What is the usual cause of Volkmann’s contracture?

Chapter 74 / Orthopaedic Surgery 709

Brachial artery injury, supracondylar humerus fracture, radius/ulnar fracture, crush injury, etc.

MISCELLANEOUS

Define the following terms: Dupuytren’s contracture

Charcot’s joint

Tennis elbow

Turf toe

Shin splints

Heel spur

Nightstick fracture

Kienbock’s disease

What is traumatic myositis?

How does a “cast saw” cut the cast but not the underlying skin?

Thickening and contracture of palmar fascia; incidence increases with age

Joint arthritis from peripheral neuropathy

Tendonitis of the lateral epicondyle of the humerus; classically seen in tennis players

Hyperextension of the great toe (tear of the tendon of the flexor hallucis brevis); classically seen in football players

Exercise-induced anterior compartment hypertension (compartment syndrome); seen in runners

Plantar fasciitis with abnormal bone growth in the plantar fascia; classically seen in runners and walkers

Ulnar fracture

Avascular necrosis of the lunate

Abnormal bone deposit in a muscle after blunt trauma deep muscle contusion (benign)

It is an “oscillating” saw (designed by Dr. Homer Stryker in 1947) that goes back and forth cutting anything hard while moving the skin back and forth without injuring it

710 Section III / Subspecialty Surgery

ORTHOPAEDIC INFECTIONS

OSTEOMYELITIS

What is osteomyelitis?	Inflammation/infection of bone marrow
	and adjacent bone
What are the most likely	Neonates: Staphylococcus aureus, gram-
causative organisms?	negative streptococcus
	Children: S. aureus, Haemophilus
	influenzae, streptococci
	Adults: S. aureus
	Immunocompromised/drug addicts:
	S. aureus gram-negative
	Sickle cell: Salmonella
What is the most common	S. aureus
organism isolated in
osteomyelitis in the general
adult population?
What is the most common	Salmonella
isolated organism in patients
with sickle cell disease?
What is seen on physical	Tenderness, decreased movement,
examination?	swelling
What are the diagnostic steps?	History and physical examination, needle
	aspirate, blood cultures, CBC, ESR, bone
	scan
What are the treatment	Antibiotics with or without surgical
options?	drainage
What is a Marjolin’s ulcer?	Squamous cell carcinoma that arises in a
	chronic sinus from osteomyelitis
SEPTIC ARTHRITIS
What is it?	Inflammation of a joint beginning as
	synovitis and ending with destruction of
	articular cartilage if left untreated

What are the causative agents?

What are the findings on physical examination?

What are the diagnostic steps?

What is the treatment?

ORTHOPAEDIC TUMORS

Chapter 74 / Orthopaedic Surgery 711

Same as in osteomyelitis, except that gonococcus is a common agent in the adult population

Joint pain, decreased motion, joint swelling, joint warm to the touch

Needle aspirate (look for pus; culture plus Gram stain), x-ray, blood cultures, ESR

Decompression of the joint via needle aspiration and IV antibiotics; hip, shoulder, and spine must be surgically incised, débrided, and drained

What is the most common	Metastatic!
type in adults?
What are the common	Breast, lung, prostate, kidney, thyroid,
sources?	and multiple myeloma
What is the usual	Bone pain or as a pathologic fracture
presentation?
What is the most common	Multiple myeloma (45%)
primary malignant bone
tumor?
What is the differential	Metastatic disease
diagnosis of a possible bone	Primary bone tumors
tumor?	Metabolic disorders (e.g.,
		hyperparathyroidism)
	Infection
What are the benign bone	1.	Osteochondroma
tumors (8)?	2.	Enchondroma
	3.	Unicameral/aneurysmal bone cysts
	4.	Osteoid osteoma
	5.	Chondroblastoma
	6.	Fibroxanthoma
	7.	Fibrous dysplasia
	8.	Nonossifying fibroma

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What are the malignant bone tumors (7)?

Compare benign and malignant bone tumors in terms of:

Size

Bone reaction

Margins

Invasive

1.Multiple myeloma

2.Osteosarcoma

3.Chondrosarcoma

4.Ewing’s sarcoma

5.Giant cell tumor (locally malignant)

6.Malignant melanoma

7.Metastatic

Benign—small; 1 cm

Malignant— 1 cm

Benign—sclerotic bone reaction Malignant—little reaction

Benign—sharp

Malignant—poorly defined

Benign—confined to bone Malignant—often extends to surrounding

tissues

Are most pediatric bone	80% are benign (most common is
tumors benign or malignant?	osteochondroma)
Are most adult bone tumors	66% are malignant (most commonly
benign or malignant?	metastatic)
What are the four diagnostic	1.	PE/lab tests
steps?	2.	Radiographs
	3.	CT scan, technetium scan, or both
	4.	Biopsy
What are the radiographic	Large size
signs of malignant tumors?	Aggressive bone destruction, poorly
		defined margins
	Ineffective bone reaction to tumor
	Extension to soft tissues
What are the radiographic	Small
signs of benign tumors?	Well circumscribed, sharp margins
	Effective bone reaction to the tumor
		(sclerotic periostitis)
	No extension—confined to bone

	Chapter 74 / Orthopaedic Surgery 713
What are some specific
radiographic findings of the
following:
Osteosarcoma?	“Sunburst” pattern
Fibrous dysplasia	Bubbly lytic lesion, “ground glass”
Ewing’s sarcoma	“Onion skinning”

What is the mainstay of treatment for bone tumors?

Surgery (excision plus débridement) for both malignant and benign lesions; radiation therapy and chemotherapy as adjuvant therapy for many malignant tumors

OSTEOSARCOMA

What is the usual age at presentation?

What is the gender distribution?

What is the most common location?

What is the radiographic sine qua non?

What is the treatment?

What is the 5-year survival rate?

What is the most common site of metastasis?

What is the most common benign bone tumor?

What is a chondrosarcoma?

10 to 20 years

Male female

66% in the distal femur, proximal tibia

Bone formation somewhere within tumor

Resection (limb sparing if possible) plus chemotherapy

70%

Lungs

Osteochondroma; it is cartilaginous in origin and may undergo malignant degeneration

Malignant tumor of cartilaginous origin; presents in middle-aged and older patients and is unresponsive to chemotherapy and radiotherapy

714 Section III / Subspecialty Surgery

EWING’S SARCOMA

What is the usual	Pain, swelling in involved area
presentation?
What is the most common	Around the knee (distal femur,
location?	proximal tibia)
What is the usual age at	Evenly spread among those younger than
presentation?	20 years of age
What are the associated	Lytic lesion with periosteal reaction
radiographic findings?	termed “onion skinning,” which is
	calcified layering
	Central areas of tumor can undergo
	liquefaction necrosis, which may be
	confused with purulent infection
	(particularly in a child with fever,
	leukocytosis, and bone pain)

What is a memory aid for Ewing’s sarcoma?

What is the 5-year survival rate?

How can Ewing’s sarcoma mimic the appearance of osteomyelitis?

“TKO Ewing”:

Twenty years old or younger Knee joint

“Onion skinning”

50%

Bone cysts

What is a unicameral bone	Fluid-filled cyst most commonly found in
cyst?	the proximal humerus in children 5 to 15
	years of age
What is the usual	Asymptomatic until pathologic fracture
presentation?
What is the treatment?	Steroid injections
What is an aneurysmal bone	Hemorrhagic lesion that is locally
cyst?	destructive by expansile growth, but does
	not metastasize