism to external stimuli is proportional to the intensity of growth". As concerns the musculoskeletal system this means, that in response to a certain degree of

a

b

a

b

c

Fig. 2.4. Fig. 2.3. Traction and compression trajection lines in the fem­ oral neck. a. Normal trajection lines in the normal hip joint. b. Alteration of trajection lines in a subluxated, valgus femoral neck.

a. Lytic bone destruction in the calcaneus of an 8-year-old boy (arrows). b. Following cu rettage the cavity was filled with ho­ mologous bone chips. c. After 3 years, full restructuring and remodeling is apparent: a normal trajection bone structure match­ ing the loading conditions has been restored.

2 . St r u ct u re a n d d eve l o p m e nt of b o n e s

damage, the younger the organism, the more severe the deformity. At the same time the re­ generative capacity is larger. The law of Roux pronounces : "The ade­ quate stimulus for bone formation is the pres­ sure". This law is supplemented with impor­ tant elements by the law of Schultz-Arndt: "Small stimuli increase the living processes, large ones decrease them and huge ones ter­ minate them". This may be illustrated by the behavior of hyaline cartilage cells: their me­ tabolism increases during a normal cyclic load, but increase of the load above a certain limit results in the demise of the cells. According to the law of Pommer-Braus: "Bone is mechanically firm, but physiologi­ cally plastic". This is of significance in the pathophysiology of fractures (see Chapter

3 . l ).

These laws provide phenomenological de­ scription of the biomechanical responses of the skeletal system to certain stimuli (hor­ mones, injuries and loading). The background of the phenomena at a cell - tissue level in­ volves the mechanism of the internal or struc­ tural remodeling. The main point is that the

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UV- beam

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vit. D

Ag. 2.S. Regu lation of the ca lcium metabolism

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9

transformation of bones is effected by activa­ tion - resorption - formation.

2.3. Hormones reg u lating the bone metabolism A number of hormones and vitamins helps in regulate the bone and calcium metabolisms (Fig. 2.5.). Parathormone (in the parathyroid gland) increases the calcium resorption and phos­ phate excretion in the kidney. It enhances the osteoclast activity in the bones. It indirectly supports calcium absorption in the gastroin­ testinal tract. All these effects result in an in­ creased serum calcium level and a decreased serum phosphate level. Pathologically high parathormone levels cause transformation of the bone, creating cystic lesions (osteo­ dystrophia fibrosa cystic a generalisata von Recklinghausen 's disease, see Chapter 1 4.). Calcitonin (in the thyroid gland C cells) is an antagonist of parathormone. It inhibits the activity of osteoclasts, increases the number -

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ACTH

STH

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2. S t r u ct u re a n d d eve l o p m e n t of b o n e s

and function of osteoblasts, which results i n a decreased serum calcium level. The secretion of this hormone is regulated by the serum cal­ cium level. Its effects described above and its pain-killing action is utilized in the therapy of osteoporosis. Somatotropic hormone (STH, in the ante­ rior pituitary lobe) is responsible for the growth of the bones, until the epiphyses are closed. Its elevated secretion (pituitary adenoma) before the closure of the growth plates causes gigantism; after that period it causes extensive thickening of the bones and overgrowth of the acral areas (acromegaly). Sex hormones, such as testosterone play im­ portant roles in the increased growth during puberty; in this period changes in the propor­ tions of the somatotropic and sex hormones are manifested in a characteristic condition: slipped capital epiphysis, epiphyseolysis capitis femoris (see chapter 2 8 . 1 ). The de­ creased estrogen secretion in women in the postmenopausal period results in osteoporo­ sis.

An elevated adrenocorticotropic hormone (ACTH) secretion stimulates the function of the adrenal cortex, leading to a calcium defi­ cit. The increased secretion (or therapeutic ap­ plication) of corticosteroids also results in a decrease in bone mass, since it inhibits the ab­ sorption of calcium in the bowels, increases the secretion of calcium in the kidney and ends in secondary hyperparathyroidism. High dose steroid administration inhibits osteoblast activity. Active metabolites of vitamin D (e.g. 1 -25-dihydroxy-vitamin D) increase the ab­ sorption of calcium and phosphate both in the kidney and in the bowels. They mobilize the calcium ions in the bone and inhibit the secre­ tion of parathormone in the parathyroid gland. Overall vitamin D participates in bone forma­ tion, and it is therefore a basic drug in osteo­ porosis. Vitamin is of significance in collagen synthesis. A deficiency of vitamin C causes pathological disturbances in osteoid forma­ tion.

3.

Mi kl6s Szen d r6i

Bone healing after various types of fractures

3. 1. Traumatic fractu res In the event of a sufficient degree of trauma, when the stress on a bone exceeds its strength, the continuity of the bone sub­ stance is interrupted and a fracture occurs.

Etiopathology. There are many classifi � a­ tions for fractures. From the aspect of the sIte of action of the force, the fracture is said to be direct if it occurs at the site of stress; and indi­ rect if it occurs at some distance from the site of the stress. As concerns the pathomechanism, we dis­ tinguish bending, torsion, compression, sn:ain and stress fractures. Bone is weakest agamst torsional stresses, followed by distraction and compression forces. Special fracture types in children are epiphyseal plate fractures and plastic deformities. This involves bending of the long bones, mostly the fibula and the ulna, which often accompanies the greenstick frac­ tures of the tibia and the radius. Fractures can be classified according to the shape and the direction of the fracture li!le: transverse fractures, oblique fractures, spIral fractures, longitudinal, Y-shaped, fragmented and comminuted fractures. The patient' s history is usually typical permits conclusions concerning the direction of the stress, the shape of the fracture and the possible accompanying injuries. Clinical features. Definitive signs are the deformity of the limb with crepitus and patho­ logical mobility at the site of the frac �re. !he presence of pain, hematoma and an Impaired function (e.g. the patient is unable to put

weight on hislher leg) are features leading to the suspicion of a fracture. Radiological findings. Anteroposterior and lateral radiographs reveal the discontinu­ ity of the bone with or without displacement. The lesion is called a fissure if there is a frac­ ture gap in only one of the cortices. In some cases, if several bones are proj ected onto each other (pelvis, shoulder girdle, spinal facets, etc.), a eT-scan is required. If a ligament le­ sion is suspected, an MRI is required. Treatment. The earliest possible and pre­ cise reduction and fixation of the fracture is important for reestablishment of the circ� la­ tion of the soft tissues. The type of fixatlOn can be external (casting with plaster of Paris, or use of an external fixateur) or internal : ei­ ther on the surface or in the medullary canal of the bone. There are three categories of fixa­ tion stability: I . positional stability (pinning or plaster immobilization), 2. mobilization stability (the most types of plate fixation) and 3 . weigh-bearing stability (some intra­ medullary fixations) . In cases of rib fracture, chest bone fracture, clavicle and vertebral body fracture spontaneous healing may occur and stable fixation is not necessary.

3.2. Fract u re healing. Types and stages. Factors influencing fracture healing Fracture healing i s a complex process regu­ lated by neural and humoral factors.

12

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3 . B o n e hea l i n g aft e r v a r i o u s ty p e s o f fract u res

Direct bone healing (primary callus) develops if the fixation is stable (osteosynthesis with a plate or an intramed u l lary device), if the gap between the broken fragments is minimal and the fragments fit well with adequate compression, and if the blood supply is satis­ factory. Fracture healing is said to be indirect if the compression between the broken frag­ ments is low and it is the naturally developing callus which p rovides the stability (plaster im­ mobilization).

Stages of fracture healing (Fig. 3 . 1 .) :

� � �

Stage 1 : Hematoma / inflammatory phase. Bleeding from the injured longitudinal endosteal and periosteal vessels leads to a hematoma. Stage 2 : Subperiostal-endosteal cell pro­ liferation. An intercellular matrix is formed, which is mostly composed of fibrous-like tis­ sue, but immature cartilage may also be pres­ ent. This matrix surrounds the broken frag­ ments . Stage 3 : Callus formation. Stem cells transform to osteoblasts, osteoclasts and chondroblasts which participate in the forma-

1 3

��p:" �J : "'::>Siri a::2'§ id eC �Q�

�

stage 1: 2: periosteum

1: muscle

3: fracture-hematoma 4: medullar cavity 5: cortical bone 6: necrotic dead bone b:

stage 2:

1: fracture hematoma

2: subperiosteal cel l proliferation

3: endosteal cell proliferation c:

3

b

stage 3:

1: net- like new bone formation

2: subperiosteal cell proliferation

3: fracture hematoma d:

b:��

00 0 0 0 c

a:

2

<:'0 ",;",: .;-" 0 >�01

� ""

1, 3: net- like new bone

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3

1

11!L: ,0

Fig. 3.1. Stages of fracture healing

stage 4:

4

2: lamellar bone

e:

4: bone marrow stage 5: 1: recanalisation of intramedullary canal

3 . B o n e he a l i n g aft e r va r i o u s ty p e s of f r a ct u r e s

tion o f immature net-like bony tissue. The cal­ cium salt content increases at this site and this will be able to fix the broken bones; it also gives X-ray signs. Stage 4 : Consolidation. The net-like bony tissue transforms to mature bone tissue due to the activity of the osteoblasts. Stage 5 : Remodellation. The spindle shaped callus fills the intramedullary canal and the gap between the broken fragments. A huge callus develops in children, or if the gap is wide, or if there is marked displacement or if the fixation is insufficient and micromo­ tions occur. The remodellation of the callus starts soon, but its duration can vary widely; this process sometimes takes years. The healing of osteotomies or other pro­ cesses on the bones is equivalent to primary bone healing since the internal fixation is usu­ ally stable. In certain cases external fixation is applied. Post-traumatic growth disturbances are common in children. Overgrowth of the af­ fected bone is often seen, due to the stimulat­ ing effect of a trauma or fracture on the neigh­ boring growth plates. If the blood supply of the growth plate is impaired (a trans­ epiphyseal fracture, a slipped epiphysis, sep­ tic conditions affecting the growth plate, etc.) shortening of the affected bone may occur. The younger the patient, the more significant the expected limb length discrepancy. The remodellation of post-traumatic bony deformities is typically seen in children. Axis deviations and rotational deformities may im­ prove within certain limits . The younger the child the greater the remodelling capacity. This usually happens during the first two years following fracture healing. After pu­ berty (at the age of 1 0- 1 1 in girls, or 1 2- 1 3 in boys) significant remodelling is usually not expected.

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13

3.3 Pathological fracture healing. Pseudo-arthrosis The d uration of fracture healing depends on factors such as the bone type, the fracture site within the bone (metaphysis or diaphysis), the type of fracture, the age and the general condition of the patient. Long bones heal within 2-4 weeks in infants, within 4-6 weeks in children but only within 8- 12 weeks in adults.

The healing of cancellous bone fractures (in the metaphyseal area) is quicker and better since the spongy bone structure provides a greater surface and quicker penetration for the immature cells and tissue elements of the early callus.

a

b

Fig. 3.2. Hypertrophic (a) and atrophic (b) pseudo-arthrosis in the tibia

14

�

3 . B o n e he a l i n g aft e r v a r i o u s ty p e s of fract u res

If the duration ofthe bone healing is mark­ edly longer than the average duration of the given fracture type, delayed callus formation is the case. This is usually caused by unstable, insufficient fixation. P seudo-arthrosis (false joint) is the term used to describe the condition when after 8 months bony fusion has not occurred yet and the pathological movement between the bro­ ken fragments is still present. There is no osteogenetic activity between the fragments. The cause is commonly the instability, bu t pseudo-arthrosis may also develop because of mechanical factors, such as too rigid fixation, improper reduction or soft tissue between the fragments; or because of biological factors : impaired blood supply, septic condition, bone defects or non-vital bone fragments at the fracture site. Various types of pseudo-arthrosis may be distinguished: hyper trophic, atrophic and sep­ tic pseudo-arthrosis (Fig. 3.2.). The clinical features include pain, edema, swelling, pathological mobility (not in all cases) and inability to put weight on the af­ fected limb. Radiology. Hypertrophic pseudo-ar thro­ sis is characterized by the "elephant-leg" X-ray sign. The narrow gap between the bro­ ken fragments is filled with fibrous and carti­ lage tissue. In atrophic pseudo-arthrosis, the broken fragments are thin and round without any signs of bone formation. The circulation of the bones is insufficient. Treatment. This depends on the cause of the pseudo-arthrosis. The hypertrophic type is commonly caused by mechanical factors (in­ stability in most cases). Proper stabilization and compression usually leads to the fusion of the fracture. In the atrophic type stabilization alone is not sufficient. Surgical intervention is required. The fibrous tissue must be removed from the pseudo-arthrosis and autologous bone grafting is then necessary to increase the

osteogene tic capacity. Septic pseudo-arthro­ sis necessitates debridement and stabiliza tion.

3.4. Pathological fractures Pathological fractures occur in weakened bones or at the sites of bony lesions due to minor traumas.

Table 3.1. Common disorders leading to pathological fracture 1.

Generalized osteopenia

a. decreased levels of bone minerals b. endocrine disorders

osteoporosis osteomalacia hyperpa rathyreoidism Cushing's disease hyperthyroidism

c. metabolic disorders of Paget's disease the bone dystrophies osteogenesis imperfecta osteopetrosis hypophosphatasia renal osteodystrophy fibrous dysplasia (polyostotic form) d. medication influencing the bone metabolism 2.

steroids cytostatic drugs

Bone defects

a. tumor- li ke lesions

juvenile bone cyst aneurysmal bone cyst non-ossifying fibroma eosinophyl granuloma

b. benign bone tumors

enchondroma giant-cell tumor

c. malignant primary bone tumors

osteosarcoma (teleangiectatic type) Ewing's sarcoma

d. osteolytic bone metastases

renal carcinoma lung carcinoma

3 . B o n e hea l i n g aft e r v a r i o u s t y p e s of f r a ct u res

�

15

Etiopathology. Different causes of in­ creased bone fragility are listed in Table 3 . 1 . The status ofa threatening bonefracture i s the condition when a pathological fracture has not yet developed, but the quality of the bone and the extent of the lesion suggest that this will probably be the case after a minor trauma. The assessment of a threatening bone frac­ ture is not easy because of the considerable number of the influencing involved factors : Is the affected bone is a weight-bearing one or not; is the site of the defect central or cortical? What is the quality of the margin of the lesion, is there is a sclerotic border? Pathological fracture are threatening in the case of pure bone lesions; and in metastases, if these mea­ sure more than 2 . 5 cm or half of the diameter of the bone and are eccentrically localized in the cortex of a weight-bearing bone (Fig. 3.3. a, b). a

b

Clinical features. Sudden pain without adequate trauma. Crepitus and an inability to walk (if a lower limb is affected). Radiology. This depends on the etiology. Diffuse osteoporosis or osteopenia may be present in generalized bone diseases. Lytic bony lesions with fracture lines may be ob­ served in local processes.

Fig. 3.3. a) Metastasis in the right femur subtrochanteric area in a case with non-operable l u ng carcinoma. There is a lytic lesion in the lateral cortex (arrows), with a threatening fracture there. b. Status after intramedu llary nailing in order to pre­ vent the fracture.

Treatment. This depends on whether the fracture has occurred or threatening; whether the etiology is known or not. In case of a threatening fracture in generalized disorders, the choice of treatment is medication alone and elimination ofthe cause of the osteopenia. In local lytic bony lesions, a number of factors should be taken into consideration. In children, even in the case of huge cysts (juve­ nile bony cysts of the humerus) the fracture can be just a bony impression without any dis­ placement due to the thick periosteum. Thus, the treatment is immobilization of the arm in a Desault' s bandage (arm-to-body bandage) for a few weeks. After healing a decision must be made concerning aspiration of the cyst or open surgery and curettage. In fractures in­ volving cysts affecting the lower limbs

16

�

3 . B o n e h e a l i n g aft e r v a r i o u s t y p e s of fract u res

(weight-bearing bones) a fixation is necessary with respect to the growth plates. In solitary bone metastases, the lesion must be totally re­ moved and the defect should be repaired. In multiple lesions, even in threatening frac­ tures, palliation is required (fixation with intramedullary nails, plates, prostheses etc.).

3.5. Stress fractu res These are partial or com plete fractures due to chronic or repeated overloading of a bone. Synonyms: march fracture, fatigue fracture.

Etiopathology. The first reported cases related to soldiers, who had developed fatigue fractures in the metatarsal bones (march frac­ ture). Cases were then published which in-

Fig. 3.4.

Fatigue fracture in the 2nd metatarsal bone with a huge ca llus.

volved athletes following extreme physical activity : stress fractures. Sometimes it may occur after a single episode of overexertion (dancing, runni ng, trekking). In 95% of the cases observed fatigue fractures develop in the lower limbs or in the pelvis . They are most commonly in the tibia and in the metatarsal bones, and with somewhat lower frequency in the femoral neck and the pelvic bone. Clinical features. Severe pain is experi­ enced initially, possibly causing an inability to walk. The pain persist even at rest. In time the pain decreases spontaneously and the pa­ tient feel no pain during the normal daily ac­ tivity, but only in response to repeated exer­ cises. The symptoms may last for months. Radiology. A fissure is observed in the cortex in a typical case. Less frequently, a complete transverse fracture may be seen with some periosteal reaction and usually a huge callus formation (Fig. 3.4.). It is sometimes difficult to detect a fissure within the callus. A CT scan may be helpful. Treatment. In most cases conservative treatment leads to complete healing. Suspen­ sion of the sporting activity, administration of NSAIDs and rest are necessary. Immobiliza­ tion of the limb is sometimes unavoidable. Promising results have been reported from the application of low-intensity shock-wave ther­ apy. After healing, the patients are usually able to resume their previous sporting activity at the same level.

4.

Kata l i n Kol lo, Adam Mester, la mas Mesza ros

Examination methods in orthopedics

4.1. Case history (anamnesis) The examination of orthopedic patients al­ ways begins with the case history and a de­ tailed interview relating to the current com­ plaints. The family history. Information is sought from the patient or possibly the family mem­ bers as to the occurrence of any inherited dis­ ease in the family. This may be significant as a number of musculoskeletal disorders and dis­ eases are inherited, and even the process of in­ heritance is known. The patient' s personal history. In cases of children it is important to know if the mother or the embryo was exposed to any noxious effect during the pregnancy. Prema­ ture birth or any other problems during deliv­ ery could be an indication of perinatal nervous system damage. Other features that are possibly of impor­ tance are the birth weight and the times at which the various stages in the motion devel­ opment were attained, i.e. the sitting up, standing up and independent gait. In female patients the times of the starting and cessation of the monthly periods may be useful data in many in view the hormonal relation to the bone metabolism. As regards the diagnosis, the most signifi­ cant data are the current orthopedic com­ plaints and symptoms of the patient. It is im­ portant to learn the time of onset and circum­ stances of the current complaints of the pa­ tient. If the disorder has been present since birth, it is most likely a congenital problem. It is important to know, when the patient or the relatives first noticed the symptoms, for the

occurrence of many diseases is linked to a cer­ tain age (e.g. osteochondroses, some types of scoliosis), and it must be determined, if the ill­ ness is chronic or acute? It is of particular rele­ vance to explore the circumstances of the on­ set, e.g. does the patient associate hislher problems with a specific injury, sudden j erk or some other event? Although only a few or­ thopedic conditions can be associated with trauma, the overwhelming maj ority of pa­ tients consider some injury to be the start of and also the reason for their disease. As injury or overload can certainly mean initiation of the symptoms but without necessarily playing a decisive role in the illness. As an example, the pain caused by a bone tumor is often asso­ ciated by the patient with some trauma, sug­ gesting to the patient that this particular injury was the cause of the disease. It is important to learn, whether the patient has detected fever, shivers or other symptoms relating to inflammation. The sequence of on­ set of the symptoms furnishes a picture of the progress of the illness. Information must be obtained regarding the earlier operations and their effects that may be relevant to the pres­ ent disease, and also regarding the patient ' s opinion o f the success o r failure o f the opera­ tion. Complaints of orthopedic patients should be classified as follows : �

Deformity. This refers to an abnormal shape or size of the body or parts of the body. It results in complaints in the maj or­ ity of the cases, but it sometimes causes only esthetic, cosmetic problems . A high proportion of deformities develop during life (e.g. scoliosis, funnel chest), and

18

�

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4 . Exa m i n a t i o n m e t h o d s i n o rt h o p e d ic s

therefore it is important to learn the time of onset, which often differs from the time it is first observed. Parents often note only the increase in a deformity, which stresses the importance of screening tests for the early detection of deformities. Pain. A very significant symptom in the orthopedic diseases is the musculoskeletal pain. The patient seeks medical help because of the pain. Pain sensitivity is individual, and the intensity of pain is regulated by a number of factors. In infants and children, pain is manifested by the avoidance of using the given limb, i.e. restriction of movement. The pain is most often located in the affected part of the body. In other cases, e.g. in conditions relating to nerve compression, the pain is experienced distant from the pressure area, in the receptor zone of the sensitive nerve (referring pain) . The diseases of j oints, postural deformities of the feet may also cause pain which presents elsewhere (e.g. knee pain caused by osteoarthritis of the hip, femoral pain caused by flatfoot) . In a number of cases the patient senses the pain in one spot or one well-defined area, but in other cases the pain is diffuse, in some cases the location of the pain may change. Pain related to movement, weight-bearing is very likely to originate from the joints and to be of musculo­ skeletal origin, while pain independent from motion may accompany other diseases of bones. Pain related to j oint illnesses may be relieved or cease in a certain position (most often in the functional midposition) of the j oint, whereas the intensive pain of tension type related to inflammation or tumors of the bones are independent of the position of the body. The nature of the pain may be sharp, stabbing, dull, splitting or oftension type. If it is accompanied by paresthesia or other sensitivity changes, consideration should be given primarily to nerve pressure. A circulatory disturbance may be suspected if the above symptoms are accompanied by changes in color and

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temperature of the given part of the body or the limb. Swelling. Pain may draw the attention of the patient to the swelling of some body part, but the swelling may be painless. Pathological effusion in peripheral joints causes fusiform swelling of the area of the joint. It is important to determine if the swelling involves one or more joints. The quantity of joint fluid is usually well observed by the patient, who can give valuable information on this subject. The first symptom of malignant bone and soft tissue tumors is swelling, which is usually progressIve. Atrophy. When this arises, patient notices that one or more limb or part of a limb is becoming thinner. The reason for this is the atrophy of the musculature. It is necessary to establish, when this process started, how rapidly it has progressed and whether it is accompanied by a loss in strength. It is essential to differentiate between the situations when the patient noticed signs of paralysis (loss of function), or only muscle atrophy related to deficient activity (after plaster fixation, pain, joint contracture or ankylosis) . Restriction of range of motion. One very frequent complaint is when the patient feels that certain motions are restricted, or that certain movements have become impossible, or only with the help of supplemental motions. For instance the patient can no longer flex the elbow, and is therefore unable to reach his/her face, or can not move up or down to stairs, etc. Gait disturbances, limping. Diseases of the lower limbs can be accompanied by walking difficulties, which may be manifested by shortening of the walking distance and difficulties in climbing stairs. The patient explains those difficulties in terms of pain and fatigue experience during walking. It is important to know when the limping started. If the patient has limped since childhood, congenital or pediatric illness may be suspected; if the limping started only some days earlier, the

4 . Exa m i n a t i o n m e t h o d s i n o rt h o p e d i c s

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problem may b e acute. Patients often mention that they limp only occasionally, following long tiring walks . Limping is often noticed by the relatives, and not by the patient. A limb length difference causes comp­ laints almost exclusively in the lower limbs. Limb length difference occurring and progressing in childhood may reflect a growth deficit of the limb (or overgrowth of the other limb), but may also be considered joint contractures (especially in hip joints).

4.2. Examination For an accurate assessment of the condi­ tion of a patient it is essential to perform a full and detailed examination. Important observations can be made while the patient is undressing or dressing. It should be noted which movements are painful, ab­ normal, and how certain tasks are performed (e.g. compensatory motions during removal of stockings). The body height and weight are recorded in all cases. The examination is divided into the fol­ lowing phases.

4.2.1. Inspection The undressed patient is inspected from every direction while standing, and while walking, which provides information regard­ ing the patient' s constitution, the state of nourishment, and any visible shape changes and deformities. Even mild muscle atrophy or swellings should be subjected to careful ob­ servation. Thorough attention should be paid to the col or of the skin, changes in color (moles, brown spots, inflammation, redness, cyanotic color related to vein congestion, etc.), and visible changes in the superficial ve­ nous system (dilated, static veins) . Scars are to be explored with special care. Linear scars indicate cuts or surgical interventions. Wide,

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19

more or less retracted scars point to secondary wound healing, and comparatively long sup­ purative processes. Changes in the hair and nails are often helpful guides to find the right diagnosis.

4.2.2. Palpation The temperature of a given area may be felt by palpation. In this case the back of the hand is to be preferred as a receptor, since its heat perception is better than that of the palm. The examiner' s hand is placed lightly on the area to be examined and the temperature there is compared with that of the environment. When limbs are palpated, this test must be comparative. It is important to determine if a given area is painful or whether pain can be provoked by applying pressure. A cool or cold feeling of a limb or part of it may lead to the suspicion of a circulatory problem. Apart from the temperature, a wet (perspiration) or dry skin may also be of significance. The skin temperature is measured exactly with the ap­ propriate equipment. Palpation can give information on the state of the tissues, collection or loss of fluid. The palpation is initially performed lightly and su­ perficially to determine the state of the skin and subcutaneous tissue (fat) . During this ex­ amination the pathways of the superficial veins, the pulse of the arteries, and the re­ gional lymph glands are palpated. Nodules and glands palpable in the subcutis may draw the attention to benign fat lumps (lipomas), connective tissue lumps (fibromas) and lumps originating from the sheaths of peripheral nerves (neurofibromas) . It must be carefully observed if these lumps are painful. The muscles, tendons, deeply-located nerves, bones and joints are examined by stronger, deeper palpation. Palpation may fur­ nish information on the state of the muscles (flaccid, spastic). Myalgic nodules are often palpable in the substance of muscles the so called, and the region of origin of the muscles can also be painful. In case of inflammation the tendon sheaths are swollen and painful to

20

�

4. Exa m i n a t i o n m e t h o d s i n o rt h o p e d ics

pressure. Cartilaginous - bony apposlhons and tumors are characterized by being immo­ bile above the bony basement and are usually hard to palpation.

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4.2.3. Alignment, axial deformities of the limbs �

The alignment of limbs is observed by comparison in a neutral position. If the longitudinal axis of a distal part of a limb corresponds to the axis of the proximal axis, the classification is a 0 degree (normal) axis. The different situations are denoted by expressions as follows (Fig. 4. 1 .) :

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The extent of an axial deformity is charac­ terized by the angle of the axes. The measure­ ment is made during the physical examination of the patient, but accurate evaluation requires the use of x-ray films. The reasons for axial deviations are the curvature of the bones of the limb, or more rarely the deformity of the joint surfaces and loosening of the ligaments. The alignment of the lower limbs is deter­ mined in with the patient in a standing posi­ tion as well, and its extent is evaluated.

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\.

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valgus: the longitudinal axis of a distal part of a limb deviates laterally from the proximal part of the limb in the frontal plane. In the elbow and knee some degree of valgus is normal. varus: the longitudinal axis of a distal part of a limb deviates from the proximal part of the limb in the frontal plane, in the direction of the midline of the body. recurvated: the distal part of a limb deviates in the extensive extension direction (sagittal deformity). antecurvated: a sagittal deformity opposite to manner to recurvated one with anteriorly convex curvature of the limb; torsion (rotation) position: rotation of parts of limbs around the longitudinal axis.

4.2.4. Examination of the joints a

Before examination of the joints the broader area of the j oint is thoroughly in­ spected with respect to changes in shape, deformities, swelling.

b

Fig. 4.1. Genu valg u m (a), varum (b) and recu rvatu m (c)

O'

35-45�• .

45 :

a

Fig. 4.2.

� 5R: O'

.. .. . .. ..

,� ---

': � :�

( .

'\

. -*-, , , . . . . . .

�,. .45' ,,'

' .:.. ' b

2!2lS

60_80 : .

.

Flexion of the cervical spine, forward - backward (a), lateral (b) and rotation (c)

O'

...

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-

:

� ' , � , ' ... ,

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...

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-

. . . . 60-80 ·

4. Exa m i n a t i o n m e t h o d s in o rt h o p e d i c s

o·

o·

�,

30 .

3"

I. . � �

o. b

2"

· ·

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.

.

21

..

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:--;

30 · _40 ·

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a

Fig. 4.3. Forward flexion of the trunk, with hip flexion (a), backward flexion of the trunk (b), lateral flex ion of the trunk (c) and rotation (d) 150- 170 ·

o·

70·

b

o· 135 · _,, 40-60 ·

-- o ·

d

Fig. 4.4.

_0·

e

Abduction and elevation of the shoulder (a), external rotation over 90 degrees with rotation of the shoulder blade (b), Flexion and extension of the shou lder (c), flexion and extension in the horizontal plane (d). External and internal rotation in the neutral position of the shoulder (e) and i n 90 deg rees of abduction (f).

22

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4 . Exa m i n at i o n m e t h o d s i n o rt ho p e d i cs 90 °

_

- - -' -

0° 80- 9 0 °

10 °

80 -90 ° b

a

Fig. 4.5. Flexion and extension of the elbow (a), supination and pronation of forearm (b)

_

35 -60 °

0° 00 "

--- � \3

�: : : �- -- -- ��

..

'. ... ... - _ ...

... -

.

: : : ' 90 0

o·

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, 100 °

" 50 - 60 ° a

c

0°

3 0 - 40 °

25-30 :

b

c

Fig. 4.6. Extension and flexion of the wrist (a), u l na r and radial deviation (b). Flexion of the metacarpophalangeal and interphalangeal joints measured by angle and by the d istance of the fingertip (c)

4 . Exa m i n a t i o n m e t h o d s i n o rt h o p e d i c s

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23

130- 140 ·

�mn'.

o·

: ��

90 ·

o·

o·

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: :

,

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,

80 .

4 0 - 5 0 · ----....-,_____ 30-40 0 -'

30 - 45 ·

e

d

Fig. 4.7. Flexion and extension of the hip tested in the supine (a) and the lateral position (b). Abduction and add uction; in extension (c) and flexed to 90 degrees (d), external and internal rotation in extension (e) and flexed to 90 degrees (f).

• •

�ooO:

::

: : : : :::��

�- � �- �

_ - - - - 5 - 10 · _

....-0.

1 2 0 - 150 ·

Fig. 4.8.

Fig. 4.9.

Flexion and extension of the knee.

Flexion and extension of the a n kle.

Fluid collections in superficially located joints with a loose capsule may expand the capsule. Depending on the quantity fluid may be demonstrated in a j oint, if the examiner places both hands on the j oint, and exerts a sudden pressure is elicited with one hand. This causes any fluid present to flow in the di-

rection of the other hand which senses the flow. Ballottement of fluid accumulation in joints covered by thick musculature cannot be detected by this method. Bursae surrounding j oints, sometimes connected to their cavity may also be palpated in forms of various elastic lumps.

24

�

4. Exa m i n a t i o n m e t h o d s i n o rt h o p e d ics

"

0°

, "

a k-i

16 °

A

/1

'.

-;-Y ' a

:-';\ a 20 °


,1

35 ° .

0°

� a , ,

B

Rg7" 4.10.

Eversion and inversion of the foot (A), pronation and supination (8)

4.2.5. Range of motion of joints (ROM) The range of motion of a joint is described in the main planes of motion. First the passive movement is tested. This always starts with the examination of the symptomless joints in the opposite limb. Movement of the j oint may be painful. If so, it is important to record, which direction and which part ofthe ROM causes pain for the pa­ tient. Pain is most common at the endpoints of the range of motion, but it may be present throughout the entire motion. The patient re­ acts to pain elicited by motion with a defen­ sive muscle action. The ROM of a j oint motion may differ from individual to individual under normal circumstances. The ROM in children is gener­ ally larger than in adults . The outcome of the ROM test is evaluated relative to the normal values for the joints on the other side. The ROM is determined by the angle in the main motion planes assessed with a goniometer. The extent of the motion is re­ corded for the neutral (0 degree) system. The ROM of the spine and fingers can be ex­ pressed in centimeters . The ROMs of individ­ ual j oints are displayed on fig 4.2 to 4. 1 0. Ex-

tension in excess 0° can be denoted as hyperextension. ROM of a particular joint in a single plane may also be recorded by that starting at one end and passing through 0° to the other end, e.g. the abduction - adduction of the hip is 1 0° - 0° - 1 5 ° . A t the passive ROM o f a joint the values may differ from the normal (average) in two ways: - ROM exceeding the average - ROM decrease (contracture). When ROM is greater than the average, it is important to learn, if this is the case in every direction or only in one particular plane, and whether this phenomenon is present in one or more joints. If many j oint exhibit an excessive ROM, joint laxity is likely, which is often a symptom of connective tissue disease. If the direction or extent of motion is abnormal, this is called pathological movement. The etiol­ ogy usually involves tearing or stretching of the limiting ligaments. A joint ROM decrease (contracture) may occur in one or more direc­ tions of movement. The extent of the contracture is characterized by giving the two endpoints . E.g. if the elbow ROM in flexion ­ extension is 3 0- 1 50 degrees, this means that the extension is limited, lacking the range be-

4 . Exa m i n a t i o n m e t h o d s i n o rt h o p e d i c s

- - - - - - - - - - - - - - - - -

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25

her own muscula ture. I t is eviden t tha t the ac­ tive ROM can no t be larger than the passive one. I t is essen tial to observe any possible oc­ casional compensa tory or supplemen tary movemen ts. A reduc tion or to tal loss of ac tive mo tion is a consequence of weakness or lack of the func tion of the muscle(s). The ac tive move­ men t is evaluated to es tablish which func tions of the muscles are diminished or missing. Pain related to the func tion of the muscle (e.g. tenosynovi tis) may also cause a decline in the ac tive ROM.

4.2.6. Assessment of muscle power

Fig. 4.11. Thomas test to detect flex ion contracture of the hip.

tween 0-30 degrees. Since the mo tion of the forearm s tops in flexion, in this case the con­ di tion is called a flex ion con trac ture. If the flexion is limi ted, ex tension con trac ture is presen t. For the de tec tion of a flexion con trac ture of the hip, tes t technique of Thomas is employed. When maximal flexion is a ttained on the uninvolved side, the o ther thigh will lift up from the examining table. The angle mea­ sured from the plane of the table is the ex ten t of the hip flexion con trac ture (Fig. 4. 1 1 .). Accordingly the con trac tures by types are flexion, ex tension, abduc tion, adduc tion, ex­ ternal and in ternal ro ta tion con tractures. The causes of con trac tures : - scarring o f the skin, - cons tric tion, paralysis of muscles, - changes in the j oin t and capsule. A to tal loss of joint mo tion (ankylosis) de­ velops when a bony union or connec tive tis­ sue adhesion preven ts movemen t. In cases of ankylosis, the posi tion of the j oin t mus t be de­ termined. The ac tive mo tion of a join t is assessed to es tablish the ROM when the patien t uses his /

The power of synergic or individual mus­ cles may be classified by physical assessmen t. The muscle power is graded from 5 to 0:

5: normal power (full function even against g reat resistance), 4: muscle function only against limited resistance, 3: muscle function against the action of g ravity, 2: muscle function only in the absence of the action of g ravity, 1: only fibrillation is visible, 0: total paralysis.

Muscle func tion may be analyzed VIa elec tromyogram (EMG) assessmen t.

4.2.7. Assessment of muscle tone The resis tance of the muscle agains t pas­ sive s tre tching (muscle tone) may be normal (normo tonia), decreased (hypomyo tonia) or increased (hypermyo tonia). In flaccid myo tonia, s tre tching in the di­ rec tion opposi te to the muscle func tion is easy, in case of hypermyo tonia, i t is difficul t.

4.2.8. Limb length assessment The real leng th of a limb is agreed by con­ sensus to be the dis tance be tween the easily palpable bony elemen ts. Limb leng th mea-

26

�

4. Exa m i n a t i o n m e t h o d s i n o rt h o p e d ics •

\t

" " " " " " " " " " ,, , , , , , , , , , , , , , , ,

If J¥- �

: ' 15

cm

I--Q--\ j /�

T

---- - -------

Fig. 4.13. 25

cm

Fig. 4.12. Leg length measurement between the a nterior iliac spine and the inner - outer a n kle. Comparative measu rement of the circumference at identical dis­ tances from fixed points.

surements are performed with the limbs in ex­ tended position; or if this is impossible, the limbs are positioned symmetrically and the measurement is made by using intermediate points . The real length of up per limbs is measured between the acromion and the styloid process of the radius . The intermediate point may be the lateral epicondyle of the humerus. The real length of lower limbs is measured between the anterior iliac spine and the medial ankle . The intermediate point may be the me-

�

t

Apparent shortening and lengthening of the lower limbs.

Above: Abduction contracture of the right hip; when lower limbs are parallel, this limb will be longer. The child is compensating by bending the knee. Below: Adduction contracture in the right hip. When lower limbs are parallel, the right limb will be shorter. The child is compensating by bending the opposite knee.

dial epicondyle of the femur or the patella (Fig. 4.1 2.). Apparent shortening or lengthening is pri­ marily a sequel of joint contractures or of ankylosis of the lower limb joints . If the lower limbs are parallel, in case of adduction contracture of the hip the limb will be shorter, in the event of abduction contracture it will be longer (Fig. 4.1 3.). Functional shortening: series of shoe raises are placed under the patient' s footwear with the patient in standing position. The pa­ tient is then asked to indicate the height at which he/she feels that the limbs are of the same length and loaded equally. The length

4 . Exa m i n a t i o n m e t h o d s i n o rt h o p e d ics

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27

discrepancy detected in this manner i s called the functional shortening. This is the elevation is needed to correct the limb shortening (e.g. by wearing an orthopedic shoe), since the op­ timal limb function is ensured in this way. In cases of intact spine the functional shortening is 0,5- 1 ,5 cm less than the real or apparent shortening, this can be compensated by lateral compensatory curvature of the lumbar area.

4.2.9. Measurement of limb circu mference An important element in the patient as­ sessment is the objective circumference mea­ surement of limbs. Theoretical\y any part of the limb could be selected for comparative circumference measurements, however it is advised to perform this in accordance with an­ atomical parameters . Changes occurring in the substance of a muscle are best measured in the muscle belly area (the mid third of the arm, the proximal third ofthe forearm, 1 5 cm above the tip ofthe patel la, the proximal third of the calf, etc.). Joint circumference measured to evaluate the intra- and periarticular swellings . The results of circumference measure­ ments are recorded either as absolute values or as differences in cm-s, the site of the mea­ surement also being noted (e.g. 1 5 cm above the tip of patel\a). Since this assessment is comparative, it must be performed with the muscles in the same state of contraction, and in the identical section of the limbs (Fig. 4.12.).

4.3. The standing position and the gait 4.3. 1. Standing position In the standing position the body is sup­ ported by the lower limbs and is at apparent rest. The entire weight is loaded onto the sur­ face of the sole that is in contact with the ground. The support points of the feet, the

Fig. 4.14. S u pported areas of the feet.

soles and the surface between them form the support surface (Fig. 4.1 4.). The relatively stable position of the standing body is ensured by the musculature that is involved in support­ ing the posture. The loading line of the body then passes through the middle of the support surface. In a resting, balanced standing posi­ tion, the loading line is in the midline of the body; looking from the side, it runs from the middle of the ears through the shoulder, hip and knee j oints and reaches the supporting surface in front of the ankles (Fig. 4.1 5.). The muscular function ensures that the centers of gravity of given organs (partial centers of gravity) match the loading line. The center of gravity of the part of the body above the lower limbs (the head, the trunk, the upper limbs) is located in the lesser pelvis in front of the sec­ ond sacral vertebra. In various postures, the loading line re­ mains within the supporting surface, but is transferred anteriorly or posteriorly (Fig. 4.1 6.). In these positions the body is still bal­ anced, but maintenance of this balance re­ quires more extensive and intensive use of muscles compared to the normal, comfortable standing. The muscle power applied is dependent on the posture, e.g. a position of "military atten­ tion" requires about 20% more energy than

28

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4 . Exa m i n a t i o n m e t h o d s i n o rt h o p e d ics

Fig. 4.15. Loading line in the case of a balanced posture.

Fig. 4. 16. Changes in loading line in different postures.

the normal posture. A fully relaxed standing demands even 1 0% less energy, since the liga­ ments play a maj or part in maintaining the posture. During standing the neural system guides the posture and coordinates the muscle function. Important roles are played by the proprioceptive, vestibular and neck position­ ing reflexes and the optical information to­ gether with the extrapyramidal system.

4.3.2. Gait During walking, the entire body moves continuously forward through alternating mo­ tion of the lower limbs. The decisive element in the gait is the movement of the lower limbs, which is accompanied by the well-coor­ dinated motion of the trunk, upper limbs and head. These motions are characteristic of the

gait. It is possible to differentiate normal, esthetically spectacular, or special, abnormal, but still not pathological gait patterns. During walking the body is first displaced from its "stable" standing position, and then regains the lost balance, this process occurring repeat­ edly. The gait may therefore be defined as a process in which the balance of the body is lost and then regained. This is a cyclic process, certain phases fol­ lowing each other repeatedly in an identical fashion. This includes the repeated periodic motion of each individual limb and the coor­ dinated periodic motion of the two limbs to­ gether. In gait analysis, the basic unit is the in­ terval between identical positions. A step is taken to mean the period of motion of the limb from one heel strike till the next heel strike. The gait cycle is characterized by timing and length.

4 . Exa m i n a t i o n m e t h o d s i n o rt h o p e d i c s

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29

Phases of the gait The step is divided by definition into two phases: •

•

stance phase swing phase

The stance phase lasts from the moment the heel touches the ground until the foot lifts off the ground. The swing phase lasts from moment of the lift-off until the heel again co­ mes into contact with the ground. During walking at a comfortable pace 60% of the cy­ cle is in the stance, and 40% in the swing phase. The stance phase

In the stance phase, the body weight is loaded onto the supported limb, the trunk con­ tinuously progresses and the foot is supported on the ground (Fig. 4.1 7.). This phase can be divided into 3 stages : - heel strike : The hip is in flexion, the knee in extension, the ankle in plantar flexion. - rolling: Gradually the entire sole touches the ground, while the trunk is continuously progressing above the foot. As soon as the trunk overtakes the ankle j oint, the heel gradually lifts off the ground and the load is transferred to the anterior part of the foot. - lift-off: As the result of the active extension of the limb (this corresponds to the plantar flexion on the foot) the foot lifts off the ground.

Fig. 4.17. Process of the stance phase.

of the distal part ofthe limb the trunk proceeds continuously above the limb (Fig. 4.1 8.). The swing phase may be divided into two stages : - limb shortening, - limb lengthening. At the start of the swing phase, the limb is behind the trunk and swings forward due to the flexion motions of the limb. While passing below the trunk it gradually becomes longer due to the extension of the knee, and the foot goes into plantar flex ion and prepares for the heel strike.

Even before the heel strike a braking mus­ cle function is initiated, which increases from the moment of heel strike and lasts till the trunk reaches a position above the ankle joint. The swing phase

From the moment of lift-off the weight of the trunk is loaded onto the opposite limb and the swinging limb proceeds forward above the ground. Together with the sweeping motion

Fig. 4.18. Process of the swing phase.

30

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4 . Exa m i n at i o n m e t h o d s i n o rt h o p e d ics

Because of the differences in the time peri­ ods of stance and swing phases there are mo­ ments during the gait, when both limbs are supported: one is still standing, whereas the other already in the stance phase; this is re­ ferred to as a double stance. The gait is assessed both on flat surface and on stairs . If possible, the patient should walk without appliances (a stick or cane), so as to allow an assessment of the ability to walk without walking aids. At the beginning of the assessment, the pa­ tient walks at a spontaneous pace, and the character of the gait, the step length and the width of the gait are observed. It is important to assess if the nature of the gait is different during fast or slow walking, what new component appears in the motion. In cases involving a minor hip flexion contracture for example the patient is able to walk normally with short steps, but ifthe walk is accelerated and the increase in step length requires full extension, a marked limp may be detected. For the measurement of step length the pa­ tient walks steadily and slowly, and the dis­ tance between the sites of two heel strikes is determined on both sides. The absolute dis­ tance is validated, since the step length will obviously be identical bilaterally. To assess the motion of one lower limb relative to the other, the term step distance is used. To assess this, - while the patent is step­ ping forward in a standing position, the dis­ tance between the heels or the distance be­ tween the heel of the forward-stepping foot and the front point of the foot left behind should be determined. Assessment is carried out bilaterally. The result always refers to the foot positioned forward. The walking width is the distance between the paths of the two lower limbs. The distance between the points at which the heels hit the ground is used to measure this. Increased walking width improves the safety of walk­ ing, so it may be considered as an indicator of an imbalanced gait. A decreased walking width is not necessarily normal, in of bilateral adduction contracture of the hip the lower

limbs approach each other, and may even cross each other.

4.4. Limping When the gait is disturbed, so that the mo­ tion of the lower limbs is no longer sym­ metrical, or the motion cycles of the lower limbs differ, the patient is said to limp. The extent of a limp can vary from the barely no­ ticeable form to a severe gait disturbance. The reason for a limp may be: � �

�

�

�

pain, ROM restriction of the joints, weakness or loss of muscle power, limb shortening, joint instability.

A protective limp may occur if any joint or loaded area in a lower limb develops pain in response to loading or moving. It is a general feature of a protective limp that the stance phase becomes shorter on the affected side, as does the swing phase on the opposite side. Typically, the patient loads the involved limb in a protective constraint position (e.g. abduc­ ted hip). The shorter stance phase results in a decreased ROM of the joints. A restriction of a joint ROM results in a limp, if the ROM needed for gait is involved. A mild restriction of joint motion may not re­ sult in a limp during slow walking; the limp may be observed only during fast walking with long steps. The total loss of joint motion (ankylosis) always causes limp, the nature and extent of which are mainly dependent on which joint is involved (hip, knee, ankle, etc.) and in what position. A limp resulting from weakness or paraly­ sis of the muscle power originates from the impaired function of the muscles involved in the gait. If the abductor muscles of the hip j oint (m. gluteus medius and minimus) are un­ able to support the pelvis in stance phase, be­ cause of muscle weakness, the pelvis will sag

4 . Exa m i n a t i o n m e t h o d s i n o rt h o p e d ics

�

31

in other cases, musculoskeletal changes pro­ duce neurological symptoms. Sensitivity, reflexes and motor functions are routinely assessed. As regards the sensor function attention is paid to the differentiation of the segmental (dermatomes) and peripheral nerve-type sensitivity changes (see anatomy) . The assessment of motor function also re­ quires a knowledge of the segmental and pe­ ripheral nerve supply. The proprioceptive and foreign and vegetative reflexes are evaluated and interpreted too in the knowledge of the re­ flex arch. Special neurological examinations

In the diagnosis ofnerve and muscle disor­ ders assessment of the reactions to electrical stimuli is a basic procedure. �

Fig. 4.19. Loading force exerted on the hip, when the center of gravity is above the swinging limb (S center of gravity, T body weight, R load exerted on the femoral head, M abductor force). =

=

=

=

on the opposite side (Trendelenburg ' s sign, Fig. 4.19.). Shortening of a limb may also produce a limp, the extent of which is approximately proportional to the degree of shortening. Compensation of shortening is possible by lateral bending of the lumbar spine, with low­ ering of the pelvis on the side of the shorter lower limb and/or a flexion (equinus) position of the foot. In the event of joint instability a limp de­ velops since the support is insecure in the stance phase. Walking both up and down stairs must also to be observed, since the nec­ essary j oint motions and functions differ in these two cases.

4.5. Neurological examinations A number of orthopedic conditions are caused by neurological system impairments;

�

�

Electromyography (EMG): Qualitative analysis of the electrical activity yields information on the location (nerve or muscle) and type of the pathology. Electroneurography (ENG): Measure­ ment of the speed of conduction in peripheral nerves may be used to determine the location and type of the neural damage. Progression neurology: Early and repea­ ted special neurological examinations per­ mit the differentiation normal or impaired psycho-senso-motor development of the newboms and infants. Recognition of the early signs of damage of the neural system ensures a possibility for successful early complex support (motion and cognitive therapy) .

4.6. Laboratory tests Qualitative and quantitative changes in various blood components help to diagnose many orthopedic conditions. Acute inflam­ matory diseases increase the number of white blood cells (WEC), while chronic inflamma­ tion rather cause increase in the number of lymphocytes, the sedimentation rate increases

32

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4 . Exa m i n at i o n m e t h o d s i n o rt h o p e d ics

in both cases. Changes in the serum proteins components (gamma-globulin increase) can be precisely monitored by separating the pro­ tein fractions (electrophoresis). A greatly ele­ vated sedimentation rate without WBC in­ crease may signal a malignancy. C reactive protein (CRP) is a good monitor of inflamma­ tion. Streptococcus infection is accompanied by an increase in the level of anti-strepto­ lysine titer (AST) produced by the organism. In the diagnosis of rheumatoid arthritis, it is vital to find the rheuma factor (e.g. the latex test). Regarding serum electrolyte tests, the se­ rum Ca and P levels are the most common monitors, of the changes in the Ca and P me­ tabolism. This metabolism can be monitored only by means of lengthy loading tests, which reveal not only numerical changes, but also the uptake of Ca and P and their excretion in the urine. Of the enzyme tests increased level of alkalic phosphatase (related to osteolytic pro­ cesses), and increased creatine - phospho­ kinase level (progressive muscular dystro­ phy) are to be mentioned. An increased serum urate level is an im­ portant indicator in the diagnosis of gout. Apart from the basic urine tests, the detec­ tion of a number of materials characteristic of some metabolic disease can be of orthopedic significance (e.g. alkaptonuria, mucopoly­ saccharidoses ) . A n impaired neurohumoral regulation i s present i n some orthopedic conditions, and therefore special hormone tests are performed in these cases. Cerebrospinal fluid tests are needed for certain differential diagnoses, chiefly the cel­ lular elements, protein and sugar levels are tested. To clarify the nature of the disease, tests of the synovial fluid can be of great help. Normally, j oint drainage is clear, transparent, straw - yellow, mildly viscous fluid, with a low count of leukocytes and a low protein content. It may become bloody following a j oint injury, or a fracture of the epiphyses. It

becomes cloudy in purulent arthritis and the agent can be cultured from it. Cultures or animal inoculation can con­ firm tuberculotic arthritis. Bacteriological tests can identify the agent and its antibiotic sensitivity.

4.7. ArthroscoPl This is a diagnostic and therapeutic method; mainly the inner aspects of the wider-spaced joints are examined. Arthro­ scopy is used most often in connection with problems of the knee, and (in decreasing fre­ quency) the shoulder, hip elbow, ankle.

4.8. Histology tests If the tests mentioned above do not satis­ factorily clarify the nature of the changes causing the complaints of the patient, a speci­ men biopsied from the area in question is sub­ j ected to histological analysis. The specimen can be obtained via a small operation or by percutaneous trocar biopsy. Among others, histology is essential to decide if a tumor is malignant or benign (see also chapter 2 1 ) .

4.9. Imaging modalities 4.9.1. X-ray tests, special X-ray investigations Imaging procedures play extremely im­ portant roles in the diagnosis, and follow-up of various conditions and in the evaluation of the outcome of the treatment in orthopedics, in musculoskeletal diseases. At least one im­ aging procedure is utilized in 80-90% of the cases, and often a number of different types of tests are involved. A variety of imaging procedures have been developed to depict different normal or pathological conditions. The referring physi­ cian must be familiar with the possibilities to

4 . Exa m i n a t i o n m e t h o d s i n o rt h o p e d ics

request the test most appropriate for provision the most information. The sequence of tests should be planned with regard to the clinical picture and the diagnostic possibilities. In un­ certain cases, consultation with the radiologist should be initiated. It is customary to start with traditional x-ray. The use of imaging procedures is important from the aspect of ef­ ficacy, but the costs are far from negligible. Certain methods may subj ect the patient to a higher radiation load (e.g. CT), which can possibly be avoided or reduced by careful planning. The various imaging methods : �

�

Traditional x-ray examination : - Subjects : Bones, j oints : shape, Size, position, axis, - motion ! / fluoroscopy, functional films / - structure of the bones and extent of the pathology: - entire skeleton - one j oint or bone - one part of a bone Traditional x-ray test using contrast: - Arthrography, fistulography, angio­ graphy, an rarely lymphography.

�

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33

MRI (magnetic resonance image) : - detailed structure of soft tissues and the medullary cavity, vessel and nerve supply, refers to histological structure

Traditional x-ray examination is the first choice in musculoskeletal, orthopedic diseases. It frequently supplies sufficient in­ formation for the diagnosis, or determines the order and sequence of further tests. Even the negative result is important, since certain changes can be excluded. At least bidirectional views of the area in­ volved are needed (Fig 4.20.), so as to deter­ mine the position of the changes in 3 dimen­ sion. If this is not enough, supplementary views are used. To differentiate between mi­ nor pathologic and normal conditions, consid­ ering the nature of orthopedic diseases (limb length discrepancies or systemic illnesses), comparative views are necessary. The technical quality of the x-ray film is very important even in the simplest cases, so that certain changes are not overlooked. In musculoskeletal diseases functional views are a

b

The other imaging methods yield more in­ formation: �

ultrasonography: soft tissues, superficial bone surfaces, vessel supply

�

Isotope tests : bone scintigraphy, single photon emission computed tomography (SPECT), positron emission tomography (PET), rather function (osteoblast activity, blood supply, localization), than morphology, and are usually capable to reveal extremely early changes : e.g. the dissemination of diseases.

�

CT (computer tomography) : - Structure of bone and cortical de­ struction, the border of pathology, - shape and structure of soft tissues; - with the use of contrast material: vessel supply, CT myelography is possible 3 dimension image reconstruction

-

Fig. 4.20. a. Antero-posterior view of the left hip: THR in a good position b. The lateral view reveals, however, that the tip of the stem protrudes from the bone backwards.

34

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4 . Exa m i n at i o n m e t h o d s i n o rt h o p e d ics c

Fig. 4.21. Fu nctional image: 12-year old boy; anteflexion during standing (a), normal position during standing (b) and retroflexion (c) pictu re of lumbo-sacral area; spondylolisthesis at LV. vertebra. Slippage of LV. vertebra mea­ sured in various positions exceeds 5%, the spine is unstable.

often needed for the detection of spinal insta­ bility and the exact localization of joints in different ROM), and they are essential in the planning for corrective operations (Fig. 4.2 1 .) . Traditional fluoroscopy provides the only means of examining the position ofjoints and bones during motion in an unloaded or loaded state. Essential information can be ob­ tained by fluoroscopy from vague sublux­ ations, instability, mobile loose bodies of j oints, pseudoarthroses, and implants sus­ pected of loosening. In certain cases overlap­ ping areas and bones concealed by implanted metal ware can be simply differentiated, and their 3 dimensional location determined. Provocation tests may also to be employed: on application of pressure to the bone instabili­ ties can be visualized. In certain orthopedic conditions special films may be necessary both in children and adults (Fig. 4.22.). Tomography is used only exceptionally, when eT is not possible, e.g. ifthe presence of a large metal implant rules out a eT test. Traditional musculoskeletal x-ray tests involving the use of contrast medium : In the era of modem imaging techniques the signifi-

cance of these test has lessened, since direct and indirect eT and MR with contrast mate­ rial provide much more information, the pro­ cedures are simpler and complications arising

a

b

Fig. 4.22. Osteochondroma originating from the inner surface of the shoulder blade and progressing in the direc­ tion of the ribs. a. Conventional a-p x-ray examination leads to the suspicion of a calcified area i n the aspect of the scapula. b. In the projected x-ray examination of the scapula the attached osteochondroma is clearly visible.

4 . Exa m i n a t i o n m e t h o d s i n o rt h o p e d i c s

from the contrast material are less frequent. These tests are feasible, when the modem im­ aging procedures can not be performed, or are not available. Arthrography: This is used to detect bod­ ies of not-bony material in the j oints. Menis­ cus ruptures, labrum deformities, j oint cap­ sule tears, pathologic swellings and ruptures of joint cavities and bursae, synovial abnor­ malities and changes in the joint cartilage are well detectable. Fistulography: The draining sinus is filled with contrast medium. At present this is used only if the ultrasonography can not un­ ambiguously reveal the extent and shape of the sinus and its relation to the bone and j oint. Myelography: contrast injected into the liquor space to diagnose space reducing pro­ cesses of the spinal canal. In the presence of eT and MR it is used extremely rarely. Angiography : The blood vessels are visu­ alized using contrast medium. This is used only rarely as a diagnostic tool. Selective or super selective angiography is performed �s part of the therapy, e.g. in preparation for sur­ gery to stop the blood supply of tumors, in embolization, or to promote the application of

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35

drugs in limited areas (regional chemother­ apy). Lymphography: The lymph vessels are filled with contrast medium. This technique is out of date.

The clinical examinations lead to the con­ dition being classified into a certain group of diseases after which a decision is made as to the best choice of imaging procedures, and when and in what sequence they should be carried out.

4.9.2. Muscu loskeletal u ltrasonography: X-ray techniques only provide limited possibilities for the checks on soft tissues. The visualization of calcifications is convincing, and maj or soft tissue swellings can also be es­ timated, but the soft tissues investigations re­ quire ultrasonography. This method is highly dependent on the technique, and requires skill. It has the advantages that no ionizing ra­ diation is involved, it is simple and can be used repeatedly useable, and it can replace painful or costly examination (positioned x-ray test, MR). During motion, functional tests furnish additional information, similarly as for fluoroscopy during bone screening. Further ultrasound-guided interventions can be performed with high level of accuracy (e.g. biopsy). Besides 2D pictures with color-Doppler and power-Doppler tests the major and minor vessels, the circulation, and the curves of ves­ sels can also be detected. Frequent indications: �

Fig. 4.23. Ultrasonography image: Swelling of the dorsum of the foot in a 68 year old female. The tendon of extensor dig. longum muscle has already diminished (1,6 mm), and is surrou nded by fluid. Tendinitis, peritendinitis.

�

Trauma: partial or complete rupture of ligaments, tendons, muscles, and the possibility ofjoint instability; in children a slipped capital epiphysis, and the sus­ picion of greenstick fracture, blood collections following trauma. Suspected fluid accumulations: bursitis, tendonitis (Fig 4.23.), arthritis, purulent

36

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4. Exa m i n a t i o n m e t h o d s i n o rt h o p e d ics

Fig. 4.24. 3 phase bone scan (courtesy of dr. Gyorke). I n all three phases an increased isotope uptake is seen in the dis­ tal metaphysis of the right femur.

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Jomt inflammations, hemophilic bleed­ ings. Abscesses, sinuses, hematomas can be detected. Swellings, inflammations: these may be of various origins. Swelling can be caused by inflammation, a soft tissue tumor, or fluid collections. Information can be obtained on the vascularity, relation to large vessels and the environment of the latter. Available cartilage and bone surfaces : the thickness, structure, IllJunes of cartilage can be tested; loose bodies are generally detected. Hip j oint dysplasia and dislocation in infants can be diagnosed in age of 4-6 weeks. The efficacy of treat­ ment can also be tested. The available surfaces of bones, and possibly the thickenings of the periosteum may be visible (callus, bleeding, pus, tumor) .

�

Peripheral nerves can be located with high resolution equipment, these should be examined in tunnel syndromes or compression symptoms of other origin.

4.9.3. Isotope procedu res The most frequent isotope test procedure is bone scintigraphy (bone scan). The most frequently used radioactive materials are complex phosphate molecules. The efficacy of investigations of changes localized in a given region of the body can be greatly enhanced by three phased bone scinti­ graphy. In this procedure, during the intrave­ nous application of a radioactive phosphate complex the lesion in question is placed be­ low the center of the viewing field of the gamma camera, and serial exposures are made (Fig. 4.24.). In cases of osteomyelitis, arthri-

4 . Exa m i n a t i o n m e t h o d s i n o rt h o p e d i c s

tis, bone tumors containing hypervascularized areas and metastases this is the most sensitive procedure, facilitating an early diagnosis most effectively. The test is not specific for either malignancy or inflammation. It rather indi­ cates whether there are any bone changes or the number of sites at which changes are de­ tected (metastasis, polyarthritis). There may be a discordance between posi­ tive clinical signs and a negative bone scan morphological imaging result. In these cases bone marrow scintigraphy may be performed as a supplementary test. Isotope testing is common, but the PET (positron emission tomography) is not yet ev­ erywhere available in Hungary. Most often the 1 8fluoro-desoxy-glukose (FDG) PET is used, this is the only method that differenti­ ates between inflammation and a tumor in­ duced metabolism increase. PET : 1 8 F-timidin and l l C-timidin tests, can visualize DNA and the cell cycle, and have higher specificity.

4.9.4. Cl scanning The most appropriate of the many tech­ niques of computer tomography must be se­ lected in order to answer a particular clinical question. For a fast test (helical CT) so as to avoid dilution of the contrast medium in blood, high-contrast visualization of ves­ sel/not-vessel structures is necessary. For the more accurate imaging of morphological de­ tails slower but more extensive data collec­ tion, with pictures of very high quality

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37

Fig. 4.2S. HRG, high resolution G: osteochondritis dissecans

at the posterior joint su rface of the talus. The well visualized bone trabecu lar system and the dissected piece have not been displaced but are already de­ marcated by a semilunar sclerotic margin.

(HRCT: high-resolution CT) are required (Fig 4.25.). One of the most recent technical advances is the multislice MDCT (multi detector row CT). This system provides very fast imaging with extremely thin slices ( 1 mm) of very large body volumes. Diagnostic angiography can be avoided, because even the fine vessel structure in a tumor can be precisely visual­ ized. MDCT has restored arthrography to the arsenal of diagnostic tools. It has been intro­ duced in doubtful MRI cases as a supplemen­ tary test for the evaluation of intraarticular trauma cases (knee meniscus, shoulder labrum injuries).

Table 4.2. Signal intensities of different materials in MRI TI-weighted

T2-weighted

strong signal

no signal

strong signal

weak signal

fat

water

water

fat

Gd

air

air

calcium

calcium

iron

iron

no signal

Proton-density

Fat suppression

strong signal

weak signal

strong Signal

bound water

free water water fat

no signal fat

38

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4 . Exa m i n at i o n m e t h o d s i n o rt h o p e d i cs

4.9.5. MRI In the process of MRI, which depends on the traditional spin echo (SE) triggering and acquisition parameters the distribution and binding qualities of hydrogen are visualized via differences in signal intensity (Table 4.2.). Detailed additional measurements can be carried out by gradient echo (GRE) tech­ niques to evaluate cartilage material and the matrix. Sequences are included to separate the fat and water signals and to be able to decide if the vertebral lesion is caused by metastasis or osteoporosis (Fig. 4.26). MRI tests as well as CT examinations can involve the intravenous inj ection of contrast material. The faster measuring possibilities of modem MRI equipments have resulted in new advantages. During dynamic contrast exami­ nations many images are generated in one second, and records can be obtained from des­ ignated sites. This is mostly important in cases of recurrent or residual tumors.

The relations of bones, surrounding soft tissues and possible skip lesions can be visual­ ized in cases of known tumors . A knowledge of the involvement of major vessels, the subcutis and the skin is also essential. For the differential diagnosis of swollen lymph glands T2 contrast media have been devel­ oped. These contain USPIO: ultra small par­ ticle iron oxide, which accumulate in nor­ mal-structured lymph glands, but not in meta­ static lymph glands.

4.9.6. I nvasive and interventional radiology Angiography and angio-intervention

The traditional image intensifying catheter angiography has been replaced by MDCTA (multi detector CT angiography). The catheter introduced into any vessel is still used if it has a some therapeutic value. The ideal method of tissue sampling is open surgical biopsy. With the help of an im­ aging method (most frequently ultrasono-

Fig. 4.26. MRI image of increased T2 signaling from Ll II. vertebral body deformed because of foreign tissue (metasta­ sis).

4 . Exa m i n a t i o n m e t h o d s i n o rt h o p e d ics

graphy) fine needle aspiration biopsy (FNAB) can be performed, or a tissue cylinder can be obtained by means of thick needle (a core nee­ dle or a thru-cut biopsy). In special cases of pain-killing (anti­ inflammatory treatment by the means of intra-articular injections, imaging techniques may be required. An example is inflamed osteoarthritic changes in the facet j oints of spine, when an image intensifier and contrast material control may aid the accurate expo­ sure. An ultrasound guided percutaneous puncture may be utilized to administer local anti-inflammatory injections, or more re­ cently to treat a fresh rupture of Achilles ten­ don; for the repair of local wound, adhesives can be applied, so that open surgery may be avoided in lucky cases.

�

39

Vertebroplasty is a new, fashionable mo­ dality of intraosseal intervention performed with a thick needle. Under an image intensi­ fier the metastatic or osteoporotic compressed vertebral body is exposed from trans­ peduncular approach. A thick path is drilled and contrast material mixed with bone cement is inj ected slowly with a proper device under high pressure. Thermo-ablation procedures are thermo­ destructive procedures directed by imaging devices. The most frequent such procedure at present is for the treatment of osteoid osteoma. It is also used in cases of painful bone metastases. In non sequestrated disc pro­ lapses laser thermocoagulation of the nucleus pulposus is mainly dealt with by neurosur­ geons.

5.

Ta mas Mesza ros

Surgical therapy in orthopedics

Orthopedic disorders may be treated surgi­ cally or by conservative methods. The likeli­ hood of surgical interventions has increased in the recent decades due to new surgical pro­ cedures, and the advances in operative safety (antibiotics, developments in anesthesiology). However although operative procedures pre­ dominate, conservative methods remain im­ portant, and they are still used extensively. The surgical procedures applied in ortho­ pedics are classified into the following types:

5. 1. Muscle - tendon operations Tenotomies are performed to solve joint contractures caused by muscle shrinkage. The tendon of the muscle is lengthened in most cases by Z tenotomy : it is cut half longitudi­ nally, a the pathological state of the j oint is corrected, and the parts of the tendon are then united by stitches in the shifted position (Fig.

5.1.) . Following the operation a plaster cast is applied in the corrected position for 3 -4 weeks. Certain muscles having a large apo­ neurosis can be lengthened by incising trans­ versely the aponeurosis or in a V shape (m. gastocnemius, biceps femoris, semimembra­ nosus recession). Tenotomies are carried out most often from an open exposure (open tenotomy), but in selected cases a trans­ cutaneous procedure is done with special sharp device (tenotome) (subcutaneous tenotomy). The advantage of open tenotomy is that it is safe and the optimal extent oflength­ ening can be achieved. During the transposition of muscles (ten­ dons) different muscles are transferred so as to be able to replace the weakened or missing functions in their new position. It is most ap­ propriate to change the path of a muscle by re­ locating its attachment to ensure its altered function (Fig. 5.2.). Plaster casts are applied

1

a

b

c

Fig. 5.2.

Fig. S.l. Z-shaped tenotomy

Transfer of the tibialis anterior muscle to the second metatarsal bone: Dissected at its attachment (a), withdrawn to an incision of the leg (b), transferred to the basis of the second metatarsal bone (first cuniform) and fixed in a drilled hole (c).

42

�

5 . S u rg i c a l t h e ra p y i n o rt h o p e d ics

until appropriate firm reattachment (3 -4 weeks), though stimulation ofthe muscle may be started earlier. Early motion can avoid ad­ hesion of the transferred muscle. An injured or missing tendon can be replaced by a func­ tionally less significant tendon (e.g. m. palmaris longus) or a conserved tendon. Scarring and shrinking of tendon sheaths may hinder the muscle function, occasionally it may be painful, longitudinal incision or ex­ cision of the scarred part is therefore per­ formed. The free motion of the tendon is also en­ sured by early exercise.

5.2. Fascia surgery Scarring and shrinking of the superficial fascia obstructs the motion. Accordingly the incision of tense bands, and the partial or total excision of the shrunk part of the fascia is per­ formed.

5.3. Bone operations Operations on bones include the excision of exostoses or other bony parts (ostectomy), the removal of centers of inflammation or other types of pathologic changes (ex­ cochleation), and other routine interventions. In an osteotomy the bone is cut with a chisel or saw. The main aims are to correct de­ formities, to relieve pain in degenerative joint diseases and to correct joint instabilities. In corrective osteotomies, the required ax­ ial correction is achieved by removing a bone wedge of appropriate shape (Fig. 5.3). Osteo­ tomy is done linearly in a transverse or oblique direction, or arched depending to the aim and the location of the correction. Re­ garding to the direction of the correction, varus, valgus, rotation, flexion, extension osteotomies can be differentiated. Multidirec­ tional correction is also possible. Correction of limb length, with elongation or shortening, is also accomplished by osteotomies. Osteotomies performed for joint instabili­ ties have the aim of changing the shape and

depth of the articular cavity so as to improve the attachment and stability of the joint head (e.g. pelvis osteotomy in dysplastic hip joints) . If it is possible to ensure fast callus forma­ tion, the preferred site of osteotomies is the metaphyseal area; some other site is elected if the maximal deformity ( e.g. curve) is else­ where. After the osteotomy, the adequate ad­ aptation of the bone ends ensured over the largest possible surface and fixation is applied until callus formation has occurred. De­ pending on the location and type of the osteotomy the fixation may be internal or ex­ ternal or some combination of the two. Inter­ nal fixation is achieved with metal plates and screws and other special devices. These usu­ ally result in motion-stabile fixation (osteo­ synthesis), permitting early mobilization. An intramedullary nail provides loading-stabile fixation. External fixation can be achieved with plaster casts, occasionally plaster slabs or an external fixation device (fixateur externe). This is primarily indicated if fast callus for­ mation is expected at the site of osteotomy or if internal fixation would comprise an unac­ ceptably great intervention. External and internal fixation are applied in combination in cases where the fixation achieved is only motion-stabile, but the oper­ ated limb is to be loaded. Epiphyseodesis. The epiphysis can be fixed to the metaphysis by bridging the growth plate with a metal plate, metal nail, screw or staple. This can be used to inhibit the growth fully or asymmetrically.

_t_s 5.4. Operations on J_oo__in

__ _ _

The therapy may necessitate joint punc­ ture. Pain related to tension of the capsule can be relieved by the evacuation of collection in the joint and the damage to the hyaline carti­ lage can be prevented. Joint puncture is to be done in sterile and aseptic conditions simi­ larly to the operations . Arthroscopy can solve certain pathologic conditions of joints (e.g. removal of loose

5. S u rg i ca l t h e r a p y in o rt h o p e d ics

a

�

43

b

Fig. 5.3. Various forms of correction osteotomies and fixation with a compression device (a) and a self-compression plate (b).

bodies, meniscus removal). Other therapeutic uses are on the increase (cruciate replacement, acromioplasty) . Arthrolysis involves the release ofthe j oint from the adhered capsule or the division of fi­ brous adhesions, which can be performed by either arthrotomy or arthroscopy. Arthrotomy is the exposure of a j oint cav­ ity. It is employed as an independent modality

to remove loose bodies, but in fact it is the first phase of all joint explorations . Synovectomy is the partial or total exstirpation of the synovial layer of a j oint capsule. It is done to solve chronic inflamma­ tion of the synovial liner. Incision of the capsule (capsulotomy) is done if a joint capsule participates in the per­ sistence of a contracture. This intervention is

44

�

5 . S u r g i c a l t h e r a p y i n o rt h o p e d i c s

limited t o certain joints because of the risk of dislocation, or to only certain areas of j oints (e.g. to save the integrity of the collateral liga­ ments) . Reconstruction and plastic surgery ofjoint ligaments and capsule. In order to ensure the normal mechanism ofjoints occasionally with replacement by a tendon, reconstruction of elongated or tom ligaments or the capsule, or some other method may become necessary. Surgical repositioning. In cases of subluxation or dislocation, the joint reduction may be conducted with a visual check-up after exposure. To ensure the position, plasty of the extended capsule (narrowing, duplication) may be performed. A rthrorisis. The j oint ROM decrease by producing a bony bumper. A rthodesis. Joints are operatively stiffened to relieve pain, to correct a deformity or insta­ bility. The joint surfaces are flattened, and the limited painful motion is sacrificed in order to achieve a painless stiff joint which is func­ tional and can be loaded painlessly. Instability, luxation, subluxation can oc­ cur following damage to joint components or in diseases causing muscle paralysis. In such cases arthrodesis of the slack, malfunctioning joint(s) results in a functional improvement of the entire limb. This is rarely done because of the ever greater expensive use of arthroplasty. In developmental abnormalities and ac­ quired diseases of the spine, various extents of arthrodesis may be necessary (spinal fusion, spondylodesis). During arthrodesis the j oint is often exposed, hyaline is resected and the bony surfaces are matched and accurately fixed (intraarticular arthrodesis) (Fig. 5.4.). The bone ends are held in position by internal and external fixing methods until bony union has occurred (3-6 month). As a general rule arthrodesis is avoided in children, until the end of growth if possible since it disturbs the progression of the epiphyses. Great care must be taken as to the position of the joint, because a good limb function can be achieved only if the j oint is stiffened in the optimal position.

5.5. Arthroplastl'. This is an operation, in which joint surfaces, epiphyses are newly formed or replaced, or epiphyses are removed to improve the mo­ tions of a joint. The aim of the surgery may also be to decrease or eliminate pain.

Types: �

�

�

�

Plastic resection. Reshaping of the epi­ physes may result in a wider (perhaps slack) range of motion. An interposed flap between the epiphyses may improve the chances of pain-free motion. Resection of one epiphysis (e.g. resection of the head of the radius) may improve the joint movements (resection arthroplasty). Endoprostheses. The most up-to-date type of arthroplasty, ensuring the best function involves the insertion of endoprostheses, manufactured from tissue-friendly materials to replace a damaged j oint. In recent decades there has been an increase in the numbers of the orthopedic interventions happened specifically because of the endoprosthesis operations . Nowadays almost all of our joints can be replaced by endoprostheses. Endoprostheses made of various tissue­ friendly metals (various stainless steel alloys, titanium and alloys) have excellent static and dynamic load-bearing pro­ perties . Among the plastics, the ultra high polyethylene weight molecular (UHMWPE) has proved best and is used as an element of almost all endo­ prostheses. Its advantage is its elasticity, which ensures the elasticity of loading especially during walking in cases of lower limb endoprostheses. Its dis­ advantage is wear of the surface, since the worn particles induce the production of granulation tissue, bone resorption and ultimately loosening of the prosthesis. Bioceramics are excellent tissue-friendly materials with a high resistance to wear.

5. S u r g ica l t h e ra p y in o rt h o p e d ics

a

�

45

b

Fig. 5.4. Arthrodesis procedures. Knee (a), hindfoot (talocalcanear and Chopart) joint arthrodesis (b), external fixation, compression following knee arthrodesis (c), intraarticu lar hip arthrodesis fixed with 2 nails (d), ischiofemoral (Brittain-type) extraarticular hip arthrodesis (e).

�

They have the occasional disadvantage of breakage or cracking which limits their use. Different forms of endoprostheses have been designed for different types of the joint damage:

- Surface-replacing endoprostheses are employed when only the joint surface and the close surrounding area are damaged (e.g. cup prostheses). - Prostheses replacing the ends of bones are inserted in cases of extensive damage.

46

�

5 . S u rg i c a l t he r a py i n o rt h o p e d ics

- Tumor prostheses can be applied if tumors cause maj or damage in the bones of a joint.

There are a large number of variants of endoprostheses with particular areas of appli­ cation. Two basic types may be mentioned: - In hemiarthroplasty, when only one part of the j oint is replaced, whereas in total arthroplasty both joint surfaces are replaced. In orthopedic diseases total arthroplasty is usual. Total endopros­ theses should ensure an almost normal range of motion relative to the original joint, and in certain j oints the stability of the joint / limb. A suitable prosthesis is selected with the regard to the state of

Fig. 5.5. Hip prosthesis with smooth surface for cemented use.

the capsule, ligaments and stabilizing muscles. E.g. if the joint capsule and li­ gament system is damaged, joint movement and stability is achieved by limited (constrained) endoprosthesis. In other cases a free range endoprosthesis (of non-constrained type) is suitable to provide motion and stability. The endoprostheses must match the body and bone size of the patients. Accordingly se­ ries of each prosthesis type are available and the proper size is selected. Modular endoprostheses have recently become popu­ lar, where implants built up from optimally sized elements are inserted. It is extremely important, that the elements of the endoprostheses must be fixed firmly to the bone yet during the operation. The fixa­ tion method of the prostheses to the bones is extremely important, depending primarily on the type of the joint and the structure of the bone. The most common technique is the bone cement fixation (Fig. 5.5.). If the prosthesis has a special surface, cementless fixation is possible (Fig. 5.6.). The long-lasting stable fixation of cementless elements of prostheses is achieved by the new cancellous bone grow­ ing into the uneven surface of the prosthesis. This anchor is sometimes only partial, thus to

Fig. 5.6. Cementless hip replacement removed because of indifferent reason. The surface has a special, rough finish, the cancellous bone may grow in to provide secondary fixation for the prosthesis.

5. S u rg i ca l t h e r a p y in o rt h o p e d i c s

�

47

come depends considerably o n the state o f the muscles (contracture, motor power etc.) and on the postoperative motion. A late problem with endoprostheses is aseptic loosening, which can occur in some cases a few years after the operation. Bone re­ sorption may occur in the prosthesis - bone interface, when the prosthesis may work loose and elicit pain during walking. The partial or complete exchange of loos­ ened endoprostheses can usually be effected with special revision prostheses, occasionally supplemented by a bone transplant. If the in­ sertion of a new prosthesis is technically im­ possible, removal of the loose prosthesis re­ sults in a pseudoarticulation (Girdlestone ' s state), and the patient will b e ambulatory but will need a walking aid and his / her life style will be limited. Fig. 5.7. Cementless hip replacement with a hydroxyapatit surface.

improve the chances of fixation, various sur­ face designs and biologically active surfaces (e.g. hydroxyapatit) are used (Fig. 5.7.). Depending on the circumstances, there may be naturally a possibility to fix one element of the total prosthesis with cement, and insert the other element in a cementless manner (hybrid fixation) . Implantation of endoprostheses may allow pain-free joint motion, but the functional out-

5.6. Operation on nerves Decompression operations are done when the peripheral nerve becomes compressed, leading to pain, sensory or motor disturbance. In the most common situation the lumbar spi­ nal nerves are compressed at the spinal canal or at the foramen by a prolapsed intervertebral disc. Several peripheral sections of the nerves may be compressed by the stricture of muscle, fascia or bony tunnels (scarring, inflamma­ tion) or tumors. Denervation. An increased muscle tone and spasm may be lessened by transection of the motor nerve.

6.

Zo lta n Cse r n a t o n y

Conservative treatment procedures

In orthopedics, conservative and surgical treatment modalities are complementary. The bulk of conservative treatment is included in physiotherapy, that is the competence of physiotherapists. Some conservative methods however, belong among the activities of phy­ SIClans.

6. 1. Immobilization This may be required to alleviate pain, to cure infection processes, for the regeneration of tissues injured during operations or acci­ dents. Bed rest. This is the simplest way to achieve immobilization. A normal or hard bed is often satisfactory, but support of the limb involved (a pillow, Braun frame), use of a high or low headrest or neck support, or sup­ port of the dorsal or lumbar spine may be nec­ essary. For immobilization of the spine, plas­ ter bed may be used, which is a plaster shell fitted to the posterior trunk. Plaster slab. either the entire limb or part of it can be immobilized or fixed with a plaster slab. The advantages of this are, that it is ap­ plied immediately following a fracture or op­ eration, the circulation of the limb can be as­ sessed and the compression of the bandage can be lessened, the wound is visible and the limb can be cooled. Synthetic immobilizing slabs can be prepared or purchased for a simi­ lar purpose. Circular plaster. This provides more sta­ ble fixation than a plaster slab. Both its appli-

a

b

c

Fig. 6.1. Plaster cast for clubfoot in a baby: a felt band is at­ tached over the pressu re areas (a), the lower limb is covered with soft cotton (b), and a circular plaster is applied (c).

50

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6 . Co n s e rvat i v e t reat m e n t p roced u re s

cation and its use require great caution. The patient must be warned about the symptoms of compression (swelling, blue skin, pain, hypoesthesia) and its dangers (ischemic limb damages, pressure sores). After lengthy use, when the soft tissue swelling has subsided and inactivity muscle atrophy has set in, the circu­ lar plaster cast may become loose, and require replacement. It is very important is to protect the skin; insertion of felt over the areas sub­ j ected to pressure (Fig. 6. 1 . a-c) and the pad­ ding. Special immobilization. Depending on the body part and indication a number of ap­ pliances are used for full or partial immobili­ zation or support (Fig. 6.2.), which are dis­ cussed in detail in chap . 1 0. Traction (extension treatment). Relative immobilization can be accomplished by the traction of the limbs. In orthopedic traction,

a

b

mainly soft-tissue traction is employed, when the traction force necessary for immobiliza­ tion is applied via a rope fixed to the skin by a cuff or adhesive. This method solves cont­ ractures caused by increased muscle spasm, the musculature around inflamed painful hip and knee j oints can be relaxed. A common ap­ plication area is in the hip and knee osteo­ arthritis. In such cases traction with a weight of 2 kg is advised for 3 hours twice a day. The other large group involves skeletal traction, when a Kirschner wire is inserted into a certain bone (calcaneus, tibial tubercle, olecranon), and kept under tension by an ap­ propriate device. It has the advantages, that it does not harm the soft tissues and is more pre­ cise than the soft tissue traction (axis, angle, force). Disadvantage is that it is invasive, there is a risk of infection and extensive bed rest is necessary. It is used only rarely in or­ thopedic practice, chiefly as part of the preop­ erative preparations.

c

Fig. 6.2.

An air-cast fixation device, used to treat partially torn ligament in the ankle, permitting motion exclusively in the sagittal plane. a} Schematic drawing of a lateral ankle ligament tear. b} Pneu matic ankle cuff (air-cast), a-p view. c} Lateral view.

6 . Co n s e rv a t i v e t re a t m e n t p roced u re s

6.2. Mobilization In cases of restriction of the ROM of joints, when a muscular spasm or the fear of the patient maintains the restriction, mobiliza­ tion may be performed under general or local, regional anesthesia. If the restriction is arthrogenic, in selected cases the method of brisement force (forced mobilization) can be tried. This demands be done great care be­ cause of the risk of vascular or nerve injury or bone fracture.

�

51

Prevention of heterotopic ossification. Bone formation in the muscles or around the joints may occur following hip arthroplasty, or in hemiplegic patients following damage to the central nervous system. In high-risk pa­ tients a daily dose of 1 00 R to the areas in­ volved is advised for 3-5 days. In hip surgery the development of periarticular ossification can be effectively prevented by non-steroid anti-inflammatory drugs. Pain relief. The use of x-ray irradiation for this purpose is gradually decreasing. In case of osteoarthritis 50- 1 00 R may be indi­ cated.

6.3. Non-weight-bearing There are a number of illnesses and condi­ tions, in which full or partial non-weight­ bearing of the lower limbs or the spine is re­ quired. The lower limbs. To relieve the load-bear­ ing of the lower limbs during walking, appli­ ances can be worn on the body of the patient (a tuber supporting brace, condyle supporting orthesis) . Another method to relieve load bearing during walking is the use of walking aids (a walking frame, crutches, stick). The spine. Total immobilization of the spine can be achieved only by bed rest (if necessary, supplemented by longitudinal trac­ tion, a plaster bed, ortheses) .

6.4. Irradiation In orthopedic therapy x-ray irradiation is utilized for 3 purposes: Irradiation of malignant tumors (see chapter 2 1 ).

6.5. Laser therapy While high performance lasers of are of use in surgery, low performance lasers (soft lasers) are employed for their anti-in­ flammatory, pain-reducing and wound- heal­ ing effects. Their use is based on empirical knowledge; their mechanism of action has not been fully elucidated yet.

6.6. Pharmaceutical treatment Pharmaceutical treatment of value in or­ thopedic therapy for very different indica­ tions. Organotropic (directed to a certain or­ gan), etiotropic (directed to the etiology), lo­ cal, systemic, symptomatic and causative forms of pharmaceutical treatment are all used. Table 6.1. lists those drugs, which may be considered for the conservative treatment of orthopedic illnesses, according to their areas of indication.

VI N

Table 6.1. Drugs in orthopedic use

Effect group / Pharmaceutical group

.....

Products

Effect mechanism

Indication

lignocaine

Lidocain 1% inj.

bupivacaine

Marcain inj. Marcain spinal heavy inj. Bupivacain i nj.

reversibly blocking the stimulus conduction capabilities of the sensitive tissues (nerve fibers), so d isconnecting the pain

elimination tests, local anesthesia in surgery

Active agent

Drugs on peripheral nerves local anesthetics

vitamins

n o :::J VI III

:;;:

QJ ....

< III

....

ro

QJ ....

3 III :::J ....

articaine

Ultracain inj. Ultracain DS Forte

procaine

Procainium HCI 2% inj.

thiamine

Vitamin B1 inj., tabl. Milgamma N inj. Neurobion inj.

" "vitamine against neuritis , its active metabolite takes part in carbohydrate metabolism as a coenzyme

nerve damage and injury

guaifenesine

Relaxil-G inj.

tolperisone

Mydeton tab!., inj.

decrease the resting tone of striated musculature without considerable effect of its voluntary contraction

chloroxazon

Myoflexin tab!.

carisoprodol+ paracetamol

Scutamil C tab!.

conditions causing spastic tone increase of skeletal muscles (lumbago, contractu res, cramps, spasticity)

tizanidine

Sirdalud tab!.

baclofen

Baclofen tab!. Lioresal tabl.

"0

o

III c.. c n

ro VI

Muscle relaxants central activity (spinal chord)

'"

Drugs in orthopedic use

Effect group / Pharmaceutical group

peripheral activity

Active agent

Products

Effect mechanism

Indication

mivacurium

Mivacron i nj.

pipecuronium

Arduan porampulla

vecu ronium

Norcuron inj.

non depolarizing neuromuscular blockers, they competitively inhibit the effect of acethylcholine on the motor endplate

relaxation of the skeletal m uscles, general anesthesia, in cases of ventillation, intubation

rocuroniumbromid

Esmeron i nj.

succinylcholin

Succinyl-Asta inj. Pantolax i nj.

lasting depolarization of the motor end plate, so the stimuli can not reach the muscle

muscle relaxation in general a nesthesia, muscle relaxation, intubation

tramadol

Contramal i nj., caps. Adamol SR ret. caps. Tramalgic i nj., caps.

opiate receptor agonist acting centrally, moderate to severe acute or chronic pain but not narcotic

paracetamol

Benuron tab!. Mexalen tab!., supp. Panadol filmtab!. Rubophen tab!., supp.

prostaglandin inhibition by connecting to the cyclooxygenase enzyme

Non opiate pain killers

ibuprofen noraminofenazon

Nu rofen tab!. Advil tab!. Algopyrin tab!., i nj. Panalgorin tab!.

to relieve mild and moderate pain or fever

(j\ n o :::l Vl ID .... < Cl>

<' ID r+

ID Cl>

r+ ....

3 ID :::l

r+

r+

'0

o

ID c.. C .... ID n

Vl

..... V1 W

�

\J1

Table 6.1. Drugs in orthopedic use Effect group I Pharmaceutical group

Active agent

......

Products

Effect mechanism

Indication

ketoprophen

Fastum u ng. Profen id gel, tabl., caps.

flurbiprofen

Flugalin drg., kup

by attaching to the cyclogenase enzyme they inhibit the prostag landins (and this way the production of inflammation and pain mediators).

joint, tendon or muscle pain, inju ry, inflammation, prevention of periarticular ossification

ibuprofen

Solpaflex creme, tabl. Spedifen granu late

naproxen

Apra nax filmtabl. Naprosyn tabl., supp.

indometacin

I ndobene gel I ndometacinum caps., supp.

diclofenac

Catafla m tabl. Diclac gel Diclofenac Duo caps. Olfen gel Voltaren gel, tabl., supp.

methyl-salicylate

Gerosan ung.

piroxicam

Erazon gel Feldene gel, caps., supp. Hotemin creme, caps, inj., supp

phenylbutazon

Phenylbutazon creme Rheosolon tabl.

Anti-inflammatory drugs non-steroid anti-inflammatory d rugs (NSAID)

azapropazon

Prolixan caps., filmtabl.

niflumin acid

Donalgin caps.

flufenamin acid

Mobilisin creme

0\ n o :::J '" ro

<

DJ .....

< ro

.....

ro

DJ .....

3 ro :::J .....

1J

(3

ro c.. c n

ro '"

Table 6.1. Drugs in orthopedic use Effect group / Pharmaceutical group

Products

Effect mechanism

Indication

nimesulid

Mesulid tabl., granu lte

COX2 is inhibited in a great extent

RA, osteoarthritis

meloxicam

Movalis tabl., supp.

celecoxib

Celebrex caps.

COX2 is inhibited selectively i n therapeutic dose

betamethason

Celestone tabl., inj. Diprophos inj.

dexamethason

Oradexon tabl., inj.

methylpred nisolon

Medrol tabl. Depo-Med rol inj. Solu-Medrol inj. Metypred tabl., inj.

They inhibit the synthesis of prostanoids by blocking the transcription of phospholipase A2 gene, besides they directly inhibit the expression of COX2 . These are the most effective antiinflammatory drugs, they effect both the acute vascular, and cellular phase

pred nisolon

Rheosolon tabl. Pred nisolon tabl. Di-Adreson F Aquosum inj.

Active agent

--------

Anti-inflammatory drugs (cont.) selective COX2 inhibitors

steroids

triamcinolon

Kenalog i nj. Polcortolone tabl.

Rheu matoid diseases 0'1 n o :::J In ro

:;:

!l) ....

< ro

....

ro

!l) ....

3 ro :::J ....

----

'0 ""

Agents for improving viscosity hyaluron acid

Hyalgan inj. Fermathron inj. Synvisc i nj.

the viscosity of the synovial tissue increases, viscoinduction, pain relief follow

OA of knee, hip, shoulder

o n ro Cl. c "" ro In

... VI VI

VI 0\

able 6.1. Drugs in orthopedic use

Effect group / Pharmaceutical group

Active agent

.....

Products

Effect mechanism

Indication

DONA

it's the natural substrate of the hyaline proteoglycanes, stimulator of their biosynthesis

Degenerative joint illnesses

Chondroprotective drugs glycose-aminsulphate

hyaline and bone Rumalon inj. extract of you ng animals

stimulator of the regeneration of hyaline

chondroitine sulphate

this is one of the basic elements of the hyaline, excellent water absorbent, so promotes the mechano-elastic qualities of the cartilage

Condrosulf powder, caps.

0\ n o ::J VI III

;:

[lj ,....

< III

,....

iD

[lj ,....

3 III ::J ,....

"0

(3

III Cl.. c n

iD VI

7.

Ta m a s B e n d e r

Physiotherapy

Physiotherapy involves the use of natural en­ ergy (thermal, mechanical, electrical) as well as chemical effects (e.g. the a bsorption of trace elements during balneotherapy at medical spas) in medicine. The most important physiotherapy methods are: �

� �

� �

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exercises (mechanotherapy), electrotherapy, heat therapy (electrotherapy together with balneotherapy), mechanotherapy (exercises, massage and ultrasound treatment), hydrotherapy light therapy balneotherapy.

An advantage of physiotherapy is that it has hardly any side-effects, but it also has the disadvantage that its effects are much less un­ derstood than those of drug therapy. Physiotherapy endeavors to utilize the procedures objectively, in another words evi­ dence-based medicine is also valid in physio­ therapy. It has already been mentioned, that both surgical interventions and conservative treat­ ment are equally important, and the conserva­ tive treatment in orthopedics includes physio­ therapy procedures. Preoperative physiother­ apy is of great significance in improving the breathing and circulatory capacities, while postoperative physiotherapy plays an impor­ tant role in maintaining the outcome of the op­ eration, and promoting the avoidance of the contractures and thrombo-embolic complica­ tions.

7. 1. Exercises The most important physiotherapy proce­ dures are exercises, which are irreplaceable. These exercises can be active, when the pa­ tient uses his / her own muscles to carry out the motion, or passive, when the physiothera­ pist moves the joints . During exercises, move­ ment is also used as a mechanical stimulus. Exercises are important elements of preven­ tion, treatment and rehabilitation. During as­ sessment of range of motion the cause of any restriction is evaluated. The causes can in­ clude pain, contracture, fluid collection, swelling, joint block. One of the basic tenets of motion therapy is that pain must be avoided. Exercises can in­ volve one phase, e.g. exercising the agonistic muscles or two phase, e.g. exercising both the agonistic and the antagonistic muscles. Dur­ ing isometric exercises, the length of the mus­ cle is unchanged, resulting in a static muscle load; during isotonic motion, the length of the muscle is changed, resulting in a dynamic muscle load. Individual exercises should be selected, if possible, and should be pursued as long as the motion is manually guided. If group exercises are advised, patients with similar capacity should be grouped together, similarly as in underwater exercises. Active exercises are less risky than passive ones following surgery, since the patient, mainly through the onset of pain, is able to judge the limits of his / her joint.

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7.2. I m mobilization, mobilization, exercises Fixation can have multiple aims : restrict­ ing or blocking movements, keeping the limb in rest, etc. In different disorders, involving inflammation plaster slab, plastic slab or cir­ cular plaster cast immobilization of the af­ fected j oint can alleviate pain and enhance healing. Immobilization is essential after certain orthopedic operations, to protect the corrected position of the j oint, e.g. following arthrodesis or osteotomy. Adherence to the principles of joint protection is indispensable in motion

therapy. Movements, which have disadvanta­ geous effects, increasing the pain, deformities and causing negative changes are to be avoided. Preoperative exercises serve to increase muscle power, promoting a successful surgi­ cal outcome. After Chiari pelvic osteotomy, when the origins of gluteus medius and minimus muscles are almost completely de­ tached, even if very regular and active exer­ cises are practiced, the hip abductor power re­ turns, and the Trendelenburg sign ceases only after some 6 months. In cases of hip osteo­ arthritis motion therapy is designed to en­ hance gluteus muscle power. Non-weight­ bearing is achieved very well in the so called

Fig. 7.1. Passive knee-moving device (CPM).

Fig. 7.2. Computer-guided traction table, with an additional mi­ crowave heating unit. Traction of either cervical or the lumbar spine can be performed.

7. Phys i o t h e r a p y Schlingel bed with a hanging grating : the re­ sistance is eliminated by means of ribbons in­ corporated into the grating over and at the sides of the treatment bed. In cases of osteoarthritis of the knee, the aim of the exercises is to raise the quadriceps power together with joint protection; in cases of ligament instability a supportive brace can be applied. Protection in cases of the very common osteoporosis may be provided by ax­ ial loading of the spine. In cases of frozen shoulder, when contractures are already pres­ ent, passive motion may be applied to the maximum range, chiefly in the subacute phase. In the chronic phase self-stretching ele­ vation exercises are ordered. In cases of prolapsed discs, McKenzie ' s method i s advised, based o n rearrangement of the nucleus pulposus-annulus fibrosus. Pas­ sive motion devices (Fig. 7. 1 ., 7.2.). move the selected joints in preset ranges and frequen­ cies continuously or periodically.

7.3. Massage Massage is a mechanical stimulus applied to the muscles, ligaments, soft tissues. Massage can be performed for hygienic (in healthy subjects), sport or therapeutic pur­ poses. Its therapeutic forms include : classical Swedish massage with the following tech­ niques : caressing, kneading, tapping, shaking, vibration; reflex zone massage; connective tissue and segment massage.

7.4. Electrotherapy Electrotherapy, i.e. the use of electricity in medicine, is a very widespread method. In musculoskeletal conditions it is used to re­ lieve pain. Electricity may cause hyperemia (mainly thermotherapy; care must be taken in cases of acute inflammations ! ) . Treatment is applied in the form of stable low-frequency (up to 1 000 Hz) galvanic current, longitudi­ nally placed along a limb (Kowarschik treat­ ment). This has an outstanding pain-killing ef-

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fect, e.g. in cases of radiculitis (sciatic nerve or brachial plexus). The current sensitivity, al­ ways dependent on the patient' s tolerance, generally is 0. 1 mA/cm2 . Iontophoresis involves the penetration of pharmaceuticals into the body through the use of electricity. The drug in ionic form slowly penetrates through the skin into the target area. The active ingredient may enter the cir­ culation, or the synovial fluid e.g. of knee iontophoresis. This procedure is used for its local effect, but it may have general effects as well. Transcutaneous electric nerve stimula­ tion (TENS). TENS is one of the most fre­ quently used pain-killing methods worldwide. Its advantage is that the treatment is possible with portable, battery-powered equipment, which allows self treatment of the patient at home. The background of higher-frequency TENS treatment (up to 1 00 Hz), is the Melzack-W all gate theory. The theory behind the lower-frequency (2- 1 0 Hz burst or acu­ puncture-like TENS) relates to the mobiliza­ tion of the endorphins in the body. Diadynamic current treatment: This en­ tails application of a form of current with two components: a basic current with 1 -3 mA and a supplementary dose current. This treatment is a good pain killer and to a less extent in­ creases the circulation. Considering, that many orthopedic patients have a metal im­ plant in their body, care must be taken to pro­ tect these such implants from the current. Medium frequency alternating current: Medium frequency treatment means therapy in the range of 1 000- 1 00000 Hz. (Fig. 7.3.). Apart from the classical interference, a num­ ber of medium frequency treatment modali­ ties are used for pain relief and muscle exer­ cises. In contrast with the low-frequency ther­ apy the medium frequency readily overcomes the resistance of the skin, does not leave red­ ness, and is effective in the depths. It is used primarily for pain-killing. Besides traditional

60

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7. Phys i o t h e r a p y

�oo , I 00 ' \i\ � \ii\ [IJ � __KLMm

•

-

Fig. 7.3.

I nterstim medium frequency interference treatment device.

plain electrodes, vacuum electrodes can also be used. Stimulation current therapy: This is used to treat peripheral damages of the mus­ cles in orthopedic and trauma patients, and also to treat atrophied muscles with a good nerve supply (muscle exercises). It is applied most frequently before prolapsed disc sur­ gery, or to treat paralysis of peroneal, tibialis anterior or extensor hallucis longus muscles occurring as a surgical complication, or fol­ lowing traumatic nerve damage. The basis of sophisticated stimulation current therapy is electrodiagnostics. The treatment should be repeated twice a day if possible. Atrophied muscles with intact nerve supply, e.g. following long bed rest or plaster removal are stimulated with a rectan­ gular impulse.

7.5. Ultrasound treatment The sound with a frequency over 1 6000 Hz is called ultrasound; it can be applied for mechanotherapy. It is generated by an inverse piezoelectric effect. Equipment generating sound with 800 kHz-3 MHz is used in physio­ therapy. Ultrasound is conducted relatively well by bones, but less so by soft tissues, wa­ ter and air. The intensity of ultrasound is mea­ sured in watt/cm2 . It necessitates a mediator material (e.g. paraffin) . Its physical effect in-

clude the application of selective heat and micromassage. It also has a biochemical ef­ fect: drugs can be infiltrated through the skin into the organs (sonophoresis). Its biological effects include : pain-killing, vasodilatation, the resolution muscle spasm, e.g. softening the connective tissue in Dupuytren contracture. It is applied in hip osteoarthritis in 3 fields for 3 minutes each, in degenerative conditions of the cervical or lumbar spine, in achillodynia or coccygeal complaints. Ultra­ sound treatment has recently been combined with various forms of current treatments (diadynamic, TENS, medium frequency treat­ ment), for stimulation of the deeper tissues. The combined treatment is time-sparing, as the two modalities may be applied at the si­ multaneously.

7.6. Pulsating electromagnetic treatment Views as to the clinical value of this ther­ apy differ. It is used clinically for its osteoblast-stimulating effect. e.g. to treat re­ flex dystrophy, to enhance callus formation, in cases of pseudo arthroses. For home use 1 00 Gauss devices with frequency range of 2 -50 Hz are used to deliver therapy, for 20-30 min­ utes.

7.7. High-frequency' treatment High frequency treatment induces endoge­ nous heat in the body. It is used in the form of shortwaves (27 MHz, 1 1 meter wavelength). Shortwave therapy can take place in con­ denser or in coil fields. Modalities can be con­ tinuous or impulsive with proper frequency) . Heat may alleviate pain in cases of chronic in­ flammations . High-frequency treatment is usually applied daily for 1 0- 1 5 minutes. Its use is prohibited in disturbances of heat sensi­ tivity and if there is a risk of bleeding. When microwaves are used, the eyes (risk of cata­ ract), testicles and the growth plates must be protected (children are not treated) .

7. Phys i o t h e r a p y

7.S. Cryotherapy Cold has a pain-reducing effect, which is produced by blockade of the A-delta and C fi­ bers, reducing the speed of neural connec­ tions. Cryo-packs, the most popular practical form. The treatment time is 1 0-1 5 minutes, can be used at home and are easily applicable to the skin. Cryotherapy can also be achieved with nitrogen gas, and in a new procedure : cooled air at minus 40 C degree is directed to the limb for 3-5 minutes . In orthopedics, the main application is in acute arthritis, joint in­ flammations, to relieve muscle spasm and for pain- killing before exercises.

7.9. Balneotherapy-health spas Balneotherapy is the branch of medicine that uses the healing effect of medicinal wa­ ters. Its arsenal includes mud therapy and the internal use of mineral waters . Climatic ther­ apy and cave therapy are further areas of balneotherapy. Hydrotherapy is a therapeutic modality based on the physical properties of water. It is used in every country of the world, mainly for the treatment and rehabilitation of musculo­ skeletal conditions . It does not demand ther­ mal water; warmed tap water is suitable. The therapeutic environment is a complex; the pa­ tient is treated in a given milieu with either mineral-, or tap water, and the effects of other physiotherapeutic procedures are also avail­ able, not to mention the effects of environ­ mental and climatic changes . The physical effects of hydrotherapy are based on three factors : - hydrostatic pressure - buoyancy - temperature Mud therapy. Mud has a large heat stor­ age capacity and a low thermal conductivity, so it is capable of inducing endogenous heat production (heat delivery is slow, and there is no risk of skin bum). Chemical characteris-

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tics: minerals present in the mud may be ab­ sorbed into the body. Applications : mud pack­ ing ( the treated limb is coated with a 2-3 cm thick layer of mud), for 1 5-20 minutes, at 42 Co. Mud compress: the part of the body to be treated is covered with mud heated in hot wa­ ter (only physical effects are expected, this procedure can be applied at home). Mud lake : this can be used at 3 8 -42 Co, the heat effect is more marked than in water at the same tem­ perature. Mud is an efficient medium in heat therapy, kills the pain and decreases muscle spasm. A weight traction bath is an underwater traction modality. The patient is suspended at the cervical or lumbar spine in water in a tub, where his / her feet do not reach the bottom, and is gradually loaded with weights (applied to the lumbar area or to the limbs). Axial trac­ tion is applied for 1 0- 1 5 minutes to treat discopathies, prolapsed discs, and hip or knee contractures. Weights are not used in cervical tractions. Weight of 1 . 5-6 kg can gradually be increased in lumbar traction, secured to belts applied to the waist or to the calves. Its use is prohibited in cases of acute j oint or nerve inflammation, after spinal fusion or spondylolisthesis. Subaqua) j et massage: A patient lying re­ laxed in water of indifferent temperature (34 CO), is massaged with a water j et at appropri­ ate pressure (0.5-2 atm) from a distance of 1 5 cm, for a usually 1 5 minutes treatment time. This procedure is used to relax spastic mus­ cles. Baths with alternating temperature: This is used for the treatment of limbs. Two baths are needed: one containing cool (with 1 4- 1 6 CO) and the other one warm (with 3 6- 3 8 C O ) water. Patient first submerges both limbs in the warm water for 1 minute, and then for 1 0 seconds in the cool water. This process is repeated ten times. The warm water causes vasodilatation, and the cool vasoconstriction. The carbonic acid bath exerts a marked effect in enhancing the limb circulation, and venous return.

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Radon bath : radon, a noble gas with a pain-killing effect, stimulates DNA repair, and stimulates the immune system; it can be combined with carbonic acid. Sulfur bath : This causes vasodilatation, decreases the sensitivity of the cold receptors, and stimulates the warm receptors. It has been assumpted by some that sulfur can penetrate into the joint cartilage.

7. 10. Com presses and packs Cold compress is applied for a maximum of 1 0 minutes . A compresses soaked in 1 4- 1 6 C o cool water to treat acute inflammations. A compress soaked in 40 Co water is warm com­ press applied for 1 5-30 minutes. Warming (Priessnitz) compress: A textile soaked in cool water is applied to the target area, covered with warm sheets.

Wet-pack: Between the Priessnitz two layers of a plastic foil is inserted. Paraffin therapy: Paraffin is a material softens in response to heat, and its physical properties are similar to those of mud. It is usually applied at 60 Co, the target area with thin brush, and then covered with a dry sheet. Packs : Packs differ from compresses in being applied to major body areas. There are trunk and limb packs, dry or wet. A wet pack is always covered by a dry one. Wash-down : This is the gentlest form of hydrotherapy. Washing-down may be done with a cool wet sponge to improve the circula­ tion. The average duration is 4-5 minutes. It is followed by rubbing with a dry cloth. A body part is usually washed with a rubber hose.

8.

Ta m a s B e n d e r

Manual therapy, acupuncture

Manual therapy and acupuncture have re­ cently become accepted by official medicine as two methods of natural medicine and are widely used in orthopedics. Acupuncture : This technique of healing has been performed for some 3 000 years and this is the best-known branch of traditional Chinese therapy. Various points of the body are stimulated manually (with needles) or by means of other devices (a laser beam, or elec­ trically). It is used to relieve chronic pain, and postoperative pain and in orthopedic condi­ tions umelated to deformities. In recent years various evidence has been published concern­ ing the effects of acupuncture (e.g. an increase ofCSF endorphin level). The theoretical basis of the treatment assumes the presence of me­ ridians in the body and the acupuncture points are located along these meridians. The major­ ity of the acupuncture points have a diameter of 0. 5-2 mm. The oriental philosophy of this

treatment is the theory of yin and yang (union and antagonism) . Manual therapy: This subdivision of medicine is concerned with the biomechanics and reversible changes of the musculoskeletal system, the diagnostics and therapy primarily being manual . Chiropractic and osteopathy (synonyms) and the so called bone setting are other terms and are also often used both by doctors to describe manual therapy. The diag­ nostic and therapeutic procedures are used both by doctors as well as by physiotherapists. A j oint block of mechanical, neural or reflectory origin that gives rise to symptoms (pain in motion, etc.) is eliminated by special manipulations. It is employed most often to treat functional disturbances of a spinal seg­ ment. Manual therapy can be dangerous if is practiced by a person without proper training in anatomy.

9.

Laj o s K u l l m a n n

Amputation - artificial limbs

Amputation is the removal of parts of the body. Most frequently tissues, organs or parts of limbs are excised, usually by a su rgical method. Exarticu lation is a special mode of amputation, when the removal is effected through the joints without cutting bones.

Amputation is generally considered by both doctor and patient to be a sign of the fail­ ure of the previous treatment. The reason is the outcome of the conspicuous loss. Never­ theless, amputation is merely an episode in the usually lengthy treatment procedure, in the course of some diseases (constriction of the arteries), trauma (severe injury of a limb), or developmental abnormalities (dysmelia, myelodysplasia) . Amputation comprises a re­ constructive operation in this lengthy treat­ ment series, done on a functionless limb (which otherwise occasionally j eopardizes the patient' s life). This reconstructive proce­ dure, often together with artificial limb supply and rehabilitation, eliminates pain, enhances mobility, and in an ideal case may result in full quality of life.

9.1. Lower limb amputation The Hungarian epidemiological data indi­ cate that the conditions requiring amputations in order of incidence are: blood vessel dis­ eases (>80%; arteriosclerosis obliterans, dia­ betic angiopathy, endarteritis obliterans), ac­ cidents « 1 4%,) primary and secondary tu­ mors « 3%), infections, limb developmental abnormalities and miscellaneous conditions « 4%). Amputations relating to blood vessel diseases are most frequent between the ages of 50 and 70 years . More than 70% of ampu­ tees are males.

9 . 1 . 1 . I ndications of lower limb amputations In blood vessel diseases, Fontaine phases Ill. (pain at rest) and IV. (gangrene), ifthere is no chance for reconstruction, amputation is the treatment of choice. In diabetes cases sig­ nificantly more amputations are done than necessary. Most of them could be avoided by well-timed and proper therapy of the diabetic foot. Following a severe crush injury of a limb immediate (primary) amputation is needed, if there is no chance of reconstruction of the vi­ tality and function of the part ofthe limb distal to the injury. (Criteria are serious damage of three out of the five types of tissue: vessels, nerve, muscle, bone, skin). Primary amputa­ tions performed as distal as possible, and are to be treated openly. After the wound has set­ tled and the general condition has improved, the final stump is formed by elective interven­ tion. If a limb tumor can not be managed by some other approach, amputation is needed. In cases of secondaries amputation is also considered if the tumor elicits unbearable pain or severely hinders living or patient care. Patients with chronic inflammation (mainly osteomyelitis) and with congenital or acquired abnormalities of the lower limbs of­ ten undergo a number of operations. Amputa­ tion is indicated, when a segment of a limb is functionally useless or an incurable, treat­ ment-resistant infection is present which rules out the use of appliances. In the period of growth, amputation done on a humerus or leg induces excessive bone growth relative to the soft tissues. It is sensi­ ble to take this fact into account when the indi-

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9 . A m p u t at i o n - a rt if ic i a l l i m bs

cation and timing of the operation are consid­ ered.

9.1.2. Su rgical technique of amputations Preoperatively the proper psychological and physiotherapy preparation is indispens­ able. Besides the general operative technique the following aspects are to be considered: 1. The extent of the wound is controlled by a well planned incision. 2. No foreign material a re to be inserted except the sutures. 3. B leeding is careful ly controlled. 4. Bones are severed with a manual saw (a framed or Gigli saw). 5. A d rain is to be inserted with the exception of transmetatarsal, transtarsal amputations. A 14- 16 Ch thick plastic or rubber tube is used to ensure d rainage. 6. Extensive infections, ischemic necroses must be exposed and treated open. 7. Wound is to be closed without tension.

Further surgical technical aspects to be taken into account are related to the nature of the different tissues. The blood supply of the skin on the anterior part of the leg and on the dorsum of the foot is poor. Deep undermining, destruction must be avoided, the skin edges must be protected from drying out. If the subcutis is thick, it should be drained sepa­ rately. In arterial occlusions partial fascia ex­ cision is not done. An atraumatic technique is especially important with muscles. Cut mus­ cles must be fixed, either to bones (myodesis) or by stitching the antagonist muscles to­ gether over the bone (myoplasty). Muscles are fixed by stitching their own fascia. The periosteum is transected sharply at the level of the bone cut. The spiky edges of bone are to be rounded. The level the bone cut is elected so that the stump can be covered with a proper muscle layer and the wound above is closed

with no tension. The vessels must be severed as distally as possible so as to protect the col­ lateral circulation. The bleeders are carefully checked and controlled. The nerves are cut high (3-4 cm above the operative field) so as to avoid their reaching the scar, and the cut ends are well covered by soft tissue. In cases of major nerves (e.g. the sciatic) the comitant arteries are also secured.

9. 1.3. Criteria of proper stump Special surgical technique aspects come into consideration at a number of amputation levels, since they have substantial effect on the prosthesis application. A transmetatarsal amputation stump is to be covered by a plantar musculocutaneous flap, which has a good blood supply and is more resistant to load-bearing (Fig. 9.1.). At the transtibial level, a conventional, long ( 1 5 - 1 7 cm) posterior fascia-musculo­ cutaneous flap (Burgess type) is approved, be­ tween the proximal and middle third. It is es­ sential to round the tibia edge and cut the fib­ ula 2 cm proximal . Removal of the soleus muscle is recommended (Fig. 9.2.). In an ideal case transfemoral amputation is done between the distal and middle thirds of the thigh. Myoplasty too may be added by at­ taching the tendons and muscles. For hip exarticulation, the surgical inci­ sion is made along the inguinal ligament and a long posterior flap is prepared.

Fig. 9.1. Technique of transtarsal amputation. (The part to be excised is shaded).

9. A m p u t at i o n - a rt i fi c i a l l i m bs

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Fig. 9.3. Dressing and fixing the transtibial amputation stump with a dynamic knee orthesis.

Fig. 9.2. Posterior flap (Burgess) technique of transtibial am­ putation. (The part to be excised is shaded).

After transtibial amputation, a flexion contracture of the knee may develop, as may a flexion and abduction hip contracture after transfemoral amputation. These can be pre­ vented by proper positioning of the limb, proper physiotherapy and the use of dynamic knee extension equipment (Fig. 9.3.). Besides stump contracture, a frequent early complication is thrombosis, which can be a source of emboli and delay prosthesis ap­ plication. Amputation is often followed by stump edema. This may be resolved by applying an elastic bandage to the stump. Mobilization commences postoperatively as early as possible, depending on the state of the patient,. It starts with breathing and limb exercises. Exercises of the stump are per­ formed with the use of phantom sensation, en­ suring the acceptance of the prosthesis into the body scheme. Early exercises and walking

Table 9.1. Lower limb prostheses Aim

Device

Maintenance walking stereotypes, walking confidence

Temporary prosthesis with prefabricated pneu matic components

After wound healing till the final form of the stump is attained

Ensuring the formation of the stump, and assessment of the abilities to use an artificial limb

An easily adaptable, inexpensive prosthesis (plaster shell, modular system)

After the final form of the stump, long term

Provision of a walking aid serving all demands

A modern, cosmetical prosthesis with a good function and durable quality

Period

From 7- 10th postop. day till the wound healing

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9 . A m p u tat i o n - a rt i fi c i a l l i m bs

are the correct protective measures against phantom pain.

9.2. Lower limb prostheses There are three different lower limb pros­ theses, which are employed in different peri­ ods with three different purposes (Table 9. 1 .).

9.2. 1. Tem porary prostheses If the wound is healing without complica­ tions, use of the first temporary prosthesis may start, when the stump is no longer tender. This is the pneumatic temporary prosthesis (Fig. 9.4.). After the wound healing, a modular tem­ porary prosthesis is used (Fig. 9.5.).

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a

---I-+--- b

Fig. 9.5. Temporary modular prosthesis with a plaster shell for the transtibial stump.

c

Advantages of temporary prostheses: �

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Fig. 9.4. Schematic drawing of a pneumatic temporary pros­ thesis. Legends: a) metal frame, b) inflatable case, c) strap preventing slipping of the case, d) height ad­ juster, e) rocker bottom.

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early mobilization maintenance of the ambulatory ability faster stump modelation prevention of contracture protection of the body scheme decisions related to prosthesis application selection of the type of final prosthesis; its trial of fitting

Prosthesis application is team work. The members of the team are the surgeon, the re­ habilitation specialist, the appliance techni­ cian and the physiotherapist.

9 . A m p u t at i o n - a rt i fi c i a l l i m bs

9.2.2. Final prosthesis This is the final aid with which to provide a long-term and reliable function and an ac­ ceptable cosmetic outcome (Fig. 9.6.). It is vital and ifthe answer yes, to select the proper artificial limb. The following factors must be taken into account:

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The a g e o f t h e patient. The elderly adapt with g reater difficu lties, and the chances of learning problem-free ambulation are less. The condition that indicated the amputation. I n vessel disorders cardiac and vertebra l vessels are also involved, which influences the weight- bearing and cooperation. I n diabetes the general metabolic changes and other tissue damages limit the outcome of the artificial limb use. The level of amputation. The hig her the level, the more energy is required for ambulation with the a rtificial limb and the more difficult to control precisely. The proprioceptive feedback is also lower in cases of higher amputations. The number of amputated limbs. The loss of both lower limbs significantly increases the energy consumption of gait. The loss of one u pper limb disturbs the harmony of walking since the motion of the lower and upper limbs is no longer coordinated and synchronized.

The ability to walk is influenced by the quality of the stump.

c

b ---+--F C

--t-+

d ---\e -----++

Fig. 9.6. Schematic drawing of a modular, final pipe-framed prosthesis for transfemoral stump. Legends: a) stump bed (case), b) artificial knee joint, c) custom made pipe frame, d) cosmetic plastic foam lining, e) ankle adapter, f) artificial foot.

1 . Length of the stump. From what has been mentioned so far it might be assumed, that a longer stump would provide a better situ­ ation. However bone-ends in the distal third of the leg can not be enveloped by muscles, and the bones in this region are tender, which may necessitate re­ amputation later. Prosthesis application can also be difficult when the femur stump is short « 5 cm below the lesser trochanter, because of the excessive hip contracture. 2 . Certain conditions are particularly disad­ vantageous, e.g. contractures of the re­ maining joints of the stump, a butt or pear-shaped stump, a scar adhering to bone, neuroma, exostosis, infection or ten­ derness, pain of different origin, and sub­ stantial muscle weakness. Additionally the characteristics of artifi­ cial limbs also effect the success of applica-

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tion. A good fit is required, with well con­ toured supporting surfaces, the shell should not constrict (to avoid venous stagnation at the end of the stump), and the proper length and axial positioning. From a practical aspect, a femoral prosthe­ sis with a knee lock is partially able to relieve the load from the other limb, which is usually also affected by the illness. During the last decade there have been substantial technical developments in the manufacturing of artificial limbs. En­ ergy-storing and returning foot, microproces­ sor-guided pneumatic and hydraulic artificial knee joints have been devised, which allow motion very similar to the physiological one . A silicone stump lining may reduce the load from the skin, but it may also induce dermatological problems. Exact stump bed making is facilitated by computer-assisted de­ sign and manufacturing procedures (CAD/CAM). Finally it must be borne in mind, that a successful gait may be expected only after ed­ ucation in the management of the stump and the prosthesis, and after mastering the proper gait pattern with the guidance of the physio­ therapist, using the other supplementary equipment and assimilating the mental inju­ ries following amputation.

9.3. Upper limb amputation The indication for upper limb amputation is most frequently trauma. The loss of fingers, especially ofthe thumb results in an enormous loss of function. Regarding the amputation and artificial limb supply of upper and lower limbs, there are two basic differences. 1 . The hand is also a sensory organ. It plays a crucial role in sensing the outer world (tac­ tile, heat perception), and in maintaining contact and communicating with the envi­ ronment and fellow human beings. In con­ trast with "useless" amputation levels in

the lower limbs therefore, as concerns the upper limbs it is important to preserve ev­ ery possible centimeter that possesses good tactility. 2. An other functional difference is, that the upper limbs perform various, basically different activities. Some of them involve the exertion of great force, whereas others demand various fine motions which are very accurately regulated. Some motions are made with great pulling force, which could possibly remove the prosthesis from the stump. Some general points may be mentioned here to illustrate the differences involved in the amputation of upper and lower limbs. �

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Tactile areas (mainly on the hands and fingers should be possibly covered by skin with preserved sensation. I n cases of bilateral transradial amputation, Krukenberg plasty may be contemplated, if the proximal half can be retained. This means separation of the radius and ulna and their covering with soft tissue. A grasping ability can be achieved with the two forearm bones. In case of transhu meral amputation the butt-shaped stump is highly advantageous, since it may prevent dislodgement of the prosthesis. Fol lowing transhumeral amputation in children bone may overgrow the soft tissues necessitating reamputation.

9.4. Upper limb prosthesis application The number of lost limbs, the level of the amputation and the basic condition all influ­ ence the prognosis of the use of the artificial limb. Stumps resulting from traumas involv­ ing bums and electrocution are often very ten­ der, and huge scars may develop. Temporary prostheses are rarely used on upper limbs. The reason is that temporary prostheses are less able to replace the lost

9. A m p utat i o n - a rt i f i c i a l l i m bs

functions than are the final prostheses. In chil­ dren with a congenital upper limb deficiency it is recommended to provide the numerous functions in a series of steps with increasingly more capable prostheses. The final prostheses are produced with mUltiple aims and with different solutions, and may be divided basically into three types.

9.4. 1. Cosmetic prostheses The exclusive aim of a cosmetic artificial limb is to conceal the loss of the limb. The cover of the prosthesis fixed to the stump de­ creases the tactile surface. Since the hand is indispensable in maintaining interpersonal re­ lations, a supply of cosmetic artificial I imbs is unconditionally necessary. If a bilateral upper limb amputee has an ac­ tive artificial hand on one side, a cosmetic

a

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71

hand should b e applied on the other side to load the spine symmetrically.

9.4.2. Mechanical prostheses Functional upper limb prostheses, i.e. me­ chanical prostheses, are powered by the pa­ tient via the muscles of the stump and/or the remaining muscles of the shoulder girdle. They replace the grasping force. There are two types of artificial hands with an universal function. One mimics the shape of the hand, but without fulfilling the silhouette of a cos­ metic hand. It does not provide a fine pinch. The other type has the shape of a double hook which can be spread against the closing spring or rubber band with the muscles of the shoul­ der girdle or elbow. Opening is ensured by properly positioned straps and bowdens at­ tached to the hooks. This hand is popularly

"""""----\-

a

b c

d

c

d

----=-

e -------U

)

Fig. 9.7. Anterior and posterior views of a universal functional, mechanical upper limb prosthesis, hook. Legends: a) shou lder strap, b) humerus support, c) bowden, d) forearm shell, e) dou ble hook.

72

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9 . A m p utat i o n - a rt i f i c i a l l i m bs

named as hook. This can be considered as functional basic artificial hand (Fig 9.7.).

9.4.3. Prostheses powered by external force Prostheses may be powered by external electrical motors. These are known as electri­ cal artificial hands. Their purpose is to pro­ vide grasping with better cosmetic qualities as compared with mechanical prostheses. The remained limb muscles switch the motors on and off, and to operate the controls allow grasping with the fingers is done by. The action potentials generated in the muscles are normally used to control the motors, but in some cases mechanical muscle motion can also be utilized. It is important, that muscle motion can only switch the motor on and off; speed and power can not be altered. Hence despite the great expectations, this artificial hand is of only a relatively modest functional value. It is less effective, than the hook for fine motion, to pinch small obj ects.

To educate the usage of this prosthesis re­ quire more patience than with lower limb prostheses, because many types of motion must be mastered. The vocational therapist plays an even more important role than the physiotherapist. The task is clearly more diffi­ cult if both upper limbs are lost or even if a single limb suffers an extensive loss. Psycho­ logical support may be essential. It must be repeated that prostheses block the tactility of a major part of the stump. The stump is covered by a case, which leads to a number of inconveniences. The above outlined modest function, and the need to change the prostheses frequently in childhood have the consequence that upper limb amputees use their artificial limbs much less frequently than do lower limb amputees. A one-hand life style can be relatively easily learned especially at an early age. The situation much more difficult in cases of bilateral upper limb amputees, but they of­ ten manage by means of simultaneous, coor­ dinated motions of both stumps and through use of their mouth, occasionaIIy with their feet.

10.

Laj o s K u l l m a n n

Orthoses, appliances for mobility

Orthoses are externally fitted applia nces which support or influence the structure of the neuro - musculo - skeletal system. Their basic aim is to restore function.

Orthoses are generally used only tempo­ rarily in traumatology, most often in cases of anatomically intact or surgically recon­ structed limbs, following an operation or an injury, until full recovery is achieved. In orthopedic conditions long-term orthosis use is usually necessary, often ap­ plied to deformed limbs, trunk. In these cases, it is essential that the orthosis is fitted accu­ rately to the body parts . Further, the devices must resist deformation, it must maintain its shape precisely and permanently. Orthoses can be prescribed for the follow­ ing purposes. �

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Lower limb length equalization with a functional aim e.g. in cases of congenital limb shortening. To provide fixation, support, e.g. in cases of leg pseudoarthroses, or degenerative spinal conditions. To limit joint motion: - pathologic joint motions, e.g. knee hyperextension following paralysis - unwanted motions (mainly temporarily) postoperatively, e.g. after cruciate liga­ ment reconstruction - in case of conditions, such as hip dysplasia To correct deformities, e.g. varus or valgus malposition of the ankle To provide non-weight-bearing, e.g. destructive processes of the vertebrae, in Perthes disease To replace lost muscle function, e.g. foot extensors

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To support muscle function, e.g. hand flexors

In the past few decades there have been significant changes as regards the materials and technology used to manufacture the orthoses. Modem light metal and plastic orthoses are noticeably less heavy, they are easy to clean, they are more esthetic. Some plastics soften in response to relatively low heat, they can swiftly be fitted directly to the body. One drawback of modem materials is that a num­ ber of patients perspire heavily in plastic sockets . Care must be taken furthermore to provide the needed firmness . I t is often inconvenient t o wear the orthoses, since they act to enforce corrective effect. In general, they are conspicuous, their wearers - specially teenagers - tend to conceal their disorders. Patient compliance with the use of an orthosis improves if exact instruc­ tions are given regarding the method of use, maintenance, together with detailed informa­ tion concerning potential problems (e.g. if some other appliance is also required), the in­ conveniences as well as the functional out­ come to be expected. Similarly to other appliances, orthoses are expected to meet the following expectations : �

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Provide the expected function fully Cause the least possible inconveniences Be safe, and not cause injury (e.g. they must not break) Be as esthetic as possible Be easy to use and maintain Be lasting (adaptation to a new o rthosis can cause inconveniences) Be inexpensive

74

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1 0 . O r t h o s e s , a p p l i a n ce s fo r m o b i l ity

It is clear that it is unlikely that all of these expectations will be completely satisfied. It is therefore especially important to check, whether the prescribed orthosis meets the functional aims . Orthoses may cause complications (e.g. pressure sores at the supported sites), and ex­ act instructions are to be given as to how to prevent these, with daily observation. It is sensible to recall the patients for repeated checkup. Brief information on the more important orthosis types will now be discussed, with the orthoses grouped by body regions.

10. 1. Lower limb orthoses These will be discussed in some detail be­ cause of their frequent use.

10. 1 . 1 . Ankle - foot orthoses These are partially able to relieve the load the ankle and hindfoot j oints. The non­ weight-bearing orthoses support the tibia condyles and the patellar ligament. When the peroneal muscles are paralyzed, a peroneal slab can be fitted, attached to the sole and the posterior part of the calf (Fig. 1 0 . 1 .) . Its lightness is an advantage, but it has the shortcoming that it often breaks at the an­ kle level. In this event prescription of a circu­ lar orthosis is advised. Ankle orthoses provide fixation of the an­ kle and hind foot joints and correct their malalignment. In cases of rigid fixation a rocker bottom shoe is needed to restore the lost ankle motions. In post-traumatic conditions, prefabri­ cated linen or plastic ankle - foot orthoses are often used in variable sizes, which can pro­ vide relative fixation.

10. 1.2. Knee orthoses These are used for temporary fixation of the knee. Lateral instability can be eliminated, while the j oint motion is undisturbed. Hyper-

extension of the knee which hinders walking, may be prevented with orthoses, which permit free flexion. Since resyriction or elimination of inappropriate movement requires extensive forces, the orthosis must be long enough to distribute the load over as large a surface of the limb as possible (Fig. 1 0.2).

10. 1.3. Knee - ankle - foot orthoses These are applied in cases of major limb length differences, muscle weakness, axial in­ stability of the knee, and varus and valgus de­ formities of the knee and ankle.

10. 1.4. Hip orthoses Immobilization of the hip is indicated in cases of hip dysplasia or dislocation. The Pavlik harness (see also Chapter 28) is a strap­ ping system attached to the trunk and lower limbs, and it prevents extension, leaving the other motions free. Partial immobilization of the hip may also be necessary in infantile cerebral palsy (sym-

� Fig. 10.1. Peroneal slab ankle - foot orthosis.

1 0 . O rt ho s e s , a p p l i a n c e s fo r m o b i l ity

metrically, on both sides), or following dislo­ cation of a hip endoprosthesis and also in posttraumatic states.

10. 1.5. Hip - knee - ankle - foot orthoses Transfer ofload bearing to the sciatic tuber is the method to accomplish non weight bear­ ing of the hip joint. This orthosis relieves weight bearing of the entire limb. It is applied most often in cases of Perthes disease.

Fig. 10.2. Knee orthosis, for extensor weakness, recurvation, and to cor­ rect lateral instability.

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In cases of simultaneous paralysis of the musculature of the lower limbs and the pelvis (e.g. myelodysplasia), this orthosis may be supplemented with a pelvic bucket, hip lock (Fig. 1 0.3.).

10.2. Upper limb orthoses The applications of the upper limb orthoses will be mentioned only briefly be­ cause of their infrequent use. Motions and ac­ tivities practised in many cases in a non-weight-bearing position. Loading can be relieved with support, suspending devices and/or orthoses. Trunk - arm orthoses may also provide the non-weight-bearing of cer­ tain upper limb joints . For upper limb orthoses modem, light ma­ terials play a decisive role, especially the ther­ moplastic and easily moldable plastics. A substantial difference from lower limb orthoses is the frequent use of elastic compo­ nents (plastic slabs, rubber bands, springs). The reason for this is based on the experience, that if certain joints are fixed elastically in proper position, motion of the distal segments can be more successful (Fig. 1 0.4) . A frequently used upper limb orthosis is the shoulder strap . In cases of negligent pos­ ture this assists retroflexion of the shoulders . It is also applied unilaterally in paralyzed pa­ tients (e.g. after stroke), it may prevent subluxation of the shoulder (Fig. 1 0.5.). Functional orthoses (therapeutic devices) may decrease harmful, symptomatic muscle tension through use of the proprioceptive feedback, e.g. an epicondyle pad.

Fig. 10.3. Hip-knee-ankle-foot orthosis with a hip and knee lock for cases of extensive muscle weak­ ness of the lower limb.

75

Fig. 10.4. Wrist- hand orthosis to fix the wrist and support grasping.

76

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1 0 . O rt h o s e s , a p p l i a n ce s fo r m o b i l ity

�\

/ -------

Fig. 10.5. Shoulder orthosis to prevent subluxation.

Fig. 10.6. Sacroiliac orthosis for degener­ ative spinal disorders.

The motions are normally based on reflex motions and sensory - motor feedback. This has led to the development of hybrid orthoses, which combine the features of traditional orthoses and functional electric stimulation, the actual motions conducting the further movements. Their indication is limited and they are expensive. They may be used only in cases of very good cooperation.

10.3. Spinal orthoses These are quite popular in degenerative spinal disorders. However the extensive use of spinal orthoses may result in atrophy of the paravertebral muscles.

Fig. 10.7. Thoraco - lumbo - sacral plastic corsette.

10.3. 1. Lumbosacral orthoses These are applied in cases of lumbar pain or instability. They are made of linen with various stiffeners (Fig. 1 0.6), but they are also produced from rigid materials (metal, plastic).

10.3.2. Thoraco- Iumbo-sacral orthoses Linen corsertes provide relative fixation. They are custom made from elastic fabric, with or without breast support. Following vertebral fracture, in Scheuermann ' s disease and occasionally in cases of inflammatory vertebral conditions, immobilization of the spine and non­ weight-bearing of the vertebrae is the aim. In

1 0 . O rt h o s e s , a p p l i a n ces fo r m o b i l ity these cases plastic trunk corsettes are fitted, fixing a longer section of the spine. They act on the basis of three point support. To attain the desired correction (reclination) an the ex­ act fit on the pelvis is aspecially important (Fig. 1 0.7) . In scoliosis, the purpose of spine orthoses is to achieve active muscular correction. The orthoses must fit on the pelvis exactly and ap­ ply tender pressure to the curvatures that the child attempts to circumvent The manufacturing of scoliosis corsettes demands excellent professional knowledge and skill. Faulty orthoses are occasionally produced, the common problems may be: � � �

no 3 dimensional effect no assistance of active correction if too tight, or malpositioned on the trunk, they may impair the breathing or kidney function

10.3.3. Cervico - thoraco - lumbo sacral orthoses These are indicated in cases of cervical scoliosis, destructive vertebral diseases or pa­ ralyses.

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77

\ Fig. l0.8. Soft cervical orthosis, so called 5chanz -collar.

10.5. Walking aids The handles of the devices listed below must be adjusted to the height of the greater trochanter. Their use must be educated. It is important that walking with two canes re­ quires a path 70 cm wide, with the crutches even the path is even wider. On a wet surface the rubber bottom of the devices may slip, re­ sulting in a fall. On the other hand a carelessly placed walking aid may disturb moving of other people causing accidents.

10.3.4. Cervical orthoses These serve for the partial or full non­ weight-bearing of the cervical spine. They are supported on the shoulder, on the occiput and the mandible. The Schantz collar made of foam, provides partial fixation (Fig. 1 0.8.).

10.4. Preventive sport appliances These orthoses are not for treatment, but rather serve to prevent injuries. Their use is considered unacceptable for sportsmen, who may demand to be provided with an orthosis for relative fixation following insignificant injuries, so as to be able to carry on competitive sports.

10.5. 1. Walking stick If a stick is used in one hand, weight bear­ ing of the other lower limb can be diminished by app . 1 0%. Around 2 5 % of the body weight can be relieved by using 2 sticks. In cases of paralysis or imbalance a stick increases the safety of the gait. With the use of special 3 and 4 legged sticks the safety of gait can further be enhanced.

10.5.2. Crutch The full non-weight-bearing of one lower limb can be achieved by using a pair of crutches. There are a few forms in use:

78

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1 0 . O rt h o s e s , a p p l i a n ce s fo r m o b i l ity

Fig. 10.11. Wal king frame

rarely prescribed in cases of diseases, defor­ mities, weakness of the hand and wrist.

10.5.3. Walking frame Fig. 10.9. Elbow crutch.

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Fig. 10.10. Armpit crutch.

armpit crutch, elbow (Lofstrand) crutch, forearm supported crutch.

In cases of intact upper limbs and a good muscle function the elbow crutch is pre­ scribed (Fig 1 0.9.). Armpit crutch may com­ press the axillar nerves causing paresis (Fig. 1 0 . 1 0.). However armpit crutches provide better walking safety for individuals in poor condition. Forearm- supported crutches are

A walking frame has two handles and four legs (Fig. 1 0. 1 1 .). It is made in two varieties : one is transferred step by step, the other rolls (perhaps with forearm support). It improves walking safety superior to that with crutches and also provides non-weigh-bearing.

10.5.4. Wheelchair The basic type is the patient-driven wheel­ chair, which is presented in fig. 10.12. The pa­ tient-driven wheelchair is a backed chair with a foldable frame which has 4 wheels, leg rest and brake. Two of the wheels are large, they hold the handrims .If the hoops are driven equally in the same direction and at the same speed, forward or backward rolling may be

1 0 . O rt h o s e s , a p p l i a n ce s fo r m o b i l ity

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79

e --------fl�

a -----tf"IIlIIII_1!I.

g -----z=.=-<J

---"":::tcl----- b

h ----I/

j k ------'�_lWPdlt+_Ir�:___J

C

-------j*-llllr

d

Fig. 10.9. Patient driven wheelchair. Legends: a) arm support, b) seat, c) custer, d) leg rest, e) push hand le, f) back, g) driven wheel, h) hand rim, i) brake, j) tipping lever, k) frame.

achieved. Driving the handrim on one side can make the wheelchair turn . The other common type of wheelchair is the electrical wheelchair. Apart from the com­ ponents listed above, it has a battery-powered

engine. Control (starting, stopping and steer­ ing) is achieved by a joystick fitted on the side more suitable for the capabilities and requests of the user.

1 1.

Ka l m a n T6t h

Orthopedic shoes and insoles

1 1.1. Shoes and orthopedic shoe People living in the area now known as Europe, have been wearing shoes since pre­ historic times. The average distance walked by a person during a lifetime is around 200 000 km. A good shoe must ensure comfort, and the fuIl function of the foot. The main pur­ pose of every shoe is to protect the foot from heat, wet and injuries, thus good design and suitable material are very important. The pos­ terior part of the shoe is of key importance. The position of the heel in the shoe is stabi­ lized by a posterior stiffener. The efficacy of the lining or other corrective supplements is only possible in the presence of a weIl­ designed stiffener (Fig. 1 1 . 1 .). Another sig­ nificant task of the heel of the shoe is to sup­ port the foot. The more dynamic the load on the foot, the more important the proper sup­ port. Selection of the correct height of the heel

" " " " "

a

b

c

Fig. 11.1. a: A shoe without a stiffener or with a loose stiff­ ener: the heel is in the valgus position. b: In a shoe without a stiffener or with a loose stiff­ ener, the wedge form correction placed on the sole is ineffective: the heel is still in the valgus position. c: A proper stiffener design supports the effect of correction lifting; when placed on the sole, the valgus of the heel is reduced.

is also fundamental. Other essential factors are the width and the alignment of the heel and the type of materials come into contact with the ground for a stable touchdown and lateral stability. The middle part of the shoe is situated ana­ tomicaIly between the sustentaculum tali and the middle metatarsal region of the foot. The basic task of this part of the shoe is to fix the foot steadily. The structure of the front part of the shoe is adequate if it aIlows the toes to move freely. This is only possible if the cap of the shoe is high enough and extends 5- 1 0 mm beyond the foot. This activity length" is es­ " sential in the selection of the shoe. Most fash­ ionable shoes (especiaIly for women) do not meet the physiological requirements, and this can cause inflammation, caIlosity, parony­ chia, etc. An orthopedic shoe is custom-made after individual size measurement, which is carried out by an orthopedic shoemaker, who utilizes a copy of the footprint, the silhouette of the foot, and the circumferences of specific parts of the foot. The event of a severely deformed foot, there is a need for plaster of Paris mold­ ing, in a medium loaded condition, before the plaster has fuIly set. An orthopedic shoe must satisfy very com­ plex demands. One of the apparently most simple is to equalize limb shortening. If the heel is raised by 1 5 mm, the forward-moving of the center of gravity causes the roIl-over turning point to move, and for this reason the distance between the front of the shoe and the ground also has to be increased. The greater the disparity to be equalized, the higher the sole must be raised in order to protect the knee and hip stability. If a shoe has a heel elevation of more than 4-5 cm, there is a

82

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1 0 . O rt h o p e d i c s h o e s a n d i n s o l e s

need for a rocker bottom. I f the elevation i s even larger than this, the sole is shaped with a bent last, resembling a rocking chair. A rolling sole supports the roll-over, while it permits certain parts of the foot to rest. The prescription must specify the largest height of the rolling sole and (depending on the part to be rested) the distance from the end ofthe heel (Fig. 1 1 .2.). It is sometimes desirable to reduce the in­ tensity in the phase of heel strike, in which case a buffer heel is employed (Fig 1 1 .3.). Distribution of the pressure on the anterior part of the foot is important when deforma­ tions are caused by metatarsalgia or rheuma­ toid arthritis, while in cases of diabetes or other neuropathic foot conditions there is a

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Fig. 1 1.3. a: A buffer heel in an u nloaded position b: A buffer heel in a loaded position.

need for complete sole surface contact. In­ structions are necessary for the construction, and positioning of special loading and load-relieving points (e.g. for patients with se­ vere rheumatoid arthritis, deformation of the hand means that the shoe should have a Velcro or clip fastener rather than laces). Supplementary therapeutic aids can be in­ corporated into orthopedic shoes (e.g. an in­ step raiser, a Bayer spring, etc.). The shoe is often connected to a walking brace or a walk­ ing apparatus and therefore the appearance also changes. It must be remembered that the wearing of such devices is a burden that causes lifelong problems for the patient.

b

� c

Fig. 1 1.2. a: A rocker bottom extending to the whole sole and with a greater heig ht causes the axis of the leg to lean back; for this reason, the knee joint comes into extension and hyperextension. This technique there­ fore is used in cases of patella chond ropathy, for ex­ ample. b: Usage of a rocker bottom placed u nder the mid­ dle of the foot is advantageous in cases of tarsal and tarsometata rsal osteoarthritis. c: A rocker bottom placed at the heads of the meta­ tarsal bones is used in cases of metatarsalgia and hallux rigid us.

1 1.2. Shoes for children At the posterior part of children' s shoes there should be a strong stiffener to keep the heel in a vertical position. Wearing sandals without a stiffener is inappropriate for young children. The heel part should incline from in­ side to outside, while the stiffener inside should extended forward to keep the heel in a stable position. If the doctor considers that an otherwise well-prepared shoe with a stiffener is not sufficient to correct a valgus flat foot, it is necessary to use a shoe with a supinating heel that compensates the outward-leaning (valgus) of the heel. The tasks of the middle part of the shoe are not to let the muscles of the sole stretch and to hold the middle part of the child ' s foot. The anterior part of a child' s shoe is significant a s concerns the position

1 1 . O rt h o p e d i c s h o e s a n d i n s o l e s and movement of the toes. The inside line of the big toe is straight until the age of 5 , after which it deviates from a straight line by only 8- 1 00• The shoe should be at least 5 mm lon­ ger than the foot, so that the toes can be moved freely. The usage of a built-in insole (except for some special indications) is improper since the pad weakens the foot muscles of the child even more. Naturally, orthopedic shoes for children are also custom-made after indi­ vidual foot size measurement, with accesso­ ries and special upper and lower part con­ struction ordered by the doctor on the pre­ scription (e.g. with a straight sole axis, and a pronating heel in cases of clubfoot) .

1 1.3. Shoe and sole insoles The insole (archer, arch support or insert) is an orthopedic aid that must be indicated, or­ dered and verified by the doctor while it is be­ ing worn. The suitable insole forms a func­ tional unity with the shoe, and therefore the form and the material of the insert should be adapted both to the foot and to the shoe.

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83

The task of the insole is t o correct and re­ tain the arched structure of the foot in every ray. Optimization of the distribution of the weight between the sole and the ground is es­ sential, since the insert transmits the body weight between the sole and the ground. The weight distribution is achieved via a pad un­ der the transversal and longitudinal arches. Adj ustment of the posterior foot j oints and keeping them in the right position is the task of the longitudinal arch pad. The pad should restore the balance of the muscles affecting the foot. It is important that the transversal arch is not corrected by the transversal pad: this takes over part of the loading from the metarsal heads, thereby relieving the weight from the metatarsal heads, and dispersing the weight on the longitudinal arch. The material of the insole must be easily shaped and molded, and it should be elastic. A well­ designed size series is essential. Even with the proper indication, a foot insole prepared with the above expectations, will be effective for only a certain period. It is duty of the doctor to inform the patient about the effects of the in­ sole, and that it will be necessary to change to a new pad at the appropriate time.

1 2.

Ka l m a n T6t h

Normal growth, growth disturbances

endings of the bone (later the epiphysis). The secondary ossifying centers typically appear after birth in the long tubular bones (Fig. 1 2 . 1 .),with the exception of the distal femur and the proximal epiphysis of the tibia. The growth of the bone itself is due to an enchondral length gain periosteal bone thick­ ening. The enchondral lengthening (Fig. 12.2.) occurs in the cartilaginous epiphysis fugue (growth plate) which remains cartilagi­ nous, and therefore remains radiologically transparent and clearly observable until the termination of growth. Growth and cell mito­ sis occur in the proliferation zone of the grow­ ing cartilage. Due to the continuous cell mito­ sis the distance between the center of the epiphysis and the center of the diaphysis steadily increases, thereby leading to an in­ crease in length. From a biological aspect, it is crucial that the epiphysis and the metaphysis have an independent and separate blood sup­ ply till the closure of the epiphysis fugue. Periosteal growth is a result of the apposi­ tional activity of the osteoblasts originating from the periosteum, as a consequence of which the width of the tubular bones in­ creases. Endosteally, within the tubular bones, e.g. from the medullary cavity, decom-

This category of diseases includes g rowth dis­ turbances of a general or a local nature that occur in childhood and involve a more than average difference in height or a the length of the limbs and / or axial deviation. The clinical pictures of these conditions are somewhat similar, despite the fact that they may be in­ duced by various endogenous or exogenous causes or even unknown.

12. 1. Physiological growth The process of skeletal development be­ gins during the embryonic phase and ends at puberty with the closure of the growth plate cartilages. At the end of the second embryonic month, the cartilaginous skeleton is already segmented as concerns the main parts, and thus the preliminary skeletal limbs are already visible. The primary ossifying center of the long tubular bones appears in the week 9, al­ though all the primary cores of the tubular bones develop during the intrauterine period. The primary ossifying center is in the middle of the embryonic cartilaginous matrix, (which will later become the diaphysis), while the secondary ossifying centers are at the two a c

c

b e

a -=---#, d

b

e -=--.......

Fig. 12.1. a, c, d, e: Secondary ossification of the vertebra. The secondary ossification nucleus appears at around the age of 16 and full ossification takes place by the age of 23-25. b: A ring-shaped secondary ossification nucleus appears approximately at the age of 7 and fu lly ossifies by the age of 23-25.

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86

1 2 . N o r m a l g rowth, g ro w t h d i st u r ba n ces

I

Table 12.1. Ratio of bone growth

4 2

Fig. 12.2. Enchondral ossification 4: cartilage proliferation zone 1: epiphysis 5: cell degeneration zone 2: growth plate 3: metaphysis 6: ossification zone

position of the bone substance also occurs re­ sulting in a gradual increase in the diameter of the medullary cavity. Both enchondral and periosteal growth oc­ curs in accordance with the biomechanical principle of the developing cartilage being perpendicular to the forces acting on it. Any intrinsic and extrinsic factor disrupting this principle can lead to a growth disturbance (e.g. closure of the epiphysis fugue due to trauma) . The tactics for the treatment of growth dis­ turbances necessitates the consider of two as­ pects. First the proportions of the growth of the epiphysis located at the distal and proxi­ mal ends are well established for all long tu­ bular bones (Table 1 2 . 1 .) . The increase in length is not linear with aging; in certain periods the growth acceler­ ates. When a particular treatment strategy is

Humerus

Proximally 80%, distally 20%

Radius

Proximally 25%, distally 75%

Ulna

Proximally 20%, distally 80%

Femur

Proximally 30%, distally 70%

Tibia

Proximally 57%, distally 43%

Fibula

Proximally 60%, distally 40%

under consideration, therefore the changes in the pace of growth have to be taken into ac­ count. Then again, there are periods during normal development (e.g. puberty) when the ossification ability has difficulty in keeping up with the pace of growth within the pro­ liferative zone of growth plates. Later on, when the pace of growth of the proliferative zone decreases, the ossification can catch up. On the other hand, if any mechanical injury should impair this certain area, it may lead to various diseases (e.g. Scheuermann ' s dis­ ease) . The development of the joint surface regions located at the ends of the long tubular bones is governed by the development within the epiphysis itself.

12.2. Growth disturbances Growth disturbances basically fall into one or other of two categories. First, there are generalized growth disturbances, that affect all developing bones leading to excessive or inhibited growth, producing a too tall or a too short body height. The cause in such cases is usually metabolic and/or endocrine distur­ bance. Secondly, there are local growth distur­ bances, where the defect involves a well de­ fined area (may be a bone) . This could be hypoplasia or hyperplasia, affecting the dis­ eased bone uniformly, while an uneven growth disturbance involving the inside of the bone may be due to the involvement of the

1 2 . N o r m a l g rowth, g r o wt h d i s t u r ba n ces epiphysis, the meta-diaphysis or the growth plate. The resulting appearance differs ac­ cording to the location of the deficiency within the bone . For example, any harmful ef­ fect occurring in the epiphysis will lead to de­ formation of the j oint' s surface (e.g. osteochondrosis dissecans, Perth es -disease) . Growth disturbances occurring in the metaphysis and / or diaphysis generally upset the growth in periosteal width and may also lead to a disparity the in axis. However, most local growth disturbances involve damage caused in the germinate layer of the epiphysis fugue. Some local growth disturbances may be highlighted from an etiological aspect: 1 . Vascularization disturbances: This group includes aseptic osteochondroses and osteochondro-necroses which can be linked to blood supply disorders of un­ known origin. A discussion of these for diseases according to age and localization is presented in the appropriate chapters . 2. Infections: Due to hematogenous spread during childhood, osteomyelitis is mainly localized in the metaphysis, close to the epiphysis fugue, which disrupts the devel­ opment of the epiphysis. In childhood osteomyelitis commonly affects the femur epimetaphyseal region. For example, if this is situated medially, then (due to the growth disturbance here), the unaffected lateral epiphyseal segment will relatively overgrow, creating a varus deformity. The younger the affected patient, the larger the axial deviation may be, and a limb length discrepancy may occur as well. 3 . Tumors: These rarely cause growth distur­ bances, but this chance should be consid­ ered nonetheless. 4. Trauma: Growth disturbances caused by childhood inj uries can be divided into two groups : direct and indirect. The growth disturbance is indirect if the inj ury does not affect the growth plate, but impairs the blood supply of the growth zone, thus pro­ ducing a growth disturbance. A growth disturbance is direct, when an injury af-

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fects the cell-division zone of the growth cartilage resulting in a bridging callus de­ velopment. A bridging callus obstructs the growth of a particular zone in the growth region and, depending on its location and the relatively greater growth of the other growth zones, leads to axial deformities (e.g. if it is medial and anterior, it leads to recurvation and varus; if it is in a lateral or central position it leads to valgus). If the damage causes closure of the whole growth plate, it will lead to a shortening of the limb. 5 . Growth disturbances caused by iatrogenic procedures: a) Post surgery: Growing cartilages may be damaged when bone injuries suf­ fered during childhood are treated. If the fracture does not affect the epiphy­ sis fugue, great care must be taken to use such fixation technique which avoids transepiphyseal fixation. b) Damage caused by x-ray: x-ray irradia­ tion used in the treatment of malignant tumors in childhood may cause growth disturbances. For example x-ray irradi­ ation used to treat the Wilms tumor may lead to radiogenic lumbar sco­ liosis.

12.2. 1. Treatment options for growth disturba nces Conservative treatment is preferred if the degree of shortening of the lower limb is less than 3 centimeters and there is no axial devia­ tion. In such cases orthopedic appliances (an increase of in thickness of the sole of the shoe) are used to compensate the growth distur­ bance. As upper limbs are concerned - as they are not weight-bearing - an upper limb short­ ening causes less functional problems. If the difference in length of the lower limbs is too considerable and even a series of surgical in­ terventions cannot compensate the difference (primarily limb development deficiencies), the use of orthoses is recommended in order to ensure the ability to walk.

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Operative treatment is required if the difference in length of the lower limbs ex­ ceeds 3 centimeters and / or an axis deviation persists. The surgical strategy should always be planned individually. Operative treatment may be applied either before or after the final closure of the growth cartilage. In case of seri­ ous growth disturbances step-by-step correc­ tive treatment is required. From an operative technical aspect, the possibilities include lengthening of the shorter limb and/or shortening the longer limb . Today, instead of maj or limb lengthen­ ing, gradual elongation techniques are consid­ ered more appropriate since the margins of elongation of muscles, nerves and veins are much more constrained when the former tech­ nique is used. Gradual diaphyseal or meta­ physeal elongation may be performed, de­ pending on whether the osteotomy was in the diaphysis or the metaphysis area. Altering the length of limbs requires ex­ treme caution. When limb shortening is per­ formed, the origin and attachment of the mus­ cles draw closer to each other which in turn leads to a certain amount of muscle weaken­ ing, determined by the degree of shortening. Limb lengthening poses a different prob­ lem: the degree of tension of the soft tissues of the body (muscles, nerves, veins) . The contracture of joints above and below the elongation is avoided by continuous physio­ therapy, nevertheless, in some cases the lengthening apparatus has to be augmented with passive supplementary elements. Fur­ ther, the pace at which the bone should be elongated is a difficult question. If lengthen­ ing progresses too rapidly, calcification can­ not proceed at the optimal pace, but if the pace of lengthening is slower than the pace of bone development, then the lengthening will cease before the desired length is achieved.

12.3. Limb deformities Limb shortenings are often encountered together with axis deformities. The deformity of the limb in question can be described by its localization, the degree of deformity and the difference in length between the limbs. In the frontal plane there are valgus and varus deformities, in the sagittal plane ante-curvation (the distal segment of the limb curves back) and retro-curvation (see Chapter 4.2.3 .), while deformities affecting the axis are called outer and inner rotation. Limb deformities may occur for various rea­ sons: � �

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I njury to growth plates (inflammation, tu mor) Post-trau matic condition Bone dysplasia (Paget's disease, fibrous dysplasia) Bone metabolism disorder (rickets, osteomalacia) Weakness of connective tissue, loose ligaments Muscle paralysis (Heine-Medin disease) Compensatory

It is important that a certain axis deviation of the limbs frequently occurs in childhood, but remains within the physiological level : in the lower limbs this involves varus and valgus deformation and torsion of the tibia, the tibia usually curving inward. The child compen­ sates for such a tibia torsion by valgus posi­ tioning of the tarsus and abduction ofthe fore­ foot. These deformities are usually rectified spontaneously during growth, and by the age of 7 to 1 0 such axial deformities have disap­ peared. If not, correctional osteotomy is ad­ vised, since a prolonged axial deformity will lead to uneven pressure on the joint and later on to osteoarthritis (see Chapter 29). Due to the many possible variations, com­ bined treatment is also an option, when the length difference and the axial deformity are corrected at the same time, either in one stage or in several stages.

13.

Tibor Viz ke lety

Bone dysplasias and developmental anomalies

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Bone dysplasias Disturbances in skeletal development and ossification demonstrate high variability in the clinical picture depending on the localiza­ tion and age. A good understanding of the bone dysplasias is provided by the dynamic classi­ fication of Rubin. Fig. 1 3 . 1 . presents the dis­ eases caused by hypoplasia or hyperplasia during skeletal development. The earlier used classification and nomen­ clature of Paris was later further developed by an international group of experts in 1 997. The diseases are divided into three groups from a practical and theoretical point of view: dysostoses, i.e. developmental disturbances of one or more bones, disruptions, i.e. secondary developmental disturbances of the bones, and skeletal dysplasia, i.e. diseases of the chondro-osseal tissue. The osteochondro­ dysplasias are a group of diseases caused by abnormal growth and abnormal development of the bone and/or cartilage (Table 1 3 . 1 .) . W e deal here only with the well-known and frequently occurring forms of bone dysplasias and developmental anomalies.

Table 13. 1. Classification of osteochond rodysplasias I.

11.

Lethal osteochond rodysplasias Chond rodysplasia pu nctata group

Ill. Skeletal dysplasias with predominant metaphyseal involvement - Achondroplasia IV. Skeletal dysplasias with predominant epiphyseal involvement - Multiple epiphyseal dysplasia

V. Skeletal dysplasias with major involvement of the spine - Spondyloepiphyseal dysplasia, congenital form - Spondyloepiphysea l dysplasia, tarda form, X- linked - Diastrophic dwarfism VI. Skeletal dysplasias with multiple dislocations VII. Dysostosis multiplex, complex carbohyd rate storage diseases - Mucopolysaccharidoses I-VI I - Mucopolysaccharidosis I-H (Pfaundler-Hurler disease) - Homocystinu ria VIII. Skeletal dysplasias with predominant involvement of single sites or segments IX. Dysplasias with prominent diaphyseal involvement X.

Skeletal dysplasias with decreased bone density - Osteogenesis imperfecta

XI. Skeletal dysplasias with increased bone density - Osteopoikilosis - Paget's disease - Osteopetrosis (Albers-Schonberg disease) XII. Skeletal dysplasias due to disorganized development of bone constituents - Dysplasia epiphysealis hemimelica - Multiple cartilaginous exostosis (exostosis cartilaginea multiplex) - Enchondromatosis (dyschondroplasia, Oilier disease) - Fibrous dysplasia - Hyperchondroplasia (Marfan syndrome) - Ehlers-Danlos syndrome - Neurofibromatosis XIII. Osteolyses

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1

11

2 12

3 4

13

5 14

15

6 7

16 17

8 18 9 10

1. Epiphyseal hemimelic dysplasia 2. Epiphysis 3. Hyperchondroplasia 4. Endchondromatosis 5. Physis 6. Metaphysis 7. Multiple cartilagineous exostoses 8. Progressive diaphyseal dysplasia 9. Diaphysis 10. Hyperphosphatasaemy 1 1. Spondyloepiphyseal dysplasia 12. Multiple epiphyseal dysplasia 13. Chondrodystrophy 14. Metaphyseal dysplasia 15. Hypophosphatasy 16. Osteoporosis 17. Craniometaphyseal dysplasia 18. Osteogenesis imperfecta 19. Osteopetrosis

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Fig. 13.1. Dynamic classification of bone dysplasias according to Rubin

13. 1. Frequently occurring osteochondrod}'.splasias 13. 1 . 1 . Skeletal dysplasias with predominant metaphyseal involvement �

Achondroplasia (chondrodystrophia fetalis, chondrodysplasia fetalis, chondrodystrophic dwarfism) Etiopathology: Achondroplasia is a developmental disturbance ofthe growth plate, a development is caused by a G 1 1 3 8A mutation of the FGFR3 gene on the chromosome 4 (4p 1 6. 3 ) . It is responsible for coding the fibroblast growth factor receptor. The muta­ tions develop only on the paternal chromo­ somes. The incidence rate of the mutation in­ creases with increasing age of the father. The altered receptor function results in inappropri­ ate differentiation of the growth plate (physis) cartilage cells and ultimately deficient en­ chondral growth.

Major clinical findings: Disproportionate dwarfism with short limbs, wide and short hands, and varus curved lower extremities. The head is disproportionately large, with a depressed nasal bridge (Figures 13.2. a, b). The endocrine and sexual functions and intel­ ligence level are normal.

The long tubular bones are short (often less than one-third of the normal length). On radiographic pictures, the ends of the bones are massive, and the acetabulum and the spine show very special radiographic features (Fig. 13.3. a, b). Incidence: This condition is recognizable at birth. The incidence rate is one patient in 3 0 . 000 live births. In the tarda form the clinical symptoms are not as markedly expressed. These dwarfs are usually intelligent with great sense of humor. Once they were jesters of the kings. Though examples present these patients may accept their dwarfism, creating closed communities, but there are nowadays increas-

1 3 . B o n e d y s p l a s i a s a n d d e v e l o p m e n t a l a n o m a l i es a

b

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Fig. 13.2. Achondroplasia a} An eight-year-old normal boy and an eight-yea r-old achondroplasia patient. b} The typical trunk and extremity length relations in achondroplasia dwarf patient (rhizomelia). a

b

Fig. 13.3. The long tubular bones are short and thick, while the metaphysis is broadened in an achondroplasia dwarf: Upper extremity bones (a) and lower extremity bones (b)

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ingly frequent requests for orthopedic length­ ening surgery to enable them to attain nearly normal height. In special cases modem limb lengthening techniques provide a possibility to reach the lower border of normal body height through bilateral elongation of the thighs and lower legs (a 1 0 cm lengthening each). These long surgical procedures we can definitely help these patients to play a more active in the society and in modem technical environment.

tarda form the abnormality of the epiphyses frequently lead to precocious and often pro­ gressive early degenerative osteoarthritis, with a short stature and short fingers . It is hard to influence the severe disturbance of joint function.

13. 1.3. Skeletal dysplasias with ma­ jor involvement of the spine �

13.1.2. Skeletal dysplasias with predominant epiphyseal involvement

Spondyloepiphyseal dysplasia congenita (SED) (Spranger- Wiedemann disease, osteochondrodystrophia deformans, Strudwick disease)

This is a hypoplasia of the epiphysis. �

Multiple epiphyseal dysplasia (MED) (Fairbank disease, dysostosis epiphysealis multiplex, dysplasia epiphysealis multiplex) In this disease abnormal epiphyseal ossifi­ cation occurs in the ossific nuclei. Point-like ossifications are observable on radiographic pictures of the cartilaginous epiphyses. This is dwarfism with shortening mainly of the upper parts of upper and lower extremities. In the a

Major clinical findings: The extremities and the trunk a re short and dwarfism is observ­ a ble at birth. Delayed ossification and defor­ m ities are visible in the radiographic pictu res.

Incidence : This is a rare developmental disease which is observable at birth . The development of the vertebral bodies is disturbed with flattening, immaturity and an­ terior ossification defects of the vertebral bodb

Fig. 13.4. Spondyloepiphyseal dysplasia congenita. Dorsolumbar kyphosis with ventral narrowing of the vertebral bodies (a) and disturbance of the ossification in the pelvic bones and femurs (b).

1 3 . B o n e d y s p l a s i a s a n d d e ve l o p m e n t a l a n o m a l i e s

ies combined with a dorsally wedged defor­ mity (Fig. 13.4. a) and lumbodorsal kyphosis. Retarded ossification of the epiphysis of the tubular bones with irregularity is common (Fig. 13.4. b) with protrusion of the aceta­ bulum. A disproportionately short stature is typical, with brachydactyly. Later muscle weakness and progressive myopia may de­ velop with slightly protruding eyes will be presented. The deformities and short stature can be corrected to a certain extent. �

Spondyloepiphyseal dysplasia tarda. Major clinical findings : A short stature due to a short spine with relatively long ex­ tremities. The radiographic pictures is typical : general ized flattening of the vertebral bodies, named platyspondyly. This is an X-linked re­ cessive disease that occurs in males. The symptoms are milder than those in the con­ genital form. In this disease, premature osteo­ arthrosis is common, most notably in the hips and shoulders.

13. 1.4. Dysostosis multiplex, complex carbohydrate storage diseases �

Mucopolysaccharidoses The group of mucopolysaccharidoses, oligosaccharidoses and glycoproteinoses in­ cludes all of those diseases in which generally disturbed ossification causing a short stature or dwarfism with an increased level of mucopolysaccharides in the urine. According to the form of genetic transmission and ap­ pearance of corneal opacity and metachro­ matic granules in lymphocytes many types of mucopolysaccharidoses can be differentiated. (Pfaundler-Hurler disease, Hunter disease, Sanfilippo disease, Scheie disease, Maro­ teaux-Lamy disease, Morquio- Ulrich disease etc.). The best known form is the gargoylism. �

Gargoylism (Pfaundler-Hurler disease) The genetic transmission is autosomal re­ cessive. The maj or clinical findings are the short stature, a di stinctive facial appearance,

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corneal opacity, mental retardation, hepato­ megaly and splenomegaly. The distinctive fa­ cial appearance is due to the wide head, the prominent frontal bone, the massive mandible and the widely spaced prominent eyes gives. The spinal column and the hands are short, and thoracolumbar kyphosis occurs . There is a significant delay in the development of the movements with mental retardation. The cor­ neal opacity is observed between the ages of one and three years. The radiographic pictures show a characteristic deformity of the verte­ bral bodies, as an ovoid-biconvex (immature) shape with anterior narrowing caused by antero-superior ossification defects . The ra­ diographic symptoms are usually more severe in the upper extremities than in the lower ones. The intramedullary space of tubular bones is widened, the epiphyses are flattened and multicentric. The radius and the ulna are short. There is an increased urinary excretion of dermatan sui fate and heparin monosulfate. The aim of orthopedic surgical interventions is to correct the extremity deformities and fa­ cilitate nursing.

13. 1.5. Skeletal dysplasias with decreased bone density �

Osteogenesis imperfecta

There is an increased generalized bone fragil­ ity. Major clin ical symptoms: Bowing deformi­ ties of the tubular bones with blue sclera in some cases (Fig. 13.5.).

Incidence: This varies with the type of the disease. It can exist at birth, but can develop later too . The bones are narrow and fragile, with poorly trabeculated spongiosa, and the cortex of the tubular bones is thin because of the quantitative and structural deficits of type I collagen synthesis leading to a lack of peri­ osteal new bone formation. There are signs of previously healed bone fractures and sub se-

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Fig. 13.5. Typical blue sclera in a child with osteogenesis imperfecta.

quent deformities. The vertebral bodies are flattened, often with a biconcave shape. In the tarda form there is a decreased bone density with thinner cortex and signs of fractures and

Fig. 13.6. Curved, deformed bones with thin cortex i n the lower extremities in an osteogenesis imperfecta pa­ tient.

microfractures (Fig. 13.6.). In addition the skin is thin and translucent, and the sclera is blue in some types. The development of the teeth may be abnormal (dentinogenesis imperfecta), point-like skin hemorrhage can occur secondary to an increased capillary fra­ gility, and there may be mild ligamentous hyperlaxity. Conductive or mixed hearing loss or deafness can develop . Four classes of osteogenesis imperfecta may be distinguished, according to time ofthe manifestation of the disease, the symptoms associated with fragility, and the type of ge­ netic transmission. Type 1 : Osteogenesis imperfecta tarda. Osteopsathyrosis. There is usually no sign of abnormal bone fragility at birth. Fractures occur later but are not too fre­ quent. The incidence of scoliosis is 20 per­ cent. The sclera is blue and ligamentous hyperlaxity is observed. Deafness devel­ ops in 40 percent of the patient. The ge­ netic transmission is autosomal dominant. Type 2: Lethal neonatal osteogenesis im­ perfecta. Many bone features can occur already during intrauterine life (some­ times more than one hundred and healed fractures can be detected). Fractures are very frequent after birth too. Because of the healing in malposition, the long tubu­ lar bones are curved, deformed and wid­ ened. The babies usually die early. The ge­ netic transmission is autosomal recessive. Type 3: Progressive deforming osteogene­ sis imperfecta. This is also congenital. Fractures already occur during the first few weeks of extrauterine life or during the first year. The long tubular bones and spinal column develop deformities com­ bined with scoliosis. The sclera of the in­ fant is blue, but later the color of the sclera normalizes. This disease with its serious outcome has autosomal recessive genetic transmission. Type 4: Osteogenesis imperfecta tarda. The fragility of the bones ranges from moder­ ate to severe. The color of the sclera is blue during the neonatal period, but later be-

1 3 . B o n e d y s p l a s i a s a n d d e ve l o p m e n t a l a n o m a l i e s comes normal. The long tubular bones and spinal column are deformed. This type can occur with or without dentinogenesis imperfecta. There is an X chromo­ some-linked version with autosomal dom­ inant genetic transmission. Therapy: Good results have recently been published following cyclic bisphosphonate treatment which provides stronger bones and decreased bone fragility. Fractures heal well by the standard treatment with the aims of good alignment and the prevention of defor­ mities. The deformities can surgically be cor­ rected by osteotomies, fixed by different types of intramedullary nails or wide Kirschner wires. Plaster fixation and skeletal or non­ skeletal traction are applicable to treat frac-

Fig. 13.7. Correction of the curved femur in osteogenesis imperfecta, with rotation of the segments and intramedullary fixation.

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tures in osteogenesis imperfecta. Seriously curved long tubular bones need multilevel osteotomies (salami osteotomy) with the cor­ rection of rotation deformity in different seg­ ments fixed by intramedullary nails (Fig. 13.7.).

13. 1.6. Skeletal dysplasias with increased bone density �

Paget's disease (osteitis deformans)

The aetiology of this disease is not known. It involves chronic disturbance of the bone transformation with abnormally increased osteoblast and osteoclast activity.

Etiopathology : Viral infection, a genetic predisposition, an endocrine malfunction or disturbance of the phosphorus metabolism are supposed as etiologic factors. The essence of the disease is osseous tissue transformation with simultaneously increased bone forma­ tion and bone resorption. The intramedullary space is usually filled up with fibrous tissue. It may occur in only one bone, rarely turns into a generalized form. It develops more frequently in males in the fourth or fifth decade of life . Major clinical findings : At the beginning the complaints are usually mild with pain in the extremities with or without weight­ bearing. The patient often observes the pro­ gressive curving deformity of the femur or tibia. The volume of the skull can increase and the hat may be noted to tightly fitting, if the disease is localized in the head too. In these cases, neurological symptoms can develop, with a mixed hearing and vision loss. Major radiologic features : The struc­ tural changes of the involved bone are very typical. The normal bone structure is lost and interspersed trabecular areas of increased or decreased density substitute the normal trabecular osseous structure of spongiosa (Fig. 1 3.8.), followed by dissolution of the cortical architecture and replacement by strands of longitudinally oriented trabeculae. The bones become thicker and curved.

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Fig. 13.8. Paget's disease: loss of normal bone structure and interspersed areas of increased and decreased density of the trabecu lae in the right pelvic half (a), and curved scabbard- like tibia (b).

Therapy: The unknown cause of this dis­ ease can clearly not be treated. Clinical, radio­ graphic and laboratory improvements can be achieved with intravenous bisphosphonate therapy. Osteosynthesis is performed in cases ofpathologic fractures of the seriously curved bones. Severe osteoarthrosis of the large j oints demands hip or knee arthroplasty. Fibrosarcoma, osteosarcoma or malig­ nant fibrous histiocytoma develop in the bones in 5-20% of patients with Paget' s dis­ ease. In cases of malignant transformation, the clinical and radiographic symptoms show rapid progression. After the definitive diagno­ sis, amputation or exarticulation is necessary. �

Osteopetrosis (Albers-Schonberg disease, marble disease, j uvenile osteopetrosis)

The term osteopetrosis is applied to a group of disorders caused by defective bone resorp­ tion due to a n impaired osteoclast function. The entire skeleton is sclerotic, and the corti­ cal bone and the spongiosa do not separate (Fig. 13.9.).

Fig. 13.9. Typical radiographic picture of osteopetrosis: the pelvis shows cortical-like radiodense bone every­ where, the intramedullary spongiosa does not sepa­ rate from the cortical bone.

The vertebral bodies show a frame-like ap­ pearance in the radiographs, the bones are brittle, and there is myelosclerosis. Defects of

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vision or hearing, facial paresis, hydrocepha­ lus can develop leading to early death. In the tarda form sclerotic changes are observed only in some regions of the skeleton, with mild clinical process.

13. 1.7. Skeletal dysplasias due to the disorganized development of bone constituens �

Dysplasia epiphysealis hemimelica ( Trevor's disease, tarsomegaly, tarsal epiphyseal aclasis) This is a consequence of epiphyseal over­ growth. Independent ossific nuclei exist adj a­ cent to the original epiphyses in the medial or lateral part of the extremity, because of the ab­ normally increased growth of articular carti­ lage. They are separated from the original epiphysis by a narrow gap, which persists dur­ ing bony maturation. This can be regarded as an epiphyseal exostosis. Resection IS sug­ gested in case of complaints. �

Multiple cartilaginous exostosis (exostosis cartilaginea multiplex, multiplex osteochondromatosis, hereditary multiple exostosis) Exostoses occur on the metaphysis of tu­ bular bones covered by cartilage. They are usually detected after two years of age. The cartilage covering the exostosis is similar to the cartilage of the growth plate, and the plane of this cartilage is perpendicular to the growth plate. It can occur rarely in cubic and flat bones too. The bones can be deformed short­ ened and luxation of the radial head and a short stature may be observed. The tendons and muscles sometimes jump over the exostosis next to the joints during movement, causing complains. An exostosis can fracture resulting in inflammation in the surrounding bursa. Surgical resection is required for large, disturbing and painful exostoses. It is also suggested in cases of an exostosis that under­ goes further growth after bony maturation, as the possibility of malignant transformation is 3-6 percent (Fig. 13.1 0.).

Fig. 13.10. Typical radiographic picture of osteochondromas on the distal metaphysis of the femur and on the proxi­ mal metaphysis of the tibia in multiple cartilaginous exostosis.

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Enchondromatosis (dyschondroplasia, Oilier's disease) This is caused by an abnormally increased cell division rate in the hypertrophic zone of the growth plate. The metaphyses of the long tubular bones are widened and islands of car­ tilage are observed inside situated parallel to the longitudinal alignment of the bone (Fig. 1 3 . 1 1 .) . Limb length discrepancy and deformity may develop, which can be treated by surgical intervention. Oilier disease is enchondro­ matosis which occurs only unilaterally. In the MafJucci syndrome the enchondromatosis is associated with subcutaneous hemangiomata. �

Fibrous dysplasia (JafJe-Lichtenstein disease)

This is a developmental disturbance of the bones. The osseous tissue is replaced by fi

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Fig. 13.11. Dyschondroplasia (enchondromatosis): Large carti­ lage islands in the proximal and distal metaphyses in the bones of the lower leg

Fig. 13.12. brous tissue and premature bone trabeculae. Monoostotic and polyostotic forms are known.

Etiopathology : The cause of fibrous dysplasia is a somatic gene mutation that re­ sults in the enhanced activity of a cell mem­ brane-linked protein (G-protein) and in­ creases the intracellular concentrations of a few proteins responsible for gene regulation. It leads to abnormal differentiation of the os­ teoblasts and the development of fibrous tis­ sue which can not be mineralized. Moreover the activity of the osteoclasts is increased re­ sulting in intensive bone re sorption. Major radiographic features : The long tubular bones show eccentric but not cortical lesions, with endosteal scalloping, occasion­ ally surrounded by a sclerotic margin. The lytic lesions are often multiple with milk glass-like radiographic appearance (Fig. 1 3 . 1 2.). Maj or clinical findings : In severe in­ volvement the softened bone often curves be­ cause of the weight bearing. The "shepherd' s crook" femur deformity i s typical i n fibrous

Fibrous dysplasia: "shepherd crook" deformity of the femur with milk glass-like lytic defects.

dysplasia. In the McCune-A lbright syndrome, the fibrous dysplasia is combined with unilat­ eral cafe-au-Iait spots with irregular margins and other disturbances of the endocrine func­ tions. Very rarely, intramuscular myxomas are coupled with fibrous dysplasia (Maza­ braud syndrome) . Therapy: Earlier the only method for the treatment of fibrous dysplasia with a severe involvement was surgical excochleation of the lesion which was than filled with bone chips. Spontaneous pathologic fractures can occur in case of seriously curved deformities, and stabilization with osteosynthesis is very difficult because the screws can not be fixed in the soft bone. Surprisingly good results have recently been published after long bisphosphonates treatment. �

Hyperchondroplasia (Marfan syndrome, arachnodactyly) The Marfan syndrome is a well-known autosomal dominant disorder with variable

1 3 . B o n e d y s p l a s i a s a n d d e ve l o p m e n t a l a n o m a l i e s expresslVlty. Its cause i s a mutation o f the fibrillin gene which results in a disturbance of elastic fib er production. The maj or clinical findings are concentrated in three regions of the body: the eyes, the cardiovascular system, and the skeletal system. Major clinical findings : Bilateral lens displacement (ectopia lentis) is typical be­ cause of the insufficient function of the sus­ pensory ligaments. Myopia is frequent and blue sclera, ptosis and cataract sometimes oc­ cur. The most serious cardiovascular manifes­ tations are aortic aneurysm, aortic dissection and insufficiency of the mitral and tricuspidal valves because of the fragmentation of elastic fibers in the aorta and valves. The most com­ mon alterations involve the skeletal system. There is abnormal activity in the proliferative layer of the growth plate. Children with Mar­ fan syndrome are tall with excessive limb and digital length, resembling spider legs (arach­ nodactyly), combined with symptoms of gen­ eralized joint laxity. Hypermobility of the ar­ ticulations, dislocations, flatfoot and a gothic high-arched palate are frequent clinical find­ ings. The pelvis is wider, the overgrowth of the ribs results in a chest deformity (pectus excavatum and carinatum) . Progressive sco­ liosis frequently occurs (Chapter 24.5 .2.2.). The major clinical symptoms are very sim­ ilar in homocystinuria. •

Ehlers-Danlos syndrome

The Ehler-Danlos syndrome is a group of heri­ table connective tissue disorders that share the common features of skin hyper­ extensibility, articular hyper mobility and tis­ sue fragility. There is genetic heterogeneity mainly with autosomal dominant inheritance.

Major clinical findings : The velvety, ex­ tendable, white and vulnerable skin is typical, with calcification after injections. Hyper­ extensibility of the articulations (rubber man), luxations, foot deformities, kyphoscoliosis, blue sclera and other developmental anoma­ lies of the eyes can occur in this syndrome. It is supposed that the causes of the disease are a

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decrease of elastic fibers of the corium and the development of abnormal collagen fibers. Therapy: The standard orthopaedic con­ servative and surgical methods are applied to treat foot deformities, recurvation of the knee and the frequent congenital hip dislocation. •

Neurofibromatosis (von Recklinghausen disease) Neurofibromatosis is a frequent disease with autosomal dominant inheritance. Its inci­ dence is 1 : 3 000. It occurs with identical inci­ dence and severity of clinical appearance in females and males. Type I neurofibromatosis (known as von Recklinghausen disease) shows mainly peripheral involvement: subcu­ taneous nodules (neurofibromas), pigmented skin lesions (cafe-au-lait spots), pigmented iris hamartomas (Lisch nodules), scoliosis, narrow, long tubular bones. Type 11 is a cen­ tral form characterized by fewer peripheral, but more intracranial lesions than in type I, in­ cluding acoustic neuromata, spinal involve­ ment, cataract. Major clinical findings : The type I form develops in infancy. A varus tibia deformity (crus varum congenitum) and juvenile pro­ gressive scoliosis are typical. Spontaneous fractures occur because of the varus deformity of the lower leg with a reduced healing ability, leading to pseudo-arthrosis of the tibia. Com­ pression fractures of the vertebrae develop be­ cause of the destruction of the vertebral bod­ ies caused by the neurofibromas leading to very progressive scoliosis with short curves and often neurological deficits (Chapter 24. 5 .2 . ) . Therapy: In cases of scoliosis early surgi­ cal intervention is suggested (spondylodesis with internal fixation). Treatment of the tibia pseudo-arthrosis is extremely difficult be­ cause of the poor healing ability. The pse­ udo-arthrosis can be resected and vascu­ larized bone graft can be used, fixed by llizarov device to compress the site of pseudo-arthrosis and to attain lengthening proximally. Unfortunately, amputation is nec­ essary in unsuccessful cases.

14.

La sz l 6 B u cs i

Metabolic diseases of the bone

Metabolic diseases of the bone develop as a consequence of various disorders related to bone formation, mineralization and remodel­ ing. These diseases are generally classified into two major categories : one category com­ prises osteopenic conditions, like osteoporo­ sis, osteomalacia, hyperparathyroidism and osteopenia associated with other illnesses. In these cases a decrease in bone substance and inadequate mineralization are observed. The other category comprises osteo­ sclerotic conditions such as Paget ' s disease, osteopetrosis, which are accompanied by an increase in bone mass as a consequence of a bone remodeling disorder. Osteopenia may develop as a result of a proportional reduction (30% organic, 70% in­ organic) in the bone components, e.g. in os­ teoporosis, or as a result of shift in this ratio, as in osteomalacia, which indicates predomi­ nantly a decrease in the level of mineral sub­ stances in the bone. In certain cases, osteo­ penia or a reduction in bone mass occurs lo­ cally (immobilization, inflammation, neo­ plasm), while in other cases it may exhibit a combined character, and develop in both a widespread manner and localized (hyper­ parathyroidism) (Table 1 4 . 1 .) .

classifications, they are grouped collectively under the term of involution osteoporosis. Etiopathology. As a result of the signifi­ cant developments in medicine in the past 1 00- 1 50 years, life expectancy at birth has in­ creased considerably, and the number of de­ cades spent with a deficiency of estrogen and gestagenic hormones entail serious risk fac­ tors for the skeletal system. The accelerated pace of everyday life, an unhealthy lifestyle (the lack of exercise, phosphate-rich nutrition,

a

b

14. 1. Osteoporosis Osteoporosis is a generalized, progressive dis­ ease of the skeletal system which involves a reduction in bone mass, impairment of the microarchitecture and a decrease in the bone density while the bone proportions are main­ tained, leading to increased fragility of the bone.

Fig. 14.1.

Postmenopausal and senile osteoporosis are generally distinguished, although in some

Reconstructed image of normal (a) and osteoporotic (b) cancellous bone tissue 3D-G.

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1 4 . Meta bo l i c d i s e a s e s of t h e b o n e

and a n extremely low calcium intake among the Hungarian population) and the ever greater use of medication harmful to the skel­ etal system (steroids, certain antiepileptic and anticoagulant drugs, thyroid medicines) fur­ ther increase the risk and account for the fact that in Hungary approximately 3 00000 men and 600 000 women are currently affected by osteoporosis. Osteoporosis is the manifestation of de­ crease in the cancellous and cortical bone sub­ stance. The bone trabeculae decompose, and microfractures develop on them (Fig. 1 4 . 1 . a, b). The cancellous bone trabeculae do not dis­ integrate in the same manner throughout the organism; in the femur neck and the vertebral bodies, the push-pull traj ection lines persist for a long time. Osteoporosis instigates bone fractures. In a large number of cases, the fracture occurs following a trivial trauma or a fall, but it may even result from coughing, sneezing or occurs spontaneously. Prior to the fracture, osteopo­ rosis does not induce any complaints; it at­ tacks its victims as a silent epidemic. The fractures habitually situated in typical locations. Following menopause, as a conse­ quence of the rapid bone density reduction,

predominantly fractures of the cancellous bone substances (the vertebral body, distal end of the radius) occur, while as time passes, the cortical bone mass also decreases. In old age, coordination disorders, the de­ terioration of eyesight, and dizziness addi­ tionally contribute to elderly patients falling without protection, and further types of bone fractures occur; in the hip area, at the proxi­ mal end of the humerus. It has been estimated that these conditions are responsible for 2528 000 fractures at the distal end of the radius, 3 0-40 000 vertebral body fractures, 1 5 000 fractures in the hip area, and 8- 1 0 proximal humerus fractures each year in Hungary. Clinical symptoms. The first step in the recognition process is conventional history recording, which discloses the risk factors, and allows identification of the affected popu­ lation with higher efficiency. The most impor­ tant risk factors are the age and a reduced min­ eral bone mass. The proven risk factors of bone fracture include a low body mass, previ­ ous bone fractures, accelerated remodeling, the regular intake of glucocorticoids, the exis­ tence of known osteoporosis-causing ill­ nesses and conditions that increase the risk of

Table 14.1. Differential diagnostics of bone metabolism diseases based on laboratory and X-ray examinations Diagnosis

Serum-Ca

Osteoporosis

N

Osteomalacia Hyperparathyroidism Secondary renal hyperparathyroidism Paget's disease

Tumor metastasis

(N

=

normal

N

N

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I nfection

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N

N

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i ncreased

t

=

decreased .l'

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=

Isotope

Frame, wedge, fish vertebra

+ (in fractu res)

Looser-zones, wedge, fish ++ vertebra Subperiosteal usuration, cysts

+

Plaited bone structure

++

Localized lytic-sclerotic

+

Localized lytic -sclerotic

+

moderately increased

'" =

+

moderately decreased

1 4 . Meta b o l i c d i s e a s e s of t h e bo n e

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Fig. 14.2. Female patient suffering from osteoporosis: increased spinal kyphosis, protruding abdomen, typical transversal plica on the torso.

Fig. 14.3. Typical X-ray image of an osteoporotic spine: "frame verte­ brae" lumbar 3 "fish vertebra ", lum­ bar 5 flat vertebra

accidents. Genetic examinations have fur­ nished an ever increasing number of data con­ firming the role of mutations of the colla­ gen- I A I gene. Among the physical parame­ ters, emphasis should be placed on decreases in body height and weight, an intensification of kyphosis, the appearance of transversal plicas on the trunk, a decrease of the distance between the lower costal arch and the iliac crest, and an increase in the ratio in the dis­ tance between the widespread arms and body height should be emphasized (Fig. 1 4.2.). X-ray signs : A traditional X-ray examina­ tion facilitates inspection of the shape of the bone and indicates whether the osteopathy is of a diffuse or a local nature. The classical ra­ diological sign of osteoporosis is a semi­ transparent vertebral body, with fine vertical streaks and sclerotic end-plates. The most im­ portant change is in the shape of the vertebra (end-plate implosion, development of wedge

vertebrae, biconcavity, fish shaped vertebrae, total compression of vertebrae, flat vertebrae) (Fig. 1 4.3.), which is most common along the thoracic and lumbar section, especially by the dorsolumbar transition. Multiple compres­ sions often occur. In tubular bones, osteopo­ rosis is manifested in a thinning of the cortical layer. An accurate assessment of bone density is not possible from a traditional X-ray exami­ nation, since it is not sensitive enough. Osteo­ porosis can only be diagnosed in case of a 3 0% decrease in the mineral components. The appearance of the bones also depends on the duration of the X-ray exposure. Osteodensitometric examinations, in which the patients ' bone mineral component contents in various positions are compared with those of a control group of the same age range, and by means of various measurement techniques (SXA, pDEXA, DEXA) , are of fundamental importance in diagnostics. In ev-

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Bone densitometry evaluation sheet of lu mbal vertebrae performed with a DEXA device.

eryday practice, both peripheral measure­ ments (the distal end of the radius, the corticalis of the central third of the radius, phalanges, the heel bone), and central mea­ surements (the vertebral bodies, the hip area) are also of maj or significance (Fig. 1 4.4.).

With the extent of deviation from the juvenile peak body mass expressed in standard devia­ tion (SO) taken as the T-score, the WHO has defined osteopenia (a moderately reduced body mass) as a T-score between -, and -2.5 SO and osteoporosis (a significantly reduced bone mineral content) T-score less than -2.5.

Table 14.2. Treatment of different forms of osteomalacia Disease

Vitamin 02

2S-hydroxy Vitamin 03

Vitamin 0 deficient nutrition

50 000 Ulweek

Malabsorption

50 000 U/day

20-200 flg/day

Osteomalacia due to anti-convulsion d rugs

50 000 U/day

20-200 flg/day

Renal osteomalacia Metabolic acidosis X-chromosome linked hypophosphatemia

7,2S-dihydroxy Vitamin 03

1-2 flg/day 50 000 U/day

1-2 flg/day 2-3 flg/day

1 4 . Meta b o l i c d i s e a s e s of t h e bo n e

Laboratory examinations. Laboratory ex­ aminations play an important role in deter­ mining the dynamics of osteoporosis, and in distinguishing the condition from other osteo­ penic illnesses (Table 14.2.). Treatment. The following drugs may be utilized in the treatment of osteoporosis: � �

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calcium Vitamin D derivatives Hormone products Bisphosphonates Tibolone Selective estrogen receptor modulators Calcitonin Anabolic hormones

Orthopedic aspects of osteoporosis. It is generally the traumatology department that handles osteoporosis-related fractures of the hip area and the wrist, in the framework of emergency care. Regarding the orthopedic aspect, the treat­ ment of vertebral fractures occurring as a re­ sult of osteoporosis is of significance. The first step is to establish how many vertebrae are fractured, and whether the fracture is sta­ ble or not. In most cases, the situation is a sta­ ble fracture with no neurological symptoms. Conservative treatment is advocated: bed rest in the first few days, alleviation of the severe pain: a calcitonin nose spray, muscle relax­ ants, non-steroid anti-inflammatory drugs (in­ creased risk of gastrointestinal ulcer ! ) . Cor­ sets should be prescribed as required by indi­ vidual conditions, since many patients can not tolerate corsets. In cases of unstable fractures, semi-flexible, elastic corsets may be pre­ scribed. Early mobilization and careful phys­ iotherapy are important. Rarely, in case of persistent complaints, severe pain or neurological symptoms, sur­ gery may be suggested, removal of the verte­ bral body fragments forced into the vertebral canal, and stabilization of the spine (flexible thoracolumbar transpedicular fixation). Per­ cutaneous vertebroplasty is a modem method, in which liquid bone cement is injected into

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the vertebral body i n question under image in­ tensifier control; as is kyphoplasty, which en­ tails inflating a balloon in the affected verte­ bral body, and then inj ecting liquid bone ce­ ment into it. It is important for the orthopedic surgeon to be conscious of the fact that screws and wires loosen more easily from weakened osteoporotic bones. Hence more stable fixing techniques should be utilized: in spine, a lon­ ger section has to be secured than for normal patients, and in hip arthroplasty, a cemented implant is advisable.

14.2. Osteomalacia (mollities ossium) Osteomalacia i s a metabolic disease reflecting a disorder in the mineralization of the newly formed osteoid, which results in the develop­ ment of an osteopenic condition, with all the relevant symptoms.

Pathology. Many factors may influence the development of osteomalacia. A vitamin D deficiency, a disorder in the its synthesis, an absorption disorder caused by bowel illness, acquired or hereditary liver and kidney dis­ eases, and intoxication caused by various heavy metals can all be root causes. Osteo­ malacia often arises in the elderly, besides the lack of sunshine, this reflects the absorption disorders developing in such patients, result­ ing in metabolic diseases of the bone. Com­ monly prescribed anti-convulsion drugs cause osteomalacia through the enzyme induction taking place in the liver. Osteomalacia can often be observed in pa­ tients undergoing dialysis, the main reason for this condition is aluminum intoxication. In a significant proportion of the cases, patients are diagnosed with a combined condition des­ ignated osteoporo-malacia. Clinical symptoms. The clinical diagno­ sis of osteomalacia is often problematic, since the patients ' complaints are not specific; the symptoms include muscle weakness in the

106

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1 4 . M eta b o l i c d i s e a s e s of t h e b o n e

Laboratory signs. Diverse forms of osteomalacia may demonstrate different signs. Both increased alkaline phosphatase levels and low Ca and P levels are often char­ acteristic of osteomalacia (see Table 1 4. l .). The result of assessment of the patient' s vita­ min D metabolites may also be decisive (see Chapter 1 4 . 1 ) . I n many cases, a bone biopsy i s necessary in order to establish an exact diagnosis. The result of the histology will unquestionably re­ veal the extreme rises in the breadth and ex­ tent of the osteoid edge, and, tetracycline trac­ ing can help in the confirmation of mineral­ ization disorders .

" " Looser zones on the meta- diaphysis o f both tibia (marked by arrows, biplanar X-ray of tibia).

proximal limbs and diffuse pain. The patients are generally gracile in build and suffer from a hypotonic condition. X-ray signs: From a radiological aspect, the