Netter's Orthopaedics (Netter Clinical Science)

488 Pages·2005·34.2 MB·English

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Preface
Netter’s Orthopaedicsis an essential text on the pathophysiology, diagnosis, and treatment of
musculoskeletal disorders. The need for such a book results from the commonality of these dis-
orders, which are second only to respiratory illnesses as a reason that patients seek medical care,
and their diversity, in that they comprise everything from injuries and infections to metabolic and
neoplastic diseases.
Patients with conditions affecting the musculoskeletal system present in many settings, re-
quiring that virtually all health care providers be familiar with the diagnosis and treatment of
these disorders. This book, therefore, is intended for use by the many clinicians who will see
these patients—students in medicine, physical therapy, and osteopathy, and residents in primary
care, orthopaedics, family practice, and emergency medicine.
The first 12 chapters of Netter’s Orthopaedicsare concerned with topics related to the entire
musculoskeletal system, and provide principles that can be applied to the management of many
disorders. The final 7 chapters are organized by region, and offer techniques of diagnosis and
treatment specific to each region. Given the widely different backgrounds of the anticipated
readers of this book, we have tried throughout to make the text as accessible as possible, pre-
senting practical information in a clear and straightforward manner.
Although the multiplicity and variety of musculoskeletal disorders may make learning this sub-
ject seem daunting, an understanding of the anatomy and basic science pertaining to the mus-
culoskeletal system, combined with fundamental principles of evaluation and treatment, can
guide most diagnostic and therapeutic interventions. Therefore, each chapter of this text begins
with relevant basic science to lay the foundation for understanding the pathophysiology, diag-
nosis, and treatment of the clinical conditions. Because knowledge of anatomy is crucial to the
evaluation and treatment of musculoskeletal conditions, this component of basic science has re-
ceived particular emphasis.
All of the authors owe a great debt to Frank H. Netter, MD, the medical illustrator who cre-
ated the majority of the illustrations in this book. Dr. Netter’s legacy, and his importance in med-
ical education, cannot be overstated. Through his art, Dr. Netter has been a mentor to thousands
of physicians and allied health professionals. His precise and beautifully rendered depictions of
the human body in health and illness communicate, as no writer can, the essential concepts of
basic science and applied medicine that every student must learn. It was Dr. Netter’s belief that
a medical illustration is of little value if it does not provide the student with an essential point that
has application in the practice of medicine. Examination of any of Dr. Netter’s works in this book
will demonstrate his dedication to that principle.
Although much of Dr. Netter’s work is just as relevant today as it was when he created it, new
techniques and procedures developed since his death in 1991 have caused us to call upon the
talents of his successors, particularly John A. Craig, MD, and Carlos A. G. Machado, MD. As will
be seen from their work, these artists, trained in the Netter tradition, faithfully uphold the high
standards that Dr. Netter set.
The authors and illustrators hope that Netter’s Orthopaedicswill be a valuable resource for
the many individuals who care for patients with these often complex and challenging conditions.
Walter B. Greene, MD
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Acknowledgments
I would like to acknowledge the staff at Saunders who worked on this book and, in particular,
Paul Kelly and Greg Otis who coordinated the development of this project, Jennifer Surich who
managed the editorial process, Jonathan Dimes who directed the art program, and Marybeth
Thiel for providing assistance and support throughout all stages of the project. I would also like
to thank Mary Berry, development editor. Their extraordinary patience and skills were pivotal in
this publication.
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List of Contributing Authors
Walter B. Greene, MD Derrick J. Fluhme, MD
OrthoCarolina Associate Partner
Charlotte, NC South Hills Orthopaedic Surgical Associates
St. Clair Hospital
Roy K. Aaron, MD Pittsburgh, PA
Professor
Department of Orthopaedics Freddie H. Fu, MD
Brown University School of Medicine David Silver Professor and Chairman
Providence, RI Department of Orthopaedic Surgery
University of Pittsburgh School of Medicine
Jeffrey O. Anglen, MD, FACS Pittsburgh, PA
Professor and Chairman
Department of Orthopaedics Barry J. Gainor, MD
Indiana University Professor
Indianapolis, IN Department of Orthopaedic Surgery
University of Missouri Hospital and Clinics
Judith F. Baumhauer, MD Columbia, MO
Professor of Orthopaedics, Chief of Division
of Foot and Ankle Surgery Lawrence C. Hurst, MD
Department of Orthopaedics Professor and Chairman
University of Rochester School of Medicine Department of Orthopaedic Surgery
and Dentistry Stony Brook University
Rochester, NY Stony Brook, NY
Philip M. Bernini, MD Lee D. Kaplan, MD
Professor of Orthopaedic Surgery Assistant Professor
Department of Orthopaedics Department of Orthopaedics
Dartmouth-Hitchcock Medical Center University of Wisconsin
Lebanon, NH Madison, WI
Eric M. Bluman, MD, PhD Keith Kenter, MD
Assistant Clinical Instructor Assistant Professor and Director of Resident
Department of Orthopaedic Surgery Education
Brown University School of Medicine Department of Orthopaedic Surgery
Providence, RI University of Cincinnati
Cincinnati, OH
Susan V. Bukata, MD
Orthopaedic Research Fellow John D. Lubahn, MD
Department of Orthopaedics Department Chair
University of Rochester Medical School Program Director
Rochester, NY Department of Orthopaedics
Hamot Medical Center
Michael G. Ehrlich, MD Erie, PA
Vincent Zecchino Professor and Chairman
Department of Orthopaedics
Brown University School of Medicine
Providence, RI
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List of Contributing Authors
Vincent D. Pellegrini Jr., MD Peter G. Trafton, MD, FACS
James L. Kernan Professor and Chair Professor and Vice Chairman
Department of Orthopaedics Department of Orthopaedic Surgery
University of Maryland School of Medicine Brown University School of Medicine
Baltimore, MD Providence, RI
Michael S. Pinzur, MD Edward D. Wang, MD
Professor of Orthopaedic Surgery and Assistant Professor
Rehabilitation Department of Orthopaedic Surgery
Department of Orthopaedic Surgery and Stony Brook University Hospital and Health
Rehabilitation Sciences Center
Loyola University Medical Center Stony Brook, NY
Maywood, IL
D. Patrick Williams, DO
David T. Rispler, MD Clinical Professor
Assistant Professor Orthopaedic Residency Program
River Valley Orthopaedics Hamot Medical Center
Michigan State University Erie, PA
Grand Rapids, MI
David J. Zaleske, MD
Randy N. Rosier, MD, PhD Surgical Director, Orthopaedics
Wehle Professor and Chair Department of Orthopaedics
Department of Orthopaedics Children’s Hospitals and Clinics
University of Rochester Medical School Minneapolis and St. Paul, MN
Rochester, NY
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one
Embryology
and Formation
of Bone
David J. Zaleske, MD
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Chapter 1
A
n understanding of embryology facilitates the study of postnatal anatomy
and the treatment of patients with congenital malformations. Furthermore,
as research elucidates the fascinating but complex embryologic process, it
has become clear that many genes and transcription factors involved in
movement from the genome to a three-dimensional organism are phyloge-
netically conserved. This complex and highly interactive process includesnormal cytodif-
ferentiation and morphogenesis, and it isrecapitulated, at least in part, in the healing of
injuries.(Note:Boneistheonlytissuethatregeneratescompletelyafterinjury[fracture].)
Abetterunderstandingofdevelopmentshouldallowmoreprecisetreatmentofmanyill-
nesses and, ultimately, tissue engineering with regeneration of specific organs.
CELL DIVISION AND THE MAIN disc (gastrula). Mesodermdevelops from two
EMBRYONIC PERIOD thickenings of ectoderm. The primitive knot
(node) forms a midline cord of mesoderm,
The 9 months of prenatal human develop-
known as the notochord. This primitive
ment can be divided into a period of cell
streakgives rise to the rest of the mesoderm,
division (weeks 1 and 2), a main embryonic
including the cardiogenic mesoderm, which
period (weeks 3 to 8), and a fetal period (en-
separates and is located in front of the
compassing the last 7 months). Approxi-
oropharyngeal membrane. Gastrulation is
mately 60 hours after fertilization, the zygote
complete when the mesoderm condenses
has progressed to a morula(“little mulberry”),
into three, initially connected columns that
a ball of cells that continues cell division as it
flank the notochord: the paraxial columns(fu-
travels through the uterine tube to the uterine
ture somites), the intermediate mesoderm,
cavity; it transitions to the fluid-filled blasto-
and the lateral plates(Figure 1-2). Mesoderm
cyst at approximately day 5. The blastocyst
that surrounds the columns becomes mes-
develops an inner cell mass (embryoblast)
enchyme, the loose embryonic connective
and an outer trophoblast as it adheres and
tissue that surrounds structures.
then is implanted within the posterior wall of
Shaping of the embryo involves bending of
the endometrium of the uterus. By the end of
the amnion around and under the gastrula
week 2, the embryo is a two-layered cell disc
(Figure 1-3). Concurrently, folding of the ecto-
of endodermand ectoderm(Figure 1-1).
derm initiates development of the nervous
The embryonic period progresses from gas-
system, and somitesin the paraxial mesoderm
trulation to folding of the embryonic disc and
initiate development of the axial skeleton.
eventual formation of the primordia of all or- The gut is formed from a tube of endo-
gan systems. It is a very dynamic period of de- derm. The lateral plate extends and splits to
velopment and morphogenesis, in which form the lining of the coelomic cavities. The
masses of cells coalesce, migrate, and re- superior portion of the lateral plate joins with
model (programmed cell death is included). the surface ectoderm to form the ventrolat-
Because this is the most active phase of dif- eral body wall somatopleure, which ulti-
ferentiation, abnormalities of development mately develops into the skin, connective tis-
that occur in the embryonic period usually re- sue, striated muscle, and bone in the limbs
sult in major birth defects. The cardiovascular and some parts of the body wall. The inferior
system is the first organ system to function at portion of the lateral plate joins with the en-
day 21/22. At that time, the embryo is too doderm to form the splanchnopleure, which
large for diffusion to satisfy the nutritional forms the walls of visceral organs and their
needs of the embryo. suspending mesenteries.
Gastrulation is the production of meso- The mesodermal notochord and the parax-
derm during the third week that changes the ial columns induce ectodermal tissue to form
bilaminar embryonic disc into a trilaminar the neural plate, thus beginning the process of
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Embryology and Formation of Bone
Figure 1-1: Cell Division: The First Two Weeks
Early morula Four-cell stage
Myometrium (approx. 80 hr) (approx. 40 hr) Two-cell stage
(approx. 30 hr)
Endometrium
Advanced morula
(4 days) Ovary
Blastocyst
(approx. 5 days) Fertilization
(12 to 24 hr)
Developing
Early implantation
follicles
(approx. 61/2 days) Mature
follicle
Embryoblast Discharged
(inner cell mass) ovum
Extraembryonic
mesoderm
Yolk sac
Endoderm
Exocoelomic cyst
Ectoderm
Amniotic cavity
Connecting stalk
Cytotrophoblast
Extraembryonic Syncytiotrophoblast
coelom
Endometrium
Approximately 15th day
neurulation; this plate then folds and invagi- neural tube and notochord into the somato-
nates to form the neural tube. Closure of the pleure. Bone development of the axial skele-
neural tube advances cranially and caudally. ton begins with mesenchymal condensations
As the neural tube invaginates, ectodermal in the sclerotome. Cells from the mesenchy-
neural crest cells from each side are joined to- mal primordia differentiate into chondro-
gether. Later, some neural crest cells migrate blasts, which become the cartilaginous pre-
to form other tissues (Tables 1-1 and1-2). cursors of the axial skeleton and bones at the
base of the cranium (Figure 1-4). Enchondral
HUMAN AXIAL SKELETAL
ossification converts these cartilage tem-
EMBRYOLOGY plates into various bones. Most bones of the
The axial skeleton includes the vertebrae, skull and part of the clavicle develop through
ribs, and sternum. Its development is initiated intramembranous (mesenchymal) ossification
by paired condensations in the paraxialmeso- with direct formation of bone in mesenchyme
derm—the somites. Each somite differentiates derived from the neural crest.
into a sclerotomeand a dermomyotome. The At each level, the somites migrate ventrally
sclerotomes separate and migrate around the to incorporate the notochord and dorsally to
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Chapter 1
Figure 1-2: Gastrulation
Formation of Intraembryonic Mesoderm from the Primitive Streak and Node (Knot)
Ectoderm
Oropharyngeal
Amniotic cavity membrane
Notochord
Primitive knot
(node)
Primitive
streak
Extraembryonic
mesoderm
Endoderm
Migration of cells
from the Yolk sac
primitive streak cavity
to form the
intraembryonic Cupola of
mesoderm yolk sac
Oropharyngeal
membrane
Spreading of
intraembryonic
Notochord mesoderm
Paraxial column Cloacal
membrane
Appearance of the Intermediate column
neural plate
Lateral plate
cover the neural tube. The precursors of the trum) of the atlas fuses tothe C2 body and be-
axial skeleton have formed by the fourth em- comes the odontoid process (dens). Parts of
bryonic week. Somites undergo rearrange- the somites may fail to segment, migrate, or
ment by division into superior and inferior rejoin appropriately. This failure is the basis
halves; then, adjacent superior and inferior for congenital scoliosis, which may be associ-
halves join together to form single vertebral ated with ribfusion at single or multiple levels
bones (Figure 1-5). Thus, the vertebral arte- (see Chapter 13).
ries are relocated to the middle of the verte-
Skeletal Muscle and Peripheral Nerve
bral body.
Vertebral bodies, the posterior bony arch, Embryology
and vertebral processes have a similar pattern Similar to the somites, myotomes are
of formation with various dimensions and nu- paired and segmented. Each segmental my-
ances (refer to Figures 13-2and 13-4 in Chap- otome is innervated by a spinal nerve. The
ter 13). Development of C1 (atlas) differs dermatomes divide into an epimere—the
from that of C2 (axis) in that the body (cen- small dorsal segment—and a hypomere—
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Embryology and Formation of Bone
Figure 1-3: Folding of the Gastrula and Early Development of the Nervous
System
Midsagittal section of folding gastrula
Cross section of folding gastrula
Notochord Amnion
in gastrula
Amnion Neural plate
Connecting
Oropharyngeal
stalk
membrane Extraembryonic
mesoderm Intraembryonic
Cardiogenic Allantois mesoderm
mesoderm
Cloacal
membrane
Yolk sac Yolk sac Notochord
Vertebrate Body Plan after 4 Weeks
Somite sclerotome
Intermediate mesoderm: surrounds the neural
Neural crest Embryonic endoderm
Nephrogenic ridge tube and notochord to
Neural plate forming gastrointestinal Nephrogenic cord form vertebral column
forming (gut) tube Genital ridge
neural tube Spinal nerve
Splanchnopleure
Somite Somatic mesoderm (endoderm plus Dermomyotome
of lateral plate lateral plate Aorta
Intermediate mesoderm) Dorsal
mesoderm Somatopleure mesentery
Intraembryonic Amnion tucking (ectoderm plus Ventral
coelom around the sides lateral plate mesentery
mesoderm)
of the folding Gut tube Umbilical
Notochord embryo cord
Splanchnic Yolk sac (stalk Amnion against
mesoderm just out of the chorion
of lateral plate plane of section)
Hepatic Dermomyotome Amniotic cavity
diverticulum Yolk sac stalk
of somite
and allantois Neural tube
within the above notochord
Septum
umbilical
transversum Sclerotome
cord
of somite
Intraembryonic Intermediate
coelom mesoderm
Amnion surrounded by Embryonic
Amnion pressed surrounding lateral plate gut tube
against the chorion mesoderm
the umbilical Yolk sac stalk
cord compressed into
umbilical cord
Dorsal Views
Neural Somites Cranial
plate appear neuropore
(day 20)
Neural Early Late
groove closure closure
of neural of neural
tube tube
(day 21) (day 22)
1.8 mm 2.0–2.1 mm Caudal
neuropore
Week 3 (late) Week 4 (early)
5