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Part 2 book “Apley and Solomon’s system of orthopaedics and trauma” has contents: The neck, the management of major injuries, injuries of the ankle and foot, injuries of the knee and leg, injuries of the hip and femur, injuries of the pelvis, injuries of the spine, injuries of the spine, injuries of the wrist,… and other contents.
17 The neck Jorge Mineiro & Nuno Lanỗa APPLIED ANATOMY ANATOMICAL CONSIDERATIONS OF THE CERVICAL SPINE The neck has a gentle curvature with an anterior convexity The bony structure of the neck is the cervical spine with seven vertebrae, arranged in a lordotic configuration of 16 to 25 degrees This physiologic lordosis is never quite reversed, even in flexion, unless under pathologic conditions Important palpable landmarks of the neck are the hyoid bone, which lies at the level of C3, the thyroid cartilage, lying in front of C4, and the cricoid cartilage, at the level of C6 (Figure 17.1) The seven cervical vertebrae are different in shape The first two, the atlas (C1) and the axis (C2), are morphologically different from all the other five vertebrae (C3–C7) that have a similar morphology The atlas arises from three ossification centres Without a vertebral body or spinous process, C1 has thick anterior and posterior arches merging laterally into large masses through which it articulates with the occipital condyles above and the axial facet joints below The axis originates from six ossification centres The vertebral body has a characteristic superior peg, the dens, which articulates with the posterior surface of the anterior arch of the atlas The dens can have a posterior angulation of up to 30 degrees The transverse ligament of the atlas runs across the back of a narrowed waist of the odontoid process, stabilizing the joint, particularly in rotation The ossification of the dens starts at 6 months of gestation, but fusion to the C2 vertebral body is only completed by the age of 5–6 years However, ossification of the tip of the dens starts at 3–5 years of age and will only be completely fused at a later stage, during adolescence The large spinous process of the axis allows for muscle insertion, namely the rectus capitis and the inferior oblique muscles The subaxial cervical spine extends from C3 to C7 With a smaller vertebral body, the subaxial cervical vertebrae, although similar in shape, differ from the vertebrae in other segments of the spine because these have two transverse foramina for the vertebral arteries, running from C6 (in 90% of cases) to C1, and two vertebral foramina for the nerve roots The vertebral body is generally 17–20 mm wide, has two that are cranial projections on each side of the vertebral body, (uncal processes) that create a more concave shape to the superior end plate and participate in the motion pattern of the cervical spine, coupling bending and rotation Occiput Posterior arch C1 Anterior arch C1 OP Soft palate C2 Facets Pedicle Lamina Intervertebral space Spinous processes TP Hyoid C6 MKS C7 Trachea Figure 17.1 Radiological anatomy of the cervical region (Reproduced with permission from: Todd MM Cervical spine anatomy and function for the anesthesiologist Can J Anaesth 2001; 48(Suppl 1): R1–R5.) REGIONAL ORTHOPAEDICS 456 The short and medially oriented pedicles connect the vertebral body with the lateral masses The diameter of the pedicles increases downwards, with C6 pedicles being the largest The cervical articular facets are oriented at 0 degrees in the coronal plane and 40–55 degrees in the sagittal plane, with the upper articulating surface oriented dorsosuperiorly and the inferior ventroinferiorly Spinous processes are often bifid from C2 to C6, and the C7 spinous process is usually longer, the reason why it is called the vertebra prominens The primary function of the subaxial cervical spine is to resist compressive forces The facets are part of a tripod of stable joints (two facets and one intervertebral disc) allowing flexion/extension, lateral bending and slight rotation Under abnormal distractive forces they may also allow subluxation or dislocation to occur (even without fracture), a displacement that is usually prevented by the strong posterior ligaments The cervical spinal canal has a triangular shape in the axial plane and its diameter decreases from approximately 17 mm at C3 to 15 mm at C7 The spinal cord elongates and ‘squeezes’ in flexion and shortens and enlarges in extension As much as 30% of cord compression can irreversibly damage the spinal cord The cervical spine contains eight pairs of nerve roots They pass through relatively narrow neural foramina, above the similarly numbered vertebra, the first between the occiput and C1, and the eighth between C7 and the first thoracic (T1) vertebra Hence, a lesion such as a disc prolapse between C5 and C6 might compress the sixth root Intervertebral discs lie between the vertebral bodies, with their posterior margin close to the nerve roots as they emerge through the foramina Even a small herniation might compress or even stretch the nerve root exiting the spine, causing radicular symptoms (with radiating pain and paraesthesiae to the shoulder or upper limb) rather than neck pain Degenerative disc disease is associated with spur formation on both the posterior aspect of the vertebral body and the associated facet joints Bone formation results in encroachment of the nerve root in the intervertebral foramen Radiating pain can also be caused by facet joint degeneration or the soft surrounding structures Facetary pain is typically aggravated with extension, lateral bending and rotation Only radiculopathy (i.e. paraesthesiae and sensory or motor compromise) with shooting pain down the arm/forearm are unequivocal evidence of nerve root compression The cervical spine motion can be analysed in three different axes: flexion/extension, lateral bending and axial rotation Head motion is a combination of all these movements The occipitocervical junction contributes to approximately 50% of the neck flexion-extension movement (the ‘YES’ joint), with a C0–C1 range of motion of 21 degrees of flexion and 3.5 degrees of extension At the atlanto-occipital joint, the movements that occur are nodding and tilting (lateral flexion) The atlantoaxial articulation contributes to approximately 50% of neck rotation (the ‘NO’ joint), with a C1–C2 range of motion of 47 degrees of axial rotation The vertebral artery loop in this region allows the artery to adapt to the normal axial rotation In the subaxial cervical spine the main motion patterns are flexion-extension and lateral bending The majority of the flexion-extension movement in the subaxial cervical spine occurs at the level of C4–C5 and C5–C6, the reason why these levels are more frequently affected in the degenerative process of the disc The majority of lateral bending occurs from C2 to C4 The least mobile segment in the cervical spine is C7–T1 because it is usually deeply seated into the upper chest SURGICAL APPROACHES TO THE CERVICAL SPINE The Smith-Robinson-Cloward approach is the most widely used for anterior cervical surgery The spine is accessed through a slightly oblique skin incision on the side of the neck (right or left) in front of the sternocleidomastoid muscle (SCM) Deeper, soft-tissue dissection proceeds with incision of platysma and then the anterior cervical fascia on the medial border of the SCM Progression medially to the carotid sheath, which is dorsolateral to the visceral space and ventrolateral to the prevertebral fascia, provides direct access to the midline of the anterior cervical spine The cervical sympathetic chain is located posteromedially to the carotid sheath The thoracic duct lies posterior to the carotid sheath on the left side Sometimes crossing the operative field, the omohyoid muscle may be divided to facilitate the access The anterior surface of the spine, just over the anterior longitudinal ligament, is separated from the pharynx by only a very thin layer of tissue with pharyngeal mucosa, constrictor muscles, buccopharyngeal fascia and prevertebral muscles The oesophagus at this level lies in front of the spine and behind the trachea Due to its soft structure it can be easily injured if caution is not taken during the approach Dysphagia is a common complication of anterior surgery of the cervical spine, although most frequently its aetiology is unclear The recurrent laryngeal nerve is another structure that is at risk in the cervical spine anterior approach It supplies motor innervation to the intrinsic laryngeal muscles that control movement of the vocal cords and also supply sensory Figure 17.2 Anatomical variations of the course of the vertebral artery (Reproduced with permission from: Wakao N, et al Risks for vascular injury during anterior cervical spine surgery: prevalence of a medial loop of vertebral artery and internal carotid artery Spine 2016; 41(4): 293–8.) CLINICAL ASSESSMENT 17 SYMPTOMS Pain originating in the cervical spine can be due to pathology either at the disc, bone, articular or musculotendinous structures or at the neural structures (nerves or spinal cord) Pain is usually localized near the midline or around the shoulder girdle, but it can also radiate to the upper limb or the occipital region A sudden onset of pain after exertion, exaggerated by coughing or straining and radiating down the arm/ forearm is the typical clinical picture of a disc prolapse with cervical root irritation or compression, sometimes associated with paraesthesia in the same area of the upper limb Pain in the cervical region can be direct, from an underlying condition, or referred, if caused by a pathologic condition at distance Referred neck pain can be muscular, developing secondarily as a result of postural adaptations to a primary pathology in the shoulder, the craniovertebral junction or at the temporomandibular joint Radiating pain down the arm/forearm can be caused by many pathologies besides herniated disc prolapse: peripheral entrapment syndromes, rotator cuff/shoulder pathology, brachial plexitis, Herpes zoster, thoracic outlet syndrome, sympathetic mediated pain syndrome, intraspinal or extraspinal tumours, epidural abscess and cardiac ischaemia Chronic or recurrent neck pain in older people is usually due to degenerative cervical spine pathology (i.e. cervical spondylosis), occurring as a result of ageing in the majority of the adult population In this age group, the source of pain is multiple: from the degenerative disc itself, associated arthritis and synovitis of the facet joints and postural changes in the alignment of the cervical lordosis It is crucial to define the characteristics of pain arising from the cervical region Apart from the onset, type of pain, duration, precise localization and radiation, it is important to define the aggravating and alleviating factors, such as pain associated with any posture or movement Stiffness may be an associated symptom, either intermittent or continuous The inability to move the neck, usually caused by pain and muscle spasm, can also be a spontaneous protective mechanism of the spine Numbness, tingling and weakness in the upper limbs may be due to irritation or pressure on a nerve root, but difficulty with hand coordination, cramping and weakness in the arms, hands and in the lower limbs, sometimes associated with an altered gait, may be the result of cord compression in the cervical spine Headache, especially occipital headache, sometimes originates from the cervical spine, but if this is the only symptom other causes should be ruled out The neck innervation to the larynx below the vocal cords Retraction of the recurrent laryngeal nerve during the anterior approach, mainly from the right side, where the nerve loops around the right subclavian artery and travels upwards being susceptible to injury by traction from the retractors, may cause hoarseness (or aphonia, if injured bilaterally) Disruption of the inferior sympathetic cervical (stellate) ganglion, which lies in front of the C7 transverse process, can result in Horner syndrome Anatomical variations of the course of the vertebral artery exist, such as medial loops of the vertebral artery or even the internal carotid artery, and these may increase the risk of surgical complications in anterior spine approaches (Figure 17.2) They are more likely in congenital and in certain degenerative conditions The posterior midline approach to the spine is also common in spine surgery It is used to address different conditions such as trauma, certain degenerative diseases and pathology of other posterior elements Longitudinal midline exposure through the ligamentum nuchae is done with dissection carried out detaching muscular insertions from the spinous processes and lamina, retracting the muscular layers laterally to access the canal/foramina In cervical decompressive surgery, from posterior or anterior, at the C5 level, C5 nerve palsy is a known complication Its aetiology is not completely understood, but it might be associated with a traction phenomenon of the shorter C5 nerve root with dorsal translation of the cord 457 REGIONAL ORTHOPAEDICS 458 Cervicogenic headache is a referred pain syndrome, usually unilateral in distribution, originating from various cervical structures innervated by the upper three cervical spinal nerves They can be the atlanto-occipital joint, atlantoaxial joint, C2–3 facet joint, C2–3 intervertebral disc, myofascial trigger points and also the spinal nerves ‘Tension’ is often mentioned as a cause of neck pain and occipital headache The neck and back are common ‘target zones’ for psychosomatic illness and therefore cause undue tension (muscle spasm) in the posterior shoulder girdle or cervical spine SIGNS Note the difference between the following: • radiculopathy – a lower motor neuron lesion resulting from nerve root compression causing conduction impairment, expressing as sensory and motor deficits and diminished or absent reflexes at the involved level • radicular pain – the result of nerve root irritation/inflammation and presents as a radiating pain down the upper limb • myelopathy – an upper motor neuron lesion, expressing with hyperreflexia below the involved level Figure 17.3 Disc prolapse A 39-year-old male with unremitting neck pain derived from cervical disc prolapse With the patient standing, look for unsteadiness and ask the patient to walk assessing the gait pattern Feel Deformity in this region of the spine usually appears as a wry neck (or torticollis) The painful neck may be fixed in flexion or rotation or a combination of both The clinical examination of the neck is only complete with the examination of the upper trunk, upper limbs and shoulder girdle The assessment of any anatomic region of the musculoskeletal system should have three phases – look, feel and move (Figure 17.4) The front of the neck is most easily palpated with the patient seated and the examiner standing behind Always remember to feel the neck from the four quadrants – anterior, posterior and lateral (left and right) The best way to feel the back of the neck is with the patient lying prone and relaxed, allowing the bony eminences to be easily palpated Feel for tender spots or lumps and note for paravertebral muscle spasm, particularly the posterolateral muscles and also assess the tension of the SCM Look Move Any deformity should be noted, assessing the neck from the front, from the side and from behind Look for facial and shoulder asymmetry Look for any scars or lumps in the supraclavicular fossa or on the midline Note any asymmetry of the pupils, drooping eyelids and dry skin, characteristics of Horner syndrome Torticollis, due to muscle spasm, may suggest a disc lesion, an inflammatory disorder or cervical spine injury, but it also occurs with intracranial lesions and disorders of the eyes or semicircular canals The ‘cock robin’ posture describes the head tilted to the side It is important to observe the prominence of the SCM, as it may give clues to the underlying cause In congenital torticollis, the muscle bulk is tightened and shortened, prominent on the tilted side and in atlanto-axial subluxation it is prominent on the opposite side Neck stiffness is usually fairly obvious by the spine being ‘splinted’ due to muscle spasm Start to assess active range of motion (Figure 17.5) Forward flexion, extension, lateral flexion and rotation are tested, and then shoulder movements Range of motion normally diminishes with age, but even then movement should be smooth and pain-free Remember that the shoulder girdle and the cervical spine are somehow synchronous in their movements – if one is injured and has a restricted range of motion, the other segment will have to compensate spontaneously Very often we see patients who present with shoulder symptoms and subsequently develop neck pain and vice versa Enquire about any painful motion Pain elicited by rotation and extension that is referred to the trapezium and shoulder blade area is very often due to facet joint pathology Movement-induced pain and paraesthesia down the arm/forearm is particularly relevant for a herniated disc prolapse (d) (h) (b) (e) (c) (f) (g) 17 The neck (a) Figure 17.4 Examination (a) Look for any deformity or superficial blemish which might suggest a disorder affecting the cervical spine (b) The front of the neck is felt with the patient seated and the examiner standing behind him (c) The back of the neck is most easily and reliably felt with the patient lying prone over a pillow; this way muscle spasm is reduced and the neck is relaxed (d–g) Movement: flexion (‘chin on chest’); extension (‘look up at the ceiling’); lateral flexion (‘tilt your ear towards your shoulder’) and rotation (‘look over your shoulder’) (h,i) Neurological examination is mandatory (i) Neurological examination Neurological examination of the upper limbs is mandatory in all cases In some patients the lower limbs should also be examined Muscle tone, power, sensation and reflexes should be carefully tested; even small degrees of asymmetry may be significant Muscle power and sensation should be examined sequentially and bearing in mind the myotome and dermatome map Test the C5 (biceps), C6 (brachioradialis) and C7 (triceps) reflexes Special tests Tests for arterial compression If the thoracic outlet is tight, the radial pulse may disappear if, when the patient holds a deep breath, the neck is turned towards the affected side and extended (Adson’s test), or if the shoulder is elevated and externally rotated (Wright’s test) Figure 17.5 Normal range of motion Flexion and extension of the neck are best gauged by observing the angle of the occipitomental line – an imaginary line joining the tip of the chin and the occipital protuberance In full flexion, the chin normally touches the chest; in full extension, the occipitomental line forms an angle of at least 45° with the horizontal, and more than 60° in young people Lateral flexion is usually achieved up to 45° and rotation to 80° each way The Spurling’s test The patient is instructed to rotate the neck to one side with the chin elevated and laterally flexed, a position in which neural foramina are narrowed: if ipsilateral upper limb pain and paraesthesia are reproduced with axial compression of the head, the test is positive and that would increase the suspicion of a disc prolapse with cervical root compression In these cases, pain may be relieved by the patient abducting the arm overhead (the abduction relief sign) 459 REGIONAL ORTHOPAEDICS Tests for cervical myelopathy The following are physical findings suggestive of upper motor neuron compromise and cervical myelopathy: • Hoffmann’s sign – involuntary flexion of the thumb and index finger distal phalanx by flicking of the terminal phalanx of the middle finger • finger escape sign – little finger abduction when the patient is asked to stretch his or her hands in front • finger fatigue test – patient fatigues when asked to open and close his or her fists quickly • Lhermitte’s sign – an electric shock-like sensation along the spine if the spine is flexed • clonus – rapid movements of the feet triggered by forceful passive motion of the ankle into dorsiflexion from a plantar position Assessment of peripheral nerve entrapments should also be carried out IMAGING Imaging examination should complement but never overcome the clinical assessment and should be directed at confirming or excluding a diagnosis X-rays The standard radiographic series for the cervical spine comprises anteroposterior, lateral and open-mouth views (Figure 17.6) The lateral view should always include the base of the skull and the cervicothoracic junction, especially in the trauma case Additional lateral dynamic views in flexion and extension can be obtained in the cooperative and neurologically intact patient In the case of an acute neck injury, if needed, dynamic views should be obtained in the presence of (a) 460 (b) the physician Oblique views can also help, especially in the trauma scenario The anteroposterior view should show the regular, undulating outline of the lateral masses; destructive lesions or fractures may disturb its symmetry The alignment of the spinous processes should be in a straight line An open-mouth view is required to show the axis and the atlantoaxial junction The lateral margin of the atlas should align with the lateral margin of the axis and the space on each side of the dens should be equal, if the neck is not rotated The lateral view should include all seven vertebrae; there have been cases of serious spinal injuries because a fracture-dislocation at C6–C7 or C7–T1 was missed The normal lateral view of the cervical spine shows four parallel lines: one along the anterior surfaces of the vertebral bodies, one along their posterior surfaces, one along the bases of the spinous processes, and one along the tips of the spinous processes; any malalignment suggests subluxation The disc spaces are inspected; loss of disc height, the presence of osteophytic spurs at the margins of adjacent vertebral bodies and inversion of the natural lordosis suggest intervertebral disc degeneration The posterior interspinous spaces are compared; if one is wider than the rest, this may signify chronic instability of that segment, possibly due to a previously undiagnosed subluxation The direction of the spinous processes should be confluent in an imaginary point on the concave side of the spine Flexion and extension views may be needed to demonstrate instability (Figure 17.7) Children’s X-rays have special particularities to be considered Because the ligaments are relatively lax and the bones incompletely ossified, flexion views may show unexpectedly large shifts between adjacent vertebrae The normal lateral X-ray of the child may show (c) Figure 17.6 Imaging – normal X-rays (a) Anteroposterior view – note the smooth, symmetrical outlines and the clear, wide uncovertebral joints (arrows) (b) Open-mouth view – to show the odontoid process and atlantoaxial joints (c) Lateral view – showing all seven cervical vertebrae an atlantodental interval of 4–5 mm (which in an adult would suggest rupture of the transverse ligament) or an anterior pseudo subluxation at C2–C3 or C3–C4 of up to 3 mm Note also that the retropharyngeal space between the cervical spine and pharynx at the level of C3 increases markedly on forced expiration (for example, when crying) and this can be misinterpreted as a soft-tissue mass However, the increase in the prevertebral cervical space in the context of trauma should raise a red flag and demand further studies (CT or MRI) to rule out an underlying unstable traumatic lesion both in children and adults Another error is to mistake the normal synchondrosis between the dens and the body of C2 (which only fuses at about 6 years) for an odontoid fracture Finally, remember that normal radiographs in children not exclude the possibility of a spinal cord injury 17 The neck Figure 17.7 Imaging – dynamic X-rays Dynamic X-ray views of a 65-yearold male with a traumatic C5–C6 disc lesion Note the instability at the disc level with anterolisthesis of C5 over C6 on hyperflexion preoperative workup and planning However, the amount of radiation for a CT scan is not negligible and this should be taken into account when the decision is made to request such an examination in a child Myelography Changes in the contour of the contrast-filled thecal sac suggest intradural and extradural compression However, this is an invasive investigation and fairly non-specific Its usefulness is enhanced by performing a post-contrast CT scan Due to its invasiveness and contrast side effects, it is seldom used routinely at present Myelography can be substituted by modern CT scan techniques Magnetic resonance imaging Computed tomography CT of the cervical spine provides excellent osseous detail It is useful to demonstrate the shape and size of the spinal canal and intervertebral foramina, as well as the integrity of the bony structures It is particularly helpful for the imagological assessment of axial and subaxial cervical spine trauma (Figure 17.8) CT also has a high performance for the measurement of the anatomical features as part of routine Figure 17.8 Imaging – CT scan A 39-year-old male with a C5–C6 unilateral locked facet well demonstrated in a sagittal CT scan frame MRI is non-invasive, does not expose the patient to radiation and provides excellent resolution of the soft tissue, such as the intervertebral disc and neural structures (Figure 17.9) It is very sensitive for Figure 17.9 Imaging – MRI scan A 41-year-old female with a C7 fracture and associated C5–C6 disc prolapse The role of MRI to assess the posterior ligamentous injuries is, nevertheless, associated with an important percentage of false positives 461 REGIONAL ORTHOPAEDICS demonstrating tumours and infection/inflammation It also provides information on the size of the spinal canal and neural foramina Its sensitivity can be a drawback: 20% of asymptomatic patients show significant abnormalities and the scans must therefore be interpreted in conjunction with the clinical picture In the trauma scenario it can help to determine the compromise of the posterior ligamentous structures, acute lesions of the intervertebral disc and the presence of oedema in the spinal cord or a cervicothoracic scoliosis There is often a history of trauma, although it can be triggered by simple neck rotation In up to 25% of cases, no underlying cause is identified In children and adolescents, acute torticollis is characterized by atlantoaxial rotational subluxation of sudden onset The correct workup of a child who presents with torticollis should include a cervical spine X-ray, and a CT scan should be considered on occasions CERVICAL SPINE ABNORMALITIES IN CHILDREN This is a common disorder in neonates and infants in which one of the SCM muscles is fibrous and fails to elongate as the child grows, resulting in a progressive deformity with a reported incidence of approximately 1% Although the aetiology is unclear, it may be associated with intrauterine packaging disorders or the result of a birth injury causing localized ischaemia A history of difficult labour or breech delivery is common Clinically, a lump can be visible in the first few weeks after birth, disappearing within a few months No deformity or obvious limitation of movement may be apparent until the child is 1–2 years old Along with the classical visible deformity of the neck, with the head tilted towards the affected side and the face rotated towards the contralateral shoulder so that the ear approaches the shoulder (Figures 17.10 and 17.11), an asymmetry of the face (hemihypoplasia) and plagiocephaly may be noticeable These features can worsen and become more obvious as the child grows INFANTILE (CONGENITAL) TORTICOLLIS DEFORMITIES AND CONGENITAL ANOMALIES A variety of deformities of the neck are encountered in children, some reflecting postural adjustments to underlying disorders and others a clinical manifestation of developmental anomalies TORTICOLLIS AND RELATED SYNDROMES TORTICOLLIS Torticollis is a cervical deformity in which the head is rotated and tilted towards one side with some lateral flexion, the so-called ‘cock-robin’ position The SCM muscle is ‘shortened’ and may feel tight and hard It is often a presenting feature of a congenital osseous cervical spine anomaly, particularly of the atlas, but it can also be acquired and the presenting sign of a tumour (for example, eosinophilic granuloma), infection (for example, discitis, lymphadenitis or, rarely, caused by an ear or upper respiratory tract infection) (a) 462 (b) Treatment Most children have a complete spontaneous resolution with time, but some cases may require physiotherapy If the diagnosis is made early, daily muscle stretching may prevent the incipient deformity (c) Figure 17.10 Congenital torticollis (a) Clinical picture of a young child with congenital torticollis Note the head tilting towards the left shoulder with slight rotation to the contralateral side (b,c) 3D reconstruction of CT images of the same child showing atlantoaxial fusion The benign SCM lump can completely disappear However, the clinician should be aware of other causes such as tumours and cysts in the neck, which may need surgical excision If the condition persists beyond 1 year, operative correction is required to avoid progressive facial deformity (Figure 17.12) SECONDARY TORTICOLLIS Childhood torticollis, as an acquired condition, has several aetiologies It may be secondary to infection (lymphadenitis, retropharyngeal abscess, discitis, tuberculosis), tumours (posterior fossa, intraspinal tumours), inflammatory disorders (juvenile rheumatoid arthritis), neurogenic causes (benign paroxysmal torticollis) or trauma and can also be idiopathic Atlantoaxial rotatory subluxation Atlantoaxial rotatory fixation is a pathological displacement of the atlas on the axis in a position that is normally accomplished during head rotation It can be associated with minor trauma or with a recent nasopharyngeal infection, tonsillectomy or even a retropharyngeal abscess (Grisel’s syndrome) It can present with an acute onset or after a period of weeks In the acute setting, there is pain and muscle spasm In fixed deformities, pain subsides but motion is restricted and the child cannot correct the deformity The mechanism behind Grisel’s syndrome is not completely understood, but anatomical factors permit that inflammation of the pharynx can lead to attenuation of atlantoaxial ligaments or the synovium The chin is shifted laterally or laterocaudally and the head fixed in this position Early diagnosis and therapy are crucial to prevent neurological complications caused by compression of the medulla oblongata by the dislocated odontoid Plain X-ray interpretation may be challenging Open-mouth views should be obtained CT scans in both neutral and maximum lateral rotation are the most helpful investigation Most cases are mild and can be managed expectantly with a soft collar and analgesics If there is no resolution after a week, halter traction (Figure 17.13a), bed rest and analgesics should be prescribed In this setting physiotherapy may be contraindicated Attempts for manual reposition without general anaesthesia are not tolerated In more resistant cases, halo traction may be required Occasionally, if the articulation remains unstable, subluxation persists or recurs easily or if there is neurological compromise, then a C1–C2 fusion is recommended 17 The neck Figure 17.11 Congenital torticollis AP view of the cervical spine of a child with congenital torticollis Note the head tilting towards the right shoulder with slight rotation to the contralateral side Figure 17.12 Torticollis Natural history: (a) sternomastoid tumour in a young baby; (b) early wry neck; (c) deformity with facial hemiatrophy in the adolescent Surgical treatment: (d) two sites at which the sternomastoid may be divided; (e,f) before and a few months after operation (a) (b) (d) (e) (c) (f) 463 REGIONAL ORTHOPAEDICS (a) (b) Figure 17.13 Atlantoaxial rotary subluxation (a) A child with atlantoaxial subluxation on halter traction Axial (b) and 3D reconstruction images (c) of C1–C2 rotatory subluxation VERTEBRAL ABNORMALITIES Congenital osseous cervical spine anomalies are rare, but their detection and complete diagnosis are needed in order to be able to establish a prognosis and treatment, as these deformities are often associated with instability and potential neurological injury associated with spinal cord encroachment Most cases are innocuous and may go undetected throughout life, with some being diagnosed only when a serious complication occurs Mutations of homeobox genes may be responsible for congenital osseous anomalies of the cervical spine that probably arise during somatogenesis The occiput, atlas and axis are formed by a separate mechanism from that responsible for the other vertebral bodies The remaining subaxial cervical vertebrae develop in a manner similar to the rest of the spine Failures of segmentation from the third to eighth weeks of fetal life can lead to several fusion defects, such as fusion of C1 to the occiput or C2–C3 These defects can be associated with congenital malformations of other organ systems, such as the kidneys and the heart Neurological signs and symptoms (head and neck pain, visual and hearing deficits, weakness and numbness in the extremities, long tract and posterior column signs, ataxia and nystagmus) can present with various anomalies including occipitalization of the atlas, basilar invagination, os odontoideum and chronic atlantoaxial dislocation Although imaging through conventional radiographs may be enough for the diagnosis, CT scan is the gold standard imaging for classifying this type of abnormalities However, taking into account the high rate of associated underlying neural abnormalities, all these cases should also be screened with MRI OCCIPITOATLANTAL INSTABILITY 464 (c) Instability at the occipitoatlantal joint has been described after trauma to the cervical spine and in association with Down’s syndrome, familial cervical dysplasia and hyperlaxity syndromes Symptoms of non-traumatic occipitoatlantal instability can include neck pain, headache, torticollis and weakness as well as vertebrobasilar symptoms such as nausea, vomiting and vertigo Arthrodesis of the occiput to the atlas for all patients with non-traumatic occipitoatlantal instability is recommended KLIPPEL-FEIL SYNDROME This rare developmental disorder is caused by a failure of segmentation of the cervical somites during the third to eighth week of embryogenesis, resulting in fusion of at least two cervical segments Congenital fusion can occur at any level in the cervical spine, but approximately 75% occur in the upper cervical spine Klippel-Feil is often associated with other skeletal and extraskeletal abnormalities such as scoliosis (60%), renal abnormalities (35%, most commonly unilateral renal agenesis), Sprengel deformity (30%), deafness (30%) and congenital heart disease (14%, most commonly ventricular septal defect) There is also an important association with fetal alcohol syndrome Other associated deformities include hand anomalies such as syndactyly, thumb hypoplasia and extra digits The classical clinical triad of children with synostosis is short neck with various degrees of neck webbing, low posterior hairline and limitation of neck mobility (Figure 17.14) Nevertheless, less than 50% have all these findings Furthermore, there is often compensatory hypermobility on the mobile adjacent segments Symptoms tend to arise in the second or third decades, not from the fused segments but from the adjacent mobile segments, and they are related to the extension of involvement of the spine and the presence of other anomalies The most consistent clinical finding is a limited range of motion of the neck, especially lateral bending There may be pain due to joint hypermobility or neurological symptoms from instability Index 998 pelvic fractures (continued) elderly 878 haemorrhage 658, 681–2, 689, 870–1 immediate management 658, 682, 689, 864 isolated 867–8 pelvic ring 868–72 pelvis achondroplasia 164 anatomy 863–4 bone tumours 192 Ewing’s sarcoma 215–16 imaging 865–7 obliquity 242, 243, 253 osteotomy 535–6, 540 Pemberton osteotomy 535 pentasaccharide 324 Peptococcus magnus 33 periacetabular osteotomy 536 pericardiocentesis 675 perilunate dislocation 811–12 perimysium 231 perineurium 280 periocardotomy 675 periosteal bone formation 121 periosteal chondroma 193, 194 periosteal reaction 18 lamellar (onion-skin periostitis) 188, 214, 215 periosteal stripping 738 periosteum 715 periostitis, syphilis 51, 51, 52 peripheral nerves blood supply 280 pathology 280–2 structure 231, 279–80 peripheral neuropathies 265–70, 302 causes 265, 266–7 classification 266 demyelinating 266–7 hereditary 267–8 infective 269–70 brachial neuritis 292, 298 Guillain–Barré syndrome 270 herpes zoster 269 leprosy 59, 270, 311–16 large-fibre 266 metabolic 268–9 alcoholic 269 diabetic 268, 636–7 small-fibre 266 peripheral vascular disease 636–7 peripheral venous cannulation 682–3 periprosthetic fractures 567, 903–4 periprosthetic joint infection 32, 44–5, 345, 567–8 peritendinitis crepitans (intersection syndrome) 423 PERK 474 Perkins’ traction 899 peroneal muscular atrophy 267–8, 639 peroneal nerves injuries 299, 300, 301, 735, 919 in leprosy 59 palsy 605 peroneal tendons dislocation 941 impingement in calcaneal injury 958 personal protective equipment (PPE) 654, 660 Perthes disease (Legg–Calvé–Perthes disease) 108, 537–40 pes cavus 267, 610, 611, 622, 623–6 pes planovalgus 249 pes plantaris 611, 624, 625 pes planus, see flat foot Petri casting 540 Peyronie’s disease 438 Phalen’s test 303 phantom limb 343 phenotype 158 PHEX gene 132, 146 phocomelia 402 phosphate, supplementation 146 phosphorus 130 photography, open tibial fractures 931 physical therapy cerebral palsy 247 flat foot 622 low back pain 520 patella dislocation 924 plantar fasciitis 642 shoulder instability 370–1 physis (growth plate) 121, 122, 125 arrest (epiphysiodesis) 337, 924 distal radius 427 injuries 742, 749–51 ankle 948–50 classification 750 distal femur 910–11 distal humerus 788 distal radius 406, 803–4 elbow fractures 785 growth arrest 742, 924, 949–50 proximal femur 896 proximal humerus 769–70 proximal tibia 924 radial neck 788–9 in osteomyelitis 39 stapling 578 stimulation 337 zones 127 pia mater 684 piano-key sign 399, 409, 416, 794, 811 Picture Archiving and Communication System (PACS) 16 pigmented villonodular synovitis (PVNS) 223, 225–6, 577, 601 pilon fractures distal tibia 946–8 middle phalanx 823 polydactyly 403–4 polymethylmethacrylate (PMMA) 346–7, 563–4 polyneuropathy, causes 265 Ponseti treatment 272, 615–17 popliteal aneurysm 603 popliteal artery, injury 734, 908, 911, 919, 932 popliteal cyst 602–3 popliteal pulse 491 position sense 12 positron emission tomography (PET) 25 post-polio syndrome 262 post-thrombotic syndrome 322 posterior aspect posterior cord syndrome 12, 860 posterior cruciate ligament (PCL) anatomy 914 injury 917 testing 914, 915 posterior interosseous nerve injury 305–6, 735 posterior ligament injury 848 posterior ligamentous complex (PLC), disruption 854 posterior longitudinal ligament (PLL) 474 ossification 474–5, 476 postural deformity 14 kyphosis 502, 504 scoliosis 494 posture back disorders 489, 490 cerebral palsy 242, 243 neurological disorders 10, 11 pothole injury 961–2 Pott’s disease (spinal tuberculosis) 480–1, 482, 508–11 Pott’s fracture 942 power, see muscle power power grip 429, 817 pre-implantation genetic diagnosis 160–1 pre-natal diagnosis 160–1 pregabalin 278 pregnancy, pre-natal diagnosis 160–1 Preiser’s disease 415 Preotact 139 prepatellar bursitis (housemaid’s knee) 602 pressure garments 727 pressure sores 722, 737–8, 742, 860 Prevent injury and Enhance Performance (PEP) programme 917 priapism 838 PRICE protocol 939 primary survey 662–4 adjuncts 661, 664 primitive reflexes 241 probenecid 86 pronation 9, 395 cerebral palsy 248 nerve root supply 233 poliomyelitis 263 testing 384, 385 Index pin-track infection 727 pinch 429 defect of 296, 297, 304 restoration in cervical cord injury 860–1 Pipkin classification 882, 884 Pirani classification 614 Pirogoff’s amputation 342 pisiform bone 399, 426–7, 805 exicision 422 pisohamate tunnel 296 pisotriquetral joint 399 arthritis 422, 825 pistol-grip deformity 556 pivot shift test 411, 574 planes of body 9, plantar fascia 641–2 release 625, 642 plantar fasciitis 635, 641–3 plantar nerves, medial/lateral 302 plantar reflex 12 plantar stress injuries 959 plantar venous compression, intermittent 324 plantar warts 646 plantarflexion 611, 612, 647 plantaris deformity 611, 624, 625 plaster casts 721–2, 728 club foot 615, 616 complications 722, 735, 736, 737–8, 933 femoral shaft fractures 899 scaphoid 808 plaster jacket 856 plastic pen test 282, 826 platelet-derived activators 333 platelet-rich plasma 561 plates (bone fixation) 329, 330, 724, 725 femoral shaft fractures 899–900 plexopathy 266 plica syndrome 588, 592–3 pneumatic compression, intermittent 324 pneumothorax 673–4 chest drain placement 676 open (sucking chest wound) 674 simple 676 tension 656, 663, 673–4 trauma casualty 656, 663 podagra 634 point mutations 158 pointing index sign 297, 298 poisonings 651 Poland’s syndrome 404–5 poliomyelitis 261–5 foot paralysis 639 post-polio scoliosis 502 post-polio syndrome 262 polyarthritis differential diagnosis 69–70 seronegative inflammatory 69 999 Index 1000 pronator syndrome 304 Propionibacterium acnes 44, 506, 513 prostate 864 prostate carcinoma 221 prostheses amputations 342–3 see also implants protrusio acetabuli 171 proximal, defined proximal femoral varus derotation osteotomy 536 proximal interphalangeal (PIP) joints hyperexension (swan-neck) 434, 435–6, 444 ligament injuries 824, 832–3 osteoarthritis 445 pseudarthrosis congenital 17, 376–7 fracture non-union 715, 739 pseudoachondroplasia 168, 169 pseudogout 27, 49, 87–8, 105, 389–90 pseudohypoparathyroidism 142 Pseudomonas spp 33, 506, 732 pseudoparalysis 35, 47, 52 psoas abscess 48, 79, 508 psoriasis 453 psoriatic arthritis 75, 77–9, 436, 487, 634 pterygia syndromes 271–2 pubic rami, stress fractures 746, 747, 867–8 pubic symphysis injury/diastasis 865, 871–2 plating 871 pulleys, fingers 828 pulmonary artery flotation catheterization 700 pulmonary artery occlusion pressure (PAOP) 700 pulmonary contusion 677 pulmonary embolism (PE) 322, 323, 323 pulmonary function tests, scoliosis 496 pulse contour analysis 700 pulse oximetry 664 pulse power analysis 700 pulse pressure 679 pulseless electrical activity (PEA) cardiac arrest 673, 675 pulses peripheral 491, 611 trauma casualty 664 punching injuries 817 pupil examination 663 pustulosis, palmoplantar 45–6, 378 Putti–Platt operation 369–70 pycnodysostosis 128 pyogenic infection cervical spine 479–80 thoracolumbar spine 505–7 pyramidal signs 477 pyrazinamide 56, 509 pyrocarbon 346 pyrophosphate arthropathy 69, 86, 87–8 elbow 389–90 knee 105, 595 Q-angle (quadriceps angle) 570, 571, 588, 606 QFracture 138 quadriceps contracture 587 rehabilitation 917 resisted action 599, 920 spasticity 245 wasting 571, 590 quadriceps active test 914, 915 quadriceps tendon 606 rupture 599, 920–1 quadriplegia 234 management 860–1 R A, see rheumatoid arthritis radial artery 428 radial club hand 402, 433 radial corner pain 398 radial nerve 396, 454 compression 305–6 injury/palsy 295–6 causes 735 elbow fractures 775, 784 humerus fractures 295, 772 wrist drop 11, 295, 407 in leprosy 59, 312, 313 sensory superficial 305, 396, 427 radial nerve, compression 743 radial pulse, postural obliteration 309 radial tunnel syndrome 306 radiation exposure 318–19 radiation necrosis 116–17 radiation-induced sarcoma 209 radiculogram 515 radiculopathy cervical 454, 455, 456, 457, 466, 471 defined 266 lumbosacral 76, 515 vs peripheral entrapment 239 radiocapitellar joint 395 radiocarpal joint 408 arthrodesis 415 instability 410 osteoarthritis 418–19 radiocarpal translocation 411 radiohumeral joint, dislocation 717 radiolunate ligaments, long/short 428 radionuclide imaging 24–5 back 492 bone tumours 183 bony metastases 150 complex regional pain syndrome 745 femoral head osteonecrosis 897 foot/ankle 613 fractures 717–18 hip fracture 888 knee 576 receptor activator of nuclear factor-kβ ligand (R ANKL) 124, 127, 132, 199, 214 antibodies 127, 139, 199, 200 reconstruction ACL 603–4, 917 hand/digits 833 limb 190, 330, 331, 334–6 chondrosarcoma 211, 213 Ewing’s sarcoma 215–16 osteosarcoma 207–8 nerve injuries 285–6 pelvic discontinuity 879 spinal tuberculosis 510 rectus capitis 455 rectus femoris, rupture 599 recurrent laryngeal nerve 456–7 Redlund–Johnell criteria 484 referred pain elbow 383 neck 457, 458 shoulder 351 reflex sympathetic dystrophy, see complex regional pain syndrome reflexes 11, 12, 231 rehabilitation acute disc prolapse 517 foot injuries 951 hip fracture 892 total hip arthroplasty 566 Reiter’s syndrome 69, 75, 76–7, 645 renal cell carcinoma 221, 222 renal dysfunction mineral bone disorder 146–7 MODS 705 reperfusion, tourniquet deflation 320 replantation surgery 339, 340 respiratory failure 703–4 resuscitative endovascular balloon occlusion of the aorta (REBOA) 682 retinoblastoma, hereditary 206 retroperitoneal injuries 687 rewarming 696 rhabdomyosarcomas 227 rheumatic fever 48 rheumatism, acute 37 rheumatoid arthritis (R A) 65–72 ankle and foot 633–4 cause 65–6 cervical spine 482–5 clinical features 67–8, 70 complications 71–2 diagnosis 69–70, 79 elbow 388–9, 394, 395 hands 48, 416, 436, 440–4 hip 561–2 investigations 68–9 knee 580, 594–5, 601 Index radionuclide imaging (continued) osteomyelitis 36, 41 osteonecrosis 111 Paget’s disease 152 stress fracture 746 wrist 400 radioscaphocapitate ligament 427 radioscapholunate ligament 428 radiotherapy bone tumours 191 Dupuytren’s contracture 438 radioulnar discrepancy 804 radioulnar joint disruption in forearm fracture 789–90 distal, see distal radioulnar joint (DRUJ) proximal, dislocation 793–4 radioulnar synostosis 385–6, 391 radius distal fractures 138, 406, 797–804 in children 803–4 Colles 138, 406, 797–9 complications 802–3 fragmented intra-articular 801–2 malunion 408–9, 412 styloid 800 volar displaced 799–800 distal osteotomy 406, 407 distal physis 427 injury 406 Galeazzi fracture–dislocation 408, 794–5 head acquired subluxation 386–7, 392 congenital dislocation 385 excision 388, 389 fractures 409, 775–6 subluxation (pulled elbow) 387, 789 longitudinal deficiency 402 longitudinal instability 409 Madelung’s deformity 405, 406 neck fractures 777 children 788–9 shaft fractures 789–92 isolated 772–3 shortening 414 styloid excision 418 fracture 800 tenderness 397, 398, 423 Ranawat criteria 484 Ranvier’s nodes 229, 280 rapid sequence induction (RSI) anaesthesia 656, 672 Raynaud’s phenomenon 424, 452 unilateral 308 Raynaud’s syndrome 452 Rb1 gene 179 reactive arthritis 69, 76–7 REBOA (resuscitative endovascular balloon occlusion of the aorta) 682 1001 Index 1002 rheumatoid arthritis (R A) (continued) monoarticular 56 pathology 66–7 prevalence 65 prognosis 72 shoulder 373–4 silent joint infection 48 synovial fluid analysis 27 tendon ruptures 444, 920–1 treatment 70–1 vs gout 86 wrist 407, 411, 415–18, 424, 425–6 rheumatoid factor (RF) 26, 65, 66, 68 rhizomelia 161 rib hump 495, 499 rib-cage excursion 491 ribs cervical 308, 309 fractures 675, 734 RICE protocol 939 rickets 132, 143–5, 579 hypophosphataemic 132, 145–6 rifampicin 57, 59, 270, 509 rim fracture 941 ring sign 807–8 Risser’s sign 495–6 road traffic accidents abdominal injuries 687 aortic injury 677–8 death/injury by road user type/age 651, 652 entrapped casualties 657–8 mortality rates 651–2 pelvic fractures 863 safety on scene 654 seat belt injuries 854, 858 whiplash injuries 852–3 robotically assisted surgery 318 rocker-bottom foot 618, 637 Rolando’s fracture 818 Romanus lesions 485 Romberg’s sign 12 romosozumab 129, 140 Roos’s test 308 rotator cuff, anatomy and function 355, 381 rotator cuff disorders 309, 355–63 after shoulder dislocation 763 calcification 89, 362–3 following acromioclavicular joint injury 761 imaging 360–1 impingement 356–7 pain 355–6 rheumatoid arthritis 373, 374 tears 357, 358 tendinitis 357–8 tests 353, 358–60 treatment 361–2 vicious spiral 360 vs cervical spine disease 469, 473 Rothmund–Thomson syndrome 206 Roux–Goldthwait procedure 587 Royal College of Surgeons of England 686 rugger jersey finger 821 rugger jersey sign 147, 171 rule of nines (burns) 692, 693 runners, long-distance 310 RUNX2 gene 169 Russell’s traction 899 sacral agenesis 261 sacroiliac joints 863, 865 ankylosing spondylitis 73, 74 injuries 872 sacroiliitis 78, 79, 485, 529 sacrum chordoma 218–19 fractures 872, 879 sag sign 574 sagittal bands, hands 826 sail sign 385, 782 Salmonella spp 33, 76 Salter osteotomy 535 Salter and Thompson classification 539 Salter–Harris fractures 750–1 distal femur 910–11 distal phalanx 821 distal radius 803–4 distal tibia 948–50 elbow 785 proximal humerus 769–70 proximal phalanx 824 proximal tibia 924 radial neck 788–9 types 750 SAM Sling™ 682 Sanfilippo syndrome (MPS type III) 172 SAPHO syndrome 46, 482 SAPS, see simplified acute physiology score sarcoidosis 70, 487–8 sarcolemma 232 sarcomas post-radiation 209 soft-tissue 179, 180, 182, 186 spindle-celled 214 synovial 226 see also chondrosarcoma; Ewing’s sarcoma; osteosarcoma Saturday night palsy 281, 296 scalp injury 684 scaphocapitate fusion 414, 415 scaphoid 399, 408, 427, 805 avascular necrosis 742, 808, 809 excision 419 fracture 108, 418, 717 fractures 804, 806–9 seat belt injuries 854, 858 secondary survey 664–5 Secretan’s syndrome 453 Seddon’s classification (nerve injuries) 281 selective digestive tract decontamination (SDD) 706 selective dorsal rhizotomy (SDR) 247 selective oestrogen receptor modulators (SERMs) 139 self-assessment questionnaires, osteoarthritis 100 self-management, osteoarthritis 101 semimembranosus, bursa 602 sensibility, deep 12 sensory examination 12, 235, 283–4 cerebral palsy 245 hand 282, 826 sensory loss diabetic foot 637 median nerve compression 303 sciatic nerve injury 299, 300 sensory nerve action potential (SNAP) 237, 239 sensory system, somatic 230–1 sepsis, mediators 702–3 SEPT9 gene 292 septic arthritis enteropathic 79 hand/fingers 447, 450–1 hip 537 in HIV 50 knee 600–1 sternoclavicular joint 377 synovial fluid analysis 27 vs gout 85 septic shock 679, 681, 698, 701 sequential organ failure assessment (SOFA) 709 sequestra, osteomyelitis 34, 41 sequestration, spinal canal 514 serratus anterior nerve root supply 233 paralysis 292 testing 353 weakness 377 Service de l’Aide Medical Urgente (SAMU) 653 Services Mobile d’Urgence et de Reanimation (SMUR) 653–4 sesamoid arthrodesis 823 sesamoiditis 643–4 sesamoids, (foot), fractures 963 Sever’s disease (traction apophysitis) 641 sex chromosomes 157 Seymour fracture 821 shepherd’s crook deformity (femur) 171, 176, 203, 204 Shigella spp 76 shingles (herpes zoster) 269 shock 657, 678–83 advanced monitoring 699–700 anaphylactic 679–80, 681, 698 cardiogenic 679, 681, 698 Index scaphoid–trapezium–trapezoid (STT) arthritis 411, 421, 422, 825 fusion 421, 422 scapholunate advanced collapse (SLAC) 419 scapholunate angle 426 scapholunate dissociation 410, 412, 805–6, 812–13 scapholunate interval, widening 411, 412 scapholunate ligament, rupture 800, 812 scapula congenital elevation 376 fractures 757–9 grating (snapping) 377 instability 377 winging 269, 292, 293, 377 scapulohumeral rhythm 353, 358 scapulothoracic dissociation 759 scarf osteotomy 628 scars 6, SCFE, see slipped capital femoral epiphysis Scheie’s syndrome (MPS type V) 172 Scheuermann’s disease 503–4, 505, 528 Schmorl’s nodes 504, 505 Schwann cells 229, 280 schwannoma 226–7 sciatic nerve injuries 299–300, 640, 735, 864, 876 hip dislocation 883 hip replacement 300 sciatic scoliosis 494, 515 sciatic stretch 491, 492 sciatica 4, 489, 514, 530 scissor gait 234, 243 scissor stance 242 scleroderma 436, 453 sclerosteosis 129 sclerostin 129, 133, 140 scoliosis 5, 14, 464, 494–502 cerebral palsy 242, 245, 253 clinical features 494–5 congenital 501 idiopathic 494, 496–501 early-onset (infantile) 500–1 early-onset (juvenile) 500 late-onset 497–9 imaging 495–6 and neurofibromatosis 501, 502 neuromuscular conditions 501 poliomyelitis 264 postural 494 spina bifida 260 structural 494, 495 scoring systems intensive care unit 707–10 spinal injuries 839 cervical 846, 847 screws, bone fixation 329–30, 724, 725 SDD, see selective digestive tract decontamination 1003 Index 1004 shock (continued) causes 698, 700 diagnosis 699 distributive 698 hypovolaemic 679, 680, 698 stages 680 unresponsive 681 management 681–3, 700–1 neurogenic 679, 681, 690, 698 obstructive 698 recognition 680–1, 697, 698 septic 679, 681, 698, 701 shoe raise 337 shoes and calcaneal bursitis 641 and hallux rigidus 630 and hallux valgus 626, 627, 628 rocker-soled 630, 930 shopping cart sign 518 short stature 161 achondroplasia 164–5 surgery to increase 338 shoulder anatomy 355, 380–1 arthrodesis 263, 290, 380 arthroplasty 373, 374, 379–80, 769 arthroscopy 29, 379 clinical examination 7, 351–4 crystal deposition syndromes 89–90 dislocation 762–6 anterior 762–4 in children 766 habitual 371, 766 inferior (luxatio erecta) 762, 765–6 posterior 764–5 recurrent 764 unreduced 764, 765 frozen (adhesive capsulitis) 365–7 imaging 354–5 instability 351, 367–72, 381 atraumatic/minimally traumatic 370–1 axillary nerve injury 294–5 classification 367–8 habitual subluxation 371 posterior 371–2 traumatic anterior (polar type I) 368–70 movements 352–3, 381 osteoarthritis 99, 374 post-traumatic stiffness 367, 764, 769 rapidly destructive arthropathy (Milwaukee shoulder) 90, 99, 103 rheumatoid arthritis 373–4 SLAP lesions 364–5 tuberculosis 372–3 weakness 263, 294–5, 351 see also glenohumeral joint; rotator cuff disorders; scapula shoulder–hand syndrome 367 sialoproteins 123 sickle-cell disease 49 bone infections 33, 37, 38 clinical features 114–15 crises 37, 114 genetics 114 osteonecrosis 108, 109, 114–15, 560 pathology 114 sickle-cell trait 114 Silastic spacers 442 Silfverskiöld test 244 silicone prostheses 346, 415 Simmond’s test 638, 639 Simmons osteotomy 486 simplified acute physiology score (SAPS) 709, 710 Sinding–Larsen Johansson syndrome 588, 600 single event multi-level surgery (SEMLS) 251 single photon emission computed tomography (SPECT) 25, 36 sinography 19, 41 sinus formation, osteomyelitis 41, 42 skeletal dysplasias classification 163, 164 diagnosis in childhood 161–2 skeletal maturity, assessment 495–6 skier’s (gamekeeper’s) thumb 443, 824–5 skin, anaesthetic 283 skin cleansing 320 skin contracture 434 skin examination hands 430, 454 knee 571 lower limb 611 skin flaps 341, 343 skin grafts Dupuytren’s contracture 439 hand injuries 828, 829, 832 open fractures 731, 732 skin lesions cast splintage 722 foot 645–6 leprosy 58, 58 psoriasis 78 Reiter’s syndrome 77 skin traction 720, 721, 899 skull 684 fractures 685 skull traction 849–50 SLAP lesions 364–5 SLC26A2 gene mutations 166 slipped capital femoral epiphysis (SCFE) 541–6 small-cell osteosarcoma 208 Smith–Robinson–Cloward approach 456 Smith’s fracture 799–800 smooth muscle tumours 226 social background 5–6 SOFA, see sequential organ failure assessment examination 837–8 facet joint dislocations 842, 848–50 history 837 imaging 838–40 immediate management 655, 689–90, 836 mechanisms 836 neural (cord) injury 255, 841, 859–61 anatomical levels 859–60 cord transection 689–90, 859 incomplete cord syndromes 860 neurapraxia 852, 859 paraplegia/quadriplegia management 860–1 root transection 859–60 in spinal surgery 499 pars interarticularis 845, 854–5 pathophysiology 835 spinal shock 254, 255, 679, 698, 837 stability assessment 840–1 thoracolumbar spine 842, 853–9 transverse processes 854, 855 spinal muscular atrophy 265, 267 spinal shock 254, 255, 679, 698, 837 spinal stenosis 255, 524–7 absolute 525 central 524 cervical spine 471, 473–8 clinical features 255, 525 congenital 164, 165, 235, 255, 524 degenerative 525, 526 foraminal 524, 525, 526 imaging 525–7 lateral recess 524, 526 low back pain 518 Paget’s disease 151, 153 spinal surgery cerebral palsy 253 complications 499 low back pain 520, 521 scoliosis 498–9, 500 spinal cord monitoring 239, 499 tuberculosis 510–11 VTE risk 323 spindle-cell sarcomas 214 spine applied anatomy 528, 530 blood supply 530 examination 489–92, 519 fusion 520 immobilization in trauma 655, 657, 662, 667 infections cervical spine 478–82 pyogenic discitis 505–7 thoracolumbar spine 505–11 tuberculosis 55, 480–1, 482, 507–11, 529 movements 456, 490–1, 528 nerve supply 530 Spine Patient Outcome Research Trial (SPORT) 517, 527 Index soft-tissue tumours 222–3 epidemiology 179 fibrous 224–5 lipomatous 223–4 muscle 226–7 sarcomas 179, 180, 182, 186 soft-tissue web 271 soleus contracture 244 tear 638, 639 somatic (diploid) cells 157 somatic nervous system 230–1 somatosensory evoked responses (SSEP) 239 Somsak nerve transfer 286, 295 Southwick angle 543 Southwick intertrochanteric osteotomy 545 space of Poirier 428 spasticity (spastic paresis) 11, 232 adult-acquired 253, 437 cerebral palsy 94, 104, 241–4 foot 639–40 hand 248, 437 tone management 246–7 Speed’s test 364 spica cast 534, 899, 907 spina bifida 256–61, 614, 615, 639 occulta 256, 257, 258 spinal accessory nerve injuries 292–3 transfer 289 spinal boards 667 spinal canal anatomy 530 stenosis, see spinal stenosis spinal claudication 525 spinal cord 530 causes of dysfunction 253–6 electrophysiological monitoring 239, 499 neurological pathways 230, 253–4 spinal cord compression achondroplasia 164 acute 254 in ankylosing spondylitis 76, 485 cervical spine 254, 456 lumbar 254 in R A 72 thoracic 254 spinal cord injury, without obvious radiographic abnormality (SCIWOR A) 255, 665, 844 spinal decompression 470–1, 516–17 cervical spine 457, 470–1, 475, 478 lumbar spine 516–17, 527 spinal injuries in ankylosing spondylitis 76, 485, 486 ASIA score sheet 839 cervical spine 461, 486, 689–90, 842–53 classification 835 1005 Index 1006 spinocerebellar ataxias 268 spinothalamic tracts 230, 253–4 spinous process, avulsion 852 spirochaete infections 50–2 spleen injury 687 splintage acute suppurative arthritis 49–50 cerebral palsy 247 hand 447, 448, 815, 830 osteomyelitis 38 radial nerve injury 296 rheumatoid hand 441–2 splinter haemorrhages 452 spondylitis enteropathic arthritis 79 psoriatic 78 spondyloarthropathies axial 72–6 peripheral 76–81 spondylodiscitis 478, 479–80, 529 spondyloepiphyseal dysplasia 166–7, 504 spondylolisthesis 521–4, 525 spondylolysis 522, 523–4, 525 spondylosis 513 cervical 457, 471–4 sporotrichosis 452 sprains 751–2 acromioclavicular joint 759–60 ankle 937 wrist 806 Sprengel deformity 376, 464 spring ligament 621, 623 spur sign 876 Spurling’s test 459 squat test 575 squeeze test, ankle injury 941 stab wounds abdominal 687 accessory nerve injury 292–3 staging chronic osteomyelitis 42, 42 osteonecrosis 112 Perthes disease 538–9 tumours 182 stainless steel implants 344 Stanmore Instability Classification 367 Staphylococcus, coagulase-negative 44 Staphylococcus aureus 32, 44, 479 bone infections 37, 732 knee infection 600 methicillin-resistant 38, 44, 449 pyogenic spinal infections 505 stature short 161, 164–5 surgery to increase 338 steal syndromes 151 Steel sign 542 Steindler transfer 290 Stener lesion 824, 825 stereognosis 12, 433 sternoclavicular joint dislocation 761–2 hyperostosis 46, 378 septic arthritis 377 sternocleidomastoid (SCM) muscle 456 benign lump 462–3 Still’s disease 80 Stimson’s technique 763 storage diseases 163, 172–3 straight-leg raising test 491, 515 streptococcal necrotizing myositis 37 Streptococcus pyogenes 32 streptomycin 57 stress fractures 746–7 clinical features 746 diagnosis 187 femoral neck 747 imaging 746–7 metatarsals 644 metatarsals (march fracture) 962 pubic rami 746, 747, 867–8 sites affected 746 spinal 522 tibia 746, 935 treatment 747 stress X-rays, knee 916 stretch reflexes 11, 12, 231 stridor 668 stroke 253, 437, 639 strontium ranelate 139–40 strut graft 510 Stulberg grading 540 Styner, James 661 subacromial bursa 373 Subaxial Cervical Spine Injury Classification (SLIC) 846, 847 subchondral bone 92 cysts 554, 555 sclerosis 95 subclavian artery 307–8 subdural haematomas 686 subscapularis 355 testing 359, 360 subtalar joint 612 arthrodesis 621 subluxation/dislocation 953 suction, oropharyngeal 670 Sudeck’s atrophy, see complex regional pain syndrome suicides 651 sulphinpyrazone 86 Sunderland’s classification (nerve injuries) 282 sunlight exposure 131, 143 synovectomy 601 elbow 388, 389 knee 595 rheumatoid hand 442, 443 synovial biopsy 56, 68 synovial chondromatosis 591, 592 synovial effusions, shoulder 373 synovial fluid 27, 345 synovial fluid analysis 27 gout 27, 84–5 tuberculosis 27, 56 synovial joints 91–2 synovial tumours 225–6 synovitis 92 acute atraumatic 27, 601 chronic 27 knee 572, 601–2 pigmented villonodular (PVNS) 223, 225–6, 577, 601 rheumatoid 66, 67, 373 transient 56, 601 synpolydactyly 404 syphilis 17, 50–2, 256 syringomyelia 256 systemic inflammatory response (SIRS) 702 systemic lupus erythematosus (SLE), osteonecrosis 82, 107, 108, 375, 436, 597, 599 T score 25, 135 tabes dorsalis 256 table-top test 438 talar tilt test 939–40 talipes calcaneovalgus 618 talipes equinovarus arthrogryposis 271, 272 cerebral palsy 249 idiopathic 614–17 spina bifida 261 talocalcaneal coalition 621 talocalcaneal joint 950, 958 talonavicular joint 610 fracture-subluxation 958, 959 talus anatomy 950 fractures 108, 951–4 osteochondritis dissecans 118, 635, 640 osteonecrosis 108, 635, 640, 742 vertical 261, 271, 618–19 tarsal coalition 619, 620 tarsal disorganization 315–16 tarsal tunnel syndrome 310, 645 tarsometatarsal (TMT) joints, injuries 960, 961 Taylor spatial frame 617 teardrop fracture 847 technetium-labelled hydroxymethylene diphosphonate (99mTc-HDP) 24 teicoplanin 43, 729 Index supination nerve root supply 233 poliomyelitis 263 testing 384 supraclavicular muscles 307 supracondylar fractures femur 734, 908–10 humerus 298, 299, 773–5 children 781–4 supraglottic airway devices 655–6, 669, 671 suprapatellar realignment 586–7 suprascapular nerve compression 307 injury 293–4 supraspinatus 355 arm abduction 294 calcification 89, 362–3 impingement 356–7 nerve root supply 233 tendinitis 357–8, 360 tendon tear 359 testing 359, 360 wasting 307, 352 surgery bloodless field 319–20 chronic osteomyelitis 43 equipment 317 infection risk reduction 320–1 intra-operative radiography 317–19 on joints 338–9 peripheral nerve injuries 310–11 planning 317, 318, 550, 551–2 robotically assisted 318 thromboprophylaxis 321–5 tissue oxygen consumption 697 tuberculous arthritis 56–7 surgical emphysema 674 sustenaculum tali 955 sutures interosseous 812, 813 nerve 284, 285 swan-neck deformity fingers 435–6, 442, 444, 821 thumb 443 swelling Syme’s amputation 342 sympathetic cervical (stellate) ganglion 457 sympathetic nervous system 231 symphalangism 404 synapse 229 synarthroses 121–2 synbrachydactyly 402 syndactyly 404 syndesmophytes 73, 74, 485 synostosis 406 radioulnar 385–6, 391 1007 Index 1008 telangiectatic osteosarcoma 208 temperature recognition 12 tenderness, examination for tendinitis acute calcific 89, 362–3 bicipital 364 knee 600 supraspinatus 357–8, 360 tendo Achilles 638 tendo Achilles avulsion 957 insufficiency 958 lengthening 251, 617, 625 rupture 638–9 tenderness 76 tendinitis 638 tightness 619, 620, 641 tendon reflexes 11, 12, 231 tendon repair hand 827–30 delayed 832 tendon ruptures Achilles tendon 638–9 after distal radius fracture 803 long head biceps 364 quadriceps 599, 920–1 rheumatoid arthritis 444, 920–1 tibialis posterior 621, 634, 640 wrist 417 tendon sheath infections, hand 449–50 tendon transfers 286 brachial plexus injury 290 cerebral palsy 247–8 leprosy 313, 314 pes cavus 626 poliomyelitis 263, 264 prerequisites for successful 286 radial nerve injury 296 sciatic nerve injury 300 spinal cord injury 860–1 ulnar nerve injury 297 tennis elbow 392–3 resistant 306 tenodesis knee ligaments 604 three ligament (3T) 412 tenolysis 832 tenosynovitis ankle 640 rheumatoid arthritis 67, 373, 444 suppurative 449–50 tuberculous 451 wrist 422–3, 425 tenovaginosis, digital (trigger finger) 439–40 tension stress principle 336 tension-band plates 724 tension-band wires 724 tensor fascia femoris 607 teres minor 355 Teriparatide 139 terminology 9–10 terrible triad injury 776 Terry-Thomas sign 411, 412 tetanus 706 tethered cord syndrome 258, 260 tetracycline 57 thenar eminence, wasting 297, 298, 303 thenar muscles, paralysis 313 thenar space, abscess 450 therapeutic intervention scoring system (TISS) 709 Thessaly test 575, 582 thigh, lateral cutaneous nerve, compression 310 Thomas, Hugh Owen 56 Thomas splint 738, 898, 899, 908 Thompson and Epstein classification (hip dislocation) 882 Thompson’s test 639 thoracic outlet syndrome 302, 307–10, 459, 473 thoracocentesis 674 thoracolumbar spine infections 505–11 injuries 842, 853–9 thoracostomy 656, 674 thorn pricks 447 3D printing 325, 551–2, 867 threshold tests 284 thrombin inhibitors, direct 324–5 thrombophlebitis, acute 323 thromboprophylaxis 321–5 thrombosis capillary 108 ulnar artery 452 throwing activities, elbow pathology 394 thumb absence 433 adduction, loss 296 amputation 833 CMC dislocation 822 congenital clasped 405 congenital trigger 405 duplication 403–4 extensor pollicis longus rupture 435 hypoplasia 402, 404 infantile trigger 439 MCP instability/dislocation 822–3 metacarpal fracture 818 movements 431–2, 437 opponens paralysis 264 paralytic deformities in leprosy 312–13 reconstruction 833 replantation 830 in rheumatoid arthritis 442, 443 ulnar collateral ligament tears (gamekeeper’s thumb) 443, 824–5 thumb pinch, restoration 860–1 fractures 963 great clawed 626 gout 634 rheumatoid 633 rigid (hallux rigidus) 629–31 valgus (hallux valgus) 626–9 lesser toe deformities 631–2 nerve root supply 233 tomography 20 too many toes sign 609, 621, 622 tophi 84, 85, 389, 436, 453, 634 torticollis 458, 462 infantile (congenital) 462–3, 465 secondary 463, 464 spasmodic 487 torus fractures, radius 804 tourniquet 319–20 amputations 341 complications 320 cuff 319, 320 deflation 320 finger 320 nerve injury 311 open fracture treatment 730 pressure and time 319–20 thromboembolism prevention 324 use in trauma 656–7, 681 toxic inhalants 691 trachea, deviation 673 tracheal intubation 671–2 tracheobronchial tree injuries 675, 677 tracheostomy 672 traction 720–1 by gravity 720, 721 complications 721 femoral shaft fractures 899, 900 children 906–7 halter 463, 464 skeletal 721 skin 720, 721, 899 skull 849–50 supracondylar fractures 783–4 traction spur 519 tranexamic acid 657, 663 transplantation surgery 340 trapeziometacarpal joint, osteoarthritis 419–20 trapezium bone 399, 408, 427, 805 excision 421 fracture 810 trapezius, nerve root supply 233 trapezoid bone 399, 408, 805 trauma, see fractures; major trauma Trauma Audit and Research Network (TARN) 652 trauma network system 659–60, 666 trauma teams 660 Trauma Units 659 Index thumb-in-palm deformity 248 Thurston–Holland fragment 750 thyroid shields 319 thyroxine 133, 141 tibia external torsion 245, 251 fractures complex regional pain syndrome 277, 935 distal in children 948–50 distal (pilon) 946–8 malunion correction 336 plateau 925–9 proximal metaphysis 924 shaft 717, 929–35, 935 spine 583, 917–18 stress 746, 747, 935 osteofibrous dysplasia 204, 205 osteotomies 578, 579, 604–5 physeal injuries 579, 751 syphilitic sabre 17, 52 tubercle/tuberosity advancement 590 apophysitis (Osgood–Schlatter disease) 187, 599, 600 injuries 924 tibial compartment syndrome 605, 736, 928, 933 tibial nerves compression 310, 645 injuries 300, 302 involvement in leprosy 59 tibialis posterior 621 tibialis posterior tendon dysfunction in flat foot 621 lengthening 617 rupture 621, 634, 640 transfer 300, 314, 640 tibiofemoral alignment 576 tibiofemoral joint 606 tibiofibular ligaments anterior, avulsion 948, 949 inferior, tears 941–2 tibiofibular syndesmosis 942, 943 Tile classification (pelvic ring fractures) 869, 870 Tillaux fractures 948–50 tinea infections 452 Tinel’s sign 12, 226, 281, 283 median nerve 303, 304 tingling tiptoe test 619 TISS, see therapeutic intervention scoring system tissue hypoperfusion 697, 698, 702 tissue typing 26 titanium alloys 344 TMT joints, see tarsometatarsal joints toenail disorders 646–7 toes clawing 265, 267, 268, 302, 314, 626, 631–2, 744 deformities in spina bifida 261 1009 Index 1010 Trendelenburg gait 234, 542 Trendelenburg test 548 Treponema pallidum 51 Treponema pertenue 52 Trethowan sign 542 Trevor’s disease 174–5 triage, major trauma 654–5, 662 triangular fibrocartilage complex (TFCC) anatomy 399, 407–8, 428 degeneration 410 injuries 810–11 traumatic disruption 409–10 trigger finger 430, 439–40 trigger thumb 405, 439 triplane fracture 948–50 triquetrum 399, 408, 805 fracture 809 trochanteric fractures 886, 895 trolley-track sign 485 Trömner sign 477 trophic ulcers 300, 314–15 tropical ulcer 52–3 Trotter, Wilfred Trousseau sign 142 Tscherne’s classification 929 tuberculosis (TB) 53–7 ankle 632–3 cervical spine 480–1, 482 clinical features 55 diagnosis 56 elbow 388 granuloma (tubercle) 54 and HIV infection 511 investigations 55–6 knee 55, 593–4, 601–2 and osteonecrosis 109 paraplegia 508–11 pathology 53–5 shoulder 372–3 synovial fluid analysis 27 thoracolumbar spine 507–11, 529 treatment 56–7, 509–11 wrist 415 tumour-necrosis factor (TNF) 66, 703 inhibitors 75, 79, 706 tumour–node–metastasis (TNM) staging 182 tumours bone, see bone tumours histological grade 181 investigations 183–6 knee 585, 603 soft-tissue 222–3 epidemiology 179 fibrous 224–5 lipomatous 223–4 sarcomas 179, 180, 182, 186 smooth muscle 226 spinal cord 255 vascular 219–20, 226 Turner’s syndrome 141 twin studies, osteoarthritis 93 two-point discrimination 283–4, 826 ulcerative colitis 75, 77 ulcers amputation stump 343 neuropathic 637, 645 plantar 300, 314–15 tropical 52–3 ulna autogenous bone graft 332 head dorsal protrusion 399, 409, 416 excision 419 longitudinal deficiency 402–3 longitudinal instability 409 Monteggia fracture 387, 717, 776, 793–4, 795 secondary dysplasia 403 shaft fractures 789–93 isolated 792 styloid avulsion 409 variance 426 ulnar artery, thrombosis 452 ulnar claw hand 58, 58, 267, 270, 296, 297, 312–13 ulnar collateral ligament (thumb MCP joint) 442, 443, 824–5 ulnar corner pain 802 ulnar nerve anatomy 395, 427, 454 entrapment/compression 304–5, 309, 390 hand 454 injuries 296–7, 735, 743, 775, 784, 786, 788 motor conduction studies 236 palsy 437 leprosy 58, 59, 270, 311–13 transfer 286 ulnar neuritis 297 ulnocarpal impaction syndrome 410 ulnocarpal ligament 428 ulnohumeral joint, dislocation 779–81 ultra-high molecular weight polyethylene 345–6 ultrasound high-resolution fetal 161 hip 550 infant 532–3 osteomyelitis 35–6 principles and applications 23 shoulder 354, 361 trauma casualty 657, 660, 665 unconscious patients 837–8 uncovertebral joints 471 upper limb congenital anomalies 400–6 deformities in cerebral palsy 248 upper limb (continued) intersegmental deficiency 402 neurological examination 459, 469 see also bones and joints of upper limb weakness 471 upper motor neurons (UMN) 230 signs/lesions 231, 233–5, 477, 639 urate crystals, synovial fluid 84–5 urate metabolism, inherited disorders 83 urate-lowering therapy (ULT) 86 urethral injury 864, 872 urethral stricture 872 uric acid, serum (SUA) 83, 84 uricase 83 urinary catheter 664, 688, 872 urinary symptoms 474, 476, 489, 515 wake up test 499 Waldenstrom staging (Perthes disease) 538–9 walking aids 102 wall test 490 Index vaccination, surgeons 321 VACTERL associations 402 vacuum sign 513 vacuum-assisted closure (VAC) 43 valgus deformities 9, 14 elbow 383, 386 hallux 610, 611, 626–9, 644 knee 570, 594, 604–5, 606–7, 928 vancomycin 43, 729 varus deformities 9, 14 elbow 386 hindfoot 264, 625 knee 14, 570, 578–80, 604–5, 928, 935 vascular access, trauma 657, 682–3 vascular bundle implantation 413, 414 vascular injuries 734–5 ankle fractures 946 elbow dislocation 780 femoral condyle fracture 910 femoral shaft fractures 902 hip dislocation, posterior 883 humerus fractures 772 knee dislocation 919 open hand wounds 826 shoulder dislocation 763 supracondylar fractures 784 tibial fractures 932 vascular sinusoids, patency 107 vascular tumours bone 219–20 soft tissue 226 vasculitis, in R A 67, 72 vasopressors 701 vastus medialis, weakness 588 Vaughan Jackson syndrome 825 venous insufficiency, chronic 323 venous plexus pumps 727 venous thromboembolism (VTE) 321–5 after femoral fracture 904 after hip arthroplasty 566 after pelvic surgery 872 incidence in surgery 322–3 pathophysiology 322 prevention 323–5 ventilation inhalation burns 693–4 major trauma casualty 656, 687 ventriculoperitoneal (VP) shunt 259, 260 vertebra plana 205, 206 vertebra prominens 456 vertebral artery 456, 457 anatomical variations 457 vertebral body anatomy 528 cervical spine 455 vertebral end plates, sclerosis 147, 171 vertebral fractures ankylosing spondylitis 76 atlas 844 axis 845 odontoid 838, 840, 842, 845–6 burst 844, 847, 856, 857 compression 529, 854–5 diagnosis in childern 843–4 distraction (Chance fractures) 854, 858 flexion-compression 855–6 fracture-dislocation 858, 859 osteoporotic 138, 140 pars interarticularis 845, 854–5 rotation/translation 854 spinous process 852 stress 522 teardrop 847 transverse processes 854, 855 wedge compression 847, 855–6 vibration syndrome, hand–arm 424, 452 villous synovitis 601 viral arthritis 70 visceral injury 687–8, 734 vitamin D 130–1 activity assessment 136 insufficiency 143 metabolites 127, 131 supplements 139, 145 vitamin D2 (ergocalciferol) 130–1 vitamin D3 (cholecalciferol) 131 volar intercalated segment instability (VISI) 411, 805, 806 volar locking plate 799 Volkmann canals 124 Volkmann’s ischaemic contracture 14, 434, 623, 735, 743, 744 1011 Index wallerian degeneration 281 war mortality 651 warfarin 325 warming, hypothermic patient 696 warts, plantar 646 Watson’s test 399, 411, 812 weakness 4–5 foot 639–40 interosseous muscle 296, 297 osteoarthritis 104 patterns of 234 poliomyelitis 262–3 rheumatoid arthritis 67 serratus anterior 377 shoulder 263, 294–5, 351 upper limb 471 Weaver–Dunn procedure, modified 760–1 web, soft-tissue 271 web-space infection 447 wedge compression fractures, vertebral 847, 855–6 weight reduction 562 weight-bearing, after tibial fractures 932, 935 Werdnig–Hoffman disease 265 whiplash injury 852–3 whiplash-associated disorder 853 Whipple’s disease 75 white blood cell (WBC) counts 36, 49 whitlow 446, 449 wide awake local anaesthetic no tourniquet (WALANT) 319 Wilson’s sign 590 Wiltse–Newman classification 521–2 Winquist’s classification 897, 898 wires, fracture fixation 724, 725 Wnt signalling system 128, 129, 133 Wolff’s law 133 wound dressings 681, 690, 691, 731 wound management hand injuries 827, 829–30 major trauma 681 open fractures 730–1, 953 Wright’s test 308, 459 wrist applied anatomy 426–8 arthrodesis 290 carpal dislocations/subluxations 811–13 cartilage calcification 87 chronic instability 408–12, 744 clinical examination 397–9 1012 congenital anomalies 400–6 deformities 406–7 Colles fracture 797 flexion 248 poliomyelitis 263 fractures carpal bones 805–10 distal radius in adults 138, 406, 797–803 distal radius in children 803–4 imaging 399–400 joints 407–8 ligaments 427–8 movements 398, 399, 427 nerve roots 233 osteoarthritis 413, 418–22, 803, 809 position of function 408 Preiser’s disease 415 rheumatoid arthritis 407, 411, 415–18, 424, 425–6, 440 sprain 806 swellings 424–6 tendon pathology 422–4 tuberculosis 415 ulnar nerve compression 305 ulnar-side injuries 810–11 wrist drop 10, 11, 239, 295, 407 X-linked disorders 159 X-rays contrast 19–20 plain film 16–18, 19 image, 16 interpretation 16–18, 19 limitations 18 soft tissues 17 xanthine oxidase inhibitors 86 Xiapex (Xiaflex) 438 Yankauer sucker 670 yaws 52 Yergason’s test 364 Yersinia enterocolitica 76 Young and Burgess classification (pelvic ring fractures) 868–9 Z deformity 313 Z-plasty, hand 439 Z score 25 Zancolli’s operation 297, 312, 437 zoledronate 147, 153 ... vertebral locations? Eur Spine J 20 13; 22 : 28 15 20 .) Treatment Spondylodiscitis is a life-threatening disease with a mortality rate of up to 20 % The principles of treatment of spinal infections are:... ‘shortened’ and may feel tight and hard It is often a presenting feature of a congenital osseous cervical spine anomaly, particularly of the atlas, but it can also be acquired and the presenting sign of. .. Lower neck, superior Diaphragm part of the shoulder part of the shoulder C5 Radiculopathy C4–C5 Superior part of the shoulder to the lateral mid-arm Superior part of the shoulder to the lateral