Orthopaedics and Trauma. Volume 24 (2010)

483 Pages·2010·51.06 MB·English

by  D Limb (Editor-in-Chief) Elsevier

Orthopaedics
and
Trauma
Orthopaedics and Trauma presents a unique collection of International review articles summarizing the current state of
k nowledge in orthopaedics. Each issue begins with a focus on a specific area of the orthopaedic knowledge syllabus, covering
s everal related topics in a mini-symposium; other articles complement this to ensure that the breadth of orthopaedic learning
is supplemented in a 4 year cycle. To facilitate those requiring evidence of participation in Continuing Professional Development
there is a questionnaire linked to the mini-symposium that can be marked and certified in the Editorial office.
Editor-in-Chief
D Limb BSc FRCS Ed (Orth)
Leeds General Infirmary, Leeds, UK
Editorial Committee
M A Farquharson-Roberts (Gosport, UK), I Leslie (Bristol, UK)
M Macnicol (Edinburgh, UK), I McDermott (London, UK), J Rankine (Leeds, UK)
Editorial Advisory Board
D C Davidson (Australia) A Thurston (New Zealand)
J Harris (Australia) E G Pasion (Philippines)
G R Velloso (Brazil) L de Almeida (Portugal)
P N Soucacos (Greece) G P Songcharoen (Thailand)
A K Mukherjee (India) R W Bucholz (USA)
A Kusakabe (Japan) R W Gaines (USA)
M-S Moon (Korea) S L Weinstein (USA)
R Castelein (The Netherlands) M Bumbasirevic (former Yugoslavia)
R K Marti (The Netherlands)
G Hooper (New Zealand)
Emeritus Editor
Professor R A Dickson MA ChM FRCS DSc
Leeds General Infirmary, Leeds, UK
Orthopaedics and Trauma
Elsevier, ISSN: 1877-1327, http://www.sciencedirect.com/science/journal/18771327
Volume 24, Issue 1, Pages 1-82 (February 2010)
1 Editorial Board, Page i

Mini-Symposium: Basic Science of Trauma
2 ( i) Init ia l resuscitat ion of the trauma victim , Pages 1-8
Nicholas S. Duncan, Chris Moran
3 ( i) An update on fracture healing and non - union , Pages 9-23
Paul J. Harwood, James B. Newman, Anthony L.R. Michae l
4 ( i i i ) A n u p d a t e o n t h e s y s t e m i c r e s p o n s e t o t r a u m a , Pages 24-28
Ian Pallister
5 (vi)T her esponseo fc hdlirent ot rauma , Pages 29-41
Simon P. Kelley
6 ( v) T h e m a n a g e m e n t o f i n t r a c a p s u l a r f r a c t u r e o f t h e f e m o r a l n e c k , Pages 42-52
John Keating, Joseph Aderinto
Knee
7 Anteroirk nep ani , Pages 53-62
Marko Bumbaširevic, Aleksandar Lešic, Vesna Bumbaširevic
Spine
8 T hea sesmento ft horacip ani , Pages 63-73
Antony Louis Rex Michael, James Newman, Abhay Seetharam Rao
Surgical Approaches
9 A nte r o l a t e r a l a p p r o a c h e s t o t h e c e r v i c a l s p i n e : t i p s a n d t r i c k s , Pages 74-79
Luca Denaro, Umile Giuseppe Longo, Nicola Maffulli, Vincenzo D enaro
CME Section
1
0 CME q u e s t i o n s b a s e d o n t h e M i n i - Symposium on “The Basic Science of Trauma”, Pages 80-
81
11 Answ e r s t o C M E q u e s t i o n s b a s e d o n t h e M i n i - Symposium on “Revision Hip Surgery”, Page
82
Orthopaedics and Trauma
Elsevier, ISSN: 1877-1327, http://www.sciencedirect.com/science/journal/18771327
Volume 24, Issue 2, Pages 83-170 (April 2010)
1
Editorial Board,Page i
Mini-Symposium: Soft Tissue Surgery in the Knee
2
EIditorial an McDe,r mPoatgt e 83
3 S (i) Biomechanics of the kne.e joint D. Masouros, A.M.J. Bull, A.A. Amis , P ages 84-91
4
)iJ( er ntoiej nekeh eto t hocseapapr lacgiSur my E.S. Stanton, Chinmay M. Gupte, Vi,s hPya Mgeash 9a2de-9v9a n
5
A( i) What's new in anterior crucniate ligament surgery?drew Unwin , Pages 100-106
6
( Oiv) Articular cartilage surgery in liver S. Schindler the kne , Pages 107-120
7
meca npetelrnad srpiear ,sraet lacMsne i)v( Alan Getgood, Angus Robertson – a current concepts review , Pages 121 -128
8 rnad p ayhreotPihsy )iv(H enry D.E. Atkinson, Jenntosfnog wilolfon itatilhebai ifer Michelle Laver, Elizabeth- nekeh e t of ygreusru seit Sharp , Pages 129 -138
9 (N vi) Patelofemoral instability eil Upadhyay, Charles Wakele,y ,P Jaogneasth 1a3n9 D-1.J4.8 E ldridge
Trauma
Curent management of long bone large segmental defects Pages 149-163
10 Nikolaos G. Lasanianos, Nikolaos K. Kanakaris, Peter V. Giannoudis
Syndrome
1
1 LCri du Chat syndromeyndsay Cuming, Donna, DPiaagmeosn 1d6, 4R-o16ui6n Amirfeyz, Martin Gargan
CME Section
1
2 CME questions based on the Mini - Symposium on “Soft Tissue Surgery in the Knee” , Pages 167-168
13 Answers to CME questions based on the Mini - Symposium on “Foot and Ankle Problems”, Page 169
Erratum
Erratum to “Basic biomechanics of human join ts: Hips, knees and the spine” [Current Orthopaedics (2006) 20, 23 –
1
4 31], Page 170
T.D. Stewart, R.M. Hall
Orthopaedics and Trauma
Elsevier, ISSN: 1877-1327, http://www.sciencedirect.com/science/journal/18771327
Volume 24, Issue 3, Pages 171-246 (June 2010)
1
Editorial Board, Page i
Mini-Symposium: The Hand
(i) The principles of surgery in the rheumatoid hand and wrist , Pages 171-180
2 Andrew McKee, Peter Burge
(i) Benign soft tisue tumours of the hand , Pages 181-185
3
Sarah-Jane Miles, Rouin Amirfeyz, Raj Bhatia, Ian Leslie
(i) Hand infections , Pages 186-196
4 Daniel J.A. Thornton, Tommy Lindau
(iv) Dupuytren’s disease, Pages 197-206
5 Sanjeev Kakar, Jennifer Giuffre, Kshamata Skeete, Basem Elhassan
(v) Carpal degenerative disease , Pages 207-216
6
Soham Gangopadhyay, Tim R.C. Davis
(vi) Flexor tendon injuries , Pages 217-222
7
P.A.G. Torrie, N. Atwal, D. Sheriff, A. Cowey
Quiz
Quiz on fot and ankle disorders , Pages 223-228
8 Dishan Singh, Lee Parker
Research
Study design in clinical orthopaedic trials , Pages 229-240
9 A.A. Qureshi, T. Ibrahim
CME Section
10 CME questions based on the Mini - Symposium on “The Hand”, Pages 241-242
1
1 Answers to CME questions based on the Mini - Symposium on “The Basic Science of Trauma” , Page 243
Book Reviews
Clinical tests for the musculo skeletal system , Page 244
12 P.A. Templeton
Orthopaedic Knowledge Update: Shoulder and Elbow , Page 244
13 Ron Dodenhoff
Shoulder arthroscopy , Pages 244-245
1
4 David Limb
The musculoskeletal system at a glance , Page 245
1
5 Joseph Aderinto
Pediatrics instructional course lectures , Page 245
1
6 P.A. Templeton
Orthopaedics and Trauma
Elsevier, ISSN: 1877-1327, http://www.sciencedirect.com/science/journal/18771327
Volume 24, Issue 4, Pages 247-320 (August 2010)
1
Editorial Board, Page i
Mini-Symposium: Malignant Bone Tumours: Principles
(i) The epidemiology of primary skeletal malignancy , Pages 247-251
2 Jos A.M. Bramer, Matthijs P. Somford
(i) The investigation and radiological features of primary bone malignancy , Pages 252-265
3
Thomas Kuchenbecker, A. Mark Davies, Steven L.J. James
(i) The principles of surgical resection and reconstruction of bone tumours , Pages 266-275
4 Ajay Puri
Amputations and Prosthetics
Major lower limb amputation – what, why and how to achieve the best results , Pages 276-285
5
Vicky Robinson, Kate Sansam, Lynn Hirst, Ve ra Neumann
Trauma
Maleolar ankle fractures. A guide to evaluation and treatment , Pages 286-297
6
Pavel Yufit, David Seligson
General
Orthopaedic and trauma surgery in HIV positive patients , Pages 298-302
7
Nicholas Lubega, W.J. Harrison
Foot and Ankle
Clubfot asesment: the complete IMAR fotprint , Pages 303-308
8
Arun K. Ramanathan, Rami J. Abboud
Research
9 TDhe use of outcome measures realating to the kne vid J. Beard, Kristina Knezevic, Sami Al -Ali, Jill Daw, s Pona,g Aens d3r0e9w- 3J1. 6P rice
CME Section
1
0 CME questions based on the Mini - Symposium on “Malignant Musculoskeletal Tumours Part 1 ”, Pages 317-318
1
1 Answers to CME questions based on the Mini - Symposium on “Soft Tissue Surgery in the Knee” , Page 319
Book Reviews
Orthopaedic Knowledge Update: Sports Medicine , Page 320
12 Roger Hackney
Surgical techniques in Orthopaedics: Arthroplasty for unicompartmental kne arthritis (DVD) , Page 320
1
3 Owen Wall, Nick London
Orthopaedics and Trauma
Elsevier, ISSN: 1877-1327, http://www.sciencedirect.com/science/journal/18771327
Volume 24, Issue 5, Pages 321-398 (October 2010)
1
Editorial Board, Page i
Mini-Symposium: Malignant Bone Tumours: Specific Tumour s
(i) O s t e o s a r c o m a , Pages 321-331
2 Thomas B. Beckingsale, Craig H. Gerrand
(i) Chondrosarcomas , Pages 332-341
3
Sophie Mottard, Vaiyapuri P. Sumathi, Lee Jeys
(iii) Ewing’s sarcoma of bone, Pages 342-345
4 Fabrice Fiorenza, Lee Jeys
(iv) Primary bone tumours of the growing spine , Pages 346-354
5 Alexandre Arkader, Vernon T. Tolo
Infection
Necrotizing soft tisue infections for the orthopaedic surgeon , Pages 355-362
6
Ross Hutchison, Punam Bharania, Francis Lam
Oncology
Curent concepts in the management of renal oseous metastasis , Pages 363-368
7
Shaishav Bhagat, Himanshu Sharma, John Graham, Anthony T . Reece
Children
Paediatric kne problems , Pages 369-380
8
Malcolm F. Macnicol
Hand and Wrist
The asesment and management of acute scaphoid fractures and non - union , Pages 381-393
9
R.D. Farnell, D.R. Dickson
CME Section
10 CME questions based on the Mini - Symposium on “Specific Bone Tumours”, Pages 394-395
1
1 Answers to CME questions based on the Mini - Symposium on “The Hand”, Page 396
Book Reviews
Orthopaedic knowledge update: musculoskeletal tumours 2 , Page 397
12 Robert U. Ashford
Musculoskeletal trauma simplified: a casebok to aid diagnosis and management , Page 397
13 Stuart Matthews
Curent orthopaedics shoulder instability – current concepts, Page 397
1
4 Lennard Funk
Erratum
Erratum to “Answers to CME questions based on the Mini -Symposium on “Soft Tissue Surgery in the Knee””
1
5 [Orthopaedics and Trauma 24 (2010) 319], Page 398
Orthopaedics and Trauma
Elsevier, ISSN: 1877-1327, http://www.sciencedirect.com/science/journal/18771327
Volume 24, Issue 6, Pages 399-476 (December 2010)
1
Editorial Board, Page i
Mini-Symposium: Pathology
(i) The pathobiology of osteoarthritis , Pages 399-404
2 Catherine Swales, Nick A. Athanasou
(i) Rheumatoid arthritis: changing beyond recognition , Pages 405-409
3
M.H. Edwards, C.J. Edwards
(i) Osteochondritis , Pages 410-415
4 Tony Freemont
(iv) Osteomyelitis , Pages 416-429
5 Martin McNally, Kugan Nagarajah
(v) Disc degeneration and prolapse , Pages 430-434
6
Colin McNair, Lee M. Breakwell
Basic Science
7
Tribology of artificial joints.D. Stewart , Pages 435-440
Medico-Legal
Informed consent , Pages 441-446
8
Gerard Panting
Quiz
Radiology quiz , Pages 447-454
9
Armin Seifarth, Philip Robinson
Surgical Techniques
Surgical aproaches for total hip arthroplasty , Pages 455-462
1
0 Andrew Graham Sloan, Henry Wynn Jones, Martyn Lonsdale Porter, Kevin Hardinge
Research
Statistical tests in orthopaedic research , Pages 463-472
11 A.A. Qureshi, T. Ibrahim
CME Section
1
2 CME questions based on the Mini - Symposium on “Pathology”, Pages 473-474
Answers to CME questions based on the Mini - Symposium on “Malignant Musculoskeletal Tumours Part 1” , Page
13 475
MINI-SYMPOSIUM: BASIC SCIENCE OF TRAUMA
assessment whilst maintaining a patent airway, immediate
(i) Initial resuscitation of the control of massive external haemorrhage, immobilization of the
patient and rapid transfer to an appropriate trauma centre. All the
trauma victim above measures should be performed in such a way as to reduce
the overall time spent at the scene of the injury so that the patient
Nicholas S Duncan
arrives at the trauma centre as quickly as possible. Another
Chris Moran important aspect of pre-hospital care is early communication
with the receiving hospital so that the trauma team can be
assembled and present as the patient arrives.
Abstract
The initial management of the trauma victim has evolved over many Changes in practice in pre-hospital care
years. Changes have occurred in both pre-hospital and hospital practice
Tourniquets
and in the overall approach to patient management. The focus of patient
Tourniquets are regularly used during transport from the scene of
care is now aimed at maintaining the patient’s physiological state whilst
injury to the care facility in the military setting. In situations
obtaining an early CT scan of the head, spine and trunk to identify all
where haemorrhage control cannot be obtained with direct
injuries. However, in the critically ill patient with active bleeding the
pressure, the application of a proximal tourniquet can be an
immediate surgical control of haemorrhage is essential. Recent develop-
effective method of haemorrhage control. The aim of tourniquet
ments in trauma management, including damage control resuscitation,
use in the pre-hospital setting is to control haemorrhage until the
more rapid imaging, improved methods of haemorrhage control and the
bleeding can be controlled in hospital, usually by surgical inter-
identification of patients who would benefit from either early total care
vention. In the military setting, tourniquets are used with success
or damage control orthopaedics have all led to improved outcomes in
in severely injured patients with major extremity vascular injury
the trauma patient.
or traumatic amputation. A study by Beekley et al1 found that
there was improved haemorrhage control in the above two
Keywords damage control; haemorrhage; resuscitation; trauma
patient groups and that tourniquet use (mean time 70 min) was
not associated with neurological deficit or other adverse
sequelae.
Introduction
Fluid resuscitation
Resuscitation of the trauma victim has evolved as new knowl-
Previously, the initial management of hypovolaemia in the
edge has become available over the years. Many of these
trauma patient involved the rapid administration of 2000 ml of
advances in trauma management occur during times of war and
Ringer’s lactate as an initial fluid challenge. More recently, there
the recent conflicts in Iraq and Afghanistan have resulted in
have been changes in practice such that the initial fluid resusci-
significant changes in the treatment of trauma away from the war
tation of the patient is gauged by palpation of the radial pulse.
zone. There is increased focus on the physiology of the trauma
Fluid boluses of up to 250 ml are given to maintain the radial
patient, attempting to identify problems at the earliest stage in
pulse, as required. In general, the radial pulse is palpable when
order to prevent the development of derangement rather than
the systolic blood pressure is >70 mmHg, which is sufficient to
reacting to its emergence. This has included changes in the
maintain cerebral and myocardial perfusion in the short term.
timing and type of surgery in an attempt to limit additional
This is referred to as hypotensive resuscitation, or permissive
physiological insults that can be attributed to the surgery.
hypotension, and is one of the components of damage control
This review focuses on the management of the severely
resuscitation. The use of small volumes of fluid avoids haemo-
injured trauma victim, looking at the changes that have occurred
dilution and reduces the risk of coagulopathy. A lower systolic
in pre-hospital management, the major changes in haemorrhage
blood pressure will allow primary blood clots to form more easily
control techniques, the concept of damage control resuscitation
and reduces the risk of secondary haemorrhage if the blood
and the timing of surgery for the trauma victim.
pressure rises before surgical control of the source of haemor-
rhage is obtained.
Pre-hospital care of the trauma victim
The management of the trauma victim at the scene has a major
Pelvic binders
impact on the overall care of the patient. The focus of pre-
In trauma victims sustaining blunt trauma, bleeding from pelvic
hospital care of the trauma patient should be on a rapid primary
fractures can be difficult to evaluate clinically. The practice of
testing pelvic stability for pelvic fractures has a low sensitivity
and specificity and has the potential to increase bleeding by
Nicholas S Duncan MRCS (Ed) BM BS Specialist Registrar in Trauma and disrupting blood clots. It should not be performed. Splintage of
Orthopaedics, Orthopaedic Department, Nottingham University unstable fractures reduces pain, decreases bleeding and prevents
Hospital, United Kingdom. further soft tissue injury from movement of the fracture. It is now
recommended that pelvic fractures, as well as long-bone
Chris Moran MD FRCS Professor of Orthopaedic Trauma, Orthopaedic fractures, are splinted prior to transport. For the pelvis,
Department, Nottingham University Hospital, United Kingdom. commercially available circumferential splints (pelvic binders)
ORTHOPAEDICS AND TRAUMA 24:1 1 Ó 2009 Published by Elsevier Ltd.
MINI-SYMPOSIUM: BASIC SCIENCE OF TRAUMA
are now recommended pre-hospital for patients suspected to C e Circulation with haemorrhage control
have severe pelvic fractures. Hypotension in the trauma victim should always be assumed to
be due to bleeding until proven otherwise. A rapid clinical
Rapid transfer to major trauma centres
assessment of the patient’s haemodynamic status can be per-
In England and Wales, regional trauma networks are being
formed by observing the level of consciousness, skin colour and
developed and the first will become operational in London in
the pulse rate. Whilst assessing the trauma victim’s haemody-
April 2010. These networks of hospitals will work to agreed
namic status, control of haemorrhage should also be performed.
protocols with a hub and spoke system of Trauma Units, with
External bleeding can be controlled by direct pressure but severe
peripheral District General Hospitals and a single, central,
limb bleeding, for example that associated with blast injury, may
designated Major Trauma Centre. In many cases, triage criteria
best be controlled by rapid application of a tourniquet.
will allow direct transfer of the severely injured patient from the
Severe pelvic fractures may result in massive, life-threatening
accident to the Major Trauma Centre, bypassing peripheral
haemorrhage. All movement of the pelvis should be avoided, as
hospitals en route. Experience in other countries has shown that
this can disrupt any blood clot that has formed and result in
the development of Trauma Centres can reduce the mortality
increased haemorrhage, which may be catastrophic. We recom-
from trauma by 20% within the local population. However, the
mend the rapid application of a pelvic binder in all victims of
development of a Regional Trauma Network is more effective
blunt trauma who have a reduction in systolic blood pressure
and reduces mortality by up to 40%. Multiple trauma is
(<110 mmHg). Examination for pelvic stability should not be
uncommon, with an incidence of about 1 per 10 000 urban
performed. It provides no clinically useful information, is painful
population per year. The best outcome, in terms of mortality and
and potentially harmful. We would also recommend that the
morbidity, is achieved in specialist units that treat 500 or more
patient is not log-rolled (to examine the spine) until the pelvis
patients with an injury severity score (ISS) of >15 per year. Thus
has been cleared with a normal pelvic X-ray. An exception to the
it is likely that each regional network will require one Major
rule may be the victim of blast injuries where an early log roll
Trauma Centre (providing all specialties on one site), per
may be necessary to identify penetrating, posterior wounds.
5 million population.
The use of pelvic binders has become more common in emer-
gency departments when managing patients with suspected pelvic
Initial assessment of the patient 3
fractures. A study by Croce et al compared their use with that of
external pelvic fixation in patients with life-threatening pelvic
On arrival in the emergency department, patients are assessed
2 fractures and found that the number of units of blood transfused at
and treated based upon their priorities using the ATLS protocol.
both 24 and 48 h was significantly reduced in patients with the
This involves a rapid primary survey with simultaneous resus-
binder. Thismayhavebeendue to the fact that externalfixators take
citation, followed by a more detailed secondary survey to identify
more time to apply, thus allowing further bleeding, whereas the
all injuries and plan for definitive treatment. In certain situations
pelvic binder is quick to apply, splints the pelvis circumferentially
the whole assessment may occur in the emergency department.
and reduces the pelvic volume. Pelvic binders in this situation are
In others, haemorrhage control may require emergency surgery,
useful intermediary devices before definitive internal fixation of
and transfer to the operating theatre will be part of the overall
unstable pelvic fractures. There is no evidence that they increase
resuscitation and management as part of ‘circulation with
damage in patients with lateral compression injuries. There are
haemorrhage control’.
sporadic reports of pressure sores after their prolonged application
2 andmost authors recommend that they are releasedwithin 24e48h
Primary survey
of application, once the patient is haemodynamically stable.
A e Airway maintenance with spine protection
This involves assessment of the trauma victim’s airway looking
for causes of obstruction, such as foreign bodies, and identifying D e Disability
fractures, soft tissue injuries and burns that may subsequently A rapid assessment of the trauma victim’s neurological status
lead to airway obstruction. The airway must always be protected involves evaluation of the consciousness level (utilizing Glasgow
in patients with reduced level of consciousness. Coma Score (GCS)), assessment of pupils and spinal cord
Whilst assessing the trauma victim’s airway, the spine injuries. A GCS below 8 must alert the attending physician to
requires immobilization and protection. For the cervical spine, potential for airway compromise.
this may be by inline traction or by triple immobilization with
collar, sandbags and tape. For the thoracic and lumbar spine, E e Exposure/environmental control
patients are initially immobilized on a spine board and move- Assessment of the trauma victim requires full exposure of the
ment of the spine avoided. patient in order to fully identify all injuries. During this stage, it is
imperative that a reduction in body temperature is prevented by
B e Breathing and ventilation
using external warming devices and warmed intravenous fluids.
The assessment of breathing involves looking at the three key
During the primary survey, X-rays of the chest and pelvis
areas that are necessary for proper ventilation: the lungs, the
should be obtained rapidly to identify potentially life-threatening
chest wall and the diaphragm. Injuries to any of these can lead to
injuries that cannot be reliably diagnosed by clinical examination.
impaired breathing and ventilation. Injuries that may be identi-
2
fied during this assessment include tension pneumothorax, flail Secondary survey
chest with pulmonary contusions, massive haemothorax and The secondary survey consists of a head-to-toe evaluation of the
open pneumothorax. patient to identify other injuries and guide further imaging.
ORTHOPAEDICS AND TRAUMA 24:1 2 Ó 2009 Published by Elsevier Ltd.